Introduction
This page contains evidence heard for child H & I.
Lucy Letby Case page contains live reporting links and opening statements including opening statements for each child.
Refer to
Wiki Navigation to locate pages for other babies.
Child H & Child I
Child H
Count 10: Attempted murder
Count 11: Attempted murder
Prosecution opening statement
Background
Child H was born in September 2015 and had breathing difficulties shortly after birth.
She was transferred to neonatal unit nursery room 1. Independent experts say there was an "unacceptable delay" in tubating her and administering a protein which helps the lungs, which the prosecution say means the case is complicated by "sub-optimal treatment" at the hospital. Additionally, Child H "was put on a ventilator she was not paralysed; she was also left with butterfly needles in her chest for prolonged periods which may have punctured her lung tissues and contributed to further punctured lungs."
The prosecution say Letby attempted to kill Child H on September 26 at 3.24am, and on September 27 at 12.55am.
Mr Johnson said Child H had previously deteriorated on the night of September 23 and required ventilator support and intubation, followed later by oxygen support. The court hears Child H responded to intervening treatment, but desaturations were "frequent" and "significant". Mr Johnson said all but two events could be explained medically and responded to with routine resuscitative measures. The two events - in the early hours of September 26 and 27, were "uncharacteristic" and required CPR.
Incidents
Letby was on duty for both those night shifts, and was the designated nurse for Child H. That night, Child H was given a blood transfusion.
At 2.15am, medical notes by a doctor showed a re-accumulation of her left-sided pneumothorax. A further chest drain was inserted to relieve the pressure. The ICU chart shows that Letby recorded having given Child H a dose of morphine at 1.25am and a dose of saline at 2.50am. The saline bolus was set to run for 20 minutes and would therefore have ended at 3.10am. Lucy Letby would have had the cover of legitimacy for accessing Child H's lines just before she collapsed again.
At 3.22am, Child H collapsed and required CPR. The attending doctor said the cause was unclear. He concluded the episode was 'hypoxia' (shortage of oxygen). Letby made notes at 4.14am, recording a lowering of the heart rate at 11.30pm which required treatment. She recorded the additional chest drain and a blood transfusion at 2am. Of the collapse at 3.22am, she recorded: "profound desaturation and colour loss to 30%, good chest movement and air entry, colour change on CO2 detector, neopuff commenced in 100% oxygen and help requested. Serous fluid +++ from all 3 drains, became bradycardic. Drs crash called and resus commenced as documented"
At 5.21am, Letby recorded a conversation between herself, the attending doctor, and Child H's parents.
During the following day, Child H was relatively stable. A different nurse was the designated nurse for Child H, still in room 1, on the night of September 26. Letby was also on duty. The designated nurse 'could not recall' if she had taken a break during the shift, but there would have been times she would have gone out of the room to get a drink or retrieve something from a cupboard. Letby was looking after a child in room 2. Child H suffered "two sudden and unexpected episodes of profound desaturation at 12.55am and 3.30am." The registrar responded to the emergency calls and on one occasion, saw Letby administering treatment, and took the history from her, assuming she was the designated nurse. The nurse noted 'pink tinged secretions' around Child H's mouth.
The prosecution say this was a similar finding to that found on three other babies in the case so far.
The nurse noted a 'profound desaturation' - a "profound drop in Child H's blood", despite air going into the lungs and carbon dioxide coming out. Both collapses at 12.55am and 3.30am had "no known cause". Child H was transferred to Arrowe Park Hospital at 5.25am, and was stabilised en route in the ambulance. Her mother, who was with her spoke of a "dramatic improvement" as soon as Child H got to the hospital. Child H returned to the Countess of Chester Hospital and the rest of her time was uneventful before being discharged. The court hears she had not suffered any permanent consequences.
Medical experts
The prosecution says medical expert Dr Dewi Evans said there was "no obvious explanation" for Child H's deterioration in those two early-morning collapses. Dr Sandie Bohin "expressed concern" at those events, and the collapses "were more significant than the others, for which there are obvious clear medical explanations". She was also "critical of the way the chest drains were inserted and managed".
Police interviews
Letby was interviewed in 2018 by police. She confirmed she had remembered Child H because she had chest drains - which the court hears are a fairly rare thing these days. For the second incident, Letby said she had not been the designated nurse so assumed she had not been caring for Child H. She identified her signatures on two medicine administrations.
In 2019, she identified her signature on more documents. In this interview, she told police she had not been the designated nurse but had been giving her treatment at the time Child H collapsed.
Facebook
On October 5, 2015, the prosecution say Letby searched for the mum of Child H, the father of Children E and F, and the mother of Child I. It was her day off.
Mr Johnson said: "We say this has to be looked in the context of everything else.
"We say it is more than an innocent coincidence that once Child H was moved out of the Countess of Chester Hospital she had no further problems."
Defence opening statement
For Child H, the defence say she was treated with three chest drains and her case, as said by the prosecution, was complicated by "sub-optimal treatment".
Butterfly needles were left in for hours "which may have punctured her lung".
The prosecution experts "appear to have no explanation" for what happened.
The harm "was nothing to do with Lucy Letby" and a cause of Child H's deterioration included "infection".
Agreed Facts
Sequence of events from records
Intelligence analyst Kate Tyndall has been recalled to court to talk the court through the sequence of events for Child H, presented as an electronic bundle of evidence.
As before, the sequence of events features medical charts, nursing/doctors' notes, significant events, plus timestamped evidence of messages recovered from Lucy Letby's phone.
22 September 2015
6.40pm: The events show Child H was admitted to the neonatal unit at 6.40pm on September 22, 2015, shortly after being born.
Text messages (1)
23 September 2015
Letby sends a message to a nursing colleague on September 23 informing her she's rearranging her shifts, and will be working with her.
She also informs her mother she's working that night as an extra shift.
She also messages another colleague to say how busy the unit is likely to be that night.
24 September 2015
The following day, Letby messages a colleague to say the "It's completely unsafe", followed by a frowning emoji.
She then messaged a friend to say: "I won't be able to make to hula hoop [exercise] – work mad so doing extra nights x".
Letby messaged colleague Sophie Ellis: "Oh Soph it was pretty bad – 18 babies, intubating on handover & baby with a sugar [reading] of 0.1! On again tonight tomorrow & Sat. Not had chance to see Corrie [Coronation Street], was it good? Xx"
Letby is then recorded as being the designated nurse for Child H for the night of September 24-25.
Dr Alison Ventress records clinical notes of a lung issue for Child H that night.
25 September 2015
1.40am/2.29am: X-rays at 1.40am and 2.29am on September 25 were taken. Child H was diagnosed with a punctured left lung.
Dr Ravi Jayaram records a desaturation for Child H and a
test was carried out for a collapsed lung.
Text messages (2)
3.07am:
Letby sent a text to a colleague at 3.07am on September 25: "Can I go now??"
The colleague responds a few minutes later: "Yes. Let's run off together and rescue [colleague] too."
On Friday, September 25
[unclear what time - Tofino) Letby messaged colleague Alisa Simpson: "Sorry didn't reply last night – you've certainly picked right week to be on hols!! Haha. ... Hope you are lucky with Glastonbury. I got tickets for Ellie at Echo
xx"
5am: Letby's medical note for the morning of September 25 recorded the "profound desaturation" at 5am, with the fings on the right hand noted to be white, along with a white patch on the abdomen.
The intelligence analyst continues to talk through the sequence of events, with descriptions of the care being given to Child H throughout the day on September 25, 2015, which includes another desaturation in the afternoon.
4.23pm: The cardiac arrest team is beeped at 4.23pm to attend the neonatal unit.
The sequence goes to the night shift of September 25-26, in which Lucy Letby is listed as a designated nurse in nursery room 1 for Child H. No other babies are in nursery room 1, with four babies (including Child G) in room 2, four in room 3 and four in room 4.
The sequence of events continues, with clinical/routine records relayed to the court on September 25.
11.05pm: A blood transfusion for Child H is begun at 11.05pm.
11.30pm: A desaturation for Child H is recorded at 11.30pm, with Letby writing the note up retrospectively at 4.14am the following day.
Observations are being taken more regularly due to the blood transfusion, the court hears.
26 September 2015
1.30am: A morphine bolus is administered to Child H at 1.30am on September 26
2am: and the blood transfusion is recorded by Letby as being completed at 2am.
However, a separate, handwritten paper record shows the blood transfusion having been completed at
3.05am. This separate record is not signed by anyone.
Letby records 'poor blood gas and 100% oxygen requirement' and a third chest drain was inserted around this time, the court hears.
Dr John Gibbs records this as being about
2.15am, as the chest x-ray showed a re-accumulation of Child H's left-sided pneumothorax (ie a collapsed lung). A further, third chest drain was inserted to relieve the pressure.
At
3.22am: Child H suffered a 'profound desaturation and colour loss to 30%'.
Letby records: 'Good chest movement and air entry, colur change on CO2 detector. Neopuff commenced in 100% oxygen and help requested.'
3.24am: An intensive care chart for Child H on September 26 records 'blood complete 0324 - RESUS'. The record is initialled by Lucy Letby.
Dr Alison Ventress confirms in a clinical record she was crash called at 3.24am as Child H "had desat requiring bagging...Sats 60s then heart rate down to less than 100 so nurses crash called, wasn't being handled at all, no trigger identified.'
Upon her arrival, Child H was 'being bagged via ETT, good chest movement, capnograph positive, sats 60%, heart rate 70 down to 50'.
A test for a collapsed lung was carried out and air was removed.
3.30am: Dr John Gibbs, consultant paediatrician, records he was called from home at 3.30am and arrived at the neonatal unit at 3.36am. He saw 'CPR in progress', and Child H had no pulse when chest compressions stopped.
The sequence of events details the series of medications administered to Child H.
3.46am: Lucy Letby's note records, for 3.46am, 'x3 doses adrenaline and x1 dose atropine given...chest compressions stopped at 0346, heart rate 180, saturations >90, placed back on to a ventilator, 30% oxygen'.
3.22am: Letby recorded, for the Child H event at 3.22am, 'profound desaturation and colour loss to 30%, good chest movement and air entry, colour change on CO2 detector, neopuff commenced in 100% oxygen and help requested. Serous fluid +++ from all 3 drains, became bradycardic. Drs crash called and resus commenced as documented'.
4.28am: Letby records a Child H family communication at 4.28am: 'Parents visiting at start of shift. Updated on condition and advised to try and rest overnight. Midwife contacted during resus to [help take mum to the unit].'
A follow-up note said parents were concerned about the possibility of brain damage, and Child H remained poorly and could relapse. Dr John Gibbs offered a blessing to be administered and the parents accepted the offer.
Child H was then blessed with parents and family members present.
7am: Letby recorded 'good blood gas at 0700 - ventilation reduced to 22/4, and rate reduced...in 26% oxygen. [Child H] appears settled.'
Text messages (3)
9am: Later that morning, neonatal unit manager Yvonne Griffiths messaged Letby after the latter's night shift, just before 9am: "Hope you have a good sleep. I just want to commend you for all you hard work these last few nights. You composed yourself very well during a stressful situation. It's nice to see your confidence grow as you advance through your career x"
Letby messages a colleague, who cannot be named, asking her how she should reply. The conversation alludes to a disagreement among the neonatal unit staff regarding a Christening for one of the babies in the unit.
Letby responds to Ms Griffiths: "Thank you. That's really nice to hear as I gather you are aware of some of the not so positive comments that have been made recently regarding my role which I have found quite upsetting.
"Our job is a pleasure to do & just hope I do the best for the babies & their Family. Thank you to you & [another colleague] for your support X".
Letby messages her colleague: "Im still frustrated/upset with what's gone on but don't think such rubbish nights & being tired help"
Her colleague responds: "Good reply as it's important they know about the bitchiness which is all it is. Yes re tired..."
The colleague added: "Anyway. You're a star. You e done yourself proud. You've given positive memories to the family whatever the outcome. Let's hope they can tease her in a few yrs about her 'attention seeking' ways. Sleep well. Xx
"Always a pleasure to work with you even if we're a '[s***] magnet' team".
Medical notes record Child H's parents were present as treatment continued for the baby girl, with further medication administered during the day of September 26.
Intelligence analyst Kate Tyndall is continuing to talk through the sequence of events, which had reached the night shift of September 26-27, 2015.
At this point, Child H was the only baby in room one of the neonatal unit, and for this night shift (September 26-27), Letby was the designated nurse for two babies in room two.
8.49pm: There is a further, profound desaturation for Child H, with a crash call made at 8.49pm.
Dr Matthew Neame recorded attending to the neonatal unit.
Text messages (4)
9.31pm: Letby, on shift, messages a colleague at 9.31pm to give an update on Child H's progress throughout the day.
She messages colleague Alison Ventress a couple of moments later to say Child H 'had a stable day', and took out the original drain at 8pm, adding 'just blocked tube, lots of secretions!'.
Letby messages her colleague, for Child H, 'I've been helping Shelley [Tomlins, designated nurse for Child H that night] so least still involved but haven't got the responsibility'.
Colleague Alison Ventress messaged Letby: "Never known a baby block tubes so often!! Glad she's had a stable day..."
11pm:Letby messages a colleague just before 11pm, lamenting that she had forgotten to record Strictly that night, and BBC iPlayer doesn't work on her iPad.
27 September 2015
12.45am: Letby then is recorded as being on Facebook at 12.45am and 12.46am, liking a post and photo.
12.55am: Child H then has a 'profound desaturation' timed at 12.55am. Nurse Shelley Tomlins recorded: 'profound desaturation to 40% despite equal bilateral entry and positive capnography'.
Staff were crash called to the neonatal unit room 1.
1.07am: Dr Matthew Neame reincubated Child H and chest compressions were started at 1.07am. Child H's heart rate dropped to 40bpm.
Adrenaline was administered.
1.23am: Chest compressions were discontinued at 1.13am.
A request was made to transfer Child H to Arrowe Park Hospital.
"No explanation" could be found for why Child H had had such a profound desaturation, the court hears.
3.30am: Child H had a further desaturation at 3.30am, and medication was administered.
4.10am: The transport team arrived at 4.10am and Child H was handed to the transport incubator at
4.45am and the handover was completed at
5.20am.
Text messages (5)
11am: Letby messaged Alison Ventress and another colleague just after 11am that day to say Child H "had resus again", but it was not as bad/long-lasting, and she was transferred to Arrowe Park.
Ms Ventress replied: "Oh crap. Do they know why she did it this time? I'm glad she's been transferred! How are you? Really rough set of nights for you. Xxx"
Letby replied: "No did exactly what she did for us , desat then didn't pick up & dropped heartrate. Looked fine again after though but made decision to transfer which I think was sensible! X"
Letby messaged her other colleague to add: "None of us had breaks what with [Child H], transfer and then this...
"It's all just so rubbish lately isn't it. And always seems to happen at night when.less people
"I think everyone is pretty burnt out and unit Been awful. Yvonne working way more than she should."
Letby and her colleague than discuss about looking "at a change of unit".
Letby messaged her colleague: "I still think about the women's. if only it were closer, would make decision much easier"
Alison Ventress messaged Letby at 1.11pm on Sunday: "Try to think of all the babies you've saved and have gone home happily with their parents. You're a fab nurse. Hope you manage some sleep xxx"
Child H was cared for at Arrowe Park Hospital between 6.10am on September 27 to 11.30am on September 30.
Child H returned to the Countess at 12.15pm on September 30, and was discharged on 5.05pm on October 9, 2015.
Facebook searches
On October 5, 2015, Letby searched on Facebook for the mother of Child H, as well as two other parents involved in the case, in the space of three minutes at 1.15am.
A corrected slide from the sequence of events is now shown to the court, showing that for the September 26-27 night shift, Shelley Tomlins was the designated nurse for Child H in room 1 - the only baby in that room that night.
Lucy Letby was a designated nurse for two babies in room 2, with another nurse, Christopher Booth, looking after Child G in room 2. Four babies, including Child I, were being looked after in room 3, and four babies were being looked after in room 4.
Witness Statements Agreed
Mother
A statement from Child H's mother is being read out to the court.
She says Child H was born in September 2015, and had "a healthy
Pregnancy", the only complication being she was a type 1 diabetic. Checks were carried out, but they were primarily for the mother's benefit, not the child.
She was admitted to medical care in September 2015 as her blood sugar levels kept dropping. Once there, staff talked about the possibility of inducing.
She went to hospital and had the view she was not to give birth for a few weeks. She was then visited by a consultant and told that, on September 22, for the birth to take place. There was a complication in that Child H would be a couple of weeks premature.
There were also 'no beds available' in the neonatal unit, or in any other equivalent centres, even as far away as Birmingham.
As preparations were made for the mum to give birth, a bed in the neonatal unit became available.
The birth took place, and Child H was "absolutely fine" and "might not even need to go to the NNU".
Both parents were allowed to hold the baby girl, but she became pale and began grunting.
Child H was then taken to the NNU for oxygen as she was "struggling to breathe".
The mother adds Child H was put on CPAP to assist her breathing.
The parents tried to go into the NNU and were informed that Child H had been placed on a ventilator. They were "quite annoyed" they had not been informed about this, and staff said they had been busy and no-one had found the time to inform them.
After several x-rays, it was established Child H had suffered a suspected lung puncture. The parents remained with her, but could not pick her up.
The following morning, nursing staff said the mum had to come to the NNU "right away" and inform the father to come too.
Child H was being treated, with "lots of medical" people surrounding her. They were resuscitating Child H.
The mum was told to sit with Child H and hold her hand. The staff successfully brought Child H back. The staff could not explain her "cardiac collapse".
Child H was then "doing really well" that day.
The parents had just gone to bed when staff knocked on the door. They said Child H was "not responding".
The parents were met with an "almost identical scene" as Child H was surrounded by medical staff. "Fortunately" this collapse did not last as long.
Following this, Child H was transferred to Arrowe Park Hospital on September 27.
The staff there removed and replaced the ventilator. They checked Child H over and a brain scan "fortunately showed no long-term damage".
Child H "improved dramatically" as soon as she was at Arrowe Park, and within 24 hours she was off a ventilator and back on to CPAP. 24 hours later she was then taken off CPAP, and made "a dramatic improvement".
She was then taken back to the Countess, and the "only difficulty" at that point was getting her to feed.
Child H stayed in the NNU until October 9, when she was discharged "earlier than normal" for a baby outpatient.
There had been "no long-term complications whatsoever" for Child H.
Father
The father's statement is now read out to court.
Child H was "quite healthy" at birth, but was "grimacing" and had complications with breathing, so was taken to the NNU.
The father says he was able to see Child H soon after, and saw she was on an incubator, with breathing assistance.
He recalls being woken up on September 26 and being called to the hospital, and seeing "a lot of commotion going on". He remembers Lucy Letby being there, doing chest massaging.
It was explained to the parents Child H had had "a collapse". He recalls Child H was "a very strange colour" and had "mottling running towards her fingers". A doctor explained the pressurised air in the lungs had caused a tear.
The parents stayed with Child H that day, and she "remained ok that day".
He said it was after they had gone to bed that they had a knock on the door and returned to the NNU.
The staff were in consultation with Arrowe Park.
The father says in the early hours of September 27, Child H was transferred to Arrowe Park, where she came on in "leaps and bounds".
The Arrowe Park was "a completely different setup" and staff were "more proactive", the father says.
Child H returned to the Countess of Chester Hospital and "nothing else really major happened" before she was discharged.
Midwife Deborah Moore
Prosecutor Nick Johnson is reading a statement (which is agreed evidence) from Countess of Chester Hospital midwife Deborah Moore. She took Child H's mother to theatre for her emergency C-section
Ms Moore says from reviewing her notes it was an 'uneventful birth and the mother did not require any additional treatment'
Unnamed nurse (1)
A member of nursing staff, who can't be named for legal reasons, recalls apologising to the parents of Child H for not informing theme sooner of their daughter's condition.
The nurse's statement, read to court, said: "We always try to inform the parents as soon as possible, but not if this is going to comprise health of the baby, if we felt the baby was going to die, parents would be informed right away – never felt the case with (Child H)'
Witness Evidence
Dr Alison Ventress
Giving evidence at Manchester Crown Court on Thursday, January 19, registrar Dr Alison Ventress said she received an urgent bleep call from nurses in the early hours of September 25.
She said she was informed Child H had breathing difficulties, poor chest movement and poor colour.
Child H’s oxygen levels plummeted shortly after her arrival and she called for a consultant to assist, Dr Ventress told the court.
More desaturations followed as Child H received a series of invasive needle treatments for a tension pneumothorax – an emergency situation where air accumulates between the chest wall and lung which causes it to collapse.
Dr Ventress agreed with Simon Driver, prosecuting, that it had been a “rocky night” for Child H.
Mr Driver asked: “Were the causes for those problems identified?”
Dr Ventress replied: “Yes, a tension pneumothorax is something that does happen. You never find an exact cause but for a premature baby needing breathing support it is a known complication of that.”
On the following night shift, she noted a “cluster” of desaturations in a two-hour period.
She said she later found a chest drain – a tube inserted to drain air – was in a sub-optimal position and it had “almost fallen out”.
Dr Ventress noted at 1am on September 26 that a combination of Child H needing more respiratory support and a drop in her blood pressure led her to think she may have another tension pneumothorax.
At 3.24am, she received a crash call from the nurses in the neo-natal unit, the court heard.
Child H had desaturated to a “level of real concern”, she said, and her heart rate had fallen below 100 beats per minute.
She said she was informed that “no trigger was identified”.
Chest compressions commenced at 3.26am when her oxygen levels and heart rate continued to drop, the court was told.
Child H was given several doses of adrenaline before compressions stopped at 3.46am when her heart rate rose to a safe level.
Dr Ventress said: “We followed the cardiac arrest protocol and she recovered, but we never found a reason why she got into that state.”
The court heard that three chest drains were put into Child H over several days before her first sudden collapse.
Cross Examination
Benjamin Myers KC, defending, asked Dr Ventress: “Do you agree there are numerous reasons why a baby on a chest drain may desaturate?”
“Yes,” said the doctor.
Mr Myers said: “If we look at the days leading up to the event on September 26, over those days there have been multiple desaturations with this little girl.”
Dr Ventress said: “Yes.”
Mr Myers went on: “Indeed in the hours leading up the event we are looking at, there was a series of desaturations over the night, weren’t they?”
“Yes,” repeated Dr Ventress.
She also agreed Child H had been suffering for a prolonged period of time from tension pneumothorax and “the reality is she had been through an awful lot of medical activity”.
Dr Ventress conceded it was “conceivable” that babies under that much intervention could suffer “quite a significant collapse”.
Prosecution
Mr Driver asked the witness: “You confirmed desaturations are not uncommon with babies experiencing the sort of problems Child H was experiencing. Are arrests as common as desaturations?”
Dr Ventress said: “No. Arrests are not all that common. I’m not saying they are impossible, but they are not all that common.”
Unnamed nurse (2)
Taken from Dan ODonohue live reporting on Twitter
A former nursing colleague of Ms Letby, who cannot be named for legal reasons, is now in the witness box. She is taking the court through her notes on Child H from 25 September 2015
Asked for her recollections of the events of 26 September, the nurse said she remembers Child H 'became unwell that night and needed some resuscitation'
The nurse is asked about 'a difference of opinion' that occurred that night over whether a baptism should be offered for Child H after her collapse. The baptism was offered to the parents, which was accepted
The nurse and a senior manager disagreed over whether it was the appropriate time for it to be offered
This disagreement arose mainly due to the fact it was early hours of the morning and the unit was busy. The nurse said it shouldn't be 'blown out of proportion'
Unnamed shift leader
The court heard that 13 children were in the unit in the early hours of September 26, with four nurses allocated to their care.
Letby was tasked with looking after a sole baby, Child H, in intensive care nursery room 1.
The evening’s nursing shift leader, who cannot be identified for legal reasons, agreed with Mr Myers that caring one-to-one for a baby such as Child H was “potentially quite a demanding job” for a nurse of Letby’s experience.
But she added: “Lucy was qualified in specialist neo-natal nursing at this time and very competent. She was not a totally inexperienced nurse … and I would trust that she would ask me if she had any problems.”
Cross Examination
Mr Myers asked the witness: “Was there an issue with Lucy Letby being relatively junior compared to others and some debate about her going into Nursery One to look after more poorly babies?”
“Sometimes, yes,” she replied.
Mr Myers said: “And sometimes a bit of an under-the-surface dispute about that, is that correct?”
The witness said: “Yes.”
Dr Ravi Jayaram
Taken from Dan ODonohue live reporting on twitter
Consultant paediatrician Dr Ravi Jayaram is now in the witness box, he is recalling the events of 26 September 2015. Dr Jayaram was called by junior colleague Dr Alison Ventress in the early hours as medics were having trouble with Child H
Child H needed a numerous procedures to drain air from her chest as she had suffered pneumothorax, this is where air leaks into the space between your lung and chest wall. Dr Jayaram is explaining this condition and how it is diagnosed/treated
Jury are being shown X-rays of Child H, which show excess air in the chest cavity. Child H had a chest drain and two needles (to drain air) in a bid to treat this
Dr Jayaram is currently describing in detail the process of inserting a chest drain
X-rays taken in the early hours of the morning of 25 September 2015 show that Child H's lung had re-inflated after the procedures. Lots of the black (air) present on previous X-rays in the chest area had disappeared
Cross Examination
Ben Myers KC, defending, is now questioning the consultant. He asks whether the act of fitting a chest drain can cause stress to a baby, he says it ‘can raise heart rate’
Mr Myers is asking whether a drain could come into contact with internal structures like the heart, Dr Jayaram says he has 'never seen that happen' - he says anatomical he can't see it, as the heart is surrounded by the lungs and the lungs would have to be punctured
Mr Myers puts it to Dr Jayaram, that due to improvements in medicine, pneumothorax is less common. He says 'generally speaking doctors now are likely to have less practice on chest drains', Dr Jayaram says he 'wouldn’t disagree with that'
He says that is why such treatments are more often carried out by consultants, as they're from a generation when they were more common
Mr Myers is asking Dr Jayaram where the optimum space is to insert a chest drain, he puts it to the consultant that the fifth intercostal space is the best area and is standard. Dr Jayaram says 'it doesn’t matter…as long as it is in, it is going to drain air'
Dr Jayaram eventually agrees that 'ideally' the fifth intercostal space is where a drain would be fitted
Discussion in court is currently centring on the use of different drains - a pig tail train and a straight drain. Child H has a pig tail drain fitted first, by Dr Ventress and then Dr Jayaram fitted a straight drain a short time later.
Dr Jayaram concedes that it would have been easier to fit a second pig tail drain, but there were none available
Mr Myers shows the jury an X-ray of the two drains in Child H. The first as established was in the 'ideal' fifth intercostal space. The second fitted by Dr Jayaram, is not in the fifth intercostal space (his notes written at the time say it is)
Dr Jayaram agrees it is 'clearly' not in there but says the drain is still in a 'good position'. He says it is in the plural cavity and that it is working
Mr Myers is repeatedly putting it to the consultant that the chest drain is in the wrong place. 'No it’s in the plural cavity, you’re focused on process rather than outcome. It needed to be put in. It isn’t going to have any great effect on heart function'
Mr Myers puts it to the medic that the tip of a drain that close to the heart could cause bradycardia if it moves, 'it could' Dr Jayaram says
Mr Myers says if the baby moves, is handled, when it breaths - can all cause the drain to move. Dr Jayaram agrees, but disputes the inference of the questions. He says any movement would be minimal
Mr Myers puts it to Dr Jayaram that he inserted the chest drain in a sub-optimal position and that this contributed to Child H's desaturations in the hours and days that followed. The consultant rejects this, he says the drain was not in the wrong place
He accuses Mr Myers of being focused on process over outcomes, he says the drain was inserted to drain air which it did.
Dr John Gibbs
Taken from Dan ODonohue live reporting on Twitter.
Dr John Gibbs, who was a consultant paediatrician at the Countess of Chester in 2015, is now in the witness box
Dr Gibbs' notes from around 5pm on 25 September show that the drain inserted by Dr Jayaram that morning had moved. Dr Gibbs fixed the drain more securely to stop it moving any further
Dr Gibbs is asked if there's any consequence to the drain moving, he says: 'The main worry is it moving out completely and falling out and being useless'
Asked if there would be any internal consequence,
Dr Gibbs says: 'Not that I’m aware of…you wouldn’t want to keep pulling and pushing, that would be rubbing against the lung. Pushing very far in would push against the heart…
'I wouldn’t expect it to cause any trauma or damage to (Child H)at all', he said
Dr Gibbs is now taking the court back over his notes from the early hours of 26 September, when Child H suffered a serious collapse which required CPR and three doses of adrenaline
Dr Gibbs' notes from the time say that it was 'unclear' why the infant went into cardiac arrest. His notes say the likely cause was hypoxia - low oxygen levels - but not clear what had caused that
Cross Examination
Ms Letby's defence counsel, Mr Myers is now questioning Dr Gibbs
Mr Myers puts it to Dr Gibbs that against the backdrop of all Child H had been through - the insertion of multiple chest drains - it was 'no surprise' she had a collapse on 26 September. Dr Gibbs says he 'was surprised' by her collapse as she had been stable
The judge has asked Mr Myers to clarify whether he is suggesting Child H's collapse came as a consequence of the procedures (chest drains/intubations etc), he says yes
He says, with particular reference to the drain fitted by Dr Jayaram, that he wants the jury to look 'where it goes and what it could have done'
Dr Matthew Neame
On Monday, January 23, in the 13th week of the trial before the jury, registrar Dr Matthew Neame told Manchester Crown Court about his involvement with the second incident and how he was twice summoned by nurses on the shift.
The first emergency crash bleep was received after a “profound” drop in Child H’s blood oxygen levels and heart rate as medics discovered her breathing tube was blocked with secretions, the court heard.
Several hours later at 12.55am on September 27, Child H suffered more profound desaturations while on a ventilator – but this time her breathing tube contained no secretions.
Child H’s heart rate plunged to 40 beats per minute at 1.07am and full resuscitation, including chest compressions and doses of adrenaline, was needed for six minutes before she recovered.
Asked how the second crash call was different, Dr Neame said: “The distinction is the lack of clear explanation for the event at this time and the fact that it has happened again in a relatively short space of time.
“Both those things would have made me more concerned about (Child H’s) condition.”
Dr Neame said he thought Letby was the nurse who he first spoke to upon his arrival to the second crash call.
Soon after Child H was transferred to Wirral’s Arrowe Park Hospital where she “came on in leaps and bounds”, said her parents, before she was discharged the following month.
In his discharge letter to Arrowe Park, Dr Neame wrote: “Thank you for accepting this baby who has had two significant episodes of bradycardia (low heart rate) requiring resuscitation, adrenaline and CPR in the last 24 hours with no clear precipitating factors.
“Her care has been complicated by the development of respiratory distress syndrome and pneumothoraces (collapsed lung) but the acute episodes with desaturation and bradycardia do not seem to be directly related to the respiratory problems.”
Nurse Shelley Tomlins
Nurse Shelley Tomlins, Child H’s designated nurse on the nightshift beginning September 26, said she would not have been in the baby’s presence throughout. She said she would have been covered by a colleague while on a break or if she had popped out of the room.
She told the court: “Given that she was unwell, I don’t think we would have left her in her room alone but I can’t be sure.”
Ms Tomlins said she she could offer no explanation why Child H’s blood oxygen levels dropped at 12.55am on September 27.
She told Ben Myers KC, defending, that her recollection of Child H was that she was a “very poorly baby”.
Nurse Christopher Booth
Fellow nurse Christopher Booth, who was on duty on both nightshifts, told Mr Myers that Letby had completed an overtime shift that week.
He said: “That was not unusual for her. She was very conscientious.”
Mr Myers went on: “Was she someone willing to work extra or have shifts changed at short notice?”
“Yes,” replied Mr Booth.
Mr Myers said: “Did you find her to be a hard worker?”
Mr Booth said: “Without doubt, yes.”
Asked if Letby became upset as events involving babies continued, Mr Booth said: “Oh definitely. It was a harrowing time. We were all upset. Without doubt, Lucy as well.”
Medical experts evidence
Dr Sandie Bohin
Today Dr Sandie Bohin, one of two paediatric experts brought in by the prosecution, was questioned in detail about the drain fitted by Dr Jayaram.
Nick Johnson KC, prosecuting, asked whether the tip of the drain might have interfered with the baby's heart or vagal nerve and therefore account for her two subsequent collapses.
Having viewed a series of x-ray images shown to the jury, the paediatrician replied: 'If the tip of a drain is abutting structures in the centre of the chest, that can cause – although I've never seen it – a failing heart rate and desaturation.
'But although it had moved, it hadn't moved after the x-ray on September 26, so I don't think that drain can be the cause of the collapses. By then it had been secured'.
Cross Examination
Cross-examined by Letby's barrister, Ben Myers KC, Dr Bohin agreed that Dr Jayaram had inserted the drain in what was technically a 'sub-optimal position'. But she added: 'He did it as a life-saving measure'.
The paediatrician agreed that there had been delays in intubating Baby H and in giving her surfactant, a protein used to help relax an infant's lungs.
The latter delay meant that when the baby was ventilated the increased air pressure needed had the effect of worsening her pneumothorax.
But again Dr Bohin insisted that staff were dealing with an emergency and that 'there was no option; it was a lifesaving measure'.
She said the butterfly needle left inside the baby's chest might have punctured lung tissue and contributed to the ongoing pneumothorax.
Mr Myers asked: 'Leaving a butterfly needle in situ is suboptimal practice, isn't it?'
Dr Bohin replied: 'Yes, because it's hazardous'.
She rejected Mr Myers' suggestion that the explanation for Baby H's two mystery collapses might have been the cumulative effect of a series of procedures she had been through.
'A baby will desaturate as the result of an event, but it's not cumulative and it certainly doesn't cause a cardiac arrest'.
Dr Bohin also rejected the barrister's suggestion that the pneumothoraces meant Baby H would have fared better if she had been moved earlier to a tertiary unit such as Arrowe Park.
'No, because they can occur spontaneously – and that would mean every baby would need to be born in a tertiary unit, which isn't practical'.
Dr Dewi Evans
Earlier, Dr Dewi Evans, the other paediatrician called as an expert witness by the prosecution, said he believed the overall care Baby H received had saved her life.
At one point Mr Myers accused him of 'deliberately identifying positive factors and ignoring the problems to support these allegations'.
Dr Evans replied: 'No, they are a series of problems that they dealt with, and the proof is she is a well little girl now'.
He added: 'I can't explain the (two) collapses, but the fact that she recovered so well before she left for Arrowe Park is a marker of clinical wellbeing and, retrospectively, an indicator that the care she had was satisfactory'.
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 is now going over the X-rays of Child H which show the drains
Dr Arthurs notes that the position of the drains have moved, but he says that the 'precise location isn’t really critical if it’s having the desired effect if it’s draining the pneumothorax' - essentially supporting what Dr Jayaram has previously said here
Cross Examination
Ben Myers KC, defending, is now questioning Dr Arthurs
He's asking Dr Arthurs about Child H and the positioning of her chest drains. Mr Myers asks if he is aware of guidelines on where chest drain should be inserted, in terms of the intercostal space
Dr Arthurs says that the guidance, to which Mr Myers is referring, 'refers to where they go in terms of the chest wall, not where they are inside chest'
Dr Arthurs accepts that a neonatologist is better placed to comment on positioning of drains and clinical impact
Child I
Count 12: Murder (with 3 prior attempts)
The prosecution say Lucy Letby attempted to kill Child I on September 30, on October 12, on October 14 and on October 22, the last date being Child I's death.
Prosecution opening statement (child I)
Background (child I)
Child I was born in Liverpool Women's Hospital, premature, on August 2015. The prosecution say Letby made four attempts to kill Child I, succeeding on the fourth attempt.Child I was born, weighing 2lbs 2oz, but in good condition. She was intubated and ventilated, then supported by CPAP, and fed through a nasogastric tube. In the first few weeks, she had "a few problems", but "all were resolved". Child I, by late September, had diminshed clinical concerns, and no breathing problems.
Incidents (child I)
For what the prosecution say was the first attempt, Letby was on a 'long day' shift (8am-8pm) on September 30. She was Child I's designated nurse in room three.
According to Child I's mum, Letby expressed concern about the child and indicated Child I would be reviewed by a doctor. When she made a nursing note, Letby "reversed the concern", and said it was the mum who had raised a concern about the abdomen, saying it was "more distended to yesterday" and Child I was "quiet...not on monitor but nil increased work of breathing”.
A review took place at 3pm - over an hour after these notes. Child I appeared mottled in colour with a distended abdomen and prominent veins. A feeding chart showed 35mls was given to Child I when asleep, but Letby had recorded Child I as "handling well and waking for feeds".
At 4pm, Letby recorded feeding Child I 35mls of expressed breast milk via the NGT.
An emergency crash call was called at 4.30pm as Child I had vomited, desaturated, her heart-rate had dropped and she was struggling to breathe. Her airway had to be cleared and she was given breathing support, and Child I was transferred to room 1.
An x-ray at 5.39pm revealed a "massive amount of gas in her stomach and bowels" and her lungs appeared "squashed" and "of small volume". The prosecution say air had been injected into the NGT to give a 'splinted diaphragm'. A doctor recorded Child I had suffered a 'respiratory arrest' at 4.30pm, struggling to breathe, she was pale and distressed, and the abdomen was 'distended and hard'. The NGT was aspirated and produced 'air+++ and 2mls of milk', after which Child I improved.
The prosecution says this is at odds with the 35mls of milk Child I was fed with at 4pm
The prosecution say "removed from the orbit of Lucy Letby," Child I's condition improved.
Child I continued to improve and was in nursery room 2 on the night of October 12 by a designated nurse different to Letby. Letby was looking after a baby in room 1. Child I was being bottle fed every 4 hours, and at 1.30am took a 55ml bottle of breast milk.
At 3am, the designated nurse left the nursery temporarily and said she asked either Letby or another colleague to listen out for Child I. The designated nurse, records show, helped another colleague with something in room 1. The prosecution say it is more likely the nurse would have asked Letby to look out for Child I. Upon the designated nurse's return to room 2, Letby was "standing in the doorway of the room" and Letby said Child I "looked pale". The designated nurse switched on the light and saw Child I was "at the point of death". She later recalled the child was breathing about 'once every 20 seconds'.
The prosecution says the jury should consider how Lucy Letby could see a child was looking pale when the room was darkened at 3.20am, with minimal lighting.The prosecution say the nurse's recollection is right, as Lucy Letby made a note at the end of her shift at 8.10am: '[Child I] noted to be pale in cot by myself at 03:20hrs … apnoea alarm in situ and had not sounded. On examination [Child I] centrally white, minimal shallow breaths followed by gasping observed.'
The registrar was called to the unit at 3.23am. On arrival, he saw nurses giving Child I full CPR. The notes suggest he had to reposition the ETT. A consultant doctor administered adrenaline, intubated and ventilated Child I.
An X-ray showed gross gaseous distention throughout the bowel and signs of chronic lung disease of prematurity (CLD).
Child I, the prosecution say, had the same problem that she had when Letby had fed her on September 30. The medical team felt that the abdominal distention had affected her ability to expand the chest and in turn caused desaturation.
Both nursing and medical staff commented on a bruised like discolouration to the right of the sternum. They assumed this was the result of chest compressions.
The category of nursing care was raised a level. "Ironically," the prosecution say, Letby was made the designated nurse, as she was more qualified.
Medical notes showed the ETT had been "displaced" and, at 4.25am, the NGT was "curled in the oesophagus", which the prosecution say would have prevented release of the pressure created by excess air in the stomach.
For what the proseution say was the third attempt, Letby had responsibility for Child I on the night of October 13.
Both Letby and a doctor recorded Child I had increasing abdominal distension, discolouration to the right and sensitivity to touch between 5am and 5.55am. The X-ray taken at 6.05ams showed widespread gaseous distention sufficient to splint the diaphragm. This prevented her from breathing properly. Child I had the same problem as before.
At 7am, CPR was required as Child I had a 'significant desaturation'.
The doctor recorded, at 7.10am: "desaturating again despite good AE (air entry), chest wall movement and negative cold light (i.e. no pneumothorax) … at about 7.45am HR (heart rate) below 60. CPR initiated… [various boluses given] … capnography positive. Chest wall movement and equal AE noted…”
The prosecution says Child I was "brought back from the brink of death right at the end of the shift, at 7.58am".
Letby noted at 8.43am: "At 05:00hrs abdomen noted to be more distened (sic) and firmer in appearance with area of discolouration spreading on right hand side. Veins more prominent … gradually requiring 100% oxygen. Blood gases poor as charted …. nil obtained from NG tube throughout. Continued to decline. Re intubated at approx. 07:00 – initially responded well … resuscitation commenced as documented in medical notes. Night and day staff members present”
That was, the prosecution say, the third attempt at murder.
Child I was transferred to Arrowe Park Hospital. She had an episode of bradycardia and desaturations after which she quickly stabilised. The prosecution say once again, a child had recovered quickly out of the care of Letby. Child I was transferred back to the Countess of Chester Hospital on October 17. On the night of October 22, Letby was on a night shift, with a different nurse being the designated nurse for Child I. Between 8pm and Child I's collapse, the only entry Letby made in any child's records was those in her charge in room 3. The prosecution say it was, from her records, a slow night for her.
Just before midnight, Child I became unsettled. Letby and another nurse attended to her but Child I collapsed and required CPR.
The on-call registrar noted Child I had a mottled blue appearance of the trunk and peripheries.
After 5 minutes of CPR, Child I's saturation rate returned to 100% and she recovered to the point of 'rooting' - ie a sign of hunger, and was 'fighting the ventilator' - ie trying to breathe independently. The ET tube was removed at 12.45am.
At 1.06am a nurse, having left the nursery temporarily, responded to Child I's alarm and saw Lucy Letby at the incubator. Child I was very distressed and wanted to intervene, but Letby assured her that they would be able to settle the baby.
"Don't worry - we will sort it out," Mr Johnson tells the jury. Child I then collapsed.
The on-call doctor arrived and resuscitation attempts were made. Purple and white mottling were noted on Child I's skin.
All resuscitative efforts were unsuccessful and treatment was withdrawn at 2.10am, and Child I was pronounced dead at 2.30am.
Baby bath comment
In the immediate aftermath, Child I's parents were taken to a private room. As the mum bathed her recently deceased child, Lucy Letby came into the room and, in the words of the mum, "was smiling and kept going on about how she was present at [Child I']s first bath and how much [Child I] had loved it.”
Medical experts (child I)
The cause of death was given by the coroner as Hypoxic ischaemic damage of brain and chronic lung due to prematurity and 1b. Extreme prematurity. All loops of bowel showed significantly dilated lumen due to increased air content – in layman’s terms they were expanded like a partially inflated balloon. There was no sign of NEC (bowel necrosis) or any other bowel problem.
The prosecution say there were signs of "earlier hypoxic ischaemic damage – in other words, the earlier attempts to kill her had caused brain damage resulting from a shortage of oxygen." Medical expert Dr Dewi Evans said he believed the apnoea monitor might have been switched off on October 13 for child I, and the deliberate administering of a large bolus of air into Child I's stomach via her NG tube on October 22/23.
Police interviews (child I)
In police interview, Letby said she could not remember the circumstances of September 30, and had taken over the care of Child I after the child had an "episode". She said she had no recollection of the events surroudning Child I's death, and said the child had been returned from Arrowe Park Hospital too quickly.
Sympathy card
In June 2019, she was asked about a sympathy card she had sent to the child's parents. She said it was not normal to do so - and this was the only time she had done so. She accepted having an image of that card on her phone.
She was asked about the October 13 incident and challenged the nurse's account, adding: "Maybe I spotted something that [the nurse] wasn't able to spot", as she was "more experienced".
Facebook (child I)
She was asked why she had searched for the parents' details on Facebook. She said she did not recall doing it.
The prosecution say Child I "was doing well by the time Lucy Letby got her hands on her.
"What happened...followed the pattern of what happened to others before and what has yet to happen to others.
"All of a sudden out of nowhere came vomiting, breathing problems and critical desaturations.
"It was persistent, it was calculated, and it was cold-blooded."
Defence opening statement (child I)
For Child I, the defence say her death was a result of "ongoing clinical problems caused by her extreme prematurity".
The air embolus is "not accepted" as a cause by the defence.The defence say CPAP treatment may have caused 'CPAP belly' in Child I, causing a distended abdomen.
Agreed Facts (child I)
Sequence of events from records (child I)
7th August 2015
Child I was born at a gestational age of 27 weeks at 8.47pm on August 7, 2015.
18th August 2015
She was transferred to the Countess of Chester Hospital on August 18, being cared from 8.30pm.
6th-13th September 2015
She was transferred back to Liverpool on September 6, before going back to Chester on September 13, at 11pm.
21st September 2015
On September 21, Letby was working a long day shift.
10.15am: During that day, Child G suffered a significant deterioration at 10.15am.
23rd-26th September 2015
Letby worked a number of night shifts on September 23, 24, 25 and 26. during this time, Child H suffered two significant deteriorations.
30th September 2015
Letby then had a few days off work before returning on September 30.
A note by the day shift nurse, Shelley Tomlins, gave a brief update on Child I for September 29, recording the mother had been present for 'cares', and regular 35ml feeds of expressed breast milk and fortifier were administered every three hours.
A subsequent note recorded Child I 'remains pale but managing to complete bottles (slow to feed as windy).'
The overnight shift nurse, Jennifer Jones-Key, said Child I continued to be fed regularly, with her tummy 'full but soft', and the father present for cares.
The sequence of events is now going on to the day shift of September 30, 2015, which has Lucy Letby as a designated nurse.
Letby was looking after three babies in room three that day, including Child I.
Child G was in room 2, with two other babies.
Two babies were in room 1.
Consultant paediatrician Dr Elizabeth Newby records, as part of an inspection for Child I as part of a 'grand round', for feeds to continue.
Feeds are continued for Child I during the day at 10am, 1pm and 4pm, of 35mls expressed breast milk and fortifier. The
10am feed is by bottle, the
1pm and
4pm are via naso-gastric tube with Child I being recorded as asleep for the latter two feeds.
On September 30, at 12.15pm, Child H is transferred back to the Countess of Chester Hospital.
At 1.36pm: Letby records Child I's temperature in the hotcot.
She adds, after a note on the 3x8 feeds: "'Abdomen appears full and slightly distended. Soft to touch, [Child I] straining++. Bowels have been opened. Mum feels it is more distended to yesterday and that [Child I] is quiet. Appears generally pale. Not on monitor...[will continue to monitor situation]"
1.48pm: "Mummy visiting, carrying out feeds and cares".
A note for the feed at 1pm is read out to the court - 'EBM+fortifier, NGT, vomit aspirated 5ml, ph5'. It is signed by Letby.
Letby records, for
3pm: 'Reviewed by Drs as [Child I] appeared mottled in colour with distended abdomen and more prominent veins. Advised to continue. Temperature within normal range with hot cot at 38 degrees. Full monitoring recommenced. within normal range.'
Observations are commenced more regularly for Child I, the court hears.
A 35ml feed at
4pm for Child I has an aspirate of 3ml, with Child I 'asleep'. It is signed by Letby's initials.
Letby notes: 'did not wake for feed at 1600 therefroe NG Tube feed given'.
4.30pm: Child I then suffers a deterioration at 4.30pm.
4.30pm on the feed chart records, for Child I, 'large vomit and apnoea - nil by mouth'. It is not signed by anyone.
Letby notes: 'At 1630 [Child I] had a large vomit from mouth and nose++ suction given. Became apnoeic with bradycardia and desatuartion (30s). Help summoned and IPPV given for approx 3min in 100% oxygen to recover. Drs were crash called.
'Transferred to nursery 1...'
A doctor [who cannot be named] records he is crash called. He notes 'Chest clear... Abdomen distended, active bowel sounds all zones'
5.23pm: Letby's mentor replies to a message Letby had sent earlier, expressing birthday wishes, at 5.23pm: 'Ah thank you so much. You ok? x'
5.39pm: An x-ray is taken of Child I at 5.39pm, with the radiologist recording: 'There is splinting of the diaphragm due to bowel distension...there is moderately severe bowel distention which is thought to involve both large and small bowel.
'The appearances are suspicious of NEC...'
5.45pm: Medication of glucose and sodium chloride is co-signed by Letby at 5.45pm and 6pm.
A CRP blood reading for Child I is 'less than 1'.
7.30pm: Child I suffered another deterioration at 7.30pm.
Letby's notes, written in retrospect at 8.26pm, record: 'At 1930 [Child I] became apnoeic - abdomen distended++ and firm. Bradycardia and desaturation followed, SHO in attendance and registrar called...
'Nil by mouth. NG tube on free drainage. Cannula inserted but tissued during saline bolus (5mls given).
'Colour appears pale but improved from earlier in shift. Abdomen appears full and distended. Veins more prominent. Not further vomits. Responsive but quiet on handling.'
For the family communications: 'Mummy present when reviewed by Drs. Had left unit when [Child I] had large vomit and transferred to nursery 1. [Mother] up to date with current plan...'
Nurse Bernadette Butterowrth, who took over care of Child I for the night shift, records: 'During handover [Child I] abdo became more distended and hard she had become apnoeic nad bradycardiac and sats had dropped. IPPV given and despite a good seal with Neopuff there was still no chest movement...'
8pm: The doctor records 'ticks' for temperature instability and apnoea for Child I at 8pm.
8.26pm: Letby's final note from 8.26pm: '[Child I] is now very pale and quiet.'
Letby responds to her mentor: 'Yes thank you. Hope you are enyour celebrations. X'
Text messages (1) (child I)
The court is shown a series of text messages sent to and from Letby's phone from that night.
The text messages related to one of Letby's female colleagues having an argument with another nurse who 'snapped at her'.
Letby messages Jennifer Jones-Key to say: "I am a bit up and down. Have not had nice shifts and not been feeling supported by some people."
Letby messages another colleague: "Let's run away!!!" and the subject turns to moving away to New Zealand, which one of the nurses is planning to do.
Letby said she could not do so as it would mean leaving her parents behind, they would be "completely devastated".
She said she had come to Chester for university and did not go back to Hereford, and added: "I feel guilty being so far away often", but it was what she wanted.
10.09pm: Letby messages colleague Alison Ventress at 10.09pm: "Families are tough aren't they!" followed by two sad face emojis.
Alison Ventress replied: "Some more than others!..."
Letby messages Jennifer Jones-Key to say she had been originally taken off the September 30 shift for working the previous Wednesday night, but was later put back on the shift.
The sequence of events relays medications which were given to Child I throughout the night shift, along with regular observations.
1st October 2015
For the day shift on October 1, Ashleigh Hudson was the designated nurse, who continues to record observations for Child I.
8.30am: Bernadette Butterworth inputs an incident, written at 8.30am for 8.30pm the previous night, about administering an antibiotic infusion over 10 minutes instead of 30 minutes. 'Although correct dose was given it was delivered at a faster rate.
'When aware of mistake, infusion was adjusted. Reg and shift leader informed'.
8.44am: Bernadette Butterworth recorded Child I, at 8.44am, was 'handling much better without desats/Bradys'.
'Was initially very pale colour has improved, abdo remains distended and firm but less distended than at beginning of shift'.
The parents were made aware of the plan of care.
A doctor, during the ward round, said it was considered to restart feeds for Child I. The parents were concerned Child I may be lactose intolerant, and that had possibly led to abdominal distention.
Letby messages her mother on October 1 to say she has arranged her shifts so she will be off for Christmas, and will be visiting her parents at that time. The mother replies: "That's fab, I could cry"
(Taken from daily roundup 26/01/23: On the afternoon of October 1, Letby messaged a colleague: “(Child I) was found gasping in cot, full resus and vented. Don’t know why. Wasn’t nice.”)
1.36pm: Ashleigh Hudson records, at 1.36pm: [Child I] appears pale but pink and well perfused...' followed by a number of medical notes.
7.48pm: The sequence of events goes to the end of October 1, with Ashleigh Hudson recording at 7.48pm: Review by Paeds SHO...abdomen is softer and less distended, ? start cautiously feeding...'
Both parents were updated on the plan of care.
Text messages (2) (child I)
14th October 2015
In WhatsApp messages read to the court, Letby asked a colleague on the afternoon of October 14 if Child I was staying on the unit.
She added: “I’d like to keep her please.”
Her colleague, who cannot be identified for legal reasons, replied: “Yes. Staying for now. OK re keeping.”
An hour later the colleague messaged: “I’ve had to reallocate. Sorry.”
Letby said: “Has something happened?”
The colleague replied: “No. Was just asked to reallocate so no one has her for more than 1 night at a time. Or 1 shift. Not just night.” Letby responded: “Yeah that’s understandable.”
- -
Claire Hocknell, intelligence analyst for Cheshire Police, has returned to talk the court through the sequence of events for Child I, focusing on the 'fourth event' in late October 2015.
The sequence continues from Child I returning to the Countess of Chester Hospital at October 17, with charts and observations shown from October 22, after Letby had been off work.
22nd October 2015
3.04am:Nurse Ashleigh Hudson records, for October 22 at 3.04am, that Child I was 'pink and well perfused', with saturation levels above 96%, abdomen 'soft and non-distended'.
Child I was 'unsettled at start of shift and rooting, settled with dummy. Settled and sleeping at present'.
8am:Nurse Caroline Oakley recorded, for 8am on October 22, Child I's observations were satisfactory.
Further observations by a colleague said Child I was 'pink, alert, active handling well'.
PM: At the end of the day, Child I was noted to be very hungry.
Hourly observations, the prosecution say, were carried through the day and were "unremarkable".
Letby begins her night shift that evening. A slide is shown to the court showing Child I was in room 1 with one other baby. Ashleigh Hudson was the designated nurse for both babies.
Letby was the designated nurse for a baby in room 2 and one in room 3. Another baby in room 3 was Child G. Two babies were in transitional care, and there was another baby whom the prosecution have been unable to confirm their location for that night.
7.45pm: Ashleigh Hudson records Child I, at the start of her shift at 7.45pm on October 22, was 'unsettled and rooting at start of shift, settled with dummy and containment holding'.
Text messages (3) (child I)
Letby messages a colleague to say that night had 'only 8 babies' in the unit, and there is a discussion over transporting a baby to Stoke.
She adds: "I think I need to see greys anatomy !!!"
Later in the conversation, Letby messages to say Child I "had abdo scan that was fine".
Letby messages colleague Jennifer Jones-Key, who had enquired "How's work". Letby replies that one of the babies she is looking after that night is being transported out that night.
The prosecution say that would then leave her with one designated baby that night.
10.57pm:
Ashleigh Hudson records at 10.57pm, 'long line removed due to constant occlusions. Neonal nurse Lucy Letby unable to flush...'
The long line was removed and the TPN [nutrition bag] was moved to a peripheral line.
Child I was observed to 'tolerate this very well'. 'Sucrose offered, but happy with dummy'. Child I was 'pink and well perfused'.
An observation chart shows three-hourly observations are made for Child I through the day (eg 11am, 2pm, 5pm, 8pm), but no record is made at 11pm.
11.57pm: Nurse Ashleigh Hudson records a retrospective note at 11.57pm that Child I was "very unsettled...due to huger as rooting. Dummy offered and containment holding to no effect."
"After repositioning, [Child I] became quiet, apnoeic and dusky in appearance. With help of neonatal nurse Lucy Letby, repositioned [Child I] on to her back, and at first applied Neopuff with 30% O2..."
23rd October 2015
12am: A crash call was made to the unit at midnight. Cardiac compressions began.
Dr Rachel Chang records, at midnight, confirming being crash called and giving chest compressions.
Ashleigh Hudson records consultant paediatrician Dr John Gibbs is also called to the unit. He arrives, according to swipe data unit, at
12.06am.
Child I was put on to a ventilator, was more alert, and crying.
The abdomen was soft and not distended prior to ventilation, the court hears.
12.23am: An x-ray is carried out at 12.23am.
12.35am: Child I was extubated and 'coped well', was 'relatively settled' and 'sucking dummy' at about 12.35am.
Dr John Gibbs recorded Child I had been 'resisting ventilation', so was extubated.
The cause was recorded as 'likely generalised lung collapse'.
Int he plan: 'If further similar collapses will need full ventilation (with paralysis)'.
Nurse Ashleigh Hudson records informing the parents of what happened.
At 1.06am: there is a further event for Child I - another collapse, the prosecution tells the court.
Nurse Ashleigh Hudson records: 'Child I became unsettled again. Dummy/sucrose offered with no effect. Slowly became dusky and O2 dropped to 60s, HR 70s. Ran to labour ward theatre to inform [senior staff].'
Letby was one of two nurses administering breathing support to Child I via Neopuff.
1.12am: Dr Rachel Chang is recalled to the unit, arriving at 1.12am.
Compressions restarted and Child I was reintubated. At this time, Child I's mother had rung the hospital and she was advised to attend hospital immediately, the court hears.
1.23am: Adrenaline is administered to Child I and Dr John Gibbs is called to the unit again. He arrives at the unit at 1.23am.
A saline bolus is administered to Child I at
1.22am. The medication is co-signed by Lucy Letby and Christopher Booth.
1.25am: Dr Gibbs records, for 1.25am, Child I had 'poor perfusion - mottled, purple-white'. Sats were in the '70s, pulse 50-60'.
More adrenaline is administered, along with sodium chloride and atropine.
1.38am: A dose of 10% glucose is administered at 1.38am, co-signed by Ashleigh Hudson and Christopher Booth.
1.40am: Another dose of adrenaline, the fifth, is made at 1.40am, co-signed by Lucy Letby and Christopher Booth.
The administration of calcium gluconate is made at 1.40am. A sixth dose of adrenaline is made for administering at 1.43am.
1.45am: Compressions stopped at 1.45am, having begun at 1.16am. Dr John Gibbs adds Child I 'remained mottled and poorly perfused'.
At 1.50am, Dr John Gibbs records: 'HR to 70, sats 70-80 and no pulse palpable. Cardiac compressions restarted at 1.50am'.
1.56am: Another dose of adrenaline, the seventh, is made at 1.56am, followed by an eighth at 2am.
Dr John Gibbs records Child I was 'not responding to prolonged resuscitation and although her heart was beating there was no effective circulation.
2.10am: '2.10am hr 40/min on monitor - no pulse (but heartbeat audible without cardiac compression)'.
Ashleigh Hudson records she and Lucy Letby had spoken to the parents about what had happened, and a decision was made to bathe Child I.
2.30am: Child I's time of death was recorded as 2.30am on October 23, 2015.
6.25am: Ashleigh Hudson records, at 6.25am: 'NGT on free drainage, produced 2mls. Minimal aspirations of clear mucus and air++ during both resuscitations'.
Text messages (4) (child I)
A colleague of Letby messages her at 6.51am: 'Hey u ok? Good shift? x'
Another colleague messages Letby at 11.58am: 'You ok? I heard about last night. Did you have [Child I]? Xxx'
Caroline Oakley records at the end of the day, '[Child I] with parents and family in bedroom 2...
'They have expressed they are very unhappy with AHCH [Alder Hey Children's Hospital] for failing to accept [Child I] for her barium enema, and want her back from AHCH post-mortem ASAP. Bereavement co-ordinator has spoken to them...'
26th October 2015
A post-mortem examination of Child I takes place on October 26.
10th November 2015
The funeral of Child I takes place on November 10. At 7.34am that day, Letby has a photo taken of a sympathy card she has written to send to the parents. The card is titled 'Your loved one will be remembered with many smiles'. It adds, in Letby's handwriting, 'Lots of love, Lucy x' on the front.
On the other side of the card, Letby has a handwritten message, in which she wrote: "There are no words to make this time any easier.
"It was a real privilege to care for [Child I] and get to know you as a family - a family who always put [Child I] first and did everything possible for her..."
The message concludes with Letby saying she was sorry she could not attend the funeral.
Facebook searches (child I)
Letby searches for the mother of Child I on Facebook at 1.16am on October 5.
On November 5, 2015, Letby searches for the mother of twins Child E and Child F at 11.41pm, then searched for the mother of Child G at 11.44pm and, in the same minute, a search for the mother of Child I.
Letby also searched for the mother of Child I at 11pm on May 29, 2016.
Cross Examination
Benjamin Myers KC, for Letby's defence, is asking Claire Hocknall questions.
He asks about the feeding chart in connection with nursing notes by Lucy Letby at 1.36pm on September 30, with addendum at 1.48pm.
The nursing note was written at 1.36pm, covering 8am-1.36pm, and the family communication is timed at 1.48pm 'mummy visiting, carrying out feeds and cares'.
Mr Myers says the feeding chart for 8am-1.48pm shows one event of mother coming for feed that morning.
He says the family communication isn't timed, and can refer to the period of 8am-1.48pm, not the time the note was written at 1.48pm.
Mr Myers refers to hourly observation charts which on occasions are not signed. He refers to two which happened in the case of Child C, where there was an hour which was not signed. The nurses who signed for each hour either side of that are not Lucy Letby, but signed by her colleagues.
Observation charts which are not signed by initials are also shown for Child I, with three in a row not initialled.
Witness Statements Agreed (child I)
Family - Mother (child I)
The court is now hearing a statement from the mother of Child I, who describes her pregnancy, and found she was having a girl at a 16-week scan.
She said at no time during any of the scans were there any concerns. She had "breezed through" past pregnancies, but five weeks after her last scan, her waters broke.
She went to the Countess, who conducted some tests to prove her waters had broken.
She was transferred to the Manchester Royal Hospital, with more blood tests conducted. She was told the baby girl would be born prior to 34 weeks and was 'safer inside' at this point.
She was sent home, with advice to go to the Countess every 2-3 days for blood tests.
After the first of those appointments, she was told not to leave due to the blood results. She was transferred to Liverpool Women's Hospital and was continually monitored.
On the 7th, the mother was in labour, and needed to get to the ward.
She was informed by a midwife she was not in labour, but the mother said she was in contractions.
She was not happy and so spoke to another midwife at the hospital she knew.
A doctor physically examined her, and she was transferred to the labour ward.
The mother said she was "too scared to push", and at some point she was told the baby was in distress, so she pushed.
Child I was born at 9.02pm, following an hour-long labour.
Child I was "doing really well" when born and was brought to the mum, before going to the neonatal unit.
The mother was later told that, as Child I only weighed 2lbs, staff were having difficulty 'getting lines in', requiring scans every time.
The mother was later able to see Child I, who was on a ventilator.
The following day, the parents saw her and she was still in an incubator, but no longer on a ventilator - she was now on CPAP.
A nurse asked if the mother wanted to handle Child I, and the mother accepted, but the saturation levels dropped once the baby went out of the incubator, and the mother was told it was a 'little too soon'.
Over the following days, Child I was 'doing really well', although the mother was informed it would depend whether Child I would pull through, which left her 'petrified'.
However, Child I continued to do 'fine'.
At five days old, Child I was transferred to a high dependency unit at the neonatal unit in Liverpool.
The following day, the family were told Child I could go back to Chester.
The mother said: "We panicked, [Liverpool] was spotless, and [Child I] was settled there.
"At the same time we had heard a virus had broken out among ward 2, so we were then relieved."
Child I was transferred to the Countess of Chester Hospital on August 18.
At first, the mother said they had reservations about Child I's care at the CoCH as the staff didn't seem to have the time for them, as they seemed so busy.
The mother said: "I felt that Chester and Liverpool had different methods (Chester concentrated on feeding, helping babies grow, Liverpool concentrated on getting babies off oxygen support).
All the time, the nurses would explain why they were doing this."
Child I was on CPAP, but the mother said the mask was too big for her, and cotton pads were used to fill the gap, and this left marks on her, which left the mother "annoyed".
Child I was moved to room 2 at the neonatal unit, where the mother met the mother of another baby [Child G].
She was very annoyed at a nurse who appeared to have a cold, which she had had for 'days' and even doctors were aware of, and was in the room. The mother said she did not want her baby to get an infection.
The mother was at home when she received a call about Child I deteriorating in health, and she was transferred to Liverpool.
Staff at the Countess suspected Child I had NEC as her stomach had swelled. She was transferred to Liverpool Women's so she would be close to Alder Hey, if surgery was required.
When the parents arrived, they were informed Child I did not have NEC, and she improved. The mother was 'not happy' that no test was taken to categorically rule out NEC as that could have informed her future care.
Child I was transferred back to the Countess.
The constant stays in hospital were 'beginning to take a toll' on the parents, so they split their time at the hospital.
The mother says she was changing Child I's nappy and was told by Lucy Letby that the baby girl's stomach looked swollen.
Letby said she would keep an eye on it.
That night, the mother was at home when she was informed Child I had deteriorated again and to come to the hospital.
When they arrived, resuscitations were being carried out on Child I.
The swelling to Child I's stomach had 'now gone down' and she was 'doing better', the mother was told by one of the nurses.
Child I was then taken back to room 2.
The mother recalled Child G had also been poorly 'a number of times' at this time in mid September.
Child I was 'looking different' and was looking around, looking like 'a full-term baby', like 'she should be at home in her bed'.
The mother had seen so many people 'not washing their hands and then touching things', so she wanted to get Child I home.
Lucy Letby offered advice on how to bathe Child I, to the mother. She offered to take photos using Child I's mother's mobile, to which the mother agreed.
Letby always appeared 'reserved' compared to other nurses, the mother added.
Child I was put on antibiotics 'as a precaution'. She could go from normal to 'almost dying' within a matter of seconds, the mother recalls.
She says staff 'made a big deal' of Child I's stomach. A test was carried out for cystic fibrosis.
The mother had felt the atmosphere in the hospital 'had changed' and she had concerns whether Child
I would be able to go home. She asked a nurse if that could be the case, and the nurse replied 'We'll see - she comes off antibiotics on Wednesday, so we'll see'.
One day, the mother was sitting there by Child I, when suddenly Child I's oxygen monitor started bleeping. The nurse - not Letby - said it was nothing to worry about, and began fiddling with the monitor.
The mother said when she left that night, things 'didn't feel right', as these had been signs before Child I became very poorly.
The mother was informed overnight Child I's monitor had been switched off as she didn't need it, and her temperature had dropped.
Child I later deteriorated and needed to be resuscitated 'at least 7 or 8 times'.
The hospital believed Child I had a bowel problem. She was not found with a swollen stomach, but was not breathing. The mother believed if the monitors had been kept on, then the situation could've been more closely monitored.
Child I recovered, but with swelling to her stomach and bruising uner her left breast bone.
She 'kept being resuscitated' and the parents were informed about Child I's deteriorations 'every day'.
A doctor told the parents they were concerned Child I 'wouldn't be able to make it.'
A couple of days later, Child I had 'picked up, but was told by a nurse that Child I's heart rate was 'still too low', and it was suggested that Child I would be Christened.
The mother said she felt that by Christening her, it would be like giving up, but they didn't.
Following the Christening, Child I's stats dropped and she was transferred by ambulance to Arrowe Park on October 15.
Arrowe Park then told the parents there was 'nothing wrong with her'. The mother felt the staff were 'being rude' and she felt she had to defend the Countess staff as they had to save Child I's life 'time and time again'.
The Arrowe Park doctor told the mother he 'couldn't understand what she was saying'. The nurse said she was going to give Child I some milk, and the mother said 'no, she's nil by mouth'. The nurse apologised and said she hadn't read the chart. The mother was angry at this.
The mother was told Child I was fine, but when the baby was turned over, she collapsed. The mother screamed at the doctor to do something.
The mother said the journeys between the hospitals would 'take it out of' Child I.
Child I improved and was transferred back to the Countess on October 17.
Child I 'didn't look herself' and it was like she was 'looking through me', the mother said to her mother.
At 12.30am on October 23, the mother woke up to find she had a missed call from the hospital. She rang through to a nurse and Child I had 'a little turn' and had been put on a ventilator.
The mother said she had to get to the hospital as she wasn't happy about Child I being back on a ventilator after all this time.
After ringing back, she was told to get to the hospital 'as soon as she can'. When they arrived, they found staff including Letby were trying to resuscitate Child I. That had been done for 20 minutes.
After some time, the mother said to them: "You can't keep doing this any more."
Resuscitation efforts ceased and Child I was passed into the arms of the mother, and Child I died shortly afterwards.
Two nurses, including Letby, asked if the mother wanted to bathe Child I.
While bathing, Letby was "smiling and kept going on about much she was present at [Child I]'s first bath and how much [Child I] had loved it.
"I wished she'd just stop talking. i think, eventually, she realised. It wasn't something we wanted to hear right now.
"I remember it was Lucy who packaged up [Child I]'s belongings."
The mother was told a post-mortem examination would need to be carried out for Child I, as the cause of death was not known.
In a subsequent statement, the mother clarified a few points from her original statement.
It was at the time she met Letby as she was changing Child I's nappy, and Letby remarked on Child I's stomach.
She said she would normally attend hospital at 9am each day and do the same thing, checking on Child I, speaking to staff, and feed (if Child I was not on a feeding tube). She would also meet family in the canteen.
At around 3pm, Letby walked in and stood by the window, about 6ft away from mother and baby.
She said: "I've noticed her belly is extended today, I'll go and check with the doctor."
The mother agreed. A medical staff member checked the belly and noted it was soft, and it would be examined.
For the October 14 incident, the mother recalls she was staying overnight at the hospital, woken up as Child I was poorly.
On each occasion they were called to the neonatal unit. she does not recall holding Child I's hand as this would have been impossible with so many staff working on Child I.
Consultant neonatalogist at Liverpool Women's Hospital
A statement from a consultant neonatalogist at Liverpool Women's Hospital is being read out.
She gives details of Child I's birth, and said Child I was born in 'very good condition'.
Child I was 'stabilised very quickly' with no concerns, before being admitted to the neonatal unit after being allowed to be shown to her mother.
Child I had 'very good gases' after being put on breathing support device CPAP.
There were readings consistent with an infection, but Child I was on antibiotics. A lumbar puncture and phototherapy were commenced.
Feeds were commenced, using expressed breast milk, on August 8 and Child I continued to be 'very stable, in spite of having an infection'.
Child I later had desaturations and bradycardias, so a second line of antibiotics was begun. The CRP infection marker was low, but the white blood cell count was elevated. A programme of five days of antibiotics began, and after a short gap in feeds, Child I continued to be fed.
Child I was stable when taken off CPAP for short periods of time.
On August 18, Child I was stable on CPAP, having four hours off it. She was tolerating feeds "very well". She had "normal tone, posture and movement".
The team at Liverpool had to wait until a bed became available at Chester before transfer was authorised on 'day 11', when Child I weighed 90g more than her birth weight, which "was good", as it was expected that babies would drop in weight in the days after birth.
"We expected [Child I] would continue to improve at Chester".
Upon Child I's return to Liverpool Women's Hospital, her blood gases and heart rate were "normal".
It was thought that Child I had suspected sepsis rather than NEC, and a course of antibiotics began to cover for both possibilities.
Child I was kept nil by mouth but was "stable" on the night of September 6.
There was a "mechnical obstruction" in the ET tube on September 7 and Child I was re-incubated. After this she "had normal gases and improved very well".
Feeds were gradually increased and the course of antibiotics ended after five days.
Child I continued to tolerate and build up feeds, which was a sign the baby girl did not have NEC.
The expectations were that Child I would return to the Countess of Chester Hospital and continue to improve.
Unnamed nurse (2) (child I)
In a statement to the court, another nurse, who cannot be identified for legal reasons, said that at about this time there were “massive staffing issues” and people were coming in to do extra shifts on the unit.
She said it was “mainly Lucy doing a lot” of extra shifts as she was qualified to carry out emergency care if required.
The nurse added: “Lucy was young, living in a doctors’ halls of residence and saving to buy a house.
“She was single and was willing and wanting to do extras.”
Nurse Shelley Tomlins (child I)
An 'agreed facts' statement is read out from nurse Shelley Tomlins, who recalls Child I.
She said she was the first one who looked after her upon her arrival, and looked after her multiple times.
She recalls Child I "definitely" had feeding and gut problems, and problems with a distended abdomen.
She said "it was like" there were blockages in her bowel.
For September 29, 2015, she was the designated nurse on a long day shift. Child I was "mottled" in appearance, with blotchy skin. She said some babies looked like that "all the time", and for some it was a sign they were not well.
She says she cannot say for certain, but the mottled appearance was "probably" all over her body.
She says Child I had a cardiac arrest "as we were looking at her".
Resuscitation attempts began and the family arrived, along with Dr Ravi Jayaram, consultant doctor.
The nurse describes the procedures done to stabilise Child I.
The nurse recalls a point when the bowels went "massive" and caused another collapse, as it impacted the lungs.
The nurse says the shift was significant for her as it was her last ever shift at the hospital, leaving the hospital a few days later.
Nurse Joanne Williams (child I)
Nurse Joanne Williams, in a brief agreed facts statement, recalls being involved in chest compressions for Child I.
Laura Eagles, in her agreed facts statement, was also asked about the October 13-14 event for Child I. She recalls from the notes the collapses happened at 7am and 7.45am. She said Lucy Letby was the designated nurse, from looing at the notes.
She recalls who else was on shift and the other babies on that night, and that it was "very busy".
She recalls CPR began at 7.45am, and the 7.45am collapse was more or less a continuation of the 7am collapse.
She said from her memory, Child I was ill for a long time, and it was difficult to separate one event from another in her recollection.
Dr David Harkness (child I)
Dr David Harkness, in his statement, said October 13-14 was "quite an eventful night" for Child I.
He said Child I deteriorated and required CPR in the early hours.
His next recorded entry was on a ward round later on October 14. He said it was suspected Child I had NEC. She had had two "quite prolonged" cardiac arrests and was on a ventilator. Blood gases were "acceptable but not fantastic, and on the poor side".
There "had been a suggestion of a collapse of the left lung", which would explain why there were problems ventilating her.
Child I's bowels were open, which was a "good sign". Blood culture tests were awaited, for signs of an infection.
Further tests were sought to check for NEC and to monitor Child I's bowels. If the signs were worsening, then surgery would be carried out.
Plans for 1-2 weeks down the line were to insert radioactive dye into the bowels to test for bowel obstructions.
By 4pm on October 14, Child I's signs had improved.
Dr Harkness says NEC is difficult to diagnose without carrying out surgery, and suspected NEC is usually treated with antibiotics.
He says he remembers Child I's death, and the parents coming back a few times over the following year.
Doctor - unnamed (child I)
The next statement is from a consultant doctor at Arrowe Park Hospital. The doctor recalls Child I was transported to the unit on October 15, with suspected NEC/inflammation of the gut, which is "not uncommon" in pre-term babies.
The intention was that Child I would be "conservatively managed" at Arrowe Park.
There was previously discussion on whether Child I should be transported to Liverpool Women's Hospital, but the decision was made to keep Child I in Chester. The following day, following further desaturations, Child I was transferred to Arrowe Park.
Child I was "pink, warm and well perfused" and her vital signs were "within normal limits". She was ventilated with oxygen, nil by mouth, on IV fluids then with TPN bags. There was also sedation medication administered.
The plan was to stabilise Child I and continue antibiotics, with seven days of antibiotics and nil by mouth.
An x-ray showed tubes and a long line were in reasonably good positions.
At the end of the shift, Child I was "stable" until a "sudden desaturation" and bradycardia at 12.16am on October 16. She was 'Neopuffed', but there was no chest movement.
A test concluded the breathing tube had potentially moved, so it was removed. At the end of the tube was dark blood, likely from Child I's previous collapse in Chester.
Child I improved in the early hours of October 16 and notes showed no fresh bleeding, and a different form of breathing support began.
Child I was stable in 35% oxygen breathing support, with "no issues" in breathing and it was "reassuring" the tummy looked fine, and the abdomen was soft.
Child I was moved to a high-dependency unit at Arrowe Park and her oxygen support requirements were diminishing.
There was "no longer a need" for tertiary requirement care, so Child I could be transferred back to the Countess of Chester Hospital.
A surgical plan was discussed for Child I, with a dye inserted into Child I to check for bowel obstructions, which would show on an X-ray.
On October 17, the transfer back to the Countess of Chester Hospital was confirmed, with Child I being transported back at 11am.
Nurse Christopher Booth (child I)
In a statement read to the court, nurse Christopher Booth said staff had got to know Child I and her family “really well” from her time on the unit since August 2015.
Child I was “quite a character herself”, he said.
Mr Booth said: “We all were fond of her and had high hopes for her. It was gut-wrenching for the (nursing) team as a group.”
He said he wrote to the ward manager to say the team involved in the resuscitation efforts were “all heartbroken”.
Mr Booth said: “I wanted her to know that as a team everyone had tried their hardest and did their best.
“If we were not such a good team we would have crumbled because there were so many horrible things going on.”
Nurse Melanie Taylor (child I)
Fellow nurse Melanie Taylor said staff were “devastated”.
She stated: “It was just pure shock. She was stable before that.
“I think her parents came in during resus. I remember them walking into nursery 1 and standing there, not really knowing what to do and myself not knowing what to say.
“The actual resuscitation is a bit of a blur to be honest.
“I remember right at the end, the doctor decided to call it and said we should stop.
“I had been looking at (Child I) and the monitor, thinking she is going to come out of it.
“My heart just dropped. When he said ‘stop’ I was just devastated, especially when I looked at the parents.”
Nurse Valerie Thomas (child I)
Nursery nurse Valerie Thomas recalled she took a phone call from Child I’s mother who asked for an update from the first collapse.
She said: “I went into room 1 and said (Child I’s) mum was on the phone, not realising (Child I) was being resuscitated there.
“Lucy Letby said her parents should come in.”
Witness Evidence (child I)
Nurse - unnamed (1)
Fellow nurse Letby, 33, is accused of murdering the baby girl, known as Child I, on her fourth attempt, while she was being cared for at the Countess of Chester Hospital’s neo-natal unit.
Her then-colleague was asked if she could recall a later conversation with Child I’s mother, who had returned to the unit to drop off cash she had raised.
She had looked after Child I the night before she died on October 23, 2015, and had dressed the baby, who had become “very unsettled”, Manchester Crown Court heard on Thursday, January 25.
The nurse, who cannot be named for legal reasons, said: “Mum came in and asked why I had dressed her and I explained I wanted to see if it settled her.
“I don’t remember saying to her that (Child I) didn’t die of prematurity. I only remember the babygro part of the conversation.”
Nurse Bernadette Butterworth (child I)
On the afternoon of September 30, she required breathing assistance from nursing staff via a face mask, after she had a large vomit and her blood oxygen levels and heart rate plummeted.
The defendant, who was Child I’s designated nurse on the shift, handed over her care to night-shift nurse Bernadette Butterworth in the early evening, when the youngster deteriorated once more.
The oxygen face mask was used again but no chest wall movement was detected, the court heard.
Miss Butterworth noted Child I’s swollen tummy and asked Letby to aspirate her nasogastric feeding tube, which obtained a “fair amount of air” and 2ml of milk.
She told the court: “She settled down. She came back to normal, her heart rate and respiratory rate.”
Doctors suspected a bowel problem as they prescribed antibiotics and ordered blood tests and X-rays.
GP Lucy Beebe
GP Lucy Beebe told police she saw a tearful Letby in conversation with a colleague in one of the care rooms at the unit.
Giving evidence on Friday, Dr Beebe said: “I remember Lucy crying with another nurse and it was very much of the gist of ‘it’s always me when it happens, my babies, it’s always happening to me a lot’.”
Prosecutor Philip Astbury asked: “Who was saying that?
Dr Beebe replied: “Lucy.”
Mr Astbury said: “You can’t remember precisely when that was?”
“No,” said the witness.
Dr Beebe said she cared for a premature-born girl, Child I, during her spell as a GP trainee doctor at the Countess of Chester.
Dr Beebe said: “I recall (Child I) because it was unusual that she was seemingly well and then became unwell.
“In my memory I felt like she was shipped out to a tertiary centre, made a rapid recovery and then was brought back very quickly.
“It certainly stuck in my memory because it had never happened to a baby I had been involved in the care of before or since, at any of the neo-natal units I worked at.”
Asked about her reaction to Child I’s death, she replied: “Shock and frustration at the time because on reflection I felt there was something else going on with (Child I) that we were not getting to the bottom of.
“It was sad because I remember the family and the whole situation was just very sad and frustrating.”
Dr Beebe agreed with Ben Myers KC, defending, and also told police, that Letby’s tearful exchange “seemed a pretty normal reaction” given the upsetting events at the hospital.
Nurse Ashleigh Hudson (child I)
Nurse Ashleigh Hudson told jurors the lights in a nursery were switched off, rather than dimmed, when she discovered Child I “pale and floppy” in her cot in the early hours of October 13.
Miss Hudson was Child I’s carer on the night-shift but she said she asked Letby or the nursing shift leader to keep an eye on the youngster as she was required to help a colleague with a routine procedure elsewhere.
She said that procedure took about 15 minutes and she then walked to a store room to collect Child I’s milk.
On her return to nursery room 2 she started preparing the milk for a feed on a counter which faced the lit corridor, she said.
She said: “I can remember at one point in time Lucy was standing in the doorway. She was leaning up against the frame. She pointed out from where she was that she thought (Child I) looked pale.”
Letby was “about 5ft/6ft” from the cot but Miss Hudson said she was closer and could not see Child I’s face as the top half of the cot was obscured by a canopy.
Fellow junior prosecutor Simon Driver asked: “Was there anything about the circumstances, the layout or the lighting within that room, which afforded Lucy Letby a better view than the one you had?”
“No,” replied Miss Hudson.
In August 2020, the court heard, Miss Hudson was taken to the unit by police officers to help her recollection of the position of the cot and the lighting at the time.
Cross Examination
Mr Myers asked: “It’s impossible, isn’t it, to recall precisely how the lighting was five years previously?”
Miss Hudson said: “Not precisely. It is an image that has been imprinted on my brain for quite some time. It’s quite vivid.”
Mr Myers said: “Is it possible that the nursery light may have been low on the dimmer rather than off?”
Miss Hudson said: “No, it was off.”
The witness said she had stood in that doorway at night and had looked at a cot in that position but it had not provided her a clear vantage point.
Miss Hudson said she approached Child I’s cot side, pushed back the canopy and peeled off her blankets.
Wiping away tears, she told the court: “That’s when I noticed she was in quite poor condition.
“She was incredibly pale in colour, almost white. She didn’t respond to me. She was very still.
“She was floppy and she was making gasping breathing movements – a handful of times within a minute.”
Prosecution
Mr Driver asked: “What was your first thought when you saw (Child I) at close quarters in that cot?”
Miss Hudson replied: “My first thought, and worry, was that she had deteriorated so rapidly that it was too late. The change in her had been remarkable.”
She said she gave Child I ventilation breaths via a face mask before Letby took over with the airway while she began chest compressions.
Child I eventually recovered after nurses and doctors fought to resuscitate her for more than 20 minutes, the court heard.
Miss Hudson said Child I was in “good clinical condition” at the start of the shift.
- -
Nurse Ashleigh Hudson is now being recalled to give evidence in the case of Child I.
The nurse is asked to look at nursing notes she had compiled early on October 22, a summary of the care provided to Child I.
She says Child I's heart rate was normal, the respiration rate was slightly elevated on a one-off reading, while her temperature was stable.
She was in room 1 of the neonatal unit, but "not an intensive unit baby" at this time. She was placed there as "a precaution measure" due to her recent medical history.
She was in an incubator, again as a precautionary measure due to her recent history, the court hears.
The nurse said the oxygen saturation levels, recorded as "96% and above", were "optimal".
Child I was "pink and well perfused", with "minimal aspirates recorded, clear fluid. Abdomen soft and non-distended," according to nurse Hudson's notes.
"She was a very stable baby considering the weeks prior," the nurse tells the court.
Child I would still have been classed as an 'HDU' baby [high dependency], as nurses would have had to check the long lines every hour, the court hears.
The nurse says she does not recall anything of note happening during that night shift on October 21-22.
Nurse Hudson recalls she was aware Child I was facing a medical procedure at another hospital which was 'urgent, but not an emergency'.
She said she took over care of Child I at 7.45pm on October 22. The prosecution ask why it would be 7.45pm rather than, say, 8pm. The nurse replies the handover was likely briefer than usual, as there was not a lot of information to pass on for Child I from the day shift at this point.
Child I's observations for heart rate and respiratory rate were satisfactory, while the temperature and oxygen saturation readings were "optimal".
Child I was not receiving ventilator support at this time.
Child I was "unsettled and rooting at start of shift" and the longline was removed due to constant occlusions. Lucy Letby was "unable to flush," so paediatric registrar Rachel Chang was informed.
Nurse Hudson's note continues: 'Dressing stripped and line pulled back, still not flushing, so removed.'
'No Oedema or duskyness'
The nurse recalls Child I reacted to the procedure "very well". Sucrose was offered, but Child I was happy with dummy. The baby girl was "pink and well perfused at this time, awake and alert".
The sucrose was sugar water which would be offered as pain relief, but if the child was happy enough to stay with the dummy, the sucrose would not be "pushed further".
The nurse said Child I was "generally quite easy to settle" and would settle "quite quickly", and would be "quite happy" when put into a cot or incubator.
The nurse recalls the events leading up to midnight.
She says, just prior to midnight, Child I was very unsettled, and tried the usual methods of containment holding, sucrose and dummy, which did not work.
She tried repositioning Child I so she was on her stomach, which sometimes settled her, but Child I continued to be very unsettled and cry.
She says sucrose would be administered for a child as a comfort measure to a child who was otherwise nil by mouth.
Child I would be placed on her stomach with her head to one side.
She said the measures to settle her "would generally work" with Child I and with other babies in general.
The nurse says she was familiar with Child I's crying, and this was an "atypical" episode.
She said it was a "type of cry I hadn't experienced her make before - loud, relentless, almost constant.
"Just a constant, very loud [cry] - something I had not heard from her before."
The repositioning was the last of the calming measure attempts.
Within seconds of that, Child I "became very quiet" and had "pauses in her breathing".
The nurse said she turned the child back on to her back and shouted for help.
"Was there a problem at this stage?" the prosecution ask.
Nurse Hudson: "Yes."
She said Child I's oxygen levels started to decrease, along with her heart rate. Ventilation breaths were given by nurse Hudson, with Lucy Letby providing assistance.
The nurse said after less than a minute, after realising it was an "acute episode", a crash call would be made to alert doctors.
The nurse recalls, from her notes, Child I was apnoeic, and dusky in appearance."
A Neopuff device was used to provide breathing support with 30% oxygen. 'Neopuff applied due to colour and apnoea.
'Colour didn't improve and [oxygen saturation and heart rate] began to drop rapidly until [oxygen saturation] 47% and [heart rate] 50. Neopuff increased to 50% then 100% with no effect."
Cardiac compressions began, and Child I was placed on a ventilator. Child I had become 'more alert and crying. Abdomen soft and non-distended prior to resuscitation, no change from handover."
Child I was recorded to be fighting the ventilator. The nurse says that was a sign Child I had recovered quite quickly, but keeping the child on the ventilator in that condition could cause lung damage, so a decision was taken to remove her from the ventilator.
Child I was "seemingly displaying normal behaviour despite what had happened" as she was also 'still rooting'.
The nurse says this episode, at about midnight, was a "very quick resuscitation" from her recollection, and no medication needed to be administered.
The court hears Ashleigh Hudson "managed to get through to [Child I's] parents after many attempts" regarding the first resuscitation. She said it was to be expected as it was the middle of the night.
Afterwards, Child I was "seemingly back to normal" with "nothing to cause concern" during that time after the first resuscitation.
Just after 1am, she was near, but not inside, nursery room 1.
The nurse says she was first alerted to Child I desaturating either from an alarm sounding on the monitor or from Child I crying.
Nurse Hudson recalls: "Lucy was already with her [at the incubator], trying to settle her. At that time [Child I's] observations were normal."
She says child I was crying "the same cry I had heard her display the first time [that night].
"Loud and relentless and unlike any other cry I had heard make prior to this night shift."
"My initial concern was she was obviously breathing...my concern was the cry was that she was going to have another episode of collapse."
She recalls articulating that concern to Lucy Letby within 60 seconds of being there.
The nurse says she said words along the lines of: "She's going to do it again, it's the same cry."
Letby responded with words of "reassaurance": "She just needs to settle," Ashleigh Hudson recalls Letby saying.
Child I became quiet, with pauses in breathing, and she became bradycardiac and her saturations "started to drift".
Oxygen delivery began again, along with ventilation breaths. They shouted for help from colleagues.
Nurse Hudson says she does not recall direct further communication with the parents, as the staff were "all in the thick of it" trying to resuscitate Child I.
The court is shown the October 23, 6.25am note by Ashleigh Hudson: "*NGT on free drainage, produced 2mls. Minimal aspirations of clear mucus and air++ during both resuscitations. Green stool and urine present post resus."
The nurse said, given previous abdominal issues for Child I, she had wanted to "make clear" what was observed during those resuscitations.
Cross Examination
Ben Myers KC, for Letby's defence, is now asking nurse Ashleigh Hudson questions.
He says the questions he is to ask, while technical, are not for lack of sympathy.
He says that in between the shifts she was looking after Child I, she was aware there had been further arrests and desaturations. Nurse Hudson agrees, and agrees that Child I was "very ill" when she had gone to Arrowe Park Hospital.
He asks if Child I needed to be looked at closely, and "there is always the potential for deterioration".
Nurse Hudson: "Yes."
"She is never completely out of the woods?"
"Yes."
"You can never become complacent."
"That was my view at the time."
Mr Myers says nurse Ashleigh Hudson was in the first 8-9 months of trained care at the time in October 2015, and would not have been intensive trained at this stage.
Ms Hudson says there were certain medical procedures which she would not be trained for at this stage, and it meant when those needed to take place, other staff, such as Lucy Letby, would do them for her.
Mr Myers asks if Child I looked unsettled at times because she was getting hungry.
"Yes."
"And at times can they be quite shouty and angry [when hungry]?"
"Yes."
Mr Myers refers to the night shift of October 21-22, to the nurse's note 'unsettled at start of shift and rooting, settled with dummy'. He asks if that was the behaviour exhibited because Child I was hungry. Ms Hudson agrees.
Mr Myers refers to a note by colleague Caroline Oakley, which notes 'unsettled at times; obviously very hungry but settles with dummy'.
Another note, by Ms Hudson, for the start of the night shift on October 22, records '[Child I] was unsettled and rooting at start of shift [7.45pm], settled with dummy and containment holding.'
Mr Myers says the issue of the long line had to be resolved during the night, which was resolved between 10.15-11pm.
Ms Hudson replies Child I was "very sensitive". Mr Myers said due to the cannula insertion and long line removal, Child I was not receiving fluid via the long line at this point.
He asks if the handling of the lines can have a distrubing effect on the baby, would there be an increase of the monitoring?
Ms Hudson says the monitoring did continue, it was just not recorded on the observation chart at 11pm, and was still visible on the electronic monitor.
Mr Myers says "All the things you would normally do to settle [Child I] didn't work?" [just before midnight]
Ms Hudson replies she called for help once she noticed Child I was "seemingly in distress, clinically", after noticing gaps in breathing after repositioning Child I. Letby arrived in response to the call for help.
Ms Hudson explains the note '[Child I] was very unsettled - ? due to hunger as rooting." She says the '?' means she was not sure of the cause.
Mr Myers asks if Neopuff was used up to the point of ventilation. Ms Hudson replies she was not sure, she would give Neopuff assistance in response to what could be seen at the time.
Child I 'attempted to cry' before being ventilated.
Mr Myers said Ashleigh Hudson was aware of Child I's history of abdominal distentions.
Ms Hudson replies she paid "specific attention" to the abdomen with this knowledge, and noted it was 'soft, non-distended' at this time.
Mr Myers said Child I recovered and 'looked better than before the incident took place?'
Ms Hudson: "Yes."
At 1.06am, Child I deteriorated once more.
Ms Hudson said she was alerted either via an alarm or Child I crying.
Mr Myers said once she entered, Lucy Letby was trying to settle Child I with a dummy. "Was this, in effect a repeat of what had gone on earlier?"
"Yes."
"You said you were concerned there was going to be a repeat...and Lucy Letby was trying to reassure you...she was going to be all right?"
"Yes."
Mr Myers refers to the family communication note, in which it was discussed with parents for Child I to be bathed, to make hand and foot prints, have photographs and gave consent for hair to be cut, and kept in the memory box.
Ms Hudson said this was the first time she had been involved with this bereavement procedure, and Lucy Letby assisted, before colleague Caroline Oakley later took over and completed the procedure.
Prosecution
The prosecution rise to clarify the noise made by Child I.
"It was loud, almost like a repetitive noise, relentless. In my interpretation, it would indicate distress, and was markedly different from before when she would express hunger, for instance."
The judge asks Ms Hudson for this 'rooting gesture' to be explained.
Ms Hudson says it's a classic gesture by babies, usually done before they cry. It can be a very specific behaviour where they rock their heads and stick their tongue out, smacking their lips.
That concludes the evidence from nurse Ashleigh Hudson.
Dr Matthew Neame (child I)
Giving evidence on Wednesday, February 1, registrar Dr Matthew Neame told Manchester Crown Court the premature-born infant, known as Child I, was “stable” when he examined her at 10.05pm on October 13.
He said he thought Letby asked him to see Child I at 5.55am on October 14 as her oxygen requirements had increased.
On examination, Dr Neame noted her abdomen was “distended”, “mottled” and with “some tenderness”.
He said he noticed Child I’s eyes were open and she “grimaced”.
Dr Neame said: “I don’t recall it clearly but it’s unusual to see mottling on the abdomen.
“My impression was the increase in abdomen distension may have caused (Child I’s) lungs to be squashed… making it hard for her to breathe.”
The court heard Letby retrospectively noted that at 5am Child I’s abdomen was “more distended and firmer in appearance with area of discolouration spreading on the right side”.
Letby, who was Child I’s designated nurse, noted she gave antibiotics at 5.05am.
She also retrospectively noted that at 5.30am Child I’s “abdo distended ++”.
Jurors were told that at 7am Child I had a “significant” drop in blood oxygen levels and heart rate.
At 7.45am, her heart rate fell “dangerously low” to below 60 beats per minute, said Dr Neame, which prompted CPR to begin.
Thirteen minutes of resuscitation from medical staff followed before she recovered.
The court has heard evidence of numerous babies having a “mottled, discoloured” appearance before collapsing.
Cross Examination
Ben Myers KC, defending, asked Dr Neame: “Your view is mottling normally means circulation is not as good as it should be?”
Dr Neame replied: “That’s right.”
Mr Myers went on: “And the underlying cause could be infection in some cases?
Dr Neame said: “Yes (but) when seen infection is usually accompanied by other signs.”
Mr Myers said: “Or low oxygen levels?
The witness said: “It can be.”
Dr Rachel Chang
Giving evidence on Friday, registrar Dr Rachel Chang said there were no concerns over Child I prior to midnight.
She was then crash bleeped to attend the cotside of the youngster who suffered a sudden drop in heart rate and blood oxygen levels.
Child I stabilised after she received cardiac compressions and breathing support, the court heard.
Dr Chang said: “I didn’t have any worrying thoughts. She has had an event. She had had lots of events.
“But I had to work with what was in front of us, which is that she recovered very quickly.”
About an hour later Child I similarly deteriorated but doctors and nurses, including Letby, were unable to revive her in a prolonged resuscitation attempt.
Dr Chang tearfully recalled how Child I did not respond to initial chest compressions and ventilation efforts.
Philip Astbury, prosecuting, asked: “Have you reflected on the death of (Child I) and the causes?”
“Yes,” replied Dr Chang.
Mr Astbury said: “And the shift, generally?”
Dr Chang said: “Yes.”
Mr Astbury said: “What has that caused you, if anything, to think?”
The witness replied: “Just that I have been never able to truly explain it. That it was awful.
“But I was never worried. I knew we had done everything and I did everything I’d done the first time I attended.
“I trusted everyone around me implicitly.”
Dr John Gibbs (child I)
Taken from BBC article 09/02/2023
Dr John Gibbs said he had written in his medical notes that he could not assign "a clear cause of death".
Ms Letby denies murdering seven babies and attempting to murder 10 others.
It is alleged the neonatal nurse attempted to kill the infant on 30 September and again during night shifts on 12 and 13 October.
The prosecution claim she harmed the baby by injecting air into her feeding tube and bloodstream before she eventually died in the early hours of 23 October 2015.
Manchester Crown Court heard how Dr Gibbs was called in urgently after Child I had rapidly deteriorated, arriving on the neonatal unit at 00:06 GMT.
"The nurses were telling me that she suddenly seemed very distress and was making an abnormal cry and that was about 10 minutes before I arrived," he said.
Child I required chest compressions but these were no longer needed by the time Dr Gibbs arrived on the unit.
He told the court Child I was "fighting" the ventilator, which meant she was resisting and was a "good sign".
But he told the court he "could not understand what natural disease could have affected her that she would have recovered so quickly".
In his medical notes, he had written: "Likely generalised lung collapse - very stiff, small vol [volume] lungs due to distress and crying".
"My suspicion was that she had cried in distress and her lungs had become much smaller and it was hard for her to breathe," he told the court.
But he added: "I admit I was struggling to understand exactly what had happened to [Child I]."
He said he returned home once Child I seemed stable, adding she was "settled, sucking her dummy [and] looking like a well baby when I left".
But within 30 minutes, he had been urgently called back to the neonatal ward as Child I had collapsed again, arriving at 01:23.
The court heard Child I was given CPR and repeated adrenaline but at 02:10 resuscitation efforts were stopped.
"We had been trying to help Child I vigorously for 50 minutes and she still had no pulse of her own, no breathing on her own and we had tried I think eight doses of adrenaline. It's often futile to continue," he said.
Child I was pronounced dead at 02:30.
"I didn't know or couldn't understand why she had collapsed and died," he said, adding he had reported her death to the coroner's office because of this.
"I felt [Child I] needed a post-mortem but it was the coroner's decision," he said.
Medical Experts Evidence (child I)
Professor Arthur Owens (child I)
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 has said there is evidence of pneumatosis (gas within the wall of the small or large intestine) on an X-ray from 30 September of Child I
Dr Arthurs has said Child I had a 'normal' bowl, as per her X-ray on 18 October and into 20 October. Looking at an X-ray from 23, there is a 'massive' dilatation of the stomach
Dr Arthurs says it is 'quite unusual to see babies with this degree of dilatation of the stomach', he says it can cause 'splits in the diaphragm' and that can lead to 'respiratory complications'
Asked how much air it would take to generate such images, Dr Arthurs said: 'We don’t know, I don’t think anybody really knows. Those experiments can’t really be carried out, we can’t experiment on babies giving them 50 or 100mls of air and taking x-rays'
He adds: 'I would guess more than 20mls of air' He is asked, in the absence of another explanation, whether 'someone has deliberately injected air' Dr Arthurs says 'I think that stands to reason'
Cross Examination
Ben Myers KC, defending, is now questioning Dr Arthurs
He put it to Dr Arthurs that from X-rays alone it was "not possible to establish a precise cause" of the air being present, Dr Arthurs agreed
Dr Dewi Evans (child I)
On Thursday, February 9, retired consultant paediatrician Dr Dewi Evans gave expert evidence at Manchester Crown Court, in the trial's first day of evidence since the previous Friday.
He stated that, in his opinion, Child I had on the first three occasions been injected with air into her stomach via a feeding tube.
But an “extremely disturbing phenomenon” of Child I’s noted “relentless, loud” crying prior to her final collapse led him to believe a different method was used.
The first collapse, he told the court, was “out of the blue”.
Dr Evans said: “She was entirely stable right up to the point of collapse.
“My opinion was that (Child I) had been subjected to an infusion of air. In other words, air had been injected into her stomach.
“That interferes with your ability to move your diaphragm up and down, and that interferes with your breathing.”
He said there was “striking evidence” from an abdominal X-ray which showed “lots of air”.
Dr Evans said he came to the same conclusion that Child I had suffered “splintering of the diaphragm” in the early hours of October 13.
On the following night shift he said her condition deteriorated again “as a result of some kind of event that had interfered with her breathing”.
In one report he prepared he wrote this collapse was “also suspicious and suggestive of inappropriate care, most likely due to the perpetrator injecting a large amount of air via the naso-gastric tube”.
He told the court an X-ray showed an “astonishingly large amount of air” in her stomach.
Dr Evans said Child I was again stable prior to a sudden deterioration shortly before midnight on October 22.
The court has heard Child I quickly recovered after medical staff gave her breathing support but less than an hour later she deteriorated again.
Nurse Ashleigh Hudson told jurors about Child I’s “relentless” and “very loud” crying from her incubator at just before midnight.
Dr Evans said: “Ashleigh Hudson’s evidence was very moving because nurses and doctors know what a normal cry sounds like.
“Babies will cry if they are hungry, or if you take a blood test because it hurts.
“This was very abnormal. A different kind of a cry. I interpreted it as the cry of a baby in pain and in severe distress.
“That is an extremely disturbing phenomenon. There was no obvious explanation why she was crying relentlessly and it was very loud.”
Asked by prosecutor Nick Johnson KC as to what his conclusion was for the cause of the fatal collapse, Dr Evans replied: “I think she was the victim of air being injected into her blood circulation. This probably explains her crying and distress, and the failure of the medical team second time round to save her life.”
Cross Examination
Dr Evans agreed with Ben Myers KC, defending, that Child I had recurrent episodes of a swollen stomach and oxygen desaturations during her time at the unit.
But he disagreed with his suggestion that Child I was “in general a very poorly baby regardless of the events we are looking at”.
Dr Evans said he thought both collapses on the night shift of October 22/23 were due to injections of air which caused a blockage to the passage of blood.
He said he could not say how much, or how quickly, air was administered as there was “not a great deal of research” available on air embolisms in babies.
Dr Evans denied Mr Myers’s assertion that it was “utter guess work” on his part.
The expert said: “It is consistent with what has happened in previous cases here.”
Extra info from Daily Round up 10/02/2023
On Thursday, Manchester Crown Court was told Dr Evans was criticised over his involvement in an application for permission to appeal against a care order involving two children – in a case unconnected to Letby.
Dr Evans supported the parents’ desire to have increased access to the children who were being cared for by their grandparents, the court heard.
Refusing permission last December, Court of Appeal judge Lord Justice Jackson said Dr Evans’ report was “worthless” and “makes no effort to provide a balanced opinion”.
He went on: “He either knows what his professional colleagues have concluded and disregards it or he has not taken steps to inform himself of their views.
“Either approach amounts to a breach of proper professional conduct.
“No attempt has been made to engage with the full range of medical information or the powerful contradictory indicators.
“Instead the report has the hallmarks of an exercise in ‘working out an explanation’ that exculpates the applicants.
“It ends with tendentious and partisan expressions of opinion that are outside Dr Evans’ professional competence and have no place in a reputable expert report.
“For all those reasons, no court would have accepted a report of this quality even if it had been produced at the time of the trial.”
Dr Evans told Ben Myers KC, defending, he had sent a letter to a firm of solicitors on the subject which he said was not intended to be used in an appeal.
He said: “I had no idea it had been sent to the court. I had no idea about this judgment until about two weeks ago.”
Dr Evans said he was “more than happy” to stand by his report.
He said: “This is the first judgment that has gone against me in 30 years.
“I have prepared dozens and dozens of reports for the family court. I’m in huge demand for opinions in the family court because of my track record as a witness.
“This is a one-off for me.”
Asked about the judge’s criticisms, he said: “I think it’s a balanced opinion actually.
“I do object to being called partisan. If you are partisan you don’t survive in the courts for long. My reports are impartial.”
Mr Myers said: “This report was brought to the defence’s attention but not by you. “If we hadn’t known about it and no one had known about it but you, would you have kept it to yourself?”
Dr Evans replied: “I didn’t know about it. If I had known about it, I would’ve informed the court.”
He told Mr Myers this was “cherry-picking of the worst kind”.
Mr Myers went on: “The reference to ‘working out an explanation’, that is precisely what you are doing in this case at various points, isn’t it?”
Dr Evans said: “It is not.”
Dr Sandie Bohin (child I)
Dr Bohin says the cause of the first of Child I's collapses were via air administered into the naso-gastric tube.
She said it would cause the abdomen to distend and "squash" the lungs, further compromising them.
Dr Bohin said, other than the distended abdomen, there were no other symptoms of NEC, a gastro-intestinal condition that Countess staff had considered as a diagnosis.
She tells the court there were no pathological reasons why the abdomen was distended, having seen an x-ray.
Dr Bohin said Countess staff did not always fill in the boxes on the chart whether a naso-gastric tube was removed or replaced. She adds the nursing staff tend to leave naso-gastric tubes in place for several days, as the procedure, while it takes "seconds", can be uncomfortable for the baby.
For the symptom of bruising on the baby girl in the second collapse, Dr Bohin rules out the cause of CPR, and "deduced" it was down to an air embolism.
For the third collapse of Child I, Dr Bohin says her opinion, based on the x-ray, the collapse, the distended abdomen and the discoouration, was via air administered into the bowel and vein.
For the fourth collapse, in which Child I ultimately died, Dr Bohin says the cause of the collapse was an air embolus, via air administered via an IV line.
She said the "extremely unusual" level of crying by Child I was "very different" and the baby girl must have been in "severe pain", and that led her to believe the cause had been via an air embolus.
Cross Examination
Benjamin Myers KC, for Letby's defence, is now asking Dr Bohin questions.
He says Dr Bohin had peer-reviewed Dr Dewi Evans's reports. She replies she has given an independent report.
Dr Bohin adds she believes Mr Myers is asking if she has merely rubber-stamped Dr Evans's reports, which she says is "less than discourteous", saying she has disagreed with some of his findings and added her own evidence.
She says she has reviewed the case and come with her own opinions, and has not "backed up" Dr Evans's reports.
Mr Myers says Dr Bohin would not have come up with the conclusion of an air embolus without first reading Dr Evans's reports. Dr Bohin disagrees.
She says she has twice seen the symptoms of air embolous, in one case involving a baby. In one case it was during a complicated medical prodecure which had risks, and in which a child was seriously ill, and the child had a cardiac arrest as a result of the air embolus.
Dr Bohin is now describing how an air embolus can result in a mottled appearance on the skin and how it can affect the body.
Mr Myers suggests Dr Bohin is adapting the air embolism cause to these collapses.
Dr Bohin: "That is not the case."
She tells the court she has looked for pathological causes to explain the collapses, and had not been able to find any.
Mr Myers says Dr Bohin is 'reaching' for air embolism as a 'catch-all' cause. Dr Bohin disagrees.
Dr Bohin tells the court when something is "out of the ordinary", it will be noted, as was the case when Dr John Gibbs noted 'mottling' at the time of Child I's first collapse.
Mr Myers asks if air embolus presents very specific type of discolourations.
Dr Bohin replies the description of the discolourations can vary among medical staff in a cardiac arrest situation when the staff have other priorities and different notes to make.
Mr Myers says Child I failed to put on weight as well as she should have.
Dr Bohin says Child I was very ill and did not put on weight during her time at Liverpool Women's Hospital. At the Countess of Chester Hospital, feeds were stopped due to complications and that meant she could not put on weight.
She says staff at the Countess stopped and started feeds and fortifier, and the reasons for the lack of weight gain were explicable
Mr Myers refers to an event on August 23, 2015 which Dr Bohin had described in her report as "suspicious", when Child I had developed an abdominal distention. This incident was when Lucy Letby was not on duty.
Mr Myers also refers to nursing notes from September 5, 2015, in which Child I was a 'well baby' but 12 hours later, 'desaturations' had been recorded, 'requiring intermittent wafting O2 [oxygen]'. The desaturations continued and Child I's oxygen saturation levels dropped to 60%.
Dr Alison Ventress recorded a 'profound desaturation, down to 50% sats', and was 'quiet, does cry when disturbed, but not usual strong cry', and 'slightly mottled'.
At 11.15pm, Child I had 'another profound desaturation to 50%'. The following morning, at 3.26am, Child I had a 'profound desaturation on ventilator' and Dr Ventress was crash called.
Dr Bohin says this was a baby with an infection who was deteriorating. Child I, had a septic screen, was on antibiotics but continued to slowly decline and was ultimately transferred to Liverpool Women's Hospital.
Dr Bohin says these weren't "sudden, catastrophic collapses" but moderate deterioration in a baby which had an infection.
Mr Myers says babies such as Child I can decline quite steeply.
Dr Bohin says babies don't suddenly collapse and have a cardiac arrest without warning. The subsequent events to September 5/6 were "very unusual".
Dr Bohin says Child I had chronic lung disease, something which could be diagnosed under the microscope, but it was not affecting her breathing at that time.
Mr Myers says such a condition could lead to an accelerated decline in a baby such as Child I.
Dr Bohin said Child I was gaining weight, not as quickly as one might expect, but she had been "very ill" and there had been stop-start points in her feeds.
Mr Myers refers to the September 30 incident, in which Dr Bohin says Child I had air administered via the naso-gastric tube.
Dr Bohin says she does not have any idea how much air would have gone down the naso-gastric tube, as it would be "impossible to say".
She says the x-rays showed "massive" distention in the abdomen, and "there had been a change".
For the October 13 incident, in which Dr Bohin says air was administered via the naso-gastric tube and via a vein, Dr Bohin had said she believed the apnoea machine had been switched off or tampered with.
She says, having heard nurse Ashleigh Hudson's evidence, Child I was breathing enough, but very slowly, not to have triggered the apnoea alarm. She says that information was not available when she compiled in her report.
Mr Myers says Dr Bohin had recorded there was no evidence the naso-gastric tube was in situ at the time of October 13.
Dr Bohin says staff were "notoriously poor" on noting whether naso-gastric tubes were in situ, inserted, replaced or removed.
Mr Myers says Dr Bohin had said there was no evidence it was in situ as Child I was bottle feeding, so the tube couldn't be in.
"Well, someone could've put one in," Dr Bohin replies.
Lucy Letby's note of 'some bruising/discolouration evident on sternum and right side of chest, ?from chest compressions', written from 19 hours after the incident.
Dr Bohin says this note is not from the time of the incident.
Dr Matthew Neame's note from the time of the October 13 incident is shown to the court, and Mr Myers says there is 'no reference to any discolouration' in that note, which described the collapse and the efforts to stabilise Child I.
Dr Bohin agrees there is not.
Mr Myers suggests the bruising appeared later and the discolouration 'does not link to that incident'.
Dr Bohin says it does, as bruising is not a result of chest compressions. It was first noted 18-19 hours later.
Mr Myers suggests Dr Bohin is using that unrelated evidence to support an air embolism. Dr Bohin disagrees.
After a short break, Dr Neame's note is shown again to the court. Mr Myers says he has been made aware the word 'mottled' appears in the note. Dr Bohin agrees she can see it.
Lucy Letby's note from the morning of October 14 is shown to the court. the note includes 'at 0500 abdomen noted to be more distended and firmer in appearance with area of discolouration spreading on right hand side'.
Dr Matthew Neame's note, made at 5.55am, is shown to the court. Mr Myers asks if it is a note from 5am. Dr Bohin says it does not say it was written retrospectively. She says if that note was related to 5am, then she had missed it.
Mr Myers asks if, from Dr Neame's note showing Neopuff was used, it could have contributed to the distended abdomen. Dr Bohin said it would not have done so to that extent.
Dr Bohin said the team did not have an obvious cause for Child I's deteriorations and she was always going to be transferred out to Liverpool on October 15.
Mr Myers refers to the location of the ET tube, NG tube and long line from a report shown to the jury. He says there is early evidence of NEC. Dr Bohin disagrees, saying the report needs to be taken in conjunction with clinical findings showing Child I had a collapsed lung and an over-inflated lung. Child I was reintubated before transfer.
Mr Myers says Dr Bohin reported for the final collapse, Dr Bohin had recorded air had been administered by the NGT and via an air embolus.
Dr Bohin says she cannot be clear whether both happened on each event, or whether it was one on each.
Mr Myers says Dr Bohin had earlier described how Child I presented at the time.
Dr Bohin said Child I had an NGT in place, but that would not have caused a distended abdomen to the extent shown.
Mr Myers says the air embolus cause was "very speculative" based on Child I's crying.
Dr Bohin says the crying was "very unusual" and air embolus was a "compatible finding" for the cause.
Mr Myers says the repeated collapses would lead a child to become weaker and sadly die.
Dr Bohin said Child I recovered so well from the first collapse she was extubated, and that she was doing well, and the first collapse had no relation to how Child I reacted to subsequent collapses.
Prosecution
The prosecution, led by Nicholas Johnson KC, rises to clarify a few of the questions.
The events around September 5 are discussed, and Dr Bohin said the incident was not notable as Child I had an infection, so there was an identifiable cause, and it was not NEC. She said it was "not a suspicious event" so had no need to flag it up as one.
She tells the court Child I "continued to be unwell and was intubated", and "had a very rocky time for a few days" before "she recovered".
The other events, Dr Bohin said, was when Child I collapsed and recovered "very quickly", or in the last case, "sadly", Child I had died.
The prosecution ask about the October 13-14 collapse, and how quickly a naso-gastric tube can be inserted and removed, and Dr Bohin confirms that can be done in "seconds".
Mr Johnson says there is no evidence "from the records" showing an NGT was in place, but "on the balance of probabilities", that was the cause - Child I receiving excess air via the NGT - which Dr Bohin favoured. Dr Bohin agrees.
That concludes Dr Bohin's evidence for Child I.
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.
Child I, received an excessive injection of air into her stomach, he said.
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 interviews summary (child I)
Mr Johnson now talks the court through a summary of Lucy Letby's police interviews for Child I.
For the first incident on September 30, Letby had no independent recollection of it. She said she did not know whether the distended abdomen was her observation or Child I's mother.
For the October 13 incident, she did recall that incident. She said she put on the light when she entered the room with nurse Ashleigh Hudson and noted Child I looked pale. Child I was shallow breathing and gasping, and the apnoea alarm was not activated. Letby could not recall giving Child I treatment prior to that event.
For October 14, Letby said she could not recall that shift.
Letby could not recall the night when Child I died, other than recalling she had died.
She said there was a feeling Child I had been transferred between hospitals too quickly.
Lucy Letby, in a subsequent police interview, said she had sent a sympathy card to the parents, and had taken a photo of the card on her phone.
She denied giving air via the NGT.
For the October 13 incident, Letby agreed it would have been difficult to see if Child I was pale without the lights being on.
She thought she and Ashleigh Hudson had been at the doorway when noting Child I was pale. She could not recall if there was a prior examination. She said “maybe I spotted something that Ashley wasn’t able to spot” because she was “more experienced than Ashley”. She said there was still light coming into the room from the corridor and there would be some natural light.
For October 14 and 22, Letby denied causing Child I any harm.
In a third interview, Letby was asked about texts following the October 14 shift, she agreed she had sent texts to a colleague saying Child I looked 'not good' and had asked to be assigned to her care.
She was asked why she had searched for Child I's mother on Facebook, and said she did not know, and could not recall doing so.
