Thirlwall inquiry report on the Countess of Chester deaths is due Tuesday

Lady Justice Kathryn Thirlwall is due to publish the public inquiry report on the Countess of Chester Hospital neonatal unit on 15 September. The inquiry was set up after Lucy Letby, now 36, was convicted of murdering seven babies and attempting to murder seven others, including one child twice. She is serving 15 whole-life terms. The inquiry was not asked to decide whether those verdicts were safe. It was asked how the hospital handled the alarms and whether anyone could have stopped her sooner.

Hearings ran for about four months from September 2024. The inquiry heard 133 witnesses and read almost 400 statements. Closing arguments were in March 2025. The report is more than a year late. The cost has passed 18.5 million pounds. Thirlwall has said public noise about the convictions caused extra distress to the families and that retrying the science was outside her terms.

The unit saw a cluster of deaths in 2015 and 2016. Consultants raised concerns from June 2015 after three babies died in quick succession. Managers did not remove Letby from the ward at that point. The report is expected to list missed chances and to recommend changes across the NHS on how a trust treats a spike in deaths and a named nurse.

The Criminal Cases Review Commission has been looking at a dossier submitted for Letby for about 18 months. Its chair has told the BBC the commission will read Thirlwall with care. That is not the same as a referral to the Court of Appeal. Earlier this year the Crown Prosecution Service said there was not enough evidence for further charges from Chester or from Liverpool Women's Hospital.

On Monday two scientists who had worked on Letby defence file stepped back. Helen Shannon, a chemical engineer, and Geoff Chase, a bioengineering professor in New Zealand, wrote last year that they saw strong doubt on two insulin poisonings. They told the Guardian they still stand by that reading of those two cases but that some arguments now being put for Letby are inconsistent with available evidence and established physiology. Their withdrawal lands on the last working day before the inquiry report.

Families of the dead children have waited through the delay. Campaigners who say the convictions rest on weak medical evidence have waited too. Thirlwall has already said she will not pause for that campaign. The document that lands on Tuesday will be read as a hospital-failure report by one group and as a new exhibit by the other. It cannot be both a full retrial and a management review. The terms of reference picked the second job.

The practical test is whether NHS England and the Department of Health adopt the recommendations on escalation, coroner referrals and the power of a medical director to pull a nurse off a ward when consultants put a name on a cluster. If those rules change, the report will have done the work it was paid to do. The CCRC file is a separate machine and will move on its own clock.