
Lady Justice Thirlwall's report criticizes hospital management for 'profound failure' in safeguarding infants
AI-generated summary
The inquiry follows the conviction of Lucy Letby for the murder and attempted murder of babies at the Countess of Chester Hospital. The report investigates systemic failures in safeguarding and management response.
Health Secretary Yvette Cooper has said officials will "urgently develop plans" to introduce live-streaming cameras on England's baby wards after an inquiry into Lucy Letby's murders and attempted murders.
Inquiry chair Lady Justice Thirlwall called for a series of urgent reforms to neonatal units, including CCTV for all cots and incubators, and restricting access to insulin.
Thirlwall said some of the babies Letby killed could have been saved if managers at the Countess of Chester Hospital had taken action earlier.
Her report criticises a "complete failure to protect babies" and a "profound failure of management, governance and safeguarding" at the hospital.
Thirlwall said this was because "no one seems to have understood that safeguarding action is required when a member of staff is suspected of causing deliberate harm and does not require colleagues to be sure of guilt."
She said it would never be possible to know exactly how many lives could have been saved if safeguarding procedures had been properly followed.
Thirlwall added her report described "dysfunctional management and governance, a gulf between hospital leadership and clinicians, and failure to understand the fundamentals of safeguarding".
Letby was moved on to administrative duties in July 2016 after consultants expressed concerns about her to the hospital's executive team.
But the inquiry has found that alarm bells should have been sounded earlier.
There were several "missed opportunities" for hospital bosses to intervene, the report said, including when three babies died in one cluster in June 2015.
Parents of the babies were "kept in the dark for years" over the concerns that their babies might have been deliberately harmed, the inquiry also found.
Thirlwall described the lack of consideration shown to parents as "reprehensible".
The report is highly critical of managers at the Countess of Chester Hospital.
Hospital bosses carried out a number of internal reviews into increased infant mortality in 2015 and 2016, but did not invite Cheshire Police to investigate until May 2017.
Letby remained on site until her arrest more than a year later.
Cheshire Police said it would "carefully review" the contents of the report and "fully consider" relevant recommendations.
Thirlwall said the hospital's former chief executive Tony Chambers behaved in a "dictatorial manner" and had "intended" to obstruct a police investigation into deaths on the ward.
Chambers, along with director of nursing and head of safeguarding Alison Kelly and medical director Ian Harvey, "dismissed the idea that Letby was deliberately harming babies", Thirlwall added.
But whether these managers believed Letby was harming babies or not was "irrelevant", Thirlwall said, adding that action should have been taken as soon as concerns were raised.
AI outlook — possibilities, not facts
Government implementation of CCTV in neonatal units.
Very likely · Within months
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