Thirlwall Inquiry Finds Complete Failure to Protect Babies

The Thirlwall Inquiry published its final report on September 15, 2026, concluding that a "complete failure to protect babies" occurred at the Countess of Chester Hospital. Lady Justice Thirlwall found that some infants would have been saved and attacks prevented if hospital management had acted on suspicions sooner and contacted police before May 2017. The report describes a systemic collapse in safeguarding, characterized by dysfunctional governance and a gulf between leadership and clinicians.

Thirlwall criticized the hospital's treatment of bereaved parents as "reprehensible" and noted that some babies should not have died. To prevent future tragedies, the inquiry issued 14 recommendations, including the mandatory installation of video baby monitors in all neonatal cots within 12 months and stricter biometric access for insulin storage by March 2027. The report also calls for a barring system for NHS managers to end the "revolving door" of unaccountable leadership.

Chief Executive Officer Jane Tomkinson apologized for the events of 2015 and 2016, stating the Trust is now a different organization with stronger governance, though she admitted more work is required. These findings emerge as the Criminal Cases Review Commission considers new medical evidence on behalf of Lucy Letby, who maintains her innocence while serving 15 whole-life terms. Meanwhile, Cheshire Constabulary continues to investigate three senior hospital managers for suspected gross negligence and corporate manslaughter.