Letby inquiry leaves key questions unanswered
The Thirlwall inquiry into the events at the Countess of Chester hospital and the crimes of Lucy Letby has left many questions unanswered. Just two months before the inquiry began, a report by Chris Henley KC was published, highlighting the “atrocious” wrongful conviction of Andrew Malkinson for rape. Henley emphasized the need for the legal establishment to recognize that the criminal courts can produce miscarriages of justice.
Henley’s report prefaced the Thirlwall inquiry, which was set up in 2023 by then health secretary Steve Barclay to investigate the hospital’s management and whether their actions contributed to the failure to protect babies from Letby. The inquiry’s terms of reference were clear, but many experts had already expressed concerns that the system may have made another mistake and convicted an innocent person.
Concerns about the inquiry’s scope
Twenty-four experts wrote to health secretary Wes Streeting, urging him to pause the inquiry or widen its terms of reference to examine the possibility of a miscarriage of justice. However, Streeting did not do so, and the inquiry proceeded with its original scope. In her opening speech, Thirlwall referred to the criticisms of Letby’s convictions, stating that it was not her role to review the convictions.
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The core premise of the inquiry was that the hospital’s managers had not acted on warnings about Letby from consultants and that they should have called in the police earlier. Thirlwall’s report criticized the “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 that the police, the Cheshire constabulary, were uniquely equipped to find the forensic truth about how the babies died.
A group of British and international experts, led by Dr. Shoo Lee, argued that there were no murders, only vulnerable newborn and premature babies, and poor care on the unit. The experts concluded that the deaths and collapses of the babies were not caused by deliberate harm, but rather by sub-optimal care on the unit. Thirlwall heard evidence about the actions taken by the medical director, Ian Harvey, and his colleagues, but her report did not adequately address the concerns raised by the experts.
During the inquiry, Thirlwall examined the processes and conclusions reached by the experts, including the postmortems carried out by consultant pathologists at Alder Hey hospital. The pathologists found no deliberate harm or suspicion of it, and Dr. Jane Hawdon, a consultant neonatologist, also did not find any deliberate harm, but identified areas of sub-optimal care on the unit.
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Unanswered questions
The inquiry did not permit solid engagement with the new experts, led by Lee, as to why they fundamentally disagree with the prosecution’s case and convictions. The Criminal Cases Review Commission is still looking at Letby’s application, and the copious expert reports submitted with it.
The inquiry’s report is based on it being a fact that Letby is guilty and Thirlwall has delivered the devastating conclusion that babies would have been protected if the hospital had acted more quickly to safeguard them from the nurse. So during two years and £18m spent on so much legal inquiry, the question has not been answered, nor was it allowed to be asked: how and why did Cheshire constabulary and the Crown Prosecution Service, and the doctors they recruited as expert witnesses, come to so wholly different a conclusion about the causes of death, from all the experts that had looked at the same medical evidence before?
Next steps and implications
The Thirlwall inquiry’s report has highlighted the need for improved safeguarding procedures and more robust systems for investigating suspicious deaths in healthcare settings. However, the report’s limitations and the lack of engagement with the possibility of a miscarriage of justice have raised concerns about the potential for similar cases to occur in the future. The inquiry’s findings will likely be used to inform policy and practice changes in the NHS, but the lack of clarity on the role of Cheshire constabulary and the Crown Prosecution Service in the case may limit the effectiveness of these changes.
