Anton Lorenz Vrba Independent Researcher, UK vrba@iow.onl
Richard D. Gill Mathematical Institute, Leiden University gill@math.leidenuniv.nl
29 September 2026
Abstract
We examine the logical and mathematical structure of Sanctuary’s recent paper (Quantum Rep. 2026, 8, 96), which argues that spin observables in the Bivector Standard Model (BiSM) are not jointly definable on a single Kolmogorov probability space, so that the CHSH quadruple cannot be formed and Bell’s and Fine’s theorems do not apply. The paper contains two constructions: local response functions of the analyser setting and a shared source phase, and a separate prescription that produces the correlation . We show that the first construction, as specified, meets the hypotheses of Bell’s theorem. Its outcome maps are defined on a common source domain with a setting-independent distribution, so the non-existence claim (Lemma 3, Corollary 3) does not hold for it, its product correlations obey the CHSH bound, and the paper’s own simulation of it yields the Bell triangle. The cosine is obtained instead from a scalar computed jointly from both stations’ phases and then digitised; it is not shown to be the correlation of the local outcomes. Execution of the supplementary programs further shows that the four BiSM_v2 populations do not form the partition stated in the paper, and that the doubled-angle harmonic attributed to the raw coherence data appears only after a sign convention is applied on the second half-cycle.
Introduction
Sanctuary’s paper “Spin Helicity and the Disproof of Bell’s Theorem” [3], together with [2], claimed that a bivector (quaternion) model of spin disproves Bell’s theorem. The published Comment [4] examined that claim. It concluded that the construction lies outside the hypotheses of Bell’s theorem rather than refuting it, and that the correlation is obtained by steps that “are heuristic mathematical procedures, not formal probabilistic identities”. In particular, the Comment identified the assembly of the correlation from separately computed polarisation and coherence contributions as “a modeling postulate”, for which “no general probabilistic theorem guarantees that such an additive assembly reproduces Bell-type statistics”.
In his Reply [5] the author accepted the first conclusion: “We agree that Bell’s theorem is mathematically valid within its stated assumptions. Our position is that bivector spin does not belong to the class of models Bell considered and therefore lies outside the scope of the theorem.” The Reply also defends the contextual construction of measurement domains, the statistical reconstruction of the phase relation, and a geometric account of the quantum limit. It offers no explicit probabilistic derivation resolving the objection to the split-and-recombine step, stating that “several issues raised by Vrba, particularly concerning the quantum limit and measurement structure, deserve fuller treatment than is possible in a short reply.”
Paper [1] develops that response. It does not supply the missing probabilistic derivation. Instead it isolates joint definability as a separate premise, which the model is said to fail, and it gives explicit rules: a phase uniformly distributed on , carried by local rotors to each station, and deterministic outcome rules. The present critique concerns the relation between the paper’s algebra and detector-level statistics. The explicit rules of [1] allow a sharper separation than was possible in [4] between two constructions: the local response functions, and the separate prescription that produces . The review that follows examines whether the joint-definability argument holds for the local responses (Section A), whether the correlation is derived from them or assembled separately (Section B), what the simulations compute (Section C), and which further claims rest on assertion rather than derivation (Sections D and E).
Unless stated otherwise, equation, section, definition and lemma numbers refer to [1]; the points of the present critique are numbered A1, B1, and so on. The supplementary material of [1] contains the programs BiSM_v1 and BiSM_v2 with their output files. Statements about the programs below rest on source inspection and output files.
A. The joint-definability argument
A1. Lemma 3 does not hold for the paper’s own definitions. Definition 12 introduces a context map , and Eq. (52) defines the outcome as . The composition is a function on for every setting , and likewise . Hence for every the four values
are simultaneously defined, and is a common domain of the kind Lemma 3 says does not exist. The proof of Lemma 3, whose argument is first set out in [5], rests on the sentence “observables are defined only after contextual instantiation”. That concerns which experiment is physically performed, not which functions are mathematically defined. Counterfactual definability in Bell’s sense requires only that the function be specified, not that the measurement be made.
A2. The explicit outcome rules are Bell-type local functions. The paper does not leave the outcome functions abstract. Eq. (15) gives the local phase for every and ; Eqs. (64) and (66) take the quantum-domain outcome as ; and Eq. (85) gives the polarisation outcome as , with the value assigned at zero. Each is a function of the local setting and the shared alone, which is Bell’s form . The sign-of-cosine rule is essentially Bell’s own illustrative model [6]; with a uniform source distribution and Bob’s opposite sign it gives the linear “triangle” correlation, as Figure 3 and Section 4.2.2 of [1] confirm.
A3. Geometric reality does not exempt from Bell’s framework. The paper states: “In the BiSM long–range EPR correlation originates from a common relative rotor phase established at separation and subsequently carried along the worldlines of Alice and Bob” (Section 2.1); the same description is given in [5]. Bell placed no restriction on the nature of : “It is a matter of indifference in the following whether denotes a single variable or a set, or even a set of functions, and whether the variables are discrete or continuous” [6]. A real, local geometric object created at the source and carried to both stations is the paradigm case of , not an exception to it. The local-response component of the model is therefore of exactly the kind Bell’s theorem addresses, and the statement that the bivector is “not a hidden variable in Bell’s sense” [5] does not hold for that component.
A4. A single Kolmogorov space is used explicitly. The paper places on with density (Eqs. (16), (70)) and uses this same space for every analyser separation: “Every segment in the simulation has the same free–flight singlet state”. The supplementary programs use a common finite grid of values for all settings, which is likewise a single space. With measurable response maps, the pushforward of under is a joint distribution reproducing the pairwise distributions of these local responses. Corollary 3 (“no global joint probability distribution exists for the CHSH quadruple”) therefore does not hold for them. The pushforward need not reproduce the separately generated pair distributions of the cosine branch (Section C).
A5. The author’s statement of Fine’s theorem, applied to the local responses. Section 5.5 states correctly that a joint distribution for the four observables “is equivalent to a deterministic Local Hidden Variable (LHV) representation”. Definition 15 asserts: “Individual measurement outcomes are real, discrete, deterministic and local.” The label alone would not settle the matter, but points A1, A2 and A4 show that the paper supplies local response functions on a common source domain and a source distribution that does not depend on the settings. For correlations formed as averages of products of these local outcomes,
for every , and integration against gives the CHSH bound; by the equivalence the author quotes, a joint distribution exists. The paper does not address the resulting alternatives:
either the reported correlations are averages of products of these local outcomes, in which case CHSH is satisfied;
or they are obtained from another quantity, in which case the locality of the response functions does not carry over to them.
The simulations (Section C) show that alternative (ii) is what occurs.
A6. Assumption 3 is not independent of Assumption 2 in the paper’s representation. The paper lists “Joint Definability” separately from “Outcome Definiteness”. Assumption 2 (“For each hidden parameter , the outcomes , are well-defined”) is stated for the settings generally; in the functional representation the paper supplies, any four settings then yield four defined values for fixed . Rejecting 3 while retaining 2 requires restricting 2 to the setting actually used, a restriction the paper does not state.
A7. The scope of Fine’s theorem. Fine’s theorem [7] concerns the scenario with two settings per party and two outcomes per setting: pairwise distributions with consistent single-observable marginals admit a joint distribution if and only if the full family of Bell–CHSH inequalities holds. A family that violates those inequalities is an instance of the theorem’s conclusion, not a case in which the theorem does not apply. Conclusion 5 of [1] states that “Bell’s theorem and Fine’s characterization remain mathematically valid within their stated premises”, which is narrower than the “inapplicability” of the title.
A8. Notation and analogy do not alter the common domain. The semicolon in is said to indicate “that is not merely another argument”; the notation does not change the domain or existence of the function. The proof of Lemma 2 moves from distinct function values, , to “distinct domains”; that step is not justified. Distinct instantiated domains need not be denied: the decisive point is that the context maps pull the observables back to the common source domain (A1). The induced-dipole analogy (Remark 1) illustrates this: a polarisability tensor fixes the response to every field direction simultaneously, so the counterfactual dipoles are jointly defined.
A9. The common-domain structure is already present in Bell’s representation. The paper states that “Bell did not isolate this common probability–space structure as a separate premise under the name of joint definability; it entered tacitly through the hidden–variable representation”. Bell wrote , and explicitly [6]. Joint definability is a consequence of that representation rather than an additional assumption, which is why it required no separate statement.
B. The correlation derivation
B1. The cosine is the scalar part of a joint product. Of the ellipsis in Eq. (13) the paper states: “We added the dots to emphasize that the two rotors do not cancel but are carried as independent phases by the separated EPR pair. The dots have no mathematical meaning expressing only locality by the product.” Eq. (14) nevertheless evaluates as the scalar part of the product of Alice’s and Bob’s rotors, in which cancels and results. The paper’s own second line of Eq. (14) shows the alternative: the product of the separate scalar parts, , which it states “obeys the CHSH bound”. The cosine is thus obtained from the scalar part of a product formed from both stations’ rotors, not from the product of the two locally generated Boolean detector outcomes. Joint processing is not itself the issue: ordinary coincidence analysis also compares records at a common later stage. The issue is which function of the records is computed.
B2. The cosine holds event by event. Eq. (20) gives the relative phase for every , so the scalar of Eq. (71) equals for every pair. Section 4.2.2 states that the correlation “emerges only statistically from the ensemble of rotor phases ”. The source phase affects the individual local quantities, but averaging over it is not what produces the cosine in : that cosine already holds event by event. The required identification of this scalar with the correlation of local Boolean outcomes is not supplied by the cancellation.
B3. The singlet operator is the identity. Eqs. (9), (13) and (72) define . Eq. (73) then writes
Inserting the identity between and yields directly. The target correlation thus enters through this algebraic representation, and no argument is given that the representation describes the detector statistics. Eq. (73) also combines matrix transposition with geometric-algebra products and uses , both as angles and as vectors; a clarification of the representation would help.
B4. The plotted mustache is a residual. Eq. (71) is the trigonometric addition identity,
The legend of Figure 3 reads verbatim “Mustache = Quaternion – Bell”, and the caption calls the mustache “Their difference”. The plotted mustache is therefore the residual between the target and the triangle; it is neither the continuous coherence term of Eq. (71) nor an independently derived contribution to a detector correlation. The cosine itself enters through the identity applied to the jointly held phases (B1, C1). The Comment [4] had described the corresponding split-and-recombine step as “a modeling postulate”.
B5. The split-and-recombine step is not connected to detector statistics. The Comment [4] identified the assembly of the correlation as a sum of separately computed polarisation and coherence contributions, , as “a modeling postulate” for which “no general probabilistic theorem guarantees that such an additive assembly reproduces Bell-type statistics”. Neither the Reply [5] nor [1] supplies the missing connection. The operators do not appear in [1], and how they relate to the continuous terms of Eq. (71) and to the populations of Section 4.3 is not stated. In [1] the recombination appears as Eq. (71), , with the two terms described as “complementary projections of a single underlying quaternion rotor” (Section 4.1). The algebraic sum is well defined and follows from the chosen rotor product. What is not established is its identification with the product of the recorded local Boolean outcomes, or with that product’s expectation. Describing and as complementary sectors does not supply this measurement relation, and the subsequent digitisation (C2) samples a new coincidence variable with mean rather than showing that the local detector products have that mean.
B6. The term “polarisation” is used for three different quantities. The term is used for: (Eq. (14), second line), which is not rotation-invariant; (Eq. (71)), which averages over to ; and the digitised triangle (Figure 3, Section 4.3). Moreover, Section 4.3.3 states that “The symmetric combination Equation (71) reconstructs the scalar invariant and produces the piecewise linear correlation”, whereas Section 4.2 states that the same equation yields . These two statements contradict each other.
B7. The Boolean benchmark is one member of the Bell-local class. The second line of Eq. (14) is said to follow “from Equation (11) by dropping the off–diagonal terms in the scalar product, ”, which “represents complete removal of the bivector phase structure”. The paper does not say which physical operation this prescription represents, or how it relates to the detector rule it specifies. The resulting product, , is then used as the Boolean benchmark that obeys CHSH. It is one example of a Bell-local correlation. Bell’s theorem, however, concerns the whole class of local response functions under a common preparation, so a comparison with this single product does not establish how the model stands in relation to that class.
B8. The rotor scalar is not shown to be a detector expectation. For a binary coincidence variable , and normalisation give , so Eq. (22) is a legitimate identity once the rotor scalar is known to be such an expectation (with the paper’s convention ). That identification is the step not supplied. The accompanying statement (“Since they are constructed from a product state of two independently propagating local rotors their use is consistent with locality”) asserts the locality of the construction rather than showing it.
C. The simulations
C1. The abstract’s description of BiSM_v1 differs from its construction. The abstract states: “Numerical simulations reproduce this correlation using only local detector events.” Section 4.2 states of : “It is not a local detector click and is never used to generate either Alice’s or Bob’s local Boolean outcome”, and Section 4.2.2 adds: “The scalar is not Bell’s response function .” is computed from both stations’ continuous phases together (Eq. (71)). The quoted statement holds for the local clicks of the Bell control, but the per-station outcomes of the cosine branch are generated from (C3).
C2. The digitisation step reproduces any prescribed mean. Eqs. (74)–(75) set whenever , with one auxiliary uniform random number per pair. Then
exactly, for any function with values in . Any correlation function with is “reproduced” in this way, including one whose four-setting CHSH combination exceeds the Tsirelson bound . The procedure samples a prescribed mean; it is not a test of whether that mean has a Bell-local realisation. The source of BiSM_v1 states that “No Malus probability P_eq=(1+R)/2 is formed or used anywhere in event generation”; the uniform threshold is nonetheless mathematically identical to sampling with that probability. The reported maximum error of (Eq. (78)) verifies the trigonometric identity in floating point.
C3. In the cosine branch the station outcomes are assigned after pairing. The paper describes the digitisation of into the coincidence variable (Eqs. (74)–(76)), but not how outcomes for Alice and Bob are then obtained. The source of BiSM_v1 shows this step: after is drawn, a further random number assigns an equal event to or , and an unequal event to or (“The equal pair is ++ or – with equal marginal weight”). The station-resolved counts in the output file are generated in this way. Alice’s recorded outcome in this branch is therefore not a function of her setting and : whether it agrees with Bob’s is decided by , a function of both settings. The marginals remain uniform, but the joint law is not of Bell’s form ; the program’s own Bell control, which is of that form, gives the triangle. Since identically (Eq. (20)), the retained phases carry exactly the difference of the two settings. Any experiment that records its analyser settings, as all Bell tests do, could generate the same coincidence data by this procedure.
C4. The paper’s local-outcome analysis is consistent with Bell’s theorem. Section 4.2.2 states that analysing the local records gives “the conventional Bell result of the piecewise–linear correlation”; executing BiSM_v1 confirms this, its Bell control giving at and at . Eqs. (80)–(81) present the two computations as analyses of “the same experimental results”. Both use the same enlarged simulated record, but they apply different functions to it, and the cosine branch also generates additional random pair labels. The enlarged record contains continuous phases and “retained local rotor geometry” (Eqs. (67)–(68)), and the paper does not establish that these are accessible detector records. The statement that “The same digitized coincidence statistics observed experimentally are thereby recovered” therefore compares a simulation using additional, jointly processed quantities with experiments that record only outcomes.
C5. The BiSM_v2 rules are not derived, and Eq. (88) does not describe the program. Several event rules are given without derivation from the bivector dynamics: the phase offsets in Eq. (84), which the program describes as implementing singlet preparation by antipodal source orientations; the factor in Eq. (85); and the “larger signed contribution” rule of Eqs. (86)–(87). Eq. (88) states that “Each event contributes to one of the four populations”, whose counts sum to . The supplementary program instead evaluates both the polarisation and the coherence rule for every event; its own comments state that “EQP+NEQP = 1 and EQC+NEQC = 1 separately” and that “the four fractions are NOT intended to sum to one”. Execution confirms that the four fractions sum to 2 at every angle. Eq. (88) therefore does not describe the implemented algorithm.
As implemented, is an average of products of local coherence outcomes, additionally averaged over absolute analyser orientation. Being generated by local functions of under a common preparation, such averages are subject to the CHSH bound (A2, A5); a harmonic shape in this angular summary does not by itself indicate a violation, which would require four consistently defined setting pairs. The program’s run report compares with on the interval only; its behaviour over the full cycle is taken up in C6.
C6. The doubled-angle harmonic appears only after a sign convention. Section 4.3.4 states that “the coherence imbalance exhibits the smooth doubled–angle, two–period harmonic”, and Section 4.3.6 that it “exhibits a doubled angular dependence and therefore has period in the analyzer separation”, from which the double-cover interpretation is drawn (E8). The implemented coherence rule does not produce this. Under the doubled-angle terms that select the blade are unchanged, while both single-angle phases change sign; away from threshold ties the coherence outcome therefore reverses, and . Execution of BiSM_v2 confirms this: , whereas . Over the full cycle the Fourier coefficient of is ; its dominant component is the first harmonic (coefficient of about ). On the data do follow , consistent with Eq. (94), , when is read as the separation folded into ; that function is not -periodic in .
The program then defines, for its portrait, an “oriented” coordinate for , describing this as a convention that “does not alter EQC or NEQC”. Only this coordinate carries a component (coefficient ) and is -periodic. The paper describes the portrait as the ordered pair of Eq. (95) and does not mention the sign reversal. The figure-eight thus contains an imposed orientation convention, and the doubled harmonic on which Section 4.3.6 relies is a property of that convention rather than of the raw populations. The lemniscate of Gerono, , illustrates the shape obtained from these two harmonics; the implemented polarisation coordinate is approximately triangular rather than exactly . The experiment proposed in Section 5.1.2 would require an operational means of controlling , resolving the two sectors, and deriving their observable statistics under that controlled preparation; the paper does not yet supply these.
D. Framing of the result
The introduction states that “Section 3 questions Bell’s locality theorem” and that “Failure of either locality or joint definability leads to failure of Bell’s locality theorem”. It also states that the work “does not challenge Bell’s derivation”, and Conclusion 5, like [5], calls both theorems “mathematically valid”. These positions are compatible only if “failure” means that the theorem’s hypotheses are not met; a theorem whose hypotheses are not met does not thereby fail.
The introduction states that “The CHSH bound applies to correlations constructed solely from Boolean outcomes ”. The bound is ; is the per- value (Eq. (62)). The same passage attributes the violation to “additional geometric effects” before any argument is given.
The paper states that “Entanglement is not required since the quaternion carries their common phase”, and that the bivector singlet of Eq. (9) “is not entangled”. Whether such a construction yields a Bell-local model depends on the conditions set out in A5: local response functions, a common setting-independent distribution, and correlations formed from products of outcomes. For the model’s local responses these conditions are met (A1, A2, A4); for the cosine they are not shown (B1, C1).
E. Physical claims made without derivation
E1. follows from the chosen function. It is obtained by maximising , which the paper calls “the simplest symmetric measure”. The maximum at is a property of that chosen function, not a consequence of symmetry as such (the equally symmetric has a minimum there), and no evolution or stability analysis links the extremum to a dynamical bifurcation. The quantum limit thus remains what [4] called a “structural postulate”.
E2. The Dirac-equation step is asserted. The coupled equation of Eq. (42) does not by itself imply the separate equalities and of Eq. (43). These require an independent restriction on the operators or their domains, which is asserted on the grounds that and act in opposite parity sectors but is not shown; a parity label is not an annihilation property. The statement “This occurs, as we show, at ” is not supported by Eqs. (37)–(44), in which does not appear; any dependence on would need to be exhibited.
E3. and Noether. The identification of with the angular momentum of the spin-1 state is asserted, without stating whether a component or a magnitude is meant. The statement that spin “does not become classical as unlike continuous variables governed by Noether’s theorem” attributes to Noether’s theorem a content it does not have: the theorem connects continuous symmetries of the dynamics with conservation laws, and does not classify discrete observables as exempt from classical limits. A fixed-spin limit and a large-spin semiclassical limit are also different and should be distinguished.
E4. No quantitative account of beta decay. Section 5.2.1 states that “A cleaved and free blade is indistinguishable from a neutrino”; Section 5.2.3 states that “There can be no neutrinos produced in the BiSM with its intact blades”. The paper distinguishes cleaved from intact blades, so these statements need not contradict each other, and it states that “no detailed BiSM reaction or assignment of charge is proposed here”. Until such a model is given, the proposal does not account quantitatively for the continuous beta spectrum and the energy and angular-momentum balance of the decay, which the neutrino hypothesis was introduced to explain.
E5. Assigned parity does not establish conservation in the decay. “The BiSM electron is odd to party [sic] while the Fermi electron of the SM is even to parity. This difference demonstrates that parity is not violated in the BiSM.” Parity assigned to one state does not show that the decay dynamics conserve parity or reproduce the asymmetry measured in the Wu experiment.
E6. Rhetorical claims supply no evidence for the alternative. Section 5.5.7 states that developments in quantum information “have no rational explanation”. The paper elsewhere acknowledges the experimental success of quantum mechanics and questions its interpretation; the statement expresses a philosophical position and supplies no mathematical evidence for the proposed alternative. Similarly, the assertion that “control of these new parameters restores determinism” (Section 5.1.1) would require preparation procedures and detector-response predictions for and , which are not given.
E7. The coherence analogy does not establish Bell-local correlations. Section 5.1.4 likens EPR correlations to “lasers, superconductors, superfluids, and Bose–Einstein condensates where collective behaviour emerges through long–range phase coherence”, and Section 4.3.5 to the double-slit experiment. The ordinary double-slit pattern invoked there is a single-particle distribution, whereas Bell’s theorem concerns joint statistics at two space-like separated stations with freely chosen settings. Macroscopic coherent systems are described quantitatively by quantum mechanics, and the analogy does not by itself supply a local model of two-station correlations.
E8. The double-cover claim is not established by a frequency ratio. Section 4.3.6 states that the original blade configuration is restored only after “a total rotation of of the blades”, and calls this “a geometric realization of the double cover ”. Unit quaternions do carry the standard double cover: with acting on vectors by , and induce the same rotation, and a physical rotation through lifts from to . Establishing that the proposed blade dynamics realise this structure requires showing how rotations about different axes, and their compositions, lift; a fixed frequency ratio about one axis does not establish it. Moreover, the period- dependence offered as its statistical signature is not present in the raw coherence data (C6). The same claim appears in [5].
F. Procedural note
The paper cites the two Quantum Reports articles [2, 3] addressed in the published Comment [4] and the author’s Reply [5], but does not cite either, or explicitly identify its responses to their specific objections, although both precede it and bear directly on its Sections 3.5, 3.6 and 5.5. The legend of Figure 3 defines the plotted mustache as the difference between the quaternion and Bell curves, the construction the Comment described as a modeling postulate. The paper’s central joint-definability argument restates, in new terminology, the argument of the Reply. The difference is that the paper now specifies explicit local response functions and a common source distribution (Eqs. (15), (16), (85), Definition 12). It is these, rather than the labels “local” and “deterministic”, that bring the local-response component within the scope of Bell’s and Fine’s theorems (A5).
G. Summary
The analysis establishes three related findings:
The local response functions of the model are defined on a common source domain with a setting-independent distribution, so Lemma 3 and Corollary 3 do not hold for them (A1–A4, A8).
Their product correlations therefore satisfy the CHSH bound, and by the equivalence the author quotes a joint distribution exists; the paper’s own simulation of these outcomes yields the Bell triangle (A5, C4).
The correlation is obtained from a scalar computed jointly from both stations’ phases and then digitised; it is not shown to be the correlation of the local outcomes (B1, B5, C1–C3). The supplementary programs further show that the BiSM_v2 populations do not form the stated partition, and that the doubled-angle harmonic appears only after a sign convention (C5, C6).
Declaration on the use of generative AI
This document was written with the assistance of Anthropic’s Claude Opus 5.5, under the direction of the authors, using material from the cited publications and the supplementary programs in [1]. Drafts were also reviewed for consistency and accuracy using OpenAI models (ChatGPT and Codex), and resulting suggestions were incorporated following manual review. Every claim in this document has been independently verified by both authors.
References
B. Sanctuary, Joint Definability, Context–Instantiated Geometry, and the Inapplicability of Fine’s Theorem, Quantum Rep.2026, 8, 96. doi:10.3390/quantum8030096 (including Supplementary Data: quantumrep-08-00096-s001.zip).
B. Sanctuary, EPR Correlations Using Quaternion Spin, Quantum Rep.2024, 6, 409–425. doi:10.3390/quantum6030026
B. Sanctuary, Spin Helicity and the Disproof of Bell’s Theorem, Quantum Rep.2024, 6, 436–441. doi:10.3390/quantum6030028
A. L. Vrba, A Collective Comment on “Spin Helicity and the Disproof of Bell’s Theorem” and Sanctuary’s Bivector Spin Framework (2023–2025), Quantum Rep.2026, 8(2), 56. doi:10.3390/quantum8020056
B. Sanctuary, Reply to Vrba, A.L. A Collective Comment on “Sanctuary, B. ‘Spin Helicity and the Disproof of Bell’s Theorem’ and Sanctuary’s Bivector Spin Framework (2023–2025)”, Quantum Rep.2026, 8, 57. doi:10.3390/quantum8030057
J. S. Bell, On the Einstein Podolsky Rosen paradox, Physics Physique Fizika1964, 1, 195–200.
A. Fine, Hidden variables, joint probability, and the Bell inequalities, Phys. Rev. Lett.1982, 48, 291.
I use this rule, Bayes’ rule, repeatedly, each time taking account of another part of the evidence. It is named for Thomas Bayes, a presbyterian minister and mathematician, who was interested in using it to find a mathematical proof of the existence of God. https://en.wikipedia.org/wiki/Thomas_Bayes
The likelihood ratio for the question at hand, based on some part of the evidence, is the ratio of the probabilities of that part of the evidence under the two competing hypotheses. More precisely, one uses the conditional probabilities of that fact given previously incorporated evidence. We have to start somewhere and we start by describing two alternative hypotheses and our probabilities or degrees of belief or personal betting odds for those two hypotheses, before further evidence is taken into account.
Let’s start with the news reports of a police investigation of a possible killer nurse at a neonatology unit in the UK; the investigation being triggered by a disturbing spike in the death rate on that unit.
I think that in the last fifty years there simply hasn’t been been a case in the UK of a killer nurse on a neonatal ward, except possibly the case of Beverley Allitt. One might argue that there do exist doubts as to the safety of her conviction, or one might argue that there can have been serial killer nurses who completely evaded detection. Did Alittit work in an intensive care unit? I also think that in recent years, every year has seen a scandalous calamity in a UK neonatal ward, leading to avoidable deaths of quite a few babies. So a priori: the relative chances of a killer nurse being responsible for the spike, or simply poor care, is in my estimation 50:1 in favour of poor care in a failing hospital unit rather than activity of a killer. If you disagree, give me your arguments for both those rates and hence their ratio. If you would like to take a different starting point, try that. Eg, what is the chance a random nurse is a serial killer? At some point one will have to use the information that this was a neonatal unit and one will have to take account of the “normal” rate of deaths on the unit. I think my choice is reasonably specific. One could argue that the prior odds should be 10 to 1, or 100 to 1, instead of 50 to 1. I expect that most people will at least agree that killer nurses on neonatal units are very rare, disastrously poor care on a neonatal unit in the UK is not rare at all.
So we are back in 2017 and hear the news and rightly we should be sceptical that there really is a case here. But clearly there are grounds to investigate what is the cause of that spike, and maybe there is more information which the police already have.
Then, many years go by. A particular nurse is detained for questioning in two successive years; and finally arrested in a third year. Two more years go by (Corona). At last, a trial begins. It turns out that roughly seven years of police investigation has uncovered no direct evidence at all (neither medical evidence, toxicological evidence, witness testimony or CCTV recordings, finger prints or DNA) of unlawful action by the nurse who has been under intensive investigation all that time. And not just no evidence against that nurse – no direct strong evidence of malevolent activity by anyone.
One might want to argue that the insulin evidence is strong toxicological evidence. We could argue about that for a long time. Even if one or two babies were given unauthorised doses of insulin there is no direct proof that Lucy Letby did that herself. There is the possibility of accidental administration (twins in adjacent cots). The argument that Lucy did administer insulin seems to have been that we know at some point she carried out other murderous attacks and it is unlikely that there were two murderous nurses working in the unit. But why do we believe there are murderous nurses working on the unit? This argument can only be made after hearing all the other evidence in the case.
So we have to estimate the probability of a 7 year police hunt for evidence of murder by a particular nurse finding no direct evidence of any malevolent activity at all by anyone, if Lucy Letby actually was innocent, and if she truly was a serial killer. In my opinion ,what we actually observed is much more likely under the innocence hypothesis than under the guilty hypothesis. If she truly is innocent the chance of finding powerful directly incriminating evidence must be rather small; if she truly is a serial killer then it must be unlikely that that no baby can be definitely proven to have been murdered or attacked. I guess the two probabilities of no hard evidence to be 95% and 5% respectively. These are probabilities of 19/20 and 1/20 respectively, so a likelihood ratio of 19. I’ll be a bit more cautious and call it 10.
We already had odds of 50:1 in favour of innocence. We have a likelihood ratio of 10:1 in favour of innocence, having learnt that police investigation uncovered no strong and direct proof of malevolent harm to any baby. The odds on Lucy being innocent are therefore now 50 times 10, or 500 to 1.
Let’s now bring in the evidence from psychology. Are there reasons to believe Lucy is a psychopath? Which surely she must be, if she is a serial killer of babies in her care. It seems there is no reason at all to suspect she is a psychopath. I think that there very likely would be strong independent signs of psychopathy in her life history if she really is a serial killer, but obviously not so likely if she is completely innocent. [Clearly she could be both a psychopath but did not actually harm or try to harm any baby. I don’t think this is an interesting hypothesis to explore. I will also not pay attention to the Munchhausen by proxy idea, that she was trying to attract the attention of an older male doctor. All the evidence says that he was more romantically interested in her, than vice versa.]
Put the likelihood ratio at 2, ie twice as likely to see no evidence for psychopathy if innocent, than if a serial killer. Actually I think it should be closer to 10. We should ask some psychologists. Lucy Letby did not sadistically kill little animals when she was a child. By all accounts, she was a dedicated nurse and cared deeply for her work.
We were at 500 to 1 for innocence. Factor in a likelihood ratio of 2 for psychological evidence. Now it’s 1000 to 1. But we are not done yet.
Next, I would like to take account of the statistical evidence that the spike in deaths is quite adequately explained by the acuity of the patients being treated in those 18 months. I would say that this is exactly what we would expect if Lucy is innocent but very unlikely if she’s a serial killer. I think this hypothesis is very adequately supported by published MBRRACE-UK statistics, and what we know about the acuity of the babies in the case. We know why acuity went up in around 2014 and we know why it went down midway in 2017. The spike seems to have been caused by hospital policy which was being made and implemented by the consultants on that unit. They should have expected it.
Say a likelihood ratio of 10. That brings us to 10,000 to 1 she’s innocent; a posterior probability of 99.99%. I haven’t yet brought in the facts of an investigation driven by tunnel vision and coached by doctors who, as we now know, were making quite a few deadly mistakes themselves. I haven’t brought in yet the innocent explanation of the post-it note. In my opinion, the post-it note is powerful evidence for innocence; it makes absolutely no sense under the hypothesis of guilt. The irrelevance of the handover notes and the notations in her diary. Facebook searches? Her alleged lies (about what she was wearing when she was arrested). Anything else?
Anyway, I am now well above 99.99% sure that Lucy is innocent and since the press conference and the report of Shoo Lee and his colleagues, we can all be even more sure that that is the case.
A year ago on LinkedIn, I was discussing the possible use of AI in criminal court proceedings with psychometrician Dr. Timo Bechger. LinkedIn uses AI to make suggestions of groups one might like to join. One day, out of the blue, it came up with the suggestion that I join the LinkedIn group called “NRA Member”, see the screen shot at the top of this post.
That led to a bantering conversation with Timo, during the course of which I wrote the following remark.
Later, I deleted it that remark. What’s left on LinkedIn is the following:
Richard Gill
Prof.dr. (em.) at Leiden University and at Richard Gill Statistics
LinkedIn has gone crazy. I make a post about Lucy Letby and they ask if I want to join the LinkedIn group for NRA members.
BTW, I agreed that it [the idea of freeing Lucy by some Rambo-like action] might have been in my unconscious mind. It certainly wasn’t in my conscious mind till Timo somehow triggered it.
Timo Bechger
Senior Scientist TCS
I understand the frustration of the scientist fighting injustice. You fight with arguments and formulae. Some may find these more scary than an AK47. In any event, the ‘target’ is to help make judges take the right decision. Given your track record they can only appreciate your involvement.
Richard Gill
In this case, the decision is made by 12 ordinary folk who have been incommunicado from the outside world for 9 months while inundated under a steady streams of lies and innuendo and pseudo-science. They (the jury) must make their own decision based on what they heard and saw in court and based only on what they heard and saw in court, together with their common-sense general knowledge of the world and of human beings. I don’t want to interfere with the legal process. I want to communicate with the authorities who allowed this to happen. And who have the power to expedite an appeal and a new fair trial and a public enquiry. Legal reform is urgently needed in the UK. And a deep look at NHS mismanagement and under-funding. Education is also in a poor state. It’s a class society and its institutions seem designed to favour those on top: those who can pay for private medical treatment, private education, expensive lawyers. And support the Conservative Party through donations, receiving peerages in return and hence yet more influence. It’s one of the last remaining theocracies. The King is head of the state church and head of state. The other is Iran. The case of Israel is discutable. There is no civil marriage in Israel.
Richard Gill
A screenshot from that post [about the AK47] is now trending news on Twitter. Someone has complained to Leiden University about me. They send me aggressive messages on Twitter. They seem to me to be a bit unhinged, I wonder who they are.
Timo Bechger
The algorithms must have picked up something hidden in your subconscious. Makes you wonder how long it will take before psychologists are replaced by chatGPT.
Fabio Rigat, PhD
Executive Director, GI Strategy Head, Late Oncology Statistics
This LinkedIn conversation started with me asking Dewi Evans to connect to me. I was amazed that he accepted. I guess my request contained a brief message too, but this is not recorded in my LinkedIn account. I suppose Dewi has it in an email sent to him from LinkedIn. It would be nice to see it.
Dewi – are you there, reading this?
Feb 3, 2024
Dewi Evans sent the following message at 11:46 AM
11:46 AM Dear Richard. I’ve read your comments re the importance of statistics in court cases. I can’t comment on specific cases currently because of reporting restrictions. I would welcome discussing this with you, as it’s a matter that is worth exploring.
Richard Gill sent the following messages at 12:30 PM
12:30 PM I agree! I am looking forward to the reporting restrictions being lifted. Hope to talk to you within a year from now…
12:32 PM Do take a look at the case of Lucia de Berk. The case is horrifically similar to that of Lucy Letby. I helped get her out of jail. Also an Italian nurse, Daniela Poggiali. I acted as expert on the applications to the CCRC of Ben Geen. I am sure he is innocent but UK criminal justice is nowadays badly tilted in favour of the prosecution.
Dewi Evans sent the following message at 12:36 PM
12:36 PM With a bit of luck reporting restrictions will be lifted after the end of the retrial due in June.
Richard Gill sent the following messages at 12:44 PM
7:03 AM I’m visiting Liverpool to give a lecture next week, dept of statistics. Will probably also check out Chester. Would you like to meet? I’m not interested in reporting restrictions. They are unfair and immoral. Science must not be stopped. Chester police sent Dutch police to my door in the night to intimidate me. This only made me speak out more loudly.
7:21 AM Do you have an email address? I’d like to send you some links and materials
8:11 AM By the way, reporting restrictions means reporters cannot write in newspapers about evidence supporting Lucy’s innocence. However, it allows the Daily Mail to publish week by week horrible stories about how evil she is, her cushy life in jail, her friendship with another killer … You and I are not reporters. There is no law against us exchanging information. You can tell me about medicine, I can tell you about forensic science. I’m sorry for you that you live in a police state. In the Netherlands there are also disturbing developments. The state is eroding civil rights. In the UK the process has got much further.
8:12 AM Fortunately, many investigative reporters are working on the case and many scientists are working on the case. The dam is starting to crack and it won’t be long before it crashes down.
Dewi Evans sent the following message at 9:37 AM
9:37 AM No problem having a private discussion. But reporting restrictions are reporting restrictions and all that. I’ve no wish to contaminate due process. I’ve no idea re Daily Mail articles. Never read it (apart from the one where they covered the Letby story after speaking to me. My easy access email is xxxx@xxxxx.xxx
Richard Gill sent the following message at 10:48 AM
10:48 AM Thanks for the email address! I do not wish to contaminate due process either. I wish to ensure due process. I can promise in advance of any discussion with you total confidentiality.
Dewi Evans sent the following message at 10:48 AM
10:48 AM Thanks Richard
Richard Gill sent the following messages at 11:37 AM
6:56 PM You asked for all the deaths and all the collapses in the period January 2015 to July 2016. They gave you all the deaths but only collapses when Lucy was there. There must have been at least 50 collapses when she wasn’t on duty, given the acuity of those infants. You were lied to, you were used.
Feb 23, 2024
Dewi Evans sent the following message at 10:31 AM
10:31 AM That is incorrect. I received information re numerous collapses. I separated them into those that were explained by the common causes- infection, haemorrhage etc and those that were not explained, ie suspicious. The name Lucy Letby was not known to me at the time. As for “at least 50 collapses” I don’t know where you got that figure from.
Richard Gill sent the following message at 10:54 AM
10:54 AM Interesting. Your story does not match the story one gets from other sources (for instance, the police themselves). I got my figure from several neonatologists and a similar figure from nurses with experience in neonatal intensive care. Secondly, “not explained” is not synonymous with “suspicious”. This confusion of words in the minds of on experts was exactly what led to the conviction of Lucia de Berk. I recommend you study it carefully!
Dewi Evans sent the following message at 11:17 AM
11:17 AM Away this weekend. Back Tuesday. Content to engage post the appeal and retrial. Information from the police was all disclosed to the Defence presumably. Those are the rules. No idea which other neonatologists involved. 2 gave reports for the Defence. They were not called. That’s a Defence issue. Read the Lucia de Berk story via Wikipedia weeks ago.
Richard Gill sent the following messages at 11:35 AM
11:35 AM I know, the defence was useless. Scandalous. The newspapers were appalling. Social media too. This was not a fair trial.
11:37 AM Lucy Letby was a whistleblower and got crushed by the NHS. Much better to put the blame on a killer nurse than on lax consultants and poor management. Focussed on cost cutting at the expense of patient care.
11:51 AM Have a. nice weekend! I just had a great visit to Liverpool and to Chester. Wonderful to see Welsh mountains in the distance from the city walls of Chester.
Feb 24, 2024
7:31 AM All deaths in the period when Lucy was fully qualified and full time (with very much overtime) at CoCH, and 15 non-fatal collapses *selected by the gang of four* and exclusively at times when Lucy was on duty. How much of the time do you suppose she was in the ward? “Since the start of our enquiries and, as the information gathering process has continued, the scope of the investigation has now widened. We are now currently investigating the deaths of 17 babies and 15 non-fatal collapses between the period of March 2015 and July 2016” https://www.chesterstandard.co.uk/news/16329278.healthcare-worker-countess-chester-hospital-arrested-suspicion-murdering-eight-babies/
9:25 AM Hi Dewi, maybe it’s time we had a chat? I don’t want to blame you. I blame NHS underfunding. Really bad police work, “experts” who don’t follow the rules (and apparently don’t know the relevant science either). The jury system, the contempt of court rules, a biased judge, a weak defence. The farce of her appeal being rejected but the CPS appeal accepted. The CCRC is utterly unfit for purpose and the next stage is going to take five to ten years. This certainly is the biggest miscarriage of justice since those big famous ones which led to the setting up of the CCRC. Of course in public you will presumably, for a while, go on saying you believe Lucy is guilty. I know all about obstinacy! Anyway: my suggestion is we do a Zoom chat, not recorded, Chatham house rules for just us two. Clear the air. I’ll tell you some things you don’t know yet, and vice versa. Win win.
Jul 8, 2024
Dewi Evans sent the following message at 10:42 AM
10:42 AM Currently getting over Covid, so back to normal next week. Afraid I don’t agree with you re the verdict. Letby was as guilty as they come. And to date, I’ve not seen a single comment from a suitably qualified person or institution that offers a reasoned defence. As for social media – best to give it a big ignoral. CCRC? As a witness of course one has to work within the system, but recognise its limitations. As for other cases, I expect that the police are investigating them. They involve displacement of breathing tubes for no apparent reason. And of course Lucy Letby was the nurse looking after the baby at the time. I’m not in touch with the police or the investigation any longer, so it will be interesting to find the outcome. My hunch is that there are quite a lot of other cases out there. [Interesting that since she was suspended in July 2016 (and I knew nothing about that before the trial) there have been few deaths at Chester apparently, and no ‘suspicious’ events.]
Jul 25, 2024
Richard Gill sent the following message at 7:27 PM
7:27 PM You would say that, wouldn’t you. Sorry, you are going to end up on the wrong side of history. “No apparent reason” does not equal “murder”. There are plenty of reasons breathing tubes get displaced. A person who gives expert evidence must be completely neutral and mention alternative explanations and margins of error. They must be fully qualified too. I’m sorry, but you are going to be in deep trouble.
Dewi Evans sent the following message at 8:07 PM
8:07 PM Richard. Just asking. Have you seen the clinical records of the babies? Have you seen / read the statements of the local medics and nurses? Have you read the statements of the parents? Were you at the trial? Does your medical experience extend beyond knowing which side of the bandaid you put on the wound? Cheshire Police are reviewing the notes of all babies at Chester, with the aid of an experienced neonatologist – I’m not involved and unaware of the findings. Don’t know if they are employing a statistician. So, Richard. Stick to your opinion. I’m still waiting for your evidence. But, for the record. None of my reports was based on “statistics”. It was based on Evidence. Look up its meaning. Her arrest, her charging, her guilty verdict had nothing to do with “statistics”. It was based on the Evidence of 6 independent experienced doctors, and the evidence of numerous local nurses and doctors. Evidence dear boy, Evidence! As for the Defence. It was their decision not to call evidence from independent clinicians and pathologists. Why do you think that was? Apart from the local plumber of course. Does one therefore assume that they consider your opinion less useful than that of a local plumber. Finally. Please do NOT make accusations about my evidence, or alleging that my evidence is not impartial. Half of my reports in criminal cases are at the request of the Defence. My most recent report for the Defence, just a few weeks ago, led to the Prosecution withdrawing the allegations within 2 hours of the opening of the trial. As for breathing tubes getting displaced for a number of reasons. For once you are correct. If you had listened to my evidence you would have known that I did not allege deliberate displacement of a breathing tube in any of the cases where I gave evidence. So, I’ll stick with the facts. Endorsed so far by judge and jury, Appeal Judge and 3 Appeal Court Judges. Not too bad I suppose. I look forward to your answers to my questions. I’m sorry if the facts (that word Evidence once more) get in the way of your opinion. But there you are. That’s a problem for you to address. Don’t see much point in engaging in a continuing dialogue. But thought that I should respond once.
Jul 26, 2024
Richard Gill sent the following messages at 11:08 AM
11:08 AM Thanks. I hope you will keep your mind open to new evidence as it comes to light, like a real scientist always does. I hope you will also bear in mind the growing criticism against our judges and courts. UK criminal justice is just as broken as the NHS. I too stick to the facts. The fact is that Brearey and Jayaram ran to the police when they realised that they were in deep shit due to the RCPCH findings. The fact is that you violated the duty of a scientific expert, but of course, as you said, you are not really. a scientist.
11:11 AM PS thanks for keeping the line of contact open! I still think that you have a fantastic opportunity to display wisdom and integrity. Do not let yourself be led by pride and vanity. Read the RSS report with great care. I talk to enough doctors who are better qualified than you to interpret those clinical notes, and many of them have access to those notes now. The arguments of appeal judges just show what big fools those people are. Also puffed up with vanity.
Dewi Evans sent the following message at 2:31 PM
2:31 PM Not seen the RSS report! You are welcome to send it, or send me the link. But as I said, my evidence had nothing to do with statistics.
Richard Gill sent the following messages at 4:07 PM
4:13 PM The defence didn’t understand medicine, didn’t understand science, didn’t understand statistics. Yeah – lawyers. Defence scored an own-goal by not disputing the interpretation of the immunoassay results. I just talked to a prominent UK professor of paediatrics. I asked him what he thought about the insulin? He basically said it was just bollocks and he explained why. This means that the evidence of Hindmarsh, Milan and Wark was just bollocks too. It may take 10 years, knowing UK criminal justice, but Lucy is going to walk free, you mark my words. Cheshire Constabulary have made enormous fools of themselves, costing the UK taxpayer millions, and by digging themselves in they are only making the debacle for themselves worse.
Dewi Evans sent the following messages at 4:54 PM
4:54 PM Who’s this professor of paediatrics Richard?
4:55 PM I’ll read the 64 page report over the weekend.
Jul 27, 2024
Richard Gill sent the following messages at 6:18 AM
6:18 AM I can’t tell you that professor’s name, sorry. Enjoy your weekend! Let me know if you have any questions about the report. It went pre-trial to defence, to prosecution, and in fact to all concerned parties. The man from the CPS said to me (at a pre-publication try out at the Newton Institute in Cambridge) “we are not using any statistics in the Letby case. They only makes people confused”. The defence too just did not understand the statistical issues, which are issues of scientific research methodology. And of forensic scientific investigation methodology. They got comprehensive advice from a very competent statistician but did not understand a word of it.
6:23 AM Sarrita Adams and I sent her medical analyses to the court during the trial, as an amicus brief. It was intercepted by Cheshire Police who sent Dutch police to my door in the night to deliver an intimidating letter. It threatened arrest next time I visited UK, two years in jail, and the cost of re-running the whole trial. The witch-burning mob doxed by mother’s address in a care home in Marlow, Bucks, and planned a demonstration outside. My Mother was 97. They also disrupted a lecture I gave at Liverpool University. The Mirror wrote that I was a sick and deluded conspiracy theorist and that I was attempting to corrupt the youth of England at the university, so the university authorities were evil too. Yep. All in a day’s work when you stand up against a witch hunt. Just so you know you are not the only guy getting publicly attacked in the media.
5:47 PM A friend – professor of mathematics – recently asked me: “I can’t understand why medical experts seem to often be so dishonest”. Here is my answer: “They are not scientists. They are trained to be rapid judges and executioners. That’s one thing. The other thing is the medical hierarchy, and clan forming. The paediatricians are more concerned with the paediatricians than with their patients. The youngest and least paid always have to get the blame to protect the reputation and earning power of the older and most highly paid.” These are unfortunately easily verifiable true facts! Think of all those who kept on supporting Prof Sir Roy Meadow. Maybe he was a good children’s doctor. He was however a lousy statistician and a lousy psychologist and this caused enormous disasters. No doubt he was a charming and amicable man. I always invoke Hanlon’s razor. Stupidity is a more likely cause of despicable behaviour than malice.
9:12 AM Here’s a name for you. Dr Svilena Dimitrova, NHS consultant neonatologist. Neonatologists against the paediatricians? CoCH had no neonatologist. Your friend well-known bully Dr Stephen Brearey “had an interest in neonatology” but was not a neonatologist. RCPCH (paediatricians!) told CoCH to recruit a neonatologist immediately.
9:14 AM I’m not saying it’s all your fault. Police lie and cheat. This has been proven again and again. Cheshire Constabulary have an especially bad reputation in this respect. I think you should cut all links with the bad guys and change sides as fast as possible, if only to save your own skin.
9:16 AM The momentum is growing. The Lucy Letby case is the biggest miscarriage of justice in the UK since the Guildford 4 and the Liverpool 6 (or were they 7 or were the numbers the other way round?). Just like the Lucia de Berk case in the Netherlands. The two cases are carbon copies of one another, but things panned out much worse in every respect in the UK. Utterly failed NHS, utterly failed CJS. Appalling gutter press. You should give an interview to a quality newspaper for a change.
Sep 13, 2024
7:07 PM Intelligent life outside the M25: what do you think of me then?
7:11 PM Babies do just suddenly drop dead. The Lucia de Berk case made that clear.
7:17 PM Unexplained and unexpected actually does happen all the time.
7:24 PM How did you exclude infection?
7:38 PM There is not one unrecordable explanation of a low C-peptide level. One of the explanations is that it is too high!!!!
9:37 AM Hi Dewi, yet again, I want to suggest you change sides! Become a hero. I know you do have the guts to do it, you are not a scared little man. I hope you’ve now studied Marks and Wark (2013) https://pubmed.ncbi.nlm.nih.gov/23751444/. It has a great summary of recommendations at the end. You see, Lucy Letby is innocent, 100% (ie, 99.99% certain, at least). Shall I show you the calculation? Science thrives on the clash of theories. As Niels Bohr once said “now we have a contradiction, at last we can make progress”. I honestly wish you well and know you are a good guy at heart. Forensic aspects of insulin – PubMedpubmed.ncbi.nlm.nih.gov
11:28 PM So you made a nice start, changing your expert medical opinion on three cases! But you are still convinced Lucy Letby was responsible. Surely that can only be by a statistical argument? But where are your statistical calculations and statistical qualifications? As far as I know neither police nor prosecution used testimony from a statistician. Lucy was often present at unpleasant events, but she worked the most hours of any nurse on that unit, and eagerly took the hardest shifts. Lucy’s defence team let her down badly, the judge was disgustingly biased. The whole disaster was not your fault. NHS managers and lawyers have a lot to answer for. Many reforms are needed. But they can only come if the system admits its failings.
11:32 PM I offered my services to defence, prosecution, and to the court. But no one wanted to know. Cheshire constabulary threatened me and sent Dutch police to my door in the night, to deliver a letter in person which I’d already received by email. Very intimidating. They needed legal proof I’d received their warning.
I just recently became aware of a deep connection between Countess of Chester hospital and radical restructuring of the NHS in the early 90’s, which brought in new layers of bureaucracy and internal competition. Don’t coordinate and distribute. Instead, let hospitals compete, survival of the fittest, dynamic leadership,and innovation! We’ll end up with better health care for less money.
The connection is Sir Duncan Nichol, former chairman of the Countess of Chester hospital trust. That’s a higher management level than the hospital executive board. Side effect of the innovations was more managers with even bigger top salaries. But Nichol is not just any manager. He’s a former NHS chief-executive, “part tycoon, part mandarin”. Read all about Sir Duncan’s innovations here: https://www.managementtoday.co.uk/uk-profile-sir-duncan-nichol-nhs-chief-executive/article/409550
Here are some more quotes from Management Today, emphasis added by myself.
“Nichol helped oversee the greatest shake-up in the health service since the war. Out went the old-style consensus management where low-grade administrators charged round trying to keep high-grade doctors happy; in came a whole raft of modern business nostrums: greater pressure on cost-efficiency and customer satisfaction, the introduction of ‘internal markets’, the separation of key functions like purchasing and service provision, and, of course, the increasing use of snappy titles like chief executive and general manager.”
“Some, still seething at the enforced changes, argue that you cannot apply market doctrines to the basic tenets of caring and curing. Others, especially those working in conventional businesses, remain unconvinced that any amount of fancy tinkering will change the nature of the beast. The last few years, they note, have still been dotted with high profile examples of cash squandering on a massive scale.”
I would recommend everyone interested in the Lucy Letby case to carefully study the 58 page appeal judgement – a board of three judges refused Lucy’s application to appeal. It is only 58 pages, it is well written and carefully argued… It is just built on heaps of false assumptions. What it says about the insulin evidence is particularly significant.
Three points specifically concern the insulin babies, babies F and L: points 14, 30 and 104 [and another on the evidence of Prof Hindmarsh, which I won’t go into right now.] Here they are in italics; my underlining.
14. A proposed ground 4 (that the jury were wrongly directed on evidence relating to the persistence of insulin in the bloodstream) was withdrawn following the refusal of leave to appeal by the single judge.
30. At trial, the integrity of the blood samples and reliability of the biochemical testing was challenged by Mr Myers. However, in her evidence at trial, the applicant [Lucy Letby!] admitted that both babies had been poisoned by insulin, but denied that she was the poisoner. The prosecution relied upon the unlikelihood of there being two poisoners at work on the unit. As the judge expressed it shortly before the jury retired to consider their verdicts: “If you are sure that two of the babies…had Actrapid, manufactured insulin, inserted into the infusion bag that were set up for them 8 months apart in August 2015 and April 2016 respectively, and you are sure that that was done deliberately, you then have to consider whether that may have been a coincidence, two different people independently acting in that way or were they the acts of the one person and, if so, who.”
104. The prosecution made some general points to rebut the allegations of bias and unreliability, including that almost every opinion given by Dr Evans was corroborated by another expert. In addition, it was pointed out that Dr Evans was the person who had identified that two of the babies had been poisoned by insulin (Baby F and Baby L). This was a matter which had eluded the treating medics and went to prove that someone was committing serious offences against babies in the unit; and it was particularly important independent evidence, bolstering Dr Evans’ credibility and reliability. Further, when Dr Evans reached his conclusions, he did so without knowing about other circumstantial evidence relied on by the prosecution in establishing guilt, including the applicant’s Facebook searches, the shift pattern evidence, and the “confession” in the note recovered from the applicant’s home on 3 July 2018
Richard’s comment on point 30: the applicant was told during the trial that it had been proven that two babies had been poisoned. Her reply was not that she admitted this fact, it was more like “well if you say it is proven it must be true. But I didn’t do it”. Notice that for the prosecution, six experts all say that this was true: Evans, Bohin, Hindmarsh, Milan, Wark; the hospital doctors had concurred (Gibbs, in particular). The defence had apparently not even looked for an expert on the insulin matter. They had raised problems about the reliability of the tests but these are ignored because Lucy herself agrees that the babies were poisoned with hospital insulin.
How can a young nurse agree or disagree with a deduction made by half a dozen senior medics that the immunoassay results proved deliberate insulin poisoning? All doctors and nurses have been taught in doctors’ or nurses’ school something about insulin metabolism and know that the ratio of insulin to C-peptide (after someone has been fasting for three hours) should be about 1 to 6. They are not taught anything about the forensic determination of deliberate insulin poisoning, which tells us that an anomalous ratio is a warning sign for something that might have been happened but it should be followed up with completely different tests which exclude a numerous sets of artefacts which can each also cause an anomalous ratio of immunoassays’ numbers. The test result comes back from the lab with a warning note printed in red with exactly this information. It was ignored by hospital doctors. The specialists weren’t called in and never told about it. The babies were nicely recovering from their hypoglycaemia and were rapidly transferred elsewhere.
Note that according to point 14 the defence had submitted and withdrawn a “ground for appeal” concerning the insulin. [I don’t know what it was, someone should find out!]. Note that the insulin is seen by all concerned as proof of presence of a murderer on the unit. The court of appeal sees it as ludicrous to suggest there are two murderers on the unit! They believe that the other evidence (air embolism etc etc) proves Lucy is a murderer. The insulin evidence shows someone tried to murder babies F and L. There can’t be two murderers. Therefore Lucy also tried to murder babies F and L.
The logic of the argument is impeccable. Just the premises of the argument are wrong.
These points do show the utter incompetence of the defence team.
One of the prosecution experts (Gwen Wark) has even published a paper Marks and Wark (2013) with a concluding list of recommendations which state that the immunoassay only suggests a possibility; in order to prove it other tests must be done. https://pubmed.ncbi.nlm.nih.gov/23751444/ They were not done. No sample was saved so they never can be done. Both babies F and L are alive and well to this day though one has cerebral palsy … linked to problems experienced during birth.
At the trial Dr. Wark confirmed the other experts’ claim that insulin poisoning had been proven. How could she? What had she written in any written testimony provided pre trial to police or CPS? Richard Thomas (Lucy’s solicitor) says that the defence team can’t say whether or not any documents exist and whether or not they saw them. The jury is not shown any such documents.
People say “the jury was given so much more, information…”. That is quite simply not true. The jury in a UK criminal trial hears what is said and it observes the body language. That’s all. It does not receive copies of written testimony of scientific experts. (This is a consequence of “open justice” with a trial by a jury of your peers).
What was the fifth ground in the original application for an appeal? The one which a single judge scrapped and the defence team then scrapped too?
Maybe some journalist should chase after that. I’m afraid the defence team is unlikely to tell us. They are not obliged to, and they can only do it if Lucy instructs them to do so. And nobody is able to talk to her.
I first became interested in the Lucy Letby (LL) case when my wife referred me to a 10 hour podcast entitled: “The Case of LL; The Facts – Crime Scene 2 Court Room”, https://www.youtube.com/watch?v=_OA0ukO7D7c. Since, I have searched for further background to this case. Richard Gill’s website raises issues around imbalance between the prosecution and the defence, or lack of it! Also, there was toxic atmosphere at the Countess of Chester (CC) neonatal unit and LL reported problems. I worked for over 25 years anaesthetizing children down to 500g, in addition to adult anaesthesia, as well as expert witness experience. I also spent 6 months attached to a Neonatal Unit. The question of whether LL committed the alleged crimes is a difficult one to answer as (a) no one actually witnessed her doing the alleged crimes, (b) there is no obvious motive, (c) the actions would be very hard to achieve and (iv) there are other alternative explanations that were not explored by the court case, or at least the 10 hour transcript.
The Countess of Chester baby unit: The main purpose of the unit was a nursey to look after and feed babies too small and fragile to leave hospital, born at the CC. There was a small 4 bedded-neonatal unit in addition to the 4 nursery rooms. LL probably wanted to gain neonatal experience hence her involvement with the 17 cited cases.
Neonates and vulnerability: Small preterm babies easily deteriorate and die. Their organs are still developing and without the advent of neonatal units in the 1980s most would die. It is only today that a baby born prematurely before 28 to 32 weeks has a good chance of survival.
Staffing levels, staff experience and standard of care: LL was only 25 years old at the time and had only been a neonatal nurse for a few years. That is not very long and she lacked experience! She still needed further training in Liverpool to advance her career. Yet, she seemed to be one of the most senior neonatal nurses (band 5) on the unit and nowhere in the transcript do we find an older, more senior or experienced colleague other than a charge nurse who managed the duties and was not hands on. Similarly, it appears that medical cover was by paediatricians who also covered the wards and there was no doctor solely on duty for the unit. Therefore, when compared to other bigger units (i.e. Alder-Hey) the level of care was limited, so it would not be surprising if a baby deteriorates, and that happens with “prems”, outcomes are not as good. So, the evidence suggests that the CC was not up to standard, and it was an overflow unit for Alder-Hey. The CC neonatal unit has since been closed down. So were the cited incidents and deaths really due to LL or a result of a poorly supported / under-funded unit looking after sick neonates that should have been elsewhere?
The prosecution case focused on a number of methods of harming babies allegedly used by LL: (i) Distending the stomach by giving too much feed or (ii) injecting air into the stomach, (iii) injecting air into the circulation causing sudden collapse, (iv) traumatising the airway and causing bleeding, (v) dislodged tracheal and chest tubes, and (vi) adding insulin to the intravenous feed. The discussion of the pathophysiology of these mechanisms was disjointed and difficult to follow. However, the connection of LL to the sudden deteriorations and deaths in 7 seemed very compelling. However, I have to take issue with a number of the prosecution’s assertions.
(i) Over-distending the stomach with feed to an extent to cause collapse and projectile vomiting. I don’t have any experience of tube feeding prems, but projectile vomiting can be a reaction to bad / infected milk? Was LL in hurry to feed the baby? I find it hard to believe this was an attempt at murder.
(ii) Most obvious was the air in the stomach and intestines at post mortem. LL must have injected air via the gastric feeding tube, or how else did it get there? Well anyone who works in theatre or resuscitation knows during mask ventilation, which all these babies had (i.e. Neopuff), that it is very easy to blow up the stomach and intestines with air / anaesthetic gases, especially if one’s technique is not perfect. I regularly had to pass a suction catheter to empty the stomach of gas at the start of surgery to deflate the stomach and improve ventilation. I even did a study on the carbon dioxide levels that often reached the level of expired gas. However, the role of the Neopuff as a potential cause was never mentioned. So what is more likely, LL injected the air or the air got there through resuscitative efforts by stressed staff.
(iii) Some of the babies suddenly collapsed and developed a strange rash on the abdomen. Some recovered rapidly. This was said to be due to LL injecting air into the circulation. Air was found to be in the blood vessels at post mortem in some deaths. The premature baby can revert to a foetal circulation (by passing the lungs) when they become unstable and this can take time to treat (revert back). Sometimes “persistent foetal circulation” manifests itself during anaesthesia until the ductus closes fully. Point not mentioned in the case but could explain the above. Also, chest compression would cause significant sucking in of air to the heart if intravenous access lines were left open to air during the resuscitation after injecting a drug (adrenaline). LL sent a Datex about a line being left uncapped by one of the doctors. So there are other explanations and mechanisms by which air could have entered the circulation.
(iv) One of the cases had trauma to oral airway and significant blood loss, I think this was one of the twins with Haemophilia, a blood clotting disorder. LL was accused of traumatising the airway. I cannot imagine how. The likely explanation would be repeated intubation attempts, not an attempt to murder the baby by LL. I recall up to seven attempts as the neonate was difficult to intubate!
(v) LL was also accused of dislodging an endotracheal tube and a chest drain which lead to deterioration in two patients. Preterm babies are very small, endotracheal tubes can easily move and become dislodged however carefully one secures them, particularly if the neck is flexed or extended! Similarly, with chest drains, the baby had bilateral drain presumably as a result of premature lungs, and one drain became dislodged / was not working and a third drain was needed. These things happen so just because LL was present does not automatically mean it was her fault. Then there was the incident with deliberate liver injury, which equally could have occurred during chest compressions by someone else?
(vi) The addition of insulin to intravenous feeds has already been mentioned by Gill from a biochemistry and reliability of blood test perspective. I don’t fully understand this one. One baby was receiving regular intravenous nutrition made up in sealed bags from pharmacy. The baby had unexplained hypoglycaemia. For three bags it persisted and when LL was not on duty the hypoglycaemia resolved. Blood were analysed insulin and C peptide. Hypoglycaemia is common in preterm babies because their mechanisms to maintain blood glucose levels are immature (i.e. glycogen stores in the liver). The child may have had an infection as Gill says there was virus circulating. That being said it difficult to image how LL managed to injected the correct and same amount of insulin into a sealed bag on three separate occasions. There is a rigid nursing protocol involving two nurses when a new bag is put up to maintain sterility. Then there was a further insulin contaminated Dextrose infusion in a second baby. BTW, LL was not the only nurse present for both these cases.
Hence, I find it very difficult to accept the verdict that Lucy Letby was responsible for all 7 deaths and a further 6 attempts at murder. I think that her case needs to be reviewed by someone with a better understanding of neonatal medicine and how a premature baby unit is run.
The following text is taken from Science on Trial, https://www.scienceontrial.com/, I will later link to the precise location on that website, and find out if the author may be named.
After having read through multiple articles detailing the timeline of the circumstances behind of the allegations, I thought I’d provide a brief but detailed history of the sequence of events resulting in Miss Letby being arrested and charged. I’m sure many of you know this timeline already, hopefully there are more details here you will find interesting. For those who don’t know the chronology, I hope the below is useful. That this was a fairly open conspiracy between senior consultants at the hospital, primarily Dr Stephen Brearey (he is in fact the architect) and Dr Ravi Jayaram, and later detectives at Cheshire Police assigned to the case titled ‘Operation Hummingbird’ is difficult to dispute. They’ve quite openly admitted it by clumsily showering praise on themselves following the trial in a bizarre attempt to characterise themselves as heroes. Although the record is fragmented and the sources are scattered, a reconstruction is possible nonetheless.
-On June 8 2015 Child A, a premature newborn twin, suddenly collapses on the neonatal unit. Dr Ravi Jayaram, who responds to the emergency alert, later testified that he noticed “pink patches, mainly on the torso, which seemed to appear and disappear and flit around. I had never seen anything like it before but my focus at the time was on ABC, airway, breathing, circulation.” He added: “I could not explain the sequence of events, why they had happened. I couldn’t explain why it had happened in the first place and couldn’t explain why the physiological responses to timely and appropriate interventions did not happen as they should have happened.” Dr Jayaram does not mention the skin discolouration in the clinical notes he made three hours after Child A died. He testified “I didn’t appreciate the clinical significance of this whatsoever”. When asked why he also failed to mention it to the coroner presiding over the inquest of Child A, Dr Jayaram replied: “My concluding remarks when I gave evidence is that I couldn’t explain how this had happened, It was not my job to say ‘it may have been this’ because at that time I had no evidence”.
-Around midnight on 9 June 2015, Child B’s blood/oxygen levels drop. She is blue, not breathing and limp.
-In the early hours of 14 June 2015 Child C suddenly collapses. He is pronounced dead at 5:50am.
-On 21/22 June 2015, Child D collapses three times, the last one being fatal. Those present notice discolouration on the babie’s skin.
-Towards the end of June 2015, after Child D’s death, Dr Stephen Brearey notices that Lucy Letby is on shift for each instance of four collapses, three of them fatal, in the last two weeks. She is the only nurse present in each case. Dr Brearey shares this informal review with Dr Ravi Jayaram. He tells Dr Jayaram that nothing linked the deaths “other than one nurse”. The deaths are reported by consultants to hospital’s trust committee for serious incidents. The hospital classifies them as “medication errors” and not a “serious incident involving an unexpected death”.
-By June 2015, Dr Brearey, Dr Jayaram and “other colleagues” all identify Miss Letby as a potential link.
-On 29 June 2016 the entire consultant body at the hospital hold a meeting concerning the collapses. Air embolism is one of the topics discussed. That evening Dr Jayaram conducts a literature search and comes across the 1989 medical paper titled “Pulmonary Vascular Air Embolism In The Newborn”. Dr Jayaram will later testify to the court that the paper describes a series of accidental events of air embolism. The context within which the research paper studies air embolism is as an inadvertent complication of mechanical ventilation. Dr Jayaram emails links to the medical paper to colleagues the next day.
-On 2 July 2015, Dr Stephen Brearey, Eirian Powell, a nurse and ward manager responsible for the nursing staff on the neonatal unit, and Allison Kelly, director of nursing at the hospital hold a meeting. Lucy’s presence when the three deaths occurred is discussed.
-By October 2015, seven infants have died in unusual circumstances. Dr Brearey openly suspects Miss Letby is harming children. Miss Letby will go on to be convicted for murdering five of these infants. The remaining two, despite being investigated by the police, were never bought to trial.
-On 23 October 2015 Eirian Powell emailed the findings of her own review of these collapses to Stephen Brearey. She states “I have devised a document to reflect the information clearly and it is unfortunate she [Miss Letby] is on [shift] – however each cause of death was different, some were poorly prior to their arrival on the unit and the other were ?NEC or gastric bleeding/congenital abnormalities. I have attached the document for your perusal”.
-In February 2016 Dr Brearey orders a half-day thematic review into the deaths and collapses with the help of Consultant Neonatologist at Liverpool Women’s NHS Foundation Trust Dr Nimish Subhedar. It finds several common links in nine unusual deaths since June 2015. Four of these were never brought to trial.
-On February 15 2016, The report is sent to Ian Harvey, the hospital’s medical director and second in charge, and Allison Kelly. It includes a table of the nine deaths identified in the review, showing Miss Letby is on shift for each one. Dr Brearey requests an “urgent meeting”. Management determine Miss Letby’s presence is a coincidence.
-On March 17 2016, Eirian Powell & Allison Kelly discuss via email how Miss Letby was a commonality in the deaths.
-On April 7 2016, Eirian Powell moves Miss Letby to day shifts to support her wellbeing because she had been present for so many of the collapses.
-On April 9 2016, Child M suffers a dramatic drop in heart rate and breathing. This occurred during a day shift and is used to suggest that deaths and collapses “follow” Miss Letby.
-In May 2016, Dr Brearey emails Allison Kelly, flagging Miss Letby’s presence at the deaths and asking for a meeting. Allison Kelly fowards the email to Ian Harvey expressing alarm that a doctor was implicating a nurse. She tells Ian Harvey that there was no evidence but that a wider review might be needed. Allison Kelly asks senior nurse managers to examine any staffing trend linked to the deaths, adding that it was ”potentially very serious“.
-On 11 May 2016 Dr Brearey and other doctors meet Kelly and Harvey to discuss their concerns about Miss Letby. The senior managers produce a two-page “assurance” document detailing why Miss Letby is not believed to be the cause of the unusual deaths. It suggested other NHS services may be to blame for the spike in deaths and that: “There is no evidence whatsoever against LL other than coincidence”. They agree to review all the deaths and keep Miss Letby on day shifts for three months. Dr Brearey feels his concerns have been dismissed.
-On 16 May 2016, a senior doctor tells Eirian Powell during a meeting: “You are harbouring a murderer”.
-On 23 June 2016 newborn triplet, Child O, dies after a number of collapses.
-On 24 June 2016 Child P, the brother of Child O, suffers an ‘acute deterioration’. He suffers a number of collapses and is finally pronounced dead at 4pm. The coroner later recorded the death as ‘prematurity’. The prosecution later claimed Miss Letby injected air into his stomach. Stephen Brearey calls hospital nursing director Karen Rees to express his concerns. He no longer wants Miss Letby working on the unit. Rees insists there is no evidence against Miss Letby and says she will take responsibility for allowing her to continue to work.
-In late June 2016 emails are exchanged between nurses, doctors and hospital executives. One of the doctors recommends calling the police. Ian Harvey replies to the chain saying concerns were being “discussed and actions taken”.
Executive directors at the hospital meet and debate calling the police for the first time. They consider the impact of an investigation and arrest, and subsequent reputational issues and impact on the trust. They acknowledge the evidence is circumstantial and express their concerns about the unit’s leadership. They fear the doctors are carrying out a witch-hunt. The trust do not contact the police.
The neonatal unit is downgraded to level 1 so that the sickest and most premature children are sent to neighbouring hospitals. Ian Harvey and Tony Chambers, the hospital’s chief executive, contacts the Royal College of Paediatrics and Child Health and asks them to review the neonatal unit’s service level. The hospital’s executives meet the doctors and tell them they considered contacting the police but decided to handle it in a different way.
-By July 2016 mortality data shows there had been 14 neonatal deaths in just over a year. An internal review by the nursing director notes that higher acuity levels, higher activity and short staffing levels may have all contributed. It does not mention any concerns around any individual. Miss Letby is called to a meeting with a senior nurse and a HR Manager. She is told for the first time of her association with the infant deaths. She is visibly upset and distressed. The decision has been to place her under supervision, alongside other staff.
-In mid-July 2016 Miss Letby is redeployed to the hospitals risk and patient safety office. Staff shortages on the neonatal unit meant supervision of her was not possible after all.
-In early September 2016, the RCPCH arrive and begin their investigation. Miss Letby is one of the first to be interviewed.
-On 7 September 2016 Miss Letby submits a formal grievance against the trust for victimisation and discrimination at being removed removed from the ward. This is after learning through her Royal College of Nursing representative of the concerns by doctors on the unit.
–In October 2016 the RCPCH report back to Harvey and Chambers. They find that what had happened ”appears unusual and needs further inquiry to try to explain the cluster of deaths“. A draft version of the report is drawn up. It raises general concerns around short staffing and clininal practices. It notes an increased volume of cases with increased acuity levels, but states this was not significant enough to explain the high mortality rate. It also says there “no obvious factors which linked the deaths and that circumstances in the unit were not materially different from those which might be found in many other neonatal units”. However it recommends detailed case reviews are needed for each of the deaths, including examination of obstetric, pathology, nursing and post-mortem indicators. It also includes a confidential section linking the deaths with Miss Letby and the subjective concerns of Dr Stephen Brearey, the neonatal lead. This section is redacted from the version circulated to the board, the doctors and the bereaved parents.*
Ian Harvey contacts Dr Jane Hawdon, a neonatalogist, asking her to carry out a forensic review of each death. Hawdon produces a five page review but tells Harvey she did not have the time to conduct the thorough investigation the royal college had recommended. Nonetheless it cited four cases which could not be explained but would “potentially benefit from local forensic review as to circumstances, personnel etc.”
The executive managers meet again and agree that not calling the police the was the right decision as the doctors’ evidence was “unconvincing”.
-In November 2016 two and a half months have passed since Miss Letby’s grievance. During the investigation, Doctors who raised concerns about her causing harm to infants, including Brearey and Jayaram, were interviewed, with their union reps present, by an investigator. The investigation finds no evidence to justify calling in the police. Instead it finds the doctors are at fault for suspecting her of murder. ”This behaviour has resulted in you, a junior colleague and fellow professional, feeling isolated and vulnerable, putting your reputation in question,“ the grievance inquiry told Letby. ”This is unacceptable and could be viewed as victimisation“.
-On 12 November 2016 HR prepare Miss Letby’s return to the neonatal unit.
-On 22 December 2016 Tony Chambers issues Miss Letby with a full apology on behalf of the hospital trust, and assures her family the doctors who had victimised her would be dealt with.
-In January 2017 the hospital board hold a meeting. Harvey states the RCPCH review found the incidents were down to issues of “leadership, escalation and timely intervention” and that it “does not highlight any single individual”.
In a separate meeting, Harvey and Chambers tell seven clinicians, including Brearey and Jayaram, that “things have been said and done that were below the values and standards of the trust.” Mediation between Miss Letby and both Brearey and Jayaram was demanded. They were told it would protect them from a referral to the General Medical Council (GMC), the doctors’ watchdog. The British Medical Association Rep advised them to write a letter of apology to Miss Letby.
-In late January the doctors write to Harvey. They ask “what is the reason for the unexpected and unexplained deaths? What should we as paediatricians do now?”
-On 1 March 2017 the paediatricians write a letter of apology to Miss Letby.
-In March 2017 the consultants seek external advice from the regional neonatal lead who agrees that several cases require further investigation. They meet again with Harvey and Chambers to ask police to investigate. At this point it was agreed. The high deaths and suspicions were raised with police through the local child death and overview panel.
-On 27 April 2017 Detective Superintendent Paul Hughes meets Dr Brearey and Dr Jayaram at the Countess of Chester Hospital. The meeting proved decisive. Dr Jayaram said “the police, after listening to us for 10 minutes, realised this is something they had to be involved in”. Whether the name Lucy Letby was mentioned at this meeting or a little later is irrelevant. The next day Operation Hummingbird was launched, and more than a year later on 3 July 2018 Miss Letby was arrested.
The most disturbing facts I came across while researching this piece was that two fundamentally vital pieces of evidence cited in the trial by the prosecution, had long been prepared by the doctors before the name Dewi Evans became remotely connected.
(i) The table that showed Miss Letby on shift for all the collapses and deaths had already been built by Dr Stephen Brearey in February 2016.
(ii) The air embolus theory had already been determined as her modus operandi as early as June 2015. Dr Jayaram had been sitting on the 1989 paper since June 2015.
Furthermore whilst not discussed above, Dr Stephen Brearey just so happens to be the very doctor who finally finds the so-called ‘smoking gun’. On 13 February 2018 discovers the blood sample for Child F which apparently proves deliberate harm in the form of insulin poisoning. Incidentally, Vincent Marks is a Doctor of Medicine and Clinical Scientist who has conducted highly relevant research into the forensic aspects of hypoglycaemia. His works include: ‘Insulin Murders’, ‘Hypoglycemia: Accidents, Violence and Murder’. He claims that a fatal dose of insulin for an adult human being is around 1,000 units. Child F’s level was 4,657 units.
*Redacted passages: “The neonatal lead [Stephen Brearey], in an effort to be thorough and explore all possibilities had identified that one nurse had been rostered on shift for all the deaths although the nurse had not always been assigned to care for that specific infant. Subsequently, the paediatric lead and all the consultant paediatricians had become convinced by the link. Although this was a subjective view with no other evidence or reports of clinical concerns about the nurse beyond this simple correlation an allegation was made to the Medical Director and Director of Nursing.
“On arriving for the visit the RCPCH Review team was told that the nurse had been moved to an alternative position around ten weeks previously without explanation nor any formal investigative process having been established. The Review team was told that the individual was an enthusiastic, capable and committed nurse who had worked on the unit for four years. She herself explained to the Review team that she was passionate about her career and keen to progress. She regularly volunteered to work extra shifts or change her shifts when asked to do so and was happy to work with her friends on the unit. The Directors understood there was nothing about her background that was suspicious; her nursing colleagues on the unit were reported to think highly of her and how she responded to emergencies and other difficult situations, especially when the transport team were involved. There were apparently no issues of competency or training, she was very professional and asked relevant questions, demonstrating an enthusiasm to lead along with a high level of professionalism.
I am a coauthor of the report of the Royal Statistical Society https://rss.org.uk/news-publication/news-publications/2022/section-group-reports/rss-publishes-report-on-dealing-with-uncertainty-i/. It is deeply distressing that the police investigation into the case of Lucy Letby and the subsequent trial made all of the mistakes in our book. The jury was never told how the police investigation arrived at that list of “suspicious” events and how it was further narrowed down to the list of charges. This is a case in which a target was painted around a suspect by investigators. We call it confirmation bias, in statistics. It is also often referred to as the Texas sharpshooter paradox.
Thanks to amateurs who report their work on Twitter and YouTube, we now know how the list of charges in the Lucy Letby case evolved. It is utterly scandalous that this history was not revealed to the court. Here is the broad picture.
Doctors reported Lucy to the police, against the wishes of the hospital board.
They told the police the exact period she had been on the ward and gave them the files on all deaths in that period and on some of the incidents: namely, exactly and only those “arrests” at which Lucy had been present.
What qualifies as an incident, what is an arrest?
There is no medical category “arrest, resuscitation” under which such events are logged in hospital administration. Probably there were about five times as many such events when Lucy was not on duty, but nobody has ever looked. There is no medical definition of such an event. No formal criteria.
“Unexpected, unexplained, sudden” are also not defined in any formal way. Nor is “stable”.
Next the absolutely unqualified, long retired, paediatrician Dewi Evans, who has a business helping out in civil child custody cases, went through those medical files looking for anomalies about which he could fantasise a murder or murder attack. His ideas that milk was injected into the stomach or air into the veins were far fetched, and later not confirmed by any other evidence. On the contrary, the actual evidence certainly contradicts the idea that Lucy Letby actually attacked any child. He never gave alternative medical explanations, as would have been the obligation of a forensic scientist. All the deaths had had a post-mortem and a coroner’s report. Every single event on the charge sheet has absolutely normal explanation. Lucy was never seen doing anything wrong.
The medical experts for the prosecution merely confirmed Evans’ diagnosis, they also did not do the job of a forensic scientist.
The defence had no experts. They had brought in one paediatrician. But at the pre-trial hearing he said he wasn’t qualified in endocrinology, toxicology, etc etc etc.
This was Texas sharpshooter, big time. Plus utterly incompetent defence.
The following text was sent to me by one of my many correspondents, wondering what to do with it, and not daring to publicise his or her ideas. I said that I could post it, so that he or she could remain anonymous. I’m not saying that the opinions here are my own opinions. One can certainly call them speculations. There is so much we don’t know, and so much that does not seem to make sense, that I think they are not idle speculations; but still, speculations they are. I will add to this post some further comments of my own, concerning the general social phenomenon that people with strange and unwelcome ideas are put away as nutty crackpots; then, if several others appear to have the same nutty crackpot idea, then they are obviously evil conspirators. The history of science is a history of crackpots: Galileo, Copernicus, Darwin, Einstein. At least, they were thought to be crackpots and they were first ignored and later fought by the establishment, the latter happening when a few people started to endorse their ideas. That’s when they became really dangerous.
From here on and till further notice, the words of my anonymous correspondent.
I’ve made several posts recently arguing that Lucy Letby didn’t get a fair trial. Some people have responded by calling me, and other with similar opinions, conspiracy theorists which led me to ask myself whether there was any conspiracy involved in the whole Lucy Letby story. What I have written here is an actual CONSPIRACY THEORY and is not based on any relevant specialist knowledge and is highly speculative so you can disregard it if you like. However, if you’re looking for a ‘possible’ explanation for the very odd police investigation, the hopelessly weak evidence used against her, the bizarre nature of the trial and the other strange observables in this case, it might be worth reading on. This is not necessarily my opinion, but my attempt to make sense of an incomprehensible conviction. It is also largely motivated by ensuring Letby is granted an appeal and a fair retrial.
If this case wasn’t political from the beginning, it certainly is now. I don’t think it was ever about justice, it was always a face-saving exercise, initiated by another failing, underfunded hospital, who knew there was doctor/consultant negligence involved in most of the unexpected deaths and events on the ward, many of which happened when Lucy wasn’t on shift. Babies dying as a result of negligence or understaffing is a bomb waiting to go off, which would have decimated the already dwindling public confidence in our NHS. That would be very damaging for the politicians who rely on public support to stay in power. Because the NHS is funded by the government and ultimately of course, the electorate.
The government, which means the electorate, fund the police too, through grants to each local force. In the last few years, the reputation of the police and public sentiment towards them has justifiably fallen dramatically and must be close to an all-time low. Is it possible that the government and senior officers were desperate to restore some faith in the police force? Cracking the ‘crime’ of the century would go down well with the public! We’ve seen how political and senior police heads roll when they screw up. This investigation was very high profile, very emotive, very long and expensive and, with their reputation in the gutter, it was important for the police to come out triumphant.
The police were called in to investigate unexplained deaths on the ward and to assess if a crime had taken place. EVERYONE who worked on that ward during that period begins the police investigation as a potential suspect. But the police began their investigation, of a potentially unfathomably serious crime scene, by strolling in and meeting with senior doctors and consultants for a briefing. They then proceeded to investigate as instructed by the doctors and consultants. Those doctors and consultants were SUSPECTS! These are the same doctors and consultants who made the accusations. Since when, in any potential murder enquiry, has the person/persons reporting the crime been discounted as a suspect before the police even reach the crime scene? Their potential negligence or the possibility that they may have been the murderer was never investigated.
And it would look terrible for the NHS if all those doctors/consultants in just one department of just one hospital were found to be negligent by the police and their neonatal ‘expert’ (with no neonatal experience). Oh the damage that would do to the NHS, and of course the government, who pay those negligent consultants’ generous wages, but underfund the hospital so badly. It’s SO much less damaging to their reputations to pin everything on one lone murderer. It certainly takes public attention away from the failures of the more powerful parties, if the public have a single villain to target with their fury and hatred. Not to mention the money it’d probably save the NHS/government in medical negligence compensation lawsuits.
The Crown Prosecution Service (CPS) and the Criminal Justice system (CJS) are also funded by the government. Following a hugely expensive investigation by the CPS and a trial costing the electorate £Millions, can you imagine the implications for our national institutions, if she’s granted an appeal and exonerated? For starters: 1. The CJS isn’t fit for purpose. 2. The CPS isn’t fit for purpose. 3. The police force isn’t fit for purpose. 4. The NHS isn’t fit for purpose and 5. The sheepish police and CPS have to begin a new, highly expensive investigation that might lead to more highly expensive criminal proceedings against negligent doctors. Far cheaper and less damaging to leave one woman sat in a cell for the rest of her life. Plus it pleases the electorate, many of whom think she should be tortured and executed ASAP. All those votes gone if she’s even granted an appeal! Countless more millions votes gone when those services are found to have failed and she’s exonerated!
And then there’s the shame they’d all face when they have to get on their knees and give Letby a grovelling apology and pay her very substantial damages. In summary, her acquittal would be a very bad day for a lot of very powerful people and institutions. It would shatter the electability of the government who have overseen all those institutions for the last 13 years.
A plausible alternative is that it was no one’s fault, not even the government. Perhaps just a statistical spike that anyone with a basic understanding would realise is not as unusual as it was painted by the prosecution. In fact, a leading independent statistician says a full analysis, including dozens of relevant factors (rather than just an amateur’s edit of a rota) shows that if there was a ‘murderer’ on the ward, an “unnamed nurse” and a doctor, were both more likely culprits than Letby.
Very weirdly, Ben Myers KC, for Letby, agreed with the prosecution to exclude from the trial, statistical evidence that more or less proved her innocence, because it was confusing? It need be no more confusing than the information in this paragraph. It simply needs an independent expert to do the analysis and present the conclusions to the Jury. Why did you agree to exclude it Mr Myers? And why did you agree not to contest an absurd insulin reading, that forced Letby to say, the insulin must have been administered maliciously when there are multiple other explanations for the reading? I also understand Mr Myers had two paediatric medical experts of his own who reviewed Dr Evans’ reports and listened to his testimony. I understand they were in the courthouse waiting to testify in Lucy’s defence, waiting to challenge Dr. Evans’ testimony. Waiting and waiting in a nearby room, but never called to testify by Mr Myers. Why? And where is Mr. Myers now? There are multiple questions hanging over his defence of Letby, but he remains silent. There’s no reason for his silence…..or is there? Myers needs to explain how and WHY he failed to successfully defend her.
She was locked up for 3 years, put through a 10 month trial, found guilty and handed down the harshest sentence possible – after the Judge let jurors leave for ‘personal reasons’ and accepted majority verdicts. The CJS has a huge incentive to prevent a retrial and her possible exoneration after the way the case has been handled.
So in summary it was in everyone’s interest that she was found guilty, except hers, and it’s in everyone’s interest that she doesn’t get an appeal, except hers.
And now it is me, Richard Gill, speaking again.
But of course, it seems to many that I also believe in idiotic conspiracy theories, and worse still, am influential enough to spread them around, like a virus. Who would believe that a British court could ever wrongly convict an innocent person! I have been labelled a crackpot and a conspirator and much worse, ending up with a recent ban on editing Wikipedia, where I had been urging editors to take account of the fact that being convicted of a crime is not synonymous with having committed a crime; and that Lucy was appealing against her conviction. Seems that Wikipedia editors in the UK do not realise that in most of the civilised world everyone has a right to an appeal, and that moreover, till the appeal is over, people are not comfortable with stating that their guilt is a fact.
Not only all that, but the Wikipedia article about myself was being vandalised by vile idiots. Fortunately some sensible people noticed this and managed on the whole to rapidly revert the vandalism. But now that I’ve been banned the Wikipedia article about me is being filled up with the most idiotic garbage.
Anyway, that’s enough for this moment, but this post will get extended soon, I am sure.
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![\displaystyle R_k=-\mathrm{Sc}\!\left[a^{T} I_{\mathrm{singlet},k}\, b\right] =-a\cdot b .](https://s0.wp.com/latex.php?latex=%5Cdisplaystyle+R_k%3D-%5Cmathrm%7BSc%7D%5C%21%5Cleft%5Ba%5E%7BT%7D+I_%7B%5Cmathrm%7Bsinglet%7D%2Ck%7D%5C%2C+b%5Cright%5D+%3D-a%5Ccdot+b+.&bg=ffffff&fg=1a1a1a&s=0&c=20201002)
![\mathbb{E}[D]= P_{\mathrm{equal}}-P_{\mathrm{unequal}}](https://s0.wp.com/latex.php?latex=%5Cmathbb%7BE%7D%5BD%5D%3D+P_%7B%5Cmathrm%7Bequal%7D%7D-P_%7B%5Cmathrm%7Bunequal%7D%7D&bg=ffffff&fg=1a1a1a&s=0&c=20201002)
![P_{\mathrm{equal}}=\frac12(1+\mathbb{E}[D])](https://s0.wp.com/latex.php?latex=P_%7B%5Cmathrm%7Bequal%7D%7D%3D%5Cfrac12%281%2B%5Cmathbb%7BE%7D%5BD%5D%29&bg=ffffff&fg=1a1a1a&s=0&c=20201002)
![\displaystyle P(D_k=+1\mid R_k)=\frac12(1+R_k),\qquad \mathbb{E}[D_k\mid R_k]=R_k,](https://s0.wp.com/latex.php?latex=%5Cdisplaystyle+P%28D_k%3D%2B1%5Cmid+R_k%29%3D%5Cfrac12%281%2BR_k%29%2C%5Cqquad+%5Cmathbb%7BE%7D%5BD_k%5Cmid+R_k%5D%3DR_k%2C&bg=ffffff&fg=1a1a1a&s=0&c=20201002)
![[-1,1]](https://s0.wp.com/latex.php?latex=%5B-1%2C1%5D&bg=ffffff&fg=1a1a1a&s=0&c=20201002)
![[0,\pi]](https://s0.wp.com/latex.php?latex=%5B0%2C%5Cpi%5D&bg=ffffff&fg=1a1a1a&s=0&c=20201002)
