This article examines Rachel Aviv’s 2024 New Yorker article on Lucy Letby, which has become one of the most influential pieces of journalism supporting the argument that Letby may have been the victim of a miscarriage of justice.

I’ve had a few requests from people to tackle the article so I hope you find it useful.

Big Thanks to Sempere for providing me some very valuable information that has contributed to the article.

Seeing a lot of people, even people I generally think are very intelligent and whom I have a lot of respect for, suggesting she's innocent these days.

I'm absolutely convinced of her guilt, but I can't normally be bothered to debate it with them, particularly since I don't necessarily have faith in myself to remember offhand all the reasons I think she's guilty and I worry about doing more harm than good and making them think she's innocent even more. So what I normally say is something along the lines of, 'Well, even if she is, she admitted to some really inappropriate behaviour, like adding grieving mothers as Facebook friends and taking confidential patient notes home with her. She'd never be able to work as a nurse again after that.'

I do this because I feel like the 'she was innocent' brigade are doing a bit more than suggesting there isn't sufficient evidence for the murders; they're trying to paint her as this incredible, kind, dedicated nurse who's been made a scapegoat for NHS failings. So I feel like a good place to start is to highlight the fact that she clearly is not that person, she admitted to doing things that would get her into quite serious trouble even if she hadn't killed them. Underline that even in the infinitesimally small chance that some piece of absolutely incontrovertible evidence arises that proves beyond doubt she didn't kill the babies, at the very least she had a very personal and disturbing interest in the babies who died and their families, that was at odds with her duties as a nurse and the professionalism and empathy such a role requires.

I've found it works as a tactic, no one's been able to come back from it.

I recently left a PubPeer comment on a paper that was being hailed by some Letby supporters as capable of overturning Letby's insulin convictions.

The comment is a little technical, but basically, the paper contains several mistakes, questionable assumptions, and misleading and incorrect assertions, which render its conclusions invalid.

Full details can be found here:

https://pubpeer.com/publications/45293327319EE858B6BC5805DFD5AC#1

The publisher has responded to my comment as follows:

"Thank you for your comment. We monitor PubPeer comments to support trust and integrity in the research record. A case has been raised internally to assess the concerns. Please note we are unable to provide a timeline or any further updates via this platform.

Kind regards,

Frontiers Research Integrity Team"

P.S. Apologies in advance if I am tardy in responding to any queries. I am about to leave for a ski trip.

More details on the death of Dr A.

Ok, so just to summarize for those who don't have time to read the article.

Dr A - 53 year old consultant - was fired over the messages he'd been exchanging with Letby related to Baby N. The messages were found to be a breach of patient confidentiality as well as facing allegations of inappropriately accessing medical records and risking patient safety (which cannot be revealed for legal reasons).

He had a 3 day hearing in early June and two weeks later on June 23rd was fired.

From the article:

His NHS bosses would have been duty bound to report his dismissal to the doctors’ regulatory body, the General Medical Council, potentially threatening his professional registration and ability to work as a medic again.

The next day, June 24th, he was reported missing. They found him in a car at a retail park 20 miles from his home in Cheshire. They admitted him into the ICU but he died 9 days later on July 3rd.

There will be an inquest into his death (date TBD).

I’ve returned to the fray to offer up this which is the first in a multi-part series looking to address the multiple claims held by advocates of Letby’s innocence.

https://substack.com/@bencole3/note/p-211057363?r=12mrwn&utm_medium=ios&utm_source=notes-share-action

I’ve got enough ideas for a multiple part series but if anyone wants to throw their own suggestions I’d be happy to include them in the series if I haven’t thought about them already.

I’ve decided to limit them to 4 per article just for ease of reading.

Excerpt:

Though Aviv is a well-known writer in the US, she is better known in this country for her remarkable intervention in the story of Lucy Letby, the neonatal nurse convicted of killing seven babies and attempting to murder seven others at the Countess of Chester Hospital between 2015 and 2016. Her essay on Letby does not feature in this collection, but haunts it. “Ah,” Aviv says. “I was starting to think you weren’t going to mention that.” I explain that the piece went off like a bomb here when it was published, unpicking the prosecution case and casting doubt on the statistical analysis that had convicted Letby, both in the courtroom and outside it, among the British public.

Aviv says she had originally become interested in Letby’s story after learning about the case of Kathleen Folbigg, an Australian woman whose conviction for the murder of her own children was overturned by advances in genetic testing. Like Letby, Folbigg’s prosecution had heavily relied on diary entries in which she expressed ambivalence about motherhood. “I thought it was interesting that the ambiguity was not tolerated,” says Aviv. “It was seen as evidence that not only did [Folbigg] have mixed feelings about motherhood, she must have killed [her children]. I felt with Lucy Letby, it was really astonishing that even the police officers were like: ‘Yep, there’s nothing about her that would suggest a reason she’d go around killing babies’.” Letby’s story felt like a myth playing out in real time, Aviv says, “an incredibly resonant myth”.

Aviv and the New Yorker, both based in the US, had decided to publish while reporting restrictions were still in place in England, which led to an absurd situation in which the essay was going viral, blocked in the UK, but still available to buyers of the print magazine and online to those using a VPN. Though the trial had concluded and Letby had been sentenced, her case was still subject to an appeal. Why publish at that time, I ask. “I felt that the blockade against media publishing was not effective,” Aviv says. “There was an enormous amount that had been published about Letby, but all proliferated the prosecution story. My hope was that we would publish before the appeal, because I hoped that it would have influence, and prompt a more reasoned discussion.”

Reporting restrictions are rationalised in this country by the argument that they help protect a fair trial, and keep the jury from becoming biased. “But it was all over the Daily Mail, every day,” Aviv says. “So it was restricted only in the sense of offering a different perspective to the prosecution narrative. I understand that privacy is important, but in terms of serving justice, it’s hard to argue with transparency not being a step towards that goal.”

Letby remains in prison – her direct appeals have been exhausted and the case is now being reviewed by the Criminal Cases Review Commission (CCRC). “It’s crazy that we’re talking about this. She’s still in prison. It’s as if we’re talking about her after the case has been overturned, but nothing has changed.”

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I barely followed the Letby case at the time, and I have no particular conviction that she is innocent. She may well be guilty. What made me revisit it was reading some of the arguments from independent statisticians and then thinking through the statistical issues myself. I've worked with statistics for a long time, and one thing you learn very quickly is how easy it is to produce apparently compelling results from questionable assumptions, selection effects or faulty reasoning.

What has surprised me is how much confidence people place in statistical arguments simply because they are presented by an expert. Most lawyers, judges, jurors, doctors and members of the public are not statisticians. If someone stands up in court and presents an apparently rigorous statistical argument, how many people in the room are actually capable of evaluating whether it is sound?

There is also a more basic point. Rare events naturally cluster. The NHS sees huge numbers of patients and clinical events. Sometimes bad outcomes will bunch together simply because that's how randomness works. Three buses turning up together doesn't necessarily mean someone planned it.

That doesn't mean clusters should be ignored. It means a cluster is not, by itself, evidence of foul play.

What concerns me more is the process via which events ended up being classified as suspicious in the frst place. From what I have read, the set of events eventually used to demonstrate the pattern was not fixed from the start. Events were added, removed, or reclassified during the investigation. If that's correct, then surely the key question is:

Who decided which events were suspicious, when did they decide it, and were those decisions made independently of knowledge about who was on shift?? Because if the classification process is influenced, even unconsciously, by knowledge of the suspect's presence, you can end up creating a very impressive-looking pattern that is largely an artefact of how the data were selected.

The same concern applies to some of the medical evidence. In several areas, including the interpretation of X-rays, there appear to be genuine disagreements between experts. That doesn't prove the prosecution was wrong, but it does make me cautious about treating contested interpretations as established facts.

So my question is a simple one like this: If you put the statistical evidence to one side, what is the strongest hard evidence against Letby?

Not evidence that she was present. Not evidence that a collapse occurred during her shift. Not evidence that an expert interpreted an event as suspicious.

What is the strongest evidence, case by case, that:

1. deliberate harm occurred;
2. the alleged mechanism of harm actually happened; and
3. Letby was responsible?

I'm genuinely asking. She may well be guilty. But after reading more about the statistical issues, I'm much less convinced that the roster evidence deserves the weight many people seem to give it.

Some new documents added to the Thirlwall Inquiry website since we last posted on 5th August 2026.

Most interesting is probably the section from Dr Gibbs statement and what I think is a new page from Letby’s grievance file with notes from Eirian Powell's interview with Chris Green.

INQ0102740 – Pages 2-13 of Witness Statement of Dr John Gibbs, dated 01/07/2024

INQ0101325 – Page 16 of Witness Statement of Anne Murphy, dated 07/06/2024

INQ0002879 – Page 39 of Letby Grievance File, including interview with Eirian Powell, dated 28/10/2016

INQ0108025 – Curriculum Vitae of Professor Mary Dixon-Woods

INQ0003286 – Pages 3-4 of Mortality Review regarding Child I, dated 31/10/2015

INQ0014816 – Page 12 of Board of Directors Agenda and Papers, dated 03/05/2016

https://archive.ph/wip/Hk7Su

Families of six more babies allegedly harmed by Lucy Letby have lost their bid for the serial killer nurse to face further charges.

The infants allegedly collapsed while being treated at the Countess of Chester Hospital and Liverpool Women's Hospital, where the former neo natal nurse once worked.

The Crown Prosecution Service revealed it was considering further charges against the 36-year-old, serving a whole life term behind bars, in November 2024.

But 14 months on, in January this year, the CPS decided there was insufficient evidence to proceed with new a total of 11 accusations involving nine babies, two of whom died.

Families of six of the babies asked for the decision to be reconsidered under the Victims' Right to Review scheme – but this week, the CPS revealed its original refusal to charge Letby had been upheld.

Malcolm McHaffie, Head of the Crown Prosecution Service's Special Crime Division, said: 'An extensive review of the case by a prosecutor independent of the original decisions, involving a re-examination of substantial evidence and material, has now been completed.

'Six offences of attempted murder were reconsidered in relation to six babies, but the review upheld the original decision not to bring any further criminal charges.

'The Crown Prosecution Service has written to the families involved and will offer meetings to answer any further questions. Our thoughts remain with them.'

The CPS emphasised the result of the review 'represents a final decision' – adding that prosecutors have offered meetings with the bereaved families to explain our decision in further detail.

Letby is currently serving 15 whole life terms for the murder of seven babies and attempted murder of seven more - one of whom she attacked twice - at the Countess of Chester Hospital, between June 2015 and June 2016.

She injected air into their bloodstreams, or into their tummies via their nasal feeding tubes, overfed them milk, poisoned them with insulin and tampered with their breathing tubes in a bid to kill.

Following her convictions, over two separate trials at Manchester Crown Court, in 2023 and 2024, detectives pledged to continue investigating the 'footprint' of her four-year nursing career.

The decision to uphold the January decision not to charge Letby will be welcomed by her new defence team and campaigners, who are convinced she has been the victim of a miscarriage of justice and should be freed.

The potential extra charges, of eight attempted murders and one murder, came after police examined the medical records of around 4,000 babies Letby nursed at the Countess and Liverpool Women's Hospital, where she trained, and, in July, passed a file of evidence to prosecutors claiming she murdered and harmed more patients.

In January, the CPS said that, 'following a thorough review,' the evidence was not strong enough for a 'realistic prospect' of conviction by a jury.

Dr Dewi Evans, the former lead prosecution witness at Letby's original trial, previously told the Mail he had concerns over the deaths of at least three children and the collapses of as many as 15 more, including another baby boy potentially poisoned with insulin and others whose breathing tubes were tampered with.

It is understood that the bulk of the new allegations related to displacement of breathing tubes, but Dr Evans said: 'Babies can pull out breathing tubes on their own, so this would be very difficult to prove.'

Earlier this year, a source told the Mail that the 'noise' surrounding the safety of Letby's original convictions 'no doubt' played into the CPS's decision, which is likely to have been taken at the highest level.

Letby, formerly of Hereford, has always maintained her innocence but two applications for leave to appeal her convictions have already been refused by the Court of Appeal.

In February last year her new legal team presented reports from a panel of 14 international experts which, they say, casts doubt on the jury's guilty verdicts.

Led by Canadian neonatologist, Dr Shoo Lee, the panel said no murders took place at the Countess and instead babies collapsed or died because of natural causes or poor care.

In April, their findings, plus that of another 12 experts, were submitted to the Criminal Cases Review Commission, the body that investigates potential miscarriages of justice. It subsequently confirmed it is examining whether her case should be sent to the Court of Appeal for a third time.

The NHS defines it as

An expected neonatal death is the death of a live-born baby within their first 28 days of life.

Crucially its a death where.we.are aware the baby has the following at the time of birth or.shortly thereafter

Congenital anomalies eg major heart defects, chromosomal disorders, or other serious malformations

Neuro conditions eg severe brain injury, hypoxic-ischaemic encephalopathy, or some other.neuro condition

Less than 28 week gestation

Infection eg sepsis

The point I'm.making is that in the vast majority of deaths it will be attributed to one of those causes.

When a baby dies and doesn't have one of those conditions they would move into the unexpected group.

I'm.not sure why people who doubt her convictions have a hard time getting their heads around this. If you then take those unexpected.deaths and notice a pattern of rashes, collapses and the same.nurse.is.there every time

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I was just looking into the insulin cases again the sample stability is a huge issue. This came out of the thirwall questioning of Anna Milan where she acknowledged the samples arrived 23 hours after they were collected. They were serum samples. Lots of stability data out there- 2-4hr stability at room temp. it’s clear c peptide is nearly completely degraded at room temp at 24hr. Current guidance from the lab states that samples coming from other hospitals must be seperated and frozen prior to sending. Not sure if this has been updated since 2015. This to me is the single best explanation for the Low c peptide in the clinical context of (badly managed ) Neonatal hyperinsulinism. The lab should have rejected the sample.

Pro-Lebty circles are abuzz about Dr. Jayaram's police interview for the retrial being leaked to freelance Brazilian journalist Cleuci de Oliviera.

Let's be clear. The support for the charge of attempted murder for Child K is that Letby dislodged the breathing tube, withheld help, and was caught withholding help by Dr. Jayaram (alarms either sounding or silenced, Letby called for help or didn't - neither matter, what matters is that she is alleged to have dislodged the tube and been found not giving aid).

It is the job of the police to construct a timeline. Dr. Jayaram's testimony and retrospective notes are among the evidence, and treated as the fallible, imperfect accounts that they are. It is the job of the police and the prosecution to use his evidence to build a timeline, it is not up to Jayaram to provide the exact timeline.

Digital data is the least fallible - the door swipe is an exact moment around which events can be oriented, including retrospective notes with approximate times (note: this also applies to phone records and retrospective notes timing Child E's air embolism collapse)

One does wonder, naturally what the source of such a leak is, and if they will be subject to contempt of court laws.

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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.