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Some babies could have been saved from death and harm at the hands of Lucy Letby if safeguarding action had been taken earlier, an inquiry prompted by the child serial killer’s crimes has found.

The Thirlwall Inquiry was launched in 2023 in the wake of the former nurse’s multiple convictions for murder and attempted murder of infants at the Countess of Chester Hospital.

Publishing her final report on Tuesday, Lady Justice Thirlwall said: “There was a complete failure to protect babies on the neonatal unit at the Countess of Chester Hospital.

“This was because 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.

“My report describes dysfunctional management and governance, a gulf between hospital leadership and clinicians, and failure to understand the fundamentals of safeguarding.”

Lady Justice Thirlwall, one of the country’s most senior judges, went on: “How many lives could have been saved had the hospital acted differently? This is something we will never know for sure.

“It is clear that some babies would have been saved and some attacks would have been prevented if action was taken earlier.”

Her investigation did not examine Letby’s convictions or motives but instead focused on the conduct of those working at the Countess of Chester, including the board, managers, doctors and nurses from when Letby started her employment in 2012.

Letby, 36, was moved from the neonatal unit to administrative duties in July 2016 after consultants expressed concerns about her to the hospital’s executive team.

Hospital bosses opted to carry out a number of reviews into the increased mortality in 2015 and 2016, and did not invite Cheshire Constabulary to investigate until May 2017, as Letby remained on site until her arrest more than a year later.

The Thirlwall report found that senior nurses never accepted that the consultants’ concerns were, or might be, justified, and that there was a prolonged delay by senior managers in calling the police.

It ruled that successive internal and external reviews commissioned by hospital leadership after concerns were raised about Letby did not address whether deliberate harm was being caused or not.

A total of 14 recommendations have been made in the report including the fitting of baby monitors in all cots and incubators in neonatal units and CCTV cameras focused on insulin storage fridges.

Lady Justice Thirlwall said baby monitors would ensure parents could observe their babies “remotely at any time” adding that NHS England should “set out a roadmap” for how it could be implemented by March 31 next year.

She also said digital devices should be used to “restrict access of insulin to authorised people”, as well as recording access to insulin units.

Another recommendation was that all managers be subject to an “individual duty of candour to all patients and colleagues”, and that a code of conduct for senior managers should “set out, at the beginning, the uncontroversial duty of every manager to put patients first.”

The chairwoman also ruled that parents of Lucy Letby’s victims were “kept in the dark” about suspicions by the hospital.

Families of the babies were not aware of concerns until the nurse was arrested and they were contacted by police in July 2018, the report concluded.

She said: “I would like to thank the parents of all the babies who died or were injured.

“Their evidence, generously given, was amongst the most thoughtful and moving any person will ever hear.

“Throughout a very difficult and prolonged process, the parents have conducted themselves with dignity and determination, with the aim that no other parents should have to experience such grief and heartache.”

Letby, from Hereford, who maintains her innocence, is serving 15 whole-life terms for the murders of seven babies and attempted murders of seven others by various means between June 2015 and June 2016.

She was twice denied permission to appeal against her convictions in 2024.

The Criminal Cases Review Commission, which investigates potential miscarriages of justice, is considering evidence presented on her behalf by an international panel of medics who claim poor medical care and natural causes were the reasons for the babies collapsing.

A court order prohibits reporting of the identities of the surviving and dead children involved in the case.

Investigations by Cheshire Constabulary into potential offences of corporate manslaughter and gross negligence manslaughter remain ongoing.

Inquests into the deaths of babies who Letby was convicted of murdering are to take place in May 2027.