The safety of babies in hospital care, and the willingness of NHS staff to speak up when something goes wrong, sit at the heart of the reflections offered by the doctor who first raised suspicions about Lucy Letby. Dr Stephen Brearey, lead neonatal consultant at the Countess of Chester Hospital when the nurse murdered seven babies and attempted to murder seven others, has said in his first interview since the publication of the Thirlwall Inquiry report that he regrets not going to the police sooner.
His words carry weight for every family who entrusts a child to a neonatal unit, because they describe a system in which warnings from clinicians did not translate into swift protective action. Dr Brearey said he had “naively” assumed that senior managers would respond to suspicions about the nurse’s involvement in a series of baby deaths. “I was naively thinking that raising concerns with senior managers, they had the same values that I did and, once they got it, they would be thinking the same way,” he said.
The timeline matters to the public understanding of what went wrong. Hospital bosses carried out a series of internal reviews into increased infant mortality in 2015 and 2016, but Cheshire Police was not asked to investigate until May 2017. Letby remained employed at the hospital until her arrest more than a year later, in July 2018. Dr Brearey led a group of seven consultants who shared the same concerns about her, and he believes that collective resolve was decisive. “I think one of the reasons we got through this and ended up picking up a police investigation is that the seven of us stuck together,” he said. “But obviously in retrospect, clearly, if we’d known what was ahead of us, we would have gone to the police earlier.”
The inquiry itself, chaired by Lady Thirlwall, found a “toxic negativity” within the NHS that continues to discourage staff from speaking out despite stronger whistleblowing guidance, and concluded that regulation was lacking. Dr Brearey claimed his warnings about Letby were repeatedly ignored by bosses at the hospital, which is now under new management. For citizens, the inquiry’s 17 recommendations read as a blueprint for safer care: CCTV for all cots and incubators in neonatal units, restricted access to insulin, mandatory safeguarding training for staff, a harmonised NHS IT system and improved data handling.
Would those measures have stopped Letby? Dr Brearey believes they would have made a difference. “It certainly would have either prevented or hastened an alarm to say things need to be looked at in more detail. I think all the suggestions are very sensible and if they are all enacted then they’ll go a long way towards preventing further incidents on neonatal units and elsewhere in hospitals,” he said.
Meanwhile, the toll on the staff who lived through those events is another dimension of public concern, because the wellbeing of the workforce shapes the safety of the care patients receive. Dr Brearey said there “wasn’t any psychological support” for staff in the aftermath of the arrest. “It really was the team looking after the team, and colleagues looking after colleagues,” he said. He compared their situation to a soldier with PTSD being taken out of the battle zone to recover, while staff on the neonatal unit kept returning to work and being re-traumatised. “If they had to stabilise a sick baby, you can understand the triggers that might elicit, and the personal costs to staff who are parents dropping the kids off to school, and not wanting to talk to other parents.”
On the prospect of wider cultural change, Dr Brearey remained sceptical about the speed of transformation in some areas. He noted that Lady Thirlwall had recommended “the uncontroversial duty of every manager to put patients first.” “It feels a bit of a sad indictment on the organisation when that has to be written down into the contracts of senior managers,” he said. “It’s one thing writing into a contract is another thing actually enacting it into the entire organisation and that takes a cultural change and cultural changes take time, and I very much hope that the NHS and the Department of Health can make that turnaround effectively. But it doesn’t feel like something that’s going to happen overnight to me, certainly, no.”
The full interview and its context can be read at https://www.bbc.co.uk/news/articles/cwg7x1prldedo. In a joint statement issued after the publication of the inquiry report, former Countess of Chester Hospital executives Tony Chambers, Ian Harvey and Alison Kelly, along with former HR director Sue Hodkinson, said they were carefully reviewing the Thirlwall report and its recommendations. They added that given a number of investigations under way and the unfinished work of the Criminal Cases Review Commission, it would be inappropriate to offer further comment at this time, and that their thoughts remained with the families affected by the tragic events at the hospital.
The hospital trust itself said: “We know that no apology or action can undo what happened at our hospital. We are however truly sorry for the events that occurred in 2015 and 2016. We acknowledge the findings of the Thirlwall report and will approach its recommendations with openness and a firm commitment to build on the progress we have already made in improving our hospital’s governance, safety and culture since that time. We are a different organisation today with new leadership, stronger governance and safety processes, and a more open culture where speaking up is encouraged and acted upon.”
Letby, from Hereford, maintains her innocence and was twice denied permission in 2024 to appeal against her convictions. The Criminal Cases Review Commission, which investigates potential miscarriages of justice, is considering her case. For the families involved, and for the wider public relying on neonatal services, the question raised by Dr Brearey’s account is whether the lessons of the inquiry will be acted upon quickly enough to protect others.