Lucy Letby inquiry chair says culture change in NHS neonatal units is ‘long overdue’

  • Lady Justice Thirlwall’s first public address as Chair of the Thirlwall Inquiry.

Every hospital in England with a neonatal unit has been asked whether they have considered installing CCTV in the wake of nurse Lucy Letby’s killing spree, it has emerged.

In August, Letby, 33, was sentenced to 14 whole life orders after she was convicted of the murders of seven babies and the attempted murders of six others, with two attempts on one of her victims.

The offences took place at the Countess of Chester Hospital’s neonatal unit, where Letby worked, between June 2015 and June 2016 – when CCTV was not installed.

Lucy Letby was sentenced to a whole life order after she murdered seven babies and the attempted to murder six others. Credit: Cheshire Constabulary/PA

One of the country’s most senior judges, Lady Justice Thirlwall, is leading the inquiry into the events, with the public hearings scheduled to start in Chester in September 2024.

What will the inquiry cover?

  • The experiences of the parents of the 17 babies who featured in the 10-month trial that Letby faced at Manchester Crown Court.

  • The conduct of those working at the Countess of Chester and how Letby was able repeatedly to kill and harm babies on the neonatal unit.

  • A focus on the wider NHS in examining relationships between the various groups of professionals, the culture within hospitals and how these affect the safety of newborns in neonatal units.

On Wednesday, the Appeal Court judge said the query about CCTV – suggested by some of the parents of babies harmed by Letby – had been included in a wide-ranging and detailed questionnaire.

The form to be completed by both the medical director and a senior non-clinical manager asks whether there is CCTV on neonatal units and, if not, whether it has been considered.

A short survey has also been sent to all neonatal midwives, doctors, nurses and managers to ask directly their views on the culture in their units.

Lady Justice Thirlwall said the CCTV query has been included in a questionnaire after it was suggested by parents of babies harmed by Letby. Credit: Thirwall Inquiry/PA

Launching the inquiry website on Wednesday, the Appeal Court judge said: “We all know that there have been many inquiries into events in hospitals and other health care settings over the last 30 years.

“The case of Beverley Allitt who murdered babies at Grantham Hospital in the 1990s comes to mind. Everyone was determined that it would not happen again. It has happened again. This is utterly unacceptable.”

She said she will seek to discover what recommendations were made in those inquiries, whether they were implemented and what actual difference they have made.

Lady Justice Thirlwall said: “No one can argue with the proposition that babies in neonatal units must be kept safe and well cared for.

“What is needed is the practical application of that proposition everywhere. In many units it will require profound changes in relationships and culture. This may not be easy to achieve but it is necessary and long overdue.

“Bringing about necessary change will require the co-operation and will of all those who are involved in and who are responsible for the babies in our neonatal units – from the ward to the boardroom.

“The parents of the babies who were murdered or suffered injuries, some lifelong, live with the consequences every day.

“On top of their grievous loss they endured years of uncertainty about what had caused death or injury. And for some, uncertainty remains.

“All have made it plain to me that they want to do all they can to make sure that no one else suffers as they do. With the help of the inquiry team and all those who will contribute to the inquiry I will do all I can to make sure that no one else suffers as they have. It is unconscionable that this situation would ever occur again.”

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