When the Thirlwall Inquiry published its long-awaited findings last week, British health secretary Yvette Cooper formally apologised on behalf of the government to the bereaved parents for a hospital and a system that failed to protect their babies.
The inquiry was set up in 2023 after the conviction of former nurse Lucy Letby for the murder of seven newborn infants and seven counts of the attempted murder of another six infants – later increased on retrial to the attempted murder of seven babies – in the Countess of Chester Hospital in 2015-16. The 822-page report is presented as a damning indictment of the neonatal unit, the hospital, and the National Health Service (NHS).
If only the hospital had acted sooner and called in the police earlier. If only nurses hadn’t taken the side of one of their own. If only managers hadn’t put the public image of the hospital ahead of the safety of babies. If only there had been openness and accountability instead of toxicity and tribalism among the staff and management. If only hospital inspectors and regulators had opened their eyes to see what was really happening. If only. If only. Because Letby had literally been let get away with murder for so long, things could never be the same again. To protect its most vulnerable citizens, the government may now introduce widespread changes as recommended by Judge Kathryn Thirlwall.
Soon, baby cots and incubators, as well as insulin storage fridges, will be fitted with video cameras to prevent doctors or nurses from harming or killing babies. Parents will also be able to monitor their babies remotely via livestreamed video to reassure themselves that nobody is attempting to poison their baby with insulin, inject air bubbles into their bloodstream or dislodge ventilator breathing tubes as Letby did.
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If a baby unexpectedly collapses or dies in future, deliberate medical harm will be considered as a differential diagnosis – and management and staff will be trained on what to do if such a suspicion arises. In the future, discussions between parents and clinicians in these circumstances will require reassurance – and, given what has happened, may also involve accusations, denials, or lingering, unvoiced parental suspicions. A review of video footage will, undoubtedly, become a part of every critical case investigation – and sometimes be needed to exonerate staff from accusations of negligent or deliberate harm.
Hospital inspectors and regulators will need to be wary – as will perinatal pathologists when they do postmortems. No doubt, police will need special training in conducting investigations in hospitals – and in addition to the chapters on medical negligence, legal textbooks will require additional ones on deliberate medical harm.
Once a place of safety for babies, a place where doctors and nurses saved the lives of the sickest babies, including those at the very threshold of survival, NHS neonatal intensive care units will now be seen as something else – a place of potential danger. And all because of the danger lurking within, all because of one, in the words of the first trial judge, “deeply malevolent” and remorseless killer nurse named Lucy Letby.
But the report fails to address the most important question of all.
What if Letby never killed or tried to harm any baby? And what if there were no crimes committed? What then for the Thirlwall Inquiry report, which cost almost £19 million (€22 million) – and for its 17 recommendations, which will cost many times that sum?
It’s no wonder that Letby’s barrister Mark McDonald has advised the pause button be pressed. Letby’s case is under consideration by the Criminal Cases Review Commission (CCRC) as a potential miscarriage of justice. Increasing disquiet among medical experts and the public had led to earlier calls from many quarters to broaden the scope of the inquiry – including for Letby to have been represented at it – and to delay the report’s publication until after the decision of the CCRC. These requests were turned down.
Thirlwall refused Letby’s lawyers permission to take part and brushed off critical commentary about the case as “noise”.
Since Letby’s prosecution, a lot has happened to convince me that she is innocent – including, importantly, the 2025 report by an independent international panel of 14 world-leading medical experts who found no evidence of murder or attempted murder. Instead, they found severe systemic problems in medical care. Panel chairman emeritus professor Shoo Lee of the University of Toronto put it bluntly: “If this hospital were in Canada, it would be shut down.”
It is worth noting that publication of the report comes hot on the heels of the Ockenden and Amos reports on poor clinical outcomes and governance failings in NHS maternity and neonatal services in Nottingham and England respectively.
The reliability of the opinions provided by expert witnesses called by the prosecution in court has also been heavily criticised by an increasing number of authoritative medics. It is of note that Letby’s original defence team did not call any medical experts in court and that neither the prosecution nor the defence reviewed any of the mothers’ maternity records – which in the context of investigating the deaths of newborn infants represents a monumental error of judgment.
Former Brexit secretary David Davis MP has also urged police to investigate the factual testimony given by one doctor during the trial.
The statistical analysis of the staff roster and the reliability of the key card door-swipe data used to pin Letby to the “crime scenes” have been debunked by experts – as well as the evidential value of her distressed confessional notes and the medical documents that she took home with her after duty. If there had been cameras, I believe Letby would not be serving 15 whole-life orders.
The stakes are now extremely high – for Letby and, of course, for the grieving parents.
As we reach the “appalling vista” moment that Lord Denning contemplated in relation to the Birmingham Six’s innocence, the stakes are also extremely high for the criminal justice system, the hospital, the NHS and the political establishment.
For the affected parents, their suffering will intensify if there is a retrial.
As for babies in neonatal intensive care units, their lives are best safeguarded by consultant neonatologists doing twice-daily rounds (and being immediately available), trained neonatal nurses, teamwork, adequate resources – not by CCTV cameras.
If Lucy Letby walks free, there will, no doubt, be an inquiry into the Thirlwall Inquiry.
- Chris Fitzpatrick is a clinical professor at UCD and a retired consultant obstetrician & gynaecologist and a former master of the Coombe hospital, Dublin
