Introduction
This page contains evidence heard for child D.
Lucy Letby Case page contains live reporting links and opening statements including opening statements for each child.
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Child D
Count 4: Murder allegation (air embolus)
Prosecution opening statement
Background
Child D was a baby girl, born as 'full-term' (ie not premature).
The court hears there is valid criticism for the hospital as the mother should have been given antibiotics to stave off infection, after her waters broke early, but she was not.
Although born healthy, Child D "lost colour" and "became floppy" in her father's arms. She was put under observation as she was showing signs of respiratory distress, by grunting, and her temperature dropped.
Child D was admitted to room 1 in the neonatal unit, placed into an incubator, and given oxygen therapy and antibiotics.
She developed a very high temperature and a rise in her heart rate.
She was inturbated, and ventilated. She improved "significantly, but was still affected by her infection".
Child D had catheters inserted and the levels of infection dropped.
"All good signs," Mr Johnson tells the court.
Incident
A designated nurse other than Letby was assigned care for Child D in room 1 on the night-shift, along with a different child in room 2.
Letby was the designated nurse for the two other babies in room 1.
On that night-shift, Child D collapsed three times. The first at about 1.30am, the second at 3am, and finally at 3.45am.
Mr Johnson: "On each occasion, those attending were struck by the sight of mottling, poor perfusion and brown/black discolouration to her skin, mainly over the trunk.
"We've heard that sort of thing before, haven't we?
"The prosecution say that this was another case of injecting a child via an IV air embolus."
At 1.15am, the designated nurse checked Child D, recording observations.
At 1.25am, the designated nurse and Letby noted the starting of an infusion.
An aspirate - drawing liquid through the nasogastric tube - is noted at 1.30am.
At 1.29am a doctor noted "an unusual...spreading, non-blanching rash" on Child D.
There is a note in Lucy Letby's records she was engaged in the care of a different baby at the time, but the prosecution say nursing notes suggest Letby and the designated nurse called the doctor to the room.
The prosecution allege either the notes recorded were simply inaccurate, or Letby was setting herself up with an alibi in someone else's medical records.
Child D was successfully resuscitated.
At 2.40am, medication was administered by Letby and the designated nurse, who then left to another room.
But Child D then collapsed at 3am. Letby was in the room, the designated nurse was not, and no-one else had a reason to be in the room.
Child D was resuscitated again but, according to the prosecution, Letby "did not leave things there".
At 3.20am, there is a record of Letby starting an infusion and Letby appears to have remained in the room, as a record shows her caring for another baby in the room at 3.30am.
At 3.45am, Child D suffered her third and final collapse. CPR began and Child D was pronounced dead at 4.25am.
The coroner gave the cause of death as "pneumonia with acute lung injury."
Medical experts
Medical expert Dr Dewi Evans, the prosecution says, observed that a child "exhibiting a window of near recovery on two occasions followed by another collapse was not consistent with the fatal evolution of antenatal pneumonia."
He added the "abdominal discolouration was indicative of air embolus".
Another medical expert said the clinical status of Child D the previous night was not that of a deteriorating baby who would be dead a few hours later.
She added the injection of '3-5ml per kilogram' of air would be sufficient to kill.
Child D had been observed in distress prior to her death, and the medical expert added this would also be consistent with cases of air embolus (air injected into the system).
The court is told none of the medical staff on duty that night had also been present for the collapses of Child A, B or C - other than Letby.
For nursing staff, two of the nurses had been on duty for one each of the other collapses.
Police interviews
Letby, in police interview, said she "cannot remember" how she got involved.
She seemed to accept that she had administered medication with a syringe at 1.25am – 5 minutes before the first collapse.
In a June 2019 police interview, she said she could not remember calling back the doctor when Child D collapsed, but it was possible she had.
Facebook
It was put to Letby, in November 2020, that she had searched for the parents of Child D on Facebook.
She said that she could not recall but accepted she had done so. She said she could not explain why she had done it.
The prosecution said: "We suggest that if you searched for that family of a baby who you had seen die you would know and remember why you had done it."
Text messages
Letby was asked about a text message in which she had referred to "an element of fate" being involved.
She said that it was 'fate that babies get unwell sometimes' but that she would have to know the context.
The prosecution say for Child D, her bad luck, or fate, was the fact Letby was working in the neonatal unit.
The prosecution add all of Children A-D were not expected to have serious problems, but only one of them survived - and only Letby was "the constant presence".
Defence opening statement
For Child D, the defence say the hospital "failed to provide appropriate care", and this was "beyond dispute" as the prosecution accepted care was sub-optimal.
Child D "was never able to breathe unaided" and there was a "strong" possibility of infection, and evidence of pneumonia after death.
Agreed Facts
Sequence of events from records
The first evidence shown to the court is Lucy Letby's shift patterns for June 2015.
It shows which days Letby was on 'long day' shifts, and 'night' shifts.
She worked long day shifts on June 2, 4, 17, 19, 27 and 28.
She worked night shifts on June 8, 9, 13, 14, 21, 22 and 23.
Child A died on the night of June 8-9, and Child B had a non-fatal collapse on June 9-10.
Child C died on the night of June 13-14.
Child D died on the night of June 21-22.
20th June 2015
4.01pm: The evidence shown to the court shows Child D was born at 4.01pm on June 20, weighing 3.13kg [6lb 14oz], and required breathing support at birth.
The Apgar scores were 8 [out of 10] at 1 minute after birth, and 9 at 5 minutes.
7.30pm: Child D was admitted to the neonatal unit at 7.30pm on June 20 'for respiratory support requiring ventilation'.
Child D was 'grunting' and her colour was 'dusky', it was observed.
Child D was placed on CPAP, with 40% oxygen support, and placed on 'double phototherapy'.
Doctor Ahmed Chowdhury noted discussing Child D with the parents, saying 'on moving baby to labour ward baby became blue/dusky. Sats 47% on arrival NNU - had bagging, sats picked up. Given antibiotics, baby put on CPAP. Not explained to parents yet'.
Notes record the administration of antibiotics and sodium chloride to Child D.
The court hears phototherapy was crried out to treat Child D's jaundice.
Child D was administered with an endotracheal tube on the second attempt.
The nursing notes record Child D was 'starting to out a few breaths in for herself now'.
An x-ray reading for Child D showed 'shadowing consistent with transient tachypnoea of the newborn [TTN, a respiratory disorder]'.
A nurse's note recorded meeting the father, who had visited the neonatal unit, and it was explained to him that Child D would be on the neonatal unit for "at least 48 hours", and the dad was "visibly upset", so "lots of reassurance" was given to him.
21st June 2015
4.30am: A further nursing note at 4.30am on June 21 showed Child D was making 'good respiratory effort', and blood gas readings were 'good', so ventilation support was reduced.
7.21am: Another nursing note at 7.21am recalls the father's visit to the neonatal unit.
It incldues: "[Father] appeared overwhelmed so lots of reassurance given."
9am: A note from nurse Kate Bissell reads, at 9am on June 21, that Child D was 'extubated...following satisfactory blood gas'.
Child D was 'initially apnoeic and required stimulation...via Neopuff/CPAP', but the breathing became more regular after a couple of minutes.
10.15am: Kate Bissell, in a subsequent nursing note, said a blood gas reading at 10.15am was subseqently taken and the results showed signs of respiratory acidosis, so Child D was put back on CPAP.
12.15pm:The blood gas was repeated two hours later and 'showed further deterioration with increasing metabolic acidosis'. Child D's perfusion was 'poor' and a doctor approved a decision to administer medication.
Dr Ahmed Chowdhury recorded a UVC and a UAC were inserted.
5.53pm: A 'family communication' note is made at 5.53pm - "Dad visiting most of the day, he is up to date with the plan of care. Mum has visited this evening."
Both parents were 'anxious' about the levels of care provided.
7.15pm: A nursing note at 7.15pm said attempts were made to get Child D off CPAP, but breathing was still 'shallow' off that, so CPAP resumed.
7.26pm: Swipe data showed Lucy Letby arrived at the neonatal unit at 7.26pm.
The handover note showed Letby was one of the nurses on duty that night, with a different nurse being the designated nurse for Child D, in room 1.
Letby was the designated nurse for two other babies in room 1.
At this time, another nurse was looking after Child B in room 3 for that night.
The court had previously heard Child B had suffered a non-fatal collapse earlier that month.
Further observations for Child D are documented throughout that night shift, until after 1am.
22nd June 2015
1.25am: A neonatal infusion prescription chart at 1.25am, for Child D, is shown to the court. Lucy Letby is one of the two nurses to provide a signature for a saline dose prescription at that time.
1.30am: Child D then first collapsed at 1.30am.
Mr Johnson: "This is within a very short time of the document with Lucy Letby's signature on, isn't it?"
Kate Tyndall: "Yes."
A nursing note, timestamped for 1.30am but written retrospectively, recalls: "Called to nursery ward...[Child D] had desaturated to 70s, required oral suction as was bubbly and had lost colour. Discolourations to skin observed, trunk/legs/arm/chin."
2.40am: Notes of medication are made.
At 2.40am, a neonatal infusion prescription chart is recorded for a sodium chloride dose with 10% dextrose. Letby is one of the two nurses signing for it.
2.44am: The medication administration update is made on the computer at 2.44am.
3am: At 3am, Child D collapsed for the second time.
The nursing note recorded for 3am: '[Child D] crying and desaturated again to 70s, commenced on 100% O2 via CPAP and picked up well but skin discoloured again..."
3.20am: At 3.20am, a further neonatal infusion prescription is made, with Lucy Letby being one of the signatories.
3.45am: At 3.45am, Child D collapses for the third and final time.
The nursing note recalled the alarm went off and Child D 'desaturated and then became apneoic. Called Letby...' Resuscitation efforts began but to 'no effect'.
A bleep alarm went off and doctors were called to the neonatal unit.
The court is shown a number of clinical notes are made by doctors for this time. These clinical notes will be discussed further when the doctors involved in them come to court to give evidence in the coming days.
They include the resuscitation efforts, administration of adrenaline doses and the decision, ultimately, to discontinue CPR.
4.25am: Child D died at 4.25am.
A nursing note by Yvonne Farmer recorded that Child D was blessed by a reverend with the family present, with hand and footprints obtained.
The note added: "Parents had lots of cuddles and said goodbye to [Child D]."
The parents were also given a bereavement box with mementoes and information on the Sands charity.
Text Messages (1)
8.36am: A text message sent from Lucy Letby to a colleague said, at 8.36am: "We had such a rubbish night.
"Our job is just far too sad sometimes."
The colleague replied: "No what happened?"
Letby: "We lost [Child D]."
The colleague: "What!!!! But she was improving. What happened?
"Wanna chat? I can't believe you were on again. You are having such a tough time."
Letby refers to Child D being "messed about a couple of times" and refers to a rash that "looked like overwheming sepsis".
She adds that two members of staff said the circumstances "would be investigated".
The colelague replies: "Dad was very anxious all day." and adds, in relation to the investigation, "What the delay in treatment?"
Letby replies: "Just overall looking into the case.
"And reviewing what antibiotics she was on if sepsis."
The colleague says Child D "was behaving septic".
She adds, to Letby: "Oh hun, you need a break."
Letby said, in her response: "But it's part of the job and it's hard for everyone."
The colleague responds: "Yes but you have had it all recently."
Letby, in her response, says: "Hmm well it's happened and that is it, got to carry on..." before referring to her planned time off.
The conversation then discusses staffing arrangements, and the difficulties of the job, before noting an instance of a happier occasion on the unit.
Letby says: "How do such sick babies get through and others get to [die] so unexpectedly?"
Her colleague, in her response, says: "We just don't have magic wands..."
The colleague refers to what Child D looked like in their care.
Letby replies: "I think there is an element of fate involved. There is a reason for everything."
The colleague adds: "It's important to remember that a death is not a failure," and says Letby is "an excellent nurse."
Letby, in her response, accepts the need to take positives from the job, but it's "just so sad to watch what families go through."
Further messages are echanged between Letby and her colleague the following evening.
The colleague asks: "How you doing?"
Letby replies: "I'm ok - trying not to think about it. Work busy but at least we have 6 tonight."
The colleague enquires about Child D and whether anything had been said about not "bringing her through sooner on Saturday".
Letby replies: "I don't think so", before adding there was a theory Child D may have had meningitis.
The colleague responds: "I'm worried I missed something."
Letby: "I don't think any of us did and she [Child D] was on the right antibiotics."
The colleague replies: "Yeah, just would treatment sooner have made a difference."
Letby asks her colleague if Child D had a lumbar puncture.
The colleague replies she was not sure it ever got done, given that the baby girl was ill and had been on CPAP.
She adds her gas reading was "appalling" when she first came through to the unit.
Letby, in her response, says: "I think we did what we could."
She then refers to the condition of the mother of Child D.
End of June 2015
Towards the end of June, Letby sent a message to a colleague: "Work has been awful."
The colleague responds: "Oh dear. Staffing probe?"
Letby, in her response, says: "We have had three unexpected deaths," adding the unit is "full".
She adds: "What I have seen has really hit me tonight."
The colleague asks: "Have you worked today?"
Letby: "No, been off since Wednesday morning and now it has all hit me."
The colleague asks if Letby tries "talking to a proper counsellor".
Letby replies that she does not think she can.
The colleague: "Why not?"
Letby: "I can't talk about it now...I can't stop crying...I just need to get it out of my system."
The colleague advises Letby to think carefully what to do, before adding: "Maybe you need to take time off."
Letby: "Work is always my priority," adding she had not cried about the incidents until then.
Facebook Searches
The court hears at 9.51pm on June 25, Letby searched for both the parents' names of Child D on Facebook.
Neonatal Charts
The trial is now resuming, with intelligence analyst Claire Hocknell returning to provide a walkthrough for the jury on neonatal unit evidence.
The chart being shown to the court is the neonatal review schedule, showing when electronic records are made, including e-prescriptions, with Lucy Letby's name highlighted on the chart.
Nicholas Johnson KC, for the prosecution, highlights the three 'infusion started' notes, each one of them happening before Child D's collapses. Lucy Letby and Caroline Oakley are the two nurses to sign for the medication and administering the infusion.
The neonatal unit review chart also shows a long list of clinical notes made following the final collapse, made by doctors, regarding the efforts to try and save Child D's life, before ultimately the decision is made to discontinue resuscitation efforts and record the time of death at 4.25am on June 22, 2015.
Cross Examination
Ben Myers KC, for Letby's defence, asks about a note which said Letby administered to a baby 'whose location is unconfirmed [as recorded on a map of the neonatal unit for that night]' on the night of June 21. Letby was a designated nurse for that baby, and two babies in room 1, that night.
Mr Myers asks about Lucy Letby and Caroline Oakley administering medication to a number of different of babies that night. Claire Hocknell confirms the records.
Mr Johnson asks to clarify the map which includes the detail about the baby 'whose location is unconfirmed' - he tells the court Letby was initially the designated nurse for that baby until 10.45pm that night on June 21, and then care was passed to a different nurse.
Witness Statements Agreed
Agreed statements read out in court not contested by defence.
Family - Father
The court is now hearing an agreed evidence statement from the father of Child D.
The court hears, from the statement, Child D died at 4.25am on Monday, June 22.
He said he does not remember any specific problems from the mother's
Pregnancy, but had "immediate concerns" when she was born, as she "appeared grey" and was not crying.
"Initially, we were reassured by the staff" - and he said he believed them, and never thought Child D would die in the circumstances she did.
The father recalls the circumstances leading up to the birth, as recalled by the mother.
He recalled the mother did not respond to inducement measures, and had mild contractions between 2am-3am on June 20, but had not dilated.
She was "encouraged to wait" for inducement methods, but she "did not want to" as she had been in labour for some time.
They were told medical staff were "monitoring the situation" and were told antibiotics were "not necessary" at this stage.
They said they agreed on a C-section, and at about 4pm, the mother went for an emergency C-section.
Child D was held above the sheet, momentarily, and wrapped up, taken to the scales.
"We weren't informed of any issues" - "I was led to believe everything was ok".
He said Child D was very quiet, which was unexpected, and held her in his arms.
He said he was not sure if Child D was given any breathing support at this stage.
He went back to the ward with Child D for a brief time, and he and the mother put pyjamas on her. However "she didn't seem interested in feeding at all".
They said they were told Child D was doing well.
"We repeatedly asked if she was ok. We just weren't comfortable with how she was."
Medical staff kept telling her Child D was ok.
A few hours later, a different paediatrician came and Child D was taken to the neonatal unit.
The parents were later told Child D was not well.
"It was a bit of a shock" when the father saw Child D in the neonatal unit, as she was "very poorly...wasn't feeding...and had lots of tubes in her mouth".
Nursing staff "always made" the father feel welcome when he arrived.
On June 21, the father went to see Child D and was "almost certain" he saw she had been taken off CPAP.
He said he frequently visited the neonatal unit, and asked staff
"It was Father's Day, and I was given a handmade father's Day card.
"The staff had put it together, and it had a message from [Child D] - with a photo stuck inside.
"On the first photo, she has CPAP. I took that with me.
"Later that day, I was given a welcome card, and a photo which showed her looking better, and not on CPAP."
In the early hours of June 22, he was woken by a nurse and to go to the neonatal unit as Child D was "poorly", and they were taken there quickly.
"When we walked in, we understood immediately it was a very serious situation.
"Andrew, the senior doctor, seemed to be in charge.
"I remember someone mentioning adrenaline, and there was a sense of urgency.
"Andrew had a phone held up to him, and he was discussing the situation with someone on the other end.
"There seemed to be some confusion over what baby they were talking about.
"The person on the other end seemed to be referring to a different child.
"They were unsuccessful in resuscitating [Child D]. they said they had been trying to resuscitate [Child D] for over 20 minutes.
"I couldn't tell you which staff were in...as I wasn't paying much attention. I didn't want to look."
He added the parents weren't in the room for too long, about five minutes.
He said he does not recall seeing Lucy Letby at this time.
He went back to the ward and informed another family member of the news.
Family - Unnamed
A statement from another family member of Child D is read out to the court.
They said they had visited Child D in the neonatal unit: "It didn't even cross my mind that she was in danger of dying.
"When she died, we just weren't prepared for it.
"Nothing I saw appeared out of the ordinary...but I didn't have anything to compare their actions to."
Dr Sally Ogden
An additional agreed evidence statement is being read out for Dr Sally Ogden in respect of Child C, in relation to a clinical note.
She refers to the clinical note from June 13, which include "bowel sounds heard".
She said she heard Child C's bowel sounds as part of a routine examination, and documented that bowel sounds were heard.
She said each individual finding forms part of the overall condition.
She couldn't recall any more information about the bowel sounds, but if they had sounded 'abnormal', then that would have been documented as an 'important' finding.
She said Child C's abdominal condition, from her observation, was 'normal'.
Witness Evidence
Family - Mother
The prosecution, led by Nicholas Johnson KC, ask Child D's mother to confirm details.
Child D's mother tells the court she developed a concern about her waters breaking, which the court hears was "well founded" as her waters broke when she woke up on June 18.
The hospital told her to "monitor the situation". She waited, and rang the hospital again, and was then told to go to hospital.
At 11.30am, she arrived at hospital, and staff confirmed her waters had broken, but did not
test.
They then checked her and her baby, "not for very long".
"Were you, in effect, sent home after being examined?"
"Yes."
The following day, the mother returned to the hospital, and saw a midwife.
"Were you examined and various checks performed on you?"
"Yes...not straight away. I had to wait."
"Did you express concern to staff at the Countess."
The mum said her waters had broken over 24 hours before, she didn't "feel right" and the baby "didn't seem to move as well" and she was concerned about infection as she hadn't been given any antibiotics.
The decision was then taken to induce.
She said staff were "very busy", and she was not placed on an IV but not for "many hours".
It was "very delayed", the mother tells the court.
The mother said she was "very worried and scared", "unwell" and "not in control" and "forgotten by the staff", as it was nearly 48 hours after her waters had broken.
On a trip to the bathroom, she noted blood had come out. She asked someone to do something.
She said she remembered seeing a doctor, and recalled a description for her.
It was the first time she had seen a doctor since her admission.
She was told that essentially both her and her baby girl were ok, and that a natural birth would be considered, and that would be reviewed 4 hours later at 11am.
At 11am, the mother was assessed again, by a different doctor. She recalls a description for the male doctor.
She was told there had been "little progress" and she said he was the "first professional who spoke to me and addressed my concerns".
The mother said it had been about 50 hours since the waters had broken and a C-section was considered, as there had been no dilation.
The mother was informed a natural birth would be the preferred option to a C-section.
By 3pm, the mother had discussed the situation with her husband and concluded she would be 'less patient' and call for a C-section if there had been no progress.
At 3pm, the mother was reviewed by the same male doctor, and he was "more concerned" about the situation, as she appeared more tense.
The doctor then confirmed she would receive a C-section as he said it was "not a good idea to wait any longer" as the baby appeared 'distressed'.
Events then moved on "a lot more quickly" after staff had initially appeared "chilled".
After the C-section decision was made, matters "moved a lot more quickly".
Child D was delivered and lifted over the screen for the mother to see.
The mother recalls seeing "no life - lifeless - she did not scream, everything was quiet in the room."
Mr Johnson asks if there was a nurse in the theatre room at this stage. The mother does not recall.
The mother was taken to a ward, while medical professionals dealt with Child D.
The mother recalls seeing Child D very briefly, in the operating theatre, before they [the staff] took her away as they had "concerns".
The mother said she was "very aware" of things going on, despite having received anaesthetic.
She did not have physical contact with Child D, but her husband did.
The mother was taken to a ward.
The mother was taken to a further room, and it was there where she had physical contact with Child D.
Her impression of Child D condition at that point was "really worried as she [was brought to my chest] but she didn't have any movement, she looked limp and pale - struggled to breathe and was making a groaning noise.
"She wasn't really responsive. There was a split-second where she opened her eyes and looked at me, and then no response.
"I tried to breastfeed her, but she was completely limp, so I was worried."
A male paediatrician informed the mother 'not to worry' as the delivery had been through C-section so the breathing wasn't as clear.
The mother said she didn't believe what he said. His attitude seemed "too careless".
The mother said she thought something was wrong with Child D and one of the midwives would assess her in 'a couple of hours'.
She said she did not want to wait that long and wanted another doctor's opinion.
The same doctor came back, but he had spoken to a consultant.
The mother said she was "not reassured" but "was glad someone took me seriously". She was then worried as Child D was taken straight to neonatal unit intensive care.
The mother said she felt "rubbish...drained" and didn't feel any relief. She was "in pain" and "knackered".
The mother said it was around 7-8pm when she was separated from Child D.
The following day was Father's Day.
The mother was given news that Child D had been "up and down" all night, struggling with feeding, and staff "didn't seem too concerned then", but Child D "wasn't great".
The mother believed she had been spoken to by a female consultant doctor that morning.
The mother said she recalled Child D needed to be on a CPAP machine and every time they tried to take her off she would crash.
She said staff did not seem overly concerned as Child D was a good-size baby and making progress, despite being 'poorly'.
Other tests showed she seemed 'fine'.
The mother said she was able to see Child D at about 7pm that day.
The mother said she had spoken to a doctor before heading to the neonatal unit.
A drawing that the mother had made, showing a plan of the neonatal unit room, is shown to the court, showing the positioning of Child D's cot, other cots, and crosses identifying a number of medical machinery.
Child D's mother said she had spoken to Dr Andrew Brunton at 9-9.30pm, and was told he was "very happy" with Child D's test results.
They had "done more scans" and she was "well" and promised her she would be able to hold and cuddle her the following day.
The mother said she was not in a good condition herself, being moved in a wheelchair and '10/10 pain', on morphine, but was happy with Child D.
Child D looked like "a good pink baby", "tiny but chubby", and looked "healthy".
The next time she saw Dr Brunton was the following night.
She and her husband were woken up 'about 4am' by a nurse to 'come quickly' as Child D was poorly.
They "rished downstairs" and Dr Brunton was "holding her" and trying "really hard" to resuscitate her.
"We were just standing there looking at [Child D] dying."
The doctor was "quite agitated" and the couple heard they "had to let [Child D] go."
The mother said she could not stay there any more and asked to be taken away.
A nurse, who the mother believed to be Lucy Letby, was holding a phone to Dr Brunton's ear, she recalled.
The mother said she had seen Lucy Letby before, when she went to see Child D in the neonatal unit at about 7pm.
The mother recalls as she was wheeled into the room, Lucy Letby was "hovering around, not doing much" with Child D, and had a clipboard, and was looking at the machinery.
"I didn't understand what she was doing", and the mother asked if Child D was fine, to which Lucy Letby said she was.
Lucy Letby "just stuck around" and was "just watching, looking over us".
The mother said she asked for Lucy Letby to "just go away and leave us [in privacy]."
Mr Johnson asks if Lucy Letby was in the neonatal unit room at the time Child D died. The mother agrees, and says other doctors were in that room.
The mother says she did not stay in that room.
The mother recalls she was taken to a private room, where Child D was, along with her husband and another family member, and a nurse she had not seen before.
The mother said she did not see Lucy Letby again.
Cross Examination
Ben Myers KC, for the defence, is now asking the mother questions.
Mr Myers says it is an "awful experience" what the mother went through, and says he has one or two questions to ask.
He asks about the 7pm neonatal unit visit on June 21.
The mother says she went there with her husband. She recalls 7pm as she 'must have looked at the clock'.
She said there was "an exchange of few words" between her and Lucy Letby.
Mr Myers asks if that was possibly another nurse. The mother replies: "I don't think so."
The judge, Mr Justice Goss, asks for clarification.
The mother said she would not have known the name of Lucy Letby at the time, but would after seeing her picture after she had been arrested.
Nurse Caroline Oakley
Caroline Oakley is now being called to give evidence. In June 2015, she was employed as a senior neonatal unit nurse at the Countess of Chester Hospital.
Mrs Oakley confirms she would at times be a shift leader, and would look after the people on that shift, not necessarily working with managers.
She confirms she had direct involvement with Child D on the night shift from June 21-22, and was her designated nurse during that shift.
Mrs Oakley says she does not recall which nurses were designated nurses for which babies that night.
Her nursing note, written retrospectively at 4.46am on June 22 for the night shift, is presented to the court.
The note records, at the handover, 'lower limbs dusky and feet bruised. Doctors aware. Feet cool to slightly warm. Observations satisfactory.'
Mrs Oakley added Child D was 'nursed on CPAP in air. antibiotics given as prescribed.'
Mrs Oakley tells the court Child D was not pink yet, and might have been sampled with heel pricks, which could make the feet bruised.
She said it was something to monitor, but was not a concern at that stage, and those observations had been relayed to doctors.
The nurse said Child D's circulation was not "100 per cent brilliant" at that point, but this was common in newborn babies.
The note records Child D was reviewed by Dr Andrew Brunton.
The decision was made to 'commence feeds and increase as tolerated', with expressed breast milk.
Blood gas readings taken at 11.52pm and 1.14am were 'satisfactory'.
Mrs Oakley said she remembered "being very happy with her" at that point of the night shift. While Child D was an intensive care patient in the neonatal unit, she was 'only requiring a little assistance' with breathing, and she was "stable".
The observation chart for Child D for that night shift is shown to the court, which shows Caroline Oakley's initials signing hourly observation readings.
The heart rate, respiration rate and temperature are recorded.
Child D's heart rate says for the first few hours, the heart rate was "completely normal" up to 12.30am. It had peaked at 1.15am, but could have been after handling and/or a nappy change, Mrs Oakley tells the court.
She said that reading was "still within normal parameters".
The respiration rate was at the "upper end of what would be considered ideal", but was still within normal parameters, Mrs Oakley adds.
The temperature readings are also "completely normal" with "no high temperature".
A further observation chart records the readings made for Child D being on CPAP.
The chart recorded Child D did not require oxygen support at this stage, having been taken off that in the early hours of June 21.
The oxygen saturation levels were '100', which meant Child D was "breathing beautifully".
Another intensive care chart is shown to the court, showing fluids administered during the evening and night of June 21.
A 'minimal' amount of 'acidic' aspirates is recorded from the stomach in the evening.
It was followed by 'mostly clear' aspirates, with occasional darker bits.
Mrs Oakley says there was "nothing" she was "worried about" from those readings.
The neonatal infusion prescription chart at 1.25am is shown to the court.
It is signed by Caroline Oakley and Lucy Letby.
Mrs Oakley says usually the nurse looking after the baby will administer it.
She confirms the two signatures made, showing they had checked the fluid.
Mrs Oakley adds: "I would presume that I connected the fluid".
At 1.30am, nurse Oakley's notes record: 'called to nursery by senior nurse...and senior nurse Letby; [Child D] had desaturated to 70s, required oral suction as was bubbly and had lost colour. Discolourations to skin observed; trunk/legs/arm/chin. Dr Brunton called to review'.
Mrs Oakley says she remembers being on her break at 1am-2am, so was in the resuscitation room where staff had their breaks. She said she had been gone because Child D was poorly.
The prosecution ask about the timing of the 1.25am medication, and if the nurse can account for that. Mrs Oakley says she cannot.
She says: "To the best of my knowledge, I remember going on my break, and remember being called back.
"I had only been gone half an hour, and had been happy with her before I left.
"I remember saying: 'What's happening?'"
Asked about the note, Mrs Oakley said the 'bubbly' bit is for bubbly saliva.
She says she does not remember specifically the exact rash discolouration, but "hadn't seen it before - it was dark, it was unusual, and the rash struck me."
Asked to expand on that, she says: "I haven't seen that rash before on a baby I have looked after. To the best of my knowledge, in my years of neonates (over 20), no."
Mrs Oakley adds: "It was unusual, I had not seen it before, and probably struggled to describe it. It was a deep red-brown...different from mottling, different from what I'd seen before."
She says sometimes babies can look 'generally white' with a 'mottled all over' appearance, whereas this was a rash 'in specific places'.
She says: "It was just different from what I'd seen before, that's what stayed with me."
The nursing note adds: 'Satuartions to 100% and O2 weaned to air. Observations satisfactory."
Mrs Oakley said she couldn't recall who was doing what, but the oxygen was turned up on the CPAP machine, and Child D responded.
The note adds: "Dr Newby called in to review; fluids increased..." and a number of drugs and solutions were administered and prescribed.
The note adds: "Discolourations resolved. [Abdominal x-ray] taken satisfactory. Continue supportive treatment [ie antibiotics]. Maintain UVC [ie don't take it out]. Decision to speak to parents later as [Child D] stable and doctors required on paediatrics. Repeat gas good."
Mrs Oakley confirms the rash-like appearance had 'resolved' between 1.30am and after the doctor's review.
She says Child D had had an episode but had responded "quickly" and "normal parameters" had resumed within an hour.
As Child D was "very stable again", and the doctors were "busy", the decision was made to let the parents rest and inform them in the morning.
Mrs Oakley is asked to put into context further observation readings at 2.30am for Child D, which had "returned to normal".
She says they would be considered "stable".
A 1.30am fluids reading records 'nil by mouth' at the time for Child D, along with 'oral secretion ++' for aspirates.
The fluids chart also notes what Mrs Oakley believes is a task carried out for Child D by Lucy Letby at 1.05am, which she said would have been noted retrospectively, as Mrs Oakley would have started her break at this time.
Nurse Oakley's nursing note adds: "[3am Child D] crying and desaturated again to 70s. Commenced on 100% O2 via CPAP and picked up well but skin discoloured again but less than previously. Dr Brunton called to review; take off NCPAP, further fluid bolus and gas 1 hour cares attended to; [passed urine] +++ and passed meconium."
Mrs Oakley says she cannot recall the events around this collapse, and says her memory of it is limited to that of her notes.
A nursing note of drug infusion, which Mrs Oakley says the doctors believed Child D would need more fluid on board, is noted at 3.20am.
The fluid chart records for 3.30am 'restart expressed breast milk (1ml).'
The prosecution say the collapses had been of concern to nurses, and why the doctors were called.
Mrs Oakley said after the review, the doctors were "happy with her" and for fluids to continue to be administered.
She added Child D had passed urine and had a wet nappy, and so she was comfortable in changing her nappy.
"If I thought she was unstable, I would not have chosen to change her nappy. If the baby's unstable, they do not tolerate handling. Even cleaning them could cause them to be unsettled, with their heart rate going up."
The nurse added 'observations satisfactory' and Child D was 'handling well'.
The final observation readings were all in normal parameters at 3.30am.
At 3.45am, the nurse noted: "Monitor alarming, [Child D] desaturated again and [stopped breathing]. Called senior nurse Letby to help. Stimulation given."
Use of Neopuff was given at 3.52pm. A senior house officer was called to help. Dr Brunton called to help, resuscitation efforts began.
The prosecution asks if Mrs Oakley has a memory of this.
She says she does note, it was "just a blur, just very busy. She 'misbehaved' [had gone poorly again]. I don't remember specifically."
She does not recall if an alarm went off. From her notes, she called Letby to assist.
The initial 'stimulation' effort was, the court hears, to tickle the feet, trunk, ears, which can in itself get a baby stimulated enough to start breathing.
Mrs Oakley says she played a part in the resuscitation efforts.
Cross Examination
Ben Myers KC, for Letby's defence, is now asking Caroline Oakley questions.
He asks if she was aware of the 'increased mortality rate' between June 2015 and July 2016, and in a police statement, said it was a 'busy and stressful time'. Mrs Oakley agrees.
He asks whether that was from increased admissions to the neonatal unit.
"There were a lot of babies."
She said she couldn't say if that was an increase, and would have to see the statistics.
Asked if there were an increased number of acutely poorly babies, Mrs Oakley replies: "I'm not sure, I worked there a long time. We used to take a lot of 24-weekers when I started [over 20 years prior].
"I remember midwives bringing babies in when we were busy."
She says she does not remember the unit being "unduly short-staffed".
Mr Myers suggests that at times of crisis, they had the staff they required.
Nurse Oakley: "Yes, as they would be called from other patients."
Mr Myers: "But maybe at other times, you didn't have as many staff as you needed?"
Nurse Oakley: "I'm not sure."
He refers to Child D as an intensive care baby.
Mrs Oakley says she wasn't a 'poorly' intensive care baby as she wasn't on ventilator support.
She says Child D was classified as an intensive care baby.
The chart showing Mrs Oakley looking after Child D in room 1 and a baby in room 2.
He says intensive care babies require one-to-one support.
"Ideally yes"
He says the fact Mrs Oakley was looking after another baby too that night fell outside the guidelines.
"That isn't in the guidelines, is it?"
Mrs Oakley: "Strictly speaking no, but it does happen."
Mr Myers: "It's important that with babies like [Child D] you remain vigilant, as they can deteriorate quite suddenly, can't they?"
Mrs Oakley: "They can, yes."
Mr Myers asks if Mrs Oakley was aware Child D had been on a ventilator until the early hours of June 21.
She says she only knows that from the medical notes.
He asks if she knew there had been a delay in giving Child D antibiotics after birth.
She says she cannot remember, but can see from the notes.
Mr Myers refers to a nursing note from June 21, during the day, that there were signs of respiratory acidosis after extubation.
Mrs Oakley says she cannot remember that note, but she would have been told about it during the shift handover.
Mr Myers refers to the note continuing with 'blood gas repeated 2 hours later showed a further deterioration 'with increasing metabolic acidosis'.
He asks whether she would have been informed of this.
Mrs Oakley: "I'm sure it would've been mentioned [at the handover], yes."
Mr Myers asks about the attempt to take Child D off CPAP at 7.15pm, but Child began shallow breathing again, so was put back on CPAP.
"What we have is a baby who has been struggling to breathe unaided [throughout the day]?"
"Yes."
Mr Myers says there are warning signs she was not in an optimal state, and an indication she was "unwell".
"If she needs help with her breathing, yes."
The observation chart is shown for Child D for the night shift is shown again to the court.
Mr Myers then refers, for context, to the previous 24 hours, showing Child D's observations were in 'the warning zone' for heart rate and breathing rate on several hourly observation readings from late on June 20 throughout the day of June 21.
A blood gas readings chart is shown to the court.
The PH readings recorded at 10.14am and 12.10pm on June 21, of 7.194 and 7.173 are 'acidic'. Mrs Oakley agrees. She adds that doctors would have a better idea of the parameters of what would be normal readings for babies.
Mr Myers, referring to other readings, says the situation is 'not as good' at 11.52pm as it was at a reading from 6.44pm.
Mrs Oakley agrees.
Mr Myers says the blood gas readings are worse at 1.14am, and point to a deterioration.
Mrs Oakley says the readings to her are not as good as earlier, and says the doctors would take action based on them.
Mr Myers refers to the break Mrs Oakley took between 1-2am.
Mes Oakley says she is not sure the 1.14am blood gas reading notes are in her handwriting.
Mr Myers refers to the 1.15am observation chart reading note, which has Mrs Oakley's signature initials.
Mrs Oakley says she would have usually expected to write those observations at 1.30am [prior readings are 11.30pm and 12.30am, with subsequent readings at 2.30am and 3.30am], and may have written them retrospectively - "it does happen".
An IV prescription chart, with Mrs Oakley's signature initials at 1.25am, is presented to the court.
Mrs Oakley said the prescription is not in her handwriting.
Mr Myers says it's not unusual for nurses to help each other out, particularly for procedures which could involve two nurses. Mrs Oakley agrees.
A fluids chart is presented, showing the gastric tube change recording '0105 - suction pp ll, AXR, bolus'.
Mrs Oakley says she believes she has written that retrospectively, and has summarised what was told for that 1.05am. She has summarised that they wanted a bolus and an abdominal x-ray.
She says she would have been told all this by Lucy Letby, by another nurse Kate Percival-Ward, or a combination of both.
Mr Myers refers to the 1.30am collapse of Child D.
Mrs Oakley says it was a short distance from the resuscitation room to room 1, and does not recall who came to get her.
Mr Myers said Child D responded well to the oxygen, and no resuscitation was required. Mrs Oakley agrees.
Mr Myers refers to the skin discolouration of Child D at the time of the first collapse.
Mr Myers: "Does that suggest the skin discolouration was all over her body?"
Mrs Oakley: "The front of it yes, but I don't know if it was all the trunk. I don't think it was all the trunk, all the legs."
Mr Myers refers to her finding the rash-like appearance being 'unusual', and a 'struggle to describe it'.
"You said you couldn't remember it - was a deep red-brown what you saw?"
"I just remember the rash, I don't remember the specifics of it, I just remember it was an unusual rash."
"Would it be fair to say the fact it was unusual that stuck in your mind?"
"It always has, yes."
Mr Myers refers to the 3am collapse of Child D.
He suggests that Mrs Oakley was present at the time of the collapse.
Mrs Oakley says she would have been in the vicinity at the time, and does not remember what she was doing.
Mr Myers says it was an episode which resolved 'quickly' and resulted in a decision to take Child D off CPAP.
He asks whether there had been a discussion about Child D's breathing support difficulties earlier that day.
Mrs Oakley says she does not remember.
She says she believes if the desaturations had gone to the 70s, the alarms would have gone off and she would have been alerted to Child D.
The 3.45am collapse is now being referred to.
Mr Myers says at that point, Child D had been taken off CPAP.
Mrs Oakley replies: "Honestly, you would have to check the times for me."
"She was stable in between these two times?"
"Definitely."
Mr Myers says there is then a more marked deterioration, as Child D stopped breathing, and nurse Oakley called for help.
Mrs Oakley agrees.
Prosecution
The prosecution rise once more, led by Simon Driver, to ask about the discolouration of Child D's skin at 1.30am.
He asks what it was that struck her about the rash appearance that was unusual at 1.30am.
"I'd not seen it before."
He asks how it had changed by 3am.
She replies the rash wasn't as pronounced, not "as bad", but she was not expecting Child D to deteriorate again.
She says she had previously experienced 'mottled' appearance in babies - 'newborn spots', or 'mottled', but "we don't specifically get rashes, in my experience".
The judge, Mr Justice James Goss, asks to clarify one matter from the 1.30am collapse.
"You said some of that was what you had been told had happened."
Mrs Oakley says the 'oral suctions' referred to what was being done to Child D before she arrived back in room 1. The part of the note from 'discolourations to skin observed' were her own observations.
Dr Andrew Brunton
No live reporting, taken from round up article 07/11/22
Registrar Andrew Brunton was called three times by concerned nurses during a night shift at the Countess of Chester Hospital’s neonatal unit in June 2015.
Child D was receiving respiratory support after she was earlier taken off a ventilator on June 21 – a day after her birth, soon after which she lost colour and became floppy in her father’s arms.
Dr Brunton told jurors at Manchester Crown Court that child D was “clinically improving” on the evening of June 21, but he was called to urgently review her at 1.40am the next day.
He said there was a concern her oxygen levels had dropped and she had developed a rash.
In his notes, Dr Brunton put: “Skin brown. Areas of discolouration – light brown across trunk (stomach).”
Child D quickly recovered and the rash vanished, the court heard, but Dr Brunton contacted the on-call consultant to review the infant.
Giving evidence on Monday, November 7, he said: “This was a completely unusual situation that I had never seen. The changes in the skin – I couldn’t explain it.”
He was called again at 3am as he was informed Child D was upset and crying, her oxygen requirements had risen again and the rash had reappeared.
Dr Brunton said: “I can’t remember the specifics but I remember her being quite agitated and upset. This stuck in my mind as she had not been like that when I examined her before.”
Child D recovered and he said he decided to withdraw CPAP (continuous positive airway pressure) respiratory support, as he thought at the time it may be the source of her agitation.
Dr Brunton noted skin discolouration again on the abdomen but not as pronounced as the first occasion, the court was told.
At 3.45am he was asked again to attend the neo-natal unit and said he ran when the request was followed by the sound of a “crash bleep”.
Child D had stopped breathing and chest compressions had started by the time he arrived, he said.
She was given a number of adrenaline doses in a bid to stimulate her heart, as well as fluids and sodium bicarbonate.
Dr Brunton said: “All of that was necessary because (Child D) was, in effect, dying in front of us.”
A discussion with her parents followed and it was agreed to stop CPR. Child D was pronounced dead at 4.25am.
Prosecutor Simon Driver asked Dr Brunton: “ Having made repeated observations and examinations on (Child D) during the course of the shift which culminated in her death, how would you summarise the evolution of her condition that night?”
He replied: “From when I came in on my night shift there were no particular worries or concerns identified, but by 1.40am to the time of her death she had dramatic deteriorations over different points.
“It was completely unclear to me why that was occurring.”
Mr Driver said: “Why was it unclear?”
Dr Brunton said: “Because I had never seen a baby behave in that manner prior to this and I have never seen a baby behave in that manner after this.”
Cross Examination
Ben Myers, defending, said Child D had breathing problems from birth, had previously needed to go on a ventilator and “nothing indicated” she would do well if taken off CPAP.
He asked the witness: “When you took the decision that she should come off CPAP, did it cross your mind it may lead to a deterioration?”
Dr Brunton replied: “Absolutely not.
“If we are trialling a baby off CPAP they can go back on it if we think they are not able to cope with it.”
Neonatal Assistant Lisa Walker
No live reporting. Taken from round up article 07/11/22
Neonatal assistant Lisa Walker told jurors at Manchester Crown Court she was “shocked” and “taken aback” when Letby, 32, asked why she had sought assistance.
Miss Walker said she and the defendant – who is accused of murdering seven babies and trying to kill 10 others – were working together in a neonatal room at the Countess of Chester Hospital when an incident took place.
She said they were feeding infants in opposite corners of the room when an alarm monitor sounded at the cot where Letby was.
Giving evidence from behind a screen on Monday, Miss Walker said the alarm indicated oxygen levels had fallen.
Prosecutor Philip Astbury said: “Why ask for help?”
Miss Walker said: “Because the baby was not picking up.”
She said a doctor also came into the room but agreed the oxygen levels had increased by that point and later left.
Miss Walker said: “Then Lucy said to me, ‘Why did you shout for help?'”
Mr Astbury asked: “In what way?”
Miss Walker replied: “Quite firmly.”
Mr Astbury asked: “How did you feel about that?”
Miss Walker said: “Shocked because you can’t have enough help in that situation.”
Mr Astbury said: “Did you explain to her why you asked for help?”
Miss Walker replied: “I don’t think I did.”
Mr Astbury went on: “Why not?”
The witness said: “Because you trust colleagues, don’t you?”
Mr Astbury said: “How did you feel?”
Miss Walker said: “Quite taken aback and shocked because it’s something you would not expect a nurse to say.”
Letby stopped the feed through a breathing tube, commenced “gentle stimulation” of the baby and, when that did not work, she gave oxygen via a facial mask, Miss Walker said.
She said the baby did not respond to the oxygen at first and she shouted for help as a nurse walked past the door.
Mr Astbury said: “Why has it stuck in your memory?”
The witness said: “It’s because I was told off for shouting for help.”
Cross Examination
Miss Walker agreed with Ben Myers, KC, defending, that she could not remember the date of the incident, or the name and sex of the baby involved.
Mr Myers said: “You didn’t see anything regarding Miss Letby’s actions towards the baby which caused you any concern at all?”
“No,” said Miss Walker.
She told Mr Myers she did not get the impression that Letby asked the question because she felt help was unnecessary in the situation.
Dr Sarah Rylance
Giving evidence via court live link from Switzerland
The next witness to give evidence is Dr Sarah Rylance.
Dr Rylance confirms she was employed at the Countess at Chester Hospital as a registrar in June 2015, and worked a long day shift on June 20 that day.
She confirms she has the clinical notes for Child D to hand.
Dr Rylance says she does not believe she was present at the birth of Child D.
The details are recorded retrospectively, that Child D was born at 4.01pm on June 20.
The note includes: 'Bleeped again as midwife not happy with her colour' - she is not able to say whether that was her being bleeped again.
Child D 'looked dusky' and had 'poor respiratory [efforts]', with initial oxygen saturations at 48%, poor respiratory effort at 7.30pm.
The note adds 'transferred into incubator'.
After being given breathing assistancevia Neopuff, Child D 'pinked up quickly and started regular resps'.
The prosecution ask for what Child D would have been assessed as.
Dr Rylance: "She responded well to the ventilation support she has been given."
"In relation to the blood gases, it's difficult to assess how that reflects on her clinical condition."
The blood gases suggest Child D had difficulties with breathing and metabolism, but Dr Rylance said she would not use the blood gases alone to make a diagnosis, but take it into context with other readings and observations.
Child D was 'transferred on to CPAP', and an IV saline solution was administered.
Child D was also started on 'triple lights' as part of phototherapy to treat her jaundice symptoms. That was the "maximum treatment" level, Dr Rylance, tells the court.
Dr Rylance's notes, also record, for Child D at 8pm, the baby girl was on CPAP, 40% oxygen, and '[saturations] 100%'.
Child D's heart sounds were "normal", with an "ok" pulse rate, and it was noted there were regular breathing efforts, "but fairly shallow" and the abdomen was not distended.
The plan was to continue CPAP and administer dextrose, and repeat a blood gas test at 8.45pm.
Dr Rylance's notes at 8.20pm record the parents were updated on Child D's condition, with "likely sepsis" and she was receiving antibiotics "to treat infection".
The doctor tells the court Child D's condition was, at this point, "responding well to interventions" and "appeared to be stabilised on the CPAP and making respiratory efforts."
"Overall I was happy with the the progress she had made, but she needed to be closely monitored and assessed."
A further entry is made at June 21, 2pm, in the clinical notes.
The entry records the insertion of a UAC and UVC into Child D.
The UVC was removed as it was 'only able to advance to 5cm'. Dr Rylance says usually "you are expected to advance it much further.
"It can be difficult and fiddly to do this procedure in new-born babies."
The UAC was inserted to 20.5cm, but did not get a blood sample back. An x-ray review found it was advanced 'way too far', and the route was 'not typical of a UAC'.
The UAC "should follow a typical route", the court hears, and the line was pulled back to 9cm.
A blood gas reading was taken and the readings were 'much improved'.
A second x-ray showed the UAC position was 'better', but the route was 'still not typical'.
The 'much improved' blood gas reading was, Dr Rylance believes, a comparison with the previous blood gas reading.
The UAC was 'actually a UVC' and adjusted to be used as a UVC.
The plan was to continue CPAP for Child D and repeat a blood gas reading, and 'try to sample UVC' for various readings.
A review is carried out at 7pm on June 21, with 'presumed sepsis' noted.
A CRP reading of 1 is recorded, having previously been 6.
Dr Rylance, commenting on those readings: "I wouldn't attach particular significance to it," as both readings were "low", and would need to be taken in context with the baby's clinical condition and observations.
Child D had been on CPAP all day, but 'in air' and 'saturating well', with 'no desat[urations].'
The initial blood gases post-exhubation at 9am were 'not good', so Child D was put back on to CPAP at 10.30am.
Dr Rylance said Child D had made good progress, and her ventilation status was "very satisfactory" at the time she reviewed her.
Under the heading 'sepsis', the CRP reading was '1', and Child D had 'not had [lumbar puncture] yet.'
Such a test is done in clinically stable babies to test infection has not spread, the court hears, but Child D was 'not stable enough' for that to be carried out.
Other observations were noted by Dr Rylance that Child D was 'responsive on handling', with 'chest clear, regular resp effort, minimal recession', abdomen 'soft, not distended'.
The feet were 'quite purple', but Dr Rylance says that would be as a result of frequent tests carried out. The court has previously heard heel prick tests would be done to get results such as blood gas readings.
Dr Rylance added: "Overall my observations were that she was stable and handling well...and responding well to treatment she had received throughout the course of the day."
Under 'impressions', Dr Rylance noted: 'stable on CPAP, tried taking her off but resp effort became irregular and desaturated a few times so put back on'.
Dr Rylance said she would not have attached a lot of significance to this, as "it takes babies some time to settle. She was obviously unwell when she came to the neonatal unit the previous evening.
"She needed a bit more time from the CPAP...allow us to transition having been ventilated and moving to breathing.
"If they don't seem to tolerate it well, you can just put them back on [CPAP].
"She was heading in the right direction, she just needed a little support from the [CPAP] machine without added oxygen."
The note added, as part of the plan, 'leave on CPAP, await CRP...leave UVC for now to allow sampling for gases, continue [antibiotics].'
Dr Rylance says she was "happy" with Child D's clinical condition, having had "a very satisfactory day" and was improving, in good colour, not needing oxygen support.
"She has shown good improvement from the condition when I first saw her on the neonatal unit the previous evening."
Cross Examination
Ben Myers KC, for Letby's defence, is now asking Dr Sarah Rylance questions.
He says there were two instances of her examining Child D.
He said that at the end of the June 20 examination, she was "happy with [Child D's] progress".
"Would you agree she was at risk of complications?"
Dr Rylance says Child D had responded well to treatment, but the blood gases were not in the normal range, and that would require close observation.
Mr Myers points to Child D having 'lost colour' and 'floppy' when in her father's arms moments after birth.
"Do you agree that is worrying at that stage?"
Dr Rylance agrees the Apgar scores of 8/10 and 9/10 aren't relevant for 12 minutes later.
Mr Myers asks if the progress of Child D is based on the reference point from the worrying signs just after birth.
Dr Rylance: "My opinion of her at the end of the shift, my reference point is from when I first had contact with her on the neonatal unit, from when she required ventilation support.
"I wasn't invovled at her birth...I can't comment on her condition at the time. My writing [on the clinical notes] is based on what I had been told.
"It's my summary, but not my observations, if that makes sense."
Mr Myers: "You will have known...she started grunting in theatre...reviewed after 1.5 hours, 'grunting but otherwise observations ok'."
Mr Myers asks if grunting can refer to respiratory effort difficulties.
Dr Rylance: "Yes it can."
Dr Rylance says she is unable to recollect whether she saw Child D prior to her neonatal unit admission, but does not believe she was involved in the review to bring her to the unit.
She said: "From the point she came to the unit, these were my direct observations."
Mr Myers asks if Dr Rylance reviewed Child D at about 7.30pm.
Mr Myers: "She presents as a baby who is seriously ill?"
Dr Rylance: "Yes...at that point she was an unwell baby."
Dr Rylance says she believes the first time she reviewed Child D was in the neonatal unit. Had she done so before, she would have noted that from a ward observation.
The venous gases taken at that time show 'marked acidosis', Mr Myers asks. Dr Rylance agrees.
Mr Myers: "You explained to us these were abnormal and indicate difficulty with the respiratory system and metabolic components?"
Dr Rylance: "Yes, that's correct."
Mr Myers says those readings are taking into account the clinical condition for Child D.
Dr Rylance: "Yes."
Mr Myers: "But at this stage, weighing up the clinical picture, it was not a good picture, was it?"
Dr Rylance: "No."
Mr Myers said at one point, Dr Rylance had referred to the examination as being 'normal', but there was quite a lot of Child D being 'abnormal'.
Dr Rylance says Child D was "not a healthy baby at this point in time".
She says she is aware Child D was later put on to a ventilator.
Mr Myers says infection is a 'leading cause' in neonatal deaths and can 'develop very quickly'.
Dr Rylance: "It can."
"As a rule, antibiotics should be given to a neonatal baby...
"There are different guidelines on whether babies should receive antibiotics, with clinical risk factors.
"When you have concerns...then you want the antibiotics as soon as possible."
Mr Myers says Child D's mother had her waters break many hours before giving birth, and that Child D was, at birth, 'floppy' and at risk of collapse.
Dr Rylance agrees Child D should have received antibiotics at this stage.
She adds this is reliant on someone else's documentation, and it is difficult to say precisely how Child D was responding at that time.
She says it would have been a good idea to start antibiotics as quickly as could be done, and that was done upon her arrival at the neonatal unit.
Mr Myers: "The reality is, from the point of collapse at 12 minutes...given everything we know, [the plan] would have been give antibiotics rapidly?"
"Yes, I think so."
Mr Myers says Child D was not given antibiotics until nearly four hours after birth, at the neonatal unit.
Dr Rylance agrees that would be the case.
"There was a four-hour delay in the delivery of antibiotics after birth?"
"Yes."
"You may not be responsible, but that falls below the standard of care for a new-born baby, doesn't it?"
"Yes."
"The purpose of antibiotics is to treat and reduce the risk of infection?"
"Yes."
Mr Myers refers to the blood gas readings on the afternoon of June 21.
Dr Rylance says there would have been a blood gas chart and the readings were presumably an improvement on what was previously taken.
Dr Rylance tells the court the intention was to insert a UVC and a UAC, "if it's possible to do so."
The court hears the 'UAC' inserted acted as a suitable UVC instead.
Mr Myers refers to the 'presumed sepsis CRP 1'.
He says the CRP reading increases from CRP 1 to CRP 6 later that night.
He says from those readings, they cannot diagnose infection on their own.
Dr Rylance: "Yes."
Mr Myers refers to an attempt to take Child D off CPAP by Dr Rylance, as noted, and an accompanying nursing note referring to the oxygen levels desaturating to the 80s.
He says "that is not a healthy state to be in, is it?"
"It reflects she needed more respiratory support, but the fact she had moved on from ventilator support, and needed no oxygen support, suggested it was improving.
"By trying to take her off CPAP, we wouldn't have done that if she wasn't stable.
"She didn't tolerate it, so we put her back on."
The improving clinical condition, Dr Rylance says, was from Child D arriving at the neonatal unit to her obersation the following day.
Mr Myers says the 'satisfactory examination' of Child D was carried out while she was on CPAP.
Dr Rylance says a lumbar puncture is "quite an invasive" procedure and there is a risk of that being carried out if a baby is still on breathing support.
In Child D's case, it was "weighed up" and it was felt it was not needed to be done at that time.
Mr Myers said Dr Rylance had identified sepsis and acidosis "at various points" and during the time she was cared for, Child D required breathing support.
He says that when Child D was taken off CPAP, she began deteriorating.
Dr Rylance agrees.
Prosecution
The prosecution, led by Simon Driver, rises to clarify about the notes made for Child D following birth.
"As of your last review on 7pm on June 21, what was your assessment of her at that stage?"
"From what I documented, [Child D] was stable...with minimal respiratory support and no additional oxygen support.
"In handling, she was responsive and making good progress and making good response to treatments over the previous 24 hours.
"She was not a healthy baby at that time [due to still requiring CPAP], but...clinically she was stable and making a lot of progress."
Nurse - unnamed
The next witness, who cannot be named due to reporting restrictions, confirms she was a neonatal unit nurse at the Countess of Chester Hospital in June 2015.
She tells the court night shifts would be "generally quieter" in terms of staffing numbers, and there were no set rules on when they would take breaks, and would depend on workloads.
When they were on breaks, another member of staff would be directed to cover for the designated baby. That role could be done by the shift leader.
The nurse confirms she was the designated nurse for two babies in room 2 on the night shift of June 21.
She said she cannot remember having any cause to be involved with Child D on the early part of that night.
A medicine chart is presented to the court showing the nurse was a co-signer for doses of medication for Child D at 9.23pm.
The nurse says her memory of Child D's collapse at 1.30am is "vague", but remembers her being "stiff" and having a "rash" on her abdomen.
She says she does not remember whether she was in the room at the time of the collapse.
She says, from her statement, colleague Caroline Oakley (the designated nurse) was not present in the room at that time.
She recalls Child D's appearance - the baby girl was 'discoloured' and "stiff". The discolouration "was like a mottled appearance", it was "an odd rash, it was unusual".
She said mottling would be blue and grey, whereas this was "not that colour". She said it was a "reddy brown" colour, which was "unusual", and this was found on Child D's abdomen.
The nurse says she wants to say she had seen this discoloured appearance again, but could not say whether that was before or after June 2015.
Asked by the prosecution to clarify, she tells the court she had not seen that discolured skin appearance in the years prior to that.
The nurse remembers Child D recovered quickly and was examined by Dr Andrew Brunton.
She says, from her notes, the rash had 'resolved' by that point.
The nurse added a similar event happened for Child D where she desaturated. She does not remember the circumstances but believed it was similar where she was given treatment, reviewed, and recovered.
She said she didn't remember seeing Child D, but would have done so as part of her shift. She said she didn't remember anything about the child's appearance or recovery.
The nurse tells the court there was further desaturating for Child D, she would have been notified to the room - but does not recall how - and there was a call for a medical review.
Full CPR was being carried out on Child D by the time Dr Brunton arrived in the room, the nurse tells the court.
The nurse recalls the efforts made to resuscitate Child D, which were made in established guidelines, and ultimately efforts were not successful.
She recalls the parents were there at the time.
After Child D had died, she recalls having a conversation with Lucy Letby on the resuscitation drugs used.
A chart advising dose levels for the drugs would usually be kept by the child, but this A4 chart, a laminated piece of paper, was missing.
The nurse said that chart was missing, and the resuscitation drugs were administered by calculating the doses with Child D's weight, and using her years of experience.
The chart "eventually turned up", the court hears, as "it must have gone missing in the stress of everything".
Lucy Letby asked the nurse how she knew what dose levels to give, and the nurse explained how she had done so.
Cross Examination
Mr Myers, for Letby's defence, asks the nurse about workloads between June 2015-June 2016.
The nurse agrees there was a higher workload during that time, with an increased acuity overall in the patients arriving in the unit.
Mr Myers asks about the 14 babies being on the unit on the night of June 21.
He says "ideally", the shift leader (which the nurse was working that night) would not be looking after babies on the unit for that shift. The nurse agrees.
Mr Myers said Child D was being looked after by Caroline Oakley, who was in room 1 (the intensive unit room), and another baby in room 2 (a high-dependency unit room), and that goes against the guidelines.
The nurse says: "It's not what the guidelines say, however, the ITU guidelines are quite specific."
The nurse says some babies in intensive care require different levels of care.
Mr Myers says, ideally, Child D would have 1-2-1 care that night.
"Ideally, yes."
Mr Myers asks about Child D's collapses that night.
The nurse confirms resuscitation attempts were only required on the third collapse.
Mr Myers asks about the rash - which the nurse described as 'mottled, white circles, with a reddy-brown colour'.
He asks if that is what the nurse remembers from telling the police, or from discussing it with colleagues.
The nurse: "No, that is how I remember the rash."
Mr Myers asks if that is how she remembers the rash, as 'reddy-brown' was not in the police statement.
The nurse agrees.
She also says she cannot remember how long the rash lasted.
Dr Emily Thomas
The court is now hearing from Dr Emily Thomas, who in June 2015 was working at the Countess of Chester Hospital.
She remembers the night shift being busy on the children's ward, and her colleague Dr Andrew Brunton being called out to assist Child D.
She recalls an unusual rash appearance at the 1.30am collapse, with purple colouring around the abdomen.
Dr Thomas said she was in the middle of a septic screening in room 2 or 3 at the time of the third collapse.
She said she believed Lucy Letby was the one who had called for help, and recalled her being upset, saying what she recalled was: "This is my second baby that this has happened to".
She did not recall seeing a rash on Child D during the resuscitation attempts.
The court also heard, from Dr Thomas's statement, there was a communication mix-up when Dr Brunton was on the telephone to what he thought was an on-call consultant, but was actually one of the parents of Child A and B.
By this time, Child A had died and Child B was being treated in the neonatal unit following a non-fatal collapse.
Previously, the court heard the parents of Child A and B would be in very regular contact with the hospital throughout the nights for an update on Child B's condition.
Dr Brunton was "mortified" when he realised the communications error had been made.
Just for extra clarification on the phone call, this is what was reported in the bbc round up article 08/11/22:
Dr Thomas also recalled her then colleague Dr Andrew Brunton, who was leading resuscitation efforts, being "mortified" when a mix-up led to the mother of Child A, also allegedly killed by Ms Letby, being contacted on the phone instead of a consultant.
Dr Brunton had wanted to speak to senior colleague Dr Elizabeth Newby for advice on the resuscitation of Child D.
Dr Thomas said Dr Brunton was "shocked" when he realised the error that had been made.
The call would have been made to Child A's mother in the early hours of the morning, just two weeks after the death of her baby.
Elizabeth Marsh
The next witness, Elizabeth Marsh, was working a night shift on June 21.
She said on this shift, she was looking after babies on the post-natal ward and babies on the neonatal unit.
She said she saw Lucy Letby giving chest compressions to Child D at the time of her third collapse.
She said she was not directly involved in the resuscitation attempts, and was involved in the transcribing of the efforts, writing the notes on a paper towel.
She said there was a short debrief at the end of that, but nothing more formal at that time.
Nurse Kathryn Percival-Calderbank
No live reporting, taken from daily round up (09/11/22)
Kathryn Percival-Calderbank recalled a night shift in which Letby, 32 is said to have administered a fatal amount of air into the bloodstream of a baby girl.
The infant, referred to as Child D, suffered three collapses at the Countess of Chester Hospital in the early hours of June 22, 2015.
On the first occasion, Mrs Percival-Calderbank told Manchester Crown Court on Wednesday, November 9, she noticed an “unusual, mosaic-type” rash on the youngster’s torso and arms which was “reddy-brown” in colour.
Child D is alleged to be the third infant murdered by the defendant in a two-week period in June 2015, with another suffering a life-threatening collapse during the same time.
Giving evidence behind a screen, Mrs Percival-Calderbank said she had worked at the unit for newborn infants since 1993.
She recalled checking in on Child D while the infant’s designated nurse, Caroline Oakley, was on a break.
“I remember looking in,” she said. “She was nice and stable, the baby seemed quite settled.
“I popped in another time about 10 minutes later. She was OK.”
Some time later, the witness said she returned to the intensive care room when alarms sounded.
Mrs Percival-Calderbank added: “The baby’s monitor was showing she was desaturating and her heart rate had dropped.
“I don’t know whether there was anyone else around at the time but I think there may have been.”
She said she checked Child D’s head position, gave “gentle stimulations” with her hand and then used a facemask to provide oxygen.
She went on: “I was assisted by someone. I can’t clearly remember who it was. I have a feeling it might have been Lucy, but I can’t categorically say.”
Asked by prosecutor Philip Astbury if she noticed anything while assisting Child D, Mrs Percival-Calderbank said: “There was a rash on her trunk and arms. It was on her body from the chest downwards.
“It was not like a normal rash that you would know if a baby was becoming septic. The blood vessels tend to more bluey.
“This seemed to be a largely mosaic-type rash and it was a reddy brown colouring.
“It was not like a spotty rash. It was oval-type markings on the skin. The vessels of the blood seemed to be meeting up with each other.
“She was quite a pale-skinned baby, so they seemed to be pronounced browny/red.”
The witness said the discolouring “seemed to disappear and dissipate after a while” and that Child D settled back into a normal pattern of breathing after doctors assisted in the intervention.
Cross Examination
Ben Myers, KC, defending, asked if the “extra detail” she had provided about the rash, compared to her police statement, was something she may have picked up in conversation at work.
Mrs Percival-Calderbank replied: “I might have done, but it’s also my recollections which have come back. It was an odd rash. It wasn’t like a normal septic rash, it was a different type of rash.”
Mr Myers said: “Can you help us with how you got the extra details?”
The witness said: “Because I started thinking about the events. As I was getting sleepless nights I was thinking about the events that happened.”
Dr Elizabeth Newby
No Chester Standard live reporting, taken from Twitter @merseyhack (09/11/22)
Consultant paediatrician Dr Elizabeth Newby is describing how she treated an alleged victim, Child D. She says D as born in good condition but needed help with breathing shortly afterwards. By the evening she needed to have a tube in her windpipe to help….
…but by the next morning D was well enough for the breathing tube to be removed. D was able to breathe on her own in air. Dr Newby “felt it was likely that there was an element of infection” as D’s mothers waters broke early and there was a delay in her having a C section birth
Dr Newby was called in to see D at 2am the following day as D had had a “profound desaturation”. [very sudden loss of oxygen levels in blood]. She was called in because D had been so stable and then had deteriorated.
Dr Newby describes unusual discolourations (“bruised areas”) on D’s abdomen. “We didn’t know what to make of them, to be honest. It was quite unusual. We felt it must be related to infection.”
She says the discolouration might be related to meningococcal disease in older children, but “I know that couldn’t apply to neonates because you don’t se meningococcal disease babies.”
Cross Examination
Cross examined by Ben Myers KC, defending Ms Letby, Dr Newby agrees that after birth D’s “condition was consistent with an infection of some sort.”
Mr Myers asks Dr Newby about notes relating to D the night before she collapsed showing that efforts to take her off CPAP (continuous positive airway pressure) were unsuccessful because D deteriorated when this happened.
Dr Newby agrees with Mr Myers that “ a baby who is unwell can have resistance to infection - to keep running at a certain level and then deteriorate very rapidly.”
Medical Expert Evidence
Dr Dewi Evans
No Chester Standard live reporting, taken from Twitter @merseyhack (09/11/22)
Court now hearing from Dr Dewi Evans, a paediatric expert instructed by the prosecution. Nicholas Johnson KC is asking him what he says about his review of the medical notes relating to Child D.
Asked about “mottling” seen on Child D’s body the first time she collapsed, Dr Evans says “its very significant and extraordinarily unusual. This is not something that happens out of the blue.”
Asked about D’s condition immediately before her collapse, Dr Evans says “Her condition could not have been better. Her condition was entirely consistent with a baby recovering from early onset pneumonia. She was doing exceptionally well and was clinically very satisfactory.”
But Dr Evans says D was “recovering” from early onset pneumonia, not that she had “recovered” from it.
Dr Evans asked what would have happened if pneumonia had caused D’s death. “You find increased amounts of clinical input would not lead to improvement.. in D’s case none of this happened. She got better.”
Dr Evans says his conclusion in Child D’s case is that death was caused by an injection of air into her bloodstream.
Cross Examination
Ben Myers KC, defending, asks Dr Evans why he thinks this. Dr Evans gives 5 reasons.
1. D’s collapse was rapid and v striking.
2. The presence of discolouration on D’s body “a pattern experienced [nurses and doctors] had never seen before and never since and it came and went.
3. Attempts to resuscitate D were unsuccessful.
4. The presence [at post mortem] of air in D’s blood vessels and
5. None of the other issues, eg pneumonia were relevant.
“What we have in [D’s] case is a full house of clinical characteristics consistent with her having suffered an air embolism, ie air has been injected into her.” says Dr Evans.
Dr Evans agrees with the defence that D was in a state of very poor health when she went to the neonatal unit.
Mr Myers refers to Dr Evans saying D was “recovering” from pneumonia, and suggests that she still had the “potential to become quite unwell.” Dr Evans says “She was in a neonatal unit , the best place on the planet for her.”
When asked by Mr Myers again about her potential to become unwell, Dr Evans says “The potential is there, which is why she was on a neonatal unit.”
Mr Myers suggests Dr Evans doesn’t want to accept problems with [D’s] respiration because that would “undermine” his conclusion that D died from an air embolus. Dr Evans says “No.”
Professor Owen Arthurs
Professor Owen Arthurs has been recalled to give evidence in respect of Child C and Child D.
Professor Arthurs is now giving evidence for Child D, and has examined radiograph images as part of his report.
The first one, at June 20, 10.22pm, is presented to the court, in which there are no abnormalities seen.
A second x-ray image of 'effectively the whole body' is shown the court at June 21, 1.32pm.
Professor Arthurs notes two features - the 'obvious one' being the UVC going up towards the heart, which has been pushed in too far.
The 'subtle' observation was a sign of infection in the child's right lung, but the magnitude was 'nothing like' that seen in Child C's case.
The third x-ray image was taken at June 22, 1.51am, after Child D's first collapse.
The UVC line has been 'withdrawn slightly'.
He explains the UVC is 'in a loop', and is 'almost certain to be outside the body'.
He says there is 'nothing unusual' in the appearance, and the diaphragm 'looks pretty clear', indicating a potential infection looks like it had improved.
Professor Arthurs says it is diffuclt to gauge between one x-ray and the other, but it would be consistent with an improving picture for a baby in air throughout that time.
A further x-ray image, taken at Alder Hey Hospital after Child D had died, is shown to the court.
The UVC is still in, and a 'black line' just in front of the spine is a 'striking feature'.
Professor Arthurs says "air is present" on what the court hears is the 'main highway' of the circulation.
Professor Arthurs says the significance of that is that it is an "unusual feature in babies who have died without an explanation".
He adds that amount of gas is consistent in babies who have died of sepsis, sudden unexpected death in infants, a road traffic collision, and two other babies in the trial. Another was Child A.
He says one of the other explanations which needs to be considered is deliberate air injection.
He says the most plausible conclusion was, in the absence of any other explanations, he considered they were 'consistent with, but diagnositic of, deliberate air administration'.
He confirms he has never seen this before in his experience.
Cross Examination
Ben Myers KC, for Letby's defence, is going to ask questions on the baby girl, Child D, first.
He asks if it was correct that, at post-mortem stage, there were normal amounts of gas found in the normal areas, including in the bowel. Professor Arthurs agrees.
Mr Myers asks about how often gases are found, post-mortem.
Professor Arthurs says for a quarter of those cases of gases found in the post-mortem examinations at Great Ormond Street Hospital, there were gases found in the great vessels areas, for which there was an explanation of post-mortem gases.
He adds if there is 'overwheming evidence' of infection, that can lead to gases appearing there, or potentially gas being redistributed in the body during prolonged resuscitation efforts.
He says administration of air is one of the explanations.
Dr Sandie Bohin
Medical expert witness Dr Bohin is giving evidence on Child D, and confirms she has made a report on her, having had access to relevant medical reports and images from the Countess of Chester Hospital and Alder Hey, plus other medical experts.
She confirms her role was to peer-review Dr Dewi Evans's conclusions from his report.
Dr Bohin says there is now an advantage in delaying the cutting of the umbilical cord by two minutes, if the baby is in good condition, which is true in premature babies.
However, if the baby is 'in extremis', the priority is on saving the life and cutting the umbilical cord immediately is the priority.
Dr Bohin said the cord was cut for Child D after two minutes.
She says Child D was in some respiratory distress due to 'grunting', which started when she was taken to the post-natal ward.
It had been noted by the parents Child D was floppy and dusky in colour. Upon similar observations by medical staff, Child D was taken to the neonatal unit.
Dr Bohin noted Child D was put on to CPAP with 40% oxygen, and during the night she had improved but was 'still not normal'.
She tells the court there were still signs of respiratory distress for Child D.
Dr Bohin confirms she has noted what medical staff noted during their observations and records.
She noted the skin discolouration observations for Child D at the time of the first collapse at 1.30am on June 22.
Dr Bohin says she would have been 'surprised' if an infection was the sole cause behind Child D's 'catastrophic collapse'.
The original cause of death, post-mortem, was 'pneumonia with acute lung injury', Mr Johnson tells the court.
Dr Bohin explains, in her opinion, Child D's condition at birth was 'good', with good APGAR scores, and delayed cord clamping which would not have been done if Child D was not in a good condition.
She says, upon the observation of Child D becoming 'floppy in her father's arms', she has had "First-time parents are desperately keen to have their baby with them - with skin-to-skin, which has a number of benefits."
Dr Bohin says she means "no disrespect" to Child D's parents, who were first-time parents, that the father could have held Child D in such a way as the baby put their head on to the father's chest, "and that can collapse slightly, their windpipe."
"I see this fairly regularly...and with inflation breaths, the baby seems fine.
"I cannot tell whether this was a clinical collapse, or [simply] an unusual position of the head."
Dr Bohin notes the inconsistent temperatures for Child D showed sign of an infection, and Child D should have been screened at that point.
It was when Child D refused to feed, that she was then, later, transferred to the neonatal unit.
Dr Bohin says newborn babies usually maintain their temperature quite well, but premature babies require more monitoring.
Child D's tempertaure was low on arrival to the neonatal unit, but says the nursing staff 'probably overdid it' in increasing the incubator temperature, as Child D's temperature and heart rate rose to levels outside normal readings.
Dr Bohin says the breathing rate was "high" and she required oxygen support.
"Breathing at that rate is hard work for babies - rather than wait for them to be tired...it's much safer for the baby to intervene rather than wait for them to collapse."
The clinical picture for Child D was 'consistent with infection', Dr Bohin says, even if the x-ray image did not show that.
The second x-ray image showed 'a small patch of' infection in the lung.
Dr Bohin says Child D, throughout June 21, was "well and stable". She required CPAP, but in air, and was "improving" despite having pneumonia as an infection, but was "getting better" with treatment.
Dr Bohin says, regarding the decision to begin feeds for Child D, indicates the baby girl was "stable" as feeds would not be administered if the child was not stable.
She says all three collapses for Child D were "sudden" and "unexpected".
"They came out of the blue...she recovered very quickly with the first two, and two of the episodes were associated with an unusual mottling of the skin.
"They didn't have any clear cause."
Dr Bohin: "She seemed to recover very quickly after the medical team's intervention and she was well again."
Dr Bohin notes, for babies on CPAP, they will often find it uncomfortable as they will try fighting it.
A baby who is "relatively well" will fight it.
However, Dr Bohin said, in relation to one of the nursing notes: "The fact she [Child D] became upset then was a concern to me, as she had tolerated it well up to then."
Dr Bohin says she believes the infection was acquired prior to birth, adding the initial administration of antibiotics was "late".
Dr Bohin said the medical team knew Child D had an infection, but there was nothing to indicate she was at imminent risk of dying.
For pneumonia, Dr Bohin said babies would show a gradual deterioration, with declining blood gases, increased respiration rate, increasing ventilation support, abnormal blood parameters, and additional medication doses.
"Taking into account the sudden nature of the collapses and the very quick recovery...I was very clear it wasn't infection, so the conclusion had to be something unusual and odd."
Dr Bohin refers to the unusual skin condition medical staff observed.
Other conditions were crossed off as they 'didn't fit'.
She concludes the collapses were caused by intravenous air administration either through the UVC or the cannula.
Dr Bohin says with air embolus, the speed and quantity of the air administered depends on whether it is fatal.
She says the first two administrations of air would have been small, but the third would have been larger to cause circulation to stop.
Dr Bohin says the suddenness of the collapse, with skin discolouration, fitted with cases of air embolus, as did the presence of air found in the 'great vessels' on post-mortem x-rays.
Cross Examination
Ben Myers KC, for Letby's defence, is now asking Dr Bohin questions.
He says that 'in the absence of infection', there had to be 'something unusual and odd' found.
Dr Bohin said she had looked at the clinical picture and had excluded the explanations more commonly found, which left the only conclusion as 'something unusual and odd'.
Mr Myers asks about the relevance for Child D being in distress.
Dr Bohin said it was a possible explanation for that seen in adults, they can "be in distress after an air embolus."
She adds there is very poor literature on this for neonatal babies, as there are few cases and little evidence of this.
Mr Myers says Dr Bohin cannot apply to neonatal babies what has been seen in adults.
Dr Bohin says neonatal babies don't have different biological systems, and a lot of the medicine relates to what has previously been done in adults.
She adds Child D had been content with CPAP before, and her being in distress was a sign of concern.
Dr Bohin said Child D was taken off CPAP, following the second collapse, in case she was being distressed.
Mr Myers: "Are you just trying to find any evidence to support your air embolus conclusion?"
Dr Bohin: "No, absolutely not."
Mr Myers: "You just take any bits that you can find to support your diagnosis?"
Dr Bohin: "No, absolutely not."
Dr Bohin adds, in relation to the skin discolouration, the rash observations noted by medical staff were like nothing she has observed for any neonate. She adds she was not there, but those observations by doctors and nurses were not ones she had found in neonates before.
She adds she is not using skin discolouration alone as her diagnosis, but fits as part of a 'constellation of features'.
She says such discolouration would be 'circular, with reddy-brown marks, which came and went', and not 'mottling'.
She adds: "There is no single distinguishing feature of an air embolus."
The 1989 medical journal review into air embolus is presented to the court, mentioning a particular case - 'blanching and migrating areas of cutaneous pallor were noted in several cases and, in one of our own cases, we noted bright pink vessels against a generally cyanosed...background."
"We have had many particular descriptions - they do not all conform to this, do they?"
"I think they're pretty similar."
"Nowhere in the clinical notes for any of the children in this, have we had [this description]?"
"We have seen reddy-brown patches on a background that is cyanosed, so yes, we have."
Mr Myers says there is 'no uniform presentation' of the skin discolouration to mark it against.
Dr Bohin says it is rare, so there isn't, and agrees that the 1989 medical journal is a reference to such evidence.
She repeats the skin discolouration observations are "remarkably similar".
Mr Myers says there is no discolouration or distress in the third collapse.
Dr Bohin: "Discoluration doesn't [present itself] but there are other features which do."
Dr Bohin says there was a catastrophic collapse and air present in the great vessels post-mortem.
She says it was not just the rapidity of the collapse but the severity of it, and that she could not be resuscitated.
Mr Myers says Child D recovered twice, which, in principle, is inconsistent with an air embolus.
Dr Bohin disagrees, saying it depends on the speed and volume of the air administered.
She said there is a treatment for air embolus.
Mr Myers refers to air embolus experiments in animal testing, and asks how that can compare between animals and neonates.
Dr Bohin said experiments are not done on monkeys any more, they aren't done on rats, but they are done on piglets as the biology is similar.
Mr Myers says Dr Bohin refers to a medical paper in which testing is done on dogs and rabbits.
"What basis do you have?"
"I have the basis in literature."
"Which is based on dogs and rabbits?"
"Yes."
Dr Bohin adds it is not ethical to do such testing in humans.
Mr Myers resumes questioning Dr Bohin.
He suggests Dr Bohin has disregarded or minimised 'certain facts that show how unwell [Child D] was'.
Dr Bohin disagrees.
A nursing chart from June 20 is presented to the court at birth.
Mr Myers says Child D was 'very unwell' at birth.
Dr Bohin says she disagrees.
Mr Myers refers to the note at 12 minutes, she was 'very unwell indeed'. Dr Bohin said she had 'an event' which required intervention, but it was not clear what her overall condition was.
Mr Myers says she had referred to the father's handling of the baby as the cause of the event.
Dr Bohin said that was one possibility, but not the only one.
She said she was "very clear" the father was not responsible for the collapse, as new fathers are nervous with holding babies, and you cannot tell whether it was an obstruction or part of a clinical condition.
Mr Myers says the mother had noted Child D 'looked lifeless' when the baby was presented to her.
Dr Bohin said Child D had just been delivered, and the cord had not been cut. If a baby was 'in extremis', the baby would not have been presented to the mother, she tells the court.
Mr Myers refers to the nursing notes made in the hours following Child D's birth.
Dr Bohin said it was clear, by the time of the neonatal unit admission, Child D had signs of an infection and was unwell.
Mr Myers said the mother had referred to being "really worried" about Child D, being 'limp' and 'without colour - a bit grey, purple', making 'grunting noises', not 'responsive'.
"That's a really poorly baby, isn't it, Dr Bohin?"
"That's the mother's interpretation, but I can't believe [the midwifery team] would have allowed...the baby to be fed or stay on the post-natal ward in that condition."
Mr Myers says the midwife team did not administer antibiotics to Child D at this stage.
Dr Bohin said that would have been a medical staff decision, not a midwifery decision, to administer antiobiotics. She agrees antibiotics were not administered at that point.
Dr Bohin says the low blood gas reading would be a concern, but would need to be put in a clinical context as part of a trend as part of the overall clinical picture.
Mr Myers refers to a table of blood gas readings, and Dr Bohin says they have deteriorated as Child D was being moved off ventilator support on to CPAP.
Mr Myers says Child D had an infection on June 21, and that was not a sign of a well baby.
Dr Bohin said she was very clear Child D had pneumonia, but was on antibiotics and improving, and 'coping on CPAP' without needing to go on a ventilator.
She agrees Child D did not manage well with being taken off CPAP, and was put back on.
Mr Myers says 'the fact a baby desaturates like that...is a sign of poor health, isn't it?'
Dr Bohin said the clinical team made a 'good judgment call' in attempting to take Child D off CPAP, as they cannot stay on CPAP forever, but it was 'perfectly acceptable' for her to be on CPAP and she was quickly put back on it.
Mr Myers refers to a blood gas reading at 1.14am on June 22 which he says is 'not normal' and a 'deterioration' on the one before.
Dr Bohin says it is not as good as the one before, but is marginal, and needs to be taken in the overall clinical context.
Mr Myers asks if Dr Bohin is sure she isn't trying to minimise such evidence as this in her overall findings.
Dr Bohin: "I'd like to make it clear my duty is to the court, to present my findings in an impartial way."
Dr Bohin says the lack of antibiotics at one stage was a 'blip' in the care Child D had received, but she presented as a 'well' baby throughout June 21.
Mr Myers says about the decision to take Child D off CPAP, after the second collapse, there would be a 'low threshold to intervene' if there were further desaturations.
He says Child D desaturated again, and says that would have been a moment to increase ventilation support.
Dr Bohin: "Not necessarily."
She said the doctor would have noted the overall clinical picture for Child D.
Dr Bohin is asked if the decision to feed Child D was a 'bad decision'.
She replies it was not a bad decision as the clinical position was stable.
Mr Myers says the decision to take Child D off CPAP was a bad one.
Dr Bohin says, given the clinical parameters, the decision to take Child D off CPAP was a right one to make.
Mr Myers asks if Child D had respiratory difficulties throughout her life.
Dr Bohin disagrees.
Mr Myers: "But she was on CPAP."
Dr Bohin said Child D was stable on CPAP, and it was not possible to see how Child D was breathing unaided unless she was taken off CPAP.
Dr Bohin adds she believed Child D died with pneumonia, not because of pneumonia.
Mr Myers concludes by asking if Dr Bohin has been 'influenced' in making her conclusions rather than looking at all the facts. Dr Bohin disagrees.
Dr Andreas Marnerides
The consultant was approached by Cheshire Police in late 2017 to review the deaths of a number of babies at the hospital, the court heard.
He gave his opinion on their causes of death after having reviewed the pathological evidence as well as information received from clinical and radiological reviews.
The “likely explanation” for the death of Child D, a girl, was an air embolism into her circulation.
Cross Examination
From Dan O’Donohue Twitter (30/03/23):
Mr Myers has taken the medic back over his evidence for Child C, D and now I. The defence lawyer is focusing his questioning on the fact he has had to rely on Dr Dewi Evans and other medics for his review.
Dr Marnerides earlier said to discount the clinical evidence in forming his reports was akin asking someone to explain physics without using mathematics
Police Interview Summary
The court is now hearing evidence of police interviews conducted with Lucy Letby in relation to Child D.
Nicholas Johnson KC says he is relaying a summary of the interviews.
Letby, in her July 2018 interview, said she did not remember Child D.
Looking through notes, she accepted she was in her care, but could not remember her. She said when administering medicine, two nurses would sign for medication, but it was not necessary for both of them to be present.
In 2019, she denied administering Child D with an injection of air, and "didn't do anything" to Child D.
Asked about the Facebook searches for Child D's parents, she said she could not recall making those searches.
Asked about messages exchanged between Letby and a nursing colleague, she was asked why she had said Child D had 'overwhelming sepsis'. Letby says she could not recall, but thought from the context of the text, she thought Child D had been rescreened for infection.
She was asked why, later that day, someone had said it could have been meningitis. She said she could not remember that being said to her.
That concludes the evidence for Child D at this stage, the court hears.
