Lucy Letby inquiry: The ‘urgent' NHS changes needed to protect patients

Eleanor Barlow/PA Wire

By Sarah Lowden

“This must never happen again,” was Lady Justice Thirlwall’s stark warning as she delivered her findings from the public inquiry into how nurse Lucy Letby was able to murder babies at the Countess of Chester hospital a decade ago.

The public inquiry began in September 2024 after Letby was imprisoned for the murder of seven babies and attempted murder of seven others. It took more than six months to hear from more than 130 witnesses.

It concluded there had been a “complete failure” to protect babies on the neonatal unit because of a “profound failure of management, governance and safeguarding”.

Thirlwall also looked beyond the Countess of Chester and at what she highlighted as wider failings within the NHS, from its ‘no blame’ culture, to its shortcomings in employment contracts and regulation.

She has put 17 recommendations to the government. Doctors.net.uk looks at some of the key changes she has urgently called for: