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Health Secretary Yvette Cooper says plans are under way to install “cot cams” in neonatal units after a damning report found hospital staff could have prevented three of killer nurse Lucy Letby’s murders.
The Thirlwall Inquiry’s final report said Letby should have been removed from the neonatal unit at Countess of Chester Hospital before Babies O and P came to harm, while if doctors had acted on abnormal insulin tests relating to Baby F, whom Letby attempted to murder, then Baby I may have also been saved.
The report says hospital executives prioritised “prevention of reputational damage” over the string of neonatal deaths and found there had been a “complete failure” to protect children.
Lady Justice Thirlwall’s report examines events that led to the former nurse’s convictions for murdering seven infants and attempting to murder seven others between June 2015 and June 2016. Letby, 36, is serving 15 whole-life orders for the crimes.
The report sets out a number of safeguarding recommendations, including the introduction of baby monitors in every cot on neonatal wards. Lawyers representing several families affected said it was vital changes were implemented.
The inquiry does not look at whether Letby was guilty, but how concerns about the nurse from other staff were handled and whether her actions could have been prevented.
Cooper orders review of NHS safeguarding ‘framework’
Health secretary Yvette Cooper has instructed Chief Nursing Officer Duncan Burton to urgently review the NHS’s safeguarding framework and training in the light of the Thirlwall Inquiry.
She told MPs: “A revised NHS safeguarding framework was published in April 2026, but I have asked the Chief Nursing Officer to urgently review the framework and the training in the light of this report. We need to look urgently at this.
“But let me be clear: this goes beyond laws and procedures, many of which are already clear. This is about leadership and responsibility.
“Safeguarding is everyone’s business, and safeguarding must be everyone’s priority.
“Concerns must be heard and acted upon. Staff who speak up must be protected and taken seriously, and I expect every leader, every board across the NHS, every professional and manager, every member of staff to uphold their safeguarding responsibilities.
“And I will not hesitate to hold the NHS to account for the highest standards of every level, because at its heart, this is what the NHS stands for: care for patients, and most of all, keeping the most vulnerable patients of all safe.”
Jane Dalton15 September 2026 19:05
NHS trusts to launch bereavement care next year, Cooper says
All NHS trusts are signed up to roll out the national bereavement care pathway in 2027, in line with one of Lady Justice Thirlwall’s recommendations, Yvette Cooper has said.
The health secretary also told the Commons she would legislate to bring in a barring system to remove poorly-performing NHS managers “as soon as parliamentary time allows”.
She said: “The government has consulted on and confirmed plans to apply a barring scheme to senior leaders and managers, not just to clinicians.
“So, we will legislate to introduce the scheme as soon as parliamentary time allows and we will consider (Lady Justice Thirlwall’s) recommendation to expand it further.”
Jane Dalton15 September 2026 18:55
Inquiry tainted by wrong premise, claims Letby barrister
Lucy Letby’s barrister has claimed the inquiry prompted by the child serial killer’s crimes was “tainted by the wrong premise”.
Mark McDonald told the Press Association: “Everything in this inquiry is tainted by the fact that they’ve worked on the wrong premise.”
But he added that he would agree with one recommendation the chairwoman made, saying: “Cameras in the neonatal unit, cameras in the cots.
“Because if they were there when Lucy Letby was working, then she wouldn’t have been on trial. She wouldn’t have been convicted, we wouldn’t be here today.”
Jane Dalton15 September 2026 18:25
NHS has seven months to install CCTV in dozens of units
Health editor Rebecca Thomas writes:
Among the 14 recommendations made in the Thirlwall Inquiry report is that to install baby monitors in all cots and incubators in neonatal units and CCTV cameras focused on insulin storage fridges.
Health secretary Yvette Cooper has promised these cameras.
There are 43 neonatal intensive care units in England, 74 high-dependency units and 39 low-dependency units.
It is not clear how many already have CCTV, but the costs should borne centrally rather than by individual trusts, Lady Thirlwall has suggested.
NHS England will be required to set out how this will be implemented by 31 March next year.
The recommendation is a first; however, it is likely to be fairly achievable, in comparison with the billions in infrastructure issues facing the NHS.
NHS England will also already have an idea of the numbers and costs needed. In 2023, every hospital in England with a neonatal unit was asked whether they had considered installing CCTV following a request by the Thirlwall Inquiry.
A survey of obstetric and neonatal unit staff also highlighted “need for improved security measures, such as CCTV and baby tagging systems, to safeguard babies and ensure the safety of patients and staff”.
Jane Dalton15 September 2026 17:58
Hospital chiefs failed to correct Letby’s misinformation, report says
Hospital bosses failed to correct misinformation Letby put out about her own future.
She was removed from the hospital’s neo-natal unit in July 2016 after consultant paediatricians raised concerns that she may have been harming babies.
Once external reviews had found no evidence of criminality and that a grievance procedure that Letby took out over her removal had been upheld, the nurse believed she was returning to the unit.
An email she sent to staff reported by the inquiry report read: “I was redeployed from the Unit in July 2016 following serious and distressing allegations of a personal and professional nature made by some members of the medical team … After a thorough investigation it was established that all the allegations were unfounded and untrue and I have therefore been fully exonerated. I have received a full apology from the Trust … I will begin making my return to the unit in the coming weeks.”
Lady Justice Thirwall, in her report published today, said she found no evidence that anyone at the hospital responded to the email, or attempted to clarify that she had not been exonerated.
“This was a further failure of management,” she said.
Letby never returned to the ward, and was arrested the following year.
Jane Dalton15 September 2026 17:30
Safeguarding bosses and head of nursing failed to act
Lady Justice Thirwall found the Safeguarding Strategy Board failed to play any role in detecting, preventing or responding to concerns about Letby between July 2015 and November 2017, during which there were six meetings.
Lady Thirwall said all executives and senior managers failed to follow safeguarding processes, and that “particular opprobrium” attaches to former director of nursing, Alison Kelly, “for her repeated and serious failures to ensure appropriate safeguarding responses were initiated”.
The judge said Ms Kelly, as executive lead for safeguarding, should have ensured concerns over Letby’s harming of babies were sent to a local-authority designated officer or police.
Lady Thirwall said: “She [Ms Kelly] did not refer the matter until March 2018, and when she did, the referral contained inaccuracies and was misleading.”
Ms Kelly and two other bosses gave evidence to the inquiry:
Alex Ross15 September 2026 17:12
‘No apology or action can undo what happened’: Hospital boss speaks out
The chief executive of the Countess of Chester has apologised over Letby’s crimes but acknowledged: “No apology or action can undo what happened at our hospital.”
Jane Tomkinson said her thoughts remained with the families and babies who had been harmed.
She said: “We know that no apology or action can undo what happened at our hospital. We are, however, truly sorry for the events that occurred.
“We acknowledge the findings of the Thirlwall Report and will approach its recommendations with openness and a firm commitment to build on the progress we have already made in improving our hospital’s governance, safety and culture since that time.
“We are a different organisation today with new leadership, stronger governance and safety processes, and a more open culture where speaking up is encouraged and acted upon.
“We firmly believe that the changes we have made, as set out in our evidence to the Inquiry, have created a safer environment for our patients and staff.”
Jane Dalton15 September 2026 16:50
Scandal-hit nursing regulator shows ‘egregious’ avoidance of responsibility
Among the organisations criticised in the inquiry is the scandal-hit Nursing and Midwifery Council, which has been subject to national scrutiny after The Independent revealed allegations of a ”toxic” culture in 2023.
The inquiry pointed to “mistakes and failures” by the regulator, including failures to impose an interim order after Letby was arrested in July 2018, as revealed by The Independent in 2024.
“It does not seem to have been appreciated that Letby had not been working as a nurse for nearly two years by this stage. An application for an interim order should have been made.”
Hitting out at the council for its response to the Thirlwall Inquiry, the report highlighted that despite acknowledging “mistakes and failures” in opening statements, in its closing evidence there was there had been an “egregious example of language avoiding responsibility”.
It said: “What needs to be said (and what the witnesses did say in evidence) is that mistakes were made. Things should have been done differently. The NMC failed in a number of respects. It is essential to recognise the failures and then to take steps to ensure that the same mistakes do not recur.”
Rebecca Thomas15 September 2026 16:32
No reason to suspect errors in insulin tests, says Lady Thirlwall
The chairwoman of the Thirlwall Inquiry has said there is no reason to think there were errors in insulin tests of two infants poisoned by Letby following claims by her lawyer that they were unreliable.
Lady Justice Thirlwall said that “suggestions from different quarters… that the testing carried out was in some way defective” was not supported by evidence.
She referred to the evidence given by principal clinical scientist at Liverpool Clinical Laboratories, Dr Anna Milan, regarding Child F and Child L.
Barrister Mark McDonald previously passed a report from seven medics to the Criminal Cases Review Commission claiming the unreliability of the insulin tests.
In her report, Lady Justice Thirlwall said: “Dr Milan explained first in writing and then clearly in oral evidence that the quality assurance process at the laboratory enabled her to be sure the test results were accurate.”
The senior judge repeated the words of Dr Milan, who said the insulin sample would not have been measured “if we weren’t sure that the analyser was performing appropriately that day”.
Her report continued: “This is what is to be expected of a laboratory providing such an important service.”
Jane Dalton15 September 2026 16:15
New maternity and neonatal commissioner to be appointed
The health secretary has confirmed a new maternity and neonatal commissioner post will be created in response to Lady Justice Thirlwall’s inquiry report.
Yvette Cooper told MPs she would speak to the maternity task force to bring forward amendments in the Health Bill to introduce the role.
She said the commissioner would address the “serious concerns around safety and standards” raised in the report.
Jane Dalton15 September 2026 15:52