The case of Lucy Letby has galvanised a significant segment of the British public, prompting extensive speculation as to why this particular case has led so many to adopt a stance and insist that theirs is the correct perspective. Among those who have made their opinions known are numerous medical and clinical staff, including doctors, psychologists, nurses, physical therapists, and social workers. Additionally, there are individuals who are unconventional supporters of the notion of wrongful convictions, such as David Davis, Nadine Dorries, Peter Hitchens, The Telegraph, and various others who likely never imagined themselves campaigning for a retrial for Britain’s most prolific convicted female serial murderer.
Social Media Dynamics
These individuals have colonised the increasingly right-wing social media forum, X. Meanwhile, in other corners of the internet, forums exist where individuals appoint themselves as Letby Experts. These Experts follow the declarations of Daily Mail journalist and Lucy Letby Court Watcher Liz Hull, expressing a visceral hatred for anyone suggesting that the scientific evidence in the Letby case is anything but absolutely watertight. The Letby Experts have made a home for themselves on the Lucy Letby subreddit page, moderated by an American woman, Amy Gulley. Gulley is nothing short of a fanatic, despite having no link to the UK, nor any element of the case. A year ago Gulley's subreddit was much smaller, with only a few hundred members. Now standing at over 10,000 members, the subreddit is a place where balanced and reasonable thought appears to be absent. The purpose of the subreddit is not to question the Letby convictions or even evaluate the evidence; this is strictly forbidden. Instead, these Letby fanatics simply exchange perspectives on the accuracy of the evidence in the case, along with their view that Letby is an evil baby killer.
Peculiarly, few commentators have paid much mind to the CoA judgment, despite this being the first confirmed court document available to the general public. Given that the only real movement forward for Letby is a Criminal Cases Review Commission (CCRC) application, it appears that it would be beneficial to at least review the CoA’s judgment, lest it reveal a glaring issue that blows a hole in either side’s perspective.
Establishing Novel Legal Precedents
What stands out the most from the CoA judgment is that it establishes the most unusual of legal precedents. In their judgment, the CoA essentially bars any further scrutiny of the reliability of the expert witness claims made in the first trial. By doing so, it establishes that there is nothing improper about a retired paediatrician changing the cause of death in seven infants whose deaths were initially deemed natural. To make matters worse, the CoA was indifferent to the reality that 6 out of 7 of the deaths were determined by autopsy and through a coronial review. Adding more exceptions to such a scenario, the CoA opined that a medic who retired from practice 15 years prior, and who is not a pathologist, neonatologist, nor forensic investigator, should be free to conduct a forensic investigation identifying causes of death that he explicitly states in his own documentation as benign and harmless.
Dr Evans, a retired medic is permitted to include evidence used to describe pulmonary vascular air embolism (air embolism due to damage to the neonate’s lung resulting in air bubbles forming in the blood returning to the heart) in place of actual evidence to describe venous air embolism (which occurs when air is trapped in the pulmonary artery, causing sudden cardiovascular collapse). Essentially, the CoA has permitted evidence that a diagnostic determination of a distinct physiological state can be identified using criteria from a different wholly distinct and unique physiological state. This is akin to using an assessment criterion for major depressive disorder to diagnose schizophrenia, under the basis that they are both broadly in the same category of mental health disorders! Thus, it may now be possible to manufacture wholly unique disorders in defendants and victims based on the application of the wrong criteria and the insistence from a medic that they know what they are doing!
The Right Expert for the Wrong Problem
Many have expressed incredulity that the CoA refused to consider the testimony of Dr Shoo Lee, the author of the prosecution’s highly cited paper on pulmonary vascular air embolism. In reality, the statements made by Dr Shoo Lee had marginal impact on the hypotheses surrounding air embolism, because Dr Shoo Lee confirmed that colour changes can occur for pulmonary vascular air embolism. Unfortunately, the defence team made an amateur mistake in their efforts to present new evidence. They attempted to use the same paper that did not describe venous air embolism to prove that the babies did not die from venous air embolism. In reality, calling Dr Shoo Lee to discuss the one paper on pulmonary vascular air embolism was a pointless endeavour.
The defence should have called the one expert that neither defence nor prosecution provided at the trial—an expert who had actually observed venous air embolism. Dr Shoo Lee was of little benefit to the defence when it came to detailing that rash was not associated with venous air embolism because his paper did not focus on venous air embolism, so it was impossible to infer much from such a paper! However, because the defence limited Dr Shoo Lee’s testimony to the narrow issue of skin manifestations, he was never able to adequately explain why his paper should never have been applied to any of the babies in this case because—one more time—pulmonary vascular air embolism does not occur by the same mechanism of action as venous air embolism, and as such, none of the symptoms associated with pulmonary vascular air embolism occur in venous air embolism!
Dr Evans’ Simple Science
Remarkably, the CoA breezed through the confused claims bounced back and forth between Johnson and Myers in their effort to claim that the science was either sound or was not. Quite why Myers focused on skin manifestations as the primary issue that was holding Dr Evans’s specious scientific hypotheses together is anybody’s guess. Still, after three days of listening to a scientific argument that lacked any basis in actual scientific reasoning, though contained a number of key words for effect, the CoA determined that the body of evidence presented by Dr Evans, for the prosecution, represented a sufficient body of evidence concerning air embolism and that there was no doubt that Letby’s convictions were safe because Dr Evans’ evidence was sound. It really was not, not least because, in support of this claim, the CoA pointed to a poorly written scientific review prepared by Dewi Evans in 2019.
In his review, Dr Evans states that his primary peer-reviewed sources of air embolism (all 18 of them) were gathered from Google searches. Dr Evans was obviously unaware that simply searching for “air embolism” AND “neonate” in the medical search engine PubMed returns 273 results (Figure 1). Quite how he only managed to find 18 papers is anybody’s guess! Still, lacking from his meagre review were any papers determining the methods used to identify air embolism as a cause of death. Further lacking was the 2015 paper which demonstrated that in preterm neonates, air embolism occurs as a consequence of CPR (Halbertsma et al., 2015).
The CoA threw its full support behind his flawed understanding of air embolism. In doing so, the CoA has redefined air embolism as an event that can only occur in clinical circumstances and further established a completely distinct mechanism of action by which venous air embolism causes death:
“Dr Evans described an air embolus as: ‘a serious life-threatening condition and found only as a complication of clinical care. If the volume of air is sufficiently large, the result is fatal. Direct injection of air via a syringe and needle is always intentional. The injected air passes through the veins eventually reaching the right side of the heart and through the pulmonary artery into the lungs. The air functions like a “bolus” or “clot” and has the same effect as a solid embolus. It obstructs the blood supply and causes rapid demise and death.’ Paragraph 39
The CoA has created a new legal and medical precedent by erroneously affirming that air embolism is only found as a consequence of clinical care. Air embolism can occur in numerous traumatic circumstances, including blunt force injury and gunshot wounds:
“A 29-year-old man was shot in the chest twice sustaining extensive contusion of the right lung… Unexpected cardiac arrest occurred hours after hospital admission due to left coronary artery air embolism.” (Temlett et al., 2011). And “We present a case of a young male patient with a fatal pulmonary air embolism following a penetrating gunshot head injury.” (Brune et al., 2018).
Contrary to the CoA inclusion into case law, air embolism can occur due to various reasons apart from complications of clinical care. One wonders whether this new specification of air embolism would mean that a defendant claiming that a gunshot victim died not of the gunshot but an undetected air embolism will not be free to argue as such because air embolism reportedly does not occur outside of clinical settings! It will be impossible to know until such an event arises!
The CoA, an Incubator for novel Medical and Forensic Definitions
A further change to medical and forensic discourse surrounding venous air embolism, as set down by the CoA, is the mechanism by which venous air embolism causes death. The CoA accepts that the evidence provided shows that air injected into a vein passes through the veins, enters the heart, and passes through the pulmonary artery, where it causes circulatory collapse. Unfortunately, the CoA’s definition of venous air embolism is factually incorrect. The cause of death in venous air embolism is due to the air bubble forming a clot (Figure 2), and that air-clot becoming stuck in the pulmonary artery. Because air is compressible, the air bubble and associated debris cannot pass through the pulmonary artery. Thus, in every forensic pathology textbook, death due to venous air embolism is brought about by pump failure in the heart due to the air becoming stuck in the pulmonary artery, whereas the CoA is claiming that this finding is wrong, and circulatory collapse is what causes death. Indeed, circulatory collapse might occur in arterial air embolism, where air in the arterial system blocks the blood supply to the organs, including the skin, thereby causing tissue damage and skin colour changes. However, venous air embolism is the apparent cause of death in these cases.
The CoA appears to be permitting Dr Evans’ air embolism review to defeat all current evidence surrounding venous air embolism. However, Dr Evans’ review is a pathetic piece of work that fails even to provide case evidence of the determination of air embolism as a cause of death. We must be forced to believe that the highest justices in the CoA are of the view that venous air embolism as a cause of death can be determined by merely inspecting a couple of radiographs, associating the presence of a nurse with an infant’s blood oxygen desaturations, the fact that the medics tending to the babies could not revive the infants following CPR, and that the medics had no idea why the babies suddenly collapsed. Aside from the coincidence of the nurse’s presence, these symptoms sound mightily like myocarditis, even down to the tachycardia prior to collapse… The cause of myocarditis is nearly always viral, however nobody so much as uttered the word to the court in the entire 10+ month trial.
Overview of Air Embolism
Smaller amounts of air in the circulation do not cause any clinical manifestations as they are broken and absorbed from the circulation.
Moderate amounts of air cause pulmonary vascular injury, leading to pulmonary hypertension and permeability pulmonary oedema. (This does not cause death)
A large bolus of air in the venous system can cause an air lock in the right side of the heart, leading to right ventricular flow obstruction and death (see Muth and Shank, 2000).
To cause sudden collapse, as claimed by Dr Evans, there would need to be the formation of an air lock, and that happens in the pulmonary artery. This causes sudden cardiovascular collapse and would produce air bubbles in the heart (Figure 3). Both the CoA and Dr Evans’s definition seem to suggest that the heart simply fails because of air bubbles in the capillaries that pass through the pulmonary artery. This is excluded by credible pathologists:
“Almost the only mechanism of death is ’pump failure of the right side of the heart. Air fills the great veins, right atrium and right ventricle, causing a froth that cannot be pumped on by the heart in systole because air is compressible. It is unlikely that air will penetrate the pulmonary capillaries in any quantity, unless some vascular shunts are present, so froth is unlikely to be seen in the left side of the heart, except in dysbarism.” Knight's Forensic Pathology, 3Ed, (Saukko and Knight, 2015)
Legal Oversights a Common Theme
Once again, Letby’s legal team has overlooked an opportunity to effectively defend their client’s rights. It seems that the peculiar claims from the CoA judgment may have warranted an application to the Supreme Court to challenge the stark departure from precedent that the CoA has apparently allowed in its invitation to change the cause of death using imaginary physiological causes of death! However, that boat has long since sailed. Still, what is so apparent is just the level of incompetence that has been allowed to persevere in this case. One is left to wonder whether anyone involved, from the prosecution experts to the convicted woman herself, understands that this entire case is predicated on repeated rounds of individuals failing to comprehend the disease mechanisms associated with several physiological states. We can get through them fairly rapidly.
Insulin Cases
Insulin binding to its receptor causes massive shifts in potassium and sodium. If a baby has an insulin concentration of 4657 pmol/L for 17 hours straight, and this concentration is maintained due to infusion of artificial insulin, then this baby would not be alive. The amount of insulin in the blood would literally cause the potassium concentration in the blood to change to such an extent that the infant would have died fairly quickly from cardiovascular collapse. In a rare case of suicide by intravenous insulin administration, a 30 year old woman administered a maximum of 600 IU of insulin via an intravenous cannula, which resulted in death. Based on prior calculations, to maintain a blood insulin concentration of 4657 pmol/L (as recorded in one of the insulin cases) it would require an infusion rate of insulin of ~43 IU/hour. In essence, by the end of the 17 hour period the baby would have received over the same amount as that which resulted in the following conditions:
“On admission, her pulse and blood pressure were not recordable. No respiratory effort was noted. Froth was coming from the nose and mouth.” (Behera et al., 2015)
Air Embolism
This is a rapid cause of death in the order of minutes. Once the air is in the vein, it quickly moves to the heart and causes cardiovascular collapse. Failure to observe the oozing frothy blood in the right ventricle of any baby suggests that venous air embolism is not a cause of death. Importantly, skin manifestations are not a feature of venous air embolism, and there is a defined method to determine air embolism as a cause of death and it does not involve relying solely on x-ray images and vague descriptions at time of collapse.
Bruising to the Liver
Dr Marnerides has apparently only observed bruising to the liver, as identified in one of the Letby cases, in preterm infants subjected to car and trampoline accidents. Quite when preterm babies are enjoying these pursuits was not a matter discussed during the trial. However the cause of the liver trauma was actually reported at the time of the event, and was contained in text messages read out in court. In a text message to Letby from Dr A, he states:
“There was a liver capsule hemorrhage in Baby O. It's not considered by SB and A to be significant. There will be an inquest.” Dr A to Lucy Letby in June 2016.
It is clear at the time the medics are aware of the cause of the collapse as they make reference to a subcapsular liver haematoma (you can read more about that here). Subcapsular liver haematomas (SLH) often occur in preterm neonates due to sepsis, birth injury, or maternal infection. When they are discovered, unless immediately managed, they are associated with a significant likelihood of mortality, there is no evidence that a SLH can be induced by the actions of another (Liakou, et al., 2022).
Overfeeding and Projectile Vomiting
These are mere fantasies. Projectile vomiting in infants usually occurs due to an occlusion of the pyloric sphincter, which is common in infants at high risk of cerebral palsy. The development of changes in tone due to the ascending vagal tone can result in increased activity of the nerves that terminate in the enteric nervous system, thereby causing difficulties with gastric emptying and resulting in projectile vomiting.
Saving the worst of Dr Evans’ Scientific Claims until Last
We can refer to Dr Evans’s own 2019 review of air embolism to demonstrate that air in the stomach is a benign event and was regularly used to assess the effectiveness of gastric surgery. In his review (Figure 5), Dr Evans states:
“At the end of the surgical procedure it was standard practice for the surgeon to ask the anaesthetist to inject air into the stomach via the nasogastric tube. A volume of air into the stomach would cause no harm and guarantee that the surgical procedure had not caused a perforation to any part of the upper GI tract during the surgery.”
Dr Evans confirmed in 2019 that passing air through the nasogastric tube into the stomach of a baby was benign and harmless. The CoA, having cited the 2019 review at paragraph 40, stated:
“Dr Evans produced his ‘Review of Published Literature regarding Air Embolus in the Newborn Infant’ in July 2019, by which time he had provided over 40 reports for the police investigation. The impetus for this work was his growing concern that the causes of the collapses and deaths of several of the babies at the unit had been the intentional introduction of air in the babies’ circulation.”
As it currently stands, the CoA observed that injected air into the stomach of infants was harmless and that the expert witness, Dr Evans, affirmed as much (Figure 5). Yet, it is anybody’s guess how the court compiled a table claiming injecting air into the stomach is not simply benign, as Dr Evans claimed in 2019, but actually lethal (Table 1.). The CoA has permitted Dr Evans’ claims in 2019 to contradict his claims later made in 2022/2023. Such a clearly impossible event cannot be true: Was Dr Evans correct in 2019 when he wrote the report, which the CoA claims legitimises the inaccurate definitions of venous air embolism but argues against the idea that air via an NG tube is harmful? Or was he correct in 2022/2023 when he told the jury that the process of pushing air down an NG tube into the stomach of a baby was sufficient to kill the baby and that this was a cause of death of three separate babies?
In the event that Dr Evans was wrong in 2019, why would one trust anything in his report? Likewise, if he were somehow right in 2019 but wrong in 2022/2023 when he testified to the jury, then why should one trust a word of what he said during the trial?
The CoA has finally informed us that George Orwell’s imagined hellscape of conformist intellectual paralysis has finally arrived. Here it is that we should believe a report that invalidates a central claim later made by its author when he is imagining causes of death, in neonates whose deaths were determined by a pathologist. How dark can one mind be to sit and imagine how these poor babies suffered and magic up fabricated physiological mechanisms? That is what the CoA is tolerating; it has permitted the peculiar imagination of Dr Evans to run wild and convince one of the highest courts in England to accept his Grimm Fairy Tales at face value. Indeed, there is a witch, a whole valley of trolls, a baying mob, and a mass of horrified spectators, and at the centre of it is the puppet master Dr Dewi Evans, who has played every element in this case. Dr Evans has made his deceit a reality; his false claims and deliberate misrepresentations have now been affirmed as English Law, awaiting some other person to walk into the trap he has set.
“And if all others accepted the lie which the Party imposed—if all records told the same tale—then the lie passed into history and became truth.” George Orwell, 1984
References
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