A statutory public inquiry has determined that the Countess of Chester Hospital failed to protect newborns, following the conviction of former neonatal nurse Lucy Letby for murdering seven infants under its care. Lady Justice Kathryn Thirlwall stated on September 15, 2026, that the hospital's management exhibited a "complete failure at all levels" to implement safeguarding procedures during the period from June 2015 to June 2016. Thirlwall noted that errors were made by nurses, doctors, and managers, leading to preventable deaths and attempted murders of infants.
The inquiry recommended that neonatal wards install webcams or video monitors in incubators to allow families to monitor their infants remotely. It also called for 24-hour CCTV surveillance over hospital refrigerators containing insulin until stricter access controls are established.
The inquiry revealed that hospital executives did not inform parents of the growing suspicions surrounding Letby while conducting internal reviews, leaving families unaware until her arrest in July 2018. Additionally, the management transferred infants' confidential medical files to external experts without parental consent, which Thirlwall described as a "reprehensible" disregard for families.
Letby, 36, received 15 life sentences for her crimes and has maintained her innocence, having been denied permission to appeal twice. There has been increased scrutiny from an international panel of medical experts regarding the forensic evidence used in her conviction, leading her legal team to submit an application to the Criminal Cases Review Commission. Thirlwall emphasized that her inquiry did not address the trial's evidence or the validity of the criminal verdicts, focusing instead on institutional failures and hospital management.