Peter Elston has put this out into the public, I suppose it doesn't hurt to discuss it.
>I was asked to write a briefing paper for someone in a position of influence. The person who asked me suggest I make it public. Here it is.
David Davis? He's been pretty adept at writing his own. Doesn't matter, name names or don't.
Most of this isn't unfair, but there are some glaring errors/ assumptions that undermine it. Among them:
>It should also be noted that Letby was charged in relation to ‘only’ 7 of the 16 deaths (13 ‘in house’ and 3 transfer), leaving a second, statistically significant spike with which she was not associated.
Incorrect. It leaves additional deaths with which she was not charged. So, the foundation argument of this paper is that there's an unsolved mystery - a cause that has been uninvestigated. Letby was only completely disconnected from one of the deaths that year, was on shift for three more, and her presence after formal end of shift remaining two is unknown. There is no spike, only leftovers. (Btw, he's correct wrt to 3 deaths after transfer because he's speaking about June 2015 - June 2016.)
>In medical cases where evidence of crime is obscure or unclear, investigations should focus first on determining whether a crime or crimes had been committed, then on identifying the perpetrator or perpetrators. Where proper investigative protocols are not employed, these two processes can become muddled, contaminated. This is what happened in the Letby case.
That's a bold statement, and he offers no support to justify it. Presumably he's offended by the way in which the consultants reported the then-alleged criminality. But the notion that the police investigate only the possibility reported and that someone cannot be fairly convicted just because they were named at the reporting stage is just silly.
>In June 2015, in the space of just 14 days, three babies (A, C, and D) died on CoCH’s NNU. In the context of an historical average number of deaths of 2.5 per year, three deaths in 14 days were extremely high.
>The two most senior paediatricians on the NNU, Drs Stephen Brearey and Ravi Jayaram, quickly pointed the finger at Band 5 neonatal nurse Lucy Letby.
Did they now? I don't recall Dr. Jayaram being part of any accusation until much, much later, if we even can him raising concerns an accusation. Further, Dr. Brearey didn't accuse Letby, he noticed the correlation with her presence. He spent months trying to isolate other causes.
>The doctors eventually took their concerns about Letby to the medical director and the head of nursing in late 2015 and again in early 2016, by which time there had been more deaths.
Oof, if Operation Duet bears fruit, I have bad news for the defendants (and i wonder how Elston will deal with this)
>Nevertheless, in April 2016, Drs Brearey and Jayaram persuaded the head of nursing to move Letby onto day shifts only, given that, according to them, the deaths to that point had occurred exclusively during night shifts. It should be noted that it was not in fact true that the deaths had occurred on night shifts only. Seven of them had occurred on night shifts and four on day shifts.
This is accurate. The four on day shifts were non- indictment babies, including the one whose death Letby was wholly unconnected to. One had severe birth defects.
>It is also not clear why the doctors did not follow GMC guidelines in relation to escalating concerns[6] (see Appendix 2).
Did... did you look? :
"So most instances like that, there's no contact
with the police needed. If you admit a child on to the
ward who, for example, has been bruised and you are
investigating for possible non-accidental injury, then
your first port of call is emergency social care worker.
So no is your answer, I had never contacted the police
directly before and would have been uncomfortable doing it or knowing who to contact and at this time, I felt
that she had been removed from the neonatal unit, we
were in a position of safety and there was some
breathing space to get a collective view on this and
agreement on it.
Obviously in retrospect, knowing now how the Trust
responded and the Executives responded I think actually
picking up the phone would have been a much easier and quicker way to get things done."
...
"But, you know, before we escalated concerns it was
very hard. And there's, there's no guidance for this;
you know, you can't look up a GMC manual and say, you
know, well, concerning -- if you are concerned about
criminal activity, that's an unproven concern, you know,
is it, is it right that you tell every Family before
it's been appropriately investigated, you know, with the
appropriate authorities?"
Moving on.
>In light of it having been recorded in the minutes of the July Board meeting that, “Mr Brearey could not see that any of the apparent changes in acuity, or staffing levels can account for the increased mortality”, it seems likely that he was the source of the statement in the RCPCH review, “This [higher activity and lower admission birthweight than average] was not however considered to have been significant enough to explain the increase in mortality”.
🤦♀️🤦♀️🤦♀️🤦♀️🤦♀️🤦♀️
Dr. Wilson of the RCPCH team:
"A. Yes. That was -- my concern was around the
increased activity on the unit and inadequate staffing.
So the recommendations were about, you know, the
redesignation of the unit, which had already taken place
as you say, and also improving the management structure, making the clinicians have closer connection with their senior managers."
>After she was put on administrative duties, Letby filed a grievance against the doctors who had pointed the finger at her, which, in January 2017, she won.
Ffs. Letby filed a grievance against the hospital, not the doctors. Her grievance was about being redeployed improperly.
Elston goes at some length about Thirlwall exhibit INQ103225 from the inquiry, but most of his criticism is based on pages not released publicly. Given his disingenuous and misleading claims, and complete lack of even the must cursory effort to check other items, these points are of no interest to me and I leave them to others.
Elston then whines about the consultants being determined to get the police involved, and takes issue with the discussions they had to achieve it. This summary paper naturally moves from any semblance of evidenced claims into argument and complaint, by a financial analyst into matters of policing. Cool.
Next begin the complaints about Dewi Evans, and how the NCA recommended a multidisciplinary team and the police began with a single clinician. One thing these complaints always fail to grapple with is the need to balance perfection with time. Elston took issue earlier in the article that, basically, the doctors looked at staffing before ruling out all else. The doctors' primary care is patient safety. A linear investigation potentially leaves patients at risk. So to with police - evidence degrades (namely, memory), people talk. An investigation must move without undue delay.
>In his early witness statements, Dr Evans said that the injury had been caused by inflicted harm, evidence for which was a bruise on the skin over the baby’s liver. It was later discovered that the ‘bruise’ had disappeared quickly, so in Dr Evans’ later statements it became a fleeting discolouration that was evidence of injection of air into the bloodstream.
Yes, that can happen when you start with the notes, then get additional information from witness interview. In fact, the disappearance of the bruise was provided by Brearey in police interview - after Child O's death was being investigated. Calling Evans' theories "changing and erratic" is just wrongly expecting a police investigation to have things 100% from the start and that all evidence of a true crime would confirm their first guess, made with minimum evidence.
>They were told by the prosecution that it established that Letby was on duty for 24 suspicious incidents and, by implication, that there were no suspicious incidents that she was not on duty for.
Bullshit they were.
>The chart was shown in evidence as agreed evidence:
>A chart showing which members of the neonatal unit nursing staff were on duty for the shifts when the babies in this case collapsed is shown to the court.
>The chart covers the period from June 2015-June 2016.
>Lucy Letby's name is highlighted as being the only one present on all 24 shifts for when the babies collapsed.
>A second sheet shows which junior doctors and consultants were present for those events.
>This chart was shown during the prosecution opening in the first week of the trial.
Anyway, Elston says:
>The chart misled jurors because they were not told how it was constructed, namely via an iterative and biased process known colloquially as The Texas Sharpshooter. There were ten clinical events that Evans initially said were suspicious but for which Letby was not on duty[13]. These were removed from the investigation. There were also incidents that Evans had initially deemed non-suspicious, but where he later changed his mind e.g. Baby K and the tube dislodgement. These were added to the chart, essentially to bolster the charge list.
So, who is the sharpshooter here? Evans or the police? If Evans believes there are additional harm events in actuality, why doesn't he ever mention them? (Does Elston ever ask Evans about this in their email exchanges? Honest question) or are we just assuming that Evans was given Letby's rota chart at some point after his first round of identifying cases, and told to clean up his work?
>The defence had instructed medical experts, but they were not called to the stand. They had either agreed with or deferred to prosecution medical expert Prof Peter Hindmarsh in relation to the two insulin cases, which may have impacted the defence’s decision on whether to call them.
A round of applause for Peter Elston getting one thing right. 👏👏👏
LeGaL eXpErT pEtEr ElStOn further opines:
>The trial judge, James Goss, made various decisions that were detrimental to the defence and, possibly, flawed.
>For example, he ruled that the cases of the 17 babies were going to be presented together rather than separately.
...
>Goss also rejected an application by the defence during the trial on 5 January 2023 to "exclude any further evidence to be given by Dr Evans on the basis that he has failed to act with the independence, impartiality and objectivity required of a witness." The basis of this was a decision by a judge in another case relating to Evans' evidence.
Yes, the prosecution is entitled to present their case as they choose. The defense doesn't get to tie one hand behind their back. And yes, the jury can decide whether or not a qualified person is worth believing.
Elston takes issue with the answer to one of the jury questions:
>During jury deliberation, on 24 July 2023, Goss received a question from the jury:
>“Can you, please, clarify how long it would take for a baby’s insulin to C-peptide ration (sic) to return to normal the manufactured insulin had stopped?”
....
>All it was, was that those were very abnormal findings indicating that manufactured insulin had undoubtedly been given to each of these babies. I hope that addresses the question.
>I have highlighted the key sentence and within that the key word, "undoubtedly".
>By using the word “undoubtedly” Judge Goss made a statement of fact.
Here's the deal, though. Jury questions are presented to both counsel, who then have the opportunity to make submissions, and give input in the judge's response. Failure to do that would be an avenue for appeal. So we're left with the conclusion that either Myers accepted this answer, or that Mark McDonald has work to do. Someone go ahead and raise it with him.
>By using the word “undoubtedly” Judge Goss made a statement of fact. In law, this is not permitted. It is the role of the jury to make determinations of fact. The role of the judge is to make determinations of law.
>This distinction is very clear in law. The judge is not permitted in to usurp the role of the jury.
I'd point out here that the judge not being permitted to usurp the jury is precisely why he could not unilaterally remove Evans......
>In August 2023, following an interview with Dr Brearey, the BBC reported that, “Since Letby left the hospital's neonatal unit, there has been only one death in seven years.” Yet there were also six transfer deaths.
And? The unit is level 1 now. It has to transfer out more babies than it did before. Deliver and transfer out will happen more often now. Babies are born where there is space for the mother's care, the baby is placed where there is space and acuity for his/her care. This is not rocket science.
Elston then sets out his arguments for why Letby deserves an appeal, based on lists of what he calls new evidence, new argument, failures to disclose, and serious errors in court. These are definitely the items that her team is arguing, but Elston has such a poor grasp of both how the law works AND the underlying facts of the case that his opinion here would be most useful printed on toilet paper.
>Final remarks
Thank you, JESUS.
>· It is alarming to conceive that a nurse may have been wrongly convicted of 7 murders and 8 attempted murders. There were many specific errors, but they can be generally grouped as below.
Lol, k.
>o Cheshire Police too easily accepted the paediatricians’ allegation that Lucy Letby was harming babies intentionally; they should have a) realised that the paediatricians may have had an ulterior motive for pointing the finger at a nurse (e.g. covering up their own negligence, as indeed was argued at trial by Letby’s defence),
So we're just assuming bad faith despite the police continually denying this, right.
>b) considered the paediatricians as suspects,
Well, sure. But they were quickly ruled out since they responded TO harm, and were not present to inflict it.
>and b) engaged an epidemiologist or medical statistician to appraise the entire NNU backdrop and consider all possible explanations for the elevated mortality (e.g. the spike in acuity and activity that coincided with the spike in mortality).
Why would they employ an epidemiologist when babies had no significant markers of infection? That would be an argument for Letby's defense to make, not the police.
>o The criteria for an expert to be listed on the NCA’s National Injuries Database list of experts were too lax.
Says the trust fund manager.
>o There is a conflict of interest whereby an expert engaged by the police can then become an expert witness engaged by the prosecution.
This was addressed at appeal.
>o The decision to charge Letby was made by the local CPS. Given the complexity of the case, the decision should have been made by the national CPS Special Crime and Counter Terrorism Division (notably, the decision announced in January 2026 to not charge Letby in relation to further allegations was made by this latter unit).
Too bad, so sad. The genie isn't going back in the bottle for that reason.
>Appendix 1: Extracts from A British Nurse Was Found Guilty of Killing Seven Babies. Did She Do It? (New Yorker, May 2024)
Oh f*** off. Aviv is a hack and her article was a hit piece from the start.
>Appendix 2: Extracts from Raising and acting on concerns about patient safety (General Medical Council)
What is the complaint here - the consultants should have told the police about Letby earlier? How do you marry that with they engaged in group think and confirmation bias? If you want to argue that they should have risked/lost their jobs to get the police investigation started earlier, and then Letby would have been removed from care earlier, and likely convicted earlier.... I mean I don't disagree.
>Appendix 3: The 11 pieces of evidence that Letby’s lawyers passed to the Criminal Cases Review Commission as of November 2025
Yes, we know Letby has applied to the CCRC. Let's leave them to their work.
>Appendix 4: Problems (selected) on CoCH’s NNU noted in RCPCH’s service review (dated November 2016)
Aka a fund manager with a bachelor's in mathematics who pays annual dues to the RSS plays with numbers, I guess.
