As the Thirlwall Inquiry continues, the investigation into the events at the Countess of Chester Hospital (COCH) continues to uncover serious systemic failures in the management of the escalating concerns from the consultant body. Testimonies from senior nurses, ward managers, and midwifery leaders have painted a troubling picture of mismanagement, ignored warnings, and a reluctance to escalate concerns - failures that have had devastating consequences for many families.

One revelation from the testimonies was how early signs of trouble were dismissed. Eirian Powell, Nursing Manager, admitted to noting a series of unexplained deaths and collapses linked to Lucy Letby, yet failed to alert authorities, assuming Dr Brearey, lead consultant on the neonatal unit, would take responsibility. This hesitation, despite clear red flags like the near-fatal morphine overdose of an infant, created a situation where serious incidents were allowed to escalate. Her defiant stance in support for her nursing colleague, clouded her judgement as to the potential for a nurse to be causing deliberate harm to children.

Failure to recognise the severity

Many within the team failed to recognise the severity of the situation, and Letby’s inappropriate behaviour toward vulnerable babies was often dismissed. This was despite a nurse (Nurse W), reporting to Ms Powell, Letby’s unusual and inappropriate response to death. This reflected a broader issue within the nursing team: an inability to consider the possibility of deliberate harm.

Police not called

Sian Williams, former Deputy Director of Nursing at COCH, described how she called on Trust bosses to contact the police but internal investigations caused significant delay. After carrying out staffing analysis, Williams concluded that Letby was 80% more likely to be on duty during a baby collapse. She took these findings to the medical director of the Trust, however the police still were not called. When asked why she then did not go directly to the police, Williams accepts in hindsight that she should have used her own initiative.

Breakdown of communication

Another highlighted issue was the breakdown in communication between medical staff and nursing teams. Powell described a toxic atmosphere where consultants were given more leeway, even when their behaviour was confrontational, which only widened the divide between the two groups. Tensions between Powell and consultants, particularly Dr Brearey and Dr Jayaram, who raised early concerns about Letby, illustrated the significant barriers to collaboration and trust within the unit.

Freedom to Speak Up policy

Several nurses shared how they felt unable to voice concerns to senior leadership for fear of repercussions. Notably, the medical staff  faced threats of disciplinary action after discussing the infant deaths. This culture of fear and intimidation left staff feeling they were undermining their colleagues simply by questioning the troubling events that were unfolding. At almost every stage in the handling of consultant’s concerns about increasing rates of neonatal death were never dealt with under the Freedom to Speak up policy, which provides protection for whistleblowers in the NHS. None of the protections of this policy were afforded to the medical staff who instead were faced with GMC referrals, the prospect of being “managed out” and advised to keep matters off email discussion.

Concerns not properly investigated

Key concerns raised by staff were not properly investigated. Powell acknowledged that the issues reported by Nurse W had not been documented or taken seriously, further delaying meaningful intervention.

One senior nurse admitted to being "too close" to Letby, saying they had met weekly for over two years. This blurred professional boundaries and potentially clouded judgment, allowing serious incidents to go unchallenged. Powell’s reluctance to involve external authorities, even as troubling patterns emerged, meant that opportunities for early intervention were missed.

Throughout the hearings, accusations of favouritism towards Letby have cast a shadow over the management of the neonatal unit. Powell, in particular, was criticised for treating Letby with leniency, which may have influenced her reluctance to act on mounting suspicions. This defensive approach points to deeper cultural issues within the hospital, where open communication was stifled, and concerns weren’t escalated when they should have been.

The systemic failures exposed by the Thirlwall Inquiry have made it clear that reform is needed in our NHS. Nursing staff have suggested several key recommendations to prevent such tragedies from happening again, including:

• Implementing stronger safeguarding procedures, especially when concerns arise about colleagues.
• Reinforcing the use of the already existing confidential reporting systems so staff can raise issues without fear of retaliation.
• Ensuring external, independent reviews of any unexplained deaths to provide impartial oversight and prompt action.

These recommendations are an important step toward rebuilding trust in the neonatal unit and ensuring future incidents are handled with the seriousness they deserve. The Inquiry has highlighted not only individual failings but also a broader culture of inaction and defensiveness, issues that must be addressed to prevent further tragedies.

The Inquiry is currently hearing from those staff at senior management level who face questioning as to their handling of staff who raised concerns, delays in contacting the police, their prioritising of reputation over patient safety and their management style, and their conduct and behaviour towards the consultants.

At Switalskis, we stand with the families affected by these devastating events. We are committed to seeking accountability and ensuring that the necessary changes are fully implemented. The lessons from this inquiry must lead to meaningful systemic change, prioritising patient safety above all else.

We can be contacted on 0800 1380 458 or by email help@switalskis.com