Lucy Letby Case: Conduct of Cheshire Police
You rescued me from embarrassment, Madam Deputy Speaker. Let us forensically analyse the prosecution of this case, using as a reference proper police procedure, prosecutorial standards, medical murder investigation guidelines, CPS guidance, the evidence from the Thirlwall inquiry and the considered critiques from these two experienced police officers. The neonatal unit at the Countess of Chester hospital was failing. Its medical management was at best inadequate and at worst appalling. Indeed, a week after Letby was suspended, the unit was downgraded and prevented from taking any more very seriously ill babies. Before the police investigation, numerous reviews looked at the Countess of Chester and found no evidence of criminal activity. The most salient was by the Royal College of Paediatrics and Child Health, which found no criminal events, but did identify numerous shortcomings in medical care at the hospital. Cheshire police ignored that, and the jury was never informed of it. Dr Watts notes, as did the assistant chief constable, that the royal college report “raised significant concerns about systemic failings…Its exclusion from court…meant alternative explanations were suppressed.” Let us also remember that this was a neonatal unit with no neonatal specialist consultants, only general paediatricians. Furthermore, the trust had dismissed all the experienced advanced neonatal nurse practitioners to save money. There was a 20% staffing shortfall. Doctors did ward rounds twice a week, rather than twice a day. We can think of the fragility of these children, yet they only got seen twice a week. There were outbreaks of multiple antibiotic-resistant infections. Pseudomonas aeruginosa, MRSA and C. difficile bacteria were all detected in the hospital. Sewage was dripping from the ceilings. Doctors followed poor counter-infection processes. The mother of triplets who moved to Liverpool women’s hospital “noticed a different level of cleanliness compared to the Countess of Chester…There were clear hygiene protocols…we were told to wash our hands before entering the Unit and then again before entering the room”, which was not the case at the Countess of Chester. It is also notable that there were 12 stillbirths in hospital at the same time as the spike in neonatal deaths—stillbirths that Lucy Letby was nowhere near. That was also ignored by Cheshire police. Why did Cheshire police decide Letby was responsible? Initially, there was no intention to launch any criminal investigation, but on 15 May 2017, that all changed. After a single meeting with two consultants—Dr Stephen Brearey and Dr Ravi Jayaram—from the Countess of Chester, Letby was explicitly identified as the focus of suspicion. Dr Watts states that “in this meeting, the language of this very experienced, very senior detective” from the Cheshire police force “moved from a measured, rational professional tone to…inappropriately emotional.” He cites the senior Cheshire police detective as saying: “I can’t describe how powerful it was…I just felt for those professionals there….I think we all owe them.” Dr Watts observes that “within 24 hours” of that meeting, Operation Hummingbird—the name of the Letby operation—was “up and running”. Within three days, news of the investigation into a potential murder at the Countess of Chester was in the national press. This investigation was initiated by a single meeting with consultants who had themselves been involved in seriously inadequate care of babies. The consultants who pointed the finger at Letby were Dr Stephen Brearey, Dr John Gibbs, Dr Ravi Jayaram and another doctor, who was anonymised for the court’s own reasons. They had all demonstrated poor care. One had wrongly punctured a baby’s liver. That baby later died. One was found by a coroner to be responsible for the death of a child after a breathing tube was inserted into the oesophagus, rather than the trachea—in other words, into the gullet, rather than the windpipe. One pushed an endotracheal tube into a baby’s lung, leaving the other collapsed. That baby later died. One clearly misled the jury by claiming that he had “virtually caught” Letby doing nothing as a baby collapsed in front of her—evidence that his own emails disproved. Those doctors could very well have contributed to the spikes in deaths attributed to Letby. Dr Watts poses an important question: “Where was the decision not to treat the doctors as suspects, or the other nurses, or the cleaners?” Justice demands that the police look at everyone. It does not permit them to fixate on one individual and build a case solely around them. Dr Watts makes it plain that that is not just a moral requirement; it is the law. Section 23(1)(a) of the Criminal Procedure and Investigations Act 1996 requires “that where a criminal investigation is conducted all reasonable steps are taken for the purposes of the investigation and, in particular, all reasonable lines of inquiry are pursued”. Paragraph 3.5 of the code of practice under that Act states: “In conducting an investigation, the investigator should pursue all reasonable lines of inquiry, whether these point towards or away from the suspect.” The Cheshire police did not follow the letter of the law or best professional practice. Dr Watts states that CPS guidelines and police guidance on the investigation of death in healthcare settings “require that decisions in ‘Sensitive, Serious and Complex’ cases are referred to the CPS Serious Crime and Counter Terrorism Division.” Remember that Dr Watts is the country’s expert in this area. He says: “It appears self-evident that this case falls into all the relevant categories of Sensitivity, Seriousness and Complexity”, but the regional CPS unit, Merseyside and Cheshire, “made the charging decisions in this case.” The requirement is made plain in the current version of the CPS referrals, approvals and notifications guidance, which states in terms that “homicide allegations involving…four or more victims and…medical authorities” should be passed on to the special crime and counter-terrorism division, which is a unit in London that specialises in complicated cases. Plainly, the Cheshire police believed that there were a lot more than four victims, so this case should have automatically gone to the special crime and counter-terrorism division. The failure to refer the case meant that proper safeguards and specialist scrutiny by independent lawyers, who had not been closely associated with the investigating team, were never implemented. That is very important. It is notable that when officers in the special crime and counter-terrorism division were involved earlier this year after the Cheshire police had put 11 additional charges to them, they turned them down flat. The special crime and counter-terrorism division stated that “the evidential test was not met in any of those cases.” After failing to refer the case to the correct CPS unit, Cheshire police then failed to listen to explicit guidance from the National Crime Agency. Again, Dr Watts points out: “On 26 May 2017, an email record indicates that the NCA…advised” Cheshire police “to appoint a panel of relevant experts; they clearly defined the disciplines and provided a comprehensive list. They were: Forensic & Neonatal Pathologists, Forensic Toxicologist and/or Clinical Pharmacologist, a Nurse with experience of special baby units, a medical expert with experience of the working practices on a special unit for neonates, an Obstetrician, and experts to review the medical statistics.” The advice was national best practice, but Cheshire police ignored it. On 28 June 2017, the NCA advisers followed up with a list of potential experts who could fill those posts. Cheshire police blatantly ignored that, too. Instead of drawing up a multidisciplinary panel, Dr Watts states, “Operation Hummingbird…built its entire medical case around one expert.” That so-called expert was Dr Dewi Evans. The warning signs were there before the trial started. Dr Watts believes that “Cheshire police were clutching at straws to find an expert, then very quickly and uncritically took a lifeline offered by Evans”. Evans ran a business providing “expert medical advice” in court cases for a high fee. We can identify at least £80,000 paid to him for the Letby case, but the rest is concealed, and the true total is likely many times higher. Evans stated: “This was my extra money, which helped keep my daughter in horses and my son in cars.” That was his motivation. He approached the NCA after reading about the case and called it “my kind of case”. Dr Watts points out that the “‘back door’ approach by an alleged expert who is clearly looking for work…should have sounded warning bells for the” senior investigating officer “and the investigating team”. Having practised as an expert witness for decades, Evans boasted he had “never lost” a case. That is not the mindset of a neutral expert; it is the language of someone who tailors his evidence to suit the prosecution’s case. This was clearly demonstrated when another very senior judge took the extraordinary step of writing to the presiding judge in the Letby case, alerting him to Evans’s failings in a previous case. I think the House should understand quite how unusual it is for a judge to take that step. Lord Justice Jackson described Evans’s evidence as “worthless”, stating that he “makes no effort to provide a balanced opinion”, and his “approach amounts to a breach of proper professional conduct”. I think that, later on, he also called it tendentious—terrifying when a single opinion will condemn a young woman to life in prison. When Cheshire police asked Evans if it should follow NCA guidance and seek other expert witnesses, he said: “I do not think it’s necessary to consider additional expert opinion at this stage.” He wouldn’t, of course. Evans was appointed as both the police adviser and the expert witness in the trial. Stuart Clifton states: “It was illogical to allow Evans to both advise and be the principal prosecution witness as there is a clear conflict of interest.” If this was not warning enough to Cheshire police, it should have set alarm bells ringing when Evans declared, after just 10 minutes of reviewing the case notes, that he suspected there was “foul play”. Dr Watts states: “Evans was not independently selected but came forward himself” and “validators used to assess his opinions were themselves selected without adequate independence…by Evans himself”. What is more, Stuart Clifton said that it was “completely illogical to allow other experts…to view the findings of Evans, since experts are expected to give evidence of their” findings “and not be corrupted by others”. Another prosecution expert, Professor Hindmarsh, was dismissed from his post as an honorary consultant at Great Ormond Street hospital before—just before—he gave evidence at the trial. During the trial, while he was giving evidence, he faced a General Medical Council investigation for failures of expertise and posing a risk to his patients: an expert witness chastised for a failure of expertise. The jury knew nothing of that. Another prosecution expert, Dr Bohin, reviewed Evans’s work. She faced numerous complaints from her patients’ families and was later criticised for ignoring a key symptom in one of her patients. These are the supposed experts that Cheshire police and the CPS chose, rather than a panel of independent experts from all relevant disciplines, as the NCA had advised. Three times Cheshire police’s due diligence failed—if, indeed, they attempted it at all. Crucial to the case against Letby was the infamous shift table presented as evidence that she was on duty for all the incidents when babies collapsed or died. Over a period of 13 months, there were 17 deaths—far more than the “normal” expected three or four deaths. Stuart Clifton states: “Missing from the chart used at trial are deaths which occurred whilst Letby was not on duty or those where adverse events took place whilst off duty”. Cheshire police, which compiled the table, chose to highlight only the shifts during which Letby was present, disregarding similar events when she was not. The seven deaths charged as murders were, in effect, selected because she happened to be on duty. As Stuart Clifton bluntly puts it: “Evans cherry picked the cases to match Letby’s shifts and Police used this in their chart to reflect her presence at those events highlighted by Evans. One has to wonder just how he settled on those children where Letby was present.” Any qualified statistician could have pointed that out to Cheshire police. In fact, one did. In April 2018, a police officer approached one of the country’s leading statisticians, Professor Jane Hutton, asking her to put a figure on the likelihood of a nurse being on duty during “all the deaths/collapses” in the unit. It is almost a rerun of the Sally Clark argument. Cheshire police had signed a consultancy agreement with Professor Hutton. Professor Hutton warned them that its whole approach was wrong. The police then told her: “The prosecutor...has instructed us not to pursue this avenue any further.” She challenges them and the prosecutor tells them to sack it. That falls in direct contravention of part 3.3 of the “Code for Crown Prosecutors”, which states: “Prosecutors cannot direct the police or other investigators.” Dr Watts added: “This occurrence is particularly egregious...it is...not appropriate for the CPS to deter the police from acquiring evidence that may be relevant and available.” Dr Watts goes on to say that the Criminal Procedure and Investigations Act 1996 “is binding upon the CPS to the same extent as the police, for the CPS to Instruct the police to ignore potentially relevant evidence would clearly be a breach of the CPIA”. But neither the defence nor the jury were told of Professor Hutton’s explicit warnings to the police. That is unsurprising really, because it obliterated the prosecution’s statistical argument—the foundation of their entire case. Professor Hutton believes the statistical errors are “similar to those in the Sally Clark case but worse.” I wrote to the chief constable about how those bogus statistics had been compiled. He refused to answer any of the questions I had raised and said he would “not be providing any further detail or engaging in ongoing correspondence”. So much for transparency and welcoming challenge. That refusal to answer questions from a Member of Parliament sits uneasily alongside his department’s extraordinary public relations campaign, which at the very least invaded the privacy rights of Letby’s parents.