Before we come to the Adjournment debate, I should inform the House that there are live inquests into the deaths of six babies, so those cases are technically sub judice under the rules of the House. However, Mr Speaker has issued a waiver for today’s debate to allow the cases to be referred to, given that the inquests have been adjourned for a number of months.
In 1998, Cheshire police arrested Sally Clark and charged her with the murder of her two baby sons. In 1999, she was convicted of their murder and sentenced to life imprisonment. That conviction and sentence was overturned by the Court of Appeal in 2003 and recognised as a gross miscarriage of justice, and Sally Clark was set free, albeit after three years in prison. However, her life had been destroyed, and just four years later she died from alcohol poisoning—the grief had driven her to drink, and it killed her. The destruction of an innocent person’s life was caused by the police, the prosecution and the court swallowing bogus statistical assertions by an alleged expert in her trial. That expert eventually resigned in disgrace, although that did not save Sally Clark.
One would think that after that case, Cheshire police and the Crown Prosecution Service would have been very careful to avoid this happening again, and to abide by all the rules and guidelines designed precisely to prevent further terrible miscarriages of justice. Let us test exactly that premise. We are uniquely assisted in the process by the fact that the behaviour of the police and prosecution has been reviewed by two separate police officers, both extremely experienced in precisely this sort of case. The first is Dr Steve Watts, a former assistant chief constable who wrote the national police guidelines on the investigation of deaths in healthcare settings, and the second is former detective superintendent Stuart Clifton—the officer in charge of the investigation that led to the conviction of Beverley Allitt, one of the most prolific child murderers in healthcare history—who was actually commissioned by The Sun newspaper to confirm Letby’s guilt. Indeed, both policemen believed that Letby was guilty—that is, until they examined the hard facts, and both now believe that the Letby case is a serious miscarriage of justice.
I spoke to the right hon. Gentleman beforehand. He has a forensic, investigative mind for these subjects, on behalf of the House, and—with your agreement, Madam Deputy Speaker—we should put on record our thanks to him for that. We in the House and this nation owe him a debt when it comes to justice.
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
Notwithstanding the points that my right hon. Friend is making, would he accept that the investigation included a range of independent, nationally recognised medical experts, including consultants and senior academics across a whole host of disciplines; and, knowing as I do that he is an enthusiastic advocate of our judicial system, that the Lucy Letby case was the longest-running murder trial in British criminal history, with a jury that considered the evidence for more than 100 hours? Lucy Letby appealed to the Court of Appeal but was refused. There was a retrial and a further appeal to the Court of Appeal, which was refused. Would he not accept the robustness of that process?
I thank my right hon. Friend for her point. However, in many ways the reason the Lucy Letby case is so important—over and above the fact that it is a miscarriage of justice—is that it highlights weaknesses in the appeal procedure and the procedure for selecting and managing experts. I am afraid that it also demonstrates that the regulations put in place by the CPIA and other Acts of Parliament were not followed in this case, and that is one of the fundamental problems today. I will come back to some of the solutions in a moment, but that is the central difficulty.
Finally, there is the question of how a police force should properly handle such complex cases, which comes back to the issue of checking that my right hon. Friend quite rightly raises. Dr Watts is clear:
“Significant investigations such as Op Hummingbird should be subject to rigorous review by independent detectives, typically from an independent police force, and best practice indicates that the officers conducting the review should be unknown to members of the investigation team.”
If such a review had been in place, it is unlikely that any of the breaches I have talked about so far would actually have happened.
I do not have time in this debate—I have had 20 minutes already—to list every egregious failure by Cheshire police, but given the Netflix documentary broadcast a little while ago, I want to pick up on the way the police treated Letby herself. They arrested Lucy Letby three times, claiming it was necessary for questioning, despite her freely volunteering to come in for questioning. Dr Watts—an assistant chief constable, let us remember—said: “That is completely wrong”. It is extraordinary that this unthreatening young girl was marched in in handcuffs, mirroring the way American authorities try to influence public opinion against suspects when they are perp walked to court. As Dr Watts said:
“The intelligence they had about Lucy was that she was nonviolent. There was absolutely no justification…for her to be handcuffed”
I congratulate the right hon. Member for Goole and Pocklington (David Davis) on securing this debate and on being a formidable campaigner for the causes that he cherishes in this place. Given the time available, I do not have long to cover the range of issues.
These are serious criminal cases. The Criminal Cases Review Commission, as the right hon. Gentleman knows, is currently undertaking a review. In that context, it would not be appropriate for me to speculate on the outcome of those processes; we must let them take their course.
A meticulous and lengthy investigation led to Lucy Letby being identified as a suspect and arrested in July 2018 in respect of the significant rise of neonatal deaths and acute, life-threatening collapses of newborn infants. I am sure we all think of the parents of those children. As I have had children in neonatal units and born into special care baby units, I can only imagine their suffering in what they have been through.
In November 2020, the Crown Prosecution Service authorised multiple charges of murder and attempted murder against Letby. The CPS deemed that there was a realistic prospect of conviction and that it was in the public interest for the cases to proceed to trial. Lucy Letby stood trial from October 2022 to August 2023. She faced 22 charges related to 17 babies, and she was convicted of seven counts of murder and seven of attempted murder. Letby was also found not guilty of two counts of attempted murder, and the jury was unable to reach verdicts on two other counts of attempted murder.
In September 2023, Letby submitted an application to the Court of Appeal against her convictions. The application was heard by three senior justices in April 2024. The justices refused the appeal. From June to July 2024, Letby was retried in respect of one of the previous attempted murder charges. Letby was found guilty, for which she received an additional whole-life order. Following that conviction, Letby submitted an application to appeal to the Court of Appeal. During October 2024, a new bench of three senior justices heard the appeal, which was again refused.
I am conscious that I have denied the Minister much time to respond—that was because I do not think she has much scope for a response—but I want to place one thought with her. One reason why we are having the debate is because Members of Parliament cannot make applications to the IOPC; only victims can do so. I think that is a flaw in the law. My argument today is that we have not followed the guidelines, and the best way to deal with that is through an expert mechanism such as the IOPC. When she goes away today, will she take with her the thought that we might fine-tune the law on that point?
I will of course take that away. We are always looking at ways to improve the IOPC system. I was with the IOPC earlier today talking about its transformation programme and the work we are trying to do.
The right hon. Gentleman made a number of remarks about Cheshire constabulary—he can have his view. His Majesty’s inspector, through his Peel inspections, has in fact given it some of the highest ratings in the country, with two “outstanding” ratings and four “good” ratings, as well as two graded “adequate”. I put that on the record in the context of this conversation. In that context, it is important that we as Members of Parliament should not undermine public confidence in the police and the criminal justice system. We need to be careful to avoid implying impropriety where none has been established.
The right hon. Gentleman said that he will write to the DPP. He will take that through its course. I end by reminding the House that this country uses due process, and due process has been followed in the convictions of Lucy Letby, with a trial by jury, upheld on appeal. I remain confident of that and of the effectiveness of Cheshire constabulary. I congratulate the right hon. Gentleman on securing the debate. I also wish you, Madam Deputy Speaker, and everyone else here a happy Easter.
I, too, wish everybody, and especially my constituents in Sussex Weald, a very happy Easter.
Question put and agreed to.
5:29 pm
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“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.
on those occasions.
Letby was also accused in court of lying about being arrested in her pyjamas, but the recent Netflix documentary proves that she was telling the truth. It is astonishing that the police officers in the court, who knew how she was dressed when she was arrested, did not intervene with the prosecutors to tell them that they had got it wrong, and instead left the jury to believe that Lucy was lying about something when she was plainly telling the truth. Frankly, it is astounding the lengths that Cheshire police was willing to go to in order to manage its own public relations—sometimes, I think, at the cost of achieving justice.
So there we have it. Despite the warning signs of the Sally Clark case, we see that Cheshire police has either ignored or broken the rules, disregarding relevant safeguards time and again. It failed to pursue alternative lines of inquiry; failed to refer the case to the appropriate specialist authorities; failed to conduct proper due diligence on the appointment of key expert witnesses; failed to engage with real experts about complex statistical evidence, and failed to correctly inform the jury of that fact; and failed on several occasions to disclose critical material to the defence.
On the evidence before us, there have been clear and serious departures from statutory guidance and multiple deviations from best professional practice. Because of the way the case was handled, I recommend that the police should provide Letby’s defence team with a whole series of documentation. Because of time, I will publish the full list online, but it should include: the senior investigating officer’s policy books and decision books; the records of identified lines of inquiry; logs kept by functional managers; and minutes of all meetings held, from the team meetings right up to the gold co-ordination meetings. That would at least start to demonstrate what went wrong here.
I should tell the Minister that irrespective of how Cheshire police responds, I shall be writing to the Director of Public Prosecutions about these issues and asking him to review the behaviour of both the CPS and the police.
I set that out to make clear that there has been a proper process, involving independent assessment by the Crown Prosecution Service, trial by a jury and two appeal processes, which has resulted in the conviction and imprisonment of Lucy Letby.