Thirlwall Inquiry Finds Letby Victims Could Have Been Saved
The public report identifies systemic failures in hospital safeguarding as a structural problem, not merely individual misconduct, raising questions about oversight across the National Health Service.
A public inquiry into the crimes of convicted nurse Lucy Letby has concluded that the deaths and near-deaths of some babies she attacked could have been prevented had safeguarding practices been properly followed, according to findings published September 15, 2026, by BBC News.
Letby was convicted of the murders of seven babies and the attempted murders of seven others, one of whom she attempted to kill on two separate occasions, at the Countess of Chester Hospital in England. She is currently serving a whole-life prison sentence following her conviction, which was delivered by a jury at Manchester Crown Court in August 2023, according to court records reported widely at that time.
The Thirlwall Inquiry, led by Lady Justice Thirlwall, was established by the UK government to examine how Letby was able to commit the offences over a period of years without being stopped by hospital management or external regulators. The inquiry takes its name from the presiding judge and is a statutory public inquiry under UK law.
Among the central findings, the inquiry determined that concerns raised by consultant paediatricians at the hospital about Letby were not acted upon with sufficient urgency by senior management. BBC News reported that the inquiry identified specific failures in the chain of safeguarding responsibility, though the full list of recommendations was being published in stages as of the report date.
The inquiry also examined the role of the Countess of Chester Hospital's executive leadership, which had previously required some doctors who raised alarms about Letby to issue apologies to her before those concerns were escalated to external authorities, according to evidence heard during the inquiry's public sessions in 2024 and 2025.
The National Health Service regulator, NHS England, and the Care Quality Commission (CQC) are among the bodies whose oversight functions fall within the inquiry's scope. The CQC had inspected the Countess of Chester Hospital during the period in which Letby was working in the neonatal unit, according to publicly available CQC inspection records.
Letby's crimes occurred primarily between June 2015 and June 2016 in the hospital's neonatal unit in Chester, England. The delay between the period of offending and the inquiry's findings, spanning more than a decade, reflects the length of time required for criminal prosecution, conviction, and then the establishment and conduct of a statutory inquiry.
The Thirlwall Inquiry received written and oral evidence from hospital executives, medical staff, regulatory officials, and the families of victims. Hearings were conducted in public and transcripts were made available by the inquiry secretariat throughout its proceedings.
Families of the victims have been represented throughout the inquiry process and are among those with a formal interest in its recommendations. Whether the UK government will accept and implement the inquiry's recommendations in full, in part, or on a modified timeline is a matter for the Secretary of State for Health and Social Care, whose response had not been published as of the report date.
The full written report from Lady Justice Thirlwall sets out the complete findings, conclusions, and recommendations. The extent to which those recommendations require legislative change, regulatory reform, or changes to NHS internal governance procedures will determine the mechanism and timeline for any resulting action.