Thirlwall inquiry has left biggest questions around the Letby case unanswered

The decision to press on with Lady Justice Kathryn Thirlwall’s inquiry into the Countess of Chester hospital, despite mounting calls to broaden its remit, has left the most unsettling question unanswered: could the police and prosecutors have got the Lucy Letby case catastrophically wrong? The inquiry, launched in 2023 and now culminating in an £18 million, 822‑page report, deliberately sidestepped any scrutiny of the criminal convictions, even as a parallel legal scandal – the wrongful conviction of Andrew Malkinson for rape – was laid bare by Chris Henley KC. The juxtaposition of these two high‑profile miscarriages of justice has sharpened concerns that the UK’s legal and health systems remain ill‑equipped to confront their own errors.

Origins of the Thirlwall inquiry and its narrow focus

The inquiry was set up by then‑Health Secretary Steve Barclay in 2023 on the premise that Lucy Letby, a neonatal nurse, was guilty of murdering seven babies and attempting to murder a further seven at the Countess of Chester’s neonatal unit. Its terms of reference were explicitly limited to examining whether hospital management failed to act on warnings about Letby and whether earlier police involvement might have prevented further deaths. From the outset, the scope excluded any review of Letby’s criminal convictions.

When Labour’s Wes Streeting took over the health brief after the 2024 general election, 24 leading experts wrote to him urging a pause to the inquiry or an expansion of its remit to consider the possibility of a miscarriage of justice. Streeting declined, allowing the inquiry to proceed on its original, conviction‑centric premise.

Henley’s warning and the parallel miscarriage of justice

Two months before Thirlwall opened the inquiry, Chris Henley KC published a scathing report on the “atrocious” wrongful conviction of Andrew Malkinson for rape. Henley warned that the criminal courts harbour a “deep‑seated … cultural reluctance” to admit mistakes, noting that “entirely innocent defendants will sometimes be convicted”. He called for a culture that recognises the risk of error across all legal roles.

Henley’s admonition reverberates through the Letby inquiry because the same systemic inertia appears to have shaped the handling of the neonatal deaths. While the inquiry scrutinised management failings, it never questioned whether the police, the Crown Prosecution Service, or the expert witnesses they commissioned might have erred in interpreting the medical evidence.

The inquiry’s findings on hospital management

Thirlwall’s report, spanning 822 pages, concluded that senior managers delayed calling the police after the deaths of two of three triplets in June 2016. She argued that the Cheshire Constabulary was uniquely equipped to uncover the forensic truth and that earlier police involvement would have “saved lives”. The report also criticised the unit’s chronic understaffing, noting that consultant neonatologists only conducted two ward rounds a week and that the unit was subsequently downgraded to stop caring for the most premature infants.

Crucially, the inquiry’s analysis of medical reviews – including post‑mortems by three senior Alder Hey pathologists, a review by consultant neonatologist Dr Jane Hawdon, and an assessment by the Royal College of Paediatrics and Child Health – found no evidence of deliberate harm. Instead, they identified “sub‑optimal care” and systemic staffing shortages. Yet Thirlwall’s final judgement rested on the assumption that Letby was guilty, not on the medical evidence itself.

The dissenting voices of international experts

A sizeable cohort of British and international specialists, led by Canadian neonatologist Dr Shoo Lee, challenged the prosecution’s narrative. Lee argued that the evidence had been misrepresented and that the deaths resulted from vulnerable, premature infants receiving inadequate care rather than intentional homicide. His team’s conclusions echoed those of the Alder Hey pathologists and Dr Hawdon – no deliberate harm, only poor clinical practice.

Despite presenting these findings during the inquiry, the experts were not afforded a platform to interrogate the police and CPS conclusions. The report notes that “there was almost no moment” in the Liverpool Town Hall sessions that addressed the stark divergence between the prosecution’s case and the independent medical reviews.

The role of the Criminal Cases Review Commission

The Criminal Cases Review Commission (CCRC), the body tasked with flagging potential miscarriages of justice, continues to examine Letby’s application for appeal, alongside the extensive expert reports submitted in support of it. While the CCRC’s work remains ongoing, the Thirlwall inquiry was deliberately insulated from this process, reinforcing its narrow focus on hospital management rather than judicial error.

Henley’s earlier call for vigilance underscores the broader risk: “Miscarriages of justice disfigure the lives of all connected to the case and make the public generally less safe.” By sidelining the question of whether the police and prosecutors erred, the inquiry may have inadvertently contributed to a further erosion of public confidence in both the health and legal systems.

Implications for future inquiries and systemic reform

The Letby inquiry’s exclusion of a review of the criminal convictions sets a concerning precedent. Future public inquiries into medical failures may be tempted to adopt similarly circumscribed terms of reference, thereby avoiding the politically fraught task of questioning law‑enforcement agencies. Yet the Malkinson case demonstrates that such avoidance can conceal deep‑seated cultural reluctance to admit error.

For meaningful reform, the legal establishment would need to embrace Henley’s recommendation of a culture that recognises the potential for mistake. This would entail granting inquiry chairs the authority to call in police and CPS representatives for cross‑examination, and ensuring that expert dissent is not merely noted but actively examined.

What remains unanswered and the road ahead

After two years and £18 million spent, the Thirlwall report offers a thorough critique of hospital management but leaves the pivotal question of police and prosecutorial error untouched. The divergence between the forensic conclusions of the Cheshire Constabulary and the independent medical assessments remains unexplained, and the public is left without clarity on whether a miscarriage of justice has occurred.

As the CCRC continues its review, the onus now lies on the government, the judiciary, and the police to decide whether to widen the scope of the inquiry retroactively or to launch a separate, independent investigation into the conduct of the original investigation. Without such a step, the Letby case will continue to cast a long shadow over the credibility of both the NHS and the criminal justice system.

This article was produced with AI-assisted research and editorial support. Reporting is based on the source material cited below. Sources: The Guardian UK; theguardian.com; Global1.News (19 September 2026).

By Erica Thornton, Staff Writer