Thirlwall Inquiry Terms of Reference

David Davis Excerpts

Thursday 16th July 2026 Commons Chamber

[David Davis (Goole and Pocklington) (Con)]

This is my third debate on the general issue of Lucy Letby, and I remind the House of what I have said before: justice must never be sacrificed for institutional self-preservation. We are awaiting the publication of the Thirlwall inquiry’s findings into the deaths at the Countess of Chester. When the inquiry was established, it was tasked with examining three areas: the experiences at the Countess of Chester and the parents named in the indictment; the conduct of the hospital’s staff with regard to Lucy Letby; and the effectiveness of NHS management and culture in safeguarding babies, and recommendations for reform if relevant.

Every question stems from the assumption that Lucy Letby is guilty beyond doubt. Since her trial and conviction, a growing body of distinguished scientific opinion has challenged the supposed evidence on which they rest. Prominent experts—heads of royal societies and royal colleges, and leading voices in medicine, statistics and forensics—have raised concerns about Miss Letby’s convictions. They have come forward in extraordinary numbers, calling for the inquiry’s scope to be revised. If the case against Miss Letby is straightforward, why have so many people with nothing to gain, but their reputations to lose, publicly challenged it?

At the outset of the inquiry, I warned the chair that by failing to broaden its terms of reference to examine credible alternative hypotheses, we risk protecting a conclusion rather than conducting a forensic search for the truth. The Post Office Horizon scandal highlighted the institutional instinct to find a convenient scapegoat. Innocent people paid the price, while the institution sought to protect itself. If the Thirlwall inquiry asks too narrow a set of questions, systemic NHS failures will go unexamined. More innocent children will die, more innocent parents will be put through agony, and another hospital will find another scapegoat—that is the consequence of getting this wrong.

So what should the inquiry’s terms of reference include? There are at least three lines of inquiry that deserve examination. Each is supported by substantial evidence. Each almost certainly contributed to what happened. Each risks being overlooked. The first is the staffing crises: this was a neonatal unit stretched beyond its limits and operating under relentless pressure. The second is poor clinical management: the unit was repeatedly tasked with caring for babies requiring the highest level of specialist capacity—capacity it did not have. The third is environmental risks: there were serious contamination problems within the hospital.

Two damning reviews of NHS maternity services more generally have now been published. The Ockenden report exposed failures at Nottingham University hospitals NHS trust that mirror those at the Countess of Chester: infections, overcrowding, under-resourcing, sustained pressure and overstretched staff—different hospitals, but strikingly similar failures. Baroness Amos has also published her final report on NHS maternity and neonatal services. Its conclusions echo with remarkable consistency the concerns raised about the Countess of Chester. Baroness Amos concluded:

“the maternity and neonatal system is not set up to deliver consistently safe, high-quality and compassionate care... It is fragmented, overly complex and too slow to…improve.”

She highlighted “unsafe and unacceptable” hospital buildings, “excessive workload pressures” and staff who felt

“ignored… when they raised concerns about whether they could provide a safe or joined-up service”.

She also highlighted “dangerous clinical environments”, senior leaders who “were not accountable” and, of course, staff who were

“fearful of being blamed when things went wrong”.

If the Thirlwall inquiry was unwilling to heed the growing concerns of experts, it cannot dismiss the conclusions of two Government reviews.

As far back as 2004, senior neonatal staff at the Countess of Chester were warning management of a

“staffing crisis which...shows no signs of abating”,

highlighting that the unit was operating 30% to 40% below the staffing levels recommended by the British Association of Perinatal Medicine. They described stress that “exceeded tolerable levels”, reinforcing that such conditions

“could increase the risk of unintentional professional negligence”.

But how did management respond? To cut costs they abolished the advanced neonatal nurse practitioners, the most highly trained specialists in their field, upon whom the entire safe working of the unit depended. One of the nurses let go later described it as “the decimation of the Nursing and Midwifery service”,

adding that

“eight registered nurses...were replaced with nursery nurses...unqualified staff are replacing qualified staff”.

She described a trust blighted by

“inefficient managers...managers to manage managers, people to tick boxes...inefficient computer programmes”,

all

“at the expense of the registered nurse/midwife”.

If management’s response was to bury the problem, what does that tell us about the state of the Countess of Chester by 2015? A system repeatedly warned to be unsafe cannot merely be treated as the backdrop to the events of 2015 to 2016—it is at least part of the explanation.

By 2012 the hospital was recruiting newly qualified nurses, often straight from university. One of them was Lucy Letby. During the years Lucy Letby is alleged to have committed her crimes—specifically 2015 to 2016—the neonatal unit was still functioning under dangerous pressure. Notably, one nurse working on the unit during this period recalled:

“2015 and 2016 were horrendously busy... They were probably the worst years I can remember in more than twenty years... Everybody was absolutely stretched to the limit... You were expected to look after the maximum number that you could—sometimes over the number that you should.”

The inquiry ought to ask, if concerns had been raised for over a decade, to what extent did those unresolved staffing failures contribute to the tragedies that followed? Were those failures addressed before responsibility was placed on Letby?

There are three levels of care in neonatal units, depending on the complexity of care that a unit is equipped to provide. Appropriate grading of a neonatal unit is fundamental to patient safety. Level 1 units accept babies with low care needs. Level 3 units accept babies needing the highest level of medical care. The Countess of Chester was a level 3 unit throughout the early 2000s, but in 2005 it was downgraded to level 2, an admittance that the unit could not handle level 3 babies.

But the unit continued to operate under immense strain, worsened by management’s decision to get rid of its hugely experienced advanced neonatal nurse practitioners. Years later, when Lucy Letby started at the Countess in 2012, conditions remained poor. There was little space, cots and incubators were stored in corridors, and mothers struggled to find somewhere to breastfeed their babies. Susan Gilby, the hospital’s chief executive between 2018 and 2022, later described the unit as “dark, dingy and cramped”, providing a “less than ideal” environment to work in. Remember, this was a level 2 neonatal unit tasked with providing short-term intensive care for fragile babies.

Indeed, the deficiencies were so serious that the trust launched a £3 million public fundraising campaign to pay for a new neonatal unit because the necessary capital funding was not available through the NHS. This was an acknowledgment that the unit was not fit for purpose. The inquiry ought to ask: was the unit being asked to deliver a level of care that it was not capable of providing?

Staff at the time certainly thought so. One nurse warned the unit manager,

“something awful is going to happen here...we can’t carry on like this”.

In late 2015, one consultant said the unit was so busy that it was running out of vital equipment, adding:

“This is now our normal working pattern and it is not safe. Things are...at breaking point. When things snap, the casualties will either be children’s lives or the...health of our staff.”

The spike in baby deaths was that breaking point.

The Royal College of Paediatrics and Child Health report from November 2016 confirmed that the unit was

“non-compliant on nurse and medical staffing levels”

when assessed against service standards for a level 2 unit. It ought to have been downgraded further, to a level 1. Indeed, it is often claimed that babies on the unit stopped dying as soon as Letby was removed from the ward. That assertion ignores perhaps the most critical fact. In July 2016, when Letby was removed from the ward, the neonatal unit was finally downgraded to a level 1.

In that moment, the risk profile changed. Fewer of the sickest babies were admitted at the Countess. The 2016 Royal College of Paediatrics and Child Health report is clear that since the redesignation from level 2 to level 1, the pressure

“has reduced and the unit is operating more in line with BAPM staffing standards. The consultants also reported that in the two months since the change infants have been sick but recovered as expected.”

The report highlighted deficiencies in staffing levels, leadership and communication, but, in the trial, it was not shown to the jury—they knew nothing of it. In July 2016, the unit was downgraded and Lucy Letby left the ward. It is irrational to assume that one of those two events was entirely responsible for the sharp reduction in deaths without testing the other event properly. The inquiry must examine both changes to determine which made the difference.

During 2015 and 2016, when the neonatal mortality rates spiked, the hospital faced infection control problems. One nurse described the unit as her “worst nightmare”. Pseudomonas aeruginosa had colonised taps in the nurseries of the neonatal unit. Pseudomonas forms a biofilm—a layer that allows the bacteria to spread within a water system—and can kill newborns. In 2012, at Belfast’s Royal Jubilee maternity hospital, three premature babies died from it. In an effort to mitigate the risks of Pseudomonas, the Countess of Chester installed filters on the taps, but the filters kept falling off. Another of the babies Letby is said to have murdered was found to have Stenotrophomonas maltophilia in their breathing tube—a bug responsible for some of the deaths at Glasgow’s scandal-hit Queen Elizabeth University hospital.

Of the 17 babies Lucy Letby is said to have murdered or attempted to murder, at least 14 babies either had an infection or were suspected to have an infection. Professor Shoo Lee’s panel identified that 10 infants were receiving antibiotics, and court proceedings identified another three. The fact that at least 13 babies were treated with antibiotics suggests that the clinicians considered infection to be a real possibility in these cases. On top of that, MRSA, C. difficile and MSSA were detected across the trust; it is not known whether they were present in the neonatal intensive care unit.

While giving evidence at her own trial, Miss Letby told jurors that the neonatal unit had problems with “raw sewage” coming from sinks. That was not an invention in the hopes of abdicating responsibility; contemporaneous messages between staff show that these concerns were raised at the time. Remember: this was a neonatal intensive care unit. One nurse suggested that an infection on the unit could be to blame. Letby agreed, describing sewage coming from the sink and overflowing toilets. She added:

“The unit needs properly assessing, I don’t think the equipment gets cleaned properly…we haven’t got the space, facilities…to maintain hygiene.”

Those messages predate any criminal investigation, and the hospital’s plumber confirmed under oath that human waste was backing up into handwashing basins. On top of the other microbiological concerns, human waste contains E. coli—another hazard to vulnerable new-born babies. Professor David Livermore, a professor of medical microbiology, is right to say:

“Infection was such an obvious cause of a spike in deaths. What investigation did they do [into this?] I’m yet to see any clarity on this.”

Even the parents themselves had initially assumed that if something had gone wrong, it was likely because of the hospital’s failings. One mother giving evidence against Lucy Letby during her trial admitted that

“I thought, the hospital’s old, it’s not very nice. It was dirty, and I thought it was along the lines of medical negligence. It never entered my mind that there was somebody intentionally harming babies”.

That is the hospital we are talking about—old, not very nice, dirty—and it does not look as though the medical management of the hospital did anything to mitigate the risk arising from those problems. A mother of three triplets who moved to Liverpool Women’s Hospital said she

“noticed a different level of cleanliness compared to the Countess”

as there were “clear hygiene protocols” at Liverpool, where, she said:

“We were told to wash our hands before entering the Unit and then again before entering the room”,

which was not the case at the Countess of Chester.

One father of a baby born at the Countess of Chester in May 2016 described the unit as “chaotic” and “failing”. He described an atmosphere of tension where

“it wouldn’t take much more”

for the unit “to blow up.” His daughter had had a difficult delivery and could not breathe at birth. He and his wife discovered three years later that she had been the sickest baby on the unit for over 24 hours. Not a single doctor spoke to them about this, while nurses repeatedly told them that their baby was “fine”. Against that backdrop, he recalls that Lucy Letby stood out as the only staff member who took time to explain his baby’s condition. The hospital itself later told him that Lucy had “saved” his daughter’s life and had gone

“above and beyond the call of duty.”

He stated bluntly that the jury in Miss Letby’s trial was not given the full picture—the systemic problems, lack of communication and overall disorder.

History judges institutions not by how confidently they defend themselves, but by whether they had the courage to confront uncomfortable truths. The Thirlwall inquiry now faces that test. An inquiry that refuses to ask difficult questions is not fearless—it is formulaic. An inquiry that overlooks credible evidence is not comprehensive—it is compromised. A major failure of the trial was that the jury was not shown evidence from authoritative sources such as the Royal College of Paediatrics and Child Health that offered a credible alternative explanation for the spike in deaths. The inquiry must not replicate that failure, and it must not lend its authority to what may be a major miscarriage of justice. It owes the parents who lost their babies, and future parents of future babies at risk, the absolute truth. It must follow the evidence and fear no conclusion.

If facts are left unexamined, lessons are left unlearned. The inquiry should heed the warnings of Ockenden and Amos, and the countless voices emerging in Miss Letby’s defence. Structural failure, institutional failure, and medical incompetence or even malevolence—every one of those explanations must be dragged into the light, and the unvarnished truth exposed.