Dr Stephen Brearey, the doctor who raised concerns that convicted killer Lucy Letby was harming babies, has said he regrets not contacting police sooner.
In his first interview since the publication of the Thirlwall Inquiry’s findings into events at the Countess of Chester Hospital in Cheshire, Dr Brearey admitted he had been too trusting of senior managers and assumed they would respond appropriately to his warnings.
He was the hospital’s lead neonatal consultant during the period when Letby murdered seven babies and tried to murder others.
Dr Brearey told the inquiry that repeated concerns about Letby were not acted on by hospital leaders.
He also described a “toxic negativity” within the NHS and urged a fundamental shift in how staff are supported when they raise patient-safety concerns.
Speaking on BBC Radio 4’s Today programme, he said he had naively believed senior managers shared his commitment to patient safety and would take action once they understood the seriousness of the situation.
The Countess of Chester Hospital conducted several internal reviews after a rise in neonatal deaths during 2015 and 2016. Cheshire Police were not contacted until May 2017.
Dr Brearey said fellow consultants stood together as they tried to alert the hospital to their suspicions about Letby.
Dr Stephen Brearey says he regrets not taking his concerns about Lucy Letby to police earlier
Lucy Letby was convicted of murdering seven babies and attempting to murder seven others while working at the Countess of Chester Hospital between June 2015 and June 2016
Looking back, he said that if the medical team had understood what was unfolding, they would have contacted police much earlier.
He said staff received no dedicated psychological support either during the crisis or after Letby’s arrest. Instead, colleagues relied on one another to cope with the experience.
Dr Brearey compared the situation with removing a soldier suffering from post-traumatic stress disorder from a war zone, while neonatal staff were still expected to return to the unit and face further trauma.
Caring for another seriously ill baby could trigger painful memories, he explained. Staff who were parents also faced the emotional strain of taking their children to school, seeing other families and struggling to discuss what they had endured.
Dr Brearey said Lady Justice Thirlwall had highlighted what should be a basic management responsibility: ensuring that patients come first.
He described it as deeply troubling that this principle had to be formally written into the contracts of senior NHS managers.
However, he said putting a requirement into a contract was very different from embedding it across an entire organisation. That would require a major cultural transformation, and he expressed hope that the NHS and Department of Health could deliver it effectively.
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He warned, though, that meaningful change would not happen immediately.
The Thirlwall Inquiry was established in 2023 after the former nurse was convicted of multiple murders and attempted murders involving babies.
When she published her 822-page final report in September, Lady Justice Thirlwall concluded that there had been a complete failure to protect babies on the neonatal unit at the Countess of Chester Hospital.
‘This was because no-one seems to have understood that safeguarding action is required when a member of staff is suspected of causing deliberate harm and does not require colleagues to be sure of guilt.
‘My report describes dysfunctional management and governance, a gulf between hospital leadership and clinicians, and failure to understand the fundamentals of safeguarding.’
The inquiry made 17 recommendations, including installing CCTV for all cots and incubators in neonatal units, restricted access to insulin, mandatory safeguarding training for staff, and an improved NHS IT system and data handling.
Brearey said had those measures already been in place: ‘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.’
Following the conclusion of the inquiry, the hospital trust 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.’
Former Countess of Chester Hospital executives Tony Chambers, Ian Harvey and Alison Kelly, along with former HR director Sue Hodkinson, said in a joint statement: ‘We are carefully reviewing the Thirlwall report and its recommendations.
‘Given that there are a number of investigations under way, and that the work of the Criminal Cases Review Commission has not yet completed, it would be inappropriate for us to offer any further comment at this time.
‘Our thoughts remain with the families affected by the tragic events that took place at the Countess of Chester Hospital.’
Letby has always maintained her innocence.
Appeals against her convictions have been rejected by the courts.
