Thirlwall Inquiry.

This week the Thirlwall Inquiry published its report detailing the failings of those responsible for the safety of babies under the care of the Countess of Chester Hospital, following the conviction of Lucy Letby. Letby is charged with the murder of seven babies and attempted murder of seven others, one of them twice.

The Inquiry was announced in August 2023 and chaired by Lady Justice Thirlwall.

The Inquiry was vast and involved 383 witness statements being obtained, and 134 witnesses providing oral evidence over 60 days of hearings. The investigation examined the experiences of family members and the conduct of staff members – from clinicians to board members. The effectiveness of NHS management and governance structures was scrutinised.

In her report, Lady Justice Thirlwall pays tribute to the courage and dignity of the parents involved in the Inquiry. It was recognised that they are continuing to grieve for their babies, and have now been living with their pain for some 10 - 11 years. Some of whom had been kept in the dark for years about the suspicions their baby might have been deliberately harmed.

The report makes for difficult reading and it was found that there was a complete failure to protect babies on the Neonatal Unit at the Countess of Chester Hospital. Lady Justice Thirlwall describes a system of dysfunctional management and governance, which is an all too familiar observation echoed across the Donna Ockenden and Baroness Amos’ reviews of maternity and neonatal services within our NHS.

Key findings include that the first three deaths in June 2015 were not considered to be a cluster of death, despite this figure being the same as the annual number of deaths on the unit, and all occurred within a two-week period. The fourth death was deemed to be an unexpected death and as such a serious incident panel meeting was held, albeit it appears that this was merely treated as a formality. Despite the death toll on the unit now standing at four (the highest it had been since 2008), there was still no connection made between the deaths, or appropriate escalation.

The report also concluded that with appropriate safeguarding action, three deaths would have been prevented, as well as attacks on seven babies.

The report found that hospital management consistently failed in their duty of candour and that their behaviour was against all safeguarding principles. There were failures to act when suspicions of harm were raised, and an unnecessary delay in contacting the police, delaying and obstructing a police investigation for almost a year. Judgement was clouded by a view that Letby “was a very good nurse”.

Speaking in an interview Dr John Gibbs, a consultant at the Countess of Chester Hospital throughout the period where Letby was able to carry out her crimes, said:

"I wish we consultants had been brave enough to follow our suspicions and escalate things to the police earlier.

"When I say, 'we consultants', I am responsible as well and if my other consultant colleagues didn't go to the police, I should have."

The report makes 17 recommendations for improvement and Health Secretary, Yvette Cooper has stated that officials will “urgently develop plans” to implement these reforms.

The recommendations include the introduction of CCTV and monitoring in all neonatal units, with live streaming in-cot monitors so that parents can observe their baby remotely 24 hours a day.

Secondly, the access to insulin should be restricted using digital devices and biometric data. Until this is implemented, CCTV should be focused on where insulin is stored.

In addition, NHS England must produce and implement a protocol setting out steps that must be taken, where there is a suspicion a healthcare professional may have caused deliberate harm.

There will also be a National Bereavement Care Pathway for neonatal deaths, to be implemented in all Trusts by the end of August 2027.

Whilst the Inquiry is damning and does indeed make for grim reading, it unfortunately mirrors many issues already raised by the maternity investigations that have come before it, and safer maternity care has never been far from the news for a number of years.

It is well recognised that too many people have been let down by substandard maternity and neonatal care; the consequences of this are far reaching and devastating. We can only hope that lessons are learnt, and that the findings of the various reports over the years are actioned. Reports do not save lives, implementation does.

If you wish to speak to our specialist Maternity Team, please email: info@lblaw.co.uk or phone 0800 652 3371.