A senior consultant who worked alongside Lucy Letby has described the findings of the Thirlwall Inquiry as “grim reading”, admitting he wishes medical staff had been “brave enough” to bypass hospital management and contact the police sooner.
Dr John Gibbs, a former consultant paediatrician at the Countess of Chester Hospital, expressed his deep regret following the publication of the inquiry’s final report on 15 September 2026. Dr Gibbs, who retired in 2017 after more than two decades at the hospital, was among the group of clinicians who raised concerns about the high number of unexplained collapses and deaths on the neonatal unit between 2015 and 2016.
The inquiry examined the delay from the point clinical concerns were first raised for the police to be called. During this period, hospital executives reportedly discouraged doctors from taking their suspicions to outside authorities, at one point ordering consultants to apologise to Letby in writing.
Reflecting on the missed opportunities to intervene, Dr Gibbs stated he wishes the clinical team had been “brave enough to follow suspicions” and act independently of the hospital’s senior leadership. He described the delay in involving Cheshire Police as a significant failure that allowed Letby to continue her attacks on vulnerable infants.
Systemic failures and ‘grim reading’
The Thirlwall Inquiry was established to investigate the circumstances surrounding the murders of seven babies and the attempted murders of several others by Letby. The findings, which Dr Gibbs characterised as “grim reading”, detailed a culture where reputational management was prioritised over patient safety.
According to the inquiry documents, there were specific failings regarding the monitoring of insulin levels and a lack of transparency when clinicians attempted to escalate their worries. Dr Gibbs was a co-signatory of a joint statement in 2016 which formally raised the alarm, yet it would be nearly a year before a formal criminal investigation was launched.
The final report of the Thirlwall Inquiry provides a comprehensive breakdown of the governance failures at the Countess of Chester Hospital. It highlights how warnings from senior doctors were sidelined by executives who were later accused of “bullying” the consultants into silence.
Lucy Letby is currently serving multiple whole-life sentences for the murders and attempted murders committed during her time at the hospital. The inquiry’s findings are expected to lead to national changes in how NHS trusts handle clinical whistleblowing and the mandatory reporting of unexpected deaths in neonatal care.
The full transcripts and evidence from the inquiry remain available to the public via the official inquiry website, providing a detailed timeline of the events that led to one of the most significant criminal cases in the history of the NHS.