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The first three deaths in June 2015 (babies A, C and D) were not viewed as a cluster of deaths, even though this was the annual number of deaths, concentrated into two weeks.
The fourth death, (baby E) in August 2015, was unexpected and therefore reviewed at a serious incident panel meeting attended by the medical director and director of nursing - but it was treated as a formality.
"What is surprising is that no connection was made by any of the people involved to the earlier deaths," Thirlwall noted.
By August of that year, the total of four deaths was the highest since 2008, and was to double by the end of the year.
Thirlwall found that if a doctor – named in the report as Dr ZA - had not disregarded the insulin test result for baby F in August 2015 then there should have been safeguarding action.
The report also found:
The safeguarding action would have prevented the attacks on babies G and H, J, K, L, M and N and the deaths of baby I, O and P
If safeguarding action had been taken by October 2015 - after the death of baby I - by moving Letby off the ward, the deaths of babies O and P would have been prevented, as would the attacks on babies J, K, L, M and N
In, February 2016 Dr Ravi Jayaram should have reported what he had seen with regard to baby K
In May 2016, no-one raised safeguarding at meeting with execs - if they had done it would have prevented the deaths of babies O and P
Thirlwall said it would never be possible to know for sure how many lives could have been saved.
But she found there was a "complete failure to protect babies on the neonatal unit" at the Countess of Chester Hospital, where Letby, now 36, murdered seven babies and attempted to murder seven others - one of them twice.
Thirlwall described a system of "dysfunctional management and governance".
She said: "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," she wrote.
"Since July 2016 there has been one death on the unit, in Sept 2019."
