The Thirlwall inquiry into the Countess of Chester hospital, where Lucy Letby was convicted of murdering seven babies and attempting to murder seven more, has released its 822-page report. The report's recommendations aim to improve NHS accountability, but the inquiry's decision to proceed while Letby's convictions are formally challenged has drawn criticism.
Inquiry Proceeded Despite Pending Case Review
Lady Justice Thirlwall had rejected calls to pause the public inquiry, stating that questions surrounding Letby's guilt lay outside her terms of reference. The inquiry, she said, would focus on the hospital and its staff, not the convictions. Eighteen months later, with the report in the public domain, her decision to press on while Letby's guilt was being formally challenged looks like a mistake, according to a Guardian editorial.
The report's recommendations include strengthened oversight of hospitals by the Care Quality Commission, more support for whistleblowers from the health ombudsman, and clearer monitoring and reporting on the deaths of children. As previous inquiries have also found, there are serious problems around accountability, openness and safeguarding in the NHS.
Report Highlights Dysfunctional Management and Governance
The report describes “dysfunctional management and governance; a gulf between hospital leadership and clinicians; and failure to understand the fundamentals of safeguarding.” These findings will resonate beyond the Countess of Chester's catchment, affecting families who have been let down by NHS hospitals in other areas.
Poor leadership, toxic cultures and resource and workforce pressures are familiar themes. Yvette Cooper presented her response to the report as part of a wider reset of maternity and neonatal services. Proposals for video monitors in neonatal wards are already being developed, she told MPs, along with plans to bar poorly performing managers.
Letby's Convictions Still Under Challenge
No one doubts that this general reset is needed. The report's analysis of the policies needed to underpin it should be welcomed. But in the case of the Countess of Chester, it is impossible to set aside questions about Letby herself, as Lady Thirlwall sought to do – no doubt partly influenced by the bereaved families' wish to proceed.
The report takes Letby's guilt, and the risks she posed to newborn babies, as a given; hence the headline finding that three babies might have survived and seven others could have been protected if hospital bosses had taken earlier action over warnings. Two attempts by Letby to appeal against her convictions have been rejected by judges. But the legal process has not yet run its course, and a decision by the Criminal Cases Review Commission on whether to refer the case to the court of appeal, as a suspected miscarriage of justice, is expected soon.
The appeal, if it goes ahead, will rest on a dossier of medical evidence related to the air injections that Letby was found to have used to kill babies, and insulin that she was found to have used to poison them. Until that decision is made, doubts will continue to swirl over the inquiry's findings.
Ministers Should Have Intervened
If any of Letby's convictions for murder and attempted murder were to be ruled unsafe, then the whole basis of the report would be undermined. For that reason alone, ministers should have intervened when Lady Thirlwall decided against a delay. An inquiry that has so far cost more than £18m, and which is calling for significant changes to NHS services upon which millions of people rely, should not have gone ahead until the criminal justice process was exhausted.
