Lucy Letby, a neonatal nurse who worked at the Countess of Chester Hospital, was convicted of murdering seven babies and attempting to murder six others following a lengthy criminal investigation and trial.
The convictions raised wider questions about what happened at the hospital’s neonatal unit, including why doctors and other clinicians’ concerns were not acted on sooner and whether opportunities to protect babies were missed.
The Thirlwall Inquiry was established to examine those wider questions and not to reconsider Letby’s convictions.
It reviewed events at the Countess of Chester Hospital between 2015 and 2018, including the experiences of families, the hospital’s response to concerns, safeguarding, NHS management, governance, scrutiny and regulation.
Liberay Legal has been following the Inquiry and its findings because they are highly relevant to maternity and neonatal care. Maternity and neonatal services are closely linked, and the Inquiry recommends stronger oversight of data from both.
When looking at whether something went wrong, it may be necessary to consider more than the care provided by an individual doctor, midwife or nurse. This could include staffing levels, whether concerns were escalated, safeguarding, incident reporting, communication and what hospital managers knew and did in response.
These are also important issues for families trying to understand what happened to their baby and whether their care was appropriate.
The final report was published on 15 September 2026, which found that there had been a “complete failure” to protect babies on the neonatal unit and that some collapses and deaths could have been avoided if concerns had been acted upon sooner.
What did the Thirlwall Inquiry find?
The report identifies profound failures in management, governance and safeguarding.
Concerns raised by clinicians were not handled appropriately, safeguarding procedures were not invoked, and parents were kept in the dark about concerns that their babies may have been deliberately harmed.
For patients and families, the wider lesson is important: when serious concerns arise, hospitals must put patient safety first, investigate promptly and communicate openly with those affected.
What needs to change in neonatal and maternity care?
Lady Justice Thirlwall made 17 recommendations, including:
- Video monitoring inside the cots within the neonatal units
- Tighter controls and monitoring around insulin storage
- Compulsory safeguarding training
- National protocol for suspected deliberate harm
- Stronger Board-level oversight of deaths involving babies and children
- Regular review of real-time maternity and neonatal data.
The recommendations also address bereavement care, medical examiners, NHS management accountability, CQC inspections and the need to ensure that recommendations from major NHS inquiries are actually implemented.
What could this mean for maternity and neonatal care?
Although the Inquiry centred on a neonatal unit, its findings are highly relevant to maternity care.
Maternity and neonatal services are closely connected, and the Inquiry specifically recommends stronger oversight of data from both services.
In a clinical negligence investigation, the relevant questions may therefore extend beyond the treatment provided by an individual doctor, midwife or nurse. It may also be necessary to consider staffing, escalation, safeguarding, incident reporting, governance, information-sharing and what senior managers knew and did in response.
Do parents have a right to ask what happened?
Yes. Parents can ask questions about what happened to their baby and what action is being taken in response to concerns.
Patients and parents should expect openness when something has gone seriously wrong.
This is actually one of the most significant findings in the report. Parents were not always told about reviews or concerns involving their babies, and the Inquiry criticised the failure to keep them properly informed.
The statutory duty of candour requires regulated healthcare providers to be open and transparent with patients in defined circumstances.
Families can ask what investigations are taking place, whether an incident has been formally reported, what the findings are and what action is being taken. For more information about the duty of candour and patients’ rights to answers, see Carlos Lopez’s guide on why it’s so hard to get answers after the NHS has harmed you.
Does a poor maternity or neonatal outcome mean there was negligence?
No. A serious injury, unexpected deterioration or death does not by itself prove clinical negligence.
Some poor outcomes occur despite appropriate treatment.
A clinical negligence claim usually requires expert medical evidence that the care fell below the appropriate standard and that this caused, or materially contributed to the injury or loss.
Each case must therefore be assessed on its own medical evidence.
When should families seek maternity or neonatal negligence advice?
Families may wish to seek specialist advice where:
- A baby has suffered a serious or unexplained injury
- An unexpected deterioration or death happens
- Explanations have changed or remain unclear
- Significant information appears to have been withheld
- A family is concerned that warning signs were missed
- Appropriate escalation did not occur.
It can help to write down what happened, keep copies of important letters and emails, and request the relevant medical records. Legal time limits apply to clinical negligence claims, although different rules can apply to children and in some circumstances.
Concerns must lead to action
The lasting significance of the Thirlwall Inquiry will depend on whether its recommendations change practice.
For maternity and neonatal services, that means recognising patterns of harm, listening to staff who raise concerns, improving safeguarding and governance, and treating families with candour.
For patients and parents, the message is important. You are entitled to ask questions about your care and your baby’s care, and serious concerns should be properly investigated.
How can we help?
Carlos Lopez and the team at Liberay Legal advise patients and families with concerns about maternity and neonatal care, including birth injury, neonatal injury, avoidable deterioration and neonatal death.
Specialist clinical negligence advice can help families understand what happened, whether independent medical evidence is required and what legal options may be available.
This article provides general information only and does not constitute legal advice. Each case depends on its individual facts and evidence.
Editorial source note
- The Thirlwall Inquiry, Final Report and Recommendations, published 15 September 2026.
- Department of Health and Social Care, Government response to the Thirlwall Inquiry, 15 September 2026.
- Department of Health and Social Care, Government to act on Thirlwall patient safety recommendations, 15 September 2026.
