The Public Inquiry looking into possible failings by professionals and bodies in relation to Lucy Letby began on the 10th of September 2024. Officially named ‘The Thirlwall Inquiry’, the Independent Public Inquiry is examining the events at the Countess of Chester Hospital during Lucy Letby’s tenure to identify any failings or missed opportunities to prevent the incidents that occurred. The inquiry, held at Liverpool Town Hall, is expected to continue until early 2025, with findings published by late autumn of that year. The Inquiry intends to make findings of fact and recommendations that will be reported publicly.

The aim is to ‘seek answers for the victims’ families and ensure lessons are learned’. Crucially to Trusts and medical professionals alike nationally, the inquiry ‘will also examine the wider circumstances, including the response and conduct of the NHS, its staff and its regulators’.

Whilst an inquiry does not make findings of criminal or civil liability, the outcome of the inquiry will play a critical role in whether criminal or civil proceedings are instigated or pursued. The report will also be crucial for the coroner’s investigation.

The implications of this inquiry to a Trust are significant as there will likely be advice given about reporting incidents of concern to the Care Quality Commission (CQC), police and how procedures should be followed to avoid an incident like this again.

So, what can Trusts and professionals alike take away from the Inquiry thus far?

1. Reporting to The CQC:

During the Thirlwall Enquiry, it has been noted the CQC carried out a routine inspection of the hospital in 2016, including both announced and unannounced visits. Just prior to the CQC visit, an internal review conducted within the trust had noted that: “some of the babies suddenly and unexpectedly deteriorated and there was no clear cause for the deterioration/death identified”.

CQC Inspectors told the Inquiry Team that as they were not made aware of this internal review during the visit and so this did not form part of their inspection. The CQC informed the Inquiry Team that this meant they could not provide guidance or question the action taken as a result of this internal review.

The Code of Governance for NHS Provider Trusts confirms that:

i. 'there should be formal and transparent policies and procedures to ensure the independence and effectiveness of internal and external audit functions’.

ii. 'The board of directors should establish procedures to manage risk’. The board of directors are responsible for ensuring ‘quality and safety’ and ‘applying the principles and standards of clinical governance’.

NHS Trusts have a statutory duty of candour to be open and honest with the CQC. This is a legal obligation and so means Trusts must be honest during inspections and when reporting on the quality and safety of the care they provide. While the guidance doesn’t specifically mandate that Trusts provide the details of internal reviews, it can be assumed that they would be highly relevant to the quality and safety of care provided which is the threshold for information sharing. Failure to comply can result in regulatory action, including fines and possible de-registration.

So, how are trusts expected to provide this information to the CQC?

i. Prior to the Inspection, Trusts should gather and review all relevant documentation, policies and procedures.

ii. In the Initial Meeting with the Inspection Team, there should be discussion about any concerns of the quality and safety.

iii. Trusts should provide their own views on their performance.

2. General Practitioners:

During the course of the inquiry, various medical consultants have advised that they felt they could have done more to report the concerns that Lucy Letby was responsible for the deaths of the babies on the ward. Consultant Dr Jayaram accepted that he ‘should have had more courage to report’.

General Practitioners have a responsibility to report patient safety incidents as part of the duty of candour described above. The Good Medical Practice Guide 2024 also advises that Medical Practitioners ‘must act promptly on any concerns you have about a patient’. The Guidance also instructs that if Practitioners have concerns about a colleague’s fitness to practice or believe a colleague may be putting patients at risk, it must be reported promptly and Practitioners ‘do not need to wait for proof’. Failure to report these incidents can result in regulatory action, the CQC has the authority to:

i. Prosecute Medical Practitioners

ii. Fine Medical Practitioners

iii. Impose Conditions on the registration or suspend or cancel registration.

iv. Implement Warning Notices to the Practitioner

3. Reporting Matters to the Police:

The Thirlwall Inquiry is considering the delay in the Trust contacting the police to report concerns. Concerns were first raised in June 2015 and yet the police were not contacted until May 2017.

Trusts should have robust policies dealing with reports to police and it is important legal advice is sought prior to a report to the police wherever possible. Trusts have legal obligations to report certain incidents to the police where the matter is serious or a matter of public interest. Any report to the police will be time sensitive and should be done as soon as possible where there is a risk of harm. It will also be necessary to consider a report to the appropriate regulatory body at this time as well. 

A failure or delay in reporting a matter to the police can have serious repercussions:

i. Regulatory action by the CQC for failure to meet its duty of candour.

ii. Legal consequences including prosecution.

iii. Reputational Damage.

iv. Financial Penalties imposed by Regulators or via legal action.

v. Specific Individuals within the Trust could be held accountable such as Board Members.

In summary, Trusts must use the Thirlwall Inquiry as a reminder to:

1. Consider internal policies to ensure these are up to date, appropriate and in line with the newest NHS and CQC Guidance.
2. Keep records, logs and minutes in relation to any matters, ensure these are formally recorded and the relevant people within the Trust notified and involved in any decision making.
3. Work with the CQC openly, honestly and with candour.
4. Seek legal advice if you are concerned or unsure of anything as soon as possible.

How we can help

We understand that these matters can be complex, fast paced and uncertain. We can provide discreet advice and assistance quickly and efficiently to assist you in any of the above matters including:

1. Reviewing your policies and confirming they are up to date and follow the relevant law.
2. CQC inspections and enquiries.
3. Internal Investigations and how these matters should be undertaken.
4. Advise Medical Professionals about their duties and obligations.
5. Professional Regulation including fitness to practise, investigations or prosecutions.
6. Preparation of structured disclosure to the police, including evidential packs and advice on disclosure obligations.