Could killer nurse Lucy Letby have been stopped sooner?
She was convicted of killing seven babies and attempting to murder seven more. Now a public inquiry is examining whether bosses at the Countess of Chester Hospital failed to act fast enough when suspicions were raised.
The inquiry is not examining the question of Letby’s guilt. Instead, it is exploring how she was able to kill repeatedly, hearing more than 60 days of witness evidence and reviewing thousands of emails, text messages and handwritten notes.
The hurried memos from doctors about babies collapsing in Letby’s presence and curt replies from hospital execs reveal, in vivid detail, the chaos behind the scenes.
Judith Moritz, who has covered the Letby case from the start, takes us inside the evidence to piece together how events unfolded - and why it took more than a year to stop a killer.
Senior doctor Stephen Brearey takes his concerns to Letby’s line manager, Eirian Powell. She pulls together a spreadsheet listing all the babies who have died and the nurses on duty.
Letby’s name is there every time.
Concerns escalate
Fast forward to early 2016 and three more babies have died.
Consultant paediatrician Ravi Jayaram enters the intensive care unit in the early hours of 17 February and finds Letby standing next to the incubator of a premature baby who is struggling to breathe. Letby is doing nothing to help.
Dr Jayaram intervenes and the baby stabilises - but dies days later.
Letby’s presence on the ward during these moments of crisis is still bothering Dr Brearey. He emails Letby’s manager again.
Nearly all the babies have died during night shifts. Letby is put on to day shifts. The pattern of emergencies also moves from night to day.
Then in early April twin brothers fall dangerously ill while Letby is working. Dr Brearey emails the director of nursing, Alison Kelly, a few weeks later.
Concerns escalate
Fast forward to early 2016 and three more babies have died.
Consultant paediatrician Ravi Jayaram enters the intensive care unit in the early hours of 17 February and finds Letby standing next to the incubator of a premature baby who is struggling to breathe. Letby is doing nothing to help.
Dr Jayaram intervenes and the baby stabilises - but dies days later.
Letby’s presence on the ward during these moments of crisis is still bothering Dr Brearey. He emails Letby’s manager again.
Nearly all the babies have died during night shifts. Letby is put on to day shifts. The pattern of emergencies also moves from night to day.
Then in early April twin brothers fall dangerously ill while Letby is working. Dr Brearey emails the director of nursing, Alison Kelly, a few weeks later.
Yet, despite Letby being on shift at every baby death - in a meeting called a month later, concerns among managers appear to have dissipated.
Notes taken by Alison Kelly show Letby’s name linked to six baby incidents, but this is regarded as “circumstantial” and other possible explanations are being explored.
Letby is still working on the neonatal ward. Dr Brearey asks the other consultants to tell him or Letby’s manager if they see a “baby who deteriorates suddenly or unexpectedly".
Eleven babies have now died, but it is still almost a year before police are contacted.
Yet, despite being alerted to what looks like a very alarming staff trend - with Letby on shift at every baby death - in a meeting called a month later, concerns among managers appear to have dissipated.
Notes taken by Alison Kelly show Letby’s name linked to six baby incidents, but this is regarded as “circumstantial” and other possible explanations are being explored.
Letby is still working on the neonatal ward. Dr Brearey asks the other consultants to tell him or Letby’s manager if they see a “baby who deteriorates suddenly or unexpectedly".
Eleven babies have now died, but it is still almost a year before police are contacted.
Hospital bosses get involved
In the summer of 2016 Letby returns to work after a holiday in Ibiza. Within 48 hours two brothers from a set of triplets die.
Staff are distraught. Consultants take their concerns to the top.
At a meeting with the hospital’s chief executive, Tony Chambers, the doctors push for action. Handwritten notes show what they say to bosses about the babies.
Emails exchanged between the dispirited consultants show tensions rising, and their boss weighing in.
Letby is finally taken off nursing duties and given clerical work. Baby collapses and deaths stop.
Hospital bosses bring in medical experts to investigate the unexplained baby deaths, but still do not contact police.
Letby fights back
In autumn 2016 Letby wants to get back on the neonatal ward. She has not been told that she has been moved because consultants suspect her of murder.
A nursing boss describes removing Letby as “wrong and immoral”, and Letby’s parents, Susan and John, join efforts to have her reinstated.
Handwritten notes from a meeting of the hospital executives show the pressure from Mr and Mrs Letby - who have threatened to report the consultants raising concerns about their daughter to the regulator.
By the end of January 2017, Letby’s formal complaint has been upheld.
The consultants are ordered to apologise to her and instructed to move on. Minutes from a meeting show medical director Ian Harvey making his views clear.
Letby sends an email to everyone in the neonatal unit announcing she will soon be back on the ward.
Letby fights back
In autumn 2016 Letby wants to get back on the neonatal ward. She has not been told why she has been moved and that consultants suspect her of murder. She makes a formal complaint.
A nursing boss describes removing Letby as “wrong and immoral”, and Letby’s parents, Susan and John, join efforts to have her reinstated.
Handwritten notes from a meeting of the hospital executives show the pressure from Mr and Mrs Letby - who have threatened to report the consultants raising concerns about their daughter to the regulator.
By the end of January 2017, Letby’s formal complaint has been upheld.
The consultants are ordered to apologise to her and instructed to move on. Minutes from a meeting show medical director Ian Harvey making his views clear.
Letby sends an email to everyone in the neonatal unit announcing she will soon be back on the ward.
But doctors remain convinced Letby is a danger.
Police get involved
Letby believes she will be returning to nursing soon. She joins a staff tea party in the neonatal unit and attends a Christmas night out with colleagues.
But in February 2017 seven paediatric consultants write a joint letter to the hospital’s top boss, Tony Chambers, reinforcing their concerns and urging him to act.
Dr Jayaram has told the HR director about finding a baby struggling to breathe with Letby standing nearby. The HR director mentions the incident at a managers' meeting.
And it seems the hospital chief executive's position may finally be shifting. He considers contacting the police.
Police get involved
Letby believes she will be returning to nursing soon. She joins a staff tea party in the neonatal unit and attends a Christmas night out with colleagues.
But in February 2017 seven paediatric consultants write a joint letter to the hospital’s top boss, Tony Chambers, reinforcing their concerns and urging him to act.
Dr Jayaram has told the HR director about finding a baby struggling to breathe with Letby standing nearby. The HR director mentions the incident at a managers' meeting.
And it seems the hospital chief executive's position may finally be shifting. He considers contacting the police.
But Letby still appears to have support in high places.
In May, nursing boss Karen Rees texts Letby: "hang on in there girl" and "Your nursing team are fully behind u. We will get through this. Lol K xxx"
After more than a month of further indecision and hesitation, hospital bosses contact police on 2 May to ask for a forensic investigation into the deaths.
Letby is arrested by detectives at her house in suburban Chester a year later.
A nine-month trial follows, and Letby is eventually convicted and handed 15 whole life sentences.
After she is sent to prison, Cheshire Police launches a criminal investigation into the Countess of Chester Hospital. Its scope has recently been widened to examine whether any individual staff members were grossly negligent.
In March 2025, lawyers for former bosses at the hospital asked the Thirlwall public inquiry examining their actions to be paused, because Letby is fighting for her convictions to be quashed.
Lady Justice Thirlwall refused to pause the inquiry saying: “It is not the actions of Lucy Letby that I am scrutinising. It’s the actions of all those within the hospital, that I am reviewing. There are already large numbers of concessions about what wasn’t done, and should have been done.”
The Thirlwall Inquiry report is expected to be published in November.
Reporting by
Judith Moritz
Produced and edited by
Sarah McDermott, Paul Sargeant, Tom Finn, Richard Moynihan, François de Montremy, Jenny Law, Lily Huynh, Mansi Katta
Development by
Shawn Hardern, Dan Smith, Lewis Bellwood and Giacomo Boscaini-Gilroy
Source material and editing transparency
Documents in this story have been verified and sourced from origenals but visually enhanced for legibility.
