Britain's long-running inquiry into nurse Lucy Letby's crimes landed Tuesday with a stark finding: some babies might have survived if the hospital had acted sooner. The government-ordered review, led by Justice Kathryn Thirlwall, concluded there was "a complete failure to protect babies" at the Countess of Chester Hospital's neonatal unit, where Letby was convicted of murdering seven infants and attempting to kill seven more in 2015 and 2016, reports the New York Times. Staff, the report said, did not grasp that safeguarding measures should be triggered as soon as a colleague is suspected of deliberate harm, not just once guilt is certain. "Errors were made by nurses, doctors and managers," Thirlwall said, per the AP. "There was also complete failure at all levels to invoke safeguarding procedures at any point."
The report paints a picture of an overstretched, outdated ward and recommends 17 reforms, including cameras on all neonatal cribs and CCTV at insulin stores. But it also sidesteps the growing challenge to Letby's convictions. An independent panel of neonatal experts last year found no evidence she killed or tried to kill any babies, blaming natural causes or substandard care instead. Statisticians and doctors have sharply criticized the trial's medical evidence, and Letby's lawyers say the inquiry was built on a flawed assumption of guilt. Her case is now before Britain's Criminal Cases Review Commission, which will decide whether to send it back to the Court of Appeal.