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    Summaries of articles by Dr Phil Hammond about the Lucy Letby case

    • Part 1: On Medical Experts And A Fair Trial
      The article, authored by Dr. Phil Hammond (MD), explores growing doubts about the safety of Lucy Letby's conviction. It highlights alternative explanations for the deaths, flaws in the statistical evidence, and the potential impact of substandard care on the unit.

    • Part 2: On Why The Nurse Should Be Allowed To Appeal
      The article advocates for Lucy Letby's right to appeal, citing "serious concerns" raised by credible experts regarding the fairness and completeness of the scientific and statistical evidence presented at her trial. It critiques the lack of defence experts and highlights the potential for bias.

    • Part 3: On The Role Of Experts
      The article analyzes the disparity in expert witnesses at the Lucy Letby trial (six for the prosecution, none for the defence) and the potential impact of this "one-sided interpretation" on the verdict. It also highlights calls for reform in how expert evidence is handled in criminal trials.

    • Part 4: On The Tactics For Appeal
      The article details the strategy of Letby's new barrister, Mark McDonald, to challenge her convictions by presenting a new narrative supported by independent experts. It critiques the prosecution's "gotcha moments" and highlights alternative explanations for the deaths.

    • Part 5: On The Thirlwall Inquiry
      The article critiques the Thirlwall Inquiry for potentially missing crucial evidence and context regarding the Lucy Letby case. It discusses the exclusion of defence experts and nursing colleagues from the inquiry and the failure of hospital governance.

    • Part 6: On Thirlwall & The Countess Of Chester
      The article focuses on the Thirlwall Inquiry and the "killer question" of how multiple deaths by air embolism were missed by numerous medical professionals but "spotted so quickly" by lead prosecution expert Dr. Dewi Evans. It also examines the role of "Team Evans" and the parents' experience of chaos on the unit.

    • Part 7: On Issues With The Prosecution
      The article outlines key issues with the prosecution's case against Lucy Letby, including the retraction of a murder method by the lead expert, suppressed statistical evidence, and the failure to consider substandard care as a cause.

    • Part 8: On the Book of Letby
      The article discusses Lucy Letby's failed application to appeal her conviction for the attempted murder of Baby K and analyzes the reliability of the expert evidence presented in the book Unmasking Lucy Letby by Judith Moritz and Jonathan Coffey.

    • Parts 9 & 10: Dr. Ravi Jayaram, Intubation Difficulties, & Second Opinions
      The article focuses on alternative medical explanations for the collapses of babies (specifically Baby N and Baby K) and critiques the actions and reasoning of the consultants who accused Letby, particularly Dr. Ravi Jayaram.

    • Part 11: The Coroner, Post-Mortem Findings, & New Expert Reports
      The article highlights the "horror" of the former coroner at discovering consultants withheld suspicions, the lack of forensic evidence in post-mortems, and new expert reports that defense barrister Mark McDonald claims will undermine the convictions.

    • Part 12: Legal Challenges By The Defence
      The article details the launch of a new appeal bid by Lucy Letby's barrister, Mark McDonald, new expert reports and the "withdrawal" of a key murder method by the prosecution's lead expert.

    • Part 13: Controversial Scientific Evidence, Dr Shoo Lee
      The article focuses on the controversial scientific evidence used to convict Lucy Letby, specifically the "venous air embolism" (VAE) theory and the misuse of a 1989 research paper by Dr. Shoo Lee.

    • Parts 14 & 15: Expert Reviews
      The article focuses on the failure to conduct a thorough expert review before Letby's trial and the subsequent commissioning of independent experts by her new defence team to challenge the convictions.

    • Parts 16 & 17: International Expert Review, Dr Dewi Evans' Response, & Grounds For Appeal
      A review by 14 international neonatology experts found "no evidence of deliberate harm". Lead prosecution expert Dr. Dewi Evans dismissed these findings as "deeply flawed and erroneous,". Thirlwall Inquiry statements from nurses who worked with Letby and do not believe she murdered babies. Grounds for Appeal: Dr Dewi Evans' U-turn, Factual Errors, Failure to Disclose, Insulin evidence debunked.

    • Part 18: Thirlwall, The Insulin Evidence, & Future Recommendations
      The article focuses on the ongoing Thirlwall Inquiry, the potential for recommendations to improve NHS safety, and the "hinge" of the insulin evidence that could be key to an appeal. It also discusses the broader implications for doctors and safety investigations.

    • Part 19: All Fall Down? Dr Jayaram's Inconsistencies, & Other Contrary Evidence
      The article casts doubt on the safety of Lucy Letby's convictions, highlighting inconsistencies in key witness testimony (Dr. Ravi Jayaram), suppressed statistical advice, police tunnel vision, and potential laboratory errors regarding insulin evidence.

    • Part 20: Appeal Court Confusion (Baby K), & Statistical Critique
      The article questions the safety of Lucy Letby's conviction, particularly focusing on the "confusion" regarding Dr. Ravi Jayaram's testimony and the lack of statistical rigor in the trial. It features a critique of three key prosecution claims endorsed by eight independent professors of statistics.

    • Parts 21 & 22: Media Conflicts, Political Intervention, & Dr Jayaram and Dr Evans Referred To GMC

    • Part 23: Appeals All Round, Dr Evans Self-Destructs, & Flaws In Evidence
      The article focuses on growing calls for Lucy Letby's conviction to be re-examined, driven by high-profile interventions and the perceived "self-destruction" of the lead prosecution expert, Dr. Dewi Evans, who has been changing his mind on key theories of murder.

    • Part 24: On The Death Of Baby O
      The article focuses on the conviction for the murder of Baby O, specifically challenging the prosecution's theory of "inflicted liver trauma." It presents new analysis from defence experts suggesting the death was actually caused by medical errors, including excessive ventilation and an accidental liver puncture by a doctor.

    • Part 25: Failure To Inform The Coroner
      The article focuses on the failure of consultants to report suspicions of foul play to the coroner at the time of the deaths, and the subsequent "writing out" of a coroner's officer who found no evidence of deliberate harm.

    • Parts 26 & 27: The Shifting Media Narrative, & Recent Documentaries
      The article, titled "Channel Hopping" (and "Smashie and Nicey" in sub-sections), analyzes the shifting media narrative around the Lucy Letby case, focusing on recent documentaries that have begun to question the safety of the convictions.

    • Part 28: Why Were No Expert Witnesses For The Defence Called?
      The article, titled "Silent Witnesses," addresses the central mystery of why the defence in the Lucy Letby trial chose not to call any expert witnesses. It concludes that this decision stemmed from a pre-trial meeting where defence experts were "outnumbered" and made critical concessions that would have been damaging if presented in court.

    • Part 29: The C4 Documentary, The Role Of The Consultants, Systemic Failures, & Expert Witness Imbalance
      The article criticizes the media coverage and the origins of the police investigation, while highlighting systemic failures (staffing, intubation) and the imbalance in expert witness resources between prosecution and defence.

    • Part 30: Dr Dewi Evans And Baby C

    • Part 31: Dr Dewi Evans Undermines The Other Prosecution Expert Witnesses
      This part focuses on the "other experts" in the Lucy Letby trial and how the lead expert, Dr. Dewi Evans, has purportedly undermined their credibility and the prosecution's case.

    • Part 32: Trial Flaws And Expert Doubts, The Police Investigation, Medical Expert Witnesses
      The article, titled "The Lessons of the Lucy Letby Case: Part 32", argues that the prosecution's case in the Lucy Letby trial was "seriously wrong" and driven by "confirmation bias." It highlights significant disagreements among prosecution experts, new doubts about the causes of death, and criticism from senior police figures regarding the investigation's integrity.

    Part 1: On Medical Experts And A Fair Trial  [link]

    Overview

    The article, authored by Dr. Phil Hammond (MD), explores growing doubts about the safety of Lucy Letby's conviction. It highlights alternative explanations for the deaths, flaws in the statistical evidence, and the potential impact of substandard care on the unit.

    Key Findings

    1. Grounds for Doubt

    • Initially accepting the verdict, MD was later contacted by numerous experts who believe the science and statistics at the trial were "incomplete and flawed" and that the case was not proven beyond reasonable doubt.
    • Reporting restrictions prevented publication of these views until July 2024, after Letby's retrial .

    2. Alternative Hypotheses for Deaths

    • National Trend: In 2015, infant mortality rose in England and Wales for the first time in a century. A survey found two-thirds of neonatal units lacked sufficient staff .
    • Random Chance: Clusters of deaths can happen by chance. A senior consultant at the hospital, Dr. John Gibbs, wrote in July 2016 that the increase might be within "expected statistical variance" .
    • Sick Babies: The unit treated more babies with lower birth weights and complex needs in 2015. Defence expert Mike Hall (unused at trial) argues prosecution experts misrepresented the "wellness" of the babies, leading the jury to believe they were stable when they were not .
    • Inadequate Care: The unit was outdated (built in 1974), cramped, and suffered from sewage backups.
      • A Royal College of Paediatrics (RCPCH) review found "insufficient senior cover" and reluctance among junior staff to seek advice.
      • Staff were "chronically overworked" and often in tears.
      • Downgraded Unit: When Letby was removed, the unit was also downgraded to Level 1 (stopping care for intensive care babies). This change in patient acuity alone could explain the reduction in deaths .

    3. Specific Medical Challenges

    • Air Embolism: Research suggests air embolism is a "not infrequent occurrence" after CPR, which these babies underwent. Prosecution claims of specific skin rashes being diagnostic of air embolism are disputed by experts like Dr. Shoo Lee, whose research was used by the prosecution but who argues it was misinterpreted .
    • Insulin: The conviction for insulin poisoning relied on "high insulin, low C-peptide" results. Experts argue the immunoassay test used is unreliable for criminal proof and requires corroboration (which was never done). One sample was taken 10 hours after Letby left, leading to an "unproven" hypothesis of bag spiking .

    4. Statistical Flaws

    • The "killer roster" showed Letby present at 25 events, but it omitted other deaths/collapses when she wasn't on duty.
    • In total, there were at least 35 deaths or collapses during the period, meaning Letby was not present for 10 of them.
    • Statisticians argue the roster only proves "Letby was on duty when she was on duty" and lacks robustness without a full statistical analysis of all shifts and staff .

    Conclusion

    The article concludes that the justice system's reliance on adversarial experts (where the defence called none) left the jury with a "highly selective" view of the science. It calls for mandatory independent expert panels and statistical input in complex medical trials .

    Part 2: On Why The Nurse Should Be Allowed To Appeal [link]

    Overview

    The article advocates for Lucy Letby's right to appeal, citing "serious concerns" raised by credible experts regarding the fairness and completeness of the scientific and statistical evidence presented at her trial. It critiques the lack of defence experts and highlights the potential for bias.

    Key Findings

    1. Expert Imbalance & Bias

    • The report notes a critical mismatch: the prosecution used six expert witnesses, while the defence used none. This created a "high risk of bias and false conclusions" .
    • Defence experts could have argued that:
      • Natural causes of death were more plausible.
      • The prosecution's use of statistics was "lamentable."
      • Alleged methods like insulin overdoses, air emboli, and "death by squirting air into the stomach" were unproven or highly improbable.

    2. Pathological Doubts

    • Six of the seven murdered babies underwent full coroner's post-mortem examinations by experienced paediatric pathologists at Alder Hey. None picked up a trace of foul play .
    • A top forensic pathologist explains that without initial suspicion, definitive tests (like for insulin) are often not done, and no photos are taken, leaving later reviews reliant on notes and memory.
    • The pathologist notes that paediatric cases have "many uncertainties" and warns against "hawkish and dogmatic" clinicians swaying juries with confidence over evidence .

    3. "Hot-Tubbing" Proposal

    • The report suggests a fairer method for complex trials is "hot-tubbing," where experts from both sides take the stand together to discuss and debate the evidence, helping the jury understand points of agreement and disagreement .

    4. Alternative Explanations

    • The author (MD) draws parallels to the Bristol heart scandal, where excess deaths were initially unexplained but found to be due to systemic failures and lack of expertise, not murder.
    • Factors like random fluctuation, sick patients, infectious outbreaks, insufficient staff, and substandard care are far more common causes of excess deaths than deliberate harm .
    • A draft report from the Royal College of Paediatrics (RCPCH) noted that nursing colleagues thought highly of Letby and saw no issues with her competency. The allegation against her was a "gut feeling" and her presence on shift, with "no other evidence" .

    5. Senior Expert Opinion

    • A "very senior practising neonatologist" reviewed the prosecution's opening statement and found it "troubles me deeply."
    • They stated the cases had "much more plausible alternative explanations" and described many prosecution comments as "medically illiterate."
    • The expert concluded: "On the basis of what I've seen, this conviction is wholly unsafe" .

    Conclusion

    The article concludes that the conviction relies on one-sided science and questionable statistics (the "spreadsheet"). It questions why Letby has not been implicated in other deaths during the same period and calls for proper statistical expertise in such trials .

    Part 3: On The Role Of Experts [link]

    Overview

    The article analyzes the disparity in expert witnesses at the Lucy Letby trial (six for the prosecution, none for the defence) and the potential impact of this "one-sided interpretation" on the verdict. It also highlights calls for reform in how expert evidence is handled in criminal trials.

    Key Findings

    1. The Expert Imbalance

    • The prosecution fielded six expert witnesses, while the defence called none.
    • Prof. Mike Hall, a retired neonatologist and unused defence expert, argues this led to an unfair trial because his view (that the babies were sicker than portrayed and likely died of natural causes) was never heard by the jury .
    • Hall also questioned the suitability of the prosecution's two main neonatal experts, noting they had retired from clinical practice 13 and 15 years before the trial began.

    2. Systemic Flaws in Expert Evidence

    • The report cites a 2011 Law Commission report identifying that "too much expert opinion evidence is admitted without adequate scrutiny" because there is no clear reliability test.
    • Juries may reach conclusions unreliable evidence because advocates do not always effectively cross-examine experts on their methodology.
    • The Ministry of Justice rejected most recommendations to fix this in 2013 .

    3. Defence Tactics

    • Letby's barrister, Ben Myers KC, attempted to have the case thrown out at "half-time" (a "no case to answer" submission), arguing the evidence was sparse and the modes of murder (like air embolism) were so unusual that no one could reliably be an expert on them.
    • The report suggests Myers may have been reluctant to call his own retired expert (Hall) after arguing that no retired expert could be reliable.
    • However, the article critiques this strategy, noting that without defence experts, there is "no expert evidence on... more plausible causes of death" to counter the prosecution .

    4. Alternative Expert Opinion

    • A senior practising neonatal expert reviewed the "half-time" ruling and argued the defence's argument was incomplete.
    • They stated the defence should have:
      1. Explained that diagnosing air embolism ante-mortem (before death) is extremely difficult.
      2. Highlighted that causes of air embolism include vigorous resuscitation, high-pressure ventilation, and poor line management—all of which were present.
      3. Pointed to the backdrop of an inexperienced, understaffed, and chaotic unit as a "plausible alternative explanation" that makes deliberate injection the least likely cause .

    5. Call for Screening

    • The author (MD) argues that if the statistical and clinical evidence had been "screened beforehand by a team of the best available experts" (as per Law Commission recommendations), the Crown Prosecution Service might have concluded it was impossible to prove the case beyond reasonable doubt .

    Part 4: On The Tactics For Appeal [link]

    Overview

    The article details the strategy of Letby's new barrister, Mark McDonald, to challenge her convictions by presenting a new narrative supported by independent experts. It critiques the prosecution's "gotcha moments" and highlights alternative explanations for the deaths.

    Key Findings

    1. Legal Change and Strategy

    • Lucy Letby has instructed Mark McDonald to draft her application to the Criminal Cases Review Commission (CCRC).
    • McDonald's primary task is to conduct a review of the scientific and clinical evidence using named experts and publish it.
    • The goal is to draw "very different scientific conclusions" from lead prosecution expert Dr. Dewi Evans to pressure the CCRC to refer the case back to the appeal court .

    2. A New Narrative: Bad Luck vs. Substandard Care

    • McDonald needs to offer an alternative to deliberate harm. The article suggests two potential narratives:
      1. Statistical Fluctuation (Bad Luck): Statisticians argue the death clusters happen by random fluctuation.
      2. Substandard Care (Most Likely): The alternative narrative is that the unit was "simply not up to the task" of coping with an influx of critically ill babies. This is supported by a damning RCPCH review (never seen by the jury) which suggests the unit failed to spot deteriorations or manage resuscitations, especially at night .

    3. "Gotcha Moments" Rebutted

    • Dr. Dewi Evans: The article criticizes Evans for his "absolute certainty" and for being the sole expert who initially identified the cases for police. It highlights his circular role: employed by police to find murder, then by the court to verify his own findings. Evans claims he excluded other causes because "there were no other causes," a statement the article challenges .
    • Insulin Poisoning: The article argues the jury should have heard from experts like Professor Alan Wayne Jones, who states the immunoassay test used is prone to false positives and insufficient for criminal proof. It also notes the failure to send samples to a specialist lab for confirmation, contrary to protocol .
    • The "Spreadsheet": The famous chart showing Letby present at all collapses is dismissed as merely proving "Letby was on duty when Letby was on duty," ignoring other deaths and the context of an understaffed unit .
    • The "Confession": The "I am evil" note was revealed post-trial to be part of a therapeutic process advised by a counsellor, a context never given to the jury .

    4. The "Third Insulin Baby"

    • Dr. Evans revealed a third case of potential insulin poisoning (high insulin, low C-peptide) in November 2015.
    • This baby survived and was diagnosed with hyperinsulinism (a natural condition) by Alder Hey specialists.
    • The report argues this is a critical inconsistency: either the specialists were wrong (and Letby poisoned a third baby), or the test results used to convict Letby can occur naturally. If the latter, "the wheels come off the prosecution case entirely" .

    5. Nurse Support

    • The report notes that none of Letby's fellow nurses gave evidence against her, and some who wanted to support her were reportedly "discouraged and threatened."
    • Written evidence from colleagues supporting Letby has been submitted to the Thirlwall Inquiry, but they have been told they won't be called to give oral evidence, fueling suspicions of a cover-up .

    Part 5: On The Thirlwall Inquiry [link]

    Overview

    The article critiques the Thirlwall Inquiry for potentially missing crucial evidence and context regarding the Lucy Letby case. It discusses the exclusion of defence experts and nursing colleagues from the inquiry and the failure of hospital governance.

    Key Findings

    1. Unheard Evidence at Trial

    • The report argues the original jury heard only "half the evidence."
    • Missing Voices: The jury did not hear from:
      • Nurse colleagues who believe Letby is innocent.
      • Letby's counsellor (regarding the Post-it notes).
      • The Royal College of Paediatrics (RCPCH) representative (on serious unit failings).
      • Pathologists (who found no foul play).
      • Dr. Jane Hawdon (consultant neonatologist) who reviewed 17 cases and found "serious failings but no evidence of foul play" .
    • Missing Experts: There was no microbiologist to discuss infection outbreaks, no embolism expert to challenge the rashes, and no statistical expert to explain random variations in death rates .

    2. "Blame Ping Pong" & Governance Failures

    • Hospital managers argue they were not informed of key incidents or suspicions by doctors.
    • Failure to Report: Doctors who suspected Letby (some allegedly calling her "Nurse Death") failed in their statutory duty to contact the coroner after every unexpected death.
    • Had they done so, a full forensic post-mortem (including definitive insulin testing) could have been conducted, potentially diagnosing or excluding murder much earlier .
    • An early barrister review (Simon Medland QC) and police assessment (Assistant Chief Constable Darren Martland) both found "no evidence of a crime" or reasonable grounds for suspicion at the time .

    3. Nurses' Questionnaire & Exclusion

    • The inquiry sent questionnaires to nurses. One colleague's responses, seen by MD, described Letby as an "exemplary nurse" who was "completely innocent."
    • The colleague believed consultants were trying to make Letby a "scapegoat" for increased deaths/collapses, which they viewed as not sinister given the high risk of the babies involved.
    • Despite this, the inquiry informed the nurse she was not on the list to give oral evidence. The article argues it is vital to hear from those who worked closely with Letby, even if they contradict the "preferred narrative" .

    4. The "Evans Factor"

    • The report reiterates that the murder charges relied heavily on Dr. Dewi Evans' ability to diagnose murder where other experts failed.
    • It notes sarcastically that a key inquiry recommendation should be to call Dr. Evans immediately for any future concerns, as he claims he would have stopped Letby after the first death.
    • However, Dr. Evans has not been contacted to give testimony to the inquiry, which the article finds inexplicable .

    Conclusion

    The article suggests the inquiry may be too focused on "stopping medical murder" the assumption of guilt, while potentially ignoring the broader context of a failing unit and the voices of those who doubt the convictions.

    Part 6: On Thirlwall & The Countess Of Chester [link]

    Overview

    The article focuses on the Thirlwall Inquiry and the "killer question" of how multiple deaths by air embolism were missed by numerous medical professionals but "spotted so quickly" by lead prosecution expert Dr. Dewi Evans. It also examines the role of "Team Evans" and the parents' experience of chaos on the unit.

    Key Findings

    1. The "Killer Question" (Missed Diagnoses)

    • The report questions how seven consultants (with >100 years' experience), three paediatric pathologists, coroners, mortality reviews, and external inspectors (CQC, RCPCH) all failed to diagnose repeated deaths by air embolism.
    • In contrast, Dr. Dewi Evans, who had not practised since 2009, claimed to spot them quickly and described the diagnosis as "easy" because babies are "simple" .
    • Evans claims he would have spotted the first murder and saved lives had he been called sooner, yet he has not been asked to give a statement to the inquiry .

    2. "Team Evans" and the Confirming Experts

    • The police assembled a team of experts (including Dr. Sandie Bohin and Dr. Andreas Marnerides) to support Evans.
    • This team allowed Evans to expand the murder method to include air via the nasogastric tube (for Babies C, I, and P).
    • The "U-Turn": Evans initially claimed Baby C was killed by air in the stomach (a view supported by the prosecution in court). However, post-trial, he decided Baby C was actually killed by air in a vein, and that air in the stomach was merely for "destabilisation" .
    • Baby O (Liver Trauma): Evans diagnosed "inflicted harm" (a blow to the liver) within 10 minutes of seeing the notes. The article notes that another expert (in a Tortoise podcast) suggested this was more likely a subcapsular haematoma, a known complication of premature multiple births .

    3. "Managerial Quandary" & Unit Failings

    • The inquiry is set to criticize managers for not calling police sooner. However, the article argues that if no doctor on the unit could diagnose the "obvious" murders, managers had no reason to call the police .
    • The real failure, the article suggests, was not downgrading the unit to Level 1 (low risk) in 2015 when staffing and expertise were clearly insufficient for high-risk (Level 3) babies like the triplets .

    4. Parents' Experience of Chaos

    • Parents of the triplets described the unit as "complete chaos" and "absolute pandemonium."
    • One father saw a nurse "Googling a procedure, a lung drain" and staff looking like they were following a tutorial rather than knowing what they were doing .
    • Parents also reported a lack of candour, broken equipment (blood gas machine), and sewage leaks .

    5. Evans Retires

    • Dr. Evans told MD he has retired from Letby work and passed 25 more suspicious cases to police (who haven't responded).
    • The report concludes by contrasting the "Team Evans" view (widespread murder by one nurse) with other experts who find "serious deficiencies" in care without evidence of murder .

    Part 7: On Issues With The Prosecution [link]

    Overview

    The article outlines key issues with the prosecution's case against Lucy Letby, including the retraction of a murder method by the lead expert, suppressed statistical evidence, and the failure to consider substandard care as a cause.

    Key Findings

    1. The "Air in Stomach" Retraction

    • Dr. Dewi Evans, the lead prosecution expert, signed a statement in August 2024 declaring that "none of the babies were killed as a direct result of the injection of air... into their stomachs."
    • This is significant because the theory of "death by splinting" (stomach distension crushing lungs) was used to explain the deaths of Babies C, I, and P and was mentioned 159 times in the trial. Evans' retraction leaves a "great hole" in the prosecution case .

    2. Suppressed Statistical Analysis

    • Cheshire Police hired Professor Jane Hutton, a statistician from the University of Warwick, to analyze the deaths.
    • However, the Crown Prosecution Service (CPS) instructed the police to stop this inquiry because the prosecutor did not agree with her line of inquiry (which required analyzing all deaths, not just suspicious ones).
    • The report suggests this was a "sound move" for the prosecution because Prof. Hutton has since become a vocal critic of the trial's statistics .

    3. The "Backstairs" Evidence

    • The trial relied heavily on swipe card data to place Letby at the scene.
    • However, it has emerged that there was another unmonitored point of entry via backstairs that used a keypad but left no data trace. Staff used this frequently, making the "on duty killer spreadsheet" potentially "worthless" .

    4. The "Substandard Care" Argument & The Hawdon Report

    • A report by the Royal College of Paediatrics found "significant gaps" in staffing and insufficient consultant presence at the unit.
    • An advisory report by senior neonatologist Dr. Jane Hawdon in October 2016 identified "major or significant suboptimal clinical care" in 14 of 17 cases reviewed.
    • Hawdon's report was excluded from evidence because Letby was only charged with 9 of the 17 cases. The article argues this exclusion was wrong because it showed babies deteriorated unexpectedly even when Letby wasn't involved, pointing to systemic failures rather than murder .

    5. Missing Forensic Proof

    • The report highlights that definitive forensic tests for insulin poisoning and air embolism were never done.
    • Doctors failed to request post-mortem CT scans or send blood to a specialist lab, meaning the chance to definitively prove (or disprove) murder was lost. The case relied instead on clinical records and disputed interpretations .

    6. CCRC Application

    • Letby's last chance is an application to the Criminal Cases Review Commission (CCRC).
    • The CCRC must consider procedural errors (like the failure to disclose the Hutton emails or allow the Hawdon report) and whether Evans' retraction invalidates the convictions .

    Part 8: On the Book of Letby [link]

    Overview

    The article discusses Lucy Letby's failed application to appeal her conviction for the attempted murder of Baby K and analyzes the reliability of the expert evidence presented in the book Unmasking Lucy Letby by Judith Moritz and Jonathan Coffey.

    Key Findings

    1. "More Hot Air?" (Stomach Air Theory)

    • The report highlights a significant flaw in the prosecution's theory that Letby murdered babies by injecting air into their stomachs.
    • It notes that Letby was not on duty when Baby I and Baby C were found to have unusual amounts of air in their stomachs, a fact the jury seemingly overlooked.
    • The authors of the book conclude that prosecution experts (Dr. Dewi Evans and Dr. Sandie Bohin) either "misinterpreted two 'stomach air' events as 'suspicious' when in fact they were innocent," or that someone other than Letby was responsible.

    2. "All Change" (Dr. Dewi Evans' Reliability)

    • The report criticizes lead expert Dr. Dewi Evans for frequently changing his mind. It reveals that Appeal Court judge Lord Justice Jackson wrote to the trial judge (Judge Goss) in December 2022 to warn him of Evans' unreliability in a previous case.
    • Baby C Case: Evans produced eight pre-trial reports but only settled on the "stomach air" theory in the witness box. Under cross-examination, he changed his theory again, suggesting Letby might have killed Baby C twice (once by stomach air, once by air embolism). The report accuses him of "theorising on the hoof".

    3. Retrospective Interpretation

    • The report argues that the case against Letby relied almost entirely on the "retrospective analysis" and "interpretative judgements" of medical records by experts Evans and Bohin, rather than hard forensic evidence.
    • It poses the question: "If Evans had been working for the defence, would Letby be a free woman?".

    4. Failed Appeal

    • The report notes that Letby's appeal regarding the fairness of her retrial (due to adverse media coverage) was rejected. The judges dismissed challenges to the original verdicts but passed the broader debate about the safety of the convictions to the Criminal Cases Review Commission (CCRC).

    Parts 9 & 10: Dr. Ravi Jayaram, Intubation Difficulties, & Second Opinions [link]

    Overview

    The article focuses on alternative medical explanations for the collapses of babies (specifically Baby N and Baby K) and critiques the actions and reasoning of the consultants who accused Letby, particularly Dr. Ravi Jayaram.

    Key Findings

    1. "Frail Babies" and Intubation Issues

    • Dr. Tariq Ali, a paediatric intensive care consultant, reviewed the notes and argues that the collapses were likely caused by "intubation difficulties" rather than deliberate harm.
    • Baby N: Dr. Ali states that the blood found in the airway "obviously came from the first attempt at intubation" by a doctor who tried three times in a stressful situation. He notes the baby had haemophilia (making bleeding likely even from minor injury) and questions the expertise of trial witnesses in intubating neonates.
    • Baby K: Dr. Ali is "incredulous" that Letby was convicted of deliberately dislodging the tube, arguing that accidental dislodgement is common in such small children and better explained by poor securing or positioning.

    2. Critique of Dr. Ravi Jayaram

    • Dr. Jayaram, one of Letby's main accusers, apologized to the Thirlwall Inquiry for not stopping Letby sooner. However, the article notes he had "no objective evidence" at the time.
    • MD's Challenge: The author (MD) emailed Jayaram to ask if there were more plausible alternatives to murder. Jayaram replied that even if the unit had the "worst staff" and "worst care," it could not explain the sudden deteriorations.
    • The "Obvious Flaw": MD argues the flaw in Jayaram's reasoning is that a unit short of experienced staff is exactly where you would expect a lack of "appropriate timely interventions," leading to sudden deteriorations.
    • The report suggests that independent experts reviewing the notes might find that the deaths were "entirely explained by medical interventions that were neither timely nor appropriate," shifting the blame from Letby to the unit's failings.

    3. The Role of Dr. Dewi Evans

    • The report claims the case against Letby only "took off" when expert witness Dr. Dewi Evans arrived and "confidently concluded" from the notes that murder had occurred.
    • It highlights that Evans changed his mind multiple times during the trial and abandoned one method of murder post-trial, yet his "belief that he is right has never waned".

    Part 11: The Coroner, Post-Mortem Findings, & New Expert Reports [link]

    Overview

    The article highlights the "horror" of the former coroner at discovering consultants withheld suspicions, the lack of forensic evidence in post-mortems, and new expert reports that defense barrister Mark McDonald claims will undermine the convictions.

    Key Findings

    1. Coroner's Horror at Withheld Suspicions

    • Nicholas Rheinberg, the former senior coroner for Cheshire, told the Thirlwall Inquiry he was "horribly disappointed" and expressed "absolute horror" that no consultant or manager passed on suspicions of foul play.
    • Consultant Dr. Ravi Jayaram gave evidence twice at the inquest for Baby A (October 2016) while secretly convinced Letby was a murderer, yet said nothing to the coroner.
    • Rheinberg stated that if this information had been shared, he would have adjourned the inquest and sought police involvement immediately .

    2. No Foul Play Detected in Post-Mortems

    • Six of the seven murdered babies underwent "absolutely meticulous" paediatric post-mortem examinations, yet no foul play or signs of air embolism were detected.
    • The report contrasts this with prosecution expert Dr. Dewi Evans, who claimed to spot the murders "very quickly, just by looking at the notes" years later. The article questions how Evans could spot what pathologists, the coroner, police, and multiple review panels missed .

    3. New Defence Evidence

    • Barrister Mark McDonald announced he is releasing evidence that "significantly undermines" Letby's convictions.
    • This includes two detailed documents (over 30,000 words each) by practising Level 3 neonatologists explaining the deaths of Baby O and Baby C. They conclude the deaths had "nothing to do with Letby" and were due to clinical care issues.
    • The report mentions that McDonald may also present statistical analysis that Cheshire Police commissioned but cancelled on the advice of the CPS .

    4. Retracted Murder Method

    • The report notes that Dr. Evans has retracted a key method of murder (air in the stomach) post-trial.
    • It questions whether this retraction, combined with the new expert reports, will be enough to speed up a referral to the Court of Appeal .

    5. Fresh Charges & Costs

    • Police are briefing the media about possible fresh charges. The article warns that if these are "hypothetical coincidences" without forensic proof, it could be a waste of public money and lead to further reporting restrictions.
    • It highlights the financial disparity: prosecution experts can earn "half a million pounds," while defence experts are working pro bono .

    Part 12: Legal Challenges By The Defence [link]

    Overview

    The article details the launch of a new appeal bid by Lucy Letby's barrister, Mark McDonald, new expert reports and the "withdrawal" of a key murder method by the prosecution's lead expert.

    Key Findings

    1. Prosecution Expert Withdrawal (Legal Challenge 1)

    • Dr. Dewi Evans, the chief prosecution expert, signed a statement to Channel 5 in August 2024 stating that "none of the babies... were killed as a direct result of the injection of air... into their stomachs."
    • This contradicts the prosecution's case presented to the jury, where barrister Nicholas Johnson KC claimed it was "plain as the nose on your face" that Letby killed Baby C this way.
    • The report argues that since Letby was convicted of murdering Babies C, I, and P using this method (which Evans now disavows as fatal), the Court of Appeal must review whether these verdicts are sound .

    2. New Defence Expert Reports (Legal Challenge 2)

    • Mark McDonald submitted reports to the Criminal Cases Review Commission (CCRC) from practising neonatal experts Dr. Neil Aiton and Dr. Svilena Dimitrova. These reports conclude that the deaths were "entirely explicable" and not due to intended harm.
    • Baby O Case: The article highlights the death of Baby O, arguing the baby was ventilated at "inappropriately high pressure settings" that pushed the liver down.
      • It alleges that Dr. Stephen Brearey (identified from transcripts) inserted a needle into the abdomen on the wrong side (right instead of left) to relieve distension.
      • The experts claim the needle lacerated the liver, causing bleeding and shock (confirmed by a halved haemoglobin level).
      • Dr. Richard Taylor, endorsing the findings, stated: "If this had happened to me, I'd be unable to sleep at night... And now there is a nurse in jail convicted of murder" .

    3. Thirlwall Inquiry Update

    • The inquiry released a 2017 email from the hospital's medical director, Ian Harvey, stating that pathologists assured him a "significant air embolus would be detected at PM [post-mortem]."
    • The report questions why, out of six babies who had meticulous post-mortems, not a single significant air embolism was found, despite Dr. Evans' theory that Letby murdered all seven babies this way .
    • Jeremy Hunt: The former Health Secretary is set to give evidence, facing questions on how a unit with "sewage leaks and manifestly unsafe staffing levels" was allowed to continue operating .

    4. Statistical Paper Rejection

    • A statistical paper questioning Letby's guilt was refused publication by the journal Medicine, Science and the Law.
    • The reviewer cited the need to hold "the suffering of the parents... firmly in mind," which the article criticizes as a potential cover-up, noting that miscarriages of justice cause more suffering in the long run .

    Part 13: Controversial Scientific Evidence, Dr Shoo Lee [link]

    Overview

    The article focuses on the controversial scientific evidence used to convict Lucy Letby, specifically the "venous air embolism" (VAE) theory and the misuse of a 1989 research paper by Dr. Shoo Lee.

    Key Findings

    1. The "Lee and Tanswell" Paper Misuse

    • The Claim: A key reason for Letby's conviction for murdering seven babies by VAE was because prosecution expert Dr. Dewi Evans and local paediatricians cited a 1989 research paper co-authored by Canadian paediatrician Dr. Shoo Lee. They claimed the paper described skin changes (discoloration) that matched what was seen on the babies.
    • The Rebuttal: The article reveals that if anyone had contacted Dr. Lee, he would have pointed out that his paper referred to Pulmonary Vascular Air Embolism (PVAE), not Venous Air Embolism (VAE), which is "very different."
    • Skin Changes: Dr. Lee states that the skin changes described in the trial did not match his research findings. Furthermore, his review suggests you "don't get localised skin changes even with fatal VAE," meaning the observed discolorations were likely due to something else (e.g., repeated doses of adrenaline).
    • Fresh Evidence: The article argues this new information from Dr. Lee is "surely fresh evidence" because it renders a large chunk of the trial inaccurate.

    2. Retracted Theories (Air in Stomach)

    • The Thirlwall Inquiry confirmed that the criminal trial found Babies C and P died from "air via nasogastric tube" and that this was also a mode of murder for Babies I and O.
    • However, Dr. Evans now argues that air in the stomach is not a method of murder. The article questions whether this makes the convictions unsafe, noting that the jury was told it was one of Letby's "favourite ways of killing".

    3. Missed Clinical Failings

    • The author (MD) expresses disbelief that prosecution experts failed to flag "serious failings in clinical care" to explain the collapses, which defence experts have now documented.
    • Sarah Davies (clinical scientist) explained that doctors failed to send blood tests to a specialist laboratory in Guildford to confirm insulin poisoning, despite this being a standard safeguarding requirement when exogenous insulin is suspected.

    4. Statistical Analysis Missing

    • The report notes that proper statistical analysis was "essential" to consider all plausible causes but "never happened".
    • It highlights that if the independent reviewer for the Chester deaths had been Dr. Evans, they would have been ascribed to deliberate harm, whereas other reviews might have found different causes, illustrating the subjectivity of the process.

    Conclusion

    The article concludes that there are "serious and credible questions" about the evidence presented in court, particularly the robustness of expert testimony and the interpretation of statistical data.

    Parts 14 & 15: Expert Reviews [link]

    Overview

    The article focuses on the failure to conduct a thorough expert review before Letby's trial and the subsequent commissioning of independent experts by her new defence team to challenge the convictions.

    Key Findings

    1. "Criminally Negligent" Failure

    • The report argues that a thorough expert review of the unit's care should have happened before Letby was accused of murder.
    • It describes the failure to do this as "criminally negligent," noting that earlier reviews (by the Royal College of Paediatrics and Child Health and Dr. Jane Hawdon) were superficial or brief, yet even they found "no evidence of deliberate harm" and "plenty of evidence of substandard care."
    • Crucially, none of the six post-mortem examinations performed by experienced pathologists at the time raised any concerns of foul play.

    2. New Independent Reviews

    • Letby's new barrister, Mark McDonald, commissioned two sets of experts to review the evidence pro bono for the Criminal Cases Review Commission (CCRC) application.
    • UK Experts: Two Level 3 neonatologists, Dr. Neil Aiton and Dr. Svilena Dimitrova, produced detailed reports on four cases. They explained the deaths and collapses as the result of clinical errors, finding "no evidence of deliberate harm."
    • International "Dream Team": To counter potential accusations of bias (as the UK experts had previously signed a letter to the inquiry), McDonald asked Canadian paediatrician Dr. Shoo Lee to convene a team of 14 international experts with no prior exposure to the case.
    • Methodology: These international experts reviewed all 17 cases, with two experts assigned to each case (and a third if they disagreed) to ensure a robust, independent analysis.

    3. Public Disclosure Strategy

    • The findings of these reviews were made public at press conferences.
    • The report suggests this tactic was triggered by "police threats of further charges" (which would silence public debate) and was intended to put pressure on the CCRC and the Court of Appeal to reconsider the safety of the convictions.

    Parts 16 & 17: International Expert Review, Dr Dewi Evans' Response, & Grounds For Appeal [link]

    • Review Findings: A review by 14 international neonatology experts of all 17 cases found "no evidence of deliberate harm" and instead found "ample evidence of substandard care" contributing to the deaths.
    • Prosecution Rebuttal: Lead prosecution expert Dr. Dewi Evans (who retired from NHS work in 2009) dismissed these findings as "deeply flawed and erroneous," stating he had not heard criticism from any individual or organization he respected. Other prosecution experts refused to comment .
    • Thirlwall Inquiry: The inquiry published unedited statements from nurses who worked with Letby and do not believe she murdered babies. Letby’s former head of nursing, Karen Rees, publicly stated she believes Letby is innocent.
    • Corporate Manslaughter: The article questions whether these findings will stop the police from pursuing corporate manslaughter charges against the hospital. Lead expert Dr. Shoo Lee noted that the "appalling" standards of care would have caused the unit to be closed down in Canada.

    Grounds for Appeal ("Spoilt for Choice")

    The article outlines several grounds ("new evidence or argument") that the Criminal Cases Review Commission (CCRC) could use to refer the case back to the Court of Appeal:

    1. Experts U-Turn

    • Dr. Evans signed a statement to Channel 5 in August 2024 admitting that "none of the babies were killed as a direct result of the injection of air... into their stomachs," contradicting the method of murder cited by the prosecution for Babies C, I, and P. The article argues this alone could make those convictions unsafe .

    2. New Evidence

    • "Confession" Notes: Post-trial disclosures revealed Letby's notes were written on the advice of her counsellor to cope with stress, not as confessions.
    • Skin Changes: Research by Dr. Shoo Lee "demolishes" the prosecution's claim that specific skin changes are signs of venous air embolism.
    • Shift Analysis: Statistical analysis showed Letby was not on duty for 10 of the 28 suspicious cases initially identified by Evans, leading to their removal from the spreadsheet.

    3. Factual Errors & Failure to Disclose

    • Statistical Suppression: The prosecution failed to disclose that police had hired (and then unhired) statistician Professor Jane Hutton to analyze the deaths.
    • Baby Y (The Third Insulin Baby): A third baby had the same "high insulin, low C-peptide" results but was diagnosed with congenital hyperinsulinism (a genetic condition). The prosecution did not disclose that their experts initially thought this was poisoning but dropped it when the natural cause emerged. Had the defence known, they could have argued the test results were not unique to poisoning .

    4. The "Best Evidence" (Insulin) Debunked

    • Prosecution barrister Nick Johnson KC called the insulin evidence the "best bit of evidence."
    • Expert Dr. Svilena Dimitrova argues the evidence is "worthless" because the immunoassay test used cannot prove exogenous insulin administration. She states that none of the babies (F, L, or Y) satisfied the necessary criteria (low glucose, genuinely elevated insulin, undetectable C-peptide) .
    • Dimitrova describes the trial's medical evidence as "the most extraordinary interlude of bad science and bad medicine in neonatology that I have ever witnessed".

    5. Police Catch-Up

    • Cheshire Police are considering charging managers and clinicians with gross negligence manslaughter (GNM) for failing to stop Letby.
    • The report suggests that if Letby shares her expert reports (proving the test was unreliable and care was poor), GNM charges could still stick, but for "very different reasons"—namely, failing to provide safe care rather than failing to stop a murderer .

    Part 18: Thirlwall, The Insulin Evidence, & Future Recommendations [link]

    Overview

    The article focuses on the ongoing Thirlwall Inquiry, the potential for recommendations to improve NHS safety, and the "hinge" of the insulin evidence that could be key to an appeal. It also discusses the broader implications for doctors and safety investigations.

    Key Findings

    1. Thirlwall's Challenge & Judicial Doubt

    • Jonathan Sumption (former Supreme Court judge) is quoted stating that Lucy Letby is "probably innocent" and deserves an appeal.
    • The report highlights the challenge facing Lady Justice Thirlwall: she must make recommendations to make neonatal care safer while her inquiry is the premise of murder. If Letby is later found innocent (meaning an innocent nurse was blamed for substandard care), Thirlwall's recommendations might "miss the point" .

    2. The "Insulin Hinge"

    • The report argues the insulin convictions are the "hinge" of the case. Prosecution experts stated under oath that the only explanation for the blood results (high insulin, low C-peptide) was exogenous insulin.
    • New Evidence: Defence experts contend this was a "clear and serious factual error." The article reveals that the Liverpool lab processing the samples was experiencing "severe calibration errors" at the time, "grossly overmeasuring insulin and undermeasuring C-peptide" .
    • Despite the judge telling jurors there was "no reason to doubt the reliability of the tests," the article asserts "there certainly is now" and this alone warrants an appeal .

    3. "Doctors in the Dock"

    • The report suggests Thirlwall's inquiry will center on the delay in reporting suspicions.
    • It states the overriding conclusion will be that safeguarding trumps everything: "if you truly suspect one of your work colleagues is murdering babies, you must tell the police immediately."
    • Police will then decide if failure to act sooner constitutes gross negligence manslaughter alongside potential corporate manslaughter charges against the hospital .

    4. Future Recommendations (MD's View)

    • CCTV & Surveillance: The article discusses potential recommendations like CCTV in units or covert surveillance, but notes the legal complexity, cost, and risk of creating a "surveillance culture" driven by fear .
    • Independent Investigation Body: The author (MD) recommends creating a single, powerful, independent healthcare investigation organization (merging existing safety bodies) to monitor data and investigate safety concerns promptly. This would replace the current system where police hand-pick "long-retired medical experts" .
    • Safe Staffing: The article concludes that most avoidable harm is due to understaffing. It calls for mandatory safe staffing levels, arguing this would save hundreds of lives and reduce litigation costs .

    5. Experts Struck by "Lack of Expertise"

    • Lawyers for bereaved parents have been offered full reports from international experts supporting Letby but have so far declined.
    • Seven of these experts have publicly stated they were "struck by the lack of expertise" of the prosecution witnesses at the original trial .

    Part 19: All Fall Down? Dr Jayaram's Inconsistencies, & Other Contrary Evidence [link]

    Overview

    The article casts doubt on the safety of Lucy Letby's convictions, highlighting inconsistencies in key witness testimony (Dr. Ravi Jayaram), suppressed statistical advice, police tunnel vision, and potential laboratory errors regarding insulin evidence.

    Key Findings

    1. Dr. Jayaram's Inconsistencies (Baby K)

    • The Email vs. Testimony: An email from Dr. Jayaram to colleagues on May 4, 2017, explicitly stated: "Staff nurse Letby... called Dr Jayaram to inform of low saturations."
    • Contradiction: This contradicts his sworn testimony and witness statement where he claimed Letby had not called for help, a point prosecution counsel used to argue he caught her "virtually red-handed" .
    • Appeal Court Reaction: The Court of Appeal had already noted "legitimate criticism" of Jayaram's evidence and inconsistencies with contemporaneous records. The article suggests this new email further warrants scrutiny into whether he committed perjury.
    • Police Report Omission: Jayaram's email also noted that Baby K's deterioration "would fit with explainable events associated with extreme prematurity," but this observation was not included in the final report to the police .

    2. Suppressed Statistical Advice

    • Cheshire Police hired statistician Professor Jane Hutton to review their case, but this was blocked by the Crown Prosecution Service (CPS) in July 2021.
    • The Information Commissioner confirmed seeing the CPS advice but refused to disclose it, citing risks to "future legal proceedings." The report questions if this suppression is because the advice would help Letby's case .

    3. Police Tunnel Vision & "Deskilling"

    • Michele Worden, a former advanced neonatal practitioner at the hospital, told police in 2018 that the "deskilling" of the nursing workforce (replacing senior nurses with less experienced ones) and maternity unit problems were likely factors in the deaths.
    • The police officer she spoke to was reportedly "not interested" in this or the Royal College of Paediatrics report, instead asking only for evidence against Letby.
    • The report argues the investigation was "entirely predicated around a pre-determined outcome" that refused to consider substandard care as a cause .

    4. The "Lab Error" Theory (Insulin)

    • Letby was convicted of poisoning two babies with insulin "high insulin, low C-peptide" results.
    • The report reveals a quality control test from the same Liverpool laboratory (May 23, 2016) where a sample known to have low insulin (108.3) and high C-peptide (873.5) was reported by the machine as having high insulin (962) and low C-peptide (130).
    • This "wildly inaccurate" result—an exact reversal of the expected values—suggests a potential machine error or human error (mixing up results). This quality control failure was known at the time of the trial but "not investigated or declared" .
    • The report posits Letby may have been convicted simply because "someone tired and overworked gets their readings mixed up every eight months or so" .

    5. CCRC Submission

    • Letby's barrister, Mark McDonald, submitted 23 reports from 24 experts to the Criminal Cases Review Commission (CCRC). These experts found "no evidence of deliberate harm" in any of the 17 cases and identified "far more plausible" causes for the deaths .

    Part 20: Appeal Court Confusion (Baby K), & Statistical Critique [link]

    Overview

    The article questions the safety of Lucy Letby's conviction, particularly focusing on the "confusion" regarding Dr. Ravi Jayaram's testimony and the lack of statistical rigor in the trial. It features a critique of three key prosecution claims endorsed by eight independent professors of statistics.

    Key Findings

    1. Appeal Court Confusion (Baby K)

    • Letby was convicted of the attempted murder of Baby K based "entirely on the evidence" of Dr. Ravi Jayaram, who testified that he caught Letby standing by the cot after she had deliberately dislodged a breathing tube.
    • Jayaram claimed he went to check on the baby because he was surprised Letby hadn't called for help.
    • However, an email from Jayaram to colleagues (dated May 4, 2017) revealed he "stated the facts" that Letby did call him to inform him of low saturations, after which he came to help .
    • The report notes this email contradicts his sworn testimony. While a "source close to the case" claimed the email was disclosed and deemed irrelevant, Letby's barrister Mark McDonald states it was not put before the appeal court .

    2. Statistical Critique The article highlights that no statistician was used to "spot or stop the statistics being butchered" during the trial. Eight professors of statistics agreed on the following rebuttals to prosecution claims :

    • Claim 1: "Letby was always there."
      • Selection Bias: The roster chart showed Letby present at 25 "suspicious" events. However, the article argues Dr. Dewi Evans initially identified 10 more suspicious events, which were removed from the chart when it turned out Letby wasn't present .
      • Ignoring Other Deaths: Letby was present for only 10 of the 13 deaths on the unit between June 2015 and June 2016. In total, the "death spike" involved 16 babies (including 3 who died elsewhere after transfer), but only 7 were attributed to Letby. The factors contributing to the other 9 deaths were not explained .
      • High-Risk Cohort: The events were presented as independent, but the roster included multiple collapses for the same babies (including twins and triplets) in an understaffed unit. The statisticians argue "substandard medical care was a highly probable contributory factor, and far more likely than deliberate harm".
    • Claim 2: "The deaths followed Letby to day shifts."
      • The report counters that four deaths occurred on day shifts before Letby moved to days (when she wasn't on duty) .
      • The two deaths that did occur after her shift change were Babies O and P (triplets), who were very high-risk. Research shows that even in uncomplicated triplet pregnancies, there is a high death rate .
    • Claim 3: "Deaths stopped when Letby was removed."
      • This coincided precisely with the unit being downgraded from Level 2 to Level 1, meaning it stopped taking high-risk babies.
      • The report argues that stopping the admission of sick babies is a "more probable explanation" for the reduction in deaths than the removal of Letby.

    Conclusion

    The article suggests the scapegoating of Letby may be a "convenient smokescreen" for wider system failures, such as understaffing and the unit accepting babies it wasn't equipped to care for.

    Parts 21 & 22: Media Conflicts, Political Intervention, & Dr Jayaram and Dr Evans Referred To GMC [link]

    • David Davis MP's Intervention: The article highlights a Mail on Sunday opinion piece by MP David Davis, who argued that "bogus statistical arguments" and "weak expert evidence" have been exposed. He concluded that Letby is "almost certainly innocent" and that the unit's poor medical management likely caused the deaths.
    • Perjury Allegation: Davis has written to the Chief Constable of Cheshire Constabulary asking for an investigation into Dr. Ravi Jayaram for potential perjury. This relates to Jayaram's testimony that Letby never called him for help with Baby K, which contradicts an email he sent to colleagues stating she did call him .
    • Cheshire Police & "The Plodcast": The article reveals that Cheshire Police paid nearly £24,000 to a media advisory company (Media Factory Limited) run by Caroline Cheetham, the co-host of the Daily Mail’s "Trial of Lucy Letby" podcast.
      • Conflict of Interest: Liz Hull, the podcast's other co-host and Mail correspondent, was listed as a staff member of Media Factory Limited during the time payments were made.
      • Exclusive Access: The podcast, which the article describes as "hugely influential" and "one-sided," secured exclusive interviews with detectives, raising questions about police impartiality and media influence .

    Thirlwall Inquiry, & GMC Competence

    • Inquiry Delay: The Thirlwall Inquiry report has been delayed until "early 2026," presumably to allow the Criminal Cases Review Commission (CCRC) time to decide on referring Letby's case to the Court of Appeal.
    • The Competence Dilemma: The article argues the General Medical Council (GMC) faces a critical issue of competence that it cannot ignore:
      • Prosecution Experts: Eight experts claim the only explanation for the deaths is deliberate harm.
      • Defence Experts: Twenty-four experts (working pro bono) claim there is no evidence of deliberate harm and that deaths were due to natural causes and substandard care.
      • Conclusion: "They can't all be right, and they can't all be competent." If the prosecution experts are wrong, the GMC must address why Chester paediatricians failed to spot their own substandard care. If the defence experts are wrong, then dozens of doctors and pathologists failed to spot "obvious" murder .
    • GMC Referrals & Refusals:
      • Dr. Svilena Dimitrova (a consultant neonatologist) referred Dr. Jayaram to the GMC for claiming the "only possibility" for Baby K's tube dislodgement was deliberate harm. She called this "medical nonsense." The GMC declined to investigate.
      • Dimitrova also referred lead prosecution expert Dr. Dewi Evans to the GMC, stating he has "no expertise in neonatology" and his comments were "medical nonsense." The GMC again declined to act but forwarded the complaint to Evans .
    • Evans' Retaliation: Dr. Evans reportedly complained to the Daily Mail about Dimitrova, calling for her to be "chucked off" the Ockenden inquiry into maternity care because of her "disgraceful" attack on him.
    • Expert Consensus: The article notes that Dimitrova's concerns are now backed by 23 other international experts, making it "inconceivable" that the GMC should continue to avoid investigating the competence of the doctors involved .

    Part 23: Appeals All Round, Dr Evans Self-Destructs, & Flaws In Evidence [link]

    Overview

    The article focuses on growing calls for Lucy Letby's conviction to be re-examined, driven by high-profile interventions and the perceived "self-destruction" of the lead prosecution expert, Dr. Dewi Evans, who has been changing his mind on key theories of murder.

    Key Findings

    1. Political Intervention

    • Jeremy Hunt (former Health Secretary) argued in the Daily Mail that the conviction should be "urgently re-examined," stating that there are "serious and credible questions" about the evidence, expert testimony, and statistical data.
    • Hunt was persuaded by neonatal experts who found "no medical evidence of deliberate harm", instead attributing deaths to "frailer-than-portrayed babies" and "substandard care".

    2. Prosecution Expert "Self-Destructs"

    • Dr. Dewi Evans, the lead prosecution expert, reportedly "snapped" when questioned by an AI software engineer (TriedByStats). Evans responded with personal attacks, suggesting the engineer "get out more" and find a "pretty young blonde female".
    • The report notes that Evans is "professionally isolated," with no other neonatal expert endorsing his view that deliberate harm was the only explanation for the deaths.

    3. "Bombshell" Flaws in Evidence

    • Baby C (Air in Stomach): Letby was accused of injecting air into Baby C's stomach an X-ray from June 12, 2015. However, Letby was not on duty that day.
      • The prosecution switched the date of the "attack" to June 13 (when she was on duty) despite expert reports not identifying harm on that day.
    • Retracted Theories: Evans signed a statement to Channel 5 in April 2024 stating that no baby died by injection of air into the stomach, contradicting the theory used to convict Letby for Babies C, P, and part of I.
    • Other Inconsistencies:
      • Baby N: Evans initially theorized "inflicted air embolism" but switched to "attempted murder by inflicted trauma" (specifically a blow to the back of the throat with a rigid tube).
      • Baby I: Evans proposed air injection down the NG tube, but when it emerged the baby might not have had an NG tube, he changed the allegation to "smothering".
      • Potassium & Prongs: He dropped initial theories about potassium chloride poisoning and dislodged nasal prongs when evidence (like Letby's absence) didn't fit.

    4. Conclusion The article argues that while experts can change their minds, it is unusual to present findings with "certainty" while excluding more plausible causes (like substandard care). It concludes that the Chester consultants who failed to consider their own shortcomings are the root of the problem, and unlike Evans, they are now "keeping very quiet".

    Part 24: On The Death Of Baby O [link]

    Overview

    The article focuses on the conviction for the murder of Baby O, specifically challenging the prosecution's theory of "inflicted liver trauma." It presents new analysis from defence experts suggesting the death was actually caused by medical errors, including excessive ventilation and an accidental liver puncture by a doctor.

    Key Findings

    1. The "Needle in the Liver" Theory

    • Prosecution Case: Lead expert Dr. Dewi Evans claimed the liver injury (ruptured subcapsular haematoma) was "inflicted harm" (assault) by Letby. He made this diagnosis within 10 minutes of seeing photographs, despite no one observing an assault.
    • Defence/New Expert View: Neonatologists Dr. Neil Aiton and Dr. Svilena Dimitrova reviewed the records and concluded Baby O died from avoidable medical errors:
      • Excessive Ventilation: The baby was subjected to "excessive lung ventilation pressures," which prevented the heart from functioning properly and pushed the liver downwards.
      • Accidental Puncture: The article argues that consultant Dr. Stephen Brearey likely accidentally punctured the liver with a needle during resuscitation efforts.
      • Evidence: The experts point to a "life-threatening fall" in haemoglobin levels recorded after the needle was inserted, indicating a massive internal bleed that was neither recognized nor treated (e.g., with a blood transfusion).

    2. Systemic Failures and "Chaos"

    • Staffing Issues: The article highlights a "medico-legal nightmare" where no consultant was present to help with intubation, and the registrar left the ward to attend other duties, causing a delay in care when Baby O deteriorated.
    • Parents' Account: The parents described the scene as "complete chaos" and "absolute pandemonium," even noting they saw a nurse "Googling a procedure" (a lung drain).

    3. Legal Implications

    • The report suggests that while the "needle in the liver" possibility was briefly conceded by prosecution pathologist Dr. Marnerides at trial, the significance of the subsequent haemoglobin drop was missed.
    • It argues that the Criminal Cases Review Commission (CCRC) might dismiss this as "old evidence," but the defence experts insist it proves the death was due to clinical failure, not murder.

    Part 25: Failure To Inform The Coroner [link]

    Overview

    The article focuses on the failure of consultants to report suspicions of foul play to the coroner at the time of the deaths, and the subsequent "writing out" of a coroner's officer who found no evidence of deliberate harm.

    Key Findings

    1. The Coroner's Disappointment

    • Nicholas Rheinberg, the former senior coroner for Cheshire, told the Thirlwall Inquiry he was "horribly disappointed" that not a single consultant or manager passed on suspicions of foul play for any of the babies Letby was later convicted of murdering.
    • Consultants also failed to report the "highly unusual skin changes" they later claimed to have seen. Dr. Ravi Jayaram testified that he didn't report them because he hadn't yet found the research paper linking such changes to air embolism.
    • The report notes that the author of that research, Professor Shoo Lee, has since confirmed that venous air embolism does not cause the skin changes described, meaning the evidence used to convict Letby was a "misinterpretation".

    2. The Whistleblowing Coroner's Officer

    • Davies (a senior coroner's officer) stated that in May 2017, Assistant Chief Constable Darren Martland asked her to review the post-mortems and records for the deceased babies.
    • She reported that she could find "no evidence of deliberate harm" but identified missing pieces of the jigsaw. The article argues this should have pointed the police toward accidental harm.
    • Cheshire Police later dismissed Davies in a statement as having a mere "administrative role" and being untrained. The article refutes this, noting she had specialist investigative training and was promoted to a senior role requiring expertise.
    • Davies eventually lost her job/resigned following a disciplinary investigation after she challenged the outcomes of two other murder investigations and shared details with experts.

    3. Unreported Medical Errors

    • The report highlights that medical errors were not reported to the coroner. For example, defence experts believe triplets Baby O and Baby P died from "resuscitation errors," specifically ventilation pressures that were "far too high," restricting cardiac function.
    • It draws a parallel to a 2015 inquest (Baby Noah Robinson) where doctors had misplaced a breathing tube into the oesophagus and ignored warnings, a shortcoming the coroner was already aware of.

    Parts 26 & 27: The Shifting Media Narrative, & Recent Documentaries [link]

    Overview

    The article, titled "Channel Hopping" (and "Smashie and Nicey" in sub-sections), analyzes the shifting media narrative around the Lucy Letby case, focusing on recent documentaries that have begun to question the safety of the convictions.

    Key Findings

    1. Dismantling the "Four Pillars"

    • The report highlights the ITV documentary Lucy Letby: Beyond Reasonable Doubt?, stating that it "meticulously dismantled the four pillars of the prosecution case":
      1. The shift chart (statistical evidence).
      2. The Post-it notes (alleged confessions).
      3. The medical theories of deliberate harm.
      4. The insulin blood tests.
    • It criticizes the trial for being "scientifically and statistically illiterate" and is scathing of the defence for calling no expert witnesses.

    2. Expert and Journalist Reactions

    • Prof. Neena Modi (UK's most senior neonatologist) is quoted stating the unit was looking after babies it was not equipped to care for ("demonstrably and recognisably on a knife edge"). She argues that problems went unrecognized until babies deteriorated abruptly, meaning deaths might have been avoided with earlier intervention.
    • Josh Halliday (Guardian journalist) admitted he was "astonished" the defence called no experts. Initially believing Letby was guilty, he now thinks there is a "realistic prospect the convictions are unsafe" after hearing new expert analysis.
    • New Legal Strategy: Letby's new barrister, Mark McDonald, has engaged international experts who agreed to review the records only if their findings were made public, regardless of the result. Letby agreed to this condition.

    3. Specific Case Doubts

    • Insulin: The article describes the prosecution's theory of "secret bag-spiking" as "fantastical." It cites defence reports suggesting low blood sugars were caused by clinical failures (e.g., leaking IV lines) and notes that a third baby (Baby Y) had similar blood results due to a natural condition (congenital hyperinsulinism) but was not included in the charges.
    • Baby O: The article argues Baby O's death was not deliberate harm but avoidable management failure. It suggests the liver injury (haematoma) could have been caused by a consultant puncturing the liver with a needle during resuscitation efforts on a baby with massively hyper-inflated lungs.

    4. Media Criticism

    • The report contrasts the ITV documentary with the BBC's Panorama, noting a shift in the BBC's titles from The Nurse Who Killed to Who to Believe?.
    • It criticizes lead prosecution expert Dr. Dewi Evans for his "absolute certainty" and for changing his mind on murder methods (e.g., from air in the stomach to air in the vein) while maintaining that Letby is "guilty as sin".

    Part 28: Why Were No Expert Witnesses For The Defence Called? [link]

    Overview

    The article, titled "Silent Witnesses," addresses the central mystery of why the defence in the Lucy Letby trial chose not to call any expert witnesses. It concludes that this decision stemmed from a pre-trial meeting where defence experts were "outnumbered" and made critical concessions that would have been damaging if presented in court.

    The Joint Expert Meeting

    In August 2022, a "high stakes" meeting was held with six experts: two for the defence (Dr. Michael Hall, Dr. Mohammed Shakeel Rahman) and four for the prosecution (Dr. Dewi Evans, Dr. Sandie Bohin, Dr. Andreas Marnerides, Prof. Peter Hindmarsh). They were required to sign a joint statement identifying points of agreement and disagreement.

    Key Points of Agreement (The Defence's Problem)

    • Insulin Evidence: The "turning point" of the meeting was the agreement regarding Babies F and L. All experts, including the defence's Dr. Hall and Dr. Rahman, agreed that the cause of hypoglycaemia was "exogenous insulin administration".
    • Tactical Withdrawal: Because the defence experts had formally agreed with the prosecution on the insulin charges, calling them to the stand would have forced them to admit this to the jury. The article argues this gave the prosecution a "big win" and left the defence without a witness to challenge the reliability of the insulin tests.

    Key Points of Disagreement

    Despite conceding on insulin, the defence experts raised significant doubts about other causes of death:

    • Air Embolism & Skin Changes: The prosecution experts cited skin discolouration as evidence of air embolism. Defence experts Hall and Rahman repeatedly stated there was "no evidence to support the claim". The article notes that post-trial research has since debunked the skin change theory.
    • Stomach Air: Prosecution experts (Evans, Bohin, Marnerides) argued that "massive gastric dilatation" (air in the stomach) was a method of killing. Defence experts disagreed, attributing it to infection or "CPAP belly" (a common side effect of breathing support).
      • Note: The article highlights that Dr. Evans has since admitted that air in the stomach is not a method of murder, leaving his colleagues Bohin and Marnerides as the sole supporters of a theory "entirely without an evidence base".
    • Baby K (Extubation): Dr. Hall argued that the dislodgement of Baby K's breathing tube was "likely to have been spontaneous," noting it happened two more times with different staff shortly after.

    Conclusion

    The defence did not call their experts because they had signed a legally binding statement admitting that "air embolus cannot be excluded" and that insulin was administered. The article suggests the defence strategy was to avoid handing the prosecution a "field day" by having their own witnesses confirm key parts of the prosecution's case.

    Part 29: The C4 Documentary, The Role Of The Consultants, Systemic Failures, & Expert Witness Imbalance [link]

    Overview

    The article criticizes the media coverage and the origins of the police investigation, while highlighting systemic failures (staffing, intubation) and the imbalance in expert witness resources between prosecution and defence.

    Key Findings

    1. Reaction to Channel 4 Documentary

    • The report describes the two-part documentary Lucy Letby – Murder or Mistake? as "pretty much the Dewi Evans show" (referring to the lead prosecution expert).
    • Evans is quoted calling Letby "evil" and "guilty as sin," while dismissing Private Eye and other critics as "God's most entitled" and part of the "great metropolitan elite."
    • He characterized international experts challenging his findings as "hired guns".

    2. Origins of the Investigation ("Framing the Problem")

    • The report examines how consultants persuaded Cheshire Police to investigate. Dr. Stephen Brearey circulated a draft document in May 2017 arguing that the spike in deaths was "unexpected and unexplained" and linked to Letby's presence.
    • However, fellow consultant Dr. John Gibbs expressed uncertainty at the time, noting that to an outsider or non-medic, many deaths seemed to have "enough reasons" (such as serious heart disorders or infection) to be explained naturally, questioning if a criminal investigation was warranted.
    • Gibbs also questioned Brearey's claim that the unit's downgrade was not a significant reason for the cessation of deaths.

    3. Medical and Systemic Failures

    • Intubation Difficulties: Dr. Tariq Ali, a paediatric intensive care consultant, identified a pattern of "multiple failed and repeated intubations" on the unit. He argued this caused oxygen deprivation (evidenced by desaturation readings and post-mortem signs) which could explain some collapses.
    • Staffing Crisis: The article highlights that staff were "chronically overworked" and often in tears. One account describes the unit as being "stretched thinner and thinner" to a "breaking point," with the acceptance of high-risk triplets (babies O and P) exacerbating the danger.

    4. The "Insulin" Trap and Expert Disparity

    • The report suggests the case likely only went to trial because of insulin results found during a retrospective notes trawl.
    • It notes that the defence "conceded" this point at a pre-trial meeting, leaving them without experts to challenge the reliability of the tests or offer alternative explanations (like insulin receptor antibodies).
    • Mary Prior KC (Chair of the Criminal Bar Association) is quoted explaining the difficulty of finding defence experts: legal aid fees are often too low to attract qualified professionals, whereas the prosecution has a larger budget. This creates a risk that expert evidence becomes "consciously or subconsciously" biased toward the prosecution.

    Part 30: Dr Dewi Evans And Baby C [link]

    1. Major Retraction by Chief Expert

    • Dr. Dewi Evans, the chief prosecution expert, issued a press statement on September 30 calling on the police and Crown Prosecution Service (CPS) to "set the record straight" regarding the murder of Baby C.
    • Evans now states that no babies in the case were killed by air injected into the stomach, a method he originally proposed and which was central to the convictions for Babies C, I, and P.

    2. The Prosecution Error

    • Letby was convicted of murdering Baby C by injecting air down the nasogastric tube, a theory heavily supported by an X-ray showing massive gastric dilation on June 12, 2015.
    • However, it emerged that Letby was not on duty on June 12 and did not start her shift until June 13.
    • Despite this, prosecution barrister Nicholas Johnson KC told the jury it was "plain as the nose on your face" that Letby injected the air, implying she must have done it on June 13, without explaining the air already present on the June 12 X-ray.

    3. Blame Shifting

    • Evans claims he noticed the date error during the trial and updated his theory to suggest death was actually caused by air injected into a vein on June 13.
    • He argues that the police, CPS, and prosecution team "confused" the dates and wrongly attributed the death to stomach air, implying the jury was misdirected by the legal team rather than by his original report.

    4. Implications for Appeal

    • The report argues that by publicly accusing the prosecution, judge, and jury of getting the cause of death wrong for Baby C, Evans may have inadvertently provided grounds for Letby's appeal.
    • The author (MD) contends that Evans' admission that stomach air did not kill any babies makes the convictions for Babies C, I, and P "unsafe".

    5. Personal Attacks

    • Evans criticized Dr. Phil Hammond (MD) for questioning his diagnosis, citing MD's "clinical limitations" as a "comedy doctor".
    • MD responds by noting that numerous independent neonatal experts have examined the same records and found no evidence of murder, suggesting Evans is isolated in his certainty.

    Part 31: Dr Dewi Evans Undermines The Other Prosecution Expert Witnesses [link]

    This (Part 31) focuses on the "other experts" in the Lucy Letby trial and how the lead expert, Dr. Dewi Evans, has purportedly undermined their credibility and the prosecution's case.

    Key Findings

    The central theme is that Dr. Evans has retracted a key theory of murder ("air in the stomach") that he originally convinced other experts to support, which was then used to convict Letby of three murders.

    1. The "Air in the Stomach" Theory:

    • Original Claim: Dr. Evans originally theorized that Letby murdered babies by injecting excess air into their stomachs via nasogastric tubes (NGT). He claimed this caused "splinting" of the diaphragm, leading to respiratory failure and death.
    • Convictions: This theory was the basis for Letby's conviction for the murders of Baby C, Baby I, and Baby P.
    • Retraction: Post-trial, Dr. Evans issued a statement (responding to a Channel 5 documentary) admitting that no babies actually died by this method, claiming they were merely "destabilized." The article notes Evans provides "no credible reference" for this method of death, and MD (Dr. Phil Hammond) states it is "unheard of."

    2. Impact on Other Experts:

    • The report argues Evans has "sold down the river" his fellow experts, Dr. Sandie Bohin (Paediatrician) and Dr. Andreas Marnerides (Pathologist).
    • Consensus Building: At a pre-trial meeting in August 2022, Evans persuaded Bohin and Marnerides to sign statements agreeing that the collapses/deaths of Babies C, I, and P were caused by "exogenous administration of air via the NGT."
    • Crucial Testimony:
      • Dr. Marnerides: Initially thought Baby C died of natural causes but changed his mind to support Evans' theory. His testimony was "crucial" for the convictions, stating explicitly that death was secondary to excessive air in the gut.
      • Dr. Bohin: Testified that massive gastric dilatation in Baby C was "most likely due to deliberate exogenous administration of air," even though it later emerged Letby had not met the baby when the X-ray was taken.

    3. Legal Implications:

    • Judge and Jury Misled: The article asserts that Judge Goss and prosecution barrister Nicholas Johnson KC relied heavily on this expert consensus. Johnson told the jury it was "plain as the nose on your face" that Letby used this method.
    • Appeal Grounds: The article argues that Evans' withdrawal of this murder method "demands action from the Court of Appeal" because the convictions were "misinformed guesswork" that has now been disavowed by its creator.

    4. Evans' Reaction:

    • When asked about his retraction, Evans reportedly gave "no comment" regarding his colleagues but described Letby to Channel 4 as "evil," "guilty as sin," and a "sociopath" (despite lacking psychiatric qualifications).
    • The report suggests Evans is "angry" that the evidence for Baby C (an X-ray) was taken when Letby wasn't present, undermining his original theory.

    In summary, the article posits that the prosecution's consensus on three murder charges has "shattered" because the lead expert has disowned the very method of killing he convinced his colleagues and the jury to accept.

    Part 32: Trial Flaws And Expert Doubts, The Police Investigation, Medical Expert Witnesses [link]

    Overview

    The article, titled "The Lessons of the Lucy Letby Case: Part 32", argues that the prosecution's case in the Lucy Letby trial was "seriously wrong" and driven by "confirmation bias." It highlights significant disagreements among prosecution experts, new doubts about the causes of death, and criticism from senior police figures regarding the investigation's integrity.

    Key Findings

    1. Trial Flaws and Expert Doubts

    • Alternative Explanations: The article challenges the prosecution's central claim that "deliberate harm" was the only plausible explanation for the collapses and deaths. It asserts there are "far more plausible and evidence-based explanations."
    • Retracted Theories: Dr. Dewi Evans, a key prosecution expert, reportedly now admits that "death by air down the nasogastric tube" (a method attributed to Letby for three murders) did not actually kill the babies.
    • Skin Changes Debunked: The theory that specific skin changes indicated venous air embolism has purportedly been "dismantled by post-trial research."
    • Baby O Disagreement: Letby was convicted of murdering Baby O via air embolism and liver trauma. However, prosecution experts disagreed on this:
      • Dr. Sandie Bohin (Paediatrician) was "unsure" about the liver trauma, suggesting it could be iatrogenic (medically induced) damage from attempts to decompress the abdomen during resuscitation.
      • Dr. Owen Arthurs (Radiologist) reported that gas seen in post-mortem X-rays was consistent with "trauma and resuscitation," not intravenous air administration.

    2. Police Investigation Failures

    • Confirmation Bias: Dr. Steve Watts, a former assistant chief constable who wrote the national policy for investigating deaths in healthcare, described the investigation as "unconsciously skewed by confirmation bias" and called the outcome an "egregious miscarriage of justice."
    • "Overawed" Investigators: Watts believes the police were "overawed" by the two consultant doctors, Stephen Brearey and Ravi Jayaram, who pushed the accusations.
    • Ignored Protocols: The National Injuries Database warned that a panel of independent experts (including forensic pathologists and toxicologists) should review the cases. Instead, the police handed the notes to Dr. Evans, a retired paediatrician with no recent high-level neonatal experience, who claimed to spot "deliberate harm" within 10 minutes.
    • Lack of Rigor: The investigation lacked statistical input to consider natural causes or other factors.

    3. Allegations of Perjury

    • Dr. Ravi Jayaram: The article mentions that MP Sir David Davis has asked Cheshire Police to investigate Dr. Jayaram for perjury. This follows the emergence of an email that contradicts his sworn testimony regarding whether Letby called him for help during a baby's collapse.

    4. Systemic Issues

    • Expert Shopping: The article criticizes the adversarial legal system for encouraging "expert shopping," where sides seek out witnesses willing to support a specific narrative rather than providing impartial evidence.
    • Lack of Accountability: It notes that experts are often not held accountable if they fail to provide impartial evidence.