Cameras should be installed above newborn cots in England. The Letby case inquiry made 17 recommendations, but did not address her guilt at all

A live-streaming camera should be installed above every cot and incubator in English neonatal units, with parents able to access it remotely at any time. This is recommended by the final report of the inquiry, presented on Tuesday at Liverpool Town Hall by Court of Appeal judge Kathryn Thirlwall, which describes a “complete failure” to protect children at the Countess of Chester Hospital. The report was published in three volumes and contains seventeen recommendations — but it did not address the question resonating most loudly around the Lucy Letby case, namely whether she is guilty. It proceeded on the basis that her conviction stands. Chester Standard ↗Letby, now 36, is serving fifteen life sentences with no possibility of release. The court found her guilty of murdering seven newborns and attempting to murder seven others — one of them twice — between June 2015 and June 2016. She denies her guilt, and the Court of Appeal has twice rejected her applications for permission to appeal against the convictions. RTÉ ↗

Three babies could have survived

The report’s starkest finding concerns the time lost. Thirlwall concluded that three children could have survived and another seven could have been protected if the hospital management had acted when doctors first raised the alarm. These are not two separate figures to be added together, but two possible intervention points, with the earlier one encompassing the later one as well. If Letby had been removed from the unit as early as October 2015, two of the triplets referred to as children O, P and R would not, in her view, have died in June 2016, and five other children would not have been harmed. If action had been taken as early as August 2015, after an undetected case of insulin poisoning, three more children would have been included — a two-month-old girl, I, who died in October, and two children who suffered unexplained collapses. One of them, a girl identified as G, is now eleven years old, has permanent brain damage and requires round-the-clock care. The Guardian ↗

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The warning signs came early. In June 2015, three children died on the unit in less than two weeks — as many as normally died there in an entire year. Yet no one assessed them as a series. In August 2015, a fourth child, identified as E, died. The twin, F, survived insulin poisoning — and the laboratory result became a missed opportunity. A doctor anonymised by the report as ZA reportedly acknowledged that the insulin could have come from outside and checked whether anyone had prescribed it, but did not investigate further or alert colleagues. Had she done so, a protective measure for the children should have followed. The hospital management did not contact the police until the end of April 2017, almost two years after the June rise in deaths. BBC News ↗

Doctors who raised the alarm found themselves under investigation

This is the part with the greatest relevance beyond Britain. The report states that senior nurses never accepted the doctors’ concerns and that management focused on the hospital’s reputation. It criticises medical director Ian Harvey for trying to “control the narrative” — ensuring that only documents supporting his version reached the table and, when necessary, writing them himself. Chief executive Tony Chambers, it says, acted dictatorially towards doctors, while presentations to the board were an “exercise in distortion”. When Letby complained about the hospital’s conduct, it was the doctors who came under investigation: three consultants were reportedly expected to apologise to her, and her return to the unit was initially being prepared. The chair of the panel reviewing her complaint described the allegations against Letby as a “witch hunt”. Chester Standard ↗

The report speaks of “toxic negativity” that still discourages people in the NHS from speaking out, even though whistleblower protections have been strengthened over the past decade. It adds a sentence that lies at the heart of the entire report: no one appears to have understood that child-protection measures are needed as soon as an employee is suspected of deliberately causing harm — not only once those around them are certain of their guilt. Suspicion is enough. The NHS, it says, still lacks a national protocol for suspected deliberate harm, unlike schools and social services, which have had one for years. Nursing Times ↗

The report did not assess guilt. And that same week, the defence team fell apart

The inquiry proceeded from the outset on the assumption that Letby was guilty, and last year Thirlwall rejected proposals from her lawyers and four hospital managers to suspend it until the Criminal Cases Review Commission ruled on the matter. “I focused on the questions set out in the inquiry’s terms of reference, not on Lucy Letby’s guilt or her conviction,” she said when presenting the report. Meanwhile, the commission has been assessing for eighteen months material from an international panel of experts who say the medical evidence for the murders does not stand up. Its interim chair, Vera Baird, said the commission would examine the report with interest and assess whether it affected its own review of the case in any way. The Guardian ↗

However, a blow came from the opposite direction the day before the report was published. Two experts withdrew from the defence team — British chemical engineer Helen Shannon and New Zealand bioengineering professor Geoff Chase, authors of a hundred-page analysis challenging two convictions for insulin poisoning. They have not changed their own conclusion: they continue to say that poisoning was “very unlikely” in those two children. But they rejected some of the other arguments advanced by the defence in the insulin cases. In a letter to the commission, they wrote that they could not support them as scientifically credible, that they had “fundamental intractable problems”, and that barrister Mark McDonald’s strategy exposed the long-term interests of his own client to “serious, unnecessary and unacceptable risk”. McDonald disagrees, arguing that the case does not stand or fall on a single expert and that the strength of the new evidence lies in its breadth and consistency across disciplines. The Guardian ↗

The camera plan must be submitted by an agency due to disappear a month later

The third notable feature of Tuesday’s events is the addressee and its timetable. Most of the deadlines in the recommendations fall on 31 March 2027. By then, hospital trusts are to monitor all child deaths at board level and meet requirements for controlling access to insulin; until biometric security is in place, they are to install cameras recording for at least 28 days on refrigerators containing it. The cameras above cots are different: by the same date, NHS England is only required to submit a plan for introducing them. According to the government, the abolition of NHS England and transfer of its powers to the Department of Health should be complete by April 2027 — a month after the deadline for the same organisation to submit the plan. The bill is currently before Parliament, and it is not even certain that the abolition will ultimately pass. Thirlwall Inquiry ↗ Institute for Government ↗

Thirlwall herself put it plainly: after NHS England is abolished, it is unclear which body will assume responsibility, and she is not reassured. She criticised successive governments for an “inexcusable” failure to implement reforms proposed by similar inquiries over the past thirty years. There is concrete evidence for this: the Care Quality Commission inspected the hospital in February 2016, and key information was withheld from it — but the report also criticises the commission for failing to ask further questions, despite having already been urged to take a stricter approach by the inquiry into newborn deaths at Morecambe Bay. Health Secretary Yvette Cooper told MPs that she was “deeply sorry” about the failures, promised a full government response within six months and described cameras above cots as a measure the authorities were preparing urgently. The Guardian ↗

How long it took next door

Central Europe has its own measure of the time that can pass between suspicion and the police. In 2006, healthcare worker Petr Zelenka administered heparin to patients in the anaesthesiology and resuscitation unit in Havlíčkův Brod. The pattern was discovered by the unit’s head physician. The hospital terminated his employment at the end of September, but filed a criminal complaint only in mid-October, and police arrested him on 1 December — by then he was already working in surgery in Jihlava. In 2008, he received a life sentence for seven murders and ten attempted murders. The time from suspicion to police involvement was therefore weeks, not years. Even so, he managed to start work elsewhere. Aktuálně.cz ↗

Limits of this perspective

The report is a document with clearly defined terms of reference, not a judgment. It does not assess the evidence on which the conviction rests and proceeds on the basis that it stands — a premise its critics, including Conservative MP David Davis, say is flawed. Davis speaks of a miscarriage of justice, while McDonald argues that errors from the trial were repeated in the conclusions. On the other hand, it remains the case that the Court of Appeal has rejected Letby’s applications twice and that the Criminal Cases Review Commission has not yet ruled. Until it does, the conviction is final. The withdrawal of the two experts is not a verdict on guilt either — both continue to stand by their conclusion about the insulin, and their dispute concerns other arguments advanced by the defence in the same cases.

The criminal investigation outside the Letby case also remains open: three former hospital managers were arrested last year on suspicion of gross-negligence manslaughter, and one of them also faces suspicion of perverting the course of justice, according to police. The investigation continues alongside parallel proceedings concerning the hospital’s responsibility as an organisation. Police have not released the names of the three people arrested. RTÉ ↗

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