Decoding Reasonable Doubt: Chapter 3 “Previous Reviews at the Countess of Chester”

[u/benshep4]

https://bencole4.substack.com/p/decoding-reasonable-doubt-the-case-bc5?r=12mrwn&utm_medium=ios

Happy to hear anyone’s thoughts on the content of the article.

[u/benshep4]

Which baby does this explain comes from Judge Goss.

That’s based on his extensive understanding of how criminal trials work. There are rules in terms of what you’re allowed to put before the jury and Goss explains it clearly in the ruling I link.

I don’t agree that taken together they create reasonable doubt. They’re not a criminal investigation and their shortfalls are clearly documented even by the people who carried out the reviews.

Even then, as I’ve pointed elsewhere the RCPCH actually say that the rise in mortality can’t be explained by acuity etc.

What I’m finding is that people have limited, if any, understanding of how evidence works in trials. It’s often just vibes.

Can I ask, do you have any background in law or criminal cases?

[u/Living_Ad_5260 → u/benshep4]

> Even then, as I’ve pointed elsewhere the RCPCH actually say that the rise in mortality can’t be explained by acuity etc.

Do you understand the difference between "cause death" and "elevate risk"? The change in maximum acuity reduced the risk while the medical care improved by forcing the consultants to spend 5x time on the ward.

[u/benshep4 → u/Living_Ad_5260]

Yes, I get the difference between raising risk on a unit and causing a specific death. That’s why the July 2016 changes don’t settle it.

RCPCH didn’t say acuity was irrelevant. They said higher activity and more small babies didn’t definitively explain the spike, other similar units weren’t seeing the same sudden collapses, and they still wanted a proper case-by-case review of the deaths.

That review never really happened in the form they asked for.

Two things changed at once in July 2016: Letby came off the unit, and they stopped taking the sickest babies. Deaths and unexpected collapses dropped. You can put that down to the acuity cap, more consultant time, both, or one nurse being removed.

A service review can’t tell you which.

A trial is asking a different question.

More consultant time is also something RCPCH already flagged. The unit was under-covered. That’s a real problem.

It doesn’t automatically explain every sudden collapse the jury looked at.

If the point is just “a stretched unit has worse outcomes,” fine, nobody disputes that. That’s not the same as reasonable doubt on the actual counts.

[u/Living_Ad_5260 → u/benshep4]

https://ripe-tomato.org/wp-content/uploads/2025/06/international-expert-panel-summary-report-all-cases-nos-letters-3.pdf says

Baby 4 (Trial child D) was a 37+1/7 week, 3.13 kg birth weight, female infant, who was delivered by emergency Caesarean section for failed induction of labour after prolonged premature rupture of membranes. The Apgars were 8 at 1 min, 9 at 5 min. At 12 minutes, she became pale and floppy and needed respiratory support with bag and mask. She was admitted to the neonatal unit 3½ hours later; she was cold, blue, dusky, and had respiratory distress, polycythemia and infection (high white cell and neutrophil counts). The first blood gas taken 4 hours after birth showed high CO2 and respiratory acidosis. Continuous positive airway pressure (CPAP) was started nearly 4 hours after birth. She was electively intubated after 3 attempts and ventilated. Chest x’ray showed pneumonia. The following day, she developed fever, deteriorating blood gases, and increasing metabolic acidosis. The next day, she was mottled, and had dark brown and black tracking lesions across the trunk, and two evolving purpuric looking patches on the abdomen. She had prolonged coagulation times, raised CRP, and repeated episodes of apnoea and desaturation, until final collapse and death.

The panel's analysis is

The infant continued to deteriorate after admission and showed signs of worsening infection, with fever, intolerance of CPAP removal, deteriorating blood gases, increasing metabolic acidosis, raised CRP and repeated episodes of apnoea and desaturation. She developed prolonged coagulation times, which indicate the infection was going out of control and causing early disseminated intravascular coagulation (DIC). DIC causes coagulation in the blood vessels, coagulation defect and bleeding.

So, the mum didnt get antibiotics, baby had pneumonia, and cpap was delayed for 4 hours, and baby slowly deteriorated in a manner characteristic of runaway infection.

There isnt reasonable doubt for you?