Three years ago, Lucy Letby, a thirty-three-year-old former nurse at the Countess of Chester Hospital, in the West of England, was found guilty of murdering babies on her ward and was sentenced to life in prison. The day of the final verdict, the country’s Health Secretary announced that the government would hold a public investigation, eventually named the Thirlwall Inquiry, into the circumstances behind the murders. The inquiry, whose findings were released this week, took almost three years, with some sixty days of hearings and more than a hundred witnesses testifying, at a cost of roughly twenty-four million dollars. The lead lawyer said that the inquiry would “serve the vital purpose of keeping babies safe in the future from those rare cases when a health-care professional intends them harm.”

In 2024, I wrote a story about the case which suggested that there hadn’t been any murders at all. Since then, there’s been a cascade of disclosures casting doubt on Letby’s convictions. The prosecution had stated that Letby had killed some of the babies by injecting air into their bloodstreams; the argument relied, largely, on a 1989 paper that described the symptoms of air embolisms in newborns. The paper’s co-author, Shoo Lee, a prominent neonatologist in Canada, was confused when Letby’s legal team at the time, working on an appeal, informed him of the role of his research. He read some of the court transcripts, discovered that his study had been misinterpreted, and eventually volunteered to review thirty-five thousand pages of medical evidence. Working pro bono, he put together a panel of fourteen medical experts, among them some of the world’s leading specialists in newborn medicine, including the head of neonatology at Children’s Hospital of Philadelphia, a former director of the neonatal intensive-care unit at Boston Children’s Hospital, and a former president of the Royal College of Paediatrics and Child Health. They produced a seven-hundred-page report that found no medical evidence that Letby had harmed any of the fourteen babies identified in her convictions. “In all cases, death or injury were due to natural causes or just bad medical care,” Lee said, at a press conference organized by Letby’s legal team in 2025.

Letby, who has been in prison for nearly six years, lost her bid to appeal, but she has applied to the Criminal Cases Review Commission, a government body that reviews potential miscarriages of justice, and is waiting for a response. Four months after Lee’s report, Jeremy Hunt, the country’s Health Secretary at the time of the deaths, wrote an editorial in the Daily Mail arguing that “the time has come for these concerns to be addressed as a matter of urgency.” Hunt had previously treated Letby’s guilt as settled, but he had read a “wide range of expert concerns about the conduct of the Letby criminal case” and done “a lot of soul searching . . . to get to this point.” He wrote that, if the deaths were caused by medical errors mistaken for murder, “lessons will not be learned and more babies will die.”

A separate group of twenty-four clinicians and scientists, including the forensic-science regulator for England and Wales at the time of the deaths, asked the Health and Justice secretaries to postpone the inquiry or amend its scope, because an investigation that was premised on Letby’s guilt “may unintentionally deflect from multiple potential causes of neonatal deaths at the Countess of Chester Hospital and thus miss the opportunities to draw the correct wider lessons for the NHS.” The Health Secretary declined to alter the investigation. “It is not for me in the discharge of my duties,” Lady Justice Thirlwall, the chair of the inquiry, said, “to seek to explore alternative theories about the deaths.”

And yet, a second, submerged story ran underneath the one that witnesses, in the course of the inquiry, were called to tell. It surfaces only in passing, in more than a thousand pages of exhibits—meeting minutes, e-mails, police interviews, handwritten notes—that were shown to witnesses during the hearings and then made public. The records trace the rift on Letby’s unit between the doctors and nurses, who had not been called to testify in her defense at trial. The nurses struggled to defend Letby from the doctors’ accusations, but were discounted.

In the report, Thirlwall characterizes the nurses’ support of Letby as “unthinking loyalty” and “tribalism,” speculating that one nurse had closed her mind because of her “long-standing belief that nurses were not treated with the same respect as doctors.” The report makes seventeen recommendations, including that all neonatal cots and incubators have cameras with live video and that, when people raise suspicions that a health-care provider has harmed a patient, managers must immediately act on them—“whether the person to whom the concerns have been expressed does or does not believe they are true.” But the records collected by the inquiry tell a different story when they aren’t pressed into a case study of an institution’s failure to recognize what was happening on its ward. The nurses, who worked beside Letby every day, also had strong instincts about who she was. But only the doctors’ impressions came to be regarded as reliable knowledge.

When Karen Rees, the head of nursing for urgent care at the Countess at the time, first learned that Stephen Brearey, a pediatrician who led the Countess’s neonatal unit, suspected Letby of harming babies, in June, 2016, she was “absolutely horrified,” she said. She asked how he had come to this opinion. In the past year, there had been a spike in newborn deaths, and Letby had been on shift for nearly all of them. Brearey told Rees that Letby needed to be removed from the unit. Rees asked if he had any additional evidence, but she said that he told her only that he had a “gut feeling.” He referred to a “drawer of doom.” “I said to him: well, share the contents of that drawer of doom with me, of which he refused,” she told the inquiry. “So I said to him: I can’t remove a nurse from a clinical practice just because of gut feeling and a drawer of doom.”

Brearey, his colleague Ravi Jayaram, and another pediatrician brought their worries to Tony Chambers, the hospital’s chief executive. At a meeting, Jayaram acknowledged that their suspicion was “entirely subjective,” contemporaneous notes read. Nevertheless, the hospital agreed to temporarily remove Letby from the unit and place her in a clerical job while it reviewed the deaths.

The accusation against Letby was so incomprehensible to the pediatric nurses that a false rumor spread that Brearey was targeting Letby because she had rebuffed a sexual advance. “I found it very difficult to act on something I didn’t believe in—it was a witch-hunt,” the deputy manager of the neonatal unit said at the time. Eirian Powell, the neonatal manager, had analyzed Letby’s shifts, in addition to multiple factors that could have contributed to each death, including congenital abnormalities and failures with transportation between hospitals. Letby was present for so many deaths, Powell said, because she was “so amenable and flexible.” Powell added that Letby was “one of my best nurses,” who “avails herself to work overtime when the acuity or unit is over capacity.” The lead nurse for pediatrics said, “No one could give us any other reason and why—why should it just be her? You know, we had highlighted in another table that one of the Registrars”—a junior doctor—“had also been present on a number of—of occasions. But for some reason it was only the nurse that was being sort of pinned.”

The Countess’s executives decided that the hospital should no longer treat babies born before thirty-two weeks, because it was “currently understaffed and under skilled,” as one report put it. They also commissioned the Royal College of Paediatrics and Child Health to review the deaths, and, at another meeting, the executives decided that they would keep Letby away from the unit until the review had been completed.

“Frustrated + defeated,” the director of nursing, Alison Kelly, wrote afterward. In an e-mail, Rees called Letby’s prolonged removal from the ward “wrong and immoral,” saying that it was “based on a senior Clinician having a ‘gut feeling’ with no evidence.” She warned of “the message that this sends out—a Clinician is being listened to and supported, with potential devastating consequences for a nurse.”

Letby filed a grievance, saying that she had been removed from her job without justification. “It is awful and I don’t know where it has all come from and why they can’t let it go,” Letby said, at her grievance hearing. “I have gone through all of this on their word.”

The chair of the grievance hearing said, “It is clear that the 2 consultants”—the British term for senior doctors—“call the shots.”

“I was disgusted by their behavior,” the grievance investigator responded. He also said that, if the pediatricians had called the police, the unit would have become a crime scene.

“I was happy for the Police to come,” Letby replied. “I had nothing to hide.”

Powell, the neonatal manager, told the investigator, “When I started my career the hierarchy and the gap between consultants and nurses was so bad. And at the end of my career, it’s exactly the same.”

In addition to the Royal College review, the hospital asked a neonatologist from a different hospital to assess each of the deaths. Neither review identified signs of deliberate harm. The pediatrics department had seven consultants, and they all signed a letter saying that they were not satisfied with the reviews, which were not forensic. Powell told Brearey that “our only issue” is the mistreatment of Letby, who was “100 % innocent.” She thought that Brearey and Jayaram had “brainwashed other consultants” into thinking Letby was to blame.

At a meeting in January, 2017, Chambers, the chief executive, who is also a former nurse, said that it was time for Letby, who had been off the unit for half a year, to start working again. The grievance investigator had completed his report and recommended that Letby return to the neonatal unit and consider submitting a bullying-and-harassment complaint against Jayaram and Brearey, who had never confronted Letby directly about their concerns.

“I just want him to do the right thing,” Letby messaged a union representative, about Jayaram, “and to be a man and see this through by talking to me as adults.”

But Letby remained in limbo, kept off the ward. “I feel as though this must be my fault and maybe I have done something wrong to the babies and blame myself,” Letby wrote to an occupational-health nurse, who met with her regularly. “Do you think that’s normal?”

The director of human resources met with Jayaram to try to come to a resolution, and then relayed what he’d said to the executives the next morning. The doctors were “not feeling loved,” notes from the executive meeting say. “They feel like battered wives.” The human-resources director reported that Jayaram said he’d witnessed Letby change the valve setting for a baby in a way that made him uncomfortable. Kelly, the director of nursing, asked why he was sharing this memory only now. Until then, he had been clear that he had not witnessed wrongdoing. The notes record Chambers saying, “They want us to throw Lucy under a bus.”

Chambers invited a chief superintendent of the Cheshire Police, along with Jayaram and another doctor, to his office, to discuss the cluster of deaths. “We are not trained to know the answer to this,” Jayaram told the superintendent, according to notes from the meeting. In an e-mail to a colleague, the hospital’s medical director wrote that, unless the doctors disclosed something new, he assumed that “there will not be an investigation and the police will assist us in a message that will allow us to close down the speculation here and deal with the issues of culture.”

At another meeting with the police, a few weeks later, the medical director was almost apologetic, saying that he was “mindful they do not want to use Cheshire Constabulary as a HR process for staff.” He ventured that the consultants, faced with a disorienting number of deaths, may have been reaching for a single answer. “If you place yourself in the mindset of paediatricians,” he told the police, according to meeting notes, “there is a strong sense of personal accountability that a clinician feels and when there is no clinical explanation they feel uncomfortable.”

Three days later, the police superintendent and a detective met with Jayaram, Brearey, and another doctor, to discuss an e-mail that Jayaram had sent them directly, bypassing the executives. “We have looked hard,” Brearey told the police. “We can’t find any explanation.” He added, “It is relatively easy to manipulate fluid, to administer drugs and or to block an airway.”

“I can’t describe how powerful it was,” the superintendent said, of the meeting. “They were just very powerful in what they were saying.” That day, the police informed the hospital that they were launching a criminal investigation.

“Hang on in there girl,” Rees texted Letby. “Your nursing team are fully behind u.”

The release of the Thirlwall Report, which is more than a thousand pages long, creates even more momentum to assume that the questions its leaders have been asking are the right ones. Three of Letby’s bosses at the Countess hospital were already arrested, in June, 2025, on suspicion of “gross negligence manslaughter,” presumably for failing to stop Letby sooner, and are currently out on bail. Three months ago, a doctor from the Countess who testified in the Thirlwall Inquiry about supportive messages he’d written to Letby was dismissed from his job at a different N.H.S. hospital, for having shared confidential patient information with her. A day after his dismissal, he was reportedly found collapsed in his car; he eventually died, of causes that have not been disclosed.

At times during the inquiry hearings, the nurses were almost browbeaten into accepting the inquiry’s premise. “Do you recognize that she was murdered by Lucy Letby?” a lawyer representing families whose babies died asked the lead pediatric nurse.

“Well, she’s been found guilty by a court of law, so yes, I do.”

“And in your opinion?”

“I mean . . .”

“Do you accept that verdict?”

“Yes, I accept that she has been found guilty.” She started a sentence and then stopped. “So yes . . . you know, I am so sorry for the Families. . . . So yes, I do accept, you know, that Lucy Letby obviously has murdered or had a part in all of those babies’ deaths.”

As part of the inquiry, at least thirty-seven nurses and midwives from the Countess were asked to respond to a series of questions. “Did you have any concerns or suspicions about the conduct of Lucy Letby?” the questionnaires asked. All but two of them said no, often emphatically. (One of the two concerned nurses reported that she didn’t remember Letby showing emotion when babies died, and the other recalled that Letby “involved herself with more babies than she needed to.”)

“Do you think if the babies had been monitored by CCTV the crimes of Letby could have been prevented?” the questionnaires also asked.

“Lucy did not commit any crimes,” a nurse who had worked on the unit for thirty-six years replied. “If there had been CCTV the footage would have proved her innocence.” ♦