Further details on Lucy Letby public inquiry published

In the hours following the verdicts delivered on August 18, when Letby, 33, was found guilty of murdering seven babies and attempting to murder six more between June 2015 and June 2016, the Government announced it would be setting up an inquiry.

It will be known as the Thirlwall Inquiry, named after Lady Justice Thirlwall, who will lead the statutory inquiry into the case.

The Government announced on Thursday (October 19) the terms of reference for the inquiry, which will focus on three broad areas.

They are what parents of all babies named in the indictment experienced at the hospital and other relevant NHS services, the conduct of staff working at the hospital including board-level staff and managers, and the effectiveness of NHS management and governance structures and processes.

The inquiry will examine whether suspicions should have been raised earlier, whether Letby should have been suspended earlier, and whether police and other external bodies should have been informed earlier.

It will also look at the responses to concerns raised about Letby from those within management responsibilities in the hospital trust, and whether the trust’s culture, management and governance structures and processes contributed to the failure to protect babies from Letby.

Letby was sentenced to whole-life orders for all 14 charges the jury found her guilty of on August 21. She has always denied the charges and has submitted an intention to appeal her convictions.

That appeal process will be concluded before a planned retrial on one of the attempted murder counts the first trial jury could not reach a verdict on. That retrial is due to take place in Manchester in June 2024.

The Thirlwall Inquiry, which is currently setting up its infrastructure at pace so that it can begin its investigations, and will be established by November 17, will also consider NHS culture.

The Government webpage for the terms of reference adds: "The order in which the issues are to be considered has not yet been decided. The priority is to conduct a thorough inquiry as swiftly as possible.

"The length and timing of the hearings and where they take place will depend on the extent and nature of the live evidence that is required and upon the actions of the police and Crown Prosecution Service."

In response to the news, Tim Annett, an expert medical negligence lawyer at Irwin Mitchell who represents parents affected, said: “The effects of what happened at the Countess of Chester Hospital and Letby’s crimes continue to gravely impact those we represent, including families who’ve contacted us since the conclusion of the criminal trial.

“We’re pleased that the call for an investigation has been heard as it’s clear there are important concerns that need addressing as part of the inquiry.

“All our clients want is for no stone to be left unturned in fully establishing how Letby was able to commit the most heinous crimes.

“We welcome the terms of the investigation which will hopefully provide families with the answers they deserve, although our clients also hope that it will be possible to investigate the full extent of Letby’s unlawful activities.

“While nothing will ever make up for the losses suffered by the families, we’re determined to working with the inquiry to ensure it’s as effective as possible in producing robust recommendations to minimise the risk of similar events in the future.

“We continue to support our clients at this distressing time.”

A non-exhaustive list of 30 questions the inquiry will intend to seek answers to has been published.

They are:

• 1. During their involvement with the Countess of Chester Hospital and elsewhere what were the parents of each child told when and by whom about the condition of their baby, what was being done to treat them and what the prognosis was?
• 2. How and when were deteriorations (sudden or otherwise) in their babies’ conditions explained to them?
• 3. Where parents raised concerns about the condition and/or care of their babies, what was done and what were the parents told?
• 4. When were they given access to their babies’ medical records?
• 5. What information were the parents given by the hospital regarding concerns about Letby’s conduct and when? What were they told was being done about the concerns?
• 6. What were the parents of each child told about the likely cause of death or injuries? When and by whom?
• 7. When were the parents of each child told that Letby was suspected of causing the death or injury to their child? Was the trust sufficiently candid with the parents throughout?
• 8. What are the views of the parents of each child as to the adequacy of the information they were given at each stage?
• 9. What was the parents’ experience of the Patient Advice and Liaison Service (PALS)?
• 10. What are their suggestions for keeping babies safe on the neonatal unit?
• 11. What was known and what should have been known about Letby’s previous work as a nurse when she began employment at the Countess of Chester Hospital?
• 12. What concerns were raised and when about the conduct of Letby? By whom were they raised? What was done?
• 13. Should concerns, including about hospital or clinical data, have been raised earlier than they were? When? What should have been done then?
• 14. Were existing processes and procedures for raising concerns used, including whistleblowing and freedom to speak up guardians? Were they adequate?
• 15. What was the culture within the hospital? To what extent did it influence the effectiveness of the processes and procedures at question 14?
• 16. Whether systems, including security systems relating to the monitoring of access to drugs and babies in neonatal units, would have prevented deliberate harm being caused?
• 17. Were existing processes used for reporting concerns to external scrutiny bodies where appropriate? If so, when and what happened? Such bodies may include NHS England (and its regional bodies), local commissioners, Monitor, NHS Improvement, child death overview panels, the Care Quality Commission, the police and the successor of any of these organisations.
• 18. When was consideration given to reporting Letby to the police? When was she in fact reported to the police and by whom?
• 19. What information about each of the deaths was provided to the coroner? Was the trust’s provision of information to the coroner appropriate?
• 20. Did the relationship between clinicians and managers, nurses, midwives and managers and between medical professionals (doctors, nurses, midwives and others) at the Countess of Chester Hospital contribute to any failure to protect babies on the neonatal unit from the actions of Letby? How did professional relationships affect the management and governance of the hospital?
• 21. Did the structures and processes for the management and governance of the hospital contribute to a failure to protect the babies on the neonatal unit from the actions of Letby? Is the management structure and governance typical of neonatal settings in other hospitals?
• 22. What was the board’s involvement in the way concerns about Letby were dealt with by the hospital?
• 23. What was the board’s oversight of clinical and corporate governance?
• 24. How was Letby managed once concerns were raised about her?
• 25. Was Letby reported to the Nursing and Midwifery Council (NMC)? When? What information, if any, was provided to the NMC, royal colleges and any other external scrutiny bodies? What was done by the bodies to whom the actions were referred? What happened as a result?
• 26. What information, if any, was provided to the General Medical Council (GMC) and what information was requested by the GMC? What was the result of any referral or discussions with the GMC?
• 27. What happened to those who raised concerns about Letby?
• 28. Whether recommendations to address culture and governance issues made by previous inquiries into the NHS have been implemented into wider NHS practice? To what effect?
• 29. What concerns are there about the effectiveness of the current culture, governance management structures and processes, regulation and other external scrutiny in keeping babies in hospital safe and ensuring the quality of their care? What further changes, if any, should be made to the current structures, culture or professional regulation to improve the quality of care and safety of babies? How should accountability of senior managers be strengthened?
• 30. Would any concerns with the conduct of the board, managers, doctors, nurses and midwives at the Countess of Chester Hospital have been addressed through changes in NHS culture, management and governance structures and professional regulation?