After Lucy Letby was sentenced to 15 whole-life terms for murdering seven babies and attempting to murder seven others, an inquiry was launched to ensure lessons were learnt.
The Thirlwall Inquiry is examining three broad themes – the experiences of all victims’ parents, how the concerns of clinicians were handled, and to ensure lessons are learnt from the case of the most prolific child serial killer in modern British history.
About 133 witnesses, including parents who lost their children, hospital executives, and Letby’s former colleagues at the Countess of Chester Hospital, have provided live evidence to the inquiry since September, with a further 396 giving written statements.
Inquiry chair Lady Justice Thirlwall is expected to publish her official report in the autumn, outlining the detailed findings and recommendations based on the evidence that has been heard.
This week, the Thirlwall Inquiry is hearing closing submissions from the various interested parties. Here’s what has been said during the key testimonies so far.
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From September 2024: Letby public inquiry set to begin
Why is it called the Thirwall inquiry and why are there calls for it to be suspended?
Opening the inquiry at Liverpool Town Hall on 10 September last year, Lady Justice Thirlwall said the probe bears her surname so that the parents do not repeatedly see the name of the person convicted of harming their babies.
She said the babies who died or were injured would be at the “heart of the inquiry” and condemned comments at the time that questioned the validity of Letby’s convictions – which the nurse tried and failed to challenge at the Court of Appeal – and some of the evidence used at trial.
The inquiry also remains separate to a 14-member expert panel, led by retired neonatologist Dr Shoo Lee and senior Conservative MP David Davis, which in February said it had analysed medical evidence considered during Letby’s trial and claimed there was no medical evidence that the nurse murdered or attempted to murder 14 premature babies.
Letby’s lawyers have since applied for a review of her case as a “potential miscarriage of justice” by the Criminal Cases Review Commission (CCRC) after two failed bids at the Court of Appeal.
On Monday, the judge said she had received a request last month from lawyers representing former executives at the Countess of Chester Hospital asking for the public inquiry to be suspended.
Lady Justice Thirlwall also said she had recently received a written request from solicitors representing Letby for her to pause the inquiry.
In the letter to the judge, which Sky News has seen, Letby’s lawyers warned Lady Justice Thirlwall that her final report would “not only be redundant but likely unreliable” if it was not put on hold until after the conclusion of the former nurse’s CCRC application.
Image: Chair of the inquiry Lady Justice Thirlwall. Pic: PA
Letby couldn’t ‘wait to get first death out of the way’
One of the nurses who started as a newly qualified nurse at the Countess of Chester Hospital on the same day as Letby told the inquiry that the serial killer had told her she “can’t wait for her first death to get it out the way”.
The nurse said she thought the comment was “strange” at the time, but she put it down to Letby just making conversation.
She also recalled Letby being “animated” when telling her she had been involved with resuscitation attempts of a child on the ward in 2012.
“It was kind of like she was excited to tell me about it,” the nurse said.
‘Likely’ Letby murdered or attacked more children
Neonatal clinical lead at the Countess of Chester Hospital, Dr Stephen Brearey, told the inquiry that he thought it was “likely” Letby murdered or started to harm babies prior to June 2015.
He agreed that “on reflection” several unexpected collapses and deaths before that date now “appear suspicious”.
Dr Brearey added he did not have concerns about those incidents at the time, saying that hospital staff “thought we were going through a busy or particularly difficult patch”.
Image: The Countess of Chester Hospital in 2023. Pic: PA
The inquiry was told that the dislodgement of breathing tubes, which was how Letby tried to kill Child K, generally occurs on less than 1% of shifts.
However, it happened on 40% of shifts that Letby worked when she was a trainee at Liverpool Women’s Hospital.
Newborn given potentially fatal morphine overdose
Two years before Letby carried out the murder of Child A, she and another nurse gave a potentially fatal dose of morphine to a newborn baby.
Neonatal unit ward deputy ward manager, Yvonne Griffiths, told the inquiry that the infant received 10 times the correct amount of the painkiller at the end of a night shift in July 2013.
Describing it as a “very serious error”, she said the infant could have died if colleagues had not spotted the error an hour later.
Letby was told she had to stop administering controlled drugs as a result of the error, a decision that she told management she was not happy about.
Letby offered ‘tips’ on how to get away with murder
In a WhatsApp exchange in 2017, Letby and union rep Hayley Griffiths discussed the US legal drama How To Get Away With Murder.
The discussion took place a year after the neonatal nurse was moved to clerical duties following concerns she may have been deliberately harming babies.
In a message to Letby, Ms Griffiths wrote: “I’m currently watching a programme called How To Get Away With Murder. I’m learning some good tips.”
To which Letby replied: “I could have given you some tips x.”
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From 2023: Former health secretary Steve Barclay on Letby inquiry
Ms Griffiths responded saying she needed “someone to practice on to see if [she] could get away with it”, and Letby replied: “I can think of two people you could practice on and will help you cover it up x.”
The union rep said: “I truly and deeply regret having started that conversation… this is completely unprofessional.”
No support or counselling given to parents
The parents of two triplet boys murdered by Letby told the inquiry they were given no support or counselling after the deaths of their children.
The children died on successive days in June 2016. Letby was their designated nurse and their deaths led to her being removed from the Countess of Chester Hospital’s neonatal unit to a non-patient facing role.
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5:47
How the police caught Lucy Letby
The triplets’ father said: “Following the deaths of our children, we didn’t receive any support or counselling from anyone. Had we received some support, we might have been in a better position to try and act on what our instincts were telling us, which was that something had gone badly wrong.”
Senior consultant: ‘I should have been braver’
Letby’s trial in 2023 heard that senior paediatrician Dr Ravi Jayaram caught the serial killer “virtually red-handed” after an incident in a nursery room at the hospital in February 2016.
Addressing that incident while giving evidence at the inquiry, Dr Jayaram said he had walked into the nursery after feeling “significant discomfort” that Letby was alone with Child K.
After walking in, he said he saw “a baby clearly deteriorating” and the child’s endotracheal tube (ET) dislodged. Despite his concern over the incident, the consultant did not tell anyone at the hospital, or the police.
Explaining why he said nothing, Dr Jayaram said: “It’s the fear of not being believed. It’s the fear of ridicule. It’s the fear of accusations of bullying.
“I should have been braver and should have had more courage because it was not just an isolated thing. There was already a lot of other information.”
Image: Dr Ravi Jayaram. Pics: Rex/ITV/Shutterstock
Hospital boss: ‘I should’ve done better’
Tony Chambers, the former chief executive of the Countess of Chester Hospital, was a key witness to give evidence during the inquiry.
During his evidence, Mr Chambers offered an apology to the families who had fallen victim to Letby and said his language had been “clumsy” in telling the killer nurse the hospital had “her back”.
“I absolutely acknowledged that we hadn’t got that right. We could have done better, we should have done better. I should have done better,” he said.
When pressed on if he tried to “stall and obstruct the police being called or this being made public”, he added: “Had that been what I had done then it would be. But I think it’s an outrageous statement and I do not believe it represents my actions.”
Image: Lady Justice Thirlwall at Liverpool Town Hall. Pic: PA
Jeremy Hunt: ‘Terrible tragedy happened on my watch’
Jeremy Hunt appeared at the inquiry in January where he apologised to the victims’ families, saying he was sorry “for anything that didn’t happen that could potentially have prevented such an appalling crime”.
Mr Hunt was health secretary at the time Letby committed her crimes in 2015 and 2016.
Image: Hunt arrives at Thirlwall Inquiry. Pic: PA
The MP told the inquiry the former nurse’s crimes were “a terrible tragedy” which “happened on my watch” and “although he doesn’t bear direct personal responsibility for everything that happens in every ward in the NHS” he does have “ultimate responsibility for the NHS”.
He recommended that medical examiners should be trained to see the signs or patterns of malicious harm in the work of a healthcare professional.
On Friday, the social fabric of England and Wales might be changed forever.
MPs are set to vote on the assisted dying bill and supporters are confident that they have the numbers to win.
But the hugely controversial legislation polarises opinion. Communities remain divided, and medical colleagues can’t agree.
Three royal colleges have withdrawn support for the bill in its current form. They want more time to be given for further scrutiny of the legislation.
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How will the assisted dying bill work?
Frank Sutton does not have time. When we went to Frank’s home in East Dulwich, London, last November to watch the vote unfold she already had terminal liver disease and cancer.
As the vote was passed with a majority of 55, Frank broke down in tears and said: “Finally, I can die in peace.”
Frank is unlikely to live long enough to see assisted dying introduced in England and Wales. If the legislation passes, it will be introduced in four years.
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Frank now suffers from diabetes and fibromyalgia.
She said: “On top of everything I’ve got, to start developing more comorbidities, I have a massive thought in my head, which I live with every day, which is, is my body, am I on the road to the end, you know, is my body just giving up?
“I mean, I was taking morphine anyway for pain, but now I’m living on morphine, and that’s not a life that you want.”
But even as MPs prepare to vote, many important questions remain over who will take responsibility for determining a patient’s mental capacity and their prognosis. The Royal College of Psychiatrists said it was approaching Friday “with trepidation”.
Image: Dr Annabel Price, the Royal College of Psychiatrists’ lead on assisted dying
Dr Annabel Price, the RCPsych’s lead on assisted dying, told Sky News: “If this bill as it stands proceeds through the rest of the parliamentary process, we as psychiatrists are left in a situation where there are so many unknowns about what is expected of us, about what patients can expect and about the safety of the process.
“We will continue to engage and there may be opportunities for reconsideration at further points in the bill. But yes, I approach this professionally with trepidation.”
The Royal College of GPs says the assisted dying process should happen outside of general practice.
Dr Susi Caesar is in favour of the bill being passed and feels it is okay for the medical community to be so divided on the issue.
She said: “I think people have the right to make their own choices and absolutely I would not want to see anybody forced into being part of this process who didn’t. Our current system is broken and this law would go a long way towards fixing it, at least for a certain group of people.”
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Psychiatrists raise assisted dying concerns
But the Royal Colleges of Physicians (RCP) also has reservations about the bill in its current form.
It says it would be hard for a panel of experts who have no connection to a patient requesting an assisted death to determine if the person is being coerced or has mental capacity.
Dr John Dean, clinical vice president at the RCP has concerns, saying: “Currently decisions clearly are made by patients but agreed by single doctors and then the social worker and psychiatrists are not meeting the patient and those that have been caring for them.
“This has to be done in keeping with modern clinical practice which is complex decisions made with patients and families by teams.”
But for patients like Frank, these concerns have not changed her mind.
She said: “I’m praying for Friday that it still goes through because, like I said, it’s not going to happen in my lifetime, but the thought that people like me who still try to look nice, who still tried to have a life and everything, that they can just have some peace of mind and they can have a weight lifted off their shoulders knowing that they’re going to be able to do it peacefully with their family.”
A damning report into the faulty Post Office IT system that proceeded Horizon has been unearthed after nearly 30 years – and it could help overturn criminal convictions.
The document, known about by the Post Office in 1998, is described as “hugely significant” and a “fundamental piece of evidence” and was found in a garage by a retired computer expert.
Capture was a piece of accounting software, likely to have caused errors, used in more than 2,000 branches between 1992 and 1999.
It came before the infamous faulty Horizon software scandal, which saw hundreds of sub postmasters wrongfully convicted between 1999 and 2015.
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What is the Capture scandal?
The ‘lost long’ Capture documents were discovered in a garage by a retired computer expert who came forward after a Sky News report into the case of Patricia Owen, a convicted sub postmistress who used the software.
Adrian Montagu was supposed to be a key witness for Pat’s defence at her trial in 1998 but her family always believed he had never turned up, despite his computer “just sitting there” in court.
Mr Montagu, however, insists he did attend.
He describes being in the courtroom and adds that “at some point into the trial” he was stood down by the barrister for Mrs Owen with “no reason” given.
Image: Adrian Montagu was supposed to be a key witness for Pat’s defence
Sky News has seen contemporaneous notes proving Mr Montagu did go to Canterbury Crown Court for the first one or two days of the trial in June 1998.
“I went to the court and I set up a computer with a big old screen,” he says.
“I remember being there, I remember the judge introducing everybody very properly…but the barrister in question for the defence, he went along and said ‘I am not going to need you so you don’t need to be here any more’.
“I wasn’t asked back.”
Image: The ‘lost long’ Capture documents were discovered in a garage
Sky News has reached out to the barrister in Pat Owen’s case who said he had no recollection of it.
‘An accident waiting to happen’
The report, commissioned by the defence and written by Adrian Montagu and his colleague, describes Capture as “an accident waiting to happen”, and “totally discredited”.
It concludes that “reasonable doubt exists as to whether any criminal offence has taken place”.
It also states that the software “is quite capable of producing absurd gibberish”, and describes “several insidious faults…which would not be necessarily apparent to the user”.
All of which produced “arithmetical or accounting errors”.
Sky News has also seen documents suggesting the jury in Pat Owen’s case may never have seen the report.
What is clear is that they did not hear evidence from its author including his planned “demonstration” of how Capture could produce accounting errors.
Image: But flaws were found within it
Pat Owen was convicted of stealing from her Post Office branch in 1998 and given a suspended prison sentence.
Her family describe how it “wrecked” her life, contributing towards her ill health, and she died in 2003 before the wider Post Office scandal came to light.
Her daughter Juliet said her mother fought with “everything she could”.
“To know that in the background there was Adrian with this (report) that would have changed everything, not just for mum but for every Capture victim after that, I think is shocking and really upsetting – really, really upsetting.”
Image: Pat died before the contents of the report came to light
The report itself was served on the Post Office lawyers – who continued to prosecute sub postmasters in the months and years after Pat Owen’s trial.
‘My blood is boiling’
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‘They knew software was faulty’
Steve Marston, who used the Capture software in his branch, was one of them – he was convicted of stealing nearly £80,000 in September 1998.
His prosecution took place four months after the Capture report had been served on the Post Office.
Steve says he was persuaded to plead guilty with the “threat of jail” hanging over him and received a suspended sentence.
He describes the discovery of the report as “incredible” and says his “blood is boiling” and he feels “betrayed”.
“So they knew that the software was faulty?,” he says. “It’s in black and white isn’t it? And yet they still pressed on doing what they did.
“They used Capture evidence … as the evidence to get me to plead guilty to avoid jail.
“They kept telling us it was safe…They knew the software should never have been used in 1998, didn’t they?”
Steve says his family’s lives were destroyed and the knowledge of this report could have “changed everything”.
He says he would have fought the case “instead of giving in”.
“How dare they. And no doubt I certainly wasn’t the last one…And yet they knew they were convicting people with faulty software, faulty computers.”
Image: Steve’s prosecution took place four months after the Capture report had been served on the Post Office
The report is now with the Criminal Cases Review Commission, the body investigating potential miscarriages of justice, which is currently looking into 28 Capture cases.
A fundamental piece of evidence
Neil Hudgell, the lawyer representing more than 100 victims, describes the report as “hugely significant”, “seismic” and a “fundamental piece of evidence”.
“I’m as confident as I can be that this is a good day for families like Steve Marston and Mrs Owen’s family,” he says.
“I think (the documents) could be very pivotal in delivering the exoneration that they very badly deserve.”
He also added that “there’s absolutely no doubt” that the “entire contents” of the “damning” report “was under the noses of the Post Office at a very early stage”.
Image: Pat Owen
He describes it as a “massive missed opportunity” and “early red flag” for the Post Office which went on to prosecute hundreds who used Horizon in the years that followed.
“It is a continuation of a theme that obviously has rolled out over the subsequent 20 plus years in relation to Horizon,” he says.
“…if this had seen the light of day in its proper sense, and poor Mrs Owen had not been convicted, the domino effect of what followed may not have happened.”
What the Post Office said
Sky News approached the former Chief Executive of the Post Office during the Capture years, John Roberts, who said: “I can’t recall any discussion at my level, or that of the board, about Capture at any time while I was CEO.”
A statement from the Post Office said: “We have been very concerned about the reported problems relating to the use of the Capture software and are sincerely sorry for past failings that have caused suffering to postmasters.
“We are determined that past wrongs are put right and are continuing to support the government’s work and fully co-operating with the Criminal Cases Review Commission as it investigates several cases which may be Capture related.”
A Department for Business and Trade spokesperson said: “Postmasters including Patricia Owen endured immeasurable suffering, and we continue to listen to those who have been sharing their stories on the Capture system.
“Government officials met with postmasters recently as part of our commitment to develop an effective and fair redress process for those affected by Capture, and we will continue to keep them updated.”
Around 30,000 deaths will be linked to toxic air in the UK in 2025, according to a report from leading doctors, as they urged the government to “recognise air pollution as a key public health issue”.
The Royal College of Physicians (RCP) warned that around 99% of the population in the UK are breathing “toxic air”.
The report says there is “no safe level” of air pollutants while noting how exposure to air pollution can shorten life by 1.8 years on average.
That is “just behind some of the leading causes of death and disease worldwide”, including cancer and smoking, the authors wrote.
The college has called on the government to take action to tackle the issue, as it urged ministers to “recognise air pollution as a key public health issue”.
In the forward of the report, England’s chief medical officer, Professor Sir Chris Whitty, said: “Air pollution remains the most important environmental threat to health, with impacts throughout the life course.
“It is an area of health where the UK has made substantial progress in the last three decades with concentrations of many of the main pollutants falling rapidly, but it remains a major cause of chronic ill health as well as premature mortality.
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“Further progress in outdoor air pollution will occur if we decide to make it, but will not happen without practical and achievable changes to heating, transport and industry in particular.
“Air pollution affects everybody, and is everybody’s business.”
The report also highlights the economic impact of air pollution as it has an estimated cost of £27bn a year in healthcare costs and productivity losses.
Dr Mumtaz Patel, president of the RCP, said: “Air pollution can no longer be seen as just an environmental issue – it’s a public health crisis.
“We are losing tens of thousands of lives every year to something that is mostly preventable and the financial cost is a price we simply cannot afford to keep paying.
“We wouldn’t accept 30,000 preventable deaths from any other cause. We need to treat clean air with the same seriousness we treat clean water or safe food. It is a basic human right – and a vital investment in our economic future.”