london —
A public inquiry into how the crimes of a British nurse convicted of multiple infanticides went undetected for so long has revealed numerous failings at the British hospital where she worked, concluding that some babies could have been saved if managers had acted sooner.
The report found evidence of “dysfunctional management and governance, a disconnect between hospital leadership and clinicians, and a lack of understanding of the basics of safety measures” at the hospital where Lucy Levy worked, the inquiry chair, Judge Kathryn Thirlwall, said on Tuesday.
“There was a complete failure to implement safeguarding procedures at all levels at any point,” she added.
Levy is serving 15 life sentences for the murders of seven children and the attempted murders of seven more between 2015 and 2016, while working at a hospital in Chester, northern England.
The case established Levy as one of Britain’s most prolific child serial killers. However, she has always maintained her innocence, and since her trial concluded in 2023, questions about the strength of the evidence on which her conviction was based have proliferated. Last year, an international panel of experts challenged the evidence presented by prosecutors.
The inquiry did not aim to investigate Ms Levy’s guilt, but instead focused on whether the Countess of Chester Hospital, where she worked, could have done more to prevent the death. Nevertheless, the findings are likely to be used by some of her supporters to strengthen the argument that systemic medical failures in hospitals are at least partly responsible for infant deaths.
More than three years into the fallout from one of the most controversial trials in recent British history, here’s what you need to know.
Levy’s criminal trial in 2023 horrified the nation.
The court heard how the former nurse, now 36, attacked infants in her care by injecting air into their blood and stomachs, overfeeding them milk, physically assaulting them and poisoning them with insulin.
Judge James Goss described her crime at the time as a “brutal, calculated and cynical campaign of child murder involving the smallest and most vulnerable of children”.
As questions grew about her crimes and how she managed to evade investigation for so long, a public inquiry was launched.
Part of the inquiry’s remit was to examine the response of Britain’s National Health Service (NHS), including whether senior staff should have acted differently when the allegations about Mr Levy’s conduct eventually emerged.
Mr Thirlwall’s report strongly criticized senior management and senior nurses for failing to act when concerns were raised about Levy, but found that “some babies could have been saved and some seizures could have been prevented if they had acted sooner”.
UK Health Secretary Yvette Cooper said she “deeply regrets” the failures identified in the report and the harm caused to victims’ families. She also said training would be urgently reviewed and announced plans to introduce “cot cams” in neonatal wards.
“This should be a turning point for the NHS,” she says.
Meanwhile, the hospital’s chief executive, Jane Tomkinson, apologized and said the hospital would address the report’s findings “with candor and with a firm commitment to building on the progress we have already made.”
Cheshire Police, the lead force involved in Ms Levy’s criminal case, said it had “carefully considered” the contents of the report and “will give full consideration to any relevant recommendations”.
Levy’s supporters argue that prosecutors based their case on circumstantial evidence, and an international panel of experts announced in early 2025 that it had found no medical evidence of murder.
On Monday, Levy’s lawyer Mark MacDonald said the 14 international experts who made up the panel had come to the same conclusion, saying the infant Levy allegedly killed died of natural causes.
“We have a psychologist’s report on the matter of what was presented to the jury as a confession. It was not a confession at all. The report from the obstetrician talks about some of the injuries that were said to have occurred and were presented to the jury as injuries, forced injuries. There were none of those,” he told the BBC.
Dr Xu Li, a neonatologist who chaired the expert panel, said a research paper he wrote in 1989 was misrepresented at Mr Levy’s trial.
Lee added: “In none of the 17 cases at trial, there was no medical evidence to support wrongful death or injury.”
The commission’s findings sparked media attention in the UK and around the world questioning the strength of the prosecution’s case.
The investigation is not directly related to Levy’s conviction, which has already been heard by the Court of Appeal.
However, her legal team submitted evidence for review to Britain’s Criminal Cases Review Commission (CCRC), which investigates possible miscarriages of justice.
According to the BBC, the chairman of the CCRC – the only body with the power to refer Levy’s case back to the Court of Appeal following two previous rejections – said the commission would pay close attention to the findings.
Mr Thirlwall said on Tuesday: “I cannot speculate or interfere with the work of the Criminal Cases Review Committee, which is applying to refer Ms Levy’s case back to the Court of Appeal.”
