The Thirlwall inquiry was launched in 2023 to examine events at the Countess of Chester hospital in Cheshire. Photograph: Christopher Furlong/Getty Images View image in fullscreen The Thirlwall inquiry was launched in 2023 to examine events at the Countess of Chester hospital in Cheshire. Photograph: Christopher Furlong/Getty Images Lucy Letby Analysis Thirlwall inquiry has left biggest questions around the Letby case unanswered David Conn Decision not to pause proceedings means £18m report does not engage with concerns over former nurse’s conviction
Just two months before Lady Justice Kathryn Thirlwall opened her inquiry into events at the Countess of Chester hospital and the crimes of Lucy Letby, a report by Chris Henley KC was published into the “atrocious” wrongful conviction of Andrew Malkinson for rape.
Henley prefaced that report with a plea for the legal establishment to recognise that the criminal courts produce miscarriages of justice. Right up to top judges in the court of appeal, Henley wrote, the system has “a deep-seated … cultural reluctance” to accept it “will on occasion make mistakes” and that “entirely innocent defendants will sometimes be convicted”.
He said the system needed a culture that acknowledges mistakes can be made and ensures “in our various roles when making decisions we are all alive to this potential risk”.
The Thirlwall inquiry was set up in 2023 by the then health secretary, Steve Barclay, on the basis that Letby was guilty of murdering seven babies, and attempting to murder seven more, at the Countess of Chester hospital’s neonatal unit where she was a nurse. Thirlwall’s terms of reference were to spotlight the hospital’s management, and whether their actions and culture “contributed to the failure to protect babies from Lucy Letby”.
View image in fullscreen Lady Justice Kathryn Thirlwall arrives at Liverpool town hall before the publication of her inquiry report on Tuesday. Photograph: Christopher Furlong/Getty Images Many distinguished experts had already looked at the evidence and expressed very serious concerns that the system had made another of its mistakes and convicted an entirely innocent person. As the Guardian reported , 24 experts wrote to Wes Streeting, who took over as health secretary after Labour’s general election win in 2024, urging him to pause the inquiry or widen its terms of reference to examine the possibility of a miscarriage of justice. Streeting did not do so.
In her opening speech in September 2024, Thirlwall, a court of appeal judge, referred to the criticisms of Letby’s convictions dismissively, referring to “a huge outpouring of comment” since the court of appeal refused Letby leave to appeal in May 2024, and to “all of this noise” that had caused distress to the bereaved parents.
“It’s not for me to set about reviewing the convictions,” she said. “The court of appeal has done that with a very clear result. The convictions stand.”
The core premise of the inquiry from the start was that the hospital’s managers had not acted on warnings about Letby from the consultants, and should have called in the police earlier. That was the central conclusion Thirlwall has reached in her 822-page report.
13:01 Damning Lucy Letby inquiry finds ‘complete failure to protect babies’ - The Latest She criticised “a prolonged delay by senior managers in calling the police” after two of three triplets, babies O and P at the trial, died in June 2016. There was an assumption throughout t…