Speaker 1: Before we begin, please be aware this episode contains discussions
Speaker 1: around infant deaths and other difficult topics. Please take care
Speaker 1: while listening.
Speaker 2: Now you'll presumably know the background of the Lucy let
Speaker 2: Be issue the miscarriage.
Speaker 3: As I view it.
Speaker 1: Member of Parliament David Davis is sitting behind a rectangular table.
Speaker 1: Beside him. To his right is Lucy Letb's current lawyer,
Speaker 1: Mark McDonald, to his left one of the world's most
Speaker 1: distinguished neonatal experts.
Speaker 2: And today what we're here to do is to present
Speaker 2: a report which is the idea, the genesis, the.
Speaker 3: Creation of Dr. Shoo Lee, who's sitting next to.
Speaker 1: Me in front of the panel waiting anxiously to hear
Speaker 1: this report. Are a gaggle of media newspapers, TV broadcasters,
Speaker 1: and in keeping with the times, a number of podcasters,
Speaker 1: all their microphones and cameras squarely focused on the group
Speaker 1: of people sitting before them.
Speaker 4: Well, thank you, sir David. My name is Shoo Lee,
Speaker 4: and I'm here to share with you the findings of
Speaker 4: the International Expert Panel on the Lucy Latvi case. But
Speaker 4: before I start, I'd like to share the syncrithies and
Speaker 4: condolences of members of the International Expert Panel with families
Speaker 4: of the affected infants. We understand their stress and their anguish,
Speaker 4: and our work is not meant to cause more distress. Rather,
Speaker 4: it is meant to give them comfort and assurance in
Speaker 4: knowing the truth about what really happened. We know that
Speaker 4: they want to know the truth, and that is why
Speaker 4: we are here to tell the truth.
Speaker 1: The truth when it comes to Lucy let Be the
Speaker 1: truth is not an easy place to land. There are
Speaker 1: some who are sure they know the court for one,
Speaker 1: has sent her away for the rest of her life.
Speaker 1: In the mind of the judge, the jury and the prosecutor,
Speaker 1: she is one of the worst serial killers in UK history.
Speaker 1: But as more and more information beyond what the juries
Speaker 1: have heard comes out, more and more people are starting
Speaker 1: to wonder if the truth might actually be one of
Speaker 1: a wrongful conviction.
Speaker 5: There is overwhelming evidence that the conviction is unsafe and
Speaker 5: if Dr Shoo Lee and the Panel are correct, no
Speaker 5: crime was committed. If no crime was committed, that means
Speaker 5: that a thirty four you old woman is currently sitting
Speaker 5: in prison for the rest of her life for a
Speaker 5: climate just never happened.
Speaker 1: I'm Amanda Knox and from Vespucci and iheartpod casts This
Speaker 1: is Doubt The Case of Lucy let Be Episode nine.
Speaker 1: The experts. On the surface, Lucy has run out of options.
Speaker 1: Nearly every level available to her in the UK court
Speaker 1: system has turned down the opportunity to rehear her case,
Speaker 1: but Lucy's lawyer Mark McDonald is hopeful that the UK's
Speaker 1: Criminal Case Review Commission will consider a new review.
Speaker 5: What I do know is that the CCRC had taken
Speaker 5: us very seriously. They've already got a team in place,
Speaker 5: They're ready to go. They've watched this conference. I've made
Speaker 5: sure they've had a link to this, They've watched the presentation,
Speaker 5: they've got this report. They're going to get the final
Speaker 5: report that they've seen what you've all seen. I'm hoping
Speaker 5: they're going to take this very seriously until we met
Speaker 5: very quickly, and we will be back in the compable
Speaker 5: very soon.
Speaker 4: The panel comprises fourteen very experienced and well known experts
Speaker 4: from highly prestigious institutions in six countries around the world,
Speaker 4: including Canada, the United States of America, Japan, Germany, Sweden,
Speaker 4: and the United Kingdom. They include ten neonatologists, one pediatric surgeon,
Speaker 4: one pediatric infectious disease specialists, one senior neonatal intensive canness
Speaker 4: and one other pediatric specialists.
Speaker 1: These experts were not paid for their time. In fact, Dr.
Speaker 1: Shoo Lee, a veteran neonatologist who lives in Canada, paid
Speaker 1: for his own trip to the UK to be part
Speaker 1: of this press conference.
Speaker 4: I decided that, you know, it was necessary to do this,
Speaker 4: even though there would be a cost to pay for
Speaker 4: me personally. I also recognized that there was going to
Speaker 4: be a lot of pressure because this was such a
Speaker 4: high profile case, in the sense that there would be
Speaker 4: public in backlash. There will be people on both sides arguments,
Speaker 4: and I'll be open to attas, etc. But if in
Speaker 4: fact this woman is innocent of the crimes that she's accused,
Speaker 4: I think you'll be all with it, and I'm prepared
Speaker 4: to pay that price.
Speaker 1: Now retired, Dr. Shoo Lee spends his days farming on his spot
Speaker 1: of land in Alberta, Canada. When he talks about farming,
Speaker 1: it sounds like something he's been doing all his life.
Speaker 4: Last day was wheat the year before there was canola,
Speaker 4: and we're actually bringing cattle on to the farm this year.
Speaker 4: I enjoy being a farmer. I love to see things grow,
Speaker 4: just like I love to see my babies grow.
Speaker 1: But it's when the conversation turns to neonatology that you
Speaker 1: see his expertise really come alive. Calm, warm and precise.
Speaker 1: He carries decades of knowledge with him, and when it
Speaker 1: comes to the Lucy let Bee case, he knows the
Speaker 1: details almost by heart. I ask him how he first
Speaker 1: became involved.
Speaker 4: I caught an email from a lawyer in the UK
Speaker 4: asking me if I would look at a case, and
Speaker 4: I was busy during harvest, and I ignored it initially
Speaker 4: because how often does one get a email from a
Speaker 4: lawyer in the UK. But then two weeks later, after
Speaker 4: my harvest, it was there again, and so I decided
Speaker 4: to answer our curiosity, and I realized that, in fact,
Speaker 4: this was genuine. What a lawyer told me was that
Speaker 4: they had used a paper that had written in nineteen
Speaker 4: eighty nine to convict her. And that stirred my attention
Speaker 4: because I don't normally do medical legal cases, but in
Speaker 4: this case, because they used my paper, I was curious
Speaker 4: about what they actually said. So I agreed to look
Speaker 4: at the case without committing to actually participating in the process.
Speaker 1: You may remember earlier in this series we heard how
Speaker 1: the prosecution's medical expert, doctor Dowie Evans, on a research
Speaker 1: paper doctor Lee published in nineteen eighty nine. In court,
Speaker 1: it was cited as evidence suggesting that unusual skin discolouration
Speaker 1: seen on some of the babies could indicate air embolism.
Speaker 1: For doctor Lee, that was the moment this case stopped
Speaker 1: being distant news. If his research had been used to
Speaker 1: support that conclusion, he needed to understand exactly how.
Speaker 4: So they asked me to look specifically at the skin
Speaker 4: discolorations and whether the interpretation of the prosecution doctors were accurate.
Speaker 4: And when I looked at it, I realized that it
Speaker 4: wasn't because what they had interpreted wasn't what I wrote about.
Speaker 4: And so I appeared at the appeal and I explained
Speaker 4: that to the judges, and unfortunately my testimony was disallowed
Speaker 4: because in the British legal system you can only present
Speaker 4: evidence at appeal that could not have been presented at
Speaker 4: the original trial, and at the original trial, since they
Speaker 4: did not call me, they lost their chance and therefore
Speaker 4: my evidence was inivisible. So her appeal was rejected, and
Speaker 4: I was a little concerned because, as far as I
Speaker 4: was concerned, the evidence that was used to convictor on
Speaker 4: the air embolism and skin discolouration was inaccurate. So potentially
Speaker 4: this is an unsafe conviction.
Speaker 1: With his evidence dismissed by the court, his work might
Speaker 1: have ended there, but it didn't sit easily with him.
Speaker 1: If the medical conclusions presented at trial were wrong in
Speaker 1: this one case, what about the others? Doctor Lee felt
Speaker 1: he had a responsibility to find out.
Speaker 4: On the one hand, I could be selfish and say, well,
Speaker 4: this is not my problem anymore. I did my part.
Speaker 4: On the other hand, I felt compelled to do it
Speaker 4: because if in fact this was wrong, a young woman
Speaker 4: would be in jail for the rest of her life
Speaker 4: without possibility of appeal or parole, which means she to
Speaker 4: die in prison. That is a horrible consequence to contemplate,
Speaker 4: and I think, I think I would lack humanity if
Speaker 4: I didn't find out whether or not that conviction based
Speaker 4: on the medical evidence was correct. I would do this
Speaker 4: only on condition that we would publish our results and
Speaker 4: make it public, regardless of whether we felt.
Speaker 6: She was innocent or guilty. I just wanted to get
Speaker 6: the truth, so.
Speaker 1: He agreed to look at the rest of the medical
Speaker 1: evidence in the case. But what that meant in practice
Speaker 1: was an enormous undertaking.
Speaker 4: So for each case, because some of the cases were
Speaker 4: very long and baby stayed in the hospital for months,
Speaker 4: it's hundreds and hundreds of pages of material, and then
Speaker 4: hundreds and hundreds of pages of laboratory results and medical
Speaker 4: charting from binesses in the unit and a Hoart rate,
Speaker 4: blood pressure, all that kind of stuff. So it was
Speaker 4: a great deal of material.
Speaker 1: Doctor Lee knew this wasn't something one person should be
Speaker 1: reviewing alone. To get through the mountain of evidence and
Speaker 1: to do it properly, he turned to the panel we
Speaker 1: mentioned earlier, bringing together those fourteen medical experts from around
Speaker 1: the world to examine the case alongside him.
Speaker 4: And we not only had new netologists, we also had
Speaker 4: one infectious disease expert, and we had a mediafic surgeon
Speaker 4: because some of the cases involved trauma, and so he
Speaker 4: wanted to be sure that we covered all the bases
Speaker 4: of a multidisciplinary team that had parensic experience, that had
Speaker 4: pathological experience, surgical, obstetric and new needle.
Speaker 6: So that was the team.
Speaker 1: The panel divided the work between them, assigning each baby's
Speaker 1: case to two experts to review independently.
Speaker 4: Each case was then assigned to two members of the
Speaker 4: team randomly, and they were asked to look at the
Speaker 4: cases independently without consulting each other initially, and we asked
Speaker 4: them to look at the medical records without referring to
Speaker 4: the prosecution witnesses or to the court transcripts. In others,
Speaker 4: just take the chart and tell us what you think
Speaker 4: was the cause of injury or death in this baby,
Speaker 4: so that they were biased by other opinions.
Speaker 1: Only after they had reached their own conclusions independently were
Speaker 1: they asked to review the evidence presented at trial.
Speaker 4: They were then asked to look at the prosecution witnesses
Speaker 4: reports to see whether or not it would change their minds,
Speaker 4: and if it did not, then they completed their report.
Speaker 4: Even though we divided up the work amount fourteen people,
Speaker 4: it still took us four months to get through all
Speaker 4: that material.
Speaker 6: It was a lot of work. Nobody paid us to
Speaker 6: do any of this, you know.
Speaker 4: I think it was doctor Dowie Evans who said that
Speaker 4: within a few minutes he had decided that one of
Speaker 4: the cases was a murder. And I'm impressed that he
Speaker 4: was able to do that because we couldn't.
Speaker 1: After months of work and with more than a dozen
Speaker 1: medical experts reviewing the evidence, the reports finally came back.
Speaker 1: The panel compared their conclusions for each baby, but even
Speaker 1: then there was still more work to do in verifying
Speaker 1: the conclusions.
Speaker 4: If the two reports on each baby agreed with each other,
Speaker 4: then that was accepted as the final result. If there
Speaker 4: was a disagreement between the two reports, then a third
Speaker 4: member was brought in.
Speaker 6: And then a consensuship was achieved.
Speaker 4: We found that there was unanimous opinion that there was
Speaker 4: no male seasons. In others, there was good reasons why
Speaker 4: each of the babies either died or suffered injury. There's
Speaker 4: a logical explanation for what happened to each baby. In others,
Speaker 4: you don't have to invoke murder to understand why the
Speaker 4: baby died.
Speaker 1: But by this point there was no clear way to
Speaker 1: put those findings back before a court, so instead, along
Speaker 1: with MP David Davies and Lucy's current lawyer, Mark McDonald,
Speaker 1: the panel decided to make their conclusions public. A press
Speaker 1: conference was organized in London and doctor Lee traveled to
Speaker 1: the UK to present the report.
Speaker 4: When I went to the UK, there was an additional
Speaker 4: burden in that I was actually coming to the UK
Speaker 4: where the majority of the opinion now was at that time,
Speaker 4: was that she was guilty. So therefore to step into
Speaker 4: the arena and say she is not, and here's why
Speaker 4: we think she is not is a huge task, right
Speaker 4: so it was unclear to me what the public reaction
Speaker 4: would be, but I felt that it needed to be done.
Speaker 1: In a room packed with journalists in London, doctor Lee
Speaker 1: stepped up to present the panel's findings. He began by
Speaker 1: laying out how the team had grouped the cases, placing
Speaker 1: the deaths and injuries into six medical categories.
Speaker 4: First embolism caused for injection of air into the intraveners system.
Speaker 4: Two splinting of die fram causper injection of air into
Speaker 4: the nasogastric tube. Three dislodged nastric and doctor killed you
Speaker 4: causing collapse. Four hypoglycemia casper injection of insulin, five trauma
Speaker 4: to the abdomen or gaestri intestinal tract, and sixth overfeeding.
Speaker 1: Doctor Lee did not go over every case the panel
Speaker 1: had examined.
Speaker 4: Mart McDonald lawyer, said, why don't we focus on the
Speaker 4: fatalities because the most important cases. Second, there were some
Speaker 4: cases that were shall we say, very obvious in terms
Speaker 4: of the causes of death or egregious in terms of
Speaker 4: the accusations that we felt that they needed to be highlighted.
Speaker 6: So those were the two conditions.
Speaker 1: The first case Doctor Lee brought up was Baby A,
Speaker 1: or as he called him, Baby one, citing the cause
Speaker 1: of death argued by the prosecution.
Speaker 4: Maybe one died from injection of air into the intravenous line,
Speaker 4: causing air embolism.
Speaker 1: This case, in particular had already drawn doctor Lee's attention.
Speaker 1: It was the prosecution's conclusion in that death and the
Speaker 1: way his research had been used to support it that
Speaker 1: it first led him to speak at the appeal.
Speaker 4: And so on the day of the collapse. Actually, BBA
Speaker 4: had two central cathetists, and these are lines that are
Speaker 4: placed into the large veins for venus access. Right now,
Speaker 4: Normally when you put in central catheteris like this, we
Speaker 4: would infuse the lines together with anticoagulants to prevent them
Speaker 4: from clotting, because central lines are notorious for clotting and
Speaker 4: causing trombus.
Speaker 1: Right a thrombus is simply a blood clot that forms
Speaker 1: inside a blood vessel or medical line, blocking the normal
Speaker 1: flow of blood, something doctors work carefully to prevent in
Speaker 1: fragile newborns.
Speaker 6: Now.
Speaker 4: In BBA, the risk of trombosis was further increased because
Speaker 4: the mother had something called antiphospholipid syndrome, which is a
Speaker 4: condition in which the immune system mistakenly creates antibodies to
Speaker 4: attack tissues in the mother's body and can trigger blood
Speaker 4: cloths to form in the arteries and veins.
Speaker 1: You see, although Baby A didn't have antiphospholipid syndrome, antibodies
Speaker 1: from the mother can cross the placenta and enter the
Speaker 1: baby's bloodstream, increasing the risk of dangerous blood clots. In
Speaker 1: Baby A's case, that risk may have been compounded by
Speaker 1: the fact that the catheterl lines had been left in
Speaker 1: place without infusion for an extended period of time.
Speaker 4: The lines were left uneffused for four hours. Clot forms
Speaker 4: very quickly. You don't need four hours of form a
Speaker 4: clock right. It forms in minutes, and if you leave
Speaker 4: a line left for four hours, you're almost begging the
Speaker 4: trumbus the form. On top of that, it did not
Speaker 4: anticoagulate the line and it did not infuse it. So
Speaker 4: after four hours you're going to get a trumpets. I mean,
Speaker 4: it's no question about it. And then after that day
Speaker 4: somebody started the infusion and shortly, very shortly after the
Speaker 4: infusion was started and the baby collapsed.
Speaker 1: According to doctor Lee, on top of the risk factors
Speaker 1: already present, allowing blood to sit in an unmaintained catheter
Speaker 1: line creates the conditions for a clot to form. Once
Speaker 1: the line is flushed or infusion restarts, that clot can
Speaker 1: break free.
Speaker 4: And when the trumpus breaks off, it can go to
Speaker 4: an archy, supplying a critical structure in a brain, for example,
Speaker 4: O in a hut that causes sudden collapse and death.
Speaker 1: Doctor Lee also pointed to findings in the post mortem
Speaker 1: that suggested a recent clotting event, evidence, he says, is
Speaker 1: consistent with a thrombus traveling through the bloodstream shortly before death.
Speaker 1: But the detail that first drew him into this case,
Speaker 1: the one tied to his own research, was something else
Speaker 1: entirely the unusual skin discolouration seen on the baby.
Speaker 4: Now, then there's this matter of these patchy skin discolorations.
Speaker 4: Because a lot of was made about the during the
Speaker 4: trial saying that these were very unusual skin discolorations. They
Speaker 4: were consistent of what I had written in nineteen eighty nine. Uh,
Speaker 4: and they seemed to be migrating and moving, and therefore
Speaker 4: this was a diagnostic of embolism.
Speaker 6: Unfortunately, that's not correct.
Speaker 4: The only skin discoloration there is diagnostic of air embolism
Speaker 4: is something called the Lee sign.
Speaker 1: You heard that right, The Lee sign, as in Dr.
Speaker 1: Shoo Lee. The clinical sign was literally named after him,
Speaker 1: and in the case of baby A, it sits right
Speaker 1: at the center of the debate over what happened. Doctor
Speaker 1: Lee first identified what would become known as the Lee
Speaker 1: sign in nineteen eighty after observing a dramatic and previously
Speaker 1: undocumented pattern of skin discoloration on a newborn.
Speaker 4: Basically, the O trees appear on the skin, and it's
Speaker 4: like a tree that fans up and it starts approximately
Speaker 4: and then moves this toilely, so you can see like
Speaker 4: a Christmas tree lighting up on a duck baby.
Speaker 1: That discovery eventually led to the nineteen eighty nine paper,
Speaker 1: the paper doctor Dowwie Evans cited at trial, But according
Speaker 1: to doctor Lee, what was described in his research was
Speaker 1: something very specific the marks discussed in court were patchy.
Speaker 1: The Lee sign, he says, looks nothing like that.
Speaker 4: Nothing patchy about it at all. These are very clear vessels.
Speaker 4: You can see the bloodvessels very clearly superimposed on the
Speaker 4: dark background.
Speaker 1: So at the press conference, doctor Lee, in no uncertain terms,
Speaker 1: revealed that doctor Evans had misunderstood his research.
Speaker 4: The prosecution in part based the allegation on the paper
Speaker 4: that I had written in nineteen eighty nine where I.
Speaker 3: Described fifty seven cases.
Speaker 4: That about ten percent of them has skinned discolourations of
Speaker 4: different kinds. At that time, I did not distinguished between
Speaker 4: arterial and venous air embolism, and in this particular case,
Speaker 4: the allegation is that she injected air into the venus
Speaker 4: system into the veins. And in the new paper that
Speaker 4: I had published in December of twenty twenty four in
Speaker 4: the American Journal of Parentetology, we actually separated the cases
Speaker 4: with arterial venus embolism from the cases with venus embolism,
Speaker 4: and what we found was that in the cases where
Speaker 4: air was injected into the veins, there were no cases
Speaker 4: of Patche's skin discolourations ever described in the literature. So
Speaker 4: the notion that these babies can be diagnosed with air
Speaker 4: embolism because they collapsed and had these skin discolourations. Has
Speaker 4: no evidence. In fact, right, none of this actually has
Speaker 4: ever been described. If this is true, it'll be the
Speaker 4: first case ever described, but it's never been.
Speaker 1: We of course wanted to ask doctor Abbas about this
Speaker 1: and so much more, but he has repeatedly turned down
Speaker 1: our requests for an interview. In other media, we know
Speaker 1: that doctor Evans is aware of doctor Lee's response. In fact,
Speaker 1: in one documentary called Conviction, we can see doctor Evans
Speaker 1: watching the press conference. Despite the author of the papers
Speaker 1: explaining the issues with doctor evans diagnosis, doctor Evans refuses
Speaker 1: to accept that he is wrong. Now in court, prosecutors
Speaker 1: pointed to one clear pattern in the collapses that Lucy
Speaker 1: let Be happened to be on shift, that when doctor
Speaker 1: Lee looked at the cases, he noticed another pattern, one
Speaker 1: that had received far less attention. Many of the babies
Speaker 1: involved weren't isolated cases at all. They were part of
Speaker 1: multiple births.
Speaker 6: Now Baby A had a twin called Baby B.
Speaker 4: Now this twin suffered the same thing in the sense
Speaker 4: that the baby also had sudden collapse within the first
Speaker 4: two days of life. But the baby survived right, So
Speaker 4: there was no pathology, et cetera. But there are common things.
Speaker 4: Number One, the baby had a similar character. Number two,
Speaker 4: they had the same mother, and as I said earlier,
Speaker 4: the mother has anti fossil lipid syndrome. And so I
Speaker 4: think that there's a commonality why these multiple babies, just
Speaker 4: you know, twins, triplets had problems because they had a
Speaker 4: similar pathology or something underlying it.
Speaker 6: In other words, that in fact.
Speaker 4: Created the conditions for these things to happen. And so
Speaker 4: it happened to one baby, it was more likely actually
Speaker 4: to happen to another because it's the same condition they's
Speaker 4: affecting the babies.
Speaker 1: So, after laying out the medical evidence surrounding Baby A,
Speaker 1: the obvious question followed. If not air embolism, then what
Speaker 1: actually caused the baby's sudden collapse. Doctor Lee brings up
Speaker 1: a few possibilities, from the high risk of thrombosis as
Speaker 1: we heard earlier, to malpractice. A post mortem on the
Speaker 1: baby showed that there was in fact a thrombic event
Speaker 1: and an IV had been inserted into the baby in
Speaker 1: order to infuse medicine, but that IV had penetrated the
Speaker 1: vein and had come out into the tissues.
Speaker 4: And so the infusion was not going into the circulation,
Speaker 4: was going into tissues, and so the air was getting
Speaker 4: swollen because the infusion was coming out. And so because
Speaker 4: of this, they removed the IV and replaced it with
Speaker 4: an unbelica venus catheter, but their first insertion was malpositions,
Speaker 4: and so they had to replace it again.
Speaker 1: Doctor Lee never says that he is sure how Baby
Speaker 1: A died, but he is sure it wasn't from an
Speaker 1: air embolism. But Baby A was not the only baby
Speaker 1: that this cause of death was given to.
Speaker 4: It was especially concerning because in many of these babies,
Speaker 4: Doctor Evans contended that the babies were stable and then
Speaker 4: they suddenly collapsed and died, and therefore it can be
Speaker 4: nothing but embolism because the babies were stable, they were
Speaker 4: doing well, So why did they collapse and die?
Speaker 6: There was no reason for that.
Speaker 4: And yet when we looked at the case, we found
Speaker 4: out was not the case. These were very sick babies
Speaker 4: who had certain conditions, and not only that, in many
Speaker 4: of these babies, they were actually getting worse every day.
Speaker 4: There was evidence, like medical and laboratory evidence that these
Speaker 4: babies were actually deteriorating and they were not picked up
Speaker 4: right and not treated. In some cases they had pneumonia
Speaker 4: or infection, or hemorrhage from a particular lesion, etc.
Speaker 6: And they were just not picked up right.
Speaker 4: So that is very concerning to us that the experts
Speaker 4: in this case did not pick up on the fact
Speaker 4: that these babies had pre existing conditions and they were worsening,
Speaker 4: and who were actually in danger of dying because of
Speaker 4: these conditions and not because they were stable. They were
Speaker 4: not stable.
Speaker 1: The important part of this report isn't that the panel
Speaker 1: members were able to determine one hundred percent why these
Speaker 1: babies died. We may never have definitive answers to those questions.
Speaker 1: What is important is that these experts offered a plausible
Speaker 1: explanation other than murder. Had the jury in Lucy's first
Speaker 1: trial been able to hear another possibility, would they have
Speaker 1: been able to find her guilty or would the weight
Speaker 1: of reasonable doubt have changed things. For more than an hour,
Speaker 1: doctor Lee went on to discuss a number of the
Speaker 1: other cases they looked at.
Speaker 4: We found that the medical histories were incomplete. It was
Speaker 4: a failure to considered the obstatric history there was disregard
Speaker 4: for surveillance warnings about bacterial colonization. There was misdiagnosis of
Speaker 4: Jesus in these babies they were carrying for babies that
Speaker 4: were probably beyond their expected ability or designated level of care.
Speaker 4: They were unsafe delays in diagnosis and treatment of acutely
Speaker 4: ill patients. There were poor skills at resuscitation and intubation.
Speaker 4: There was poor supervision of junior doctors in procedures like intubation.
Speaker 4: There were poor skills in basic medical procedures like insertion
Speaker 4: of chest tubes. There was lack of understanding about basic
Speaker 4: things like respiratory physiology and how to mechanically ventilate the baby.
Speaker 4: There was poor management of common neuronytal conditions like hypoglycemia.
Speaker 4: There was a lack of knowledge about commonly used equipment
Speaker 4: in the NICU. There was failure to protect infants who
Speaker 4: were at risk, for example, hemophilia, from a trauma during intubation.
Speaker 4: There was a lack of teamwork and trust between the
Speaker 4: health professions. There were also statements given by many witnesses
Speaker 4: which point to serious resources and infrastructure deficiencies. And these
Speaker 4: specific concerns that were expressed by individuals include inadequate numbers
Speaker 4: of appropriately trained personnel in the unit, lack of training
Speaker 4: for assigned nursing roles, inadequate staffing and workload overload, poor
Speaker 4: plumbing and drainage resulting in the need for intensive cleaning
Speaker 4: in the unit. There was poor environmental temperature control in
Speaker 4: the facility. There was difficulty in finding the doctor when
Speaker 4: the need arose. Some higher risk infants had been born
Speaker 4: and cat for at higher level institutions, but were born
Speaker 4: and cared for in this hospital, and they were delayed
Speaker 4: in transfer or sick infants to higher level facilities.
Speaker 3: When they need arose.
Speaker 4: So these are not things that we invented. These are
Speaker 4: statements given by people who work in the unit. Our
Speaker 4: conclusions of this panel, therefore, was that there was no
Speaker 4: medical evidence to support malfeasons causing death or injury in
Speaker 4: any of the seventeen cases in the trial. In summary,
Speaker 4: Ladies and Gentlemen, we did not find any murders. In
Speaker 4: all cases, death or injury were due to natural causes
Speaker 4: are just bad medical care.
Speaker 3: Lucy was charged with.
Speaker 4: Seven murders and seven attempted murders. In our opinion, the
Speaker 4: medical opinion, the medical evidence doesn't support murder in any
Speaker 4: of these babies.
Speaker 1: It was a striking moment. After months of analysis, the
Speaker 1: panel had delivered a clear conclusion, one that challenged the
Speaker 1: central claim of the prosecution's case.
Speaker 4: The room was extremely attentive, and one of the reporters
Speaker 4: said to me afterwards, you could hear a pin drop.
Speaker 4: I think it was a moment of clarity for many
Speaker 4: people who thought all along that she was guilty, and
Speaker 4: suddenly a lot of reporters and other people in the
Speaker 4: room were saying, wait a minute, maybe we got it wrong.
Speaker 1: Following doctor Lee's comments, the panel is opened for the
Speaker 1: media to ask their questions. In a country where the
Speaker 1: story of Lucy Ledbe and her sensational crimes have dominated
Speaker 1: the news cycle for years, this news conference was well attended.
Speaker 3: I'll start, I'll get right across from right to left, Sir.
Speaker 1: Many of the questions asked concerned doctor Dowie Evans, especially
Speaker 1: presient considering he used doctor Lee's research to help convict
Speaker 1: let Be.
Speaker 4: When it comes to doctor Evans' testimony and his opinions,
Speaker 4: I would ask you to ask three questions. First of all,
Speaker 4: the first question would be if our panel found so
Speaker 4: many problems with the medical care provided by this team
Speaker 4: at this hospital.
Speaker 3: How is it that doctor evidence from none?
Speaker 4: The second question that I would ask is this, he
Speaker 4: seemed to be rather selective in his use of information.
Speaker 3: So if he wasn't selective, if all the.
Speaker 4: Information was used, in fact, you would come to a
Speaker 4: very different conclusion than what he came to.
Speaker 3: So was he just callous or was it deliberate?
Speaker 4: The next question that I would ask, even when there's
Speaker 4: obvious cause of death, why did he go around looking
Speaker 4: for malfeasans?
Speaker 1: Doctor Lee wasn't the first to raise questions about doctor Evans.
Speaker 1: Many people were concerned with the retired pediatrician's lack of expertise,
Speaker 1: the speed in which he found wrongdoing, the quality of
Speaker 1: his assessments. Amazingly, some of those concerns were actually raised
Speaker 1: during Lucy let Bey's first trial by another judge.
Speaker 2: Three months into the murder trial, Letby's defense team applied
Speaker 2: for evidence from Dally Evans to be excluded due to
Speaker 2: an adverse judgment from a judge in a previous case.
Speaker 1: MP David Davis brought this up in Parliament. How Lord
Speaker 1: Justice Jackson of the Court of Appeal took the extraordinary
Speaker 1: step of writing to Lucy's trial judge to warn him
Speaker 1: about doctor Evans. Justice Jackson wanted to Judge Goss to
Speaker 1: know that in another case, a report by doctor Evans
Speaker 1: was quote.
Speaker 2: Worthless and makes no effort to provide a balanced opinion
Speaker 2: close quote in an extraordinary and so I can see
Speaker 2: unprecedented invasion that very judge or Justice Jackson actually wrote
Speaker 2: the trial judge with his judgment on doctor Evers attached,
Speaker 2: clearly indicating how unsuitable events was.
Speaker 1: That warning seemed to fall on deaf ears.
Speaker 7: I think it's quite clear with hindsight that there were
Speaker 7: holes throughout this entire process, and it holds the two
Speaker 7: a flawed set of evidence and an incomplete set of
Speaker 7: evidence being presented to the jury, and therefore calls into
Speaker 7: a question whether the jury was sufficiently well informed to
Speaker 7: enable them to reach a reliable verdict.
Speaker 1: Doctor Nina Modi was one of the members of Dr.
Speaker 1: Shoo Lee's Expert Hannele.
Speaker 4: Professor of Nina Modi, is one of the most senior
Speaker 4: newonthologists here in the UK. She is the Professor of
Speaker 4: Neonittle Medicine and Westin International and Imperial College London, Honorary
Speaker 4: Consultant to the Chelsea and Westminster NHS Foundation Trust and
Speaker 4: President of the European Association of Peranittal Medicine and a
Speaker 4: former President of the Royal College of Pediatrics and Child Health.
Speaker 3: Here in the UK.
Speaker 1: One of the big questions she has is how the
Speaker 1: court system in the UK defines an expert.
Speaker 7: So the law looks at your qualifications, but it doesn't
Speaker 7: necessarily address the issue how experienced you are and how
Speaker 7: recent your experiences. So you know, I am qualified in pediatrics,
Speaker 7: but I'm a neon natologist. I haven't worked in big
Speaker 7: children's pediatrics for a very very, very long time. It
Speaker 7: would be even though my qualifications that I am a pediatrician,
Speaker 7: it would be completely inappropriate for me to be commenting
Speaker 7: on a pediatric case because I'm not experienced.
Speaker 1: Doctor Modi believes that doctor Evans's lack of experience impacted
Speaker 1: the investigation into Lucy Ledbe right from the start.
Speaker 7: There were then flaws in the police investigation, for example,
Speaker 7: not looking at the ebcetric notes, not speaking to obstetricians.
Speaker 7: That was then amplified by what happened in court with
Speaker 7: the prosecution. None of the prosecutions expert witnesses drawing attention
Speaker 7: to some obvious features and facts that were present in
Speaker 7: the medical notes and which would have led to different
Speaker 7: conclusions regarding the causes of the baby's deaths. And then
Speaker 7: there was failure on the part of the defense to
Speaker 7: mount an adequate challenge to the prosecution. Tragedies like this,
Speaker 7: of course, are going to be emotional, but a court,
Speaker 7: to my best knowledge, should not be a place where
Speaker 7: emotion holds sway, but where facts and evidence holds sway.
Speaker 7: And that's I think even more pertinent point where one
Speaker 7: considers the anguish of these families who are being told
Speaker 7: we don't know what's caused your baby's death, to we
Speaker 7: do know what's caused your baby's death, to again actually
Speaker 7: a lot of people saying we don't think that the
Speaker 7: right conclusions have been reached. I mean, order agonizing rollercoaster
Speaker 7: that must be for them. What's also emotional and deeply
Speaker 7: worrying is the possibility of a miscarriage of justice on
Speaker 7: this scale. Can we actually trust the legal process? And,
Speaker 7: as my nursing colleagues fear, you know, will I be next?
Speaker 7: Prior to the press conference, the headlines on the papers
Speaker 7: in relation to Lucy let Bee's trial had all been
Speaker 7: along the lines of here is the worst serial killer
Speaker 7: Kate has ever seen, here as an evil person. But
Speaker 7: after that press conference, there were more and more and
Speaker 7: more questions that seemed to be raised in various parts
Speaker 7: of the press. So with hindsight, it does look as
Speaker 7: though that press confidence changed the perception of the public.
Speaker 1: It's hard to pinpoint the moment that a narrative shifts.
Speaker 1: It happens in stages. My family started to notice a
Speaker 1: shift in the American media about halfway through my first trial.
Speaker 1: TV pundits and journalists were finally asking, where's all this
Speaker 1: evidence we were promised? But only during my appeals trial,
Speaker 1: when independent experts were finally appointed to review the DNA,
Speaker 1: did I sense a shift in the courtroom.
Speaker 2: Lucy Letbee was convicted of murdering seven infants and attempting
Speaker 2: to mote seven more. She received multiple concurrent full life sentences.
Speaker 2: The case horrified the nation. It seemed clear a nurse
Speaker 2: had turned into a serial killer. Now, I initially accepted
Speaker 2: the tabloid characterization of let Be as.
Speaker 3: An evil monster.
Speaker 1: As we've heard throughout this series, that characterization of Lucy
Speaker 1: let Be it ran deep. Years of blaring headlines, guilty verdicts,
Speaker 1: and denied appeals reinforced that image, and press blackouts prevented
Speaker 1: competing narratives from taking hold. But slowly, as journalists and
Speaker 1: experts and politicians like David Davis began to ask critical questions,
Speaker 1: the story started to change.
Speaker 2: But then I was approached by many experts, leading statisticians,
Speaker 2: neonatal specialists, forensic scientists, people who are more knowledgeable than
Speaker 2: the purported experts whose evidence convicted let me, though, all concerned,
Speaker 2: but what they perceived as false analyzes and diagnoses used
Speaker 2: to persuade a lay jury to convict Letby.
Speaker 1: Experts like Jane Hutton. You may recall Jane from earlier
Speaker 1: in the podcast. Her experience with the Cheshire Police during
Speaker 1: their investigation cemented the idea that detectives were looking for
Speaker 1: evidence that fit their theory.
Speaker 3: You don't start by assuming that there's murder when you
Speaker 3: have no evidence.
Speaker 1: Professor Hutton had been approached by the Cheshire Police before
Speaker 1: Lucy Letby was arrested to help legitimize the infamous ledger
Speaker 1: that showed Lucy Leutby was in the hospital and on
Speaker 1: duty for every single death now.
Speaker 2: From the start of the case, Cheshire Police picked up
Speaker 2: on the doctor's statistical argument, supposedly pointing to let me.
Speaker 2: In April twenty eight, team, an officer on the investigation
Speaker 2: approached the leading statistician, Professor Jane Hutton, and asked her
Speaker 2: to put a figure on the likelihood of a nurse
Speaker 2: being on duty quotes during all the deaths and collapses
Speaker 2: close quotes in the unit. Of course, this is a
Speaker 2: false proposition, as Letby was not on duty for anything
Speaker 2: like all the deaths, but that was glossed over at
Speaker 2: the trial that notwithstanding, Professor Hutton informed the police that
Speaker 2: any proper statistical inquiry should not concentrate on one member
Speaker 2: from the outset. Instead, it required full proper research into
Speaker 2: all possible explanations for any increase in babies collapsing, including
Speaker 2: their medical conditions and prematurity, as well as the broader
Speaker 2: performance of the unit.
Speaker 3: You think that would be.
Speaker 2: Common sense really. Cheshire Police then signed a consultancy agreement
Speaker 2: with Professor Hutton, But then in twenty twenty one, after
Speaker 2: let Be had been charged, the police wrote an email
Speaker 2: to Professor Hutton and I quote it in terms, we
Speaker 2: have had a further meeting this afternoon, where we have
Speaker 2: informed the prosecutors we were looking into the validity of
Speaker 2: the statistical evidence in this case. The prosecutor has instructed
Speaker 2: as not to pursue this avenue any further at present.
Speaker 2: Now this appears to be in direct contravention of the
Speaker 2: Code for Crown Prosecutors, specifically Part three Decimal three of
Speaker 2: the Code. Prosecutors cannot direct the police or any other investigators. Again,
Speaker 2: the jury was never informed of Professor Hutton's explicit advice
Speaker 2: to the police that their statistical approach was flawed.
Speaker 1: The jury and Lucy's trial were never told about any
Speaker 1: of this. What they saw was a chart that had
Speaker 1: Lucy on shift for every death, a chart that many
Speaker 1: experts say was deeply flawed, not only based on bad statistics,
Speaker 1: firstly in the fact that they did not include all
Speaker 1: the staff that were working, but also there were other
Speaker 1: deaths on that ward when Lucy was not on shift.
Speaker 1: None of these were represented on that chart. This is
Speaker 1: actually a known logical error called the Texas sharpshooter fallacy.
Speaker 1: A man fires a hundred bullets at the side of
Speaker 1: a barn, then he walks up and draws a bullseye
Speaker 1: around the tightest cluster and says, see, look how accurate
Speaker 1: I am. But despite those flaws, David Davis says, it
Speaker 1: became very powerful evidence, evidence that Dr. Shoo Lee believes
Speaker 1: has led to a wrongful conviction and an innocent woman
Speaker 1: in prison for a crime she didn't commit, a crime
Speaker 1: that many believe didn't actually happen.
Speaker 4: Can you just imagine yourself in her shoes? If she
Speaker 4: was innocent and in jail and told that she's going
Speaker 4: to stay there until she dies, that would be a terrible,
Speaker 4: terrible injustice.
Speaker 6: I cannot imagine how anyone could survive.
Speaker 1: The next time on doubt the case of Lucy let Be.
Speaker 1: It ruptured like my sense of identity.
Speaker 4: I knew that I wasn't responsible for hurting a child,
Speaker 4: but I'm bad because this is happening, and I have.
Speaker 3: To go away and accept this.
Speaker 5: Somehow this turns out to be wrong, every single level
Speaker 5: of the British establishment will be towards to shreds. Lucy
Speaker 5: let Be will be freed, These convictions will be overturned.
Speaker 5: The only question is right.
Speaker 1: Doubt. The case of Lucy let Be is brought to
Speaker 1: you by the spoocy iHeart Podcasts and Knox Robinson Productions.
Speaker 1: I've been your host Amanda Knox. This episode was written
Speaker 1: by Kathleen Goldhar and Natalia Rodriguez. Senior producer is Natalia Rodriguez.
Speaker 1: The co producer was Lucy Ditchmont. The assistant producer was
Speaker 1: Amy Gill. The sound designer is Tom Biddle. Story editing
Speaker 1: by Kathleen Goldhar. Legal advice was provided by Jack Browning.
Speaker 1: The producers at iHeart Podcasts are Chandler Mays and Katrina Norvell.
Speaker 1: The executive producers were Joe Meek, Amanda Knox, Christopher Robinson,
Speaker 1: Daniel Turkin, and Johnny Galvin. Thank you for listening.