David Davis

I am not in the habit of issuing trigger warnings, but I must warn the House that this speech will cover deeply distressing events. I will discuss infant deaths, failures in care and allegations of a grave miscarriage of justice. Lucy Letby was convicted of murdering seven infants and attempting to murder seven more. She received multiple concurrent full-life sentences. The case horrified the nation. It seemed clear: a nurse had turned into a serial killer. I initially accepted the tabloid characterisation of Letby as an evil monster, but then I was approached by many experts, including leading statisticians, neonatal specialists, forensic scientists, legal experts, and those who had served at the Chester hospital and are afraid to come forward. The experts included a past president of the Royal Statistical Society and a past president of the Royal College of Paediatrics and Child Health—people who were more knowledgeable than the purported experts whose evidence convicted Lucy Letby. They were all concerned by what they perceived as the false analyses and diagnoses used to persuade a lay jury to convict Letby. Sadly, none of us is a stranger to miscarriages of justice; there have simply been too many. The Birmingham Six, the Guildford Four and the Stockwell Six are the famous ones, but the Exeter University miscarriage database lists nearly 500 people who have been wrongfully imprisoned. Astonishingly, wrong forensic evidence is responsible for 81 cases leading to over 500 years of unjust imprisonment. Many of those cases involve caregivers convicted by medical expert testimony asserting deliberate harm where causes of death were in fact natural. Those people were all exonerated, but those who doubted their guilt were initially met with the same fierce public pushback that now faces those who question Letby’s guilt. So what has happened here? The Countess of Chester hospital neonatal unit suffered a sharp increase in deaths, from a typical two to four a year to 17 in one 13-month period. When hospital senior management became aware of the elevated mortality in June 2016, they were alarmed and commissioned some investigations. The most notable was carried out in November 2016 by the Royal College of Paediatrics and Child Health, whose report noted many failings on the unit, all of which—at least in part, if not in total—could have been the cause of the deaths. The report highlighted inadequate staffing levels, delayed escalation of concerns to tertiary units and “disconnection between the neonatal leadership and the trust’s government and risk management processes.” In essence, because of a mixture of inadequate resources and poor medical management, the hospital was not capable of keeping those very fragile babies alive. That fact was recognised by the hospital when the neonatal unit was downgraded in July 2016 and stopped taking babies of less than 32 weeks’ gestation. The report, offering completely different reasons for the deaths, was never shown to the jury. Some consultants had attempted to blame Letby for the deaths. A redacted section of the report states: “The consultants explained that their allegation was based on Nurse L being on shift on each occasion an infant died (although not necessarily caring for the infant) combined with ‘gut feeling’. There was no other evidence or history to link Nurse L to the deaths, and her colleagues had expressed no concerns about her practice.”