On Friday 18th August, jurors of the Lucy Letby trial returned their verdict, finding the former nurse guilty of 7 counts of murder 7 counts of attempted murder following a gruelling 22 day deliberation. The trial, which started in October 2022, saw some of the most horrific and devastating evidence of any murder trial in recent memory. As a solicitor who has spent the past 10 years of my career representing bereaved families, I can say that hearing loved ones recount their experiences of loss never gets any easier. It’s even more difficult when you think that those deaths could have been prevented. As we now look ahead to Letby’s sentencing, which is expected to happen later this year, we must remind ourselves that although she will be going away for a long time, the risk of this happening again won’t be going with her.

The question we have collectively been asking ourselves since this trial began is ‘how could this have happened?’. From the second we are brought into this world, we put our complete trust into the brilliant NHS and the medical care providers and staff that keep it running. We trust that no matter what happens, at least those providing our care will have our health and wellbeing as their number one priority. This devastating situation has reminded us that even in the NHS, things slip through the cracks. We must question how Lucy Letby was able to get away with this for so long. For this to be a trial of 18 victims instead of 1 tells us that the processes currently in place to prevent this kind of heinous behaviour are simply not working. Now we have to ask ourselves, how do we make sure this never happens again?

Unfortunately, even with Lucy Letby serving a lengthy prison sentence, the risk of another tragedy similar to this one reoccurring is very much a real one. If it happened once, without a solid investigation into how this happened and subsequent change, it could happen again. A public inquiry is the only way to make sure we, and arguably more importantly, the hospital management, learn from the catastrophic failings that allowed this to go on for so long. A public inquiry would independently investigate the NHS, the Countess of Chester Hospital, and the safeguarding processes that are currently failing to safeguard patients from this kind of malpractice.

What are the failings that allowed this to happen?

The only way to find out the full extent of these failings is to launch a public inquiry. However, we have already heard from the trial that other members of staff were raising their concerns about Letby and outright asked for an internal investigation to be launched by the hospital. Those concerns were dismissed, and staff were told to ‘not make a fuss’.

We also discovered in the trial that In June 2015 a review was undertaken by nursing manager of the neonatal unit, Eirian Powell into 3 deaths. At that point a connection with Letby was noticed. Later in 2015, Powell and consultant paediatrician Dr Brearey had a meeting with Alison Kelly, the hospitals head of risk. This was a clear opportunity for intervention. Why did nothing come of this review? Why wasn’t a full-scale investigation launched at this stage? What did they discover in this review, and should it have been a cause for concern?

Lead Paediatrician Dr Ravi Jayaram and his colleagues raised concerns with senior managers in October 2015 and February 2016 and asked for the unexplained deaths to be investigated but was told that nothing was going on. This is once again an example of the institution turning a blind eye to a very serious issue raised by clinical experts. The concerned doctors asked for a meeting with the directors but were ignored for 3 months, which tells us the hospital management clearly prioritised protecting the hospital and its reputation over protecting their patients. Dr Jayaram also claimed that he and his colleagues were getting pressure from the senior management at the hospital not to make a fuss.

Following the deaths of 2 triplets Baby O and Baby P, in June 2016 Dr Brearey raised his concerns with hospital executive Karen Rees. He said he did not want Letby to come in the following day or until there could be an investigation. Karen Rees declined that request and confirmed she was happy for Letby to go to work the following day.

The need for a full-scale public inquiry is clear.

What is a public inquiry?

A public inquiry is a major investigation that is launched by the government to investigate large-scale catastrophes caused by serious failings at the hands of a public body. Some examples of a public inquiry include the Manchester Arena Inquiry, the Grenfell Inquiry and the ongoing Covid Inquiry. Statutory public inquiries have the power to compel witnesses to take the stand under oath, which would include those directly involved in the events, and order the release of crucial evidence to understand the role of these failings in contributing to the loss of life. The inquiry can subsequently put forward recommendations for change to make sure the same catastrophe is never repeated. It is crucial that if a public inquiry is launched, it must be statutory to ensure a fair investigation.

Why do we need a public inquiry now?

Public inquiries are a huge undertaking and have the tendency to last for a long time. If a public inquiry was launched today, we wouldn’t see any hearings for at least a year. It’s important that an inquiry is launched sooner rather than later, as the destruction of vital evidence only becomes a criminal offence once the inquiry has officially started. We’re call on the Prime Minister to launch a public inquiry, and to launch it now, before any more lives are lost unnecessarily.

Once Letby is sentenced to life imprisonment, there will be a collective sigh of relief that the danger has passed and babies will be safe, but a system that willingly turns a blind eye to unexplained deaths, dismisses the concerns of respected clinicians and according to reports, pressures those raising concerns to be quiet, is a system that will allow the next Lucy Letby, the next Harold Shipman, the next Colin Norris, the next Victorino Chua to get away with murder. This simply cannot happen. It's on the government to launch an inquiry, and to do it now.

Nicola Brook is a public inquiries expert who has represented bereaved families in some of the biggest public inquiries and inquests in UK history, including the Manchester Arena Inquiry, the Hillsborough Inquests and the ongoing Covid Inquiry. Find out more about Nicola and her work here.