Thirlwall Inquiry publishes its final report: 'a complete failure to protect babies'

Lady Justice Thirlwall published her final report on 15 September 2026 in Liverpool, in three volumes with a summary report and 17 recommendations. She found "a complete failure to protect babies on the neonatal unit at the Countess of Chester Hospital", describing "dysfunctional management and governance; a gulf between hospital leadership and clinicians; and failure to understand the fundamentals of safeguarding", and concluded that the collapse and deaths of some babies could have been avoided had safeguarding practices been followed. The report finds a prolonged delay by senior managers in calling the police, and is critical of the internal and external reviews commissioned instead: the RCPCH service review "could not and did not address the doctors' concerns and should never have been undertaken". Rather than being believed, the consultants who raised concerns were investigated under Letby's grievance and three were told to apologise to her; the report calls the handling of that grievance "deplorable". Parents were kept in the dark for years and their consent was not obtained before their babies' records were shared. The Inquiry was not a criminal appeal: it did not examine whether the convictions are safe and cannot overturn them.