Dr. Stephen Brearey, a lead neonatal consultant at the Countess of Chester Hospital,has admitted he should have alerted the police sooner regarding the actions of Lucy Letby. This admission follows the release of the Thirlwall Inquiry report, which investigated the deaths and attempted murders of infants between 2015 and 2016.
The May 2017 police call and the cost of "naivety"
Dr. Stephen Brearey told the Thirlwall Inquiry that he and other consultants repeatedly raised alarms about Lucy Letby, yet these warnings were largely ignored by hospital leadership. While internal reviews into the spike in infant deaths occurred throughout 2015 and 2016, the Countess of Chester Hospital did not contact Cheshire Police until May 2017.. Dr. Brearey noted that he had been "naive" to assume that senior managers shared his values and would act decisively once the concerns were presented.
As reported by the BBC Radio 4's Today programme, Dr. Brearey described a "toxic negativity" permeating the NHS. He argued that the culture surrounding the reporting of concerns is fundamentally broken, suggesting that clinicians often feel unsupported when challenging the hierarchy. This delay in police involvement meant that Letby remained in a position to cause harm long after clinicians had become suspicious.
Lady Justice Thirlwall's 822-page indictment of neonatal safeguarding
The final report from the Thirlwall Inquiry, spanning 822 pages, concluded that there was a "complete failure" to protect babies within the neonatal unit of the Countess of Chester Hospital. Lady Justice Thirlwall found that hospital leadership failed to grasp a basic tenet of safeguarding: that action must be taken when a staff member is suspected of deliberate harm, even if absolute proof of guilt is not yet available.
According to the report, the hospital suffered from dysfunctional governance and a significant divide between the clinicians on the front lines and the executives in leadership.. To prevent future tragedies, the inquiry proposed 17 specific recommendations. These include the mandatory installation of CCTV for all incubators and cots in neonatal units, stricter controls over access to insulin, and an overhaul of NHS IT systems to better handle safety data.
PTSD and the "sad indictment" of manager contracts
Beyond the clinical failures , Dr. Stephen Brearey highlighted the severe psychological toll on the staff who worked alongside Lucy Letby. He compared the experience of the neonatal team to soldiers suffering from PTSD who are forced to remain in a battle zone, noting that staff were retraumatised daily as they continued to treat sick infants without professional psychological support.
Dr. Brearey also criticized the recommendation that the duty to put patients first should be explicitly written into the contracts of senior managers. He described this as a "sad indictment" of the organization, arguing that such a fundamental ethical requirement should be an inherent part of the culture rather than a contractual obligation. he warned that while the Department of Health and the NHS may seek a turnaround, cultural change of this magnitude does not happen overnight.
Tony Chambers and the former executives' joint review
In the wake of the findings, the Countess of Chester Hospital trust issued an apology, stating that no action can undo the events of 2015 and 2016. The trust claims it has since evolved into a different organization with new leadership and a more open culture regarding safety and governance.
However, a significant point of contention remains regarding the accountability of previous leadership. Former executives Tony Chambers, Ian Harvey, and Alison Kelly, along with former HR director Sue Hodkinson, issued a joint statement saying they are "carefully reviewing" the Thirlwall report. It remains unclear whether these specific individuals will face professional or legal consequences for the "dysfunctional management" cited by Lady Justice Thirlwall, or if the "review" process will serve as the extent of their engagement with the findings.
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