In the quiet corridors of a children's hospital, the most vulnerable of lives were lost — not only to the deliberate harm of one nurse, but to the accumulated silences of an institution that looked away. The Thirlwall Inquiry, publishing its findings this week, has laid bare how the Countess of Chester Hospital failed its smallest patients between 2015 and 2016, when Lucy Letby murdered seven babies and attempted to murder seven more. A senior consultant, Dr. John Gibbs, has now stepped forward to accept a share of that institutional failure, acknowledging that collective hesitation — the unwi
Senior doctor regrets not escalating Lucy Letby concerns to police sooner
Lucy Letby murdered seven babies and attempted to murder seven more on the neonatal unit between 2015-2016; parents were kept unaware of concerns for years.
I wish we consultants had been brave enough to escalate things to the police earlier
Mark
What strikes you most about Gibbs's statement?
Mimi
That he's not deflecting. He could have said the managers were the problem, or that one doctor missed the insulin results. Instead he's saying: I was there, I had chances, I didn't take them. That's rare.
Luke
But we should be careful about the scope of his responsibility versus the managers'. The report says managers had multiple opportunities to act. Gibbs is a consultant, not an executive. He's taking on guilt that may not be entirely his to carry.
Mark
So the real failure was institutional, not individual?
Mimi
Both. The managers actively resisted the consultants' concerns. They were determined to convince the doctors that Letby was innocent. That's not a passive failure—that's active obstruction.
Luke
Right. And that's what makes the timeline so damning. June 2015, three babies die in a cluster. Police aren't called until May 2017. That's a two-year gap where hospital leadership had the power to act and chose not to.
Mark
What about the parents? They didn't know any of this was happening?
Mimi
They were kept in the dark for years. Thirlwall called it reprehensible. Imagine learning years later that your baby's death might not have been natural, and that the hospital knew or suspected it.
Luke
The report says some babies could have been saved if action had been taken sooner. We should be precise about that—it's not saying all of them. But even one is a failure of that magnitude.
Mark
And now there's this question about whether Letby was actually guilty, with the CCRC reviewing the case.
Mimi
Gibbs says he hasn't changed his mind that she's guilty. But he also says it's important the evidence be examined because serious people have raised concerns.
Luke
That's the tension. The conviction stands, she's serving whole-life sentences, but the evidence is being reviewed. We don't know what the CCRC will find.
Mark
So what comes next?
Mimi
Reforms. CCTV on all cots, restricted insulin access, changes to how concerns are escalated. Whether they're enough, we'll have to see.
El Pulso
- An 822-page inquiry has confirmed what many feared: hospital managers had multiple chances to stop Lucy Letby and chose, repeatedly, not to act.
- Dr. John Gibbs has broken from professional silence to say plainly that he and his fellow consultants failed the babies in their care and should have gone to police far sooner.
- A cluster of three infant deaths in June 2015 was a visible warning sign that hospital leadership dismissed, and police were not called until May 2017 — nearly two years later.
- Blood test results from August 2015 suggesting a baby had been poisoned with insulin were overlooked, with multiple doctors cycling through the unit and none acting on the evidence.
- Parents were kept uninformed for years about the possibility their children had been deliberately harmed — a silence the inquiry described as reprehensible.
- As the Criminal Cases Review Commission examines Letby's convictions amid a wave of online conspiracy theories, authorities are now racing to implement reforms including live-streaming cameras on neonatal wards.
In the quiet corridors of a children's hospital, the most vulnerable of lives were lost — not only to the deliberate harm of one nurse, but to the accumulated silences of an institution that looked away. The Thirlwall Inquiry, publishing its findings this week, has laid bare how the Countess of Chester Hospital failed its smallest patients between 2015 and 2016, when Lucy Letby murdered seven babies and attempted to murder seven more. A senior consultant, Dr. John Gibbs, has now stepped forward to accept a share of that institutional failure, acknowledging that collective hesitation — the unwillingness to follow suspicion all the way to its necessary conclusion — cost lives that might have been saved. It is a reckoning not only with one hospital's governance, but with the human difficulty of acting on uncomfortable truths before certainty arrives.
Dr. John Gibbs spent more than two decades at the Countess of Chester Hospital. He was present during the years when nurse Lucy Letby murdered seven babies and attempted to murder seven more on the neonatal unit. When the Thirlwall Inquiry released its final report this week, he read it and found it sobering.
The inquiry's central conclusion was unsparing: the hospital had completely failed to protect the babies in its care. Lady Justice Thirlwall found that police should have been called earlier, that managers had repeatedly dismissed consultants' concerns, and that some of the babies who died might have lived had executives acted when they had the opportunity.
Gibbs has now spoken publicly about his own share of that failure. He told the BBC that consultants must accept collective responsibility, and that he personally should have escalated suspicions to police sooner. 'If my other consultant colleagues didn't go to the police, I should have,' he said. He apologized to the families of the babies who died.
The timeline is damning. A cluster of three infant deaths in June 2015 should have triggered alarm; it did not. Internal reviews were held in 2015 and 2016, yet police were not invited to investigate until May 2017. Gibbs also pointed to blood test results from August 2015 that indicated a baby had been poisoned with insulin — results that were overlooked, despite multiple doctors having the opportunity to review them in the weeks that followed.
The eleven months between Letby's removal from the unit and police involvement were, Gibbs recalled, deeply difficult. Hospital managers worked to persuade consultants they had suspected the wrong person. Throughout this period, parents were kept entirely unaware that their children may have been deliberately harmed — a failure the inquiry called reprehensible.
Letby was convicted in 2023 and is serving fifteen whole-life sentences. She maintains her innocence. The Criminal Cases Review Commission is now examining her convictions, and online conspiracy theories have complicated the public understanding of the case. Gibbs said he has not changed his view of her guilt, but accepts that serious questions deserve serious scrutiny.
The inquiry has called for urgent reforms: CCTV on all cots and incubators, restricted access to insulin, and live-streaming cameras on neonatal wards across England. The question that remains is whether these measures will arrive in time to ensure that what happened at Chester cannot happen again.
Dr John Gibbs spent more than two decades at the Countess of Chester Hospital before retiring. He was there in 2015 and 2016 when Lucy Letby, a nurse on the neonatal unit, murdered seven babies and attempted to murder seven more. When the Thirlwall Inquiry published its final report this week—an 822-page document examining how the hospital failed to stop her—Gibbs read it and found the experience sobering.
The inquiry's central finding was unsparing: there had been a complete failure to protect the babies in that unit. Lady Justice Thirlwall concluded that police should have been called earlier than they were, and that hospital managers had repeatedly brushed aside the concerns raised by consultants like Gibbs. Some of the babies who died might have lived if the hospital's executives had acted when they had the chance. Instead, they had multiple opportunities to intervene and did not take them.
Gibbs has now spoken publicly about what the report means to him. He told the BBC that he accepts consultants must share responsibility for some of what went wrong. "I wish we consultants had been brave enough to follow our suspicions and escalate things to the police earlier," he said. He was clear that this was not just about others—it was about him too. "When I say, 'we consultants', I am responsible as well and if my other consultant colleagues didn't go to the police, I should have." He acknowledged that he and his team had failed the babies and apologized to their families.
The timeline matters. Letby was moved off the neonatal unit in July 2016 after consultants finally raised concerns with hospital executives. But the inquiry found that alarm bells should have sounded much earlier. In June 2015, three babies died in a cluster—a clear warning sign that hospital leadership ignored. Internal reviews were conducted in 2015 and 2016 to examine the spike in infant deaths, yet Cheshire Police was not invited to investigate until May 2017. Letby remained at the hospital until her arrest more than a year after that.
Gibbs also spoke to a specific failure within his own team. A doctor had disregarded blood test results from August 2015 that suggested a baby had been poisoned with insulin. While one colleague had missed the significance of those results when they came back from the lab, Gibbs recognized it as a collective failure. "Others of us were on call and covering the neonatal unit over the next week or two before the baby moved out of the unit. We all had the opportunity to review the notes." The opportunity existed; it was not taken.
The eleven months between Letby's removal from the unit and police involvement were, Gibbs said, extraordinarily difficult. Hospital managers were determined to convince the consultants that Letby had been wrongly suspected. The atmosphere was tense and stressful. Parents, meanwhile, were kept in the dark for years about the possibility that their babies might have been deliberately harmed—a lack of consideration that Thirlwall described as reprehensible.
Letby was convicted in 2023 and is serving fifteen whole-life sentences. She maintains her innocence and has twice been denied permission to appeal. The Criminal Cases Review Commission, an independent body that examines potential miscarriages of justice, is now reviewing her convictions. In the months since her conviction, online conspiracy theories and claims from some academics and medical experts have suggested she was wrongly convicted. Gibbs said this has been difficult to contend with. "I particularly find the misinformation that's on the internet is difficult to deal with," he said. "I haven't changed my mind that I think Lucy Letby is guilty." But he also acknowledged that because some serious people have raised concerns, it is important that the evidence be examined.
The Thirlwall Inquiry has called for urgent reforms: CCTV on all cots and incubators, restricted access to insulin, and other safeguards for neonatal units. Health Secretary Yvette Cooper said officials will urgently develop plans to introduce live-streaming cameras on England's baby wards. The question now is whether these changes will come in time to prevent what happened at Chester from happening again.
Citas Notables
I feel we failed the babies and I apologise to the families for that.— Dr John Gibbs, consultant paediatrician
A complete failure to protect babies on the neonatal unit at the Countess of Chester Hospital— Lady Justice Thirlwall, describing the hospital's response in the inquiry report
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