00:00The Thirlwall inquiry has found that some babies would have been saved and some attacks prevented if action had been
00:08taken earlier over concerns about Lucy Letby.
00:11The inquiry examined the conduct of staff and leaders at the Countess of Chester Hospital from Letby starting her employment
00:17in 2012 through to her removal from the neonatal unit in 2016.
00:22Lady Justice Thirlwall said there was a complete failure to protect babies on the neonatal unit.
00:28She found hospital management and governance were dysfunctional with the gulf between hospital leadership and clinicians.
00:35The report says staff did not understand that safeguarding action was required when a member of staff was suspected of
00:40deliberately harming babies.
00:42The inquiry highlighted Child F who Letby attempted to murder by insulin poisoning in August 2015.
00:48Lady Justice Thirlwall said that if the insulin results had been acted upon, contacting police would have been unavoidable.
00:56Letby was moved to administrative duties in July 2016, but Cheshire Constabulary was not invited to investigate until May 2017.
01:06The report says parents were kept in the dark about suspicions until Letby's arrest and police contact with families in
01:11July 2018.
01:12Fourteen recommendations have been made, including baby monitors in neonatal cots and incubators.
01:17CCTV focused on insulin storage fridges and tighter controls over access to insulin.
01:22Investigations into potential corporate manslaughter and gross negligence manslaughter remain ongoing.
Comments