Thirlwall Inquiry: first Preliminary Hearing

16 May 2024

Lady Justice Thirlwall has held the first Preliminary Hearing in the public inquiry into the events at the Countess of Chester Hospital and their implications following the conviction of former neonatal nurse Lucy Letby.

The statutory inquiry was established following Letby’s conviction and sentence for seven counts of murder and seven counts of attempted murder. The offences took place at the Countess of Chester Hospital, part of the Countess of Chester Hospital NHS Foundation Trust.

The Inquiry, which is anticipated to commence hearing evidence in September 2024, will investigate:

A. The experiences of the Countess of Chester Hospital and other relevant NHS services, of all the parents of the babies named in the indictment.

B. The conduct of those working at the Countess of Chester Hospital, including the board, managers, doctors, nurses and midwives with regard to the actions of Lucy Letby while she was employed there as a neonatal nurse and subsequently, including:

(i) whether suspicions should have been raised earlier, whether Lucy Letby should have been suspended earlier and whether the police and other external bodies should have been informed sooner of suspicions about her

(ii) the responses to concerns raised about Lucy Letby from those with management responsibilities within the trust

(iii) whether the trust’s culture, management and governance structures and processes contributed to the failure to protect babies from Lucy Letby

C. The effectiveness of NHS management and governance structures and processes, external scrutiny and professional regulation in keeping babies in hospital safe and well looked after, whether changes are necessary and, if so, what they should be, including how accountability of senior managers should be strengthened. This section will include a consideration of NHS culture.

The Inquiry’s full Terms of Reference can be found here.

Jason Beer KC is instructed on behalf of NHS England.

Jonathan Dixey and Jennifer Wright are instructed on behalf of the Department of Health and Social Care.


Jason Beer KC

Call 1992 | Silk 2011

Jonathan Dixey

Call 2007

Jennifer Wright

Call 2018

Related areas

Public Inquiries


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