Ep 63-Lucy Letby (Part Two) When Medicine Meets Reasonable Doubt

A case can feel settled in court and still feel unsettled in science. We take on Part 2 of the Lucy Letby story by walking through what the jury heard, what the Court of Appeal later weighed, and why so many clinicians, statisticians, journalists, and legal observers keep arguing about what the evidence can truly prove.

We unpack how investigators tried to reconstruct events inside a neonatal intensive care unit where babies are medically fragile and sudden deterioration can have many causes. We explain the prosecution’s “bigger picture” approach: alleged methods like air embolus, overfeeding, insulin poisoning, shift timing, documentation found at home, and the argument that there was no other reasonable explanation. Then we sit with the uncomfortable flip side: how pattern evidence can be shaped by selection, and why a defense that does not call its own medical expert leaves jurors hearing one set of clinical conclusions as “the” story.

If you care about true crime, medical evidence, healthcare failures, or miscarriages of justice, this is the kind of episode that will stay with you. Subscribe, share with a friend who loves evidence-based debate, and leave a review telling us the question you cannot stop thinking about.

Resources: 

R -v- Letby Final Judgment - 02.07.24

Letby Sentencing R.

Lucy Letby found guilty of attempting to murder baby following retrial | The Crown Prosecution Service

https://www.judiciary.uk/wp-content/uploads/2024/07/LETBY-Sentencing-remarks-July-2024-Anonymised.pdf

Court of Appeal Judgment Template

RSS - RSS statement on the statistical aspects of the Lucy Letby case

‘I am evil I did this’: Lucy Letby’s so-called confessions were written on advice of counsellors | Lucy Letby | The Guardian

Lucy Letby: No medical evidence to suggest murder, experts conclude | The BMJ

A British Nurse Was Found Guilty of Killing Seven Babies. Did She Do It? | The New Yorker

Transcript

SPEAKER_00 0:54

Amanda.

SPEAKER_01 1:01

Don't know what I'm doing there.

SPEAKER_00 1:05

I just hit my elbow too. I don't know if that came through. Oh, jeez. Who decided it was the funny bone? Because it ain't funny to any. Well, it's not funny to the person it's happened to, maybe to other people. But anyway, how are you? Hey, hi.

SPEAKER_01 1:20

Good. You're a working mom now. I am a working mama.

SPEAKER_00 1:27

Oh, that's so hard. I remember that. I balled my eyes out for I don't know how long and then realized that that the baby was super happy where they were. And then I bawled more because I was like, why don't they miss me?

SPEAKER_01 1:42

Yeah, I knew I would cry a lot. So I went to the daycare with my pockets lined with Kleenex. And my husband went with me, which was fabulous. We were walking up to the door, and there's like a separate entrance to the daycare part. And I was there was another family walking up at the same time. So I was like, Adam, let them go first. Cause I don't, I don't know. I don't remember how to get in. You know, like, you know, we have like codes and whatever, you know. And so the mom of this other family says, Is it your first day?

SPEAKER_00 2:18

Oh, and you're like, does it show that? Is it that obvious?

SPEAKER_01 2:22

I literally said, Is it that obvious? And she goes, Oh, I remember. And she was like, It's so hard. And she said, If I see you crying in the bathroom, I won't judge you.

SPEAKER_00 2:34

Oh, and that's literally making it worse. Bless her heart. Like, I'm gonna ball some.

SPEAKER_01 2:39

Yeah, I was I was like, I already came prepared with Kleenex. And then you know, you act you act like you're so strong when you're handing off your baby. And I'm like, so what do I do? Just give them to you. Like, oh god. You know, and he he's just chill, he's a chill, happy baby. So I was like, okay, bye. I had like text my boss, like, not me crying all the way to work today.

SPEAKER_00 3:04

Oh god. See you soon. It gets easier until you have the next thing, which is kindergarten. And then you know what I mean? It's like this always something. Yeah, it's just always another thing. And it's a good thing to have these historic moments because it means we're doing our job, you know, we're getting him through it. Yeah. But boy, it's hard, really hard.

SPEAKER_01 3:27

Yeah, so that was that was hard, but we got lots of updates from excuse me, I'm so tired back to work. We got lots of updates from the daycare throughout the day, and you know what? He looked like he loved it. So, and he's very tired in the evening, still a great sleeper, so it's all good, and it feels good to be back to work. I do love my job. I love being a mama, and I love my job, so all is good.

SPEAKER_00 3:51

Back in biz nasty. Yeah, for uh just a few weeks before summer break, y'all. You timed that well, my friend. You did, you did. Oh, listen, it snowed today up here. Did you guys kid me? Oh god, yeah, it's snow. It's like you gotta be kidding me. Cinco de Mayo, and it's got snow. But and I mean it didn't stick. I was just insulted that it was there, you know.

Oral Health And Heart Plaque Link

SPEAKER_01 4:20

Um horrible. I mean, I wore a jacket today, but definitely no snow down here. Horrible. Hate that for you. Well, I did remember when I was re-listening to our episode from last week, there was not really a correction or more of a fun fact that I forgot to share. So I'll share that. I had my friend Brie text me when she was listening to our episode, and she had shared that the plaque on the heart is when we were talking about those little nanobots, you know, going through and cleaning things up. Yeah. So she shared that the plaque on the heart is actually also from the mouth, and probably not all of it, but a lot of it, and it causes heart disease, stroke, etc. So, you guys, we talk often about how oral health is so important and a big picture into your overall health.

Warnings And Why This Case Hurts

SPEAKER_00 5:12

So that blows my mind. So you you have plaque under your teeth, so you naturally swallow it and it gets absorbed into your bloodstream. Oh, Amanda. Yeah. You guys brush and floss your teeth. Hosh, we may have to pause for a break so I can go do that. I have spinach in my lunch and it's in my teeth. Well, that's not plaque, though. Spinach can get in there, no problem. Spinach is healthy. I never, never would have. That blows my mind. Thank you, Brie, for blowing our minds. Brush your teeth, everybody. Another correction is that here we are with part two of Lucy Leppy. But guess what, folks? This is an unprecedented three pada.

SPEAKER_01 5:57

Three patter, everyone. We got it. Three patterns. You know, dot dot dot. And then you can see like the three bubbles like for the iPhone. I'm just like, oh my god, what is happening? And she's like, I don't know how to tell you this, but my next uh, you know, episode is 37 pages. And I said, absolutely, no, it's not. Nope, no, it's not. I said, you need to find where you're gonna take a break in that one, and it's going to be a three-parter because we are not doing that.

SPEAKER_00 6:37

I love how she wasn't even like there was no sugar coating or like, oh maybe cut a little something. Absolutely. Absolutely not. We aren't doing that. Thank you. So you're welcome, everybody. You can thank uh Dr. House for her boundaries. Her boundaries end somewhere after page 20. So thank goodness for that. Thank you for redirecting me. But so there we go. We're doing part two. Um, but before we start, I just want to talk about the same warnings that we did last week that we talked about. This episode discusses infant deaths, neonatal medical emergencies, murder convictions, alleged hospital failures, and disputed medical evidence. This is a deeply upsetting case. And no matter what anyone thinks about the conviction, the families at the center of this case lost babies, watched babies collapse, or have had to live for years with trauma that most of us could never imagine. And also, because this case involves babies and surviving children, there are reporting restrictions. We're going to follow the court's anonymized naming system and refer to the babies by letters only. The Court of Appeal judgment specifically notes that reporting restrictions protect living child victims, siblings and parents of deceased children, and some medical and nursing personnel. And one more legal note: Lucy Lepbe is legally convicted of murder and attempted murder, and those convictions currently stand. She continues to deny harming any baby, and her legal team is pursuing review through the Criminal Cases Review Commission, heretofore referred to as CCRC. So today we're going to do two things at once. We're going to explain what the courts decided and then explain why the case has become so contested after conviction.

SPEAKER_01 8:30

Quick sidebar, you guys aren't going to hear that she's um going to edit this out. But last week I stumbled over a word several times towards the end of it. I don't even remember what the word was anymore, but I was listening to it now. I was like, oh my God, I thought she was gonna edit that out. So thank you all for listening to me stumble on a word, but that was my correction.

SPEAKER_00 8:52

Oh, I might have lost some steam towards the end. I also had some constructive, constructive feedback from someone who said that our medical mishap was we were a little bit overlaping on our banter. So, you know, sometimes your girls just doing her best. But we do appreciate feedback. So that's uh I'm sorry that I let you plunder or flo flounder over. See, there you go, flounder over some words, and you know what? We're human, so human.

SPEAKER_01 9:26

Um okay, so basically back to this thing. It's not um this is not like a everybody picks a team type of thing when we're gonna be talking about the conviction and and such.

SPEAKER_00 9:36

Yeah. So I mean, it's not sports, it's medicine, law, statistics, grief, institutional failure, and probably one of the most disturbing criminal cases in modern British history.

SPEAKER_01 9:48

Yeah, I can't believe how recent this case is. I know.

How Police Built A Pattern Case

SPEAKER_00 9:52

Which is why there's a part three because there's developments happening as we speak. Anyway, the sources are largely based on the book Unmasking Lucy Letby by Jonathan Coffey and Judith Moritz, who are incredible journalists. And the remaining resources will be listed in our show notes. So to summarize, last week we ended with the hospital finally bringing police into what started as a clinical and managerial crisis. By then, Lucy Letby had been removed from the neonatal unit. Consultants had raised alarms, management had treated parts of it like a workplace conflict, like a personality issue. And the question had changed from that to why are these babies collapsing? And then to, could someone be causing this? And that's where part two begins. But first, let's talk about our first sponsor. Alley cats, you need to elevate your hair care routine with Yarick plant-based hair care. It's the ultimate fusion of nature and luxury. Their organic vegan shampoos, conditioners, and mousse are meticulously crafted to feed your hair with a potent blend of vitamins, minerals, and essential oils. Free from alcohol, parabens, and sulfates, the products deliver a nourishing experience that your hair deserves. Embrace the power of clean beauty with yark, where every drop is thoughtfully curated to enhance your hair's natural beauty while respecting the planet. Transform your hair care regime into a holistic self-care ritual with yark because your hair deserves nothing but the best. Visit Yarick Hair at Y-A-R-O-K-H-I-R dot com for 15% off with our codes Stay Suspicious. So the investigation begins. When Cheshire police became involved, they weren't walking into a straightforward crime scene. There wasn't a single weapon or CCTV of an assault. There was no eyewitness saying, I saw her inject something. Not one dramatic moment where the entire truth became obvious. Instead, investigators were handed a nightmare puzzle. Hundreds of thousands of pages of medical notes, shift records, lab results, nursing records, text messages, expert reports, and the memories of people who had been working under extreme stress years earlier. The investigation that followed had to look backwards into a neonatal unit where babies were already medically fragile, where deterioration could be natural, where infection, prematurity, respiratory distress, gastrointestinal problems, and human error were all real possibilities. The prosecution case against Lucy Lepbee wasn't built like a typical murder case. It was totally circumstantial. The Court of Appeal later summarized the prosecution position this way. Between 2015 and 2016, Lepbe was alleged to have harmed babies in her care by several different methods, including air embolus, air forced into the abdomen, force feeding milk, insulin poisoning, and physical trauma. And the prosecution relied on expert medical evidence, staff evidence, records, shift patterns, and other strands of evidence.

SPEAKER_01 13:09

So not just one smoking gun, more like a whole bunch of pieces that the prosecutor said formed a bigger picture. And that's the tension of the whole case.

SPEAKER_00 13:18

And so the defense was like, no, what you're calling a picture is a pattern that's being imposed after the fact. For example, they gave they gave a big spreadsheet of like all of these dramatic medical issues like collapses and things that happened, and then when Lucy Letby was present during those times. But they didn't show all of the medical issues that happened. They just showed the ones where Lucy was present. So it just looked like, you know, I mean, that's part of it. But so the thought was, you know, okay, on the defense side, is this a tragic cluster of sick babies that had poor care? Because they were understaffed. They were overwhelmed. Um, is this a case of confirmation bias? By November 2020, Letbee had been charged. By the time the trial began at Manchester Crown Court in October 2022, she faced 22 counts of murder or attempted murder involving 17 babies. And that trial would last almost a year.

SPEAKER_01 14:21

And wasn't, and the defense probably brought this up, but wasn't Letby one of the like only qualified nurses on the unit for these medically like really complex ones, right? So like that feels a little unfair.

SPEAKER_00 14:37

She'd gotten her certification in, you know, NICU babies, basically. And there, I don't know if there were there were like maybe one or two other nurses out of the whole, I think it was something like in their 30s, maybe 40s roster of nurses that were, you know, rotating on that unit. So she would be very often be placed there because of her qualification. So you're right. Yeah. So for 10 months, jurors heard about babies whose names they would never know, baby A through baby Q. Some died, some survived, and all of their families were changed forever. So let's talk about what the jury heard. The prosecution's case had several major pillars. First, there was the medical evidence. So for some babies, prosecutors argued that air had been injected into the bloodstream, causing an air embolus. For others, they argued that air had been forced into the stomach or bowel through a nasogastric tube. And in some cases, they alleged overfeeding with milk. And in two of the most important surviving cases, they alleged insulin poison. Then there was the timing. Again and again, prosecutors said Lephe was present when babies deteriorated, not just present on the ward generally, but associated with the care of multiple babies at the time of their collapse or death. And then there were documents. The prosecution pointed to clinical notes, nursing records, handover sheets that she actually took home. They found them in her home. So she had copies of the records, or, you know, we have something called like a registration sheet or face page when someone checks in of their demographics that often when people are charting or trying to keep track of babies on the floor will hold on to these sheets, like to say, okay, you know, this is all the information I need in order to get hold of this family and follow up or whatever. But she took those things home. They also found Facebook searches for families of babies and handwritten notes that they argued, the prosecution argued, showed consciousness of guilt. So we're going to talk about a later appeal of Baby K. The Court of Appeal described some of the prosecution's non-medical evidence as including Lepbee's presence, alleged false entries, handover documents taken home, Facebook searches, and statements in private notebooks of hers. And the prosecutors said that these instances were consistent with guilt. Also, the jury heard fourth the absence of another explanation. So what else could reasonably explain how these babies collapsed if it weren't for this conviction that we're putting forth? So that absence of another reason why this could happen was central. The prosecution said these babies didn't collapse in ordinary, expected ways. They said that the explanations offered by natural disease, prematurity, infection, or chance didn't account for what happened. And then there was Letby herself. She testified in her own defense. She denied harming any baby. She said she loved her job. She said she'd never done anything meant to hurt a child. But one point that's become more important in the public debate after the trial is this. Although the defense had instructed expert witnesses and served expert reports, no expert medical evidence was ultimately called on Lepbee's behalf at trial. And this is so frustrating. So they had a medical expert who reviewed all of the cases, all of the prosecution, all of all of this, spent years on this, and ultimately became out on Lepbee's side and would was willing and wanted to testify that medically the evidence that the prosecution was saying was evidence was not evidence and should be called into question. But somehow the defense never called him to the stand. And he is not allowed to talk about it. There's, I guess in England, a I don't know what you call it, what do you call it when they're gag, gag order? So he's not, and I don't know if that's what they call it in the English system, but he's not allowed to talk about why. And so that's something the authors of this book wrote about too. Like she could have had this defense. Like, what what why? Why wasn't he called? Did they think there were too many holes in his theory? Anyway.

SPEAKER_01 19:01

That would be for the jury to decide. That just that feels like not a fair trial that the jury heard the prosecution experts, but no defense medical experts.

SPEAKER_00 19:13

And yet it was the defense themselves, the defense team that decided not to call him. I know. It's so strange. I want to know more. I know. The journalists that are that were investigating the case that wrote this book interviewed him, but he wasn't allowed to say what. All he could say was, I had very compelling, you know, and I don't understand myself why it wasn't called.

SPEAKER_01 19:33

And the fact that he himself is like, I don't understand why I was called. I felt like he he him feeling like he could have brought forth, you know, a good defense for her. I'm so curious.

Air Embolism: Real But Hard To Prove

SPEAKER_00 19:46

I know, right? So the only defense evidence that was called besides Letby herself was a plumber. A hosp a hospital plumber. So he talked about how the drains were bl consistently a problem, and they would back up sewage and stuff into the patient rooms. And so, you know, you have a medically fragile baby there. Obviously, you don't want them, you know, inhaling sewage or whatever. So he said, you know, yeah, there were there was a period of time where that was a problem and sinks were backing up in patient rooms, but I fixed it kind of thing. Or I don't know. So that was I would, I don't know, but it was around the time that that collapses were happening. And I hope I get to this later because I know I wanted to write it down, and I don't know if I did, but I do understand why there were suspicions because typically in a year they might lose three babies, and then in two years they lost 22 babies or 17 babies, 18 babies. Yeah. So I mean it was an ex exponential increase. So I mean, obviously, we need sus we need to look at you know post-mortem why this happened. But anyway, so the defense cross-examined the prosecution experts hard, but they didn't bring their own, they didn't bring their own expert, but they challenged the prosecution experts and they suggested alternative explanations, which were fed to them by this expert witness from for the defense. But why not let him do it himself because he's the expert? This is like secondhand, like kind of with the with the base knowledge of medical stuff, when you could get the expert themselves to explain. But anyway, suggestions in cross-examination aren't taken by the jury as evidence, right? So that became a major point later when Leppy tried to appeal. And that's why after conviction, a lot of people came back with to this question Did the jury get enough competing medical evidence to evaluate what really happened? What was reasonable? Where was the doubt? So, but now we're gonna break for a chart note. Sounded like a train whistle. Welcome to the chart note segment where we learn about what's happening in medicine and healthcare. All right, but this is totally, I can't get away from Lucy. So this is gonna be about Lucy. Before we go further into more doubts about her conviction, we need to stop and talk about one of the most important medical theories in this case air embol air embolism or air embolus. And it sounds simple at first. I mean, it's it's air that gets into the bloodstream and blocks blood flow, and the baby collapses. But the science, and more importantly, the proof, is more, much more complicated than that.

SPEAKER_01 22:38

Okay, so let's start with the basics then. Tell us what is an air. Embolism.

SPEAKER_00 22:43

An air embolism happens when air or gas gets into a blood vessel. So it's like a bubble that can travel through the circulation and block blood flow. Cleveland Clinic describes it as a rare but serious condition that can happen when air gets into a vein or artery, and it can become life-threatening because the bubble can block circulation and trigger tissue damage. So if you imagine the bloodstream like plumbing, blood is supposed to move smoothly through the vessels. But if a bubble gets into that system, it can act almost like a plug. It can interfere with blood reaching important organs like the lungs, heart, brain, and other areas.

SPEAKER_01 23:18

Yeah, like the organs. No bueno. It's like a tiny little airlock.

SPEAKER_00 23:22

Right. And that word airlock is actually useful here. If air enters the venous system, it means the veins. It usually travels back towards the right side of the heart and then the lungs. So small bubbles might be filtered out or absorbed, but larger or faster-moving air bubbles can overwhelm the system and cause sudden cardiovascular collapse. So if air enters the arterial system, meaning the arteries, the danger can be even more immediate because the arteries carry blood to organs like the brain and the heart, which we kind of need. Air there can obstruct blood flow and cause stroke-like injury, heart injury, or death. And in a premature baby, the margins are small. A newborn's blood volume is already tiny. A preterm baby's physiology is so fragile. So even though we have to be careful about assigning exact volumes, the basic principle is this: a volume of air that might seem minuscule in an adult would be catastrophic in a very small baby.

SPEAKER_01 24:21

So medically, air embolism is real.

SPEAKER_00 24:24

Completely real. No serious person saying is saying that air embolism is fake, but the question in the Lepbee case isn't can air embolism kill a baby? Because we know it can. The question is, can you prove after the fact that this specific baby collapsed or died because of air deliberately injected into the bloodstream, and then prove who did it? And that's where things get tough. Because in neonates, air embolism is rare. One of the key papers discussed in the Lepbee case was the 1989 Lee and Tanswell paper, Pulmonary Vascular Air Embolism in the Newborn. Fascinating reading. That paper described pulmonary vascular air embolism as a rare and almost fatal, comp almost always fatal complication of positive pressure ventilation in newborns. At the time, the paper said only about 50 cases had been described in world literature, and that typical babies in those reports were premature, very low birth weight, and often had respiratory distress syndrome, and often had air leak problems connected to ventilation. So the classic neonatal literature was not describing a simple, common, easy-to-spot phenomenon. It was describing a rare event, usually in very sick, ventilated babies, often with other lung problems.

SPEAKER_01 25:40

So already we are not in clean science territory.

SPEAKER_00 25:44

Right. We're in rare event medicine. And rare event medicine is hard to bring into a criminal courtroom because when something's common, then doctors have lots of data, more studies, more experience, more confidence about what it looks like and how it behaves. But when something's rare, the literature may be built from case reports. Doctors may go their entire careers seeing very few cases or none. And the signs may overlap with many other catastrophic neonatal problems. So the Court of Appeal later acknowledged this exact difficulty. In reviewing the air embolism evidence, the trial judge's ruling noted that because fatal air embolism is rarely identified, the medical literature and clinical expertise are necessarily limited.

SPEAKER_01 26:27

So even the court recognized that this was not a huge settled body of research then.

SPEAKER_00 26:33

Right. Yeah. The court ultimately allowed the prosecution evidence to go to the jury, and Letby's appeal was refused. So legally, this didn't overturn anything, but scientifically, it shows why this part of the case is so contested. So can you tell us then what would an air embolism look like in a baby? Well, potentially it could look like a sudden collapse. Oxygen levels drop, the heart rate falls, the baby may become pale, blue, mottled, or discolored, and there may be difficulty ventilating the baby. And then there may be shock, arrhythmia, or cardiac arrest. But here's the problem: those signs aren't unique to air embolism. A premature baby can deteriorate suddenly from sepsis or respiratory failure, a heart problem, a clot, an infection, a misplaced or displaced tube, necrotizing entercolitis from metabolic problems, complications of prematurity, and even from resuscitation itself. So a visible collapse tells you something terrible's happening, but it doesn't tell you why. And in part when we talked about these issues, this is exactly why the early cases became so difficult to interpret. I describe babies like baby B and baby D having sudden collapses and strange skin discoloration, which later became part of the prosecution's error embolism theory. But at the bedside in real time, those signs are still being interpreted inside the chaos of neonatal medicine. And the skin discoloration issue became especially important. At trial, staff described unusual color changes in some babies, modeling, patchiness, purplish, reddish-brown discoloration, pale areas, changes that seemed to appear and disappear. And the prosecution argued that these changes were consistent with air embolism. But after conviction, Dr. Shu Li, one of the authors of that 1989 paper that everything was being based on, became central to the appeal discussion. In the Court of Appeals, Dr. Li's evidence was summarized this way: air bubbles can be absorbed quickly, so skin effects might be transient, only lasting seconds to minutes. Pale or white patchiness can appear to migrate, but those signs are so nonspecific, they could also be caused by other conditions, including hypothermia, sepsis, allergy, viral illness, or immune reactions. Dr. Lee's position was that it was very difficult, if not impossible, to distinguish the kind of discoloration from air embolism by appearance alone. And this is the very author of the paper in 1989 that all of this was, you know, ideas of how we would decide that these babies that Lucy was caring for had, you know, issues from air embolism or died from air embolism. So he's saying, actually, that's not true anymore. We know this now. Yeah, that feels huge. It's huge because if the skin signs aren't specific, then they can't, then skin signs can't safely do all the work. A baby looking mottled or blue or strangely discolored might be consistent with air embolism, but consistent with is not the same as diagnostic of. And that distinction is everything.

SPEAKER_01 29:37

Yeah, sister. Say it again louder for those in the back.

SPEAKER_00 29:41

Consistent with means that it could fit, but diagnostic of means that it proves or very strongly identifies the condition. So consistent with is still, there's still reasonable doubt, right? And isn't that what we're supposed to do as a jury? Anyway, in the Court of Appeal discussion, Dr. Lee's view is that pallor, cyanosis, and modeling can have many causes and should not be used alone to diagnose error embolism. He also said air embolism can happen without any skin discoloration at all. So discoloration can be a clue, but it's not a fingerprint.

SPEAKER_01 30:16

So did you come across then how would doctors be able to prove or can they prove air embolism then?

SPEAKER_00 30:23

Honestly, it would have to be real-time evidence, like somebody sees air enter a line, or somebody putting air into a line, or capturing imaging air in the heart or vessels during an event of somebody putting in a line, or immediate echocardiography or CT evidence, or at autopsy, there's careful post-mortem imaging and examination done in a way that preserves and interprets gas properly. But in a fast neonatal collapse, that's not what we're thinking about. We're not thinking forensic evidence. We're thinking save the baby. I mean, the clinical team isn't standing there going, wait a second, you know, yeah, they're doing compressions, they're ventilating, they're inserting lines and giving fluids and medications and moving quickly because seconds matter. And that emergency treatment can complicate later interpretations of what happened.

SPEAKER_01 31:12

Yeah, for sure. So because resuscitation itself can make changes to the body.

SPEAKER_00 31:19

Exactly. After death, gas in the body can also come from multiple sources. It might reflect a true air embolism, but it can also be related to decomposition, resuscitation artifacts, trauma, medical procedures, or postmortem changes. A forensic radiology paper on postmortem CT explains that although postmortem CT can be better than ordinary autopsy at identifying gas pockets, distinguishing true fatal air embolism from postmortem putrefactic gas, which is that decomp gas, can be challenging because imaging findings overlap. The authors say careful attention to history, timing, mechanism, distribution of gas, decomposition, and autopsy findings is essential. So again, the problem isn't that air embolism can't be found. It can. The problem is that gas in the body is not automatically proof of criminally injected air. So we'll bring this back to Leppy. In Lucy Leppy's case, the prosecution didn't say we have one perfect test proving air embolism. They argued from the whole picture. Sudden, if we step back and we see, oh my gosh, there's all these sudden, unexpected collapses, unusual skin discoloration, lack of natural explanation, Lucy's presence, timing, and other alleged methods of harm, now we have a broader pattern. And the Court of Appeal noted that the prosecution's position that skin discoloration was not being treated as diagnostic by itself, but as one piece of evidence consistent with air embolism when combined with other clinical circumstances. So that's the prosecution side. But the doubt side, the defense side, says, well, that's where the danger lives. Because when a rare diagnosis is made retrospectively from nonspecific clinical signs in medically fragile babies without direct proof of observation of air being injected, then the interpretation can become vulnerable to confirmation bias. So confirmation bias, for example, if you already suspect Lucy Lepi, then sudden collapse plus modeling skin plus her presence can start to look like air embolism. But if you don't start with Leppi as the answer, those same signs might lead you through a much wider medical differential: infection, respiratory disease, heart problems, line complications, prematurity, poor care, or some combination of events.

SPEAKER_01 33:40

So we know now that air embolism is possible, but obviously proving it is the difficult part.

SPEAKER_00 33:47

Yeah, and there's really three separate proof problems. First, you have to prove that it happened, that it was an air embolism. And second, you have to prove that it was caused deliberately, not by disease, ventilation, line problems, resuscitation, or another medical mechanism. And third, you have to prove who caused it. So those aren't the same questions. A baby can collapse suddenly, that doesn't prove air embolism. A baby can have air in the body, that doesn't prove deliberate injection. A nurse can be present, that doesn't prove she caused it. And a theory that can be medically possible without being legally proven beyond reasonable doubt.

SPEAKER_01 34:23

That really feels like the whole issue with this case, then, doesn't it?

SPEAKER_00 34:27

Yeah, it really is. Air embolism sits right at the intersection of medicine and law. I mean, medicine often works in probabilities. Doctors say, well, this fits or this is consistent with this is unlikely, this is possible. We can't explain this naturally. But criminal law needs something stronger. And we've we've had cases of this come up in the past. I mean, we need proof beyond reasonable doubt. And I think this came up when we were talking about the psychopath test, where it's like the courtroom wants black and white, and medicine is not black and white. So, you know, just that's why error embolism evidence is so controversial in Lucy Leppie's case, because it was used as part of the prosecution's explanation for the sudden collapses and deaths, but the underlying science, you know, shows that it's rare. It's a rare condition with limited literature supporting its identification. There's non-specific signs, transient physical changes that could be related to something else that could be happening. And post-mortem interpretation is difficult. So the diagnosis is actually like excluding other causes.

SPEAKER_01 35:34

So the simple version is that air embolism is real, but it's hard to prove after the fact. And like you alluded to earlier, that's probably not the first thing people are thinking about when a baby's collapsing.

The Note That Became A Headline

SPEAKER_00 35:48

Yeah, and I hope not. I mean, I hope that when a baby's collapsing, we're thinking like, do whatever it takes, which people do, but not let's get imaging. Right. So again, we're not talking about whether air embolism exists. It's that the question is whether evidence safely proves that these babies were deliberately harmed by air and that Lucy Lepbe was the person that did it. And so that's as we mentioned, is so much harder to prove. So when people say the babies had strange color changes, that matters, but it can't carry the whole case by itself. I mean, those are a warning sign, not a verdict. And if there's one sentence I'd want listeners to remember from this chart note, it's this Medical possibility is not the same as criminal proof. And that's why this part of the Letby case remains so heavily debated. But now back to the story. One of the most emotionally powerful pieces of evidence wasn't a lab result or an x-ray, it was a note. Police found handwritten notes at Letby's home. Some phrases appeared to be self-condeming. The phrase that became infamous was, quote, I am evil, I did this, end quote. The prosecution treated those notes as significant. They argued that they showed guilt. But the defense argued the opposite. The notes were the writings of a distressed, isolated young woman who had been accused of murdering babies and was spiraling psychologically. And I don't know if I mention it later, but I gotta mention it now. She was in therapy and her therapist told her to write out her worst fears and like, you know what I mean? Okay, uh, kind of work it out through writing.

SPEAKER_01 37:25

I'm glad you shared that now because hearing that, I was like, that's that feels a little hard because you writing I am evil, I did this, that sounds pretty damn easy. Yeah.

SPEAKER_00 37:36

Oh, for sure. Oh, and I do say if I just had a little patience, my my net my next paragraph. This part of the case has become even more contested after conviction. In 2024, The Guardian reported that the notes had been written after counseling sessions and that Ludby had been advised by professionals to write down her troubling thoughts and her feelings as a way to cope with this extreme stress. The same article noted that the notes also came contained denials and distress phrases, including I haven't done anything wrong, and quoted experts who questioned whether the notes should be treated as reliable evidence of confession at all.

SPEAKER_01 38:11

Yeah, so I'm glad they also noted that she had written, I haven't done anything wrong, because only sharing I am evil. I did this, that sounds devastating.

Verdicts, Sentencing, And Baby K Retrial

SPEAKER_00 38:21

Exactly. Because otherwise, you know, I'm evil is a phrase that lands like a punch, but I mean this was a therapy exercise. So we we all want one sentence to solve the case, but a human mind in crisis can produce frightening, contradictory, self-blaming thoughts. So and that doesn't automatically, I think we all should agree, make them legally meaningless, but it does mean they have to be interpreted with caution. So at trial, the jury heard the notes as part of a much larger case. They did not convict on the note alone, but I'm sure it didn't help. In the public imagination, that phrase became almost shorthand for the entire prosecution. And in August 2023, after months of evidence, the jury returned its verdicts. Just remember, the trial started in October of 2022. So this is long, long trial. Lucy Lepby was convicted of seven counts of murder and seven counts of attempted murder. She was found not guilty of two counts of attempted murder, and on six further attempted murder counts, the jury was stalled. They could not reach a verdict. On August 21, 2023, she was sentenced. She didn't attend the sentencing hearing. She stayed in her cell. Mr. Justice Goss sentenced her in her absence. In his sentencing remarks, he said she had murdered seven babies and attempted to murder six others over almost 13 months while employed as a neonatal nurse at the Countess of Chester Hospital. He imposed whole life orders. That means no minimum term, no parole, no release. Yeah, and the judge's remarks were severe. He described a gross breach of trust. He said the babies were the smallest and the most vulnerable, and he emphasized that she maintained her denial. For the families, sentencing didn't bring their babies back. It didn't undo the years of uncertainty, and it didn't undo what they lived through at the hospital during the investigation or through the trial. And for the public, the case seemed for a moment settled. But it was not over. Remember, the first jury didn't reach verdicts on six attempted murder counts, so prosecutors decided to retry Lepby on one of them, the attempted murder of Baby Kay. Baby Kay was extremely premature, born at 25 weeks gestation in February 2016. The prosecution case was different from some of the first trial cases because it relied heavily on direct evidence from Dr. Ravi Jiarum. According to the CPS, he said he walked into the nursery and found Baby Kay desaturating, with Lepby standing nearby and not helping or raising the alarm. The baby's breathing tube had become dislodged. Lepby denied trying to harm Baby Kay. In July 2024, a second jury convicted her of attempted murder. She received another whole life order, bringing the total to 15. The CPS said that the orders would run concurrently and that Lepby would never be released from prison. One detail is important here. Baby Kay later died after transfer to another hospital, but Lepby was not convicted of causing her death. The 2024 sentencing remarks specifically state that Baby K's death could not be attributed to Lepby's actions. The conviction was for attempted murder.

SPEAKER_01 41:39

And that distinction matters.

SPEAKER_00 41:43

It matters a lot. In a case like this, the emotional precision matters. I will say again, this is circumstantial, that if this was an isolated case, if it would take were taken on its own without any information about all of the other convictions, there's no proof that just because she was standing there that she was the one that dislodged the baby's tube or how long it had been happening.

SPEAKER_01 42:08

Yeah, he could have just woken it up at the most optimal time to make it look affordable.

SPEAKER_00 42:13

Right. But in light of her convictions, the fact that she was standing there not doing anything when a baby was having desaturation was, you know, further evidence for attempted murder.

SPEAKER_01 42:26

Maybe she's running through the checklist in her head.

unknown 42:29

Yeah.

SPEAKER_00 42:30

What do I do? She's in shock.

SPEAKER_01 42:32

I don't know. Devil's advocate.

SPEAKER_00 42:34

Right. Letby's first attempt to appeal the 2023 convictions was refused. The Court of Appeal considered several grounds, including arguments about expert evidence and a request to admit fresh evidence from Dr. Shu Li, the neonatologist and co-author of the 1990, the 1989 paper on air embolism in newborns that the whole prosecution rested on. The defense wanted to use Dr. Li's evidence, current evidence, to challenge how the prosecution experts relied on skin discoloration as part of the air embolist theory, but the Court of Appeal rejected the application. It said none of the grounds advanced were arguable on the criteria for admitting fresh evidence hadn't been met. So then after the Baby K retrial, Lepby also sought leave to appeal that conviction, but that appeal was narrower. It focused on whether she could receive a fair retrial given the intense publicity after the first convictions. Like I was saying, it colored everyone's yeah, it was bias, natural bias, right? Knowing that she'd been convicted of killing babies. I mean, it's only natural that you would go, well, yeah, she was standing there and this baby died. I don't care what happened, she's gotta be guilty. The court of appeal refused that application as well, saying the judge had been right to allow the retrial to proceed and emphasizing that the second appeal did not decide the wider debate about the original case. So by late 2024, both direct appeal attempts had failed and legally the convictions stood. But outside the courtroom, the debate was growing. But it does mean we should be careful about assuming that strange equals murderer.

SPEAKER_01 44:15

Yeah, that kind of feels like the whole theme of this case, right? Like how much weight can each piece of evidence actually carry.

SPEAKER_00 44:22

Right? Exactly. Reasonable doubt does not always announce itself with a dramatic new suspect or a single piece of DNA. Sometimes it comes from realizing that the case you thought was simple is actually full of assumptions, stacked on top of assumptions. And in Lucy Lepbe's case, that's the question that Amanda Knox's podcast is pushing into the Open. We're going to talk more about Amanda Knox. If you don't know who she is, we'll I'll be talking more about her in the next episode. But she was a wrongly accused of murder of her roommate. So she has a podcast just kind of raising questions about the case and coming from a place of someone wrongfully accused. I think it's interesting to include her her thoughts on this. But she questions was Lucy let be convicted because the evidence proved beyond reasonable doubt that she deliberately harmed those babies, or was she convicted because inside a failing system, a series of tragedies was turned into a story that became almost impossible to question? So that doesn't answer the case, but it changes about how we listen or think about it.

SPEAKER_01 45:27

And that feels like it makes the next part even more important.

Appeals Fail As Scientific Doubt Grows

SPEAKER_00 45:31

It does, because now we have to look at the evidence that created that certainty and the evidence that may be starting to crack it. And so this is where the case becomes even more, if you can believe it, incredibly difficult. Because after the convictions, more doctors, statisticians, legal commentators, journalists, and scientists began raising questions. Questions about statistics, about the shift chart, which is what I was talking about, where it was like it was unbelievable. You know, every single shift that Lucy'd been on when babies had crashed, instead of every single shift, you know, and this is these are the ones where we had a medical incident and and the whole staff, you know. Some arguments were about the air ambulus, the handwritten notes, whether the prosecution experts had overreached, why the defense didn't call its own expert witness, and somewhere about a failing neonatal unit that turned a crisis of care into a criminal case against one nurse. So scapegoatism. And to be clear, the questions aren't exoneration. I think if we aren't allowed to question convictions, you know, we aren't going to learn or get better at our criminal process, right? So just because we're questioning it doesn't mean that it's necessarily wrong, but I think it bears review. So a public debate isn't an appeal judgment and a podcast isn't a court, but the questions were serious enough that Lepbee's legal team submitted an application to the Criminal Cases Review Commission, the body that can investigate possible miscarriages of justice, and if appropriate, refer a case back to the Court of Appeal. So the CCRC said it received a preliminary application on Lepbee's behalf in early February 2025 with additional materials submitted throughout the year. As of its February 2026 statement, the review was underway. The CCRC also emphasized that it doesn't determine guilt or innocence. Its role is to decide whether new evidence or argument creates a real possibility that a conviction would not be upheld.

SPEAKER_01 47:31

So the CCRC is not saying she's innocent then.

SPEAKER_00 47:35

Correct.

SPEAKER_01 47:36

And it's not saying either that the conviction is unsafe. Correct. So basically it's saying we are reviewing.

SPEAKER_00 47:47

Exactly. But that review is where the post-conviction expert evidence might actually come into play and matter. In February 2025, an international panel of medical experts led by retired Canadian neonatologist Dr. Shu Lee, that we mentioned before, publicly disputed the medical evidence used to convict Letby. According to the Associated Press reporting, the panel said it found no sign of a crime and concluded that natural causes or bad medical care explained the deaths and the deteriorations that it reviewed. Dr. Lee said at the press conference that they did not find murders. The panel also raised concerns about staffing, resuscitation skills, delayed treatment, misdiagnoses, and the interpretation of error embolism evidence. The only thing that wasn't in there was the plumbing. Still so odd that the sewage problems, but okay. So the British Medical Journal similarly reported that the panel claimed there was no medical evidence to support malfeasance and that the baby's deaths or injuries were the result of natural causes or poor medical care.

SPEAKER_01 48:53

That's a huge claim.

SPEAKER_00 48:55

It's enormous. But again, here's the careful part. This wasn't a court judgment. It wasn't the Court of Appeal overturning a conviction. It was an expert challenge being used by Lepbee's legal team as part of the post-conviction process. So the prosecution and police have continued to stand by the convictions. The Court of Appeal had already rejected the 2024 appeal, and the CCRC process was still ongoing. So listeners may ask, how can all of these things be true at once? They can be true because the legal system and the scientific debate are not always moving at the same speed. The legal system asks, was the conviction safe according to legal rules, evidence admitted at trial, and appeal standards? And the scientific debate asks, were the medical conclusions correct? Were alternative causes properly considered? Did experts overstate what could be known? And these questions overlap, but they're not identical. And they're what drive me crazy and make us. I think you're on the same page as me that make us really enjoy this podcast, creating this podcast, right? Because these things are things that keep us up at night. But so that's that's it for part two.

SPEAKER_01 50:13

Would you like to do that? Leaving us hanging like that. Do you want me to do sponsor two?

SPEAKER_00 50:22

Yes, please. I thought I had a little blurb about how I wanted you to do it.

SPEAKER_01 50:27

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SPEAKER_00 52:16

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SPEAKER_01 52:27

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SPEAKER_00 52:30

That sounds amazing.

SPEAKER_01 52:32

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SPEAKER_00 52:36

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Sponsor Break And A Needed Laugh

SPEAKER_01 52:39

Can you bottle that up for my eye? Thank you. Do you have it on tap? Thank you. Without further ado, I guess it's uh time for a quick little yawn. I hope you all yawned and you're a psychopath. And it's time for a medical misap. Subject. Medical mishap. The blood pressure cuff chose violence. Yikes. Okay, Ellie cats. After this heavy case, I think we need a palate cleanser, and I'm here for the subject line. Yes, please. My nervous system needs a snack and a nap. Oh, a snack. I need a snack. So again, the subject line is the blood pressure cuff chose violence, and this week's medical mishap comes from listener Maddie.

SPEAKER_00 53:35

Maddie, I'm obsessed.

SPEAKER_01 53:38

Maddie. Okay, it says Hi, Jenna, and Amen. Someone else trying to sing like you. You see that? There's a lot of A's in there. First of all, I love the podcast. You two somehow make me laugh, learn, and question every institution in America, all at this one time, which is honestly a talent. So here's my medical mishap. I recently went in for a routine checkup. Nothing dramatic, just your standard. Yes, I'm tired. No, I don't drink enough water. Yes, I know I should exercise more. Please don't look directly at my cholesterol kind of visit.

SPEAKER_00 54:16

Oh, I feel that so hard.

SPEAKER_01 54:19

That feels like the yes, I know I need to floss more. And especially now, y'all, you don't want that shit in your heart. Okay, back to the email. The nurse calls Maddie back, and Maddie writes that this nurse is lovely. She takes the weight, rude, but expected, asks the usual questions, and then grabs the blood pressure cuff. Now I have what I lovingly refer to as dramatic arms. They are not tiny, they are not dainty, they are working arms, okay? Yes, girl. They carry yes, queen girl. They carry groceries in one trip. They open jars. They have lived.

SPEAKER_00 54:59

Yes.

SPEAKER_01 55:01

I love the open jars part because I have a cheater thing like my grandma used to use, one of those grippy things, you know? So you go Maddie. I don't have dramatic arms. I have windy ons. The nurse wraps the cuff around my arm, hits the button, and we both continue chatting like normal people. Mm-hmm. And then the cuff starts inflating and inflating and inflating. And at first I'm like, okay, she's getting snug. Then I'm like, oh wow, she committed. And then I'm like, is this blood pressure reading or is this machine trying to extract state secrets? So Maddie goes on to write that her hand starts tingling, fingers are turning into little Vienna sausages. And I'm trying to stay casual because I don't want to be dramatic, but internally I'm saying goodbye to my family, lol. Um the machine keeps squeezing and suddenly it makes this angry little beep like I have done something wrong. The nurse looks at the screen and says, hmm, didn't get it. LL, no shit. Didn't get it. Ma'am, it got my soul. So she says, she says, let's try again. And before I can say, maybe we let the arm emotionally recover, she hits the button again. And round two begins. And at this point, I am sweating. My arm is trapped. My Apple Watch thinks I'm doing cardio, and I'm pretty sure my wedding ring flashes before my eyes.

SPEAKER_00 56:38

Oh no.

Medical Mishap: The Cuff Chose Violence

SPEAKER_01 56:40

The cuff tightens so much that I accidentally make eye contact with a nurse and whisper, is it supposed to feel like I'm being swallowed by a python? And she immediately bursts out laughing and says, No, absolutely not. And then she looks closer and realizes the cuff is the wrong size, which I'm sure we've all been thinking, right? Hello, wrong size, ding bat. Size. So now my blood pressure is officially 900 over I no longer trust technology. She removes the cuff, gets a bigger one, and suddenly it is fine. Easy, peaceful, dare I say, spa-like by comparison. And the new reading? Normal. The nurse goes, Great! Blood pressure looks gun. DA. That was my input. Sorry, not Maddie's. And I say, that is because the threat has passed. Anyway, please remind your listeners: if the blood pressure cuff feels like it's trying to take your arm as collateral, maybe speak up sooner than I did. Love you both. Stay safe. Stay suspicious, and stay suspicious of medical equipment with too much confidence, Maddie. Oh my god.

SPEAKER_00 57:45

Maddie, the threat has passed is exactly how I feel every time they take the cut the cuff off.

SPEAKER_01 57:53

I'm just also thinking like this person was sitting there just chatting up with you. Like, I'm sure the people in the room next door could probably hear that the cuff was trying to take your arm like a python. Like, that's not quiet when that's happening.

SPEAKER_00 58:07

Also, ma'am, it got my soul, needs to be on a mug. Oh, yeah, yeah, yeah, yeah, yeah. I like that. Yeah, yeah, yeah.

SPEAKER_01 58:14

Oh okay, yeah. So, anyway, yeah, it's like that moment where it's like, okay, this is fine, and then suddenly hands are purple, and I just feel like Maddie is probably there, like starting to feel like she's in a confessional booth. Like, uh. So, anyway. Listen, everyone listening pressure cuffs, look out for them.

SPEAKER_00 58:35

Right? Everyone listening, may your cuffs be correctly sized. Your portals actually schedule the appointment, and your vital signs not require an exorcism. Amen.

SPEAKER_01 58:47

Okay, Ellie Cats. Uh, that's part two episode on Lucy Leppy. We're at 101 right now before editing, so hee hee. You're welcome. There's still 17 pages more where that came from. We know this one is emotional, complicated. It's still developing. I know I had text Jenna recently, like, oh my god, this just popped up on my news. Like, there it's still developing, it's ongoing, and so forth. So we'll keep an eye on the CCRC review, the Thurwall Inquiry Report, and the ongoing hospital leadership investigation for part three next week. Meanwhile, don't you miss a damn beat. Subscribe or follow Doctor in the Truth wherever you enjoy your podcast for stories that shock, intrigue, and educate. Trust, after all, is a delicate thing. You can text us directly through our website, don't you know? Email us your story ideas, medical mishaps, and comments. And you better be sure to follow us on Instagram, Facebook, and Tiki Talk. Download, rate, and review so we can be sure to keep bringing you more horrific stories. Until then, stay safe and stay so good.