Skip to content

July 2026: Government declines to widen the Thirlwall terms of reference (16 July) · new 100-page insulin report to the CCRC challenging the trial evidence (9 July) · Thirlwall report still expected no earlier than September · inquests relisted to 2027 · Shoo Lee Panel: no medical evidence of deliberate harm.

Lucy Letby Facts
Methodological

Datix records — the system that saw a struggling unit

The prosecution’s claim: The prosecution argued it did not rely on the Datix incident record because, it said, Letby covered her tracks.

Last updated
2 min read

Prosecution claim

The prosecution argued it did not rely on the Datix incident record because, it said, Letby covered her tracks.

Counter-evidence

Datix is the mandatory NHS incident-reporting system — every crash call, equipment failure, deterioration and medication error is supposed to be logged. The 2015–2016 Datix record for the unit — partly examined at the Thirlwall Inquiry — shows a unit under severe clinical strain: staffing gaps, sewage and plumbing failures, late transfers of extremely preterm infants, pharmacy mix-ups. The Panel argues that this picture, which the jury never saw in full, is itself exculpatory: it explains the cluster of deteriorations without a deliberate-harm hypothesis.

Key point: The Datix record is evidence not of wrongdoing by one nurse, but of a unit operating outside its safe envelope.

What the jury heard

The jury was largely not shown the full Datix record — the Crown's case didn't rely on it, and the defence's access was limited by disclosure.

What the Panel says

The Panel considers the wider Datix picture consistent with a unit caring for babies beyond its designation. That context is itself alternative explanation.

What independent experts add

  • Datix logs a known sewage back-up and related equipment failures in the 2015–16 period.
  • Medication dispensing errors are logged against the hospital pharmacy that supplied the unit's TPN.
  • Staffing-gap entries (consultant-rota and senior-nurse-shift gaps) are present at high frequency through the indictment period and constitute a documented Level-2-unit-overload signal.
  • Equipment-failure entries include the documented sewage back-up onto the neonatal unit floor, identified by independent reviewers as a plausible infection-vector that the prosecution did not address.

Further reading

Source: Thirlwall Inquiry evidence bundles (2024–2026 hearings); NHS-reviewer submissions to the inquiry; science4justice.nl line-by-line analysis of the Datix record; RCPCH 2016 review documentation.