Open Letter to the Chief Constable of Cheshire Police - From Nineteen Nurses

Dear Chief Constable,

We write today to raise serious concerns formally.

These concerns relate to the conduct and integrity of Cheshire Constabulary’s investigation under Operation Hummingbird, in respect of the Lucy Letby case at the Countess of Chester Hospital. The issues outlined below, based on direct observations made during both the trial and the Thirlwall Inquiry, raise concerns about the professionalism, fairness, transparency, and thoroughness of the investigation.

Concerns:

1.     Failure to comply with the requirements of the Criminal Procedures and Investigations Act 1996 S23(1) (a), and its associated Code of Practice. The Senior Investigating Officer (SIO) and the investigation team failed to follow all reasonable lines of enquiry.  The investigation was inappropriately focused on one individual.

2.     Failure of Investigative Objectivity as required by the Practice Advice on Core Investigative Doctrine (2012): The SIO did not adopt an objective, broad-based approach. Hospital consultants, notably Dr Stephen Brearey, who initially accused Lucy Letby, were treated solely as witnesses rather than potential Targets of Interest (TOIs). This failure to address conflicts of interest allowed accusers undue influence, compromising the investigation’s impartiality. In particular, the investigation believed one account from the outset, as demonstrated by DCS Wenham's evidence to the Thirlwell enquiry.  The SIO and the investigation did not recognise the dangers of investigative bias or put in place measures to mitigate its detrimental impact.

3.     Access to Sensitive Evidence: Staff from the neonatal unit under investigation were granted access to sensitive medical notes and police evidence. This posed significant risks of evidence contamination or bias, undermining the integrity of the investigation.

4.     Failure to Engage Independent Oversight of the Investigation, Contrary to the recommendations of the Murder Investigation Manual 2006: There appears to have been no independent professional review or oversight at any stage in order to ensure that the investigation was being effectively and appropriately directed and in order to mitigate investigative biases and conflicts of interest.

5.     Failure to follow best practice and the advice of the National Crime Agency (NCA) to appoint a range of relevant experts to review medical records. At an early stage, the NCA advised Op Hummingbird to appoint a range of relevant experts to review the material; they also provided suggested names of experts with appropriate expertise.  Op Hummingbird ignored that advice and inappropriately appointed a single ‘expert’ who had inveigled himself into the investigation.

6.     Failure to Investigate Systemic Issues: The investigation focused predominantly on Lucy Letby, neglecting systemic failures at the Countess of Chester Hospital, such as staffing shortages, treatment delays, and inadequate supervision, as noted in the 2016 Royal College of Paediatrics and Child Health report.

7.     Inappropriate and Inaccurate Data Analysis: The analyst involved failed to accurately represent critical data, specifically staff entry and exit times from the neonatal ward. This misrepresentation may have skewed the investigation’s conclusions.

8.     Failure to appropriately challenge Statistical Evidence; It is clear that the assertions of ‘experts’ reporting to the investigation were not appropriately challenged by competent expertise.  In particular, Dr Jane Hutton was excluded from reporting upon a statistical chart that was adduced in evidence to assert that nurse Letby was present at the deaths and injuries of babies.  Apparently, on the instructions of CPS, Dr Hutton was dispensed with inappropriately. Additionally, this fact was not disclosed to the defence in accordance with the Criminal Procedures and Investigations Act 1996.

9.      Apparent Lack of Covert Evidence Gathering: While operational details may be sensitive, it appears that covert evidence-gathering tactics were not employed. Given the gravity of the offences, the absence of such methods raises concerns about the investigation’s thoroughness and effectiveness.

Yours sincerely

Nineteen Nurses

When Scrutiny Is Downgraded:

Unanswered Concerns in the Lucy Letby Investigation

The Lucy Letby case is often described as one of the most significant criminal prosecutions in modern British history. Given the scale of the allegations, the gravity of the convictions, and the profound impact on families, clinicians, and public trust, the police investigation underpinning the case ought to withstand the highest level of scrutiny.

Yet a detailed submission raising concerns about Operation Hummingbird, Cheshire Constabulary’s investigation into events at the Countess of Chester Hospital, was rejected as a formal complaint — not on its substance, but because the author was “not directly involved in

the case.” using the police Reform Act 2002

Nineteen nurses resubmitted the matter as a concern. It was later described by the Professional Standards Department as “not categorised” and ultimately forwarded merely as information to the Major Crimes Team responsible for Operation Hummingbird itself.

This procedural journey matters. The issues raised are not abstract or speculative: they go directly to investigative integrity, evidential standards, and governance failures in a case carrying life-sentence consequences.

What follows is an examination of those concerns, why they are problematic, and what the police response reveals about gaps in accountability.

Why the Police Refused to Accept a Complaint

Cheshire Constabulary stated that it could not accept a complaint from an individual or organisation not directly involved — that is, not a victim, suspect, or police officer.

That decision immediately placed the submission outside the statutory complaints framework (police reform act 2002)

meaning there was:

• No formal recording obligation

• No assessment for referral to the IOPC

• No requirement for investigation or outcome

This raises a serious question: who can raise systemic concerns about policing if only insiders are permitted to complain? In cases involving complex institutions, insiders may be conflicted, implicated, or silenced — precisely when external scrutiny is most necessary.

The Concerns Raised — and Why They Matter

1. Failure to Follow All Reasonable Lines of Enquiry

(Criminal Procedure and Investigations Act 1996, s.23)

The first concern is that the investigation failed to pursue all reasonable lines of enquiry, instead becoming prematurely focused on a single individual.

Under the CPIA, investigators are legally required to pursue evidence that both implicates and exculpates. In the Letby case, concerns were raised that once suspicion fell on Lucy Letby, alternative explanations — including systemic failures — were not robustly explored.

Why this matters: once an investigation narrows too early, confirmation bias can shape evidence gathering, interpretation, and disclosure.

2. Failure of Investigative Objectivity and Management of Bias

(Core Investigative Doctrine, 2012)

The investigation is said to have failed to maintain objectivity. Hospital consultants — notably Dr Stephen Brearey — who initially raised accusations against Letby were treated solely as witnesses rather than as potential persons of interest, despite clear conflicts.

Evidence given to the Thirlwall Inquiry by senior officers indicates that one narrative was accepted from the outset. There appears to have been no effective mitigation of investigative bias.

Why this matters: unmanaged bias undermines the reliability of conclusions, particularly in cases involving professional hierarchies and institutional pressure.

3. Access to Sensitive Evidence by Interested Parties

Staff from the neonatal unit under investigation were reportedly given access to sensitive medical notes and police material.

This presents obvious risks:

• Contamination of evidence

• Retrospective alignment of accounts

• Reinforcement of a dominant narrative

Why this matters: Evidential integrity is foundational. Allowing potentially interested parties access to sensitive material risks undermining the entire evidential chain.

4. Absence of Independent Oversight

(Contrary to the Murder Investigation Manual 2006)

There appears to have been no independent professional oversight or review of Operation Hummingbird at any stage.

The Murder Investigation Manual emphasises independent oversight specifically to counter:

• Groupthink

• Investigative drift

• Conflicts of interest

Why this matters: without oversight, errors can compound unnoticed — especially in long-running, high-profile investigations.

5. Ignoring National Crime Agency Advice on Expert Evidence

At an early stage, the National Crime Agency advised Operation Hummingbird to appoint a range of relevant experts to review the medical records and even suggested suitable candidates.

That advice was allegedly ignored. Instead, a single expert was appointed — someone who had effectively inserted himself into the investigation.

Why this matters: reliance on a single expert increases the risk that unchallenged assumptions or errors become treated as settled fact.

6. Failure to Investigate Systemic Failures at the Hospital

The investigation focused predominantly on Lucy Letby while neglecting systemic problems at the Countess of Chester Hospital, including:

• staffing shortages

• treatment delays

• inadequate supervision

These issues were explicitly identified in a 2016 Royal College of Paediatrics and Child Health report.

Why this matters: systemic failures can generate patterns of harm that resemble intentional wrongdoing. Ignoring them risks mistaking correlation for causation.

7. Inappropriate and Inaccurate Data Analysis

Concerns were raised that staff entry and exit times from the neonatal unit were inaccurately represented, potentially skewing investigative conclusions.

Why this matters: data analysis carries an aura of objectivity. Errors or misrepresentations can falsely reinforce a theory of guilt. The jury in the first trial was unaware of this error.

8. Failure to Properly Challenge Statistical Evidence

Statistical charts were used to assert that Lucy Letby was present during deaths and collapses. However:

• Expert statistical evidence was not appropriately challenged

• Dr Jane Hutton was excluded from reporting at the direction of the CPS

• This exclusion was not disclosed to the defence, contrary to CPIA obligations

Why this matters: statistical evidence is powerful but dangerous when misused. Courts have repeatedly warned against implying causation from presence alone.

9. Apparent Absence of Covert Evidence-Gathering

Despite the gravity of the allegations, there appears to have been no covert evidence-gathering.

Why this matters: Covert tactics are often used to test hypotheses objectively. Their absence raises questions about investigative thoroughness.

From Complaint to “Concern” — and Then Nowhere

After the police refused to accept the submission as a complaint:

• It was resubmitted as a concern

• Police stated it was “not categorised”

• It was passed as information to the Major Crime Team — the same structure responsible for Operation Hummingbird

No independent body assessed it. No formal response was required. No governance mechanism ensured separation between scrutiny and subject.

Governance Failure and the Lack of Overlap

Good governance relies on overlapping safeguards. In this case, those safeguards failed to intersect.

If someone is not:

Directly involved in the case or

• A victim

• A suspect, or

• A police officer

Then even detailed, evidence-based concerns about a major investigation can fall into a procedural void.

That lack of overlap allows serious questions to be neutralised not through rebuttal, but through administrative classification.

Conclusion

The Lucy Letby case demands confidence — not only in verdicts, but in the investigative processes that led to them.

Rejecting a detailed submission because of who raised it, downgrading it to an uncategorised concern, and routing it back to the very team under scrutiny exposes a troubling accountability gap.

Whether or not these concerns ultimately withstand challenge, they are precisely the kind that a mature, transparent policing system should be willing — and required — to examine.

When scrutiny is deflected rather than engaged, the damage is not confined to one case. It is done to public trust itself.