Thirlwall Inquiry Cost Millions But Sidestepped The Central Lucy Letby Question

The Thirlwall Inquiry has run for two years and cost millions of pounds, yet it deliberately stopped short of answering the central question about Lucy Letby's guilt. That decision has left the report vulnerable to being overtaken by parallel legal review and new scientific assessments.

Timing And The Criminal Cases Review Commission

Lady Justice Thirlwall began the inquiry amid criticism of what she called the "noise" from commentators questioning the convictions. In her closing remarks she made clear the inquiry would not determine whether Letby was guilty of murdering seven babies and attempting to murder seven others, adding that "it's not for me to second-guess or cut across the world of the Criminal Cases Review Commission (CCRC)".

That cautious approach sits uneasily with the decision to publish the report now, while the CCRC continues to consider whether to refer the case back to the Court of Appeal. If the CCRC does ask for a fresh appeal, as some observers expect possibly later this year, parts of the inquiry could be rendered legally or practically redundant.

New Evidence And Expert Reassessment

Recent scientific studies and a reassessment of medical evidence by an international panel — which included Prof Neena Modi, former president of the Royal College of Paediatrics and Child Health — have highlighted factors that may explain the infant deaths. Research cited in the debate points to unusual insulin spikes in newborns and identifies prematurity and substandard care as plausible contributors.

Lady Justice Thirlwall has previously criticised the 'noise' about whether Lucy Letby is guilty - Getty Images Europe/Thirlwall Inquiry

Those voicing doubts about the prosecution's case are not marginal figures: several respected clinicians and scientists have publicly raised concerns despite potential professional and personal risk. Several families have also reported incidents of substandard care at the Countess of Chester Hospital that affected infants when Letby was not on duty, adding weight to questions about systemic failures.

Recommendations And Potential Benefits

Even if the inquiry avoided making a finding on criminal culpability, many of Lady Justice Thirlwall's recommendations aim to improve neonatal safety and institutional accountability. Notable proposals include:

• Better data monitoring to detect patterns of harm earlier;
• Creation of an independent expert panel to investigate serious allegations of harm rather than relying solely on internal reviews;
• Improved safeguarding and clearer channels to encourage staff to speak up about patient safety concerns;
• Practical measures such as baby monitors on all cots and incubators in neonatal units and CCTV in insulin stores, which Letby's defence says could have affected the trial outcome.

Mark McDonald, representing Letby's defence, said improved monitoring and safeguards "would have significantly impacted the outcome at trial" and argued the absence of such measures was consequential.

What This Means Going Forward

The inquiry's reforms could meaningfully reduce risks to infants and lessen the chances of staff being wrongly accused if properly implemented. At the same time, publishing a comprehensive report while the CCRC's independent legal review remains active raises questions about timing and the potential for overlapping or conflicting outcomes.

Ultimately, the value of the Thirlwall Inquiry will be judged both on whether its recommendations are enacted to improve neonatal care and on how the legal process evolves in response to the CCRC's findings.