# Thirlwall Inquiry into Countess of Chester Hospital > Live situation record from CLSTR: https://clstr.news/situations/thirlwall-inquiry-into-countess-of-chester-hospital > Updated: 2026-09-17T11:45:12.000Z. Sources: 33. Developments: 2. The Thirlwall Inquiry has released its findings regarding the deaths of infants at the Countess of Chester Hospital between 2015 and 2016. The investigation, led by Lady Justice Kathryn Thirlwall, identified a “complete failure at all levels” to protect newborns, citing dysfunctional management and a significant gap between leadership and clinicians. The inquiry detailed the “disturbing behaviour” of former neonatal nurse Lucy Letby, noting instances of “inappropriate jolliness” with grieving parents and comments suggesting she viewed the deaths as “exciting” events. While the report focused on institutional failures, it also addressed the hospital's failure to invoke safeguarding procedures even when suspicions of harm were raised. To improve neonatal safety, the inquiry issued recommendations including the installation of video monitors for parental viewing and 24-hour CCTV for insulin storage. The findings come as the Criminal Cases Review Commission reviews evidence regarding Letby’s convictions, amid scrutiny over whether the inquiry sufficiently explored alternative causes for the infant deaths. ## Timeline ### 2026-09-17: Thirlwall Inquiry details Lucy Letby’s behavior following infant deaths The Thirlwall Inquiry report details Lucy Letby’s “disturbing behaviour” following infant deaths at Countess of Chester Hospital and provides recommendations for hospital safety. 2 sources. https://clstr.news/cluster/thirlwall-inquiry-details-lucy-letbys-behavior-following-infant-deaths ### 2026-09-14: Thirlwall Inquiry finds systemic failure to protect babies at Chester hospital The Thirlwall Inquiry found a “complete failure” to protect babies at Countess of Chester Hospital, citing dysfunctional management and recommending new safety measures like incubator cameras. 32 sources. https://clstr.news/cluster/lucy-letby-inquiry-report-due-as-defence-experts-withdraw --- Cite as: Thirlwall Inquiry into Countess of Chester Hospital. CLSTR, https://clstr.news/situations/thirlwall-inquiry-into-countess-of-chester-hospital