Contents

Contents

¶Volume I Foreword vi Part One 1 Chapter 1. Background 3 Chapter 2. The neonatal unit, 2015 to 2016 11 Chapter 3. June 2015: Baby A, Baby B, Baby C and Baby D 32 Chapter 4. Risk and Patient Safety Department 59 Chapter 5. August to September 2015: Baby E, Baby F, Baby G and Baby H 73 Chapter 6. August 2015 to February 2016: Baby I and Baby J; concerns increase; reviews 98 Chapter 7. Care Quality Commission inspection, February 2016 123 Chapter 8. February to April 2016: Baby K, Baby L and Baby M 141 Chapter 9. April to May 2016: The executives 157 Chapter 10. June 2016: Baby N, Triplets O, P and R 172 Chapter 11. 24 and 25 June 2016: Exchanges between the doctors and managers; Baby Q 188 Chapter 12. Safeguarding 203 Chapter 13. Why was action not taken sooner? 234 Volume II Part One continued Chapter 14. Events at the end of June 2016 1 Chapter 15. Early July 2016: Discussions; downgrade of the neonatal unit; Silver Command; risk and reputation 20 Chapter 16. Meetings on 13 and 14 July 2016 35 Chapter 17. July 2016: Redeployment of and support for Letby 45 Chapter 18. Nursing and Midwifery Council 60 Chapter 19. Speak Out Safely 76 Chapter 20. The RCPCH review 87 Chapter 21. Reports: Dr Hawdon and Dr McPartland 125 Chapter 22. September 2016 to January 2017: The grievance 145 Chapter 23. January to March 2017 176 Chapter 24. Referral of deaths to the coroner 195 Chapter 25. NHS England and the Countess 221 Chapter 26. Contacting the police 248 Chapter 27. Events in 2018; the Inquiry 2023 to 2026 274 Chapter 28. The current position 289 Chapter 29. Bereavement care 297 Chapter 30. Parents' further recollections 301 Volume III Part Two 1 Chapter 31. Implementation of recommendations of inquiries 3 Chapter 32. Medical examiners 11 Chapter 33. CCTV and monitoring 22 Chapter 34. Insulin 26 Chapter 35. Data – reading the signals 30 Chapter 36. The NHS 41 Chapter 37. Training and regulation of managers 51 Chapter 38. Duty of candour 77 Chapter 39. Culture of the NHS 88 Chapter 40. Freedom to Speak Up Guardians 96 Chapter 41. Patient safety, safeguarding and employment law 108

¶Chapter 42. Care Quality Commission 113 Chapter 43. The Health Services Safety Investigations Body 121 Chapter 44. Memorandum of Understanding 130 Part Three 139 Chapter 45. Recommendations 141 Appendices Appendix 1. Terms of Reference 151 Appendix 2. Summary of Nuffield report on Inquiry questionnaire 155 Appendix 3. The Picker report 169 Appendix 4. Witnesses who gave oral evidence 172 Appendix 5. Chair's rulings 179 Appendix 6. Inquiry process 200 Appendix 7. Inquiry team 204 Appendix 8. Core Participants and legal representation 206 Appendix 9. Acronyms 208

¶Note on references Endnotes are in the following format. • Documents published on the Inquiry website: Document reference number/page number/ paragraph number (where applicable). • Oral evidence: Name of witness Date of oral evidence Transcript page/Transcript line number(s). • Publicly available documents: Author or organisation, title, date (URL). Where a particular element of a reference is not applicable or is unavailable, it is omitted.

Foreword

¶The year 2026 marks the eleventh anniversaries of the births and deaths of Baby A, Baby C, Baby D, Baby E and Baby I, the births and collapses of Baby B, Baby G, Baby H and Baby J, and the injuries to Baby F. It marks the tenth anniversaries of the births and deaths of Baby K, Baby O and Baby P, the births and collapses of Baby M, Baby N and Baby Q, and the injuries to Baby L. The parents of those babies have waited years to know the detail of what happened at the Countess of Chester Hospital between early June 2015, when Baby A died, and 2018, when Lucy Letby was arrested. In August 2023, after a ten-month trial, Letby was convicted of the murders of seven babies (Baby A, Baby C, Baby D, Baby E, Baby I, Baby O and Baby P) and the attempted murders of a further six babies (Baby B, Baby F, Baby G, Baby L, Baby M and Baby N). She was convicted at a retrial in June and July 2024 of the attempted murder of Baby K. Two applications for leave to appeal were dismissed in July and October 2024 respectively. An application was made to the Criminal Cases Review Commission (in February 2025) seeking a referral of the case back to the Court of Appeal.

¶This Inquiry was set up in October 2023. Witnesses were identified, documents were obtained. Evidence hearings began in September 2024. A total of 134 witnesses gave oral evidence over five months. In March 2025 I heard closing submissions and an application to pause the Inquiry, which I refused. My ruling on the application, on 19 March 2025, may be found on the Inquiry's website.

¶At the beginning of the hearings, I said that the experience of the parents would be at the heart of the Inquiry. The evidence about this appears in Part One of the Report. Part Two deals with the wider NHS. Part Three contains Recommendations and Appendices.

¶I would like to thank the parents of all the babies who died or were injured. Their evidence, generously given, was amongst the most thoughtful and moving any person will ever hear. Throughout a very difficult and prolonged process, the parents have conducted themselves with dignity and determination, with the aim that no other parents should have to experience such grief and heartache.

¶The Rt Hon. Lady Justice Thirlwall DBE

Part One