“I alerted the police to 25 other suspicious cases at the Lucy Letby maternity hospital,” says a key witness

Critics of the case have argued that the death rate for the Countess of Chester was unusually high, even when the Letby deaths were taken into account. While two or three deaths per year were common in the neonatal unit, there were 17 deaths linked to the unit, only seven of which were blamed on Letby.

Dr. Evans confirmed that 10 deaths were never presented to the jury because they lacked “significant consistencies” that suggested wrongdoing. To be included in the indictment, the deaths had to have occurred “unexpectedly” and “unexplained” from conditions that affect babies, such as an infection, sepsis or a congenital problem.

“There were issues with all seven of these (babies) that were suspicious,” he added. “Why did this baby collapse?” That’s suspicious. Babies don’t do this all of a sudden.

“Why didn’t these babies respond to resuscitation? That in itself is suspicious.

“Most surprising were the comments from neonatologists who should know better, commenting on cases where they had not seen the clinical records and had not been to court.”

Outside experts have pointed to problems on the ward that may have increased the babies’ risk of death. The ward was understaffed, cramped and admitted more vulnerable babies than usual. Since the trial, it has also emerged that the neonatal unit was hit by an outbreak of Pseudomonas, a bacteria known to be fatal to vulnerable babies.

At the Thirlwall Inquiry, which is currently examining how the deaths could have been prevented, parents of the babies who died spoke of unhygienic practices on the unit and described scenes of “chaos” and “pandemonium”.

A father told the hearing how he had caught doctors and nurses Googling how to perform a life-saving procedure, describing the hospital’s operating theater “like something out of a horror movie”.

“There were protocols for everything.”

The year before the deaths in Letby, a premature baby died after doctors accidentally inserted a breathing tube into his esophagus when it should have gone into his trachea. Several of the babies also experienced medical accidents on the ward, including four incidents in which umbilical venous catheters (UVCs) were misplaced or fell out.

However, Dr. Evans believes concerns about the hospital have been overblown.

“I think the criticism of the Chester unit as dysfunctional is misplaced,” he said.

“Before Letby began her carnage, survival rates for even the smallest babies in Chester were very good, as good as the Office of National Statistics figures for England and Wales.

“There were protocols for all sorts of things that you don’t get in a dysfunctional unit. When the babies collapsed, the counselors were there. And then the nurses’ and doctors’ testimony (at the trial) showed that they clearly knew what they were doing.

“I didn’t know about the case of the baby whose tube went into the esophagus instead of the trachea. That’s unfortunate. Unfortunately, that could have happened anyway. This is not an attempt to defend it.”

A former pediatrician from Carmarthen, Dr. Evans, 75, retired from practicing medicine in 2009 and founded a company called Dewi Evans Pediatric Consulting, which provides expert medical advice on legal matters such as child abuse cases and criminal proceedings.

In 2017, just a month after the first report was received by Cheshire Police, Dr. Evans reported the investigation in the local newspaper and sent an email to the National Crime Agency saying: “If Chester Police have no one in mind I would be happy to help. Sounds like my case.”

He had already worked on 49 cases for the NCA and received thousands of pages of unredacted medical notes from the Countess of Chester.