Safeguarding practices at a UK hospital were not followed, potentially allowing nurse Lucy Letby to harm more babies, a public inquiry has concluded. Lady Justice Thirlwall, chairwoman of the inquiry into the crimes of Lucy Letby, stated that it is impossible to determine precisely how many lives could have been saved.

However, the inquiry found a "complete failure" to protect infants on the neonatal unit at the Countess of Chester Hospital. Letby was convicted of murdering seven babies and attempting to murder seven others, with one infant targeted twice. She received multiple whole life sentences for her crimes.

The inquiry's findings highlight a "dysfunctional management and governance" system. If the babies Letby was convicted of murdering were removed from the unit's annual death toll, the figures for 2015 and 2016 would have been three deaths per year, consistent with previous years. Since July 2016, only one death has occurred on the unit.

Early deaths were not recognized as a cluster. The first three deaths in June 2015, concentrated within two weeks, were not viewed as a collective event. A fourth death in August 2015 was deemed unexpected and reviewed formally, but no connection was made to earlier fatalities, Thirlwall noted.

Specific missed opportunities were identified. The report suggests that if a doctor had not disregarded an insulin test result for one baby in August 2015, safeguarding action should have followed. This action, the inquiry found, would have prevented subsequent attacks and deaths.

Furthermore, the inquiry determined that if safeguarding measures had been implemented by October 2015, following the death of another infant, Letby could have been moved from the ward. This would have prevented further deaths and attacks.

Hospital executives were found to have repeatedly failed in their duty of candour towards parents, investigators, and regulators. Their conduct was described as "high-handed, against all safeguarding principles, and foolhardy." The medical director was noted for attempting to control the narrative by presenting a selective view of evidence.

The inquiry's conclusions raise significant questions about accountability and the effectiveness of existing safety protocols within healthcare settings. The findings underscore the critical importance of robust safeguarding procedures and transparent management to ensure patient safety.