Lucy Letby’s hospital trust has been slammed for a string of emergency care failings, including unsafe corridor care that led to elderly patients developing delirium.
The Countess of Chester Hosptial, where Lucy Letby worked and was convicted of murdering seven babies and attempting to murder seven others, was criticised by the Care Quality Commission (CQC) over delays in the care of sepsis patients, as well as elderly patients who were left for so long that they developed “corridor-induced delirium”.
The hospital was also criticised for having “visibly dirty equipment” and out-of-date medical devices, including some with damaged wires hanging out.
The watchdog has handed the trust a formal warning notice over the failures identified after the CQC’s inspection in February 2025. Concerns included:
- Mental health patients being left with staff who were sleeping or on their phones
- Patients with fractured hips are forced to sit in wheelchairs when they should have had beds
- Inspectors found 59 incidents of delays to providing sepsis treatment, 44 of which were because the trust failed to take patients from ambulances quickly enough
- Evidence that “long stays on the corridor” and the deterioration of patients because of this was “normalised”
The watchdog described the department as “gridlocked”, with patients telling inspectors it was “as busy as a nearby motorway”.
It said: “Patients were frequently treated in unsuitable and unsafe areas, including corridors, with little privacy.”
“Patients were left on trolleys or in chairs for extended periods, leading to deconditioning and unmet basic needs,” it added.
The report found some staff were “task-focused and lacked compassion”. It also warned about cultural issues within the A&E department and found that some staff did not always feel they could raise concerns or that concerns would be acted on if they did so.
In one incident, the CQC’s inspectors had to inform the trust’s chief executive after they saw a staff member speaking “discourteously” in front of patients. The comment was described as “serious and inappropriate”.
It also highlighted concerns over the trust’s use of an external company to provide staff to monitor mental health patients in A&E, after inspectors found patients were left unattended.
Inspectors said: “We observed a staff member employed by this service using their mobile phone and placing themselves away from the patient behind a door where constant observations could not be maintained for a period of 15 minutes.
“Incident data also showed an incident where ED staff had found the third-party provider staff asleep whilst on continuous observations.”
Overall, the report said: “The service’s culture did not ensure staff consistently modelled positive or professional behaviours, with instances of inappropriate behaviour not in line with the trust’s vision and strategy.”
It stated that the department’s leaders “lacked clarity and consistent visibility” and warned that “governance and accountability were weak, with repeated failures to address known risks”.
“Staff experiences with raising concerns were mixed.”
Jane Tomkinson OBE, chief executive officer of the Countess of Chester Hospital NHS Foundation Trust, said: “We are disappointed by the recent rating of our Urgent and Emergency Care services by the CQC following their unannounced inspection in February 2025. Whilst we have seen improvements, it is clear that the actions taken in the last 12 months need to be enhanced to consistently deliver the experience and care our patients deserve.”
She said that during the inspection on receipt of the warning notice, the trust took immediate action and remains focused on addressing the long-standing challenges.
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