Lucy Letby. Cheshire Constabulary via AP, File

An English judge issued a scathing report Tuesday blaming dysfunctional management and a "complete failure at all levels" to protect babies at the hospital where neonatal nurse Lucy Letby was convicted of murdering seven newborns.

The inquiry into baby deaths found the Countess of Chester Hospital, in northwestern England, could have saved some infants from death and injury if staff had acted sooner when children began collapsing, Justice Kathryn Thirlwall said.

"Errors were made by nurses, doctors and managers," Thirlwall said. "There was also complete failure at all levels to invoke safeguarding procedures at any point."

The inquiry heard from more than 130 witnesses and considered 400 statements over six months, BBC News reported.

Letby, 36, is serving a life sentence for the murders of seven babies and attempted killing of seven others. She has maintained her innocence, and a defense team backed by dozens of scientists who have questioned the evidence against her are seeking to clear her name.

Thirlwall's inquiry did not review Letby's convictions but looked at how institutional failures exposed babies to repeatedly be harmed at the hospital and how staff and management responded and treated parents.

She focused on the failure of staff to intervene when it became clear someone was deliberately harming babies.

"How many lives could have been saved had the hospital acted differently?" she said. "It is clear that some babies would have been saved and some attacks would have been prevented if action was taken earlier."

Thirwall said the parents of babies were "kept in the dark for years" over concerns that their children may have been deliberately harmed, BBC News reported. Thirlwall found their treatment to be "reprehensible" and said hospital executives used the risk of upsetting the parents as a convenient argument to justify not calling the police.

Letby was convicted in 2023 of the murders of seven infants and attempted murders of six others — including two attempts on one child. A case in which jurors couldn't reach a decision was retried and Letby was convicted in July of another attempted murder. She was sentenced to 15 life terms with no chance of release. She is only the fourth woman in the United Kingdom to receive such a term.

"If all the babies whom [Letby] was convicted of murdering were removed from the annual number of deaths in the neonatal unit, the mortality figures would have been three in 2015 and three in 2016 — broadly consistent with previous years," Thirwall wrote, according to the BBC.

Prosecutors said Letby harmed babies in ways that left little trace, including injecting air into their bloodstreams, administering air or milk into their stomachs via nasogastric tubes, poisoning them with insulin and interfering with breathing tubes.

She was the only employee on duty in the neonatal unit when the children collapsed or died between June 2015 and June 2016. Prosecutors described her as a "constant malevolent presence."

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