Photos: Ravi Jayaram, Steve Brearey, John Gibbs (supplied)

Paediatricians at Countess of Chester Hospital were very concerned that there may be a killer in their midst. Taking their concerns seriously may have saved lives, but they were shut down. However, their persistence played a key role in the most high-profile UK court case of the past year.

In August 2023, after a 10-month trial held at Manchester Crown Court, a jury found former paediatric nurse Lucy Letby guilty of the murder of seven babies and the attempted murder of six more, all of whom she was responsible for caring for at the Countess of Chester Hospital’s neonatal unit in 2015 and 2016.

Letby was found guilty of killing newborns in her care by injecting air into their bloodstream, poisoning them with insulin and force-feeding them milk.

Sentencing Letby to spend the rest of her life in prison, Mr Justice Goss said she had shown a “deep malevolence bordering on sadism”.

The 11-person jury, composed of seven women and four men, acquitted Letby on two counts of attempted murder and was unable to reach a verdict on six further counts. These outstanding counts related to five babies.

One count of attempted murder was retried in June 2024, and the following month she was found guilty of this offence too.  Her convictions are currently under review by the Criminal Cases Review Commission after her defence team applied for a referral back to the Appeal Court based on reports by medical and scientific experts instructed by her lawyers.

That Letby’s actions were brought to the attention of police is largely due to the persistence of the medical team working on her unit.

Dr Stephen Brearey, the unit’s lead consultant, first expressed his concerns to a hospital executive in July 2015. He also discussed his concerns with colleagues Dr Ravi Jayaram and Dr John Gibbs. They and the other paediatric consultants at the Countess of Chester raised concerns through hospital channels, first about the cluster of deaths, and later that they suspected Letby was responsible and wanted her removed from the unit, but felt they were being silenced to protect the hospital’s reputation. In 2017, Jayaram, Brearey and other consultants met with the police to share their concerns, resulting in the criminal investigation. The police later said Brearey and Jayaram had provided them with “the golden thread”.

The behaviour of hospital management at the Countess of Chester became the subject of an investigation into gross negligence manslaughter. In June 2025 three former members of the hospital's senior leadership team were arrested and bailed.

Separately, hearings for a full public inquiry with statutory powers led by Court of Appeal judge Dame Kathryn Thirlwall commenced in September 2024 and delivered its final report in September 2026. A total of 134 witnesses testified and 383 witness statements were received.

The inquiry did not examine Letby’s guilt, treating the convictions as settled. Its terms of reference covered three over-arching categories. It examined the experiences of all the parents of babies named in the indictment for Letby, both at the Countess of Chester Hospital and other related NHS services. The inquiry also investigated the conduct of hospital staff and managers, including delving into the hospital’s culture as well as the role played by the hospital board and senior management. Finally, the inquiry looked at NHS culture, including governance structures and management. In this activity, it was tasked to look at “external scrutiny and professional regulation in keeping babies in hospitals safe, whether changes are necessary and if so what they should be”.

The public terms of reference specifically included “governance and escalation processes in relation to concerns being raised about Letby”.

The Thirlwall Inquiry was highly critical of senior managers who knew the doctors suspected Letby of harming babies but failed to act to protect them. Instead, they stalled a police investigation. The inquiry found the consultants’ concerns “were held in good faith and were based on their clinical judgement". They were retaliated against for raising the alarm, including with threats of being referred to the General Medical Council, but resisted the pressure to back down because their concerns had not been addressed.  

The inquiry also found executives were engaged in “an exercise in spin, steering the Board away from concerns about criminal acts and the necessity of a referral to the police”, misled the National Health Service, and withheld information from the coroner. It identified failings in the actions of the Care Quality Commission and the Royal College of Paediatrics and Child Health, which had recommended an HR rather than criminal process “when concerns had been expressed about the deliberate harm and killing of babies”, describing this as “a serious misjudgement”.

Recommendations included installing in-cot cameras in every neonatal unit, locked and monitored insulin storage, and a one-page national protocol requiring action on any good-faith suspicion of deliberate harm.

In the aftermath of Lucy Letby’s conviction, many have questioned why whistleblowers in the NHS are still treated so poorly, despite recent attempts to improve the system. To address this issue, the Thirlwall inquiry recommended that NHS whistleblowing oversight be moved to the Parliamentary and Health Service Ombudsman, whose powers should be expanded to cover “investigating complaints that whistleblowing in the NHS has not been dealt with adequately” and “assisting whistleblowers by referring their concerns to the relevant NHS bodies and overseeing the response”.

The courageous and persistent actions of the Countess of Chester paediatric team, made in the most traumatic circumstances, make them clearly deserving winners of Blueprint’s UK Whistleblowing Prize for 2023.

This write-up was updated in September 2026 to reflect the findings of the Thirlwall inquiry