1. Introduction

The Report

1. This Summary report is an introduction to the main themes and findings of the Inquiry. It will be understood by reading the Report in full, which contains references to supporting material.
2. The Report is not a recitation of all the evidence. I have made findings about what happened at the Countess of Chester Hospital (the Countess) from 2015 to 2018 on the balance of probabilities, having considered the evidence and the submissions made on behalf of all Core Participants.
3. My focus has been on the questions asked in the Terms of Reference, not on the guilt of Lucy Letby or on her convictions. My starting point was the experiences of the parents. I have divided this Report into three parts: Part One (in Volumes I and II) deals with Parts A and B of the Terms of Reference since those two parts combine to give an account of events at the Countess. Part Two (in Volume III) responds to Part C of the Terms of Reference. Part Three (in Volume III) contains the recommendations and appendices.

Hindsight

4. No one expects people who are giving evidence about events that happened 10 or 11 years ago to give a perfect account of what precisely they knew and when precisely they knew it. During the hearings, I was reminded by Counsel for the senior managers not to use hindsight and to avoid hindsight bias when approaching the facts. There are two points to make about that. The first is that, inevitably, anyone looking back at events between 2015 and 2018 does so knowing what happened in 2023, and what came before and after 2023. That cannot be avoided. It is the case whenever a witness gives evidence in any proceedings. I have approached the evidence of the witnesses with that in mind and acknowledging that, in the main, witnesses were doing their best to help the Inquiry. Whenever there is a difference of recollection between witnesses, or where the position is not clear from the oral evidence, I have looked at what the other evidence shows they knew or should have known at the time of the events or decisions about which they were giving evidence. Where there is documentary evidence that assists, I have referred to it. Some witnesses remembered nothing at all about an issue or topic unless it was set out in a document, and even then a document did not always prompt recollection. Second, when assessing the evidence, particularly about decisions made many years ago, I have reminded myself to consider the position of the witness acting at that time, knowing what they knew at that time, not what I or they have learnt since, in order to make a finding about the quality of a decision.
5. Some of the witnesses (Mr Stephen Cross, Ms Sue Hodkinson and Ms Alison Kelly) made contemporaneous and often detailed notes of meetings of which no formal minutes were taken (the majority of the meetings with which I am concerned). Sometimes there are several notes by different witnesses of the same meetings. The notes have been a useful aid to assessing the evidence of witnesses at the Inquiry.
6. In setting out what was known to have happened to the babies at the Countess, I have, where necessary, relied on contemporaneous medical or nursing records in addition to the oral evidence, and, on occasion, on later reviews. I have kept references to the babies’ medical records, and other similar documentation, to a minimum to protect the families’ privacy, whilst acknowledging that many records have already been placed in the public domain without warning or even reference to the parents.
7. The Report sets out a dispiriting and at times shocking account of multiple and repeated mistakes and failings by organisations and individuals. In the time that has passed since these events, some of the people involved have reflected long and hard on their actions and, in particular, what they could and should have done differently. Many have apologised unconditionally to the parents of the babies for the mistakes they made.

Context

The Countess

8. In 2015, the Countess of Chester Hospital was a 600-bed district general hospital with about 4,000 staff. Part of an NHS Foundation Trust, the Countess had a good reputation with NHS England and with the regulator, the Care Quality Commission (CQC).
9. Mr Tony Chambers, a former nurse, was the Chief Executive from 2012 to 2018. Mr Ian Harvey, an orthopaedic surgeon, was appointed Medical Director in 2012. He retired in 2018. Ms Alison Kelly, a nurse, was the Director of Nursing and Quality from March 2013. All three of these executive roles were demanding and well paid. In addition to her full-time role as Director of Nursing, Ms Kelly worked occasional shifts as a nurse.
10. Ms Sue Hodkinson was appointed the Director of People and Organisational Development (Human Resources (HR)) in 2013. Ms Lorraine Burnett, a former nurse, became Director of Operations in 2016. Mr Stephen Cross, a former police officer and qualified solicitor, became Director of Corporate and Legal Services in 2012. Mr Cross died in 2025. There were also two Chief Finance Officers at this time.
11. Sir Duncan Nichol CBE, former Chief Executive of the NHS, was Chair of the Foundation Trust Board. There were five other Non-Executive Directors, of whom two were chartered accountants, one had a background in retail and business, another came from a local authority, and one was a former nurse and midwife who joined the Board in 2016.
12. Until 2009, paediatrics and maternity services formed the Women and Children’s Division. That division was abolished in 2009, along with the role of Clinical Director for the division. Maternity services and obstetrics were separated from paediatrics. Paediatrics (including neonatology) was moved into the Urgent Care Division with the very much larger Accident and Emergency Department. Maternity services and obstetrics became part of the Planned Care Division.
13. As a result of the reorganisation, the profile of paediatrics (including neonatology) was diminished. Its voice was not heard on the Board. Instead of a Clinical Director, there was a Lead Clinician for children’s services (Dr Ravi Jayaram, a consultant paediatrician), who had no regular meetings with the Medical Director.

The neonatal unit

14. Until July 2016, the neonatal unit was a Level 2 local neonatal unit, caring for babies born at or after 27 weeks’ gestation and weighing 800 grams or more. It was equipped to provide intensive care for up to 48 hours, with babies requiring longer-term or complex care transferred to the Level 3 units at Alder Hey Children’s Hospital (Alder Hey) or Liverpool Women’s University Hospital (Liverpool Women’s). Level 1 units provide special care for babies born after 32 weeks’ gestation.
15. The unit was one of the larger Level 2 units in the Cheshire and Merseyside Neonatal Network (the Neonatal Network), with 16 cots spread across four nurseries.
16. At the time of these events, the neonatal unit was cramped and outdated, had repeated problems with the plumbing and lacked facilities for mothers to stay with their babies. It was very inconveniently located on a different floor from the post-natal ward. The description of the neonatal unit in 2015 and 2016 is echoed in the findings of the NHS Maternity and Neonatal Infrastructure Review, published in September 2025, and referred to in Baroness Amos’s final report of the National Maternity and Neonatal Investigation in June 2026. It is plain that many of the same issues persist across the country. In the absence of funding for better facilities, a fundraising appeal, BabyGrow, was launched to raise £4 million for a new, more modern unit. Photographs of Letby were used in the fundraising campaign. By the end of June 2016, the fundraising had stalled at £2 million and it was costing more to run than the funds raised were generating. The appeal was closed in 2017. Funding was made available for improvements: first, the neonatal unit was replaced in 2021; and then, in 2025, a large modern women and children’s unit opened, providing integrated family care for babies and their families. This welcome change represents a huge improvement in neonatal care at the Countess.
17. At the time of these events, the neonatal unit was separate from the main children’s ward. Dr Stephen Brearey, a consultant paediatrician, was the Lead Clinician for the neonatal unit. Ms Eirian Powell, a senior nurse (band 7), was the Manager of the neonatal unit.
18. The doctors (junior doctors and six consultants in 2015) were based on the main children’s ward. The nurses were based on the neonatal unit and worked exclusively there.
19. Having heard evidence from nurses, junior doctors and consultants, along with nurse managers, I am satisfied that relationships on the neonatal unit within each staff group and across the groups ranged from good to excellent.
20. A consultant was allocated the role of paediatrician of the week. The paediatrician of the week would lead a ward round on the neonatal unit on two days of the week. On the other five days, a registrar would lead the ward round and would discuss their findings and decisions with that consultant at a later morning handover.
21. During 2015 and 2016, the neonatal unit was very busy. Nurses spoke in evidence about peaks and troughs but the workload was considered manageable. Nursing staff shortages were covered by people taking on extra shifts when asked to do so. Shortages of junior doctors were covered by consultants acting down – and there was a shortage of consultants too. An application to the Board for funding for two further consultants for the Paediatric Department had been refused in 2014. At the end of 2015, the consultant paediatrician Dr ZA approached Mr Chambers directly about the need for more consultants. In early 2016, Dr Susie Holt was appointed, taking the number of consultant paediatricians to seven.
22. The unit received very few visits from senior managers. Other nurses considered neonatal nursing very niche and tended not to come to the unit. However, the atmosphere on the unit was positive and mutually supportive. The nurses were a cohesive group and were respected by the doctors (consultants and juniors) who, in turn, were respected by the nurses. The junior doctors were well supported by consultants. There was strong team working. Relationships frayed in 2016 when suspicions were expressed about Letby.

Deaths on the neonatal unit

23. In the years preceding 2015, the number of deaths on the neonatal unit at the Countess was consistently low. The number of deaths against the number of admissions each year was:
    • 2010: 1 death; 422 admissions
    • 2011: 3 deaths; 514 admissions
    • 2012: 3 deaths; 556 admissions
    • 2013: 2 deaths; 460 admissions
    • 2014: 3 deaths; 557 admissions
24. In 2015, eight babies out of 468 admissions died on the neonatal unit. In addition, two other babies born at the Countess were transferred to other hospitals, where they died. Three of the eight babies who died at the Countess were babies in respect of whom no charges were brought against Letby. Two of them died from severe congenital abnormalities. The third died from prematurity with sepsis. Letby was charged with and convicted of murdering the other five babies: Baby A, Baby C, Baby D, Baby E and Baby I.
25. There were 496 admissions to the neonatal unit in 2016. In the first six months, five babies died. Three babies who died in January, February and March all died from congenital abnormalities. No charges were brought against Letby in respect of these deaths. Letby was charged with and convicted of murdering the other two babies – Baby O and Baby P, two of three triplets – in late June 2016. Following their deaths, and as a result of serious concerns persistently expressed by consultant paediatricians, Letby was moved off the unit into a non-clinical role in the Risk and Patient Safety Department in July 2016. At about the same time, the neonatal unit was downgraded to Level 1, with a higher limit of gestation for admission of 32 weeks. The babies named on the indictment (the list of charges in the Crown Court) who had died in 2015 and 2016 ranged in gestation from 23 weeks and 6 days to 37 weeks and 1 day.
26. If the babies whom Letby was convicted of murdering were removed from the annual number of deaths in the neonatal unit, the mortality figures for the Countess would be three deaths in 2015 and three deaths in 2016, broadly consistent with previous years.
27. Since July 2016, there has been one death on the neonatal unit, in September 2019.