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The long-anticipated findings of a public inquiry into how Lucy Letby was able to murder seven babies at a hospital neonatal unit will be published on Tuesday.
Two years after the evidence was heard in Liverpool, Lady Justice Thirlwall will publish her report into the actions of the NHS and other institutions at the time Letby carried out her crimes at the Countess of Chester Hospital in 2015 and 2016.
The inquiry’s key objectives are to seek answers for the victims’ families and ensure lessons are learned
It comes as the Criminal Cases Review Commission (CCRC), which investigates potential miscarriages of justice, considers an application by her Letby’s legal team to send the case back to the Court of Appeal.
Dame Vera Baird, who is chairwoman of the CCRC, has said she will be paying attention to the report findings.
In 2023 and 2024, Letby was found guilty of the murders, plus attempting to murder seven others, and is now serving 15 whole-life prison orders.
Here is the timeline of events:
2015
8 June – MURDER: Child A is born six weeks premature and given to Letby on her night shift. He “deteriorates rapidly” and dies within 90 minutes of Letby coming on duty.
8-11 June – ATTEMPTED MURDER: Child A’s twin sister, Child B, is injected with air by Letby – and survives after being resuscitated.
14 June – MURDER: Child C, born seven weeks premature, dies as a result of air being injected into his stomach. Letby is seen standing over his monitor as his alarm sounds.
22 June – MURDER : Child D, a full-term baby girl, dies 36 hours after her birth at the Countess of Chester Hospital. Letby had injected air into the child’s bloodstream.
End of June/July: A meeting takes place between neonatal lead consultant Dr Stephen Brearey and director of nursing Alison Kelly, along with other bosses, to discuss an informal review undertaken by Dr Brearey of Child D’s death. His findings reveal an “association” with nurse Lucy Letby and her presence at the recent collapses.
4 August – MURDER: Child E dies after air is injected into his bloodstream. The baby’s mother interrupts Letby in her attack, but doesn’t realise it.
5 August – ATTEMPTED MURDER : Blood sugar levels of a prematurely born baby boy, Child F, fall dangerously low, and a blood sample is sent for tests at the Royal Liverpool Hospital. The baby survives.
7 September – ATTEMPTED MURDER: Baby G left severely disabled by Letby, who tries to murder her twice, the second instance on 21 September, through air via her nasogastic tube.
23 October – MURDER: Child I, a prematurely born girl, dies on the unit. Concerns are raised again by some consultants in an email.
2016
8 February: A “thematic” review by an independent neonatologist based at Liverpool Women’s Hospital takes place. The review, requested by Dr Brearey, does not find a reason for the increased number of deaths and collapses, but concerns remain over Letby as the report is forwarded to nursing director Ms Kelly and medical director Ian Harvey.
17 February – ATTEMPTED MURDER: Child K taken to neo-natal unit’s intensive care room after being born premature. Letby seen dislodging breathing tube from baby. Baby taken to hospital and dies three days later.
9 April – ATTEMPTED MURDER x 2: Another youngster, Child L, suffers a hypoglycaemic episode in which his blood sugar level plunges. At around the same time, his twin brother, Child M, unexpectedly collapses and requires full resuscitation before he recovers. A blood sample from Child L is sent for tests at the Royal Liverpool Hospital.
3 June – ATTEMPTED MURDER: Child N, a newborn boy with haemophilia, attacked by Letby who thrusts nasogastic tube into his throat.
24 June – MURDER x 2: Child P, one of a set of triplet boys, collapses and dies a day after the death on the unit of his newborn brother, Child O. Dr Brearey phones the duty executive on call, Karen Rees, a senior nurse in the urgent care division, to say that he and his consultant colleagues do not want Letby to work her next scheduled shift on 25 June, but she rejects the plea.
25 June – ATTEMPTED MURDER: Ninety minutes into Letby’s day shift, Child Q, a prematurely born boy, needs breathing support after his blood oxygen levels and heart rate plummet. He goes on to make a full recovery.
29 June: Consultants meet to discuss recent “inexplicable” events and then urge hospital bosses to remove Letby from the unit as a safety measure.
30 June: Letby works her last nursing shift on the neonatal unit.
7 July: Hospital bosses reduce the neonatal unit service by cutting cot spaces and increasing the gestational age limit for admission from a minimum of 27 to 32 weeks.
15 July: An email is sent to all nursing staff informing them that they will each undergo a period of clinical supervision – after medical director Mr Harvey asked the Royal College of Paediatrics and Child Health (RCPCH) to conduct a review of the unit’s service. The email states: “Lucy has agreed to undergo this supervision first on Monday 18th July.”
19 July: Letby starts an administrative post in the hospital’s Patient Experience Team.
7 September: Letby registers a formal grievance procedure against her employer. Around this time, the Royal College of Nursing union informs her by letter about allegations surrounding her involvement in a number of deaths.
November: The RCPCH says it found no obvious factors linking a total of eight deaths in the neonatal unit in 2015 and five deaths up to July 2016. However, it did uncover significant gaps in medical and nursing rotas, and insufficient staffing for the provision of longer-term high dependency and some intensive care.
2017
18 May: Cheshire Police announce they have launched an investigation following “a greater number of baby deaths and collapses” at the hospital between June 2015 and June 2016. The probe will focus on eight deaths and will also review seven further deaths and six non-fatal collapses.
3 July: Letby is arrested at her home in Westbourne Road, Chester, at 6am, and officers search the three-bedroom property. Searches also take place at her parents’ home in Hereford and her place of work in the hospital’s Risk and Patient Safety Office. Police say the investigation has widened to 17 deaths and 15 non-fatal collapses between March 2015 and July 2016.
2019
10 June: Letby is re-arrested at her parents’ home.
2020
10 November: Letby is arrested again before she is charged, and appears in court for the first time two days later.
2022
4 October: Letby goes on trial at Manchester Crown Court accused of the murders of seven babies and the attempted murders of 10 others.
2023
21 August: Letby given 14 whole-life terms after being found guilty by a jury of murdering seven babies and the attempted murder of six others. She was found not guilty of two counts of attempted murder. Verdicts not reached on six counts of attempted murder.
2024
24 May : Letby loses her bid to appeal her murder and attempted murder convictions.
12 June: Retrial starts over an attempted murder charge jury could not reach a verdict on in the previous trial.
2 July: Letby found guilty of attempted murder of Child K.
5 July: Letby sentenced to a whole-life order for the attempted murder of Child K.
9 September: Thirwall Inquiry, looking into the events surrounding the crimes of Letby, begins. In Lady Justice Thirlwall’s opening statement, the senior Court of Appeal judge said she would also probe what recommendations had been made from previous inquiries into events in hospitals and other healthcare settings, and what difference they made.
24 October: Letby loses bid to challenge conviction for the attempted murder of a baby girl dismissed by the Court of Appeal.
October: Cheshire Police launch an investigation into corporate manslaughter at the Countess of Chester Hospital.
2025
9 January: Former health secretary Jeremy Hunt says the attacks by Letby could have been spotted earlier with the “dots joined up” by an independent medical examiner. He told the Thirwall Inquiry that he acknowledged the “appalling crime” took place under his watch and he bore ultimate responsibility for the NHS.
February: Evidence completed in Thirwall Inquiry, with report expected in 2026.
4 February: International panel of medical experts reveals alternative causes of death for seven babies murder by Letby. Evidence to be sent to the Criminal Cases Review Commission, which investigates potential miscarriages of justice.
March: Police investigating the hospital where Letby worked widen the scope of their investigation to include gross negligence manslaughter.
1 July: Three people who were part of the senior leadership team at the hospital while Letby worked there are arrested by Cheshire Police on suspicion of gross negligence manslaughter.
2026
15 September: the Thirlwall Report is set to be published