A list of useful/interesting organisations and individuals in relation to Lucy's case that I shall add to/keep current (please contact me with suggestions)

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Links to interesting organisations:

The View Magazine

The only publication by and for women in the justice system

www https://theviewmag.org.uk

email admin@theviewmagazine.org

tel 07591 185 151

The Criminal Cases Review Commission - The CCRC looks into criminal cases where people believe they have been wrongly convicted or wrongly sentenced. These cases are for those who have already lost their appeal. If we do find something wrong with a conviction or sentence, we can send the case back to the Court of Appeal. To launch a fresh appeal, we need something important like strong new evidence or an argument that makes the case look different now. https://ccrc.gov.uk

Appeal: a charity and law practice that fights miscarriages of justice and demands reform

https://appeal.org.uk

Manchester Innocence Project: paving the way to freedom for victims of a miscarriage of justice

https://www.manchester.ac.uk/discover/magazine/features/manchester-innocence-project/

https://www.socialsciences.manchester.ac.uk/connect/making-a-difference/justice-hub/manchester-innocence-project/

The Innocence Project London: aims to undertake thorough and objective investigations into alleged wrongful convictions of individuals who maintain their innocence and have exhausted the criminal appeals process

https://blogs.gre.ac.uk/innocence-project-london/

Innocence Project London is a member of the Innocence Network. Find out more about us at https://IPLondon.org

Cardiff University Innocence Project - conducts casework, research, and advocacy on the topic of miscarriages of justice and is the only university Innocence Project in the UK to have helped overturn cases at the Court of Appeal

https://www.cardiff.ac.uk/pro-bono/cardiff-university-innocence-project

Inside Justice - an award winning charity that conducts casework investigations on behalf of people who claim they’ve been wrongly convicted

https://www.insidejustice.co.uk

The Justice Gap - A magazine about law and justice and the difference between the two

https://www.thejusticegap.com

Centre for Justice Innovation (seeks to build a justice system which everyone believes is fair and effective)

https://justiceinnovation.org/aboutcji

Miscarriages of Justice Review Centre, University of Sheffield - provides Sheffield law students with a unique opportunity to investigate cases of people convicted of serious crimes who are maintaining their innocence

https://www.sheffield.ac.uk/law/undergraduate/probono/miscarriages-justice-review-centre

Miscarriages of Justice Awareness Society

https://www.facebook.com/groups/MOJASUoS/

Miscarriages of Justice Registry, Exeter University (an interdisciplinary research group specialising in behavioural and data science research, and applying this research to the legal system and in legal arguments)

https://evidencebasedjustice.exeter.ac.uk/miscarriages-of-justice-registry/

The British False Memory Society (formed in 1993 to deal with issues relating to false memory)

https://bfms.org.uk

bfms@bfms.org.uk

Justice - A law reform and human rights charity, working to reform the UK justice system with a focus on the most vulnerable and marginalised in society

https://justice.org.uk

Innocence Network UK (INUK) - Educating to overturn and prevent the wrongful conviction of innocent people (no longer operating but some useful info)

http://www.innocencenetwork.org.uk

Innocence Project London School of Law University of Greenwich Old Royal Naval College, Greenwich London SE10 9LS Tel 020 8331 9461 https://www.iplondon.org/ Email: Louise.Hewitt@greenwich.ac.uk Retired Supreme court judges contact info: https://www.supremecourt.uk/about/former-justices.html The Supreme Court For general enquiries, please contact us at: The Supreme Court Parliament Square London SW1P 3BD Switchboard: 020 7960 1500 or 1900 DX 157230 Parliament Sq 4 Text Relay: Callers with a text phone can talk through Text Relay by calling 18001 followed by our main numbers 0207 960 1900 or 0207 960 1500. Email for general public enquiries only. We recommend that you check our 'Frequently Asked Questions' page before emailing us with queries - we have worked hard to ensure the list is as comprehensive as possible. Instant & free solicitor answers legal questions:

Links to influential people:

Your MP

https://members.parliament.uk/FindYourMP https://www.scienceontrial.com/forum/letter-writing/my-letter-to-my-mp

Max Hill KC, Director of Public Prosecutions:

https://www.iap-association.org/getattachment/IAP-General-Meeting-Forum/26th-General-Meeting/Max-Hill-QC-biography.pdf.aspx?lang=en-US

The Rt Hon Victoria Prentis KC MP, Attorney General

https://www.gov.uk/government/ministers/attorney-general

Michael Tomlinson KC, Solicitor General

https://www.gov.uk/government/news/michael-tomlinson-reappointed-as-solicitor-general

The Rt Hon Alex Chalk KC MP, Lord Chancellor and Secretary of State for Justice

https://www.gov.uk/government/people/alex-chalk

The Rt Hon Suella Braverman KC MP, Secretary of State for the Home Department

https://www.gov.uk/government/ministers/secretary-of-state-for-the-home-department

The Rt Hon Steve Barclay MP, Secretary of State for Health and Social Care

https://www.gov.uk/government/people/stephen-barclay

Jon Robins, The Justice Gap

jon@thejusticegap.com

Toby Young, British social commentator

https://www.spectator.co.uk/writer/toby-young/

Jesse Norman MP (MP for Hereford and South Herefordshire, Lucy's home constituency)

https://www.jesse4hereford.com

Chris Mullin ex MP - miscarriage of justice campaigner

https://www.chrismullinexmp.com/speeches/miscarriages-of-justice

Andrew Malkinson - wrongfully convicted and jailed in 2003 for the rape of a 33-year-old woman in Salford, Greater Manchester

https://en.wikipedia.org/wiki/Wrongful_conviction_of_Andrew_Malkinson

Michael O’Brien, miscarriages of justice campaigner (wrongly convicted together with two other men of the 1987 murder of Cardiff newsagent Phillip Saunders. They spent 11 years in prison before their convictions were quashed)

Liam Allan, miscarriages of justice campaigner (faced a lengthy prison sentence after police failed to disclose vital evidence proving a false rape allegation)

Eddie Gilfoyle, miscarriages of justice campaigner (spent 18 years in prison for the murder of his wife)

The family of Ben Geen, a former nurse who was convicted of murdering two patients and causing grievous bodily harm to 15 others

Annie Brodie-Akers, co-founder of Centre for Justice Innovation

Phil Bowen, Director, Centre for Justice Innovation (Phil Bowen leads the organisation, setting and overseeing the implementation of its overarching strategy. Prior to being Director, Phil spent the majority of his career in the British civil service, working for the Home Office, Ministry of Justice, and as a delivery adviser to the Prime Minister on criminal justice reform.)

pbowen@justiceinnovation.org

07816 967361

Twitter: @PhillipBowen45

Suzanne Smith, Senior Innovative Practice Officer, Centre for Justice Innovation (Suzanne leads the Centre's practice work on women in justice and court reform, including procedural fairness and criminal problem-solving courts.)

ssmith@justiceinnovation.org

Stephen Whitehead, Head of Evidence and Data, Centre for Justice Innovation (As head of Evidence and Data, Stephen leads our research team, ensuring that our work is rigorous and provides insights that can have a real impact on the criminal justice system.)

swhitehead@justiceinnovation.org

Michael Naughton

Michael's PhD thesis was on the routine nature of miscarriages of justice as evidenced by successful appeals against criminal conviction and the extensive forms of harm that are caused by such miscarriages of justice to victims, their families and society as a whole from a zemiological perspective.

http://michaeljnaughton.com/?page_id=15

Dr Louise Hewitt, Associate Professor in Law, National Teaching Fellow 2021

Director Innocence Project London, Director IICE Undergraduate Research Hub, Faculty of Liberal Arts and Sciences, School of Law and Criminology, University of Greenwich

"Talk to me about: law of evidence, wrongful convictions, innocence projects, undergraduate research and disability hate crime"

Email: Louise.hewitt@greenwich.ac.uk

T: 0208 8331 9461 (Direct)

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In the 1960 movie The Magnificent Seven, Cajun gunslinger Chris Adams (played by Yul Brynner) and his six fellow gunmen were good guys, hired to protect a small village in Mexico from a group of marauding bandits. The seven prosecution medical experts in Lucy's trial were not "good guys". They were The Maleficient Seven.

maleficent [ muh-lef-uh-suhnt ] adjective

doing evil or harm; harmfully malicious: maleficent destroyers of reputations

https://www.dictionary.com/browse/maleficent

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It has been suggested that 'incompetent counsel' should be grounds for Lucy's appeal - many have wondered why the defence did not do a better job of rebutting the arguably flawed testimony of the seven prosecution medical experts (see www.rexvlucyletby2023.com) or allowed Lucy during police questioning to be asked if she thought someone had poisoned one of the babies with insulin (she was not qualified to answer that so the solicitor should have immediately nipped that in the bud but didn't).

It also seems that another grounds might be the judge's decision during the trial to rule as a Contempt of Court the www.rexvlucyletby2023.com site which robustly set out the science that supported non-malevolent interpretations of the exhibits (X-rays, blood tests) and professional witness testimony (strange rashes, collapses etc). Statistician and miscarriage campaigner Richard Gill, who had published links to the website, received a warning letter on 7 July from Cheshire Constabulary, as detailed on his own website (see https://gill1109.com/2023/09/20/contempt-of-court/ ). A second letter he received on 17 July noted that Cheshire Police had also heard from the author of the www.rexvlucyletby2023.com so it seems they were also contacted.

My question would be, how did Judge Goss determine that the www.rexvlucyletby2023.com site was a Contempt of Court? He is not a scientist, so would have had to consult those qualified to determine whether or not it represented robust science (it certainly looked like it did) and therefore whether it was a Contempt of Court and thus inadmissible. The only experts on hand qualified to judge the science in relation to the X-rays (a radiologist and a pathologist) and the blood tests (a haematologist, an endocrinologist, and a biochemist,) were the prosecution experts (the defence expert was a neonatologist). Did he consult experts elsewhere? If he did, who were they and on what basis did they discount the science? If it was the prosecution experts he consulted (the radiologist, the haematologist, the the pathologist, the endocrinologist, and the biochemist) that is a clear conflict of interest. And if the judge did not consult any experts, that seems to be a dereliction of duty. We shall see.

According to https://www.gov.uk/contempt-of-court ,

‘Contempt of court’ happens when someone risks unfairly influencing a court case. It may stop somebody from getting a fair trial and can affect a trial’s outcome.

Contempt of court includes:

• disobeying or ignoring a court order
• taking photos or shouting out in court
• refusing to answer the court’s questions if you’re called as a witness
• publicly commenting on a court case, for example on social media or online news articles

It seems clear that the judge can only have considered the rexv website to be a Contempt of Court of the basis of it having publicly commented on the case. Below is what the gov.uk website has to say on that.

Publicly commenting on a court case

You might be in contempt of court if you speak publicly or post on social media.

For example, you should not:

• say whether you think a person is guilty or innocent
• refer to someone’s previous convictions
• name someone the judge has allowed to be anonymous, even if you did not know this
• name victims, witnesses and offenders under 18
• name sex crime victims
• share any evidence or facts about a case that the judge has said cannot be made public

The rexv website did none of the above.

As for the 5 July letter received by Richard Gill, I am wondering how the rexv website could have been a "flagrant and serious contempt of court" if none of the above applied. Also, the hearing involved the judge, the defence and the defendant, not the prosecution. Might it have been possible that the defence thought the rexv site was a threat to Lucy and thus argued to the judge that it was a Contempt of Court? In which case the judge could simply have agreed. If the defence wanted the rexv site to be admitted as evidence, surely that would have involved the prosecution. Or, more likely, it was the defence that received the information about the rexv site, they showed it to the judge who immediately deemed it a Contempt of Court and thus inadmissible, and this would not have required the involvement of the prosecution.

In relation to 'incompetent counsel', putting aside the fact that it is not listed as one of the three specific grounds of appeal in https://www.judiciary.uk/wp-content/uploads/2021/07/Blue-guide-July-2021-Final-1.pdf (see A5 below) and that reference to complaint about conduct of trial representatives is only noted in relation to fresh legal representatives (see A4 below), might it be possible that it was not so much the defence counsel that was incompetent but the defence team's medical expert, neonatologist Michael Hall? And even then, incompetence may only have played a minor role.

During pretrial discussions between the two teams of experts (at which the lawyers would not have been present) Michael Hall would have been faced with the bank of seven prosecution experts, many of whose testimony he would not have been qualified to rebut. The seven prosecution experts comprised two paediatricians, an endocrinologist, a biochemist, a haematologist, a radiologist, and a pathologist. Michael Hall, a neonatologist, would not have been qualified to rebut anything other than the testimony of the two paediatricians. The issue may thus have been a lack of funding to pay for more defence experts, rather than the incompetence of the one expert the defence team could afford. And clearly legal aid would have been insufficient to engage the required experts.

A4. Applications by fresh legal representatives (CPD IX 39C)

A4-1. (ii) If these queries result in privileged information being included within, or as an attachment, to the grounds of appeal (including but not limited to, explicit or implied complaints about the conduct of trial representatives), then a signed waiver of privilege must also be lodged with the grounds of appeal.

A5. Specific grounds of appeal

A5-1. Applications to call fresh evidence

A5-2. Insufficient weight given to assistance to prosecution authorities

A5-3. Applications based on a change in law

Per Experts and pretenders - examining possible responses to misconduct by experts in criminal trials in england (2020) Freer, in relation to when to call an expert, "the only general requirement is that the expert’s evidence is on matters likely outside of jurors’ knowledge". In other words, if the only expert testimony the jurors in Lucy's case heard was from the prosecution side saying that crimes had been committed, probably by Lucy, and that since the testimony was on matters beyond their understanding so they had no choice but to accept it, is it really any wonder that they found Lucy guilty? Perhaps the surprise is that they only found Lucy guilty in relation to 14 of the 22 counts.

Now, in relation to A5-1 above, I understand that new expert testimony that debunks original expert testimony can be deemed fresh evidence and thus grounds for appeal. Might the appeal court judge argue that such experts were available at the time of trial? I'm not enough of an expert to know the answer to that. I do know that the Court of Appeal sets the bar very high. I also know there is precedent in relation to appeals being granted on the basis of new expert testimony.

For example:

Wrongly imprisoned (in 2003 for four murders and three attempted murders of patients under her care) Dutch nurse Lucia de Berk was eventually exonerated (according to statistician Richard Gill who campaigned for her innocence) because the original expert toxicologist, faced with the correct interpretation of the data by a second toxicologist, withdrew their incorrect testimony (they blamed the the public prosecutor and the Court for withholding critical information from them).

As for the UK, in 1997, Anthony O'Doherty was convicted of murder but later cleared by the Court of Appeal (https://www.belfasttelegraph.co.uk/news/ex-supergrass-is-cleared-of-attack/28081422.html). His case and exoneration are described in Court Scrutiny of Expert Evidence (2003):

O’Doherty was convicted in 1997 of aggravated burglary and causing grievous bodily harm with intent, based in part on expert testimony that it was highly probable that his voice was the voice heard on the tape of a 999 call made at the time of the burglary. The expert in question, Mrs. McClelland, used only auditory techniques (essentially, careful listening and comparisons of specific sounds and words) in making her comparisons between the voice of the defendant and the voice on the tape, despite the fact that the vast majority of experts in the field place greater reliance on acoustic techniques (that is, techniques involving spectral and other quantitative analysis by machines of the respective sources). This was the same fact pattern as Robb, in which the Court of Appeal for England and Wales held that the witness was permitted to offer similar testimony. The other evidence against the defendant included the testimony of a policeman familiar with his voice that the voice on the tape was his, the jury’s own comparison of the voice on the tape with that of the defendant, and a series of calls on the victim’s mobile phone to the defendant’s house shortly after the burglary.

Following a referral of the case by the Criminal Cases Review Commission, the Court of Appeal for Northern Ireland, in a judgment by Nicolson, LJ, granted the defendant’s application for the reception of fresh evidence, consisting of testimony from three defence experts and two prosecution experts. The defence experts attacked the technique of relying solely on auditory evidence in voice identification, and also presented their own acoustic analysis which they asserted established that the voice on the tape was not that of the defendant. Although Mrs. McClelland largely supported her trial testimony, the other prosecution expert, Dr. French, could assert no more than that it was “rather more likely than not” that the voice on the tape was that of the defendant, and largely agreed with the defence experts that carrying out both auditory and acoustic analysis was “best practice.” Indeed, Mrs. McClelland herself, despite expressing scepticism about acoustic analysis, now regularly performs such analysis.

Back to witnesses...

There are three types of witness: members of the public, professionals, and experts.

The first two of these witness types attest to their memory of events ("I saw him at the bus stop", "he was wearing a green jacket", "I saw a strange rash", "I was called to repair a sewerage leak") though professionals can also provide opinion ("I believed the strange rash meant...").

The third type of witness, the expert, provides their opinion about facts (a blood test or an X-ray) within their area of expertise or about evidence (the testimony of a doctor acting as a professional witness saying they saw a strange rash). Generally speaking, facts are objective (blood tests/X-rays) while evidence, although pertaining to facts (a strange rash) can be subjective ("I saw a strange rash", "I did not see a strange rash").

In Lucy's case, there were two types of witnesses: professional and expert (although the plumber was not a medic, as were almost all the other "non-expert" witnesses, he was still a professional).

The professional witnesses were mostly doctors and nurses who attested to things like who was where, what they saw, what was happening to the babies, etc (the doctors also opined as to their interpretation of what they saw in relation to the babies - the strange rashes, sudden collapses, etc.)

The seven prosecution medical experts (two paediatricians, an endocrinologist, a biochemist, a haematologist, a radiologist, and a pathologist) provided their interpretation (opinion) of the facts/evidence that was relevant to them and their area of expertise (the radiologist would have considered the X-rays, the endocrinologist, the haematologist and the biochemist would have considered the blood tests, the paediatricians would have considered the doctors' testimony about the strange rashes and sudden collapses, etc).

According to the Crown Prosecution Service:

"Medical evidence" means the evidence of medically qualified persons, including psychiatrists, which is admissible to furnish the court with information outside the knowledge of a judge, bench or jury. Evidence given by a suitably qualified doctor that simply reports the injuries sustained by a victim to an assault is not evidence of opinion and is rarely likely to be disputed...Prosecutors need to be aware that where a doctor expresses a view as to the cause or likely cause of an injury, this is opinion and is subject to CrimPR19, unless an admission can be obtained from the Defence, or the medical evidence is not otherwise disputed (https://www.cps.gov.uk/legal-guidance/expert-evidence).

CrimPR19 refers to Part 19 of https://www.legislation.gov.uk/uksi/2020/759/pdfs/uksi_20200759_en.pdf, "Expert Evidence".

In relation to expert witnesses, according to Wikipedia (underlining mine):

In England and Wales, under the Civil Procedure Rules (CPR), an expert witness is required to be independent and address his or her expert report to the court. A witness may be jointly instructed by both sides if the parties agree to this, especially in cases where the liability is relatively small. Under the CPR, expert witnesses may be instructed to produce a joint statement detailing points of agreement and disagreement to assist the court or tribunal. The meeting is held quite independently of instructing lawyers, and often assists in resolution of a case, especially if the experts review and modify their opinions. When this happens, substantial trial costs can be saved when the parties to a dispute agree to a settlement. In most systems, the trial (or the procedure) can be suspended in order to allow the experts to study the case and produce their results. More frequently, meetings of experts occur before trial. Experts charge a professional fee which is paid by the party commissioning the report (both parties for joint instructions) although the report is addressed to the court. The fee must not be contingent on the outcome of the case. Expert witnesses may be subpoenaed (issued with a witness summons), although this is normally a formality to avoid court date clashes.[26] From: https://en.wikipedia.org/wiki/Expert_witness

According to Court Scrutiny of Expert Evidence (2003):

Although English law imposes some limits on the subject matters of expert evidence, it has traditionally imposed very few limits on the methodology or reliability of expert testimony. This position stands in marked contrast to the law of the United States, where this issue has been prominent both in the case law and in scholarly commentary, and where court scrutiny of expert testimony is more exacting.

Experts and pretenders - examining possible responses to misconduct by experts in criminal trials in england (2020) Freer has this to say about "rogue experts":

Therefore a more desirable solution would be to uncover rogue experts before they get as far as giving evidence. To achieve this I would suggest a peer-review college, where acknowledged academic and practitioner experts in the relevant area were used to peer-review the work of the expert whom a party hoped to instruct. Once that individual had been peer-reviewed that process would not need to be carried out again unless the expert asked for it, on the basis that they had assimilated further or different knowledge since their previous assessment. Any assessment could set out the topics on which an expert would be suitably experienced and knowledgeable about to give advice and/or evidence, on the basis of peer review of their published work and practical experience.

Two other interesting papers about expert evidence are Explaining and trusting expert evidence - what is a sufficiently reliable scientific basis (2020) Ward and Scientific disciplines and the admissibility of expert evidence in courts (2022) O'Brien et al.

The paper Variability in the analysis of a single neuroimaging dataset by many teams also describes how experts' interpretations of the same data can vary, something Lucy's defence may be faced with if it gets a chance to rebut the prosecution's experts' testimony.

In Lucy's trial, it seemed that little weight was given to the original postmortems that found no evidence of harm (why the consultants did not alert the pathologist to their suspicions about Lucy when they fist had them in late June/early July 2015 is another question entirely).

Below are all the references in the Chester Standard reports of the trial to the key individuals relating to pathologists, namely the coroner Nicholas Rheinberg, the original pathologist George Kokai, and the prosecution's expert pathologist Andreas Marnerides.

What I think comes across clearly is how little mention there was at trial of Rheinberg and Kokai, and how the prosecution's expert pathologist Marnerides disputed everything in the original postmortems.

Title: Mr

First name: Nicholas

Last name: Rheinberg

Gender: M

Group: Legal

Subgroup: Crown

Role/job: Coroner

Employer/association: HM Coroners, Cheshire

Recording a verdict of misadventure, coroner Nicholas Rheinberg told the inquest in Chester in February 2015: ‘There were very considerable signs [the tube was incorrectly positioned] and I find it surprising these signs were not realised.’ https://www.dailymail.co.uk/news/article-4518212/Baby-deaths-Countess-Chester-Hospital-probed.html

Letby also managed to slip through the gaps in the coronial system. Hospital managers asked the Cheshire coroner, Dr Nicholas Rheinberg, to investigate the seven baby deaths in February 2017. The coroner declined, according to sources, telling the trust he was not a “quality-assurance service” for the NHS. Rheinberg retired that year. https://www.thetimes.co.uk/article/damning-email-told-of-chaos-on-lucy-letby-ward-kd9s28k5f

Title: Dr

First name: George

Last name: Kokai

Gender: M

Group: Medical

Subgroup: Doctor

Role/job: Pathologist

Employer/association: Alder Hey

Child C

Mr Myers says, for the case of Child C, he looks at the post-mortem evidence of whether there was a gastrointestinal blockage. He refers to the agreed evidence by the pathologist, Dr Kokai, who conducted the post-mortem examination, who recorded a 'distended colon' for Child C, which was not normal. He says Dr Marnerides refused to accept this evidence, who said the bowel was 'normal'. https://www.chesterstandard.co.uk/news/23615797.recap-lucy-letby-trial-june-27---defence-closing-speech/

Dr George Kokai carried out a post-mortem examination for Child C. He noted a distended colon, which Dr Marnerides said was "not an abnormality". He said the potential complication was a twisted colon that would lead to "obvious" symptoms of pain. There was evidence of "acute pneumonia". Dr Marnerides said one could die of pneumonia or with penumonia. He said the former was plausible, but upon hearing further clinical evidence, he reviewed his opinion. He said babies dying of penumonia experience gradual deterioration, which was not the case here. He said he revisited the cause of death, viewing images of a distended stomach, and no evidence of NEC. Prof Arthurs said the small bowel was dilated. Dr Marnerides observed a dilated stomach and bowel, and noted Child C had been off CPAP for over 12 hours. No air had been obtained from aspirates before the collapse. He had never known CPAP belly being the cause of an arrest in a baby in his years of experience. He said, in his opinion, the cause of Child C's collapse was of excessive air administered into the stomach via the naso-gastric tube. https://www.chesterstandard.co.uk/news/23628455.recap-lucy-letby-trial-july-3---judges-summing/

Child I

Dr George Kokai carried out a post-mortem examination of Child I. Dr Andreas Marnerides was dependent on the report. Dr Marnerides said Child I did not have NEC. He was "very sceptical" that Child I died of natural causes. He said the collapses were more likely to be excessive air administered to the stomach, via the NGT. The defence say a similar event happened for Child I on August 23, a day when Letby was not on duty. https://www.chesterstandard.co.uk/news/23634101.recap-lucy-letby-trial-july-5---judges-summing/

Child O

Dr George Kokai carried out a post-mortem examination [of Child O]. Dr Andreas Marnerides reviewed, and said injuries to the liver were the result of impact trauma. He said during treatment, small bruises could be caused to the surface of the liver, and would not be extensive. He says the liver is not in an area where CPR is applied. He has only seen this kind of injury to the liver before in children, not babies, from accidents involving bicycles. He did not think CPR could produce this extensive injury to the liver, and has never heard of this sort being accepted as such. He also found internal gastric distention, and concluded there had been an air embolus. Prof Arthurs also referred to radiograph images, taken post-mortem. He said the gases were an 'unusual finding'. https://www.chesterstandard.co.uk/news/23636819.recap-lucy-letby-trial-july-6---judges-summing/

Title: Dr

First name: Andreas

Last name: Marnerides

Gender: M

Group: Medical

Subgroup: Doctor

Role/job: Patholigist (paediatric)

Employer/association: Guy's and St Thomas' NHS Foundation Trust (https://www.guysandstthomas.nhs.uk/our-consultants/andreas-marnerides)

General reference

He [Myers] says of Dr Andreas Marnerides, a pathologist, "is not a clinician, is not a paediatrician or a neonatologist", which "puts some limits [on his expertise]". He says his expertise is on what happens following a death, not in life. He says Dr Marnerides is "reliant" on the evidence of others, something which he agreed. He says he made a lot of reference to Dr Dewi Evans, and it is "too late in the day" to "insinuate" it is someone else. https://www.chesterstandard.co.uk/news/23613176.recap-lucy-letby-trial-june-26---defence-closing-speech/

Child A

Dr Marnerides said it appeared Child A, a twin boy, died as a result of an injection of air into his bloodstream. https://www.chesterstandard.co.uk/news/23422288.lucy-letby-baby-suffered-liver-injury-akin-road-traffic-collision/

The judge refers to expert witness Dr Andreas Marnerides' evidence. His expertise, the court is told, is on the pathology of conditions on those who had died. He said there was "no evidence of infection" or "any other abnormalities". He said he could see, from his study, "empty structures" of fat or air in Child A - after testing, he ruled out the former. He said he could see evidence of air in the brain when the baby was alive. The findings "could not be taken as absolute proof of air embolus". He said there was "no evidence of any natural cause of death", or any of natural disease. He took the view that Child A's death was of air embolus via injection. https://www.chesterstandard.co.uk/news/23628455.recap-lucy-letby-trial-july-3---judges-summing/

Child C

The note recorded bile on a blanket and black-stained fluid for Child C. He says nurse Yvonne Griffiths hasn't signed for a 9am reading on June 12, and something was entered for noon and not signed. He says bile on a blanket and black fluid is recorded in the nursing note at 6.30pm, but is not noted on the fluid chart.He says a radiograph was taken at 12.36pm. Dr Evans, Dr Bohin and Dr Andreas Marnerides had all regarded the image as a 'suspicious event' of harm. He says Letby was not on duty. Dr Anne Boothroyd recorded 'marked gaseous distention of the stomach'.Mr Myers says the jury should take this as "proof" the experts can "get it wrong".He says if this event happened when Letby was on duty, Letby would be accused of causing it.....He refers to the agreed evidence by the pathologist, Dr Kokai, who conducted the post-mortem examination, who recorded a 'distended colon' for Child C, which was not normal. He says Dr Marnerides refused to accept this evidence, who said the bowel was 'normal'. https://www.chesterstandard.co.uk/news/23615797.recap-lucy-letby-trial-june-27---defence-closing-speech/

Child C, a boy, was subjected to an excessive infusion/injection of air into his nasogastric tube, he [,Dr Marnerides,] said. https://www.chesterstandard.co.uk/news/23422288.lucy-letby-baby-suffered-liver-injury-akin-road-traffic-collision/

Mr Johnson says the jury know, as a fact, from Dr Andreas Marnerides, that Child C did not have a problem with his gut, as there was no sign of infection or sepsis. There was no evidence of Child C having had an obstruction in his bowel....Dr Marnerides said there was "nothing unusual" about Child C's bowel. He concluded Child C died "with pneumonia not from pneumonia" and the gas in the bowel could not be explained by infection or an abonormality in the bowel. He said "air must have been injected into the nasogastric tube", splinting the diaphragm, which would have compromised Child C's breathing and killed him. He added: "I have never in the past 10 years, come across even a suggestion that 'CPAP belly' would lead to the deterioration of a baby, let alone this gastric distention that would lead to [a baby's death]." https://www.chesterstandard.co.uk/news/23603440.recap-lucy-letby-trial-june-21--prosecution-closing-speech/

Dr George Kokai carried out a post-mortem examination for Child C. He noted a distended colon, which Dr Marnerides said was "not an abnormality". He said the potential complication was a twisted colon that would lead to "obvious" symptoms of pain. There was evidence of "acute pneumonia". Dr Marnerides said one could die of pneumonia or with penumonia. He said the former was plausible, but upon hearing further clinical evidence, he reviewed his opinion. He said babies dying of penumonia experience gradual deterioration, which was not the case here. He said he revisited the cause of death, viewing images of a distended stomach, and no evidence of NEC. Prof Arthurs said the small bowel was dilated. Dr Marnerides observed a dilated stomach and bowel, and noted Child C had been off CPAP for over 12 hours. No air had been obtained from aspirates before the collapse. He had never known CPAP belly being the cause of an arrest in a baby in his years of experience. He said, in his opinion, the cause of Child C's collapse was of excessive air administered into the stomach via the naso-gastric tube. https://www.chesterstandard.co.uk/news/23628455.recap-lucy-letby-trial-july-3---judges-summing/

The judge refers to the case of Child C. He says medical experts found it difficult to conclude the cause of death, but Dr Marnerides said it was air administered into his stomach via the naso-gastric tube. Letby said she did nothing harmful to Child C, and a cause such as a gastrointestinal blockage cannot be excluded, that Child C should have been treated at a tertiary unit, and there was a failure to react to bile aspirates, vomiting, and an overall lack of care. https://www.chesterstandard.co.uk/news/23628455.recap-lucy-letby-trial-july-3---judges-summing/

Child D

The “likely explanation” for the death of Child D, a girl, was an air embolism into her circulation. [Dr Marnerides] https://www.chesterstandard.co.uk/news/23422288.lucy-letby-baby-suffered-liver-injury-akin-road-traffic-collision/

Another medical expert, Dr Marnerides, had ruled out sepsis, and concluded Child D was killed by an air embolus.  https://www.chesterstandard.co.uk/news/23603440.recap-lucy-letby-trial-june-21--prosecution-closing-speech/

Mr Myers refers to the pathologist's report for Child D, recording damaged lungs, "continuing respiratory problems". Presence of infection is "not ruled out" following negative microbiology tests, as Child D had been on antibiotics. Mr Myers said despite that, Dr Marnerides "preferred" air embolus as a conclusion. He said he had taken into account clinicians' views of how well Child D was doing. Mr Myers says Child D was not doing well on respiration. https://www.chesterstandard.co.uk/news/23615797.recap-lucy-letby-trial-june-27---defence-closing-speech/

Dr Andreas Marnerides said pneumonia was likely to be present at birth for Child D. Professor Arthurs talked of a 'black line' in front of the spine indicating gas in the great vessels, which was "unusual" in children who had died without an explanation. It was present in "two other children", one of whom was Child A. There was "more air" in Child D than Child A. One explanation was someone was injecting air into the child, and the radiograph images were consistent with, but not diagnostic of, externally administered air to Child D. Dr Marnerides said the presence of air in such a vessel was "significant". He said from a pathology point of view, air embolus could not be proved. He said there was "no other natural disease" that could explain Child D's death. He said in his opinion, Child D died with, not from, pneumonia. He concluded the 'likely explanation' was air embolus. https://www.chesterstandard.co.uk/news/23631372.recap-lucy-letby-trial-july-4---judges-summing/

Child E

He [Dr Marnerides] told the court he could no offer no opinion on the death of Child E, a twin boy, because no post-mortem examination took place. https://www.chesterstandard.co.uk/news/23422288.lucy-letby-baby-suffered-liver-injury-akin-road-traffic-collision/

Child I

Another girl, Child I, received an excessive injection of air into her stomach, he [Dr Marnerides] said. https://www.chesterstandard.co.uk/news/23422288.lucy-letby-baby-suffered-liver-injury-akin-road-traffic-collision/

Dr Marnerides said at the time of Child I's death, she had no acute illnesses or abnormalities in the bowel, other than presence of air. The presence of gas had "no pathological cause". He said the collapses were air administered from the NG Tube. https://www.chesterstandard.co.uk/news/23606159.recap-lucy-letby-trial-june-22--prosecution-closing-speech/

Dr Marnerides said Child I did not have NEC. He was "very sceptical" that Child I died of natural causes. He said the collapses were more likely to be excessive air administered to the stomach, via the NGT.  https://www.chesterstandard.co.uk/news/23634101.recap-lucy-letby-trial-july-5---judges-summing/

Child O

Dr Andreas Marnerides, the reviewing pathologist, thought that the liver injuries were most likely the result of impact type trauma and not the result of CPR….He certified the cause of death to be “Inflicted traumatic injury to the liver and profound gastric and intestinal distension following acute excessive injection or infusion of air via a naso-gastric tube” and air embolus. https://www.chesterstandard.co.uk/news/23035356.recap-prosecution-opens-trial-lucy-letby-accused-countess-chester-hospital-baby-murders/

Paediatric pathology expert Dr Andreas Marnerides had told jurors he concluded Child O died because of “inflicted traumatic injury” to the liver, as well as receiving fatal injections of air into the stomach and bloodstream....“I have never seen this type of injury in the context of CPR so I would say the force required would be of the magnitude of that generated by a baby jumping on a trampoline and falling.” He agreed that smaller internal bruising to the liver sustained by Child O’s triplet brother Child P – who Letby is alleged to have murdered the next day – could be capable of being caused by CPR. But asked if “rigorous” chest compressions could be the cause of the internal bruising in Child O’s case, Dr Marnerides said: “I don’t think so, no." “This is a huge area of bruising for a liver of this size. This is not something you see in CPR.” Mr Myers said: “So you don’t accept the proposition that forceful CPR could cause this injury in general terms, do you agree it cannot be categorically excluded as a possibility?” Dr Marnerides replied: “We are not discussing possibilities here, we are discussing probabilities. “When you refer to possibilities, I am thinking for example of somebody walking in the middle of the Sahara desert found dead with a pot and head trauma. “It is possible the pot fell from the air from a helicopter. The question is ‘is it probable?’ and I don’t think we can say it is probable.” Mr Myers asked: “Is it possible in your opinion for at least some of what we see in the damage to the liver arising from the insertion of a cannula?” The consultant said: “I would consider it extremely unlikely. I would expect some kind of perforation injury.” https://www.chesterstandard.co.uk/news/23424649.letby-trial-forceful-cpr-not-cause-babys-liver-damage/

Jurors were shown post-mortem examination photographs which showed two separate sites of bruising, as well as areas of a blood clot. Prosecutor Nick Johnson KC asked the consultant: “How does that injury come to be in a child of (Child O’s) age?”...Mr Johnson said: “Looking at this sequence of photographs, can you rule out the possibility that these injuries were caused by CPR?” Dr Marnerides said: “I cannot convince myself that in the setting of a neonatal unit this would be a reasonable proposition to explain this. I don’t think CPR can produce this extensive injury to a liver.”....Dr Marnerides said: “In my view, the cause of death was inflicted traumatic injury to the liver, profound gastric and intestinal distension following acute excessive injection/infusion of air via a naso-gastric tube and air embolism due to administration into a venous line.” https://www.chesterstandard.co.uk/news/23422288.lucy-letby-baby-suffered-liver-injury-akin-road-traffic-collision/

During Child O's resuscitation in his final collapse, a doctor had said efforts were made to decompress Child O's abdomen. In cross-examination it had been suggested this was the cause of the liver injury. Dr Brearey and Dr Marnerides had rejected this, Mr Johnson tells the court. https://www.chesterstandard.co.uk/news/23600333.recap-lucy-letby-trial-june-20--prosecution-closing-speech/

Dr George Kokai carried out a post-mortem examination. Dr Andreas Marnerides reviewed, and said injuries to the liver were the result of impact trauma. He said during treatment, small bruises could be caused to the surface of the liver, and would not be extensive. He says the liver is not in an area where CPR is applied. He has only seen this kind of injury to the liver before in children, not babies, from accidents involving bicycles. He did not think CPR could produce this extensive injury to the liver, and has never heard of this sort being accepted as such. He also found internal gastric distention, and concluded there had been an air embolus. https://www.chesterstandard.co.uk/news/23636819.recap-lucy-letby-trial-july-6---judges-summing/

Earlier, Dr Marnerides said the most likely explanation for the death of Child P was excessive air injected via a nasogastric tube into his stomach. https://www.chesterstandard.co.uk/news/23424649.letby-trial-forceful-cpr-not-cause-babys-liver-damage/

Child P

Dr Marnerides said he had no evidence to indicate a natural disease that would account for Child P's death. He thought small haematomas to the liver were potentially the result of CPR, or as a result of prematurity, and did not have enough to say it was an impact injury. He said there was no clinical evidence for a natural cause. He said having considered other accounts, he concluded there was gastric distention caused by excessive air injected into the stomach. https://www.chesterstandard.co.uk/news/23636819.recap-lucy-letby-trial-july-6---judges-summing/

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The views expressed in this communication are those of Peter Elston at the time of writing and are subject to change without notice. They do not constitute investment advice and whilst all reasonable efforts have been used to ensure the accuracy of the information contained in this communication, the reliability, completeness or accuracy of the content cannot be guaranteed. This communication provides information for professional use only and should not be relied upon by retail investors as the sole basis for investment.

© Chimp Investor Ltd

The notion that the prosecution's experts in Lucy's case were independent as they were legally obliged to be is laughable

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The prosecution in Lucy's case engaged seven medical specialists to provide expert (opinion based) testimony. Of the seven listed at the bottom of this post, it appears that only Evans and Bohin advertised their commercial expert witness services in the public domain. This however does not mean that the other five were not registered somewhere as willing to provide expert witness testimony, just that they registered this interest privately with an expert witness company that acted as their agent.

If you tell one of these companies/agents that you want a paediatric radiologist, they will then contact the paediatric radiologists on their books. For example, this document (https://www.judiciary.uk/wp-content/uploads/2022/03/Newsletter-Spring-2022.pdf) lists Dr Owen Arthurs (the prosecution's expert radiologist in Lucy's case) as being contactable on ExpertsLondon@ejudiciary.net even though you will not find him listed on https://www.ewi.org.uk/directory (referred to at the bottom of the document) or anywhere else. And here he is talking about being an expert witness: https://www.youtube.com/watch?v=Qvl1ZqoZqsc.

Also, the notion that the prosecution's experts were independent is laughable. If an expert does not support the prosecution's case of guilt they will not get selected. And if they are not selected they will not get paid. This is, frankly, the mother of all conflicts of interest. This issue is particularly heinous in in Dewi Evans' case since it was he who touted for the work, as jurors heard on 6 March:

From: https://www.chesterstandard.co.uk/news/23370074.medic-denies-touting-job-helping-lucy-letby-police-probe/:

On Tuesday, March 6, jurors were read an email sent by Dr Evans to the National Crime Agency (NCA) in May 2017, ahead of his involvement with Cheshire Police. In his message to “Nick” at the NCA’s national injuries database, Dr Evans wrote: “Incidentally I’ve read about the high rate of babies in Chester and that the police are investigating. “Do they have a paediatric/neonatal contact? I was involved in neonatal medicine for 30 years including leading the intensive care set-up in Swansea. I’ve also prepared numerous neonatal cases where clinical negligence was alleged. “If the Chester police had no-one in mind I’d be interested to help. Sounds like my kind of case. “I understand that the Royal College (of Paediatrics and Child Health) has been involved but from my experience the police are far better at investigating this sort of problem.”

Fieldfisher sets out the role of the expert witness and the test of an expert's independence in https://www.fieldfisher.com/en/insights/expert-witnesses-the-independence-factor:

As an expert’s role is to assist the court, independence is key. Experts must be ‘uninfluenced by the pressures of litigation’ (CPR Practice Direction (PD) 35 (2.1)), and are duty-bound to provide ‘objective, unbiased opinions on matters within their expertise’ to resolve the proceedings, not assuming the role of an advocate. An expert’s duty to the court ‘overrides any obligation to the person from whom experts have received instructions or by whom they are paid’ (CPR 35.3 (2)). A useful test of ‘independence’ is that the expert would form and provide the same opinion had the instructions been provided by the opposing party in the proceedings.

(For those who wish to know more, the rules on expert witnesses in the courts of England and Wales are governed by Civil Procedure Rules (CPR) r.35. See https://www.justice.gov.uk/courts/procedure-rules/civil/rules/part35).

As if touting for work was not bad enough, it was Evans himself who in December 2017 determined that crimes had been committed which meant the case would go to court and he would get paid.

From : https://news.sky.com/story/how-the-police-caught-lucy-letby-12933640

The force began to examine the deaths of 17 babies and the non-fatal collapses of 16 more, some of whom have been left with life-changing injuries. Tens of thousands of medical files were prepared for a neonatologist - an expert in young infants - found via the National Crime Agency.Then in December 2017, their expert came back with his response. These deaths were not the result of natural causes. Operation Hummingbird had begun.

The more of the 33 events Cheshire Police was examining that Evans could deem murders/attempted murders, the longer the trial would take, the more testimony he would have to provide, and the more he would get paid. Unfortunately (for him) he could only deem eight of the deaths as murders and six of the collapses as attempted murders.

From: http://www.chesterstandard.co.uk/news/16332233.home-searched-after-baby-murder-arrest-belongs-to-chester-childrens-nurse/

Cheshire Police announced yesterday that an unnamed healthcare worker was being questioned in relation to the murder of eight babies and the attempted murder of a further six. It comes after police launched an investigation in May last year into the deaths of 17 babies and 15 non-fatal collapses at the Countess of Chester Hospital between March 2015 and July 2016.

Anyway, Dr E, you must have been furious that you couldn't deem 19 of the events as crimes. Still, 14 is not a bad day's work. You were still going to get paid a tidy sum.

By the way, Dr E, why did Sky News write that you were a neonatologist? Did you tell the police that's what you were? Also, it wrote "neonatologist" not "retired neonatologist". If you did not tell the police that you were a retired paediatrician which is what you were, that's naughty.

The list of shame:

Title: Dr

First name: Dewi

Last name: Evans

Gender: M

Group: Medical

Subgroup: Doctor

Role/job: Consultant paediatrician (rtd)

Employer/association: Dewi Evans Paediatric Consulting Ltd (no website - https://find-and-update.company-information.service.gov.uk/company/07341254)

Commercial expert site: https://www.expertwitness.co.uk/expert/5763c7f0ca2f3af2228b5f41

Title: Dr

First name: Sandie

Last name: Bohin

Gender: F

Group: Medical

Subgroup: Doctor

Role/job: Consultant paediatrician

Employer/association: The Medical Specialist Group LLP (https://www.msg.gg/clinical-team/consultants/dr-sandie-bohin/)

Commercial expert site: https://paediatricexpert.com

Title: Prof

First name: Peter

Last name: Hindmarsh

Gender: M

Group: Medical

Subgroup: Doctor

Role/job: Endocrinologist (paediatric)

Employer/association: University College London Hospital (https://www.uclh.nhs.uk/our-services/find-consultant/professor-peter-hindmarsh )

Title: Dr

First name: Anna

Last name: Milan

Gender: F

Group: Medical

Subgroup: Doctor

Role/job: Clinical biochemist

Employer/association: Royal Liverpool and Broadgreen University Hospital NHS Trust (http://pathlabs.rlbuht.nhs.uk/ccfram.htm)

Title: Prof

First name: Sally

Last name: Kinsey

Gender: F

Group: Medical

Subgroup: Doctor

Role/job: Haematologist (paediatric)

Employer/association: Leeds Teaching Hospitals NHS Trust (https://www.leedsth.nhs.uk/a-z-of-services/leeds-cancer-centre/services/childrens-and-adolescent-oncology-and-haematology/services/haematology/) and St. James University Hospital (https://severe-chronic-neutropenia.org/en/partners/uk)

Title: Prof

First name: Owen

Last name: Arthurs

Gender: M

Group: Medical

Subgroup: Doctor

Role/job: Radiologist (paediatric)

Employer/association: Great Ormond Street Hospital (https://www.gosh.nhs.uk/our-people/staff-z/owen-arthurs/)

Title: Dr

First name: Andreas

Last name: Marnerides

Gender: M

Group: Medical

Subgroup: Doctor

Role/job: Patholigist (paediatric)

Employer/association: Guy's and St Thomas' NHS Foundation Trust (https://www.guysandstthomas.nhs.uk/our-consultants/andreas-marnerides)

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The views expressed in this communication are those of Peter Elston at the time of writing and are subject to change without notice. They do not constitute investment advice and whilst all reasonable efforts have been used to ensure the accuracy of the information contained in this communication, the reliability, completeness or accuracy of the content cannot be guaranteed. This communication provides information for professional use only and should not be relied upon by retail investors as the sole basis for investment.

© Chimp Investor Ltd

The cast list of people involved with Lucy's case as derived from every single Chester Standard report on the case and the trial

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I have spent rather a long time compiling this list from Chester Standard articles and others but I think it will prove very useful. What I will do next is start to add notes underneath each individual summarising the key aspects of their testimony (or, if they did not testify, the key aspects of their involvement in Lucy's case).

Detail from David and Goliath, a colour lithograph by Osmar Schindler (c. 1888)

Source: https://en.wikipedia.org/wiki/Goliath

There are over 100 individuals on the list. There may be others I should add. Please let me know if I have missed any out. Also, please let me know if there is something specific you think I should mention in relation to (a) specific individual(s). It should be something factual i.e. something that is from a credible source.

Judges

Title: Mr

First name: James

Last name: Goss

Gender: M

Group: Legal

Subgroup: Crown

Role/job: Judge

Employer/association: Manchester Crown Court

Title: Mr

First name: Ian

Last name: Dove

Gender: M

Group: Legal

Subgroup: Crown

Role/job: Judge

Employer/association: Liverpool Crown Court

Defence side

Title: Ms

First name: Lucy

Last name: Letby

Gender: F

Group: Medical

Subgroup: Nurse

Role/job: Defendant

Employer/association: CoCH

Title: Mr

First name: Benjamin

Last name: Myers

Gender: M

Group: Legal

Subgroup: Defence team

Role/job: Defence (barrister)

Employer/association: Exchange Chambers

Title: Mr

First name: Richard

Last name: Thomas

Gender: M

Group: Legal

Subgroup: Defence team

Role/job: Defence (solicitor)

Employer/association: Russell & Russell

Title: Mr

First name: Lorenzo

Last name: Mansutti

Gender: M

Group: Tradesman

Subgroup: Tradesman

Role/job: Plumber

Employer/association: CoCH

Title: Mr

First name: John

Last name: Letby

Gender: M

Group: Family and friends

Subgroup: Family and friends

Role/job: Father

Employer/association: Family and friends

Title: Ms

First name: Susan

Last name: Letby

Gender: F

Group: Family and friends

Subgroup: Family and friends

Role/job: Mother

Employer/association: Family and friends

Title: Mr

First name: Charles

Last name: Letby

Gender: M

Group: Family and friends

Subgroup: Family and friends

Role/job: Uncle (John Letby's brother)

Employer/association: Family and friends

Title: Ms

First name: Janet

Last name: Cox

Gender: F

Group: Family and friends

Subgroup: Family and friends

Role/job: Lucy's friend

Employer/association: Family and friends

Title: Ms

First name: Dawn

Gender: F

Group: Family and friends

Subgroup: Family and friends

Role/job: Lucy's childhood friend (very bravely and helpfully did BBC interview expressing, in absence of a true confession by Lucy, 100% belief in her innocence)

Employer/association: Family and friends

Title: Dr

First name: Michael

Last name: Hall

Gender: M

Group: Medical

Subgroup: Doctor

Role/job: Expert (neonatologist)

Employer/association: Expert (neonatologist)

Note: Dr Hall was never called to testify by the defence. Why was this? Was it because his opinion (no crimes were committed) differed so much from that of the prosecution's experts (22 crimes had been committed) that he was unable to present it?

Title: Dr

First name: Marie

Last name: Oldfield

Gender: F

Group: Scientist

Subgroup: Doctor

Role/job: AI and Ethics Expert

Employer/association: Expert (statistics/risk)

Note: My belief is that Dr Oldfield was engaged by the defence to analyse/counter the evidence presented by prosecution witness Claire Hocknell who was engaged by Cheshire Police as an intelligence analyst but I have been unable to confirm this.

Individuals who do not appear to have been believed by the prosecution side

Title: Mr

First name: Nicholas

Last name: Rheinberg

Gender: M

Group: Legal

Subgroup: Crown

Role/job: Coroner

Employer/association: HM Coroners, Cheshire

Recording a verdict of misadventure, coroner Nicholas Rheinberg told the inquest in Chester in February 2015: ‘There were very considerable signs [the tube was incorrectly positioned] and I find it surprising these signs were not realised.’ https://www.dailymail.co.uk/news/article-4518212/Baby-deaths-Countess-Chester-Hospital-probed.html

Letby also managed to slip through the gaps in the coronial system. Hospital managers asked the Cheshire coroner, Dr Nicholas Rheinberg, to investigate the seven baby deaths in February 2017. The coroner declined, according to sources, telling the trust he was not a “quality-assurance service” for the NHS. Rheinberg retired that year. https://www.thetimes.co.uk/article/damning-email-told-of-chaos-on-lucy-letby-ward-kd9s28k5f

Title: Dr

First name: George

Last name: Kokai

Gender: M

Group: Medical

Subgroup: Doctor

Role/job: Pathologist

Employer/association: Alder Hey

Mr Myers says, for the case of Child C, he looks at the post-mortem evidence of whether there was a gastrointestinal blockage. He refers to the agreed evidence by the pathologist, Dr Kokai, who conducted the post-mortem examination, who recorded a 'distended colon' for Child C, which was not normal. He says Dr Marnerides refused to accept this evidence, who said the bowel was 'normal'. https://www.chesterstandard.co.uk/news/23615797.recap-lucy-letby-trial-june-27---defence-closing-speech/

Dr George Kokai carried out a post-mortem examination for Child C. He noted a distended colon, which Dr Marnerides said was "not an abnormality". He said the potential complication was a twisted colon that would lead to "obvious" symptoms of pain. There was evidence of "acute pneumonia". Dr Marnerides said one could die of pneumonia or with penumonia. He said the former was plausible, but upon hearing further clinical evidence, he reviewed his opinion. He said babies dying of penumonia experience gradual deterioration, which was not the case here. He said he revisited the cause of death, viewing images of a distended stomach, and no evidence of NEC. Prof Arthurs said the small bowel was dilated. Dr Marnerides observed a dilated stomach and bowel, and noted Child C had been off CPAP for over 12 hours. No air had been obtained from aspirates before the collapse. He had never known CPAP belly being the cause of an arrest in a baby in his years of experience. He said, in his opinion, the cause of Child C's collapse was of excessive air administered into the stomach via the naso-gastric tube. https://www.chesterstandard.co.uk/news/23628455.recap-lucy-letby-trial-july-3---judges-summing/

Dr George Kokai carried out a post-mortem examination of Child I. Dr Andreas Marnerides was dependent on the report. Dr Marnerides said Child I did not have NEC. He was "very sceptical" that Child I died of natural causes. He said the collapses were more likely to be excessive air administered to the stomach, via the NGT. The defence say a similar event happened for Child I on August 23, a day when Letby was not on duty. https://www.chesterstandard.co.uk/news/23634101.recap-lucy-letby-trial-july-5---judges-summing/

Dr George Kokai carried out a post-mortem examination [of Child O]. Dr Andreas Marnerides reviewed, and said injuries to the liver were the result of impact trauma. He said during treatment, small bruises could be caused to the surface of the liver, and would not be extensive. He says the liver is not in an area where CPR is applied. He has only seen this kind of injury to the liver before in children, not babies, from accidents involving bicycles. He did not think CPR could produce this extensive injury to the liver, and has never heard of this sort being accepted as such. He also found internal gastric distention, and concluded there had been an air embolus. Prof Arthurs also referred to radiograph images, taken post-mortem. He said the gases were an 'unusual finding'.  https://www.chesterstandard.co.uk/news/23636819.recap-lucy-letby-trial-july-6---judges-summing/

Title: Dr

First name: Francis

Last name: Potter

Gender: M

Group: Medical

Subgroup: Doctor

Role/job: Consultant anaesthetist

Employer/association: Alder Hey

A registrar doctor, who cannot be identified for legal reasons, told Manchester Crown Court on Monday, March 6, how he was asked to review Child N from about 7.30am on June 15….Giving evidence on Monday, the doctor said: “I saw blood at the back of the throat … that prevented me from seeing where the entry to his airway was.”. He said he also noticed “a degree of swelling”. Prosecutor Simon Driver asked: “ What did you notice first?” The doctor replied: “I think I will have seen the blood first because that is such an unusual thing to see at the time of intubation.” He said he could not see where the blood was coming from or what had caused the swelling....Another doctor told the court he too could not intubate Child N following a further sudden deterioration in the afternoon, after 3ml of blood was withdrawn from his nasogastric tube. Dr Huw Mayberry said: “I could see the vocal cords but I was unable to get a very clear view because there was substantial swelling within the airway. “The swelling was unlike anything I had encountered previously. It looked quite large and reddy-pink in colour.”...Dr Gibbs said the “serious life-threatening deterioration” only improved after a consultant anaesthetist [Dr Potter], called from Liverpool’s Alder Hey Children’s Hospital, managed to intubate at his first attempt. He told the court he “couldn’t understand” why two consultants, two registrars and two anaesthetists had failed previously to intubate Child N throughout the day, but said the adrenaline may have helped reduce the swelling....Alder Hey anaesthetist Dr Francis Potter told jurors that he did not see blood or swelling in Child N’s throat when he successfully inserted the breathing tube. Following his transfer to Alder Hey, Dr Potter said Child N’s stay was “fairly uneventful”, although there were episodes of “apnoea” in which he would temporarily stop breathing. Dr Potter said apnoea could simply be a sign a child was unwell or it could have a more specific reason. https://www.chesterstandard.co.uk/news/23366941.lucy-letby-unusual-presence-blood-throat-baby/

Alder Hey consultant anaesthetist Dr Francis Potter was asked to give evidence. Mr Myers said he had told the court his interest was paediatric intensive care, and he had experience with airway problem resolution. He said the intubation was managed with 'relative ease'. He said Dr Potter had been "surprised" there had been difficulties in intubating Child N as he said the Countess of Chester Hospital team was "pretty competent". He says Dr Bohin "comes to the rescue [of the prosecution]" by not agreeing with the opinion of Dr Potter. He said Dr Bohin said the drugs given to Child N would have reduced the swelling. He said it was a disagreement between the two prosecution witnesses. https://www.chesterstandard.co.uk/news/23621368.recap-lucy-letby-trial-june-29---defence-closing-speech/

Title: Mr

First name: Tony

Last name: Chambers

Gender: M

Group: Exec

Subgroup: Director

Role/job: Chief Executive

Employer/association: CoCH

Title: Ms

First name: Alison

Last name: Kelly

Gender: F

Group: Exec

Subgroup: Director

Role/job: Director of nursing/Deputy chief executive

Employer/association: CoCH

Title: Mr

First name: Stephen

Last name: Cross

Gender: M

Group: Exec

Subgroup: Director

Role/job: Director, Corporate affairs & legal services

Employer/association: CoCH

Prosecution side

Title: Mr

First name: Nick

Last name: Johnson

Gender: M

Group: Legal

Subgroup: Crown

Role/job: Prosecutor

Employer/association: Number 7 Harrington Street Chambers

Title: Mr

First name: Simon

Last name: Driver

Gender: M

Group: Legal

Subgroup: Crown

Role/job: Prosecutor

Employer/association: Number 7 Harrington Street Chambers

Title: Mr

First name: Philip

Last name: Astbury

Gender: M

Group: Legal

Subgroup: Crown

Role/job: Prosecutor

Employer/association: St Johns Buildings

Prosecution's "independent" expert witnesses

The prosecution in Lucy's case engaged seven medical specialists to provide expert (opinion based) testimony. For further discussion, see my latest post, https://www.chimpinvestor.com/post/independent-experts-yeah-right.

Title: Dr

First name: Dewi

Last name: Evans

Gender: M

Group: Medical

Subgroup: Doctor

Role/job: Consultant paediatrician (rtd)

Employer/association: Dewi Evans Paediatric Consulting Ltd (no website - https://find-and-update.company-information.service.gov.uk/company/07341254)

Commercial expert site: https://www.expertwitness.co.uk/expert/5763c7f0ca2f3af2228b5f41

Title: Dr

First name: Sandie

Last name: Bohin

Gender: F

Group: Medical

Subgroup: Doctor

Role/job: Consultant paediatrician

Employer/association: The Medical Specialist Group LLP (https://www.msg.gg/clinical-team/consultants/dr-sandie-bohin/)

Commercial expert site: https://paediatricexpert.com

Title: Prof

First name: Peter

Last name: Hindmarsh

Gender: M

Group: Medical

Subgroup: Doctor

Role/job: Endocrinologist (paediatric)

Employer/association: University College London Hospital (https://www.uclh.nhs.uk/our-services/find-consultant/professor-peter-hindmarsh )

Title: Dr

First name: Anna

Last name: Milan

Gender: F

Group: Medical

Subgroup: Doctor

Role/job: Clinical biochemist

Employer/association: Royal Liverpool and Broadgreen University Hospital NHS Trust (http://pathlabs.rlbuht.nhs.uk/ccfram.htm)

Title: Prof

First name: Sally

Last name: Kinsey

Gender: F

Group: Medical

Subgroup: Doctor

Role/job: Haematologist (paediatric)

Employer/association: Leeds Teaching Hospitals NHS Trust (https://www.leedsth.nhs.uk/a-z-of-services/leeds-cancer-centre/services/childrens-and-adolescent-oncology-and-haematology/services/haematology/) and St. James University Hospital (https://severe-chronic-neutropenia.org/en/partners/uk)

Title: Prof

First name: Owen

Last name: Arthurs

Gender: M

Group: Medical

Subgroup: Doctor

Role/job: Radiologist (paediatric)

Employer/association: Great Ormond Street Hospital (https://www.gosh.nhs.uk/our-people/staff-z/owen-arthurs/)

Title: Dr

First name: Andreas

Last name: Marnerides

Gender: M

Group: Medical

Subgroup: Doctor

Role/job: Patholigist (paediatric)

Employer/association: Guy's and St Thomas' NHS Foundation Trust (https://www.guysandstthomas.nhs.uk/our-consultants/andreas-marnerides)

General reference

He [Myers] says of Dr Andreas Marnerides, a pathologist, "is not a clinician, is not a paediatrician or a neonatologist", which "puts some limits [on his expertise]". He says his expertise is on what happens following a death, not in life. He says Dr Marnerides is "reliant" on the evidence of others, something which he agreed. He says he made a lot of reference to Dr Dewi Evans, and it is "too late in the day" to "insinuate" it is someone else. https://www.chesterstandard.co.uk/news/23613176.recap-lucy-letby-trial-june-26---defence-closing-speech/

Child A

Dr Marnerides said it appeared Child A, a twin boy, died as a result of an injection of air into his bloodstream. https://www.chesterstandard.co.uk/news/23422288.lucy-letby-baby-suffered-liver-injury-akin-road-traffic-collision/

The judge refers to expert witness Dr Andreas Marnerides' evidence. His expertise, the court is told, is on the pathology of conditions on those who had died. He said there was "no evidence of infection" or "any other abnormalities". He said he could see, from his study, "empty structures" of fat or air in Child A - after testing, he ruled out the former. He said he could see evidence of air in the brain when the baby was alive. The findings "could not be taken as absolute proof of air embolus". He said there was "no evidence of any natural cause of death", or any of natural disease. He took the view that Child A's death was of air embolus via injection. https://www.chesterstandard.co.uk/news/23628455.recap-lucy-letby-trial-july-3---judges-summing/

Child C

The note recorded bile on a blanket and black-stained fluid for Child C. He says nurse Yvonne Griffiths hasn't signed for a 9am reading on June 12, and something was entered for noon and not signed. He says bile on a blanket and black fluid is recorded in the nursing note at 6.30pm, but is not noted on the fluid chart.He says a radiograph was taken at 12.36pm. Dr Evans, Dr Bohin and Dr Andreas Marnerides had all regarded the image as a 'suspicious event' of harm. He says Letby was not on duty. Dr Anne Boothroyd recorded 'marked gaseous distention of the stomach'.Mr Myers says the jury should take this as "proof" the experts can "get it wrong".He says if this event happened when Letby was on duty, Letby would be accused of causing it.....He refers to the agreed evidence by the pathologist, Dr Kokai, who conducted the post-mortem examination, who recorded a 'distended colon' for Child C, which was not normal. He says Dr Marnerides refused to accept this evidence, who said the bowel was 'normal'. https://www.chesterstandard.co.uk/news/23615797.recap-lucy-letby-trial-june-27---defence-closing-speech/

Child C, a boy, was subjected to an excessive infusion/injection of air into his nasogastric tube, he [,Dr Marnerides,] said. https://www.chesterstandard.co.uk/news/23422288.lucy-letby-baby-suffered-liver-injury-akin-road-traffic-collision/

Mr Johnson says the jury know, as a fact, from Dr Andreas Marnerides, that Child C did not have a problem with his gut, as there was no sign of infection or sepsis. There was no evidence of Child C having had an obstruction in his bowel....Dr Marnerides said there was "nothing unusual" about Child C's bowel. He concluded Child C died "with pneumonia not from pneumonia" and the gas in the bowel could not be explained by infection or an abonormality in the bowel. He said "air must have been injected into the nasogastric tube", splinting the diaphragm, which would have compromised Child C's breathing and killed him. He added: "I have never in the past 10 years, come across even a suggestion that 'CPAP belly' would lead to the deterioration of a baby, let alone this gastric distention that would lead to [a baby's death]." https://www.chesterstandard.co.uk/news/23603440.recap-lucy-letby-trial-june-21--prosecution-closing-speech/

Dr George Kokai carried out a post-mortem examination for Child C. He noted a distended colon, which Dr Marnerides said was "not an abnormality". He said the potential complication was a twisted colon that would lead to "obvious" symptoms of pain. There was evidence of "acute pneumonia". Dr Marnerides said one could die of pneumonia or with penumonia. He said the former was plausible, but upon hearing further clinical evidence, he reviewed his opinion. He said babies dying of penumonia experience gradual deterioration, which was not the case here. He said he revisited the cause of death, viewing images of a distended stomach, and no evidence of NEC. Prof Arthurs said the small bowel was dilated. Dr Marnerides observed a dilated stomach and bowel, and noted Child C had been off CPAP for over 12 hours. No air had been obtained from aspirates before the collapse. He had never known CPAP belly being the cause of an arrest in a baby in his years of experience. He said, in his opinion, the cause of Child C's collapse was of excessive air administered into the stomach via the naso-gastric tube. https://www.chesterstandard.co.uk/news/23628455.recap-lucy-letby-trial-july-3---judges-summing/

The judge refers to the case of Child C. He says medical experts found it difficult to conclude the cause of death, but Dr Marnerides said it was air administered into his stomach via the naso-gastric tube. Letby said she did nothing harmful to Child C, and a cause such as a gastrointestinal blockage cannot be excluded, that Child C should have been treated at a tertiary unit, and there was a failure to react to bile aspirates, vomiting, and an overall lack of care. https://www.chesterstandard.co.uk/news/23628455.recap-lucy-letby-trial-july-3---judges-summing/

Child D

The “likely explanation” for the death of Child D, a girl, was an air embolism into her circulation. [Dr Marnerides] https://www.chesterstandard.co.uk/news/23422288.lucy-letby-baby-suffered-liver-injury-akin-road-traffic-collision/

Another medical expert, Dr Marnerides, had ruled out sepsis, and concluded Child D was killed by an air embolus.  https://www.chesterstandard.co.uk/news/23603440.recap-lucy-letby-trial-june-21--prosecution-closing-speech/

Mr Myers refers to the pathologist's report for Child D, recording damaged lungs, "continuing respiratory problems". Presence of infection is "not ruled out" following negative microbiology tests, as Child D had been on antibiotics. Mr Myers said despite that, Dr Marnerides "preferred" air embolus as a conclusion. He said he had taken into account clinicians' views of how well Child D was doing. Mr Myers says Child D was not doing well on respiration. https://www.chesterstandard.co.uk/news/23615797.recap-lucy-letby-trial-june-27---defence-closing-speech/

Dr Andreas Marnerides said pneumonia was likely to be present at birth for Child D. Professor Arthurs talked of a 'black line' in front of the spine indicating gas in the great vessels, which was "unusual" in children who had died without an explanation. It was present in "two other children", one of whom was Child A. There was "more air" in Child D than Child A. One explanation was someone was injecting air into the child, and the radiograph images were consistent with, but not diagnostic of, externally administered air to Child D. Dr Marnerides said the presence of air in such a vessel was "significant". He said from a pathology point of view, air embolus could not be proved. He said there was "no other natural disease" that could explain Child D's death. He said in his opinion, Child D died with, not from, pneumonia. He concluded the 'likely explanation' was air embolus. https://www.chesterstandard.co.uk/news/23631372.recap-lucy-letby-trial-july-4---judges-summing/

Child E

He [Dr Marnerides] told the court he could no offer no opinion on the death of Child E, a twin boy, because no post-mortem examination took place. https://www.chesterstandard.co.uk/news/23422288.lucy-letby-baby-suffered-liver-injury-akin-road-traffic-collision/

Child I

Another girl, Child I, received an excessive injection of air into her stomach, he [Dr Marnerides] said. https://www.chesterstandard.co.uk/news/23422288.lucy-letby-baby-suffered-liver-injury-akin-road-traffic-collision/

Dr Marnerides said at the time of Child I's death, she had no acute illnesses or abnormalities in the bowel, other than presence of air. The presence of gas had "no pathological cause". He said the collapses were air administered from the NG Tube. https://www.chesterstandard.co.uk/news/23606159.recap-lucy-letby-trial-june-22--prosecution-closing-speech/

Dr Marnerides said Child I did not have NEC. He was "very sceptical" that Child I died of natural causes. He said the collapses were more likely to be excessive air administered to the stomach, via the NGT.  https://www.chesterstandard.co.uk/news/23634101.recap-lucy-letby-trial-july-5---judges-summing/

Child O

Dr Andreas Marnerides, the reviewing pathologist, thought that the liver injuries were most likely the result of impact type trauma and not the result of CPR….He certified the cause of death to be “Inflicted traumatic injury to the liver and profound gastric and intestinal distension following acute excessive injection or infusion of air via a naso-gastric tube” and air embolus. https://www.chesterstandard.co.uk/news/23035356.recap-prosecution-opens-trial-lucy-letby-accused-countess-chester-hospital-baby-murders/

Paediatric pathology expert Dr Andreas Marnerides had told jurors he concluded Child O died because of “inflicted traumatic injury” to the liver, as well as receiving fatal injections of air into the stomach and bloodstream....“I have never seen this type of injury in the context of CPR so I would say the force required would be of the magnitude of that generated by a baby jumping on a trampoline and falling.” He agreed that smaller internal bruising to the liver sustained by Child O’s triplet brother Child P – who Letby is alleged to have murdered the next day – could be capable of being caused by CPR. But asked if “rigorous” chest compressions could be the cause of the internal bruising in Child O’s case, Dr Marnerides said: “I don’t think so, no." “This is a huge area of bruising for a liver of this size. This is not something you see in CPR.” Mr Myers said: “So you don’t accept the proposition that forceful CPR could cause this injury in general terms, do you agree it cannot be categorically excluded as a possibility?” Dr Marnerides replied: “We are not discussing possibilities here, we are discussing probabilities. “When you refer to possibilities, I am thinking for example of somebody walking in the middle of the Sahara desert found dead with a pot and head trauma. “It is possible the pot fell from the air from a helicopter. The question is ‘is it probable?’ and I don’t think we can say it is probable.” Mr Myers asked: “Is it possible in your opinion for at least some of what we see in the damage to the liver arising from the insertion of a cannula?” The consultant said: “I would consider it extremely unlikely. I would expect some kind of perforation injury.” https://www.chesterstandard.co.uk/news/23424649.letby-trial-forceful-cpr-not-cause-babys-liver-damage/

Jurors were shown post-mortem examination photographs which showed two separate sites of bruising, as well as areas of a blood clot. Prosecutor Nick Johnson KC asked the consultant: “How does that injury come to be in a child of (Child O’s) age?”...Mr Johnson said: “Looking at this sequence of photographs, can you rule out the possibility that these injuries were caused by CPR?” Dr Marnerides said: “I cannot convince myself that in the setting of a neonatal unit this would be a reasonable proposition to explain this. I don’t think CPR can produce this extensive injury to a liver.”....Dr Marnerides said: “In my view, the cause of death was inflicted traumatic injury to the liver, profound gastric and intestinal distension following acute excessive injection/infusion of air via a naso-gastric tube and air embolism due to administration into a venous line.” https://www.chesterstandard.co.uk/news/23422288.lucy-letby-baby-suffered-liver-injury-akin-road-traffic-collision/

During Child O's resuscitation in his final collapse, a doctor had said efforts were made to decompress Child O's abdomen. In cross-examination it had been suggested this was the cause of the liver injury. Dr Brearey and Dr Marnerides had rejected this, Mr Johnson tells the court. https://www.chesterstandard.co.uk/news/23600333.recap-lucy-letby-trial-june-20--prosecution-closing-speech/

Dr George Kokai carried out a post-mortem examination. Dr Andreas Marnerides reviewed, and said injuries to the liver were the result of impact trauma. He said during treatment, small bruises could be caused to the surface of the liver, and would not be extensive. He says the liver is not in an area where CPR is applied. He has only seen this kind of injury to the liver before in children, not babies, from accidents involving bicycles. He did not think CPR could produce this extensive injury to the liver, and has never heard of this sort being accepted as such. He also found internal gastric distention, and concluded there had been an air embolus. https://www.chesterstandard.co.uk/news/23636819.recap-lucy-letby-trial-july-6---judges-summing/

Earlier, Dr Marnerides said the most likely explanation for the death of Child P was excessive air injected via a nasogastric tube into his stomach. https://www.chesterstandard.co.uk/news/23424649.letby-trial-forceful-cpr-not-cause-babys-liver-damage/

Child P

Dr Marnerides said he had no evidence to indicate a natural disease that would account for Child P's death. He thought small haematomas to the liver were potentially the result of CPR, or as a result of prematurity, and did not have enough to say it was an impact injury. He said there was no clinical evidence for a natural cause. He said having considered other accounts, he concluded there was gastric distention caused by excessive air injected into the stomach. https://www.chesterstandard.co.uk/news/23636819.recap-lucy-letby-trial-july-6---judges-summing/

CoCH's medical directors

Title: Dr

First name: Ian

Last name: Harvey

Gender: M

Group: Medical

Subgroup: Doctor

Role/job: Medical Director

Employer/association: CoCH

Title: Dr

First name: Nigel

Last name: Scawn

Gender: M

Group: Medical

Subgroup: Doctor

Role/job: Executive medical director

Employer/association: CoCH

CoCH's consultant paediatricians

Title: Dr

First name: Stephen

Last name: Brearey

Gender: M

Group: Medical

Subgroup: Doctor

Role/job: Consultant paediatrician

Employer/association: CoCH

Title: Dr

First name: John

Last name: Gibbs

Gender: M

Group: Medical

Subgroup: Doctor

Role/job: Consultant paediatrician

Employer/association: CoCH

Title: Dr

First name: Ravi

Last name: Jayaram

Gender: M

Group: Medical

Subgroup: Doctor

Role/job: Consultant paediatrician

Employer/association: CoCH

Title: Dr (cannot be named for legal reasons)

First name:

Last name: B

Gender: F

Group: Medical

Subgroup: Doctor

Role/job: Consultant paediatrician

Employer/association: CoCH

Title: Dr

First name: Satyanarayana

Last name: Saladi

Gender: M

Group: Medical

Subgroup: Doctor

Role/job: Consultant paediatrician

Employer/association: CoCH

Title: Dr

First name: Sudeshna

Last name: Bhowmik

Gender: F

Group: Medical

Subgroup: Doctor

Role/job: Consultant paediatrician

Employer/association: CoCH

Title: Dr

First name: Elizabeth

Last name: Newby

Gender: F

Group: Medical

Subgroup: Doctor

Role/job: Consultant paediatrician

Employer/association: CoCH

CoCH's radiologists

Title: Dr

First name: Amer

Last name: Rehman

Gender: M

Group: Medical

Subgroup: Doctor

Role/job: Consultant radiologist

Employer/association: CoCH

Title: Dr

First name: Ann

Last name: Boothroyd

Gender: F

Group: Medical

Subgroup: Doctor

Role/job: Radiologist (paediatric)

Employer/association: CoCH

Title: Dr

First name: Stavros

Last name: Stivaros

Gender: M

Group: Medical

Subgroup: Doctor

Role/job: Radiologist (paediatric neuroradiologist)

Employer/association: CoCH

CoCH's paediatric registrars

Title: Dr (cannot be named for legal reasons)

First name:

Last name: A

Gender: M

Group: Medical

Subgroup: Doctor

Role/job: Registrar

Employer/association: CoCH

Title: Dr

First name: Gail

Last name: Beech

Gender: F

Group: Medical

Subgroup: Doctor

Role/job: Registrar

Employer/association: CoCH

Title: Dr

First name: Andrew

Last name: Brunton

Gender: M

Group: Medical

Subgroup: Doctor

Role/job: Registrar (specialist trainee)

Employer/association: CoCH

Title: Dr

First name: Rachel

Last name: Chang

Gender: F

Group: Medical

Subgroup: Doctor

Role/job: Registrar (paediatric)

Employer/association: CoCH

Title: Dr

First name: Katarzyna

Last name: Cooke

Gender: F

Group: Medical

Subgroup: Doctor

Role/job: Registrar

Employer/association: CoCH

Title: Dr

First name: Katherine

Last name: Davis

Gender: F

Group: Medical

Subgroup: Doctor

Role/job: Registrar (paediatric)

Employer/association: CoCH

Title: Dr

First name: Peter

Last name: Fielding

Gender: M

Group: Medical

Subgroup: Doctor

Role/job: Registrar (paediatric)

Employer/association: CoCH

Title: Dr

First name: Jonathan

Last name: Ford

Gender: M

Group: Medical

Subgroup: Doctor

Role/job: Registrar

Employer/association: CoCH

Title: Dr

First name: David

Last name: Harkness

Gender: M

Group: Medical

Subgroup: Doctor

Role/job: Registrar

Employer/association: CoCH

Title: Dr

First name: Rachel

Last name: Lambie

Gender: F

Group: Medical

Subgroup: Doctor

Role/job: Registrar

Employer/association: CoCH

Title: Dr

First name: Jennifer

Last name: Loughnane

Gender: F

Group: Medical

Subgroup: Doctor

Role/job: Registrar

Employer/association: CoCH

Title: Dr

First name: Huw

Last name: Mayberry

Gender: M

Group: Medical

Subgroup: Doctor

Role/job: Registrar (paediatric)

Employer/association: CoCH

Title: Dr

First name: Matthew

Last name: Neame

Gender: M

Group: Medical

Subgroup: Doctor

Role/job: Registrar

Employer/association: CoCH

Title: Dr

First name: Sally

Last name: Ogden

Gender: F

Group: Medical

Subgroup: Doctor

Role/job: Registrar (paediatric)

Employer/association: CoCH

Title: Dr

First name: Sarah

Last name: Rylance

Gender: F

Group: Medical

Subgroup: Doctor

Role/job: Registrar

Employer/association: CoCH

Title: Dr

First name: James

Last name: Smith

Gender: M

Group: Medical

Subgroup: Doctor

Role/job: Registrar (specialist)

Employer/association: CoCH

Title: Dr

First name: Anthony

Last name: Ukoh

Gender: M

Group: Medical

Subgroup: Doctor

Role/job: Registrar

Employer/association: CoCH

Title: Dr

First name: Alison

Last name: Ventress

Gender: F

Group: Medical

Subgroup: Doctor

Role/job: Registrar

Employer/association: CoCH

CoCH's junior doctors

Title: Dr

First name: Lucy

Last name: Beebe

Gender: F

Group: Medical

Subgroup: Doctor

Role/job: Junior doctor

Employer/association: CoCH

Title: Dr

First name: Jessica

Last name: Burke

Gender: F

Group: Medical

Subgroup: Doctor

Role/job: Junior doctor

Employer/association: CoCH

Title: Dr

First name: Emily

Last name: Thomas

Gender: F

Group: Medical

Subgroup: Doctor

Role/job: Junior doctor

Employer/association: CoCH

Title: Dr

First name: Christopher

Last name: Wood

Gender: M

Group: Medical

Subgroup: Doctor

Role/job: Junior doctor

Employer/association: CoCH

Other medical/scientific

Title: Mr

First name: Ian

Last name: Allen

Gender: M

Group: Medical

Subgroup: Pharmacist

Role/job: Pharmacist

Employer/association: CoCH

Title: Dr

First name: Gwen

Last name: Wark

Gender: F

Group: Medical

Subgroup: Biochemist

Role/job: Director

Employer/association: Guildford RSCH Peptide Hormone Laboratory

Senior nursing staff

Title: Ms

First name: Karen

Last name: Rees

Gender: F

Group: Medical

Subgroup: Nurse

Role/job: Nursing chief

Employer/association: CoCH

Title: Ms

First name: Karen

Last name: Townsend

Gender: F

Group: Medical

Subgroup: Nurse

Role/job: Nursing chief

Employer/association: CoCH

Title: Ms

First name: Eirian

Last name: Lloyd Powell

Gender: F

Group: Medical

Subgroup: Nurse

Role/job: Neonatal Unit Manager

Employer/association: CoCH

Title: Ms

First name: Susan

Last name: Brooks

Gender: F

Group: Medical

Subgroup: Nurse

Role/job: Midwife

Employer/association: CoCH

Nurses

An undetermined number of nurses who were granted anonymity in order to secure their appearance and testimony at trial

Group: Medical

Subgroup: Nurse

Role/job: Nurse

Employer/association: CoCH

Title: Ms

First name: Caroline

Last name: Bennion

Gender: F

Group: Medical

Subgroup: Nurse

Role/job: Nurse

Employer/association: CoCH

Title: Ms

First name: Kate

Last name: Bissell

Gender: F

Group: Medical

Subgroup: Nurse

Role/job: Nurse

Employer/association: CoCH

Title: Ms

First name: Vicky

Last name: Blamire

Gender: F

Group: Medical

Subgroup: Nurse

Role/job: Nurse

Employer/association: CoCH

Title: Mr

First name: Christopher

Last name: Booth

Gender: M

Group: Medical

Subgroup: Nurse

Role/job: Nurse

Employer/association: CoCH

Title: Ms

First name: Bernadette

Last name: Butterworth

Gender: F

Group: Medical

Subgroup: Nurse

Role/job: Nurse

Employer/association: CoCH

Title: Ms

First name: Amy

Last name: Davies

Gender: F

Group: Medical

Subgroup: Nurse

Role/job: Nurse

Employer/association: CoCH

Title: Ms

First name: Nicola

Last name: Dennison

Gender: F

Group: Medical

Subgroup: Nurse

Role/job: Nurse

Employer/association: CoCH

Title: Ms

First name: Tanya

Last name: Downes

Gender: F

Group: Medical

Subgroup: Nurse

Role/job: Nurse

Employer/association: CoCH

Title: Ms

First name: Laura

Last name: Eagles

Gender: F

Group: Medical

Subgroup: Nurse

Role/job: Nurse

Employer/association: CoCH

Title: Ms

First name: Sophie

Last name: Ellis

Gender: F

Group: Medical

Subgroup: Nurse

Role/job: Nurse

Employer/association: CoCH

Title: Ms

First name: Mary

Last name: Griffiths

Gender: F

Group: Medical

Subgroup: Nurse

Role/job: Nurse

Employer/association: CoCH

Title: Ms

First name: Yvonne

Last name: Griffiths

Gender: F

Group: Medical

Subgroup: Nurse

Role/job: Nurse

Employer/association: CoCH

Title: Ms

First name: Ashleigh

Last name: Hudson

Gender: F

Group: Medical

Subgroup: Nurse

Role/job: Nurse

Employer/association: CoCH

Title: Ms

First name: Tracey

Last name: Jones

Gender: F

Group: Medical

Subgroup: Nurse

Role/job: Nurse

Employer/association: CoCH

Title: Ms

First name: Jennifer

Last name: Jones-Key

Gender: F

Group: Medical

Subgroup: Nurse

Role/job: Nurse

Employer/association: CoCH

Title: Ms

First name: Minna

Last name: Lappalainen

Gender: F

Group: Medical

Subgroup: Nurse

Role/job: Nurse

Employer/association: CoCH

Title: Ms

First name: Elizabeth

Last name: Marshall

Gender: F

Group: Medical

Subgroup: Nurse

Role/job: Nurse

Employer/association: CoCH

Title: Ms

First name: Elizabeth

Last name: Morgan

Gender: F

Group: Medical

Subgroup: Nurse

Role/job: Nurse

Employer/association: CoCH

Title: Ms

First name: Rebecca

Last name: Morgan

Gender: F

Group: Medical

Subgroup: Nurse

Role/job: Nurse

Employer/association: CoCH

Title: Ms

First name: Samantha

Last name: O'Brien

Gender: F

Group: Medical

Subgroup: Nurse

Role/job: Nurse

Employer/association: CoCH

Title: Ms

First name: Caroline

Last name: Oakley

Gender: F

Group: Medical

Subgroup: Nurse

Role/job: Nurse

Employer/association: CoCH

Title: Ms

First name: Kathryn

Last name: Percival-Ward/Percival-Calderbank

Gender: F

Group: Medical

Subgroup: Nurse

Role/job: Nurse

Employer/association: CoCH

Title: Ms

First name: Belinda

Last name: Simcock

Gender: F

Group: Medical

Subgroup: Nurse

Role/job: Nurse

Employer/association: CoCH

Title: Ms

First name: Melanie

Last name: Taylor

Gender: F

Group: Medical

Subgroup: Nurse

Role/job: Nurse

Employer/association: CoCH

Title: Ms

First name: Valerie

Last name: Thomas

Gender: F

Group: Medical

Subgroup: Nurse

Role/job: Nurse

Employer/association: CoCH

Title: Ms

First name: Shelley

Last name: Tomlins

Gender: F

Group: Medical

Subgroup: Nurse

Role/job: Nurse

Employer/association: CoCH

Title: Ms

First name: Lisa

Last name: Walker

Gender: F

Group: Medical

Subgroup: Nurse

Role/job: Nurse

Employer/association: CoCH

Title: Ms

First name: Joanne

Last name: Williams

Gender: F

Group: Medical

Subgroup: Nurse

Role/job: Nurse

Employer/association: CoCH

Title: Ms

First name: Belinda

Last name: Williamson

Gender: F

Group: Medical

Subgroup: Nurse

Role/job: Nurse

Employer/association: CoCH

Police

Title: Mr

First name: David

Last name: Keane

Gender: M

Group: Legal

Subgroup: Police

Role/job: Police and crime commissioner, Cheshire

Employer/association: Cheshire Police

Title: Mr

First name: Nigel

Last name: Wenham

Gender: M

Group: Legal

Subgroup: Police

Role/job: DCS

Employer/association: Cheshire Police

Title: Mr

First name: Paul

Last name: Hughes

Gender: M

Group: Legal

Subgroup: Police

Role/job: DS

Employer/association: Cheshire Police

Title: Ms

First name: Lucy

Last name: Kennedy

Gender: F

Group: Legal

Subgroup: Police

Role/job: DS

Employer/association: Cheshire Police

Title: Ms

First name: Nicola

Last name: Evans

Gender: F

Group: Legal

Subgroup: Police

Role/job: DCI

Employer/association: Cheshire Police

Title: Ms

First name: Claire

Last name: Hocknell

Gender: F

Group: Legal

Subgroup: Police

Role/job: Intelligence analyst

Employer/association: Cheshire Police

Title: Mr

First name: Darren

Last name: Riley

Gender: M

Group: Legal

Subgroup: Police

Role/job: Civilain Investigator

Employer/association: Cheshire Police

Other CoCH executive

Title: Dr

First name: Susan

Last name: Gilby

Gender: F

Group: Exec

Subgroup: Exec

Role/job: Chief Executive (2018 - 2022)

Employer/association: CoCH

If you would like to post comments and replies about this post, please do so on the Forum by clicking here (opens in new window so this blog post page stays open for you to view). The Forum is visible only to members which makes it preferable to the Blog for members’ conversations.

The views expressed in this communication are those of Peter Elston at the time of writing and are subject to change without notice. They do not constitute investment advice and whilst all reasonable efforts have been used to ensure the accuracy of the information contained in this communication, the reliability, completeness or accuracy of the content cannot be guaranteed. This communication provides information for professional use only and should not be relied upon by retail investors as the sole basis for investment.

© Chimp Investor Ltd

https://twitter.com/PaulBrandITV/status/1702707099354939527

Background on a selection of the hundreds of wrongful convictions in the UK over the years

In Wix there are two types of posts: Blog posts and Forum posts (this is a Blog post). I will disable comments on Blog posts, but you can still post comments and replies to comments on a specially created post in the Forum (moreover, comments and replies in Forum posts are only visible to members). To post comments and join the conversation about this post or Lucy's case in general, please click here to go to the Forum (opens in new window so this blog post page stays open for you to view).

Firstly, if you are someone who was or is wrongly convicted (or a family member thereof) and your case is not mentioned in this blog post, I apologise. It would have been impossible to write about all the hundreds of wrongful convictions (and I may not know about all cases of suspected wrongful conviction). If you would like your case to be included in this post please email me on peter@chimpinvestor.com.

This blog post is more for reference than it is an article (I will be writing a proper article soon about miscarriages and what the future path for Lucy might be based on other cases). However, if you read through the cases you should get a sense of how big a problem wrongful conviction is and has been in this country. You might also get a sense that although we are good at banging people up who are innocent, we do (eventually) exonerate many or perhaps even most of them. This latter process however it seems could do with improving (many/most is not good enough) and speeding up, and obviously there are poor practices that lead to people being wrongfully accused or convicted in the first place.

One fabulous resource I came across is The Miscarriages of Justice Registry at the University of Exeter. The registry is "an interdisciplinary research group specialising in behavioural and data science research, and applying this research to the legal system and in legal arguments." It contains details of over 300 people who have been acquitted following successful appeals and can be found here: https://evidencebasedjustice.exeter.ac.uk/miscarriages-of-justice-registry/the-cases/case-search/.

In addition to the database, it has many other great resources. The four "issues wikis" below are particularly interesting.

Issue Wiki: False confession

https://evidencebasedjustice.exeter.ac.uk/miscarriages-of-justice-registry/the-issues/false-confession/

Issue Wiki: Witness evidence

https://evidencebasedjustice.exeter.ac.uk/miscarriages-of-justice-registry/the-issues/eyewitness-id/

Issue Wiki: Disclosure

https://evidencebasedjustice.exeter.ac.uk/miscarriages-of-justice-registry/the-issues/misconduct-disclosure/

Issue Wiki: Forensic evidence

https://evidencebasedjustice.exeter.ac.uk/miscarriages-of-justice-registry/the-issues/forensic-evidence/

Actual wrongful convictions/accusations (notable)

Sally Clark

"Clark was convicted in November 1999. The convictions were upheld on appeal in October 2000, but overturned in a second appeal in January 2003, after it emerged that Alan Williams, the prosecution forensic pathologist who examined both babies, had failed to disclose microbiological reports that suggested the second of her sons had died of natural causes." (from https://en.wikipedia.org/wiki/Sally_Clark)

Also: https://www.manchestereveningnews.co.uk/news/greater-manchester-news/sally-clark-child-death-case-1111844

Donna Anthony

"Following the overturning of Angela Cannings's conviction, twenty-eight cases, including that of Donna Anthony, were referred to the Criminal Cases Review Commission (CCRC), and Anthony was freed in April 2005." (from https://en.wikipedia.org/wiki/Donna_Anthony)

Also: http://news.bbc.co.uk/1/hi/england/somerset/4431851.stm

Victor Nealon

"The wrongful imprisonment of Victor Nealon occurred in 1996 when the British postman Victor Nealon was mistakenly convicted of attempted rape. He was released in 2013 after spending 17 years in jail, 10 years more than his recommended tariff, because he continued to protest his innocence." (from https://en.wikipedia.org/wiki/Victor_Nealon)

Siôn Jenkins

"Billie-Jo Margaret Jenkins (29 March 1983 – 15 February 1997) was an English girl who was murdered in Hastings, East Sussex in February 1997. The case gained widespread media attention and remains unsolved. Her foster father, Siôn Jenkins, was originally convicted for the crime, but after two retrials in which the jury was unable to reach a verdict he was formally acquitted. He has been denied compensation on the grounds that there is no evidence to prove his innocence." (from https://en.wikipedia.org/wiki/Murder_of_Billie-Jo_Jenkins)

Angela Cannings

"Angela Cannings was wrongfully convicted and sentenced to life imprisonment in the UK in 2002 for the murder of her seven-week-old son, Jason, who died in 1991, and of her 18-week-old son Matthew, who died in 1999. Her first child, Gemma, died of Sudden Infant Death Syndrome (SIDS) in 1989 at the age of 13 weeks, although she was never charged in connection with Gemma's death. Her conviction was based on claims that she had smothered the children, but was overturned as unsafe by the Court of Appeal on 10 December 2003. Cannings was convicted after the involvement in her case of Professor Sir Roy Meadow, a paediatrician who was later struck off, then reinstated, by the General Medical Council." (from https://en.wikipedia.org/wiki/Angela_Cannings)

John Corcoran

"A few days after Gorrie's murder, unemployed 21-year-old John Anthony Mark Corcoran of Warren Park, Havant, was questioned about the murder....Corcoran, of Plumley Walk in Havant, was tried and found guilty of Gorrie's murder in December 1999....In January 2003, Corcoran had his conviction for the murder overturned on appeal. The grounds were that the judge had misdirected the jury in his summing up." (from https://en.wikipedia.org/wiki/Murder_of_Helen_Gorrie)

An unknown or unpublished number of sub-postmasters

"The British Post Office scandal is a miscarriage of justice involving the wrongful civil and criminal prosecutions of an unknown or unpublished number of sub-postmasters (SPMs) for theft, false accounting and/or fraud. The cases constitute the most widespread miscarriage of justice in British legal history, spanning a period of over twenty years; aspects of the scandal remain unresolved." (from https://en.wikipedia.org/wiki/British_Post_Office_scandal)

Barry George

"Barry Michael George (born 15 April 1960) is an Englishman who was found guilty of the murder of English television presenter Jill Dando and whose conviction was overturned on appeal." (from https://en.wikipedia.org/wiki/Barry_George)

Sam Hallam

"Sam Hallam (born 1987), from Hoxton, London, is one of the youngest victims of a UK miscarriage of justice after an appeal court quashed his murder conviction in 2012." (from https://en.wikipedia.org/wiki/Sam_Hallam)

Ched Evans

"R v Evans and McDonald was the prosecution of two footballers, Ched Evans and Clayton McDonald, who were accused of the rape of a woman. On 20 April 2012, Evans was convicted and sentenced to five years imprisonment. McDonald was acquitted. Several people were later fined after naming the woman on Twitter and other social media websites." (from https://en.wikipedia.org/wiki/R_v_Evans_and_McDonald)

Also: https://www.bbc.co.uk/news/uk-wales-36099522

Andrew Malkinson

"Andrew Malkinson (born 23 January 1966) is a British man who was wrongfully convicted and jailed in 2003 for the rape of a 33-year-old woman in Salford, Greater Manchester...Malkinson made another application to the CCRC in 2021, and, in 2022, a man was arrested in connection with the original crime. The CCRC referred the case for appeal, and the conviction was quashed by the Court of Appeal in July 2023, using evidence from the 2007 re-testing of samples, which identified a man who had subsequently been placed in the National DNA Database." (from https://en.wikipedia.org/wiki/Wrongful_conviction_of_Andrew_Malkinson)

Barri White and Keith Hyatt

"Barri White and Keith Hyatt were jailed in 2002 [for the murder of Rachel Manning] and had their convictions quashed in 2007." (from https://www.bbc.co.uk/news/uk-england-beds-bucks-herts-24284921)

John Kamara

"John Kamara was convicted of the brutal 1981 murder of betting shop manager John Suffield, who was tied to a chair and stabbed 19 times in a botched robbery on Lodge Lane, Toxteth. However in 2001, he was freed by the Court of Appeal after the conviction was declared unsafe." (from https://www.liverpoolecho.co.uk/news/liverpool-news/innocent-man-imprisoned-20-years-27505577)

Patryk Pachecka and Grzegorz Szal

"Patryk Pachecka and Grzegorz Szal, have been unanimously acquitted of Murder and Manslaughter after a trial at the Central Criminal Court...Both men were convicted of Murder in December 2017 and sentenced to life imprisonment with a minimum term of 18 years, while the killer escaped responsibility. Their convictions were overturned in January 2021." (from https://www.libertaschambers.com/media-hub/murder-conviction-quashed-for-patrtk-pachecka/ )

Trupti Patel (wrongly accused/acquitted)

"Trupti Patel is a qualified pharmacist from Maidenhead in Berkshire, England, who was acquitted in 2003 of murdering three of her children, Amar (5 September 1997 – 10 December 1997), Jamie (21 June 1999 – 6 July 1999), and Mia (14 May 2001 – 5 June 2001)." (from https://en.wikipedia.org/wiki/Trupti_Patel)

Other notable

Suzanne Holdsworth

Winston Silcott

Judith Ward

Derek Bentley

Stephen Downing

Stefan Kiszko

(from https://www.theguardian.com/uk/2009/mar/18/miscarriages-justice-history)

The Bridgewater Four

The Birmingham Six

The Stockwell Six

The Guildford Four and Maguire Seven

(from https://www.crimeandinvestigation.co.uk/shows/british-injustice-with-raphael-rowe/innocent-men-four-wrongful-convictions-from-the-uk )

Suspected wrongful convictions in UK (those who remain incarcerated)

Colin Norris

"Colin was a nurse in Leeds when a non-diabetic patient fell into a hypoglycaemic coma. As one of the staff on duty that night, Colin was questioned and eventually convicted on four counts of murder and one of attempted murder, of elderly hospital patients. Inside Justice first became involved with this case when the highly experienced investigative journalist Bob Woffinden brought Colin to the attention of our Advisory Panel. His case has been with the CCRC since 2011. In collaboration with the BBC, a documentary was made which you can view here BBC Panorama: The Innocent Serial Killer. You can also listen to a Radio Leeds interview with Paul May." (from https://www.insidejustice.co.uk/about-us/our-cases.php)

Also: https://www.theguardian.com/law/2021/feb/12/colin-norris-serial-killer-nurse-conviction-court-of-appeal

Roger Kearney

"Roger was convicted of murdering his lover Paula Poolton after her body was found in the boot of her car in 2010. The prosecution described a high level of interaction between victim and attacker yet no forensic evidence was found to incriminate Roger. In 2016 the Advisory Panel of Inside Justice, investigating Roger’s case, was filmed by the BBC,. The resulting two-part documentary Conviction: Murder at the Station can be viewed here and here. Today, cutting edge forensic techniques could be used to identify the killer in this case but Hampshire Constabulary has lost, destroyed and contaminated key exhibits contrary to statutory guidance. Doing so has denied Roger Kearney the chance to prove his innocence.

CCTV footage, which still exists, could be subjected to new analysis which could form the basis of a new appeal but Hampshire Constabulary has repeatedly refused Inside Justice access to this material." (from https://www.insidejustice.co.uk/about-us/our-cases.php)

Kevin Nunn

"Kevin was convicted of the murder of his girlfriend Dawn Walker in 2006 and sentenced to life imprisonment with a minimum tariff of 22 years. Although the crime scene was rich in forensic opportunity, nothing implicated Kevin. He maintains his innocence and has taken his case to the Court of Appeal, the High Court, the Supreme Court and the CCRC. Kevin came to us in 2014 for help in the final lead-up to the Supreme Court. Efforts to persuade the CCRC to finish the forensic investigation of Kevin’s case continue and Inside Justice is working with others to develop a national protocol for post-conviction disclosure of evidence. This, in the interests of justice, is vital." (from https://www.insidejustice.co.uk/about-us/our-cases.php)

David Reece

"Convicted by a 10-2 majority in March 2018 as part of a conspiracy to import and supply Class A drugs, David Reece has consistently maintained his innocence....We have made a short film about David’s day in court. Our belief remains firm that there is something wholly wrong with David's conviction and we must now do everything we possibly can, with all the expertise Inside Justice has, to find that one thing that could get us back to the Court of Appeal, but we need your help." (from https://www.insidejustice.co.uk/about-us/our-cases.php)

Also: Read the Judgment handed down by the Court of Appeal (Criminal Division) and Inside Time article, February 3rd 2020

Michael Stone

"Michael Stone (born Michael John Goodban in 1960) is a British man who was convicted of the 1996 murders of Lin and Megan Russell and the attempted murder of Josie Russell, and who is a suspected serial killer. He was sentenced to three life sentences with a tariff of 25 years for the Russell killings. Stone maintains his innocence and continues to contest his conviction. His legal team argues that the serial killer Levi Bellfield could possibly be the true perpetrator of the attack." (from https://en.wikipedia.org/wiki/Michael_Stone_(criminal))

Also: https://www.bbc.co.uk/news/uk-wales-42144445

Ben Geen

"Fresh evidence has emerged that it is claimed undermines the conviction of a nurse jailed for life 17 years ago for murdering two of his patients and poisoning 15 others. Benjamin Geen, then 25, was given a minimum 30-year sentence in 2006 largely on the basis that he had been on shift at the time of an “unusual” number of cases of respiratory arrest in the emergency ward of Horton general hospital in Banbury, Oxfordshire." (from https://www.theguardian.com/law/2023/jul/31/new-evidence-claimed-to-undermine-nurse-benjamin-geen-conviction-for-killing-patients)

Also: https://bengeen.wordpress.com

Omar Benguit

"On Friday 12 July 2002, at around 2:50 am, 26-year-old Jong-Ok Shin was murdered on Malmesbury Park Road, Richmond Park, Bournemouth...Omar Benguit was arrested on 22 August, almost six weeks after the murder, after being named as the killer by a police informant. Beverly Brown, a heroin addict and prostitute, claimed that she was with Benguit and two other male heroin addicts on the night of the murder...It was also argued by the defence that an Italian man, Danilo Restivo, convicted of two other murders who was living in the area at the time, was a more likely suspect for the crime. It was suggested that the murder of Shin resembled similarities between Restivo's other murders." (from https://en.wikipedia.org/wiki/Murder_of_Jong-Ok_Shin)

Also: http://www.omarbenguit.co.uk

Matthew Hamlen

"Justice in Jeopardy: The Matthew Hamlen Case - A six part series examining the Double Jeopardy conviction of Matthew Hamlen for the murder of Mrs Georgina Edmonds. A murder investigation that got it badly wrong not once, but twice. Seriously flawed forensics, deliberate non disclosure to the defence, other suspects ignored ... a litany of failures that culminated in the conviction of an innocent man." (from https://hi.player.fm/series/justice-in-jeopardy-the-matthew-hamlen-case)

Luke Mitchell

The murder of Jodi Jones is a Scottish murder case from June 2003 in which a 14-year-old schoolgirl was murdered in woodland in Dalkeith, Scotland. Her semi-nude body was discovered behind a wall by her 14-year-old boyfriend Luke Mitchell’s dog Mia, hours after her death...Mitchell rapidly became a prime suspect in Jones' murder. He was arrested on 14 April 2004, convicted of her murder on 11 January 2005 at age 16, and sentenced to serve a minimum of 20 years' imprisonment. Mitchell continues to protest his innocence, and several attempts to overturn his conviction have failed...In May 2007, a BBC ScotlandFrontline Scotland documentary examined a theory that the murder might have been committed by a student who was alleged to have handed in an essay about killing a girl in the woods a few weeks before the murder. A friend of this suspect saw him soon after the murder and claimed that he had scratches on his face. The documentary also challenged the theory that Mitchell was an obsessive Marilyn Manson fan and had a keen interest in the Black Dahlia murder, stating that there is no evidence that Mitchell knew of the Dahlia case until after the murder. (from https://en.wikipedia.org/wiki/Murder_of_Jodi_Jones)

Also: http://news.bbc.co.uk/1/hi/scotland/6634611.stm

Philip Peace

Philip Peace was found guilty in February 2021 of murdering his five-month old baby daughter, Summer. "The collapse of a five-month-old girl was not caused as a result of pneumonia according to an expert, a trial heard. Dr Dewi Evans, a consultant paediatrician, told jurors that Summer Peace had developed the condition after her collapse. Dr Evans told Birmingham Crown Court there was no evidence of Summer having pre-existing pneumonia prior to her collapse. He said he would expect a baby to show “clinical features” – a number of symptoms – which he hadn’t found, jurors were told....The professional said the collapse would not have been caused by pneumonia and concluded, in his opinion, that it was caused by head trauma, a judge heard. Mr Michael Turner QC, defending Summer’s father Philip Peace in the trial, questioned Dr Evans to see if it was possible the condition could be pre-existing. Mr Turner cited sounds heard by paramedics, described as noisy and bubbling, when they listened to Summer’s chest as possibly being evidence of the condition. Dr Evans, in response to the cross-examination, said it could be explained through transmitted noises – noises from the throat – due to the baby’s size. He added it could also be – in conjunction with the first explanation – could be food or liquid being aspirated into her lungs which causes aspiration pneumonia." (from https://www.expressandstar.com/news/crime/2021/02/04/dudley-baby-death-trial-collapse-of-five-month-old-summer-not-due-to-pneumonia-expert-tells-court/#:~:text=Trauma,condition%20could%20be%20pre%2Dexisting)

Also: https://www.bbc.co.uk/news/uk-england-birmingham-56198043

Lucy Letby

"Colleagues of killer nurse Lucy Letby continue to insist that she is innocent - even after the baby murderer was jailed for life earlier this week. Nurses who worked alongside Letby, 33, at the Countess of Chester hospital and remain there now are reportedly struggling to accept that she murdered seven babies and tried to kill another six. (from https://www.dailymail.co.uk/news/article-12440411/Nursing-colleagues-Lucy-Letby-insist-innocent-working-hospitals-baby-unit.html)

Also: https://www.mirror.co.uk/news/uk-news/lucy-letbys-friend-explains-convinced-30776086 and https://www.chimpinvestor.com/post/do-statistics-prove-accused-nurse-lucy-letby-innocent and https://rexvlucyletby2023.com and https://www.scienceontrial.com

In Wix there are two types of posts: Blog posts and Forum posts (this is a Blog post). I will disable comments on Blog posts, but you can still post comments and replies to comments on a specially created post in the Forum (moreover, comments and replies in Forum posts are only visible to members). To post comments and join the conversation about this post or Lucy's case in general, please click here to go to the Forum (opens in new window so this blog post page stays open for you to view).

gillgage This is a very interesting read and gives us increasing cause for hope. Thanks to Peter for collating all this relevant information.

The views expressed in this communication are those of Peter Elston at the time of writing and are subject to change without notice. They do not constitute investment advice and whilst all reasonable efforts have been used to ensure the accuracy of the information contained in this communication, the reliability, completeness or accuracy of the content cannot be guaranteed. This communication provides information for professional use only and should not be relied upon by retail investors as the sole basis for investment.

© Chimp Investor Ltd

This blog post is not to facilitate member discussion. It is to leave messages of support for Lucy, her parents, her family and her friends at this difficult time.

Please feel free to post messages of support on SOT (see below), on this blog post, or on the forum section of this website. They will reach Dawn. Comments on this blog post and on the forum will be monitored closely and anything inappropriate will be deleted. Please also post only messages of support here and on the forum section. Any comments or questions about messages of support can be posted on the general discussion blog post.

Also, if you want to be anonymous, I suggest you use a 'display name' that does not identify you (you can change this in your profile section). You might prefer this, whether in relation to leaving messages of support or generally.

The below is on SOT.

Polardaisy2203Polardaisy2203Polardaisy2203Polardaisy2203Sep 01

POST MESSAGES OF SUPPORT TO LUCY HERE

in Letter Writing

Hi all, as most of you know I have been in touch with Lucy's friend Dawn and asked about how to contact her with messages of support. I now have an update! And some reassurance. Dawn and Lucy's parents are fully aware of the (growing) support. They are, of course, relaying the message to Lucy. But, given the circumstances, it's not straightforward so we will have to wait patiently for any news of an appeal. Dawn told me that she will be informed of news on this site so please, IF YOU HAVE ANY WORDS OF SUPPORT FOR LUCY POST IT HERE in the comments and Dawn will be informed and compile them to be handed to Lucy at an appropriate time. Thank you ❤️

....................................

The views expressed in this communication are those of Peter Elston at the time of writing and are subject to change without notice. They do not constitute investment advice and whilst all reasonable efforts have been used to ensure the accuracy of the information contained in this communication, the reliability, completeness or accuracy of the content cannot be guaranteed. This communication provides information for professional use only and should not be relied upon by retail investors as the sole basis for investment.

© Chimp Investor Ltd

One fabulous article on scienceLucyLetby subreddit about sepsis and a snippet of trial testimony that might explain why Lucy was scapegoated

Below is a snippet of the testimony on 26 April of CoCH neonatal unit manager Eirian Lloyd Powell.

"Ms Powell said Letby made mistakes, as everyone did, but was "good at reporting mistakes", and would report mistakes that other nurse practitioners or medical staff had made, regardless of seniority."

26 April 2023 (http://www.chesterstandard.co.uk/news/23484044.recap-lucy-letby-trial-thursday-april-27/)

We have five useful bits of information here:

1. We know that Lucy was "good at reporting mistakes".
2. We know she had no qualms about reporting senior doctors.
3. Given that Powell specifically mentioned that Lucy would "report mistakes, regardless of seniority, I think we can infer that this may have been unusual and that other nurses feared the consequences of reporting senior doctors (after all, this would make sense).
4. If Lucy made reports, these should be in the hospital's computer system.
5. When Powell made this comment she was being questioned by prosecution barrister Nicholas Johnson KC. He would not have wanted the Court to hear that Lucy reported senior doctors. So, I think we can infer that Powell went out of her way to make this remark and that therefore she was a supporter of Lucy (did not believe she was a killer).

If it was indeed usual for nurses to not report senior doctors, I wonder how the likes of Drs Gibbs, Brearey and Jayaram felt when Lucy reported them as she probably did.

The below article (https://www.reddit.com/r/scienceLucyLetby/comments/16cga3g/i_found_a_confirmed_case_of_a_newborn_developing/) was posted on the scienceLucyLetby subreddit (https://www.reddit.com/r/scienceLucyLetby/) yesterday. It is brilliant research. Thank you Nessie In The Loch (https://www.reddit.com/user/nessieintheloch/) for doing such fabulous work and for letting me reproduce it on this site.

I found a confirmed case of a newborn developing sepsis at the Countess of Chester neonatal unit in June 2015—the same month babies A, C and D died, and baby B had an 'unexpected collapse.' In fact, this confirmed case of sepsis likely overlapped with the events related to babies A-C.

First, some context: In 2013, The Chester Standard teamed up with the Countess of Chester Hospital for a charity campaign dubbed 'Babygrow Appeal'. The goal was to raise £3 million to build a new neonatal unit for the hospital, to replace the old, cramped one where Lucy Letby supposedly killed and harmed over a dozen infants.

If the name 'Babygrow Appeal' sounds familiar, it's because much has been made in the press about Letby's involvement with the campaign. Mind you, she was not the only familiar face to take part—Stephen Brearey and John Gibbs did as well—to name just two.

As part of the partnership, The Chester Standard ran weekly stories about parents' and babies' experiences at the neonatal unit.

One of those stories highlighted the "emotional rollercoaster" a couple went through when their son, whom I'll refer to as "James," was born eight weeks premature. While the article is meant to be a feel-good piece, what it reveals could shed new light on the accusations against Lucy Letby.

June 2015: Sepsis in the Neonatal Unit

Baby James was born on June 6, 2015, eight weeks ahead of his due date. He was taken to the neonatal unit straight away, and placed in intensive care.

He eventually recovered enough to be taken out of intensive care. But his relatively stable condition was short-lived: when James was eight days old, according to his mom, "he became very poorly with septicaemia, and his arms, leg and tummy all swelled up."

Septicaemia and sepsis are not necessarily synonymous—there are medical distinctions between the two. But when it comes to communicating with laypeople, the NHS uses the terms interchangeably.

Going by his mother's account, James's septicaemia diagnosis came on or around June 14, 2015. In short order, he was transferred to Liverpool Women's Hospital—where, according to his mom, "he recovered quite quickly."

After a four-day stay at the hospital in Liverpool, James was transferred back to the Countess of Chester. There, he began to deteriorate again. In his mother's words,

Just as things started to look up, a lump appeared on James's chest which got bigger and turned out to be an abscess.

The MRI scan showed he also had abscesses on his elbow and ankle as well, and he underwent a bone scan to check on an infection in his hip area. He was taken back to Liverpool Women’s as doctors thought he might need an operation.

In short, a baby boy at the neonatal unit in June 2015 developed an infection so severe that it led to sepsis—possibly twice. The unit, in turn, was so ill-equipped to treat him that it twice had to transfer him to another hospital.

Possible Overlap with Babies A-C

To recap:

• June 6: Baby James is born at the Countess of Chester. He is sent straight away to the neonatal unit, where he initially spends time in the intensive care nursery.
• ~June 14: James is diagnosed with septicaemia. He is transferred to Liverpool Women's Hospital for emergency treatment.
• ~June 18: James is back at the Countess, where he soon develops a noticeable lump on his chest that turns out to be an abscess. Further scans reveal additional abscesses in his elbow and ankle, and a bone infection in his hip area. His condition is so grave that he is at risk for surgery. He is once again transferred to the hospital in Liverpool.

Compare that to the timeline for babies A to D:

• June 8: Baby A, a boy, dies. The previous evening, he had been given medication for "suspected sepsis." He was being treated in the intensive care nursery, in a cot right next to that of his twin sister. During this period, it emerged at trial, a third baby had also been staying in the intensive care room, alongside the twins. And while, to my knowledge, the third baby's identity was not revealed at trial, it could have been James, considering the overlap in dates.
• June 10: Baby B, who is Baby A's twin sister, collapses but survives. Lucy Letby will later be convicted of trying to murder Baby B on this occasion.
• June 14: Baby C, a boy, dies. A day earlier, his doctor had written "suspected sepsis" under "problems." He was also being treated for pneumonia. Even prosecution witness Dewi Evans, in a 2019 report, wrote that, "infection may be a significant factor in his collapse." In an earlier report, from 2017, Evans had written, "One may never know the cause of (his) collapse. He was at great risk of unexpected collapse."
• June 22: Baby D, a girl, is pronounced dead. A post-mortem examination conducted shortly after her death would identify the cause as "pneumonia with acute lung injury." Before these results had come in, though, Baby D's doctors had had no idea she'd even had pneumonia. And though they'd suspected she had had an infection, they had started her on antibiotics a full four hourslater than they should have. The delay had been inexcusable, but was characteristic of the hospital's sub-optimal standards: A nationwide investigation had revealed the Countess of Chester to have been the fifth worst-performing hospital in the NHS when it came to treating sepsis in a timely manner. The investigation found that only 33% of the hospital's patients who needed treatment for sepsis were given antibiotics within the appropriate timeframe.

Conclusion

The deaths of three babies and collapse of a fourth in a single month—June 2015—caught the attention of Stephen Brearey, the lead consultant in the neonatal unit at the Countess of Chester Hospital. After ascertaining that Lucy Letby had been on shift for the four events, he began to suspect her of murder.

But there could have been a simpler explanation: babies in the neonatal unit during the month of June 2015 could have been at an especially high risk of serious infection—a risk that could have been exacerbated by the cramped premises. The unit, in turn, had been demonstrably ill-equipped to provide these newsborns with the care they needed.

It's a hypothesis that should not have seemed so outlandish to Brearey himself. When profiled by The Chester Standard in 2013, as part of the Babygrow Appeal charity drive, Brearey gave the following explanation for why the hospital was in dire need of a new neonatal unit:

The nurses on the unit do wonderful work and are very professional despite the lack of space around the incubators. Neonatal intensive care has improved in recent years but requires more equipment which we have very little space for. In addition, the risks of infection for the babies is greater, the closer they are to each other.

Update

The baby whom I've been referring to as "James," as well as his mother, were pictured with none other than Lucy Letby—as well as John Gibbs—in a Chester Standard article published on August 6, 2015.

A quick closing note, and something for all of us (myself included) to keep in mind: While I strongly believe that the details of this baby's experience in the neonatal unit provides important context to the accusations against Lucy Letby, the family featured in these articles deserves privacy. I've tried to shield them by referring to the baby with a pseudonym, though I realize it's not enough to anonymize them completely. Let's just all remember that the family itself has nothing to answer for—and, though unlikely, may not even realize their experience is relevant to the Lucy Letby case in any way.

The views expressed in this communication are those of Peter Elston at the time of writing and are subject to change without notice. They do not constitute investment advice and whilst all reasonable efforts have been used to ensure the accuracy of the information contained in this communication, the reliability, completeness or accuracy of the content cannot be guaranteed. This communication provides information for professional use only and should not be relied upon by retail investors as the sole basis for investment.

© Chimp Investor Ltd

Here are your suggestions in response to my "Calling All Chimps!" post, posted on the blog or sent privately, about what we can do, over and above posting comments and responses on the blog, to help Lucy

There have been some great suggestions as to how we can collaborate more, how we can work together more, how we can be more active. I have zero experience in this sort of thing, other than blog writing, so if any of you can step up, please do.

First, some background.

My rather limited understanding about the work required to get an individual a fair trial* is that it essentially involves two main strands, which can be described as "inside the Courtroom" and "outside the Courtroom". In relation to Lucy, the former will involve her legal team (solicitor/barrister who will be in close contact with Lucy and her parents), the solicitor firm's research resources, and the various experts called upon (medical/scientific) to debunk (this time effectively) the prosecution's evidence presented at the first trial.

That first strand is not where we sit, though of course if you are an expert who is qualified to provide a different (correct!) interpretation of the two blood tests (haematologist? endocrinologist?), the X-rays (radiologist?), the Post-It note, the hoarding of handover sheets, text messages, Facebook searches (psychiatrist/psychologist?), the roster data (statistician?), etc, then please contact Lucy's defence team when we know who they will be (she will have one whether or not she applies for leave for appeal, though I'm sure we all feel/hope she will apply, we just don't know if she will).

So, we are involved with the latter strand (i.e. the work that goes on outside the Courtroom) and the main thrust of that relates to reaching out to two groups: a) the general public and, b) those in some sort of position of power who can have a positive influence in some way over Lucy's case. Both will involve a good understanding of the various issues relating to the case. If we are to persuade people we must educate ourselves about all aspects of the case (what the prosecution evidence was in the first trial, what the correct interpretation looks like, the public inquiry, the ongoing police investigation, etc.

We also need to know whom to contact, whether politicians, lawyers, scientists, celebrities, journalists, other advocacy groups, etc to tell them about the case and to ask them to do what they can.

Rather than going away as individuals to learn more detail about the case, we should probably pool resources to help each other achieve this, and indeed also have regular groups calls on which we can discuss the case (see suggestions below). Also, rather than each of us building a list of those we should contact, we should as a group build a database of those to contact, including keeping a record of all contact (see suggestions below). And please, if you have experience in these things, shout!

It feels odd that there may be other groups out there thinking similarly about what can be done to help Lucy. It feels odd to be thinking about how to help Lucy without having got her endorsement or that of her parents. I suspect Lucy and her parents are very busy right now, and anyway the trauma of the verdicts is still raw. The situation is very fluid. There may come a time when there is an "official" campaign, endorsed by Lucy and her parents, which of course would be great. Until then, if we as members of this blog want to come together and work together, support each other, great.

Before I list the various suggestions, one thing that I believe would help with all of them is to have somewhere to meet physically, whether to chat together or to work together. My flat is a ten minute walk from Euston Station, London. I have a decent sized area/room that is currently unused (I've been thinking for ages about what to do with it!) where I could set up a square table with eight chairs or so. The room also has a big empty wall which could be used as a notice board. I could get a large whiteboard too. And there's a pub right across the road!

I have thought long and hard about this as it would be a commitment that I would want to be able to follow through on, but I would be delighted to open up that space (and the fridge and biscuit tin!) to anyone who would like to drop by, whether to chat or to work on the case (yes, there will be work to be done).

Security would be paramount so there would have to be a way of vetting those who would like to drop by. Many of you have already proven without doubt by way of your comments, responses, private messages etc, that your credentials and motivations are gold-plated. However, there would probably need to be something more secure and systematic in place. Perhaps a two step process. The first step would be to put you on a list, having provided sufficient details to be verified. The second step would be to have some sort of booking system, including issuance of a number that you can shout into the intercom. This all sounds very covert but I have been told by a number of people that we have to be very very careful. After all, the ramifications of what we are doing could be serious (let's hope they are).

I will have a think about this and contact you by email.

So, below are various suggestions that you have made.

Letter/email writing/sending

One of you copied me in on a great letter they sent to their MP and a couple of cabinet ministers, together with an attachment laying out the key issues as they saw them. They have said we are welcome to use both the content of the letter and the document. I will put them into some sort of template form and provide further details in another blog in the very near future. The idea would be that all you need to do is some simple copying and pasting, then either press send or put in envelopes.

Creating various databases (of people to write to for example, names, addresses, email addresses etc) that can be stored in a secure shared drive for everyone to access.

There are various steps here:

1. Set up a secure shared drive. If any of you is an IT expert and has ideas on this front, please let me know.

2. Decide what sort of databases we need. Are there off the shelf options?

3. Decide who should be responsible for maintaining these databases.

Very clear fact sheets about unjust trial, stats etc simply written, easily printed, easily distributed. Sent to whomever, wherever. Maximizing potential, possibly, of far away weak ties not just strong localized ones.

I understand that a team at Science on Trial is doing exactly this. Please do join SoT if you haven't already and see what they have on that front. I will continue to write, and I think my future blogs could well focus on specific aspects and therefore constitute material that could easily be converted into "fact sheets". If you like writing, speak up and we can coordinate (I'm not precious about being the only author on this blog, though I do think it would be good to keep it well organised etc.)

Other documents/papers in the public domain that are of interest?

I have loads of PDFs saved off that I can start putting in individual blog posts, whether academic papers, articles about forensic science, articles about previous miscarriages etc.

Never underestimate word of mouth, people frequently make this error in the world of social media. Just talk to people, colleagues, family, friends, etc, and be honest with them about how you see the case. Continue with the social media, just remember it’s ephemeral and people are busy and distracted. Don’t shout at them and move on if they’re not receptive, it will may have planted some doubt in the recess of their mind and then when they see a social media post …… Convincing just one person is enough (although more than one is better, of course), they will then convince others and on it goes. It really does work. I’ve convinced 5 people in a week and they are forwarding on material that I send them. What you’re looking to do is to counter the MSM propaganda, which is what we are all bombarded with everyday when we watch, listen or read any MSM. You’ll feel a lot better psychologically if you ban it all!

Totally totally agree

While I greatly appreciate the platform you have provided and all the work you seem to have done, it’s a little deflating reading an article basically saying ‘sooo… now what?’. There‘s no plan then? No fund or anything? Or is that somewhere else?

There will be a way to fund Lucy's legal team directly at some point. If we do things that need funding, I'm sure we will find the right way to do that.

I would really like to see pieces from the likes of Scott Mclachlan, Norman Fenton, Mark McDonald, and others who are not sold on Lucy's guilt. Any chance of that, Peter? Particularly valuable would be pieces from medical professionals who can seriously challenge the expert medical evidence. The reality is that the serious work is being done over at SOT. Our contribution here at Chimp? Simply communicating to all and sundry our disquiet over Lucy's conviction. All and sundry includes friends, acquaintances, news media, those columnists who need challenging/converting. Everyone and anyone. Always remember to be civil and balanced.

I think that "communicating to all and sundry our disquiet over Lucy's conviction" is not a simple matter. Nor is it secondary to other work - it is hugely important. Also, it will involve a lot of work and a lot of coordination (see earlier). I think the idea of linking blogs to the work of others involved in this is a great idea, perhaps with summaries of some sort. If anyone sees anything that they think should be on this blog, please say.

Yes to this. And a legal voice as conductor.

It would be great to have an authoritative legal voice who can provide credible and useful insights into where things go from here, what the legal issues are etc. If that person could be you, please say and I will set you up as an author.

Yes, the stuff on SOT is beyond my understanding, but it is the really important stuff that is going on now. SOT will overturn Lucy's conviction, Chimp can help in that regard. We are better than a talking shop, we can influence public opinion and change the mood from "Lucy the serial killer of babies" to perhaps not, and eventually to something better still.

Yes. As you say, we can influence public opinion. This blog is not about putting together the science that will be useful to Lucy's legal team. It is as you say about influencing public opinion. And writing to influential people. And putting stuff on this site that journalists will read (and that we can actively send to journalists).

Hi Peter - There will be people who have invested a significant amount of time already in campaign support who will understandably be a little confused and wonder what's happened to lead to this. It strikes me that the previous collaboration made sense and appeared to be making progress but multiple strands has the potential for confusion and blurring of vision. Are you able to expand at all and explain how this will fit with other activities towards a common goal?

This blog is very different to what SoT is doing. I suspect the four entities (SoT, Richard Gill, LawHealthAnd Tech, Chimp, and the various others too who have posted videos for example) could be considered members of a football team, each doing something different but important. SoT may be the equivalent of Erling Haaland but the others are doing something useful too. As mentioned in another response, the science is critical but the Court of Appeal will drag their heels if there is no public pressure on them. I think this is where other parties can help. And there is absolutely nothing to stop the various parties collaborating.

Peter.you ask for suggestions on how we can go forward . In late June I was in London and whilst wandering around Westminster, I took the opportunity to observe the Supreme Court at work. The public can do that, which is as it should be, and that open access impressed me greatly. A lot of what was said was legalese and went over my heard, but what has remained with me is the demeanour of the learned , articulate and well meaning judges who I saw at work that day. I just know in my heart that they and their counterparts are committed to justice. So how on earth has this unprecedented injustice come about?? And why was the presiding judge in LLs trial so vitriolic in his condemnation of her? He was anything but impartial, unlike any other judges I’ve observed. I am still very disturbed by the whole thing.

I wonder If we could get a Supreme Court judge to at least read this blog- or even a list of the main bullet points of the flaws in the prosecution- they may agree to help? Am I being naive? I believe we do need a figure with a National profile to help here. A politician? I’ve always admired Gordon Brown. Or a NHS Consultant? As we know there of the latter who believe in this cause. Another Q. Has LL decided to appeal? Time is going on isn’t it? I worry that she is not going to bother. She must be mentally wrung out, poor vulnerable girl.

Finally, whilst out hillwalking yesterday I met a nurse and we fell into conversation. She told me that she has doubts about this conviction, as so many of her colleagues do. Another resource which could be harnessed? Please keep up the good work. Sorry if I have rambled on. Thank you.

What a super message. I certainly think we can send the aforementioned letters/emails to Supreme Court judges (past and present) and to the various other parties mentioned. And really lovely to hear about the nurse who has doubts about the conviction. As mentioned previously, although Lucy is at the centre of this, her case is about more than just her. It is about reforming the NHS. It is about reforming the justice system.

Hi, I think the work you (Peter and others) have done exposing issues with the evidence, and bringing people together to question whether this was a fair trial is admirable. However this blog talks about supporting Lucy and campaigning for her release. I personally think the focus should be on scrutiny of the facts and establishing the truth - not just for her (if she is indeed innocent) but also: a) for the sake of the families so they know what happened, b) to protect future babies by identifying if there were any other causes eg. Infection, poor hygiene, poor medical practice etc, c) to hold power to account within the NHS and justice system

Great message. I agree, and think that future blogs can focus on specific aspects of the case, scrutiny of the facts, establishing the truth, understanding how we got here etc. And, as you say, for the families, for future babies and their parents, and to help build a better NHS and a better justice system.

What are the various aspects of Lucy's case that we should be thinking about?

In no particular order, below is a list of things that I know in my case I want to really understand well and focus on.

1. The public inquiry: is there any way it can consider the possibility that Lucy is not a killer but that there were other explanations for the spike in deaths and collapses?

2. Operation Hummingbird: what is the ongoing investigation about?

3. The various legal routes for Lucy going forward (the Court of Appeal, CCRC, Supreme Court).

4. The grounds for appeal: a) the judge's appalling summing up, b) incompetent councel, c) the Cheshire Police Youtube video (is that new evidence?), d) new scientific interpretation of the medical evidence.

5. What was the evidence that convicted Lucy and how can it be countered.

6. Previous miscarriages/exonerations (Sally Clark, sub postmasters, Barry George, Daniela Poggiali, Lucia de Berk, Angela Cannings, and many more).

7. Other suspected cases of wrongful conviction (Colin Norris, Ben Geen, Omar Benguit, Roger Kearney, Michael Stone, and many more).

8. Looking after ourselves and each other. I suspect we are all getting rather stressed out about the thought of this young person locked in a cell 23 hours a day, thinking they will be there forever, and thinking they did not get a fair trial, that the system let them down.

Finally, the above is essentially a brain dump. Mine and yours! I am not an expert. I have not done this before. Some of you may have read the above and thought, oh, he's missed that, or not touched on that. If that is the case, please let me know and I can add to this post. This is not like a newspaper. Articles can be added to, improved. Importantly, while I enjoy writing and have put what I think is an ok blog site together, the next steps that are needed, the action that you have suggested/asked for will be a team effort.

* Several of you have said that we will be seen as far more credible by the media, politicians, opponents even, if our stance is that Lucy deserves a fair trail rather than that she is innocent which makes sense. Lawyers uses the phrase "unsafe conviction" and we should do likewise. We do not want to seen as a bunch of "crazies" but as a group of thoughtful, rational specialists and nonspecialists who have an abhorrence of injustice. Yes? No?

The views expressed in this communication are those of Peter Elston at the time of writing and are subject to change without notice. They do not constitute investment advice and whilst all reasonable efforts have been used to ensure the accuracy of the information contained in this communication, the reliability, completeness or accuracy of the content cannot be guaranteed. This communication provides information for professional use only and should not be relied upon by retail investors as the sole basis for investment.

© Chimp Investor Ltd

More must be done to improve the use of science in the courtroom

"Most lawyers are terrified of science. So are judges. So are jurors." - M. Chris Fabricant, Director of Strategic Litigation, The Innocence Project

“No matter how many times Bayesian statisticians try to explain to me what the prosecutors fallacy is I still do not understand it and nor do I understand why there is a fallacy” - one of the UK’s most eminent judges (from https://www.eecs.qmul.ac.uk/~norman/papers/bayes_and_the_law_revised_FINAL.pdf)

"You've seen one dead girl with bites on 'em, you've seen 'em all" - Michael West, disgraced forensic dentist

"It is quite clear therefore that outside the field of DNA (and possibly other areas where there is a firm statistical base), this court has made it clear that Bayes theorem and likelihood ratios should not be used." http://www.bailii.org/ew/cases/EWCA/Crim/2010/2439.pdf

"Sometimes the "balance of probability" standard is expressed mathematically as "50 + % probability", but this can carry with it a danger of pseudo-mathematics, as the argument in this case demonstrated. When judging whether a case for believing that an event was caused in a particular way is stronger that the case for not so believing, the process is not scientific (although it may obviously include evaluation of scientific evidence) and to express the probability of some event having happened in percentage terms is illusory. " http://www.bailii.org/ew/cases/EWCA/Civ/2013/15.html

"The chances of something happening in the future may be expressed in terms of percentage. Epidemiological evidence may enable doctors to say that on average smokers increase their risk of lung cancer by X%. But you cannot properly say that there is a 25 per cent chance that something has happened: Hotson v East Berkshire Health Authority [1987] AC 750. Either it has or it has not." http://www.bailii.org/ew/cases/EWCA/Civ/2013/15.html

"Imagine being in jail where everyone thinks you are the scum of the earth, the lowest human being that walks the earth. The thick end of it is that she lost five to six years of her life in what was state-sponsored torture." John Batt, a solicitor and writer who was a member of Mrs Clark's defence team, https://www.theguardian.com/society/2007/mar/17/childrensservices.uknews

"Sally Clark, the solicitor wrongly convicted of murdering her two baby sons, was found dead by her family at her home yesterday" https://www.theguardian.com/society/2007/mar/17/childrensservices.uknews

"I think justice can be served without a statistician"

"Exactly. A statistician in a case like this is purely white noise"

- a Websleuths conversation https://www.websleuths.com/forums/threads/uk-nurse-lucy-letby-faces-22-charges-7-murder-15-attempted-murder-of-babies-5.641465/page-36#post-17863003

"Proper use of probabilistic reasoning has the potential to improve the efficiency, transparency and fairness of criminal trials by enabling the relevance of evidence – especially forensic evidence – to be meaningfully evaluated and communicated. If more widely and effectively used, it could lead to fewer cases being revisited by the Court of Appeal." https://www.eecs.qmul.ac.uk/~norman/papers/stats_courtroom_webdraft.pdf

"..when you have eliminated the impossible, whatever remains, however improbable, must be the truth" (Sherlock Holmes in The Sign of the Four, ch. 6, 1890)

"To change people's hearts and minds about criminal justice, people really have to care more about accuracy and reliability than about retribution" - Peter Neufeld, Co-Founder, The Innocence Project

Court of Appeal bans Bayesian probability (and Sherlock Holmes)

https://understandinguncertainty.org/court-appeal-bans-bayesian-probability-and-sherlock-holmes

Keith Harward (exonerated through DNA). DNA excluded Harwood. Next step was to do CODIS (Combined DNA Index System) search. Ran the profile through the data bank and got a hit - Jerry Crotty. Dana Delger; Keith Harward; John Prante.

https://abcnews.go.com/US/sailor-declared-innocent-murder-rape-spending-33-years/story?id=38249082

How a Bogus Bite Mark Sent Charles McCrory to Prison. Bite-mark analysis was key to Charles McCrory's 1985 conviction. The science has since been debunked — so why is McCrory still in prison?

https://theintercept.com/2022/03/12/bite-mark-evidence-charles-mccrory/ and https://www.theguardian.com/us-news/2022/apr/28/forensics-bite-mark-junk-science-charles-mccrory-chris-fabricant

The American Board of Forensic Odontology (ABFO) developed a study. First step. 100 cases where there had been bite mark evidence. Sent to board certified diplomates who were asked whether the bite mark was human, not human, or suggestive of human. Tried to look at level of agreement among diplomates. President (Dr Freeman) thought study would prove the first step i.e. that there was a high level of agreement. Result? Some of the cases one third each! After the study, Dr Freeman decided he was no longer going to do bite mark analysis for the prosecution.

The views expressed in this communication are those of Peter Elston at the time of writing and are subject to change without notice. They do not constitute investment advice and whilst all reasonable efforts have been used to ensure the accuracy of the information contained in this communication, the reliability, completeness or accuracy of the content cannot be guaranteed. This communication provides information for professional use only and should not be relied upon by retail investors as the sole basis for investment.

© Chimp Investor Ltd

Many of you have asked how we can come together more actively

I have received so many messages of thanks the last few weeks for my articles and for providing a place where you can feel connected with others who want to support Lucy. Quite a few of you have asked how we can become more active, so this post is really asking you for any suggestions you might have.

You may first be interested to know where the name 'Chimp Investor' came from. My profession was financial services and there is an anecdote about a chimpanzee throwing darts at a list of investments, and performing better than most professional fund managers! (My approach to investing is very statistically- rather than narrative-driven. This interest in statistics led me to so-called cluster cases like Lucy's which can be appraised statistically, and indeed to a range of other topics.)

Also, for anyone interested, I completed a geology degree recently at Birkbeck College, London, and did my dissertation on human evolution in Africa (understanding human evolution and evolution generally involves a lot of geology). So, I Iearned a lot about our cousin the chimpanzee as well as about our ancestors (other Homo species such as habilis and other genera such as Australopithecus and Ardipithecus).

Also, using a 'cute' animal in one's branding can be effective!

Now, chimpanzees are our closest relatives (genetically, they are closer to humans than they are to gorillas). They are intelligent. And the idea of a group of chimps rising up to challenge the justice system is simply delicious!

So, Chimps, we have a mission.

The mission is Lucy.

The mission is to help protect NHS health workers in future who could be subjected to false accusations and possible imprisonment (a nurse in Birmingham has just been arrested on suspicion of 'poisoning' - in fact, the related 'surge in fatalities' could well be a summer virus which is very possibly the case with Lucy. I also wonder if the 'poison' referred to is insulin).

The mission is to help improve the justice system, the system that anyone of us could become a target of.

You have been posting fabulous comments on my posts and having some fabulous conversations with each other (also, many comments have included information that is very useful and could well end up helping Lucy's effort to be exonerated).

There are now more than 400 of you who have become a Chimp in the last four weeks. That number is growing quickly. Some of you have asked what more we could do. This is likely to be a long fight so we might as well start thinking now.

So, please, if you have ideas, share them in the comments box, have conversations via the comments feature. I'm sure 400 intelligent creatures should come up with some great ideas! I will collate them and put them together in a new post, perhaps toward the end of this week.

I know that many of you will also be members of Science on Trial. Sarrita did incredible work putting the Rex v Lucy Letby website together and she along with members is doing incredible things with the SoT site.

This is not a competition. This is about the mission at hand. There will be overlap (which is good). I'm sure we can work together.

So, I very much look forward to seeing your suggestions.

By the way, the collective noun for a group of chimpanzees is a whoop.

Onward, Chimps!

Whoop whoop!

The views expressed in this communication are those of Peter Elston at the time of writing and are subject to change without notice. They do not constitute investment advice and whilst all reasonable efforts have been used to ensure the accuracy of the information contained in this communication, the reliability, completeness or accuracy of the content cannot be guaranteed. This communication provides information for professional use only and should not be relied upon by retail investors as the sole basis for investment.

© Chimp Investor Ltd

The retired paediatrician testified as an expert in a case in 2018 when he was not licensed to practice by the GMC

In November 2018, Dr Dewi Evans testified in the case of a six-week-old baby. It is possible that in doing so he broke rules.

Figure 1 below sets out the guidance from the Academy of Medical Royal Colleges for healthcare professionals giving expert testimony. It states that, in order to demonstrate legitimacy,:

Healthcare professionals giving expert evidence must hold the appropriate licence to practise/registration and be in, or sufficiently recently in, practice. This is essential if producing a report from direct assessment and/or examination of the patient.

If there are circumstances where this is not the case the healthcare professional must be able to demonstrate why it is appropriate for them to still act as a witness and that they have maintained the appropriate expertise.

If the case relates to historical events the healthcare professional should ideally have been in practice at the time of the events in question or be able to demonstrate understanding of the standards applicable at the time and the context of the incident.

Figure 2 below is the General Medical Council record for Dr David Richard Evans (https://www.gmc-uk.org/doctors/1503009). It states that Evans was 'Registered without a licence to practise' from 26 Aug 2015 to 16 Jul 2019.

Figure 3 below is an extract from Dr Evans' LinkedIn profile (https://www.linkedin.com/in/dewi-evans-211194a3/?originalSubdomain=uk). It states that Evans was a consultant paediatrician until July 2009, and thereafter (from September 2010 to the present) a Director of Dewi Evans Paediatric Consulting.

Figure 4 below is the December 2018 article in The Southern Daily Echo about the case of the six-week-old (https://www.dailyecho.co.uk/news/17269039.doctor-claims-bite-baby-death-intentional/ ). It states that, "Winchester Crown heard from consultant paediatrician Dr Dewi Evans". It appears that Dr Evans is testifying as an expert rather than as the child's paediatrician. This is supported by the fact that Dr Evans lived in Carmarthen in 2018 (see LinkedIn profile) while the trial was being held in Winchester. He's also referred to as a 'consultant paediatrician' rather than a 'retired consultant paediatrician'.

The article also states that, "Dr Evans told the jury he thought the defendants’ accounts of either the baby being dropped or falling from a sofa didn’t explain the injuries, which included a fractured femur, rib fractures, and the bite to the nose". This also sounds like the testimony of an expert considering the injuries rather than the child's paediatrician testifying about that relationship.

So....

Do any of you (with experience in these matters or otherwise) think that Evans broke the rules? If yes, was the offence a serious one? And if yes, what might the ramifications be in relation to his testimony at Lucy's trial?

Figure 1: Guidance from the Academy of Medical Royal Colleges for healthcare professionals giving expert testimony (from https://www.aomrc.org.uk/wp-content/uploads/2019/05/Expert_witness_0519-1.pdf)

Figure 2: General Medical Council record for Dr David Richard Evans (https://www.gmc-uk.org/doctors/1503009)

Figure 3: Extract from Dr Dewi Evans' LinkedIn profile (https://www.linkedin.com/in/dewi-evans-211194a3/?originalSubdomain=uk)

Figure 4: Article in The Southern Daily Echo (https://www.dailyecho.co.uk/news/17269039.doctor-claims-bite-baby-death-intentional/ )

Doctor claims bite to baby before his death was ‘intentional’

1st December 2018

A DOCTOR told a murder trial he thought a six-week-old baby had been “hurled by the leg” and his head “smashed against a hard surface” shortly before dying.

Winchester Crown heard from consultant paediatrician Dr Dewi Evans who also said the baby, who died on February 11, suffered an “intentional” bite to the nose.

It comes as the boy’s 17-year-old father stands trial for murder, while the 19-year-old mother is accused of neglect. Neither can be identified for legal reasons.

Dr Evans told the jury he thought the defendants’ accounts of either the baby being dropped or falling from a sofa didn’t explain the injuries, which included a fractured femur, rib fractures, and the bite to the nose.

The court previously heard from a teenage witness, who also cannot be named, that she was smoking with the mother outside her flat when they heard a “thud”. They went back inside where she said the father was picking up the baby.

Later, she said the father had been playing with the baby when he “managed to bite his nose”, although she admitted she did not directly see either incident.

However, the court today heard that was disputed by the mother, who said in a police interview she was inside crying when she heard the incident, and that she also didn’t see it.

She said they had been arguing and was not aware of the full extent of the baby’s injuries, some of which are alleged to have been caused before that night.

The mother added: “I really, truly wish I had broken up with him in October when I was pregnant,” after saying he had been “violent” towards her. During the police interview, she also described him as “very controlling”, but said she had never known him to hurt the baby.

When questioned why she didn’t call police over the father’s behaviour on the night the baby died, she responded: “I don’t know.” She was then accused of “allowing this to happen through your own inaction”, which she denied.

Both deny the charges. The trial continues.

The views expressed in this communication are those of Peter Elston at the time of writing and are subject to change without notice. They do not constitute investment advice and whilst all reasonable efforts have been used to ensure the accuracy of the information contained in this communication, the reliability, completeness or accuracy of the content cannot be guaranteed. This communication provides information for professional use only and should not be relied upon by retail investors as the sole basis for investment.

© Chimp Investor Ltd

The prosecution case that was built around Lucy may appear robust but is fragile and at some point will collapse

My heart goes out to the parents of the babies that were the subject of the Lucy Letby trial, whether the thirteen that Lucy was found guilty of harming or the four that she wasn't. It also goes out to the parents of the babies that are now the subject of the new phase of the Operation Hummingbird investigation, to those of the baby that died in May last year at the paediatric intensive care unit at Birmingham Children’s Hospital where harm is now alleged (I wonder if the 'poison' referred to is insulin? I.e. whether it's one that gets produced naturally by the body), and to all parents of babies that have died on a neonatal unit or experienced some sort of injury in recent years and who may now be worried that harm was inflicted. This is an utterly tragic situation.

As for Lucy, in the wake of the verdicts so much doubt is being cast on her being a killer. People are becoming aware that the main prosecution medical expert Dewi Evans was just a retired paediatrician and thus was not qualified to give evidence, whether about neonatology or about air embolism in neonates.

They are becoming aware that the 1989 paper on which he based his diagnosis was not relevant to the incidents in Lucy's case.

They are becoming aware that air embolism cannot be diagnosed from an X-ray, let alone whether an air embolism is the result of air having been administered malevolently (it can be the result of sepsis - incidentally, this observation about sepsis was made by one of the prosecution's very own experts, paediatric radiologist Prof Owen Arthurs).

They are becoming aware that Evans himself said that there was very little research on air embolism, something perhaps the prosecution wished he hadn't said.

They are becoming aware that Evans may not have been licensed to practice when he got involved in the police investigation. The General Medical Council 'search the register' page says that David Richard Evans was 'Registered without a licence to practise' from 26 Aug 2015 to 16 Jul 2019 (Evans joined the investigation in May 2017).

They are becoming aware that Evans testified under oath that he was not an expert. According to The Chester Standard, when asked at trial "by Mr Myers if he was being 'an expert' in being 'an expert witness', Dr Evans replied: 'I think that's far too flash for me. My role is to assist the court on some extremely challenging issues. I call myself an independent medical witness, not an expert.'"

However, his LinkedIn profile says that he provides "expert medical advice regarding clinical issues where child abuse is suspected or where there are allegations of clinical negligence". (Also, Dr Evans, shouldn't you have been investigating whether there had abuse or negligence, not where 'it is suspected', thus eliminating the potential for confirmation bias? No mention of you being a retired consultant paediatrician either which some might argue is misleading.)

They are becoming aware that Evans is registered on the site Expert Witness, the site that says "Let us do the hunting whatever expert you need. Please call our free SearchLine today on 0161 834 0017" though his entry now lists only his name and nothing else.

They are becoming aware that Evans probably got paid for his services, and by the prosecution, an obvious conflict of interest.

They are becoming aware that it was not Evans who was approached by the police but the other way round. He approached the National Crime Agency in May 2017 by email. The below is an extract from ,The Chester Standard published on 7 March 2023 titled, 'Medic denies ‘touting for job’ helping Lucy Letby police probe'.

In his message to “Nick” at the NCA’s national injuries database, Dr Evans wrote: “Incidentally I’ve read about the high rate of babies in Chester and that the police are investigating. Do they have a paediatric/neonatal contact? I was involved in neonatal medicine for 30 years including leading the intensive care set-up in Swansea. I’ve also prepared numerous neonatal cases where clinical negligence was alleged. If the Chester police had no-one in mind I’d be interested to help. Sounds like my kind of case. I understand that the Royal College (of Paediatrics and Child Health) has been involved but from my experience the police are far better at investigating this sort of problem.”

(Incidentally, Dr Evans, where did you 'read about the high rate of babies in Chester and that the police are investigating'? It wasn't public knowledge at that time. Might someone have told you about it rather than you having read about it?)

They are becoming aware that he was admonished by a judge in a previous case for presenting worthless evidence.

When asked about the judge's admonishment in that previous case, Evans replied “This is a one-off for me". Hmm, not sure about that, Dr Evans.

Evans had been involved in controversial cases on several previous occasions. Here are some of them.

#1: The case of a 2-year-old girl and her 4-year-old elder brother

Extracts from the judgement:

"In his judgment the trial judge was critical of Dr Evans, suggesting that his evidence should have been more considered and structured than in fact it was."

"The fact that the trial judge in the present case was unimpressed by Dr Evans left him open to being more persuaded by the evidence of Dr Primrose."

"They also agreed that there were probably two separate impacts or events causing the injuries rather than one, a departure from Dr Evans’ written report."

#2: The case of a six-week-old baby who died in 2018

Extract from the article:

"Winchester Crown heard from consultant paediatrician Dr Dewi Evans who also said the baby, who died on February 11, suffered an “intentional” bite to the nose."

"Dr Evans told the jury he thought the defendants’ accounts of either the baby being dropped or falling from a sofa didn’t explain the injuries, which included a fractured femur, rib fractures, and the bite to the nose."

#3: The case of abuse of a young girl by the Neath Port Talbot State Child Protection Machinery

Extract from the article:

"Behind the scenes Dr Dewi Evans of Singleton Hospital had already been manipulating events. Writing to Dr Dazell of Alder Hey Liverpool on 9 April 1997, he provides a summary of Bonnie’s case, which contains errors and untrue statements. In particular he describes the operation to remove Bonnie's appendix as revealing an appendix that was “long and swollen”. He also describes the recovery as uneventful apart from some “redness around the appendectomy scar”. Either Evans was misinformed or this was a blatant lie, since Bonnie’s appendix was normal, and she had suffered a massive post operative infection and abscess of the wound."

#4: The case of a 17-month old baby girl who was admitted to the Erne Hospital in Enniskillen in 2000 and who later died

According to the article, "Dr Dewi Evans, a consultant paediatrician from the Department of Child Health in Swansea, criticised the hospital at an inquest today dealing with the death of Lucy Rebecca Crawford."

#5: The case the collapse and subsequent death in 2017 of a five-month-old girl

Philip Peace, 42, of Himley Road in Dudley, denied murder and manslaughter of his daughter, Summer.

According to the article, "[Dr Evans] said the collapse would not have been caused by pneumonia and concluded, in his opinion, that it was caused by head trauma, a judge heard.

The article went on the say that:

"Mr Michael Turner QC, defending Summer’s father Philip Peace in the trial, questioned Dr Evans to see if it was possible the condition could be pre-existing. Mr Turner cited sounds heard by paramedics, described as noisy and bubbling, when they listened to Summer’s chest as possibly being evidence of the condition. Dr Evans, in response to the cross-examination, said it could be explained through transmitted noises – noises from the throat – due to the baby’s size. He added it could also be – in conjunction with the first explanation – could be food or liquid being aspirated into her lungs which causes aspiration pneumonia."

#6: The case of Claire Roberts who died at the Royal Victoria Hospital for sick children in October 1996.

The note for Professor Brian Harding in the case cites "The clear difference of opinion between the pathologists concerned, with Dr. Dewi Evan’s hypothesis perhaps providing evidence in favour of Dr Herron’s analysis rather than that of Dr Harding."

Other exhibits in the case relating to Evans can be found here, here, and here.

Then there is the excellent Law, Health and Technology Newsletter and its article LL Part 6: The Incredible Dr Dewi Evans. I shall let you read it.

In another killer caregiver case, Dutch nurse Lucia de Berk was sentenced to life imprisonment in 2003 for four murders and three attempted murders of patients under her care. In 2004, after an appeal, she was convicted of seven murders and three attempted murders. According to statistician Richard Gill, who campaigned for her innocence, Lucia was eventually exonerated because the original expert toxicologist withdrew his testimony. He did this because another toxicologist (who had been suggested to the Court by the defence and whom the Court accepted) came along with the correct interpretation of the toxicology data. And he saved face when he withdrew his testimony because he was able to blame the the public prosecutor and the Court for withholding critical information from him.

In Lucy's case, the Rex v Lucy Letby website sets out systematically what it believes to be the correct science in relation to air embolism, all carefully referenced. Moreover, there are likely to be those with even greater specialist expertise coming forward to rebut what Evans presented at trial. (Incidentally, the Rex v Lucy Letby website also sets out different and carefully researched scientific interpretations in relation to insulin , air in the gut and sudden collapse, so experts may well come forward in due course offering different opinions on those too).

Dr Evans, you have the chance to withdraw your evidence now. Don't wait until you are forced to. Please. A young woman sits in prison on a full life term. It's possible you weren't given everything by the prosecution, that you were a victim too. People would be sympathetic.

The public is also becoming aware that the maternity unit of The Countess of Chester where Lucy worked was in chaos, and was still in chaos in 2022, five years after Lucy was taken off the ward.

They are becoming aware that there were numerous incidents on the unit that Lucy was not charged with. And, most importantly, they are becoming aware that the death rate on the unit did not fall after Lucy was taken off it. In fact, it rose.

In relation to this last point, I first raised suspicion about Lucy's case over ten months ago when her trial started. In my blogs about Lucy's case that I published in June and July this year I cited Countess of Chester Hospital data obtained through a freedom of information request that showed there had been a spike in neonatal deaths in 2015 and 2016. I derived from this data that there had also been a spike in deaths that Lucy had not been charged with, and that therefore the prosecution was essentially asking the jurors to believe that as well as a serial killer on the unit there was something else causing the deaths (in fact, I don't believe the jurors did see this data).

I then saw the Rex v Lucy Letby website which presented ONS data showing that neonatal deaths in Chester and Cheshire West had actually risen after Lucy was taken off the unit, that there had been no sharp fall per the hospital data. How could this be?

Some have rightly pointed out that the ONS data is for the Chester and Cheshire West while the FOI request data is for The Countess of Chester only. Well, we have everything we need to calculate the neonatal death rate (deaths per 1,000 births) for Chester and Cheshire West not including The Countess of Chester.

The result is as below:

Table 1: Deaths per 1,000 births for Chester and Cheshire West not including The Countess of Chester (rate for England also included for comparison)

Rate 1 Rate 2 England

2015 -9.9 -5.9 2.6

2016 -1.7 -1.7 2.7

2017 3.3 3.3 2.7

2018 7.2 7.2 2.7

Rate 1 is calculated based on the inclusion of two deaths in August and October 2015 that Lucy was charged with that were not in the FOI data (since these increased the rate at CoCH, they lowered the rate outside CoCH). Rate 2 is based on FOI data that do not include these two deaths.

Now, a negative death rate is absurd, so there must be something wrong with one or both data sources. Also, if the neonatal death rate in Chester/Cheshire West outside of CoCH in 2018 was 7.2 per 1,000 deaths, someone should have raised the alarm, given that the rate for the whole of England that year was 2.6. Nobody did.

As for the media coverage since the verdicts were announced on 18 August, it too is getting absurd. Below are some examples.

Fact: It is unusual for a serial killer to use different methods.

Media response: Ah ha! A sign of her deviousness.

Fact: The unit was in chaos.

Media response: Ah ha! Lucy must have taken advantage of that to hide her killing spree. (C'mon, peeps, which is more likely?)

Fact: Lucy was calm during police interviews.

Media response: Ah ha! How cold! How calculating!

In relation to the famous Post It note which many claim is a confession, according to the BBC's Lucy Letby: The Nurse Who Killed, the police discovered it "inside her diary". Why did Lucy not write in her diary? Seems like the obvious place to write those sort of innermost thoughts. And why did the police feel the need to move the note to take a photograph of it rather than leaving it where it was found? (see Figure 1.)

Might Lucy have written it somewhere else? That might explain why it was not written in her diary but on a Post It note, along with many other scribblings crammed on the little square piece of paper (at home she surely had plenty of paper so no need for crammed writing. And she had a diary). Finding the note at home was certainly supportive of the police's case. She was in her safe space, after all. As opposed to, for example, writing it in her prison cell after a police interview during which she had been put under extreme pressure. For example.

Figure 1: Police photo of the famous Post It note

Source: BBC Panorama (Lucy Letby: The Nurse Who Killed)

Fact: She wrote "I am evil, I did this" and "I killed them" on a note.

Media response: A ha! A confession!

Well, no. At around 45:50 on the BBC's Lucy Letby: The Nurse Who Killed, renowned criminologist David Wilson says in relation to the note:

Well, it seems like a confession. But it might be she is saying, 'It is alleged I killed them. It is alleged I am evil, I did this'. I have worked on a number of murder cases whereby you get people writing strange notes all the time. It's evidence of their underlying stress, mental health problems. It's not necessarily evidence of guilt. I just think this is the ramblings of someone who is under extreme psychological pressure.

Had Lucy been a killer, it is very likely she would have confessed. That she is likely innocent, it is extraordinary that she did not. More pertinently, any confession would have been a false one. False confessions are real phenomena. They happen. Many exonerations are based on it being determined that the convicted person made a false conviction. Under incessant questioning by police, people start to believe they did it. They want the questioning to stop. They are told that confessing will help them.

It also seems absurd to me that in virtually the same week that wrongly-convicted (on the back of flawed DNA evidence) Andrew Malkinson had his case overturned after spending 17 years in prison, few wondered if Lucy's conviction might just possibly have been the result of similarly bad evidence. Quite the opposite.

Immediately after Lucy's verdict, the neonatal consultants at CoCH were on TV blaming the hospital for failing to heed their warnings about Letby. Why, if they suspected Lucy of harming babies, did they not tell the police? Or the coroner? Or do everything in their powers to get Lucy off the unit? Surely, as consultants they had the power to do this. More to the point, they had an ethical obligation. They may well also have had a legal obligation.

While Lucy is at the centre of this case, fighting what could well be an unsafe conviction is not ultimately about her. No. It is about protecting all NHS healthcare workers in future from unfounded accusations and possible wrongful convictions. It is about protecting everyone from becoming a victim of poor scientific evidence presented in the courtroom. It is about you (and if you think this couldn't happen to you, think again).

There is a huge disconnect between on the one hand the stark reality of the verdicts and the public's strong belief that Lucy is Britain's worst baby killer, and, on the other, the reality of the evidence supporting the case for there having been a miscarriage of justice. It is like being in The Twilight Zone.

Lucy must be Britain's worst baby killer. After all, she failed to murder six babies on seven occasions. Who'd have thought it was so hard to kill a tiny, vulnerable, premature baby.

The views expressed in this communication are those of Peter Elston at the time of writing and are subject to change without notice. They do not constitute investment advice and whilst all reasonable efforts have been used to ensure the accuracy of the information contained in this communication, the reliability, completeness or accuracy of the content cannot be guaranteed. This communication provides information for professional use only and should not be relied upon by retail investors as the sole basis for investment.

© Chimp Investor Ltd

I thought I would republish this article which I wrote as Lucy's trial got underway just over ten months ago. It has not had as many views as my recent pieces so many of my new followers will not have seen it.

As another 'angel of death' case gets underway in Manchester, the spotlight is turned once again on use of statistics by prosecutors and investigation objectivity

There have been a number of cases over the years in which doubts emerged about the guilt of caregivers accused - and in some cases convicted - of murdering those in their care. Some doubts led to accusations being dropped, some to convictions being overturned, and some still linger, with those convicted remaining in prison. In many if not most cases, the doubts related to whether the prosecution had used statistics correctly at trial and/or whether the original investigation had been biased against the accused.

This week the trial of nurse Lucy Letby got underway in Manchester. Letby is accused of murdering seven babies in her care and of attempting to murder ten others. I am not suggesting she is innocent. It is possible that there is incontrovertible evidence against her as was the case with Harold Shipman. However, what I do know is if there isn't, this is yet another case in which there is scope for bad statistics and a biased investigation to be presented to the jury. And therefore for another miscarriage of justice.

There is a recognisable pattern in situations that lead to a caregiver being accused, rightly or wrongly, of malevolence. First, someone recognises what they think is a statistical anomaly in data - for example, a high number of deaths on a particular ward over a certain period compared with what would be considered normal. Then, one of two things happens: either direct evidence of malevolence is found - as was the case with Shipman and his forged wills etc - or it isn't. If no direct evidence of malevolence is found, the 'cluster' can either be attributed to chance, to a non-malevolent cause, or to malevolence.

The last of these generally involves:

• an erroneous belief that the cluster in question could not possibly have been due to chance,
• there being no 'non-malevolent' causes identified, investigated even,
• other flawed reasoning/conclusions.

Looking at each of these in turn:

1. Disbelief in possibility of chance

Let's say on a hypothetical ward the expected number of deaths per year, based on the national average for the type of ward in question, is 20, and that this is consistent with what the ward in question has experienced - most years the number of deaths has been between 15 and 25 and very occasionally a little outside this range, never less than 10 and never more than 30 . Then, one year, the ward experiences 40 deaths. If the number of deaths per year is assumed to follow a Poisson Distribution - one in which events occur at a constant mean rate i.e. 20 per year, and are independent of each other, another example of which being the number of calls received in a particular hour of the day at a call centre - as is reasonable, the chance of such an occurrence is 0.0028%, one in 36,000. Many would think this is so unlikely that the cluster must be attributable to something other than chance.

Wrong.

The mistake that is made here is to think only of the ward in question. If there are 1,000 such wards across the country, then in a 20 year period - 20,000 ward years - there is a very high probability, well over 50/50, that one of them will experience 40 deaths in one year. Nothing suspicious whatsoever. Just luck. Or, rather, bad luck.

Think about the case of a rollover lottery that gets won by Ms XYZ. The chance of Ms XYZ specifically winning is minute, one in tens of millions perhaps. However, the chance of somebody winning is 100%. In caregiver cases, it is natural for many of those involved - the hospital administrator, the police, the prosecution, juries, the public etc - to focus on the 0.0028% number not the 50/50. In which case, unsurprisingly, the possibility of chance is dismissed. There must be a cause, they say.

2. No 'non-malevolent' causes having been identified

Let's say that, instead of 40 deaths in one year on the above mentioned hypothetical ward, there were 100. Assuming a Poisson Distribution, the probability of this occurring on a particular ward in a particular year is one in 3,571,854,227,384,530,000,000,000,000,000,000,000. Not even a trillion wards and a trillion years would give the cluster even the slightest chance of occurring! Thus, in this instance, it is reasonable to assume that it must have had an active cause.

In such cases where chance can be dismissed, all possible causes should be carefully considered. In practice however this does not always happen - sometimes, people jump to conclusions and assume there is a murderer out there. Two such cases are noted in Green et al. 2022:

A cluster of deaths in a neo-natal ward in Toronto was initially associated with a nurse, who was suspected of malevolent activity. Only later was it discovered that new artificial latex products in feeding tubes and bottles could have been responsible. An apparent increase in death on a neonatal ward in England raised similar suspicions until a medical statistician identified the date at which the death rate rose, and a neonatologist recognized it as the date when the supplier of milk formula was changed. As these examples show, an increase in deaths may be caused by factors that are not immediately apparent, even to those involved. Such factors may require considerable expertise to discover and could be missed entirely in some instances.

In the cases above, fortunately, so-called confounding causes of the clusters were identified, and miscarriages of justice were avoided. But this does not not always happen. For example, a hospital administrator tasked with investigating confounding variables such as a change in hospital practices, product or treatment might naturally prefer the cluster to be attributed to misconduct rather than to an administrative mistake. His perhaps. Indeed, Green et al. 2022 recommends that such investigations be carried out by independent parties.

3. Other flawed reasoning/conclusions

In no particular order:

• Suspicion may be directed onto a nurse who is not liked or is deemed to be a bit odd;
• Better nurses will tend to notice and signal a death earlier than a worse nurse, so deaths are more likely to be registered in their shifts not later.
• Better nurses will tend to clock in earlier and leave later, so deaths are more likely to occur on their watch given the longer time they spend on the ward.
• A disproportionate number of deaths occur or are noticed/registered in the morning. Thus suspicion is more likely to fall on nurses who do more morning shifts than others do.
• Better nurses will tend to be entrusted with harder tasks, ones perhaps where the risk and thus incidence of death is higher.
• A fall in deaths following removal of suspected nurse from the ward may be due to bad publicity and people avoiding that hospital rather than a murderer being no longer present.
• During investigations, causes of death get reexamined by pathologists and there may be a tendency or pressure to recategorise deaths as unnatural, driven perhaps by a desire to atone for perceived past error. Incidence of potassium or of elevated insulin levels may be deemed unnatural - i.e. evidence of poisoning - when there are in fact completely natural explanations.
• If a particular nurse is already under suspicion, there may be a tendency to recategorise as unnatural only deaths that occurred when the suspected was on duty. As noted in Green et al. 2022, "Regardless of how it occurs, this kind of bias would undermine the fairness of the investigation by causing an increase in the count of “suspicious” deaths associated with the nurse. The higher count would arise from the very suspicions that the investigation is supposed to evaluate – an example of circular reasoning".
• It may later be determined that a nurse under suspicion was not in fact on duty when one of the deaths previously deemed unnatural and attributed to them occurred. Rather than this casting doubt on the case against the suspected nurse as it should, and it perhaps introducing the possibility of another perpetrator, there may be a tendency simply to re-re-categorise the death as natural and to press ahead.

All the above have occurred in real cases. Investigations/judgements get conducted/handed down by humans, and humans are fundamentally flawed. These flaws can relate to a poor grasp of probability and statistics, for example conflating the probability of an animal having four legs if it is a dog with the probability of it being a dog if it has four legs, the equivalent of the issues set out in 1. above. Or they can relate to innate bias, for example confirmation bias or the fundamental attribution error. Humans are also influenced by the tabloid media, so prefer lurid explanations to mundane ones.

Caregivers who have either been wrongly accused or convicted, or where there is for good scientific/statistical reason for suspicion of such, include Lucia de Berk, Daniela Poggiali, Jane Bolding, Sally Clark, Susan Nelles, Ben Geen, and Collin Norris*. If it turns out there is no direct evidence against Lucy Letby, let's hope her name doesn't join the list.

* Details of all these cases can be found online. And there I'm sure are others, perhaps many others, that I have not come across and thus did not mention.

The views expressed in this communication are those of Peter Elston at the time of writing and are subject to change without notice. They do not constitute investment advice and whilst all reasonable efforts have been used to ensure the accuracy of the information contained in this communication, the reliability, completeness or accuracy of the content cannot be guaranteed. This communication provides information for professional use only and should not be relied upon by retail investors as the sole basis for investment.

© Chimp Investor Ltd

The fight to exonerate Lucy Letby has begun and you can be part of it

On Friday Lucy was found guilty of murdering seven babies and attempting to murder a further six on seven occasions. She was found not guilty on two counts of attempted murder and no verdict could be returned in relation to the six other counts of attempted murder.

The last ten months must have very traumatic for the parents of the 15 babies whom the prosecution alleged Lucy murdered or attempted to murder. They must have been difficult for the parents of Children H, J, K and Q who on Friday found out that the jury did not agree that Lucy had harmed their babies. They must have been difficult for the parents of babies who died at COCH in 2015 and 2016 but where harm had not been alleged, particularly since Cheshire Police is now investigating the deaths; this must be doubly traumatic. Why did the police not investigate before? The parents could have had closure by now.

And, whether or not Lucy actually committed the 14 acts of harm of which she was found guilty, they have been difficult ones for her and her family. If it was you, or your daughter, or your granddaughter, or your sister, etc, you would have been traumatised. Moreover, you would want to move to appeal as soon as possible, particularly if you were the wrongly convicted or a close family member thereof - let's face it, anyone who has read the Rex v Lucy Letby website must surely understand the scientific evidence presented at trial was deeply flawed.

Writing about Lucy's verdict being a miscarriage of justice in the immediate aftermath of the trial is not insensitive as many allege. It is not vitriol directed at parents - indeed, I and the author of the Rex v Lucy Letby website have received lots of abuse which is ironic given it is from people who believe Lucy was an abuser and want her punished. Where is your reason, people? No, writing about a miscarriage straight away is not wrong. It is what anyone would have done. It is what you would have done.

There are many who believe Lucy is innocent. Along with the abuse there have been countless messages of support. In the coming days, weeks, and months we will become very organised. We will shout from the rooftops at every opportunity about the flawed science, as well as advocating for the science that should have been seen by the jurors. And we will shout about other inconsistencies in information that is in the public domain. Our approach will be entirely rational, factual, logical. It will be fair. It will be relentless.

We will be careful about what we say. We will not accuse those who testified against Lucy at her trial of malice; that would be libel. But we don't need to make accusations. By presenting facts that are in the public domain - science, testimony at trial, public statements, etc - it will become clear how this miscarriage occurred and who is to blame for it.

If you would like to join a group whose aim is to bring together key scientific minds, those who can provide other sorts of help, and those who simply have a strong sense of justice - and then to go into battle - watch this space. A Lucy Letby Appeal Campaign will be up and running very soon and I will post details on my blog about it as soon as it is.

The views expressed in this communication are those of Peter Elston at the time of writing and are subject to change without notice. They do not constitute investment advice and whilst all reasonable efforts have been used to ensure the accuracy of the information contained in this communication, the reliability, completeness or accuracy of the content cannot be guaranteed. This communication provides information for professional use only and should not be relied upon by retail investors as the sole basis for investment.

© Chimp Investor Ltd

The jurors had little choice but to find Lucy guilty, given the flawed scientific evidence with which they were presented

Lucy Letby has been found guilty of murdering seven babies and attempting to murder a further six on seven occasions. She was found not guilty on two counts of attempted murder and no verdict could be returned in relation to the six other counts of attempted murder. The Crown Prosecution Service has 28 days to decide whether to retry Lucy for these latter six counts (let's hope it does as so much more will emerge about the flawed evidence that was presented at trial by so-called scientific experts over the last 10 months).

Lucy being found guilty is I am convinced a miscarriage of justice of gargantuan proportions. People will of course ask how it could be, given the large number of people involved, whether doctors, the police, experts, nurses, other hospital staff, etc. Moreover, Lucy's defence team could and should have debunked the scientific evidence presented by the prosecution, whether through effective questioning of the prosecution's experts or presenting its own. It failed on both counts. Of six autopsies conducted at the time, five found natural causes, one was 'unascertained'.

Why the defence failed is something that is only likely to become clear in the coming months and years. The scientific evidence was presented by medical doctors, something that would not happen in the US - scientific evidence gets presented by scientists. In February, the jury heard that the expert presenting the evidence in relation to air embolus, retired paeditrician Dewi Evans, had been admonished previously by a senior judge for presenting "worthless evidence". The paper presented by Evans on which he based his claims of harm was old and anyway not relevant to the cases in Chester. Evidence that air embolus can be the result of resuscitation - duh! - was not presented.

It also turns out that the prosecution's insulin expert UCL’s Professor Peter Hindmarsh's assertion that exogenous insulin was administered may have been wrong (in fact the scientist who created this fabulous website debunking all the scientific evidence told Lucy’s barrister back in March of their analysis).

And what about the high number of other so-called excess deaths that occurred on the unit in 2015 and 2016? And why didn't the number of deaths decline after Lucy was taken off the ward (Chart 1)? The case stank from the beginning and it stinks even more now - let's face it, it would have made more sense for Lucy to be convicted on all 22 charges rather than 14.

Talking of stink, the only witness the defence presented other than Lucy herself was the plumber who testified about sewerage on the unit. This is relevant because very viable alternative suspects are viruses such as enterovirus and parechovirus. These are summer viruses which correspond with the clustering of the 22 deaths and collapses in the summers of 2015 and 2016. And they are water borne i.e can be carried in sewerage. Importantly, they can kill, particularly very premature babies who are obviously vulnerable.

Let us hope that the analysis in this fabulous website is quickly peer reviewed and found to be correct, and that Lucy can be granted an appeal at the earliest opportunity.

I am today ashamed to be a national of a country whose justice system allowed such a horrific injustice to occur.

Chart 1: Deaths among neonates at the Countess of Chester/Chester and W. Cheshire

Source: ,Countess of Chester Hospital, ,MBRRACE, ,ONS

Chart 1 above presents data from three different sources, the hospital itself, MBRRACE, and the ONS. The data are conflicting. While the ONS data is for Chester and Cheshire West, not just the hospital, it can be considered a proxy given that the hospital accounted for an average of 80% of Chester and Cheshire West from 2015-2020. Unfortunately, the ONS data only starts in 2015 so one is unable to ascertain whether its data showed a big increase from 2014. Why is there a discrepancy? It is hard to know but one possibility is that the ONS data come from the coroner while the hospital and MBRRACE data come from the hospital.

The views expressed in this communication are those of Peter Elston at the time of writing and are subject to change without notice. They do not constitute investment advice and whilst all reasonable efforts have been used to ensure the accuracy of the information contained in this communication, the reliability, completeness or accuracy of the content cannot be guaranteed. This communication provides information for professional use only and should not be relied upon by retail investors as the sole basis for investment.

© Chimp Investor Ltd

The Poisson probability distribution sheds more light on the Lucy Letby case

I am not a lawyer. Nor am I a medical expert. But I have what I think is a decent grounding in statistical analysis which permits me a useful perspective in relation to so-called 'cluster cases', legal cases (often pertaining to the medical world) where there is an unusually high number of events (e.g. deaths of patients) that is deemed suspicious (the Lucy Letby case in which she is accused of murdering 7 neonatal babies on the HDU (high dependency unit) at the Countess of Chester Hospital and attempting to murder a further 10 on 15 occasions is such a case). The probability distribution known as the Poisson distribution is particularly useful in such cases and in Letby's case yields some remarkable findings.

What is the Poisson distribution?

The Poisson distribution describes the distribution of rare events (in time or space) where events are unrelated to each other and the likelihood of an event occurring (in a unit of time or space) is fixed.

Real world examples of events that are 'approximately Poisson distributed' ('perfect' does not exist in the real world) are the number of calls received by a call centre in one minute, the number of stars that can be seen through a telescope, the number of zircon crystals in a cubic inch of sand, the number of radioactive decays per second (note that stars and zircon crystals are 'events' in space while telephone calls and radioactive decays are events in time).

If, based on historical average, the likely number of calls received by a call centre in one minute is 1.2 (among the millions of telephones from which calls could be received i.e. rare) then the probabilities of receiving 0, 1, 2, 3, etc in one minute can be calculated using a mathematical formula (see https://en.wikipedia.org/wiki/Poisson_distribution), and are as below:

Number of calls rec'd Probability (%)

in one minute

0 30.1%

1 36.1%

2 21.7%

3 8.7%

4 2.6%

>5 0.8%

Exactly the same probabilities would pertain in the case of zircon crystals where the average number in a cubic inch of sand was 1.2 (among the hundreds of thousands of grains of sand i.e. rare). Or 1.2 radioactive decays (among billions and billions of atoms) or 1.2 stars in the viewfinder of a telescope (that could contain many more). Cool, huh?

In relation to neonatal deaths (which thankfully are rare) you might expect the number per year (at a hospital, in a particular region, or the country) to decline over time given improvements in care, but the improvement will not be rapid (the rate for England as a whole improved from 1.28 per year per 1,000 live births in 2013 to 0.97 in 2020, a rate of 4% per annum - see MBRRACE UK Perinatal Surveillance Reports 2013 to 2020 on https://www.npeu.ox.ac.uk). So the likely number per year can be considered fixed. And neonatal deaths are going to be independent of each other (the condition of a particular baby is unrelated to the condition of another).

So, neonatal deaths are going to be approximately Poisson distributed. Unless, that is, there is something else going on that is influencing things e.g. the presence of a serial killer, a staff shortage, poor medical care, or contamination of some sort.

Lucy Letby was charged with 7 murders during a 13 month period: 3 in June 2015, 1 in August 2015, 1 in October 2015, and 2 in June 2016 though, strangely, there was no record of the deaths in August and October 2015 in the hospital's official records (see https://www.whatdotheyknow.com/request/521287/response/1255362/attach/3/FOI%204568.docx?cookie_passthrough=1).

The hospital's neonatal deaths data can be combined with the information pertaining to the murder charges in the chart below.

Source: ,https://www.whatdotheyknow.com/request/521287/response/1255362/attach/3/FOI%204568.docx?cookie_passthrough=1

If we remove the 7 alleged murders from the above, we end up with data pertaining to non-suspicious deaths, as below. This series should be Poisson distributed (unless in addition to a serial killer there was something else going on e.g. a staff shortage, poor medical care, or contamination of some sort.)

Source: ,https://www.whatdotheyknow.com/request/521287/response/1255362/attach/3/FOI%204568.docx?cookie_passthrough=1

Now, the period we are interested in is the one during which Letby is alleged to have been on her killing spree, from June 2015 to June 2016. There were 9 non-suspicious deaths during this period, from July 2015 to March 2016. We want to know the probability of there being nine deaths during the nine month period in question (July 2015 to March 2016).

To determine this we calculate the expected number per month, which we can calculate based on the average outside of the nine month period in question (the answer is 0.18 per month). To calculate the probability of nine deaths in a nine month period, we first multiply this monthly average by nine to get the expected number of deaths in any nine month period (0.18 times 9 equals 1.65). We then use this average to calculate the probability of there being nine deaths during the nine months from July 2015 to March 2016.

The answer?

0.0048% or 1 in 20,845!

In other words, there is a 1 in 20,845 (0.0048%) probability that the nine deaths occurred by chance. Conversely, there is a 20,844 in 20,845 probability (99.9952%) that the nine did not occur by chance i.e. that in addition to a serial killer there was some other factor at work.

Given that it is extremely unlikely that there were two unrelated factors simultaneously causing the number of deaths in 2015 and 2016 to be elevated (serial killer plus something else) and that the probability of the 'non-serial killer factor' is virtually 1, this must surely cast doubt on the prosecution's assertion that Letby is a murderer (this is neither a legal nor a medical argument but a purely statistical one).

There is another possibility, namely that Letby was responsible for all or many of the nine 'non suspicious' deaths but left no trace. However, given that it is clear the prosecution's case was driven first by roster data (note similarities with Lucia de Berk case) and subsequently by alleging various methods of killing (air embolism, insulin administration, other acts of harm, etc) it would seem that the reason that Letby was not charged with any of them was that she wasn't on duty (surely if Letby had been on duty, and given the inconsistency in the medical evidence presented by the prosecution for the 22 charges and the circumstantial nature of it, a way would have been found to charge her with them. Perhaps the reason parents did not demand in the press they be investigated is that they were told by the police Letby was not on duty so could not be connected with them). Moreover, if Letby was clever enough to use undetectable methods in relation to some or all of the nine deaths, why also use highly detectable and risky methods such as insulin administration in others? One would also have to question, if Letby was so adept, why she failed on 15 occasions (the attempted murder allegations).

The only way the case makes sense statistically is if Letby is not a murderer.

The views expressed in this communication are those of Peter Elston at the time of writing and are subject to change without notice. They do not constitute investment advice and whilst all reasonable efforts have been used to ensure the accuracy of the information contained in this communication, the reliability, completeness or accuracy of the content cannot be guaranteed. This communication provides information for professional use only and should not be relied upon by retail investors as the sole basis for investment.

© Chimp Investor Ltd

Statistical analyses, a damning 2016 report by the Royal College of Paediatrics and Child Health (RCPCH), and various other factual inconsistencies in publicly available official documents, may constitute reasonable doubt

Please forgive the personal touch but I have written this post in memory of my Mum who passed away recently and who many years ago was a nurse and midwife. I don't know for certain that Lucy Letby did not commit the crimes of which she is accused (I don't think she did) but, regardless, nurses everywhere should be greatly appreciated and applauded. This post is for them. And my Mum.

As readers of my blog will know, I have an interest in so-called cluster cases - criminal trials where there is an apparently high number of occurrences of some event. For example, 'excess deaths' at a hospital, within a family or among a GP's patients. Or wicked postmasters fiddling books.

In such cases, particularly ones where the evidence is purely circumstantial, a grasp of statistics is critical. Since this is often lacking, whether among judges, jurors or, most worryingly, defence lawyers, there is scope for a miscarriage of justice to occur i.e. for an innocent person to be found guilty.

Where there is a cluster, it is important first to determine the probability of the cluster occurring purely by chance. In the case of 'excess deaths' on a particular hospital ward, this involves considering the probability of the 'excess death' rate occurring somewhere on that type of ward, not on one specific ward. If it is determined that the probability is low, then the cause must be investigated. Also, such investigations can be biased - they may be conducted by those who would be implicated in some way by the true cause of the 'excess deaths' being determined.

The trial, currently underway in Manchester, of Lucy Letby, the neonatal nurse at The Countess of Chester Hospital (COCH) accused of murdering 7 babies and of 15 attempted murders (pertaining to 10 babies) between June 2015 and June 2016 is a cluster case, and one where the evidence is purely circumstantial. The hospital first investigated an elevated number of deaths of very premature babies in February 2016. Almost five years later, in November 2020, Letby was charged, though at first she was charged with 8 murders and 10 attempted murders.

I should make it clear that I do not know if Letby is innocent. How could I? Nor am I going to speculate - what I present in this post are information and data gleaned from publicly available official documents, statistical analyses of said data, and references in the media to official documents, official announcements, court dialogue (all links provided). Finally, and importantly, whether Letby is innocent or not, the parents of the babies that are the subject of the trial have gone through and continue to go through a truly terrible experience.

Below is a list of the various official sources of information and data that I refer to in this post or have read in the course of my research.

Document 1: Royal College of Paediatrics and Child Health (RCPCH) Service Review of the neonatal service at the Countess of Chester Hospital (COCH), dated November 2016 (Link 1: http://allcatsrgrey.org.uk/wp/wpfb-file/rcpch_invited_review_nov_16_final_-for_dissemination-_08_02_17_1_30pm-pdf/, Link 2: https://pdf4pro.com/cdn/www-coch-nhs-uk-7537c.pdf, Link 3: http://www.coch.nhs.uk/media/141843/rcpch_invited_review_nov_16_final_-for_dissemination-_08_02_17_1_30pm.pdf. Note that this last link to the document on COCH's own website now goes to a page that says, "There seems to have been an error, please navigate to the page on the menu above").

Document 2: Care Quality Commission (CQC) Inspection Report, Countess of Chester Hospital NHS Foundation Trust, dated 17 May 2019 (Link: https://api.cqc.org.uk/public/v1/reports/75694247-129f-4e2d-8a12-b2e59d3245ca?20210116074506)

Document 3: Care Quality Commission (CQC) Inspection Report, Countess of Chester Hospital NHS Foundation Trust, dated 15 June 2022 (Link: https://api.cqc.org.uk/public/v1/reports/0257680c-6a9a-49fe-ac39-a5c982f58985?20221129062700)

Document 4: Care Quality Commission (CQC) Inspection Report, Countess of Chester Hospital NHS Foundation Trust, dated 30 September 2022 (Link: https://api.cqc.org.uk/public/v1/reports/85aed0ff-145b-4572-ab44-08bcd3124f78?20221129062700)

Document 5: Number of deaths (monthly) by type (late fetal loss, stillbirth, early neonatal, late neonatal, post neonatal) at the Countess of Chester Hospital NHS Foundation Trust, January 2013 to October 2018 (Freedom of Information Request Link: https://www.whatdotheyknow.com/request/521287/response/1255362/attach/3/FOI%204568.docx?cookie_passthrough=1)

Document 6: Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries across the UK (MBRRACE-UK), Perinatal Surveillance Report, UK Perinatal Deaths for Births from January to December 2015 (Link: https://www.npeu.ox.ac.uk/assets/downloads/mbrrace-uk/reports/MBRRACE-UK-PMS-Report-2015%20FINAL%20FULL%20REPORT.pdf)

Document 7: Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries across the UK (MBRRACE-UK), Perinatal Surveillance Report, UK Perinatal Deaths for Births from January to December 2016 (Link: https://www.npeu.ox.ac.uk/assets/downloads/mbrrace-uk/reports/MBRRACE-UK%20Perinatal%20Surveillance%20Full%20Report%20for%202016%20-%20June%202018.pdf )

Background/RCPCH service review (Nov 2016)

By way of background, "the Royal College of Paediatrics and Child Health (RCPCH) was invited to review the neonatal service at the Countess of Chester Hospital (COCH) following re-designation [demotion] from level 2 Local Neonatal Unit (LNU) to level 1 Special Care Unit (SCU) in July 2016 due to concerns about increasing neonatal mortality. A number of causes had been postulated but there was no definitive explanation for the trend". This is the opening statement in the Executive Summary of the final copy of the RCPCH report dated November 2016 (hereafter referred to as the 'RCPCH report').

The findings of the RCPCH report were announced to the media in February 2017, along with the report itself. Although it was the hospital itself that downgraded its own neonatal unit, the RCPCH team that visited in September 2016 found significant failings by the unit in relation to reporting, staffing, practices, etc.. The team made various recommendations that it said should be implemented before a reinstatement of the unit as an LNU should be considered.

Missing deaths

The below neonatal deaths data is taken from an official COCH document that was made public as a result of a Freedom of Information request.

Source: COCH, https://www.whatdotheyknow.com/request/521287/response/1255362/attach/3/FOI%204568.docx?cookie_passthrough=1

According to the RCPCH report, "On 8th February 2016 a half day 'high level' thematic review of ten of the cases took place with the involvement of the ODN clinical lead." (RCPCH report clause 3.7)

Given that the "half day 'high level' thematic review" took place on 8 February 2016, it would appear that the ten cases reviewed were the ten early neonatal deaths from June 2015 to January 2016 in the above table (Table 1.1). Of these ten, Letby was later charged in relation to just three of them. In other words, she could not be connected with seven of them.

Also, she was later charged with two murders in August and October 2015 (Children E and J). But, as can be seen in the table above, there were no deaths recorded in either August or October 2015. The data in the tables above are up to October 2018, so one would assume that there was plenty of time to correct any mistakes i.e. to include the two deaths in August and October 2015.

High incidence of 'non-malicious deaths' (those which Letby has not been charged with)

Letby is accused of murder in relation to 7 of the deaths in 2015 and 2016, but there were 11 for which she has not been implicated (Chart 1) presumably because she could not have been responsible for them (in fact, the defence, in its opening, said that she could not have been responsible for some of the 7 deaths that she has been connected with).

If we assume that 'non-malicious' deaths are distributed according to the Poisson distribution (deaths are independent of each other and occur at a rate of 2.7 per year, the average of 2013, 2014 and 2017), then the odds of there being 11 deaths (the ones Letby has not been accused of) over a two year period purely by chance is 1 in 83. In other words, the prosecution is asking the jury to believe that there is both a serial killer at work as well as some other factor (e.g. faulty equipment, understaffed unit, incompetence among medical staff) causing the deaths. And that these two factors both started and stopped at exactly the same time. Quite a coincidence!

By the way, for those who might be tempted to think the high death rate fell in 2017 (actually it was from mid 2016) because Lucy Letby was "caught", remember that COCH's neonatal unit was downgraded in June 2016 and so no longer was allowed to care for higher risk babies.

Chart 1

Source: https://www.whatdotheyknow.com/request/521287/response/1255362/attach/3/FOI%204568.docx?cookie_passthrough=1

In the case of Beverley Allitt, the nurse found guilty in 1993 of murdering four infants, attempting to murder three others, and causing grievous bodily harm to a further six at Grantham and Kesteven Hospital, Lincolnshire, between February and April 1991, roster data (see below) determined (unlike in Letby's case) that she was present at all 25 of the suspicious incidents that were investigated (Allitt was not charged for all of them).

Figure: Roster data in Beverley Allitt case

Source: The Beverley Allitt Tapes (Woodcut Media, Sky Crime documentary)

It should also be noted that Allitt never testified at her trial (according to the Greensboro News and Record, Allitt was not "in court for nine weeks of her 13-week trial because of [an] eating disorder and did not testify. Colleagues and psychiatrists were unable to suggest a motive, and she has made no public statements" (https://greensboro.com/english-nurse-convicted-in-death-of-infant-patients/article_bec86764-b5ed-5bf1-8d5d-719e01ff22db.html). Letby on the other hand chose to testify and spent nine days on the stand being cross examined (you can read all the reports in The Chester Standard and judge for yourself how she did). Furthermore, during the hours of police questioning, Letby did not once invoke her right to silence (again, you can read many of the various exchanges cited at trial in The Chester Standard). This, too, is unlike Allitt, who after a certain point of police questioning refused to say anything further.

Then there is the case of nurse Colin Norris who was convicted in 2008 of murdering four elderly patients and attempting to murder two others in 2002 (his case was recently referred to the Court of Appeals following a scientific finding that hypoglycaemia can have a natural cause and in the elderly often does - according to the prosecution the hypoglycaemia in Norris' 'victims' was due to him having injected them with insulin). Norris was originally charged with five murders, but before trial roster data determined that for one of them he was not present so could not have been responsible. The police then started looking for second murderer, right? Er, no - they just decided that a death that they were previously certain was a murder was not in fact a murder, and reduced the count to four.

High incidence of multiple pregnancies in relation to murder/attempted murder charges

"The obstetricians were confident in their ability to manage high risk pregnancies including twins and triplets to later stages of gestation, and where cots and appropriate safe staffing are available it is preferable for families to be able to stay locally following delivery. The obstetrics team had expressed concern about four of the deaths particularly, which were discussed at the perinatal M&M meeting and found to have no antenatal indicators of concern. The review team was however concerned at whether there were sufficient staff for the LNU to care for triplets, for example, albeit post 34 weeks." (Clause 4.4.14, RCPCH Report)

Chart 2 below shows that the percentage of multiple pregnancies in relation to the murder/attempted murder charges was way higher than in the general population. For example, in the general population, 1.2% of pregnancies are multiple pregnancies. In the case of the pregnancies at COCH where there was a murder charge, 50% were multiple pregnancies (3 of 6). In other words, it may be that the deaths and collapses reflected the high risk nature of multiple pregnancies rather than the presence of a murderer.

Chart 2

Source: https://www.itv.com/news/granada/2022-10-14/who-are-the-children-alleged-to-have-been-murdered-by-lucy-letby, https://www.raisingmultiples.org/faqs/faq-what-are-the-odds-of-having-a-multiple-birth/

Higher activity/lower admission birthweight than average

"Further in-depth analysis by the neonatal lead in July 2016 examined activity and acuity from June 2015. This included admissions per month, time between deaths, total care days per month, IT care days per month, birthweight and prematurity. This was not a systematic review but concluded that there was higher activity and lower admission birthweight than average during the period corresponding to the increase in mortality. This was not however considered to have been significant enough to explain the increase in mortality." (Clause 3.8, RCPCH Report)

I would be interested to know if the term "significant" was used in its strictly statistical sense (i.e. statistical significance). I presume not, because the conclusion appears to be that of the 'neonatal lead', not a statistician. Also, it appears that the higher activity/lower admission birthweight was not considered sufficiently significant because it could not solely explain the increase in mortality. Why could it not have been deemed to have been a contributing factor, one among others? Then, what about nonlinearity? Presumably there is a point at which a small percentage increase in activity/decrease in birthweight leads to a large increase in mortality. To what extent was this considered by the neonatal lead?

Problems with UVCs/new UVC guidance (UVC = umbilical venous catheter)

"Following reflection both individually and in discussions the consultants noted that several of the infants had collapsed unexpectedly and had been surprisingly unresponsive to resuscitation, despite the staff following standard protocols in each case. One surviving infant was mentioned as having needed resuscitation for similar collapses over three nights but subsequently recovered, although the review team did not see details of 'near misses' such as this. The consultants did not initially consider that there were any links between the episodes of collapse in the infants that died but subsequently they began to note similarities. For example some of the infants displayed a sudden mottling appearing after a few minutes of resuscitation, usually starting on the limbs, and on at least one occasion on the central abdomen and chest. The consultants had considered a number of possible causes for this appearance but there remained no definite explanation." (Clause 3.11, RCPCH Report)

If staff "followed standard protocols", why was there a need for new UVC guidance, per clause 3.7? Indeed, there have already been several mentions during the trial of problems with UVCs in relation to a number of the babies, as below. To what extent did the consultants consider that the collapses may have related to the UVC issues? Since it would have been the consultants who inserted the UVCs, might they have preferred to have honed in on Lucy Letby rather than incorrect insertion of the UVCs?

Extract from Chester Standard reports mentioning issues with UVCs:

Nurse Melanie Taylor, who was the designated nurse for Child A on the shift before he died, gave evidence in court to say she had had "no concerns" with him and he was "stable", but issues with a cannula and a UVC meant he was not receiving fluids for a couple of hours that afternoon. https://www.chesterstandard.co.uk/news/23062657.death-baby-lucy-letby-case-came-completely-blue-witness-says/

References to issues with UVCs in other Chester Standard articles reporting on the trial:

A chart shows any 'major events' that took place for Child A. One was UVC lines at 1pm.

Attempts to fit an umbilical vein catheter (UVC) twice failed

An addendum by Miss Taylor just after 7pm recorded the UVC was in the wrong position, and was reinserted, but was still in the wrong position.

The UVC was in the 'wrong position' twice - it had been taken out and re-inserted, but was still in the wrong place. Another option was sought.

Dr Beech said the UVC had come out of Child C during a previous shift

The trainee doctor was called to insert a UVC (a catheter) into Child A on the afternoon of June 8. Following an X-ray, the catheter was "not ideally placed".

The radiology report said, from the x-ray, the ET tube was 'in satisfactory position' following the reintubation, along with the NG tube, while a UVC line required further adjustment.

The UVC was removed as it was 'only able to advance to 5cm'. Dr Rylance says usually "you are expected to advance it much further.

A further note was made to say the UVC 'continued to ooze'.

A second x-ray image of 'effectively the whole body' is shown the court at June 21, 1.32pm. Professor Arthurs notes two features - the 'obvious one' being the UVC going up towards the heart, which has been pushed in too far.

UVC still in situ, but in wrong position

Small number of deaths in 2016

According to the 2016 MBRRACE-UK (Mothers and Babies: Reducing Risk Through Audits and Confidential Enquiries) Perinatal Mortality Surveillance Report, the number of neonatal deaths at COCH in 2016 was low ("entry suppressed because of small number of deaths"), per the below screenshots. And yet according to the hospital data presented above, deaths in 2016 were high. The discrepancy is puzzling and in view of everything should be investigated.

Source: MBRRACE-UK Perinatal Mortality Surveillance ,2015 and ,2016 Reports

Dr Dewi Evans

Dr Dewi Evans was one of the medical experts called by the prosecution.

Asked at the trial on 14 October 2022 by prosecution barrister Mr Myers if he was being 'an expert' in being 'an expert witness', Dr Evans replied: "I think that's far too flash for me. My role is to assist the court on some extremely challenging issues. I call myself an independent medical witness, not an expert."

And yet on Dr Evan's LinkedIn profile (below) he states that he provides "expert medical advice".

Below is an excerpt from The Chester Standard's report of the trial on Thursday, 9th February, 2023.

A REPORT from expert witness Dr Dewi Evans in an unrelated civil case was described as “worthless” by a senior judge, jurors in the trial of Lucy Letby have heard. Retired consultant paediatrician Dr Evans has been called by the prosecution to give his opinions as to why a number of babies suffered collapses at the Countess of Chester’s neo-natal unit. On Thursday, Manchester Crown Court was told Dr Evans was criticised over his involvement in an application for permission to appeal against a care order involving two children – in a case unconnected to Letby. Dr Evans supported the parents’ desire to have increased access to the children who were being cared for by their grandparents, the court heard. Refusing permission last December, Court of Appeal judge Lord Justice Jackson said Dr Evans’ report was “worthless” and “makes no effort to provide a balanced opinion”. He went on: “He either knows what his professional colleagues have concluded and disregards it or he has not taken steps to inform himself of their views. Either approach amounts to a breach of proper professional conduct. No attempt has been made to engage with the full range of medical information or the powerful contradictory indicators. Instead the report has the hallmarks of an exercise in ‘working out an explanation’ that exculpates the applicants. It ends with tendentious and partisan expressions of opinion that are outside Dr Evans’ professional competence and have no place in a reputable expert report. For all those reasons, no court would have accepted a report of this quality even if it had been produced at the time of the trial.”

Source: https://www.chesterstandard.co.uk/news/23312472.lucy-letby-trial-judge-described-expert-witness-report-worthless/

Below are some interesting excerpts from the RCPCH report that was published and given to the media in February 2017

"Since June 2015 the paedriatric consultants have become concerned about a higher than usual number of neonatal deaths on the unit, several of them being apparently 'unexplained' and 'unexpected'. Most of these infants had post-mortem examinations, all cases had been reviewed by the mortality and morbidity meeting (M&M), and one had undergone a Root Cause Analysis review, with some also being examined by obstetric secondary review. On 8th February 2016 a half day 'high level' thematic review of ten of the cases took place with the involvement of the ODN clinical lead. A summary internal review of the nursing observations, staffing and junior doctor rotas for the 12 hours before the deaths was then conducted. No definite causal correlation was identified between the various cases, however a number of recommendations (such as new UVC guidance) resulted from the high level review." (RCPCH clause 3.7)

Comment: There were various mentions of issues in relation to fitting of UVC in both the RCPCH report and at trial (more detail earlier in this post).

"Where neonates may require surgery (e.g. swollen abdomen) there is some confusion about the protocol with some clinicians contacting the surgical team at Alder Hey immediately, and others talking through the situation with the neonatologists in LWH or Arrowe Park first. These pathways were explored in a surgical review in April 2016 which made six recommendations for service providers and five for the network including a communication improvement plan and a single surgical model to reduce confusion and delays." (RCPCH clause 3.7)

Comment: "confusion about the protocol" among clinicians sounds concerning

"Most of the consultants had been on duty for at least one of the deaths. Further in-depth analysis by the neonatal lead in July 2016 examined activity and acuity from June 2015. This included admissions per month, time between deaths, total care days per month, IT care days per month, birthweight and prematurity. This was not a systematic review but concluded that there was higher activity and lower admission birthweight than average during the period corresponding to the increase in mortality. This was not however considered to have been significant enough to explain the increase in mortality." (RCPCH clause 3.7)

Comment: Why were higher activity and lower birthweight not considered to have been significant enough to explain the increase in mortality? Presumably the relationships (between activity/birthweight and mortality) are not linear i.e. above a certain activity or below a certain birthweight, mortality increases non linearly (perhaps exponentially). Furthermore, witnesses at the trial talked about 'very high number' of admissions.

"Following reflection both individually and in discussions the consultants noted that several of the infants had collapsed unexpectedly and had been surprisingly unresponsive to resuscitation, despite the staff following standard protocols in each case. One surviving infant was mentioned as having needed resuscitation for similar collapses over three nights but subsequently recovered, although the review team did not see details of 'near misses' such as this. The consultants did not initially consider that there were any links between the episodes of collapse in the infants that died but subsequently they began to note similarities. For example some of the infants displayed a sudden mottling appearing after a few minutes of resuscitation, usually starting on the limbs, and on at least one occasion on the central abdomen and chest. The consultants had considered a number of possible causes for this appearance but there remained no definite explanation." (RCPCH clause 3.8)

Comment: If staff followed standard protocols, why was there a need for new UVC guidance? Also, Letby was only charged in relation to seven of the fourteen deaths from June 2015 to June 2016. What about the other seven, which would still have constituted an unusually high number? Why wasn't Letby charged in these cases?

"In response to this allegation and the high acuity and activity on the unit the Medical Director, Nursing Director and Trust Board decided on 7th July to reduce the designation of the service to a Special Care Unit (SCU) caring for infants from a minimum of 32 weeks gestation pending an external review by the RCPCH, and the change appeared to have been handled sensitively and effectively by management with good network and public engagement." (RCPCH clause 3.9)

Comment: It is far from clear in the RCPCH report to what "this allegation" refers but it seems to be an allegation that the elevated number of deaths were the result of harm. However, the decision to downgrade was also due to the high acuity and activity on the unit. In other words, it seems to be quite a coincidence that the elevated number of deaths was due to both harm having been inflicted and high acuity/activity.

"Two of the cluster of deaths were not reported; the current policy indicates that not all deaths need to be submitted as DATIX, if they are "expected deaths", and in 2015-6 only 10 of the 13 deaths were reported as incidents on the neonatal incidents summary. The definition of 'expected' was not available but presumed to be that used in safeguarding/child death panels and it was not clear who is responsible for DATIX entry. Other areas in the hospital report well but the neonatal unit have for some time apparently been less systematic in reporting." (RCPCH clause 4.4.5)

Comment: Reporting protocols were clearly not followed which is alarming

"There are however significant gaps in both medical and nursing rotas" (RCPCH report Executive Summary)

"The arrangements for investigating neonatal deaths must be strengthened; review findings appear to be reported at several different meetings but it is unclear at which the resulting actions are monitored. Despite sound structures, there seems to be disconnection between the neonatal leadership and the Trust's governance and risk management processes. Reviews highlighted examples of poor decision making, delays in seeking advice, and delayed retrieval of infants to tertiary units." (RCPCH report Executive Summary)

"The physical separation of the tertiary centres and lack of tight protocols for transfer to them remains a risk as is the commissioner indecision around integration of the three network transport services, leaving an under-resourced, single clinical transport team in Cheshire and Merseyside." (RCPCH report Executive Summary)

"The service…is non-compliant on nurse and medical staffing levels, environment and accommodation for parents, support from the community neonatal team and postnatal follow-up." (RCPCH report clause 4.1)

"The paediatrics team has self-assessed against the 2015 'Facing the Future' standards for acure paediatric care, and stated complaince with all standards except the first - consultant presence at times of peak activity. There has been a 'hot week' system since 2008-9 but a single consultant is insufficent to safely cover both the paediatric and neonatal wards." (RCPCH report clause 4.1.5)

"There is insufficient storage space resulting in many pieces of equipment being stored in corridors. Direct visibility from one area to another is poor, and infants are moved regularly to accommodate acuity - an extra risk in the system." (RCPCH report clause 4.1.6)

"BAPM standards suggest that an annual report should be prepared for each neonatal unit. No such report had been produced for COCH due, presumably, to pressure of activity so this valuable opportunity for influence had been lost." (RCPCH report 4.1.7)

"The paediatric service (including neonates) struggles to fill its Tier 2 (middle grade) posts and medical staffing numbers are inadequate for a Tier 2 LNU, although sufficient for a Level 1 SCU." (RCPCH report 4.2)

"Although…on-paper compliant…there are only two scheduled consultant ward rounds per week on the neonatal unit, yet five on the paediatric wards. This would not meet training requirements or RCPCH and BAPM guidance for a LNU." (RCPCH report 4.2.1)

"The investigation reports from the infant deaths showed a pattern of insufficient senior cover and a reluctance to seek advice. Given the acuity of the unit (pre 7th July) there should have been a greater level of consultant presence on the ward." (RCPCH report 4.2.2)

"The review team was not aware of any strategic plans to stabilise the Tier 2 rota such as development of ANNPs or appointment of specialty grade doctors, despite an annual agency cost of around £125k. In one of the cases the nurses had expressed concern about the capability of the locum registrar whose agency had previously been advised not to offer the doctor to the Trust again. The nurses took steps to ensure the consultant was aware but it was not clear to the Review team that the locum recruitment process was sufficiently robust for such a situation not to recur and no learning/action was documented for this case." (RCPCH report 4.2.4)

"There are however no ANNPs [at either Tier 1 or Tier 2 level." (RCPCH report 4.2.7)

"The CQC indicated that neonatal staffing was of concern, requiring the Trust to "Ensure staffing levels are maintained in accordance with national professional standards on the neonatal unit and paediatric ward" but the detail of what this meant was not available in the public domain and no other concerns were raised in their report. The nurses on the unit were also supporting transitional care in the maternity unit and administration of antibiotics for infants from Cestrian Ward which depleted their availability for sick infants in the LNU." (RCPCH report 4.2.10)

"In terms of acuity network data available to the team had indicated that COCH has a significantly higher proportion of late gestation admissions (over 37 weeks) than other local units - 10.73% compared with 5.69% average for the 22 units, and this had been raised for several years. The 2015-6 data available in October showed the figure had fallen to 7.8%, lower than the other two units in the region. A number of possible reasons for the higher level had been suggested including the transitional care arrangements, differences in obstetric approach, reluctance to discharge, low thresholds to transfer in or inexperienced medical staff but the increasing trend towards the network norm was commendable and should continue." (RCPCH report 4.2.11)

"There were however some historical issues around senior level decision making. Some nurses reported that external escalation was not always as timely as it could have been, and nurses did not feel empowered to participate. Although the nurses work to a relatively traditional model, they reported that they will support escalation more "vigorously" depending upon which consultant or locum is on duty. Relationships are starting to improve although recent events around the reconfiguration had damaged relationships between senior nursing staff and the consultants and thus may need active intervention to restore trusting working relationships." (RCPCH report 4.3.2)

"Leadership at senior Trust level appeared to be somewhat remote from the day to day issues taking place in the unit and representation on key decision making network groups was sometimes at a very high level with delays in feeding back to the operational team." (RCPCH report 4.3.7)

Comment: On 20 September 2018 it was reported that COCH chief executive Tony Chambers had resigned (https://www.nationalhealthexecutive.com/News/trust-chief-executive-resigns-amidst-infanticide-investigation/211926). Chambers had been chief executive since 2012 and so was at the helm during the period of elevated deaths in 2015 and 2016.

"Although the ward can be really busy, everyone wants to progress, but the nurses felt there had been a dip in morale since the changes and information about the temporary reconfiguration had not been shared, even with the Band 6 nurses who had to manage the enquiries from anxious parants over the weekend following the announcement. Mention of installing CCTV on the unit without explanation had unsettled the nursing team further although the Unit Manager had strived to reassure them." (RCPCH report 4.3.8)

"Until early 2016 there was a Risk and Patient Safety Lead but the role was redesigned when she left the Trust (around the time of the CQC visit) and the post of Risk Midwife was established and filled in May." (RCPCH report 4.4.6)

"The review of deaths carried out by the (neonatal lead) consultants that, together with two additional deaths, triggered the unit's reconfiguration in July 2016 did not use a recognised RCA process nor did it involve the governance lead/risk manager. The staffing grid in particular was not validated." (RCPCH report 4.4.8)

"The RCPCH review team recommends that the death/near miss reviews process requires further strengthening and follow corporate process." (RCPCH report 4.4.9)

"The review team was concerned that it was only when the data was formally reviewed by the analyst did management realise how busy the unit was; this had not been raised as a risk since the neonatal team had just continued to work harder." (RCPCH report 4.4.12)

"Not all of the caes underwent a post mortem despite this being recommended in BAPM 2011." (RCPCH report 4.4.13)

"The review team was however concerned at whether there were sufficient staff for the LNU to care for triplets, for example, albeit post 34 weeks. (RCPCH report clause 4.4.14)

"The RCPCH review team was concerned that the CDOP did not appear to be alert to the cluster of neonatal deaths, and for at least some there should have been a Rapid Response Meeting within 5 working days of notification. If the cause of death is not not clear then no death certificate can be written and the case must be referred to the coroner. (Recommendation: The CDOP should consider whether its processes could have detected the cluster of deaths and initiated external review more swiftly)." (RCPCH report 4.4.25)

"All those the review team spoke to told us that there are significant capacity pressures on the Cheshire and Merseyside Neonatal Transfer service, which contribute to delays in transferring infants out promptly." (RCPCH report 4.5.1)

"There were several reports that the doctors will wait too long before escalating concerns about an infant, both from junior to consultant and also to the network and when they do seek tertiary level advice, the transport team is not informed sufficiently early to be on 'standby'. Consequently when a decision to transfer is made, there may be further delay as the transport crew and an appropriate vehicle are mobilised. If the team is on another retrieval or undertaking a 'park and ride' surgical engagement then either the transfer must wait or another team mobilised from elsewhere in the network. With the Cheshire and Merseyside transport team having no 'out of hours' administrator to mange the cot bureau function it is incumbent on the referring clinician to identify and mobilise an alternative team. Since the re-designation of the unit there were reports that the consultants can spend up to 4 hours trying to find an available cot and retrieval team due to the increased demand for transfers. This is an unacceptable waste of senior medical time, and should be raised as an incident on DATIX. Other services in the UK create a 'conference call' so those giving advice and those on the transport team are aware of the status of infants which may require transfer. (Recommendation: Ensure tertiary advice calls include an 'early warning' or conference call to the transport team to enable better planning and deployment of the crew)." (RCPCH report 4.5.2)

"COCH is the busiest non-NICU in the C&M network, with 4800 cot days (3773/79% of which were SC/TC days). Analysis by the network of cot numbers and activity in its annual report had identified COCH as an outlier with over-provision of IC cots and under-provision of SC cots." (RCPCH report 4.5.7)

"The network's 'top table' review in January of a death in October 2015 was reported to have triggered improved data collection across other units, and another death in December 2015 also exposed inadequate liaison between COCH clinicians and the transport team. There appears to be no formal mechanism or process for joint M&M review across the network for infants who have been transferred between units and no mechanism to trigger closure of a unit when it has reached capacity." (RCPCH report 4.5.9)

"The COCH works naturally with Arrowe Park NICU and is considering working more closely together (see 3.14). Where neonates may require surgery (e.g. swollen abdomen) there is some confusion about the protocol with some clinicians contacting the surgical team at Alder Hey immediately, and others talking through the situation with the neonatologists at LWH or Arrowe Park first. These pathways were explored in a surgical review in April 2016 which made six recommendations for service providers and five for the network including a communication improvement plan and a single surgical model to reduce confusion and delays." (RCPCH report 4.5.10)

"The unit took 11% of network admissions but experienced 13% of the deaths in 2015. The consultants had explored a number of factors themselves but not in a systematic way nor following sound governance and root cause analysis processes, and the involvement of the network clinical governance group had been relatively supervisory, working on the summaries of cases rather than examining each in detail." (RCPCH report 4.6.1)

"A number of recommendations have been included in this report which draw out areas of non-compliance with standards or where practice might have improved. To summarise: - Staffing levels are inadequate when mapped to the actual activity and acuity of a LNU under the BAPM standards, both from a nursing and a medical perspective. -Escalation of concerns to tertiary units for advice or transport was sometimes delayed and network agreement to encourage a lower threshold for escalation and discussion is required. - Most of the infants had undergone a Post Mortem from one of the three perinatal pathologists at Alder Hey but these did not include systematic tests for toxicology, blood electrolytes or blood sugar since the infants died in hospital. - In order to thoroughly examine the issues detailed case review of all the deaths (prioritising the unexpected deaths) should be conducted by an independent expert. The personnel issues cannot be resolved formally until this is completed." (RCPCH report 4.6.2)

June 2022 Care Quality Commission (CQC) Inspection Report

On 15 June 2022, six years after the Letby was alleged to have committed her last murder/removed from duty, the BBC published an article titled "Countess of Chester Hospital maternity services unsafe" ,(https://www.bbc.co.uk/news/uk-england-merseyside-61808681).

This was in response to the Care Quality Commission (CQC) publishing its Inspection Report of Countess of Chester Hospital NHS Foundation Trust, dated 15 June 2022, of an unannounced inspection in February and March in the same year (https://api.cqc.org.uk/public/v1/reports/0257680c-6a9a-49fe-ac39-a5c982f58985?20221129062700).

Below is the article (underlining mine).

A hospital has been ordered to make urgent improvements after a damning inspection found its maternity unit was unsafe.

The department at Countess of Chester Hospital was found to have a dangerous lack of staff and suitable equipment, the Care Quality Commission said. The hospital also scored the lowest rate nationally for staff morale, inspectors found. Bosses said they were "working hard" to make improvements. Countess of Chester Hospital NHS Foundation Trust remains rated as requires improvement overall. The unannounced inspection in February and March was prompted by concerns about the quality of care in certain areas. It covered medical care, surgery, maternity care and urgent and emergency services, as well as leadership. Inspectors found several failings at the maternity unit. Notably there were not enough staff with the right qualifications or skills to keep women and babies safe, or suitable equipment. The report also said the trust did not learn from compromised safety incidents to avoid them happening again. It said between April and November last year five patients had major haemorrhages after giving birth at the hospital, resulting in a need for unplanned hysterectomies. Not all those incidents were reported as serious and action plans were not completed quickly, the CQC said, and one patient's lifesaving surgery was delayed as there was no hysterectomy kit in that part of the hospital. Staff morale was said to be the lowest at any NHS trust in the country with some staff saying there was a culture of bullying and discrimination, while not all staff felt respected, supported and valued, inspectors said. High waiting times were also highlighted, with just 13% of patients showing symptoms of breast cancer being seen within two weeks, when the national target is 93%. Inspectors did find staff were caring and knew how to protect patients from abuse, while the urgent and emergency services were able to maintain a "good" rating. Karen Knapton, the CQC's head of hospital inspection, said the trust had "work to do to ensure people consistently receive the safe and effective care they have a right to expect". "We recognise NHS services are under enormous pressure," she said. "However, senior leaders must be visible and have good oversight to manage and mitigate challenges and risks - and we found this was lacking." Trust chief executive Dr Susan Gilby, said work was under way to address "key areas for further improvement". "In our maternity department, we have implemented and are continuing to develop measures to ensure we can consistently provide patients with the safe and effective care they have a right to expect," she said. Dr Gilby said the hospital also wanted to recognise "the work which has taken place to embed a culture of compassionate care and treatment across services".

The views expressed in this communication are those of Peter Elston at the time of writing and are subject to change without notice. They do not constitute investment advice and whilst all reasonable efforts have been used to ensure the accuracy of the information contained in this communication, the reliability, completeness or accuracy of the content cannot be guaranteed. This communication provides information for professional use only and should not be relied upon by retail investors as the sole basis for investment.

© Chimp Investor Ltd

An update on where I think we are in the business cycle with respect to growth, inflation and markets

I haven't written for a while about what has been happening on the economic and markets front. This is largely because little has changed, whether in my head or outside it.

Inflation came down a bit from its peak, but there is now more talk about it being "sticky" (bond yields have bounced, following declines). My view, as I have documented clearly in recent months, has been and still is that inflation would fall a bit (perhaps to mid-single digits) as a result of some sort of recessionary environment, then bounce back because central banks prioritised growth over inflation (implicit abandonment of 2% targets).

However, the recent movements in inflation and bond yields have nothing to do with recession expectation and related reduction in interest rates (interest rates are still rising!) We still have those to look forward to, though when they might happen is anyone's guess.

While the fall in bond yields in January may have been due to the easing in inflation in many parts of the world, the bounce back reflects the reality that economies are still running hot (inflation may have fallen slightly but it remains high).

Why have economies not slowed in response to the increases in interest rates across the world? There are a few reasons:

1. although high inflation lowers economic growth and is thus fundamentally bad, there will always be those who benefit from it along with those who suffer (a cost rise for someone is a revenue rise for someone else);

2. consumers are still running down savings that they accumulated during lockdown either as a result of fiscal stimulus or lower spending on travel and entertainment;

3. it is possible that consumer debt defaults are now increasing but are being absorbed by banks and thus not "spilling over";

4. although interest rates have been increased greatly over the last couple of years, they may still not be high enough to cool economies;

5. nominal wages are now rising at high rates - this helps consumers deal with high inflation but it does not cool the economy or indeed bring down inflation;

6. economies do not behave linearly. They hit tipping points at which things start to change rapidly, increasing unemployment being a key one. We have simply not hit this tipping point yet.

In relation to 2. above, consumers in the UK during the height of covid (March 2020 to February 2021) paid down £14.7 billion of credit card debt. Since February 2021 credit card debt has increased by £12.1 billion (see Chart 1 below). In other words, there is still scope for increasing credit card debt to sustain consumer spending for a little while longer, though of course higher mortgage rates will also be limiting consumers' ability to spend (as indeed will higher interest rates on credit card debt be limiting scope to borrow more).

Chart 1

Source: Bank of England

As for point 3. above, it was reported recently by Credit Strategy that, "More than 18,000 new StepChange Debt Charity clients completed full debt advice in January 2023, which is at least 22% higher than any single month in 2022. This stark data suggests that more and more people are struggling with debt in the new year following almost 12 months of rising living costs."

Of course there are still many who think central banks can engineer soft landings. I suppose that is still possible but soft landings are rare. Throughout history, the only things that have really ever brought down high inflation are hard landings.

Thus, we appear to still be in the peak phase of the business cycle in which interest rates rise in response to rising inflation but have not yet caused a meaningful growth slowdown or, worse, a recession. Equities and bonds behave poorly during this phase as rising/high inflation hits bonds, and equities are hit by higher real interest rates (this impacts equities' valuation) in response to rising inflation and the anticipation of a meaningful slowdown caused by higher interest rates (this impacts earnings).

Gilts have hardly started to perform well, and could well resume their declines of the last couple of years if inflation turns out to be stickier than previously thought, wage demands persist, etc. As for equities, ignore the talk about the FTSE 100 being close to all time highs. A high proportion of earnings from FTSE 100 companies comes from overseas so the index does not reflect the domestic economy. And remember that the high inflation over the last two years has eroded the purchasing power of both equities and bonds. The 14 per cent rise in consumer prices that we have seen since the end of 2020 would turn a 7% increase in nominal equity or bond values into a 7% decrease in real terms. And spare a thought for those poor overseas investors in UK equities and bonds who have lost further real value because of sterling's weakness in recent months and years.

Conclusion? Continue to keep some powder dry. We have yet to see the worst of the peak phase.

Additional information:

In relation to Chart 1, a reader asked how the data would look if it was adjusted for inflation. This was an excellent question, as I bang on about the importance of making that adjustment - I should have explained that it would not have changed anything i.e. that inflation-adjusted numbers would still have suggested there was scope for further credit card borrowing to sustain consumer spending. Nevertheless, the below chart presents both nominal and inflation adjusted numbers, and shows that based on inflation-adjusted numbers, the case for spending being sustained is even stronger. Note that the below pertains to amounts outstanding (rather than monthly changes as in Chart 1 above) and so includes writedowns (which Chart 1 above doesn't).

The important conclusion is that while it may be tempting to think that it is a good thing that economic growth is sustained, it isn't. Sustained economic growth just means that inflation stays high, which means that interest rates have to rise even more, which means that performance of bonds and equities in real terms during this peak phase will be even worse. Be careful what you wish for....

Source: Bank of England

The views expressed in this communication are those of Peter Elston at the time of writing and are subject to change without notice. They do not constitute investment advice and whilst all reasonable efforts have been used to ensure the accuracy of the information contained in this communication, the reliability, completeness or accuracy of the content cannot be guaranteed. This communication provides information for professional use only and should not be relied upon by retail investors as the sole basis for investment.

© Chimp Investor Ltd

"Every single person who confuses correlation and causation ends up dying" - Hannah Fry, mathematician, author, and radio and television presenter

Data is too often presented in an unfair, unclear and misleading way

I recently challenged two senior investment professionals in relation to things they had said publicly that I disagreed with. They were both "copied" but neither disputed my challenges. What was perhaps more interesting, and certainly more depressing, were the comments I received from third parties.

In the case of the first, surprise was expressed that I had challenged the professional in question. Little about the points I had made. I had been extremely careful to make sure that my points were fact based, but it was still a bit galling that the attention seemed to be elsewhere.

In the case of the other, I had pointed out that a chart had been presented in a misleading way. It used two vertical (y) axes, one for each line, but they did not correspond. This is something that statisticians warn about, and that regulators pounce on when it appears in public (renowned statistician David Spiegelhalter devoted a large part of his excellent book, The Art of Statistics, to the matter).

However, I received comments from individuals, themselves senior financial professionals, that betrayed a worrying lack of understanding about the need to be careful when communicating complicated investment concepts to retail investors/non experts. The fact is that making only a suggestion that there is causation as the aforementioned chart did is not good enough. It is important that one must also provide the logical explanation for it. If indeed it exists, that is.

With this latter remark in mind, it's time for something a bit more lighthearted.

I don't know who Tyler Vigen is, but he or she must have spent many many hours trawling through disparate data series looking for pairs where there was a high degree of correlation, creating charts, and putting them on a website, Spurious Correlations.

Tyler assumed the high correlations were spurious. But what if they weren't? Below are Tyler's charts, together with my entirely logical explanations for them. I have done five, and would welcome your suggestions for the rest (or indeed better ones for my five). There will be a prize, and it might even correlate with the best entry!

By the way, there are two explanations for each chart - it would be utterly irresponsible of me to assume a particular direction of causation.

Finally, thank you, Tyler, for your fabulous website. And thank you, Hannah, for your brilliant quote at the beginning of this post.

A. More math doctorates awarded means a greater understanding of the link between greenhouse gases and atmospheric temperature, of the need for clean energy, and thus of the need to stockpile uranium...

B. Uranium stored at US nuclear power plants produces dangerous radiation which turns people into math geeks...

A. The best place to practice spelling is outdoors...where the venomous spiders live...

B. It has been proven that spider venom enhances memory. While it won't have done those who died any good, it did help the survivors...

A. Americans who buy Japanese cars later feel they have betrayed their country. With that comes a great sense of remorse that leads them to...

B. Suicide attempts by crashing of motor vehicle tend to be more successful in bigger, heavier cars that have more momentum. This leads to a perception that bigger, heavier cars are more dangerous and an increase in demand for smaller Japanese cars...

A. The older the winner of the Miss America competition, the more she is admired by older generations who are more familiar with steam engines and thus how hot vapours, objects etc can be used to get rid of their annoying spouse...

B. The more murders by steam, hot vapours and hot objects, the more finger print evidence gets destroyed, the fewer crimes get solved, the greater the demand for youngsters to become crime stoppers, and the fewer youngsters there are to enter Miss America competitions, thus favouring older entrants (ok this is particularly absurd but then so too is collecting data about steam, vapour, hot object murders).

A. The more cheese people people eat, the weirder their dreams, the more they toss around in their sleep, and the more likely they are to get fatally entangled in their bedsheets...

B. The more entangled bedsheet deaths, the greater the fear of going to bed, the more people stay up snacking, which for many means higher consumption of cheese slices...

The views expressed in this communication are those of Peter Elston at the time of writing and are subject to change without notice. They do not constitute investment advice and whilst all reasonable efforts have been used to ensure the accuracy of the information contained in this communication, the reliability, completeness or accuracy of the content cannot be guaranteed. This communication provides information for professional use only and should not be relied upon by retail investors as the sole basis for investment.

© Chimp Investor Ltd