What will the research focus on?
Survey Mission Details As published on the website and mentioned above, the three areas of focus are:
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the experiences of the Countess of Chester Hospital (CoC) and other NHS associated services, and the experiences of all the parents of the infants named in the indictment;
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In relation to the actions and subsequent conduct of Ms Lucy Letby, who worked as a neonatal nurse, the conduct of those working at the CoC, including its officers, managers, doctors, nurses and midwives,
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These include the NHS management and governance structures and processes, external oversight, the effectiveness of professional regulation, whether and if so what changes are needed to ensure that babies are cared for safely and well in hospitals, and how accountability of senior managers should be strengthened.This section examines the culture of the NHS.
The committee published a “non-exhaustive” list of 30 questions to investigate, including: hereChief among them is the question of what happened in the hospital at the time when questions were being raised such as:
What concerns were raised about Letby's conduct, when were they raised, who raised them, and what was the response?
Should concerns about hospitals and clinical data have been raised earlier? When? What should have been done then?
Were existing processes and procedures for raising concerns, such as whistleblowing or parental freedom of speech, used? Were they appropriate?
The investigation will not reexamine Letby's murder and attempted murder convictions.
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The experiences of the Countess of Chester hospital (CoC) and other relevant NHS services, of all the parents of the babies named in the indictment
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The conduct of those working at the CoC, including the board, managers, doctors, nurses and midwives with regard to the actions of Lucy Letby while she was employed there as a neonatal nurse and subsequently
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The effectiveness of NHS management and governance structures and processes, external scrutiny and professional regulation in keeping babies in hospital safe and well looked after, whether changes are necessary and, if so, what they should be, including how accountability of senior managers should be strengthened. This section will include a consideration of NHS culture
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The inquiry published what it described as a “non-exhaustive” list of 30 questions to examine, which can be found here. Key among them are questions about what happened in the hospital at a time when questions were being raised, including:
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What concerns were raised and when about the conduct of Letby? By whom were they raised? What was done?
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Should concerns, including about hospital or clinical data, have been raised earlier than they were? When? What should have been done then?
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Were existing processes and procedures for raising concerns used, including whistleblowing and freedom to speak up guardians? Were they adequate?
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What the inquiry will not be doing is re-examine the convictions of Letby for murder and attempted murder.
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Today at Liverpool town hall the Thirlwall inquiry will begin a week of hearing opening statements, as it seeks to examine how former nurse Lucy Letby was able to murder babies over a period of two years at the Countess of Chester hospital’s neonatal unit.
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Letby, 34, was sentenced to 15 whole-life orders after she was convicted of murdering seven babies and attempting to murder seven others across two separate trials.
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The inquiry, chaired by Lady Justice Thirlwall, will consider the experiences of the parents of Letby’s victims, look into the conduct of staff at the hospital and assess whether suspicions should have been raised earlier, whether Letby should have been suspended earlier and whether the police should have been brought in sooner.
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The inquiry will examine wider NHS culture and consider the effectiveness of its management and governance structures. It is expected to last about four months, with a report to be released next year.
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We will bring you updates from the opening day of the inquiry here.
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Main Events
Jamie Grierson
Before the hearing, Tamlyn Bolton“The families represented by Switalskis Law Firm have experienced unimaginable pain and anguish,” said Senior Associate Attorney at the Switalskis Law Firm, which represents the victims' families. “The facts and issues explored in this investigation will be of deep concern to each family whose infants were murdered or assaulted by Lucy Letby.”
“Their babies were born, harmed and died in 2015 and 2016 and they have already endured years of anguish. But this inquiry will be the first opportunity to hear evidence about how Lettie was allowed to harm as many as 18 babies before she was removed from the neonatal unit at Countess of Chester Hospital.”
“The facts and issues uncovered by this investigation should be of serious concern to all families who have received or will receive NHS maternity, neonatal and paediatric services, as well as to members of the public who need to trust that patients are safe. For the families we represent, that trust has been shattered.”
Nine months ago, Judge Thirlwall The investigative committee has made her opening statement public, and it is also available to watch on video.
In it she said:
We all know that there have been many inquiries into incidents in hospitals and other healthcare settings over the past 30 years. The case of Beverley Allitt, who murdered an infant at Grantham Hospital in the 1990s, springs to mind. Everyone was determined that this would never happen again. Yet it has happened again. This is completely unacceptable. I would like to know what recommendations these inquiries made and whether they have been implemented. What changes have been made? Where is the responsibility for the mistakes that have been made?
No one would disagree that babies in neonatal units must be safe and well cared for. What is needed is to put that into practice everywhere. In many units, radical changes in relationships and culture will be required. This may not be easy to achieve but it is necessary and has been long overdue. Barriers to change must be identified and removed where they have not already been done. Where good practice exists, it must be shared. To bring about the necessary change we need the cooperation and willingness of all those who are involved and responsible for babies in neonatal units, from the wards to the boardroom. This inquiry relies on that cooperation to address this vital challenge.
The parents of babies who were murdered or permanently scarred live with the consequences every day. In addition to their heartbreaking loss, they went years without knowing what caused the deaths or injuries – and some still don't. They all made it clear to me that they want to do all they can to ensure that no one else has to go through what they did. I have already mentioned one of the ways they suggested this could be achieved. With the help of the investigation team and all those who cooperate with the investigation, I intend to do all I can to ensure that no one else has to go through what I did. It would be unacceptable to allow this to happen again.
The full text of the November 2023 opening statement can be viewed below. here.
Felicity Lawrence
There are calls for the inquiry to be postponed or even changed. Felicity Lawrence reported in The Guardian in August:
A group of leading UK neonatologists and statistics professors are calling on the government to postpone or change the terms of the hearing, raising concerns about the conviction of neonatal nurse Lucy Letby.
In a private letter to ministers, seen by the Guardian, 24 experts said they feared the restrictive terms of the inquiry could prevent lessons being learned about the “possible death by negligence, presumed to be homicide”, which occurred on the neonatal unit at the Earl of Chester Hospital (CoC).
Despite the guilty verdict and the Court of Appeal decision, a small but growing number of experts have expressed concerns about the evidence presented at the trial. In a July article published by The Guardian, several experts came forward to express concerns that Letby's conviction was not valid.
Read more: Lucy Letby investigation should be delayed or rescheduled, experts say
Unlike other recent public inquiries, such as into the response to the Covid-19 pandemic and the Post Office Horizon IT scandal, the Thirlwall inquiry is not being livestreamed to the public.
Access has been allowed to key participants and limited media. At the inquiry's preliminary hearing in May, lawyers for the victims' families argued that the hearing should be livestreamed and made public, in part to “combat conspiracy theories.” But a ruling that month said: Judge Thirlwall ruled against.
Part of the justification given in the ruling was that there was a risk of violating court orders during the proceedings. Rachel Langdale KCAs lawyer for the investigative committee, he said he had to comply with a court order prohibiting the identification of several people involved, including all of the babies.
Jamie Grierson and Josh Halliday explain the study:
The Thirlwall Commission was set up to look into the events and their aftermath at the Countess of Chester Hospital after Lucy Letby was tried and subsequently convicted of murdering seven babies and attempting to murder seven more.
The three main areas being explored in the inquiry are the experiences of the victim's parents, the attitude of hospital staff towards Ms Letby during her time working there, and the effectiveness of NHS management.
The inquiry is chaired by Senior Court of Appeal Judge Dame Katherine Thirlwall. Counsel for the inquiry is Rachel Langdale KC, who was previously lead counsel for the key participants in the public inquiry into Mid Staffordshire NHS Foundation Trust and has previously represented local authorities and individuals in investigations into children in care and safeguarding.
Key participants include the families of the children named in the indictment, represented by a lawyer team, the Royal College of Paediatrics and Child Health, the Department of Health and Social Care, Countess of Chester Hospital NHS Foundation Trust, the Nursing and Midwifery Council, the Care Quality Commission and NHS England.
The first week will see opening statements by lawyers for the Investigative Committee and legal representatives representing the key participants.
Welcome and opening summary…
Liverpool City Hall today begins a week of opening hearings for the Thirlwall Inquiry, which aims to investigate how former nurse Lucy Letby murdered babies in the neonatal ward at the Countess of Chester Hospital over a two-year period.
Letoby, 34, was convicted of murdering seven infants and attempting to murder seven more in two separate trials and received 15 life sentences.
The inquiry, chaired by Judge Thirlwall, will take into account the experiences of the parents of Mr Letby's victims, examine the behaviour of hospital staff and assess whether allegations should have been raised earlier, whether Letby should have been suspended sooner and whether police should have intervened sooner.
The inquiry will look at the overall culture of the NHS and the effectiveness of its management and governance structures, and will last for around four months with a report due to be published next year.
We will provide you with the latest information from the start of the investigation here.
