Dr Svilena Dimitrova

When I first heard about Lucy Letby's case, I had no reason to doubt the allegations against her. I began following the case because, as a neonatologist with a further interest in risk management and patient safety, I felt I needed to understand how it could possibly happen that someone could murder or attempt to murder any babies on my unit without anyone seemingly noticing or doing anything about it. I worried - could this have happened to me and my colleagues? And I hoped if it had, we would have noticed and acted on it properly much sooner. As I followed the case via the media, I became increasingly confused by the medical evidence being presented. At first, I assumed the journalists simply didn’t understand the expert testimony and were not reporting correctly - surely no one could genuinely believe claims as medically absurd as babies being murdered by injecting air into a nasogastric (NG) tube? I had this conversation with many colleagues - Neonatal consultants, doctors in training and neonatal nurses. We were all really shocked by what was being reported. But I decided to wait until after the trial concluded before forming any real opinion as it was only then that enough information would become available that would make it clear as to what was actually said. After the convictions, like many of my colleagues, I sat down to watch the interview with aspiring TV star doctor Ravi Jayaram. My jaw dropped as I heard his appallingly misleading statements about extubation made on national television. I have still kept the messages I exchanged with Neonatal colleagues that evening. All of us who watched were saying - surely he didn't just say that the only possibility for a 25 weeker to have extubated was for it to have been done deliberately? I cannot even begin to explain how absolutely ridiculous that statement is. The sensational manner in which it was also delivered immediately made me ask myself - did I make a cognitive error in assuming no actual real doctors could have said the medical nonsense reported by the journalists? Is it possible that the experts and medical witness doctors involved really have said things that were so ridiculous in court and got the judge and jury to believe this nonsense? I then started looking through the information publicly available post-trial and I discovered that yes, this kind of flawed medical reasoning had indeed been accepted as fact. I was really shocked and decided to speak up, which I did as soon as the media gag was lifted. Thank you to Felicity Lawrence @guardiannews for making me feel safe to speak up. At the stage when I first spoke up, I still didn’t know whether Lucy Letby was innocent. What I did know, however, was that the medical basis of her conviction was deeply flawed. I also knew - but this is due to my law degree rather than me being a Neonatologist - that there were multiple legal reasons for why this conviction was unsafe as well. However, I wasn't as interested in this as I wouldn't want for someone's sentence to be quashed on legal grounds if they were genuinely guilty. It remained possible, as far as I could see, that Letby had harmed the babies. What was certain, however, was that if she did, she certainly didn't do it in the way that was claimed. However, it stands to reason that a serial killer could more easily operate in a unit where substandard care was the norm - when overall competence is low, people are far less likely to recognise when something is seriously wrong - something I know very well from personal experience of being a clinician dealing with risk, and having worked for the CQC and the Ockenden inquiry. After some time, I was instructed as an expert in the case. I took some annual leave and temporarily left the Ockenden review so I could give myself some time to properly look through everything. I then discovered many incidents of significantly substandard care with subsequent lack of insight by the clinicians involved and an almost complete absence of meaningful learning from mistakes. Unfortunately - neither of these are uncommon events in maternity and neonatal care these days. And neither is scapegoating someone. However - what was truly stunning in this case, and was definitely new to me at that point in time, was scapegoating via the criminally convicted serial killer route (usually people are just bullied out via employment tribunals, GMC/NMC and occasionally via the criminal courts for Gross Negligence Manslaughter route). For one year now, I have lived with the knowledge that a committed hard working competent nurse is in prison for crimes that never happened, whilst the doctors responsible for very poor care remain celebrated as “heroes” and continue practising without consequences. And the medical experts also continue to practise with no consequences. Putting this out here for the record. Not much else I can do. Thank you so much to @drphilhammond for continuing to expose this disgraceful MoJ. @drphilhammond @legalmarkmc @DavidDavisMP @DavidRoseUK @PeterElston1 @Michelehal7344 @reasonoverfear @DOckendenLtd @wesstreeting @PrivateEyeNews @Jeremy_Hunt @MartynPitman @Voice4theDead

Thank you for the share, @drphilhammond Why do I have no regrets about speaking up? When a system is influenced or controlled by people who consistently choose to behave in abusive ways (let’s call them “individuals who consistently exhibit abusive behaviours" but I do want to acknowledge that people always have the option to change if they choose to) – in the world as it currently stands, there is nothing you can do except expose it publicly. You can report crimes, raise concerns, and present evidence - but ultimately, the authorities decide what they investigate and what they ignore. That imbalance of power can result in zero consequences for those actually responsible whilst it can take very little (and in Letby’s case – nothing) for the situation to be turned against an innocent person. In NHS trusts, this is often someone speaking up and attempting to hold the individuals who consistently exhibit abusive behaviours and their (often naïve) supporters accountable. The result is a predictable complete inversion of justice - the perpetrators’ actions are overlooked, while the individual raising concerns is investigated, discredited, and undermined. This pattern has been demonstrated in very many cases I have supported whistleblowers, and indeed in the Letby case. Chris Day and Martyn Pitman are also fine examples. As were the GNM cases of Hadiza Bawa-Garba and David Sellu. Whether in healthcare or other systems, the dynamic is identical – the individuals who consistently exhibit abusive behaviours and their (often naïve) supporters in positions of power are protected, while those challenging them face consequences. The root cause is complete lack of accountability for those in charge of all systems created, allegedly, to protect the public. Whilst individuals who exhibit the same abusive behavioural patterns occupy positions of authority across institutions - police, regulatory bodies, NHS Trusts, the judiciary etc - there is no incentive to investigate one another and plenty of incentives to investigate those who challenge them. But when those in power benefit from the status quo, why would they disrupt it? This is why public exposure in current times is the only remaining path - expose, expose, expose. With dates and names and times and evidence. Engaging the public at scale is essential, because meaningful accountability has not yet happened and it will only ever happen when pressure reaches a critical mass. Are we there yet? No. But the process has begun. Meaningful change always builds gradually. As more people become aware and more cases come to light, momentum grows. We need to move to a point where accountability can no longer be avoided. I have not finished “speaking up”. I have only just started. And I have so much to say when it comes to patient safety and NHS cover-ups from my many years of supporting whistleblowers behind the scenes that I probably could retire now and write several trilogies in 5 parts about it all. All clearly evidence based. (For those who don’t understand the trilogy in 5 parts reference - google the Hitch-hiker’s guide to the Galaxy. It’s as worth a read as the LoR…) @wesstreeting @PrivateEyeNews @hannahsbee @drcmday @MartynPitman @DHSCgovuk @CareQualityComm @gmcuk @parthaskar @guardiannews @BBCNews @Channel4News @channel5_tv @Michelehal7344 @MichelleWelshMP @Whistler_News @LucyLetbyTrials @DavidDavisMP

What world we live in? The world that is the predictable and heavily historically precedented outcome of what happens when people who haven’t outgrown their ego state hold all the power cards. Victims of ego-driven personalities cannot negotiate their way out of abuse when they have no power cards UNLESS they unite as they are by far the majority. However, modern society is heavily focused on individual wants which means collective action is highly unlikely to happen any time soon. All of this is the predictable outcome in large societies governed by disconnected leaders - leaders who remain trapped in an ego-driven mindset, whose underlying operating system leads them to believe that their desires outweigh the rights of others and feeling justified in doing whatever it takes to satisfy them. Things will not change for the better until people recognise the simple truth of the fact that genuine happiness cannot be built on another person’s suffering. And lasting fulfillment is impossible when it comes at the cost of harming others. And for now, we, as a society, are far far far away from this mindset. We will get there eventually but things will get worse first.

Eat breakfast Seeing tents in Gaza blown up Drive kids to school See kids in Iran being blown up Get to work See kids being blown up Have lunch See kids being blown up Get home See kids being blown up Cook dinner See kids being blown up …and repeat What hell are we living in?!

The problem is that an MHPS investigation can be spun by a good lawyer to not technically be a “disciplinary proceeding”. After it concluded, a referral was sent to the GMC and Hindmarsh DID disclose that and his interim conditions to the police (but just the referral rather than the Trust inquiry report findings - or so the police say. It looks like they didn’t ask for the details!). So I think you will find it that this will be spun under the “he didn’t technically break any rules” category…. (Hope I’m wrong though!)

Criminal Practice Direction 7.4.1 requires an expert to disclose: "any adverse finding, disciplinary proceedings or other criticism by a professional, regulatory or registration body or authority, ... whether or not that finding, proceeding or criticism since has been resolved."

Police and CPS say that they were unaware that Prof Hindmarsh, who gave crucial insulin / C-peptide evidence at her trial, was under investigation by his employer over "serious concerns in his medical work." theguardian.com/uk-news/2026/m…

Really happy to see this amazing investigative journalism work by @guardian - credit to Felicity Lawrence and David Conn. theguardian.com/uk-news/2026/m… So what now? Unfortunately, I suspect you will find that neither Hindmarsh, nor the GMC, nor Cheshire Police, nor the CPS technically breached the rules. That said, the probity of Hindmarsh is certainly questionable. More importantly, I would argue that the actions - or lack of action - by the GMC, aided and abetted by Hindmarsh’s lawyers (presumably funded by his defence union), are what really need to be called out. Let me elaborate. Suppose a number of people - patients and/or staff members - make complaints about someone to an NHS Trust. These complaints may be vexatious, mistaken but made in good faith, well-evidenced, or any combination of the above. The Trust is then obliged to investigate. If the allegations are sufficiently serious, the Trust may impose interim conditions (e.g. gardening leave/re-deployment etc) on the individual pending a formal investigation, usually conducted under the MHPS framework (Maintaining High Professional Standards). The quality of such investigations can vary enormously - from thorough and evidence-based to little more than carpet-sweeping exercises, with many possibilities in between. However, if the Trust ultimately concludes that serious misconduct may have occurred, it is required to refer the matter to the GMC. What happens next? The GMC reviews the information provided by the Trust and decides whether the case warrants a formal investigation. Importantly, the hearing itself is not conducted by the GMC but by the Medical Practitioners Tribunal Service (MPTS). The GMC may impose interim restrictions on practice while the case awaits tribunal. The MPTS then examines the evidence and determines the outcome. Now consider where Hindmarsh stood during the Letby trial. He was clearly under formal investigation by his Trust. However, he was not strictly obliged to disclose this. The guidance only requires experts to declare matters they believe could significantly influence the proceedings. A competent lawyer could easily argue that Hindmarsh considered the allegations unfounded and therefore did not believe they were relevant to the case. In that sense, it could be framed as a private employment matter. That is simply a consequence of how lax the rules governing expert witnesses are in this country. The next question could be, however, what would an honourable person be reasonably expected to do in that situation? Well, I would suggest that Hindmarsh could have said to Cheshire police/the CPS: “We have a problem. I am currently under investigation by my Trust for X, Y and Z. These are the allegations, this is the evidence, and this is my response. Are you still comfortable using me as an expert witness while this is ongoing?” Did Hindmarsh do that? According to the police, as per this article, he did not. Now the next question. When Hindmarsh was referred to the GMC, they imposed severe interim restrictions pending an MPTS tribunal. Hindmarsh DID disclose that to the police. But they are now saying they never saw the Trust investigation (referred to in this article as “inquiry” which is what Trust formal investigation reports are often called) that actually led to the GMC referral in the first place. So next obvious question. Did @cheshirepolice and the @CPSUK really understand how serious the allegations made against Hindmarsh by his own Trust were? What expertise were they relying on to judge how significant that referral actually was? Without someone who understands how these regulatory processes work, they may not even have realised that there would be a formal inquiry report for them to ask for. This, once again, is evidence that @cheshirepolice were completely out of their depth with this investigation in several respects. When investigators do not fully understand the systems they are dealing with, important lines of inquiry can easily be missed. In this case, as we have seen time and again, @cheshirepolice appear to have overlooked large amounts of evidence that simply did not fit their “serial killer” narrative. That should be deeply embarrassing - not just for the police, but for a criminal justice system that, more than a year after the CCRC application was filed, still appears unable to confront the scale of this MoJ. The information now emerging in the media has been known to Letby’s current legal team for many months. Next question. Why does it have to be exposed by investigative journalists for the CCRC to take actions to resolve this clear MoJ? @VeraBaird And back to Hindmarsh. If I were an honourable person who believed I had been vexatiously referred to the @gmcuk following a flawed or rogue Trust investigation - something that does happen, particularly to whistleblowers - I would be keen to clear my name before an MPTS tribunal. So next question is - did Hindmarsh do that? No. Instead, he removed himself from the GMC register and thus avoided the tribunal. Now, it is possible he simply had enough and did not want to go through the tribunal process. MPTS hearings, like the criminal justice system itself, can sometimes go badly wrong and lead to miscarriages of justice. He is also an old man with a good pension and is likely financially secure. From that perspective, one could understand the “I can’t be bothered with this” reaction - choosing to walk away rather than endure a long, stressful public process at the end of a career. That said, if someone had attempted to smear my name in that way at the end of my professional life, I would definitely want the opportunity to clear it, rather than choose to step away. Unless, of course, there was another reason - namely that a full hearing might have brought matters into the public domain that one would prefer to have remained behind closed doors for good… The Letby case is an epic miscarriage of justice enabled by systemic flaws AND by individuals operating within those systems who either lack sufficient experience or have motivations that are not aligned with “doing the right thing”. So the issue is not simply one of system failure or individual failure. It is both. System flaws can, in principle, be fixed relatively easily. Cultural problems - where the wrong people occupy positions of authority are much harder to address. Accountability at senior levels in this country is currently as good as non-existent. And until that changes, MoJs – which both mean innocent people being scapegoated and guilty people escaping scrutiny - and often being promoted as a consequence, aka “falling upwards” - will continue to happen. There is still more "dirt" to come out. Thank goodness for intelligent and hard-working investigative journalists and for the brave whistleblowers who continue to come forward. @drphilhammond @PrivateEyeNews @guardiannews @LucyLetbyTrials @Channel4News @channel5_tv @SkyNews @BBCNews @DavidDavisMP @ShabanaMahmood @ccrcupdate @cheshirepolice @CPSUK @cheshirepolice @hannahsbee @MartynPitman @drcmday @amandaknox @Michelehal7344 @reasonoverfear @ShaunLintern @Voice4theDead @VeraBaird

I have now given an interview for a podcast about the Lucy Letby case. I made this decision not simply because an innocent person is in prison, but because there continue to be no consequences for those who were responsible in orchestrating this clear miscarriage of justice. If you’d like to listen, the links are below. YouTube: youtube.com/watch?v=nocREV… Apple podcast: podcasts.apple.com/gb/podcast/tru… @drphilhammond @ClarkeMicah @PeterElston1 @NadineDorries @Michelehal7344 @MichelleWelshMP @wesstreeting @cheshirepolice @Channel4News @channel5_tv @BBCNews @SkyNews @PrivateEyeNews @guardiannews @MartynPitman @amandaknox @Voice4theDead @guyrowlanduk @reasonoverfear

You do realise, @sophwilkinson - that there is such a thing as evidence, right? In this case, the evidence was there and it was presented and examined by a judge (who, unlike some judges in the UK, paid attention to the evidence…). It was far from being one person’s word against another. The evidence actually showed that this lady perverted the course of justice, and attempted blackmail. And what there was no evidence for, despite appropriate examination, was rape. Automatically believing allegations without scrutiny is just as problematic as refusing to properly investigate serious crimes in the first place. It harms both men and women because it harms innocent people. Oh - and there’s also the small matter that women are just as capable of wrongdoing as men. Why? Because both men and women are human. I hope that this hasn’t somehow become a controversial statement in modern society. 🙄🙄🙄

@Michelehal7344 Michele, this is quite a serious allegation. against @DOckendenLtd on my feed. What evidence do you have that Donna Ockenden has made statements that families have been harmed before their cases were reviewed by the relevant specialists on her team?

“You cannot know that someone is a victim of wrongdoing simply because they say so. Allegations deserve to be taken seriously - but they also deserve proper examination. When someone pressures others to suspend critical thinking entirely, that in itself is a red flag.” Is this not what Donna Ockenden does when she says she advocates for harmed families? How does she know they’re harmed when they approach her? From what I can see on her web page, Donna only worked for a minimum length of time as a clinical Midwife before moving into senior managerial positions Plus she’s not an obstetrician and she’s not a neonatal nurse or a neonatologist. She is completely dependent on other people writing her reviews and yet she can collectively say these families were harmed Please can you explain this Donna? @NadineDorries @wesstreeting @drphilhammond @MartynPitman @DOckendenLtd @MichelleWelshMP

I can confirm that everything with regards to the GMC referral information exposed in the article about Professor Hindmarsh is accurate. My sincere thanks to the brave whistleblower who brought this information to Felicity Lawrence. theguardian.com/uk-news/2026/m… I look forward to the day when people recognise that having a medical degree, impressive titles, or polished communication skills does not make someone incapable of poor judgment. Sometimes bad decisions stem from a lack of insight into one’s own limitations; other times they may arise from fear, pressure, ego, or even malice. Professional status does not grant immunity from human flaws. Over the course of my 20-year career, I have worked alongside many doctors. The uncomfortable truth is that there are a significant number I would not trust to care for someone I love. It is also important to acknowledge that “paid guns for hire” exist in every industry - individuals who will tell you what you want to hear for the right price or the right advantage. They often know one another and understand exactly who to call upon for a particular narrative or task. Unsurprisingly, networks of people with similar ethics tend to gravitate toward one another. When such individuals rise to positions of influence, what happens is that we get scandal after scandal. This is what is happening in the NHS right now - but it happens in every institution led by bad leaders (be it them being bad on purpose or not!). Don’t put bad people in positions of power - hardly an innovative proposition without heavy historical precedent, is it? At the same time, there are those on the opposite side who present themselves as advocates for victims while failing to examine evidence critically. Blind endorsement of victimhood without scrutiny causes just as much - if not more - harm. You cannot know that someone is a victim of wrongdoing simply because they say so. Allegations deserve to be taken seriously - but they also deserve proper examination. When someone pressures others to suspend critical thinking entirely, that in itself is a red flag. Raising concerns when something appears questionable is responsible. Blind allegiance - to individuals, institutions, or narratives - is not. Truth requires a willingness to examine evidence, even when it is uncomfortable There is much more to come - when the time is right. @guardian @guardiannews @drphilhammond @hannahsbee @MichelleWelshMP @Michelehal7344 @RupaHuq @gmcuk @RCPCHtweets @BAPM_Official @cheshirepolice @CPSUK @Voice4theDead @MartynPitman @ClarkeMicah @sarahknapton @PrivateEyeNews @Channel4News @channel5_tv @SkyNews @BBCNews @willcpowell @JamesTitcombe @DrNeenaJha @DavidDavisMP @wesstreeting @ShabanaMahmood @Thirlwall_Inq @LucyLetbyTrials @PeterElston1

If you want to do this story justice, you also need to speak to people who have raised concerns about patient safety and were ignored, sidelined, or pushed out through internal processes. Some of these cases have come to light through whistleblowing tribunals, General Medical Council proceedings, and in certain instances even criminal prosecutions for gross negligence manslaughter. Many others, however, have simply taken early retirement or left the profession altogether. It is worth examining the cases of David Sellu and Hadiza Bawa-Garba in relation to gross negligence manslaughter, and Martyn Pitman and Chris Day in relation to whistleblowing. There is guidance available that illustrates how trusts “manage out” whistleblowers, typically through MHPS formal investigation and employment procedures. hcsa.com/wp-content/upl… Drawing on nearly 12 years of informal experience supporting whistleblowers, I can confirm that the above document accurately reflects what often happens to healthcare professionals who speak up about patient safety concerns in a Trust who doesn’t listen. Similar processes are also used against individuals who are scapegoated for wider institutional failures, as seen in the cases of David Sellu and Hadiza Bawa-Garba. This does not even touch on ongoing cases, some of which are not yet in the public domain. And this is not historical - it is happening in real time. @PrivateEyeNews @MartynPitman @drcmday @parthaskar @alisonleary1 @AliJaneMoore @Channel4News @channel5_tv @SkyNews @BBCNews @BBCBreaking @DavidDavisMP @Voice4theDead @drphilhammond @TheBMA @gmcuk @MichelleWelshMP @wesstreeting

@NHSEngland @NHSGIRFT

On matters relating to patient safety, there is currently no accessible mechanism that allows concerns by patients or healthcare professionals to be examined independently and promptly. On one side, patients currently have no access to an independent case review service. If concerns about unsafe care are not adequately addressed within a department or Trust, the remaining options are limited to litigation or campaigning for a public inquiry - processes that are adversarial, slow, costly, and triggered only after serious harm has occurred. The same is true for healthcare professionals. From my perspective as a doctor, if I raise a patient safety concern about risk of harm which is inadequately addressed and request that it be independently examined, I must ask the Trust itself to initiate that review. The Trust can refuse. If I escalate externally, I risk disciplinary action, reputational damage, or dismissal as several high profile whistleblowing cases have demonstrated. Even if the concerns are ultimately proven correct, that often becomes apparent only years later - after prolonged internal procedures, GMC/NMC/employment tribunal or in some cases even criminal proceedings. This pattern has been seen repeatedly, including in cases such as @MartynPitman and @drcmday. In the meantime, patients remain exposed to risk. The problems faced by whistleblowers and by patients who have been harmed are not separate - they are two sides of the same systemic failure. Patients often feel unheard, dismissed, or gaslit when they present evidence of harm. Both groups encounter delay, defensiveness, and internal processes that lack true independence and are at risk of retaliation. These issues must be addressed together, not in isolation. Internal risk and investigation systems currently involve organisations effectively marking their own homework. We need: 1. Open access to independent medical review of care. Patients and healthcare professionals must be able to request an impartial clinical assessment of whether care met appropriate standards. 2. Independent scrutiny of the governance processes themselves when concerns have not been adequately addressed internally. It is not enough to assess the clinical incident alone. The system must also examine how the concern was handled - whether the investigation was thorough, done by a person with the required expertise to a good standard, whether risks were appropriately recognised/addressed or minimised, and whether conflicts of interest affected decision-making. The review process must also be prompt. This is of paramount importance because delayed investigations are a form of punishment. Timeliness is essential to fairness and safety. I propose that we should aim to establish an Independent Patient Safety Review and Accountability Service which is empowered to examine both clinical care and governance failures, and to ensure accountability for individuals where appropriate. Accountability must extend to leadership as well as frontline staff. I am certain that if such a service were properly commissioned and led by individuals with experience, independence, and integrity, it would cost significantly less than what we currently spend managing the consequences of failure. The financial burden of avoidable harm - including litigation costs, repeated public inquiries, compensation payouts to harmed patients, and the wasted skills of whistleblowers who were managed out - far exceeds the likely cost of early, independent intervention. We are currently funding crisis response instead of prevention. If this proposal resonates with you, my DMs are open for anyone who wishes to discuss it further. @wesstreeting @DavidDavisMP @JamesTitcombe @hannahsbee @drphilhammond @Channel4News @BBCNews @channel5_tv @SkyNews @NadineDorries @Sajhawkins1 @gavinstpier @guardiannews @drcmday @MartynPitman @RCPCHtweets @BAPM_Official @LucyGoBag

@TheBMA @bmj_latest @HSJnews @DHSCgovuk

Note that the International Homicide Investigators Association were advertising Cheshire police's upcoming talk about Lucy Letby as early as February 2024 – when reporting restrictions were in full force. All well and good, I'd say, since the organisation is headquartered in America, the event was set to take place in America, and British courts don't have jurisdiction over the entire world. But let's not forget that Cheshire police reported the New Yorker, an American magazine, to the attorney general's office, for breaching British reporting restrictions, when it published a detailed investigative article about Letby, in May 2024. Rules for thee, but not for me.

Finally, this is being exposed. Thank you so very much for this extremely important article to @sarahknapton and @Telegraph. telegraph.co.uk/news/2026/02/1… People often ask me why I have never gone into medico-legal expert work, even though I have a law degree. This is exactly why. On paper, expert witnesses are “independent” and owe their duty to the court. It sounds great. In reality, the system is adversarial - and adversarial systems reward resources, repetition, and narrative control. The prosecution has institutional funding and the ability to instruct multiple experts to reinforce the same case theory. They are also able to cherry pick experts (I addressed this issue at length in my law degree dissertation in fact). Example - if I give the prosecution a report that doesn’t support their narrative, they can bin it. This is at the foundation of repeated miscarriages of justice when it comes to cases involving complex scientific or medical evidence - and not just in the court systems! NHS Trusts employ the same selective listening tactics when they want a convenient scapegoat for failures - @MartynPitman can tell you more about that from personal experience - and I can confirm that having examined it, his story runs in identical patterns to the evidence of many others I have gathered through supporting genuine whistleblowers over the last 11 years. Going back to the courts, however, when a well-funded group of experts presents a unified opinion, it carries weight simply because of the numbers. The defence? Completely different situation. Legal aid budgets are tight. Expert hours are capped. Rates are lower. In many cases, they can only afford one specialist who would often be a clinician who is not experienced at navigating the criminal justice system. So when you end up with one legally inexperienced expert saying X and 7 "professional witness" (ie legally experienced) experts saying Y in front of a jury, what do you realistically expect a jury to do? They are not neonatologists. They are not scientists. They are not statisticians. They can’t spend months interrogating methodology. Human instinct says - ten experts’ opinions matter more than one. That’s social psychology. That's how the witch trials happened. We seemingly have learned nothing from them. When someone publicly talks about having “won” or “lost” cases, it shows how adversarial the mindset actually is. (And this is what Dr Dewi Evans said – only ever lost one case (interestingly, when he worked for the defence…..). Public statements. How embarrassing for the legal justice system – this in itself should warrant a quash of Letby’s convictions, shouldn’t it? He, after all, was the star expert whose reports started this off - and were merely peer-reviewed. @ccrcupdate If Dr Evans was truly independent and assisting the court, what exactly was he talking about when he referred to "winning"? And please let's also remember - once this process commences and there is an innocent party - be it a whistleblower, be it a scapegoat for any other reason - whether one "wins" or "loses", it’s the process that is the punishment. Years of investigation. Public vilification. Suspension. Financial ruin. Reputational destruction. Even without a conviction, your life as you knew it is as good as being effectively over. That creates perverse incentives for what are almost always the actual wrong-doers - when I say "wrong-doers" - I don't necessarily mean with intent. Plenty of people do wrong things whilst in fact thinking they are right. It appears that the COCH consultants all thought the care they provided was reasonable, if not excellent. There are 16 neonatologists out there, myself included, who don't quite agree. But... as far as those who think they did nothing wrong are concerned, the process alone against whoever they are vilifying creates distraction away from the original problem of the care, doesn't it? And let's face it - allegations alone can achieve reputational damage, regardless of whether the evidence stacks up, as long as they are repeated by enough people enough times. And that is what the HR process found was happening to Letby. But the jury didn't even get to hear about any of that. Judge Goss didn't allow it. The MoJ victim ends up getting tied up defending themselves whilst no-one ever meaningfully examines the substance of what actually happened. The process then becomes about how many people repeat the same story, how loudly and how confidently - not about whether the underlying analysis stands up to scrutiny. It is such a mess. And it's been going on for years. I am so happy to see it finally exposed. The Letby case is one great example of this. And there is a lot more to come as all these maternity/neonatal and other healthcare scandals unfold. Watch this space. @DavidDavisMP @wesstreeting @PrivateEyeNews @drphilhammond @PeterElston1 @ccrcupdate @VeraBaird @CPSUK @gmcuk @RCPCHtweets @BAPM_Official @NHSGIRFT @NHSEngland @Michelehal7344 @MartynPitman @PeterElston1 @guardian @Channel4News @channel5_tv @CheshireLive @cheshirepolice