Judith Moritz and Lauren Hirst
Reporting from Liverpool

We are shortly going to be moving to reporting on remarks from inquiry chair Lady Justice Thirlwall, who is delivering a statement. Before then, here's a summary of the report's key findings:

• The deaths and near-deaths of some babies who were attacked by nurse Lucy Letby could have been prevented if safeguarding practices had been followed
• The inquiry chair Lady Justice Thirlwall says it will never be possible to know for sure how many lives could have been saved, but has found there was a “complete failure to protect babies on the neonatal unit” at the Countess of Chester Hospital
• Thirlwall says “this must never happen again” as she calls for a “series of urgent reforms to practices” in neonatal units
• She highlights a “profound failure of management, governance and safeguarding”
• She describes a “dysfunctional management and governance, a gulf between hospital leadership and clinicians and a failure to understand the fundamentals of safeguarding”

We can bring you more now from the inquiry.

The failings at the Countess of Chester were not just down to one organisation and its staff, the inquiry made clear. The culture of the NHS played a part too.

It said there was a tendency across NHS management to become pre-occupied with avoiding blame and focusing on reputation management - something that was apparent in the approach over Letby.

And despite attempts over the last 10 years to bring in protections for whistleblowing there was still evidence of a “toxic negativity” that discouraged people working in the NHS to speak out.

Regulation was also found lacking. The Care Quality Commission inspected the Countess of Chester in February 2016 – Letby carried on attacking babies until June of that year. Key information was withheld from inspectors, but the regulator was criticised for not showing enough curiosity to look beyond what they were being told.

What makes this worse is that only a year before, the CQC had been warned by the inquiry into baby deaths at Morecambe Bay NHS Trust that it needed to take a tougher approach.

Nat Wright
Health reporter

We're continuing to bring you lines from the recently published report - as a reminder, you can watch her news conference live at the top of the page.

Lady Justice Thirlwall has made 17 recommendations which include CCTV for all cots and incubators in all neonatal units, restricted access to insulin, obligatory safeguarding training for staff, a harmonised IT system across the NHS and better handling of data.

She says there should be the creation of Suspicion of Deliberate Harm Protocol and guidance; a panel of experts should be set up to be called upon where concerns emerge about an individual and harm to patients.

By 31 March 2027, all hospital trusts must have in place effective mechanisms forboard level monitoring of all deaths of children and babies.

Further checks are needed when managers are being moved to different trustswith a code of conduct for managers (which was published in July 2026) to be amended with suggested wording"I will make the care and safety of patients my first concern and act to protect them from risk."

There should be without-notice Care Quality Commission (CQC) inspections and inspectors should not take things at face value; the CQC should be reviewed once a year at first and then every three years after.

The function of the National Guardian’s Office should be taken over by the Parliamentary and Health Service Ombudsman in England which should be given greater powers to investigate whistleblowers’ concerns.

Lauren Hirst
Reporting from Liverpool

Here is more from the inquiry report.

While the Thirlwall Inquiry did not look at Letby’s guilt, it found:

• Letby ignored management instructions when she disliked them. and shouted at her manager
• Falsified records, while one infant in her care was found covered in their own faeces
• She was repeatedly untruthful in her dealings with friends and colleagues, and
• Had an inappropriate and callous nature noted by patients

We can bring you more from the report now.

• The first three deaths (babies A, C, and D), in June 2015, were not viewed as a cluster, even though this was the annual average number of deaths, concentrated within two weeks
• The fourth death of baby E in August 2015, was unexpected and therefore reviewed at a serious incident panel meeting attended by the medical director and director of nursing - but it was treated as a formality. “What is surprising is that no connection was made by any of the people involved to the earlier deaths," the report says
• If Dr ZA had not disregarded an insulin test result for baby F in August 2015 then there should have been safeguarding action. The report says this would have prevented the attacks on babies G and H, J, K, L, M and N and the deaths of baby I, O and P
• If safeguarding action had been taken by October 2015 - after the death of baby I - by moving Lucy Letby off the ward, the deaths of babies O and P would have been prevented as would the attacks on babies J, K, L, M and N, the report says
• Dr Jayaram should have reported what he had seen regarding baby K in February 2016
• In May 2016, no-one raised safeguarding at a meeting with executives - if they had done it would have prevented the deaths of babies O and P

We're continuing to bring you key details from the inquiry report, published minutes ago.

Parents of the babies were “kept in the dark for years” over the concerns that their babies may have been deliberately harmed.

Lady Justice Thirlwall found the lack of consideration shown to parents was “reprehensible”.

Hospital executives used the risk of upsetting the parents as a convenient argument to justify not calling the police.

Lady Justice Thirlwall, the inquiry's chair, is speaking now.

We'll be covering her statement here, which you can also watch live at the top of this page.

“It should never have been about nurses against doctors. It was about keeping babies safe," the inquiry chair writes.

The doctors were not given the protection of the Speak Out Safely whistleblowing policy.

Senior managers tried to "manage out" the consultants and spoke of referring them to the General Medical Council.

"No-one seems to have understood that safeguarding action is required when a member of staff is suspected of causing deliberate harm - and does not require colleagues to be sure of guilt," Lady Justice Thirlwall writes in the report.

She describes a “failure to understand the fundamentals of safeguarding”.

She says that “all the safeguarding guidance in the world makes no difference to the safety of babies if those to whom concerns are expressed do nothing".

Thirlwall notes that “there is still no NHS wide protocol on deliberate harm".

Judith Moritz
Reporting from Liverpool

The deaths and near-deaths of some babies who were attacked by nurse Lucy Letby could have been prevented if safeguarding practices had been followed, according to the public inquiry into her crimes.

The inquiry chair Lady Justice Thirlwall has said it will never be possible to know for sure how many lives could have been saved, but has found there was a “complete failure to protect babies on the neonatal unit” at the Countess of Chester Hospital, describing a “dysfunctional management and governance”.

The inquiry has just been published, and we are working to bring you the key findings. We'll have more shortly.

The Thirlwall Inquiry report, which has examined whether concerns about Lucy Letby could have been acted on sooner by the Countess of Chester Hospital, will be released shortly at 12:30 BST.

Some members of the media, including the BBC's special correspondent Judith Moritz, were able to review the report this morning.

They have been poring over its findings, which we're able to report shortly. Stick with us.

Judith Moritz
Reporting from Liverpool

Image source, Pool

This is a report which has taken much longer to produce than Lady Justice Thirlwall first envisaged.

When she finished hearing evidence back in March 2025, she indicated that she hoped to publish her findings by November that year. In the event, it’s taken almost a year longer than that.

That has been seen as a puzzling delay by some – but others, including lawyers representing some families, have told me they see it as a sign of her thorough approach. They tell me they are hopeful that the report will achieve change across the NHS.

Thirlwall Inquiry has explored why the NHS keeps repeating similar mistakespublished at 12:19 BST

12:19 BST

Nick Triggle
Health correspondent

As well as what went wrong at the Countess of Chester Hospital, the Thirlwall Inquiry has been exploring what lessons there are for the wider NHS - and why the health service keeps repeating what appears to be similar mistakes.

Analysis by the inquiry’s legal team has already highlighted how hundreds of recommendations made by previous inquiries into NHS failings have not been implemented properly.

It is also likely to set out the difficulties whistleblowers face when trying to raise the alarm and to what extent a lack of accountability among NHS managers contributes to the problems.

Over the last 30 years there’s been a long line of reports and investigations that have repeatedly seen similar themes emerge from the inquiries into the nurse Beverly Allitt, who murdered four babies and children in 1991, and the failings at Mid Staffordshire NHS Trust, to the recent scandals involved maternity services in different parts of the country.

Two key questions need answering on this - why and what can be done about it?

Image source, Getty Images

A solicitor representing several families of Letby's victims has said today's report will be a moment of significance for those affected, while also being about "understanding how these devastating events were able to happen".

Tamlin Bolton, of law firm Irwin Mitchell, says: "The publication of the Thirlwall Inquiry’s findings will likely be difficult reading for our clients and for everyone affected by Lucy Letby’s actions who have already had to go through both a criminal trial and several months of evidence for this inquiry."

The solicitor says systems within the NHS "failed" to sufficiently identify the risks of the case and respond to them appropriately.

Bolton says the firm will consider the findings of Lady Justice Thirlwall carefully with the families, but adds "it is vital that lessons are learned" and the government implements any recommended changes.

"Families need to have confidence that everything possible is being done to prevent similar failings happening again, whether in Chester or elsewhere in the NHS," she says.

Will this report change the debate about Lucy Letby?published at 11:51 BST

11:51 BST

Judith Moritz
Reporting from Liverpool

The quick take is this: the report won't change the narrative about Lucy Letby's guilt or innocence because it didn't examine that subject at all. That wasn't its remit.

Lady Justice Thirlwall said she had "approached the inquiry on the basis that Lucy Letby is guilty of the crimes of which she has been convicted".

She emphasised that it was not her role "to set about reviewing the convictions", telling the inquiry: "The Court of Appeal has done that, with a very clear result."

But there is also a longer, more complex answer.

Whatever the report's conclusions, Letby's convictions will stand. However, the inquiry hasn't operated in a vacuum. There are other parts of the legal system which will have an eye on its findings.

And the chairwoman of the Criminal Cases Review Commission (CCRC) - the only organisation with the power to send Letby's case back to the Court of Appeal - has told the BBC the CCRC will be paying close attention to Thirlwall.

Dame Vera Baird said: "We will be looking at the report with interest to assess whether it has any bearing on our review of the case."

The CCRC has given no indication of when it will make its decision.

Lucy Letby's defence lawyer is insisting her case hasn't been undermined after two members of her defence team withdrew on Monday.

The defence team has submitted evidence to the Criminal Cases Review Commission (CCRC), which is reviewing material relating to her convictions, and is not involved in the inquiry.

Helen Shannon and Geoff Chase claimed some of the evidence being put forward on her behalf was inconsistent with the available evidence and science.

Mark McDonald, Lucy Letby's defence lawyer, told the BBC he was "sad that they've gone" but insisted the two experts still believed Lucy Letby was innocent. He said he "fundamentally disagreed" that the case had been undermined.

The CCRC has the power to send Letby's case back to the Court of Appeal and says it is paying close attention to today's report.

Judith Moritz
Reporting from Liverpool

While questions over Letby's convictions weren't within the scope of the Thirlwall Inquiry, it didn't stop the subject making itself felt within the hearing room.

Just as the inquiry was wrapping up, the hospital's former executives applied for it to be delayed until the Criminal Cases Review Commission (CCRC) has made its decision.

The CCRC is the only organisation with the power to send Letby's case back to the Court of Appeal, and is currently reviewing material relating to Letby’s convictions.

Letters pushing for a delay were also written to the inquiry by Letby's lawyers and Sir David Davis, an MP who has campaigned on her behalf.

Sir David argued that an inquiry "predicated on the presumption that Lucy Letby's conviction is safe, when there is now a wealth of authoritative voices questioning that conviction, will only undermine the conclusions arrived at by your inquiry and potentially lead to more babies dying unnecessarily".

Lady Justice Thirlwall refused the requests to pause the inquiry. She said that she was not scrutinising Letby's actions, but those of the officials and managers who were responsible for responding to the crisis.

The families of babies whom Letby has been convicted of murdering and attempting to murder did not want the inquiry to be paused.

Richard Scorer, who represents three of the families, previously told the BBC that the fact that Letby's convictions still stand is crucial.

"That's the legal reality," he said. "And the noise about her convictions doesn't change that."

Lucy Letby's story has become a culture and information war - as campaign to free her continuespublished at 11:08 BST

11:08 BST

Judith Moritz
Reporting from Liverpool

Image source, Getty Images

This is a case which has rarely been far from the headlines.

At the same time as the inquiry heard its evidence, the Lucy Letby story increasingly became something of a culture and information war – both in the media and online.

Forums, websites and protests emerged among those dedicated to supporting Letby’s cause – and also those on the other side of the debate who firmly believe she’s guilty.

Opinions have become deeply entrenched. Both sides will scrutinise the Thirlwall report – but it’s likely each will find material in it which supports their point of view.

Letby has previously been denied permission to appeal against her convictions on two occasions.

The case has been referred to the Criminal Cases Review Commission (CCRC) after a panel of experts assembled by Letby's legal team concluded "there was no medical evidence" to support her convictions.

The Thirlwall Inquiry is not examining nor determining whether Letby is guilty or not guilty.

Instead, it has explored how she was able to kill repeatedly, hearing more than 60 days of witness evidence and reviewing thousands of emails, text messages and handwritten notes.

The objectives of the inquiry are to "seek answers for the victims’ families" as well as examining the response of the NHS and its regulators.

Since its launch, the inquest examined three main areas:

1. The experiences of the Countess of Chester Hospital - where Letby worked - and other relevant NHS services, and all the parents of the babies named in the indictment
2. Employees' conduct at the hospital, including the board, managers, doctors, nurses, and midwives with regard to Letby's actions
3. The effectiveness of NHS management and governance structures and processes, external scrutiny and professional regulation in keeping babies in hospital safe and well looked after

Image source, Reuters

In her first public address when the inquiry began, chairwoman Lady Justice Thirlwall pledged to do "all I can" to meet the expectations of bereaved families.

"The parents of the babies who were murdered or suffered injuries, some life-long, live with the consequences every day," Thirlwall said in November 2023.

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

"All have made it plain to me that they want to do all they can to make sure no-one else suffers as they do."

The judge said she, with the help of the inquiry team, would "do all I can to make sure that no-one else suffers as they have".