Lucy Letby Case 11 Wiki

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    This page
    contains evidence heard for child O & P (triplets) and child Q.

    Lucy Letby Case page contains live reporting links and opening statements including opening statements for each child.

    Refer to Wiki Navigation to locate pages for other babies.

    Child O & P (triplets) and Child Q

    Child O & P (triplets)

    Child O - murder allegation
    Child P - murder allegation

    Prosecution Opening Statement (child o)

    Background (child o)

    Child O and Child P were two of three triplet brothers, the court hears.

    Child O weighed 2.02kgs, which was good for a premature triplet. He was in good condition and made good progress.

    He was stable up to June 23, when he suffered what Dr Evans said was a “remarkable deterioration” and died.

    Between June 15 and June 23, Lucy Letby had been on holiday in Ibiza.

    Child O's body was examined after his death and an injury to his liver was found.

    Incident (child o)

    Letby was working the day shift on June 23 and was the designated nurse for Child O and P, in room 2, with another child.

    The prosecution say this "gave her an open opportunity to sabotage the babies".

    The third of the triplets was in room 1, the doctors believing he was the most needy of the triplets.

    Letby also had the responsibility of supervising a student nurse that day.

    The designated nurse recorded 'no nursing concern - observations normal' for Child O.

    There are three records of feeds by Letby, at 8.30am, 10.30am, and 12.30pm - the earliest signed by the student nurse, the latter two signed by etby.

    In a note made by the doctor at 1.15pm, there was '1x vomit post feed' with 'abdomen distended'.

    Child O was put on to IV fluids as a precaution.

    Child O's heart rate was 160-170, blood gases were low, and raised CO2 level.

    The doctor recorded the results as 'not normal' for a child breathing on their own and treated for suspected 'NEC'.

    It was thought down to Child O's swallowing of air or the passing of a stool earlier.

    An x-ray taken at the time showed a moderate amount of gas in the bowel loops throughout the abdomen

    Letby noted at 8.35pm - 'reviewed by registrar at 1.15pm - [Child O] had vomited (undigested milk) tachycardic and abdomen distended. NG tube placed on free drainage … 10ml/kg saline bolus given as prescribed along with antibiotics. Placed nil by mouth and abdominal x ray performed. Observations returned to normal”.

    Prior to Child O's collapse, a colleague said of Child O: "“he doesn’t look as well now as he did earlier. Do you think we should move him back to [room] 1 to be safe?"

    Letby did not agree.

    The prosecution say this echoes the final, fatal collapse of Child I.

    Letby had taken Child O's observations at 2.30pm as 100% oxygen saturations and normal breathing rates.

    From her phone, she was on Facebook Messenger at the time, and at 2.39pm, the door entry system recorded her coming into the neonatal unit.

    Within a few minutes of that, Child O suffered his first collapse.

    Letby called for help, having been alone with Child O in room 2 at the time.

    Child O's heart rate and saturations had dropped to dangerously low levels. A breathing tube was inserted by the medical staff and he was successfully resuscitated. He was kept on a ventilator.

    At 3.49pm, Child O desaturated again. doctors removed the ET and replaced it "as a precaution". Letby's written notes suggest she was the one who called for help.

    Child O suffered a further collapse at 4.15pm which required CPR. Those efforts were unsuccessful and Child O died soon after treatment was withdrawn at 5.47pm.

    A consultant doctor noted Child O had an area of discoloured skin on the right side of his chest wall which was purpuric.

    He noted a rash at 4.30pm, which had gone by 5.15pm, and did not consider it purpura, but unusre what it was or what had caused it.

    The doctor was particularly concerned about Child O's death as he was clinically stable before these events, his collapse was so sudden and he did not respond to resuscitation as he should have

    After the shift, Letby sent a series of messages to the doctor on Facebook, and to her colleague. She suggested Child O "had a big tummy overnight but just ballooned after lunch and went from there."

    Medical experts (Child o)

    A post-mortem examination found free un-clotted blood in the peritoneal (abdominal)space from a liver injury. There was damage in multiple locations on and in the liver. The blood was found in the peritoneal cavity. He certified death on the basis of natural causes and intra-abdominal bleeding.

    He observed that the cause of this bleeding could have been asphyxia, trauma or vigorous resuscitation.

    The prosecution say no-one would have thought a nurse would have assaulted a child in the neonatal unit.

    Dr Dewi Evans concluded Child O's death was the result of a combination of intravenous air embolus and trauma. The liver injury was not in his view consistent with vigorous CPR. His view was that the liver damage would have occurred before the collapse and contributed to it and was probably the reason for his symptoms through the morning. As for the air in the bowel loops, Dr Evans concluded that that was consistent with excessive air going down via the NGT.

    Dr Bohin concluded concluded that together with the chest wall discolouration seen by the doctor that was indicative of air having been injected into Child O's circulation. She agreed that the abdominal distension was due to excess gas via the NGT.

    Dr Andreas Marnerides, the reviewing pathologist, thought that the liver injuries were most likely the result of impact type trauma and not the result of CPR.

    He thought that the excess air via the NGT was likely to have led to stimulation of the vagal nerve which has an effect on heart rate and would have compromised Child O's breathing.

    He could not say whether it was either of these factors in isolation or in combination which caused Child O's death.

    He certified the cause of death to be “Inflicted traumatic injury to the liver and profound gastric and intestinal distension following acute excessive injection or infusion of air via a naso-gastric tube” and air embolus.

    Police interviews (child o)

    In police interview, Letby said she had responded to child O's alarm at 1.15pm and found he had vomited.

    She responded first at 2.40pm and discovered mottling all over with purple blotches and red rash. She said that his abdomen just kept swelling and suggested thatsometimes babies can gulp air when they are receiving assistance from Optiflow, as Child O was.

    Facebook (child o)

    A year later, on the anniversary of Child O's death, Letby carried out a search on Facebook on the surname of the child.

    Prosecution opening statement (child p)

    Background (child p)

    The prosecution allege Child P was murdered the following day from brother Child O.

    Incident (child p)

    Letby was the designated nurse for Child P.

    Letby fed Child P donor expressed breast milk at 8am, 10am, noon, 2pm and 6pm.

    The final feed, if accurately recorded, was about 13 minutes after Child O had died.

    A feeding chart is presented to the court.

    All the feeds from 8am-4pm are signed by a student nurse and co-signed by Letby.

    The 6pm feed is signed only by Letby.

    The court hears on the day shift feeds there is nothing more than a 'trace' aspirate (checking if there is anything in the stomach before the baby is fed), apart from a small amount of vomit at noon. The 8pm feed - the first after Letby's shift, produced a 14ml milk acidic (pH3) aspirate.
    The court hears because Child O had died in unusual circumstances, Child P was reviewed by Dr Gibbs at 6pm. The abdomen was “full … mildly distended”. There was no tenderness and he had active bowel sounds – good signs.

    He was screened for infection.

    An x-ray taken at 8pm showed striking gaseous distension throughout the stomach and whole bowel.

    Lucy Letby made her nursing notes at 8.24pm - therefore she was still in the neonatal at this time, Mr Johnson tells the court.
    The allegation is Letby "deliberately caused the problems" as she was ending her day shift, so she would not be detected, Mr Johnson tells the court.

    On that night shift, milk feeds were stopped for Child P on the grounds that a further large part-digested aspirate was drawn up the NGT at feeding time.

    At 6.39am, a nurse recorded the abdomen was "soft and non distended."

    25ml of air had been aspirated by one of the nurses, and the NGT had been placed on "free drainage".

    Mr Johnson said the "problem" Child P had when Letby handed over to the night shift had been resolved. The problem appeared to be air.
    When the next day shift happened, Letby was Child P's designated nurse again.

    He was with his other brother - the third of the triplets - in room 2.

    The court hears as events unfolded, while Letby was the designated nurse for the other triplet, care was transferred to another nurse.

    Text messages Letby sent to a doctor at just after 8.30am suggest she had sent, or was sending, her student with a baby who needed an MRI scan.

    A registrar noted Child P, at 9.35am, had “desat + bradys” and had a moderately distended / bloated abdomen and slightly mottled skin.

    Letby's nursing notes from that night (9.18pm-10pm) recorded: "Written in retrospect...NG tube on free drainage - trace amount in tube. Abdomen full – loops visible, soft to touch … Reg...arrived to carry out ward round – [Child P] had apnoea, brady, desat with mottled appearance requiring facial oxygen and neopuff for approx. 1 min. Abdomen becoming distended. Decision made to carry out bloods and gas (approx. 09:30)”

    The prosecution says it follows the problem with which Child P had been handed over by Letby to the night shift, but then apparently reappeared within 90 minutes of Letby taking over again.

    15 minutes later, Child P had an acute deterioration. A crash call went out. Child P was intubated and improved, and efforts were made to transfer him to Arrowe Park Hospital

    Child P desaturated again at 11.30am. He was given adrenaline.

    His spontaneous circulation improved but he continued to deteriorate through the day.

    A punctured lung was identified from an x-ray taken at 11.57am, treatment started at 12.40pm.

    The transport team arrived at 3pm. Just before they arrived, Child P's blood gases were taken and were satisfactory.

    A doctor was hopeful of Chils P's prospects.

    The court hears Letby said to her something like:"he’s not leaving here alive is he?"

    Child P's final collapse came at 3.14pm and, despite resuscitative efforts, he died at 4pm.

    A post-mortem examination had the coroner concluding Child P died from Sudden Unexpected Postnatal Collapse but he was unable to identify the underlying cause. He certified the cause of death as “prematurity”.

    Medical experts (child p)

    Medical expert Dr Dewi Evans initially suggested the cause of death was complications from his pneumothorax. He was, however, suspicious of the large volume of air in the stomach and intestines evident on x-ray. In his subsequent reports Dr Evans concluded that excess air in the stomach could have “splinted” Child P's diaphragm compromising his breathing.

    Dr Sandie Bohin also concluded that the abdominal distension splinted Child P's diaphragm resulting in an inability fully to expand his lungs and causing his collapse. Subsequent resuscitation and intubation involved high ventilatory pressures, which together with vigorous resuscitation, can cause pneumothorax. She described the abnormal gas pattern seen in Child P's stomach through to his rectum which she concluded it was caused by the exogenous injection of air via the NGT – describing that as “the only plausible explanation”.

    This excess gas splinted the diaphragm, compromised breathing and it caused Child P's collapse.Mr Johnson tells the court: "As with all these cases – it is the coincidence of problems happening when Lucy Letby was about and the coincidence of the same problems happening with different babies at different times, which we suggest is so telling and indicates that it was her malign hand at work."

    Police interviews (child p)

    In police interviews, Letby said the student nurse fed Child P at two-hourly intervals on June 23, and she had fed Child P alone at 6pm.

    She said she had agreed to be Child P's designated nurse because the parents had asked for some continuity.

    Early in the shift, around 8am, she said could see “loops” in his tummy and brought these to the attention of the doctor, and notes were made later that day.

    If what she noted was true, the prosecution say, it would say when she took over the care from the previous night, he had a developing problem, but the prosecution says we know that was not the case.

    A note by a nurse at 6.39am 'ran contrary' to Letby's note, as the problem 'had been resolved' during the night.

    Mr Johnson: "This is another example of Lucy Letby making factually false entries in the notes to cover herself."

    Letby denied deliberately causing Child P any harm.

    Defence Opening Statement (child o)

    For Child O, the allegations are "various". An air embolus is "not accepted" and the defence point towards an infection, along with "CPAP belly".

    The "liver injury" was "caused during resuscitation", the defence say. The prosecution "do not accept that", Mr Myers tells the court.

    Defence opening statement (child p)

    For Child P, the defence agree the collapse could have occurred by a splintered diaphragm, but do not agree with how it was caused.

    The defence say Optiflow is a cause.

    The defence agree once Child P collapsed, it was unclear why he did not respond to resuscitation, but that did not point to deliberate harm.

    Agreed Facts (child O & P)

    Sequence of events from records (child o)

    Intelligence analyst Kate Tyndall is now talking through the sequence of events for Child O, who was born at 2.24pm on June 21, 2016, the second of the three triplets born.

    21st June 2016
    Child O was born in 'good condition', 'cried immediately' and had a 'good tone' and a heart rate over 100bpm. He weighed 2.02kg - 4lb 7oz.

    22nd June 2016
    The sequence of events then records what happens from 1pm on June 22. Child O had been admitted to the neonatal unit after birth and cared for there.

    The court hears during this time, Lucy Letby is on holiday in Ibiza. She is informed by a doctor colleague via Facebook Messenger that triplets have been born and are being cared for at the neonatal unit.

    Text Messages (1)

    Letby responds to a Whatsapp from colleague Jennifer Jones-Key that she is working Thursday, Friday and Saturday, on her return from holiday.

    She adds: "Yep probably be back in with a bang lol"

    5.13pm: The doctor Facebook messages Letby on Wednesday, June 22 at 5.13pm: 'How was the flight?...Day has been rubbish. Lots of unnecessary stress for nnu and too much work to fit into one day. I may have (over)filled the unit again..."

    Letby: "...Oh that's not good back to earth with a bump for me tomorrow then!..."

    Doctor: "...Yes, you might be a bit busy..."

    6.29pm: A nursing note by Samantha O'Brien on Wednesday records: 'No signs of increased work of breathing...CBG carried out this AM at 1045, good result....respiratory rate remains stable. Baby nursed in incubator...temp within normal limits.'

    'Fluid requirements checked and correct...10% dextrose infusing via cannula in left hand, site became puffy throughout day....feeds of donor EBM also commenced at 1300hr, currently having 4mls 2 hr...'

    Text messages (2)

    Letby messages the doctor 'Yep just got a few bits for lunch (although maybe I won't have time to eat).

    The doctor replies he wasn't sure he'd eaten apart from a cereal bar before the triplets arrived.

    Letby asks: "What gestation are the trips? I don't mind being busy anyway..."

    Doctor: "33+5 [weeks gestation]. 3x Optiflo..."

    After more messages, the doctor asks Letby if she has any choice where she is working.

    Letby: "No, not with this new handover. Shift leader of night shift allocates for the day shift and vice versa. If your on a run of shifts you tend to stay with same babies."

    Letby adds due to the skillsets, she tends to work in nursery room 1.

    Letby adds she feels "most at home with ITU [intensive treatment unit] and the girls know that Im quite happy to be in 1 so works out well most of the time."

    The doctor replies: "...I like it when you're in itu - everything feels safe and well organised..."

    Letby: "Awe that's nice to hear, Huw often says that too - see what happens tomorrow."

    Letby adds there is a potential job opening on the unit which she believes she might be lined up for.
    doctor: 'If you didn't want it now, could you defer?'

    Letby: 'Yes good to know and worth thinking about...& yes, I'm sure she would let me defer.'

    23rd June 2016
    Nurse Sophie Ellis records, on the night shift for Child O, in a note written at 2.19am on June 23: '[incubator] temperature reduced due to temperature of 37.3C - to check hourly as appropriate. All other observations stable. Pink, warm and well perfused....abdo full but soft.'

    A note at 6.41am recorded a TPN nutrition bag was stopped as Child O had reached full feeds of donor expressed breast milk, and was 'tolerating well'.

    At 7.32am 'abdo loos full slightly loopy. Appeared uncomfortable after feed.'

    Child O was checked and settled.

    7.30am: The day shift begins at 7.30am. During this shift, Child O died.

    A rota for the day shift records four babies in nursery 1, three in nursery 2 - including Child O and Child P, three in room 3 and two in room 4.

    Samantha O'Brien is the designated nurse in room 1 for the other triplet, Christopher Booth is the designated nurse for Child Q in room 1, Lucy Letby is the designated nurse for Child O and Child P and one other baby in room 2.

    Letby records, for Child O:...'Observations within normal range...nil increased work of breathing. Donor EBM via NH tube. Minimal milk aspirates obtained...'

    Text Messages (3)

    Letby messages a colleague after 8.30am to say she had a student nurse in but 'no time to do anything'.

    Letby adds: 'She's nice enough but bit hard going to start from scratch with everything when got 3 babies I don't know and 2 hourly. Ah well...'

    The Whatsapp conversation continues over the following hour.

    Dr Katarzyna Cooke records for Child O: 'No nursing concerns observations normal'.

    The plan was to continue weaning Optiflow, establishing feeds and prescribing vitamins for Child O.

    Text Messages (4)

    Letby messages a doctor colleague to ask if he will be present in the NNU after he has been at the clinic. The doctor replies he is.

    Letby adds the student is 'glued to her'.

    Letby messages the doctor: 'I lost my handover hset - foud it in the donor milk freezer!! (Clearly I should still be in Ibiza)'

    The doctor adds he 'dropped some sweets off to keep everyone going'

    Letby: 'Ahh wondered where they had come from'

    Letby adds she had forgotten her sandwich, and jokingly asks if she can go home. The doctor replies there's a cheese roll going spare, then offers to get her something for lunch.

    Letby replies: 'Tapas?'

    She adds: 'It's ok thanks I've got a few bits with me'

    Vitamins are prescribed for Child O.

    12.10pm: The doctor records a brain scan for Child O at 12.10pm, noting normal observations.

    12.30pm: Letby records a fluid chart at 12.30pm with 'trace aspirates'. A similar reeading was recorded earlier that morning.

    1.15pm: A doctor's clinical notes record at 1.15pm, Child O 'vomits and has distended abdomen. 'Trace bile 1x vomit post feed No blood'

    'Unlikely NEC, most likely distention secondary to PMec.'

    Letby records, for 1.15pm: '[Child O] had vomitted [undigested milk], tachycardiac and abdomen distended. NG tube placed on free drainage...blood gas poor as charted...saline bolus given as prescribed with antibiotics. Placed nil by mouth and abdominal x-ray performed. Observations returned to normal'

    Text Messages (5)

    Letby messages a nurse colleague 'How's it going have you got some sun?' at 2.07pm.

    The nurse replies: '...How's your day?'

    Letby: "It's busy!!.."

    An x-ray report of 'possible onset of sepsis' by a consultant radiologist said Child O's appearance had improved on a subsequent image. 'NEC or mid gut volvulus cannot be excluded'.

    The x-ray is not time stamped but is understood to have happened prior to Child O's collapse.

    2.40pm: A doctor notes: 'Called to see [Child O] at [about] 1440. Desaturation, bradycardia and mottled. Bagged up and transferred to Nursery 1. Neopuff requirement in 100% oxygen...'

    Letby records: 'Approx 1440 [Child O] had a profound desaturation to 30s followed by bradycardia. Mottled++ and abdomen red and distended...'

    2.46pm: Shift leader Melanie Taylor is recorded as entering the neonatal unit at 2.46pm.

    3pm: The doctor records Child O was intubated '1503-1508' 'at first attempt'.

    Dr Stephen Brearey records for Child O at this time: 'small discoloured ? purpuric rash on right wall'

    3.44pm: Child O suffered another event at 3.44pm, the court hears.

    3.49pm: Bleep data for a crash call is made at 3.49pm.

    A consultant writes a retrospective note '[Child O] had been intubated about 3pm when [doctor colleague's] fast bleep went off. Arrived to find [Child O] was being bagged. Desat to 35...'

    3.51pm: Lucy Letby's note 'Drs crash called 15:51 due to desaturation to 30s with bradycardia, minimal chest movement and air entry observed. Reintubated...'

    Morphine is administered to Child O.

    4.15pm: A doctor records a further collapse for Child O at 4.15pm, and chest compressions commence.

    4.19pm: Lucy Letby records, in notes written retrospectively at 8.35pm for 4.19pm: 'CPR commenced 16:19 and medications/fluids given as documented...IV fluids 10% glucose...morphine...'
    Adrenaline is given to Child O at 4.26pm, as well as a prescription for sodium bicarbonate.

    A consultant records adrenaline and compressions given to Child O.

    4.30pm: Dr Stephen Brearey records being called back at 4.30pm.

    5pm: Lucy Letby records, at about 5pm: 'Placed back on to ventilator. Dopamine commenced....Flecks of blood from NG tube. Discolouration to abdomen. Unable to obtain heel prick...due to poor perfusion.'

    The records show attempts to resuscitate and stabilise Child O were unsuccessful. Child O was baptised.

    5.47pm: Child O passed away at 5.47pm on June 23, 2016.

    Dr Stephen Brearey records: 'After 30 mins of resus, futility of resus explained to parents. Parents and team agreed to stop CPR. [Child O] passed to mum.'

    6pm: Child P suffers an event at 6pm, the court hears.
    8.09pm: Following the death, his brother Child P was reviewed on the neo-natal unit by a consultant who ordered an abdominal X-ray. The subsequent X-ray, timed at 8.09pm, noted “gas filled loops throughout the abdomen”, Manchester Crown Court heard.

    A post-mortem blood test revealed 'nothing untoward', the court hears.

    Lucy Letby records, for the family communication: 'Parents kept updated on events throughout the afternoon - were present for some of the resuscitation and maternal grandmother present for support.

    '...Time alone [for parents and Child O] given. Photographs taken on mobile. Aware of need to keep lines/ET Tube in at present.

    '[Child O] taken to family room to be with parents. Cooling cot arranged.'

    Text Messages (6)

    The doctor messages Letby if she is ok.

    Letby: 'Think so, just finishing my notes. Can't wait to get home.'

    Letby also messages a nursing colleague about how the day had gone badly 'Lost a triplet'.

    She adds, in a message to the doctor, she was not going to vote that day.

    Letby messages the nursing colleague to say Child O 'went very suddenly' and 'had a big tummy overnight but just ballooned after lunch and went from there'.

    The nurse replies: 'Big hugs'.

    Letby says the other two babies were being screened, as it was not known why Child O had collapsed.

    She adds: 'I want to be in Ibiza'

    The nurse replies: 'Poor parents'

    Letby said Child O had died on the student's first day of a four-week placement. She adds who was on duty that day.

    The nurse replies: 'Lots of consultants then'.

    The nurse messages: 'We don't have any luck with 33-34wkrs'

    'Never seem b able to tell do u'

    Letby: 'No, deteriorate so quick'.

    Letby said one colleague was upset about what had happened.

    She adds: 'Yeah worried she's missed something'

    The nurse, in part of her reply, says: 'Wow identical triplets! Didn't know that even happened'

    Letby's mother messages her daughter to say it was sad what had happened on the first day back after Lucy Letby's holiday.

    Letby replies: 'Yep it's just as well I love my job!'

    The doctor messages Letby to say the debrief didn't find anything that was missed for the events of Child O.

    Letby messages the doctor to say 'apparently' she had sounded bossy around the time of the baptism call for Child O.

    The doctor says he would interpret it as being proactive.

    Letby says she has 'broad shoulders' and had apologised, saying it could have been interpreted as being overly direct.

    The two agree it had been a stressful situation.

    Letby said she had been 'blubbering at work' and the doctor replies a cry is needed at times, adding 'You should have seen me at the Hoole Roundabout'.

    24th June 2016 (limited reporting on details as no live reporting)
    On June 24, Letby was also assigned the day shift care of the surviving triplet, the court heard.

    Text Messages (7)

    Ahead of the shift a doctor, who cannot be identified for legal reasons, messaged Letby: “Are you OK? It’s rubbish not to sleep well in the middle of 3 long days. Hope your day goes OK.”

    Letby replied: “Hmm maybe. I’ll be watching them both (Child P and the surviving triplet) like a hawk.

    “I’m OK. Just don’t want to be here really. Hoping I may get the new admissions.”

    9.35am: Child P collapsed on numerous occasions from 9.35am onwards and required resuscitation after his heart rate and blood oxygen levels plummeted.

    3pm: A transport ambulance team had arrived at the Countess of Chester at 3pm in preparation for transferring Child P to a specialist hospital.

    3.15pm: Medics, including Letby, were unable to revive the youngster from his final collapse at about 3.15pm and he was pronounced dead at 4pm.

    4pm: Child P dies at 4pm on June 24,

    When he died, his parents “begged” the team doctor to take their surviving triplet instead, which he agreed to.

    A&E Fainting / Dr A

    Following taken from Chester Standard 20/03/2023
    Letby received a needle prick to her finger during the final resuscitation attempt, jurors were told.

    Routine blood checks were required at the hospital A&E department where Letby later fainted.

    She was later offered a lift home by a concerned doctor who friends had previously teased her about flirting with him.

    Facebook message exchanges between the pair were read out on Monday, March 20 at Manchester Crown Court, in the 21st week of the trial before a jury.

    The doctor, who cannot be identified for legal reasons, asked Letby: “Have you been seen yet?”
    Letby replied: “Yes just got back. I made a fool of myself whilst there.”

    The doctor, who was also involved in the resuscitation efforts, said: “I asked them to be quick for you. How did you make a fool of yourself?”

    Letby responded: “They said someone had asked for me to been seen asap and they knew what had happened today.

    “Everyone talking about it whilst I was there. I fainted.”

    The doctor asked: “Oh are you OK now?”

    Letby replied: “Bit shaky but OK. Writing my notes. They were reluctant to let me go as on my own.”

    The doctor said: “You could have bleeped me. I’m almost a responsible adult!

    “Do you need a lift home?”

    After she was dropped off by the doctor at her home address, Letby messaged him: “Thank you for the lift and for talking to A&E.”
    The doctor said: “I can’t have you walking back in the dark after a rubbish day, mini needlestick and an A&E faint.”

    He later asked: “What are u doing? I can’t concentrate on anything.”

    Letby said: “Wanting to (cry emoji).”

    The doctor said: “Did in car. Must have looked a right mess when I got in.”

    Letby replied: “I keep thinking of them (Child O and Child P) both in the cot together. So peaceful yet beyond words how awful it is.

    “So sad. The family thanked me when I took (Child P) in dressed. And I know age doesn’t make it any easier/harder but such a lot to go through at a young age.”

    The doctor said: “I don’t know how it would be possible to get over losing a child, let alone 2.”

    Letby responded with a crying emoji and wrote: “Think my head may explode…”

    25th June 2016
    On June 25 – when Letby is accused of attempting to murder another baby, Child Q, during the morning of a day shift – she messaged the same doctor: “Nice lunch break, Told by mum about needlestick and got a huge lecture about not being careful enough, overworked, doing too much etc.”

    The doctor replied: “That’s not what you need. She’ll be concerned that you’re not looking after yourself. Huge lectures aren’t fun are they?”

    Letby said: “My parents worry massively about everything and anything, hate that I live alone etc. Didn’t know whether to tell them or not but I thought I better had in case anything comes of it. Lectures are not fun.”

    The doctor responded: “It sounds hard for all of you. I’m sure ‘letting go’ of your child (probably the most precious thing in your life) is difficult, especially if you don’t stay local or do a job renowned for bad conditions and potential risks. What did you tell mum?”

    Letby said: “I know, I feel bad because I know it’s really hard for them especially as I’m an only child and they mean well, just a little suffocating at times and constantly feel guilty.

    “Told her I was fine, accidents happen, wasn’t anyone’s fault, just one of those things and bloods etc all precautionary.”

    9.10am: and an event for Child Q happens at 9.10am on June 25.

    27th June 2016
    The doctor messages Letby on Monday, June 27 about the care for Child Q, and a Facebook conversation takes place.

    A reference is made to clarify paperwork for a prescription for Child O during the resuscitation attempts.

    29th June 2016
    On June 29, a Datix form is filed in which Child O 'suddenly and unexpectedly collapsed'.

    30th June 2016
    Letby files a Datix form on June 30, in which it was recorded that equipment required for a procedure during resuscitation was not available on the unit.
    It was clarified in July 2016 Child O did not lose peripheral access.

    Facebook searches

    On June 23, 2017, Letby searched for the surname of Child O, Child P and the surviving triplet on Facebook.

    Witness Statements Agreed

    Family - Mother (child o & p)

    A statement from the mother of Child O, Child P and the other triplet is read out to the court.

    She says she had a 12-week scan at the Countess of Chester Hospital 'which seemed to take a bit longer than normal', where her partner realised there was more than one baby. It was confirmed she had triplets.

    The triplets would be identical, she was informed, and she was referred to Liverpool Women's Hospital to see a specialist. She was informed there was an 80% chance one of the triplets would be smaller than the other two.

    Two weeks later she went for a follow-up scan, and everything was 'fine', as were further fortnightly scans.

    She was informed the triplets were 'unlikely' to stay at the Countess of Chester Hospital neonatal unit, as there would not be the space for three nursery beds, and they may have to be treated at Birmingham.

    On June 21, the mother was admitted to the Countess of Chester Hospital, was assessed, and advised to go for a C-section.

    She went to theatre at 2pm, and the triplet boys were born shortly afterwards. They had been named in advance, and the babies were named in the order they came out.

    In recovery, she was brought pictures with the boys and their birth weights recorded.

    The mother was taken to see all the baby boys, and handled all of them.

    On the neonatal unit, there "didn't seem to be any routine for washing hands".

    All the triplets were in nursery room 1, and they were all brain scanned, with no concerns.
    The following day, the mother was taken to see the triplets, and was informed all were doing well.

    She said she asked on numerous occasions, about expressing milk, but no-one came to help until after Child O passed away, when a nurse called Lucy handed her an information leaflet.

    On June 23, the mother was in the ward and still struggling to walk. About 10-15 minutes after the father had been to the unit, he came back with a consultant doctor, who informed her Child O's stomach had swollen and 'needed a little help to breathe, so a tube had been put down his throat'. He was calm and said this was normal.

    The mother was put into a wheelchair, and upon arrival at the nursery, she said: "By the time I got there, it was a scene of chaos". A lot of doctors and staff surrounded Child O.

    "I remember nurse Lucy was there, all the time."

    "The staff appeared to be in a state of panic, and it didn't seem controlled at all."

    The mother said she sat outside, and could not bring herself to be too close, as Child O kept arresting and changing colour. "He was swollen all over his body".

    At some point, another doctor arrived and told the mother "things weren't looking good" for Child O, and said if he did survive, he would likely have brain damage.

    Child O passed away at 5pm.

    Child P and the other boy were in nursery room 2.
    The mother said: "This whole episode had come like a bolt out of the blue. On the face of it, everything seemed to be going well with the triplets.

    "As a family, we were naturally devastated.

    "With hindsight, there were a number of things we found unusual."

    The mother said she didn't expect a student nurse to be looking after one of the babies.

    She said they kept seeking reassurance that the other two boys were fine.

    A doctor, who was "quite upset", said she was very sorry for what had happened to Child O, and photos were taken of the baby boy.

    The mother said she didn't sleep at all that night. She, at one point, asked the midwife to check if the other two boys were ok. She was reassured they were fine.

    The following day, they went to the neonatal unit and were informed by a nurse the two boys had "been like angels", behaving all night and feeding regularly.

    The mother recalled having breakfast and freshening up.

    She then heard voices and saw a midwife was present and advised to go to the neonatal unit, as Child P was unwell.

    "I was devastated. A couple of hours earlier he had been fine.

    "I called my mum to tell her it was happening again."

    When she arrived, she said it was "like deja vu" and the situation was "chaotic" with people "running around" in nursery room 2, where both boys were.

    The mother said she sat outside "for long periods of time".

    At one point, a young doctor looked to be Googling 'how to insert a line'.

    They needed to do this process as Child P's lungs had collapsed during CPR.

    "This alarmed me".

    The mother was informed they were looking to transfer Child P to Liverpool, but they needed to stabilise the baby first as he kept collapsing.

    She was told things were "looking a lot more hopeful" for Child P - he looked veiny, but his stomach was not distended like Child O's was.

    At some point, the transport team arrived. The reaction from the transport team was "incredible to watch" as "they just took over".

    'Even the consultant took a back seat'. "We were reassured, he seemed calm."

    Child P passed away.

    The mother said she and her partner "begged" the transport team to take the surviving boy with him to Liverpool Women's Hospital.

    The mother said she had to discharge herself from the Countess of Chester Hospital, and asked for her care to be transferred to Liverpool. "They refused, which was the last thing I needed."

    The mother travelled to Liverpool, having stopped to pick up some clothes along the way, and were .

    "We were just made to feel at ease - the two hospitals felt like night and day."

    The staff said the surviving baby boy could be treated there for as long as there was a bed available, but did not need intensive treatment.

    The surviving baby stayed at the hospital for three and a half weeks.

    The mother said she was "surprised" there was not 1:1 nursing care for the triplets, and a student nurse was looking after them, with Lucy Letby 'popping in'.

    Lucy Letby was "extremely emotional" and "in pieces" after Child P passed away. She was "in floods of tears", the mother said. A doctor also arrived and "was also upset".

    Family - Grandmother (child o & p)

    A statement from the grandmother of the triplets is now being read out.

    She said she was aware the triplets were identical and couldn't be told apart, apart from their identity tags, and were in differently coloured blankets, and were all of good weight.

    "All was well, up until June 23."

    She was informed "something was wrong" with Child O.

    She left work and travelled to the hospital, and upon arrival, Child O was being baptised, and the parents were "hysterical" and "at a loss".

    The grandmother recalls Lucy Letby was there, and was "softly spoken".

    Child O continued to deteriorate, and a Dr John Gibbs was called to the unit, who asked Lucy Letby how many shots of adrenaline had been administered, and Lucy said she was not sure, three or four. Dr Gibbs replied: "Well, what was it, Three or four?" Lucy Letby appeared to be referring to a scrap of paper for records which had yet to be updated.

    Lucy Letby was in the unit, and the grandmother said: "I remember thanking her for her assistance during the ordeal."

    The grandmother said she could not recall what happened with Child O, as she was too busy consoling the parents.

    When she received the "awful call" about Child P being unwell, the grandmother was at home.

    She arrived at the hospital and saw a number of doctors surrounding Child P. There had been "a signficiant improvement" in Child P's condition. His condition 'seemed fine' for an hour or two, but then took a dramatic turn for the worse.

    Outside the nursery room, a nurse researched a procedure on a desktop computer.

    "I was a little surprised at this, as I assumed the staff knew what they were doing. I thought they were possibly just confirming the procedure."

    Child P continued deteriorating and the call was made to transfer him to Liverpool, but Child P sadly passed away.

    It was decided that as the transport team were already present, they would take the surviving boy to Liverpool Women's Hospital, as they were not sure if there was a congenital condition.

    A doctor informed the family there would be post-mortems for Child O and Child P to establish the causes of death.

    Family - Father (child o & p)

    A 15-minute video interview is now being played, as agreed evidence, with the father of the triplets. The video interview was recorded in December 2019.

    He says, for June 23, the scene was "a mess".

    He recalls being taken to the unit by a nurse 'asap', "there's something going on".

    He said he and the mother both "panicked".

    He recalls there was "definitely swelling" on Child O, but could not recall why, and, getting upset and pointing to his hands, he says there were 'bright blue' veins.

    He said medical staff were doing 'not a lot', and seemed to be concentrating on Child O's temperature.

    He said there were "lots of people, rushing in and out".

    He recalls seeing a 'pot belly' appearance for Child O, which then had 'gone down'.

    The ordeal lasted "ages" for Child O. It "seemed like hours".

    The doctor could offer 'no explanation' for what had happened to Child O which has resulted in him dying, the father recalls.

    The interview talks about the events of June 24.

    The father recalls having spent time with the two boys.

    He recalls the scene for Child P was "worse than the day before", and was "pandemonium".

    He said there was nothing of the sign for Child P of a swollen belly.

    He said the medical staff did not have any explanation for why Child P was unwell.

    The transport team arrived, but Child P passed away within 10-15 minutes.

    He recalls he and the mother asked the transport team to take the surviving baby boy to Liverpool Women's Hospital.

    The father adds: "I am sure it was Lucy Letby who wheeled the two boys to us. She said how sorry she was.

    "I'm pretty certain she dressed them up."

    He said it was Lucy Letby's job to do up the memory box, which included an SD card containing memories of Child O and Child P.

    The surviving baby stayed in Liverpool for 'about 11 days' and there were 'no complications at all' apart from a 'small hole in his heart', and remained stable.

    Doctor - unnamed

    A statement from a doctor is read out to the court.

    The doctor said she was aware of the triplets beforehand.

    She recalled that Child O was a good size for the gestational age, and for being a triplet. His heart rate was "absolutely fine". He was "crying and making good respiratory efforts". The oxygen levels were "just on the low side", so CPaP was supplied and the oxygen levels rose.

    Child O was "stable and nice and warm", wearing a hat. Child O was shown to the father and the doctor congratulated him.
    Child O was given mild breathing support.

    The doctor explained to the father Child O was "doing really well".

    The doctor recalled feeling "positive" and it was "a good day", and the triplets "were definitely progressing well".

    On June 22, no issues were highlighted during her long day shift, and on June 23, she was not in work. She received the news Child O had died on her next night shift.

    Senior nurse - Kate Bissell

    Kate Bissell, senior nurse, in her agreed statement, says she was involved in Child O's care from delivery. She recalled all triplets were a good size, and the mum had done well to get to 33 weeks.

    Child O needed a 'little respiratory assistance', which was 'to be expected'. He was put on antibiotics, which was standard care.

    Child O 'remained stable' throughout the rest of the shift.

    Witness Evidence

    Nurse - Sophie Ellis

    The trial is now resuming, with nurse Sophie Ellis giving evidence.

    She confirms she was the designated nurse for Child O and Child P for the night shift on June 22-23, 2016.

    She recalls Child O was reviewed towards the end of that night shift as he had "quite a full abdomen".

    The nurse recalls Child O was "very stable" that night with no concerns, and the only thing to report was a full abdomen at the end of that shift.

    At one point, nurse Ellis says the temperature is 'a little high', so the incubator temperature is turned down.

    The oxygen saturation readings were recorded as 'very good - what we would like', at 97% and above. Child O was recorded as not requiring additional oxygen, and was on Optiflow.

    Feeds were "gradually increased throughout the day", and administered "every two hours".

    The nurse's note is shown to the court, made at about 2.30am, and records 'stable' observations for Child O and that the baby boy was 'tolerating feeds well. Part digested milk aspirates, under half of feed volume 4 hourly. Abdomen full but soft'.

    The recordings were 'reassuring', nurse Ellis tells the court.

    The addendum at 7.32am records '[Abdomen] looks full slightly loopy. Appeared uncomfortable after feed. Reg Mayberry reviewed. Abdo soft, does not appear in any discomfort on examination. Has had bowels open. To continue to feed but to monitor'

    Nurse Ellis says this was something notable for Child O, hence the need for a second opinion. It was not a concern in intself, taking into context other observations, but it was "one to keep an eye on".

    Notes show Child O had 'ECG dots' - a way to measure heart activity - removed at 11pm as it was no longer needed. A cannula was removed at 5.30am on June 23, and antibiotics had been stopped at 6.41am as it was understood "everything was ok".

    Child O's Optiflow was also weaned down at 6.30am as the baby boy was "managing well".

    The nurse tells the court Child O had managed feeds, antibiotics were stopped, and he had a "very stable" and "positive" night overall for June 22-23.

    The nurse was informed Child O had passed away at the time of her next night shift.

    Cross Examination
    Benjamin Myers KC, for Letby's defence, is now asking Sophie Ellis questions.

    He asks about the feeds and aspirates for Child O during the night shift.

    He asks if the feeds of 10-12ml of donor expressed breast milk every two hours is normal.

    The nurse replies it was normal feeding policy for babies of that weight and gestational age.

    Mr Myers asks if it is usual for babies to have aspirates of under half their feeds.

    The nurse replies that reading would suggest Child O was tolerating his feeds that night.

    The nurse says she wouldn't always record a full aspirate for every feed, but would do so if there was a concern for the baby.

    Nurse - Melanie Taylor

    Giving evidence on Thursday, March 9, nurse Melanie Taylor said that at one point she had looked into room two and had a “gut instinct” something had changed with Child O.

    The shift leader said: “I can’t specifically remember what it was that I was not happy about but he didn’t look as well as when I started the shift.

    “I can’t remember the reasoning behind it. Sometimes it can be just a gut instinct. Sometimes they (the baby) can present very slight things.

    “I remember saying it out loud to Lucy.

    “I asked whether she felt we should move him into nursery one. She said ‘no’. She felt it was OK and
    wanted to keep him in nursery two and wanted to keep the brothers together.

    “I guess it’s a joint decision. Lucy was the one looking after him. She knew him and was with him all day.”

    Ms Taylor went on: “With hindsight, I wish I had been a bit firmer. I remember being put out that she was quite insistent. I think because I felt she was undermining my decision.

    “She said ‘no’. Quite plainly ‘no, I don’t feel like he should be moved’.

    “I don’t think from me it was ‘he needs to be moved now’. It was more of a feeling than any hard evidence.

    “I had a gut instinct he didn’t seem as well.”

    Philip Astbury, prosecuting, asked: “What was the advantage of room one?

    She replied: “Just the ability to have more space if anything was to deteriorate. We have more equipment on hand. We have got the emergency trollies in there.

    “The resources are closer to hand and easier to get to.”

    She said her “gut instinct” came about “an hour or two” before the first collapse of Child O in the mid-afternoon.

    Ms Taylor said she could not recall how she was alerted to the deterioration but that Letby was in room two when she attended.

    Child O stabilised before he was moved to intensive care room one where he collapsed again about an hour later but could not be resuscitated.

    Ms Taylor told the court she was “surprised” at Child O’s deterioration.

    Cross Examination
    Ben Myers KC, defending, asked the witness: “Do you recall Miss Letby explained she wanted to keep him (Child O) with his brother?”

    “Yes,” Ms Taylor said.

    Mr Myers said: “All other things being equal, keeping them together as far as you can is desirable, isn’t it?”

    Ms Taylor repeated: “Yes.”

    Dr Stephen Brearey

    A senior paediatrician at the Countess of Chester Hospital told an executive that he and his consultant colleagues were “not happy” with the defendant continuing to work on the neo-natal unit.

    Dr Stephen Brearey said he raised the matter with nursing chief Karen Rees following the deaths of two brothers on successive days in June 2016.

    The prosecution say the infants, Childs O and P, were the 15th and 16th victims of Letby, 33, who denies the murders of seven babies and the attempted murders of 10 others between June 2015 and June 2016.

    On Tuesday, March 14, Dr Brearey, head consultant on the unit, told Manchester Crown Court he held a staff debrief following the deaths of Childs O and P on June 23 and June 24.

    Nurse Letby was present at the debrief, he said, and he asked her how she was feeling.

    Dr Brearey said: “I can remember suggesting to her she would need the weekend off to recover from the traumatic events.

    “She didn’t seem overly upset in the debrief, or upset at all, and she told me she was on shift the next day, which was a Saturday.

    “I was concerned about this because we had already expressed our concerns to senior management about the association with nurse Letby and the deaths we had seen on the unit.

    “So, following the staff debrief, I phoned the duty executive on call, Karen Rees, senior nurse in the urgent care division.

    “She was familiar with our concerns already. I explained what had happened and and I didn’t want nurse Letby to come back to work the following day or until this was all investigated properly.

    “Karen Rees said ‘no’ to that and that there was no evidence.

    “I put it to her was she happy to take responsibility for this decision in view of the fact that myself and my consultant colleagues all wouldn’t be happy with nurse Letby going to work the following day.

    “She responded she was happy to take that responsibility.

    “We had further conversations with executives the following week and action was taken.”
    Additional reporting from Chester Standard (15/03/23)
    Yesterday, the court heard that in June 2015, senior paediatrician at the Countess of Chester Hospital Dr Stephen Brearey conducted a review into the circumstances of the death of Child D that month.

    An “association” with Letby and her presence at a number of collapses up to that point were noted, the court heard.

    Dr Brearey told the court a meeting followed with director of nursing Alison Kelly in late June or early July 2015.

    He said: “I think my comment at the time during the meeting was ‘it can’t be Lucy, not nice Lucy’.

    Cross Examination
    Ben Myers KC, defending, said: “I would suggest that once Ms Letby had been identified as someone, or a factor, that caused concern there was naturally a bias against her in the way she behaved and the way it was interpreted, do you agree?”

    Dr Brearey replied: “I disagree.”

    A further review of collapses at the unit from a neonatologist based at Liverpool Women’s Hospital took place in February 2016, the court was told.

    Dr Brearey said he sent a report of those findings to the director of nursing and the hospital’s medical director as he asked for another meeting.

    He confirmed that during this period there was no formal complaint made to the police.

    Mr Myers asked: “If somebody hurt a baby on your unit and you believed you had the identity of the person responsible, you’d report it to the police wouldn’t you?”

    Dr Brearey said: “I think you are making it a bit more simplistic than it was. It was not something that anyone wanted to consider, that a member of staff is harming babies.

    “Actually, the senior nursing staff on the unit didn’t believe this could be true up until the point and beyond when the triplets (Child O and P) died.

    “None of us (the consultants) wanted to believe it either.

    “This all became very exceptional and it took a step back to think about it. The nature of these collapses, the unexpected nature of them, the lack of response to resuscitation, the unusual rash noted on a number of occasions and each time the association with Nurse Letby.”

    He said he wanted to “escalate” concerns within the hospital management rather than go directly to the police.

    He said: “I needed executive support and that was what we were after.”

    Dr Brearey said there were “no more events” after Letby left the neo-natal unit.

    He said: “It was the same staff doing the same job and there were no sudden collapses.”

    The consultant told Simon Driver, prosecuting, that between the deaths of Child D and Child O he was unaware that two other babies had returned blood results which showed abnormally high insulin levels.

    Senior Nurse Kathryn Percival-Calderbank

    On Tuesday, March 21, senior nurse Kathryn Percival-Calderbank told jurors that Letby was “unhappy” if she was allocated shifts in either room three or four.

    She said: “She expressed that she was unhappy at being put in the outside nurseries.

    “She said it was boring and she didn’t want to feed babies. She wanted to be in the intensive care”.

    Mrs Percival-Calderbank, who qualified as a nurse in 1988, added: “If anything was going on within nursery one you would find she would migrate there, as we would all do to go and help. She would definitely end up in nursery one to assist.

    “It was more that we were worried for Lucy’s mental heath because it can be upsetting, emotional and sometimes exhausting as well at the end of a shift, if you’re constantly put in that stressed situation all the time.

    “Sometimes you’ve got to come out of that environment and be in an outside nursery.”

    She recalled an argument – some time before June 2016 – with Letby who was “upset” at a shift allocation.

    “Lucy went into the outside nursery but she was not happy with the decision,” she said.
    Cross Examination
    Ben Myers KC, defending, asked the witness: “Is it right she made it plain that she preferred to work in the intensive care aspect of operations?”
    “Yes,” replied Mrs Percival-Calderbank.

    Mr Myers said: “Did she use the word ‘boring’?”

    The witness said: “Yes, that’s what she said.”

    Mr Myers said: “There were times when she ended back in nursery one and everyone would be ready to help when there was an issue, wouldn’t they?”

    “Yes,” said the witness.

    Mrs Percival-Calderbank agreed with Mr Myers that Letby would be “particularly keen to assist” and “would be there very quickly if an issue arose”.

    She also agreed the concern among nursing staff was it could be “very stressful and upsetting” to work long periods in intensive care and it was beneficial for mental well-being to spend time away from nursery one.

    Mr Myers said: “But she didn’t really want to hear that and she wanted to do the intensive care, is that right?”

    “Yes,” said the witness.

    Doctor - unnamed

    Letby, 33, was said to have made the “absolutely shocking” comment ahead of a planned transfer of the infant to another hospital.

    The youngster continued to deteriorate as his heart rate and blood oxygen levels dropped, and died less than four hours later before the move from the Countess of Chester Hospital could take place.

    Recalling the conversation with Letby, a consultant, who cannot be identified for legal reasons, told Manchester Crown Court on Tuesday, March 21: “I just said, the transport team are going to be here soon, almost thinking out loud.
    “Literally counting down the minutes before they arrived and desperately wanting this baby to get better, and thinking we are just totally out of our depth and maybe someone else can help.

    “Staff nurse Lucy Letby then said ‘he is not leaving here alive, is he?’, which I found absolutely shocking at the time.”

    “I said ‘don’t say that’ and left the room.”

    Letby is accused of murdering the newborn infant, known as Child P, and his triplet brother, Child O, on successive day shifts in June 2016.

    Later the consultant said she remembered another “unusual” event involving Letby after Child P had been pronounced dead.

    She said: “ I went to speak to the parents, myself and Lucy Letby were there. I remember feeling, I don’t how to face them or how to say this.

    “I told them about that (Child P) was going to need a post-mortem.

    “Staff nurse Letby was behind me – one of the things I found unusual was she was almost very animated.

    “She was saying to the parents ‘do you want me to make a memory box like I did for (Child O) yesterday?’ I remember thinking this is not a new baby, this is a dead baby. Why are you so excited about this?

    “I found that very inappropriate, the way it was said.”

    She said she remembered the brothers’ father was “absolutely sobbing and literally begging” for the surviving triplet to be taken from the Countess of Chester.

    The consultant said: “Even though I didn’t beg, in my heart and mind I just wanted him to leave because that’s the only way he was going to live.”

    Cross Examination
    Ben Myers KC, defending, asked her: “Is that because you thought the Countess of Chester’s neonatal unit was unable to cope or are you suggesting that Lucy Letby poses such a danger to small babies?”

    The doctor replied: “It definitely was not because the Countess of Chester was not able to cope with a baby like (the surviving triplet). They were completely normal triplets who were expected to run a healthy course.

    “I was extremely worried. I couldn’t understand what had gone on in the last two days. In my mind what had gone on was not normal.

    “At that point in time I just wanted (the surviving triplet) to be in a safe place.”

    Mr Myers asked: “Because of the danger posed by nurse Letby?”

    “Yes,” she said.

    The barrister went on: “Did you call the police?”

    “No,” said the consultant.

    Mr Myers said: “If you really thought a nurse was hurting or killing babies you would have been yelling it from the rooftops, wouldn’t you? What about other babies on the unit?”

    She explained that at the time she thought the “correct thing” to do was to raise the matter with her colleagues a few days later, and with the neonatal ward manager.

    Mr Myers accused her of “dramatising for the benefit of the jury and these proceedings”.

    The doctor replied: “No, that’s honestly how I felt at the time. I have no intention of dramatising events. It’s tragic enough as it is.”

    She told Mr Myers she was unaware there was a “focus” on Letby being present at the time of child deaths.

    She said she had no reason to suspect her of anything up to the point of the deaths of Child O and Child P.

    Mr Myers asked: “Did you hear gossip, comment, finger-pointing about Lucy Letby?”

    She replied: “Yes, but vaguely. Nothing concrete implicating deaths and increasing mortality rates.”

    Mr Myers said: “Who were making these comments?”

    The doctor said: “Other junior doctors, some consultant colleagues. But again not in a way that would make you think anything untoward in the way of harm being done was going on.”

    Mr Myers suggested Letby was only voicing her concern about Child P in the hours before he died.

    The consultant replied: “I can only speak for myself.”

    Mr Myers went on: “Do you think there is a danger here – because it’s Lucy Letby we are dealing with – for her comments to be taken out of context and made to sound quite a lot worse?”

    The consultant said: “I found it unusual given the circumstances.”

    She agreed all the medics involved with Child P, including Letby, were trying their best in looking after him.

    Dr John Gibbs

    Dr John Gibbs told jurors that a number of “key safety measures” were then introduced including the removal of Letby from the neonatal unit.
    However a month later he said hospital bosses wanted Letby – whom the consultants had identified as “the common link” to the collapses – back on the unit.

    He told the court: “We said that should only happen if CCTV was put in each room in the unit.

    “The CCTV didn’t come and neither did staff nurse Letby.”

    Dr Gibbs, now retired, went on: “In the 11 months before the police got involved, after we raised concerns about the deaths of (Child O and Child P), senior management were extremely reluctant to involve the police to discuss what had happened because we had to keep insisting the police be involved.”

    Dr Gibbs reviewed Child P’s condition shortly after the death of Child O on June 23.

    He told the court: “‘I remember feeling uncomfortable when I arrived on the unit and saw (Child O) and I thought ‘Oh no, not another one’.

    “I’d become increasingly concerned, and my consultant colleagues shared the concerns, at the accumulating number of unusual, unexpected and inexplicable collapses and deaths happening on the neonatal unit and the fact that staff nurse Letby had been involved in all of them.

    “The deaths of the two triplets was a tipping point for realising something abnormal and wrong was happening on our unit.”

    Cross Examination
    Ben Myers KC, defending, said: “The reality is, as we stand here now, you are heavily influenced by a bias against nurse Letby that applies to all of you.”
    Dr Gibbs replied: “I was most heavily influenced by what was happening to babies on the unit… there was only one common factor.”

    Mr Myers asked: “You didn’t contact the police, did you?”

    Dr Gibbs said: “That was difficult. Nurse Letby seemed to be involved in all of the cases that involved me. Other consultants were involved with other babies.

    “None of us regrettably realised two babies had been poisoned by insulin, so we didn’t have the full picture.

    “After the deaths of the triplets – very regrettably too late for them – because the concerns had reached a tipping point, safety measures were introduced and one of the key safety measures which the consultants were insistent on was Lucy Letby be removed from the neonatal unit and that was not a simple, straightforward decision.”

    Mr Myers said: “You took your time asking for CCTV if your suspicions were so great, Dr Gibbs?”

    Dr Gibbs replied: “I said increasing concerns were growing over that time. The tipping point was the tragic deaths of the triplets which, looking back, should not have happened in healthy boys.”

    He said that Dr Stephen Brearey, the senior consultant in charge of the unit had previously flagged concerns to management in 2015 about the association with Letby and collapses of babies.

    Last week Dr Brearey told the court he urged a hospital executive not to allow Letby to work the day shift after the death of Child P on June 24.

    He said that she refused and it is alleged Letby attempted to murder another baby, Child Q, on June 25.

    Jurors were told Letby submitted a formal grievance to management after she was removed from the unit.

    The court has heard the surviving triplet brother was transferred to Liverpool Women’s Hospital after his parents “begged” for a move following the deaths of his siblings.

    Medical Experts Evidence

    Dr Dewi Evans

    Giving evidence on Wednesday, March 15, expert witness Dr Dewi Evans told Manchester Crown Court he believed Child O was the victim of an “air embolus” – in which gas bubbles block blood supply.

    The retired consultant paediatrician said a “small discoloured purpuric rash” had been noted on the youngster’s chest during his rapid deterioration on the afternoon of June 23.

    Dr Evans said: “I considered that the rash was consistent with (Child O) having received a injection of air into his circulation, his blood circulation.

    “My opinion was that (Child O’s) terminal collapse was him being the victim of an air embolus.

    “I couldn’t find any evidence where this could have occurred accidentally.”

    Dr Evans said it “repeated the pattern” seen in the case of Child B, a twin girl, who also had a noticeable rash during her collapse – which she survived.

    Jurors were told Dr Evans had concluded in an earlier report, in June 2018, that the cause for Child O’s collapse was trauma to the liver.

    A haematoma – bleeding – had been found in the liver during a post-mortem examination.

    Dr Evans said: “If there was a purpuric rash – little blood spots under the skin – there had to be a cause. It was indicative of direct trauma.”

    He later learned from the police that the doctor who observed the rash had further explained it disappeared a short time after.

    Dr Evans said: “This made a big difference to the interpretation of the rash. If it’s a purpuric rash it will last quite some time – days, hours.”

    Letby is also accused of murdering Child O’s newborn brother, Child P, on the following day.

    Cross Examination (child P)
    Benjamin Myers KC is cross-examining medical expert Dr Dewi Evans, who has written reports on all babies involved in the trial.

    The cross-examination today is focusing on Child P, one of two triplets who died at the Countess of Chester Hospital.

    In his reports, Dr Evans suggested the cause of death for Child P was complications from his pneumothorax. He was, however, suspicious of the large volume of air in the stomach and intestines evident on an x-ray.

    In his subsequent reports Dr Evans concluded that excess air in the stomach could have “splinted” the baby's diaphragm compromising his breathing.

    Mr Myers is first asking about the efforts to save Child P's brother Child O, about damage to the liver. Mr Myers asks if this could come as a result of chest compressions. Dr Evans says if the compressions are done properly, this would not be the case.

    A video is shown to the court showing the correct procedure on providing chest compressions to an infant.

    Mr Myers again asks if it is possible for damage to be caused to the liver by several minutes of 'vigorous' chest compressions. Dr Evans says he has never seen it in his experience.

    The questions now move on to Child P.

    Mr Myers confirms what Dr Evans had written for his three reports concerning Child P, involving complications to the pnuemothorax.

    Dr Evans said his view was that he could not explain, at the time of the first report, any other cause for why resuscitation was not successful.

    Dr Evans confirms he could come up with no 'natural cause' for Child P's death.

    Mr Myers asks about the 'splinting' of the diaphragm Dr Evans had written about in his report for Child P.

    He says in a following report, 'it is necessary to scrutinise the night care from June 23/24'.

    Dr Evans said it was the 'option at the time'. He says there was excess air in the x-ray from the night before which destabilised the baby, and meant he was unable to take feeds properly.

    He says in light of evidence given by local staff over the past few days, additional air was given to Child P during the morning of June 24 which splintered the diaphragm and caused the collapse.

    He says there were two events - excess given prior to the x-ray, which destabiised the baby, and further air into the stomach on the morning of June 24.

    He says that is a "more accurate way of explaining the events".

    Dr Evans says the most recent of his reports is from 2019, and he has since had a far better understanding of the clinical sequence of events as a result of the trial in 2023.

    He said he was "more concerned" from his evidence at the time about the night care, when
    Child P was not taking feeds and had a bradycardiac event.

    He adds he does not believe Child P would have collapsed without an additional administration of air in the morning.

    Mr Myers says Dr Evans has "shunted" the sequence to the point where Lucy Letby was on duty for that day shift on June 24. Dr Evans denies this, saying if he was wanting to put Letby in the frame, he would have included events from the June 23 day shift, when Letby was also on duty.

    Dr Evans says an "extra dollop" of air would have been administered just before 9.40am on June 24.

    He says Child P could have been suffering the consequences of an administration of air from the previous night by the following morning, but that would have been insufficient to cause a collapse, not without a further administration of air.

    Mr Myers says Dr Evans is "coming up with ideas and theories" rather than relying on the medical evidence available. Dr Evans says that is "incorrect".

    Mr Myers says Dr Evans has "invented an extra dollop of air".

    Dr Evans says he is satisfied, from a clinical perspective, about the additional administration of air on the morning of June 24.

    He says it is not a "guess" but a "clinical assessment".

    A blood gas result for Child P is shown to the court from June 23, showing 'normal gas readings'.

    Dr Evans says an administration of air would not necessarily lead to a baby "crashing". It would lead to them not tolerating milk.

    Observations for Child P are shown for the night of June 23.

    Dr Evans says there is more to a baby than a pair of lungs, there is also the stomach and intestines. The 'first administration of air' did not affect the breathing, he tells the court, but led to Child P being unable to feed. The 'second administration of air' the following morning caused splinting of the diaphragm, he says.

    Mr Myers repeats that Dr Evans has 'invented a theory' of a dollop of air to get it 'over the line'.

    Dr Evans denies this.

    Dr Owen Arthurs

    Giving evidence on Thursday, March 16, Dr Owen Arthurs, professor of radiology at London’s Great Ormond Street Hospital, said the June 23 X-ray of Child P was “very similar in appearance” to one taken of Child O.

    He told the court: “This is gas throughout the gut. This degree of gas is quite unusual in a baby like this.”

    He said potential causes were infection or necrotising enterocolitis (NEC), a common bowel disorder in premature-born babies.

    An alternative explanation was the administration of air via a nasogastric tube, he said.

    Dr Arthurs came to the same conclusions regarding an X-ray of Child O, captured hours before his death.

    He said: “This shows a lots of gas in his stomach, small and large bowel. This is more than what would be expected in a normal baby.”

    Dr Arthurs agreed with Ben Myers KC, defending, that another possible explanation for Child P’s dilation was an “unidentifiable cause”.

    Dr Sandie Bohin

    Prosecutor Nicholas Johnson KC says Dr Bohin has completed a total of five reports for Child P.

    Dr Bohin confirms she had looked through all the clinical notes for Child P, including one by Lucy Letby where she had written about the NG tube being on free drainage at 8am.

    A note at 6.39am by Sophie Ellis, from the night shift, said Child P's abdomen was 'soft and non distended', with '25mls air aspirated' and 'NG Tube placed on free drainage'.

    Letby later noted, at about 9.30am, Child P had an apnoea, brady, desat with mottled appearance, requiring facial oxygen and Neopuff for approx 1min. Abdomen becoming distended.'

    A consultant doctor was called to the nursery where Child P was.

    Child P had a 'speedy recovery' that morning and Dr Bohin is asked if that was normal.

    Dr Bohin: "No, it was not."

    Child P then desaturated again at 11.30am and was given adrenaline and paralysed with a drug to aid ventilation. His circulation was restored but he continued to deteriorate throughout the day.

    Dr Bohin is now telling the court about the adrenaline doses which were administered to Child P throughout June 24, their concentrations and totals.

    Dr Bohin explains the rate of adrenaline administered to Child P, according to the medical notes, was not calculated correctly - it was double what it should have been.

    Dr Bohin says the excess adrenaline would not have had any adverse effect, as it began to be administered after Child P had the collapse and was already suffering metabolic acidosis.

    She says it is "impossible" to quantify any effect on lactic acidosis.

    It did not adversely affect the blood pressure or heart rate, Dr Bohin adds.

    Dr Bohin tells the court she was concerned about the gas in the initial abdominal x-ray, which had been taken as a 'precaution' with no concerns about the abdomen, but it was "full of gas" and "abdominal distention right through".

    The x-ray was "abnormal".

    Throughout the night, Child P became intolerant to feeds, and the abdominal distention was reduced, but then Child P's abdomen became "distended and loopy" in the morning. That was "difficult to explain".

    Dr Bohin says Child P should have had a further x-ray sooner after he first collapsed, and more attention paid to the pneumothorax.

    The ventilatory pressures were "quite high" for Child P, who had no underlying lung disease.

    This was not a criticism of the staff, Dr Bohin says.

    For a cause to the collapse, Dr Bohin says she could find no reason why there was excess air from the previous night, and there was splinting of the diaphragm.

    It was something "striking and out of the ordinary".

    Child P had shown no signs of infection, and no evidence was found.

    Dr Bohin says her conclusion was air had been administered via the NG Tube.

    She cannot explain why Child P had further collapses on June 24.

    Mr Johnson has one more point to raise with Dr Bohin.

    He asks her about the adrenaline dose rates being double what they should be, and if that was beyond a safe limit.

    Dr Bohin explains the limits, in accordance with guidance, would have been within limits, but the higher the rate, the more the risk of side-effects.

    Higher doses would be administered in extreme circumstances, on guidance from a consultant.

    Side effects would be rising blood pressure, rising heart rates, irregular heart rates, and, in very high doses, and constricting of blood vessels.

    Cross Examination
    Mr Myers is now asking Dr Bohin questions.

    He asks about the need for an x-ray to have been taken sooner. Dr Bohin said that would have been needed when looking for the cause of a collapse.

    Mr Myers says Dr Bohin had, in her report, identified a particular issue with the adrenaline, which she had recorded as a "high starting dose".

    Mr Myers says the ventilator settings were also 'high'. Dr Bohin agrees the settings did not need to be as high as the oxygen requirement was not so high.

    Dr Bohin says the pneumothorax could have contributed to the collapse, but would not have caused it.

    Mr Myers says the care offered to Child P was, in Dr Bohin's words, 'muddled' and 'unusual' following the baby boy's collapse.

    Dr Bohin said 'questions need to be answered' about the ventilatory strategy and the high doses of adrenaline, but the latter issue had been raised and answered by doctors in court.

    She adds that neither of those issues had caused the initial collapse of Child P.

    Mr Myers asks about the rate of adrenaline administration. Dr Bohin says the starting rate depends on what the child has, their condition, and what they have been administered before.

    Dr Bohin says doctors wanted to give a 'large dose to kick-start the heart', as Child P had suffered a cardiac arrest. Even at this rate, the dose was ineffective, Dr Bohin adds.

    Mr Myers asks about a "very high" lactate reading Child P had at 10.46am on June 24. Dr Bohin says it is "impossible" to quantify, to what degree, the effect adrenaline doses would have had on the lactate levels, particuarly on Child P, who had previously had a cardiac arrest which would have raised lactate levels in any case.

    Mr Myers moves on to question about the cause of Child P's collapse.

    He says it is not mentioned in Dr Bohin's reports about any additional administrations of air that morning. Dr Bohin says there is not.

    He says the only evidence of abdominal distention is from 4am. Dr Bohin says it was identified then, it went away, then it is noted as appearing 'distended and loopy' again in the morning.

    Mr Myers asks if Dr Bohin says the splinting of the diaphragm is from air administered the night before. Dr Bohin disagrees.

    Dr Bohin says the collapse was 'unexpected and completely unexplained'.

    The collapse happened 10 minutes after Dr Anthony Ukoh examined Child P and found the abdomen 'moderately distended / bloated'.

    Dr Bohin says an issue she has had in the course of the trial is there does not seem to be consistent practie among nursing staff in the aspirations of feeding tubes, but in this case, when there was 25mls of air aspirated early on June 24, that was "normal".

    Benjamin Myers KC continues to ask Dr Sandie Bohin questions.

    He refers to the case of Child G, in reference to milk and pH levels, where a pH level from the aspirates was recorded as '4' on September 7, 2015, at 2am.

    Dr Bohin had said a pH level of 4 was 'very acidic', and there was not milk in the tummy, as the milk would 'buffer' the pH level and 'neutralise it'.

    For Child P, the feeding chart on June 23, 2016 at 8pm records 14ml of milk aspirated and a pH level of 3.

    Mr Myers says 20mls of milk is aspirated several hours later, with a pH level of 3.

    Mr Myers says that it can mean milk could have been present in the stomach for Child G, even with a pH level of 4.

    Dr Bohin said milk would 'buffer' the pH level. She adds the trial has moved through so many babies since Child G, she would need to know the clinical context for Child G.

    Mr Johnson asks to clarify the meaning of 'buffer'.

    Dr Bohin said it would effectively neutralise it.

    Nicholas Johnson rises to clarify pulmonary hypertension as a possible diagnosis.

    Dr Bohin says it can affect blood flow and blood pressure. In neonates, its an attempt for them to return to the conditions where they were in their mummy's tummy, but staff don't want that in terms of making sure a baby is clinically stable.

    "It's a very difficult thing to treat," Dr Bohin adds.

    Dr Bohin adds one of the treatments is making sure the blood pressure in the body, not the lungs, is high, through treatment.

    That concludes Dr Bohin's evidence for Child P.

    Dr Andreas Marnerides

    Child O

    On Wednesday, March 29, paediatric pathologist Dr Andreas Marnerides said Child O died partly due to an “impact-type” internal liver injury – discovered after the baby’s death.

    Jurors were shown post-mortem examination photographs which showed two separate sites of bruising, as well as areas of a blood clot.

    Prosecutor Nick Johnson KC asked the consultant: “How does that injury come to be in a child of (Child O’s) age?”

    Dr Marnerides, who practises at London’s St Thomas’ Hospital, said: “The distribution, the pattern and the appearance of the bruising indicates towards impact-type injury. I’m fairly confident this is impact-type injury.”

    He explained the photograph showed “extensive haemorrhaging into the liver”, which he had only seen previously in a road traffic collision and in non-accidental assaults from parents or carers.

    Mr Johnson said: “Looking at this sequence of photographs, can you rule out the possibility that these injuries were caused by CPR?”

    Dr Marnerides said: “I cannot convince myself that in the setting of a neonatal unit this would be a reasonable proposition to explain this. I don’t think CPR can produce this extensive injury to a liver.”

    Mr Johnson said: “In so far as you have spoken about an impact-type scenario for causing that internal injury, would you necessarily expect to see any outside sign on the skin itself?”

    The consultant replied: “You can have the most devastating injury internally and nothing can be observed externally. That is very common.”

    Mr Johnson went on: “What in your view was the cause of death of (Child O)?”

    Dr Marnerides said: “In my view, the cause of death was inflicted traumatic injury to the liver, profound gastric and intestinal distension following acute excessive injection/infusion of air via a naso-gastric tube and air embolism due to administration into a venous line.”
    Child P
    Taken from Dan O’Donohue Twitter (30/03/23)

    Dr Marnerides said in his review of Child P, he could not find anything to 'indicate natural disease for the baby's death'

    To assist the jury with his findings in relation to Child P, Dr Marnerides is presenting photographs of the baby boy's liver, taken at post-mortem, to the court. The images show small bruises on the outside of the boy's liver

    Dr Marnerides tells the court that the bruising, although a lot smaller, is in the same area that it was found in Child P's brother Child O. The court heard yesterday that Child O suffered a liver injury akin to a road traffic collision.

    The medic says the bruising found 'could' be the result of CPR - asked whether it could be another impact injury, he says 'I don’t have enough to say that'

    Dr Marnerides says having reviewed all the evidence, it is his opinion that Child P died as a result of 'excessive injection of air into the stomach'
    Cross Examination
    On Thursday, March 30, Ben Myers KC, cross-examining, said: “Can you assist with how little force could be involved?”

    The consultant at London’s St Thomas’ Hospital said: “I think there is no way of measuring a force in a baby because we don’t conduct such experiments on babies.

    “I have never seen this type of injury in the context of CPR so I would say the force required would be of the magnitude of that generated by a baby jumping on a trampoline and falling.”

    He agreed that smaller internal bruising to the liver sustained by Child O’s triplet brother Child P – who Letby is alleged to have murdered the next day – could be capable of being caused by CPR.

    But asked if “rigorous” chest compressions could be the cause of the internal bruising in Child O’s case, Dr Marnerides said: “I don’t think so, no.

    “This is a huge area of bruising for a liver of this size. This is not something you see in CPR.”

    Mr Myers said: “So you don’t accept the proposition that forceful CPR could cause this injury in general terms, do you agree it cannot be categorically excluded as a possibility?”

    Dr Marnerides replied: “We are not discussing possibilities here, we are discussing probabilities.

    “When you refer to possibilities, I am thinking for example of somebody walking in the middle of the Sahara desert found dead with a pot and head trauma.

    “It is possible the pot fell from the air from a helicopter. The question is ‘is it probable?’ and I don’t think we can say it is probable.”

    Mr Myers asked: “Is it possible in your opinion for at least some of what we see in the damage to the liver arising from the insertion of a cannula?”

    The consultant said: “I would consider it extremely unlikely. I would expect some kind of perforation injury.”

    Earlier, Dr Marnerides said the most likely explanation for the death of Child P was excessive air injected via a nasogastric tube into his stomach

    Child Q

    Child Q - attempted murder allegation

    Prosecution opening statement (child q)

    Child Q was born on June 22 - the day after Child O and P. He was premature but a good weight, and on CPAP for the first 20 hours.

    He was admitted to the neonatal unit as he needed breathing support, but was initially stable.

    He had a catheter in place via his umbilicus for nutrition, however he was well enough to commence feeding via his NGT. Initially he was put into room 1.

    Nursing staff noted small amounts of bile when they checked his NGT on June 23-24. These were not of sufficient concern to stop him being fed milk.

    A different nurse was Child Q's designated nurse on the night shift for June 24. She monitored him through the night, and fed him 0.5ml of milk every 2 hours at 3am, 5am and 7am.

    The nurse was content with the condition, although the blood gases deteriorated slightly, so she referred the results to a doctor. The doctor reviewed them and was not concerned.

    Incident (child q)

    The day shift on June 25, Letby was on duty and was Child Q's designated nurse. Child Q had been moved into room 2.

    Letby made notes on Child Q's fluid/feeding chart at 8am. Child Q was receiving nutrition Babiven via a UVC.

    Just after 9am, Letby and the nurse were together in nursery 2, and it was feeding time. The other nurse attended to another child in the room.
    According to the record, Child Q's heart and respiratory rates both increased for a short period of time.

    But, the prosecution say, the feeding chart shows something 'unusual'.

    That chart is shown to the court. The 9am fluid chart, in Letby's handwriting, appears unfinished, with numbers noted for fluids, but no record for the feed or Letby's signature initials at the bottom of the 9am column.

    The prosecution suggests something caused Letby to leave halfway through doing this.
    Letby signed for medication for another baby at 9.04am.

    The other nurse agreed to keep an eye on Child Q at 9am.

    A few minutes later, Child Q's monitor alarms activated to alert staff to a deterioration in his condition.

    Mr Johnson: "We say that Lucy Letby had sabotaged [Child Q] and had injected him with air and a clear fluid into his stomach via the NGT. She was trying to kill him."

    The nurse called for help and was joined by another nurse. Child Q had been sick and nurses used a suction catheter while respiratory support was given. Lucy Letby appeared soon afterwards together with doctors who were responding to the call for help.

    Medical notes indicates doctors were called to the unit at 9.17am as Child Q had "just vomited" and oxygen saturation levels were in the "low 60s".

    The prosecution say medical staff gave him assistance with breathing using a Neopuff device and applied suction to clear his airways. The records indicate not only had his oxygen dropped but also his heart rate. He is described as “mottled” in appearance and, most significantly, a substantial amount of air was aspirated from his stomach via the NGT.

    Mr Johnson tells the court the air had been put in there by Letby, as if the feeding chart had been followed correctly at 9am, the person feeding - Letby - would have aspirated Child Q's stomach to check there was nothing there before administering the 0.5ml milk feed.
    Another nurse's medical note on an 'apnoea/brady/fit chart' notes: "09:10; brady 98; desat 68; fit ?; baby found to be very mucousy, clear mucous from nasopharynx oropharynx removed clear fluid +++.

    "O2 via neopuff given post suctioning. Dr... emergency called to attend.

    "NGT used to aspirate stomach by Nurse L Letby”

    The prosecution say given that Letby was Child Q's designated nurse and she performed the aspiration of air, it might be thought surprising that she did not make the note – yet she did make notes in records of other babies’ notes at about the same time.

    Mr Johnson: "We question whether this is an attempt by her to create a documentary alibi."
    Computerised nursing notes made by Letby for that morning: "“09:10hrs [Child Q] attended to by SN... – he had vomited clear fluid nasally and from mouth, desaturation and bradycardia, mottled ++. Neopuff and suction applied. [Registrar] attended. Air ++ aspirated from NG tube”.

    Following the collapse, blood was taken to test for infection and other parameters. A venous blood gas test showed results suggesting that he was unwell but this had resolved by 11.12am. He was started on a course of antibiotics as a precaution.

    The doctor's view recorded at the time said Child Q's collapse was a result of “presumed sepsis with jaundice”.

    At that stage a chest x ray was taken which showed nothing untoward. The more detailed blood tests were recorded at 1.50pm and showed slightly abnormal results which were treated.

    Child Q had made a reasonable recovery through the day and at 7.20pm was "looking tired". Doctors took the decision to intubate him because his respiratory rate was down to 19 (low)and his heart rate was between 160-200 bpm (high). At that stage his blood gas readings were good.

    The prosecution say Lucy Letby was "worried" when she got home that night.

    She texted a doctor at 10.46pm and asked "do I need to be worried about what Dr G was asking?"

    The doctor sought to put her mind at rest and told her that Dr G was only asking to make sure that the normal procedures were carried out. She replied that after Child Q had collapsed she (LL) had walked into the equipment room and Dr G had been asking the other nurse who was present in the room (when Child Q had collapsed) and how quickly someone had gone to him because she (LL) had not been there.

    She continued her texts to the doctor, telling him that she had needed to go to her designated baby in room 1.

    The following day, Child Q's gases were unsatisfactory, but he had been extubated 4 hours earlier and was in air with high saturations.

    Medical staff noted a 'mildly dilated loop of bowel' on Child Q's left side and raised the possibility of NEC and surgery.

    Child Q was transferred to Alder Hey, where he quickly stabilised and no surgery was required.

    The prosecution say this was "another child who had suffered life-threatening problems and...when out of the orbit of Lucy Letby, he made a rapid recovery."Other than three days the following week, that was the last time Lucy Letby worked in the neonatal unit at the Countess of Chester Hospital, the court is told.

    Medical experts (child q)

    Medical expert Dr Dewi Evans said Child Q's collapse was due to 'inappropriate care', and he had been injected with air via the NGT.

    The significant amount of air aspirated from his stomach 'could not have arisen in any other way'.

    Dr Sandie Bohin noted Child Q was well up until June 25 and believed something happened between 9am and his collapse.

    He was only being fed what Dr Bohin describes as “tiny” amounts of milk yet he had taken in “copious amounts of air” from the NGT. This was abnormal.

    The effect of a large volume of air in the stomach would “squash” the lungs leading to desaturation and instability. Although a baby may recover quickly after such an event, he may remain unstable for some time thereafter.

    She agreed with Dr Evans’ conclusion that events were consistent with the introduction of a large amount of air via the NGT.

    A professor reviewed brain imaging of Child Q taken in November 2019 - more than three years later. He found evidence of abnormalities which whilst they were not diagnostic of him having suffered a brain injury as a result of being given excessive air and liquid via his NGT, they could be explained.

    Home search (child q)

    In Letby's home search, officers recovered the handover sheet from the morning of June 25 which included Child Q's name. This was a document which should not have left the hospital.

    Police interviews (child q)

    When interviewed by police, Letby agreed Child Q had been well enough for her to leave him on the morning of June 25.

    When asked about the excess air aspirated from his stomach, she suggested babies sometimes gulp air when they vomit. She denied putting excess air down the NGT.

    Defence opening statement (child q)

    For Child Q, the defence say there was viral-drawn aspirates, indicating a bowel problem, supported by a diagnosis of NEC.

    "A poorly funcitioning bowel" had led to Child Q vomiting.

    Agreed Facts - Child Q

    Sequence of events (child Q)

    22nd June 2016
    Child Q was born at 4.09am on June 22, 2016, in initially poor condition, appearing 'blue, occasional gasp, poor tone'. Inflation breaths were given and oxygen support at 80% O2 was administered.

    The 'Apgar scores', indicating a newborn baby's condition out of 10, are '4' at one minute, '7' at five minutes and '9' at 10 minutes.

    Registered nurse Amy Davies said child Q cried at deivery, was stabilised and transferred to the neonatal unit, intubated and given antibiotics.

    The sequence says Child Q was treated at the neonatal unit between 8.30am on June 22 to 7.40am on June 24.

    23rd June 2016
    On June 23, at 5.47pm, Child O died and at 6pm, Child P had an event where his abdomen was distended.

    24th June 2016
    The day shift of June 24 is when Child P - triplet brother of Child O - died, prosecutor Nicholas Johnson KC reminds the court.

    Child P had a collapse at 9.30am on June 24.

    The sequence records a series of observations taken for Child Q throughout the day.

    4pm: Child P's time of death is 4pm on June 24.

    9.06pm: Nursing notes for Child Q, written by Amanda MacKenzie, record at 9.06pm: 'Thought to have a few bradycardias in a cluster this morning but seemed to be a loose ECG lead when checked - nnone noted following changing the lead.

    'Nystatin not given - very heavy workload on unit'.

    11pm: The medication for nystatin is prescribed at 11pm.

    Text Messages (1) (baby Q)

    A Facebook message sent from a doctor to Lucy Letby at 11.49pm: 'Did you talk to Belinda about allocation for tomorrow?'

    Letby: 'Yes, she's going to try and give me a lighter workload...'

    Letby adds this will be difficult given there are only five on the staff rota.

    Child Q was noted as having small levels of bile in his aspirates from the fluid chart, but these were not enough to stop him being fed as normal.

    25th June 2016
    Nurse Samantha O'Brien recorded, within her nursing notes at 5.20am on June 25: 'Having trophic feeds of donor expressed breast milk, 0.5mls 2 hourly due to moderate aspirates. Abdomen is full but soft.'

    No respiratory distress was observed.

    6.36am: Letby messages a nursing colleague at 6.36am enquiring about the night shift.

    The reply begins 'OK', before giving details of what was done that night and babies in the unit.

    7.30am: Nurse Samantha O'Brien records at 7.30am a blood gas test result was 'not as good' as the one previously, but still 'acceptable'.

    The day shift handover takes place at 7.30am. Lucy

    Letby is a designated nurse for Child Q, in room 2, and a baby in room 1.

    Three babies are in room 1, two in room 2, three in nursery 3 and four in room 4.

    One nurse is looking after two babies in room 1, one nurse is looking after four babies in rooms 2-4, and another nurse is looking after four babies in rooms 3-4.

    9am: An observation chart is shown for Child Q for June 24-25. The heart rate and breathing rate are shown as being in the normal range up until 9am, when Child Q collapsed. Both then increase to an area out of the normal range at the time of the collapse.

    Child Q had been 'in air' prior to the collapse.
    A fluid balance chart is shown for Child Q.

    The 9am reading is not initialled, and do not record a feed at that time.

    9.01am: Child Q collapsed at 9.01am.

    An apnoea/brady/fit chart is shown to the court - the brady is '98', desat '68', fit '?', duration '3 minutes intermittently'.

    'Baby found to be very mucousy, clear mucous from nasopharynx oropharynx, clear fluid+++ , O2 via Neopuff, given post-suctioning. Dr...emergency called to attend. 'NGT used to aspirate stomach by nurse Lucy Letby'.

    The prosecution say Child Q had been fed 1.5mls of milk from the night, and had been due to be fed at 9am.

    Lucy Letby, in a nursing note, records: '0910 ...Child Q had vomitted clear fluid nasally and from mouth. Desaturation and brady, mottled++. Neopuff and suction applied. Air++ aspirated from NG Tube...'

    9.17am: The doctor called to the unit records 'called to NNU @ 0917 desaturation Had just vomited and then desaturated to low 60s. Minor bradycardia. Bagged with Neopuff circuit...'

    Child Q was transferred from nursery room 2, the high dependency unit, to nursery room 1, the intensive treatment unit.

    Medication is administered to Child Q during the morning.

    Child Q is x-rayed and the report notes: 'Respiratory deterioration now needing CPAP'.

    The x-ray records nothing unusual, the prosecution say.

    Letby writes notes for child Q, written retrospectively at 12.53pm: 'Septic screen carried out....NG Tube on free drainage. -3mls milk/mucous aspirate. Abdomen soft and non-distended. Perfusion improved...intermittent episodes of tachypnoeia...'

    1pm: Letby records for family communication at 1pm: 'Parents visited shortly after [Child Q] had been screened and commenced on CPAP. Mum upset++ and dad has since stated mum upset that she was not contacted on postnatal ward about need for intervention.'

    Letby adds she explained the situation and apologies were given.

    Text Messages (2) (child Q)

    Letby messages a nursing colleague about the situation on the neonatal unit, adding: 'All going on lol'

    Letby also messages a doctor colleague between 12.18-1.16pm.

    Further observations are made for Child Q during the afternoon.

    Letby notes: 'Observations stable, continues to ahve low respiratory rate with minimal effort at times. Appears plethoric++ this afternoon....Remains on free drainage...'

    For the family communication note, Letby notes: 'Midwife phoned on behalf of mum to express concern that staff had not contacted parents when [Child Q] needed CPAP. Expained reasons for this and encouraged mum to visit...'

    The parents visited the unit.

    Letby adds: 'Apologies were given for not updating them but...[treating Child Q] was priority at the time. Mum appears happier...'

    6.40pm: Letby messages a nursing colleague via Whatsapp at 6.40pm 'Girls all rushing around outside', adding one of the nurses was 'stressing', and the situation was 'madness lol'.

    Further medication is administered to Child Q in the evening.

    A deterioration is noted in Child Q which required his intubation. The notes are recorded by a doctor.

    7.30pm: Letby notes before the shift handover at 7.30pm: 'Respiratory rate declining (15-19bpm) and intermittent pauses in breathing. Blood gas stable but on downward tred and [Child Q] appearing 'tired'.

    'Oxygen requirement developing....decision made [following consultation with doctor] to electively intubate. Drugs given as prescribed...'

    Care of Child Q was handed over to staff nurse Amy Davies.

    Text Messages (3) (child Q)

    A record of Facebook messages between Letby and a doctor colleague is recorded between 4.11pm and 8.31pm.

    Letby then adds: 'Wow, I think I might be almost finished' to the doctor. She also messages her mother.

    Colleague Minna Lappalainen then messages: 'Thank you for being a good friend today', adding a heart emoji.

    Letby: 'Don't need to thank me Minna, I'm always here for you. Please don't feel you're alone...'

    Lappalainen: '...But really I'm really happy u were there for me....'

    Letby: 'Take care, hope you sleep well, see you tomorrow'.

    Sophie Ellis messages Letby: 'Hope your feeling ok today'

    Letby: 'Thanks Soph, another busy day today but ok today and off tomorrow....'

    Ellis: 'I think you deserve more than a day off...'

    Letby: '...It's been awful but we'll be ok'.

    Nurse Amy Davies, in her nursing notes, records Child Q was '...unsettled at the beginning of the shift but has settled. Temperature is elevated, humidity and incubator temp altered accordingly. HR is elevated up to 208 at times. Dad has visited...'

    Observations are taken for Child Q.

    Messages (4) (child Q)

    Letby messages a doctor at 10.48pm:

    Letby: Do I need to be worried about what Dr Gibbs was asking?

    R: No

    R: He was asking to make sure that normal procedures were being carried out.

    R: What exactly did he ask?

    LL: I walked into equipment room, he was asking Mary who was present in room and how quickly someone had gone to him as I wasn't in the room.

    LL: He asked who was there, I said I had popped out of room but Mary was in room and Minna at the desk.

    R: All he was doing was checking that there wasn't a delay and that a room had been left empty.
    Was he HDU level because of uvc?
    There is nothing to worry about.

    LL: Ok. Was worried because I Wasn't with him at time, but Mary was in room and Minna outside, I had [designated baby who was not Child Q] in 1.
    ITU because of uvc

    R: You can't be with two babies in different nurseries at the same time, let alone predict when they're going to crash......

    LL: I know, and I didn't leave him on his own. They both knew I was leaving the room.
    Feel better now

    R: Nobody has accused you of neglecting a baby or causing a deterioration.

    LL: I know. Just worry i haven't done enough

    R: How?

    LL: We've lost 2 babies I Was caring for and now this happened today, makes you think 'am I missing something/good enough'

    R: Lucy, if anyone knows how hard you've worked over the last three days it's me. The standard of care delivered is tertiary nicu level. if *anybody* says anything to you about not being good enough or performing adequately I want you to promise me that you'll give my details to provide a statement. I don't care who it is and I don't care if I've left the trust.

    R: Promise?

    LL: Well I sincerely hope I won't ever be needing a statement

    But thank you, I promise

    R: And I don't either.

    You'll know that the coch nicu mortality rate is a bit higher than the network average. It makes people (consultants) look at trends and patterns. That may have been why DrG came to ask.

    As for the self doubt - you asked me this morning did I dream because I was worried about having missed something?

    No, and I don't think you did either.

    In fact for [another baby] you knew he was unwell and flagged it up immediately.
    I don't know the beginning of the [a separate baby] story because i arrived after the bleep.
    You didn't miss anything that I would expect an experienced itu trained nurse to spot.
    From a resus point out view you were flawless. It's why I am so happy to work with you. You don't flap, you give perfectly sensible suggestions and things run seamlessly. (You must be good Rackham said so (seldom praises)).

    R: No more doubt - it's not you, it's the babies.
    I don't know what happened to [Child O] and [Child P], and accept that the pm may not give any useful answers.
    I Do wonder if they may have had adenovirus - it's terrible in neonates / perinates.
    [Child Q] is different.
    His behaviour is more bacterial (tachy, temp, reduced uo)
    I wouldn't be surprised if his bc comes back positive.

    LL: Thanks, really appreciate you saying that.

    LL: So relieved that it's you who has been there throughout.

    R: It's true. You are one of a few nurses across the region...that I would trust with my own children.
    If you're worried - I'm worried. You should do the APNP course, you'd be excellent.

    LL: Don't know what to say Thank you

    R: Self doubt finished?

    LL: I think so, thank you ++

    26th June 2016
    The sequence of events says the messages between Letby and the doctor continue from 12.18am-1.36am on June 26, on topics not related to Child Q.

    At 8.15am on June 26, nurse Amy Davies records for Child Q, improved blood gas readings through the night.

    'From 0200-0600 [Child Q] was very settled, minimal handling carried out, HR reduced to 158-170....Gas repeated at 0623, poor result...Dr contacted [and reviewed]...'

    Child Q was transferred to Alder Hey on June 26 and was treated there until June 28.

    7.50am: On June 26, Letby is messaging a nursing colleague from 7.50am.

    The nursing colleague was working at the time.

    The nurse says Child Q was improving but then had 'crap gas' at 5am.

    She adds 'staffing is s***e isn't it'.

    Letby: 'Bloody hell. It's not safe is it especially with what's gone on'

    'I worry that we have got a bug or virus on the unit'

    The nursing colleague replies: 'Virus would explain a lot'.

    Letby messages the doctor colleague: 'Will you let me know how [Child Q] gets on today please'

    'Of course I will' is the reply.

    The messages continue throughout the morning.

    12.19pm: The doctor adds at 12.19pm: '[Child Q] has nec'

    Letby: 'Ok that's good in a way to have a cause. Going to AHCH [Alder Hey Children's Hospital]?

    'Is he stable?'

    Doctor: 'Ish. Ventilation was up and down overnight...'

    Letby messages a nursing colleague to say Child Q was 'unwell with NEC, going to picu'

    The response: 'Oh no poor [Child Q]! Who's told you that?'

    Letby responds that the doctor let her know.

    The nurse later messages Letby: They think [Child Q] could be a volvulous apparently'

    Letby responds: 'Oh no.'

    27th June 2016
    The doctor messages Letby on June 27 at 10.55am - 'Not sure if the unit is open for transfers. Few managers/directors around this morning'.

    The doctor adds it's 'odd' Child M was only at Alder Hey for 14 hours as he was coming back to the Countess of Chester Hospital. He says there is a lack of beds at Alder Hey, and it's disruptive for the parents. Letby agrees.

    The final sequence of events concludes by noting Child Q was looked after at the Countess of Chester Hospital between June 28 and July 25, 2016, when he was discharged.

    A diagram shown at the end of the June 25, 2016 day shift shows there are three babies, including Child Q, in nursery 1, two in room 2, three in room 3 and four in room 4.

    Letby is the designated nurse for Child Q only at the end of the shift, with care of her other designated baby being transferred to another nurse.

    Witness Statements Agreed (child Q)

    Family - Mother (child Q)

    A statement is read from Child Q's mother.

    She said Child Q was born on June 22, 2016 at 04.09am.

    She describes her Pregnancy as "difficult" and pushed for a 9-week scan at the Countess of Chester Hospital.

    Outside the womb, a problem was found. One twin was inside the womb, the other was outside the womb. She was sent for surgery and Child Q's twin was removed.

    Child Q was born at 31 weeks + 3 days gestation. The mother had a heavy bleed and had to have emergency surgery. She was not able to see her son for 12 hours after the operation.

    Child Q was admitted to the neonatal unit in room 1 as he had problems with his breathing, the court hears.

    The mother said she was not able to hold Child Q, but able to put her hands in the side of the incubator. When she talked to him, he opened his eyes for the first time.

    The following day, Child Q had a feeding tube, off breathing support, but at the end of the day, she was told he would have to go back on breathing support, which made her upset.

    She says at no point were they told Child Q had a collapse, and believed the staff would try and 'play things down' in regard to his situation.

    At one week of age, Child Q was transferred to Alder Hey for a potential procedure to have part of his bowel removed, although this was not required ultimately.

    Child Q has 'been in and out of hospital' several times a year since as he has a weakened immune system, the mother adds.

    Family - Father (child Q)

    The father's statement says his wife had a "very difficult pregnancy", and was in and out of hospital every six weeks, and taken in at 26 weeks due to 'very heavy bleeding.'

    She was stabilised and put in the women and children's building at the hospital, and would have a number of bleeds.

    At 31weeks +3 days, the father received a phone call telling him the mother was going into labour. He was not allowed to attend the birth due to the mother's condition.

    He saw Child Q when Child Q was being transferred to the neonatal unit, and "he was tiny". The mother was still under anaesthetic.

    At one afternoon, the father went to visit Child Q and was prevented entry by staff. He was told: "There was nothing to worry about", Child Q had a 'chest infection', and the unit was 'screened off and shut down'.

    He returned to the mother, and they decided to go to the neonatal unit together.

    He said the staff told them they were running some tests. Later, the parents were allowed to return to the neonatal unit. They asked a doctor what had happened and Child Q had had a 'blip', was 'tired', and needed breathing support.

    Within the following couple of weeks, the parents were told Child Q had a 'serious bowel infection' and awaiting an ambulance to transfer to Alder Hey. By the time Child Q went to Alder Hey, he had recovered.

    He returned to the Countess and recovered 'really well', progressing through the neonatal unit nursery rooms.

    Child Q was later diagnosed with cerebral palsy and still had bowel issues, but was 'coping well'.

    Midwife - unnamed (child Q)

    Prosecutor Philip Astbury is now reading out some agreed statements. The first is from a midwife at the Countess of Chester Hospital, who describes the condition of Child Q at birth. The mother had lost a total of over 1.8 litres in blood prior to giving birth via an emergency C-section.

    The baby was born in 'good condition for his gestational age'.

    Child Q was taken to the neonatal unit and there were 'no major concerns' for the mother or baby, taking into account the mother's blood loss.

    Nurse Christopher Booth (child Q)

    Neonatal nurse Christopher Booth, in a statement, said he did not remember Child Q independently, but did so from looking at notes made at the time.

    He recalls Child Q was receiving CPAP, then taken off that breathing support during the day. Child Q was 'coping well, self ventilating in air'.

    He had an 'unremarkable shift' and had 'no concerns' for Child Q, before passing care to nurse Tanya Downes.

    Witness Evidence (child Q)

    Nurse Tanya Downes (child Q)

    Nurse Tanya Downes has now been called to court to give evidence. She confirms that, at the time in June 2016, she was working as a nurse at the Countess of Chester Hospital at the neonatal unit, and worked the night shift on June 23-24.

    She says Child Q was in room 1 of the neonatal unit.

    She says when waiting for the handover, she was standing by room 2, she recalled a baby in an open-top cot. She looked in and saw a baby 'didn't look too clever' in terms of condition and perfusion. She recalls it was on the night of June 23, the night of the EU Referendum.

    She said she had got in early to get herself a cup of tea and get ready for the shift.

    Room 2 was 'quite busy' with staff. A female staff member with blonde hair was standing by the cot. She does not recall the name of the baby.

    She said she had 'never seen anything like that' on Child Q - they looked 'mottled, but not mottled - a darker kind of mottling'.

    She says she could see from the baby's chest upwards, the top part of the body.

    She says the nurse was 'just standing by the bottom of the cot'.

    She said this did not look unusual as there was a lot of activity in the room.

    Ms Downes is asked to look at her nursing note from 10.02pm on June 23. Observations are recorded and Child Q is 'in air requiring no respiratory support'.

    The note adds 'Aspirated 2mls bile and blood flecked aspirate at 2130, awaiting paed review, stomach not bloated, bowel sounds in all four quadrants'.

    The feed of milk was stopped following the bile aspirate being recorded on June 23, Ms Downes tells the court, following consultation with the paediatrician. Nutrition was increased via TPN bags.

    A milk feed of 0.5ml is made via the NG Tube at 2am.

    'Minimal' aspirates are recorded at 1am and 2am.

    An observation chart records 'normal' heart rate, respirations and temperature for Child Q.

    Cross Examination
    Benjamin Myers KC, for Letby's defence, says Ms Downes was working as a 'bank nurse' at the Countess of Chester Hospital on that night.

    Mr Myers asks about the incident in room 2 Ms Downes saw.

    Mr Myers says, according to Ms Downes, the nurse was wearing 'dark blue scrubs', which would be worn by senior nurses.

    Ms Downes agrees with Mr Myers that Child Q was one of a number of babies at the neonatal unit who appeared to have bowel problems.

    For the June 23 night shift, Mr Myers refers to the intensive care chart earlier that day, for '2ml light bile' aspirate recorded at 09.31am.

    Ms Downes said she was aware of that, but had no major concerns.

    A '2ml bile/blood' reading is made by nurse Downes at 2130.

    Mr Myers said Ms Downes had asked for a review by a paediatrician. Ms Downes says there was a concern as it was blood-flecked. The cause of it could be 'a number of things', but it was 'a warning sign'.

    Ms Downes agrees this led to enteral feeds being stopped.

    Mr Myers asks about the 1.5ml aspirate at 4am on June 24.

    Ms Downes says it could be a mixture of milk and stomach acid. No blood is noted and a pH reading isn't made.

    Ms Downes recalls Child Q was recalled to hospital follwing his discharge in July 2016, with 'gut problems'.

    Ms Downes recalls she treated him at the out-of-hours clinic.

    The prosecution rise to clarify about the make-up of the blood-flecked aspirate for Child Q. Ms Downes explains the aspirate had the appearance of coffee granules.

    That concludes Ms Downes's evidence.

    Nurse Mary Griffith (child Q)

    Giving evidence at Manchester Crown Court on Monday, April 3, during the 23rd week of the trial before a jury, nurse Mary Griffith said Letby had asked if she could keep an eye on Child Q while she went to check on another baby in a different nursery.

    Mrs Griffith said she had started feeding the baby in her care when she heard an alarm go off at Child Q’s incubator.

    She told the court: “I looked over my shoulder and I noticed his saturations had dropped.”

    She said she called for help from nursing shift leader Minna Lappalainen, who was at the nursing desk station opposite.

    Mrs Griffith said the passage of time between Letby leaving and the alarm sounding was “minutes” but she could not say exactly how many.

    Nurse Minna Lappalainen (child Q)

    Asked what she saw when she was first to arrive at the incubator, Ms Lappalainen said: “He had been sick. I turned him on his side and made sure his airway was alright.”

    She had noted clear mucous coming from the baby’s mouth and nose which was suctioned clean.

    Asked why she recorded “clear fluid +++”, she said: “The clear fluid means the mucous I’m cleaning. There is no feed in it, no milk in it. It’s like saliva.”

    A face mask was then used on Child Q to help pick up his blood oxygen levels, the court heard, and an emergency call was put out for a registrar to attend.

    Ms Lappalainen also recorded Child Q’s nasogastric tube was used to aspirate his stomach by “Nurse L Letby”.

    The court heard the defendant made a separate note of “air++ aspirated from tube”.

    Ms Lappalainen said, according to her notes, Child Q recovered from the episode – which lasted three minutes “intermittently”.

    She said she was not aware of any further incident on the day shift involving Child Q.

    The court heard Child Q was moved to intensive care nursery one after the incident and Ms Lappalainen took over the care of Letby’s second designated baby.

    Nick Johnson KC pointed out an unsigned observation chart entry for this baby was made at 8.30am.

    He asked Ms Lappalainen: “If this child had observations at 8.30am, would you expect the child to be observed at 9am?”

    The witness replied: “Not necessarily if the patient is stable.”

    Cross Examination
    Ms Lappalainen agreed with Ben Myers KC, defending, that Child Q stabilised “relatively quickly”.

    Mr Myers said: “And the doctors were called because this was an appropriate thing to do?”

    “Yes,” said the witness.

    Mr Myers went on: “It was not the type of incident where you were overly concerned.”

    Ms Lappalainen said: “I was not overly concerned but I wanted him to be checked out.”

    She said it was “perfectly acceptable” for nurses to ask a colleague to keep an eye on a baby if they had to leave a nursery.

    Dr John Gibbs (child Q)

    The court earlier heard from consultant paediatrician Dr John Gibbs, who told jurors how he demanded to know who was caring for Child Q after his collapse.

    Dr Gibbs said that by late June 2016 there was a "heighted concern" about baby deaths at the hospital.

    "I remember wanting to know who had been looking after [Child Q] at time he had desaturated," he said.

    "I wouldn't normally want to know who was looking after patients.

    "I was worried about what was happening on the unit," he added.

    Dr Gibbs has previously told jurors between June 2015 and June 2016 Ms Letby's presence had been noted as a "common factor" in "unusual" baby collapses and deaths at the Countess of Chester Hopsital.

    The consultant said the deaths of triplet brothers, Child O and P, on successive days in late June 2016 became a "tipping point" for his team.

    Dr A (child Q)

    Ben Myers KC, defending, earlier questioned a doctor, who cannot be named for legal reasons, about messages he sent to Ms Letby in late June 2016 in relation to the death of Child O.

    The court has previously heard the boy was found to have an "impact" injury to his liver in a post-mortem examination that was akin to having been in a road traffic collision.

    In Facebook messages to the nurse, originally of Hereford, he said that another doctor on the unit had told him she was "upset" and concerned that Child O's liver injury "may have been caused by her chest compressions".

    He told Ms Letby he spent 20 minutes "in a cubicle going over everything" with the doctor.

    The doctor told Mr Myers it was a "busy time on unit" and "a lot of introspection" was occurring.
    He said he wanted to "reassure" the doctor the correct CPR procedure had been followed, but when pressed by Mr Myers as to whether he could remember the CPR he said "I don't".

    "I think I was managing the airway and at some point changed positions, I don't recall who was doing what. I was focusing on the task in hand," he said.

    Medical Experts Evidence (child Q)

    Dr Dewi Evans (child Q)

    Giving evidence on Wednesday, April 5, expert medical witness Dr Dewi Evans said he believed water or saline, possibly together with air, was put down Child Q’s stomach via a nasogastric tube (NGT).

    The trial at Manchester Crown Court has heard the infant vomited clear liquid shortly after 9am on June 25, 2016.

    His heart rate fell and his blood oxygen levels also plunged before he recovered “relatively rapidly” after he received breathing support from neonatal staff.

    Dr Evans told the court that Child Q was “not quite well” from the night before and was apparently unable to tolerate small feeds of milk.

    But he said the feeding problem would not explain the “very significant” deterioration.

    Dr Evans said: “I think we are dealing with two separate incidents.”

    Medics later suspected that Child Q may have a bowel disorder common to premature babies, the court heard.

    The youngster was transferred to intensive care at Alder Hey Children’s Hospital but surgeons there found no further issues and he was returned to the Countess two days later.

    Prosecutor Nick Johnson KC asked Dr Evans: “If a significant quantity of clear fluid was vomited, what view did you come to?”

    The retired consultant paediatrician said: “There was enough clear fluid injected down into his stomach to make him vomit.

    “He was unable to breathe properly because his tummy was full of liquid.”

    Dr Evans said that “air++” was noted to have been emptied from Child Q’s stomach after he received breathing support from a Neopuff face mask but he said “very little” of the latter was taking place.

    He went on: “So it could well be as well as having clear fluid down his NGT he had some air injected into his stomach as well.”

    Dr Evans said he was “certain” that the suspected bowel problem, necrotising enterocolitis (NEC), was not a factor in the vomiting incident.

    Cross Examination
    Ben Myers KC, defending, pointed out to Dr Evans that in three earlier reports he had concluded that the deterioration was due to “inappropriate care” with “a lot of air” given via his NGT.

    Mr Myers said: “I am going to suggest that fluid is something you have added at a late stage.”

    Dr Evans replied: “I think in all these cases I have said in evidence, on a number of occasions, that I had to rely on notes that I have been presented with, and the more accurate the information we get, the more accurate the opinion is.”

    Mr Myers said: “What you are focusing on at that point exclusively is air. Now you have reached this point where you have added fluid now to keep the mechanism going, keep the allegation going, rather than reflect the facts?”

    Dr Evans said: “No, no, no. You have got it wrong again.

    “We are here now and we have heard the evidence from the people who were looking after him.

    “So going on about what I wrote in 2017 and 2018 is rather missing the point.”

    Dr Sandie Bohin (child Q)

    Taken from Dan O’Donohue Twitter (06/04/23)

    Medical expert Dr Sandie Bohin is now in the witness box. She was asked to review the findings of Dr Dewi Evans - who reviewed all the cases on instruction from Cheshire Police in 2017

    Prosecutor Nick Johnson KC asks Dr Bohin if there could be a natural/obvious explanation for 'clear fluid' being aspirated from Child Q on the morning of 25 June (soon after the baby boy collapsed and required resuscitation)

    She says: 'No, I don’t know where plus plus plus of clear fluid (as written on nursing note) comes from given at that time he had not had any feed since 2hrs previously, only a very tiny amount of milk..'

    She added: 'What was aspirated here was clear fluid not milk, I can’t explain where it would have come from'. She concludes that liquid/air was forced down his NG tube

    Cross Examination
    Ben Myers KC, defending, is now cross examining Dr Bohin. He references evidence from a nurse, who cannot be named, who said she saw mucous at Child Q's mouth, he puts it to her that this could be clear liquid referred to and asks if it was could it cause breathing difficulty

    She says it is unlikely it would be mucous, but says if it was, in that volume, it could cause issues

    Dr Sandie Bohin (child Q)

    Taken from Dan O’Donohue Twitter (20/04/23)

    Dr Arthurs was asked by Cheshire Police to review a number of radiographs for Child Q. He tells the court that on one of the radiographs, taken 20hours after the baby boy's collapse, he noticed an 'abnormality'

    Police Interviews Summary (child Q)

    Taken from Dan O’Donohue Twitter (06/04/23)

    Nick Johnson KC has just read a summary of Ms Letby's police interview in relation to the collapse of Child Q. In this she denied doing anything to harm the baby boy and said it was a 'coincidence he became unwell when she came on duty'

    Dr Arthurs is talking the jury through the radiograph, he points out two areas in the bowel of Child Q - he says it could be a sign of pneumatosis, which is an early sign of necrotizing enterocolitis (a serious condition in newborns)