Further thoughts on Lucy Letby

Her defenders have some explaining to do

When I wrote about Lucy Letby last weekend, I didn’t realise how widespread Letby trutherism had become. I certainly didn’t expect the Guardian and the Telegraph to come out batting for her, but that’s what happened on Tuesday. Attempts to suppress the infamous New Yorker article led to a Streisand effect and reporting restrictions during the re-trial seem to have bottled up a lot of scepticism about the case that has now burst forth. Unless Letby confesses or the Home Secretary orders a re-trial, this story will run and run.

Letby’s defenders are not all headbangers and I can understand why they have their doubts about the conviction. Her text messages at the time and her statements under interrogation are all consistent with her being a conscientious and caring nurse. Even the “I killed them on purpose” note has to be read in the context of her other notes protesting her innocence and her deteriorating mental health. It would not be the most surprising thing in the world if she turns out to have been the victim of an extraordinary set of circumstances.

Nevertheless, it would be quite surprising, and if you’re going to spend your time trying to free her, I beseech you to familiarise yourself with the case. Part of the problem is that there is no easy way to fact check the various claims and counter-claims. When I said in the previous post that I have not read the 7,000 page court transcripts, some people took it as a self-own, but the transcripts are not available online and, as far as I know, never have been (the author of the New Yorker article claims to have read them but I am not sure how). The transcript of the appeals court judgement is available online and should be read by anyone who is interested in the case. It gives a very different impression to that given by the three articles mentioned above.

The New Yorker and Telegraph articles argue or imply that the Countess of Chester neonatal wards were full of very premature and sick babies who were at death’s door and that there was nothing suspicious about the spike in deaths in 2015-16 which could have been the result of chance or under-staffing. It was only in retrospect that the cluster of deaths was seen as strange and it was then that the police brought in Dr Dewi Evans who decided that any death he could not explain was due to air embolism and must therefore have been murder.

This is what the Telegraph says…

Throughout the trial, the prosecution insisted that the babies who had died or been harmed at the Countess of Chester were in relatively good health. 

Infants were variously described as “in good condition”, “stable”, “all observations normal” “doing well” and even “excellent”.

Yet it is clear that many of the babies were born desperately early, had extremely low body weight and, from birth, were beset with numerous complications. 

“Doing well” is obviously a relative term when you’re talking about premature babies in the intensive care wing of a neonatal hospital. The point is that they didn’t look as if they were suddenly going to die. And we know that such babies rarely die because there were only two or three deaths of early neonates per year in the Countess of Chester, except in the two years when Lucy Letby was working in intensive care.

The Telegraph continues…

The experts said Baby A could be considered “stable” because he did not require oxygen ventilation and was doing “so well” that medical staff decided to start giving him some feeds.

But the other babies who died were also vulnerable and initially, nobody considered their deaths to be suspicious, merely a natural outcome of prematurity, illness and even sub-optimal care. 

For doctors to consider a death to be ‘suspicious’ would require them to believe that one of their colleagues was deliberately murdering babies. Naturally enough, this thought did not occur to them until the evidence began to mount. Nevertheless, the pathologist in the Baby A case said (at the time) that the death was “unascertained”.

Baby B, the twin of Baby A was born at just 31 weeks, blue and floppy and needing resuscitation, to a mother suffering from an auto-immune disease that can increase blood clots, and both babies initially needed help breathing.

Likewise, Baby D was delivered by C-section and within 12 minutes of birth had lost colour and become floppy in her father’s arms, later showing signs of respiratory distress and an infection. 

She had been born early when her mother’s waters broke early putting her at risk of health problems with breathing, feeding and infection. Her mother should have been given antibiotics but was not, an error for which the hospital was criticised. 

After death, the coroner ruled Baby D had died from pneumonia with acute lung injury.

Put like this, it seems almost inevitable that these babies would perish from natural causes. But neither the Telegraph, the Guardian nor the New Yorker have much to say about how these babies actually died. So let’s look at what the appeals court transcript says about these three cases, starting with Baby A:

Dr Bohin explained that she would have expected Baby A to have had a number of problems in the neonatal period but, surprisingly, he had not and whilst he needed some respiratory support he was breathing room air. She accepted that it had not been ideal that Baby A had been without fluid for four hours but did not accept that this would have caused a sudden collapse. She disagreed with the suggestion that a baby in this condition might deteriorate dramatically and suddenly.

Dr Sandie Bohin is a practising consultant neonatologist who was brought in to assess Dr Dewi Evans’ expert opinion. She agreed with him on all the crucial issues. Bohin isn’t mentioned much by Letby truthers because they like to imagine that the case against her was constructed by Evans alone.

The shift leader on duty at the time of Baby A’s collapse said that she had never seen a baby look that way before. Baby A was, she said, “very white with sort of purply blotches and very cyanotic.” Dr Harkness, a registrar who was then in the fourth year of his neonatal training, an ST4, described the skin discolouration as purple/blue with red and white patches which were all over the body from shortly after the collapse until the death. He said that the only other time that he had seen this sort of discolouration was on Baby E. Dr Jayaram, the on call consultant, arrived at 20.23 and described Baby A as having unusual patches of discolouration. The skin was very pale to blue but there were unusual pink patches mainly on the torso which would “flit around.” It was, he said, very unusual and not something which he had seen before.

So that’s three medics who were there at the time saying that what happened to Baby A was extremely unusual. In Evans’ opinion, the collapse and death were caused by air embolism…

Dr Evans said that he had prepared a number of reports about Baby A but that he had not known about the reported skin discolouration when he had first made the diagnosis of air embolus as the witness statements (of the medical professionals treating Baby A) had not been sent to him. He had made a diagnosis on the basis that:

i)  Baby A had collapsed suddenly when in a stable condition;

ii)  there was no evidence of infection or lack of oxygen and the modest fluid loss which had resulted from a delay in putting the line up had not been sufficient to cause the sudden onset unexpected collapse;

iii)  the sudden collapse of a baby, even in the neonatal unit was unusual. Typically there would be warning signs and babies do not go from a normal heart rate and normal oxygen saturations without some warning signs;

iv)  when he had prepared his first report the only other contender for the collapse was the administration of a noxious substance but he accepted in his evidence that there was nothing to support that diagnosis. He was therefore left with air embolus as the explanation;

v)  if the witnesses’ accounts were reliable then the pattern of discolouration and flitting movements was what you get in air embolus.

Dr Bohin agreed with this.

Professor Arthurs [consultant paediatric radiologist] said that Baby A’s imaging showed the gas that would normally be seen in a post-mortem state. There was however another “line of gas” just in front of the spine. This was an unusual finding in the absence of a bony fracture or overwhelming sepsis. The presence of the line of gas was unexplained. He noted that Baby A had an umbilical venous catheter in situ and gas can be introduced into vessels through catheters and devices. He also had a longline. He concluded that the most “pragmatic conclusion” was that gas had been introduced via one or other of those lines.

And there was more physical evidence for the embolism theory…

Dr Marnerides [forensic pathologist and histopathologist] identified the presence of an air bubble at post-mortem histology of the brain and lungs. He said that the presence of the air bubbles was highly suggestive of air embolus, although not conclusive.

Clearly, there was a lot more to this case than Dewi Evans arbitarily deciding that the unfortunate death of a sick infant was actually murder by air embolus. The death was unexplained at the time, three medics said they had never seen anything like it, two neonatal experts ruled out every cause of death except air embolism and two other experts described evidence that was, at the very least, consistent with air embolism.

I’m in no way qualified to pass judgement on the science, and you probably aren’t either, but that was the case. A baby who was expected to live suddenly collapsed and died for no obvious reason. Air embolism was not suspected at the time because it could only have happened if someone had deliberately set out to harm the child - and no one could imagine that - but in retrospect there are a number of clues pointing in that direction and at least three expert witnesses think that is exactly what happened. It is not idle speculation.

The case of Baby B was very similar to that of Baby A (who was her twin brother). Both Evans and Bohin said that Baby B was stable and that her collapse was unexpected. Alternative explanations for the collapse, such as infection and lung problems, were ruled out. As with Baby A, several medics witnessed discolouration that they had never seen before.

At 00.30 Nurse W was in the nursery drawing up medication when the monitoring alarmed. She said that Baby B looked very pale and ill and had blotchy skin. She recorded that Baby B was cyanosed in appearance and that her colour changed rapidly to purple blotchiness with white patches. In her 20 years’ experience as a nurse she had not seen such skin discolouration before. Dr Rachael Lambie was the registrar. Her unchallenged evidence was that the most memorable thing about Baby B was her colour. She was “dusky, so a grey-white colour and then there were patches of discolouration of the skin that were sort of reddy/purple. It would flash up, it lasted around 10 seconds, disappear and then reappear and it was flitting around her body.” She said that the skin colouration was very unusual and not something which she had seen before or since. It was “a very strange and profound colour change.” Dr Y (a consultant paediatrician at the hospital since 2005) saw discolouration which was purple and affected the right abdomen. She too was puzzled by its cause.

The case of Baby D - who, it is important to note, was not born premature and who weighed seven pounds - was similarly exceptional:

Nurse Percival Calderbank checked on Baby D and found her to be settled and stable. She checked again 10 minutes later and found her to be satisfactory. Shortly after this, the monitoring alarm went off and Baby D was found desaturating and with her heart rate dropping. The applicant accepted that she made the unsigned manuscript entry in Baby D’s blood gas chart timed at 01.14 shortly before the collapse. Nurse Percival Calderbank said that Baby D had a “reddy blue/reddy brown rash.” She said that she had not seen anything like it before and described it as being like a mosaic. Baby D’s designated nurse described Baby D’s skin discolouration as being dark and unusual and a deep red-brown colour. She had not seen anything like it before.

… Baby D collapsed again for the third time at 03.45 when she stopped breathing. No skin discolouration was noted. On this occasion, Baby D could not be resuscitated. According to Dr Brunton, he had never seen a baby behave in that manner before or since.

As with Baby A, there were three experienced medics on the scene who don’t recall seeing anything like this before. And, again, we have evidence from X-rays…

Professor Arthurs identified a striking black line from left to right in front of the spine which was either gas in the aorta or the inferior vena cava. He said that he had never seen this quantity of gas in one of the main great vessels where no reason (for example, sepsis or trauma) could be found. It was also present in Baby A. He said that one of the explanations for this finding was that someone was injecting air into the child. In the absence of any evidence that suggested that Baby D had died of overwhelming sepsis or any of the other explanations that had been put forward he concluded that the radiographs were consistent with air embolus.

This was confirmed by another expert…

Dr Marnerides said that the presence of gas in the large intra-abdominal vessel was significant and that body decomposition could not explain its presence. Nor in his view could the presence of infection explain the death.

In the opinion of both neonatal expert witnesses, this was another case of air embolus.

Dr Evans said that Baby D was stable and that the sudden nature of her collapse was incredibly unusual. She was recovering from pneumonia at the time of her collapse. The skin discolouration which came and went was not something which had been seen in a neonate before. The events were all therefore consistent with air embolus.

Dr Bohin said that Baby D had been born in good condition, her pneumonia had stabilised and she was recovering at the time of her collapse. Very graphic descriptions had been given by the nursing and medical team of the skin discolouration associated with the first two collapses and this sort of discolouration fitted with previous cases of air embolus seen in adults and to a lesser extent in children. In concluding that the cause of the collapse was air embolus she had excluded conditions which featured on her list of differential diagnoses and was therefore she said left with looking for something which was “unusual and odd.”

The appeals court focused on the cases of air embolism with particular reference to discolouration because that was a question raised in Letby’s appeal¹. The summaries of the cases do not discuss Letby’s involvement because that was not the specific issue at hand. Nevertheless, the summaries clearly show that these were not normal deaths and they cannot be explained by under-staffing or inadequate care. They also show that it was not Dewi Evans’ testimony alone that pointed to air embolism or to Lucy Letby. His diagnosis was supported by physical evidence, multiple witness statements and another neonatal expert.

Letby’s apologists might say that the witnesses were influenced by Dewi Evans’ theory about air embolism and started creating false memories of events that had taken place 7 or 8 years earlier to fit the theory. But according to Dr Jayaram, it was the consultants who joined the dots in June 2016:

One of the possible explanations which had emerged from that conversation [between consultants] had been air embolus as an explanation for the collapses. This meeting prompted him [Jayaram] to do a literature search which is when he had found the Lee and Tanswell paper. He said that the following morning he had sent the link to his colleagues because that paper seemed to have described the skin discolouration that he and others had seen. He described the “physical chill” that had gone down his spine when he read the paper because it fitted so closely with what had been seen.

Three months later, after Letby was removed from the ward, the Countess management initiated a review by the Royal College of Paediatrics and Child Health. Published in November 2016, that review stated that there had been “a higher than usual number of neonatal deaths on the unit, several of them being apparently ‘unexplained’ and ‘unexpected’”.

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…

This was six months before Dewi Evans had any contact with the police about the Letby case in May 2017. For his part, Evans says that he suspected air embolism before he knew anything about the discolouration of the babies.

The accounts above only scratch the surface of a case that lasted ten months and they only relate to 3 of the 22 charges against Letby, but they should be enough to dispel the myth that the victims were all desperately ill, tiny babies who died due to natural causes and/or neglect. In addition to a further 4 deaths, there were 15 collapses AKA attacks AKA attempted murders, of which Letby has been found guilty of 8. Letby truthers rarely mention the collapses but they were a big part of the case and they were all, to a greater or lesser extent, unexplained and, taken together, suspicious.

If Letby’s convictions are to be overturned it will take a lot more than complaining about ‘coincidences’ and accusing Dewi Evans of conducting a one-man campaign against her. It would require something not unadjacent to a conspiracy involving numerous medics and expert witnesses to be uncovered. It would require the prosecution’s theory about what happened to be dismantled and replaced by a more plausible theory. Perhaps that is possible, I don’t know, but the first step to doing it is to accept that there was something extraordinary happening at the Countess of Chester hospital between June 2015 and June 2016 that requires explanation.

Other posts on this subject:

Is Lucy Letby innocent?

Lucy Letby and the Texas sharp shooter

Lucy Letby and the statisticians

1. Letby’s lawyer sought to admit fresh evidence from Dr Shoo Lee, co-author of a scientific paper cited by the prosecution, who says that “[the] only skin discoloration that is specific to air embolus is ‘bright pink vessels against a generally cyanosed cutaneous background’”. The appeal judges said that his testimony would not have made a significant difference to the prosecution’s case and that the defence had the opportunity to call him as a witness in the original trial.