Thirlwall Inquiry Terms of Reference

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.

It is an honour to respond for the Government in the last debate until September. I extend my thanks to you, Madam Deputy Speaker, as well as to the other Deputy Speakers and Mr Speaker, for your stewardship of this House, and to everyone who works here in Parliament and in our constituency offices. I also thank all our NHS staff, who are keeping the service going despite record demand over the summer. The right hon. Member for Goole and Pocklington (David Davis) has raised an extremely serious matter. I want to start by expressing my heartfelt sympathy to all the families who were affected by the terrible events at the Countess of Chester hospital—as a mother of two daughters, I cannot begin to imagine what they are going through. On top of their grief, they have been subject to a level of press scrutiny that would match anything we have faced as Members of this place. They have been left in limbo, waiting for answers. As someone who advocates for constituents at my own trust, I know that this will take an additional toll on their mental health, and all of us in this Chamber can agree that they deserve closure. The previous Government established the Thirlwall inquiry in October 2023 to examine the events at the Countess of Chester hospital NHS foundation trust. Its terms of reference are available online. Lady Justice Thirlwall’s recommendations will help us to understand what went so wrong at the Countess of Chester. Her inquiry has now finished hearing evidence, and the final report will be published at the earliest practical date. Lucy Letby was found guilty by her peers, following two criminal trials. She is currently serving 15 whole-life sentences for murder and attempted murder, and her convictions were upheld by the Court of Appeal. This is an independent judicial process, and it is not for the Government to comment on judicial decisions or appeals. The right hon. Gentleman has called for the inquiry’s terms of reference to be amended or expanded to reflect the ongoing public debate around the safety of Miss Letby’s convictions, but the point of the inquiry is not to rehearse Lucy Letby’s trial; it is to focus on how people within the trust responded based on what they knew, or should have known, at the time of the events. The inquiry is now in the report-writing stage, and I have every confidence that the chair will consider all the evidence when drawing conclusions and writing her report and recommendations. I do not consider that there is a case to either amend or expand the terms of reference, based on the information currently available. There is a separate process going through the Criminal Cases Review Commission, which received a full application in relation to Miss Letby’s case in April 2025. The merits of the application are solely for the CCRC to consider and, if appropriate, to refer the case for further consideration to the Court of Appeal. An application to the CCRC does not in itself indicate that the convictions are, or are likely to be, unsafe. Again, the right hon. Gentleman will understand that this is an independent process, and it is not for the Government to comment on, nor intervene in, individual applications. I am aware that the right hon. Gentleman has also called for the inquiry to be paused or suspended while the CCRC is reviewing Miss Letby’s application. An application was made by legal teams for Miss Letby and former executives at the trust to the inquiry chair to consider exercising her powers to pause the inquiry under section 17 of the Inquiries Act 2005. An application was made in parallel by the same legal teams to the then Secretary of State, my right hon. Friend the Member for Ilford North (Wes Streeting), to suspend the inquiry under section 13 of that Act. The basis for both applications was that the inquiry should be halted until the CCRC had determined Letby’s application. In March 2025, the chair refused the application and set out her reasons in detail. For transparency, that has been made available online. In her judgment, the chair considered, among other things, the question of fairness, and she was satisfied that the inquiry process had been fair and would not become unfair because there is a possibility that all the convictions were unsafe. My right hon. Friend the Member for Ilford North agreed with that reasoning. It would not be appropriate for the Government to speculate on the outcome of the CCRC’s determination, and we should take into account that the families have not supported any pause or suspension of the inquiry either. Even if, hypothetically, we did take that unprecedented step, I concur with my right hon. Friend that any suspension would create unnecessary delays and become a barrier to the families receiving the answers they deserve. There has been no new information that would make us think twice about this decision, nor change the terms of reference, and there is a strong public interest in the inquiry being concluded as soon as possible. That is why this Government shall not suspend the inquiry pending the outcome of Miss Letby’s application to the CCRC to review her convictions.

The Countess of Chester hospital is the local hospital for me and for many of my constituents. They will rightly want to know the outcome of the inquiry. On top of these historical matters, last year the CQC rated the Countess of Chester hospital’s urgent and emergency care services inadequate and found that the overall hospital requires improvement. While I recognise the work that the trust is doing to deliver against its improvement plan, and I thank it for its communication with me, there is still vital work to be done. Can the Minister set out what she is doing to ensure that it makes those improvements, so that my constituents can be reassured that they will be getting access to the best possible healthcare, as they deserve?

The hon. Member makes some important, valid points. Of course, the Countess of Chester hospital will want to know the outcome of the inquiry. As she rightly says, the CQC has been in and has made lots of recommendations, especially because of the inadequate rating. I have asked for a submission from the CQC to understand what progress has been made. I have been informed that there has been some progress, but equally there are lots of areas in which there has not been progress. I am making sure that I am receiving regular updates, because, as the hon. Lady rightly says, every parent wants to see change. In the end, this is about so many lives. Parents have had to go through such heartbreaking situations just to get to justice, and they do deserve disclosure. I therefore really do thank her for her intervention. Where the inquiry identifies lessons on safeguarding vulnerable patients or on how management responds to patient safety concerns, the Government will examine them rigorously and take forward all recommendations that are deliverable, justified and in the public interest. There is a huge amount of interest, inside and outside the Chamber, about the professional regulation of managers in the NHS. We all know that the NHS needs and deserves the best leaders. We are committed to supporting their development and professionalism, and to strengthening accountability where they fall short. Work is already under way to develop an NHS college of leadership and management to support and develop NHS leaders. In addition, we will legislate in this Parliament to enable the Health and Care Professions Council to begin to operate a statutory barring system for senior managers. The mechanism will enable the Health and Care Professions Council to prevent senior NHS leaders whose conduct is unacceptable from working again in senior roles. The Government have also launched the maternity and neonatal taskforce, personally chaired by my right hon. Friend the Secretary of State, which will translate Baroness Amos’s recommendations into action. The right hon. Member for Goole and Pocklington has campaigned against Government overreach his entire career; I respect him for that. I know that he will agree with me that our democracy rests on a separation of powers, and I trust our independent judiciary to get on with the job. There are well-established criminal processes and procedures for how expert evidence is used at criminal trials. In our democracy, there are also routes for people to challenge convictions if they protest their innocence—even for Lucy Letby. It is not for me or the Government to undermine those processes. Our attention should remain on the families and parents impacted by the case and on continuing to work towards providing answers and closure for them. That is what the Government are focused on, and we trust the Thirlwall inquiry to give us those answers. Question put and agreed to.