An international panel of neonatologists and medical experts reviewing the deaths of babies at the Countess of Chester Hospital has found no evidence of murder by the former nurse Lucy Letby – instead it revealed a plethora of plausible causes of the deaths as a result of misdiagnosis, failings in basic skills and poor medical care. The panels’ report was a damning verdict on the NHS, the hospital and the consultants who ran the unit and were in some cases involved in the care of the babies. ‘If this was a hospital in Canada, it would be shut down,’ said Dr Shoo Lee, who chaired a group of 14 world-leading experts from six countries.
The report raised serious questions about how the courts appear to have failed to get to grips with highly flawed evidence. Experts also expressed concern about the ability and willingness of the Court of Appeal to revisit a prosecution case that has been so comprehensively challenged by leading experts in the field. Dr Shoo Lee, a professor emeritus at the University of Toronto and founder of the Canadian neonatal foundation, explained that he had paid for his own flight from Canada to address the media. He stressed the unparalleled experience of the panel who reviewed each death in pairs with a third panel member being involved in a further review if there was difference in opinion. The experts received no money for their involvement, had little prior knowledge of the Letby case and agreed to undertake the review only on the basis that any report would be published irrespective of whether it was favourable to the former nurse or not.
Their conclusions could not have been clearer.At the end of a dramatic presentation, Dr Shoo Lee said: ‘There was no medical evidence to support malfeasance in any of the 17 cases.’ Instead, he explained: ‘Injury of all the effected infants were due either to natural causes or to errors in medical care, serious problems related to medical care of patients in this hospital, problems related to teamwork and collaboration at Chester neonatal unit,’ he said. ‘In summary, ladies and gentlemen, we did not find any murders.’
- You can read the interim report and bios here
- You can read Jon Robins on the Letby case here
- Illustration from Rachel Aviv’s New Yorker article on the Letby case
Lucy Letby is presently serving seven whole life tariffs for the deaths. The Court of Appeal has rejected her case and an application has just been made to the Criminal Cases Review Commission (CCRC).
The interim report – a full report will be submitted to the CCRC shortly – listed 14 problems in relation to the medical care of the 17 cases, including ‘poor skills’ in relation to resuscitation and intubation, ‘poor supervision of junior doctors’, a lack of skills in ‘basic medical procedures’ and a lack of knowledge about ‘commonly used equipment in a unit’. There was further concern about disregard for warnings over an outbreak of bacteria on the unit; misdiagnosis of diseases; and ‘lack of teamwork and trust between health professionals’.
‘You shouldn’t be using wrong evidence to convict someone’
Dr Shoo Lee described the panel he convened – which featured experts from the US, Japan, Germany, Sweden – as ‘the crème de la crème, the dream team of neonatology. You are not going to find any better.’ It included 10 neonatologists, one pediatric surgeon, one pediatric infectious disease specialist, one senior neonatal intensive care nurse, and one other pediatric specialist. The panel members had little knowledge of the Letby case with the exception of Prof Neena Modi, a professor of neonatal medicine at Imperial College London. A past-president of both the British Medical Association and Royal College of Paediatrics and Child Health, Prof Modi revealed that she had been so concerned about the treatment of the medical evidence during the trial that she had contacted the defence lawyers only to receive a polite letter but no further engagement.
Prof Modi said: ‘What we have shown is that they were plausible reasons – very, very plausible reasons – for these babies’ deaths. If you take the totality of the 17 cases, there was a combination of babies being in the wrong place, delayed diagnosis and inappropriate or absent treatment.’ She said it was not the panel’s brief to comment on ‘the wider issues facing the NHS’. ‘But I would say to you, there are clearly systemic factors that are at play that we’ve identified.’ She went on to say: ’The NHS has been under great strain and staffing has been a problem at many, many neonatal units around the country.’
The weight of experience of a panel that claimed to present some ‘500 plus years’ of professional experience – Profs Shoo Lee and Modi have published 400 research papers each – is stacked up against a prosecution case mainly built around the highly contested evidence of a retired consultant paediatrician Dr Dewi Evans who was making a living as an expert witness in the courts. It was Dr Shoo Lee’s 1989 paper that Evans relied upon. Dr Shoo Lee testified in the Court of Appeal that it was misunderstood.
Explaining how he got involved in the case, Dr Shoo Lee said did not usually undertake medical legal cases. ‘I just don’t enjoy them,’ he told journalists. ‘In this particular case, I was curious to see what exactly they used my paper for. When I saw the evidence that they gave, I was disturbed because it was wrong. After I gave evidence at the appeal, I realized she had no where to go because she had exhausted all avenues of appeal – yet to me the evidence was wrong. I didn’t know at the time whether she was innocent or guilty, what I did know was that the evidence that was used to convict her was wrong – and to me that’s a problem. You shouldn’t be using wrong evidence to convict someone.’
The battle ahead
Lucy Letby’s new barrister Mark McDonald said there was now ‘overwhelming evidence’ the nurse was wrongly convicted. ‘The reason Lucy Letby was convicted was because of the medical evidence presented to the jury. That today has been demolished.’
There was little confidence in the ability of the criminal appeals system to deal with such a weight of expert opinion. The Criminal Cases Review Commission (CCRC) took the unusual step of issuing a press release yesterday to confirm it received Letby’s application earlier this week – it already seemed to be underplaying concerns and managing expectations as to a timeline for responding. ‘We are aware that there has been a great deal of speculation and commentary surrounding Lucy Letby’s case, much of it from parties with only a partial view of the evidence,’ the watchdog said. ‘We ask that everyone remembers the families affected by events at the Countess of Chester Hospital between June 2015 and June 2016. At this stage it is not possible to determine how long it will take to review this application. A significant volume of complicated evidence was presented to the court in Ms Letby’s trials.’
Mark MacDonald, who represents a number of high profile clients and CCRC applicants including Ben Geen and Michael Stone, told journalists he had experience of waiting for eight years for a decision from the CCRC. ‘But what I do know is that the CCRC are taking this very seriously,’ he said. ‘They’re ready to go, and I hope that having they’ve watched this conference… and they’re going to this very seriously and deal with it very quickly.’
There is building pressure on the Court of Appeal to be receptive to revising evidence that was dealt but misunderstood at trial. David Davis, the Conservative MP and former government minister who has championed Letby and chaired yesterday’s press conference, said: ‘We need to reconsider the basis on which we accept evidence as new for the purposes of appeals’. ‘If your lawyers make a mistake, you’re banged up for life,’ the MP continued.’ That’s not justice. It may be judicially convenient – but it’s not justice.’ He flagged the ongoing Law Commission review of the criminal appeals system as an opportunity to tackle the conservatism of Court of Appeal.
The same concern was expressed by the former director of public prosecutions, Ken Macdonald on Radio 4’s World at One program yesterday. He described the Court of Appeal as a ‘hostile place’ for appellants arguing that it should approach cases with ‘an open and inquiring mind’. Instead, he described its track record as ‘mottled’.
‘In many of these great miscarriages of justice cases, they’ve had to go back two or three times to the Court of Appeal before they eventually got it right. One of the consequences that should happen – and I emphasize should – is that the Court of Appeal itself may want to revisit the way it approaches its work to make sure that it is sufficiently inquiring, sufficiently independent and unburdened by notion that its job is to uphold rather than overturn.’ MacDonald was asked if the court’s mind could be ‘too closed’. ‘It can be a real battle in the court of appeal,’ he added.
Panel report: ‘No evidence of murder’
Conclusions
- There was no medical evidence to support malfeasance causing death or injury in any of the 17 cases in the trial
- Death or injury of affected infants were due to natural causes or errors in medical care
- There were problems related to the medical care of patients at the Countess of Chester Hospital neonatal unit
- There were problems related to teamwork and inter-disciplinary collaboration at the Countess of Chester Hospital neonatal unit
Findings
- Baby 1: alleged that baby died from injection of air into the intravenous line causing air embolism resulting in collapse with patchy discolorations of the skin and death. The panel said there was no evidence of air embolism and pointed to new research showing that patchy skin discoloration has never been reported in infants with venous air embolism
- Baby 4: The panel found the baby died of systemic sepsis, pneumonia and disseminated intravascular coagulation and reported a delay in recognizing respiratory distress after birth – again, there was no evidence of air embolism as argued by the prosecution.
- Baby 6: It was alleged that the baby had been given insulin through the infusion bag leading to hypoglycemia. The panel found the baby had hypoglycemia for multiple reasons including sepsis, prematurity and ‘poor medical management’ and insulin levels were ‘within the norm for preterm infants’
- Baby 7: It was alleged that thee baby was deliberately overfed and had air injected into her stomach through the nasogastric tube, causing the vomiting and clinical deterioration. Again, the panel detected no evidence to support air injection.
- Baby 9: It was alleged that air was ‘injected’ into the stomach via a naso-gastric tube. It was alleged that the apnoea alarm was deliberately turned off, resulting in delay in response to a
collapse. The panel found Baby 9 died of respiratory complications caused by respiratory distress syndrome and chronic lung disease complicated by bacterial colonization. The panel found doctors ‘failed to respond to surveillance warnings, did not recognize the diagnosis, and did not treat her with the appropriate antibiotics. This was a likely preventable death’. There was no evidence of air causing splinting of the diaphragm or of air embolism but it noted: ‘There is evidence that the apnoea alarm was not turned off.’ - Baby 11: It was alleged first episode of clinical deterioration was caused by deliberate dislodgment of her endotracheal tube and that incubator alarms were deliberately turned off. There was no evidence to support dislodged tube. The initial intubation had been ‘traumatic and poorly supervised’. ‘The consultant did not understand the basics of resuscitation, air leak, mechanical ventilation, and how equipment that were commonly used in the unit work.’ There was evidence that the incubator alarms were not turned off.
- Baby 15: It was alleged that baby received trauma to the abdomen, and that air was injected into the nasogastric tube – accusation subsequently changed to
deliberate injection of air into his circulation. Baby died from a subcapsular liver haematoma caused by traumatic delivery – not recognised ante-mortem.
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