After Lucy Letby was sentenced to 15 conditions for the murder of seven babies and tried to kill seven others, an investigation was launched to ensure lessons were learned.
The Thirlwall investigation examines three broad themes – the experiences of all parents of all victims, how the concerns of clinicians were dealt with, and to ensure that lessons are learned from the most productive children’s series in modern British history.
About 133 Witnesses, including parents who lost their children, hospital managers and former colleagues from Letby at Chester Hospital, have given live testimony since September, with a further 396 written statements.
The closing statements this week come days after a police investigation into corporate manslaughter expanded to include gross negligence.
The investigation also heard that two baby deaths still remain the subject of continuing police investigation, which Letby was questioned in prison.
The investigative chairman, Lady Justice Thirlwall, is expected to publish her official report in the fall, with the exposition of the detailed findings and recommendations on the basis of the evidence heard.
But what has been said so far during the most important testimonies?
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As of September 2024: Letby Public Inquiry will start
Victims are the ‘heart of the investigation’
Lady Justice Thirlwall, who opened the investigation in Liverpool City Hall on September 10 last year, said the investigation carried her from so that the parents did not repeatedly see the name of the person convicted of the damage of their babies.
She said the babies who died or were injured would be the ‘heart of the investigation’ and condemned comments at the time that questioned the validity of Letby’s convictions – who tried to challenge the nurse and failed to challenge the Court of Appeal – and some of the evidence used during the hearing.
The investigation also remains separate to a 14-member expert panel, led by the retired neonatologist, Dr Shoo Lee and senior Conservative MP David Davis, who said in February that they analyzed medical testimony during Letby’s trial, claiming that there was no medical evidence that the nurse killed or attempted to kill 14 premature babies.
Letby’s advocates have since applied for a review of her case as a ‘potential miscarriage of justice’ by the Criminal Care Review Commission after two failed bids at the Court of Appeal.
Chairman of the investigation Lady Justice Thirlwall. Photo: Dad
Letby could not ‘wait to get the first death out of the way’
One of the nurses who started on the same day as a newly qualified nurse at Chester Hospital, Letby told the investigation that the serial killer told her she “can’t wait for her first death to take it out”.
The nurse said she thought the remark was “strange” at the time, but she put it down that Letby just had a conversation.
She also remembered that Letby was ‘animated’ when she told her that she was involved in resuscitation efforts by a child in the hall in 2012.
“It was as if she was excited to tell me about it,” the nurse said.
‘Probably’ Letby killed or attacked more children
Neonatal clinical lead in the County of Chester Hospital, dr. Stephen Brearey, told the investigation that he thinks it is “likely” that Letby killed or began to damage babies before June 2015.
He agreed that “on reflection” several unexpected crashes and deaths before that date now seem “suspicious”.
Dr Brearey added that he had no concern about the incidents at the time, saying that the hospital staff “thought we were going through a busy or especially difficult patch”.
The gravin of the Chester Hospital in 2023. Pic: PA
The investigation was told that the disruption of breathing tubes, which made Letby to kill Child K, usually occurs at less than 1% of the shifts.
However, this happened at 40% of the shifts that Letby worked when she was a student at Liverpool Women’s Hospital.
Newborn possibly deadly overdose of morphine
Two years before Letter carried out the murder of Child A, she and another nurse gave a potentially fatal dose of morphine to a newborn baby.
Neonatal Unit Ward deputy manager Yvonne Griffiths told the investigation that the baby had received ten times the right amount of painkiller at the end of a night shift in July 2013.
She described it as a ‘very serious error’, and she said the baby could die if colleagues had not noticed the mistake an hour later.
Letby said she should stop applying controlled medicine because of the error, a decision she told management that she was not happy.
Letby offered ‘tips’ on how to get away with murder
In a WhatsApp exchange in 2017, Letby and the Union Rep Hayley Griffiths discussed the US legal drama how to get away with murder.
The discussion took place a year after the Neonatal nurse was moved to clerical duties, following the concern that his possibly infants deliberately harmed babies.
In a message to Letby, Ms Griffiths wrote: “I am currently looking at a program called How to Get Away with Murder. I learn some good tips.”
To which Letby replies: “I could have given you some tips x.”
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From 2023: Former Health Secretary Steve Barclay on Letby Investigation
Ms Griffiths replied, saying she ‘needs someone to practice to see or [she] Can get away with it “, and Letby answer:” I can think of two people you could practice and will help you cover it. “
The trade union representative said: “I really regret that I started with the conversation … it’s completely unprofessional.”
No support or counseling given to parents
The parents of two triplets killed by Letby told the investigation that they received no support or counseling after the death of their children.
The children died on consecutive days in June 2016. Letby was their designated nurse and their deaths led her to be removed from the Countess of the Neonatal Unit of Chester Hospital to a non-patient.
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How police caught Lucy Letby
The father of the triplets said: “After the death of our children, we received no support or counseling from anyone. If we received a little support, we might have been in a better position to act on what our instincts told us, what was something bad.”
Senior Consultant: ‘I should have been brave’
Letby’s trial in 2023 heard that senior pediatrician Dr Ravi Jayaram virtually caught the serial killer “handed over with a hand over after an incident in a nursery in the hospital in February 2016.
Dr Jayaram addressed the incident while giving evidence during the investigation, saying that he entered the nursery after he felt “significant discomfort” that Letby was alone with Child K.
Read more from Sky News:
Letby Defense asks for miscarriage of the investigation of justice
Letby interviewed more baby deaths in prison
After walking in, he said he was “a baby clearly deteriorating” and uncovered the child’s endotracheal tube (ET). Despite his concern about the incident, the consultant did not say anyone in the hospital or police.
Dr Jayaram explained why he didn’t say anything: ‘This is the fear of not being believed. This is the fear of mockery. This is the fear of accusations of bullying.
“I should have been brave and should have had more courage because it wasn’t just an isolated thing. There has been a lot of other information. ‘
Dr Ravi Jayaram. Photos: Rex/ITV/Shutterstock
Hospital boss: ‘I should have done better’
Tony Chambers, the former CEO of the Gravin of Chester Hospital, was an important witness to give evidence during the investigation.
During his testimony, Mr. Chambers offered an excuse to the families who became the victim of Letby, saying that his language was ‘clumsy’ to tell the killer nurse that the hospital had ‘her back’.
“I absolutely admitted that we didn’t have it right. We could have done better, we should have done better. I should have done better,” he said.
When he insisted if he tried to “make it publicly called”, he added, “If that was what I did, it would be. But I think it’s an outrageous statement and I don’t believe it represents my actions. ‘
Lady Justice Thirlwall at Liverpool City Hall. Photo: Dad
Jeremy Hunt: ‘Terrible tragedy happened on my watch’
Jeremy Hunt appeared during the investigation in January where he apologized to the victims’ families and said he was sorry “for anything that could not have happened that could not have prevented such a disturbing crime”.
Mr. At the time, Hunt was Health Secretary Letby committed her crimes in 2015 and 2016.
Hunt arrives at Thirlwall investigation. Photo: Dad
The MP told the investigation that the crimes of the former nurse were “a terrible tragedy” that “happened on my watch”, and “although he does not bear direct personal responsibility for everything that happens in every section in the NHS”, he has “ultimate responsibility for the NHS”.
He recommended that medical investigators be trained to see the signs or patterns of malicious damage in the work of a healthcare person.
