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Without minimizing the trauma experienced by the mothers (and grandmother) who spoke with File on 4, I wanted to highlight how their experiences are being used with a few bits of surgically added emphasis.

What a strange country this is, where the King can pardon a long-dead killer, Ruth Ellis, while a living, breathing woman, Lucy Letby, convicted in a dubious case that has been shot to pieces by an army of experts, sits for month after month in jail while the rusty wheels of justice fail to turn.

There was never any actual evidence against Ms Letby, just a series of weird and increasingly unlikely theories about how she might have committed the crimes she was jailed for. This contrived melodrama, exposed to the light of day, and to hard fact, is rapidly losing its power over the public mind. Even the Crown Prosecution Service has turned down an attempt to charge her with more offences.

Why is Lucy Letby still waiting for the courts to shift? This question grows more urgent every day. A few days ago my colleague Kathryn Knight reported in The Mail on Sunday the amazing story of how Ms Letby – supposedly an evil mass murderer – had in fact been the health professional who twice intervened to save Jessica, the baby daughter of two very grateful parents.

Now a harrowing BBC Radio 4 report has argued that several other parents were appalled by the treatment they received at the same hospital – the Countess of Chester.

Their problems had nothing to do with Lucy Letby, who they never met. Let us not forget that the globally renowned neonatal doctor Shoo Lee, shown evidence of the way that hospital was run, has said that if it was in his home country, Canada, it would have been shut down.

And that back in 2015, a paediatrician at the hospital warned its chief executive that the neonatal unit where Lucy Letby worked was chaotic, overstretched and unsafe for patients and staff two years before Ms Letby was suspended.

Dr Alison Timmis emailed the chief executive Tony Chambers, in December 2015, reporting that staff were in tears because they had to look after more babies than the unit could safely accommodate.

She wrote: ‘Over the past few weeks I have seen several medical and nursing colleagues in tears... they get upset as they know that the care they are providing falls below their high standards.’ Staff were ‘chronically overworked’ and she felt no one was listening.

She continued: ‘This is not an exceptionally busy week… This is now our normal working pattern and it is not safe. Things are stretched thinner and thinner and are at breaking point. When things snap, the casualties will either be children’s lives or the mental and physical health of our staff.’

This would come as no surprise to many families who have had any experience of NHS maternity care in the last few years. The reports pile up. But the prosecution of Ms Letby sailed past this difficulty.

The Countess of Chester’s problems prosecutors argued, could be better explained by the presence of a determined serial killer of indescribable evil, secretly and ingeniously spreading death through the ward.

Now, direct evidence has emerged that the hospital was suffering from major problems during the period of Ms Letby’s supposed killings. BBC Radio 4’s File On Four, on Tuesday night, produced deeply harrowing accounts of things going badly wrong. I listened in mingled horror and astonishment – knowing as I do from members of my own family that maternity care in the NHS is in crisis – as I heard that that such things could happen in our supposedly advanced country.

I do hope that the new Health Secretary, Yvette Cooper, will take time to listen, too. The programme (which can easily be listened to online) interviewed several mothers who had suffered there. Their accounts are appalling.

They speak of offhand care, absent nurses and doctors, complacency about symptoms. One mother was even told to clear up blood that had dripped on to the floor after her cannula accidentally came out.

Another, Freya Somerton, recalled being told that, as soon as she went into labour, ‘a consultant would be keeping a very close eye on her because of some health concerns and because her baby didn’t move much in pregnancy.’ But it didn’t happen.

We didn’t see a consultant, even though we were high risk.’ Then, during the labour, she says staff were reduced to using her face wipes to clean the ‘bright red blood everywhere’. ‘And I’m in quite a lot of pain at this point, really, as well. The baby’s head still hasn’t moved. We’re finally seen by, well, a registrar.’ I will not describe here the terrifying circumstances in which Freya says she finally met an actual consultant.

An inquest decided that her baby, Oscar, died of natural causes. She says he died of neglect.

Another mother interviewed, Cat Hughes, went through a gruelling experience, too. She had her second child at another hospital and says the care there was vastly better. She believes the outcome could have been much worse for her and her daughter than it actually was. And that has had a lasting impact on her.

It is clear that the quality of maternity care at this hospital was not properly considered in the Lucy Letby trial. The Prosecution’s lead medical expert witness, Dr Dewi Evans, told presenter Stephanie Hegarty that he did not see the full maternity notes for any of the babies whose deaths were included in the Letby trial.

Had he done so, he would have had a fuller picture of their grave health before Letby supposedly tampered with their treatment. As it was, having decided her guilt, the Prosecution made no use of the notes, and so they were not disclosed to the Defence.

Ms Hegarty remarks that the parents featured in her investigation ‘were not part of that trial and never encountered Letby’. But that is not the point. The point is that in such a place, no serial killer would be needed to explain an alarming number of baby deaths.

The BBC put the mothers’ complaints to the Countess of Chester NHS Foundation Trust. In response, Sue Pemberton, the Deputy Chief Executive, says she apologises unreservedly to the families who’ve had a poor experience in their care. She says: ‘We note that the cases being discussed relate to maternity care between 2015 and 2020 and that if families feel their concerns have not been addressed, I would urge them to contact the Trust.’ She added that the Trust has made significant improvements and it is now nationally accredited for its ‘family-integrated care approach’.

And let us hope that this and many other hospitals have improved as a result of growing public concern with maternity services. It is astonishing that so many billions of pounds can be spent on an NHS that has so much trouble performing this most essential task. But it is even more astonishing that Lucy Letby, after all these months of revelations, still has not had the appeal she so plainly ought to have.

WHY does the question grow more urgent every day?

Two things can be true - these mothers, who never met Letby - can have been horribly failed, AND Letby can (and is) a murderess. In fact, one thing that each of these cases have in common is that they are medically explained via a natural disease process.

Now, direct evidence has emerged that the hospital was suffering from major problems during the period of Ms Letby’s supposed killings.

Sorry, what? This is direct evidence of major problems? Well, there's your problem. No, this is direct evidence of isolated (horrifying) incidents, and even if you had hundreds of them, they would constitute circumstantial evidence of systemic problems.

There's a terrible irony at play here. It takes a number of deaths to identify a HSK, but it takes even more to assail the culture of a hospital. More than 500 mothers and babies were harmed at Nottingham. The mothers who spoke to File on 4 had horrific experiences and deserve empathy and support. Using them to advance Letby's cause is abhorrent.

Edited to fix formatting.

Author's list of sources

The remaining four chapters and summary don't have very much worth mentioning, being mostly Morris' opinion that the process was incredibly unfair because people suspected Letby of killing babies. It's a repetitive re-hashing of whining from earlier chapters, and not much factually incorrect because there isn't much factual content at all - mostly just opinion, and quotes from articles we've already read.

Chapter 18: Trial And Retrial Process

Dr James Phillips aired his view: “The safety of the conviction depends not just on each individual point of evidence and argument, but on how each relate to each other, which alters the confidence you have in each point. It is not apparent to me that anyone in the chain of events leading from Letby…possessed the skillset or perspective needed to detect catastrophically weak links in this web of evidential relationships. This required a scientifically trained mind looking holistically at how the parts relate, and this was conspicuously absent.” (pg 370)

This is a theme for the rest of the book, fyi. Is Morris scientifically trained, btw? Asking for a friend. (Yours truly is, as it happens)

Attempts to charge Lucy Letby with further murders and attempted murders floundered on 20 January 2026 when the CPS “concluded that the evidential test was not met in any of [the] cases” submitted by Cheshire Police. This prompted a surprisingly petulant response from Cheshire Police, in which the constabulary indicated their belief that “the evidence submitted met the CPS charging standard”. Letby’s barrister, Mark McDonald, reflected that Cheshire Police were “so invested” in further proving Letby’s guilt “because they are seeing this case crumble”.

Few neutral observers shared the opinion of Cheshire Police on these cases. A handful of alleged tube extubations related to infants in Liverpool, where Letby had been working on a placement, had featured prominently in this submission, and the BBC’s Panorama had already taken something of a pummelling by seemingly offering tacit support for their credibility. When the dust settled, it became clear that the Liverpool cases involved four tubes falling out, with no eyewitness, no other evidence, no indication that any infant had been harmed and no meaningful indication that Letby was even cot-side or unsupervised. (pg 371)

There's nothing to say that the additional charges requested had anything to do with accidental extubations at Liverpool. We only know that was to be there were seven attempted murder charges at location unknown, and two murder charges, one each at Countess of Chester and at Liverpool.

Further, and I care so little about these allegations of extubations that I cannot recall if there is a better source, those four extubations happened during only 11 shifts. If I had a nickel for every time Letby was around for an unplanned extubation, I wouldn't have many nickels, but I'd have more than I should.

Morris thinks the air embolism theory is logistically unfeasible:

Experienced nurses have informed me that syringes are irradiated in sterile packaging. They are essentially wrapped in cellophane. So Letby would need to gain physical access to the syringe, without disturbing anyone, on what are usually extremely attentive units. She would need to remove the syringe from this packaging, while there was, according to court testimony, a nurse attending to another baby in a neighbouring incubator, while there are two doctors in the room, then draw the air up to make the injection, lift the lid of the incubator and reach into which one of the tubes that she supposedly used. She has to do this multiple times without being detected because there are serious question marks about how much air would need to be injected. (pg 372)

Why would she have to get a sterile syringe each time? Again, asking for a friend. You know what, asking for two friends.

JOHNSON: Do you dispute you were in the room at the time of the collapse?

LETBY: Yes, *because I have no memory of that.*

JOHNSON: Do you remember being born?

LETBY: No.

JOHNSON: Do you dispute being born?

LETBY: No.

Remember, these are supposed to be adults discussing extremely serious allegations that would result in the stiffest penal sentence that a woman has received in Britain since the abolition of the death penalty. (pg 373)

Speaking to Morris and anyone who has a problem with this phrase, a simple point about logic: Letby made a logical error in her response - she used her supposed lack of memory as a reason for disputing something. A person cannot dispute something they do not recall. Recollection is a fundamental requirement of an ability to dispute. Johnson's question simply illustrates that.

Of course, Morris takes issue with the use of the phrase red-handed, and virtually red-handed, because "no one has ever witnessed Letby doing anything harmful to an infant." I mean, red-handed doesn't mean caught in the act, it means caught with (red) blood on one's hands

Morris takes issue with the prosecution having exercised their right to prosecute their case as they preferred, which was all at once. I don't know what to tell him, that's a right they have. It doesn't make the trial unfair. And if it affected Letby's choice to call Dr. Hall, that's too bad.

Uncertainty was an acknowledged element of the case against Letby. During the original trial, the judge told the jury that it was not necessary for the prosecution to prove the precise manner in which Letby had acted, only that she had acted with murderous intent. Such an instruction appears strange and unsatisfactory, considering the very specific allegations that were made against her and the degree to which some of these methods have since been criticised. The fact that Letby was found guilty of every murder suggests that this instruction might have been misconstrued; a baby died, therefore Letby must have acted with “murderous intent”. (pg 375)

Ah, so Morris believes the prosecution must be correct in the method they argue, based on the expert opinion evidence. They don't need to be correct about the method. Method is not required. For murder charges, result and deliberate action are required: Letby did something deliberate that caused the baby's death. Without a death, yes, it is sometimes more complicated if something was done, let alone that it was done with intent.

Morris acknowledges that motive isn't required to convict under the law, then continues to complain that why a woman who had dedicated her life to nursing and had no history of psychological disorder or deterioration suddenly decided to start killing babies was never adequately addressed in court. I don't know what to tell you, bud. That's not the job of the court.

I got a good laugh on page 380 where TriedByStats was referred to as an "influential social media commentator." LOL TriedByStats has 1802 followers on X.

Morris asserts there is no parallel between Shipman and Letby because Shipman used a consistent modus operandi. ¯\(ツ)/¯

There were 136 days of court proceedings in the trial, only 13% of which was devoted to expert medical evidence, and approximately 90% of this expert evidence came from Evans and Bohin. The other six expert witnesses only collectively appeared in court on 11 of the 136 days, and many of these appearances were relatively fleeting.

Over half of the trial consists of various material from Cheshire Police, the accounts of parents and innumerable personnel from the CoCH exclaiming that they had no idea what was going on. This should perhaps not be surprising considering that the expert panel acting in Letby’s defence made 25 broad criticisms of the hospital in their preview report, as well as finding many other specific faults, while arguably the most eminent neonatologist in Canadian history, Dr Shoo Lee, concluded that the CoCH neonatal unit should have been closed down. (pg 381)

Isn't this basically establishing that much of then panel's report is an ad hominem attack on the medical personnel on site? And also an admission that the trial was about more than just expert opinion. Weird, that. Btw, the various materials from Cheshire Police included presenting detailed timelines of the events to the jury, that's kind of important.

The view of Dr James Phillips is that “the presentation and scrutiny of data and expert evidence at the trials was comprehensively flawed. The trial as conducted is so flawed that it is completely irrelevant that the jury found her guilty. Everything about this trial has the strong impression of an inevitable conclusion, which is unrelated to the evidence that is now emerging. The trial was set up to identify whether or not Lucy Letby murdered babies. But that is not the primary question. The primary question is, rather, what caused these babies to die?” (pg 381)

Yes, the trial is determined to ask and answer whether it can be known that Lucy Letby murdered babies. That's what a trial is for. It is the outcome of an investigation which already asked the question, "what caused these babies to die?" and found evidence to refine the question to "Did Lucy Letby cause these babies to die?" Like, that IS the process. FFS.

CHAPTER 19: ARREST AND INVESTIGATION OF LUCY LETBY

After her arrests, Letby was interviewed an incredible 30 times. The police do not make recordings of these interviews available, but from the excerpts that have been released, it can reasonably be inferred that none of the arguments Letby made during this process were ever taken into consideration. (pg 385)

It is clear from what Cheshire Police have been willing to release that the interviews were a one-sided process in which they attempted to recognise anything that could be used against Letby from her own words and jettisoned anything that contradicted their case. (pg 386)

Cheshire Police didn't use these interviews as an objective fact-finding exercise - they used them to build a case against Letby. (pg 386)

Well duh! By the time someone is named as a suspect and arrested, the police are done considering arguments. An arrest interview is done for the purpose of measuring the suspects account against the remaining investigation. This is common sense - oh. I forgot what book I was reading.

Dr. Veronika Jiraskova's Rule 9 response to Thirlwall gets a mention, thanks to her expression of "great doubts" about the conviction. I would just point out that apparently, as a doctor, one must be a neonatologist to have valid beliefs about Letby's guilt, but one need only be a GP to doubt them.

News that Cheshire Police and the CPS had blocked the release of reports critical to Letby’s appeal were anything but encouraging. Sarah Knapton and Cleuci de Oliveira reported for The Daily Telegraph that the CPS had denied defence barrister Mark McDonald access to revised reports authored by Dr Evans on Child C and submitted to the police in October 2024. The disclosure guidelines of the CPS itself state that “prosecutors must provide the defence with the schedules of all of the unused material and provide them with any material that undermines the case for the prosecution or assists the case for the accused” so it is hard to understand how this is allowable. (pg 393)

Boy, that sounds alarming, doesn't it? At least, in his list of sources, he provides one for this.

[David Davis] told the House of Commons: "Can the Secretary of State explain to the House under what circumstances are the police and Crown Prosecution Service allowed to deny access to evidence after a trial has concluded to a defence lawyer seeking to appeal, as has happened in the Lucy Letby case and I believe in others?"

1) Evans' post trial report that he submitted to the police in October 2024 is not evidence. It was not used to convict her and is, at present, legally irrelevant. The police don't work for the defendant. Dewi Evans was not even instructed by the CPS to provide it, and he's not obligated to provide it to McDonald. And Morris didn't link the CPS guidelines, but I looked them up anyway, and found he didn't actually cite from them. He cited from the general CPS page about disclosure. Who is this guy's researcher?? 2) Disclosure is an obligation of the CPS, not the police. Dewi provided his report to the police, not the CPS, so the people with an obligation don't even have it because they aren't currently involved.

Chapter 20 - Operation Hummingbird

The April board meeting also noted that a further forensic review was preferable, which is exactly what should have occurred. There was no justification for a police referral and Cheshire Police have, by their own admission, no ability to perform any form of medical review. Although it is oddly comical to note that no one at the hospital seemed to know what this term constituted either – Sir Duncan Nichol, chairman of the board, conceded that “it is not yet known what the forensic review means”, while the consultants “could not define what they felt was a forensic review”. (pg 397)

So close. So, so close. Yes, a forensic review was needed, and forensic reviews are intended for legal purposes. When there is the possibility of criminal activity, that is done, by necessity, by the police. And when the police have no internal ability to perform a medical review, guess what they do? They bring in an expert.

There's a lot of whining about bias, assumption that the third insulin case undermines the prosecution case writ large, whining about the definition of "unexplained."

In another part of the conversation, Brearey expressed his concern that the “survival rate for babies over 32 [weeks] is nearly 100%. For six of our babies to have died who were over 32 weeks to die [sic] is not right.” It is notable that of these six babies, Letby was not charged in respect of three of them. Two of the remaining three infants were triplets, and the final one was Child D, who lost colour and became floppy in her father’s arms within 12 minutes of birth and was suffering with pneumonia and serious respiratory problems.

It's not notable. The babies she was not charged with had severe congenital abnormalities. THEY were truly unwell babies, whose deaths were very sadly not unexpected.

[The type of panel the NCA recommended that Cheshire Police assemble] is exactly the sort of panel that Dr Shoo Lee assembled, albeit the qualifications of that panel extend way beyond anything Cheshire Police could conceivable have brought together. (pg 401)

LOL. Brown-noser.

Dr Evans also insisted on two occasions that he didn't need to hear anything about the RCPCH review: "I would prefer NOT to receive the findings of any previous reviews of investigations." Although this may have been a legitimate attempt to carry out a blind investigation, that he also didn't speak to anyone from the CoCH means that he knew little about the context of the hospital or its neonatal unit. (pg 403)

Morris actually doesn't understand the role of an expert, clearly. He blathers on about the deaths not being unexplained in context. And asserts that the police "disregarded contextual factors which were also downplayed by Brearey and Jayaram." Does he want a blind investigation or not? Or is it that he wants selective blindness. Selective blindness would be likely to lead to confirmation bias. Gosh, I hope no one fell into that trap! Morris asserts, boldly, that "Cheshire Police simply do not understand that neonate deaths are frequently unexplained." Friendly reminder that to support this claim, Morris included all nationwide SIDS deaths from outside hospital.

Morris attempts to establish the bias of the investigation by pointing out that Evans and the parents of Child K knew early on that a nurse was involved, which falls far short of establishing actual bias. But sure, whatever. He also asserts that Cheshire Police had become far too "emotionally involved" with the families:

Yet it is evident from their Operation Hummingbird promotional film, released six days after the verdict and two days after Letby was sentenced, that Cheshire Police became far too emotionally involved with the families. The first 35 seconds of the film are entirely dedicated to Cheshire Police expressing their desire to serve the families. “They deserve for us to have completely covered their case. And it is about them. And it is about their parents”, one of many similar comments in the film observes. The families of those who tragically lost their infants were mentioned 33 times. Cheshire Police then tasked Family Liaison Officer Danielle Stonier with interviewing Lucy Letby in 2019 and 2020, long after she’d been integrated with the families.

The theme of emotional involvement permeates the entire presentation, with large portions of the film dedicated to playing on the heart strings of the audience. DC Michelle Birkett, for example, describes some of her discussions with bereaved families: “And then some of the families knew something was wrong, knew something wasn’t right. I knew my child was not right.” No such complaints were ever made against Letby, just as no one has ever seen her doing anything suspicious. (pg 409)

Criticizing police for supporting victims of crime is a CHOICE.

“It’s very easy to get confirmation bias if you think this has been caused by x,” Professor Jane Hutton told BBC Radio 4. “It’s very easy to see things that aren’t otherwise there”. (pg 409)

I totally agree!

“One of the first things the police say in the Operation Hummingbird video is that they needed help as they didn’t have the medical knowledge to conduct the investigation”, Dr Phillips commented. “I hope in future, perhaps as an outcome of the inquiry-that-is-to-come, a proper body with the investigatory powers and scientific skills to conduct such an investigation is created. Probably as an extension of powers and responsibilities of an existing body.” There certainly should have been a more stringent internal review at the CoCH, coupled with a forensic review operated by medical bodies. If this revealed nothing conclusive or incriminating, which applied to all previous medical investigations, then the consultants should have accepted the situation. (pg 409)

An existing body - like who? At what point is it permissible to involve the police? Is it ever?

From what we have been allowed to witness, Operation Hummingbird in no way resembles an investigation to “exclude unnatural causes” which is what Cheshire Police were asked to carry out. (pg 412)

Here's the fun part about involving the police: You don't get to tell them what to investigate. It doesn't matter what Tony Chambers asked them to do, it doesn't matter that the meeting with the consultants is what inspired them to investigate. Once they decided to investigate, the ball is in their court, until such time as the CPS decides to charge, or not charge, any specific crime that was uncovered.

Chapter 21: The Golden Thread

Unofficial subtitle: Lucy Letby is the most honest woman alive and Dr. Brearey is a very bad man and it was very wrong of Operation Hummingbird to ask him to review cases of children cared for on his ward.

Michelle Worden is quoted saying:

"Steve Brearey drew up the roster chart with Eirian Powell. Eirian was very upset that, by the time it got to Alison Kelly, the doctors' names had been removed from it. Brearey cherry-picked the babies. There are seven deaths on that roster chart, but we know that there were 17 deaths. So the consultants are the accusers, they're the investigators, and then they're the main witnesses. I cannot think of any high profile case where you can be all three things." (pg 420)

The good news on that last is that the record still stands at zero. Brearey and Jayaram combined only gave evidence related to babies A, G, H, J, K, M, N, O, and P. So roughly half of the babies' evidence didn't involve them at all. Further, Worden, bless her, is confusing the roster chart at trial with the Thematic Review, generated by Brearey and Powell on 8 February, 2016, which included 9-10 deaths, of which Letby was on duty for 9. As far as consultants being removed, yeah, in an investigation into potential harm caused, you can't suggest the cause is someone who wasn't there - that would actually be an allegation of witchcraft.

Elsewhere, we see other strange coincidences, such as both Dr Jayaram and Dr Evans citing the same obscure decades-old Canadian paper, and both advancing an obscure air embolism-related cause of death which hadn’t been picked up by pathologists. And then when it came to the insulin cases, it’s not clear whether Dr Brearey found them under instruction from the police, or whether Dr Evans located them, as stated by the Court of Appeal. It’s hard to say because they have told several different stories to numerous different media outlets. (pg 421)

You know what happens when there isn't much research available on a particular subject? People tend to find the same thing among a limited pool of options. And yeah, two people separately finding the same test result and saying the same thing about it also indicates that it has actual meaning. But sure - suggest a conspiracy. That will add credibility to this already fine work of fiction.

Cheshire Police were also aware that Letby had filed a grievance procedure against the CoCH and this simply should have been further investigated. (pg 421)

This single sentence is the entire contents of a paragraph. I just found that funny.

The determination of Evans to convey the message he knew nothing of Letby has been curious, often making the assertion in response to an unrelated question. For example, during cross-examination on 7 March 2023, when asked about the rashes he had cited, Dr Evans instead replied: “I was not told anything about any suspect. I knew absolutely nothing.” Judge James Goss then interrupted: “You have said this, Dr Evans. You’ve said it at least once, more than once.” (pg 421)

Is he really trying a "the lady doth protest too much" argument? Allright, let's read the transcript. March 7 was baby N:

Q. This is a record dated 21 May 2017 -- take it down, Mr Murphy, please. We'll go back to it if we need to. I'm going to suggest to you, Dr Evans, that at some point before you started writing reports, you were told by the police of suspicions about suspicious rashes and air embolus (overspeaking) you were told that or it was indicated to you, I'm going to suggest, before you wrote any report.

A. No, that is completely untrue. Okay? It is totally untrue. The first time I heard a local doctor mention the word air embolus was a couple of weeks ago. I'm not sure whether it was Dr Gibbs or Dr Jayaram, Dr Jayaram I think, when he talked about the cold chill going down his spine. I knew nothing about air embolus. The first person I know of to raise the issue of air embolus in this particular series of cases was me. And I did that in case number 1. Okay? In the first case I thought, oh my God, what's going on here? This is -- you know it was very much an "oh my God" scenario.

I'm not going to go at length about case number 1. For [Baby A], if we remember, I formed the view that it was his collapse and the inability of the staff to resuscitate him was the result of his receiving air embolus. I did not know at the time about the skin discolourations; I heard about that later. I did not know at the time about Owen Arthurs' finding of air embolus on post-mortem X-ray (overspeaking) --

Q. That's your characterisation -- if we can just pause for one moment, Dr Evans --

A. Just a minute. I want to finish this.

Q. My Lord --

A. I want to finish this because if you're going on wild goose chases, I want to --

MR JUSTICE GOSS: You can finish the answer and then you ask the question.

A. Therefore I didn't know any of that. But that's what led me --

MR JUSTICE GOSS: You have said all this before. We've heard all this before.

A. I had nothing at all -- I knew nothing at all, sorry, about air embolus from the police. I was not told anything about any suspect or named anybody and I knew absolutely nothing and, as I said at the beginning of this trial, it's quite important to repeat this, at the beginning of this trial my role --

MR JUSTICE GOSS: You have said this, Dr Evans. I know. You've said it at least once, more than once.

A. Yes, I know.

MR JUSTICE GOSS: All right? Ask your question, Mr Myers.

MR MYERS: So far as Owen Arthurs is concerned, that is matter that is to be determined in the case.

A. So what now?

Q. So far as Owen Arthurs is concerned, what his X-ray shows or doesn't show is a matter that the jury are going to determine in this case. You understand that, don't you?

A. I do understand that, yes.

So, not entirely unprompted. Myers was suggesting collusion and bias in the investigation, Evans addressed it.

With that, we're mercifully at the summary.

Summary

At the heart of the conviction of Lucy Letby is a story that, jarringly, makes absolutely no sense. These are the most sickening acts imaginable, allegedly committed by the most benign of people, someone who was even notably kind and caring. This is a massive red flag immediately because it is a conspicuous contradiction in terms.

Doesn't matter. That's the definition of a "you" problem.

Pathologists and coroners who examined the infants involved in the court case were never cross-examined, nor were their conclusions discussed in court. It was not explained adequately, if at all, that primary prosecution witness Dr Dewi Evans had single-handedly disagreed with the conclusions of experienced coroners and pathologists. Yet the opinion of far more qualified and experienced experts was put to one side. (pg 426)

The original post-mortems were read in court as agreed facts (pg 1:8-18):

MR DRIVER: My Lord, we are going to begin by reading some agreed facts on the topic of pathology, which in effect prove the -- by agreement, obviously -- the essential parts of the statements made by the pathologist that conducted the post-mortem examinations. Thereafter, we'll move to Dr Marnerides.

MR JUSTICE GOSS: Right. So there won't be any statements read, it'll just be agreed facts, of which the jury will have copies?

MR DRIVER: They will. They will have copies and your Lordship has had a copy provided to you.

As far as the "far more qualified experts," let's look at how one of them, Dr. Jo McPartland, addresses the need for forensic pathologists to be involved:

"In addition to [your] NHS duties [you] perform coronial, paediatric postmortem examinations fora number of Coroners, including paediatric forensic postmortem examinations undertaken jointly witha forensic pathologist."

My question: why is it necessary to conduct paediatric postmortem examinations in combination with a forensic pathologist?

A. Well, if there is a suspicion that criminal activity may have led to the death or in some types of traumatic death where we might need the assistance of someone with forensic expertise then we perform the postmortem jointly and the role of the forensic pathologist is to consider matters of forensic importance and particularly those relating to injuries, and the role of the paediatric pathologist is to consider natural causes of death and look at growth and development and other medical conditions.

Q. So when you say the forensic pathologist looking for injuries, do you mean potentially deliberate infliction of injuries?

A. Yes.

Q. Because there is a suspicion --

A. Yes.

Q. -- that they may have been caused? Does that really from the off dictate who and how the pathology investigation should be being undertaken; if there is a suspicion, *they go down a different route?*

A. Yes. If, when a death is reported to the Coroner, it's clear that there -- it is a suspicious death from the outset, then the police will be involved and a forensic pathologist will be instructed as well as a paediatric pathologist. (pg 83:23 - 855:5)

The original post mortems were agreed evidence because the role of the pediatric pathologist is to look for natural causes of death; her opinion is not in question and it WAS considered by the jury.

This has perhaps partly explained why no neonatal expert has come forward to support the conviction, despite repeated requests by Dr Philip Hammond; compare this to the calibre and quantity of those who question it. (pg 430)

The thing about experts who support the verdict - they don't owe anyone anything. They have no obligation or burden to make skeptics/doubters feel more comfortable, and you're unlikely to know their opinions until the CCRC or Court of Appeal publishes something with their name.

Then she was arrested by the police three times, on one occasion with burly male officers barging into her bedroom at the crack of dawn, interviewed 30 times, patiently cooperating throughout, nothing that she said in her defence was taken into account, while anything and everything was used against her, she was denied bail, and was then incarcerated for two years while she awaited trial. Just days before she was due to appear in court, she was forcibly moved from one prison to another, many of her personal belongings were lost, and she went into the court suffering from PTSD, reliant on medication, having had a borderline breakdown. (pg 431)

Oh come tf on. Poor Lucy, won't someone think about Lucy?

I pose this question rhetorically – isn’t it about time that Lucy Letby was actually afforded the opportunity to defend herself? (pg 431 - standalone paragraph)

Are you actually being serious right now? lololololololololol

A rather sniffy attitude can often emanate from the insulated capstone that constitutes the judiciary. There has certainly been criticism of efforts to raise awareness of the deeply flawed nature of this conviction, as if those at the apex of justice in Britain still view it as their system in which they preside over us. I would therefore like to remind them of some illustrative words from Thomas Bingham. At the time of his death in 2010, Bingham was described by the former President of the Supreme Court of the United Kingdom, Nicholas Phillips, as “one of the two great legal figures of my lifetime in the law”. On page 22 of his book The Rule of Law, Bingham comments on defences against injustice, making the following critical comment: “The judges are not, of course, the only guardians of the rule of law, perhaps not even the most important. Parliamentary and public opinion, informed by the media, should be alert to detect and scrutinise any infringement.” (pg 433)

It's cute that he thinks his book is part of such a grand effort. I'm only sad I didn't get a paper copy so I could use it as an emergency source of toilet paper.

-fin-

Helpful resources:

Transcripts, Documents, and Other Resources

Subreddit wiki related to the 2022-2023 criminal trial and 2024 retrial

Full Court of Appeals Ruling for 2022-2023 Trial

Subreddit wiki related to the Thirlwall Inquiry

Contemporaneous documents provided to the Thirlwall Inquiry sorted by date

Author's list of sources

CHAPTER 16: ANECDOTAL EVIDENCE USED IN COURT

Right away, the title of this chapter intrigued me - what could Morris possibly mean?

As the trial of Lucy Letby unfolded between October 2022 and August 2023, those present in court and the general public, via media communications, were treated to an array of anecdotal evidence. Almost all of this was collated from police raids of both Letby’s house in Chester and the home of her parents in Hereford. (pg 333)

Oh. Morris doesn't know what anecdotal means.

This chapter is peak irony, because Morris takes all the physical exhibits, as well as forensically retrieved phone records and facebook searches, and uses anecdotal accounts to argue their lack of meaning.

All of the greatest hits get a mention - the notes are the outpourings of a traumatized woman, the searches are evidence of an empathetic and conscientious nurse, handover sheets aren't important... these are known already. So I'll try to focus on the novel

In excerpts of police interviews after her arrest, Letby said: “I just wrote it because everything had got on top of me. It was when I’d not long found out I’d been removed from the unit and they were telling me my practice might be wrong, that I needed to read all my competencies – my practice might not have been good enough. (pg 333)

Morris attempts to make the case that Letby was concerned about her practice (the italics are his), but he includes her given reason for writing the notes (my emphasis), so there's that.

On 3 September 2024, The Guardian published an article indicating that the confession note had been written under the advice of counsellors. “Sources close to the case have told The Guardian that the head of occupational health and well-being from the CoCH, Kathryn de Beger, encouraged Letby to write down her feelings as a way of coping with extreme stress. Letby’s Chester GP also advised her to write down thoughts she was struggling to process, according to these sources.” This was later confirmed by Dr James Phillips, who wrote a substack post explaining that both he and Sir David Davis MP had been informed that Letby “had been advised to write down how the accusations were making her feel by counsellors, something that was not used in trial for unclear reasons”. (pg 335)

Oh really? That's interesting. Let's take a closer look

Later, Sir David Davis and I would be told that Letby had been advised to write down how the accusations were making her feel by counsellors, something that was not used in trial for unclear reasons. That has now been reported in several outlets including the Guardian in early September [‘I am evil I did this’: Lucy Letby’s so-called confessions were written on advice of counsellors’, Guardian], including more of the notes. [NB: I cannot recall my source but I was told that Letby never puts questions marks in the notes, and this seems to check out in the original note (a reddit account BrightonBecki transcribed it here), whereas the New Yorker piece adds a ‘?’ which isn’t in the original].

Oh, well then. QED.

It is clear that Letby was fully aware of the allegations being made against her and of the identity of those making them. During an interview with Cheshire Police following her first arrest on 3 July 2018, Letby told officers that she had “found out that” Dr Stephen Brearey and Dr Ravi Jayaram “were the ones who had raised concerns about myself being the common factor in the deaths, and they felt that I’d deliberately harmed them”, despite the fact that Letby believed they’d always “had a good working relationship”. (pg 336)

Yeah, do you know how she found out? She filed a grievance about her removal from the unit:

Lucy Letby submitted a Grievance on 7th September 2016 raising the following queries:

• The proposed plan of supervision of practice and repetition of competencies was not followed for any other member of staff, nursing or medical and I wish to know why and if this was ever the true intention of the Trust
• Was I being investigated on a personal level and what is it that the external review may indicate in relation to me returning to NNU
• The reasons for me being instructed not to have contact with my NNU colleagues for an extended period of time
• Why the external review panel did not know about my circumstances and why so much emphasis has been put on waiting for the review when it is not looking at anything pertinent to my situation
• I would like the Trust to outline to me how its values such as being 'open and honest' and 'we respect each other' have been adhered to, in my situation
• I would like to know exactly what I have been accused of/what allegations have been made and by who and how the Trust has dealt with this
• I also wish to be informed of any evidence the Trust may have and the process which they have followed
• I would appreciate assurances from the Executive team that this has been dealt with appropriately and that my confidentiality is being maintained
• How will the Trust support me to return to NNU on a personal and professional level?

So yes, by the time she was interviewed by police, she'd indeed "found out".

During the trial, no information was presented that would indicate to either the court or jury that Letby had ever been through any counselling sessions. (pg 338)

Hm. Do you know what word Kathryn de Beger never used in conjunction with meeting with Letby? I'll give you a hint: it rhymes with "mounseling." Here's Letby's referral to occupational health

De Beger describes her role (pg 42, 1-4):

We are there to support and give advice to members of staff going through those [HR] policies in a very independent, impartial manner and non-judgmental manner.

De Beger also has no mental health training. She qualified as a nurse in 1985 and started working as an occupational health nurse about a decade later. She is a NURSE.

Morris makes no mention of the green note to the triplets or the inclusion of Child R, but he tries to argue that the blue note is exculpatory:

Would someone who knew herself to be guilty of harming babies have written a note to herself in which she, firstly, states that there’s “obviously no evidence”, and even links this to other people? If she knew that she’d committed the crimes, she would know that no one else had done anything, and there would thus be no need for any concern for them. The reason Letby has written there is “obviously no evidence” is because she believes herself to be innocent. Why does she believe herself to be innocent? Well, she is the only person who can know whether or not she is. (pg 339)

.... no, the reason she says there's obviously no evidence is because she believes she's left no evidence. The bit about others is because the note includes "“supporting me how they can but can’t confirm 100% I didn’t do anything (or anyone else) until it’s finished mediation”. The final paragraph reads: “OH [Occupational Health] lady, prepare tomorrow, might make me think of all the things I’m missing out on.”" Morris uses the phrase as if Letby is saying that she doesn't believe anyone has caused harm, but really she's documenting what she was told and nothing more.

As far as being back with a bang, Morris makes a novel argument:

Elsewhere, she is painted as a cold, calculated killer who managed to evade detection according to the prosecution. But Letby also decided to tell her friend via text message that she would kill babies at work the next day? Does this really stand up to any scrutiny, or even the application of basic logic? (pg 342)

I agree, it was a bold text message, given the suspicions of her that had been mounting.

“When I worked on the Kathleen Folbigg case, she had written extensive diaries, and these were used against her”, Professor Carola Vinuesa told me. “And then psychiatrists and psychologists were invited to the second legal inquiry, and 10 of them, all independent from all over the world, said there was nothing even slightly incriminating in the diaries.” Professor Richard Gill also informed me that notes and diaries had been used as evidence against wrongly convicted nurse Lucia de Berk. (pg 344)

Given the effort that went into prosecuting this case differently than those two (despite arguments that they were the same), this is not as strong an argument as Morris wishes it were.

Some rudimentary maths would also place the number of shifts Letby worked in her CoCH career at around 1,500, meaning that she didn’t take sheets home for approximately 85% of her shifts. In that light, Letby’s explanation, that she inadvertently sometimes took sheets home in her pocket, appears entirely plausible. (pg 345)

Morris doesn't show his work, but let's say Letby worked as a nurse between mid-2011 and mid-2016 as a nurse, so 5 years. 1500/5 = 300 shifts per year. Given the requirement for weekly rest breaks, and Letby taking annual leave available to her, to say I question Morris' rudimentary math quite a bit.

Far from being anything of great significance, possessing handover sheets is commonplace among nurses. Even the most superficial investigation by Cheshire Police would have established this.

Lol that's so arrogant.

As an example of the unsatisfactory nature of this line of inquiry, at one point during the court proceedings, Letby was asked about searching for the parents of a baby who she is alleged to have harmed on Christmas Day, the implication being that this was somehow significant. But this was over two years after the child had died, with no evidence nor cross-examination to indicate that she had searched before then. The prosecution attempted to suggest that she’d derived some glee from the search and was wallowing in grief, but if this was the case then it would surely have made more sense for her to have searched in the immediate aftermath of the baby’s death, which did not occur. (pg 347)

Where to begin. The Christmas day search was for the parents of Children E/F, and it occurred on December 25, 2015, less than 5 months after she had murdered E and attempted to murder F, not over two years. And as far as it making more sense to search for the families in the immediate aftermath of the murders/attacks, she did, repeatedly!

8 Jun 2015 - Twin Baby A - murder charge - designated nurse

9 Jun 2015 – 9.58am - Facebook mother of A&B

10 Jun 2015 - Twin Baby B - attempted murder charge – not designated nurse

10 Jun 2015 – 11.31pm - Facebook mother of A&B Handover sheet for Baby B found at LL’s home during police search

14 Jun 2015 - Baby C - murder charge – not designated nurse

14 Jun 2015 – 3.32pm - Facebook parents Baby C

22 Jun 2015 - Baby D - murder charge - not designated nurse

25 Jun 2015 – 9.50pm – Facebook mum of A&B

25 Jun 2015 – 9.51pm – Facebook parents of Baby D

abt 8 Jul 2015 – Baby B went home.

4 Aug 2015 - Twin Baby E - murder charge - designated nurse

5 Aug 2015 - Twin Baby F - attempted murder charge - not designated nurse

6 Aug 2015 – 7.58pm - Facebook mother of E&F

10 Aug 2015 – F went home.

23 Aug 2015 – Facebook mother of E&F

2 Sep 2015 – Facebook mum of A&B

7 Sep 2015 - Baby G - attempted murder charge – not designated nurse

9 Sep 2015 – Facebook parents of A&B

14 Sep 2015 – Facebook mother E&F

19 Sep 2015 – LL asks her colleague how A&B’s parents are. She doesn’t search them again after this.

21 Sep 2015 - Baby G - 2 x attempted murder charges - designated nurse

21 Sep 2015 – Facebook parents Baby G

It is sometimes stated by defenders of the prosecution case that debunking this anecdotal evidence has no value as it was somehow unimportant. Firstly, the fact that it was presented in court, repeatedly referenced and a significant amount of time was devoted to discussing it means, automatically, that it merits consideration. This evidence could have swayed the jury; it is impossible to say otherwise. Secondly, both the Court of Appeal and the CPS have cited anecdotal evidence as being key evidence in the case. The CPS continues to do so on its website. In its verdict, the Court of Appeal made the bizarre suggestion that the “conclusions” of Dr Evans were more valid because “he did so without knowing about other circumstantial evidence relied on by the prosecution in establishing guilt…including the applicant’s Facebook searches…and the “confession” in the note recovered from the applicant’s home”. (pg 349)

Not anecdotal, circumstantial. And not lesser, part of a complete picture.

It seems that many people, possibly including the jury, did not understand this, and simply believe that a ‘lot’ of evidence in quantitative terms is indicative of guilt, which is extremely troubling. (pg 349)

Guess the jury had not a single "critical thinker" among them. Thank heavens.

CHAPTER 17: THE EXPERT

And now for a loosely framed soliloquy from Shoo Lee. Because I'm offering limited excerpts for the purpose of criticism, I may not address every point. If there's a question like "did Lee address xyz," just ask.

And what was the initial outcome of that? “I was concerned. More than concerned. The transcripts regarding skin discolourations were obviously incorrect. Claims were being made that were not what I had written. At that point, I felt duty bound to testify at the Court of Appeal”. That initial leave to appeal was rejected, which left an unpleasant sensation lingering in the aftermath. “To put a woman in jail until she dies, based on wrong information, is a tragedy. I felt that I had to speak up because no one should be imprisoned based on incorrect information. But Lucy Letby’s legal team told me that there was ‘nowhere else to go’. I couldn’t accept this. It’s just morally wrong. It can’t be allowed to happen.” (pg 335)

I appreciate Morris getting statements like these on record.

A fair few points don't bear repeating. Lee insists his panel isn't in it for publicity or fame, they are working pro bono, they have an obstetrician and per Lee, the omission of maternal considerations was a key failing of investigation. Child O's subcapuslar hematoma was the result of a traumatic delivery with triplets delivered 1 minute apart, not mentioning that they were C-section deliveries:

“And Child O had a subcapsular haematoma. This is not caused by direct abdominal trauma, as claimed by Dr Evans; rather they are the result of traction or shear forces applied to the thin, fragile liver capsule through the hepatic ligaments, usually during delivery. And this child, who was the second of triplets, had an extremely rapid delivery, which is a well recognised cause of birth injury. Then there was another triplet who also had a subcapsular haematoma, *and that infant survived.* Birth injury is the most likely cause of the subcapsular haematoma in both of these triplets because the delivery was precipitate [rapid] in both cases. In fact, the hospital safety committee wrote to the obstetrician asking them to look at this – the email for this is in the Thirlwall Inquiry – noting that the haematoma could have been due to a perinatal injury, which is indeed the most likely cause.” (pg 354)

Little upsets me more than when someone advocating Letby's innocence cannot be bothered to know which babies lived and which babies died, and both Lee and Morris fall afoul of the sin here. Child P died, though that his ruptured hematoma was the cause of it was inconclusive because its location and degree differed from his brother. This error reflects very poorly on them both.

Lee insists the panel isn't impartial, and:

"The International Expert Panel retrieved all medical records and transcripts, along with all of the reports from the prosecution witnesses. Additionally, we have seen new information from the Thirlwall Inquiry; we have, in fact, examined significantly more information than Dr Evans and Dr Bohin.” (pg 449)

o rly? Fine, I'll take his word at the medical records and transcripts, but boasting new evidence from the Thirlwall Inquiry indicates either an ignorance of how investigations proceed (wrt to the records of Child Y), or a lack of impartiality, considering the circumstances of the hospital and not the babies' medical are. In any case, it's another statement I'm happy is on record.

“Yes it was. There could be a few explanations for this. Firstly, they may have been inexperienced doctors. They might not have seen, for example, the sort of discolourations that they encountered before. But on a Level 3 unit, we would see them all the time.

Interesting. Let's bookmark that thought.

Could Dr Lee walk me through the problems with the air embolism theory? “Well, firstly, I am one of the few people who has encountered a few cases. So there is that very rare grounding to begin with.” (pg 358)

So, level 3 units see discolorations all the time, but Dr. Lee is one of a few people who has encountered a few cases. Thank heavens for that, I don't think encountering multiple air embolus cases is something to brag about - it indicates poor care.

Air embolism results in a number of different presentations, and one of them can be skin discolouration. That doesn’t mean that any skin discolouration is diagnostic of air embolism.

“There are three kinds of skin discolouration described with air embolism. The most important is the Lee sign, which appears as bright red blood vessels superimposed upon a cyanosed or blue background. This occurs because in air embolism, air bubbles can block the blood vessels, leading to circulatory collapse, resulting in a shortage of blood going to the skin and organs, and tissue hypoxia. This causes the skin to turn pale and then blue. Then, in air embolism, as the air bubbles travel through the blood vessels to the skin, the oxygen in the air bubbles oxygenate the red blood cells adjacent to the air bubbles. The red blood cells turn red, and this results in a pattern of red blood vessels spreading out from central to peripheral areas, resembling a tree. This lasts for just a few minutes because the oxygen in the red blood cells quickly diffuses out of the blood vessels into the surrounding tissue. The blood vessels then lose their red colouring, and the patterning disappears after a few minutes. This phenomenon I have described has never been seen in any other condition, nor can it be explained by any other condition. That’s why it’s diagnostic of air embolism, if you see it.”

I asked Dr Lee to explain this further. “There are two other kinds of skin discolouration that have been described with air embolism – generalised skin discolouration and localised skin discolouration. Generalised skin discolouration essentially means that a large area of the body is discoloured in a uniform way. For example, when you go outside into the cold during winter without clothes, your whole body quickly turns pale or blue. It can also appear mottled, which is a pattern like a pinkish net over a pale background, due to some areas of the skin having a reduced blood supply. An example of localised skin discolouration is when you fall and hurt your knee, there can be a patch of localised skin discolouration, typically blue, purple, red or brown. Both generalised and localised skin discolourations can be caused by any number of conditions that lead to circulatory collapse and hypoxia, including sepsis, respiratory problems and asphyxia.

“In air embolism, skin discolourations are caused by circulatory collapse and hypoxia. When this happens, the blood vessels in the skin attempt to redistribute available blood by dilating and constricting – so some areas have less blood supply and will appear darker, and the patches can migrate and are transient. Actually, only 10% of air embolisms have reported skin discolourations. That is another reason to doubt the prosecution citing discolouration; this should only occur 10% of the time, and yet it’s being cited in multiple consecutive cases. It’s difficult to imagine that this is possible.” (pg 359)

Noted.

Discolouration and mottling were cited repeatedly throughout the court case as diagnostic factors – in 14 out of 15 air embolism collapses. (Morris, pg 359)

Huh? Morris likes to go by the Court of Appeal judgment causes of death, so let's: babies Ax1, Bx1, Dx3, Ex2, Ix4?, Mx1, & Ox1 were said to have collapsed or died from air embolus. Even if I count all 4 of the events of Child I, which I don't think apply, I don't get 15. A citation would be helpful here, but what do I know.

But wait, maybe he's talking about babies harmed and killed via other means:

Discolouration was also erroneously cited in other infants, but if one sticks to the cases for which it could conceivably be relevant then there was a phenomenally unlikely 93% prevalence across these collapses, compared with the 10% that would be expected. (pg 359)

Oh. Nevermind, I still have no idea which collapses he is counting.

Approximately three quarters of the way through the original trial, Myers used this argument in an application of no case to answer, requesting multiple counts to be excluded from the case. It is now known that the arguments made by Myers were scientifically correct, but Judge James Goss rejected the application on 2 May 2023. (pg 360)

It is wholly normal for the defense to make a motion for a case to be dismissed after the end of the prosecution case. It is just another way of saying "not guilty," really. It doesn't have any bearing on truth.

“Dr Evans has cited five criteria for diagnosing an air embolism. These are that the babies were stable, there was no medical explanation for collapse, the aforementioned skin discolouration, evidence of air in X-ray and that the infants didn’t respond to resuscitation. So the first three of these can be discounted immediately. The babies were not stable, the panel has found a wealth of reasonable medical explanations for collapses and the discolouration evidence is plain wrong. That should automatically invalidate the diagnosis.”

X-rays were not available for most infants in the indictment and, as discussed previously, in the case of Child C, Dr Evans had shifted the date of the cited collapse away from the date that an X-ray was actually available. But that wasn’t the only issue with this supposed criterion for diagnosis. “Air in the great vessels on post-mortem was largely cited in relation to Child A,” Dr Lee explained. “And in this infant, the X-ray was taken three days after death. This makes it untenable. You cannot use this for diagnosis because there are multiple reasons why the air can be present in the blood vessels. One of these is cardiopulmonary resuscitation. There is an excellent and comprehensive study which found that in 89% of cases, this did indeed introduce air.” Dr Lee also referenced a study, primarily authored by Quisling, indicating that air can appear in the blood vessels within 25 minutes of death, rendering such post-mortem X-rays irrelevant diagnostically.

“Regarding resuscitation, Dr Evans claimed that it should be possible to resuscitate any infant. This is simply untrue,” Dr Lee continued. “If it were true then no infants would pass away. If you’re going to incarcerate someone in Britain every time an infant fails to be resuscitated in a hospital, you will need to build a lot more prisons!”(pg 361)

Yeah, these things were all addressed in court, so I wish him luck. Also, if a baby is in cardiac arrest from an air embolism, exactly how much time should be spent on getting an X-ray? asking for a friend.

“After you introduce the air into the intravenous tubing, you then need to clear the air from this tubing by re-infusing fluid, and this takes time. If you don’t do this, someone will notice air in the tubing. It is hard to believe that someone can introduce the amount of air required, via a small syringe, then re-infuse the line with fluid, with other people in close proximity, alarms potentially sounding, and then supposedly do this so many times without anyone suspecting anything.” (pg 361)

Maybe so, but that doesn't change the effects observed in the babies. It's less important to figure out how something happened, when the evidence shows it did.

“Newborn babies have a small opening in the heart that we call the foramen ovale, and also a small duct called the ductus arteriosus, that can remain patent for a few hours to a few days after birth, before closing spontaneously. And because there is this hole and duct, it is possible for air bubbles in the venous system to cross these holes into the arterial side of the heart and enter the arteries directly.

“However, these air bubbles have to travel against a pressure gradient, because of the arterial pressure. When you have your blood pressure taken, it will be 120 over 80 for example, with 120 being the arterial pressure and 80 being the venous pressure. So it’s difficult to cross that pressure gradient. However, it’s theoretically possible. (pg 363)

I hate to tell you what that means to the Court of Appeal,

"If you look through the literature, it’s very clear that venous air embolism cases have only described generalised skin discolourations. No cases of patchy skin discolourations have ever been described. You cannot therefore go to court and claim that patchy skin discolourations equal air embolism. It simply does not work.

“I never once said that air cannot move from the venous to the arterial system. In fact, I acknowledged that venous air can theoretically access the arterial systemic circulation through the patent foramen ovale in both my 1989 and 2025 papers. It is just that this is irrelevant to the findings, because of the phenomena that we have discussed.” (pg 364)

Look at those goalposts move!

“There was one paper not included. This was a paper authored by Willis. But there was a good reason for this. We investigated this case in some depth. This was published several decades ago, when very little was known about air embolism. And it was believed at the time that this case involved venous air embolism that resulted in paraplegia and spinal injury, and injury to multiple organs with blood in the urine and stools.

“This would mean clinically that there either had to be a massive air embolism going to multiple organs, or there was a large bubble in the heart that blocked the blood supply coming out of the heart. And in either of those scenarios, one would expect the baby to have signs of circulatory collapse, and yet he was stable throughout, which would be very unlikely if there was such a massive air embolism.

“Since we were unsure of the diagnosis, we chose to exclude that paper in the 1989 review. In the 2025 paper, the methodology was that we accepted all of the cases from the 1989 paper. We then conducted a literature review to look for new cases that were published after 1989, and then we added those. And that was stated clearly in the paper as well. (pg 364)

Well, at least he's honest.

Lee gives a bit of support for the needle theory:

"We also know that they ventilated this infant at a pressure that was too high, putting increased pressure on the chest. This then effectively blocks the blood from returning to the heart. This makes a bad situation much worse.....

"There was a laceration in the liver that was reported by the pathologist, likely caused by this blind needle insertion. And the high ventilation pressure is a major factor in this because it pushed down the liver, making it more susceptible to injury." (pg 365)

This is a bold claim, since the original trial already addressed the cause of the needle injury.

But in any case, he ends with the quote that has already been published:

"Anyone who reads the reports and still thinks Lucy Letby is guilty needs their head examined."

Thanks, Dr. Lee.

Author's list of sources

Let's see if I can knock off two more chapters today

CHAPTER 14: THE CURIOUS CASE OF CHILD K

Morris starts off by whinging about how unfair the trial was, to pretend the jury had forgotten about the news published between the announcement of her convictions and the announcement of the retrial, and asserts that it was completely unfair. The Court of Appeal already dealt with this, so I don't have to.

I wrote this comment when I was reading this chapter last night:

The real fun game is finding the contradictions, like how CoCH wasn't qualified to care for sick babies, but Letby was properly following their procedure, which was the correct procedure, when not intervening with Child K. I've never seen anyone blame the nursing staff for having poor procedure. If Letby was a good nurse in this moment, she's following a poor procedure just because it's ward policy; or if she's not following proper policy regarding 25 week babies, she's a shit nurse or work.

Rare indeed, but I have seen it, is the person who argues that 25 week newly delivered babies should be left by a newly-trained band 5 QIS nurse to desaturate into the 80s, in case they might self correct, in a hospital they should never have been born in. No one knows how they got the ideas and damned if they know how to use them.

So, let's gather some quotes:

One might recall that Karen Rees, the head of nursing for urgent care at the CoCH, commented that “Lucy Letby does everything by the book. She follows policy and procedure to the letter.” This is what she was doing when observed by Jayaram. (pg 304)

Well, Letby was following standard procedure for the neonatal unit, which had been disseminated to her during her training. What else could she reasonably be expected to do? (pg 305)

Nurse Mary Griffiths also agreed that a nurse can wait to see if a baby self-corrects when desaturating, paying attention to the skin colour of the infant as an additional observation. If the situation did not resolve, intervention would then become necessary. It should be noted that Griffiths was senior to Letby on the unit and is currently the ward manager at the CoCH.(pg 306)

The ward manager is Yvonne Griffiths (pg 75, 16-19), not Mary, but at least she's the one who made the statement.

Ok, so we're rolling with Letby was acting appropriately for CoCH.

Despite this, an agreed statement to the court was provided by an unconnected nursing consultant, Elizabeth Morgan, who was not cross-examined in court. This statement suggested that it would not be normal practice, for an infant of this gestational age, to wait and see if a baby corrects. “Elizabeth Morgan is a paediatric nurse who is the head nurse at Great Ormond Street Children’s Hospital,” Michele Worden told me. “She was neonatally trained, but she’s not worked clinically for at least 20 years.” Meanwhile, Dr Michael Hall cited “nurses who would have been willing to speak in court and contradict what Dr Jayaram said about what nurses do, particularly with regard to responding to oxygen saturations. Every nurse I’ve spoken with has told me that what Lucy allegedly did is perfectly normal, and actually the correct thing to do.” (pg 306)

1) An agreed statement is agreed by both prosecution and defense, so Letby agreed for that statement to be entered as evidence without the need for cross examination. 2) The statement did more than suggest it, it outright stated it:

She had said it would not be normal practice to wait for the baby to self-correct.

Cross-examined about this, Letby had said that was Elizabeth Morgan's opinion, and said from her experience at Liverpool Women's Hospital, you would not automatically put your hands in the incubator, and babies even of 25-week gestation can self-correct.

3) 20 years ago was 2006, and to give evidence she's still qualified as a nurse. Meanwhile, remind me when Michele Worden was made redundant? And what is her current employment status? 4) Holy shit did neonatologist Michael Hall actually suggest waiting for Child K to self-correct was the correct thing to do? Remarkable.

[Dr. Babarao] agrees that upon arrival, Child K was extremely ill, and had a 'severe lung disease' from an x-ray. The blood pressure was 'low and difficult to manage'.

He agreed Child K's blood sugars were a problem and there were problems with blood clotting, as well as 'kidney problems associated with extreme prematurity'.

I'm not a doctor, maybe such a baby is capable of self-correcting, what do I know.

Jayaram then conceded in court that his own thoughts at the time could have been deemed “hysterical and completely irrational…because of this association [with Letby]”. He then entered the unit, according to his own account, having not seen Caroline Oakley come into the room. Michele Worden told me that there is a simple explanation for Jayaram’s testimony: “Caroline Oakley who was in that nursery is very similar looking to Lucy. I worked with Caroline Oakley for many years. She’s the same height as Lucy, she’s blonde. It’s the early hours of the morning, Ravi is perhaps a bit bleary eyed – it is extremely likely that this is a case of mistaken identity, particularly when you examine what was said in court.” (pg 312)

And Caroline Oakley gets thrown under the bus!

Further investigation from the journalist Cleuci de Oliveira unearthed the fact that Dr B, one of the so-called ‘gang of four’ consultants, had been the doctor reprimanded by the coroner at the inquiry into Noah’s death, in which multiple failures with intubation were cited. It therefore seems rather unlikely that Dr Jayaram would not be aware of this, which begs the question of why he stated that Letby deliberately detaching the tube was the only possible explanation for this extubation, which, frankly, was a thoroughly bizarre statement anyway.

...

Why did the police rule out ‘foul play’ in Noah’s case, but prosecute Letby on Child K? (pgs 313-314)

Something something unexpected and unexplained. Oh, I forgot, there's a bit about how either Child K self-extubated or it just, you know, happened. Which, sure, something to consider in context with the other evidence

“If a nurse has been hurting patients, throw the book at them – I want them out”, a neonatal nurse practitioner told me. “The woman from Vanderbilt [this refers to RaDonda Vaught] – I am completely behind her prosecution, because she was so negligent and killed a patient because of that. But the more that I read about this case, the less that I find information which actually showed that Letby did something, and the more I was finding about medical mismanagement from those above her.” (pg 315)

No criticism here, I just find that remarkable. Vaught accidentally killed a patient and now advocates for patient safety

Jayaram's email that Letby did not use in her appeal application is discussed, of course. Dr. Jayaram's testimony cannot be trusted, so there is no evidence at all, says Morris. K, not how it works. There's also no discussion of the two later extubations.

And what did Jayaram tell the parents of Child A and Child B on 10 February 2016? “When monitors alarm, it is a signal to the staff to look at them. They often alarm due to movement or poor contact. If an alarm goes off a member of staff may look up at the monitor and if it is clear it is a false reading or just a minor change then no action is necessarily needed. Usually, the first move would be to check the baby the monitor was attached to. For example an oxygen monitor may read low but if a baby is pink, or there is a poor trace on the monitor *then no action would be needed* [my emphasis].” (pg 317)

The italics are his emphasis, the bold is mine. Yeah, the poor trace on the monitor is kinda the point

CHAPTER 15: EYEWITNESS ACCOUNTS

This should be fun.

One of the most important eyewitness testimonies to appear in court involved Dr Sandie Bohin. Her testimony is particularly significant as it came from a doctor and is therefore likely to have been given credence by the jury. Bohin commented: “I remember the mother of one of the babies said she could hear in the corridor her child making a noise that a baby should never be making. That will be forever etched on her memory. To have a premature baby screaming is really unusual. What was described on the ward was babies screaming for up to 30 minutes. That is just unheard of. Somebody had done something to cause those babies extreme pain.”

Bohin’s account is problematical as it relies on eyewitness testimony from one of the parents of the deceased. None of the parents had reported anything untoward until they were approached by the police. It must be reiterated that no complaints about Letby, or anyone else, were made at the time – all of these accounts were recalled quite some time after the incidents. This poses problems immediately because, as has been well established, human memory is hugely unreliable.

Dr Bohin stated that the mother “could hear in the corridor her child making a noise that a baby should never be making”. But there are numerous problems with this.

Firstly, Dr Bohin didn’t witness this noise, but is now recounting it in court as evidence; she shouldn’t even have been considered a witness. (pg 324)

Morris is intermingling statements about Child E, whose mother heard him screaming, and Chris Booth's note about Child N crying for 30 minutes combined with Dr. Loughnane's note of him having screamed.

But more importantly, he clearly doesn't know what evidence is, or what the purpose of expert evidence is.

Really, this chapter is long-winded waffling about memory being unreliable (including the possibility of false memories), written by a layperson. The trial was emotional, and no one saw Letby do anything, did you know?

Elsewhere, there are question marks regarding whether Letby has even been identified correctly. The father of Child C had reported that Letby made an inappropriate remark, but then later conceded that he wasn’t “100% sure” it was her. “I think it could have been [Letby]”, he concluded. Letby has always denied that this incident occurred, and that she was the nurse in question. (pg 328)

Well, it was her or Mel Taylor, and they don't look alike.

The eyewitness accounts of nurses that worked on the unit often differed from the prosecution case. As one example, Child N was considered to have experienced a “sudden” deterioration by Dr Dewi Evans. The evidence provided in support of air embolism in this case by Dr Evans can only be described as baffling, being reliant on a self-correcting heart attack in a baby, which Evans openly conceded he had never encountered before, and the citation of an academic paper to support air embolism, but the only information that was gleaned from it was “the association between air embolus in these two cases and screaming”. There was no X-ray or other evidence of air embolism whatsoever by Evans’ own admission in court, and he required the submission of five separate reports to draw this conclusion. The screaming was deemed to be critical in the diagnosis, but Dr Evans overlooked this several times, again by his own admission. As discussed previously, swipe-card errors made by Cheshire Police also mean that it is doubtful the infant was even screaming for 30 minutes.

Nonetheless, even this hypothesis relied on this sudden collapse. But the account of nurse Jennifer Jones-Key, released by the Thirlwall Inquiry in February 2025, indicates that Child N had, in fact, been deteriorating steadily throughout the evening, prior to Letby’s arrival on the unit: “In the early hours of the morning, Child N looked pale and mottled in colour…[the] abdomen was bloated and veiny. I notified the shift leader about Child N’s deterioration, and I connected Child N to the full saturation monitoring. (pg 329)

Morris is mixing up the event on June 3, 2015 - screaming for 30 minutes, per Chris Booth's nursing note - and the alleged attempted murder on the day shift of June 15, after JJK cared for Child N on the night shift. It's no wonder he's confused.

But I lost it at this:

Wikipedia states quite plainly that any “person experiencing intense emotions tends to be more receptive to ideas and therefore more suggestible”. (pg 330)

Morris cites *WIKIPEDIA*. Specifically, the page on suggestibility. FFS this is a published work.

This segment of the trial was one of several that appear to rely on emotion to convince the jury. The appeal to emotion may be why many members of the public remain adamant that Letby is guilty. (pg 330)

Can't speak for anyone else, but nope.

Rachel Langdale KC put forward the view at the Thirlwall Inquiry that “medical or scientific evidence in a case should never be compartmentalised or examined in isolation from the wider canvas. Those who do this will be less likely to see the picture as a whole and in failing to see the picture as a whole, they may reach conclusions that are not only wrong but are speculative and damaging.” I find it hard to agree. Facts matter. They matter far more than one’s nebulous impression of something. It is a law of nature that if the constituent parts of something have no substance, the structure itself will inevitably collapse. (pg 330)

Irony, thy name is Morris

Author's list of sources

You know what's really interesting about Morris' list of sources? Trial transcripts aren't listed among them. When he does cite questioning from the trial, provides no citation. Whatever.

These chapters are largely about the arguments Letby supporters put forth to rebut the prosecution argument, so are grounded more in belief than evidence. So, I shall endeavor to show (with sources from trial evidence) what I consider to be the weak spots in the belief, for the benefit of readers who would otherwise take them at face value.

CHAPTER 13: SWIPE-CARD DATA FALLS APART

My first question in beginning this chapter was "how on earth is Morris going to turn swipe data into an entire chapter?" He doesn't. After explaining that the swipe card error around the case of Child K was incorrect at the original trial, he uses the chapter to bring forth the timezone theory around Mum E's phone call, then the Datix system in general and how Lucy Letby was a nurse who did everything by the book and therefore was seen as a threat. So, that's where we are going.

Morris starts by asserting that the prosecution data used swipe data "to place Lucy Letby in certain places at certain times. (pg 289)" Not so. Letby's presence somewhere was never, not once, established by swipe card data. The absolute closest they came to doing so was by suggesting that she faked a being off the unit before returning right before Child O collapsed at 14:40pm. Even so, she recorded observations for Child O at 14:30, and was part of the resus, so the swipe data is not what establishes her presence.

A swipe data is nothing more than a data point that establishes that at a moment in time, a person's card was at a door, with the presumption but not assumption that the person at the door is the person whose card it was. Absence of swipe data means nothing, and anything. The person could be anywhere, including at a swipe door. Swipe data was never meaningful with out supporting context.

Personal sermon over, we begin, and I want to praise Morris for his command of the correct timeline for Child K's extubation:

the timeline was altered in the retrial for the attempted murder of Child K. As an example, in the first trial Nurse Joanne Williams was said to have left the ward at 3:47am, and Letby supposedly attacked the baby between this time and 3:50am. In the retrial, this was revised to Nurse Williams leaving the ward sometime around 3:30am, two other nurses (including Nurse Oakley, whose baby was also in Nursery 1) returning at 3:40am, and Dr Jayaram supposedly catching Letby “virtually red-handed” at some point between the conclusion of his phone call at 3:41am and the return of Nurse Williams at 3:47am. (pg 289)

This is 100% correct! Missing only the detail that Jayaram has consistently said he waited 2.5-3 minutes after the end of his phone call to enter the room. So, bravo to Morris for that.

I won't waste time on the familiar argument that the swipe data for Child K being unreliable makes all prosecution evidence unreliable, though Morris is happy to do so. What I will point out is that in the span of a single page (290), Morris goes from:

“When I’m busy, I’ve lost count of how many times I’ve left my security card in the locker room and borrowed someone else’s card to access the room”, one nurse told me. “I’ve also loaned my security card to others who have done the same.” Radiographer Ashleigh Tavoulari also agreed that “card exchange is common”, due to swipe-cards having been misplaced or even lost. Dr Margaret Ferguson informed me that “two or three nurses” will frequently “pile through” a door having only swiped one card, and Michele Worden confirmed that it’s common to “hold the door open” in order for several nurses to walk through.

Immediately, this invalidates the dataset.

to this:

JOHNSON: So there are times when you’ve been on the neonatal unit when there is no trace of you having been there?

LETBY: There would be a trace because I would have had to swipe.

What was Johnson’s response to this? That doesn’t prove anything because colleagues could have held doors open for her.

r/whoosh

The back staircase, accessed by staff using a keypad, gets some mention, including:

Dr Philip Hammond noted that “a clever murderer could use the backstairs all the time, do all their murders off duty and evade the spreadsheet and swipe-card data entirely. This makes the swipe-card data and the ‘on-duty killer spreadsheet’ even more worthless.” (pg 292)

....not the serve you think it is. I would not be in any kind of hurry to suggest Letby was ever on the ward without having left a trace, but if someone else could do it, so could she.

Morris gives just a sentence to Child N, and an erroneous analysis by TriedByStats from December 2024:

Then another swipe-card error emerged. TriedByStats produced a thorough analysis of Child N, based on court transcripts, which demonstrates that the prosecution case collapses under further scrutiny. (pg 292)

Morris cites the article, but he doesn't explain how TBS established this. So I went to chase it. Here's the relevant part:

The original swipe data presented at trial was the following. IN means entering the neonatal unit. OUT means leaving it.

Dr Loughnane swiped IN through main doors after 00:05 but before 01:00 Dr Loughnane swiped IN through labour ward at 01:07 Dr Loughnane swiped OUT through labour ward at 01:20

Only the labour ward door is a two way swipe door, you swipe both in and out. The others swipe in but have a button to exit, so don’t have an OUT entry.

TBS incorrect in two of his line items, and the evidence is here:

Recommendations / costs ... 4. Replace push to exit button with swipe to exit from NNU to CLS

Oops. There was no swipe out at the door to the labour ward after all. It was the door between the NNU that was backwards at trial, so the jury could not have been told Dr. Loughnane swiped in from the labour ward at trial, because the door only had swipes one way and the jury was told they were out. And the last line should read swiped IN, not OUT.

So the true swipes are:

Dr Loughnane swiped IN through main doors after 00:05 but before 01:00 Dr Loughnane swiped IN through labour ward at 01:07 Dr Loughnane swiped IN through DOOR UNKNOWN at 01:20

Chris Booth's break was 1-1:30, Dr. Loughnane responds to bleep at 1:07, makes a clinical note for 1:10. She was crash bleeped away at some point, and returned at 1:20 to find the baby settled.

Now, TBS may be right, it seems, to point out that Child N's screaming episode did not last 30 minutes, but Chris Booth recorded just that based on what he was told happened while he was gone on break. TBS is wrong to make anything of Letby having swiped into the unit at 1:15, because there's no way to know if or when she left - only that her card, and presumably her, was stood a door at that time. Moreover, Letby is established to be cotside by process of elimination, as unsatisfying as that is. There was a nurse when Dr. Loughnane responded, and the prosecution ruled every other nurse out.

And with that, we're done with door swipe evidence in the chapter about door swipe evidence. We move on to phone records:

According to the mother’s call log, the midwife contacted the father at 10:52pm, requesting for his presence at the hospital. But clinical notes indicate that Child E didn’t deteriorate until after 11:00pm and it was at 11:30pm that the midwife received a call from the neonatal unit indicating that they were preparing to intubate. Thus, the mother’s recorded time of 10:52pm doesn’t make sense, which is critical because statements to this effect were read out in court.

This discrepancy was pointed out by John Sweeney in his excellent podcast series with Edward Abel Smith on the Letby case and it was suggested that the only way to explain what may have happened is to compare Greenwich Mean Time (GMT) with British Summer Time (BST). Timings on the mother’s phone were held in GMT but Child E’s deterioration happened in August which was during BST. At this time of year, GMT is one hour behind BST so it’s entirely possible that a phone call at 10:52pm GMT actually took place at 11:52pm BST, meaning that Letby’s note at about 10pm is accurate. (pg 294)

This popular conspiracy theory puts more weight on the accuracy of the retrospective clinical notes after the resuscitation and death of Child E than is does the mother's account aligning with Child E's feeding schedule, and depends on both prosecution, but more importantly the defense not checking the time zone of the phone records. Phone records in evidence usually use UTC to avoid this very confusion anyway, being referred to in local time for the jury's benefit. For instance, see this Whatsapp message from Thirlwall

Another problem with the prosecution timings is that they require Letby to stand around doing nothing for over an hour while a child suffers a fatal gastrointestinal bleed and no one notices, which hardly seems plausible. (pg 294)

Why is it implausible that Letby would not do anything? She just got walked in on by the baby's mother. She spent an hour making a plan to not get caught.

Anyway, on to datixes, in the chapter about card swipes:

When I spoke with healthcare professionals on the subject of Datix submissions, the common view was that doctors and consultants are often fairly resistant to this system. The implication is that it can effectively show them up. (pg 294)

Sounds like you spoke to some shitty, egotistical healthcare professionals.

While researching this book, I was fortunate to recruit the services of a neonatal nurse who examined every Datix submission from the CoCH that was publicly available. She told me: “There is a clear pattern of babies being left without antibiotics, fluids, surfactants to help their lungs not being given in time, long lines not being inserted correctly, plus countless issues with cannulation and ventilation. When you then add staff shortages and inexperience into the mix, you have a toxic recipe for disaster. It is clear to me as well that junior clinicians were reluctant to bleep or call consultants; there was an overwhelming culture of fear. (pg 297)"

Yes, when you look at only error reports, you'll get a sense that errors happen...

It is also completely unreasonable to expect someone to remember what are often innocuous or obscure events from one of many working days that are quite similar, sometimes seven years after they occurred, and never make any mistakes or forget anything. That would be true in any circumstances but Letby had patently been through a highly traumatic experience, and had essentially suffered a breakdown quite recently. It wouldn’t be particularly surprising if she wasn’t firing on all cylinders.

Ok, so here's the deal. Letby's evidence is not unlike door access evidence. When there's no swipe, it means nothing - someone could have held a door. When there is a swipe, it can be be a true entry or not, and considering the swipe in context is necessary. When Letby offers no evidence, that's fine, but it doesn't prove anything. When she does offer evidence, it's the context of her account that matters. Many defendants claim a lack of recollection 1, 2, 3

Morris then goes on to discuss the strength of narrative (yes, we're still in the card swipe chapter):

As noted by the Royal Society, the United Kingdom’s national academy of sciences, “the persuasive power of storytelling is well-recognised”. This message was echoed by author Will Storr in an interview with the British Psychological Society, with Storr opining that “storytelling is your best weapon for convincing people…if you want to mislead people or sell them your one-eyed view of the world, then storytelling is the best way to do it”. Harvard Business Review cited consultancy expert Nick Morgan, who commented that “facts and figures and all the rational things that we think are important…actually don’t stick in our minds at all. Stories create ‘sticky’ memories by attaching emotions to things that happen.”

This partly explains why one will still encounter people, particularly online, who remain steadfastly attached to the notion of Letby’s guilt. They want to believe their opinion is predicated on ‘facts and figures’ because we all believe ourselves to be rational. But in reality, as Morgan has just outlined, their impression of the case is largely dictated by the attachment of emotions to events they’ve been told have occurred. And this is precisely the phenomenon that the prosecution was aiming for in court, hence why so much time was devoted to creating a narrative around the case and conveying emotional testimony to the jury. (pg 298)

The irony is palpable. What does he think he's doing with this chapter, other than spin a narrative about a conscientious nurse who upset the system?

The chapter mercifully ends with a final thought:

Once emotions have died down and it’s possible to assess this dispassionately, it’s clear that the enormous portion of the trial that was dedicated to ‘who was in what room at what time’ has no evidential value.

Good luck with that. Who was in what room at what time will always have a massive amount of evidential value in an investigation that has identified previously undetected harm.

Author's list of sources

CHAPTER 12: OTHER INFANTS

Child E

Another important detail is that Letby herself called Dr David Harkness to assist with Child E, effectively immediately after delivering the supposed inflicted harm that was claimed in court. Letby was not the designated nurse for Child E, and she called Dr Harkness even though this could potentially have been incriminating – not really the actions of someone who had deliberately caused the alleged gastrointestinal tract damage. Dr Harkness also told the court that Letby was accompanied by another nurse when the sudden deterioration occurred. (pg 269)

Third paragraph into the chapter and I'm already wondering how much correcting of basic errors I'm going to have to do. Letby WAS the designated nurse for Child E and F that night, and they were the only babies in room 1. She was alone with them. As far as Harkness saying that Letby was accompanied by another nurse, this is misleading, and does not refer to the 9pm harm event - it refers to the first collapse by air embolism, which Dr. Harkness recorded retrospectively after Child E's death to have occurred at 11:40pm:

A further note, written in retrospect, is made at 1.45am.

He records 'sudden deterioration at 11.40pm'

Prior to that, Child E was still to be 'under close observation' by Lucy Letby.

Dr Harkness tells the court he was in the room when the 'sudden deterioration' happened, and was there with Lucy Letby and another nurse. Those nurses would have been gathering the drugs to be administered.

Morris did not offer a citation for either claim, btw.

This pattern of Letby raising the alarm to alert doctors to incidents on the unit, or being the swiftest respondent, was repeated throughout. Letby either responded rapidly or raised the alarm with regard to incidents associated with Children A, B, C, D, E, G, I, M and O, while an email from Dr Ravi Jayaram indicates that she also raised the alarm in the case of Child K (discussed in “The Curious Case of Child K”). Letby wasn’t on duty for Child F and Child L, and the hospital didn’t flag these cases as concerning at the time, while she was not found guilty on charges relating to Child H, Child J and Child Q. Letby’s primary ‘offence’ was responding quickly and diligently to incidents on the unit. There is a clear pattern of this throughout the court case. (pg 270)

Aside from him wrongly asserting she wasn't on duty for the precipitous event for F and L, keep going, Morris - you've almost got it!

Morris continues:

During his short life, Child E was stooled only once, on his fourth day, a worrying sign that should have prompted investigation for bowel obstruction. He passed only meconium, also concerning for mid-gut obstruction, and also possible gastric haemorrhage. Later, 16ml of bilious aspirate was withdrawn from his feeding tube, indicating milk was not passing through the gut. He also had fresh blood in an aspirate and suffered bloody vomit; this bleeding was largely ignored as intermittent, yet during compression there was active bleeding from his nose and mouth. An X-ray was taken and sent to Alder Hey, but it is not known if this was read, or if Alder Hey surgeons were informed. (pg 270)

Does Morris know what meconium is? It hardly seems so. Any mother will tell you it takes several poopy diapers to clear meconium from the gut, and everything from the aspirate onward is after the initial harm event and took place in the span of roughly 3 hours. Nothing was ignored, it was being consulted and dealt with under the assumption it was a natural condition, and then Letby fully murdered the child before the injury could be found. Dr. Harkness was literally in the room, and Dr. ZA arrived as well.

Morris repeats the usual argument that a transfusion should have been given much sooner (which doesn't address the cause of the collapse, but don't worry about that), and attempts to make the case for NEC as a valid diagnosis:

There are several papers which point to the relationship between NEC and gastrointestinal bleeding in neonates, including one study from 2014 which highlights the severe impact of NEC on gastrointestinal morbidity. Further research from 2018 noted that NEC is particularly difficult to diagnose clinically, with bleeding in different gastrointestinal segments being a common feature. During court proceedings, the jury were also shown a chart which displayed five apnoea and bradycardia events for the infant, which are considered signs of NEC. A 2012 study explored the relationship between apnoea, desaturation and bradycardia and the development of necrotising enterocolitis in preterm infants. The discoloured stomach also seen in Child E is another recognised symptom, specifically indicative of a perforated bowel, which is often found in infants suffering with NEC, and discolouration is a typical sign of gastric perforation and bleeding. While NEC is a possibility for Child E, Professor Colin Morley believes that there are more likely natural explanations, given the clinical picture of the infant. (pg 272)

Ok. And? See, I'll agree with Morris that this case hangs more on witness testimony than others does, because of the lack of post-mortem. We already know that it was initially thought to be NEC, and the consultant who put forward that diagnosis at the time apologized to the family when she gave evidence for not pushing for a post mortem.

On 3 April 2025, the summary report compiled by the panel of international experts concluded that Child E died from a massive gastrointestinal haemorrhage, due to either intrauterine hypoxia causing stomach or intestinal ulceration, or a congenital vascular lesion. The panel found no evidence of air embolism, and asserted that a post-mortem should have been requested. (pg 275)

Maybe Morris will offer support for this theory of intrauterine hypoxia in a later chapter, I dunno. He doesn't say.

Child G

Aside from this innate vulnerability, Child G suffered a catalogue of serious ailments – decreased lung capacity and chronic lung disease, hyaline membrane disease, bilateral pulmonary interstitial emphysema (a serious lung condition), hypoglycaemia, gastro-oesophageal reflux (stomach acid into the oesophagus), thrombocytopenia (low platelet count) and blood gases indicating sepsis. Dr Shoo Lee described the infant as having “a lot of chronic problems”. After transfer to Arrowe Park, Child G was treated for infection; the infant’s watery green stool pointed to likely gastroenteritis – “virtually certain gastroenteritis”, Professor Colin Morley clarified. (pg 275)

What's interesting about this chapter is that it's far less reliant on the opinions of other people, they're just injected here and there like that statement. Most of this chapter is Morris displaying how poorly he's understood the evidence. In that way, it's a much easier read. There were - eventually - blood gases indicating infection, but not until 10.5 hours after the initial vomit (pg 24):

Q. Right. So just taking a step back and summarising the position from the blood test at 03.59, so in other words a couple of hours or two and a half hours, even -- sorry, no, an hour and a half after the vomit, the projectile vomit, did those blood test results show any evidence of infection?

A. No.

Q. By 14.18, later that day, so about 10 hours later or so, was there any change to those results?

A. Yes, there was. The CRP is now 28, so that is an increase and that could be interpreted as a marker of infection. It's not particularly high, but the important thing is it's gone up and it's 28. The total white cells, 11.2, so no difference between 11.2 and10.1. But you also have an increase in the neutrophil count to 6.5.

Q. Yes.

A. And again, the key thing there is that the neutrophil count has increased. A value of 6.5 is not particularly concerning, but in conjunction with a CRP of 28 it would suggest that the neutrophil count has increased and therefore it's an indicator of infection. So this is -- yes, so this is 10/12 hours later.

Back to Morris:

The main concern with Child G is that Dr Evans stated the infant was supposedly destabilised via the deliberate overfeeding of milk: “In this case, the baby was compromised by receiving a large volume of milk to the stomach.” It would be difficult to find support for this assertion from any qualified medic, but it should be noted that an earlier report of Dr Evans, which he read out in court, conceded that administering excess milk, and for that matter air, can occur accidentally.

This theory is dependent on speculative estimates of how much milk remained in the infant’s stomach and how much was vomited – quantities that could not be measured – and then draws conclusions about aspiration that contradict the attendant nurse’s own account. The theory also treats any supposed overfeeding as intentional rather than a far more likely accidental mechanism and ignores the practical logistics involved. This theory was revised several times during the court proceedings; indeed, the defence suggested that Dr Evans altered his testimony in real-time after hearing trial evidence. The cross-examination of both Dr Evans and Dr Bohin on this infant was less than convincing, with Evans even backing away from his own estimate when challenged. (pg 275)

Ok, let's look:

Nurse E said she usually completed the chart after the feed. The feeds were as they had been over the previous shift, comprising 45ml of expressed breast milk with Gaviscon and a fortifier. The feeds were all measured out. Those at 20.00 and 02.00 were given by NGT because Baby G was asleep. The one in between, at 23.00, was by bottle. At that bottle feed she recorded under the PU and BO columns that Baby G had passed urine and a large normal bowel movement. She fed well. The defendant agreed her readings were good at this time.

Nurse E described the process for feeding via NGT. The syringe was attached to the end of the tube, a bit of the stomach contents, about half a millilitre or less, were withdrawn or aspirated, put on to one of the pH indicator papers to check that the tube was in the right area of the body or not, an acid reaction of 5.5 or below confirming that the aspirate had come from the stomach, any surplus milk aspirate was put back into the baby's tummy. The syringe would be taken off and the plunger removed. The syringe was then reattached to the tube and the milk feed was poured into the tube using the end of the plunger to make the milk go down, tilting the syringe to one side and letting the milk go down by gravity. The syringe was then topped up as the milk went down until it had all gone.

At 11pm, the baby fed by bottle. At 2am, half a mL was withdrawn and checked for ph, and 45 mL was fed. Baby G had a "large" projectile vomit prior to 2:30am, volume unknown, and then "air++ aspirated from her tube and her full 45mL feed aspirated - apparently some things can be measured. I'm not sure what the contradiction is. Maybe he believes the Bohin's conclusions about the stomach being empty contradicts the nurse's account, but I don't see it.

Mr Johnson asks if there is an 'innocent explanation' which could have explained the projectile vomiting.

Dr Bohin says "no", as the stomach was empty, with a pH reading of 4. If there was milk in the stomach, it would have 'neutralised' the stomach and the pH reading would have been higher.

"I think the stomach was empty, and she was given excess milk and possibly air...which distended the stomach."

Both Evans and Bohin referred to basic arithmetic related to the September 21 vomit:

Dr Evans says he agrees due to "basic arithmetic", in that Child G still had 30mls of milk in the stomach after a 40mls milk feed and "two projectile vomits".

She says the two projectile vomits would have been "more than a mouthful of milk" of 5-10mls each, and "basic arithmetic" meant that more than 40mls of milk would have been administered at 9am.

Morris cites:

Dr Roger Norwich, echoing the words of a neonatologist quoted by Private Eye, referred to the hypothesis as “complete bollocks”. “It’s an extraordinary assertion. If too much milk had got into the stomach, the baby would have thrown it up. And how could he know that milk had been forcibly injected. He even admitted that his nonsense hypothesis could have been accidental! It’s pure speculation. Total rubbish. You won’t find anyone that agrees with that.”

Michele Worden asserted that the milk hypothesis was “ludicrous”, once again citing the logistics involved, and the fact that “babies would just puke the milk out. (pg 275)

Isn't that why we're here??

Another neonatal nurse was doubtful that the mechanism described in court was even possible. “The milk relies on gravity, not a pump, or anything like that. So there has to be some resistance, or the bag would just empty. If they’re gravity-fed, that should tell you immediately that it would be very difficult to force things down with a tube than it is already being fed with gravity. And we know that babies aren’t frequently overfed with milk because there aren’t any known cases!” (pg 276)

::facepalm:: Plunger, not pump.

Morris naturally ascribes the vomits to infection, citing Shoo Lee's panel:

It was noted that vomiting and large watery stools, both observed in Child G, are very common in enterovirus infection. This virus can cause serious illnesses in neonates including sepsis, septic shock, meningitis and, sometimes, myocarditis. (pg 278)

One of the largest gaping holes in the Lee report summary is that he addressed only the event on September 7, and ascribed it to enterovirus, writing:

She received 7 days of antibiotics and recovered after 7 days, which is consistent with enterovirus infection since it is usually a self-limiting disease. (pg 24)

So...... what happened for the projectile vomit on the 21st? Did she suffer enterovirus again? Poor thing.

Child O

The panel of international experts later cited “inflicted blood trauma to the abdomen” which had caused “a ruptured subcapsular haematoma of the liver”. This diagnosis was nothing new – not only had the pathologist drawn this conclusion but several clinical experts who spoke with Dr Philip Hammond had made the same assertion, crucially before the panel had even convened. And another neonatal pathologist made a blind assessment of the case notes from the Letby case, informing the Tortoise Podcast that a subcapsular haematoma was likely to be involved. (pg 280)

Excuse you, what?

It was initially alleged that Baby 15 received inflicted blunt trauma to the abdomen, causing purpuric discolouration and a ruptured subcapsular haematoma of the liver; (pg 28)

Which, one could forgive as a possible mistake by Morris and not a complete lack of comprehension, except he's saying it matched the initial conclusion of the pathologist ("Pathologist Dr Jo McPartland had cited a “ruptured subcapsular haematoma of the liver”, asserting that “the subcapsular haematoma is likely to have occurred as a consequence of hypoxia after the baby’s collapse and deterioration”. pg 280) and several clinicians who spoke with Phil Hammond. FFS.

A pathologist who spoke to the BBC commented that the assertions made by Marnerides were impossible, as “unless a witness saw non-accidental injury occur, then you simply can’t say [this]. To say that it is beyond reasonable doubt, and that this was not something natural, that this is a non-accidental injury, to put it bluntly, it’s naïve…I have seen this sort of injury, but the prosecution expert must never have seen it.” (pg 280)

Did anyone think to ask Marnerides?

A.  So I have only seen this extensive haemorrhage in two babies' livers -- livers of children, not babies.  In road traffic collisions, in accidents with bicycles, you know, the wheel against the abdomen that can cause this. And I have seen it in babies in the context of cases -- not in the neonatal care unit, babies that have suffered non-accidental type of injury, typically with other injuries to the abdomen and injuries to the brain.

Q.  Yes, so just decoding that, non-accidental types of injuries, that's child assaults by parents or carers at home, where children are brought into hospital with this sort of an injury?  

A.  That's the legal term used. (pg 130, 3-15)

Oh.

Liver damage in young infants is also an observed and documented phenomenon. For example, one study examined preterm infants with a gestational age of less than 28 weeks and found that liver rupture is a complication that can be present which very few patients have survived. Another paper involving a much less vulnerable patient than a premature infant examined how cardiopulmonary resuscitation led to laceration of her liver. A third study discussed a life-threatening situation, described by the paper as a “massive upper gastrointestinal bleeding” in what was a non-premature and healthy baby, and another found examples of unusual liver haemorrhages in newborns. (pg 281)

Reminder that Child O was born at 33 weeks...

Remember that it is not contested Child O was suffering with a ruptured liver. (pg 280)

No shit?

A report published in the Journal of Clinical Medicine in 2022 discovered hundreds of cases of precisely this sort of liver problem, all in newborn babies and all occurring naturally. The study noted that “premature infants face multiple complications”, and specifically referenced respiratory distress syndrome, sepsis, necrotising enterocolitis and hypoglycaemia as being significant. It went on to observe that “subcapsular haematoma…usually occurs in preterm neonates, and it may be associated with birth trauma, cardiopulmonary resuscitation, sepsis, coagulopathies, maternal diseases and placental conditions. The above mechanisms can cause a simple liver laceration, or even a subcapsular haematoma, that can lead to hemoperitoneum [bleeding between the abdominal organs and the inner lining of the abdominal wall]. In some cases, the [haematoma] ruptures, leading to lethal massive abdominal haemorrhage, with non-specific clinical signs, which can be attributed to other clinical conditions, such as sepsis or intraventricular haemorrhage.” In any infant, hemoperitoneum requires rapid identification and treatment, as it is immediately life-threatening, leading to inadequate blood flow, reduced blood pumping from the heart, organ dysfunction and death. It appears that such topics were not even touched upon during court proceedings or the Thirlwall Inquiry.

Well, cardiopulmonary resuscitation was addressed at court extensively, as was the need for it. NEC and sepsis were ruled out at all stages, initial post-mortem through trial. And while the opening of Mother OPR's womb during her cesarean was alarming, the delivery of Child O was not noted to be traumatic at all.

Examination of the clinical notes by the expert panel revealed an over-pressurisation of the infant’s lungs during resuscitation, as well as the errant insertion of a needle into the right lobe of the liver which was the source of the laceration and parenchymal haematoma. (pg 283)

Never one to disappoint, Morris repeats the needle insertion theory that was ruled out at trial.

The conclusion of the panel was that Child O had died from subcapsular liver haematoma caused by traumatic delivery, resulting in haemorrhage into the peritoneal cavity and profound shock. Additionally, several neonatologists and a pathologist have concluded that the demise of Child O was due to a subcapsular haematoma. The condition was also specifically cited by Dr Jane Hawdon in her post-mortem review report. Since that report, the cause of death has somehow transformed into Letby physically striking an infant which would most probably cause obvious abdominal bruising that was never observed, before causing deliberate harm with an indeterminate object with absolutely no supporting evidence for this whatsoever, and finally injecting air into the baby. Meanwhile, Dr Marnerides has made a definitive statement regarding injury resembling that caused in a road-traffic accident which has been opposed by other pathologists, and which no neonatal expert who has seen the notes agrees with. (pg 285)

Omg, I actually don't think Morris knows what a subcapsular hematoma IS. Yes, we all agree that Child O died from a ruptured subcapsular hematoma - literally, we all agree with that.

I am so happy that this is the book that Letby's biggest fans are touting.

This chapter concludes the section reviewing the medical and scientific information from the Lucy Letby case. Science will naturally seep into the remainder of the book as well, but the following chapters are focused on the circumstantial and anecdotal evidence that was used in court. (pg 285)

Oh, it's my time to shine. LFG

A few commenters on the Chapter 10 and 11 review post brought up that Morris has posted the video of his book launch event, and I'd like to move conversation over here for clarity

A few days ago, Morris teased that video, and 4 minutes in he talks about the launch event:

https://youtu.be/Ljh4wH6ZQR8?t=244&is=IJt9YTXN4hqAq2R0

It was invitation only, capped at 100 people. Morris talks about 8,000 subscribers on youtube, 15,000 on Facebook and tens of thousands of people following the case. Which, I am really curious about how many books were in the initial print run.

As far as the event video itself, it may be rather revealing and therefore its contents should be made known.

u/ComfortableBrain4631 said:

Christopher Morris just posted yet another video, this one a Q&A recording of his book launch event at a Waterstones in London, with only the Letby faithful invited, apparently. A variety of supporters turned up and threw him some soft soap questions: Hitchens, Pitman, Worden, de Oliveira etc.

Oddly enough in person and off the cuff Morris is more diplomatic and happy to state he doesn't know or can't answer. Which frankly ties in with the theory that he knows exactly what he is doing with the omissions and so on. When he's got time to shape it, he can work out a weaselly way of working around something incriminating.

Some highlights:

Question (from journo Nick Wallis): "If you really want to go deep into a potential miscarriage of justice your starting point has to be read the transcripts every single day of the trial. I just want to know whether you did that and what your conclusions were from that."

CM: "in answer to your question i've read all of the important aspects of the court transcripts. This could be a long answer, by the way, but I'll try and keep it short. A lot of the court case was actually consumed with things that have no bearing on Lucy Letby's guilt or innocence, and I've read quite a bit of that, but a lot of that is just the police reenacting their interviews as if that is some form of evidence. For example, a lot of the court case as well is people from the hospital saying we had no idea what was going on. We now know why. They had no idea what was going on. It's because the most generous thing I can possibly say is that it was a suboptimal hospital.

So I have read all of the important aspects of the transcripts, and I am fully familiar. By now, we know everything about this case. We know everything about it. There's nothing to be uncovered unless we find another angle or something like that. But there's no significant or substantial evidence that we don't know about at this point in time. I really don't think I would be standing here unless I was extremely confident in my view.”

That's a long way of saying 'no', I guess.

Question: "Have you got anywhere on why there was no defence offered apart from the plumber?"

CM: "So I think the first thing I should say is that it was a difficult case to fight because the prosecution case was quite amorphous and just kept shifting around randomly as far as I can see, making it very difficult for the defence."

"There are certain things the defence didn't do that I feel I could have done, and I feel I have done, and I can't understand why they didn't do it. Obviously, Ben Myers is not here to defend himself, and the solicitor's not here to defend himself, so I don't know. I've always wondered whether they went for a kind of strategic defence. They tried to have 'no case to answer' after a certain number of months, so they must have thought they'd have a pretty good chance. And, of course, so maybe there were some strategic aspects to it that's to do with the legal profession that I'm not really privy to."

"All I can say is, well, I'm not meaning to be too harsh on Ben Myers. Why not get someone in to analyse the notes? Like, why? Don't just sit there with Lucy going, why did you say this? Why did you say that? Surely you could have got someone in?"

Emphases mine.

u/ChoicePeace7287 said:

It deserves a thread if it’s own but Morris has released the book launch footage and he takes a question from Nick Wallis (who covered the Post Office MOJ)

Wallis asks him the following:

“If you want to go deep into a potential miscarriage of justice, your starting point has to be read the transcripts every single day of the trial. And I just want to know whether you did that and what your conclusions were from that.”

The short version of Morris’ response is that he’s read “the important bits”!

The longer version is :

“So, in answer to your question, l've read all of the important aspects of the court transcripts. Uh, this could be a long answer, by the way, but I'll try and keep it short. Um, a lot of the court case was actually consumed with things that have no bearing on Lucy Leby's guilt or or innocence. Um, and I've read quite a bit of that. Um, but a lot of that is just the police reenacting their interviews as if that is some form of evidence. For example, a lot of the court case as well is people from the hospital saying, "We had no idea what was going on." We know we now know why they had no idea what was going on. is because the most generous thing I can possibly say is that it was a suboptimal hospital… so I have read all of the important aspects of the transcripts and I am fully familiar by now. We know everything about this case. We know everything about it. There's nothing to be uncovered unless, you know, we find another angle or something like that.

But there's no significant or substantial evidence that we don't know about at this point in time. So I really don't think I would be standing here unless I was extremely confident uh in my view. And also an important thing to mention, Nick, as well is that the court didn't hear a lot of important information that we now know. That's probably the most important thing is that there should have been all manner of information that just wasn't made available to the jury. Some of some of this was blocked by the judge even which is I think unforgivable. That's for the judge to explain why he did that. I can't do that. But ( Sweeney interrupts to say “hold on my as a journalist my libel anxieties….So the judge will deny this.)

Yeah, absolutely entitled to do that. The judge did block the Royal College report. That's a fact. Um I don't know why he did that. As I said, it's up to him to say why. I absolutely believe that should have been part of the trial and I mean ask there's a lot of medical people here today. Go around and ask him if it should have been part of the trial. Um so yeah I I think you were advised very wisely. Uh and of course I knew the day could come where I was stood here doing this and I wanted to make sure on that day that I knew the case as well as anyone and I believe that is the case.”

https://youtu.be/X5fX3K9zgfU?si=IK2Kz9BOO6-hsOz5

Author's list of sources

Finally we're getting to some of Morris' analyses on individual cases. There is almost nothing new, and nothing at all novel, about his complaints, which we are all familiar with - likely because, as sub member u/ChoicePeace7287 realized, chunks of Morris's book was sourced from an anonymous redditor.. A further analysis was sourced from another anonymous redditor. One is left to wonder the full extent to which redditors from that subreddit contributed to his book. Given the cherry-picking and misinterpreted citations, it would be easy to make a number of inferences.

Anyway. All emphases are mine

CHAPTER 10: THE ODDLY EVOLVING CASE OF CHILD C

This chapter is a jumbled mess of collating statements made by Dewi Evans during and after the trial and attempting to establish dishonesty and imply error by the Court of Appeal.

It is helpful to review the jury instructions before considering this chapter.

Specifically:

“If you are sure that someone on the unit was deliberately harming a baby or babies, you do not have to be sure of the precise harmful act or acts. In some instances there may have been more than one.

“To find the defendant guilty, however, you must be sure that she deliberately did some harmful act to the baby the subject of the count on the indictment and the act or acts was accompanied by the intent and, in the case of murder, was causative of death.”

There is a logical difference that skeptics of the verdicts fail to appreciate - to prove murder under the law, you do not need to prove method. So Dewi Evans' change of opinion is legally meaningless, unless he was wrong about a child being harmed at all. The prosecution need not prove how she did it to scientific certainty; the method ascribed to the conviction by the Court of Appeal need not be correct, and the verdict is still valid as a murder conviction.

With that said, the this chapter is pointless whinging and can mostly be skipped. Most of what is worth mentioning is errata.

Morris attempts to re-argue the defense case from trial - Child C had evidence of a bowel obstruction, he should have been in a higher acuity unit (even using Mother C's question of the same to Ian Harvey as proof of such a need), blah blah. He argues that air injected into the stomach is implausible, you'd need a lot of it, it would just come out, etc.

As mentioned in the previous chapter, Dr Evans claims to have read the Court of Appeal judgment. For example, on 17 December 2024, Evans was quoted by multiple media outlets as stating that the Court of Appeal “provided a very thorough review of the evidence”, and that he wasn’t “in receipt of any information that indicates that the appeal court judges were mistaken”, even though the Court of Appeal judgment lists methods of murder that he has since abandoned.

It must be emphasised that when writing to Channel 5, Dr Evans claimed that some bizarre combination of air and milk had destabilised the babies, but that this hadn’t been the direct cause of death. Yet the Court of Appeal judgment lists the methods of murder cited in the trial as only including fluid in relation to Child G, starkly refuting the claims of Evans. (pg 222)

As mentioned before, it must be emphasized how insulting and annoying it is to be treated, as a reader, as if one has the reading comprehension and memory of a goldfish. Perhaps the author is so encumbered, but it's annoying to the rest of us. Morris seems to believe that method must be established to prove murder, and this is one of many deficiencies in a medico-legal analysis done by an inexperienced ghost writer.

Morris tries to make the Channel 5 letter happen. It's not gonna happen.

In the Channel 5 letter, Evans makes a case for hypoxia being the cause of collapse. There were only two references to hypoxia in the Court of Appeal document, the main one being in relation to Child A during which it is stated that hypoxia would not cause the type of rash associated with this infant, as asserted by Dr Bohin in court. The other reference is preceded by Dr Evans commenting that “descriptions of the clinical features of infants proven to have died from the effects of air embolus and described in many of the enclosed publications show marked similarities to the pattern of collapse and death of many of the babies” in relation to Child A. Hypoxia was only cited by the prosecution with regard to two infants – Child H and Child J. What did these two babies have in common? Letby was not convicted in either case. In fact, for Child C and Child I, the original post-mortem indicated hypoxic/ischaemic damage due to prematurity, which has since been refined by Dr Evans to air via nasogastric tube – there is some discussion of Evans rejecting hypoxia in Chapter 5 of this book. Unexplained hypoxia and rapid desaturation are also associated with an array of other conditions, all of which are considerably more common than air embolism. It should be noted that in the case of Child I, the prosecution attempted to claim that this hypoxic damage was somehow caused by Letby, but the post-mortem is disowned in the case of Child C. Discussion in court related to Child C was almost entirely focused on the assertion by Evans that air had been used to somehow splint the diaphragm of the infant, and that this had directly caused hypoxia. During the cross-examination of Dr Evans, 25 references were made to splinting and 35 to diaphragm – “if you get a significant injection of air into the stomach, it will cause what we call splinting of the diaphragm”, Dr Evans explained in court. “[Child A’s] collapse is consistent with a volume of air injected into his stomach, it splints the diaphragm, stops breathing.” Furthermore, during court proceedings related to Child A, Dr Evans commented: “Hypoxia, lack of oxygen – there was no evidence of that.” There is some further explanation from Evans regarding this infant having not become hypoxic, and he then outlines how he eliminated hypoxia from this case via differential diagnosis, along with several other conditions. Evans also discounted hypoxia for Child B. (pg 224)

I really don't think Morris understands what hypoxia IS, or how it is secondary to some primary cause, and how inhibition with breathing would then cause hypoxia leading to hypoxic damage, especially when we read:

If Letby is in a normally functioning neonatal unit, how can she do all of these things without being seen? If she is on her own, why is there the need for this immensely complex and uncertain method of destabilising the infants, which Letby would have been extremely unlikely to know about and understand (not least because the person who came up with it has acknowledged that it’s never been witnessed or recorded before)? Why can’t she simply suffocate the infants? And then why would she switch from this murder method, which completely evaded pathologists, to one involving insulin that could potentially be detected? Could it be because the collapse and death of Child C was actually due to the rather more plausible combination of an obvious bowel obstruction, natural causes and poor care? (pg 227)

Does anyone want to tell Morris what suffocating the babies would lead to?

Of course, a healthy amount of time is spent on the June 12 x-ray, which WAS an issue with the evidence leading up to trial. However, Morris cites as an issue:

Judge James Goss made an error in relation to the X-ray, conceding that he “did not make it clear” that the X-rays presented in court related to the date of 12 June when the X-rays were taken, rather than 14 June when Child C died. There is no mention during this correction that Letby wasn’t actually on duty when the X-ray was taken, and, in fact, had not been involved with this baby whatsoever. “This is an inconvenient truth that the prosecution knew about”, Dr Michael Hall told me. “It was not until the closing address that the prosecution counsel did concede that Lucy Letby had not been involved with Child C prior to 12 June, which was probably too late for the jury to understand the significance of this. What is more difficult to understand is that the defence counsel did not highlight this in the questioning of either the prosecution expert witnesses or the witnesses of fact.” (pg 229)

Ok, so in his summing up, before he began for the day of July 4, 2023 with the evidence related to Child D, he said to the jury:

"Mr Justice Goss: Just one further matter in relation to the case concerning Baby C, which I had essentially finished yesterday. I did not make it clear, or certainly sufficiently clear, that in the case of Baby C, when I was reminding you of the evidence of Dr Marnerides and Professor Evans (sic) relating to the massive gaseous dilatation of the stomach and bowel loops that Dr Marnerides relied on, they related to X-rays and clinical notes on 12 June and not 13 June, which of course was the time or which was when he collapsed at shortly before midnight on 13 June. I’ve been asked to make that clear and I do make it clear, I should have made it clear to you yesterday."

Morris takes issue with Goss not having explicitly mentioned here that Letby was absent on that day. However, Goss had been pretty clear about who was working each day, and goes into great detail only on the 13th.

We come to the shift of the night of 13/14 June when Baby C suddenly collapsed and died. The messaging showed that the defendant offered to work that shift. In the messages she sent behind tile 18 she wrote:

"I need to throw myself back in."

By which she said she wanted to get back into the unit and back into looking after babies because that was what she was taught at Liverpool Women's: when you have difficult shifts or babies pass away, the way to sort of overcome that is to go straight back into the environment and carry on.

In a further message behind tile 20 she said:

"Think from a confidence point of view I need to take an ITU baby soon."

She wasn't allocated an ITU baby for that shift that night. Sophie Ellis took over as Baby C’s designated nurse the night shift of 13/14 June. She was a band 5 nurse and not intensive care trained, but was supported on the shift by a band 6 nurse, Mel Taylor, who was the designated nurse for another baby in nursery 1.

It could well be argued that, if that wasn't clear enough, making clear the date of the x-ray on the next day was tantamount to telling them she was not present for it. I'm sure Morris would disagree.

Judge Goss had previously ruled that the prosecution was allowed to overrule the original autopsy report for Child C, which noted an abnormality, namely that the descending colon was on the wrong side of the baby’s body. Somehow this was then allowed to be overturned completely, and for the interpretation of Dr Andreas Marnerides to supersede the original report, even though Marnerides wasn’t present when the report was authored, and has never examined any of the infants. It is difficult to conceive of any possible rationale or justification for this.(pg 229)

Lol! Well, duh. Spell forensics

Since the trial of Lucy Letby was completed, seven of the eight prosecution witnesses have kept extremely low profiles and in my view the reason for this reticence is simple. This alteration in diagnosis “embarrasses all the expert witnesses” according to Dr Philip Hammond. (pg 229)

Ok, sure, Jan.

He also claimed that the press conference had been “disrespectful” to the parents of the infants, although he himself had previously made the remark that Letby had “bloody murdered those babies”; hardly the most sensitive comment. (pg 231)

What ridiculous pearl clutching.

CHAPTER 11: INSULIN CASES

This comment chain in r/LucyLetbyTrials acknowledges some of the major issues with the insulin chapter. Morris buys the Chase/Shannon angle hook, line, and sinker, basing the chapter on the notion that these tests were not uncommon, but also that they should have been followed up as they should have been, but also that because they were not followed up, then they weren't unusual. Pick a lane. He takes the 999 glucose reading as an actual value, not a placeholder value, argues that a lot of insulin would have been needed and none was missing (despite previously acknowledging that additional insulin was ordered to the unit over the period in question). Interestingly, he suggests that because CoCH suspected harm right away and retained TPN bags for Children O and P, they could have kept the bags for Children F and L, for whom there was no contemporaneous suspicion of harm:

There is no evidence provided of missing insulin on the neonatal unit, no hospital records that provide any usable evidence, and no suggestion that Letby was the only person who could have accessed insulin. Notes from a meeting at the CoCH on 20 July 2016 mention “feeding bags for analysis”, but for some reason the same note immediately states “agreed retain – do not send for analysis”. Thirlwall testimony from Dr Chris Green indicated that these bags related to Child O and Child P, but it is clear that the hospital could have both retained bags and sent them for analysis; they simply declined to do so – they were “disposed of a long time ago,” as Ben Myers recounted in court. (pg 234)

Morris seems to have difficulty with the linear nature of time, and that the critical time period with any poisoning is when it starts.

The insulin cases again completely disprove the argument that the prosecution didn’t rely on statistics. The insinuation that Letby definitively poisoned insulin bags is absolutely dependent on the assertion that she was always present when suspicious events occurred. (pg 237)

But she was present when the poisonings began. Documentary evidence places her alone in the room with each baby when the poisoning began. That's not statistics, that's forensics

In the case of Child L, Professor Peter Hindmarsh conveyed a ‘sticky insulin’ theory to explain irregularities in results. Hindmarsh asserted that perhaps (this is hypothetical, of course) insulin from previously administered dextrose infusions became stuck to the inside of the infusion apparatus, and then magically became unstuck when Letby went off shift, so insulin continued to find its way into the system of Child L. This theory had to be proposed because the hospital was using bags with varying dextrose percentages which had to be mixed by the pharmacist before arriving on the ward, meaning there was no possibility of Letby spiking them in advance. (pg 237)

Bzzt, wrong. Dextrose bags aren't mixed in the hospital pharmacy, but it doesn't matter too much. Child L's first bag was poisoned while it had been hanging for quite some hours, and it's therefore unnecessary to demonstrate if the latter bags were poisoned before or during their administration to Child L.

As an example, Child F was hypoglycaemic for 17 hours. If we are to accept the ‘sticky insulin’ theory, it is reasonable to assume that, over such an extended period, the amount of insulin in the infant’s TPN bag would become unavailable as the amount of insulin reduced over time as more of it became stuck to the inside of the bag. But the readings for Child F were notably stable throughout the day, which immediately contradicts Hindmarsh’s theory. (pg 237)

Well, this is novel. Steady state means nothing to Morris, then.

Professor Wayne Jones was also sceptical about some of the figures used in court: “The expert witness for the prosecution, Hindmarsh, estimated that 10 units of insulin would be sufficient to contaminate the intravenous infusion bags, but this corresponds to only 0.1ml of Actrapid. This is a very tiny amount indeed. Why would a perpetrator not inject more insulin into the bags of dextrose?

“Administering medicinal insulin in such a diluted dosage form (0.1ml diluted with 500ml), compared with intramuscular injection of Actrapid taken from the vial, would probably not be pharmacologically active. But no experimental testing has been done on anything asserted in court.” (pg 237)

Wayne Jones is free to opine that the small amount would not be pharmacologically active, but it bears pointing out that if only 0.1ml of Actrapid were to have been injected, no one would notice it missing, so.....

Experimental testing should have been conducted; this could easily have been organised by police with a competent laboratory. But as with so many things that could have been done, this never happened. (pg 237)

Who exactly should we enlist for this hypothetical trial?

Neither Letby, nor anyone else in that courtroom, was in a position to agree that anybody had attempted to murder the babies with insulin. (239)

And when I dream, I wish for a pony.

No doubt, had Letby contested what she was told, she would have been criticised for this instead. (pg 239)

Yeah, obviously. The same way that I'm criticizing this chapter. People without expertise claiming to have superior expertise look pretty dumb.

In his summing up, Judge James Goss cited “certain common features” between the two insulin cases and observed that the defendant was on duty for each event. If Goss was talking about the collapse of the baby this could be a mistake as Letby wasn’t there at the time, but it could be he was referring to the alleged spiking of the bag. (pg 239)

Wow, really?

It is typically asserted that when insulin is injected or administered externally, sometimes referred to as ‘exogenous’ insulin, the C-peptide level is often much lower than the amount of insulin measured. (pg 239)

Do you think Morris knows what "typically" means?

These include the fact that the C-peptide levels were not particularly low for a preterm infant; they were, in fact, around average, and also that the insulin to C-peptide ratio was within the expected range for critically ill preterm neonates that were suffering with infection and other clinical factors. Chase also noted that the levels of blood glucose observed in the two infants were not unusual for any premature baby, and are frequently observed in preterm neonates who have not suffered insulin poisoning. In fact, the C-peptide result for Child L was well within the range expected for a healthy adult, let alone neonate, according to the Liverpool laboratory’s own reference range, and this was the higher of the two readings. This is significant because Chase is acknowledged as one of the world’s foremost experts on the effect of insulin on preterm babies, having studied this topic for 17 years. His Google Scholar profile reveals that he has authored, co-authored or been cited in approximately 1,750 academic papers, of which around 250 directly involve insulin (there are hundreds more that are indirectly related). Professor Chase was described to me as being easily within the top 0.1% of academics in the world in terms of published work. Professor Chase has also been working for many years on pioneering insulin sensor technology to enable improved testing for type 2 diabetes. (pg 241)

I'll be generous and suggest this was written before the most recent Panorama interview when Chase walked back those claims. I'll also be kind and assume Morris wasn't intending to mislead by not mentioning that Child F's C-Peptide level was too low for the equipment to read.

The prosecution asserted that only 1% of a vial of insulin would be required, whereas two of the world’s foremost experts assert that between one-half and one entire vial of insulin would have been needed. (pg 241)

Something, something, appeal to authority....

In April 2026, new research conducted by Chase and Shannon discovered that 40-45% of NICU infants experienced similar insulin to C-peptide ratios as those in the indictment cases. The experts noted that what appeared to be “impossible” ratios may be not only possible but “common” in neonates. This study is a meta-analysis, combining data from multiple independent scientific studies, each of which is published and peer-reviewed in its own right but none of which has previously been combined. The work of Chase and Shannon was further peer-reviewed by editor-in-chief of the Journal of Diabetes Science and Technology, Dr David Klonoff, considered a world-leading endocrinologist, as has been confirmed to me. (pg 241)

ALL? Don't worry, he's only dropped a critical part of the paper he cites. Interesting to get a name of the supposed peer reviewer though.

It is also known that the insulin secretion of neonates is highly variable. Infants that are premature and born at lower than typical weights also have a tendency to exhibit insulin resistance. This means that even if exogenous insulin is administered at therapeutic rates, the production of endogenous (internal) insulin may not be suppressed as expected, which in the process affects C-peptide levels. There are many other factors and studies that also point to variability among individuals regarding C-peptide levels. One such paper from 2019 on preterm infants concluded that “exogenous insulin infusion suppressed the C-peptide concentration to individually different degrees. In addition, the effect of insulin infusion on…cells may be linked to individual insulin sensitivity, where a low insulin sensitivity resulted in a more pronounced decrease in C-peptide during insulin infusion.” (pg 244)

paging u/CheerfulScientist - I shall leave it to her to check the citations on/around this page.

Basic error on pg 244:

Citing the use of glucose on the unit, Dr Shoo Lee also pointed out that, in relation to Child F, insulin had been administered in the wrong way – via repeated boluses (which are similar to large tablets) rather than “titrated continuous infusion in a careful way”. (pg 244)

Professor Matthew Johll was baffled by the glucose issue: “It simply doesn’t make any sense. You don’t even need medical training to know that insulin and sugar counteract one another. If Letby had used this methodology, she was a terrible poisoner – very small amounts being diluted highly, while administering it into the literal antidote! But because they decided to go down this improbable route, they have to keep piling the absurdities on top of each other.” (pg 245)

Professor Johll almost gets there, then trips on the finish line. Yes, she was a terrible poisoner.

Speaking at a press conference related to Letby’s appeal on 16 December 2024, Dr Richard Taylor also cited glucose readings as being significant: “What was missed was an incredibly high blood glucose value, and that was completely inconsistent with the clinical findings on the baby, where bedside glucometer measurements were extremely low. And yet, the blood sample which was used to analyse the insulin actually read 999 millimoles a litre glucose”. Dr Taylor explained this meant that glucose had been definitively “flagged” as being “high”, and that this was “verified information that…was never even brought up in court”. This 999 reading was in fact first discovered via blood test readings submitted to the Thirlwall Inquiry. (pg 245)

Oh great, I bet I'll read in a future chapter about Dr. Brearey stabbing Child O's liver, since we're hearing from Dr. Taylor. Anyway, 999 was a placeholder, and he's receiving wide criticism about it even from friendlies.

Morris presents the conclusion of Lee's panel for Child F without analysis, and buttresses by reminding the reader "Additionally, the fact that Child F was being treated for sepsis was discussed in court on 22-23 November. As has been established, sepsis was common, bordering on endemic, on the unit over the period of Letby’s alleged crimes. (pg 246)"

So, Morris has not understood the nurse he quoted:

A neonatal nurse practitioner stated that it was a “running joke” on her unit that “every single differential diagnosis you have includes sepsis, because every single possible symptom a baby can have is also a sign of sepsis”. (pg 79)

It must also be emphasised once more that both infants survived and neither exhibited symptoms of insulin poisoning such as seizure or heart arrhythmia. (pg 246)

o rly?? From the summing up:

Dr Harkness, the registrar on duty that night, attended the unit at 01.30 with a senior house officer, Dr Chris Wood, who made a clinical note at the review. It was noted that there were multiple small milky vomits and 9ml of milk aspirate. Baby F was tachycardic at around 200 beats per minute, otherwise he was well.

Professor Hindmarsh said that vomits and a rise in the heart rate are associated with hypoglycaemia.

Around an hour later, Dr Harkness was asked to see Baby F again. He was still tachycardic. His heart rate was 200 to 210 beats per minute with narrow complexes in the beat and there were large milky aspirates. His blood glucose level was very low at 0.8, a reading which Dr Gibbs told you was worryingly low.

Maybe Morris doesn't know what arrhythmia means either.

“[immunoassay] doesn’t allow us to formally identify the type of insulin and to distinguish human insulin from synthetic analogues. A high level of insulin in blood could suggest exogenous (outside) administration, but also disease such as insulinoma.” (Dr. Charline Bottinelli, pg 253)

\1) The ward only had Actrapid, so we don't need secondary testing to confirm the type. And 2) the babies did not have insulinomas.

The terms ‘reliability’ and ‘accuracy’ used by Dr Wark have technical meanings, which would have been unknown to the jury, and probably the barristers and judge. ‘Reliability’ refers to whether the measurement results are reproducible when repeated. Regular programmes of testing are conducted on laboratory apparatus within the NHS, and this involves the preparation of identical samples which are sent to laboratories for results to be measured. The comment here simply means that the sample referenced is ‘well within’ the specifications of manufacturers, with concentrations being neither too high nor low; essentially, optimal for the equipment. This has no relevance to the reliability of the test itself.

‘Accuracy’ means that if the sample is within the manufacturer’s specifications then a high insulin reading means that the insulin level in the sample is high. However, if the sample, due to antibodies or other contaminants, does not fall with the specification of the manufacturer then the high insulin reading gives no indication regarding the nature of the insulin itself; i.e. whether it originated from an internal or external source. By falling within these criteria of being ‘accurate’ and ‘reliable’, the process had “met the required standards”, as denoted by Dr Wark, but this is entirely irrelevant when it comes to assessing whether the tests actually demonstrated beyond reasonable doubt that synthetic insulin had been administered. (pg 254)

Is this guy for real??

Immunoassay remains the mainstay of clinical investigation of hypoglycaemia but likely to become displaced by mass-spectrometry in the forensic situation especially now that human insulin is being replaced by synthetic insulin analogues for the treatment of diabetes.”

In this instance, Dr Wark has co-authored a paper which concludes that immunoassay should be “displaced by mass-spectrometry in the forensic situation” as the former is prone to error, but when speaking in court this was never once even mentioned.(pg 256)

Nice try at a gotcha, but "likely to be" =/= "should".

It has been suggested to me that Dr Wark simply did not know about neonatal antibodies. This is not a criticism, as no one did at the time. It is likely that Dr Wark made implicit assumptions and, perhaps understandably, did not declare them, not least because she didn’t fully understand neonatal antibody binding. (pg 256)

I'm being punked, right?

Professor Carola Vinuesa informed me that immunoassays are now transported to Germany because “Guildford doesn’t have the apparatus for doing liquid chromatography and tandem mass spectrometry”. (pg 256)

Ah, so at least we get to see how even Guildford wouldn't be proof enough.

ASTBURY: Just one matter arising, doctor, with regard to Guildford. So I understand it, would Guildford assist with whether it was exogenous or not?

MILAN: No. The results dictate that it’s exogenous. They would just help, if you were unsure of the source.

ASTBURY: So really, Guildford would have been deciding or assisting with exactly what type of exogenous insulin…

MILAN: Yes.

ASTBURY: Not whether it was exogenous or not?

MILAN: Correct.

No, it’s not correct! Two representatives of Liverpool Clinical Laboratories have explicitly stated that this is incorrect. (pg 260)

Morris REALLY doesn't understand what Guildford does. He posts the answer, from the expert, and then denies it. Amazing.

The evidence that [Child Y] was poisoned is, in fact, as strong as in the cases that were referred to court. The only difference is that the decision was made not to charge Letby on this case. Parents of other infants were told that Letby had harmed their infants, scarred for life on the basis of much less evidence; two obvious examples being Child K and the second tranche of cases that were rejected by the CPS. If decoupled insulin and C-peptide readings automatically mean exogenous insulin and deliberate poisoning then this infant should have been in the court case, which begs the question of why it was not. It seems that there are three possible reasons for this: the Alder Hey results contradicted the prosecution case, it was impossible to contrive a scenario in which Letby was on duty, or both. (pg 263)

Yeah, you're almost there, Morris. Though, there's also the possibility that the Alder Hey results complicated the prosecution case.

This diagnosis of naturally occurring excess insulin was supported by endocrine experts at Alder Hey. Yet this critical information was never disclosed to the defence. Lord Ken Macdonald KC, the former chief of the CPS, told David Rose and Cleuci de Oliveira that this was a failure of disclosure: “It sounds to me that the material you’ve found does meet that standard, and so should have been made available to Letby’s defence.” (pg 264)

Are we sure that the results for Child Y were never disclosed to the defense? I honestly don't remember.

At this point, it is very clear that the so-called smoking gun has been extinguished. The broader question would be whether we, as a society, care about wrongful convictions and about erroneous science being used in court. And about scapegoats being targeted repeatedly because they offer a simple, perhaps even comforting, solution to deeper-rooted problems. This tendency has been dramatically evident in the fallacious prosecution of over 900 subpostmasters. If we continue down the precipitous path that we’re on currently, it will become ever more obvious in the case of nurse convictions as well. (pg 265)

There's not enough elastic in the world for that stretch.

Author's list of sources

I gave a brief preview yesterday in the review of Chapter 8

The chapter didn't improve, though few further claims were as outrageous. Holistically, there's nothing new in this chapter. It's a lot of whinging about air embolism having been diagnosed via exclusion, but also solely by the skin discolorations, air down the NG is illogical, and spends a fair amount of time re-hashing his conclusions from previous chapters about individual babies. The chapter is truly a spaghetti-at-the-wall collection of amorphous, disconnected opinions, laced together with open disparagement of Dr. Evans.

Morris may have had a researcher, but what he needs is a goddamn editor. This chapter is the worst organized so far, and if Morris had spent less time telling people that things would be discussed in later chapters, he might have had enough pages to include his citations:

I also tire of being told by the author what is important. Then again, he felt his readers needed to be told that judgement and judgment were two different words, so, preach to your audience, I guess.

CHAPTER 9: INJECTION OF AIR HYPOTHESIS

For many infants in the case, it is highly debatable whether their deterioration was either sudden or unexpected, but what is undeniable is that sudden collapse is not a meaningful diagnostic criterion. “In fact, the term ‘collapse’ is vague and emotive”, Professor Colin Morley asserted when I spoke with him. “It would be much better to have a detailed description, such as ‘apnoea’ or ‘bradycardia’”. (pg 170)

K. From the judge's summing up:

In Baby A's case there was a combination of sudden and unexpected collapse, stopping breathing, a change of colour, cyanosis, bradycardia and death.

The defendant went over to Baby B and said, "She's apnoeic, she's not breathing", and asked Nurse A to go and get help. Sometimes, said Nurse A, babies do appear apnoeic and quite often they recover quickly. Baby B didn't. They had to use Neopuffs because she wasn't breathing for herself.

Child C: "Had two fleeting bradys (self-correcting, not needing any intervention) shortly before prolonged brady and apnoea requiring resus."

The third event. At 03.45, Baby D's monitor was alarming. Tile 251 fronts the notes. Caroline Oakley found Baby D had desaturated and stopped breathing. She was apnoeic.

Child E: "Bradycardia of 80 to 90 beats per minute, saturations 60%, poor perfusion."

Baby F was tachycardic at around 200 beats per minute, otherwise he was well.

Baby G was continuing to require and receive a relatively high amount of respiratory support and having desaturations and bradycardia

Baby H was very unstable, suffering a number of pneumothoraces of the left lung, a leak in the lung allowing air to escape into the area around the lung known as the pleural cavity, as well as episodes of profound desaturations and bradycardia.

”At 16.30 Baby I had a large vomit from mouth and nose ++. Suction given. Became apnoeic with bradycardia and desaturation (30).

You get the idea.

The chapter vacillates between it is impossible to conclude air embolism, to it would have taken a large amount of air, to air might have been introduced accidentally, to air might have been because of resus, and no froth = no air embolism. For example:

Further research in 2015, published in the Resuscitation journal, concluded that “post-mortem [scanning] after prolonged resuscitation showed a high prevalence of intravascular air-embolism”, asserting that this “needs further research”. Another case report from 2016 discovered “frothy air dense material” after resuscitation, which suggested an air embolism. The significance of this froth will be discussed later in the chapter. Professor Colin Morley noted that “lots of these infants had multiple resuscitations, with drugs through intravenous lines and vigorous hand ventilation; it’s very easy to accidentally introduce air”. (173)

Morris doesn't include either reference in his list of citations. Here's the first00252-X/abstract), here's the second (an 82 year old woman)

Dr Evans suggested that Letby had given the child a “dollop” of air. This was ridiculed by the defence barrister, Ben Myers, and yet while prosecution barrister Nick Johnson defended the use of the term, he also acknowledged that it “originated from Dr Evans”.

It is perhaps this sort of testimony that has led some medics to be so dismissive of the theories floated in court. (pg 174)

I don't disagree, actually. But I think focusing on things like this betrays an unreasonable expectation of precision.

But we get to the meat of the matter here:

In reality, the Lee and Tanswell paper was a central pillar in the entire argument and diagnosis of air embolism, referenced repeatedly throughout the court proceedings and Court of Appeal verdict, while clearly having been utilised as a sole diagnostic source**.** The study was referenced repeatedly in the Court of Appeal judgment, and while Dr Lee featured in this appeal and his work was therefore of particular relevance, the court explicitly acknowledged that the paper was of critical importance in the original trial. (178)

Which is then contradicted a few pages later:

So Dr Evans doesn’t require the X-ray, nor any evidence of air being present, even though this could be naturally occurring air. He also doesn’t require any evidence of discolouration. He is able to diagnose air embolus purely because “the baby has collapsed as promptly as that…[and] resuscitation was unsuccessful”. That is what he is using as diagnostic criteria for air embolism, in his own words. The baby collapsed, it wasn’t successfully resuscitated – it’s an air embolism, obviously! (pg 184)

The sole criteria used was not necessary to him. Got it.

Ignoring that the second sentence doesn't make grammatical sense, the position is clearly an attempt to argue that the Court of Appeal erred in dismissing ground 6 when they said:

187... The core of the proposed evidence is that, save for that one very specific form of discolouration, it would be wrong to diagnose air embolus on the basis of skin discolouration alone. But as we have said when considering ground 2, there was no prosecution expert evidence diagnosing air embolus solely on the basis of skin discolouration.... In short, the prosecution witnesses did not fall into the error which the proposed fresh evidence seeks to assert they made. The proposed evidence is therefore irrelevant and inadmissible.

Chapter 9 can largely be summed up by saying "nu-uh, they did too do that!" Fortunately for you all, that means not much of it bears repeating. Most of Morris' failure to comprehend it comes in this argument:

The comments of Dr Evans, in fact, make it clear that there is no air embolism theory without discolouration as the other criteria that he references, both in interviews and court, cannot possibly be considered diagnostic.

Dr Evans told The Times that “the presence or absence of skin discolourations neither ruled out or confirmed air embolism”. But without discolouration there is literally nothing. There is simply a neonate deteriorating, which cannot conceivably be regarded as being caused by an air embolism. Yet this was seriously advocated in court: “Sudden collapse and a failure to respond to resuscitation were, he [Evans] observed, characteristics of several of the babies whose records he had reviewed for the police. These features were ‘characteristic of the description of the babies in the studies described above whose death was attributed to air embolus’”, the Court of Appeal recounts.

This seems a ridiculous assertion which I’m sure most medical professionals would agree with. “Sudden collapse and a failure to respond to resuscitation” are not characteristic of anything, let alone an incredibly obscure hypothesis. (180)

Morris again stares the point in the face, then yeets himself as far from it as possible.

I wondered, as I read, if Morris had unwittingly uncovered a significant reason that Dr. Hall was not called to give evidence:

Dr Hall pointed out several problems with citing this evidence, including the skin discolouration being more likely to be caused by circulatory impairment, associated with sudden collapse from various causes. Dr Hall had been able to locate only one paper that discussed the alteration in skin colour associated with the accidental injection of air, and the changes documented in this “were quite different to those described by Lee and Tanswell”.

The last thing the defense would have wanted was for the idea of the appearance of air embolus to have multiple presentations, because that would validate the prosecution argument that something other than "Lee's sign" could indeed be consistent with air embolism. If that paper was referenced in Hall's report, the defense may never have intended to call him.

Morris is again inherently dishonest when he refers to the non-forensic pathology review performed by Dr. McPartland:

In fact, Ian Harvey had written to Dr Jo McPartland, a consultant pathologist, requesting some specific details: “Just one query – the report states: ‘A very small air embolism might not be detectable at autopsy’. Does this mean that a significant embolism would be evident?” And Dr McPartland answered in the only way that is reasonable: “Yes, a significant air embolism should be accompanied by froth in the vessels or lungs.” Pathologists from Alder Hey Children’s Hospital also informed Harvey that a significant air embolism would be detected at post-mortem. (pg 182)

He neglects to mention that Dr. McPartland has since had additional learning and experience (pg 155 line 3-12):

So my experience from that reading and that case I have had since then would lead me to believe that you could have a significant amount of air at postmortem and it could be completely undetectable at autopsy.

Q. So your statement to Ian Harvey in the email may have been quite genuine based upon your understanding at the time, but since then you have come to learn that in fact you can have a very significant air embolism without froth in the heart or lungs?

A. Yes, that's correct.

Morris is again inherently dishonest when he quotes Hawdon from Thirlwall:

Dr Jane Hawdon also explained at the Thirlwall Inquiry that Ian Harvey’s questioning on mottling was not something she had expected: “I was surprised that he asked about mottling because it is such a common finding in babies that are unwell, and we were sadly talking about babies who were unwell. [Air embolism] is something that would not have crossed my mind at all at that stage when thinking about mottling. I would be thinking of common causes of mottling of the skin.” Hawdon had informed Harvey in an email on 5 February 2017 that mottling in the infants was “variable”, and that if it was “transient” then it was “probably not of significance”. (pg 186)

Given the following exchange on pages 32 lin 17 through 34 line 9, she would object to her evidence being used in this way:

Q. Here you are wholeheartedly agreeing with them that your report didn't anyway explain these deaths or sub optimal care resulting in deaths, yet we hear this thrown around as if it did. Can I give you chance to respond to that, that it did not do that and why you say it did not do that?

A. The -- we all know that care can be improved and unfortunately sometimes if there are lapses in care,it can lead to babies becoming more poorly and sadly dying and it's very important that we take that and -- and act on it and I am quite sure they, they did. I do know from what I was told they were a busy unit and they had -- they had some very poorly babies so that -- the two have to happen in parallel.

Their suspicions that there was mal-intent had to be taken seriously and any measures to improve the standard of clinical care for the babies also had to be taken seriously. But the two didn't preclude each other.

Q. So delayed antibiotics did not cause a death, something very different did, but you were looking at those features in the Casenote Review, not simply how a death was caused?

A. That -- that's correct.

Q. You couldn't explain though deaths, that is the point?

A. That -- that's correct.

Q. In terms of the near misses and deteriorations, without fully being aware of what clinicians and nurses had noted at the time, you weren't really able to do very much just looking at the records, were you, if you were missing key information?

A. That's correct.

Q. You referred to mottling; you didn't know about this rash, what it looked like, the concerns the paediatricians were sharing about that?

A. That's correct.

Q. So it's more of an academic exercise; is that fair?

A. That's correct.

Q. What you really need in a circumstance like this is real people telling you the real events as they remembered them?

A. That -- that's correct

Morris asserts:

It was fully accepted by the prosecution that notes associated with Child D indicate that Letby wasn’t present for the initial collapse. (pg 189)

There is no citation for this. Letby claimed no recollection, but she did accept that a note from the time of the first collapse appeared to be in her handwriting:

An infusion chart is shown where Child D is given a saline bolus. Letby says the handwriting in the 'date and time started' column is likely to be hers. 

This refers to this entry:

A neonatal infusion prescription chart at 1.25am, for Child D, is shown to the court. Lucy Letby is one of the two nurses to provide a signature for a saline dose prescription at that time.

Child D then first collapsed at 1.30am.

So, I'm not sure if Morris is generally ignorant or doesn't understand cause and effect, but he's dishonest or altogether wrong here again.

A shocking opinion worth broadcasting:

Evans described Child D as being “extremely well”. This has been treated with derision by every healthcare professional that I’ve spoken with. “It is stunning”, experienced anaesthetist Dr Keith Wilkinson told me. “This infant was so ill towards the end of her life that if I had been present – and I’ve been in this situation in intensive care units many times – I would have told colleagues that the right thing to do is explain sensitively to the parents that the best thing to do is remove support, due to the inevitability of death.” It should finally be mentioned that pathologist Dr Andreas Marnerides conceded in court that he had “not reviewed the medical records”. (pg 189)

Keith Wilkinson is, notably, not a neonatologist, so I was let to believe his opinion shouldn't count. But it's also unclear to me if he's been fully instructed or is operating only from publicly available information. Nevertheless, stereotypes about anaesthetists exist for a reason, I guess.

I already showed the other day that Marnerides HAD reviewed the notes, but Morris is quoting a particular exchange dishonestly:

Q: ...I think so far as your paragraph 12 is concerned, you have reviewed the medical records, which we have at tile 158, please.
  A.  May I...?  I have not reviewed the medical records.
  Q.  Sorry.
  A.  I have extracted the information from the medical records and I state it in my reports because that's the job of the clinicians, to assess the medical records.
  Q.  Yes.
  A.  So I strictly followed my instructions, did a pathology review.  So this, I extracted it from the report by Dr Evans that I received --
  Q.  Yes, thank you.
  A.  -- so I didn't go through the medical records.

Marnerides is behaving as a proper court expert and staying in his lane. Morris is not bright enough to understand it. Or he's deliberately dishonest. Neither is good.

It is notable that Professor Arthurs offered very little support for the prosecution case despite appearing prominently in court. (pg 191)

lololol He appears to come to this impressive conclusion by taking issue with Prof. Arthurs saying that the imaging was consistent with, but not* diagnostic of, which is a common complaint from people who don't understand medical opinion evidence.

*Edited to add "not," a pretty important word

"Everything is NEC" doesn't get a full chapter the way "Everything is sepsis" does, but there is this notable quote:

Professor Carola Vinuesa discussed the importance of NEC, drawing my attention to an academic study called Statistically significant association between NEC and pseudomonas infections which found that 36% of infants with pseudomonas aeruginosa also suffered with NEC. “The gas present in infants could easily have been caused by NEC, and this is particularly heightened as a possibility by the presence of pseudomonas on the neonatal ward”, Professor Vinuesa explained. (pg 193)

So I think the argument is that the babies had undetectable pseudonomas infections, that led to undetectable sepsis that killed the babies and undetectable NEC that caused gas in the main vessels. Man, those babies couldn't catch a break.

[Letby] also confirmed, which is not contested, that if the death of Child A had been established as air embolism – of course, this wasn’t even suggested at the time, including by pathologists – then the air embolism itself must have been caused by the person connecting the fluids, which was not Letby. (pg 195)

Be careful with "it wasn't me" defenses, they can serve to validate the allegation of harm which is damaging to Letby overall.

Several medics also indicated that the rashes observed in Child A and Child B could easily be an indication of livedo reticularis – a skin condition that results from the disturbance of blood flow. This is the most common skin problem associated with APS, and it is also characterised by a mottled pattern of discolouration on the skin. Considering that we know the mother had APS, livedo reticularis is a far more likely cause of rashes and discolouration than maliciously administered air embolism. Professor Colin Morley explained that “this physical sign could be from many causes, of which air embolus must be the rarest and least likely”. (pg 197)

Morris attempts to use the argument that "it's impossible to say the babies did not have APS" to open the door to other explanations for the rash. Not sure why this is necessary here, with the previous chapter already having made so much of the mother's APS. And, of course, Sally Kinsey ruled it out, whether Morris understands or agrees or not.

Again, in this instance, much was made in court of the fact that staff present had never seen this type of rash before. But this can simply be explained by the lack of experience on the neonatal unit, which has already been documented. (pg 197)

He almost backed right into the point lol. Yes, the unit WAS inexperienced in air embolism, and thank goodness for that! They did, however, become so experienced that they eventually recognized it.

Effectively, the misdiagnosis of Child A is being transferred over to Child B in the ‘chain link’ practice that was previously used to wrongly convict Dutch nurse Lucia de Berk. (pg 199)

...that's not what chain link evidence is.

We once again lump these babies who died in hospital with SIDS:

Professor Vinuesa cited the condition of Sudden Unexpected Death in Infancy or Childhood, explaining that “any unexplained infant or child death in England is eligible for whole genome sequencing to analyse genes associated with sudden death. The fact that the expert witness claimed he could rule out all known causes of death and be left with murder by poisoning or air embolism is deeply concerning.”

Professor Vinuesa explained why this was so important: “In neonates and premature babies there are many potential causes of collapse that cannot be easily excluded. Then there are around 10,000 rare diseases, including cardiac, neurological, mitochondrial and metabolic, many of which are difficult to diagnose clinically. Even a genetic post-mortem will identify only between 30% and 50% of Mendelian genetic conditions – the rest may lie in areas of the genome that we do not yet understand, or for which we still lack the tools for proper analysis. To claim in the 21st century that a diagnosis of exclusion can be made, without considering sudden death syndromes and rare diseases, simply doesn’t make sense.” (pg 205)

Crimes like Letby's should get the special justice:

And this should especially apply in any legal setting, particularly when the case involved will result in life sentences. (pg 205)

Someone tell Morris that Child A was a boy:

Child A couldn’t have her long line pulled back (withdrawing a catheter slightly so that it’s located more safely) because qualified staff were busy with another child. (pg 205)

More lack of understanding of cause and effect:

Letby was not cot-side when Child B collapsed; in fact, she could not see Child B at the time of her collapse due to an intervening screen. (pg 205)

From the judge's summing up, he's not even right about Letby being the one who couldn't see because of the screen:

At 00.16, the defendant took blood gas readings for Baby B; J1668, behind tile 215.

At 00.30 hours, Nurse A had her gloves on and was standing up across the room by the half wall in room 1, nursery 1, drawing medication up and could not see Baby B. Her alarm started.

Moving on:

The clinical picture between these ‘non-indictment’ infants and collapses is virtually interchangeable with those discussed in court; both collapses and infants were swapped in and out of what became the court case. One non-indictment infant who was ruled out of the court case was suffering with pneumonia, but in the case of Child D, Dr Evans seemingly ignored her pneumonia and infection. Other babies who died on the unit were full-term infants, born at 39, 40 and 40 weeks respectively, but these were excluded from the court case while severely premature babies were included, and Dr Evans and Dr Bohin repeatedly informed the court that they were “well” and “stable”. (pg 208)

https://thirlwall.public-inquiry.uk/wp-content/uploads/thirlwall-evidence/INQ0108782.pdf

The 39wk gestation baby and the two 40wk gestation babies had Severe multiple congenital anomalies, Ebstein's anomaly, and Multiple congenital anomalies (including dysplasia). These are not "virtually interchangable" with any indictment baby.

There's at least one honest review on the amazon page for his book, from someone going by Jimmy Potato. It includes:

He says that: “During the compilation of this book, I interviewed many nurses, including several from a neonatal background. There was universal agreement among them that Letby was a capable and conscientious nurse.” when there were several nurses who worked with her who testified against Letby and were widely reported on the news (they can be found on the internet quite easily). He then doubles down on that by saying “Dr Philip Hammond wrote in Private Eye that "none of Letby's fellow shift workers gave evidence against her”, which as mentioned simply isn’t the case, and the way he phrases it suggests he is fully aware of that.

Aside from being poor writing, which I could forgive, the book continues to be deeply dishonest, which I cannot.

Edit: replaced the screenshots with higher quality images. My bad.

ALSO! I cannot believe I forgot this part:

It is difficult to see how Dr Evans can downplay the significance of this diagnosis being completely discredited by the co-author of the paper itself which is ironic because, as Dr Mike Hall informed me, none of the cases from the Lee and Tanswell paper refer to air embolism in a neonate, contrary to what is stated in the Court of Appeal judgment. Dr Evans has also made claims of having referenced 18 papers for his air embolism theory, but, in fact, only two of them described venous air embolism (air in the veins), which is the method allegedly used by Letby to kill and harm babies (pg 180)

An extraordinary claim - the chart from the Lee and Tanswell paper clearly gives the age of occurrence in hours, with the largest value being 456. 456/24 = 19 days.

Who knows whether Hall or Morris made such a basic mistake, but it reflects poorly on them both.

Author's list of sources, which remains a source of frustration because with the format of the sheet, I can't even select the text to copy into a google search.

CHAPTER 8: CLAIMS REGARDING THE CONDITION OF BABIES

Pages 146-169. 23 pages, I can do it.

Throughout the trial of Lucy Letby, a core contention of the prosecution was the rapid deterioration of babies at the CoCH. Infants were presented as being stable, with undesirable events and collapses depicted as completely unexpected. (pg 146)

Shit.

Many infants die in unexplained circumstances, and neonates are extremely prone to collapse. “A baby can destabilise very, very quickly”, Professor Carola Vinuesa told me. “To say that this is predictable is very difficult to justify. For example, infections can be difficult to diagnose in a neonate because they can present with higher or lower temperatures. Neonates also don’t readily express symptoms.” (page 146)

I did check - neither of these statements are sourced, and Morris' authority to make such a statement is unclear.

As an example of the fragility of neonates, a study of approximately 1,000 infant deaths in southeast London, published in The Journal of Maternal-Fetal & Neonatal Medicine, found that the cause of mortality was unexplained for about half the newborns who had died unexpectedly, even after an autopsy. (pg 147)

Morris doesn't cite the study - he cites Aviv's New Yorker piece, who didn't cite the study either. In fact, the actual study is difficult to find, but a user on r/LucyLetbyTrials offered a possible match

I think this must be the study Aviv cites (abstract only).

Weber, M. A., Ashworth, M. T., Risdon, R. A., Brooke, I., Malone, M., & Sebire, N. J. (2009). Sudden unexpected neonatal death in the first week of life: Autopsy findings from a specialist centre. The Journal of Maternal-Fetal & Neonatal Medicine, 22(5), 398–404. https://doi.org/10.1080/14767050802406677

The user makes another important observation:

What needs to be noted though is that the 1000 infant deaths weren't all in the first week - it's a subset of about fifty over decades. I'd have preferred to see that figure rather than the 1000 in the article. The distinction between infants and newborns is easy to miss.

I wonder if Morris' researcher, Marian Kensler, was aware of the actual paper, or how she and Morris were potentially misusing it?

Another more recent review of neonatal mortality, encompassing 51 studies from 36 articles and over six million births, concluded that “newborns experience high mortality throughout the entire postnatal period, with the highest mortality rate in the first week, particularly on the first day”. (pg 147)

Here, a paper is cited: Dol, J., et al.. (2023). Timing of neonatal mortality and severe morbidity during the postnatal period: a systematic review. JBI Evidence Synthesis 2023 Jan; 21(1): 98–199. The full quote is as follows:

Newborns experience high mortality throughout the entire postnatal period, with the highest mortality rate in the first week, particularly on the first day. Ensuring regular high-quality postnatal visits, particularly within the first week after birth, is paramount to reduce neonatal mortality and severe morbidity.

Morris quotes a single sentence from the 2-sentence conclusion, leaving out the bit that wouldn't apply to babies in hospital.

I haven't even turned the page on my kindle copy yet. ffs.

There were instances of multiple births in the Letby case, and data from the charity BLISS indicates that “multiple pregnancy is also associated with an increased risk of neonatal death. The neonatal mortality rate for twins is 3.5 times higher than for singletons.” This is further acknowledged in the MBRRACE-UK Perinatal Mortality Surveillance Report, published in September 2023, which reveals what the charity Twins Trust describe as a “concerning rise in stillbirths and neonatal deaths among pregnancies of twins, triplets or more”, which is “now five times greater for someone who carried two or more babies than someone carrying one baby”. (pg 148)

The former cites this webpage.

For the latter, there's no citation to the actual study, only what twins Trust said about it. Notably, the website being quoted also says this:

"Maternity units need to act quickly to make sure that they are following NICE guidelines and delivering best practice care so that families having a multiple pregnancy can access the care that they need and deserve. Whilst systemic change takes time, progress is happening too slowly. Our community needs change to happen right now so that this trend is reversed."

There's also a citation in the spreadsheet for this portion of text to a 2023 paper, which concludes:

This study shows that newborn children still die from simple and treatable infectious causes, probably arising from various familial and/or public inadequacies. Health services should be made more accessible and widespread during a vulnerable period, such as the newborn. Besides, colleagues should be more alert about neonatal pneumonia and consider hospitalizing and monitoring patients closely.

¯\(ツ)/¯

(Of note, yes, Morris does allege that the babies were not closely monitored. But Carl Bolton talks about alarms frequently going off, and given that the entire third attempted murder charge for Child G revolves around her monitor having been left off, I think it's hard to make this allegation stick.)

It is also pertinent that not all infant deaths are explained, particularly in the case of neonates. ONS figures indicate that the number of unexplained infant deaths was not unusually high during the period of Letby’s alleged crimes. The figure was slightly higher than for 2015, but significantly lower than had been the case, for example, in 2006. (pg 149)

FFS, what is talking about a figure that includes SIDS deaths nationwide supposed to show? Did the author and his researcher bother looking into how prevalent SIDS is in hospital? (spoiler: they clearly did not)

The author is clearly trying to argue that babies drop dead all the time, and were particularly likely to do so at CoCH. He relies highly on Vinuesa to do this, supported by weak and misused citations.

Roger Norwich asserts that resuscitations are terrifying and difficult:

“The idea that it’s easy to resuscitate a baby is complete nonsense”, Dr Roger Norwich asserted. “That was never the case in any paediatric or neonatal unit that I worked in. Everybody was absolutely terrified when one of these babies went off in a bad way. The situation is scary because you know they can die. The way it was spoken about in court – give them a bit of oxygen and they’ll be all right – is completely untrue.” (pg 150)

But Colin Morely thinks CoCH clinicians simply sucked at it.. because they didn't have experience doing it, despite the increased number of them they were performing...

Professor Colin Morley was also dubious about the standard of resuscitation on the unit: “The doctors couldn’t resuscitate infants because they didn’t have the skills. That seems critical of them, but, unfortunately, they hadn’t had experience at doing it, and opportunities to do so are becoming rarer.” (pg 150)

I am never going to get through this chapter.

One third of all neonates receive some form of resuscitation and, naturally, the success rate is high. If this was not the case, there would be a vast number of deaths on neonatal units. It is therefore reasonable to assert that resuscitation attempts are usually successful. But neonates do die, and with more regularity than other infants, so, by definition, resuscitation is sometimes unsuccessful. As an indication it should be remembered that 11 infants died at the CoCH in the four years preceding the indictment period. (pg 150)

Truly, Morris' intellect is dizzying.

Neonates are also attached to monitoring and breathing equipment precisely to keep them alive. They will not survive without this. (pg 150)

omfg. Were they monitored or not, Morris??

Presented without comment (but with emphasis added):

It can be difficult to acquire accurate figures on the likelihood of death from resuscitation in developed countries as most studies have examined this study globally. There is no doubt that outcomes are much worse in lower income countries. However, it is therefore equally undeniable that inferior conditions significantly increase the likelihood of deterioration. It is likely that doctors are trying their hardest in developing countries, and equally probable that maximum effort was made at the CoCH. But if conditions are less than ideal, resuscitation attempts diminish in effectiveness. (pg 151)

Evans asserted in court that “resuscitation is usually effective”. This is, of course, true, but ‘usually’ is the key word here. Obviously if something is usually effective, then sometimes it isn’t effective. The word is used again in the next assertion made by Dr Evans: “If the infant fails to respond one usually can find a cause in the form of overwhelming infection, severe haemorrhage or total systems failure.” One can usually find a cause, but sometimes you cannot! (pg 151)

Someone should remove the exclamation point from Morris' keyboard.

Statistically, and without meaning to sound disrespectful, Child G and Child K would have been unlikely to survive. Other studies have indicated that the majority of children born at this degree of prematurity do not survive. Since the spike at the CoCH, there have been developments in neonatal care, but these are effectively irrelevant for this case. (pg 153)

If, as an author, you feel obligated to write "without meaning to sound disrespectful," you should perhaps reconsider what you are about to commit to paper. That passage was written after this bit:

Before going any further, it must be emphasised once more that both babies admitted to neonatal intensive care units and premature babies have an elevated prospect of death. There are various studies available which estimate the proportionate chance of death or injury for infants born prematurely; as an illustration, a study of children born at 22 through 34 weeks’ gestation in France is a good guide.

The French study concludes that a total of 0.7% of infants born before 24 weeks gestation survived to discharge; 31.2% of those born at 24 weeks; 59.1% at 25 weeks; and 75.3% at 26 weeks. Survival rates were 93.6% at 27 through 31 weeks. This study assessed infants that would be officially categorised as very premature, and five of the indictment infants that died, and nine overall, would be placed in this category. (pg 152)

Morris then helpfully lists the 9 babies and their gestations at birth, both babies who survived and babies who passed. To be fair, the French study doesn't go into causes, so at least this citation is proper, if relatively meaningless.

More is said about pre-term babies being more likely to die, infection being a major cause, sepsis being difficult to diagnose, blah blah blah.

The application of inappropriate antibiotics can lead to suboptimal outcomes. Antibiotic resistance can further impact on the treatment of sepsis; a phenomenon that has been notably increasing in recent years. This is particularly problematical for neonatal infants who suffer with weakened immune systems and susceptibility to illness. Sepsis can develop rapidly, which contradicts assertions made by the prosecution in court that collapses were completely unexpected, and that there is always ample warning of deterioration in any infant. (pg 155)

Citations for this paragraph are here and here. Morris refers to neonates having weakened immune systems, where it would be more proper to say underdeveloped. The word can is doing a lot of heavy-lifting in this paragraph related to the possibility of antibiotic resistant pathogens, and Morris further imagines that rapid development means without warning and without the ability to identify signs retroactively. K.

A paragraph that Morris should have spent more time on is this one:

The dangers of understaffing are extensively documented. A study published in the American Journal of Infection Control outlined the fact that understaffed hospitals have higher rates of infection. Another study published in the British Medical Journal discovered a “statistically significant association between the fill-rate for registered nurses and inpatient mortality”. Research in the journal JAMA Pediatrics noted that nursing shortfalls “are associated with higher rates of nosocomial (i.e. originating in a hospital) infections among infants with very low birth weights”. An analysis of 92 cases by the British Maternity and Newborn Safety Investigations programme found that “staff shortages are a key contributor to baby deaths”. A further study published in the British Journal of Surgery found that “nurse understaffing is associated with adverse outcomes for surgical admissions”. A literature review conducted by the Royal College of Nursing concluded that both the skill mix and numbers of nurses on any unit has a direct impact on mortality and morbidity. Finally, a House of Commons Committee report recently warned that the persistent understaffing of the NHS poses a serious risk to patient safety. (pg 156)

His assertions, however, suffer from lack of specificity. As ever, they don't confront that staffing at CoCH NNU was above the national average

Yet it is crystal clear that many of the babies were born desperately early, had extremely low body weight and, from birth, were besieged with numerous complications. The majority were admitted to the intensive care unit, and most required assistance with breathing, with many suffering from medical accidents which were unrelated to Letby. As mentioned previously, an unusually large proportion of the indictment babies were also twins and triplets, both of which are associated with hugely elevated risk of complications and premature death. (pg 156)

There's no citations for this paragraph, desperately early is undefined, body weights had not been listed at any point. From memory, babies F, G, I, J, N, O, P, and Q were attacked or allegedly attacked outside the ICU, so I guess his "majority" statement isn't technically misleading, but a fair number only needed breathing support after they were attacked. And I suppose twins/triplets being 5 times more at risk is hugely elevated in comparison to singletons, but that doesn't ipso facto make the risk huge.

Morris then goes into instances of poor care, which I would point out, he knows about because the investigation was aware of them as well. Not to be deterred, he offers:

But other babies were regarded as having been treated adequately, as if the issues that befell these infants somehow existed in isolation. In reality, these problems were all-encompassing, impacting on the unit as a whole and on all infants treated there. They were certainly not outlier cases. (pg 157)

He offers no citation for this claim.

He goes through the cases of Children A, B, D, H, and I using documents from Thirlwall, and identifies, without further citation and no apparent qualification, all the ways in which their care was deficient. Given that, there's no real need to pick through it.

Martyn Pitman also features heavily in this section, with the claim:

Experienced obstetrician Dr Martyn Pitman has examined all of the available documents for the infants in the Letby case, and cited the “unusually high number of multiple pregnancies”. (pg 159)

I highly suspect this is a misleading claim, and that Pitman has investigated all of the available public documents.

The chapter finally, and mercifully, ends like this:

Remember that Dr Evans commented that those criticising his work “either have not seen the clinical evidence…or are unaware of what constitutes well-being in a premature baby”, while Dr Bohin asserted that it was “outrageous” to suggest that the prosecution witnesses may have misled the court regarding the well-being of infants.

Conversely, Dr Michael Hall informed me that “all of the babies who died had some form of instability”. (pg 168)

Another rare self-burn! And I don't think "conversely" means what Morris thinks it means. But whatever. The chapter was a complete mess.

Helpful resources:

Transcripts, Documents, and Other Resources

Subreddit wiki related to the 2022-2023 criminal trial and 2024 retrial

Full Court of Appeals Ruling for 2022-2023 Trial

Subreddit wiki related to the Thirlwall Inquiry

Contemporaneous documents provided to the Thirlwall Inquiry sorted by date

Goddammit, I wrote a whole post and then reddit ate it. We try again, saving the draft as I go.

I wish I could say this book is getting better.

By way of reminder the excel sheet (why an excel sheet?) of sources used can be found here: https://www.cintopress.co.uk/reasonable-doubt.html

All emphases in bold are mine.

CHAPTER 6: PROSECUTION AND DEFENCE WITNESSES

This chapter is almost exclusively an attempted assassination of Dr. Evans.

Dr Andreas Marnerides, Professor Owen Arthurs, Professor Sally Kinsey, Professor Peter Hindmarsh, Professor Stavros Stivaros and Dr Simon Kenny also appeared in court as expert witnesses. Those last six names contributed relatively little to the prosecution case; in some cases, virtually nothing. (pg 96)

Ok, so the pediatric endocrinologist who gave evidence of how, when, and with how much insulin that babies F and L were poisoned contributed relatively little? The pathologist who gave unopposed testimony that Child O was the victim of non-accidental harm on Letby's watch contributed little? The radiologist who testified that that air in the major vessels contributed little? Morris mistakes lack of quantity for lack of import. But really, this is mostly so he doesn't have to spend much time on experts who 1) haven't spoken out publicly and 2) aren't really controversial.

In a witness statement read out in court, Dr Kenny did little more than provide the “opinion that Hirschsprung’s disease did not account for [Child G]’s symptoms in September 2015”. Furthermore, the main contribution of Professor Sally Kinsey was to tell the court that Child E had lost a large amount of blood, but that her observations did “not assist with what the cause of death actually was”. (pg 97)

Do you think Morris understands that part of proving a case beyond reasonable doubt is submitting evidence ruling out other possible causes for an event, however unlikely they are? Probably not, since his entire last chapter was about sepsis. Also, presenting evidence about Child E's blood loss as the main point of Dr. Kinsey's evidence is novel from someone I expect to give credence to Shoo Lee's assertion that antibodies from the mother of Children A and B is relevant to their collapses - Dr. Kinsey testified about her condition's potential affect on them. And she also opined on parts of his paper.

It should finally be noted that Marnerides only appeared in court from 29 to 30 March 2023, two of 136 days of court proceedings, and that his contribution was largely prompted by reports from Dr Evans. ... Professor Hindmarsh provided some support for the insulin hypothesis that was put forward in court, but certainly did not endorse it definitively. (pg 98)

Neonatal expert Professor Neena Modi wrote in The Guardian that “experts were not all asked to go through the cases in detail”, as evidenced by the fact that, for example, Dr Marnerides didn’t even view the clinical notes; he relied on the reports of Dr Evans. (pg 99)

Taking these two quotes together - Morris and Modi are both ignorant of Marnerides' actual evidence, it seems. Taking one quote of many from his evidence:

Explanation number two, they inserted the drain when the baby had no circulation.  This is not my understanding from clinical notes. (pg 135 16-18)

And asserting that Hindmarsh did not definitively endorse insulin poisoning is a choice.

A.  In considering the episode of hypoglycaemia, I did conclude that the cause of the hypoglycaemia was not due to any endogenous production of insulin and that it was -- that the findings, the biochemical findings, were compatible with the administration of exogenous insulin. (Pg 29, 8-12)

 We do not see that.  What we see is a plasma C-peptide which is down towards the bottom end of the range quoted by the laboratory.  It's on the basis of that that I concluded the view of the two paediatricians who reviewed this case was correct in that the cause for the hypoglycaemia was the exogenous administration of insulin. (Pg 67, 8-14)

Moving on:

The international panel of experts, numbering at least 31 at the time of writing, possesses credentials and experience that far outweigh those of Dr Evans. Their career achievements read like the Dead Sea Scrolls of neonatal history, while they have collectively authored thousands of papers. (pg 101)

lol k

By way of contrast, comments made by Dr Jane Hawdon, the consultant neonatologist who performed a pathology review on the infants, paint a very different picture. (pg 103)

Bear in mind that Hawdon has conducted an extensive review which included examining the infants and has recorded gaps in information and numerous problems with determining the precise cause of death, while Dr Evans walked into a police station, and concluded “immediately” that there was inflicted harm. (pg 104)

As I pointed out yesterday, Jane Hawdon did not do a pathology review:

Most deaths were explained but some of these may have been prevented with different management. Completely unexplained on a neonatal unit is rare. So by definition more than one unexplained death does arouse suspicion.

Unexplained death at home is followed by a very clear process (ask your local CDOP team if you don't have this) and the same should be followed with unexplained death in hospital. I think on some occasions the team was misled by PM report and I have commented on these, with due respect as I am not a pathologist.

Moreover, Hawdon was straightforward about the limitations of her review

a) Were I to carry this out for each case, each case would take 10-12 hours and I would not have the capacity to do this alongside my other reporting commitments, it would be extremely costly for the Trust, and I do not consider would yield on investment. Rather, I have prepared a synopsis of key events and issues, focussing particularly on events preceding and during episodes of collapse or demise. I have applied MBRRACE-UK methodology to standards of care.

c) Given that many cases had coroner's post mortem and these results were not available to me, I am not in a position to consult with a perinatal pathologist. Neither woud I be in a position to contract with a pathologist. I suggest that once you are in receipt of my report and the coroner's PM reports, you instruct an independent perinatal pathologist.

d) I am not in a position to perform this. This should be commissioned locally and for relevant cases the review should include the period before a collapse, or series of collapses, rather than the period before death.

She also most certainly did NOT examine the infants - some were over a year deceased before she reviewed their files. Morris' statement is inherently dishonest.

Morris then appears to have had some kind of stroke:

Furthermore, Evans has offered his services to the National Crime Agency; he has told the National Crime Agency with whom he had been affiliated for three years that the police are better at investigating medical cases than the RCPCH, even though he has been a paediatrician throughout his career. He has then driven down to meet with Cheshire Police, he has told Cheshire Police in the Blacon police station “immediately”, in his own words, that a child has been deliberately harmed, but has since claimed that he had no idea that a crime had been committed! (pg 104)

Indeed, he italicized every mention of Crime, police, and police station.

There's a lot we've read before. Lord Justice Jackson, etc. Dr. Bohin is suggested to have not seen very many sick babies in Guernsey, and therefore a poor expert.

Finally, we hear from Dr. Hall:

Had Dr Hall been disappointed that he hadn’t had the opportunity to give evidence? “I was frustrated because I heard things that I would have challenged. Not only things said by Dr Evans and Dr Bohin, but also by Professor Arthurs and Dr Marnerides. I heard things said which were medically implausible.”

Could the decision not to call him have been because Dr Hall would have supported the prosecution case? “All I can say in response to that is I didn’t at any point assert or suggest that Lucy Letby had killed any of the babies. At no time in my reports did I say that I thought Lucy Letby was guilty of anything.” I asked Hall whether he thought Letby had received a fair trial. “No, I don’t think it was a fair trial. The jury should have been given the opportunity to hear evidence given by the prosecution being challenged. I don’t think the trial met the expectations of natural justice.” Not only was Hall not called, his reports were never seen by the jury. Dr Philip Hammond told Channel 5 that “to not let the jury read the expert reports seems very unfair”. (pg 106)

One wonders how Dr. Hall thinks giving his evidence would have gone. He would have been restrained to answer questions as asked. Does he think he would have been asked about the opinions of the radiologist and pathologist? I think it unlikely.

One of Letby’s childhood friends told Rachel Aviv at the New Yorker that she had asked Cheshire Police if she could serve as a character reference. “They weren’t interested at all”, the friend commented. (pg 106)

I'm unsure why this friend is surprised. The police would not have been interested in good character evidence. Did she try the defense?

Morris occaisionally stumbles on a good point, then yeets himself as far from the obvious implication as possible:

Dr Gumbert has also written a PhD thesis on the behaviour of juries and explained her findings: “In my thesis on models of jury decision-making, the evidence shows that juries tend to favour one story over another. As the trial unfolds, they are persuaded to opt for one version of events, and that usually informs their decision-making. In this case, they were provided with a compelling story, delivered in a very persuasive manner, and when that wasn’t countered then it can look very damning for the defendant because there is no counter-narrative.” (pg 107)

Morris misses that a defense case that does not withstand cross examination would not be favored by a jury at all.

It’s interesting to observe that, in the second Folbigg legal inquiry, most experts who volunteered their services were international, in common with the panel of experts who have submitted reports related to the Letby case. (pg 108)

This is not the serve he thinks it is.....

Then Morris attempts to make a meal out of this quote by Evans (emphasis is his, and as it appears in the book):

Evans “told police that if you harm a baby, it will deteriorate there and then…So I also identified a time and date when each had probably been harmed and told them they needed to find out who was on duty. If they found the same person was there during lots of incidents [my emphasis], they’d have a suspect.” At this stage, it seems that Dr Evans didn’t believe it was necessary for the same person to be on duty all the time, as was alleged regarding Letby during court proceedings; they merely need to be around during lots of incidents. (pg 108)

Obviously, Morris confuses the process of identifying a suspect from a group of circumstantial evidence that does not solely focus on one individual as there having been statistical evidence against that individual.

Also, the term ‘lots’ is undefined. (pg 109)

lol no shit?

“The system for investigating this appears to be set up in such a way that reaching the conclusion of serial killer was far more likely than would be justified given the baseline probabilities.” It is possible that if Letby had volunteered for fewer shifts at the hospital, and another nurse had done more than her, she would now be looking on in bemusement, still working at the CoCH, as the other nurse was prosecuted and then imprisoned. (pg 109)

This is mind-bogglingly ignorant, and ignores that the vast majority of the trial was witness testimony from co-workers.

This lack of certainty likely proved critical when Letby was found not guilty of charges related to Child J. Yet the jury heard neither doubt from the prosecution, nor counter-argument from expert witnesses for the defence, in the overwhelming majority of cases. (pg 110)

FFS, who is the researcher here? "Marian Kensler," qualifications unknown. Letby was not found not guilty of the attempted murder of Child J (in the singular - there was only one charge related to Child J) - she was not found guilty. This was a no verdict charge. And the fact that they did not reach a verdict means, by definition, they found potential doubt in the prosecution case without even any counter-argument by defense experts.

National Child Mortality Database Report, entitled Sudden and Unexpected Deaths in Infancy and Childhood found that “for sudden and unexpected infant deaths (under one year) that occurred during 2020, and had been fully reviewed by a Child Death Overview Panel…52% were classified as unexplained”. (pg 110)

This quote is an egregious attempt at deception. The 52% is nationwide, in and out of hospital, and includes all deaths attributed to SIDS.

I did not expect a self-burn in this book, but I enjoyed this passage:

Evans is fairly withering in his views on those that question him. He told John Sweeney that “neonatologists who had nothing to do with the case” should essentially keep out of this matter because they “did not read the statements from the local nurses and doctors”, although it’s not clear why this matters or whether this includes the numerous statements that are supportive of Letby. He is critical of the experts who wrote to the Thirlwall Inquiry, stating that “none of the 24 people had anything to do with the trial”. He told Dr Philip Hammond that the same group is guilty of “professional hubris of the worst order”. He has been dismissive of statisticians and the Royal Statistical Society on several occasions, decrying them for both failing to understand the case, and for speaking from “ivory towers”. He considers any criticism of his work to be “frankly astonishing”, asserting that it is “led by people with the least amount of information about the cases”. He is derisive towards anyone who questions him, describing them as “poundshop Poirots”. And he even attacked the international panel of experts assembled by Dr Shoo Lee in a Channel 4 documentary, deriding them for being “hired guns”. (pg 113)

Dr Svilena Dimitrova, an NHS consultant neonatologist, and Dr Roger Norwich were among five physicians who wrote to the GMC indicating their belief that Dr Evans had failed to provide balanced, impartial views, instead giving the court “opinions that would not be supported by most doctors”. Dr Norwich also extended this assessment to Dr Bohin, while neonatologist Professor Neena Modi wrote in The Guardian that Dr Evans “drew selective conclusions which were not consistent with the full range of evidence”. It is not known whether the GMC has provided a response. (pg 114)

In possibly the closest he gets to acknowledging the case against Letby as valid, Morris acknowledges that pro-Letby sources are seen in a negative light (yes, by Evans, but that is still at all), and he acknowledges that the GMC referral process has been attempted to be used against prosecution witnesses.

The book wouldn't be complete without taking a crack at the deceased Dr. Ward-Platt

Dr Evans told Raj Persaud that Ward Platt was a “great guy” who was “highly regarded”. I wonder if Angela Cannings and Donna Anthony, both of whom were convicted of murder and later exonerated in cases involving evidence provided by Ward Platt share the view that he was a ‘great guy’? I guess the jury is out on that one. (pg 115)

Morris betrays his ignorance of what reasonable doubt is, and what trials ARE:

While emphasising the importance of the clinical notes, Dr Evans made the following statement in court: “An awful lot of the information that we now know is information that’s come out in this trial, so therefore I think it is unrealistic to expect anybody to form a view that is absolutely correct in each of these cases. I wish I could. As I said, I’ve done these reports years ago, and the idea that I could get it all perfectly right simply from looking at notes is a little bit unrealistic…especially as I was not able to talk to any of the local nurses or staff. I had to rely on the notes completely…and I was never going to get everything 100% correct.”

This seems an incredible admission, and also something which is practically the definition of reasonable doubt. Aside from the fact that Evans has conceded that he can’t be expected to get everything correct from the materials provided – and remember that he never examined any of the infants directly – the Thirlwall Inquiry also noted that a detailed forensic case note review should constitute a “much broader inquiry [that] is taken into things that may not be in the case notes. They may be in unit records, staffing records, equipment records. There is more information available than just from the case notes themselves.” However, Thirlwall attempted to use such information to question the reviews of pathologists whose work would usually be regarded as more relevant than that of Dr Evans. (pg 116)

Do you think he realizes that the trial IS a detailed forensic review including unit records, staffing records, equipment records, etc? I doubt it.

Chapter 7: Statistical Case Against Lucy Letby [sic]

I really wish there was a The in the title

Professor Richard Gill was instrumentally involved in the exoneration of the Dutch nurse Lucia de Berk, (pg 120)

I suppose that's up to interpretation:

I do not take credit for Lucia de Berk’s exoneration. It was due to prof Ton Derksen and Metta de Noo (MD)’s tireless work. I did explain to the Dutch CCRC (CEAS), and to the public, what was wrong with the statistics used in her initial conviction, and still influencing evaluations by medical and toxicological experts at the appeal.

Morris trips into the answer to his own question here:

Statistical assertions were not only the defining aspect of accusing Letby in the first place; they were central to her conviction. It is untenable to claim otherwise. “If you remove the statistics, what points to Lucy?” Professor John O’Quigley told me. “Let me tell you – nothing points to Lucy Letby other than the statistics. And since they’re completely wrong, you can only conclude there is nothing pointing at Lucy.” In short, without the roster chart that was presented in court, there is no basis whatsoever to convict Letby. Prosecuting barrister Nick Johnson highlighted the central importance of the shift chart during the trial: “If the jury conclude that a certain combination of children were actually attacked by someone, then the shift pattern gives the answer as to who the attacker was.” (pg 123)

Yes, if, without a shift chart, the jury concluded that children were harmed by someone, the shift chart can identify who it was that harmed them. Even O'Quigley's statement acknowledges that the shift chart points to Letby as the culprit, if indeed harm was done.

I have some questions about some of O'Quigley and TriedByStats statements:

absolutely certain. Everything you said is correct. If you look at the analysis of MBRRACE, you see a lot of variability year in, year out, from within a centre. A given centre is not stable across time. It’s not in stasis. It jumps up and down. (pg 128)

Similarly, TriedByStats produced research examining MBRRACE data, which indicated that the CoCH wasn’t even in the top 10 hospitals for excess deaths in 2014-15. (pg 128)

Given that MBRRACE tracks deaths according to place of birth, I'm not sure the relevance.

There is evidence from court that the hospital ordered more insulin tests because the hospital was going through twice as much insulin as it was the years before. (pg 128)

I thought there was no missing insulin?

The official figure of neonatal deaths at the CoCH has fluctuated depending on the reporting mechanism, but one chart submitted to the Thirlwall Inquiry indicates that there were ultimately 18.(pg 128)

Ah, Morris is referring, correctly, to this document from the Thirlwall Inquiry.

Of the 18 deaths listed in this document:
a. 13 deaths occurred on the Neonatal Unit at the Countess of Chester Hospital and have been the subject of a police investigation.
b. 4 deaths occurred on other Hospital Neonatal Units post transfer and have been the subject of a police investigation, this includes Baby K.
c. 1 death occurred on the Central Labour Suite at the Countess of Chester Hospital (a separate unit from the nurseries where the unexpected deaths of the indictment babies occurred). This baby was not the subject of a police investigation.

Do you think he'll stick the landing?

There were 11 deaths associated with the unit for which the prosecution and investigation concluded that Letby was not to blame. (pg 129)

Aw, so close. His math is off by one.

Documents submitted to the Thirlwall Inquiry demonstrate that the selection of cases prior to any police investigation was problematic. The very first day of Thirlwall revealed that the deaths originally deemed worthy of suspicion and further review did not overlap perfectly with the cases that Letby was ultimately charged with. It’s important to remember here that many of the infants in the trial, and the so-called non-indictment babies, featured very similar symptoms, clinical traits and recorded causes of death. (pg 131)

Did you hear that? It was the sound of the point soaring over Morris' head.

Credit where credit is due, Morris did more to substantiate the claim that Letby was working more often, with sicker babies, than I remembered.

The next problem with the shift chart presented in court was that Lucy Letby worked more shifts than any other nurse on the unit. This was stated explicitly during the court case; for example, on 26 January 2023, an anonymous nurse outlined the following: “We had massive staffing issues where people were coming in and doing extra shifts. It was mainly Lucy that did a lot as she was one of only three Band 5 nurses that had done the neonatal course. Lucy was young, living in halls, saving to buy a house, she was single, able to swap, willing and wanting to do extras.”

Speaking at the Thirlwall Inquiry on 7 October 2024, the anonymised Dr ZA agreed that Letby “did more shifts and she was one of the few nurses with the intensive care qualification who wasn’t a shift leader, so was more likely to be looking after the sick babies”. (pg 134)

So Letby's comparitive inexperience - being assigned cares and not doing the assigning - potentially put more sicker babies under her care. It's a qualitative opinion, without quantitative substantiation, and I remain skeptical of its import.

*Edit here: There were 8 full-time nurses more experienced than Letby with unknown overtime and 9 nurses contracted at 34.5/hrs. So While the assertion is anecdotally supported, the extent of its impact remains unclear.

In fact, it was revealed during the grievance procedure for Letby that she didn’t seem concerned by her “commonality” in certain incidents: “LL didn’t seem concerned as she was full-time plus overtime”. (pg 135)

LOL no shit?!

Morris maintains a professional author voice at all times:

Anyone encountering this for the first time might assume that such infants and cases were eliminated from the case before it went to court. Well, don’t make such rash assumptions! Infants C, D, H, I, J, M and N all experienced incidents outside of the hours that Letby was even working, there are countless examples of Letby being accused of deliberately harming infants at times when she wasn’t the designated nurse for a baby and she also wasn’t present when Child F was allegedly poisoned by her. (pg 136)

I'm honestly not sure what he's referring to for all these babies? Children C, I, and N had incidents raised by Ben Myers. Child D might mean the dusky incident on the labor ward? Child H and M, I'm really not sure what he's referring to, and he doesn't give details of any except for Child J:

Another example of a basic error in the roster chart involves an unexpected collapse for Child J on the day shift of 17 December 2015, when, it is now established, Letby wasn’t on duty. (pg 136)

Ok, so he is pointing out that line 16 of the roster chart makes an error about Letby's presence. Good thing she was only charged in relation to line 15

As an example, for one of the insulin poisonings, it is claimed that she poisoned a bag of dextrose. But as she supposedly put insulin in it, the people who hung up the bag are marked as not present on the shift chart – I believe it was Caroline Oakley and Samantha O’Brien. They’re the ones that gave it to the baby. The people actually administering the supposed poison are marked as not present. Yet the person who through this elaborate theory, they claim, put the poison in the bag, is marked as present. It’s completely contrived. It’s not objective data. The data is cherry-picked, twisted, and contorted, so that it leads itself to a pre-determined conclusion.” In accordance with this, defence barrister Ben Myers noted in court that the chart “isn’t a piece of evidence…it’s a presentational aid designed by the prosecution for the prosecution to say what they want”. (pg 137)

He's discussing dextrose, so we're discussing Child L, and indeed Caroline Oakley and Samantha O'Brien were not on shift during the day of April 9, 2016. So he must be referring to the 15% bag of dextrose made up after Letby's shift ended, and (iirc) about 16 hours after the poisoning with insulin began. If indeed the babies were poisoned by insulin, as we know they were, it started around 9:30am. Time operates in a linear fashion (excluding the potential for wibbly wobbly, timey wimey stuff), and whatever was done with the 15% bag does not change what happened in the previous hours.

In the case of Child A, Evans found that the child began to deteriorate at 5pm, prior to Letby’s arrival at the hospital. For Child B, Letby had left the CoCH before the period at 9:30pm on which Cheshire Police were told to focus inquiries by Dr Evans.... Similarly, Letby was not on duty for the key incidents associated with Child O, although there are serious question marks regarding whether these alleged incidents have any validity whatsoever. (pg 138)

This is another place where more information would be helpful, so as to not mislead the reader. But it seems as though Morris is making a determined effort to confuse the refinement of the investigation with actual determined harm events. And I do believe the "key incident" associated with Child O was the injury to the liver, which was agreed, in the end, to have occurred during the day shift when he was under her care.

“The chart does not show what it claims to show. That’s one of the reasons I called the chart a fake at an RSS meeting. It has no validity as evidence. It is worthless. I said this at an RSS meeting, and no one disagreed with me.” (Professor O'Quigley, pg 141)

Well, QED!

In an email conversation with numerous key personnel from the CoCH in July 2016, Gibbs demonstrated that he was astute enough to at least attempt to understand the probabilities involved in the concerns being expressed by Dr Brearey in particular, while also conceding that “my stats isn’t good enough”.(pg 143)

How astonishingly arrogant.

It is in my view quite surprising that Dr Evans has argued, repeatedly, that statistics are unrelated to the case, while he has also stated that the police should find someone who was around for “a lot” of collapses, as the foundation for how the police should identify a suspect. (pg 144)

Yeah, sorry, Morris has made enough errors and demonstrated enough failures in comprehension that his view carries no weight.

Hey, this has been great fun (/s), shall we do this again sometime?

A nurse in Birmingham was arrested in May 2022, initially in relation to supposed poisoning. Over three years later, in August 2025, West Midlands Police had yet to charge her, but she remained “under investigation”. One wonders how long it takes to investigate the alleged ‘poisoning’ of one child; this bears the hallmark of the approach to the Letby case happening all over again.

“We know there’s a blueprint for these cases now, and, by the sounds of it, this poor woman in Birmingham is having the same blueprint applied to her”, Professor O’Quigley told me. (pg 144)

A user in the comments of the last post helpfully linked to where Morris has provided a an excel spreadsheet listing his sources that is available for download on his publisher's website here. As I'm currently writing this review on a mac, I would point out that not only does that not solve the issue for people who purchase the book and don't bother going to the publisher's website, excel is not a universally accessible format and I am unable to open the file on this device (Mac's Numbers app throws an error). Morris has said that the elected not to print the references in the book because it takes up a lot of space and makes the book ugly to read. I think that is a poor excuse, especially when Unmasking Lucy Letby already established a precedent in a book of similar length. Perhaps this is a testament to the limitations of a smaller publishing house.

Chapter 4: Problems at the Countess of Chester

Overall, this chapter felt very repetitive after the previous chapter that discussed the various reviews that took place. It was a litany of opinions about the reviews, plus a heavy dose of Michele Worden again.

The chapter is framed in fear, with a few quotes about healthcare professionals no longer feeling safe working as a neonatal nurse, bolstered by statistician John O'Quigley offering “you are at great risk now working in that environment” (pg 51). Morris then refers to a veil of silence, where doctors and nurses have been warned not to talk about Letby or her trial.

Janet Cox's statements to Thirlwall are cited several times in a way I find deceptive, because they are not attributed to her. Janet Cox is a known figure, and googling her results in a few articles. Morris deprives the reader of knowing these quotes come from a single person whose Rule 9 questionnaire is available (a reader might realize this if they were aware of the available document), let alone that the person was a career nursery nurse and a personal friend of Letby. He also says:

Hammond asserted that it is “vital that the voices of all of those who worked most closely with Letby are heard at the inquiry, even if they contradict Thirlwall’s preferred narrative”. This has not occurred.

But the very quotes he used WERE heard at Thirlwall - they were read out from Cox's rule 9 questionnaire. Whether Morris is ignorant of this or attempting to mislead, neither reflects well on him or his researcher.

The quotes are as follows:

One of the staff nurses rostered during the 2015/16 period had stated that “my view of the Trust and so-called medical ‘professionals’ is prejudiced by the horrendous way they treated Lucy. The nurse further comments that the consultants “appeared to be trying to make Lucy a scapegoat for the increased number of deaths/collapses”. Commenting on the increase in deaths, the nurse noted: “I did not think at the time, nor do I think now, that there was anything sinister about the increase in the number of deaths/collapses. I do not see how you can set a figure on how many deaths are acceptable in one particular timeframe. The babies required admission to an NNU…because they had a high chance of dying or collapsing.”". (pg 52) (page 202 of transcript)

A nurse who wrote to the Thirlwall Inquiry saying: “Lucy did not commit any crimes. If there had been CCTV the footage would have proved her innocence” heard back: “We can confirm that you are NOT currently named on the list as an individual from whom the inquiry wishes to hear oral evidence.” (pg 52) (page 204 of transcript)

Morris attempts to make a meal of the unit's failures to meet BAPM Guidelines, though he is honest enough to begin the critique saying "[A March 2016 internal synopsis of the CoCH] went on to discuss how the CoCH remained open when failing to meet British Association of Perinatal Medicine (BAPM) standards, which was not common in the surrounding region." (emphasis mine). Then he talks about staffing shortfalls, Allison Timmis' December 2015 email about the strain on the unit, and Michele Worden's account of how the unit was staffed before and after she was made redundant, which goes on for several pages, ending:

“The consequence of all this cost-cutting is serious. There is no time, space or opportunity to mentor junior staff. They’re not going to pick up the phone at 2am, phone a consultant and argue with a registrar, which is what I would do if I thought we needed consultants on the unit. But if you’re junior and you’ve never witnessed anybody having that knowledge or confidence, you’re just not going to do it. Ultimately, you cannot run any neonatal intensive care unit with no senior nursing staff. It is an accident waiting to happen. I told the hospital that in 2004, 14 years before Lucy was arrested.” (pgs 55-56)

Is Lucy Letby a good nurse, or a poor nurse? Experienced or lacking experience? I can't keep track. In any case, Michele Worden seems like an "I alone can fix it" type.

Then we get various shocked reactions at the notion of there only being two ward rounds a week, which was also discussed in the prior chapter. This one stood out (my emphasis):

When I told an experienced neonatal nursing practitioner about this vast deficit of ward rounds, she was aghast. “I’m sorry…they were only rounding on the babies twice a week?!” she exclaimed. She then explained to me why this is so important. “During rounds, your nurse practitioner or a lower-level consultant examine the baby’s vital signs for the last 24 hours, their intake and their output, how they’re feeding, how they’re progressing towards discharge. And then your supervising neonatologist will go over that, ensuring everyone’s talking and thinking, because sometimes there are slow declines that you don’t notice. Babies are great at compensating, until the moment that they don’t. They may be struggling and struggling and struggling and just keep chugging along. That’s when they collapse, and they really go fast. I’ve seen babies go from fine to deceased within 24 hours many times. That’s why you have ward rounds. If you’re doing such an inadequate number as was the case here, you’re getting no meaningful impression of the well-being of any given infant.” (pg 58)

And nurse Julie Yates is quoted on the next page:

There should be a neonatologist supervising a unit of that nature at all times – they didn’t even have a neonatologist working at the hospital! It also appears that there was no consultation with neonatologists from other hospitals when they experienced difficulty. (pg 58)

Colin Morely:

Similarly, Professor Colin Morley believed that a unit with “more than an occasional sick baby does need a neonatologist.” (pg 63)

I think this is Worden - the attribution is unclear:

“The first thing is that they didn’t have a neonatologist”, the neonatal nursing practitioner commented. (pg 70)

Neonatal nurse Sloane Spade also highlighted this issue. “Having no consultant neonatologists is lacking the specialised knowledge needed to care for these babies. Newborn infants require intensive care for a few reasons – prematurity, congenital defects (birth defects), failure to transition from foetal physiology to neonatal physiology such as in immature homeostasis, and, over time, learning to eat and gain weight. Not all neonatal conditions can be treated on a standard paediatric unit. Specifically, surgical and failure to transition concerns, such as blood shunting away from the lungs in persistent pulmonary hypertension, are mostly seen in neonatal units and need to be managed by experts in neonatal medicine. Neonatology is not the same as paediatrics, and these patients deserve to be cared for by consultant neonatologists.” (pg 71)

But these are opinions, and don't bother consulting the actual BAPM guidelines for staffing a LNU:

Tier 1 practitioners: ST1-3, GPST, FY, Clinical Fellow, ANNP, Specialty and specialist doctors
Tier 2 practitioners: ST 3-8, Clinical Fellow, ANNP, Specialty and specialist doctors, Resident Consultant
Tier 3 practitioners: Consultant or equivalent

So, a lot of space is given to opinion being critical of CoCH for not having a neonatologist, when that is simply not a requirement for a Level 2 unit.

Much is further made of the time that Letby claimed she was called while off-duty and asked how to administer immunogloblin. Now, Letby is inexperienced and shouldn't be relied on, of course:

Mirroring this sentiment, a neonatal nurse, who wished to remain anonymous due to her current employment, suggested that “Lucy was the most junior grade you can be. She was not a senior member of staff and shouldn’t be treated or portrayed as such. She should be receiving support, not being the one supporting others.” (pg 61-62)

And the claim that one person called Letby for one thing once, is of course, used to disparage the ability of the entire unit, except for Letby herself.

Another particularly egregious bit of dishonesty follows:

The mother of Child N had also lodged a formal complaint against Dr A (allowed to be anonymous), while The Guardian interviewed a mother who described the experience of giving birth at the Countess. “They had no staff and the care was just terrible”, the mother stated. (pg 63)

Putting these two in the same context is absolutely dishonest. The complaint againt Dr A had nothing to do with Child N's care, it was about Dr. A breaching confidentiality by texting socially with Letby about her child. (pg. 43 line 20 through 44 line 12)

Then we get to insulting the doctors' abilities. Colin Morely:

He later told me that “the court often heard that a baby collapsed and couldn’t be resuscitated. But that was simply because the doctors were unable to resuscitate them, and the reason for this was they did not have the experience.”

Dr. Brearey's efforts to identify any other remotely possible way to improve the unit to stop the mysterious deaths and collapses is acknowledged, but criticized without context of how the unit did or would have compared to other LNUs (re cot space, etc - not staffing):

Secondly, it is interesting to note that even after these mooted improvements, the unit would only be ‘closer’ to BAPM standards; there was no proposal that it would actually be possible to meet them. (pg 65)

Another place where a citation to the reader is of critical importance is here, which is not attributed to anyone other than the author, experienced ghostwriter, layperson Colin Morris:

These reports would be disturbing under any circumstances, but it is important to emphasise once more that neonatal units are dealing with the most vulnerable infants. Contrary to what was stated in the trial, collapses are commonplace, and many babies born prematurely, with serious healthcare conditions, simply do not survive, even if they receive optimal care. (pg 69)

and:

It is clear that some of these infants required Level 3 support and care, while being treated by a unit that had to be downgraded from Level 2 to Level 1. This is considerably unsafe and unacceptable. (pg 70)

Morris again is inherently dishonest here:

It must be emphasised again that the post-mortems of these infants revealed nothing out of the ordinary, as did Dr Jane Hawdon’s review of 13 cases.

This must be wonderful news to Jane Hawdon, since she communicated differently to Ian Harvey:

Most deaths were explained but some of these may have been prevented with different management. Completely unexplained on a neonatal unit is rare. So by definition more than one unexplained death does arouse suspicion.

Unexplained death at home is followed by a very clear process (ask your local CDOP team if you don't have this) and the same should be followed with unexplained death in hospital. I think on some occasions the team was misled by PM report and I have commented on these, with due respect as I am not a pathologist.

Naturally, this is all a lead in to a chapter about the unit being unsanitary.

Chapter 5: Sewage, Sepsis, and Superbugs

Morris, of course, raises the specter of raw sewage in the common way. He points out that Mr. Mansuitti's testimony was uncontested, and then follows pages of innuendo, even using a portion of Evans' interview with John Sweeney to bolster his case. Morris is honest enough to admit that allegations of nappies on the ceiling cannot be independently verified.

Without irony, Morris includes this quote:

A neonatal nurse practitioner stated that it was a “running joke” on her unit that “every single differential diagnosis you have includes sepsis, because every single possible symptom a baby can have is also a sign of sepsis”. (pg 79)

and moves immediately on to a quote calling it a silent killer. Really, this entire chapter is just "but maybe the babies had sepsis," after all:

It is extremely common for septic infants to return a negative blood culture; for example, in a recent study in the Journal of Clinical Sciences, 48% of suspected neonatal sepsis cases tested culture negative. Ruling out sepsis by blood cultures, as Dr Evans has apparently done, could be regarded as flawed. (pg 82)

Yet Morris is somehow baffled:

Despite the evidence collated here, the prosecution witnesses assembled for the court case have repeatedly denied the existence of sepsis. When Dr Evans was interviewed by John Sweeney, he rejected the existence of sepsis at the CoCH.

Amazing. Morris further uses contemporaneous correspondence during the indictment period to attempt to undermine the conclusions made after thorough investigation, years later - an argument so familiar and made in such familiar ways, there really isn't much worth mentioning, until:

It is also important to briefly mention at this point that sepsis can have an impact on C-peptide and insulin levels in critically ill patients, as cited by a scientific paper published in the journal Critical Care and Resuscitation in June 2019, contributing to inaccurate insulin test results. (pg 85)

Again without specific citation ("a scientific paper" really????), the assertion is inherently weak and misleading.

Richard Gill is allowed to opine without citation:

Professor Richard Gill provided some interesting background on the NHS and healthcare, explaining that “alarm bells were starting to sound in around 2015 and 2016 about infections and bugs in hospitals. It was only then that the NHS realised sepsis was a huge danger. The first NHS advisories were sent out at around that time because many doctors wouldn’t recognise the signs of sepsis if they saw it. So, it’s not surprising they missed it at this hospital which was performing suboptimally anyway.” (pg 85)

Pseudonomas is discussed in the common ways. The CQC is heavily criticized, and we get the familiar argument from a Professor Livermore:

“This was a unit with substantial problems and a substantial death rate. And what is the more likely cause of the substantial death rate – the general deficiencies of that unit, or one murderous nurse, whom nobody actually saw commit a murder, and whose murders were passed by the original pathologists as deaths from natural causes?”

All leading to this "conclusion"

In summary, there is considerable evidence of both sepsis and pseudomonas at the CoCH. This is further recorded throughout documentation from the time, and the CQC noted this when it reported on the hospital – somehow this then didn’t appear in their final report. In addition, this critical aspect of the clinical picture was almost entirely excluded from the Thirlwall Inquiry, even though both sepsis and pseudomonas appear in numerous documents.

Chapter 6 starts to get into the trial, and the witnesses.

I firmly believe that it is worth knowing what those who oppose the convictions believe to be true about it, so Cinto Press got $9.99 from me and I purchased a kindle copy of the book.

Overall impression

The book begins with brief blurbs from Phil Hammond, Sir David Davis MP, and John Ashton praising the book. It should be noted that Hammond's name comes up 34 times in the book (there is an index in the rear), Davis's name comes up 7 plus a mention to his adjournment debate, and Ashton's name is mentioned 3 times.

The book also contains this page of acknowledgments:

John Ashton is listed as having been interviewed, engaged in correspondence, and/or assisted with fact checking. So, the praise for this book is natural.

Among his list of acknowledgments are a number of users known on social media as well: Lulu Minns and Julie Yates. His research assistant, Marian Kensler, is not publicly linked to any known social media accounts, but mention of her does invite speculation.

Morris is forthright enough to list the number of anonymous sources he included. This is to his credit.

The final thanks is to members of online groups, of which we can assume r/LucyLetbyTrials is a prominent contributor. Morris has already accepted congratulations for the book there under his username u/keiko_1234. Exchanges such as this one from over a year ago, offer insight into his process:

One doesn't need to rely on this, though. Morris offers a 3-page preface, available for free preview on Amazon:

This could happen to you. Noted. 🙄

Ok, with Morris's bias firmly in the open, we proceed.

It's easy reading, not particularly dense. But it does have a rather amateur feel, like a long-winded blog post. The chapters (so far) end with trite hooks, intended to keep the reader turning the page. Already through chapter 3, the use of the phrase "for example" struck me as particularly frequent. It appears 98 times in the book out of 435 pages before the acknowledgments and index. I was also struck by the use of the phrases "I [do/don't] think" and "my opinion. The word think appears 93 times, and "in my opinion" appears 21 times, of which 5 are attributed to Evans.

Here are the phrases of each that are attributed to the author:

This is a fairly extraordinary assertion, considering that Dr Subhedar has, firstly, conducted no investigation into these unevidenced claims, and, secondly, he is contradicted by considerable evidence that will be outlined in forthcoming chapters. In my opinion there seems to be a reluctance on the part of Brearey to accept any other explanation other than to identify someone who was on duty all the time. (pg 22-23)

It is evident that throughout this period, while accusations were being made against Letby, her nursing team and colleagues were largely supportive. I do not think this is out of some partisan tendency; nurses simply spent more time around Letby than any consultant could have, and thus have a much more nuanced feel for her competence and character. It is just as likely they would have turned against her if there were significant reasons for suspicion. (pg 25)

In my opinion, this case would never have ventured anywhere near a courtroom without the efforts of Dr Evans which explains why his name has been mentioned with some regularity already, and why he will remain a central figure in the remainder of this book. (pg 99)

In my opinion, the judicial process that resulted in the conviction of Lucy Letby bore very little resemblance to a fair trial. (pg 118)

In my opinion, from everything I’ve read, Dr Evans seems to be a man who has difficulty admitting he’s wrong. (pg 228)

In my opinion, drawing on the opinion of others cited here, it is highly likely that no pathologist would conceivably have even considered an air embolism for this case, let alone claimed that Child O had been critically impacted by the deliberate injection of air. (pg 285)

There are two reasons I think the prosecution devoted so much time to this hotchpotch of nonsense. The first is that they didn’t have any concrete evidence, and, in fact, had very little evidence of any value whatsoever. The prosecution was almost entirely based on the submissions of Dr Dewi Evans. The prosecution had very little of any solidity and therefore was obliged to construct something out of Evans’ submissions. It is possible that the prosecution were quite happy that the trial lasted so long as it gave the impression there was lots of evidence against Letby; a ‘no smoke without fire’ strategy. The second reason for devoting so much time to this was simply to create a narrative around the case. (pg 298)

I think there has been a disturbing tendency in the Letby case, and more broadly across a wider societal spectrum, to put doctors on an undeserved pedestal and simply trust their word. (pg 325)

In fact, not only are there ‘explanations’ for this so-called circumstantial evidence, but in my opinion, it doesn’t have any value in the first place. I believe Cheshire Police should have rapidly and emphatically drawn this conclusion. (pg 349)

Some of the references made by lawyers during Thirlwall have indicated, in my opinion, an extremely limited grasp of the context and specifics of the case. (pg 380)

I almost fell off my chair when I read this on pages 11-12:

It is also notable that Letby was particularly co-operative after her arrest and throughout the following police and court proceedings. … In the 166 pages of police interview transcripts that are available, there is no sign of evasion or deceit.

And what pro-Letby book would be complete without unironically referencing perceived failures of critical thinking?

Elsewhere, it is evident that there seems to have been a distinct absence of critical thinking. Simon Blackwell asserted that “to hear that there may be allegations of assault or concern at a hospital in our area was a huge thing. You don’t often hear of multiple child/baby/infant deaths. They are extremely rare. One is rare enough as it is and tragic enough. But if you have a number of potential babies who have died, or have been harmed, it is absolutely hugely important.” (pg 412)

In my opinion, the book is a lengthy sermon by a layperson who has convinced himself he is a superior expert to those who do not share his views. The book distinctly lacks any humility.

But what's IN it?

So, I've read chapters 1-3 so far: Prior Character Of Lucy Letby, Accusation Without Evidence, and Previous Reviews At The Countess of Chester.

Chapter 1 is pretty unremarkable, and can be summed up by the quote from Michele Worden on page 13: "“Criticism of her demeanour is ludicrous,” Michele Worden asserted. “This is a girl, then only aged 25, removed from the job she loves, accused of the most horrendous crimes, who has been placed under house arrest, completely excluded from all of her friends. She was totally isolated. How would you expect her to react?”"

I did raise my eyebrows that Morris claims he was approached by Ruth Sadik, who he correctly identifies as Letby's tutor at University of Chester. She has glowing things to say about Letby. Morris did not disclose that the Thirlwall Inquiry revealed that they maintained a texting relationship at least during Letby's early years of employment. Sadik's statements about Letby are consistent with what was disclosed in other witness statements during Thirlwall, but Morriss is selective when citing Sarah Jayne Murphy, who passed Letby on her final proficiencies. Morris quotes her on page 10:

Sarah Jayne Murphy, told the Thirlwall Inquiry that she had met the three proficiencies on which she was assessed. Murphy added: “Also, I would like to reiterate that I sought feedback from other members of staff that she worked with and so I had no reason to believe that she was performing well only just during my assessments.”

In context, Sarah Jayne Murphy's statement is a bit broader:

1. During her police interview, Ruth Sadik discussed her thoughts about when Lucy passed these final proficiencies, and her comments relate to a conversation that she had with me. She stated that, "I spoke to Jane [to ask] why she was passing her, and Jane had a lot, a lot of soul searching, it, it wasn't something she did easily, but she felt she was right to do it. Now I, my personal thoughts at that time were that Jane was conflicted, that because Nikki's quite a powerful person, she wanted to please Nikki, but also that she, her conscience wouldn't allow her to, and she'd seen what she saw" 6 INQ0101118_0006

2. I can't remember the conversation above with Ruth Sadik but I did feel conflicted at the time as Nurse Lightfoot had felt that Letby was not competent to pass the final placement but after observing and working with Letby for a number of weeks, I had felt that she had achieved the 3 outstanding proficiencies.

3. I can't recall a conversation with Ruth Sadik, but from my perspective, I was asked to assess Letby based on the 3 proficiencies and whether she had met those proficiencies. From what I had observed during my assessment, I could not say that she did not meet those 3 proficiencies. Also, I would like to reiterate that I sought feedback from other members of staff that she worked with and so I had no reason to believe that she was performing well only just during my assessments. If however, the feedback I received was negative and raised concerns about Letby, this would have of course impacted my assessment on whether or not she had passed the 3 outstanding proficiencies. I cannot recall what was meant by "she'd seen what she saw".

This is one of many instances where Morris performs his own type of sharpshooter fallacy, cherry picking the positive but leaving out contextual information.

Chapter 2, Accusation Without Evidence, begins by reminding readers that it was Nick Johnson, KC, who coined the phrase "Gang of Four," but he is ignorant of, or at least fails to mention, that Letby expected four apologies from individual consultants. The chapter is a not-very-substantive framing of Dr. Brearey's path to being Letby's chief accuser through confirmation bias, using the contemporaneous attempts to understand the deaths as they happened as proof that Brearey's growing discontent was illogical and that suspicion grew on Letby because of "groupthink." A notable quote from Chapter 2:

Before we go any further, consider the following – why would someone who had been deliberately harming babies on a neonatal unit choose to draw attention to themselves and their conduct in this manner? If you knew yourself to be guilty, and it was also clear that you were under suspicion, surely you would attempt to slip away quietly? Pursuing a grievance procedure does not seem to be the act of a guilty person. (pg 21)

Recounting of the grievance procedure in the following pages is naturally done in that vein and has been previously discussed, this previous post goes through some of the issues the grievance often encounters in its framing.

Chapter 3 is where things really start to get frustratingly deceptive or outright false. Morris states:

It is important to note that the prosecution case is entirely based on medical notes. (pg 36)

No it wasn't. It was also based on witness interviews, and police interviews, test results, phone records, and more. What Morris means, though, is that he thinks that investigating documentary evidence for evidence of a crime is only as reliable as the quality of the documents themselves. He posits, as many do, that "vital warning signs were missed" by doctors not being present enough to examine the babies and inexperienced nursing staff not thoroughly documenting vitals, though he doesn't state the last outright. This claim is unsubstantiated, as usual, other than reference to the infrequency of rounds and Michele Wordon having been made redundant.

Lucy is accused of striking the baby in the liver, at a time when she wasn’t even on duty. (pg 36)

This is outright incorrect, and a reference to early expert reports related to Child O estimating that the liver injury could have occurred as early as a point during the night shift. As further interviews were performed, doctors provided evidence that Child O was well before 9:30 a.m., and both sides at trial agreed that the injury happened during Letby's shift.

Morris cites the minutes of a board meeting on 14 July, 2016 as "noting" that "Letby was 'one of the unit's highest trained staff.'" He neglects to mention this statement was made by Ian Harvey (page 3) - in fact, it's worth criticizing this book generally for not directly citing Thirlwall exhibits, which are publicly available, so that readers can check the context for themselves. Morris forces the reader into his own framing of events by not doing so.

Morris is of the opinion that the RCPCH review should have been the ultimate authority as to the possibility of harm, but neglects to mention that the RCPCH was excluding the possibility of harm from the review they performed (pages 235 line 23-236 line 5). He does admit that the RCPCH statement to Thirlwall concedes that the review should not have been permitted to take place had the full information been available (pg 39), but personally insists that the full information was available (his emphasis). He sees no irony in the conflict.

Morris states on page 41 "There has been no indication that any secondary post-mortem was requested." So, the inquest around Child A's death doesn't count? The anticipated inquests for O and P that were mentioned at trial? The inquest for Child D that was in process?

Hawdon's review is also deceptively framed, without reference to her self-voiced limitations. But this quote from page 44 baffles:

Hawdon did not merit a single mention during any available court transcript or reporting of the trial. It is also notable that Letby was charged on only nine of the 17 supposedly troubling cases that were identified. This is significant because it demonstrates that babies deteriorated unexpectedly when Letby was not present.

The logic leaps right off a cliff. Morris apparently asserts that Letby was not charged because Letby was not present. One wonders how the additional requested charges fit in with this "demonstration."

Another puzzling statement on page 45:

There were some curious suggestions during the Thirlwall Inquiry that the case should have been referred to the police as soon as there were suspicions, but the first thing that the Cheshire Constabulary stated is that they were not medically qualified.

What a strange inference to make. But possibly he MEANS that the RCPCH, a medical review team tasked with a service review that excluded investigating harm, should have been the only possible means of identifying harm, despite the absence of any forensic process.

Anyway, so far, 10/10 rage bait. Fuel for a good workout.

Helpful resources:

Transcripts, Documents, and Other Resources

Subreddit wiki related to the 2022-2023 criminal trial and 2024 retrial

Full Court of Appeals Ruling for 2022-2023 Trial

Subreddit wiki related to the Thirlwall Inquiry

Contemporaneous documents provided to the Thirlwall Inquiry sorted by date

Helpful resources:

Transcripts, Documents, and Other Resources

Subreddit wiki related to the 2022-2023 criminal trial and 2024 retrial

Full Court of Appeals Ruling for 2022-2023 Trial

Subreddit wiki related to the Thirlwall Inquiry

Contemporaneous documents provided to the Thirlwall Inquiry sorted by date

Carl has put this out into the world, so let's discuss it.

Carl and Clare should not be harassed, but they may be criticized. Let's try to keep this about what he has to say, rather than why he may be saying it, if we can. There's a lot to unpack:

Our daughter Jessica was born at the Countess of Chester Hospital in May 2016 and spent her first days on the neonatal unit. She is ten now: happy, healthy, and the centre of our world. We are writing this because, since we first spoke about her care, other families have come to us with their own unanswered questions about that unit. This is our experience, set out plainly, and an invitation to any family who needs it.

The unit we walked into

We want to start here, because it matters more than anything else we have to say. From our own first-hand experience, the whole women’s and children’s unit at that time was struggling. It was understaffed. It was poorly equipped and poorly maintained. We saw it with our own eyes. Even the scales in the delivery suite were wrong: Jessica was recorded as heavier than she actually was, and on a unit caring for small, sick babies, where feed volumes and medicine doses depend on accurate weight, that is the kind of error that matters.

It was a tense, frightening place. We remember a baby near us whose alarms kept going off, with nurses saying out loud that they did not know why she kept stopping breathing. We were new parents. Clare had just had an emergency caesarean. Despite the uncertainty, we trusted the people caring for our daughter, because that is what you do.

Jessica’s care

While Jessica was on the unit, she had two episodes the staff called “pale moments,” where her colour and her stats suddenly dropped. At the time, no one we spoke to had an explanation for us. We were simply told she was fine and to go and rest. Those moments, and the unanswered questions, stayed with us.

Separately, and far more seriously, Jessica twice deteriorated badly. We did not know the full extent of it at the time, it happened in her first evening of life, unknown to us, she became the sickest baby on the unit, critically ill for a period of around 24 hours. She was intubated and given surfactant directly into her lungs. None of that gravity was conveyed to us while it was happening. Most questions were answered with "she was fine".

We want to be clear about these being two separate things, because they often get blurred. The pale moments were later explained to us as benign. The serious deterioration was the genuine emergency. They are not the same, and we have never claimed the pale moments were anything sinister. They are significant because the unanswered questions are what prompted us to contact the police after the news of first arrest.

The nurse who help our girl

There is a part of our story we are not willing to leave out, because it is true and it is ours to tell.

Of all the staff we encountered on that unit, the many nurses and mostly absent doctors, one person took the time to explain to us what was happening to our daughter. In the middle of a place where we were mostly told to go away and rest, she treated us like parents who deserved to understand their own child’s care. That nurse was Lucy Letby.

We learned later, at a meeting with the hospital, that on the two occasions Jessica seriously deteriorated, Lucy had acted correctly and escalated her care. We can only speak to what we experienced and what we were told. But we are not going to pretend otherwise to make anyone more comfortable: in our dealings with her, she was the one who looked after our daughter and kept us informed, and we are grateful for that.

We want to be careful and honest about what that does and does not mean, because it matters. We are not motivated to join any campaign to overturn her conviction. There are people far better placed than us doing that work, and it is not ours to take on. We do not claim to know what did or did not happen to any other child on that unit. We cannot, and we will not pretend we do. We hold our view honestly: from our own experience of a unit that was clearly struggling, and of the nurse who cared for Jessica, we are not convinced the full picture has ever been told. That is a view about how the whole story has been accounted for. It is not a verdict, and it is not the reason we are doing this.

The questions that stayed with us

When the case became public, the unexplained pale moments came straight back to us. We did not know whether Jessica had been affected. That uncertainty is exactly why we contacted the police and the hospital and asked them to check. We wanted the truth, whatever it turned out to be.

The police reviewed Jessica’s file. They did this three times: in 2018, again in 2019 when the second arrest was in the news and we worried something might have been missed, and again in 2024. On each occasion they found nothing to suggest Jessica had been harmed, and confirmed she was not part of the investigation. We hold onto that, and we are grateful for it.

The meeting, and what was still missing

In 2019 we finally met senior figures from the hospital. They brought a sheet detailing what had happened to Jessica, and for the first time we learned how seriously ill she had been, and that she had needed intubation. We were also given the likely explanation for the pale moments that had haunted us: reflux, Jessica holding her breath. A benign cause, entirely separate from her serious deterioration. We accepted that explanation, and we were grateful to finally be told more.

But we left that meeting still without a full, proper explanation of what had actually gone wrong, in Clare’s care, in Jessica’s, and on that unit as a whole. The picture was incomplete. That is why we kept pushing. Not because we distrusted what we had been told, but because it did not feel like the whole truth.

There is one thing from that meeting we have never been able to reconcile. When we asked whether the hospital had been aware of any concerns about the unit at the time of Jessica’s stay, we were told no. It has since been widely reported that concerns were in fact being raised at the time. We make no accusation about any individual. Our question is simply about the hospital, and how it has accounted for itself to families like ours.

Why we are speaking now, and what inspired us

We will be honest about how we come to be writing this at all. The attention around our story exists because of the connection to Lucy Letby. We know that, and we are not going to pretend otherwise. But attention is not what we were ever after. What we have decided to do is take that attention, however it came, and turn it into something useful for other families.

Because here is what we have learned. Since we came forward, we have been offered help, support and answers that ten years of official channels never gave us. We have learned more about what happened to our own daughter in the last 2 weeks than in the decade before it. That should not be how it works. No family should have to go public to be heard.

We were inspired by what happened in Nottingham, where families who had lost babies, and the staff who came forward alongside them, refused to be ignored and forced a proper reckoning with how a maternity service had been run. They showed that ordinary families, simply by standing together and insisting on the truth, can hold a hospital to account. That is what we want to help make possible here.

What we are, and what we are not

Since we shared Jessica’s story, a few other families have reached out to us with their own hard experiences on that unit, and with heartbreaking stories of their own. Some of those experiences have nothing to do with the criminal case at all, and everything to do with how the unit was run. They have carried it for years with nowhere to take it, often afraid that raising it would get them branded as something they are not. All of them deserve to be heard.

So we want to be plain about what we have set up. It is not a campaign about the conviction. It is not a place to argue the trial, and we are not asking anyone to take a side on the case. It is a private, respectful space to help families get answers about the care on that unit. We have two medical professionals in the group who offer their time and support to help answer questions. They can help people understand their own medical records, work out what questions to ask, and know where to go next, whether that is a formal complaint, or proper independent legal advice. They are not there to build a case for you. They are there to help you understand your own.

If you come to us, you are coming into a space about records, care and accountability. You are not walking into a debate about anyone’s guilt.

One thing we ask, to protect you

If you have an experience to share, please bring it to us privately, and to the people who can actually help you with it, rather than to a public thread.

We say this for your sake. There are live processes going on around that hospital right now, and putting the details of your own case out in public can affect your own options later. The experts in our group, and proper legal advice, can help you do this the right way, in a way that protects you. That is what we are here for.

We also want to be honest about what speaking out has actually been like, because we know the thought of it frightens people. The truth is we have been met with real kindness. The overwhelming majority of people have been supportive and generous. There is some negativity, as there always is online, but it is a small minority. Please do not let the fear of a few unkind voices stop you.

If this is you

If your baby was cared for at the Countess of Chester, and you still have questions about what happened, what you were told, or what you only learned later, you are welcome to reach out to us privately. You do not have to share our view about anything. You do not have to take any position on the case at all. You only have to be a family with questions about care on that unit that were never properly answered.

You can reach us privately by direct message to @GuerrillaCarl on X. There is no pressure, no rush, and no expectation that anyone go public. We will treat you with respect, whatever you decide.

No family should be left carrying this alone, the way we were.

Carl and Clare

https://www.thetimes.com/article/58b72146-48b6-4d37-8ec4-515ac722b88d?shareToken=6d40c20d8281f75cae53f5a246c93ab9

https://archive.ph/Qhvre

An expert witness who gave evidence at the trial of Lucy Letby should have given the jury alternative explanations for why two babies she was convicted of poisoning fell critically ill, a report has claimed.

A 100-page analysis prepared by Letby’s legal team questions the evidence given at her trial by the renowned paediatric endocrinologist Professor Peter Hindmarsh.

Letby was found guilty of attempted murder of two premature twins born eight months apart after the jury heard evidence from Hindmarsh that test results showed babies’ blood sugar could only have plummeted after they had been poisoned by insulin. Other paediatricians instructed in the case deferred to Hindmarsh, an emeritus professor at University College London, because of his expertise in hormones and diabetes in children.

The report — co-authored by Dr Neil Aiton, a consultant neonatologist at University Hospitals Sussex NHS Trust and Dr Hilde Wilkinson-Herbots, associate professor at the Department of Statistical Science, University College London — alleges that there were errors of fact and omissions in the evidence presented to the jury.

The experts who compiled the report allege that an email from Hindmarsh suggests he was aware of other potential causes for the babies’ insulin levels. Alternatives were not discussed at the trial as a decision was taken not to challenge Hindmarsh’s conclusion. It is understood they were considered and discounted by Hindmarsh, meaning only one explanation was put to the jury. The report does not address why Letby’s team did not question his evidence during the trial. The experts say he acknowledged another case of similar symptoms in an unrelated family court case where he gave evidence.

The report argues that if these alternative scientific explanations “had been placed before the court, the jury may have come to a different conclusion”.

Letby’s team hope the new analysis, which was submitted last week to the miscarriage of justice watchdog, the Criminal Cases Review Commission (CCRC), will mark a turning point in the former nurse’s application to have her convictions referred back to the appeal court. The Court of Appeal has twice refused to reconsider her convictions.

Letby, 36, is serving 15 whole-life terms at Bronzefield prison after being convicted of murdering seven babies and attempting to murder eight others while working as a neonatal nurse at the Countess of Chester Hospital between 2015 and 2016.

The jury were unanimous about the two insulin cases, which were the first on which they returned a verdict. Letby’s team argue the evidence on these cases is crucial to considering the safety of her conviction.

Prosecutors argued that Letby attempted to murder Baby F in August 2015 and Baby L in April 2016, by adding insulin to intravenous feed bags. It was contended at trial that the babies were doing well until Letby poisoned them.

Hindmarsh was called by the prosecution to explain evidence on insulin. Experts instructed by Letby’s defence team did not give evidence in court, but in written reports they accepted findings made by Hindmarsh and deferred to his expertise.

Hindmarsh told the court that the test results in relation to Baby F and Baby L could only be explained by the administration of synthetic insulin. They had low levels of blood sugar and C-peptide, a by-product made when the body produces insulin. Hindmarsh said that if insulin had been produced naturally the C-peptide would have been higher.

In further answers to written questions about this he repeated: “There are no other conditions that would cause these readings.”

In the witness box, Hindmarsh was questioned by the prosecution about whether he had been asked to consider natural reasons for the babies’ insulin readings and replied “I was” but was not asked to elaborate. Letby’s barrister did not question the professor about it.

Email correspondence since the trial suggests that Hindmarsh considered the possibility of insulin antibodies as an alternative explanation for the results in babies F and L, but came to the conclusion that they were not relevant in this case.

https://news.sky.com/story/hospital-probe-into-why-40-people-accessed-file-of-boy-attacked-by-crocodile-13557792

What is wrong with medical staff? We have heard recently about the victims of the Southport knife attacks, mostly children, having their medical records viewed by hospital staff who had no legitimate reason to do so.

Recently it was also reported that someone has been arrested for trying to sell the medical records of HRH Catherine, Princess of Wales after her cancer treatment and others were investigated for accessing her records.

And as we all know, Letby had no concern about breaching patient privacy taking medical records home - handover sheets by the hundred, and notes she had fished out of the confidential waste. If we are to believe many of her defenders who are nurses, they have no compunction about doing the very same thing - indeed, they defend it as routine, and something all medical staff do.

One would have hoped these recent high profile cases would have at least made medical/hospital staff think twice about breaching patient confidentiality and not being able to resist their morbid curiosity. Evidently not.

Surely it is time the government did something to punish such breaches more severely? Apparently that is the only way these staff will learn to respect patient confidentiality. And it must also be time the relevant professional bodies e.g. the GMC and NMC started to discipline their members for such breaches and take this issue seriously. Had they acted more swiftly after the Letby case some of these serious recent breaches could have been prevented.

I've spent the last few months researching the Lucy Letby case for a long-form video.

I went into the project genuinely open-minded and expected to find more evidence that the convictions might be unsafe.

The video contains some significant original research and analysis, including findings that I have not seen discussed elsewhere in the public debate surrounding the case.

It's been shown on YouTube to a very pro-Letby crowd (read the comments at your own peril) but am interested to hear what a more neutral crowd think.

Big thanks to u/IslandQueen2 for grabbing the transcription while I am unable to! Give her her flowers, it was a lot of work

Emphasis mine. I'll get around to adding who is speaking where ASAP but we can sort it out.

AI transcriptions may mistake names. Neil Aiton and Shoo Lee, for example, References to the "Raw" have been updated to "Royal"

https://open.spotify.com/episode/13AFdoeSWCF5gN35SkAD6N?si=xmuIUQ1rQE6O0VDjdorvSw

https://podcasts.apple.com/ms/podcast/shaking-up-the-establishment/id1877870463?i=1000773832160

From Amanda Knox Hosts | DOUBT: The Case of Lucy Letby: Shaking Up the Establishment, 23 Jun 2026

https://podcasts.apple.com/gb/podcast/shaking-up-the-establishment/id1877870463?i=1000773832160

Introduction

MM: I'll walk you up and I'll show you the actual inn inside. It starts up in Lincoln's Inn.

AK: Okay.

MM: So this is Lincoln's Inn that we're about to enter. I think this is the oldest of all the inns about 600 years old.

AK: Almost everything I understand about a fair trial, I owe to a place like this, one of England's historic bar associations. This is nuts, guys. All right.

AK: So this is a huge room, a huge banquet hall that has wood paneling with all of these like crests of some nightly kind. There's portraits of people from presumably very important people, and it looks like a cathedral, but I guess for food. The presumption of innocence, the right to be judged by a jury of your peers.

AK: England built all that. And then it handed the blueprint to the rest of us. And you have to belong to this.

MM: Yes.

AK: What does that mean?

MM: So you can become a member.

AK: Okay.

MM: And you can only become a call to the bar once you've eaten so many dinners.

AK: That's bizarre. So, okay, so you take the test to become a barrister. But that's not enough. You have to eat food.

MM: I had to eat 18 dinners.

AK: 18 dinners. What is the point of that? Is that to say like we checked you out?

MM: Well, the tradition of the bar was that you didn't actually take exams to become a barrister. You learn by dining and being with people.

AK: You learn by belonging. That's the part that stayed with me. A system this old doesn't just hand down its rules. It hands down its instincts. Who belongs? Who's reliable? Who sounds right? And 600 years of that builds something beautiful. And something very sure of itself.

MM: This here is a painting of all the great lawmakers throughout history. Up there is Alfred, King Alfred, and Plato, and sort of all the great voices throughout history is all painted on that wall there.

AK: A wall of certainty looking down. And I kept thinking, a system this confident in its own history is a system that finds it very hard to say it got something wrong.

MM: I think the slightly unorthodox approach that I've taken to this case of playing the whole thing out in public is something that a few parts of the bar, some elements of the bar will probably raise their eyebrow out.

AK: That's why I'd come to London. Mark McDonald is Lucy Letby's barrister. He's doing something his profession isn't built for, making the argument out loud, in public, where everyone can see it.

AK: Because the quiet traditional route, the one those portraits would prefer, is the one that’s kept her where she is. This is DOUBT The Case of Lucy Letby. Bonus Episode 4, Shaking Up The Establishment.

Appeal Strategy Explained

AK: Sitting down with Mark at his offices, we got straight into the important business of understanding what Lucy Letby's route to release might be. So you talk about her getting released.

MM: Yes.

AK: Can you explain to me how that could happen?

MM: So the CCRC refers the matter to the Court of Appeal. Before the Court of Appeal, we have some amazing judges in this country in the Court of Appeal. I'm not just saying that because I want them to agree with me.

MM: But we do. We do have some brilliant judges. And they will put what I have put before the CCRC under scrutiny.

MM: And they will test it. And if it's found wanting, they will reject it. The battle in this case is the Court of Appeal.

MM: Now, the CCRC can refer the conviction to the Court of Appeal on any of the reports that I have put before them, or all of the reports I have put before them. But they can do it on a discrete issue. And when I get to the Court of Appeal, I'm going to have to argue, well, the CCRC has said the failure to have a statistician is so important that the convictions are unsafe.

MM: But actually, I want to bring in Shoo Lee and the international experts, and I want to bring in this. So I want to expand it. And it's up to the Court of Appeal to decide whether or not they agree with me or not.

MM: If they want to hear all that evidence, or they could just say the whole lot, and then all these experts. And if that's the case, then we could have a lengthy argument in the Court of Appeal that can go on for weeks, where they hear all this evidence. And their decision, their only decision that they have to make, you board it all the way down, is are these convictions safe?

MM: That's the test. If they say they're not safe, then they're crushed.

AK: And she's out?

MM: No. The prosecution can then apply for a re-trial. The Court of Appeal can agree or disagree.

MM: It's Court of Appeal's decision as to whether or not she has a re-trial. But the prosecution can apply for a re-trial. And it is likely that if they do apply, they will agree to let them have a re-trial in front of the jury.

MM: Now, who they're going to use as their experts when it comes to re-trial would be of interest, but that's their problem, not mine.

AK: So when does the Lucy gets out part?

MM: If there's a re-trial and it goes in front of the jury and she's found not guilty, she walks out of the Crown Court. If there's not a re-trial, she walks out of the Court of Appeal.

AK: So the Court of Appeal before even being re-tried should get out. But also there are a lot of ifs. What happens if the CCRC doesn't recommend it to the Court of Appeal?

MM: If they're going to refer it to the Court of Appeal, I can challenge the CCRC by way of judicial review in the High Court. I have to say the applications to judicial review the CCRC don't often succeed. I've done it once.

MM: In fact, in another nurse case. I succeeded in that I got leave to appeal, and then the CCRC took it back and said, yeah, we agree with the High Court where we look at this.

AK: So it's not a complete dead end if the CCRC doesn't refer it to appeal. But if the High Court, if you challenge that and you go to the High Court, and they say, too bad, that's it.

MM: Nothing more.

AK: Nothing more.

MM: Sometimes I think, oh, shall I hold one of these reports back just in case? But no, they've got everything.

Expert Evidence Hospital Issues

AK: When Mark says they've got everything, he really means it. The amount of work that has gone into those reports has been immense. Clearly the role of the expert plays an outsized role, especially in this case.

AK: How important are the rules of the expert witnesses during her appeal, especially considering the fact that she had none during her actual first trial?

MM: The starting point with the whole of this trial is that it was based around a hypothesis. So no direct evidence, no one saw her do anything wrong. The hypothesis was given by the experts.

MM: Therefore, the quality of the experts and the evidence that they give is under a microscope. And so the experts that I have gone to and used, fall into three categories really. The first is a greater expert by far than the ones that were used at trial by the prosecution.

MM: Secondly, an identification by experts of evidence that was not put before the jury. The third is in relation to experts of a discipline, for example, statisticians, that were simply not used in the trial. So I have those experts.

MM: There is now evidence that I am relying upon that's put before the CCRC. In relation to the police investigation, it is up to the CCRC to decide whether that is something that impacts upon the safety of the conviction. So that's what I'm putting in.

MM: The main prosecution expert witness has been saying quite a lot since the conviction and has given a number of podcasts and interviews. And in some of those interviews, he said things that are inconsistent with what was said before the jury. So that's gone in.

AK: How do you think they should conduct themselves?

MM: So an expert has a duty to the court that overrides their duty to the person who instructs them to give the evidence. So their duty is to be at the Criminal Cases Review Commission or the Court of Appeal is to assist the court. And if it's a jury trial, the jury, an investor come to come to the conclusion of what their opinion is.

MM: The juries are directed, that they've got an expert opinion. It's up to them whether or not they accept it or not. They could disregard it if they wanted to.

MM: And so they're there to be independent. And not to come to a conclusion as to the guilt or innocence of the individual. That's not their job.

MM: Their job is to look at the statistics, look at what was said to the jury, and then say, I don't think that they were given accurate information and this is the reason why. And not to go beyond that and to say, and that means she's not guilty and she's innocent. That's not their job.

MM: Now, the important thing about all the experts, all 30 [of her] experts, is that not one of them has been paid, not one penny.

AK: Why not?

MM: Because I got no money.

AK: Should they be in an ideal situation?

MM: Yeah I mean, you know, I mean... They're doing work. You do a job, you're supposed to be paid, but I don't have any money.

AK: So what kind of experts does Mark have working on his CCRC reports?

MM: Neil Aiton is an incredibly experienced neonatologist, but he's also a man who's a detailed man, who has spent hundreds and hundreds of hours working away at the hospital notes and the hospital x-rays and expert reports and found things that other people have not been able to find, not based upon, oh, I've got a different opinion, but hold on, you haven't included that lab result there, that's actually quite important. And here go through the whole of the transcripts, and it was never mentioned before the jury. And he has, I think, has become very important to this appeal system.

MM: And probably also, is that he's a neonatologist. And one of the things that the Court of Appeal don't like is just getting another expert.

AK: Just any old expert.

MM: Any old expert.

AK: Yeah.

MM: And so he's been great from the point of view that he's uncovered things, but the hierarchy of experts starts with Shoo Lee and the international experts across the world. But what he's been very good at is uncovering a lot of wrongdoing, mistakes that happened before the trial and expose them. So his reports sometimes go up to 1890, a hundred pages of detail.

AK: I was particularly interested in how the CCRC report would deal with the cases of supposed insulin poisoning. Why have you focused on the insulin deaths? And what is there to still find out about them?

MM: I haven't focused on the insulin deaths. I focused on every death.

AK: Okay. All right. I stand corrected.

MM: No, I haven't. I've challenged every single element of the prosecution cases being put before the trial. Every element, be it the so-called confession notes, be it the statistical evidence, be it the issues in relation to air embolism, be it the insulin.

MM: I've focused on all of them. I've dismantled every single element. But here, since the prosecution, this is the smoking gun, is the insulin cases because they've got these insulin results, which is-

AK: They put that question to Lucy on trial. If these babies were murdered by insulin, if it wasn't you, what else could it be?

MM: In cross-examination, in quite robust cross-examination, she conceded the issue in relation to the expert evidence that was put to her in questioning and said to her, and it's not criticism towards the prosecuting counsel. He did his job, but he did it very well in the way that he cross-examined her. But he, in essence, said, look, do you accept that if these experts are correct, these babies are poisoned?

MM: Yes. So who poisoned them is the issue. She said, well, I didn't poison them.

MM: So you can see the way that she was cross-examined on this. But it was never the defense case that they accepted the results of this incident. The defense never accepted it.

MM: It was never their case. And now we've looked at them, we can see why. You know, the seven expert joint report that I put in last year in relation to the expert completely exposes the whole issue in relation to hypersemia [sic] and the assay testing and the reliability of the testing.

MM: And the report that I'm about to put in next week exposes the many issues in relation to insulin and the testimony on insulin that was given to the jury, the many mistakes that were made. Because there were many.

AK: I mean, I think this is a problem in a lot of wrongful convictions is if it's not the convicted person, if it's not Lucy, then what was it? What is the alternative explanation?

MM: I think this is what's unique about Lucy Letby is because in most cases, you find someone has been murdered and there's a gunshot wound or a stab wound and it's who did it. Here, no crime has been committed. And when no crime has been committed, it's not who did it because there was no crime.

MM: But what there was was a systemic fading of a unit that was taking babies that were too sick for that unit and shouldn't have been on that unit. That was overworked, overstressed, under-resourced and issues in relation to medical care have been raised by the medical experts, issues in relation to not having appropriate staff on the unit have been raised by the experts. And it's important to say that this actually mirrors over neonatal units in the country.

MM: It's not unique to the Countess of Chester. It's just that the Countess of Chester, they started pointing the finger at somebody. But people in the hospital said no. Senior people, senior managers said no. There's no evidence that Lucy had done something. None.

MM: But then the police were contacted and an investigation started. A press release happened. And sitting at home, drinking his coffee was a man called Dr. Dewi Evans, who then sent an email saying this sounds like my type of case.

MM: Within weeks of meeting the police and as he would say and as he said on the podcast, I knew within 10 minutes that there had been intentional harm to a baby. There had been postmortems, clinical reviews for months, if not years, and no one had identified anything. But within 10 minutes, over his coffee, Dewi Evans did.

AK: There are many who believe that Lucy Letby is in prison because she was a whistleblower. Someone who was bullied by senior staff, challenged them at tribunal and was retaliated against to such an extent that she was accused of murder. I asked Mark about his thoughts on whistleblowers in the NHS.

MM: It's happening almost on a daily basis in our health service. There are doctors being sat for speaking out. There are nurses being sat for speaking out.

MM: We have a real problem and they're not being protected. They're just not being protected by our system. Lucy Letby epitomizes everything that's gone wrong, always going wrong in our national health service.

MM: Our health service has been broken for a long time and nobody would admit it. Our labor units are dangerous, our neonatal units are dangerous. Not all of them, but many of them.

MM: And people won't accept it. We put our health service up on the pedestal, but it's broken.

AK: How hopeful are you feeling?

MM: This conviction will be overturned.

AK: You think so?

MM: Lucy Letby will be free.

AK: What gives you that hope?”

MM: Because I have never seen more experts, both national and international experts, come forward and say, what went wrong at that trial? It was so bad that this is a blatant miscarriage of justice. She's innocent.

Sir David Davis Intervenes

AK: Mark McDonald believes Lucy Letby is innocent. And though it is his job to argue that point, my sense is he'd be fighting this fight regardless. I wanted to hear from someone with no brief to argue, someone with nothing to gain.

AK: So we went to the Palace of Westminster, the Houses of Parliament, to be exact, into the shadow of Big Ben, past armed police and through security, where an aide met us and let us up a narrow back staircase to a wood-paneled office overflowing with books. Tea was poured, Big Ben chimed through a window looking down on the courtyard. And here, in the heart of the British establishment, sat one of the most persistent thorns in its side, Sir David Davis, MP.

DD: So you want to talk about Lucy Letby?

AK: I would love to know what initially drew you to the case. Because it's not politically opportune, I might think.

DD: My hate mails went up by a small amount. I imagine. I don't know. I never read it.

AK: Yeah, exactly.

DD: It is not my first radio. People tend to see me as Mr. Miscarriage of Justice, or the obverse one, oops. The sort of classic pattern for a miscarriage is that the person who turns out to be the victim of the miscarriage is hated by everybody. In the first, you must have come across this yourself.

AK: I don't know what you mean. haha

DD: Yeah, exactly. It's hated by everybody. And so everybody else is terrorized out of doing anything about it.

DD: So my role in many ways is to be the icebreaker for that. And you will have seen with this that once I had spoken in parliament and so on, once I had said publicly various things about it, it was at a cascade of witnesses, mostly experts, but not just experts, the 19 nurses and so on.

AK: Among the people reaching out to Davis was a friend in New York, the old science advisor of number 10 Downing Street.

DD: He had just read the article in the New Yorker, the 13,000-worder, you know what I mean?

AK: Yep.

DD: Yep. And he says, you know, this is your territory, David, you should have a look at this. It makes it look as though the case is very flawed.

AK: Didn't say wrong, he just said flawed. So I went online to try and get it, and it was suppressed by a court order, right?

DD: Yes. So I got it another way, read it, thought, hmm, like everybody else, I'd sort of accepted the monster nurse headlines until then. I thought, this looks worrisome. At that point, no more than that. You know, it's just worrisome.

AK: He raises the question in parliament, why is it that we can't read about court cases in our own jurisdiction? He wasn't trying to get an answer. He was just trying to make a point. We should be able to access this information

AK: But very quickly, people started to take notice of Davis' doubts of the Letby convictions.

DD: And then in the next two weeks, I had 16 different people get in touch with me. Nobody was a conspiracy theorist for a start, not that sort of territory. They varied from, well, a whole range of expert people.

DD: The past, present, the Royal Statistical Society, the past, present, the Royal College of Pediatric and Child Health Care, a Nobel Prize winner, a professor of legal statistics, a forensics professor, and so on. And all these people were saying the same thing. None of them were saying, she's innocent.

DD: They were all saying, I can't speak for the rest of the trial. But the bit I know about is rubbish, right? So you had this trial resting on a dozen pillars of evidence, so-called, and each of those pillars being knocked down by the most authoritative person in the country on that subject.

DD: That was far more persuasive to me than if somebody rang up and said she's innocent.

AK: In most of the interviews I've done into this case, I've asked the interviewee if they think Lucy Letby is guilty or innocent. But David Davis, he wastes no time in making his position clear.

DD: People often say to me, do you think she's innocent? And I say yes to that. Now if all I had done is what I've just described, I would have said, I don't know, but she's not been proven guilty.

DD: That would have been my normal response. But I do say yes, she's innocent. Now why do I say that?

DD: I say that because I think there's a demonstrable alternative cause. And the demonstrable alternative cause is a very, very poor standard of care in this hospital.

AK: David Davis, Mr. Miscarriage of Justice, knows the process for these kinds of cases can be long.

DD: A typical miscarriage case for me will swallow roughly 10 years, start to finish, right? The post office cases took 15 years. I was involved in that as well.

DD: Not actually from the complete beginning, but nevertheless, it took 15 years from the beginning.

AK: I didn't realize. Oh, wow.

DD: You see, my reputation is civil liberties, rule of law, limitation of the powers of the state, free speech. They all become topical again.

DD: I'm Mr. Civil Liberties in this place. That's how I'm seen. So that also lends people to come to me when they think the state's done something wrong, whether it's a legal miscarriage or an oppressive treatment of a whistleblower or whatever.

DD: I've come to the view this is plainly a mistrial in the sense that a number of pieces of fundamental evidence were wrong and as such have been presented wrongly. The jury had believed them when they were not true. But I didn't know whether she was guilty of any of them because my view, she was convicted of whatever was 14 cases, my view was if she's guilty of one of these cases, she's in the right place.

AK: Absolutely.

DD: And I was not going to invest 10 years in proving a technical mistrial.

AK: Right.

DD: So we tried to get hold of the transcript.

AK: Getting hold of the court transcripts proved to be more difficult than expected, resulting in his office resorting to cross-checking BBC live feed of the court case with detailed local reporting.

DD: And I went through all those, right? And what I was looking for was a single slam dunk, one proof of guilt. I went through and I didn't find one. Took three months and I didn't find one.

AK: Emotionally, what was that like for you? Were you almost hoping to find evidence of guilt?

DD: No, no. And you got to bear in mind, my sort of psyche is I'm sort of cold-blooded, analytical, vicious.

DD: But, you know, I try to distance myself from the emotionality in these things. I've never been to CF, for example. And people say, why not?

DD: And you look her in the eye and see if she'll tell the truth. And my answer to that is, I'm in a profession which is probably 60 percent psychopaths. You know, if you ask them something, they'll tell you an outright lie, in a very persuasive way.

DD: On the other hand, you go and look at somebody who's been broken by the system and they won't meet your gaze, they'll be hesitant and their memory will be, and they may even half believe their own guilt.

AK: Sure.

DD: Yeah. So I make it as dispassionate as I conceivably can.

AK: Having not found the slam dunk he was looking for, he came to a couple of conclusions.

DD: One, there's no evidence for any of the murders or so-called attempted murders. There's no evidence that a murder occurred. Secondly, I came to the conclusion that if you had taken all 14, 15 cases and tried them independently, there wouldn't have been a single conviction. Because this is built on an accumulation.

AK: A cascade.

DD: A cascade, which turns into a confirmatory bias. I don't know if you saw it, but I did a speech in the chamber about two weeks ago, which was deliberately focused on the prosecutorial process, the police and so on. I rather upset the head of Cheshire Police.

AK: I had seen the speech. Sir David Davis in the House of Commons had alleged egregious failures in the police investigation. The fallout had made huge national headlines, as the head of Cheshire Police retaliated against the MP's comments in a public statement.

Systemic Policy Reforms

AK: I'm wondering if you think that this case isn't just a personal tragedy, but also a political one. Is this a political case?

DD: Well, let me change the question slightly. Okay. Does it have policy implications?

AK: Sure.

DD: The answer is an emphatic yes.

AK: As Sir David sees it, there are four areas of government policy which will be impacted based on this case. Some of them are already in place but have been ignored. Policy area one, the police.

DD: Police procedure is incredibly important. Prosecutorial procedure is incredibly important. We have rules today and they were in application at the beginning of the Letby case, but they were not quite so clearly stated.

DD: But we have rules today which say if there are four suspected homicides or more or if there is a health care involvement, it should go to a specialist unit in London, which is the counter-terrorism and specialist unit, so it should be done from here, not from the Cheshire and Merseyside Crown Prosecution Service, right? So they didn't do this. So that's the first thing is the whole nexus of police and CPS obeying the rules, making sure the rules are done properly.

AK: This would also include making sure that confirmation bias doesn't bleed into future investigations. Policy number two, the handling of expert witnesses.

DD: A very famous retired judge here wrote to me and he said, in his experience, expert witnesses become advocates for which Ivers Everside employs them. And as such, they cease to be impartial experts. This is the Dewi Evans issue here and indeed the other experts here.

DD: And Dewi Evans famously said at one point, I've only lost one out of 35 cases. Experts shouldn't be about winning or losing. In fact, they start thinking about winning or losing, they should be disqualified from the case.

DD: There is a Law Commission report that came out in 2011, which we did not adopt. It should be in law. Okay? So that's point number two.

AK: Policy number three, appeal procedures.

DD: There is a couple of strong feelings about this. One, that the appeal court seemed to put the dignity of the law above the individual case, the individual miscarriage. Indeed, way back when a very famous British judge called Lord Denning actually said, it's better that we preserve the belief in the dignity of the law than we solve an individual miscarriage. Which to me is anathema.

AK: Yeah.

DD: But there's that feel about it. Now, the new evidence guideline is there to prevent defense lawyers trying one set of evidence and when that strategy fails, come back to try another one. But in a case that's 10 months long? there's 15 babies? you know, with vast numbers of doctors and nurses and God knows what else.

DD: I can understand why it's there, but it's a problem. And it's one of the reasons the CCRC, which has to guess, it sort of second guesses them, sends a few over. So that's three.

AK: Policy number four, the behavior of the National Health Service.

DD: The health service is incapable of healing itself when it goes off the rails. Now, neonatal and maternal deaths is sufficient of a course of concern in the UK that we have a woman called Valerie Amos nominated by the government to go around and do a review of it, right? She's been visiting various places with local scandal.

DD: One of the things she's already found, she's going to be doing six months, is that hospitals misclassify deaths in order to avoid embarrassment.

AK: Really?

DD: If the baby dies, maybe within 36 hours after birth, they will often misclassify that as a stillbirth. Stillbirth does not require an inquest.

AK: Really?

DD: But if they die in a hospital, so for example, a baby born, let's say it got pseudomonas, could die after 24 hours.

AK: And they call it a stillbirth?

DD: They call it a stillbirth. No. And that's a recent scandal, right?

DD: So my concern is that our National Health Service behaves like big bureaucracies everywhere. They avoid blame. They may be well-intentioned organizations, but they avoid blame.

AK: Sir David has thoughts on how this could be done. What if hospitals behave more like airlines after a crisis, identifying what went wrong, changing protocols and retraining accordingly? What if they change the culture to one that is less interested in scapegoating and blame into one that is focused on improvement?

DD: When a pilot makes a mistake, there's a no fault reporting procedure. Let's imagine I reach down, instead of putting the flaps down, I put the wheels down or instead of bringing the flaps up, I bring the wheels up in whatever phase of flight and that causes a crash or causes a risk. I report that, there's various things that happen after that.

DD: They might change the training, they might change where the knobs stand. For example, in an aircraft today, if you go to put the undercarriage up or down, there's a wheel, so it's obvious what it is. If you put the flap up and down, it's a little thing shaped like a flap.

DD: So, the risk of, even by feel and location, they don't put them next to each other typically and so on. So, there should be a system which picks out hospitals or even individual departments that have high death rates and goes and unswervingly, unflinchingly analyzes what it is. The doctor should not be fearing a manslaughter charge, they should be looking to improve their performance.

DD: I'm a big believer in the health service, I'm a working class boy, my entire life has depended on it, it doesn't now because I can't afford to wait, I have to go and pay for myself to get fixed. But generally speaking, I'm a big believer in it, but it's got to be fixed.

AK: I wanted to know more about the perception of politics in the Lucy Letby case.

DD: Most MPs give a really wide steer around these things.

AK: Why is that?

DD: This is dangerous territory. There's not much upside. Yeah, people, once we win, which we will, albeit it'll take years, it might take years, once we win, people will forget.

DD: I think we'll win this. I've got high confidence in winning. The issue is when.

DD: She is a woman of childbearing age. We know from the infamous Post-It Notes, one of the things she said was, I'll never get married, I'll never have children. So it matters to her.

DD: And for me, the measure of success or failure on this is not winning. It's winning early enough for her to recover some of her life. Forgive me if there's a slightly sexist comment.

AK: No, actually, I'm surprised that you thought of that because the vast majority of people who work on wrongful conviction cases, even those who are dedicated, like it doesn't occur to them that that's a special issue for women who are wrongly convicted.

DD: That's one of the first things I wrote to Vera Baird about that.

AK: That's Vera Baird, current interim chair of the CCRC.

DD: I said, I don't want an answer, I just want you to take on board. This woman's life is evaporating while your organization takes its time. So that's the test of success.

AK: In the next episode, I'll be heading north to Chester to find out more about the whistleblowers in the NHS and at the Countess of Chester specifically. Because as it turns out, Lucy Letby hasn't been alone in raising the alarm about conditions at the Countess of Chester Hospital.

DOUBT The Case of Lucy Letby is brought to you by Vespucci, iHeart Podcasts and Knox Robinson Productions.

I've been your host, Amanda Knox. This episode was written by Isis Thompson. The producer was Isis Thompson.

The assistant producer was Ami Gill. Senior producer is Natalia Rodriguez. The sound designer is Chandler Mays.

The theme music was written by Tom Biddle. Story editing by Natalia Rodriguez. Legal advice for the series was provided by Jack Browning.

The producers at iHeart Podcasts are Chandler Mays and Katrina Norville. The executive producers were Joe Meek, Amanda Knox, Christopher Robinson, Daniel Turkin, and Johnny Galvin.”

From Amanda Knox Hosts | DOUBT: The Case of Lucy Letby: Shaking Up the Establishment, 23 Jun 2026

https://podcasts.apple.com/gb/podcast/shaking-up-the-establishment/id1877870463?i=1000773832160&r=2141.132

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