The Lucy Letby case: A Critical Thinking Approach

Written by Professor Gloria Moss PhD; FCIPD on September 23, 2023. Posted in Current News

Professor Gloria Moss, a respected British academic, writer and researcher, takes a Critical Thinking approach to the evidence concerning the UK’s ‘worst child serial killer‘, Lucy Letby, who was convicted of  7 murders and 7 attempted murders of new borns at Manchester Crown Court in August 2023.

The following is the basis of a live news talk interview of Dr Moss on TNT Radio’s Sky Dragon Slaying show, broadcast live on Saturday 23rd September, 2023 at 7pm to 9pm Eastern.

The chronology   

Lucy Letby (LL) worked at the Countess of Chester neonatal unit from 2012. From at least 2014 this was a Level II unit, taking very premature babies. From mid-2015 to mid-2016, 15 infants died, and a similar number had major collapses. This was far more than in the preceding and subsequent periods (see Figure 1 below).

The consultants raised alarms, leading to internal investigations then a review by the Royal College of Paediatrics and Child Health (RCPCH), commissioned in mid-2016 and published in November 2016.  Note that over the period 2015-2016, there was also an increase in stillbirths in the hospital.

Figure 1: Timeline of neonatal deaths at Countess of Chester Neonatal Unit (from Chimp Investor). These data are from an FoI and specific to the hospital (source:  Livermore, 2023)

In June 2015, infants A, C and D died.  Child E died in August and Child I in October. By late 2015, a senior doctor at the neonatal unit emailed the Chief Executive, Tony Chambers, to warn that chaotic conditions meant it was unsafe for patients and staff.  He said that staff were in tears because they were ‘chronically overworked’ and forced to have more babies than could be safely cared for in the unit.   The senior doctor, who cannot be named for legal reasons, wrote: ‘This is now our normal working pattern and it is not safe. Things are stretched thinner and thinner and are at breaking point.’   At the time he was writing, the ward had a fifth fewer nurses than it should have done, and LL was undertaking a lot of overtime to fill the staffing deficit.

In June 2016, two of three triplets, O and P, died.  In the same month, a meeting of Exec Directors had concerns about the unit leadership and fears that the doctors were carrying out a ”witch-hunt’, accusing LL of being behind the spike in deaths since she had been on shift for each incident.  By July 2016, LL was moved away from her frontline nursing duties on the neonatal unit and initiated a grievance procedure against the Trust on 7 September.  She alleged victimisation, bullying and making false claims by the consultants and discrimination by the hospital.  Her union representative emailed hospital bosses outlining ”grave concerns“ about her treatment, and demanding to know the grounds for the investigation.  Post-mortems, performed for six of the seven deaths for which Letby ultimately was convicted, recorded “natural causes”.

The doctors who had raised concerns about her being a baby killer, including Dr Brearey and Dr Jayaram, were interviewed along with their union representatives where an investigator grilled them about Letby’s bullying complaint.   Ten hospital staff were interviewed as part of Letby’s complaint and many had threatened to call the police if she was allowed back on the ward. Not everybody agreed with them, however. One senior nurse gave evidence saying the doctors were operating ”a witch-hunt“, adding: ”I hope she returns to the unit . . . we would be delighted.“

On 12 November, the grievance investigation was completed.  It found no evidence to justify calling in the police. In fact, it found that the doctors were at fault for suspecting her of murder, writing that ”This behaviour has resulted in you, a junior colleague and fellow professional, feeling isolated and vulnerable, putting your reputation in question,“ the grievance inquiry told Letby. ”This is unacceptable and could be viewed as victimisation.“   The report stated that the hospital would aid her professional development by supporting her with a master’s degree or an advanced neonatal course. She was also offered weekly welfare meetings with a senior nurse. Documents show hospital managers proposed offering her an observational role at Alder Hey Children’s Hospital in Liverpool as well as support for a potential master’s degree or advanced nurse training.

Three days later, HR and senior nurses discussed Letby’s possible return to the neonatal unit and three days before Christmas 2016, Tony Chambers issued her with a full apology on behalf of the hospital trust and was also offered her a role at Alder Hey.  He assured her family that the doctors who had victimised her would be ‘dealt with’ and according to one of the doctors, Dr Brearey, the doctors were told that a line had been drawn, and that “we were not to cross that line, and if we were to cross that line there would be consequences.”  The doctors were forced to sign the apology letter.

By November, the RCPCH report, expressed concern about the unit’s staffing and safety, stating that it was unsuitable for Level II care, and by that point the unit had been downgraded to Level I provision anyway.

In January 2017, the hospital held an extraordinary board meeting, at which the board, chaired by Sir Duncan Nichol, was updated on the RCPCH review. Nichol was head of the NHS at the time of the Beverley Allitt scandal (Allitt was the  nurse found guilty of injecting infants with insulin and air bubbles in 1993).  The Medical Director, Dr Ian Harvey, stated that the report had found the incidents were down to ”issues of leadership, escalation, timely intervention“ and that it ”does not highlight any single individual“. He said some case reviews were continuing but were not expected to change that finding.

The doctors were not invited to the board, and a victim impact statement from Letby’s grievance was read out. ”There was an unsubstantiated explanation that there was a causal link to an individual,“ Chambers said. He told Nichol he was “seeking an apology from the consultants”.

By now, Drs Brearey and Jayaram, along with five other clinicians, were being backed into a corner by management. In January they met Chambers and Harvey and were told: “Things have been said and done that were below the values and standards of the trust.”

Managers also demanded “mediation” between LL and Drs Brearey and Jayaram and Dr Harvey told them it would protect them from a referral to the General Medical Council (GMC), the doctors’ watchdog.  Their BMA union rep told them while there were “disturbing similarities to Beverley Allitt” they should agree to write Letby an “apology letter” which they reluctantly agreed to.

In late January 2017, they wrote to Chambers asking for a full investigation: “What is the reason for the unexpected and unexplained deaths? What should we as paediatricians do now?”  On February 5, The Sunday Times reported that deaths in the baby unit at the hospital were being investigated.  In a letter to LL dated 1 March, all the paediatricians apologised stating. “We are sorry for the stress and upset that you have experienced in the last year”.  Later, Dr Susan Gilby who replaced Chambers as Chief Executive of the Countess of Chester hospital at the end of 2018, reported that the Medical director at the hospital, Dr Ian Harvey, had urged her to report Dr Brearey and his consultant colleagues to the General Medical Council.  In July 2022, she complained of bullying by the ex BBC accountant Chairman (appointed in 2021), Mr Haythornthwaite and subsequently resigned, claiming constructive dismissal.

Applying Critical Thinking:   human, structural and medical issues                                     1                      

Much has been written about the case and subsequent conviction of LL.  It is not the place of this article to call into question the conviction but rather to draw attention to the human, structural and medical issues that may have played a role in the high incidence of deaths in the neonatal unit.  Some/ many of these were ignored or downplayed during the trial, and the importance of airing these issues may be one reason why doctors, academics and scientists are calling for an appeal so that all issues can be thoroughly aired.

Much of the medical and scientific evidence presented here is taken from the ‘Science on Trial’ website as well as from evidence presented to the court and reported in the media.  We will now look at three issues, the human, the structural and the medical, that will all have influenced events at the Countess of Chester neonatal unit.

1.Human issues 

Both LL and subsequently the Chief Executive, Dr Susan Gilby, spoke of a culture of bullying at the hospital.  In both cases, the two people reporting on this were both women, and the reported and alleged bullying came from men senior to them.  The bullying against LL was the subject of a Grievance procedure that went in LL’s favour and we await the outcome, via a Tribunal hearing, of the alleged bullying suffered by Dr Susan Gilby.  Both would constitute cases of ‘downward’ bullying, with women as the object of bullying by men.

Research finds that men bully more than women (60-75% of those who bully others in the workplace are men) with women as a frequent target (60-75% of the targets are women).  Research also reveals a bullying culture in the NHS.

Critical Thinking approach                                                                                                                             A complete picture of the situation at the Countess of Chester neonatal unit cannot be formed without considering these human elements since people’s behaviour is influenced by the cultures within which they work.

2.Structural issues

The report from the Royal College of Paediatrics and Child Health (RCPCH) November 2016 highlighted a large number of structural issues (a-h below):

a.There was insufficient staffing for a Special Care Unit (SCU)

b.Consultants only held 2 ward rounds per week (non-compliant with the guidance from the British Association for Perinatal Medicine, BAPM).  The report notes that “there should have been a greater consultant presence on the ward”.

c.21% shortfall in nursing staff levels in 2014-5.  Band 5 and 6 nurses are frequently agency staff.

1. The ward had insufficient senior cover
2. The unit did not comply with conditions for a Tier 1 and Tier 2 rota
3. There was a reluctance to seek tertiary level advice and escalate concerns in a timely manner
4. Physical separation from tertiary units
5. Inadequate lighting in the unit

Note that of the 7 consultants in the unit, only one was expert in neonatology.  Proposals were underway to appoint 2 additional consultants, one with expertise in neonatology and another in diabetes.  Note also that there is no nationally agreed template on conducting morbidity reviews in neonatology.

As corroboration of points (a)-(e) highlighted by the RCPCH, an anonymous senior doctor (paediatrician)  spoke of under-staffing at the neonatal unit, writing of  chaotic conditions that meant it was unsafe for patients and staff two years before Letby was suspended.  This doctor emailed hospital chief executive Tony Chambers in late 2015, stating that staff were in tears because they were ‘chronically overworked’ and forced to have more babies than could be safely cared for in the unit.

The senior doctor, who cannot be named for legal reasons, wrote: “This is now our normal working pattern and it is not safe. Things are stretched thinner and thinner and are at breaking point.”   At the time of the email, also reported by The Sunday Times, the ward had a fifth fewer nurses than it should have done.   Letby’s trial heard that she volunteered for extra shifts and so was often left alone with babies.

A further structural problem concerns the plumbing at the unit.   According to a plumber called to give evidence at the trial, the pipes in the ceiling above the unit were leaking a ‘regular infusion of a toxic brew of microbes’.  A contaminated water system of the kind described in his testimony can cause clusters of neonatal unit deaths because preterms – and 94% of the infants included in the indictment were born preterm (ie born at < 37 weeks of pregnancy) – do not have a functioning immune system.    The microbes could easily become aerosolised and colonise all sorts of places, setting the scene for sepsis, pneumonia , encephalitis and other problems.

Critical Thinking approach:  the gravity of the structural problems in the neonatal unit highlighted by the RCPCH report, the senior paediatrician and by the plumber, make it appropriate to ask to what extent these factors were fully aired and factored into the evidence and judge summaries offered at the trial.  They do not appear, for example, to be present in the thinking of one of the expert witnesses on the prosecution side, Dr Evans, who, in September 2023, was recorded as stating that “These tubes can come out accidentally, but for so many to come out is very, very unusual, especially in what I consider to be a good unit” .  There is no evidence to support the statement that this Unit was a ‘good’ one and Dr Evan’s statement suggests that he was not fully apprised of the structural challenges besetting the unit.

3.Medical issues

A.Possible medical errors

The medical and scientific evidence presented at the website ‘Science on Trial’ highlights the possible incidence of a number of medical errors, including, but not limited to the following points (a)- (g).  We say ‘possible’ since further investigation would confirm the extent to which these were genuine professional errors:

a.Several infants were noted as requiring a lumber puncture (presumably to ascertain risk of meningitis) but Child C and D died before this was performed by medical staff.

b.Ventilators.  The consultant (Dr Brearey) and the registrar (Dr Ventress) attempted to ascertain the cause of desaturation in an infant on a ventilator.  Both determined that the cause was equipment malfunction even though the phenomenon recurred once the ventilator was changed and no diagnostic steps were taken prior to their removing the infant from the ventilator.  The removal from the ventilator was not discussed as a factor in the infant’s death.

1. Ventilarors: Where Child I is concerned, Dr Gibbs removed the Child from the ventilator at 12:45 am, despite her showing signs of seizure activity (lip smacking, posturing) and despite the fact that she had repeated periods of apnoea. After removing the child from the ventilator, Dr Gibbs left the ward and returned home. At 2:10 am, Child I was pronounced dead. Given that 85% of sudden infant deaths occur during the night-time hours, one might question the removal of a child from a ventilator at night time when fewer clinical staff are available.  Moreover, it is known that it is a significant challenge to wean extremely premature infants from mechanical ventiliation.

d.Two infants were reintubated by doctors before surfactant (substance that reduce the tensions between two liquids) was administered and there was no assessment as to whether these failings contributed to their deaths.

e.LL was accused of dislodging a breathing tube, with the prosecution stating that the baby could not have played a role in dislodging the tube since it was sedated.  In fact, it has been proven that the baby was sedated after the tube was inserted, and not before.  This means that the baby could have played a role in dislodging the tube and so no human agency is needed in explaining this death.

f.The prosecution alleges that LL turned the baby monitor off.  In fact, a doctor had failed to turn it back on following examination of the baby, with a nurse other than LL testifying to the fact that the doctor apologised for failing to turn it back on.  The doctor is believed to have denied this in his testimony in court

h.Child J’s mother compared conditions at the Countess of Chester Hospital and Alder Hey, stating that the staff at the Countess of Chester hospital “did not take her or her husband’s concerns seriously when they raised them”.  In the parents’ view staff in Chester “did not have the same competence and ability” as those at Alder Hey.

B.Failures in the probing of scientific evidence 

Based on the scientific and medical evidence presented in ‘Science on Trial’ and other reports, it would appear that insufficient evidence was presented to the court in respect of six issues, namely:

1.The incidence of air embolism

2.The presence of sepsis

3.The prematurity of the infants and the impact on treatment regimes and likely survival

4 The presence of insulin

5.The notion of stability in infants

6.The conduct of the medical investigations

We will look briefly at these six issues, drawing exclusively on evidence in evidence presented in ‘Science on Trial’ as well as accounts from the court proceedings and other articles.

1.Air embolism: in blood:

Dr Dewi Evans, one of the medical experts called upon at the trial by the prosecution suggested that LL had injected babies with air, causing their death.  This was said to apply to injection into the veins of childs A and D and into the stomachs of child C, I and P.  The court appears not to have been presented with full evidence concerning the following six points (a) –(e):

1. The single publication that Dr Evans referred to – a 1989 paper – explicitly associates the occurrence of air embolism in neonates with a mean gestational age of 30 weeks, but certainly less than 37 weeks. The paper cautions the use of post-mortem xrays stating that: “Postmortem radiographs need to be interpreted with caution as intravascular air may appear as early as 25 minutes after death” (ibid, p.508). So, unless the xrays were obtained within 25 minutes of death, they cannot be relied upon for a diagnosis of air embolism.
2. None of the autopsy findings suggested that the children died due to air embolism and so the question arises as to whether the pathologist(s) and coroner responsible for those autopsy reports were negligent in their duties.
3. There is no evidence to support the claim that air injected into the gut via a nasogastric tube causes a splinting of the diaphragm sufficient to limit the regulation of breathing
4. Despite being aware that Child C was born with air in his stomach, Dr Evans claimed that LL injected air into stomach and bowel of this child. According to evidence presented in the Science on Trial website, it would not have been possible to successfully inject air into the stomach and bowel of the child since an air bubble would have formed in the tube rather than in the child’s body.
5. Air embolism is a “rare complication of intensive care” (Beluffi and Peroti). By way of example, CPR in preterm infants is associated with systemic air embolism in the gut.

2.Sepsis

The medical records report ‘possible sepsis’ for every infant, and the symptoms experienced by the deceased infants may indeed signal an infection of some nature.  Despite this, no infectious disease expert was called to present witness testimony to the court to concerning the following six points:

a.why no investigation surrounding infectious diseases took place and why no infectious disease was ruled out

b.what possible disease pathogens pose a risk to neonates during the perinatal period, some of which can be associated with sudden neonatal collapse/ death.

c.what sort of infection prevention protocol was implemented

d.how often environmental swabs were taken, for example of air ducts, to identify pathogens and the results

e.what special precautions were taken to protect the neonates

f.whether the staff were instructed in strict antiseptic protocols

A witness was called by the Defence who testified to the presence in the unit of a ‘regular infusion of a toxic brew of microbes leaking from the pipes in the ceiling above’.  A contaminated water system of the kind described could result in microbes becoming aerosolised and colonising all sorts of places.  Since preterms – 94% of the infants included in the indictment were born preterm (ie born at < 37 weeks of pregnancy) – do not have a functioning immune system, this sets the scene for sepsis, pneumonia, encephalitis and other conditions.

3.No context was provided as to the dangers present in premature babies

Despite 17 out of 18 of the infants included in the indictment being born preterm (ie born at < 37 weeks of pregnancy), this was not a focus of the expert witnesses’ statements. These are figures based on the data available at the time of writing this note in September 2023 (see Table 1 below):

Table 1:  Data available at Sep 2023 on the proportion of infants included in the indictment that were preterm

In England and Wales, the incidence of perinatal death for very preterm infants in 2015 was ~ 8%

Of the 17 infants included in the indictment, 4 were very preterm (< 32 weeks) and there was no discussion of the increased mortality associated with:

a.low body weight (< 1000gr)   The court appear to have ignored findings from Jensen et al, 2015, that death for extremely preterm babies is associated with mechanical ventilation

b.twin births

c.male gender

d.maternal complications

1. excessive cardiopulmorary resuscitation that exceeded the ILCOR guidelines

4.Insulin  Child F and L 

At the heart of the case were two babies who were identified in 2018 by Dr Brearey, a consultant in the neonatal unit at the hospital, as having exceptionally high levels of insulin. The high insulin concentration led to the prosecution witnesses’ theory that Lucy had spiked the nutrient feed, given to babies intravenously, with insulin to cause the infants deliberate harm.

They claimed that the bag was rigged to run over 48 hours but there appear to be a number of logistical issues that may, according to other commentators, have been given insufficient attention in the trial.  Just two of these are the following:

a.the bag had to be changed after LL went off duty because of problems with the line

1. the normal practice is for two staff members to check dispensing and administration of medicines so it is not clear how LL could have administered insulin without other personnel being aware of this at the time.

In terms of scientific evidence, one of the expert witnesses, Professor Hindmarsh, claimed that a high insulin concentration could only occur due to exogenous administration.  However, as the Science on Trial website points out, this is not scientifically plausible for two reasons:

a.studies demonstrate that 50% of infants born to mothers with gestational diabetes – the case of child L – have maternal insulin autoantibodies (MIAAs) in their circulation at birth (Ronkainen et al, 2008).

b.Insulin delivered via a bag may not be well absorbed by a neonate.  So, although Professor Hindmarsh testified that there are no studies detailing the adsorptive properties of insulin, there is in fact research showing that:

(i) insulin adsorption to the venous lines can result in a decrease of insulin delivery by as much as 70%

(ii) the formation of bonds to the plastic bag delivering the ternary parenteral nutrient (TPN) solution and/or dextrose saline solution can reduce insulin delivery by up to 60%

(iii) insulin added to TPN and/ or dextrose solutions is unstable and results in decreased bioavailability of insulin by ~40%.

5.Assertions of stability in neonates without supporting medical evidence

The prosecution stated that a child born at 29 weeks gestation was ‘very stable’ prior to experiencing a bout of sudden projectile vomiting.  However, white matter brain injury is present in up to 50% of very low birth weight infants (Romero-Guzman and Lopez-Munoz 2003, Agut et al, 2020), there had been no assessment of the infant child’s brain to ascertain if they were suffering from this condition. one that would account for the apparent stability of the child.

6.The conduct of the medical investigations                                                                                              It is apparent that a crucial element in the Lucy Letby case is the reliability of the original investigation.  At least three questions appear not have been addressed during the trial:

1. Dr Dewi Evans undertook the initial triage of the infant deaths, ascertaining which he considered to be suspect deaths rather than deaths that he stated were from ‘the usual problems’. Dr Evans retired as a paediatrician in 2009 and since he is neither a forensic scientist, nor a pathologist, nor someone with formal training or a background in the principles of scientific research, and neither is he a neonatologist, questions have been asked as to whether he had the appropriate skills to undertake the investigative task assigned to him.
2. Dr Dewi Evans undertook the initial triage of infant deaths that were to be considered suspect. According to Professor David Livermore (2023), Dr Evans reviewed 30-something deaths and collapses, distinguishing 15 (eight murders and seven attempted murders) whose deaths were not natural and in respect of whom he thought that (a)air was injected (b) milk injected into their stomach (c) trauma experienced or (d) with high insulin levels injected into their systems. Unfortunately, his workings are not published and so the precise reasons why he excluded seven deaths cannot be examined (Livermore, 2023). As mentioned in (a) immediately above, he did indicate during an interview on Talk radio that “they died for the usual problems why small babies die: haemorrhage, infection, congenital problems”.

c.Dr Evans conducted the investigation with the assistance of those consultants employed by the Countess of Chester Hospital, in the neonatal ward.  Given their presence on the ward and the fact that they were employed by the same employer as the accused, several voices have questioned their involvement in the investigation.

It should be noted that O’Sullivan (2023) has quoted the fact that Dr Evans’ testimony has been discounted in a previous case, writing that:  ‘In previous trial work the Lord Justice of Appeals had rejected Dr Dewi Evans’ evidence, describing it as “tendentious and partisan expressions of opinion that are outside of Dr Evans’ professional competence” which had “no place in a reputable expert report.”

Individual case histories:  information concerning individual deceased children is contained in Appendix A.  This information is taken from that found in the website ‘Science on Trial’ as well as from trial reports.

Critical Thinking approach:  where the medical aspects of the case are concerned, asking the questions posed by scientists, doctors and academics on the Website ‘Science on Trial’ and elsewhere produces very different conclusions from those arrived at by the court which neglected to pose these questions.   This strongly suggests that many questions need to be answered before final conclusions can be relied upon, one reason why commentators such as Professor David Livermore are calling for an Appeal at which the evidence omitted from the first trial can be aired and debated.

Conclusions

A Critical Thinking approach to the evidence presented at the trial and subsequently by commentators suggests that many issues have failed to be presented or examined in the requisite depth at the first trial of LL.   An appeal would focus on the three issues presented here namely those relating to the human issues at play (a culture of downward bullying perpetrated by men on women); to the serious structural issues at play (inadequate staffing and plumbing that could have given rise to sepsis) as also the multiple medical and scientific issues.

This article is intended as a non-partisan contribution to the ongoing debate, drawing on evidence available from other sources including, but not limited to, the ‘‘Science on Trial’ website.  A set of indicative references can be found in Appendix B, with details of six of the infants that died presented in Appendix A.

About the author:

Gloria Moss PhD FCIPD (Prof) Is the author of c.80 peer reviewed journal and conference papers and 8 books.   She is a Social Scientist with a background in People Management and Organisational Psychology and has been a long-time reviewer for Peer Review journals.  She is a strong advocate of a Critical Thinking approach to evidence and has co-authored the book Light Bulb Moments and the Power of Critical Thinking, written with Katherine Armitage.   A revised edition of this book was published in 2023 by Truth University Press and copies can be obtained from Truth University by emailing [email protected]  

APPENDIX A

Information concerning individual deceased infants

ChildA                                                                                                                                                                             In the case of Child A, Child B’s twin brother, the defence barrister, Mr Myers, noted that the supposed skin discolourations were not mentioned in contemporaneous notes and were not mentioned to the coroner after his death.  Mr Myers stated that what happened in the case of Child A was “suboptimal care, inadequate staffing and a collapse and death in front of everyone and when Ms Letby had been there for 20 or so minutes”.

“There’s no suggestion in evidence she did anything physically to [Child A] at all,” Mr Myers was on record as stating.

Mr Myers went on to remind the jury that at some point after 17:00 on 8 June 2015, Dr David Harkness inserted a long line into Child A, which was intended to deliver fluids.  He said medical notes stated the line should be “pulled back” since it was “not properly sited”.  “The line was too close to the heart,” he said.  “It was left there when it should have been moved, fluids were put down it and [Child A] went into fatal collapse 20 minutes after that.”

He said the prosecution had “bowled out” allegations without any support in fact and had been “lumping everything together and saying it must be [Ms Letby] because she’s there”. (for this, see https://www.bbc.co.uk/news/uk-england-merseyside-66034286).

The evidence given by Professor Owen Arthurs, Gt Ormond St, does not mention this since he refers only to the fact that there is “a line of gas just in front of the spine. That is an unusual finding.”  He claimed that such an image would not be seen in deaths by natural causes but had been documented in cases of road traffic accidents and sepsis infection.

He went on: “In my opinion this was an unusual appearance. In the absence of any other explanation this appearance is consistent with, but not diagnostic, of air having been administered.”  One may well ask why Professor Arthurs not draw attention to the possibility of sepsis in the infant.

He also stated that Child A did not have intravenous fluids for up to four hours on June 8 before he received glucose through a “long line” plastic tube at 8.05pm (shortly after the defendant came on duty).  Earlier on in the shift, a cannula to a blood vessel stopped working, followed by two failed attempts to correctly insert a catheter in the belly button.  Prof Arthurs told the court it was “possible” that gas could have been introduced by one of those above devices.

Professor Arthurs stated that he was unable to ascertain from the image alone that an air embolism – a gas bubble which enters a blood vessel – was the cause of Child A’s death.   He based his opinion on a published peer-reviewed study in 2015 which looked at how common it is that gas occurs in older children who have died, albeit with “very few babies” included in the study.  One can well question the wisdom of placing exclusive reliance on this 2015 study.

Dr Dewi Evans, retired consultant paediatrician from Camarthen, also gave evidence.  He cited a 1989 paper on air embolism in infants – in that 11% of 53 children had displayed signs of skin discolouration but there was no tangible evidence of this in Baby A, only the word of a registrar.

Child F

The prosecution have claimed that this boy was poisoned with insulin via his feed bag by Ms Letby in August 2015.   The court has heard the boy’s blood samples showed an “extremely high” insulin level and a very low C-peptide level.  A medical expert for the prosecution previously told the court that had “only one explanation”, which was that the child “received insulin from some outside source”.   How could LL have known which bags were going to be given to Child F?   She’d have had to spike all of the bags and yet no other child was affected.

Child G

The court heard that at around 15:30 BST on 21 September, Child G was cannulated by doctors and placed on a Masimo monitor, a portable device that continually measures oxygen saturations and heart rate levels.

A nurse, who cannot be named for legal reasons, previously told the jury that shortly after the procedure, Ms Letby shouted for help from the nursery where Child G was.  She said that she responded and noticed that the monitor had been switched off, which was “not normal protocol”.

Mr Myers said the prosecution suggested in their opening that Ms Letby turned the monitor off, but in evidence her colleague had refuted that. In her evidence, she said Dr John Gibbs and Dr David Harkness had apologised to her, as they had not switched the monitor back on after carrying out a procedure on the infant.

“If it hadn’t been for [that nurse], we would be left with the usual wall of denials,” Mr Myers said.

He said the claims in the prosecution opening showed a “common theme of blaming Ms Letby” for other peoples’ failures (for this, see https://www.bbc.co.uk/news/uk-england-merseyside-66045260).

Child K

Dr Jayaram claims to have found LL in Feb 2016 dislodging a baby’s breathing tube before he came into the room.  He claimed that the baby was sedated and so the dislodging of the tube must have been intentionally caused, rather than occurring as a result of movement by the baby.  In fact, the baby had not been sedated.   Clinical notes showed that Child K was given morphine following her collapse, and not before.  What is more, Dr Jayaram  never raised a formal internal complaint via the Datix reporting system about this alleged incident.

Child L

Was born to a mother who was seriously unwell and had a diagnosis of gestational diabetes.  This would produce non-immunoglobulin transfer of maternal insulin into foetal circulation, increasing at delivery, and yet Professor Hindmarsh asserted that the insulin must have been delivered via dextrose/ TPN solutions.  Yet, studies demonstrate that 50% of infants born to mothers with gestational diabetes have maternal insulin autoantibodies (MIAAs) in their circulation at birth (Ronkainen et al, 2008).  Prof Hindmarsh is Emeritus Professor from UCL.

Child P                                                                                                                                                                    Dr Evans considered that an “excessive” amount of air detected in Child P’s bowel on the evening of 23 June could only be explained by “additional air” having been injected. The court heard that the air “destabilised the baby” and he was unable to take feeds on the evening of 23 June.   The infant eventually stabilised, but by 09:50 BST on 24 June he collapsed and required breathing support.  Child P collapsed several more times on 24 June, before being pronounced dead at 16:00 after 45 minutes of unsuccessful resuscitation attempts.

Another expert witness, Dr Bohin, included in her report on Child P that there was “unacceptable delays” in the treatment of a pneumothorax, a collection of air outside the lung.  Dr Bohin agreed that “questions need to be asked of the clinicians involved” in Child P’s ventilation strategy that day.  After it was drawn to her attention that she had noted an “unusual” starting dose of adrenaline given to Child P on the morning of 24 June (Child P having been administered “precisely double” the intended dose), Dr Bohin’s stated that she did not “think it had any adverse effect, in that the infusion was started after [Child P] had at least two of his collapses”.   It would be prudent to have a second and third opinion as to whether the likely ill-effects of the mal-administration of adrenaline should be discounted as a cause.

                                                                  APPENDIX B

INDICATIVE REFERENCES

Please refer to the ‘Science on Trial’ for more complete references: www.scienceontrial.com

Medical articles quoted during the trial by expert witnesses

Deepak, L., Amer, R. And Elsayed, Y. (2018), Cardiac air embolism in neonates:  a hemodynamic perspective, Annals of Journal of Perinatology, 35 (7), 611-15, https://pubmed.ncbi.nlm.nih.gov/29186727/

Lee, S.K. and Tanswell, A.K.(1989), Pulmonary vascular embolism in the newborn, Archives of Disease in Childhood, 64, 587-10 https://adc.bmj.com/content/archdischild/64/4_Spec_No/507.full.pdf  https://pubmed.ncbi.nlm.nih.gov/29186727/

Paper on the tests for good evidence:

https://outlook.live.com/mail/0/inbox/id/AQQkADAwATY0MDABLWQwODgALWVjNjMtMDACLTAwCgAQAJBv0VKmInpIhAOSkZiPpq8%3D

Articles questioning aspects of the trial

Livermore,David (2023), https://dailysceptic.org/2023/09/11/lucy-letby-must-be-allowed-an-appeal/. 11 September

O’Sullivan, J. (2023) – https://principia-scientific.com/shocker-is-key-expert-witness-in-uk-nurse-baby-killings-trial-exposed/, 25 August

Science on Trial papers concerning the lack of reliability of expert witnesses https://www.scienceontrial.com/post/the-lucy-letby-trial-breaking-down-the-case-law-on-the-reliability-of-experts?postId=6fa95a11-cd68-4d59-b357-891033818d4b&cid=fc915f17-ad58-45a9-a459-5525afeb925f

https://www.scienceontrial.com/post/the-lucy-letby-case-issues-of-reliability

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