THE THIRLWALL PAPERS: A Special Investigative Journal
Institutional Failure, Clinical Negligence, and the Question of Miscarriage of Justice at the Countess of Chester Hospital
EXECUTIVE SUMMARY: The Scapegoat Hypothesis
The Thirlwall Inquiry was established to determine how a "serial killer" was allowed to operate unchecked in a British neonatal unit. However, a forensic examination of thousands of pages of transcripts, internal emails, and expert reports reveals a different reality. Instead of confirming the guilt of Lucy Letby, the Inquiry has exposed a hospital in a state of "chronic" operational collapse, flooding with raw sewage, and a specific group of consultants who, unable to explain deaths caused by their own clinical limitations, resorted to speculative theories to shift the blame.
This journal combines findings from independent investigative reports and exclusive evidence to present a unified timeline of failure. It posits that Lucy Letby is likely the convenient scapegoat for a National Health Service in crisis, convicted on the basis of "crystal ball" guesses rather than hard medical science. The evidence suggests she is the victim of a calculated retaliation by consultants who, having failed to remove her through HR processes, utilized a "lazy" police investigation to frame clinical negligence as murder.
SECTION 1: THE "GANG OF FOUR" AND THE CONSTRUCTION OF THE "RASH"
The narrative that Lucy Letby was a killer did not originate from forensic evidence, but from a whisper campaign orchestrated by a small clique of consultants.
1.1 The "Gang of Four"
The accusation was driven by four key consultants: Dr. Stephen Brearey, Dr. Ravi Jayaram, Dr. John Gibbs, and Dr. Murthy Saladi.
The Inquiry documents reveal that these four began discussing Letby as a common factor in June 2016. However, their suspicions were not based on clinical proof but on a statistical coincidence: Letby worked the most hours and took the sickest babies, so she was naturally present at more collapses. Instead of investigating the unit's failures, they began to collude, sharing suspicions and reinforcing a bias that "it must be Lucy."
1.2 The "Exclusive" Rash: Evidence of Collusion
A critical anomaly in the evidence is the "skin discoloration" or rash, which became the hallmark of the " air embolism Air Embolism: A blockage of blood supply caused by air bubbles in a blood vessel or the heart. In this case, it was diagnosed retrospectively based on "skin rashes" that the original researcher (Dr. Shoo Lee) testified were misidentified. " theory.
Selective Vision: The Inquiry evidence shows that the specific, fleeting "murderous rash" described by the prosecution was only "noticed" by these consultants once they had already decided Letby was guilty. Nurses and parents often saw nothing, or described "mottling" (a common sign of sepsis).
Fabricated Narratives: The consultants retrospectively reshaped these common symptoms into a "pathognomonic sign of murder" to fit their theory. The similarity in the consultants' descriptions, which emerged months or years after the events, suggests a cross-contamination of memory—they were effectively telling each other what they saw until their stories matched.
Dr. Shoo Lee’s Rebuttal: The scientific basis for this "rash" came from a 1989 paper by Dr. Shoo Lee. Dr. Lee has since stated his research was misused by the prosecution expert Dr. Dewi Evans, confirming that the "rashes" described at Chester were not the signs of air embolism described in his work.
1.3 The "Crystal Ball" Confession
Buried in the evidence is a handwritten note by Dr. Ravi Jayaram from a meeting on June 29, 2016. In this private brainstorming session, consultants were struggling to find a cause for the collapses. Dr. Jayaram wrote:
"How: Cannula air embolism crystal ball" > (Source: Thirlwall Inquiry Evidence, Document [INQ0106816], Page 6)
This note is a smoking gun. It proves that "air embolism" was a speculative guess ("crystal ball") rather than an observed medical fact. Dr. Jayaram admitted in evidence that they were "speculating about the mechanism of murder."
SECTION 2: THE TIMELINE OF RETALIATION
The move to involve the police was not an immediate response to crime, but a retaliation against Letby winning her employment grievance.
2.1 January 2017: The Grievance Upheld
In late 2016, Letby was removed from the unit based on the consultants' unsubstantiated rumors. She filed a formal grievance.
The Outcome: In January 2017, the hospital Board ruled in Letby's favor. They found "no evidence" of wrongdoing and ruled that the consultants had based their allegations on "gut feeling" rather than fact.
The Apology: The consultants (Brearey, Jayaram, Gibbs, Saladi) were forced to sign a letter apologizing to Letby for their "inappropriate comments."
"Dear Lucy... We would like to apologise for any inappropriate comments... We are very sorry for the stress and upset that you have experienced..." > (Source: Thirlwall Inquiry Evidence, Document [INQ0003187])
2.2 May 2017: The Retaliation
Humiliated by the grievance ruling and facing the prospect of Letby returning to the unit (which would expose their bullying), the consultants escalated the situation.
The Push: Dr. Brearey and Dr. Jayaram pushed the hospital executive to contact the police.
The Motive: The timeline suggests this was a tactical move. By turning an HR dispute into a criminal investigation, they effectively blocked Letby's return and protected their own positions. The "police investigation" became the ultimate weapon in a workplace vendetta.
SECTION 3: A FLAWED AND "LAZY" POLICE INVESTIGATION
The police investigation (Operation Hummingbird) failed to objectively seek the truth, instead adopting the consultants' narrative as fact and working backward to prove it.
3.1 Listening Only to the Accusers
The police investigation was characterised by "confirmation bias." They relied almost exclusively on the testimony and medical interpretations of the "Gang of Four"—the very people who needed Letby to be guilty to hide their own clinical failings. They failed to rigorously explore alternative causes such as the sewage, the staffing crisis, or the specific medical errors of the doctors.
3.2 Dr. Dewi Evans: "Theory Shopping"
The police relied on expert witness Dr. Dewi Evans, whose methodology has been exposed as deeply flawed.
Changing Theories: Dr. Evans frequently changed his mind about how a baby died to fit the timeline of Letby's shifts. If she wasn't at the bedside for an air embolism, he would change the theory to "air down the NG tube" or "trauma."
Fabrication: He invented theories that didn't exist in medical science (such as the "diaphragm splinting" theory) solely to explain how Letby could kill without leaving a mark.
For a deeper dive into the lead expert witness, read our investigation into Dr. Dewi Evans and the 'Hired Gun' scandal.
3.3 Sacked Experts and Discarded Opinions
The Inquiry has heard that the police initially consulted other experts who did not agree with the homicide theories.
The Suppression: Instead of accepting this exculpatory evidence, these experts were dismissed or not used. The police effectively "shopped around" until they found an expert (Evans) who was willing to support the murder narrative, silencing those who saw natural causes.
3.4 The Fabricated Door Data
A cornerstone of the prosecution case was the swipe card data showing Letby's movements.
The Error: It has emerged that the door data presented to the jury was flawed. The police and prosecution reconstructed a timeline that placed Letby in Nursery 1 at critical moments based on erroneous data interpretation.
The Reality: In several instances, the "lock data" or swipe times were manipulated or misunderstood to create a window of opportunity that did not strictly exist, fabricating a new theory of "how" she killed to match the flawed data.
SECTION 4: THE PRECEDENT OF FAILURE - BABY NOAH ROBINSON
To understand the baseline competency of the medical team, one must look to 2015, just prior to the indictment period. The case of Baby Noah Robinson serves as a grim precedent.
An inquest found that CoCH doctors had wrongly intubated the baby's oesophagus (food pipe) instead of the trachea (windpipe) twice.
The Negligence: Doctors pumped air into the stomach while the baby suffocated. Clear signs that the tube was misplaced—including X-rays and carbon dioxide detectors—were ignored by the medical team.
The Relevance: This proves that the doctors at CoCH had a documented history of catastrophic airway mismanagement. They were capable of killing babies through incompetence and "air in the stomach" long before they blamed Letby for it.
SECTION 5: THE "MURDER WEAPON" WAS THE HOSPITAL
While prosecutors painted a picture of a pristine unit stalked by a killer, the Inquiry documents reveal a hospital that was a biological deathtrap.
5.1 The Sewage Crisis
The physical environment of the Neonatal Unit (NNU) was bio-hazardous. Plumber Lorenzo Mansutti testified to the Inquiry that he was called out "weekly" to deal with drainage issues.
The Reality: Raw sewage and "foul water" frequently flooded the floors and sinks of Nursery 1, the intensive care room where the sickest babies (and the alleged victims) were treated.
The Lethal Mechanism: Sewage contains lethal bacteria like Pseudomonas and E. coli. In a unit where staff testified they couldn't wash their hands properly because sinks were blocked with human waste, "unexplained sepsis" is a tragic inevitability of environmental negligence, not murder.
5.2 The "Acuity" Cover-Up and Downgrade
The unit was designated "Level 2" (high dependency) but was frequently accepting "Level 3" (intensive care) babies it was not staffed or equipped to treat.
Dr. Timmis's Warning: In December 2015, Consultant Dr. Alison Timmis emailed the CEO warning the unit was "unsafe," "chronically overworked," and that staff were in tears.
The Deletion: When preparing the report for the police, Dr. Stephen Brearey admitted in an email:
"I've added a paragraph saying acuity and staffing is irrelevant" > (Source: Thirlwall Inquiry Evidence, Document [INQ0005340])
The Downgrade Correlation: When Letby was removed, the unit was simultaneously downgraded, ceasing to take the sickest babies (Level 3). The deaths stopped because the dangerous patients were sent elsewhere, not because a killer was removed.
SECTION 6: DETAILED CASE-BY-CASE ANALYSIS
The prosecution relied on attributing natural tragedies to malicious acts. A detailed review of the Inquiry evidence and expert analysis reveals a different reality for each child.
Baby A (Alleged Air Embolism)
The prosecution claimed Baby A was injected with air. However, Document [INQ0102350] indicates the true cause was thrombosis (blood clots) and sepsis. Post-mortem findings showed high D-dimer levels, indicative of clotting. Furthermore, Dr. Shoo Lee has confirmed that the "rash" cited by the prosecution—a key piece of evidence—was not the specific sign of air embolism described in his research.
Baby B (Alleged Air Embolism)
The claim was attempted murder by air embolism. The clinical reality points to shock and mottling. The "rash" observed was the non-specific mottling common in sick babies. Staff were hyper-vigilant following the death of Baby A, leading to confirmation bias where common symptoms were reinterpreted as suspicious.
Baby C (Alleged Air Injection)
The prosecution claimed Baby C had air injected into their stomach. In reality, the baby suffered from pneumonia and intubation failure. Crucially, Document [INQ0102740] and X-rays show air was present days before the collapse when Letby was not on duty. Dr. Tariq Ali found evidence of intubation failure by the medical team, suggesting the "air" was a result of resuscitation attempts, not murder.
Baby D (Alleged Air Embolism)
The post-mortem explicitly listed "Pneumonia with acute lung injury" as the cause of death. Document [INQ0000762] reveals the hospital failed to administer antibiotics despite the mother's known infection risk, leading to severe pneumonia. Shockingly, the death was reported on the Datix system but graded as "No Harm," highlighting a culture of minimizing adverse outcomes.
Baby E (Alleged Trauma/Air)
No post-mortem was ever performed, a catastrophic failure of the SUDIC protocol Sudden Unexpected Death in Childhood: A mandatory safeguarding protocol that requires immediate multi-agency investigation (police/coroner) after an unexpected death. The hospital's failure to trigger this meant no forensic evidence was gathered at the time. protocol. The "bleeding" cited as evidence of trauma is a classic symptom of Necrotising Enterocolitis (NEC), a condition where the bowel dies. Document [INQ0000194] shows the hospital refused to investigate this likely natural cause.
Baby F (Alleged Insulin Poisoning)
The evidence points to a lab error or auto-immune issue. The immunoassay test used is notoriously unreliable for forensic purposes without mass spectrometry confirmation. Document [INQ0000844] highlights a "collective failure" by the medical team to verify the results at the time, and the baby showed no symptoms of a hypoglycemic crash (such as seizures or coma), which contradicts the high insulin reading.
Baby G (Alleged Overfeeding)
The clinical signs of projectile vomiting are indicative of sepsis and severe reflux, common in high-acuity neonates. Document [INQ0018064] reveals that the prosecution's calculations regarding stomach capacity were mathematically flawed. Dark bile aspirates were ignored, and there were multiple failed cannula attempts.
Baby H (Alleged Air Injection)
The allegation is contradicted by evidence of a Pneumothorax (lung collapse). This is a known complication of CPAP breathing support. Document [INQ0102740] indicates that chest drains were poorly managed by the doctors on duty, leading to the collapse.
Baby I (Alleged Air Injection)
The medical history shows the baby had "stubborn" abdominal distension and required repeated transfers between hospitals. This suggests chronic underlying issues such as Chronic Lung Disease or NEC, rather than acute murder. Document [INQ0108782] supports the view of a baby with long-term, complex gut issues.
Baby J (Alleged Smothering)
Baby J was a complex surgical patient with stomas. Document [INQ0014196] notes that parents found the baby covered in faeces due to poor hygiene, leading to stoma complications and necrosis. The "harm" was likely the natural progression of necrotic bowel and infection due to poor care.
Baby K (Alleged Tube Dislodgement)
The charge relied on the claim of tube dislodgement. Document [INQ0003159]—Dr. Jayaram's own email—confirms Letby called him for help, contradicting his testimony of her "doing nothing." Expert Dr. Tariq Ali noted that accidental tube dislodgement is a common occurrence in active 25-week premature infants and likely happened here.
Baby L (Alleged Insulin Poisoning)
Like Baby F, this was based on the same unreliable immunoassay test. The clinical picture did not match poisoning, pointing again to lab error or metabolic anomaly.
Baby M (Alleged Air Injection)
The baby recovered quickly. Document [INQ0014234] suggests a transient medical issue such as a collapsed lung (pneumothorax) or pneumonia, similar to Baby H, rather than an attack.
Baby N (Alleged Throat Trauma)
The prosecution claimed throat trauma was inflicted by Letby. Document [INQ0101111] contains evidence from Dr. Tariq Ali finding multiple failed intubation attempts by doctors who were "ramming" the tube. The bleeding was iatrogenic (doctor-caused), not the result of a nurse's attack. Baby N also had haemophilia, making him prone to bleeding from such procedures.
Baby O and Baby P (Alleged Liver Trauma)
These identical triplets were alleged to have suffered liver trauma. The evidence in document [INQ0060264] suggests the liver injuries were caused by aggressive CPR chest compressions on fragile organs. This occurred in a unit that was "chronically overworked" and caring for high-risk triplets it was not equipped to manage.
Baby Q (Alleged Liquid Injection)
Document [INQ0014421] reveals that doctors prescribed the wrong antibiotics, and the baby likely suffered from NEC, a common bowel issue in preterms. The "liquid injection" theory covers up a medication error.
CONCLUSION: THE ULTIMATE SCAPEGOAT
The Thirlwall Inquiry documents paint a picture of a "perfect storm":
A Crumbling Hospital: Flooded with sewage and bacteria.
A Staffing Crisis: Overworked nurses and junior doctors managing complex patients beyond their skill level.
A Consultant Body in Denial: Unable to explain the rise in mortality caused by these systemic failures, they latched onto the "crystal ball" theory of a killer nurse.
By blaming Lucy Letby, the Trust solved all its problems. They didn't have to explain the sewage, the staffing shortages, the failed intubations, or the missed infections. They avoided Corporate Manslaughter charges for negligence and instead became victims of a "monster." The evidence suggests Lucy Letby is not a serial killer. She is the convenient scapegoat for a National Health Service in crisis.
Thirlwall Inquiry Evidence Documents: [INQ0106816], [INQ0003159], [INQ0005340], [INQ0003187], [INQ0102350], [INQ0102740], [INQ0000762], [INQ0000194], [INQ0000844], [INQ0018064], [INQ0108782], [INQ0014196], [INQ0101111], [INQ0060264], [INQ0014421].
Accurate analysis backed up by internationally acknowledged experts. Lucy Letby is a victim of institutional scapegoating. She must be released and assisted to rebuild her shattered life. The families of the babies who died deserve compensation and the police and their so called expert witnesses must be impartially investigated. Why numerous NHS and justice system safeguards and guidelines were ignored warrants a full independent enquiry without restrictions as were imposed on Thirlwall
ReplyDeleteThe trial judge Goss was also criminally biased. He was warned by Lord Justice Jackson about the reliability of Evans as an expert witness, but ignored his warning allowing his fantasies to be presented as facts.
ReplyDeleteDrs Bohin and Evans told the court and the jury that the ONLY possible cause of collapse of Baby M was 'air embolism' resulting from introduction of air into the venous system by Lucy Letby.
ReplyDeleteThis was a lie
Baby M had a prominent Eustachian valve and PFO which is documented as a cause of neonatal collapse. This was never mentioned by either. In addition the criminally negligent judge has given counsel ( Myers and Astbury) instructions that in his own opinion ( he is a judge with no medical qualifications) that the Eustachian was normal as a result of his negligent misinterpretation of a radiology report that he did not understand.
Evans and Bohin totally ignored the possibility that baby M had suffered a severe Apnoea of Prematurity leading to his collapse. A condition which can be relatively benign if babies are supervised correctly but also a well documented cause of major collapse and death. This baby a small IUGR premature 33 week prem would be a prime candidate for AoP.
What were the jury told? NOTHING.
Evans and Bohin further went on to claim that baby M later made a recovery with no further problems and this was, they claimed, that Lucy Letby had caused an air embolism. In fact both conditions are noted in the literature to generally self resolving with time so the 'proof' was actually medical bollux.
Unbelievably the next day another of these 4 consultants who were deeply involved in the persecution of Lucy Letby, and who had not been involved in the management of the baby during the critical event, reviewed baby M on the following day when he was still having profound apneas and he started treating the baby from guess what????.....AoP.
So what did he do? He started treating baby M for AoP with the standard regime of Caffeine citrate. To adapt a well known Dewi phrase or saying....Baby got better!!! Surprise surprise. So where were the ONLY diagnoses of Evans and Bohin and why did that consultant not tell the court of the diagnosis....since he started the treatment he must have made the diagnosis, so why did he not tell the court?
So that's baby M and to use the logic applied by the learned judge to Lucy if you believe this medical expert witness evidence was a lie you should apply that to all their other evidence.
The whole trial was a farago of lies from beginning to end but if you are a cunning and ruthless prosecutor like Johnson you probably know that if you thrown enough shit at a wall some of it will stick.