Context
Mr Justice Goss delivered his summing-up to the jury at Manchester Crown Court in July 2023, across several court days. The summing-up is the last sustained judicial exposition the jury hears before retiring to consider verdict, and its influence on deliberations is disproportionate. This expanded summary tracks the summing-up’s structure and, for each strand, identifies the specific directions post-conviction commentary has argued were inadequate.
The expert-evidence direction
The summing-up addressed the expert evidence. A modern UK expert-evidence direction would normally walk the jury through the methodological framework of each expert, the limitations of that framework, and the comparative standing of the experts’ qualifications. In particular, where a prosecution expert has approached police offering his services, has been out of routine NICU practice for over a decade, and has been publicly criticised in an unrelated family-court matter, those features are relevant to the weight the jury attaches to his opinion.
The summing-up on Dr Evans’s evidence covered his conclusions. The extent to which it walked the jury through the methodological and instructional features is the specific matter the Bar Council letter and the October 2025 CCRC application materials address.
The statistical direction
The Royal Statistical Society’s post-Sally-Clark guidance is the canonical UK reference for statistical directions in criminal trials. It warns specifically against presenting patterns derived from selected events without making the selection effect explicit to the jury. The summing-up addressed the shift-rota chart but, on the public record, did not walk the jury through the specific selection-effect problem the RSS framework flags.
Prof. Richard Gill’s “tale of two Lucies” lecture and Prof. Peter Green’s subsequent commentary both identify the specific direction that should have been given.
The Post-it notes direction
The jury was asked to read “I am evil I did this” as a confession. The summing-up addressed the notes. A direction consistent with modern clinical-psychology understanding would have placed the highlighted phrases in the context of the whole document (which contains contradictory lines), distinguished private self-blame writing from forensic confession, and reminded the jury of the sustained-accusation context in which the notes were written.
The clinical-psychology expert reports filed with the October 2025 CCRC application address the self-blame reading at the level of detail a fair direction would have required.
The institutional-context direction
A fair summing-up in a case of this structure would also walk the jury through the institutional context: the unit strain, the outbreak, the infrastructure failures, the scope limits of the 2016 RCPCH review, the scope limits of the 2016 CQC inspection, and the eventual arrest of the executives whose scope-limiting decisions put police referral off for eight months. Much of this documentary picture only fully crystallised through the Thirlwall Inquiry in late 2024. The summing-up in July 2023 could not, therefore, have captured it.
The CCRC framing
The CCRC can consider the adequacy of the summing-up as one ground on which a conviction may be unsafe. The question for the Commission is not whether the 2023 directions were wrong by 2023 standards. It is whether, given what is now known, a Court of Appeal would conclude the 2023 jury had been adequately equipped. That question is answered by the independent-expert evidence now before the Commission.
Read alongside
Judge’s summing-up — short summary, Our summing-up analysis, Evidence: summing-up framing, The Sally Clark parallel.