contains evidence heard for child E (twin).
Lucy Letby Case
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Child E (twin)Count 5: Child E - Murder allegation (air embolus & bleeding from trauma)
Prosecution opening statement
Child E, a boy, was born premature in July 2015.
The prosecution say this is the twin brother of the child poisoned with insulin.
Child E was born, weighing less than 3lbs. He was given oxygen, then weaned to air, and transferred to nursery 1.
The court hears Child E was at risk of a serious gastro-intestinal disorder, NEC, and was started on antibiotics, IV fluids and caffeine. He had a nasogastric tube inseted. Fluids were inserted the following day via a long line.
He had a "mild, transient high blood sugar" was was corrected with "a very low dose of insulin", then given tiny quantities of milk the following day, every two hours. The following day after that, he had two small vomits and air was aspirated, but otherwise the feeds were well tolerated and increased incrementally to 2ml every 2 hours. The nursing notes indicated he was stable, on a tiny dose of insulin to correct high blood sugar.
At 9pm on August 3, 2015, the mother decided to visit her twin sons, and "interrupted Lucy Letby who was in the process of attacking Child E", the prosecution say, although the mum "did not realise it at the time". Child E was 'acutely distressed' and bleeding from the mouth. The mum said Letby attempted to reassure her the blood was due to the NGT ittirating the throat.
"Trust me, I'm a nurse," Mr Johnson told the court.
Letby said the registrar would be down to review Child E, and urged her to return to the postnatal ward.
The mum called her husband when she got to the labour ward, in a call lasting four minutes and 25 seconds, at 9.11pm.
Letby made a note in Child F's records (Child F being the twin of Child E), "after she had got rid of" the mum, Mr Johnson said.
The next time the mum visited Child E, he was in terminal decline. The prosecution say the mum was "fobbed off" by Lucy Letby.
Two records are made at 4.51am, after Child E had died. The later note records: "Mummy was present at the start of shift attending to cares. Visited again approx. 22:00. Aware that we had obtained blood from his NG tube and were starting some different medications to treat this. She was updated by Reg xxxxx and contained [Child E]. Informed her that we would contact her if any changes. Once [Child E] began to deteriorate midwifery staff were contacted. Both parents present during resus."
The prosecution say Letby's note suggests the mum was present at the start of the shift (7.30pm-8pm), and returned at 10pm, when "neither is true".
The prosecution say 9pm was an important time, as it was the time Child E was due to be fed, by his mother's expressed breast milk. The mum said that is why she attended at 9pm. "She was bringing the milk".
The phone call at 9.11pm to her husband also fits the mum's timing, the prosecution add. Letby's notes also show: "prior to 21:00 feed, 16ml mucky slightly bile-stained aspirate obtained and discarded, abdo soft, not distended. SHO [Senior House Officer] informed, to omit feed." The prosecution say the nursing notes made are false, and fail to mention that Child E was bleeding at 9pm. They mention a meeting that neither the registrar or the mother remember.
A record of feeds - a feeding chart - is shown to the court.
At 9pm, Letby has recorded information to detail the volume of fluids given via the IV line and a line in Child E's left leg, and the 9pm feed is 'omitted'.
In the 10pm column is '15ml fresh blood'.
The SHO said he had no recollection of giving advice to omit the 9pm feed.
He was on the paediatric ward most of that night, until Child E entered a terminal decline. He believes the only time he had anything to do with Child E was in a secondary role to the registrar in an examination at 10.20pm.
The registrar recalled being told Child E had suffered a blood-flecked vomit.
He does not recall seeing any blood on Child E's face, but regarded the presentation as undramatic.
But "around half an hour to an hour later there was a large amount of fresh blood which had come up" Child E's tube.
The prosecution said: "This was the first indication of any serious problem so far as the medical staff were concerned.
"There was a further loss of 13 mls of blood at 23:00 hrs."
"13mls may not sound much, but [the doctor] had never seen a small baby bleed like this."
This was the equivalent to 25 per cent of Child E's blood volume, a figure which the prosecution say is an under-estimate in context.
The prosecution add that at 11.40pm, Child E suffered a sudden desaturation.
His abdomen "developed a striking discolouration with flitting white and purple patches."
CPR was started, but Child E "continued to bleed".
Although Letby was participating in the resuscitation of Child E, she co-signed for medication given to another baby in room 4.
Child E was pronounced at at 1.40am.
The on-call consultant said Child E was a high-risk infant who had shown signs of NEC.
The parents did not wish to have a post-mortem, the consultant did not deem one necessary, and the coroner's office agreed.
The prosecution say: "As subsequent reviews have established – that was a big mistake."
Dr Dewi Evans said Child E's death "was the result of a combination of an air embolus and bleeding which was indicative of trauma". The air embolus was "intentionally introduced" into Child E's bloodstream via an IV line "to cause significant harm".
Medical expert Dr Sandie Bohin agreed the cause of death was air embolus and acute bleeding. She concluded that the cause of the bleeding was unknown but acknowledged “fleetingly rare” possible natural causes that could not be ruled out in the absence of a post-mortem.
Dr Bohin concentrated on the abdominal discolouration and concluded that air was deliberately introduced via an intravenous line.
In police interview, Letby said she could remember Child E and he was "stable" at the time of the handover, with nothing of concern "before the large bile aspirate". She said she and another member of staff had disposed of the aspirate and the advice was to omit the feed. She said Child E's abdomen was becoming fuller and there was a purple discolouration, so had asked a doctor to review Child E. She said she had got blood from the NG tube.
She was asked about the 10pm note and said if there had been any blood prior to the 9pm feed, "she would have noted it".
She said it was after 9pm that the SHO had reviewed Child E but could not reall if it was face-to-face or over the phone.
She said she could remember the mum leaving after 'the 10pm visit'.
In a June 2019 interview, she was pressed over a conversation with the SHO.
She said she had no independent memory of it.
She said she could not remember the mum coming into the room at 9pm with milk, nor Child E being upset, with blood coming from the mouth.
She said she would not have told the mum to go back upstairs.
"We have a stark contrast between what the mum says and what Lucy Letby says," Mr Johnson tells the court.
"You know he was due to be fed...breastmilk. You know, we say, that is why [the mum] was there.
"This has been wiped out of the records, by Lucy Letby, because she knows the consequences of [the mum] being right about this."
In a November 2020 interview, Letby is asked why she had sent a text referring to Child E had queried whether he had Down Syndrome. She said she could not remember whether there had ever been any mention of Downs in the medical notes.
The prosecution say Lucy Letby "took an unusual interest" in the family of Child E. She did social media searches on the parents two days after Child E’s death, and on August 23, September 14, October 5, November 5, December 7, and even on December 25.
The prosecution say there were further searches in January 2016.
Defence opening statement
For Child E, the defence say there is "no evidence of an air embolus", or of "direct trauma" that led to blood loss.
There was "no clear explanation" on the cause of death, but that was not a presumption of guilt.
The defence say the absence of a post-mortem meant the prosecution could "float suggestions of deliberate harm".
Sequence of events from records
Text Messages (1)
27th July 2015
The first evidence refers to text messages sent to and from Lucy Letby's phone on July 27, asking if Letby, on her time off, will be back in time for a debrief regarding the death of Child A. Letby says she will be looking to get back in time for that.
29th July 2015
Child E was 1.327kg at birth (2lb 14oz), with APGAR scores of 7/10 at 1 minute and 9/10 at five minutes (APGAR scores recording how well a baby is presenting in the minutes after birth).
Clinical notes refer to the admission of the twins to the neonatal unit.
30th July 2015
The debrief for Child A takes place on July 30, with Letby having confirmed her attendance in a text message prior.
1st-2nd August 2015
Letby is then the designated nurse for Child F on the night shift of August 1 and August 2. Melanie Taylor was the designated nurse for Child E on the night of August 2.
Melanie Taylor's notes record for Child E for that night shift: "Self ventilating in 24% oxygen, resps 6-70, minimal recession evident."
Text messages (2)
A message sent from nursing colleague Jennifer Jones-Key to Lucy Letby at 10.34pm on August 2 says: "Hope work ok".
Letby replies: "...yeah it's fine, bit too Q word really."
The reply: "Don't complain as Wed and Thurs horrible lol! It will pick up again."
3rd August 2015
The court is shown further nursing notes by Melanie Taylor recording two Brady desats (slow heart rate) at the early hours of August 3, requiring 'gentle stimulation' to correct. One of the Bradys is recorded as lasting 45 seconds.
Child E's tummy was 'soft, not distended', had satisfactory blood gas readings and heart/respiratory rate, and fluids were being administered. The bowels were not yet opened.
Melanie Taylor's notes at the end of the night shift said 'feeds tolerated, tummy remains soft'.
A family communication note is also made by the nurse.
"Mum and dad visiting at start of shift, mum has been 2x with [expressed breast milk] overnight."
A 'Kangaroo care record' is presented to the court, documenting the times when the parents were able to have physical contact for Child E, and how long it lasted, and how well it was tolerated.
A nurse's record notes for that day that mum 'had long periods of skin to skin [contact]'.
The note records, at 10.44am, Child E was 'self ventilating in 25% ambient oxygen. No signs of respiratory distress...pink and well perfused....handles well. Caffeine given as prescribed.'
A doctor's note at 11.45am on August 3 records Child E has 'suspected sepsis', 'hyperglycaemia', and was 'off lights' for jaundice, with 'good gases'.
Child E was 'tolerating well' expressed breast milk.
The baby boy was 'not examined at present as having cuddles with mum'.
The plan was to 'examine later' and increase feeds.
Aspirates were 'ok'.
Dr Emily Thomas made clinical notes at 2.10pm on August 3, noting: 'examination of [Child E] as having skin to skin on [ward round earlier that day]. Good tone and movements, handling appropriately throughout the day.'
Child E was placed on a small dose of insulin, given via infusion.
A nursing note at 5.24pm said Child E was 'self ventilating in air', blood gas reading was 'satisfactory', and feeds were increased.
Dr Emily Thomas made clinical notes, with a CRP reading less than 1, Child E was on 23% oxygen, and antibiotics were 'likely to stop at 36 hours as improving'.
A series of other observations are made.
A shift handover for August 3, 2015, the night shift, is shown to the court. Letby is named as a designated nurse.
Letby is the designated nurse for both Child E and Child F in nursery room 1 that night.
The list shows three babies in room 2, one in room 3, and four in room 4. There is also a baby in the transitional care unit.
An observation chart is shown for Child E.
The 'cares' row has one tick, recorded at 7pm, signed by Letby's colleague from the day shift.
Letby's note for 8pm at August 3 is written, written at 4.51am retrospectively, to say: "Mummy was present at start of shift attending to cares."
A further Letby note reads: 'Prior to 9pm feed, 16ml 'mucky' slightly bile stained aspirate' recorded for Child E.
The neonatal fluid chart for the 9pm column records, under milk feeds, 'omitted', and the word 'discarded' is in a non-specific line. For aspirates, the note '16ml mucky' is made.
To the right of that, at the 10pm column, is '15ml fresh blood' on aspirates.
The two columns for that chart are signed by Lucy Letby's initials.
The phone records showing the calls made from Child E and Child F's mum to the father are also shown, including calls at 9.11pm
Dr David Harkness records readings from 9.40pm, written at 10.10pm, 'asked to see patient re: gastric bleed'.
'Large, very slightly bile-stained aspirate 30 mins ago.'
14ml of blood vomit is also recorded.
Letby records: "At 10pm large vomit of fresh blood. 14ml fresh blood aspirate obtained from NG tube. Reg Harkness attended. Blood gas satisfactory..."
Child E was 'handling well'.
Letby's further note: 'Mum visited again approx 10pm. Aware that we had obtained blood from his NG tube and were starting [treatment]...'
Dr Harkness noted Child E was 'alert, pink, well perfused', with an abdomen which was 'soft, not distended' and no bowel sounds.
The note adds 'G I [gastrointestinal] bleed ? Cause'
A neonatal fluid balance chart is shown to the court, with no name or notes for the 11pm column.
Letby's retrospective nursing notes said: 'NG tube on free drainage. Further 13mls blood obtained by 11pm. Beginning to desaturate and perfusion poor. Oxygen given via Neopuff'.
Child E was said by Letby to be 'cold to the touch' and was beginning to 'decline'.
Dr Harkness noted '13ml blood-stained fluid from NGT on free drainage.'
Child E's blood pressure was 'stable' and saturates' remained 60-70%', and 'making good respiratory effort', and was 'crying'.
A plan of action, including x-rays and medication, was made.
A note for 11.30pm on the observation chart has no record of a heart rate made, and blank readings for cot temperature, and no initials recorded. Blood pressure and respiratory rate are recorded.
Child E then collapsed at about 11.40pm.
Letby recorded, retrospectively: "11.40pm became Bradycardiac, purple band of discolouration over abdomen, perfusion poor, CRT 3secs.
"Emergency intubation successful and placed on ventilator..."
Dr Harkness records, in clinical notes at this time, written retrospectively, 'Sudden deterioration at 11.40pm, brady 80-90bpm, sats 60%, poor perfusion, colour change over abdomen purple discoloured patches'.
The note adds, after an improvement in sats, 'purple discolouration in abdomen remained', and a plan of action noted for Child E.
Further notes by Letby: 'Required 100% oxygen, saturations 80%, SIMV 22/5 rate 60. Further saline bolus and morphine bolus given. 2nd peripheral line sited..."
"Once [Child E] began to deteriorate, midwifery staff were contacted."
The latter note is written, retrospectively, at 4.51am.
4th August 2015
A further observation reading for Child E, made by Letby, is taken at 12.15am, with a heart rate 'down from where it had been earlier', and a drop in temperature, recording he was on 100% oxygen.
A consultant paediatrician arrives at the neonatal unit at 12.25am.
An x-ray is taken at 12.27am, relating to the chest and abdomen.
A further, 'acute deterioration' for Child E, is noted by Letby at 12.36am. 'Resus commenced as documented'.
The consultant paediatrician noted CPR commenced, along with ventilations, and medications.
A blood transfusion is started for Child E at 12.50am, and several adrenaline doses are administered.
Letby's note, for 1.01am, reads 'chest compressions no longer required'.
For 1.15am, Letby notes 'further decline, resus recommenced'.
CPR was discontinued at 1.23am - 'resus discontinued when [Child E] was given to parents. [Child E] was actively bleeding...'
The time of death was recorded as 1.40am on August 4.
Letby's note: 'both parents present during the resus. Fully updated by nursing and medical team throughout. Parents wished for [Child E] to be baptised....
'Child E was bathed by myself and photographs taken as requested, both were present during this. Consent obtained for [hair] and hand/footprints...
The official documented report for the incident is made by Letby - 'unexpected death following gastrointestinal bleed. Full resus unsuccessful'
A 'checklist for staff following neonatal death' is presented to the court, for Child E.
It records what levels of 'emotional support' were offered to the parents.
Letby noted at 8.21am 'Parents resident on unit overnight. Wish to be left alone'.
Ben Myers KC asks to clarify that the nursing notes made, which have been gone through in 'broken up parts' in the sequence of events, are actually made of larger notes. The intelligence analyst agrees.
Text messages (3)
4th August 2015
The text message sent from a colleague of Letby to Letby's phone at 8.58am on August 4 says: "You ok? Just heard about [Child E]. Did you have him? Sending hugs xx"
Letby responds: "News travels fast - who told you? Yeah I had them both, was horrible."
The colleague responded that she had been informed by someone at the handover 'told me just now'. 'Had he been getting poorly or was it sudden?'
Letby responds Child E had a 'massive gastrointestinal haemorrhage'.
The colleague said Child E 'had always struggled feeding'.
Letby responds that Child E was 'IUGR [Intrauterine growth restriction] and REDF [Reversal of umbilical artery end-diastolic flow]' and believed Child E was 'high risk'.
She added: "I feel numb".
A series of text messages to and from Letby's phone are shown to the court.
At 7.55pm, Jennifer Jones-Key messaged Lucy Letby: "Hey how's you?"
Letby responds: "Not so good, we lost [Child E] overnight."
The response: "That is sad. You are on a terrible run at the moment. Were you in [room] 1?"
Letby: "I had him and [Child F]"
Ms Jones-Key: "That is not good, you need a break..."
Letby: "It's the luck of the draw...unfortunately."
Ms Jones-Key: "You do seem to be having some very bad luck..."
Letby: "Not a lot I can do really - he had a massive haemorrhage, could have happened to any baby really."
Ms Jones-Key says Letby "did everything you could", adding she had seen a haemorrhage in babies before, and was 'horrible' to see.
Letby replies: "This was abdominal", and she had previously only seen pulmonary.
9th August 2015
On August 9, at 10.17pm, Letby messages a colleague saying she had said goodbye to the parents of Child E and Child F, and said they had cried and both hugged her, saying they would never forget the care the staff provided.
The colleague responds: "It's heartbreaking, but you have done your job to the highest standard with compassion and professionalism."
The colleague added: "You should feel very proud of yourself."
Letby responded she felt sad after what had happened.
The colleague adds: "They know everything possible was done" and was in Child E's "best interests".
Mr Myers refers to the sequence of events showing Letby searched for the mum of Child E and Child F several times on Facebook in the weeks and months after Child E died. He asks if it is correct Letby also searched for the names of parents who are not part of this case. The intelligence analyst agrees.
The court is shown evidence that Letby searched for the mum and dad of Child E and Child F on Facebook nine times in the following months, the vast majority for the mother. The first of the searches was on August 6 at 7.58pm
, and one of the searches is at 11.26pm on December 25.
The final two searches were made in January 2016, the last on January 10 at 11.03pm.
Witness Statements Agreed
Midwife Susan Brookes
A statement by Susan Brookes is read out, dated April 2, 2019. She was a registered midwife at the Countess of Chester Hospital in August 2015.
She said there would have been two midwives working that night shift.
She said her responsibilities included making sure the mother was well and providing emotional support when needed.
Her 'midwife notes' are presented to the court, showing the mum of Child E was 'post-natal well', and one of the twins had 'deteriorated slightly'.
At 11.30pm on August 3 she had a call from the neonatal unit to ask Child E's mother to go down in 30 minutes as Child E had a bleed and required intubating - 'very poorly'.
She said the mum was very upset and she thought the 30-minute was 'unreasonable' and asked to go sooner.
At midnight, the midwife stayed with Child E's mother for 10 minutes in the corridor outside the neonatal nursery room where Child E and Child F were, and the mum was eventually allowed in once medical staff had stabilised Child E.
Nurse Caroline Oakley
The next evidence is an agreed evidence statement from nurse Caroline Oakley, who was shift leader on August 3, and was involved in the resuscitation efforts for Child E, but does not recall who was doing what, as it was a team process.
She adds she does not recall attending a debrief for Child E following his death.
Family - Mother
The mother of Child E and F is now giving evidence.
She confirms she gave birth to identical twins in July 29, 2015 at the Countess of Chester Hospital.
She had been expected to give birth in Liverpool Women's Hospital, but due to capacity reasons she was taken to the Countess of Chester Hospital.
She believed the twins were in 'good condition for the gestation they were in' at birth.
She said she had physical contact with the twins a few hours after giving birth to them, in the neonatal unit.
She says she was only able to spend "a few minutes" with them due to their respective conditions.
On July 30, she tells the court she was able to visit the twins in the neonatal unit, from upstairs in the post-natal wards.
She said that would take about 5-10 minutes to get from one place to the other, due to having had a C-section, which made the journey time longer.
She said she was able to cuddle Child E as he wasn't on CPAP, while Child F was on CPAP.
She says she had decided she wanted to feed the twins her breast milk, and was helped to express that, and in the meantime had agreed to donor milk, but was able to provide her breast milk in due course as, she said: "That was very important to me."
She confirms she expressed breast milk and dropped that off at the neonatal unit that day.
She said: "It was the only thing I could do for them at that point. It was important to me. It was non-negotiable."
She confirms she was given support by nursing staff to do this.
She said Child E was progressing better, of the two twins, over July 30-31, but both were doing "really well" by August 1.
She says she was keen to get home and was keen to transport both babies to a hospital closer to home, and was waiting for two ambulances to be provided.
She said she and her partner were under the impression both babies were well enough to travel.
By that stage, she had had skin-to-ckin contact with both twins, and both were managing "fine".
"We were never informed about anything to say they weren't fine."
By August 2, the couple were still waiting for transport.
She said on that day, the twins were both out of their incubators by this stage.
Child E was breathing "easily" and Child F was "great".
She says she does not remember any specific conversation about insulin production for the twins, but remembers it being mentioned, and that it was 'normal' for premature babies.
By August 3, she said the twins were "great - doing really well".
"We were absolutely thrilled that both boys were doing so well and we couldn't have asked for any more than that. They were both progressing."
The father was commuting to and from the hospital at this time, and on August 3 he had gone home to "prepare the house" as it was "imminent" that the babies were going to be transferred to another hospital and she would be able to go home.
She said he left the hospital at about 5pm. At that time, she was "having skin-to-skin contact" with Child E, which ended at "half past 6ish".
She changed his nappy and had cleaned him, around the eyes and neck.
She said she was still "sore and sensitive" but "over the moon" as her two boys were "perfect".
She said she went up to the post-natal ward to express breast milk and have something to eat, 'between 7pm and 8.30pm'.
She then took the expressed breast milk "straight down" to the neonatal unit where her twins were.
She said she arrived there "a touch before nine o'clock."
The mother had drawn a plan of the neonatal unit layout, as she remembered it, to police. That is now shown to the court.
She tells the court she had gone into room 1, where the twins were, as was Lucy Letby, the only other adult in the room beside the mum.
She said she could her her son crying and it was "like nothing I'd ever heard before".
The mum walked to the incubator, to see blood coming out of Child E's mouth, and panicked as she "believed that something was wrong".
Lucy Letby was at the workstation at the time, the mum tells the court.
A video of the neonatal unit room one is shown to the court.
The mum, fighting back tears, tells the court which incubators her twins were located in - both in adjoining ones.
She said she heard "crying" - a sound which "shouldn't have come from a tiny baby. I can't explain what that sound was...horrendous. It was screaming more than crying."
She said she heard it in the corridor in the unit itself, and entered the unit through the door where the twins were.
Lucy Letby was "busy doing something, but she wasn't near [Child E]."
She said she immediately went to Child E and used a 'containment technique' which she had been taught, to make him feel calmer, but "it didn't work".
Child E "continued to make the same noise".
She said she was there for "about 10 minutes" in that room.
She said: "There was blood on his face, around his mouth."
She tells the court she was asked by police to draw, on a drawing of a child's face, where the blood was coming from.
She tells the court the blood was coming "around the mouth"
Nicholas Johnson KC says it is 'almost like a goatee beard'.
The judge asks for clarification, and the mum says the blood was 'a little above the lips, but mostly below'.
The mum said she asked Lucy Letby why Child E was bleeding and what was wrong.
She said Letby replied the feeding tube was rubbing the back of the throat and that would have caused the blood.
The mum said she accepted that explanation, but was concerned about it.
The mum said Letby "told her to go back to the ward", and she did what she was told as Letby "was in authority and knew better than me and I trusted her - completely."
"She said the registrar was on his way and if there was a problem, someone would ring up to the post-natal ward."
She said she accepted that explanation and returned to the post-natal ward.
Upon her return, she rang her husband as "she knew there was something very wrong".
"I knew I needed to speak to him, and tell him."
The court hears the telephone records, including timings, were obtained.
The call to her husband was made at 9.11pm, and lasted 4 minutes and 25 seconds.
She said she rang her husband about her concerns, and remained on the post-natal ward.
She returned to the neo-natal ward "later on that evening", sat in the corridor, watching a team of people around Child E's incubator.
Mr Johnson clarifies this was at the time Child E was being resuscitated.
In the time before that, the mum said she was "panicking", having conversations with the midwife, and was "panicking and waiting, waiting, following the rules".
She said Letby had told her the rules to go back to the post-natal ward and wait for anything further.
She was later told by the midwife and to ring her husband. The midwife called the husband at 10.52pm, telling him to come to the hospital, after the neo-natal rang the maternity ward.
She said she does not know why the midwife rang, but assumed it was because she was "very upset" and "knew there was something wrong".
The mum was taken to the neo-natal ward and the medical team were 'working on Child E' and were unsuccessful in their resuscitation attempts.
She had contact with Lucy Letby after Child E had died.
She tells the court she was asked if she wanted to bath Child E, but at that moment she did not feel able to.
Fighting back tears, the mum says: "I was just...broken, and I couldn't. Lucy Letby bathed him in front of me in the neo-natal unit.
"After he was bathed, he was placed in a white gown.
"I just remember being thankful as we had no clothes for him as he was so little.
"He was given back to us, and put in his incubator, and that is where he stayed."
Mr Johnson asks if there was a potential post-mortem raised by one of the doctors.
The mum says the husband asked a few questions and they were told by the doctor a post-mortem "wouldn't tell them much" more than what they had already been told by the doctor, and it would delay the transfer back home.
"We just wanted to take him home."
The mum adds they were given a "memory box" by Lucy Letby which "totally surprised" her and included a memory card, a lock of his hair, a teddy, hand/footprints.
The mum said she was "so overcome with emotion" by that, as she had no other memories for Child E.
Another teddy was provided, and the teddies were swapped, so Child F had Child E's teddy bear, and vice versa.
Lucy Letby also presented a picture of Child F, having 'rolled over and cuddled the [Child E] bear', which she said was 'so amazing' so she had taken a picture to give to them.
The mum tells the court she had written a card, with a picture of Child E and Child F on the front, expressing the parents' thanks for staff on the neo-natal unit.
The mum tells the court, for Child F, he has never had any bleeding issues in his life.
Ben Myers KC, for Letby's defence, expresses his sympathy for what the mum has gone through, and says that nothing he says will seek to minimise anything the mum did in caring for her twins.
The mum confirms these were her first babies.
The mum is asked if any of the times she said to the court were not correct, on her recollection, given she made a statement to police two years after the events.
The mum confirms the time she went to the neo-natal unit on August 3, 2015 was correct.
Mr Myers suggests the mum went down at about 8pm, at the time of the hand-over, and went down at about 10pm with the breast milk, and went again when Child E was being resuscitated.
The mum says she "absolutely" disagrees with that.
Mr Myers says, for that supposed 9pm time, the observations were the screaming and the blood coming out of Child E's mouth. The mum agrees.
Mr Myers asks, for the crying, there were other staff about at the time.
"At no other time did any other staff come into the room, did they?"
Mr Myers suggests the screaming was "not as bad as that [horrendous]."
The mum says it was horrendous.
Mr Myers asks about the blood seen.
The mum says, other than around the chin, the other blood seen was above the lip, and no blood anywhere else, and the blood was "not coming out" or "going on the bedding".
The mum agrees with her statement the blood was "not fresh".
The mum says, and nods, it was blood.
Mr Myers asks about the midwife seen. The mum says this was the first time she had seen this midwife, as there had been others seen, and she was "distraught".
She said she was "distraught" and "knew there was something very wrong".
She confirms the first name of the midwife, when asked by Mr Myers if the midwife was "Susan Brooks".
The mum said she told her husband "there was something very wrong", cannot remember telling the midwife that, but said she was very upset at the time.
Mr Myers says, for the 10.52pm phone call, she mentioned to her husband about the blood coming out of Child E.
The mum says she does not remember the 10.52pm phone call as the midwife got in contact with the husband.
Mr Myers suggests the mum was not as worried at the 9.11pm phone call as she was at 10.52pm.
The mum says she disagrees with that.
Mr Myers says he suggests the mum went with the breast milk as 'late as 10pm', that Lucy Letby never mentioned the tube was 'irritating Child E'.
The mum disagrees with both those suggestions.
The mum says she did not see anyone else at 9pm when she went to the unit.
Mr Myers asks if there was a conversation between Letby, a doctor, and her, regarding medication.
The mum says she disagrees, and said she was told by Letby the registrar 'would be down [to the neonatal unit room]', but did not make an appearance.
Mr Myers asks about the resuscitation attempt. The mum says she could not see what was going on, other than several medical staff being present at the time.
The mum says she is now aware there are bereavement procedures, such as memory boxes.
Mr Myers asks about the discussion with the post-mortem was with a female doctor. He asks if it was because there was 'little point' in having one, according to the doctor.
The mum says she felt 'persuaded' not to have one in that case.
The mum is asked, by Nicholas Johnson KC, about the appearance of the blood on Child E. It was "stained - not dripping, smudged. It didn't look completely dry, but it was darker."
She says it is "really hard to explain" the colour. It was "not bright red, it was darker than that. I don't know how else to explain that."
That completes the mum's evidence.
Family - Father
The father of Child E and Child F is now giving evidence.
He confirms the birth date for Child E and Child F.
Mr Johnson asks about the progress on their twins.
The father says he was "very happy" with the twins' progress before the phone call on August 3, they were doing "good".
He confirms he had gone home on the evening of August 3, and then received a phone call from his wife that night.
He tells the court the phone call he received from his wife at 9.11pm, wo was "upset and very worried" about the bleeding from the baby's mouth.
He said he was sure the medical staff knew what they were doing, and she was panicking over nothing.
The second phone call was split between the midwife and his wife. He was told: "Don't panic, but get over here now."
Mr Myers asks if the bleeding was referred to at the 10.52pm phone call, rather than 9.11pm. The father replies it was not; that was referred to in the 9.11pm phone call.
That completes the father's evidence.
Dr Christopher Wood
Dr Christopher Wood has now been called to give evidence.
He confirms that in August 2015, he was on a four-month trainee placement at the Countess of Chester Hospital, as part of his GP training, and was present at the birth of Child E and Child F.
After assisting with the delivery, he did not have contact with the twin boys until the night of August 3-4.
He said he was on call, primarily on the paediatric unit as it was an area where he was "more comfortable", but would be called to the neonatal unit if needed.
He was the more junior doctor to the other one present that night, Dr David Harkness.
He said he was called to the neonatal unit as part of a crash call, having been in the doctors room in the paediatric unit, writing up notes.
He says he didn't recall being on the neonatal unit that night, prior to the crash call at 11.40pm.
He confirms signing for a prescription of morphine bolus for Child E.
Dr Wood says he would have had very little experience of intubating babies, so he would have done the prescription as a formality.
The accompanying medical note by Dr Wood says 'Sats 60-70%
'Morphine bolus - sats improved to 80%'.
He recalls he immediately attended upon notification of the crash call.
He said a number of people were ready, and resuscitation attempts had already begun upon his arrival.
He said the best thing to do was do other jobs while more experienced members of the team did more specialised aspects of the resusciation.
He recorded notes and made sure things weren't missed.
Dr Wood had made a note of staff present during the resuscitation - a team of six, including himself, Dr Harkness, a further doctor, and three senior nurses including Lucy Letby.
Clinical notes made by Dr Wood record the efforts to resuscitate Child E from 12.37am. Five doses of adrenaline are administered during the efforts.
While chest compressions stop at 1.01am, with ventilations continuing, Child E's heart rate fell again at 1.15am and CPR recommenced.
At 1.23am, CPR stopped and Child E was cleaned.
At 1.24am, ventilation [efforts] stopped and Child E was given to the parents.
A pathology report is shown to the court, showing Child E with 'relevant clinical details: GI bleed'.
Dr Wood says he cannot recall details surrounding this.
Ben Myers KC, for Letby's defence, says Dr Wood was split between the paediatric and neonatal wards.
He says Dr Wood had 'very little experience with neonates'. Dr Wood agrees.
Mr Myers asks if this was Dr Wood's last night shift with the Countess. Dr Wood says he believes the following night was his last one.
Mr Myers says if you lose a significant quantity of blood from a neonate, that would be different from an adult losing a significant quantity of blood, as there could be time to 'seal a gastric bleed' in an adult. Dr Wood agrees.
A clinical note is shown with 'plan - discuss with surgeons, with x-rays'.
Mr Myers asks if Dr Wood was aware surgeons were at the Countess of Chester Hospital who were capable of performing gastric surgery on neonates of the size of Child E.
Dr Wood: "I'm not aware of that. I would imagine most [likely] this would be Alder Hey [Hospital in Liverpool]."
Mr Myers says, for the birth, there were 'potential complications' for the twins. Dr Wood agrees.
Mr Myers says the doctors for the neonatal unit were shared with the maternity and paediatric units, and their duties were split.
Dr Wood says that was the case, but the doctors would normally be assigned a specific unit per shift.
Mr Myers refers to the night of August 3.
Dr Wood confirms he was the only senior health officer covering paediatrics and the neonatal unit, with Dr Harkness the only registrar covering those units that night.
Mr Myers asks if Dr Wood recalls at 9-10pm, receiving a report of a bile-stained aspiration on the neonatal unit.
Dr Wood says he doesn't recall - he doesn't remember.
Mr Myers asks if doctors would receive news of such reports from the neonatal unit.
Dr Wood says he probably would not have received a call from the registrar to him about it.
He adds he was on the paediatric unit by himself, and it was his understanding that, therefore, Dr Harkness would have been on the neonatal unit 'at some point during the evening'.
Mr Driver rises to ask about the bile-stained aspirate via a phone call. He asks in Dr Wood's capacity as a GP trainee, if he had received any data/information about a neonatal unit patient, what he would have done.
He replies if he had received a call from a nurse, he would have taken action, and if it was from a registrar, it would have most likely been out of courtesy.
In the former case, he would have recorded it in his notes and would have sought advice from the registrar.
Nurse - Unnamed (1)
The next witness to give evidence is a nurse who cannot be named due to reporting restrictions.
The Countess of Chester Hospital neonatal nurse has previously given evidence earlier in the trial.
She has returned to give evidence in the case of Child E.
She confirms she was the designated nurse for Child E during the day of August 3 (8am-8pm), as well as the designated nurse for Child F.
She made a note at 10.42am, regarding family communication: 'mum on unit from 9am onwards, fully updated by myself and reg. Had long periods of skin-to-skin.'
The nurse said she recalled the skin-to-ckin contact, and during this shift, Child F was unable to have a 'cuddle', but 'containment holding' instead.
Child F remained on CPAP (a level of respiratory support), and was not as stable.
Child E was breathing by himself, requiring a little supplementary oxygen, and therefore 'could have as many cuddles as they [the mum and Child E] wanted'.
Child E was, in the nurse's 10.50am 'top to toe' clinical note: 'self ventilating in 25% ambient oxygen, no signs of respiratory distress. Heart rate and temperature stable. Pink and well perfused. Cap refill 1 second'.
The observations were 'normal'.
The nurse added the fluids which were being provided, via a longline infusion.
Child E was on a 'cautious feeding regime', based on guidelines in the neonatal unit.
Child E, it was also noted, 'handles well'.
A 'minimal to 1ml partially digested milk' was obtained from the NGT aspirates, which the nurse says was normal, and was a sign Child E was digesting the milk being fed.
The nurse's addendum is made, retrospectively, at 5.24pm that day.
A CRP reading was 'less than 1', which the nurse explains any reading of less than 10 is 'a good sign'.
The antibiotics would 'be reviewed at 36 hours [treatment]'.
The blood cultures were 'currently negative' - in absence of bacteria.
Child E remained self ventilating in air, with 'satisfactory' blood gas readings.
The nurse says Child E had a blood sugar reading of 18.5mmols, which was "too high".
A doctor was informed and insulin was 're-commenced t a rate of 0.02/units/kg/hr'.
Feeds were increased as Child E was 'tolerating his feeds'.
The court hears a 'PKU' was taken with parental consent, which was a neonatal blood screening taken from every baby at about Child E's age [if the parents agree], looking for various potential [inherited] conditions, with results to follow.
An observation chart is shown for Child E, from 6pm on August 2 to 5pm on August 3.
The respiratory rate, the court hears, is 'normal', and the baby boy was said to be stable.
A second observation chart is shown with the nurse signing for readings at 6pm and 7pm.
The nurse agrees with Mr Driver the observations show "stable trends" for Child E.
Mr Driver asks about the blood sugar readings.
The nurse says she found that level in a blood gas reading, which was 'outside the parameter' so constulted a doctor, and action was taken following guidelines for insulin to be commenced.
The blood gas reading chart is shown to the court, which shows the nurse took the sample for Child E at 2.38pm on August 3.
The glucose reading of 18.4 was the only 'abnormal' reading recorded, the court hears.
The neonatal fluid balance chart for Child E on August 3 is shown to the court.
The nurse explains the milk levels given to Child E that day.
The aspirates recorded 1ml partially digested milk at 9am, which was 'replaced [in the NG tube] as [Child E] had worked hard to digest that milk', as 'normal practice'.
The nurse explains the 1ml milk was taken out, put back in, and a 1ml additional milk feed was administered.
'Minimal aspirates' are recorded for 11am and 1pm, with a 'moderately high' level of urine recorded at 1pm.
Minimal aspirates are recoreded at 3pm, with 1ml aspirate at 5pm. That was a 'normal finding' and was replaced.
At 7pm, another 'minimal aspirate' is recorded.
At 7pm, there was also urine recorded, and a sign Child E's bowels had opened by this time.
Asked for the assessment of Child E, the nurse says: "[He] was doing well on that shift, apart from the high blood sugars. It can be a worrying factor, it could be a stress response."
Ben Myers KC, for Letby's defence, asks about Child E's condition on August 3, that he was 'doing well for a baby of that gestation', except for the blood sugar reading.
He asks if the nurse was aware of a number of risk factors associated with him.
The nurse agrees, and agrees Child E was premature, and there were risks associated with that.
She says she would have also been aware of risks of twin births, and agrees with Mr Myers Child E 'could be vulnerable to health complications'.
Mr Myers asks about Child E's first shift involving Child E on the night of July 29-30, referring to the nurse's note at 12.17am: 'NCPAP commenced at 10.50pm as oxygen requirement increased to 30% and required Neopuff x2 for apnoea.'
A chart is also shown of Apnoea/Bradys, recording five such incidents for Child E between August 1-3.
Mr Myers says, talking through the chart with the nurse, one Brady happened at August 1, no apnoea is identified, but heart rate dropped to 79bpm and desat reading was '84', and the duration was 45 seconds.
That is confirmed by a separate doctor's note, which required 'gentle stimulation' to resolve.
The second desat happens on August 2 at 6.20am, with a reading of '83-88', lasting two minutes.
The nurse says gentle stimulation is putting a hand on the abdomen gently, or very carefully giving the baby a light tickle.
She says if the situation does not improve, the baby's chin would be placed into a neutral position to help the airway, and/or administer oxygen.
This episode required, according to a nurse's note, 'facial oxygen was required for a short period - had hiccups at the time'.
The third was a brady and a desat for 30 seconds, which was 'self-correcting'.
The fourth was a Brady and desat at 11.50pm on August 2, lasting 45 seconds, requiring gentle stimulation to resolve.
The fifth and final episode was at 1am on August 3, with brady and desat in the '70s', lasting 45 seconds, requiring gentle stimulation to resolve.
The fluid chart is shown to the court once more for Child E on August 3.
Mr Myers asks about the blood glucose readings, and what the parameters should be.
The nurse says the readings should be above 2.6, and the upper limit is not defined in pre-term babies (Mr Myers says the upper limit is 6 for full-term babies). The nurse says it would be a worrying sign.
Mr Myers asks if the reading of 18.4 is 'worryingly high'. The nurse agrees. She says the cut-off point for insulin to be prescribed would either be '12 or 14'.
She agrees the blood sugar readings of 12.8, 18.4, 13.5, 12.9 are 'at the higher end of normal', with '18.4' being 'particularly high'.
A chart showing a form of insulin - Actrapid - is administered on several occasions to Child E.
The first is on July 31 at 6.45am, and the rate of insulin administration lowers at 2pm on August 1 and is increased slightly again at 2.10am on August 2.
A prescription for 3pm on August 3 is made, but then crossed out, then redone with 'a correct dose'. The nurse says the previous, crossed out one, was 'an incorrect dose' of 0.05units/kg/hr. The second is the 'correct dose' of 0.02units/kg/hr.
Insulin of a neonatal is a "continual infusion", the nurse tells the court.
Mr Myers says the insulin administration is 'a feature' of Child E's treatment during his time at the neonatal unit. The nurse agrees.
The blood gas chart for August 3 is shown, with the nurse having signed a blood gas reading taken at 2.38pm.
Mr Myers suggests the pH reading of 7.293 is outside the normal range of being under 7.3, by being slightly acidic. The nurse says she was trained that anything above 7.25 was normal.
Mr Myers suggests that the blood gas readings suggest a case of acidosis.
The nurse says the readings taken are within the parameters, and the doctor would, in any case, make the decision.
Mr Driver, for the prosecution, rises to ask a matter of the brady and apnoea chart, which recorded five episodes with Bradys and desats. The nurse did not record any of these episodes.
He asks if the episodes recorded on August 1-3 would lead the nurse to adjust her opinion of Child E's stability/well-being.
The nurse says the chart is "not a worrying trend of information".
Mr Driver asks if the insulin prescription are four separate doses, or one continuous administration.
The nurse says the first dose is administered at July 31, 6.45am, and that dose remains unchanged until 2pm at August 1, and the dose is reduced.
It would be the same infusion, via a syringe of diluted sodium chloride, administered via a computer.
The court hears the insulin would be paused in the event of the syringe being emptied or the insulin expiring, and a replacement dose would have been prescribed prior to that.
Mr Myers asks further about the insulin dose.
The nurse says, for the dose she administered, that was a fresh solution.
The previous one, the notes the previous dose was administered from 2.10am on August 2.
The judge asks if that dose of insulin would have ended after 12 hours, as the insulin would expire thereafter.
The nurse says you would have to check the relevant nursing notes for that. She can only say to the court the insulin dose she administered at 3pm on August 3 was a fresh dose, and Child E had not been on insulin.
Consultant - unnamed
No live reporting - taken from Chester Standard daily round up 16/11/22
During her evidence on Wednesday, November 16, a consultant paediatrician – who cannot be identified for legal reasons – turned from the witness box to Child E’s parents sitting in the public gallery and made her apology.
The doctor was the on-call consultant when Child E deteriorated rapidly late on the evening of August 3, 2015 and died in the early hours of the next day.
Jurors heard that necrotising enterocolitis (NEC) – a serious gastro-intestinal disorder – was entered as the cause of death on Child E’s death certificate.
The doctor told the court: “At the time I felt (Child E) had NEC which had led to his collapse and deterioration so I discussed that with the coroner and we agreed for that to be put as (Child E’s) cause of death.”
She said the infant was a “high-risk baby” and also took into account a colleague’s observations of gastro-intestinal bleeding and abdominal discolouration.
Prosecutor Simon Driver asked: “Any clinical factors that militated against that conclusion?”
The consultant replied: “I considered them fully at the time but the fact that (Child E’s) observations were very stable up to the point of collapse does not normally fit with NEC.
“And the abdominal X-ray not showing any signs of NEC over an hour before he died – I don’t think I gave that enough weight at the time; that the X-ray had been normal.”
She told the court she now did not think NEC was the cause of death.
The doctor went on: “A post-mortem would take place if we didn’t feel we had a cause of death. It can be requested for any baby who dies if the parents want that investigation.
“The parents were understandably devastated that Child E had died and were not keen on a post-mortem and I didn’t want to make a terrible situation any worse so I didn’t push, which is something I now regret.”
Ben Myers KC, defending, said: “This is precisely the type of situation where a post-mortem would have been very helpful, isn’t it?”
The witness said: “And I regret for not pushing for a post-mortem at that time.”
Mr Myers said: “But at the time you were questioning NEC and at the time you didn’t have an obvious explanation?”
The doctor replied: “I completely agree with hindsight. I should have requested a post-mortem. I was keen to avoid that, to avoid any distress.”
She turned to Child E’s parents and said: “I apologise to them that I didn’t push for that.”
Mr Myers suggested: “You, in effect, steered them away from a post-mortem?”
The witness said: “I don’t believe that was the case.”
On Monday, Child E’s mother told jurors the doctor told them a post-mortem “would not tell us very much”.
She said she and her husband decided not to ask for one “largely” because it was explained to them there was “little point”.
Nurse - Unnamed (2)
No live reporting - taken from Andy Gill Twitter 16/11/22
Court now hearing from a nurse who worked on the neonatal unit at the Countess of Chester in 2015. She’s telling the jury about how nurses administered various drugs and treatments to the babies on the unit.
The nurse agrees with Ben Myers KC, defending, that neonates can sometimes deteriorate rapidly, and that sometimes they can deteriorate when they’d appeared quite stable. When asked if it follows that such babies can die she says “sometimes”.
Nurse agrees with Mr Myers that at the time some aspects of the neonatal unit at Chester were “quite old”. “Plumbing and drainage would not function as you would have expected.” The nurse says “correct”. Also agrees “at times” it was difficult to get hold of doctors when needed.
Dr David Harkness
Dr Harkness, a paediatric registrar at the Countess of Chester Hospital in summer 2015, is being asked about Child E on the night shift of August 3.
He says they started that shift at about 8.30-9pm. He explains, with working in different hospitals, it is difficult to remember the shift patterns.
He explains there would have been a handover period, where he would have read a handover sheet for the various patients and any outstanding conditions those patients had.
There would be one sheet for the paediatric ward and one for the neonatal ward.
If there were any sick children in A&E, the doctors would have been responsible in attending to them too.
He says the handover period would have lasted about 30 minutes.
He says some tasks would have required him to work with Dr Christopher Wood, his colleague on the night, and some would have been done solo.
He says his tasks would have included speaking to nurses and seeing the neonatal unit babies.
He says if there was nothing outstanding happening on the neonatal unit, he would be there at 10-10.30pm.
He says for this night he was called over at 10pm, having been called over because Child E had blood in his vomit.
'Small amounts of blood' - minuscule blood flecks - were spotted when the NG Tube was brought out of Child E, he recalls.
The court is shown Dr Harkness's note from 10.10pm on August 3, which says 'asked to see patient [Child E] regarding gastric bleed.
'Large, very slightly bile-stained aspirate 30mins ago.'
The note adds: 'Sudden large vomit of fresh blood and 14ml aspirate.'
The doctor is given the opportunity to look through his clinical notes, and Lucy Letby's nursing notes from that shift, to see the chronology of events that night.
The court is now shown the 10.10pm note.
He says it is not clear, from his note, how much of the 14ml aspirate contained 'fresh blood'.
He says the fresh blood was what he had witnessed, having been called over to see it. The court hears he did not see the child vomit, but saw the fresh blood as a product of it.
He notes Child E's blood pressure was 'very good', a CRT reading was good, the heart rate was 'normal' and saturation rates were good, with minimal oxygen support.
"At that point in time, everything is fine, except for the blood in the aspirate," he tells the court.
Child E was also 'pink, well perfused', the lungs were 'clear', the abdomen was 'soft, not distended'.
Dr Harkness notes 'GI bleed ? Cause', and tells the court that is a possible diagnosis for the bleeding, and a plan of action with administration of antibiotics is made.
The note 'close observation' is made, emphasising the designated nurse - Lucy Letby - was to monitor Child E closely in room 1.
Dr Harkness says, from his recollection, he does not believe he left the unit as the bleed was 'something unusual' in Child E so he does not believe he went very far.
For the 11pm note, he says Letby called him into room 1, where 'Further GI blood loss and desaturation to 70%' is noted.
A '13ml blood-stained fluid from NGT on free drainage' is noted.
He says he remembers seeing 'fresh, red blood in the tube', with the contents of the stomach.
He says the free drainage setup would have allowed the vomit to come out rather than go into the baby's lungs.
He says the origin of the blood must have come from somewhere in the oesophageal tract, down to the stomach. It rules out blood coming from the lungs.
The saturates 'remained 60-70% in 100% O2', with Dr Harkness said 'because of Child E's condition', the oxygen requirement had gone up from 'minimal support'.
He says Child E was still trying to breathe at this time.
The comment 'crying' is added in the note.
Dr Harkness says the child is still well enough to be awake enough and conscious to cry.
He said just the note 'crying' would suggest it was a 'typical cry'.
Dr Harkness says the fact Child E was crying would mean he would have had to have been taking deep breaths to do so.
The plan of action was 'replace losses' - getting fluid back in.
'Strict fluid balance' - the court hears, 'knowing how much to put back in'.
Dr Harkness says he is planning to intubate Child E and do an x-ray to check Child E's lungs and abdomen to try and explain why the baby was deteriorating.
The type of intubation was 'elective', which was not on the level of 'an emergency situation', the court hears.
Dr Harkness says he would discuss the result of the x-ray with surgeons at Alder Hey and seek advice from them.
Dr Harkness said he would then have been preparing to intubate and get the equipment ready.
Prescriptions are made from 11.28pm-11.30pm for a number of drugs.
A further note, written in retrospect, is made at 1.45am.
He records 'sudden deterioration at 11.40pm'
Prior to that, Child E was still to be 'under close observation' by Lucy Letby.
Dr Harkness tells the court he was in the room when the 'sudden deterioration' happened, and was there with Lucy Letby and another nurse. Those nurses would have been gathering the drugs to be administered.
The notes record 'brady 80-90bpm, sats 60%, poor perfusion, colour change over abdomen, purple discoloured patches'.
He says: "This was a strange pattern over the tummy and abdomen, which didn't fit with the poor perfusion - the rest was still pink, but there were these strange purple patches."
He says some of the patches were still pink, but others were purple-blue, were unusual.
He likens the purple-blue colour to be what you would see after going for a swim in cold water and coming out, with 'purple-blue' colour on the lips.
The rest of the skin was 'normal colour'.
The abdomen had 'purple patches', which didn't fit with an anatomical part of the body. He says it is difficult to describe in any detail, without a photo.
He says he has seen this in Child A before and had not seen it on any other baby, outside of the babies in the case.
The patches were 'different sizes' and in the region of 1-2cm big - 'not dots'.
The areas were 'on the abdomen - not above the chest or below the groin - in the middle section'.
The patches 'did not fit with the perfusion' seen.
He tells the court if the abdomen was dusky or white, then the whole of the body would gradually take that colour too.
He says in the case of an affected blood supply, the blood would be lost from the legs first and the body would pull the blood 'into the middle of the body'.
"But on this occasion, it is the middle where you are seeing these discolourations?"
Dr Harkness confirms he has never seen these discolourations before or since, outside of the babies in this case.
Dr Harkness's notes record 'intubated as an emergency at 11.45pm'
He says although there were risks associated with this, the 'safer option' for Child E was to do things as an emergency.
An ET tube was inserted, with 'good air and chest movement' recorded, and the tube was recorded to be in the correct place.
Child E was also 'put on ventilator', with 100% oxygen.
The saturation readings were '60-70%', and after a morphine bolus was administered, those improved to 80%.
The 'purple discolouration of abdomen remained', it is noted.
Child E's blood pressure had dropped but was still in the normal range.
The plan was to administer further medication, but there was a concern that administering a drug to make the heart beat faster would lead to 'worse bleeding'.
Dr Harkness says 'from his recollection' the blood had settled and there was no further substantial amount of blood recorded.
Dr Harkness said he and a colleague were stood at the end of the incubator, discussing what medication and plans were being put in place for Child E, when Child E collapsed "in front of our face when we were stood there".
Dr Harkness recalls the resuscitation efforts began, and Child E's heart rate recovered at 1.01am, and the parents had arrived by that time.
He tells the court the blood supply was 'very poor'. He says during CPR, blood was coming out of Child E's nose and mouth, suggesting the blood pressure was low. He says the sight was "not very nice, particularly".
Dr Harkness is asked about the bleeding seen on Child E.
He says: "I have never seen it in a baby, to this extent." He says he had seen the level of blood in a teenager, but not, relatively, in a baby as small as Child E.
Dr Harkness is asked about Letby's nursing note made on the night shift of August 3, which refer to Child E's mum visiting at 10pm and she was informed by Letby and Dr Harkness about blood coming from the NG Tube. It refers to 'she was updated by Reg Harkness and contained [Child E]'.
The note is shown to the court.
Dr Harkness confirms it was the note shown to him. He does not know what 'contained' meant in the context.
He says he does not remember if the mum was present at that time.
A pathology report for Child E is shown, with 'PT and APTT' readings. Those are two tests for blood clotting measurements. They were 'high, but not enough to be shocked by'.
The readings were 19.5 and 53.6, compared to the normal ranges of '12.5-15' and '26-35' respectively.
Mr Myers asks about the sequence of events.
He refers to a police statement Dr Harkness made, where the doctor says: "I was asked to review [Child E] by Letby [following the finding of a dirty aspirate].
'Looking at the notes it was 10pm-10.30pm...I only came on at 9pm'.
He described, in the statement, the aspirate which was largely mucus-y.
He said he could not be sure if there was a fleck of blood around Child E's face [on examination].
'[Child E] looked relatively settled and there was nothing to suggest that was ging to change'.
The statement adds: 'However, around half an hour to an hour later there was a large amount of fluid which came up the tube.
'From memory it was 12-14ml of blood which for a baby was a substantial amount'.
Child D brought up further 'fresh blood' in quantities which he had 'not seen [in sudden cases] since'.
Mr Myers asks about the initial stages from the first clinical note, at 10.10pm.
Dr Harkness confirms he has been asked to review Child E, following the bile-stained aspirate '30 mins ago'.
Mr Myers said all of what had happened in the 10.10pm note, had happened by 10.10pm.
Dr Harkness says this was a 40-minute period of several year ago. He said this was potentially a period of 9.30-10.10pm.
He said it would 'match up' with the note.
In the police statement, Dr Harkness said he would have been 'bleeped' by Lucy Letby.
He says that would have been the most common approach to be alerted to the nursery room 1.
He said he had seen 'a dirty aspirate which may have contained blood flecks and bile'.
Mr Myers says the police statement said Child E had 'nothing dramatic' around the baby's face, and could not be sure if there were any blood flecks.
Child E was 'not in distress' and 'appeared fine'.
Dr Harkness says he does not know if he saw Child E's mother, and does not have a clear recollection. He says it could be the case, looking at the notes provided.
Mr Myers asks if Dr Harkness had 'any particular concerns' from the first reading. Dr Harkness says there wasn't. He agrees the second note, with blood vomit, was 'more concerning' and suggested a gastrointestinal bleed.
Mr Myers asks if such a bleed was 'serious'.
"Potentially," Dr Harkness replies.
Mr Myers suggests that a GI bleed should have led to a blood transfusion.
Dr Harkness says if there were other observations which collated that, he would have done so, but at this point, he would not have done so, as the blood vomit could have had other causes.
He said a blood transfusion 'may have come up in a conversation' with a fellow doctor. Mr Myers asks why that wasn't documented. Dr Harkness says he cannot answer that.
The clinical note for 11pm is shown to the court, which the court hears refers to the 'large amount of fresh blood'. Dr Harkness was called into the unit.
The '13ml blood-stained fluid' is a 'significant quantity', Dr Harkness confirms.
Mr Myers said this follows other blood which came out earlier, and a typical baby would have had something 'in the region of 120ml' in him at that time.
Dr Harkness agrees.
Mr Myers said there had been 27mls of blood and aspirate taken from him in that time, which was 'up to a quarter' of Child E's blood. Dr Harkness agrees.
Mr Myers says the heart rate is 'normal', but the saturation rate is 'low'. He says the heart rate 'should be higher'.
Dr Harkness says: "Not necessary - there are multi factors to that. It's part of a separate conversation with expert witnesses."
He says it is not as simple as saying one reading should go up in line with others. He says blood pressure was normal, and there were other factors to consider.
Mr Myers says the pairing of heart rate and saturations is 'not normal'. Dr Harkness says it is abnormal, in the sense that the heart rate is normal and the saturations rate is abnormal.
Mr Myers asks why a consulation with surgeons was required following x-rays.
Dr Harkness says advice would have been taken from them once the extra results would have been acquired from the x-rays.
Mr Myers says he could have been dealing with a 'very serious situation indeed'.
Dr Harkness: "Potentially."
Dr Harkness says things were "changing" but Child E was still "stable".
Mr Myers: "Are you suggesting that a baby who has lost a quarter of its blood is not an emergency situation?"
Dr Harkness "What I'm suggesting is there are things to do and there is time to do it."
Mr Myers says transfusion was not being considered at this point, and one of the 'obvious things' to consider.
"It is something you had failed to consider, isn't it?"
Dr Harkness says it was likely considered, but accepts it was not documented at the 11pm note.
Mr Myers suggests it was a "serious mistake" not to consider blood transfusion.
Dr Harkness: "I disagree."
Mr Myers asks about the staffing levels that night, and asks what would have happened if he had been called to the A&E department.
Dr Harkness said he would have contacted the on-call consultant at that time to come over in that instance.
Mr Myers: "I would suggest you were out of your depth at this point."
He adds that is "wrong and disrespectful to my ability."
Mr Myers says blood transfusion is not considered.
"But we do have a plan, and we do have a discussion with a consultant."
Mr Myers says the intubation should have happened earlier.
Dr Harkness says there are benefits to an elective intubation compared to an emergency intubation, as the latter could cause stress and complications to the baby.
He said that 'now' this would still have been the course to take in that situation.
The court hears the preparations are made for the intubation during a half hour.
Dr Harkness disagrees with Mr Myers that it was a "delay" and was using his time "appropriately".
"You make more mistakes when you are not taking your time."
Mr Myers says the blood transfusion is mentioned for the first time at a later note, after 11.40pm.
Dr Harkness says it would not have been appropriate to give more saline boluses without administrating fresh blood.
He disagrees a blood transfusion was not considered earlier.
He says his documentation is not as thorough as it would be now, and agrees in hindsight, it should have been documented more clearly.
The 'skin discolouration' observation is noted, and that it later 'remained' on the abdomen.
A nursing colleague had referred to 'discoloured abdomen' in a retrospectively written note at 1.30am.
Mr Myers said Dr Harkness had referred to the discolouration being 'strange' and 'unusual', and 'appearing and disappearing'.
That does not appear in the medical note, Mr Myers says.
Dr Harkness says that observation had "stayed with him" and the clinical note he made at the time was not 'forensic'.
Mr Myers reads out part of Dr Harkness's statement to the police, referring to the discolouration being on the abdomen.
Dr Harkness says he does not recall the part of the statement of the discolourations' 'path to the body', and said he would not agree with the wording of that.
He says he has not been in discussions with anyone in relation to these observations.
Mr Myers said by October 2018 (by the time of his police statement), there had been discussions in the hospital about the skin discolourations.
Dr Harkness said there were discussions to say it was unusual, but refutes any of the details of the discolourations had been discussed.
Mr Myers says Dr Harkness is 'putting details together' from various observations. Dr Harkness: "No."
Mr Myers says Child A's skin discolouration, as referred to by Dr Harkness in court earlier in the trial, were not mentioned in the clinical note at the time or the note to the coroner.
Mr Myers says 'red patches' found on Child A were not mentioned for Child E.
Dr Harkness said the overall discolouration observations were 'similar enough'.
Mr Myers refers to Child E's collapse 'in front of the medical staff'.
He says by this point, "there had still been no transfusion".
Dr Harkness said there was no further evidence of bleeding after the second bleed.
Mr Myers: "The reaction to the second haemorrhage was far too slow wasn't it?"
Dr Harkness: "I disagree."
Mr Myers says a blood transfusion, for O-negative blood, is noted at 12.50am on the medical notes.
Dr Harkness says the O-negative blood [a type which can be suitable for all blood transfusions] would be used in this instance as seeking a specifically matched blood type at this stage would take too long in acquiring it from the donor fridge.
The note of 12.36am - CPR commenced, is mentioned. The transfusion would have followed.
Mr Myers says, in 'distressing detail' relayed by Dr Harkness earlier in court, it had been discussed about blood coming from Child E's mouth and nose during CPR.
Dr Harkness said blood would 'keep coming out' until the cause of it is found.
Mr Myers says the cause of death would be 'acute blood loss'.
Dr Harkness said that cannot be known without a post-mortem examination.
He says the blood loss could be a factor, but it is not 'black and white'.
He said it was 'not his place' to call for a post-mortem examination.
Mr Myers says the blood loss seen would normally be 'fatal'.
Dr Harkness said it could be 'linked'.
Mr Myers asks if the actions taken were 'far too slow'.
Dr Harkness: "No."
"Would you have admitted it if it was?"
The prosecution rise to ask about the timing of Dr Harkness 'meeting the mother of Child E'. Dr Harkness said that would have been the case, based on a nursing note.
The prosecution ask if that was from looking at Letby's note.
Dr Harkness agrees.
The prosecution say Dr Harkness's clinical note does not refer to meeting the family.
Dr Harkness said it could be documented, but would depend on the level of detail of the discussion.
Dr Harkness's interview with police from September 2018 is relayed to the court.
Dr Harkness is asked about the skin discolouration, and says it is 'similar [between Child A and Child E]' and is not a rash.
The interview transcript says Child E's discolouration was 'around the abdomen and chest', with 'purple patches' that 'suddenly come on'.
"It came so quickly - not affected by the monitors or anything".
"It was just this purple and pale patches".
He was asked in the police interview if that was symptomatic of other cases, and Dr Harkness said that was not.
Medical Experts Evidence
Dr Dewi Evans
No live reporting, taken from Chester Standard round up article 18/11/22
Giving evidence on Friday, expert medical witness Dr Dewi Evans said he thought Child E had suffered a fatal air embolism - a blockage of the blood supply - after a treating medic noticed "unusual" purple patches on the child's abdomen.
He said a second "major" issue was "significant haemorrhaging from the upper gastrointestinal tract, somewhere between the mouth and the stomach".
Dr Evans said: "I think he (Child E) suffered trauma from some other form of injury and there were a number of bits of equipment on a neo-natal unit that are relatively rigid.
"Plastic tubes used for suction, for instance, so it could have been interference with that."
He said another medical instrument known as an introducer - a thin wire surrounded by plastic which can be used to intubate a baby - would be "more than sufficient to cause trauma if used inappropriately".
Dr Evans said: "I cannot be 100 per cent certain what caused the trauma to the gastrointestinal system but it had to be some kind of relatively stiff (equipment) which was sufficient to cause this extraordinary bleeding."
Prosecutor Nick Johnson KC asked the consultant paediatrician if there could be an "innocent explanation" for the level of bleeding.
Dr Evans replied: "No. The other explanation for this is a bleeding ulcer. I have never seen a bleeding ulcer cause this sort of presentation."
In his initial reports Dr Evans said he was "at a loss" to explain the haemorrhaging and it was not possible to say if any deliberate harm took place because of an absence of a post-mortem.
In a further report - after he reviewed a statement from Child E's mother who described "horrendous crying" from her son and blood around his mouth - he suggested something "had been done or used" to cause trauma.
Dr Evans suggested that a nasogastric tube could have been thrust into the baby's stomach with inappropriate force.
However, he told the court he later saw the type of tube used by the hospital at the time and ruled out it could be capable of causing such damage.
Child E suffered a sudden deterioration from 11.40pm on August 3, the court has heard, and later died early the next morning after staff were unable to resuscitate him.
Dr Evans said, in his opinion, Child E was "stable" leading up to the beginning of the "massive" haemorrhaging during the night-shift.
Cross-examining, Ben Myers KC, defending, said: "The haemorrhaging that Child E experienced on August 3 and 4 could be due to some form of ulceration or bleeding from the stomach from natural causes, albeit not normal?"
Dr Evans replied: "I don't think so."
On the expert's initial belief a nasogastric tube could have been used to harm the child, Mr Myers said: "You were looking for something that could possibly support an allegation of deliberate harm that you must have known was not realistic?"
Dr Evans said: "I disagree."
Mr Myers went on: "You are actively trying to find things that would support this allegation even when there is no evidential basis?"
The witness replied: "Child E had massive haemorrhaging from his upper gastrointestinal system and that is not something that occurs as a result of some kind of natural phenomenon."
Dr Sandie Bohin (child e)
No live reporting, taken from Chester Standard round up article 18/11/22
Fellow expert medical witness Dr Sandie Bohin agreed with Dr Evans that an air embolism was the cause of death.
She added: "I have never seen a baby have a gastrointestinal haemorrhage in this way.
"I think the bleeding may have made him unstable but I don't think that is what caused his death. I don't think that is what caused him to collapse and need CPR."
Mr Myers said: "He died because of a catastrophic bleed, didn't he?"
Dr Bohin replied: "I don't believe that is so."
On Thursday Mr Myers suggested that medics were too slow during the night-shift to order an emergency blood transfusion for Child E.
Prof Sally Kinsey
Professor Sally Kinsey, a blood expert, is going to give evidence in relation to a number of the cases so far in the trial.
Professor Kinsey confirms she was approached by Cheshire Police to look at several cases in the course of this trial. One is yet to come, while the other three are the cases of Child A and Child B (both twins) and Child F.
She also confirms she has looked at the records of Child F's twin brother, Child E, for the purpose of her investigation.
She has written reports for each case and set out the relevant backgrounds for each child, the court hears.
Prof Kinsey says to determine whether Child E had a hereditary blood condition, the records of surviving twin brother Child F were examined.
The sequence of events is now relayed for Child E.
Prof Kinsey noted she had observed from the nursing notes, a naso-gastric tube had been present for Child E, and the aspirates were 'unremarkable'. The abdomen was 'soft, not distended' and Child E's bowels opened.
At August 3, 10.44am, Child E was 'pink and well perfused'.
The professor confirms she had recorded Lucy Letby's nursing note for August 4, 2015, an observation chart for Child E on August 4, and blood gas record for Child E recording a decline for the baby boy.
Prof Kinsey said the "striking thing" was there had been a big change [a drop] in the haemoglobin levels for Child E from 10.21pm at August 3 to 1.05am on August 4.
It was significant in that Child E had lost blood in the aspirates, and would only have had a calculated total blood volume of 142ml in his system at that time.
Prof Kinsey said, for her conclusion for Child E, the haemoglobin count had been normal, as had the platelet count, prior to the deterioration.
"This was spontaneous bleeding, with no clear explanation."
The case now turns to Child F.
Mr Johnson says the significance of Child F is on a comparative basis to identical twin brother Child E.
Prof Kinsey confirms she has had access to Child F's medical records, which was for the context of Child E on a haematological level.
She said she looked at the history of Child F, and 'one or two things happened' which helped her in her investigation.
She said there were three blood investigations for Child F, over the space of two and a half years, which showed 'normal results'.
Child F had had a physical accident when a small child, and there were no haematological-related problems when he was checked, the court hears.
Child F was said to be 'slightly iron deficient' when tested at the age of two years old, but that was 'normal for infants'.
The blood results were "completely normal" for Child F.
The bleeding for Child E in August 2015, based on that medical history, was "not spontaneous", Professor Kinsey tells the court.
Skin discolourations were noted for Child E, the court is told.
Mr Johnson asks about the issue of air embolus as a cause for Child E's death.
Prof Kinsey has produced diagrams to display how an air embolus in the body can present itself externally.
These diagrams are shown to the court.
Haemoglobin is found in red blood cells.
Deoxygenated haemoglobin is blue in colour, while oxygenated haemoglobin is bright red.
A diagram is shown on how part of the air/blood circulation system works in a body.
Further diagrams explaining the circulation system are presented to the court.
She is now explaining an embolus, which is something which "shouldn't be there" in the body.
It is most commonly found from a blood clot which has broken off, and an embolus gets stuck in the blood vessel, causing damage.
She adds there are other types of emboli, such as a fat embolus, or embolic conditions which can cause a stroke or heart attack.
Mr Johnson asks if air is injected into the system via a syringe, what would happen.
Prof Kinsey explains the heart would be pumping, and the air bubbles would be broken into larger and tiny bubbles. The lungs would be able to cope with the smaller air bubbles, but the lungs would struggle with the larger air bubbles.
In babies, air bubbles would be going in the arterial circulation - blood returning to the heart passing straight out again without being oxygenated through the lungs.
This would lead to the changes in skin colour - a 'fluctuating' colour pattern, and would, the court hears, lead to the types of sin discolourations as described by doctors and nurses so far in the trial.
The court hears, in adults, the air bubbles would go to the lungs, if not blocked. If the bubbles are blocked, it could cause a pulmonary embolism.
In babies, there is a section of the heart, called the oval foramen, which would still be open, meaning the air bubbles would go to the arterial circulation.
The air bubbles would be absorbed by the haemoglobin, causing skin discolourations which move around the body and a mixture of blue, pink and purple discolouration, Mr Johnson summarises. Professor Kinsey agrees.
Ben Myers KC, for Letby's defence, is now asking Prof Kinsey questions.
He says his questions are more concerned on the nature of an air embolus.
For the haematology, he asks for Child E, whether it is a general point that such a child would not develop the levels of blood clotting as you would see in a more developed child or adult. Prof Kinsey agrees.
Asked about the 'no explanation for spontaneous bleeding', Mr Myers says if that is from a haematological reason. Prof Kinsey agrees.
Mr Myers says that does not rule out the possibility Child E had a gastro-intestinal haemorrhage. Prof Kinsey agrees.
Mr Myers asks about the principle of experts giving evidence, and their areas of expertise.
He refers to Prof Kinsey's expertise in haematology and certain paediatric specialisms, and her reports. They include focus on cancers and blood disorders.
Mr Myers: "Air embolus does not feature in your expertise, does it?"
Prof Kinsey: "No."
Mr Myers refers to the diagrams of gas exchange, which are 'standard images' in the way gas exchange works in the body.
Mr Myers: "In no way are they designed to explain an air embolus."
Prof Kinsey: "They were produced to explain the gas exchange and circulation."
Mr Myers: "What you are doing in your evidence is to take that understanding of circulation and gas exchange and use it to explain how an air embolus is displayed."
Prof Kinsey: "Yes."
Mr Myers says Prof Kinsey has, at times, commented on the issue of air embolus in her reports for Childs A, B and E.
Prof Kinsey: "Only in the changes to the colour of the skin, very impactful."
Mr Myers refers to the summary/opinion for Child A, and whether there was any haematological significance for Child A. He says that is not in dispute.
He refers to the conclusion, which he says relies on comment from [medical experts] Dr Dewi Evans and Dr Sandie Bohin, and the description from [Countess of Chester Hospital consultant] Dr Ravi Jayaram of the skin discolouration for Child A.
Mr Myers refers to the 1989 medical journal review: "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."
Prof Kinsey confirms she is drawing a parallel between the 1989 journal review and what had been observed by doctors and nurses.
She tells the court she was "shocked" by Dr Jayaram's description of skin discolouration for Child A, which she said came before she had considered the possibility of air embolus.
She said she knew this is what air embolus was like, and knew from her own education, before seeing that description matched what was said in the 1989 medical journal review.
Mr Myers says Dr Jayaram's clinical note - 'legs noted to look very white and pale before cardiac arrest' does not contain the full details from her report. Dr Jayaram did not add anything further to the skin discolouration observation in the report to the coroner, Mr Myers adds.
Mr Myers: "The description you read came from his statement [to police] two and a half years later."
Prof Kinsey agrees.
Prof Kinsey's report, dated November 1, 2022, is referred to.
Mr Myers says Prof Kinsey was asked to give further consideration as to how an air embolism worked.
She says she was asked to give further explanation on the features of an air embolism. She said she was not an expert in such mechanisms, but has provided an explanation.
Mr Myers says the report notes there is very little medical literature in relation to air emboli.
Mr Myers: "You have used your knowledge of blood and circulation to assist this?"
Prof Kinsey: "Yes."
Mr Myers says part of the limited medical literature relates to decompression in deep-sea divers, colloquially known as 'the bends', and that in those circumstances, nitrogen bubbles would be in the circulation longer than oxygen bubbles. He asks Prof Kinsey if that is the case.
Prof Kinsey: "I don't know the answer to that question."
Mr Myers says the research paper in question [for 'the bends'] dealt with four overweight deep-sea diving adults.
Prof Kinsey: "Yes, there were many limitations to their findings."
Mr Myers said the results were "very specific based to the people [in that study]."
Mr Myers asks if the symptoms of decompression sickness would always result in skin discolouration. Prof Kinsey said it would not.
Mr Myers asks if that can be applied to babies - if an air embolus could always lead to skin discolouration observations. Prof Kinsey said it would not.
Prof Kinsey says the problem with decompression syndrome, in comparison to air embolus in infants, is the bubbles get larger as the deep-sea diver returns to the surface.
Mr Myers says that is another limitation of the available medical literature for air emboli.
Prof Kinsey says the reason that study was used in her report was that skin discolouration had been an observation in that study, as it had been in cases of air embolus.
Prof Kinsey says the scale of the air embolus problem would depend on the size of the air bubble and the type of vessel that it is in.
Upon a question from the judge, Prof Kinsey says she has never encountered any discussion about nitrogen bubbles in the system, other than in deep-sea divers.
She says the biggest factors for any air embolus would be the size of the air bubble and the vessel that it is in.
What was not a factor in her discussions was the quantities that made up the air [ie what amount was nitrogen, what amount was oxygen, carbon dioxide, etc].
Professor Arthur Owens
Taken from Dan O’Donohue Twitter 03/02/2023
Consultant paediatric radiologist Owen Arthurs is first up in the witness box this morning. He's giving expert evidence on CT scans, X-rays and other images in this case
Dr Arthurs published a study in 2015 on the prevalence of air, post mortem, in infants. That study looked at 48 children. Of the 48, six were comparable to this case - but in each of those cases there were clear explanations for the presence of air in vessels
He agreed with prosecutor Nick Johnson that it is 'very rare' to find air vessels without an obvious explanation
We've gone backwards a little in timeline (the expert wasn't able to make it to court earlier), Dr Arthurs is discussing the case of Child E. It is alleged that Ms Letby fatally injected air into the bloodstream of the baby in June 2015
Court is now being shown a radiograph of Child E. Dr Arthurs agrees there is 'no significant abnormalities' present. Prosecutor Nick Johnson asks if an air embolis would show up on such a radiograph
Dr Arthurs says an air embolis is not present and to see it there would have to be 'a lot of air' and the radiograph would have to have been 'done almost immediately' after the injection