By Ilkay Cetin
28th of January 2026
Introduction
In any functioning justice system, the possibility of error must be not merely acknowledged but actively guarded against. The consequences of wrongful conviction are catastrophic: innocent people lose their liberty, their reputations, and often their lives, while the actual causes of harm—whether criminal perpetrators or systemic failures—go unaddressed. The public’s trust in the entire edifice of law depends on the system’s willingness to examine itself honestly and correct its mistakes.
Two recent cases in England expose deep structural problems in how the criminal justice system handles doubt, evidence, and institutional self-protection. The cases of Lucy Letby and Auriol Grey are superficially very different—one involves the alleged murder of seven babies by a neonatal nurse, the other a fatal encounter between a pedestrian and a cyclist on a pavement. Yet beneath the surface, they share troubling commonalities that reveal how the system can become more invested in defending its conclusions than in pursuing truth.
Both women are innocent. Both have become victims of a system that, having made errors, proved incapable of acknowledging them. In Grey’s case, this was eventually corrected—though only after a year in prison for something that was not a crime. In Letby’s case, the injustice continues, and an innocent woman remains in a cell serving fifteen whole-life sentences for crimes that did not occur.
Part One: The Auriol Grey Case
The Incident
On 20 October 2020, Auriol Grey, a 46-year-old woman with cerebral palsy and partial blindness, was walking along a pavement on the ring road in Huntingdon, Cambridgeshire. Celia Ward, a 77-year-old retired midwife, was cycling along the same pavement in the opposite direction. CCTV footage captured what happened next: Grey shouted “get off the fucking pavement” and made a gesture with her arm. Ward fell from her bicycle into the road, where she was struck by a passing car and killed.
It was, by any measure, a tragedy. A woman lost her life, a family was devastated, and the driver of the car—who had her two-year-old daughter with her—had her life “turned upside down.” The question was whether it was also a crime.
Crucially, CCTV footage showed that Ward did not fall from her bicycle immediately when Grey shouted. The Court of Appeal judgment later noted that Ward “would likely have been able to see the appellant from some 85 metres away and, despite the appellant’s unusual gait, did not stop.” Grey shouted when Ward was still at a considerable distance. Ward continued cycling directly toward Grey, and the fall occurred only when they were close together. This sequence of events is important: Grey did not strike Ward or cause her to fall through any physical contact.
The Prosecution
Cambridgeshire Police investigated, led by Detective Sergeant Mark Dollard. Grey was charged with unlawful act manslaughter—a charge that requires proof that the defendant committed an unlawful act (the “base offence”) that caused the death.
The first trial ended with a hung jury—the jurors could not agree on a verdict. Rather than reconsidering whether the case should proceed, the Crown Prosecution Service pushed for a retrial. At the second trial, Grey was convicted and sentenced to three years in prison.
The Problems
Almost immediately, serious questions emerged about the prosecution’s case.
Was the pavement even a shared-use path?
The prosecution’s narrative assumed that Ward was cycling lawfully on a shared pedestrian-cyclist path. But this was never established. Cambridgeshire County Council stated publicly that they “cannot categorically say it is a shared use path as we could not find any legal records to evidence this.”
The judge at sentencing simply asserted it was a shared path, but on what basis? Local investigative journalism by CambsNews used Google Street View archives to examine the signage over the years. They found that a shared-use sign had been installed near the incident location—but only in 2022, two years after Ward’s death. At the time of the incident, there was no such sign at or near the location, and none in the direction Grey had come from.
What about the physical environment?
The pavement was described as 2.4 metres wide, but this tells only part of the story. As one analyst noted, the path “is narrow and has obstructive signpost and traffic light poles.” The usable width—the space actually available for a pedestrian and cyclist to pass—was never properly measured or considered. The path lacked all the usual characteristics of a shared-use facility: no grass verge separating it from the road, no clearly marked exits for cyclists, and constant interruptions from side roads.
No responsible cyclist, it was argued, would choose to use it. It was simply a raised footpath beside a busy ring road.
What was the unlawful act?
This proved to be the fatal flaw in the prosecution’s case. Unlawful act manslaughter requires proof of a “base offence”—some crime that the defendant committed which then caused the death. But what crime did Grey commit?
She shouted. She gestured. The CCTV showed no physical contact. As Adrian Darbishire KC, her appeal barrister, told the court: “Hostile gesticulation is not a crime, otherwise we would have 50,000 football fans each weekend being apprehended.”
The prosecution never clearly identified the base offence to the jury. The trial, as the Court of Appeal would later find, “proceeded on the basis that some kind of unlawfulness, undefined and unspecified, was sufficient.”
What about Grey’s disabilities?
Grey has cerebral palsy affecting her right side and is partially blind. In her police interview, she explained that she perceived the bicycle as travelling fast toward her in the middle of the pavement and felt anxious about being hit. She said she “may have unintentionally put out her hand to protect herself.”
These disabilities were acknowledged but, according to the sentencing judge Sean Enright, did not explain her actions. Yet how can a court properly assess the “hostility” of a gesture made by someone with impaired motor control? How can it evaluate the “unreasonableness” of a reaction by someone who is partially blind and saw a vehicle approaching on a narrow path?
The Appeal
Grey spent a year in prison before the Court of Appeal heard her case in May 2024. The judgment was devastating for the prosecution.
Dame Victoria Sharp, delivering the ruling, found that “the prosecution case was insufficient even to be left to the jury.” The court had “no hesitation in concluding that the appellant’s conviction for manslaughter is unsafe.”
Critically, the judgment noted: “Had Mrs Ward not died, we regard it as inconceivable that the appellant would ever have been charged with assault.”
Read that again. The Court of Appeal found that the only reason Grey was charged at all was because someone had died. The underlying conduct—shouting and gesturing—would never, on its own, have warranted prosecution. The gravity of the outcome had caused the system to work backwards to find a crime.
The CPS Response
What happened next reveals the institutional mindset at work. After the Court of Appeal quashed the conviction, the CPS barrister asked for the case to be sent back to the Crown Court for a third trial.
Consider the sequence:
- First trial: Hung jury
- Second trial: Conviction
- Court of Appeal: Conviction quashed as unsafe; prosecution case “insufficient even to be left to the jury”
- CPS response: Please let us try her again
The request was denied. But the fact that it was made at all demonstrates something important about how the system operates. Despite it being obvious that there was no base crime—no unlawful act had ever been identified—the prosecution’s instinct was to keep pursuing a conviction.
Grey’s conviction was only overturned because solicitor Ben Rose of Hickman & Rose took on her case pro bono and identified the fundamental legal flaw that everyone else—the police, the CPS, prosecuting counsel, Grey’s original defence lawyers, the trial judge, and the single judge at the initial appeal—had all failed to spot. As Rose later told the Law Society Gazette, it was “one of the most shocking miscarriages of justice I have known.”
The Detective
DS Mark Dollard, who led the investigation, told the press after the original conviction: “Everyone will have their own views of cyclists on pavements and cycleways, but what is clear is Grey’s response to the presence of Celia on a pedal cycle was totally disproportionate and ultimately found to be unlawful, resulting in Celia’s untimely and needless death.”
But Grey’s response was not unlawful. There was no crime. Dollard either knew this or should have known it. Hostile gesticulation is not a criminal offence. Shouting at someone is not a criminal offence. Yet a woman with cerebral palsy and partial blindness was prosecuted twice for doing precisely these things.
Dollard was also involved in another cyclist death case in the same area—prosecuting a drunk driver who killed cyclist Christopher Mardlin in 2021. Whether a particular focus on cyclist-related deaths influenced the determination to secure a conviction in the Grey case, regardless of the legal basis, remains an open question.
The Aftermath
After Grey’s conviction was quashed, her family released a statement: “There has been unnecessary and prolonged suffering and vulnerable people like Auriol need better support from the justice system—we hope lessons will be learnt.”
Her lawyers were more pointed: “Misconceived prosecutions and wrongful convictions such as this cause untold pain to all those affected, including the family of the deceased, as well as the person wrongly accused.”
A disabled woman spent a year in prison for waving her arm and shouting on a pavement. She was prosecuted twice, and the CPS wanted to prosecute her a third time—for something the Court of Appeal said was never a crime in the first place.
Questions Never Answered
Several questions about the Grey case remain troubling:
1. Why didn’t Ward stop? As noted earlier, Ward could see Grey from 85 metres away. Despite Grey’s “unusual gait” (caused by her cerebral palsy), Ward continued cycling directly toward her rather than stopping or dismounting. If Grey was as threatening as the prosecution claimed, why did an experienced cyclist continue toward her?
2. Why was the pavement status never established? This was surely a fundamental question. If the pavement was not legally designated for cycling, then Ward—not Grey—was arguably the one acting unlawfully. Yet this basic fact was “never clearly established one way or another at trial,” and the judge simply asserted it was a shared path despite the council’s inability to confirm this.
3. Why were the obstructions not measured? The presence of poles and signs that reduced the usable width of the pavement was noted but never properly assessed. No measurements of the actual passable space were taken.
4. Why did the first jury’s uncertainty not prompt reflection? When twelve citizens cannot agree that a crime has been committed, that should be a signal to reconsider. Instead, it prompted a second prosecution.
5. Why was Grey prosecuted at all? The Court of Appeal ultimately concluded that “had Mrs Ward not died, we regard it as inconceivable that the appellant would ever have been charged with assault.” The entire prosecution was driven by the tragic outcome, not by any criminal conduct on Grey’s part.
Part Two: The Lucy Letby Case
The Convictions
Lucy Letby, a neonatal nurse at the Countess of Chester Hospital, was convicted in August 2023 of murdering seven babies and attempting to murder seven others between June 2015 and June 2016. She was sentenced to whole life imprisonment—one of only four women in British history to receive such a sentence. A subsequent retrial in 2024 resulted in conviction for an additional attempted murder.
The case made Letby, in the words of countless headlines, “Britain’s worst child killer in modern history.” The trial lasted ten months. The prosecution presented expert medical testimony about air embolisms, insulin poisoning, and forced overfeeding. They showed handwritten notes found in Letby’s home containing phrases like “I am evil, I did this” and “I killed them on purpose.”
For most observers, the case was closed. A monster had been caught and punished.
The Doubts Emerge
Almost immediately after the conviction, however, serious questions began to be raised—not by conspiracy theorists or professional contrarians, but by medical experts, statisticians, and legal professionals.
The statistical evidence
A key piece of prosecution evidence was a chart showing that Letby was on duty every time one of the charged incidents occurred, while no other nurse was present for all of them. On its face, this seemed damning.
But statisticians identified fundamental problems with this reasoning. The chart only included incidents for which Letby was charged. It excluded six other deaths during the same period that Letby was not charged with—because she wasn’t present for them. The jury was not told about these other deaths.
As Professor Jane Hutton of the University of Warwick observed: “If you want to find out what went wrong, you need to consider all deaths, not just a subset of them.”
The statistical presentation also fell victim to what experts call the “Texas sharpshooter fallacy”—drawing a target around wherever the bullets happened to land. If you select only the incidents where Letby was present and then observe that Letby was present at all of them, you have proven nothing.
Professor Hutton had been engaged by Cheshire Police to review the statistical approach during the investigation. But in 2021, after Letby had been charged, the CPS instructed the police not to pursue this avenue of inquiry. The jury never heard Hutton’s concerns that the statistical evidence was fundamentally flawed.
The Royal Statistical Society convened a meeting in September 2024 to discuss concerns about the case, where parts of the prosecution’s evidence were “harshly criticised” and comparisons were made with evidence used in previous miscarriages of justice involving nurses.
The medical evidence
The prosecution’s medical case rested heavily on the expert testimony of Dr Dewi Evans, a retired paediatrician. He concluded that the babies had been deliberately harmed through methods including air embolism (injecting air into the bloodstream) and insulin poisoning.
But this evidence has since been challenged by experts across multiple specialties.
The air embolism theory relied partly on research published in 1989 by Dr Shoo Lee of the University of Toronto. The prosecution argued that distinctive skin discolouration seen on some babies was diagnostic of air embolism, citing Lee’s paper.
Lee himself has since said his research was misused. His paper studied air embolisms in arteries, not veins. The skin discolouration he described would not occur from venous air embolism. “When I saw the evidence presented by the prosecution, I was disturbed,” Lee said. “It was incorrect.”
In February 2025, Lee convened a panel of 14 international medical experts—including 10 neonatologists, three paediatrics experts, a senior neonatal intensive care nurse, and an engineer—to review all of the cases from Letby’s trials. They were provided with the medical records and relevant witness testimony. They accepted no payment and committed to releasing the findings even if they did not favour Letby.
Their conclusion: “We did not find any murders. In all cases, death or injury were due to natural causes or just bad medical care.”
The insulin evidence has also been challenged. Experts have argued that the type of blood test used is too prone to error to be relied upon in a criminal trial. A guidance note from the laboratory that conducted the tests recommends confirmatory analysis with a more accurate test if insulin administration is suspected—but no further testing was done. A quality control test conducted by the laboratory around the same period had given a falsely high insulin reading. The jury was not told about this.
Perhaps most strikingly, Dr Evans himself has since changed his position on key aspects of the case. He no longer agrees with the prosecution’s account of how some of the infants died. He has said he no longer believes any of the infants were killed “as a direct result” of air injected into their stomachs via nasogastric tubes—one of the methods the prosecution had alleged.
The defence that wasn’t
One of the most troubling aspects of the trial is what didn’t happen. Letby’s defence called only two witnesses: Letby herself, and a plumber who gave evidence about drainage problems at the hospital.
No expert witnesses were called to challenge the prosecution’s medical evidence. No statisticians testified about the flaws in the data presentation. No neonatologists offered alternative explanations for the deaths.
This means the jury heard essentially one side of the complex medical and statistical arguments. As one commentator observed, “the jury did not get a fair opportunity to hear a balanced view of the evidence.”
Why the defence made these choices is unclear. Some have suggested the original defence team did not appreciate the weaknesses in the prosecution’s expert evidence. Whatever the reason, the practical effect was that twelve jurors were asked to evaluate highly technical medical and statistical claims without hearing from experts who could explain why those claims might be wrong.
The handwritten notes
The handwritten notes
The notes found in Letby’s home—particularly the phrase “I am evil, I did this”—were presented by the prosecution as a confession. Prosecutor Nick Johnson KC told the jury the note was “literally a confession.” They have been used repeatedly in media coverage to reinforce the impression of guilt. But the context in which they were written tells a very different story.
By the time Letby wrote these notes in 2016, she had already been subjected to months of behind-the-scenes accusations. Doctors at the hospital had been spreading rumours about her since 2015. In July 2016, she was removed from clinical duties without explanation—effectively told she was suspected of harming babies, though never formally accused. She was transferred to an administrative role, isolated from her colleagues and her vocation. Her professional identity as a nurse—something she had worked toward her entire adult life—was being systematically destroyed.
The hospital’s own internal processes later vindicated her. In September 2016, Letby raised a formal grievance about her removal. In January 2017, that grievance was upheld by the board, which determined her removal had been “orchestrated by the consultants with no hard evidence.” The chief executive met with Letby and her parents in December 2016 to apologise on behalf of the trust, assuring them that the doctors who had made the allegations would be “dealt with.” In February 2017, the consultants were ordered to send Letby a letter of apology, which they did.
Crucially, it emerged after the trial that the notes were written on the advice of medical professionals as a therapeutic exercise. The Guardian reported in September 2024 that Kathryn de Beger, the head of occupational health and wellbeing at the Countess of Chester Hospital, encouraged Letby to write down her feelings as a way of coping with extreme stress. Letby’s GP also advised her to write down the thoughts she was struggling to process. This context—that the notes were produced as part of counselling sessions in which Letby was advised to write out her troubling thoughts and feelings—was not mentioned during court proceedings. The jury never knew.
So when Letby wrote those notes, she was not a nurse caught red-handed who was expressing remorse. She was a young woman whose career had been destroyed by allegations that her own employer’s formal processes had concluded were baseless. She had been told, effectively, that she was a baby killer—by people in positions of authority over her—while simultaneously being told by the hospital’s own investigation that there was “no hard evidence” against her. And she had been specifically advised by her counsellor and GP to write down her darkest thoughts as a way of processing the trauma.
The notes themselves reflect this psychological turmoil. They did not contain a simple confession. They contained contradictory, anguished statements: “I killed them. I don’t know if I killed them. Maybe I did.” They also contained denials: “I haven’t done anything wrong.” And they contained expressions of despair: “Please help me,” “I can’t do this any more,” “Why me?” They also referenced her family, her pets, work colleagues, and repeated suicidal thoughts.
Defence counsel Ben Myers KC argued at trial that these were “the anguished outpouring of a young woman in fear and despair when she realizes the enormity of what is being said about her”—anguish, not guilt. The notes are consistent with someone who has been repeatedly told she is evil and is trying to process that accusation. They are consistent with someone wondering whether the authority figures accusing her might somehow be right, even though she has no memory of doing what they claim. They are consistent with someone in psychological crisis, doing exactly what her counsellor told her to do.
What they are not is a confession. A confession involves an admission of something the person knows they did. These notes read more like someone asking herself whether the accusations could possibly be true—and concluding that they must be wrong, even as the weight of authority bearing down on her creates terrible doubt.
Post-conviction, experts have been scathing about the use of the notes as evidence. Professor David Wilson, a criminologist at Birmingham City University who specialises in serial killers, told The Guardian: “Many people will say things when they are under stress and feeling bereft that seem to imply one thing but mean nothing at all, other than reflecting the underlying stress. I always thought Letby’s notes were meaningless as evidence. If they were written as part of therapy you can underline that point three times and write it in bold and capital letters.”
Richard Curen, chair of the Forensic Psychotherapy Society, added: “Doodling, journalling is a way of taking control of your thoughts. I don’t think it relates to a confession of any kind.”
Yet no expert forensic psychologists were called at trial to give evidence on how to interpret the notes. The jury was left to draw their own conclusions about complex psychological material, without professional guidance, and without knowing the notes had been written on the advice of counsellors.
The hospital’s problems
Evidence has emerged that the Countess of Chester Hospital’s neonatal unit was struggling during the period in question. There were concerns about understaffing, inadequate training, and patient acuity exceeding the unit’s capabilities.
Documents from the ongoing Thirlwall Inquiry revealed that many nurses at the hospital “had no issue with Lucy Letby’s conduct or behaviour, but had concerns about patient acuity, understaffing and immense pressure on the neonatal unit.”
Dr Lee’s expert panel went so far as to suggest that the hospital “would have been shut down” in Canada due to the quality of care. If the deaths were caused by systemic failures rather than deliberate harm, then the prosecution of Letby has not only imprisoned an innocent woman but has also allowed the actual causes to go unaddressed.
The Original Pathology
Perhaps the most striking fact about the case is this: the majority of the infants Letby was convicted of murdering had undergone autopsies. None of the original pathologists’ reports suspected an unnatural death.
It was only later, after Letby had been identified as a suspect, that the deaths were reinterpreted as murders. The diagnoses of deliberate harm were made retrospectively, by experts working for the prosecution, who knew they were looking for evidence of murder.
This is the opposite of how forensic investigation should work. Instead of following the evidence to a conclusion, the investigation started with a conclusion and looked for evidence to support it.
The Appeals
Letby has twice applied for permission to appeal her convictions. Both applications were rejected by the Court of Appeal.
However, these rejections were based on procedural grounds—primarily that the arguments being raised could and should have been made at the original trial. The Court of Appeal’s role is not to retry cases but to assess whether the original trial was properly conducted. The fact that the defence failed to call expert witnesses, for example, cannot easily be remedied on appeal.
This creates a troubling dynamic. If your original defence was inadequate, you may be trapped by that inadequacy regardless of how strong your case might be with better representation.
Letby’s new legal team has now submitted an application to the Criminal Cases Review Commission (CCRC), which investigates potential miscarriages of justice. The CCRC has the power to refer cases back to the Court of Appeal if it finds new evidence or arguments that create a “real possibility” the conviction would not be upheld.
The expert panel’s findings, the changing testimony of prosecution witnesses, and the concerns about statistical and medical evidence will all form part of that application. The CCRC has confirmed it is treating the case as a priority, but complex reviews routinely take years—the CCRC’s own statistics show that cases lingering beyond two years are common, and the most complicated investigations can take far longer. Meanwhile, an innocent woman remains in prison.
The Thirlwall Inquiry
In parallel with the legal proceedings, a public inquiry led by Lady Justice Thirlwall is examining how Letby was “able to commit her crimes” at the hospital. The inquiry is investigating management failures, whistleblowing processes, and regulatory oversight.
But there is a fundamental problem: the inquiry’s entire premise is that Letby is guilty. Its terms of reference assume the convictions are sound and focus on how the system failed to catch a killer sooner.
In March 2025, lawyers for Letby, lawyers for the former hospital executives, and MP David Davis all requested that the inquiry be paused pending the CCRC review. They argued that if the convictions were eventually overturned, the inquiry’s findings would be “not only redundant but likely unreliable.”
Lady Justice Thirlwall refused, stating: “The inquiry does not become unfair because there is a possibility, as it is asserted, that all the convictions are unsafe.”
This creates a deeply problematic situation. If the inquiry proceeds and publishes findings based on the assumption of guilt, and the CCRC subsequently refers the case back, the result will be an official government report built on a false foundation. The inquiry will have examined the wrong question entirely—not “how did institutional failures kill babies and lead to an innocent nurse being blamed” but “how did we fail to catch a killer.”
The inquiry’s refusal to pause also serves an institutional function. By proceeding on the assumption of guilt, producing findings, and making recommendations, it creates another layer of official endorsement for the conviction. This makes it politically and institutionally harder for the CCRC to refer the case back, even if the evidence warrants it.
The Hospital Executives
In July 2025, three former senior leaders from the Countess of Chester Hospital were arrested on suspicion of gross negligence manslaughter and willful misconduct in public office. The former chief executive, medical director, and director of nursing were questioned and released on bail. The investigation remains ongoing, with police stating there are “no set timescales” for its conclusion.
These arrests are predicated on Letby’s guilt. If she is eventually cleared, the basis for prosecuting the executives collapses—or, more accurately, transforms into something quite different. They would no longer be accused of failing to stop a killer; they would be accused of presiding over a failing unit and then facilitating the wrongful prosecution of one of their staff.
The Families
The families of the babies have understandably been vocal in defending the conviction. They sat through the trial, heard the evidence, and believe justice has been done. One mother described the expert panel’s findings as “a publicity stunt” and said the families “already have the truth.”
Their grief is real. Their certainty is understandable. But their belief in the verdict does not make the medical evidence more robust or the statistical reasoning less flawed.
The families also face a profound psychological burden. If Letby is innocent, they have spent years directing their grief and anger at the wrong person. They have participated in a process that imprisoned an innocent woman while the actual causes of their children’s deaths—whether systemic failures, inadequate care, or simply tragic natural outcomes—went unaddressed.
This is not a criticism of the families. It is an observation about the impossible position they have been placed in, and about the weight of cognitive dissonance they would face if the conviction were overturned.
Part Three: Common Themes
The Letby and Grey cases are different in scale and detail, but they share troubling structural similarities that illuminate how the justice system can fail.
1. Working Backwards from Outcomes
In both cases, the severity of the outcome—death—appears to have driven the search for a crime rather than the other way around.
The Court of Appeal said explicitly of Grey: “Had Mrs Ward not died, we regard it as inconceivable that the appellant would ever have been charged with assault.” The underlying conduct was only treated as criminal because it happened to precede a death.
In Letby’s case, the original pathology reports found no evidence of unnatural death. It was only after she was identified as a suspect that the deaths were reinterpreted as murders. The conclusion preceded the investigation.
This is a dangerous inversion of proper procedure. Deaths in hospitals are common, especially in neonatal units treating premature and seriously ill babies. Deaths on roads are common, especially where infrastructure forces pedestrians and cyclists into conflict. The fact that someone died does not mean someone committed a crime.
2. Failure to Establish Basic Facts
Both prosecutions proceeded without establishing fundamental factual questions.
In Grey’s case, whether the pavement was legally a shared-use path was “never clearly established one way or another at trial.” The council said it couldn’t confirm the path’s status. Investigative journalism found that the signage was installed after the incident. Yet the judge simply asserted it was a shared path.
In Letby’s case, the statistical chart excluded six deaths that occurred during the same period. The jury wasn’t told about them. The quality control test that gave a falsely high insulin reading wasn’t disclosed. The original pathology findings weren’t given the weight they deserved.
These aren’t minor details. They go to the heart of whether crimes occurred at all.
3. Expert Evidence That Shifted
In both cases, key expert evidence has proven unstable.
Dr Evans, the prosecution’s lead expert in the Letby trial, has since changed his position on how some of the babies died. He no longer supports theories he advanced at trial. This isn’t necessarily improper—experts can and should revise their views as they learn more—but it raises serious questions about whether the jury’s verdict rested on foundations that no longer exist.
In Grey’s case, the prosecution never clearly articulated what unlawful act Grey had committed. The Court of Appeal found the case was legally deficient—not merely weak, but fundamentally misconceived.
4. Prosecutorial Persistence Despite Doubt
Both cases demonstrate the system’s reluctance to admit uncertainty.
Grey’s first jury couldn’t agree. Rather than take this as a signal to reconsider, the CPS pushed for a retrial. When the Court of Appeal quashed the conviction, the CPS asked for permission to try her a third time—even though the court had just ruled there was no identifiable crime.
Letby’s legal team has raised serious concerns about the medical and statistical evidence. International experts have concluded the deaths were due to natural causes or poor care. Yet the system continues to defend the conviction, the inquiry proceeds on the assumption of guilt, and former hospital executives are being prosecuted based on that assumption.
5. Institutional Self-Protection
Perhaps the most troubling common theme is the way institutional interests align against acknowledging error.
If Grey’s conviction was wrong, then DS Dollard’s investigation was flawed, the CPS’s charging decisions were wrong (twice), the trial judge’s directions were legally deficient, and a disabled woman spent a year in prison for nothing. Multiple agencies and individuals would be exposed as having failed.
If Letby’s conviction is wrong, the implications are vastly larger. The police investigation, the CPS charging decision, the expert witnesses, the trial judge, two Court of Appeal panels, the ongoing public inquiry, and the arrests of hospital executives—all would be implicated in a catastrophic miscarriage of justice. Careers would be ended. Lawsuits would follow. Public trust in multiple institutions would be shattered.
The system has powerful incentives to defend its conclusions, even when those conclusions are challenged by evidence that would, in other contexts, be considered compelling.
The Recent Attempt to Pile On More Charges
Just this week, on 20 January 2026, a development occurred that reveals the institutional dynamics at work with stark clarity. Cheshire Constabulary had submitted evidence to the CPS asking for eleven additional charges against Letby—two murders and nine attempted murders relating to babies at both the Countess of Chester Hospital and Liverpool Women’s Hospital.
The CPS refused. Frank Ferguson, head of the CPS’s Special Crime and Counter Terrorism Division, announced that “the evidential test was not met in any of those cases.”
Cheshire Constabulary’s response was extraordinary. In a rare public statement disagreeing with the CPS, the force said the decision was “not the outcome we anticipated” and added: “There will be some who will feel that this is news worth celebrating. We do not share this view.”
Consider what this statement reveals. The police are publicly expressing disappointment that they cannot secure more convictions against a woman whose existing convictions are being actively challenged by 26 international experts who have concluded that no murders occurred. Rather than treating the CPS refusal as an opportunity for reflection, they frame it as something people might “celebrate”—as if wanting an innocent woman not to face additional wrongful charges is somehow unseemly.
Letby’s barrister Mark McDonald responded: “Lucy Letby has always maintained her innocence—she has never hurt a child and never would. It is vital that the case is now referred back to the Court of Appeal as a matter of urgency. Thirty-one reports have been submitted to the CCRC, compiled by 26 internationally renowned experts, which provide overwhelming evidence that no babies were murdered. The reality is that a young innocent woman is in prison for crimes she has not committed.”
The attempt to bring more charges, at this moment, looks less like the pursuit of justice than an attempt to shore up a conviction that is visibly crumbling—to add another layer of charges that might make it harder for the CCRC to recommend referral back to the Court of Appeal.
6. The Families’ Role
In both cases, the families of victims have been invoked as reasons to suppress scrutiny.
Questioning Grey’s conviction was framed as disrespectful to Celia Ward’s grieving widower. Questioning Letby’s conviction is framed as tormenting the families of dead babies.
But this conflates two separate things. The families’ grief is real and deserves compassion, regardless of whether the convictions are sound. Their emotional investment in the verdict is understandable but cannot be a reason to avoid examining whether the verdict was correct.
If the convictions are wrong, the families have been misled—given a false narrative about what happened to their loved ones, directed to hate the wrong person, and denied the truth about the actual causes of death. Protecting them from scrutiny is not compassion; it is a continuation of the harm.
Part Four: What This Means for Justice
The Problem of Infallibility
The criminal justice system operates on the principle that juries, properly directed, reach correct verdicts. This is a useful legal fiction—it allows the system to function—but it should not be mistaken for truth.
Juries can only evaluate the evidence presented to them. If the prosecution’s evidence is flawed, if the defence fails to call experts, if statistical reasoning is misapplied, if expert testimony is later revised—the jury’s verdict, however sincerely reached, may be wrong.
The system acknowledges this through the appeals process. But the appeals process is designed to catch procedural errors, not to retry facts. If the original trial was properly conducted according to its own rules, the verdict stands—even if those rules allowed fundamentally flawed evidence to be presented as definitive.
The CCRC’s Limitations
The Criminal Cases Review Commission exists precisely for cases where the normal appeals process cannot remedy an injustice. But it is under-resourced and overwhelmed. Applications can take years to process. The CCRC recently confirmed that only 3% of applications are now supported by solicitors, down from a third previously.
And the CCRC faces its own institutional pressures. Referring high-profile cases back to the Court of Appeal creates conflict with the judiciary and invites criticism if the referral is unsuccessful. The safer institutional choice is often to decline to refer.
The Weight of Public Opinion
Both Grey and Letby were tried and convicted in the court of public opinion long before their legal proceedings concluded.
Grey was portrayed as an aggressive woman who killed an elderly cyclist because she didn’t like bikes on pavements. The narrative was simple, emotionally compelling, and wrong.
Letby was portrayed as a monster who murdered helpless babies. Tabloid headlines called her “evil.” The handwritten notes were reproduced endlessly. By the time the trial concluded, most of the public had already reached their verdict.
This matters because jurors are drawn from the public. Witnesses are influenced by public narratives. Judges, though trained and expected to be impartial, are not immune to the climate in which they operate. And once a conviction is secured, public opinion becomes a force actively resisting any attempt to question it.
Anyone who raises doubts about Letby is accused of harassing grieving families. Anyone who pointed out problems with the Grey prosecution was accused of defending aggressive behaviour toward vulnerable cyclists. The emotional charge of the cases makes rational analysis feel transgressive.
The Cost of Getting It Wrong
Auriol Grey’s conviction was wrongful—the Court of Appeal has confirmed this. A disabled woman lost a year of her life, was branded a killer, and was subjected to the terror of imprisonment for something that was not a crime. The actual causes of Celia Ward’s death—inadequate infrastructure, the conflict between pedestrians and cyclists, perhaps Ward’s own decision to continue cycling toward someone she could see from 85 metres away—were never examined because everyone was too busy prosecuting Grey.
Lucy Letby’s conviction is wrongful. When this is finally acknowledged, the implications will be staggering. Britain’s “worst child killer” will be revealed as an innocent woman who spent years in prison, sentenced to die there for crimes that never occurred. The actual causes of the babies’ deaths—systemic failures, understaffing, inadequate training, or simply the tragic reality that premature babies sometimes die despite everyone’s best efforts—will have been obscured for years by a false narrative of murder. The families will have been denied the truth. A public inquiry will have examined the wrong question. Hospital executives will have been prosecuted on a false premise.
And the message to every nurse, doctor, and healthcare worker would be chilling: if deaths occur on your watch and someone decides you must be responsible, the system may construct a case against you that cannot be effectively challenged.
Conclusion: A System That Knows It Got It Wrong
The most disturbing aspect of both cases is not that errors were made—all human systems make errors—but the institutional resistance to acknowledging and correcting those errors, even when those within the system must know something is badly wrong.
When the Court of Appeal quashed Auriol Grey’s conviction and ruled that there had been no identifiable crime, the CPS’s response was to ask for another trial. Not acceptance, not reflection, not acknowledgment—just another attempt to secure the conviction they had already pursued twice.
When international medical experts concluded that there was no evidence of murder in the Letby case, the response from Cheshire Constabulary was to submit evidence for eleven more charges. When the CPS refused those charges just days ago, the police publicly complained and suggested that anyone pleased by the decision was disrespecting the families. The inquiry refuses to pause. The families are deployed as shields against scrutiny. Anyone raising doubts is accused of bad faith.
This is what institutional self-protection looks like. But it is more than that. The desperation of Cheshire Police’s attempt to pile on additional charges—at the very moment when 26 experts have concluded no murders occurred—suggests a system that knows its original case is collapsing and is frantically trying to shore it up. The petulant tone of their statement about “celebrating” suggests an institution that has invested so heavily in Letby’s guilt that it cannot process the possibility of error.
The Auriol Grey case ended, eventually, with vindication—though only after she had served a year in prison for conduct that was not a crime, and only because Ben Rose was willing to take her case pro bono and identify the fundamental legal flaw that everyone else had missed.
The Lucy Letby case has not yet reached that point. But the trajectory is clear. The medical evidence that underpinned the conviction has been demolished by the very experts whose research the prosecution relied upon. The statistical reasoning has been exposed as fundamentally flawed. The key prosecution witness has changed his testimony on crucial points. The CCRC is reviewing the application. Every week brings new revelations that chip away at the prosecution’s case.
Yet an innocent young woman remains in prison, serving fifteen whole-life sentences for crimes that did not occur. The system that put her there continues to defend its actions, continues to seek new charges, continues to treat any questioning as an attack on grieving families rather than a necessary examination of whether justice was done.
This is not justice. It is the protection of institutional reputation at the cost of individual liberty. It is a system that has become so invested in its own infallibility that it cannot acknowledge the possibility—indeed, the increasingly obvious reality—that it got things catastrophically wrong.
The cases of Auriol Grey and Lucy Letby are different in their details but united in what they reveal: a justice system that has lost the capacity to say “we got this wrong” and mean it. In Grey’s case, the system was eventually forced to acknowledge error by the Court of Appeal. In Letby’s case, that acknowledgment is being resisted at every level, by every institution involved.
But the truth will out. It always does. The question is how much longer an innocent woman must suffer before the system finally admits what is already obvious to anyone who examines the evidence: Lucy Letby did not murder anyone. The babies died because of systemic failures in a struggling hospital. And the prosecution of Letby served the interests of everyone who preferred a monster to blame rather than a system to fix.
Until the CCRC refers this case back to the Court of Appeal—as it must—every day that passes is another day of injustice. Another day of an innocent woman in a cell. Another day of the system protecting itself rather than pursuing truth.
That is not justice. It is its opposite.
This analysis is based on publicly available information including court judgments, journalistic investigations, expert panel findings, and parliamentary proceedings. The author believes, based on this evidence, that Lucy Letby is innocent and that her conviction represents one of the worst miscarriages of justice in modern British history.
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