contains evidence heard for Child A & B (twins)
Lucy Letby Case
page contains live reporting links, opening statements including opening statements for each child.
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Child A & B (twins)Count 1: Child A - Murder allegation (air embolus)
Count 2: Child B - Attempted murder (air embolus)
Prosecution opening statement (child a)
Child A, a boy, was born premature in June 2015, the younger of a twin child (Child B). Medical records for Child A's birth are shown to the jury, including the names of which medical staff were present at the birth, and the condition of Child A, plus medical observations. Child A was in "good condition" at birth, and taken to the neonatal unit ICU. 13 hours later, he was breathing "in air" without the requirement of extra, medically administered, oxygen.
A medical chart records the fluids going in and out of Child A. Child A was given 1ml of milk via a nasogastric tube at 4pm and 6pm. A nurse had looked after Child A that day. She handed over care to Letby at 8pm before she had been able to administer intravaneous fluids. The fluids were started at the time of the handover - the nurse assisting Letby. Child A was stable at the time of the handover.
The connection of the fluids, Mr Johnson said, would have been after 8.10pm, and it was recorded on the infusion prescription chart at 8.05pm.
At 8.20pm, Child A was reported to have white feet and hands, and Letby called a doctor to the incubator at 8.26pm, as child A was deteriorating.
Resuscitation procedures began, with adrenaline administered to stimulate the heart.
Doctors observed "an odd discolouration on Child A's abdominal skin - flitting patches of pink over blue skin that seemed to appear and disappear".
Mr Johnson said: "This proved to be the first of a series of similar presentations on the skin of babies suddenly and catastrophically collapsing at the CoCH NNU over the succeeding months. "It is a hallmark of some of the cases in which Lucy Letby injected air into the blood streams of some of these small babies." "All resuscitation techniques which would be expected to bring a baby back to life failed."
Child A was pronounced dead at 8.58pm. He had died, Mr Johnson said, within 90 minutes of Lucy Letby coming on duty. She was recorded as being the only witness associated with Child A's collapse.
The doctor noted, at 8.26pm, that Lety was showing an oxygen mask to Child A's face. The monitors showed Child A had a normal heart rate and good oxygen saturations, and a normal ECG, but was not breathing. The doctor noted: "an unusual blotchy pattern of well perfused pink skin over the whole of [Child A]'s body coupled with patches of white and blue skin … all over his body."
The case was referred to the coroner and the cause of Child A's death was 'unascertained' at the time.
Medical expert Dr Dewi Evans suggested Child A's collapse was "consistent with a deliberate injection of air or something else into [Child A]'s circulation a minute or two prior to deterioration," Mr Johnson told the court. Only Letby was present.
Another medical expert said the cause was "not some natural disease process, but a dose of air "deliberately administered".
An independent pathologist described the cause of death was 'unascertained', in that there was nothing in the autopsy that pointed to why Child A had died, but the cause was most likely 'exogenous air administration through the longline or UVC'.
Said explanations are also backed up, the prosecution say, by an independent radiologist.
When interviewed by police regarding the circumstances over Child A's death, Letby said she had given fluids to Child A at the time of the change of shifts. She said within "maybe" five minutes, Child A developed 'almost a rash appearance, like a blotchy red marks on the skin'. She said she had wondered whether the bag of fluid "was not what we thought it was".
In an interview in June 2019, Letby said she had asked for all fluids to be kept from the bag at the end to be checked, but the prosecution said there was was no record of her having made such a request.
It was suggested by police that Letby had administered an air emolus. She replied it would have been very hard to push air through the line.
In a November 2020 police interview, police put to her that Letby had tracked the family of Child A on Facebook. She said she had no memory of doing so but accepted it if there was evidence on her computer doing so.
Prosecution opening statement (child b)
Child B is the elder twin sister of Child A, born in June 2015. She required breathing support via a ventilator at birth. Attempts to fit an umbilical vein catheter (UVC) twice failed, so a long line (IV) was inserted for fluids to be administered successfully. Breathing support gradually lessened and Child B was stable.
A designated night-shift nurse was responsible for Child B. Shortly before midnight, the blood/oxygen levels had fallen to 75% and the Cpap nasal prongs were dislodged from Child B's nostrils. The nurse repositioned the prongs and the levels recovered.
Just after midnight, Letby started a bag of liquid feed with Child B, with the nurse, through an IV line.
At 12.16am Letby - while not Child B's designated nurse - took her blood gases.
About 28 hours after her twin brother had died, at about 12.30am, Child B's alarm sounded and Letby had called the nurse to the child's incubator. Child B was not breathing.
A crash call was put out at 12.33am, and resuscitation began. The nurse noted purple blotches and white patches all over Child B's body, and the heart rate had dropped.
In a witness statement three years later, Letby's colleague, the designated nurse for Child B, said she and Letby had been preparing antibiotics at the time of the collapse.
After efforts to resuscitate Child B, Child B "recovered very quickly". A doctor subsequently found "loops of gas filled bowel".
The prosecution say this was a finding replicated many times in the upcoming cases.
Child B improved until being discharged the following month.
Dr Dewi Evans concluded Child B was "subjected to form of sabotage" that night, the court hears.
Another medical expert said an airway obstruction would cause a "sudden desaturation and reduction in heart-rate", but would not account for the "florid change in skin colour and perfusion noted at the time".
The medical expert said a "relatively quick recovery" would "only be explained by a dose of air...deliberately administered in the bloodstream".
A blood expert added "no blood disorder would account for the sudden deterioration suffered by [Child B]."
"The prosecution’s expert paediatricians say that the collapses and skin mottling were the result of air being injected into their bloodstream. "The first injection caused the death of [Child A], the second the dangerous collapse of his sister.
"We say that there is no plausible alternative to an air injection [air embolus]. The fact that it happened in 2 cases just over 24 hours apart shows that these were no accidents.
In police interview, Letby was asked about the circumstances regarding the connection of a liquid feed bag at 12.05am. She said she had looked at paperwork for the lipid syringe (an addition to the liquid feed bag to children not being given milk), and said the prescription was "not her writing" but "she had signed for it" and "ideally it should have been co-signed by somebody".
The rules are that two nurses have to sign for things administered to a baby.
Letby told police she had conducted observations on Child B, but the other nurse was the allocated nurse.
Letby also said it was the other nurse who had alerted her to the problem with Child B.
In a June 2019 police interview, Letby said it was her signature on the blood gas record at 12.15am, just before Child B collapsed.
The prosecution say this is an example of Lucy Letby signing the charts for a baby who was not her designated patient at a time just before the child collapsed.
In November 2020, Letby was asked by police about a handover sheet relating to Child B found at her home address in a search.
The sheet showed she had been the designated nurse for two babies in a different room that night.
Mr Johnson said: "Here you can see that we have twins who were born prematurely but in pretty good condition.
"No one expected them to face grave problems, yet both suffered unusual symptoms within a short time of each other which in interview Lucy Letby said were similar. "Lucy Letby was the only person present [with Child A] at the time he collapsed...and was in the room when the same happened to [Child B].
"We also say that you are entitled to look at the evidence of what happened to [Child A and B] in the context of one, what Lucy Letby did to other children and two, most starkly, her having poisoned [two other children] with insulin."
Defence Opening StatementChild A
The defence do not accept, for Child A, an air embolus was the cause, but one of "sub-optimal care", as a result of either "lack of fluids" or "various lines put into him, with potential to interfere with his heart rate".
"You will hear in this case, that the air present after death does not indicate an air embolus."
Mr Myers said air present in the abdomen "can happen post-mortem".
For Child B, the defence say she had been born in a "precarious condition" and there were no signs of diagnosing an "air embolus".
The defence say prosecution experts had been "influenced" into believing harm was done.
The defence say Child B had other episodes where she struggled to breathe, after the indictment.
Defence Lucy Letby Evidence (child a)Lucy Letby gave this evidence on 5th May 2023, taken from Chester Standard
The focus turns to the case of Child A, born on June, 7, 2015, twin of Child B. Child A died the following day.
Mr Myers is retelling the notes for Child A's birth. Child A, a baby boy, was born with antiphospholipid syndrome.
He died the following day.
Mr Myers refers to nursing notes, referring to the UVC line being in the wrong position on June 8 for Child A. It was reinserted but was still in the wrong position. A long line was inserted.
Care was handed over to Lucy Letby at 8pm.
Mr Myers refers to retrospective nursing notes written by Lucy Letby on the morning of June 9.
The notes include: 'Instructed line not to be used by registrar. [Child A] noted to be jittery, was due to have blood gas and blood sugar taken.
'At 20.20 [Child A's] hands and feets noted to be white. Centrally pale and poor perfusion. [Child A] became apnoeic. Reg in the nursery. [Child A] making nil respiratory effort...'
Child A later died.
Lucy Letby says that, around the time of this taking place, she had moved to Ash House in June 2015.
She said she was "still in the process of moving an unpacking" at the time of Child A's events.
She says she had received a text message that morning asking her to work that night's shift.
A text message from Yvonne Griffiths from 9.21am on June 8, 2015 is shown to the court asking Lucy Letby to work that night.
Letby tells the court she was "frequently" asked to come in and cover neonatal unit shifts at short notice, saying she was very "flexible".
Letby tells the court the first she knew she was going to be caring for Child A, in nursery room 1 was when she arrived for the handover at 7.30pm.
She recalls there was "a lot of activity" in the nursery, with Dr David Harkness doing a line procedure and nurse Melanie Taylor sorting fluids for Child A. She explained Child A had been without fluids for a few hours.
An intensive care chart is shown for Child A - after 4pm on June 9, the 'cannula tissued' which meant Child A's fluids had stopped, the court is told.
A clinical note is shown to the court about the UVC and long line insertions.
Letby says she was told by Dr Harkness and nurse Taylor the long line was suitable for use to administer 10% glucose.
A collective handover had taken place prior to Letby arriving at the nursery, lasting about 20 minutes.
Letby tells the court when fluids are administered via a long line, one of the two nurses present has to be sterilised, and in this case that was nurse Melanie Taylor, handling the bag, cleaning the long line, attaching the bag to the long line 'port' on Child A's left arm and making sure the line was 'flushed'.
Letby was, she says, the 'dirty nurse' (ie unsterilised) for this procedure.
Letby say she turned her attention to hanging the bag on to the drip stand cotside and programming the pump.
Letby says the "usual practice" is for the line to be flushed with sodium chloride prior to fluid administration. She says she did not observe if that took place.
The 10% dextrose solution is shown from a fluid prescription chart as beginning at 8.05pm.
Letby says Melanie Taylor went over to a computer to start writing up notes.
Letby said she was doing some checks - on cotside equipment, suction points, emergency equipment.
She says Dr Harkness at this point was doing a procedure on twin Child B at this point.
Letby says she observed Child A to be "jittery".
Letby says "jittery" was an abnormal finding for Child A. It was "an involuntary jerking of the limbs".
She says she remembered it was "noticeable".
Child A's monitor sounded and his "colour changed".
Letby says the alarm sounded, but she did not know what it indicated at the time.
She says she noted Child A' "hands and feet were white".
She went over to Child A, who was not breathing, so they went to Neopuff him.
Letby and nurse Taylor disconnected the 10% dextrose, on Dr Harkness's advice.
Referring to 'centrally pale', Letby says that refers to Child A being pale in the abdomen and torso.
Child A was apnoeic - "not breathing".
Nurse Caroline Bennion was also in nursery room 1, and had been during handover, the court hears.
Letby says she began the 'usual procedure' of administering Neopuff to Child A.
Child A's heart stopped and a 'crash call' was put out. Letby says that is an emergency line for doctors to arrive urgently. Dr Ravi Jayaram arrived immediately and another nurse arrived shortly afterwards.
Letby says she cannot recall the resuscitation efforts, and says it was "an unexpected, huge shock", saying she had just gone through the doors and "then this was happening".
Child A died shortly before 9pm.
Letby says she, as designated nurse, arranged hand and foot prints for Child A as part of the hospital's 'bereavement checklist' which the court heard about on Tuesday. A nursing colleague helped assist in the hand and footprints, as that was a two-staff procedure.
A baptism was offered to Child A during resuscitation, and Child A and Child B were baptised together. The court hears this was part of the practice.
Letby said she felt after Child A, the bag of fluids and the long line "should be retained". She says she labelled the bag as "at the time...we should be checking everything in relation to the line and fluids" as it could be "tested" afterwards.
She says she did not know what happened to the bag afterwards.
Letby said, in reaction to Child A's death, she was "stunned, in complete shock...it felt like we had walked through the door into this awful situation - that was the first time I met [Child A] and [Child A's] parents".
A nursing colleague messaged Letby on June 9, praising her for how she handled the sitation with Child A: "...You did fab."
Letby responded: "...Appreciate you saying that & Thanks for letting me do it but supporting me so well x"
Letby says the network of support among colleagues in messaging each other outside of work was "something we all did".
Mr Myers asks why Letby searched for the mum of Child A on June 9 at 9.58am.
Letby says "it was just curiosity" that she wanted to see the people behind that "awful" event, and the parents "were on my mind".
She says it was a "pattern of behaviour" she had, as she searched the name as part of a "quick succession" of name searches in a short period of time.
Letby says there was a debrief after Child A had died, a few days later, led by Dr Jayaram, which discussed if there was anything to learn from the event.
Letby said it was "more clinically based" rather than emotional support.
She said the event "affected her" emotionally, and denies causing Child A any deliberate harm.
Letby says, of that night: "You never forget something like that".
Cross examination (child a)
Lucy Letby gave this evidence on 18th May 2023, taken from Chester Standard
Mr Johnson asks about the case of Child A.
Letby says she did have independent memory of Child A.
"Before [Child A], had you ever known a child to die unexpectedly within 24 hours of birth?"
LL: "I can't recall - I'm not sure."
Letby says she can recall "two or three" baby deaths prior at the Countess of Chester Hospital, and "several" at her placement in Liverpool Women's Hospital.
Mr Johnson says Letby had previously told police it was "two" at Liverpool. Letby says her memory would have been clearer back then.
Letby says it was discussed at the time Child A's antiphospholipid syndrome could have been a contributing factor at the time.
Letby tells the court "in part", staffing levels were a contributing part in Child A's death, due to a lack of fluids for four hours and issues with the UVC line.
She says they were "contributing factors", and put Child A "at increased risk of collapse".
"I can't tell you how [Child A] died, but there were contributing factors that were missed."
Letby says the issues with Child A's lines "made him more vulnerable", with one of the lines "not being connected to anything".
Letby is asked why she didn't record this on a 'Datix form'.
LL: "It was discussed amongst staff at the time...I didn't feel the need to do a Datix, it had been raised verbally with two senior staff, one Dr Jayaram, one a senior nursing staff."
She adds: "I don't know why [Child A] died."
Letby says if the cause of death was established as air embolous, then it would have come from the person connecting the fluids, "which wasn't me".
Mr Johnson: "Do you accept you were by [Child A] at the time he collapsed?"
LL: "I accept that I was in his cot space, checking equipment, yes...I was in his close vicinity."
NJ: "Could you reach out and touch him?"
LL: "I could touch his incubator - the incubator was closed."
NJ: "Could you touch his lines?"
Letby says "there's no way of knowing" from the signatures, who administered the medication between the two nurses, Letby or nurse Melanie Taylor.
Dr David Harkness recalled to the court: "There was a very unusual patchiness of the skin, which I have never seen before, and only seen since in cases at the Countess of Chester Hospital."
Letby disagrees with that skin colour description for Child A.
She agrees with Dr Harkness that Child A had "mottling", with "purple and white patches".
Letby says she cannot recall any blotchiness.
"I didn't see it - if he says he saw it...that's for him to justify.
"It's not something I saw.
"I was present and I did not see those."
Dr Ravi Jayaram said Child A was "pale, very pale", and referred to "unusual patches of discolouration."
Letby: "I don't agree with the description of discolouration, I agree he was pale."
Letby disagrees with the description of Child A being blue, with pink patches 'flitting around'.
An 'experienced nurse of 20 years', who the court hears was a friend of Letby, said: "I've never seen a baby look that way before - he looked very ill."
Letby agrees Child A looked ill. She disagrees with the nurse's statement of the discolouration, or the blotchiness on Child A's skin.
"I agree he was white with what looked like purple markings."
Letby agrees with the statement that the colouring "came on very suddenly".
Mr Johnson refers to Letby's police interview, in which Letby was asked to interpret what she had seen on Child A.
Letby explained to police mottling was 'blotchy, red markings on the skin'
Child A was "centrally pale".
In police interview, Letby was asked about what she saw on Child A. She said: "I think from memory it [the mottling] was more on the side the line was in...I think it was his left."
Letby tells the court she felt Child A was "more pale than mottled".
She says it was "unusual" for Child A to be pale and to have discolouration on the side", but there was "nothing unusual" about the type of discolouration itself.
Mr Johnson asks about the bag being kept for testing.
Letby says she cannot recall if she followed it up if the bag was tested. She had handed it over to the shift leader.
Letby is asked if she accepts Child A did not have a normal respiratory problem. Letby agrees.
Mr Johnson asks if Letby has ever seen an arrhythmia in a neonate. Letby: "No, I don't think so, no."
Mr Johnson says air bubbles were found in Child A afterwards.
"Did you inject [Child A] with air?"
Mr Johnson asks if Letby was "keen" to get back to room 1 after this event.
Letby says from her experience at Liverpool Women's, she was taught to get back and carry on as soon as possible.
Letby had been asked what the dangers of air embolus were, and she had not known.
"Were you playing daft?"
"No - every nurse knows the dangers."
Letby said she did not know how an air embolous would progress, but knew the ultimate risk was death.
The trial is now resuming. Nicholas Johnson KC says there is one thing he overlooked from the morning's evidence.
He asks Lucy Letby why she said "blotchiness" rather than "mottling" in part of her police statement.
"I think they are interchangeable," Letby tells the court.
Defence Lucy Letby Evidence (child b)Lucy Letby gave this evidence on 5th May 2023, taken from Chester Standard
Mr Myers turns to the case of Child B, Child A's twin sister.
Child B was born on June 7, 2015, weighing 1,669g. Mr Myers says Child B was born with antiphospholipid syndrome, as noted on a clinical note.
Mr Myers notes that, at birth, Child B was 'blue and floppy, poor tone, HR approx 50.'
Resuscitation efforts were required, with a series of inflation breaths. Intubation was successful after a couple of attempts, and Child B stabilised on the evening of June 7.
Mr Myers refers to nursing notes written retrospectively on the morning June 10.
Child B had desaturated to 75% 'shortly before midnight', with Child B's CPAP prongs pushed out of nose.
'Prongs and head reposition. Took a little while and O2 to recover. HR remained stable.'
'0030. Sudden desaturation to 50%. Cyanosed in appearance. Centrally shut down, limp, apnoeic. CMV via Neopuff commenced and chest movement seen...'
'Became bradycardiac to 80s. Successfully intuinated...and HR improved quickly. 0.9% saline bolus given and colour started to improve almost as quickly as it had deteriorated. Started to breathe for self...'
Lucy Letby says she does not have much recollection of the night shift for June 9-10, in respect of Child B.
A diagram shows Letby was in nursery room 3 for that night shift, looking after two babies. Letby says without that diagram, she would not have recalled who was doing what from that night.
Mr Myers asks how Letby would know if a nurse needed assistance in a non-emergency situation. Letby says they would come and ask.
Letby says CPAP prongs can be dislodged "very easily" and it happened "frequently" in babies.
Before 12.30am, Letby says she believed she carried out a blood gas test
on Child B, at about 12.15am.
A fluid chart is shown to the court.
She says at 10pm on June 9, lipids were administered.
A blood gas chart is shown with a reading at 12.16am, with Lucy Letby's signature initials.
She says it was "usual practice" that two nurses would be involved in the blood gas test, and she says she had no other involvement with Child B in the run-up to her deterioration.
Letby is asked about a morphine bolus administered to Child B, as referred to in police interviews, when establishing contact with the baby.
Mr Myers says, to be clear about the timing of this morphine bolus, a prescription is shown to the court, with the 'time started' being 1.10am. The court hears this is 40 minutes after the collapse.
Letby says she cannot recall, "with any clarity", events in the build-up to Child B's collapse.
She says she knows there was a deterioration "fairly soon" after the blood gas test.
She said both she and a nursing colleague were in nursery 1 when Child B's colour changed - "becoming quite mottled", "dark", "all over". She says the nursing colleague alerted her to the deterioration.
Letby is asked if she had seen that mottling before. Letby said it was not unusual but it was a concern, in light of Child A's death the night before.
Child A was "pale" but Child B had "purple mottling".
She says she and the nursing colleague were joined by a doctor at that point.
Letby said she was asked to get the unit camera from the manager's office to take a picture of the mottling.
She says on her return, Child B had stabilised and returned to normal colouring, and there was no mottling to photograph. She said she had the camera with her, and she had returned to the nursery "very quickly".
Letby says she believes she administered some of the prescribed drugs for Child B after the collapse.
A blood gas test taken at 12.51am is signed by Letby. She says as it is a two-nurse procedure, the signature does not indicate whether that was also the nurse who took the initial blood sample.
Letby says following Child B's collapse, other doctors came to the nursery room, but she cannot recall who.
She says presumably the designated nurse would have communicated with the family following the collapse.
An observation chart shows Letby took observations for child B at 1am. She says this was "not unusual" for nurses to do this, especially if the designated nurse was busy elsewhere. The court hears this could be if that designated nurse is speaking with the parents.
Sequence of events from records (child a)
Mr Myers turns to the case of Child B, Child A's twin sister.
Child B was born on June 7, 2015, weighing 1,669g. Mr Myers says Child B was born with antiphospholipid syndrome, as noted on a clinical note.
Mr Myers notes that, at birth, Child B was 'blue and floppy, poor tone, HR approx 50.'
Resuscitation efforts were required, with a series of inflation breaths. Intubation was successful after a couple of attempts, and Child B stabilised on the evening of June 7.
8th June 2015
The package records Child A was transferred to the neonatal unit at 2.41am on June 8, as a note written retrospectively recorded.
A 24-hour observation chart records Child A's heart rate, respirations and body temperature.
Further medical charts are shown as part of the electronic evidence package, along with the intelligence analyst's transcribed summary.
At this stage, the full details of these charts will not be analysed. The prosecutor, Nicholas Johnson KC, explains doctors and nurses will be called into court later to provide more context on these notes.
One of the clinical notes includes a very basic sketch of lungs and the abdomen, to describe Child A's condition, which noted the child looked stable.
The medical records also show an x-ray was taken on Child A, using a portable x-ray machine.
A record labelled 'family update' is made at 7.12am about how 'dad had visited [the neonatal unit] multiple times throughout the night', with the mum not being well enough to visit the twins as she was still in recovery.
Another note, made for 7.30am, describes who was working in what role for the following shift, such as the paediatrician of the week, the on-call consultant, the registrar and other clinical staff, registered nursing staff including the shift leader, the designated nurse, and other nurses.
Other staff listed for this shift are a nursery nurse and a student placement.
The evidence also shows text messages sent between Letby and colleagues.
, a message is sent to Letby asking her to split her shifts. She replies: "Yes that's fine...is it busy?"
The reply: "We have 3 on CPAP...twins last night...wanted six staff on."
Letby replies: "No problem."
an outgoing Whatsapp message from Letby to a friend says: "...I'm working tonight and tomorrow now as busy."
Letby sends another Whatsapp message: "Will just have a quiet one today. Slept well. They have 3 30wkers on CPAP."
Her colleague replies: "It will calm down again soon then."
Further Whatsapp messages are exchanged, which go into 'a social nature', up until 10.10am.
A message from another colleague of Letby's is sent to Letby.
She replies: "I've been moved forward as busy. Doing tonight and tom."
After friendly messages are exchanged, the conversation then turned to work, and how busy
work had been.
The evidence records an x-ray taken of Child A's chest and abdomen taken, along with notes at 1.53pm indicating no concerns with the child at that time.
Letby's colleague sends a Whatsapp at 2.11pm to Letby: "Oh well, you'll just have to kick me if I start nodding off."
The medical charts show hourly observations are made of Child A.
a cannula is tissued and Child A begins to be fed expressed breast milk for the first time.
The note for fluids also shows 10% glucose is provided at 8pm by Lucy Letby.
Swipe data shows the nurses coming on for their night shift. They include, at 7.22pm
, Lucy Letby.
Child A was said to be 'stable' in a nursing note, which concludes 'Care handed over to Lucy Letby at 8pm'.
Letby's nursing note is written in retrospect at 7.56am the following day
, after Child A had died.
Part of the note was 'care taken over at 8pm, emergency equipment checked, fluids calculated.
'[Child A] nursed on CPAP, peep 5-6cm in air. Observations stable.'
A medical note shows there is no record on the 8pm time slot of Child A's temperature - but there are other hours on the chart prior to that where the temperature is not recorded either, the court hears.
A chart shows any 'major events' that took place for Child A. One was UVC lines at 1pm.
The prosecution point out the '10% glucose commenced at 8.05pm', signed by Lucy Letby, as a 'major event' on the chart for the 8pm timeslot.
A further retrospective nursing note, by Letby, refers to the administration of 10% glucose via a long line.
Child A was noted by Letby, to be 'jittery'.
Records show a nurse other than Letby is 'using the computer' at 8.14-8.15pm, where she is referring to the family of Child A and B being updated on the condition of Child B.
Lucy Letby's retrospective note recorded: 'At 8.20pm Child A's hands and feet noted to be white. Centrally pale and poor perfusion.'
Further nursing notes are shown to the court showing the registrar was called for, as Child A had become apnoeic.
He was then 'making nil respiratory effort' and, later, no heart rate was detected.
The nursing notes record that, despite 'full resuscitation efforts', Child A 'passed away at 8.58pm'.
The court is shown a series of doctors' clinical notes, written in retrospect on the collapse of Child A before 8.30pm on June 8, and the failed attempts to resuscitate him.
Letby's notes, written in retrospect, record the time of death for Child A, at 8.58pm, that Child A and B were baptised together, and a lock of hair and hand/footprints taken for Child A in accordance with the parents' wishes.
Sequence of events from records (child b)
Child B's lungs were examined to be "clear" and the child was "very alert" and "active", on the morning of June 9.
A 'weaning programme' note is made at 11am, which is for the weaning of Child B off breathing support.
A further nursing note showed Child B was 'very stable' after being weaned off CPAP and allowed time to be with Child B's mum, before returning to CPAP with a view to further weaning off.
A nursing note recorded in the afternoon of June 9 said "maximum support" was being offered to the family of Child A and B, who were still "understandably" very upset.
Child B is in room 1, while Letby is assigned to look after two babies in room 3.
The court hears one of Letby's colleagues is the designated nurse for Child B and another baby in room 1. Following Child B's collapse, another nurse took over looking after the other baby in room 1.
Nursing notes written by the designated nurse, written in retrospect, found Child B's CPAP prongs had been pushed out of the nose, and oxygen saturation levels had fallen to 75%, before midnight. The prongs were repositioned, and after "a little while", the oxygen levels recovered.
The heart rate was stable and there was "good respiratory effort throughout". Child B was observed to be "stable" prior to midnight.
Letby is then involved with administering nutrition at 12.05am. Letby is a co-signer for the nutrition prescription at 12.05am on June 10.
A blood gases record by Letby of Child B is made at 12.16am and another at what appears to be 12.51am, the latter "during neopuffing".
The designated nurse's record for the desaturation and collapse event at 12.30am, written retrospectively, includes the notes: "Sudden desaturation to 50%.
"Colour changed rapidly to purple blotchiness with white patches.
"Emergency call for doctors put out."
A 'fast bleep' alert for a nurse to attend the neonatal unit as soon as they can is made at 12.33am.
The court hears this is a 'crash call'.
Following emergency treatment, Child B was placed on a ventilator and 'good air entry' was noted.
A doctor entered the neonatal unit at 12.34am and the on-call consultant was called at home at 12.36am.
Child B's "colour started to improve almost as quickly as it had deteriorated", and morphine treatment began, while the parents were called to the unit and kept informed at cotside.
Child B was also noted, from a note at 12.45am, to have a "full/mildly distended" abdomen.
Clinical notes recorded by the consultant recorded for 12.50am: "Suddenly purple blotching of body all over with slowing of heart rate.
"Bagged and then tubed by registrar. Heart rate came up. Adrenaline not required."
A blood gases record by Letby of Child B is made at 12.16am and another at what appears to be 12.51am, the latter "during neopuffing".
Letby is recorded taking the hourly observations at 1am for Child B in room 1.
The prosecution reminds the court Letby was the designated nurse for two babies in room 3 at the start of her shift.
A note timed at 1.09am from an x-ray said Child B's lungs were "mildly hyperinflated" and "clear".
Further medication is administered to Child B during the night, with Letby again listed as a co-signer.
At 2.40am, the 'purple discolouration' had been 'almost resolved'. The cause was '??', and Child B had been 'stabilised at present'
A nursing note made by one of Letby's colleagues on Wednesday, June 10 at 8.09am recorded that the family were "very upset" after the non-fatal collapse of Child B at 12.30am the previous night.
Child A, the twin brother, had earlier died on the evening of June 8.
The colleague's response said the shift had been "manic", and there had been "no change" with Child B.
Letby enquired again about Child B that night, at 10.08pm, and was informed Child B was "looking really good".
A message sent from Lucy Letby on Whatsapp to a colleague at 12.04pm included the request: "Will you let me know if any change with [Child B]."
A text message at the end of June, from Letby, said: "I had a mini meltdown last night about what's happened at work...
"I just need some time off with mum and dad."
The message was sent following the deaths of Child A, C and D and the non-fatal collapse of Child B.
Facebook Searches (child a)
9th June 2015 9.58am:
Letby searched on Facebook for Child A's mum's name at 9.58am on June 9.
10th June 2015 11.31pm
Letby is recorded making another search on Facebook for the mum of Child A and B at 11.31pm on June 10.
25th June 2015 9.50pm:
A further search is made on June 25 at 9.50pm.
2nd or 9th September 2015
Letby had made a further search on Facebook for the mum of Child A on September 2, 2015.
(Chester Standard report 2nd September, BBC 9th September)
Ms Hocknell is asked by the defence about Letby's Facebook searches.
She is asked whether Letby searched on Facebook for the parents of children other than those listed in the charges.
Ms Hocknell confirms that is the case. "There are a lot of searches for different people."
Messages with colleagues
Reporting on the messages has been very poor with different media outlets reporting different messages and cherry picking bits. It's been too difficult to collate it all in the wiki so please see the links to read the reports from the media
Chester Standard live reporting - Tuesday 18th October
Chester Standard article - 18th October
BBC News article - 18th October
Mail Online article
Witness Statements AgreedAgreed witness statements read out in court and not contested by defence
Family - Mother
The first witness statement is dated from 2017 and is from the mother of Child A and B.
She confirms she had been diagnosed, prior to her Pregnancy
, with a blood disorder, and had been given medication to treat it.
She discovered she was pregnant and it was decided the blood condition would be monitored and managed throughout.
It was planned for the babies to be delivered at a medical centre outside of Chester, at full term.
The mother was admitted to the Countess of Chester Hospital, and was "very upset", as there had been medical issues diagnosed, and she had been only a week away from moving to the area where the specialist outside of Chester would have delivered the babies.
The mother had an emergency caesarean section as her blood pressure levels were high, and the twins were delivered.
Afterwards the doctor was "surprised" at how well she was doing, and the mother asked if she could see her children. She was told once she was well enough to sit in a chair, she would be taken to see them.
As time passed, she said: "I was getting a little anxious as I just wanted to see my children".
It was about 12-1pm on June 8 when she went to see Child A and B, who were both in incubators.
She stayed with the twins for about an hour, and was told to rest on advice of the nursing staff back in her room.
At about 8pm, a male member of staff came into the room.
"You need to come in quickly, there is something wrong with twin 2."
"All I can remember is coming in and seeing what felt like hundreds of people trying to resuscitate [Child A]."
The mum was asked for permission by medical staff to stop resuscitative attempts.
"I couldn't bring myself to say stop.
"The only thing I could bring myself to do was nod my head.
"One of the things that upsets me the most is I never had the chance to hold him in my arms."
The mum said, following the death of Child A: "I was frantic, anxious and extremely upset."
Afterwards, the mum said she wanted a member of the family to keep an eye on Child B at all times.
After saying goodbyes to Child A, upon her return, she was asked if she wanted to hold Child B, who couldn't be out of the incubator for a prolonged period of time.
"I felt joy and sadness at the same time."
The couple were woken up by a female member of staff to come quickly to see Child B.
She said: "My heart sank - not my baby, not again."
They were told Child B had suffered a similar situation to Child A, but had stabilised.
Blotches and mottling had been on Child B.
"[The consultant said] she had never seen this before - I remember being surprised by this."
Said consultant had asked to take photos of the blotches, but by the time a camera was arranged, the blotches had disappeared.
The mum did take a photo the following day, noticing the hands and feet were still "a little discoloured".
The photo, dated June 10 in the morning, is presented to the court.
The mum said she would always go to see Child B at the neonatal unit each day from 9am, until the start of the night shift, and would set an alarm to call the designated parent line every 2 hours during the night.
"I was, and still am, extremely protective of her."
"I couldn't help myself."
It was said to the mum from a member of the Countess staff that Child A's death, if 'unascertained' from the coroner, could have come from her blood condition. She was "furious" upon being told this, and sought answers.
That concludes her statement.
Family - Father
The father of Child A and B has also provided a statement.
He said everything was "fine" with the pregnancy up to the 28-week check-up appointment, when concerns were raised over the mum's medical symptom.
The mum had contacted the specialist doctor based outside of Chester to see if it was possible for the babies to be delivered as planned, but the couple were told it was "too risky".
The father said the mum did not have the opportunity to see the children that first night, having had general anaesthetic for the birth.
He said he took several photos of Child A and B in the neonatal unit that night, and showed them to the mum.
The mum had said no-one else in the family was allowed to see the children before she had the opportunity to do so.
The father said the mum was getting increasingly anxious to see the children, and with assistance, was able to get in a wheelchair to the neonatal unit.
The father remembered "a nurse called Lucy" explained the baby monitor machines to him, as he was nervous about them.
The parents returned to the delivery room after about an hour.
Later, they were told by a nurse to come to the neonatal unit: "There's something wrong."
"You need to come quick, it's twin 2."
I can only remember seeing 'hundreds' of people trying resuscitate.
"We were asked if we were religious, and if we would like to say a prayer."
The parents were told resuscitative attempts had failed.
"Neither one of us wanted to say stop.
"[The mum] was hysterical.
"I said something along the lines of 'you have to let him go, he's not there any more, you have to let him go'.
"She nodded her head and that gave permission.
"One thing that upsets us both is we never had the chance to hold [Child A] when he was alive.
"We were told he was doing fine, breathing by himself, and doing well."
While the mum rested, the father stayed with other family members and Child B.
The father said Child A was brought to them by Lucy Letby, prior to the child's transfer to Alder Hey for a post-mortem examination.
Upon their return, they were asked if they wanted to hold Child B. The father said he was too scared to, because of Child B's tiny size, and the child needed to be kept in an incubator or her body temperature would drop.
It was 'shortly after shift change-over' at 8pm when the parents returned to the neonatal unit and had had very little sleep. The other family members had left the unit for rest.
This was the first time since that none of the family members were by Child B.
It was shortly afterwards when a nurse came in to say: "You need to come now"
The father said: "I didn't know what to think. My heart sank."
They found Child B had stabilised, after the oxygen saturation levels had fallen sharply.
The father had said the consulatant nurse had given a 'crossed-fingers' to the nurse on duty when she left, as a 'good luck - I hope the child survives]'.
Child B was in the neonatal unit for a further 4 weeks, and the mum went to hospital on a daily basis, including after she had been discharged as a patient herself, arriving at 9am.
The father said they had wanted to be kept updated on Child B, day and night, 'no matter what'.
Family - Grandmother
The third 'agreed fact' statement is from the grandmother of Child A and B.
She recalls the whole family was "thrilled" at the news of the pregnancy, and were aware of her daughter's blood condition, and arrangements had been made for her treamtent prior to, and for the delivery itself.
The grandmother recalls a "commotion" in the operating theatre, and incubators being brought in.
The mum was "quite poorly" afterwards.
Nursing staff had told the mum the babies were "doing well" and "both fine", the grandmother recalled.
The grandmother had popped in to the neonatal unit to see the babies "very briefly", noting they were "very small and fragile" before returning to see her daughter in the labour ward, as she was still poorly.
It was 'about 8.30-9pm' on Monday, June 8, when one of the nurses ran past the door, saying "It's one of the twins".
"I could tell there was a problem, my heart sank. I just immediately thought she was referring to [my daughter's] babies."
"Your baby is very poorly, or has collapsed - it was something along those lines.
"We went into the neonatal unit room 1. A member of staff held the doors open for us.
"The minute I went into that room and saw that baby boy, I knew he was gone.
"Everybody was desperately trying to help him.
"The room seemed full of medical staff.
"[My daughter] was sobbing uncontrollably at this point - 'please don't let my baby die, please don't let my baby die'."
The family were told the situation was not good for Child A.
The grandmother said a doctor had come over to say, three or four times during the resuscitation attempts, saying the situation did not look good and if Child A survived, he would likely be left with brain damage and other complications.
Eventually the mum nodded her head silently to indicate to staff to stop.
The grandmother recalled that the following, Child A was placed into a cot, adjacent to Child B's incubator. A nurse had placed a comfortable chair for the mum to sit in, next to the babies.
She said the mum would not leave the children unsupervised.
Later, the grandmother was awoken by a mobile phone call from the father.
"The only words I could remember him saying were 'the baby's collapsed, she's really poorly."
The family members made their way to the neonatal unit.
She said: "I was having chest pains, thinking I was going to have a heart attack. I was struggling to breathe, I couldnt think anything other than I hope [Child B] is OK.
"Once we got in, she was not looking good. There was mottling."
Child B later stabilised.
Consultant - unnamed (1)
Dr Gail Beech
Dr Andrew Brunton
Dr Christopher Wood
Neonatal Assistant Lisa Walker
Nurse Joanne Williams
Nurse Melanie Taylor
The next witness to give evidence is Melanie Taylor, who is in court. She was employed as a nurse at the Countess of Chester Hospital in the neonatal unit in 2015.
The court hears she came on duty at about 7.30am on June 8
, the twins having been born the previous night shift.
A computerised record shows she was the designated nurse for that day shift for Child A.
Miss Taylor explains records of the various medical charts would be cotside, including hourly observations.
"The observation charts would be written as we were doing them," Miss Taylor explains.
Miss Taylor confirms she had recently become a band 6 nurse in 2015, having worked at the hospital for several years.
She tells the court Child A and B were in neighbouring incubators in the neonatal unit.
Child A was "stable", on nasal CPAP.
Miss Taylor explains the medical observations made for Child A during the day shift, via retrospective notes.
The respiratory rate was 'slightly raised at times', but Miss Taylor said this was not unusual.
Miss Taylor: "I had no concerns with him, he was stable - on CPAP, but stable.
"One thing was he didn't have fluids for a couple of hours because of issues with lines.
"The cannula - that 'tissued' at some point during the shift [the vein has 'gone' and it cannot be suitable for a cannula to be used there].
"A UVC was attempted to be put in - but it has to be x-rayed and under sterile conditions and in the right position before we can use that line."
The UVC was in the 'wrong position' twice - it had been taken out and re-inserted, but was still in the wrong place. Another option was sought.
"They attempted to...[use a] long line, which again has to be done under sterile conditions by a doctor, and again x-rays have to be used."
Miss Taylor said Child A would not have had fluids for 'about a couple of hours'. A reading on the chart to say 'cannula tissued' is made by Miss Taylor in the 4pm
A small amount of expressed breast milk is administered at 4pm and 6pm
via the naso-gastric tube.
Miss Taylor said she had "no concerns" from the neonatal intensive care unit observation chart measuring Child A's heart rate, respiratory rate and body temperature each hour.
An addendum by Miss Taylor just after 7pm
recorded the UVC was in the wrong position, and was reinserted, but was still in the wrong position.
Notes shown on the screen record: "Aware no fluids running for a couple of hours," adding a long line was inserted by the registrar.
Miss Taylor said she would have relayed the observations to Lucy Letby at the hand-over, and there were no concerns other than the lack of fluids Child A had had for a couple of hours.
The 10% dextrose IV fluid is prescribed, via long line, prescribed by a doctor. A prescription form is shown the court and Miss Taylor explains the various columns and signatures.
Miss Taylor: "All fluids will be checked by two nurses - it is signed [on the prescription form] that I have checked it with Lucy Letby."
The time and date the medication is started is June 8 at 8.05pm.
Miss Taylor explains emergency equipment checks are made at the time of the hand-over - in this case, 8pm
Miss Taylor said she would have started writing up a nursing note, but Child A then started deteriorating, so the note would not have been saved on the computer.
She said she would have been able to see Child A's incubator when sat at the computer.
She said: "Lucy Letby was standing by the incubator. Initially I stayed there [when Child A started deteriorating] as he was fairly stable and Lucy Letby was there, but when I realised he was not recovering from deterioration I got up to help Lucy Letby."
She said the baby monitor would have alarmed.
Miss Taylor said she is unable to say how long she had been away from the incubator, and thinks it was after the dextrose was administered.
Miss Taylor said she thought Child A was going to recover "quite quickly" as such desaturations were not that uncommon, but when it became clear he was not going to recover she went to help.
"I kept thinking he was going to recover, but he didn't."
Miss Taylor said she was not directly involved in the resuscitation, but involved in getting adrenaline medication.
The following day Miss Taylor was called back to the hospital to finish the notes which had not been completed at the time, 'due to the trauma of what had gone on'.
Ben Myers KC, for the defence, is now questioning Miss Taylor.
Mr Myers: "Do you find that even with the notes, it can be difficult to recall what happened?"
Miss Taylor: "It is, but...in my witness statement, if I was not sure, I said I was not sure."
Mr Myers examines the staffing levels at the Countess of Chester Hospital neonatal unit.
'For babies in intensive care, it should be one nurse to one baby', he tells the court, and 'one nurse to two babies' for high-dependency babies, and 'one nurse to four babies' in the special care nursery room, he tells the court.
Rotas would be relayed to staff "a month in advance", Miss Taylor says.
"If they [the neonatal unit] were busy", then some nurses would be asked to come in "at short notice".
Miss Taylor explains the shift leader gives the hand-over to the new nurses coming in for the following shift in a 'huddle', lasting '10-15 minutes'. The shift leader would be a 'band 6 nurse'. The shift leader is "usually pre-allocated", but could change.
There would be a 'handover sheet' with babies' names and an outline of care provided the previous shift.
Mr Myers: "And that handover sheet would be kept by him or her throughout the shift?"
Miss Taylor: "Yes, that's correct."
"Generally," that handover would last until about 8pm, the court hears.
Mr Myers explains that some duties "require two nurses", such as administering medication and checking it is correct.
Mr Myers points to a section of the intensive care unit chart for Child A, where a different nurse to the designated nurse has signed for the observations at 4am on June 8. The designated nurse has signed for other hours including 2am, 3am and 5am.
He asked Miss Taylor: "There is absolutely nothing unusual about that, is there?"
Miss Taylor responds: "No."
Mr Myers said Child A would have required "constant observation" despite being deemed "stable" in the neonatal unit. Miss Taylor agrees.
He added that pre-term babies would also be "prone to infection". Miss Taylor agrees.
Mr Myers: "They can be prone to collapses, can't they?"
Miss Taylor: "I don't know if I would agree with that, exactly."
Mr Myers said a baby fitted with a UVC would be 'intensive care'. Miss Taylor agrees. Child A had become an 'intensive care baby' during the day shift as he had required.
Mr Myers said Miss Taylor would have been looking after an intesive care baby (ITU), as well as another baby which required a lot of care - which falls outside the guidelines.
"In terms of ITU, they technically are intensive care, but not as intensive - some babies require a lot of hands-on, one-to-one care. Some technically become ITU, but in terms of care, they are more like HDU."
Mr Myers: "Were there, at the time, a lot of poorly babies?"
Miss Taylor said that particular shift was a busy one, she recalls. She accepts that an increased number of poorly babies coming into the unit would create an increased demand on nursing staff.
Mr Myers asks why a baby's temperature would not necessarily be recorded every hour on the chart.
Miss Taylor says the temperature records involve putting a thermometer under the baby's arm, which the "babies don't like", while a heart rate is done on the monitor, while the respiratory rate would be manually counted through observation.
Mr Myers asks if handling babies (for example, to take their temperature) could led to an increase in the baby's stress, which would lead to an increased risk of deterioration.
Miss Taylor: "...to a certain degree, yes."
She adds if a temperature is recorded for one hour in a stable reading, the baby's temperature would not necessarily be taken on the following hourly check.
Melanie Taylor's nursing note for June 8 is shown to the court, at 1pm.
It documents the insertion of the UVC for Child A.
Miss Taylor said she cannot remember the two attempts of insertion of the UVC, but sees it is made on her notes.
The note, written at 7.05pm, says: "UVC in wrong position, reinserted...again in wrong position. Cannula tissued. Doctors busy on ward 30. Aware no fluids running for a couple of hours. Long line inserted by Reg Harkness. awaiting X-ray. Remains settled on NCPAP. Enteral feeds of donor expressed breast milk started at 1ml/2hourly."
The intensive care chart is shown to the court, showing 'cannula tissued' at 4pm.
Miss Taylor explains she might have written 'cannula tissued' retrospectively, so it could be before or after 4pm when that was noted.
Mr Myers said Miss Taylor would have had to wait for a doctor to put a long line in.
Mr Myers: "You said it was very busy - and that caused a delay, didn't it?"
Miss Taylor: "Yes."
Mr Myers: "It's important to make sure the tip of the long line is in the right position, isn't it?"
Miss Taylor: "Yes."
"It's a sterilised procedure? It's very thin."
Miss Taylor says she's not too familiar with the long lines as she is not involved with the procedure.
The judge clarifies Mr Myers' question, asking if it is important to get fluid in once the long line is in place. Miss Taylor agrees.
Miss Taylor says she is not aware of anything that might have been running through the long line prior to the 8pm 10% dextrose administration.
Mr Myers adds "the conventional practice" is for fluids to be administered immediately in the long line after it is inserted.
"Yes. Ideally we would get an x-ray first."
Mr Myers says there was a delay because the doctor was delayed elsewhere.
Miss Taylor: "I think so."
Miss Taylor is asked about the retrospectively written note at 9.28pm on June 8, which begins.
"Observations stable, pink, well perfused. UVC still insitu, but in wrong position, to be used if no other access available.
"Long line inserted by reg Dr Harkness, secured, x-rayed. 10% dextrose run through and connected to long line."
An observation chart showing the respiration rate is 'elevating', Mr Myers says, throughout the day is shown to the court.
"Yes, a little," replies Miss Taylor.
A blood gas record chart shows the lactate levels had increased on the records of 12.13am, 6.37am and after 2pm, with levels at 1.6, 2.6 and 2.7. The latter two readings are, Mr Myers says, outside of the desired area. No other records are given.
Miss Taylor says she does not know what time the long line was inserted.
Mr Myers says there was a delay in getting the x-ray.
Miss Taylor: "From memory, I cannot remember the timings, but possibly."
Letby's notes, written retrospectively at 7.56am on June 9, are shown to the court. They begin: "Glucose commenced via long line...UVC remained in situ from day shift, instructed line not to be used by registrar.
"[Child A] noted to be jittery, was due to have blood gas and blood sugar taken.
"At 8.20pm [Child A] hands and feet noted to be white. Centrally pale and poor perfusion..."
Mr Myers: "He should have been getting fluids during this four-hour period, shouldn't he?
Miss Taylor: "Yes."
Miss Taylor says she cannot remember whether it was herself or Lucy Letby who administered the fluids.
Mr Myers said "two nurses" are involved in the process, and one has to be in sterile conditions.
Miss Taylor: "I honestly don't know whether it was me or Lucy [who was in sterile clothing]."
The defence say it was Miss Taylor who was the one in sterile clothing for the fluid administration, with Lucy Letby assisting. Miss Taylor says it could have been that, or the other way around.
Mr Myers: "When the deterioration commenced, you were at your computer making notes?"
A note by Miss Taylor is made at 8.18pm for Child B.
"It shows you were at the computer at 8.18pm?"
"Was Dr Harkness also in that room?"
"I don't remember."
"You could see where [Child A] incubator was, and the alarm sounded."
"When you went over to Child A, could you recall whether he was breathing or not?"
"I don't recall."
"Would it be fair to say that what followed makes it difficult to recall - that there is a lot of activity surrounding the cot?"
"When you realise that extra support is needed, yes."
Mr Myers: "Lucy Letby went to support the family at one point, do you recall that?"
Miss Taylor: "I don't remember that."
Miss Taylor says if Letby was the designated nurse, she would be involved with assisting the resuscitation attempts.
She adds that designated nurses would often be the one to provide support to the family afterwards.
Memory boxes, Miss Taylor says, are collated with permission of the family.
Mr Myers: "Do you recall about whether there was any discussion about whether the fluid bag should be kept?"
Miss Taylor: "I don't recall that, no."
Miss Taylor is presented with an interview transcript, dated February 7, 2018, one of a series of interviews she had involving babies in her care at the Countess of Chester Hospital.
The interview says Miss Taylor believed that sometimes, babies collapsed with no explanation.
Miss Taylor: "When I said that, that is what I believed to be true - whether that's my rational brain, trying to rationalise what happened."
Mr Myers reads from the statement: "It's a shock to us, because we have such a low rate."
Miss Taylor: "That is what I believed, that was my opinion at the time. I tried to rationalise what happened at the time. Whether that's true - I'm not medical - but that was my opinion at the time."
The prosecution say this interview concerned a different set of twins.
Miss Taylor: "I feel like I shouldn't have said that - I tried to rationalise that, because as a nurse, that is what I tried to do."
The prosecution shows the intensive care chart to the court again, focusing on the feeding records between 4pm-8pm.
The feeding of expressed breast milk at 4pm and 6pm were "trophy feeds". Miss Taylor explains small amounts of food are for the stomach to be lined so it could help get the stomach used to future feeds.
A 6pm 'output' of 25mls of urine is noted. Miss Taylor says that is weighed via the nappy - a "tried and trusted method", the prosecution say.
"Does that show fluids were passing through [Child A]?"
"Does it follow that fluids that go out must have gone in?"
"It does that fluids that have gone in through the day, yes."
Blood gases records were noted by the defence as "being outside the optimum range".
The prosecution say with those records in mind, was Child A still 'stable'?
Miss Taylor: "Yes."
She explains the elevated respiratory rate was not uncommon, and other symptoms, such as the baby grunting, would be noted as part of a bigger picture. The elevated respiratory rate and blood gas level would not be, in isolation, uncommon, but still "relevant".
Miss Taylor says she does not remember Child A being "jittery", and had not documented it in her notes. She says if she had seen Child A being jittery, she would have noted it.
She adds it would be considered as part of a bigger picture. "It does not necessarily [mean] a concerning cause, but it is something to consider."
That concludes Miss Taylor's evidence for Child A and B.
The court hears she will be asked to return to court to give evidence on other babies.
Dr David Harkness (child a)
The next witness to give evidence is Dr David Harkness.
The court hears that in 2015 he was a paediatric registrar, sometimes based at the Countess of Chester Hospital.
He confirms he has, since then, been interviewed by police, and made witness statements about more than one baby which was a patients at the neonatal unit.
He is being asked about the case of Child A.
He confirms that at the time, he was a registrar and was on duty on the evening of June 8.
His clinical notes, written in retrospect at 9.30pm, record for 5pm: "UVC in situ on my arrival on NICU at 5pm. No definitive access at this point, so I've left in situ with plan to remove if long line sited or pull back to low position is long line not successful."
He said he was looking after children outside of the neonatal unit prior to 5pm, and on his arrival, his "first port of call" was seeing Child A.
He says the UVC is preferred as a feeding method to the long line, and can be moved to a low position as a short-term measure until something better is in place.
The prosecution say a UVC was in place, an x-ray was taken before it was used for purpose of adminsitering fluids.
If it is "imperfect" in position, the optinos are withdrawing, or adjusting it. The latter would be on a short-term basis. The doctor agrees.
A note by Dr Harkness at 7pm: "Long line inserted at 1st attempt."
A sticker confirming the insertion of the long line is placed.
An x-ray review sticker is also placed, timed 7.09pm.
Dr Harkness said he was junior at the time, so would have recommended the long line be moved back slightly, as outlined in his recorded note, but now he would say the long line was in the right position.
Dr Harkness said because the night of June 8 was a "traumatic event", his memory of entering the unit room was "quite fresh" and he explains there were three babies in the nursery room 1 - the intensive care unit, at the time, and two of them would have been Child A and Child B. He describes which incubators they would have been in, which are adjacent to each other.
A video of the layout of the nursery room one is played to the court and Dr Harkness confirms where Child A and Child B would have been located.
Dr Harkness's x-ray review said at the time the x-ray was available to review, he was "scrubbed inserting a line into another patient", which meant he had to adhere to sterilised conditions, he explains.
The doctor's opinion at the time was the position of the long line was "less than perfect", the prosecution said.
Dr Harkness said that following consultation and in accordance with guidelines, the position of the longline was "actually correct".
He said he was "just about finished with [another baby]" when he was called to Child A at 8.26pm.
Bagging was started "via Neopuff immediately".
The saturations, which "should be in the 90%'s", were in the '70s-80%'s'. The heart rate was "slightly on the lower side", Dr Harkness records.
He said he can remember the events.
He said he was called "by nursing staff" over problems with Child A's breathing.
A junior doctor took on the responsibility of making contemporaneous notes for Dr Harkness during the event, the court hears.
He said it was "most likely nursing staff" who started the Neopuff bagging process by the time he arrived.
"Good chest movement seen" meant there was not a blockage, Dr Harkness explains.
Dr Harkness said as far as he was concerned the longline was the last thing which was inserted, so he removed it at 8.27pm.
He said: "That was my immediate thought. In hindsight...there was no possible link [between its insertion and the collapse]."
He said if the long line had been moved further in, towards the heart, it could have caused a significant increase in the heart rate, or other heart complications. There was no evidence then, or since, which had supported that, he explains.
Help was called at 8.27pm.
Child A was "intubated at the first attempt".
The note records intubation was at 8.28pm.
Child A's heart rate fell to 60-70 the same minute, it was noted. Dr Harkness had said ideally the heart rate should be above 100, and chest compressions are started when the heart rate is at 60.
Chest compressions were started and fluids including adrenaline are administered.
The court hears while air was still getting into the lungs, "unfortunately" there was no heart rate detected at about 8.33pm.
Further chest compressions and medicinal doses are given up to 8.49pm.
A heart rate of 50-60 is noted at 8.50pm, and a further adrenaline dose is given, but then there is no heart rate again, and CPR continues until 8.57pm.
At that point a review was carried out by Dr Ravi Jayaram in attendance, and no heart rate was present.
Dr Harkness says: "It was felt the kindest thing to do was to stop resuscitation."
Dr Harkness said the circumstances of Child A's death were "very unusual and very unexpected."
He said: "It was very surprising to be called back [to Child A] at this time [as he had been stable].
"It was very unusual - the skin [patterns] I had never seen before, and I have only seen again at the Countess of Chester Hospital.
"I was faced with a baby unexpectedly deteriorating."
Dr Harkness noted there was "unusual skin colouring."
Dr Harkness said he had only ever seen this "patchy" skin colouring and pattern in one other baby at the Countess of Chester Hospital, when dealing with the case of Child E and F.
Dr Harkness said he could not remember the exact pattern of the skin at the time as he was "busy trying to save [Child A's] life" at the time, but "it was unusual enough for me to make notes and document it."
He added he had, with his experience of being a doctor, "unfortunately" seen dying or dead children patients and the type of skin blotching and patterns that would be found, "but not a pattern like this".
Dr Harkness is asked to examine a clinical note.
During the time he was looking at a third baby in the room, he was scrubbed up and sterilised for a procedure which "takes a lot of concentration."
"Typically, you are left to your own devices."
He said it was shortly after that (about 1-2 minutes), he was urgently called to Child A.
Dr Harkness is now being asked questions by the defence.
Mr Myers says what happened was "a tragic event".
He said "You have given us a description of skin evidence which was unusual."
Dr Harkness agrees the skin patches of purple, blue, red and white were "very striking", but adds he was not forensically analysing the skin at the time.
Mr Myers refers to notes retrospectively written at 9.20pm-9.30pm and attributed to Dr Harkness, which does not refer to skin condition.
"You could have put anything you wanted in these notes?
"Nowhere do you make reference to skin colour."
Dr Harkness said the "significance" of the skin colour changes was noted later, following conversations and the non-fatal collapse of Child B.
The defence asks Dr Harkness if he had been "influenced" in his recollections, that had led him to form the impression of the skin pattern in Child A.
He said at the time it was an "emotional" time, as it was "one of the first" neonatal deaths he had seen in his experience, and he had fond it "greatly upsetting".
He added that at that time his documentation may not have been as detailed.
The defence say the skin patterns are also not referenced in Child A's inquest report from October 2016, but "pale and poor peripheral perfusion".
Dr Harkness admits it's "not clearly documented" but he would still have been in an emotional state.
Mr Myers asks that by the time of the police statement, his impression had been formed.
Dr Harkness says his statement of observations in the cases of Child E and F had jogged his memory for Child A's skin patterns.
Dr Harkness says "there was no evidence" for the long line to have moved in Child A.
"This has been proved on the post-mortem."
Mr Myers says would the long line have still been in there at the time of the post-mortem?
Dr Harkness: "No, and there was no damage [found] there [where the long line had been]."
Dr Harkness said the long line was removed at 8.27pm as a "theoretical" concern "based on no evidence at the time". He said the last new thing, as far as he could know, was the addition of the long line at the time of the collapse.
He adds: "The logical thing was to remove it."
Mr Myers: "There are dangers with a long line too close to the heart?"
Dr Harkness: "Yes...that was my concern at the time. There was no evidence at the time or subsequently that that long line did any damage."
Mr Myers refers to the x-ray review from 7.09pm, and the position of the long line at that point.
Dr Harkness noted it was "to be pulled back."
He explained the review took plce at 7.10pm - it would have been reviewed during the procedure I was doing."
He said his view the long line was to be pulled back was made 'with his experience and knowledge at the time'.
"It was not a danger then and it's not a danger now. With my experience and knowledge then, that was my assumption. The guidelines and subsequent experience say...it was fine. It's ideal."
Dr Harkness said he likely inserted the long line 'between 6pm and 7pm'.
Dr Harkness explains the x-ray dept takes 15-30 minutes to come to the department with a portable x-ray.
"You wouldn't expect to report these in 30 minutes. An hour would be more likely."
Mr Myers: "Surely if the long line was in the wrong position, you would want to know immediately?"
Dr Harkness says "In an ideal world" the x-ray would have been made available immediately, but "in reality" it was "impossible".
He agrees the x-ray result could have been available more quickly with extra staff and if he had not been treating another patient at the time.
The decision to administer the 10% dextrose was because it was "safe" for all over the body.
Dr Harkness said he was able to review the x-ray as soon as the image was made available from radiology, and fluids were able to be administered at that point, as he wanted to check for the x-ray first.
He says there would be "reluctance" from nurses to administer fluids without having seen an x-ray first.
He says, from his experience, medical staff are "much more keen" to administer the fluids, while nurses would want to see the x-ray result first.
Dr Harkness says the long line was in the right position, and the use of it was appropriate.
The prosecution ask one more qeustion about the "striking discolouration".
Dr Harkness: "Categorically, yes, there was discolouration."
That concludes Dr Harkness giving evidence for Child A.
Senior Nurse Caroline Bennion (child a & b)
The next witness to give evidence is senior neonatal practitioner Caroline Bennion, who was present for the delivery of Child A and Child B in June 2015.
She recalls that Child B required assistance at birth, and that support was given for her. She explains more support was required for her than Child A.
Child B "recovered well" and, after review, she was tried off the ventilator as she was "vigorous" and was breathing by herself.
She is now being asked about "the significant event" for Child A on the evening of June 8. Child A suffered a collapse and died during that evening.
She says she was in the room when that collapse happened. She knew that she had taken the handover - a "comprehensive update" from the day-time shift staff - from 7.30pm, and carried out equipment checks.
She said, from reading her statement, she was "next to [Child B]" and "still doing" her checks and completing observations and safety checks at the time.
She said she "wouldn't have left" Child B.
She said she remembered Lucy Letby asking for help on Child A.
"When it became more obvious she needed assistance and [Child B] was safe, I went over to help."
She said she did not have a recollection whether the alarm went off.
She said it was a "busy evening" with babies having long lines put in, and the nursery was "quite full" with the cross-over of day and night staff.
She also said Dr Harkness was in at the time.
She recalled she helped Lucy Letby give some ventilation breaths via the Neopuff device.
She said there was no crash call put out as the doctors were already in attendance.
The nurse recalls drawing up the emergency drugs required during Child A's emergency treatment.
Child A passed away following a series of resuscitation attempts.
The nurse said she then returned to treatment of Child B.
The court is shown the nurse continued to take hourly observations for Child B.
She confirms "nothing unusual" was noted during the rest of that night shift for her.
Questioned by the defence's Ben Myers KC, the nurse says she had many years of experience in neonatal care.
She is asked about if there were challenges in staffing levels.
The nurse replies: "We were always very fortunate to have a lot of senior staff."
"There were occasions where we had busier periods, but that is the nature of a neonatal unit."
The nurse agrees the babies were "vulnerable" and "could deteriorate very rapidly".
She agrees 'it was known' a deterioration could happen when a baby was almost ready to go home.
Ms Bennion is asked about medication that is given to babies who would 'otherwise be at risk of infection'.
For Child A, she is asked about such a prescription, and a 'clinical indication' is for 'suspected sepsis' on June 7 at 10pm.
The administration of the dose is dated at June 7, 10.46pm.
Ms Bennion is being asked about blood gas records for Child A. The blood gas machine was "on the unit" in the next room, taking about 3-4 minutes, providing an automatic read-out to be attached to the chart.
Ms Bennion is shown a copy of the neonatal record chart, about how some of the tasks and times are shown taking place on the hour, when they might be around that time.
My Myers says that as some tasks take some time, it could give the impression a member of staff was 'in two places at once'. The nurse agrees.
Ms Bennion is now being asked about Child A's collapse, and that Lucy Letby had called for assistance.
She said: "We have an emergency buzzer which could be pulled, but there were so many staff that a nurse can call for assistance.
Mr Myers: "That would be appropriate?"
Ms Bennion is asked if there was any 'formal support' for nurses, particularly for dealing with incidents such as when an infant died.
She said there was no formal support, but said of the nursing team: "We were very supportive of each other."
She said there was "no formal procedure or form for everyone to fill in."
She added: "Under the direction of the medical staff, a debrief would always be offered. We have a supportive management team and...in the network of our close unit [if a nurse did not want to return to room 1 for the following shift following a traumatic event the previous shift], that can be provided."
"Even after a tragic event, you have to remain professional in the care you give."
Ms Bennion adds, from a follow-up quesion from the prosecution, that simultaneous observation of two babies would not happen, even if the documentation would appear as simultaneous on the records.
She is asked about the "speed of the deterioration" of Child A. Ms Bennion said it was "very rapid, very sudden".
"It's like a jigsaw, you're putting in observations, but there was nothing to say [Child A was going to collapse].
"However it has happened, and it can happen."
(End of reporting)
Nurse unnamed (child a)
The next witness is someone who was also working at the Countess of Chester Hospital, as a neonatal nurse in June 2015.
She describes, on staffing levels: "There were definitely periods when we were short-staffed, periods when we were ok."
For shifts when they were 'short on numbers', they would look to bring staff and swap on the rota, or if anyone could do an extra shift.
Agency or bank nurses were a possibility, but didn't happen very often.
The nurse was the shift leader at the neonatal unit on the night-shift for June 8. Lucy Letby was one of the designated nurses.
The nurse remembers walking by the neonatal unit room 1 and seeing Dr Harkness in there at the incubator for Child A.
Swipe data showed her coming into the neonatal unit at 8.20pm.
She said: "I was like, something has happened.
"With my experience, I was thinking he was having a sort of 'episode' that babies can have."
She believed it was down to one of a number of medical conditions.
She recalls seeing who else was in the room.
She recalls the Neopuff device was being used to give Child A breaths, as he had "stopped breathing".
She recalled being told it had happened "suddenly".
She recalled being involved in the resuscitation attempts, and was physically holding Child A at the time.
She recalled she had "never seen a baby look that way before", with a skin discolouration on a pattern she had "never seen before".
Asked to describe the discolouration, she said he was "white with purple blotches", with a bit of "blue", and it had "come on very suddenly".
"Just very unusual, it was," she added.
There was no live reporting on Monday 24th October. For a round up of the remainder of this nurse’s testimony please refer to the round up article https://www.chesterstandard.co.uk/n...se-thought-not-again-baby-suddenly-collapsed/
Dr Ravi Jayaram (child a)
There was no live reporting on the day he took the stand but this article gives the most information
Unnamed consultant paediatrician (child a & b)
The trial is now resuming, with someone who was a consultant paediatrician at the time of June 2015, giving evidence in court in relation to Child A and Child B.
She said she "cannot recall" the events for Child B's collapse at 12.30am on June 10, as it was seven years ago, and her recollection would be based on the statement she had given to police.
The court is shown clinical notes made by her, written retrospectively at 2.40am on June 10, 2015.
She was called at home at 12.36am, and arrived at the neonatal unit at 12.50am.
She recorded Child B "went apnoeic [stopped breathing]", followed by "suddenly purple blotching of body all over, with slowing of heart rate."
The consultant says the 'purple blotching' would have been the registrar's account of events, relayed to her.
The registrar also relayed Child B was bagged and tubed, and the heart rate went up, with adrenaline "not required".
The consultant noted, for her observation: "Upon my arrival purple blotching right mid-abdomen and right hand." The baby was "pink and active".
The prosecution asks: "Do you have any independent recollection of that now?"
The consultant replies: "No."
The consultant relays the various medical observations that were recorded at the time, including blood gases, protein levels, and heart rate.
The consultant tells the court discussions had been ongoing since the evening of June 9, in light of Child B's twin brother dying, on whether Child A and/or Child B had been affected by the mum's blood condition.
Consultants at Great Ormond Street Hospital had said they "did not feel" the mother's condition would affect the baby "in any way", while consultants at Alder Hey Hospital suggested further blood tests being carried.
Following Child B's collapse, the blood observations taken were 'good', the court heard, and meant the requested extra tests were "held off".
Child B was restarted on antibiotics "as a precaution".
There was still concern her circulation had to return to normal, so the consultant noted more fluid was administered to help with that.
The consultant's notes add: "Spoke to parents.
"Purple discolouration almost resolved.
The consultant says, from looking at her notes, she was "quite puzzled" by that as there were two question marks.
The notes add: "Stabilised at present.
"[Nil by mouth].
"Repeat gas and wean as tolerated."
The notes conclude for further tests to be repeated at 7.30am, at the end of the night shift.
Ben Myers KC, for Letby's defence, asks about "one area" on the clinical notes talked about.
Mr Myers asks about the purple discolouration, and that by the time the consultant had arrived, she had noted what she had seen at 12.50am, and had 'almost resolved' by the time of the note at 2.40am.
She tells the court: "I think this was something I was puzzled about, and wondering what it would be."
She says other causes were ruled out as such a rash had "come out of nowhere" and had "almost completely gone" a couple of hours later.
She added she was "a little bit confused" and was "trying to put in place all the safe things" she could do to treat Child B.
Medical Expert Testimonies
Prof Owen Arthurs (child a & b)
Prof Owen Arthurs, is a consultant paediatric radiologist at Great Ormond Street Hospital.
The court hears he has reviewed "many of the children in this case", and will be asked questions about Child A and Child B.
Prof Arthurs is asked about a post-mortem x-ray for Child A.
He comments "unusual findings" in gas and air found in the baby boy, including "a line of gas just in front of the spine".
He said such a finding is not found in cases of 'natual causes' death in babies.
Trapped air such as this, Prof Arthurs explains, could be found in cases such as road traffic accidents, or infection such as sepsis - overwhelming infection in the organs of the body, or "very occasionally" outside of hospital in 'sudden unexpected death in infants'.
Prosecution: Have you seen this much gas in a baby before?
Prof Arthurs: "Only in one other case, which I think we'll explain later on [another of the children in the Letby case]."
Prosecution: "What was your final opinion?"
Prof Arthurs: "This was an unusual appearance. In the absence of any other explanation...this is consistent with...air being administered."
Ben Myers KC is now questioning Dr Arthurs.
He asks questions about 'air in the body' and analysis of them.
Mr Myers: "Radiographic evidence of air embolus is rare, isn't it?"
Prof Arthurs: "Yes."
"On post-mortem imaging, the presence of air may also be the result of medical procedures or placement?"
Mr Myers asks if the presence of a UVC or long line for some time could lead to air in the system. Dr Arthurs agrees.
Prof Arthurs says the "assumption that an image is needed to prove an air embolus is wrong".
Prof Arthurs says his review of the cases involved him, to give a conclusion of 'unusual', having to look through a number of past cases.
Mr Myers says that translated to similar findings in 25% of the total number of past cases he had gone through.
Mr Myers says Prof Arthurs looked at 500 cases at Great Ormond Street Hospital, which after narrowing down the criteria, amounted to 38 babies aged under two months, and of those, eight had gases in the greater vessels.
Prof Arthurs said there were "no unexplained cases" of gases in that location. The causes found included trauma, a road traffic accident, sudden unexpected death in infants or congential heart disease.
Mr Myers said that does not include many cases of babies in similar circumstances of death of babies aged under four days old.
He says there are "many variables" in such a study.
Prof Arthurs says air can be 'distributed' in the system during CPR.
For Child A, Mr Myers says "one possibility" of the air seen on the image is air administration.
He says others can be through resuscitation or post-mortem changes.
Prof Arthurs: "Yes."
For Child B, the radiograph image shown from June 10, about 40 minutes after the time of the non-fatal collapse.
Mr Myers: "On that image, there are no features which support an air embolus diagnosis?"
Prof Arthurs: "Yes."
He clarifies from a question by the prosecution that it could not be concluded either way.
Prof Arthurs says his observational study was from "a large body of evidence".
The judge, Mr Justice Goss, asks about the study as the jury has not seen it.
Prof Arthurs said the study was carried out for children (up to 18 years old) in 2015 and looked at 35 cases, with 10 having some gas in the larger vessels. The study was published, peer-reviewed and available in literature.
He tells the court "probably none" were of premature babies.
The study was performed independently of the trial, the court hears, and was prior to Prof Arthurs' own review, for babies, carried out later at Great Ormond Street Hospital, involving hundreds of cases.
(End of reporting)
Dr Dewi Evans (child a & b)
Independent medical expert Dr Dewi Evans has returned to give evidence in respect of Child A.
He confirms he has written four separate statements in respect of Child A, the latter two being clarification on technicalities.
The first report was written in November 2017, the second in May 2018.
Dr Evans said he became involved in the case in July 2017 by the National Crime Agency.
He visited Cheshire Police where they had concerns about a number of deaths in the Countess of Chester Hospital which were "unusual" and "far more deaths than they would expect".
The deaths had "followed collapses in babies" which were "otherwise quite stable" and involved collapses where resuscitation attempts were not successful.
He said: "I thought I could help, advise review case notes and form an opinion that led to the collapses of [Child A and Child B]."
He said "despite the prompt resuscitation in [A's] case", Child A had died despite doing "very well".
He said his job was to look at the "clinical evidence".
He added that Child A was the first case he looked at, and subsequent reviews of other children had reinforced his opinions for the conclusions of Child A and B.
He said "a pattern became apparent in the cases", which he described as "quite disturbing and quite unusual."
For Child A, Dr Evans confirms he had received clinical records for the baby boy to review, and had received statements from Countess of Chester Hospital medical staff for the case.
Dr Evans explains to the court certain medical procedures such as cannulas, UVC and long lines.
Dr Evans said there is a connection between the insertion of a long line and 'cardiac tamponade', where fluid obstructs the heart and is a "deadly serious condition".
He added that, "sadly", he was aware of a case which happened in Swansea where a baby had died as a result of that.
He said such cases are where a long line has been in place "for several days".
Diagnosing such a condition post-mortem would also be "relatively straightforward" as fluid would be detected outside the heart.
For Child A, he had not come to the conclusion that cardiac tamponade was the likely cause of death.
Dr Evans says, from looking at Dr Harkness's clinical notes at the time, the efforts to save Child A were "very good standard resuscitation procedures."
He added: "[It is] what you would expect in any neonatal unit in 2015."
Dr Evans said, just before Child A's collapse, he was "in a stable condition". In his report he had described his condition as "perfectly satisfactory."
He added: "He was as well as could be expected. All the markers of well-being were very satisfactory. He was in air, not needing additional oxygen, heart rate in normal limits, oxygen saturation normal - it had been in the 90s...respiratory rate slightly above normal rate but that was the only marker outside normal rate."
He said Child A "had survived the most dangerous journey of his life" and, although he needed care for feeding himself, he "was doing really, really well" and "everyone one the unit would have been really pleased with how he was."
Dr Evans said he had not been presented with evidence of the discolouration, as the court has heard through this trial, for Child A.
He said it was not noted in the evidence he had received.
He adds: "I think the rash in [Child A's] collapse fits together and fits a significant diagnosis...of air embolous [injection of air into the circulation]."
"Somehow air had got into the circulation...I found this opinion without knowing about the rash and without anybody suggesting expressing concern of air embolus."
He rules out other conditions such as sepsis, a lack of fluids or hypoxia as causes, or contributing factors to the collapse.
He said he had "only one" conclusion, that Child A had received an air embolus, "through an IV line".
He said with the systems in place, and the medical equipment, and medical staff being "obsessive" about making sure patients are not injected with air, "there was no way this could have been done by accident".
He said the collapse was "not really" likely as "all the markers were satisfactory" and the medical staff had elt comfortable enough to allow the baby girl to be out of the incubator for a short time so she could be handled by the mum.
He said that was "not something you would do" if the child was not stable.
He said the two conclusions he had for Child B's collapse were "smothering" or an "air embolus".
He said the discolouration was a "striking feature" which had been seen in Child A arrived and went "very quick".
He said if the rash was associated with other conditions, it "tends to stay".
Dr Evans tells the court the collapse was "very similar" to that of Child A, but what happened was "less severe".
He said "either the volume of air [injected] was less, or the volume of air in the circulation got there more slowly, or a combination of the two."
Asked by Mr Johnson if there were any other possibilities to the cause of the collapse, Dr Evans replies: "I could not think of anything else.
"The doctors did a really good job in saving her.
"There was no evidence of sepsis, problems with the lungs, nothing unusual about the chest x-rays, lungs were full of air...nothing else to explain this collapse which again was sudden and unexpected."
He added: "We have heard numerous doctors saying they have never seen this before. I feel I can say the same. It's very unusual."
Ben Myers KC, defending, says Dr Evans has prepared a "large number of reports" over the years, and air emboluses feature in "a number of them" - "literally dozens". Dr Evans agrees.
Dr Evans is asked to explain the features of an air embolus.
He adds: "An air embolus will lead to a sudden and unexpected collapse. A patient, otherwise stable, collapses. And by collapse, I mean change of colour, stops breathing...reduced heart rate, and death. This occurs all of a sudden.
"There are additional features - you don't get all the features in all the cases. The two main associated features are unusual skin discolouration and the presence of air in 'great vessels' - various parts of the body. Those are the compounding features which lead to a diagnosis of air embolus.
"This occurs when there is no other explanation...which fits the collapse, and when resuscitation is unsuccessful.
"Resuscitating patients [for doctors] is part of our bread and butter, so resuscitating is well known. When that is unsuccessful, it adds to the confirmation [of an air embolus diagnosis]."
Dr Evans relays one case of a baby who had died in Swansea from an air embolus, from what "should have been a regular surgical procedure", when recalling it was "absolutely awful" and led to a criminal trial.
He said he had not been involved in the report so was unaware of any discolouration in that baby.
He says he has never come across such skin discolouration in a collapse in 'hands-on experience'.
"That is something I am relieved and pleased about, actually."
Mr Myers said the diagnosis is 'one of exclusion' - ruling out alternatives until there is one explanation left.
Dr Evans said there is more to the case than that. He said his original conclusion was without knowing about the skin discolouration in Child A.
He adds that if you discover additional information, that "simply firms up your diagnosis".
Dr Evans states that air embolus cases are difficult as there are "isolated" case reports, and the systems are put in place in modern times so the conditions are not repeated - "that is not a criticism, that is a compliment", hence there is "very little new research".
He adds that doctors may be reluctant to "spread news" of mistakes in cases where there may have been an air embolus.
Dr Evans said he was tasked with investigating a "clinical condition", not a "crime", when he became aware of the Countess of Chester Hospital case, when tasked by the National Crime Agency.
He said the scenarios added up to a "constellation of worries" on what went on between June 2015 and June 2016.
He adds that in past cases, he has been brought in by police and the conclusion was accidental, so the case was closed with no further police involvement.
He is asked about his 'state of mind' in his approach to the cases.
"My state of mind was very clear - let's find a diagnosis. Nothing to do with crime. Let's identify any specific collapse, and see if I can explain it.
"There were occasions where I couldn't explain it, and occasions where I found something deeply suspicious.
"There were incidents I found disturbing."
He was asked to investigate 33 cases in total, with two insulin cases later.
He said there were two babies were born in unsurvivable conditions, with obvious medical diagnoses.
He said: "The name Lucy Letby meant nothing to me. I didn't know the staff.
"I was the easiest physician and the most difficult. I was a blank sheet of paper. I had no idea and relied entirely on the evidence I could see from the clinical notes and applying my clinical experience and forming an opinion to the cause."
He said he asked to have one case file to have "an idea" of what he was dealing with.
Mr Myers: "Was the phrase 'air embolus' used at all?"
Dr Evans: "No. The first person to use air embolus, as far as I was concerned, was me.
"I need to give the NCA a compliment, they never gave me a steer. They are good, professional people."
Mr Myers turns to the case of Child A.
He asks that pre-term babies such as Child A are 'prone to complications'?
Dr Evans: "That is why we have neonatal units."
He adds that the care he received meant he had overcome the most difficult parts of his life and was "stable" prior to his deterioration.
Mr Myers asks if Child A was "perfectly satisfactory" prior to the collapse, as according to Dr Evans's notes.
Dr Evans says he does not want to engage in semantics, but adds that, for a pre-term baby in the position he was in, Child A was "satisfactory" and "really good".
A clinical note is presented to the court, with a number of 'problems' listed.
Dr Evans: "I would call them issues, not problems.
"This is what any competent junior doctor would list as the issues present.
"We have got to deal with the fact he is pre-term, he has breathing support, we need to establish feeds, there are concerns over suspected sepsis.
"Any doctor would write this things down."
An x-ray review is presented, with the note 'RDS [respiratory distress syndrome] type picture'.
Dr Evans is asked about that comment. He says: "I have seen the report, it's not too bad actually. This is why we put babies on CPAP."
A blood gas record showing a 'high' number for lactate (2.6 - outside the range up to 2) is shown.
Dr Evans explains he wouldn't be "particularly" concerned at such a reading, in the "whole picture", as he says one or two readings would be outside the normal range.
He describes the reading as "marginal", with all the other readings "normal", and Child A was "handling well".
He said he would not interpret an oxygen reading from a capilliary sample from a 'heel prick'.
He says if he saw such readings, knowing if the baby was "in air", he would not be "rushing to stick needles in him" unless there was a change in condition in the baby.
A NICU observation chart is presented for Child A, including the respiratory rate.
Mr Myers says the readings are "not stable."
Dr Evans disagrees, saying the readings are "within range".
The 'increase' in the respiratory rate readings were down to the insertion of the long line and UVC, handling of the baby and a heel price procedure which caused the baby discomfort.
Dr Evans said he would expect the heart rate to go up with an increased respiratory rate, which would be a concern. But as the heart rate had remained stable, he said he would "not be concerned" and Child A "was not even requiring oxygen", with saturation levels at about 97-99 per cent, "was about as good as it gets".
Dr Evans says "it happens" that children on neonatal units can go without fluids for four hours.
He said it was not ideal, and "unfortunate", but it did not make a "clinical difference" in this case.
He said a child which had missed out on that level of fluids for that time would not have subsequently collapsed and died.
Dr Evans reiterates that the context of other readings had "all the markers" of a stable baby.
"This was a baby who was stable prior to him collapsing," he said, referring to the words other doctors had made in evidence.
Dr Evans dismisses alternatives put forward by the defence, including 'infection', saying such evidence would appear on a post-mortem examination.
He dismisses a suggestion of a 'rapidly spreading infection' in the baby as "ridiculous", as he said such evidence would again be found post-mortem by a pathologist.
Dr Evans said his conclusion of an air embolus was based on a baby "suddenly crashing" and, "more significantly", followed by "resuscitation which was unsuccessful".
He adds the subsequent x-ray and skin discolouration reports had firmed his opinion.
"A collapse of this speed in a baby unit, with full medical care, is very unusual these days."
He adds that Child A, given all the factors, is normal, and in "the safest place on the planet" for their needs.
"Neonatal unit care is as good as it gets.
"It has come on leaps and bounds [over the years]."
Mr Myers says skin discolouration can be a sign of illness, or due to underlying circulation problems, or infection, or blood pressure issues (secondary to something else).
Dr Evans agrees.
Mr Myers asks if it would be "flawed" to diagnose skin discolouration as an air embolus.
Dr Evans: "Discolouration is a general term, noting there is something present on the skin, as noted by a doctor or nurse. You can't say it is due to a specific condition."
Mr Myers refers to a 1989 Study
which showed, following 50 cases involving an air embolism, only '11 per cent' involved skin discolouration.
Dr Evans said he had come to his initial conclusion of an air embolus for Child A before becoming aware of the skin discolouration.
The judge rephrases a question of Mr Myers to ask that "failure of resuscitation", of itself and in isolation, is not a consequence of an air embolus.
Dr Evans agrees. He says in combination with all factors already presented - including air in the great vessels, sudden collapse and skin discolouration, the conclusion is that of an air embolus.
He says an air embolus is not "common", but is rare and unusual.
Dr Evans said in 14 of the 17 cases he had completed his preliminary reports by November 2017, and was unaware of any medical staff member being a suspect.
He became aware of the name 'Lucy Letby' for the first time upon her arrest in July 2018 when he read her name in the press.
He said he was the first to come up with a diagnosis of an air embolus, and this had been agreed by a peer review by Dr Sandie Bohin, plus by a medical expert who began to peer review his reports but sadly, before completing the review, became seriously unwell and died.
Mr Myers asks about the non-fatal collapse of Child B, who needed breathing support at birth, as a clinical note shown to the court shows.
An x-ray review has the note 'RDS type picture', as also shown for Child A.
Dr Evans agrees with Mr Myers that a child such as Child B is 'prone to desaturations'.
Mr Myers presents a clinical note to the court from June 19, 12 days after Child B was born, noting there were desaturations recorded - if not on the same scale as those recorded during the non-fatal the collapse - and on June 20 when "the apnoea alarm went off" on three occasions, with oxygen saturation "down to 70-80% each occasion".
A paediatric asessment dated July 14 for Child B is presented to the court, in which 'breathing problems' are noted along with 'mottling'.
Mr Myers: "There are some respiratory issues associated with her health?"
Dr Evans: "Nothing compared to what we would call the 'index event' (the collapse). She needed resuscitating."
Mr Myers asks about the differential diagnosis for Child B, concluding there was either an air embolus, suffocation, or someone had removed the prongs on purpose.
Dr Evans said, in his opinion, he was "on the ball from the start" in considering an air embolus.
He said his opinion was reinforced by colour changes "every 10 seconds" as mentioned by a Countess staff member in court.
The theory of removing the CPAP prongs on purpose is discussed.
He says it's possible for a baby to move them by accident.
He is asked if smothering is a possibility, to which Dr Evans says he has since discounted.
Mr Myers said it is a 'key aspect' that the inability to successfully resuscitate Child A had led to an air embolus. He adds that child B recovered, and that is "inconsistent" and "contradicts the air embolus theory".
Dr Evans: "No it does not. We cannot do studies where we inject air into babies and see what happens."
He adds that the volume and speed at which air is injected, along with the skill of the resuscitation attempts, can make a difference as to whether the baby survives or dies.
Dr Evans says, under questioning by Mr Myers, he would be happy to hear of an alternative explanation from a medical perspective for Child B, but he is happy with the conclusion he has made for Child B, that she had had an air embolus.
The prosecution refers to the clinical note from June 20, following the desaturations recorded. The note adds Child B 'self-corrected'.
Dr Evans: "It's a bit frightening, but she self-corrected. These things happen in babies."
He reiterates that those events noted on June 20 are a long way from what happened when Child B suffered a non-fatal collapse.
Dr Sandie Bohin (child a & b)
Independent medical expert Dr Sandie Bohin has now been called in to give evidence for Child A. She is detailing to the court her medical and professional background.
Dr Bohin says she was asked to peer review Dr Evans's reports and was to find whether she agreed with them, disagreed with them, or had additional findings to present.
She has also considered other findings from other independent experts in the case.
The prosecution ask Dr Bohin to clarify whether she had also seen a post-mortem report for Child A, and the reports of Countess medical staff. She confirms that was the case.
Dr Bohin explains Child A was, for a baby born 10 weeks premature, a "stable baby", on breathing support via CPAP but not requiring oxygen ventilation, and was doing "so well" that medical staff decided to start giving him some feeds.
"If he was unstable in any way they would have done so," she tells the court.
The UVC placement and long line placement did not have any contribution to Child A's death, Dr Bohin tells the court.
Was the stopping of breathing for Child A caused by his prematurity, the prosecution asks.
Dr Bohin said it could be ruled out as there were no previous episodes, and caffeine had already been administered to counteract it as a precaution.
The discolouration seen, while seen in collapses in other infants, "did not explain" the pink blotching that came and went in Child A, Dr Bohin tells the court.
She says the "only plausible explanation" for Child A's collapse is an air embolus.
Dr Bohin said doctors and nurses are "absolutely meticilous" in making sure even "the tiniest air bubble" is not injected by accident into a patient's circulation.
She adds that even if air was accidentally administered, there is an electronic pump system which would detect the air and stop the administration.
Dr Bohin explains to the court that could be bypassed further down the line by administering the air embolus via a connector normally used for administering drugs.
Dr Bohin is asked how much of an air embolus would be considered fatal to a child of Child A's size?
She says that 3-5ml of air per kilogram of body weight "could be fatal".
She explains Child A weighed 1.6kg [about 3.5lb].
"A teaspoon of air?" Nicholas Johnson KC, prosecuting, asks.
"Well, that is 5ml of air, so yes," replies Dr Bohin.
Mr Johnson: "What, in your opinion, killed [Child A]?"
Dr Bohin: "[Child A] was killed by an air embolus."
Dr Sandie Bohin is now giving evidence in respect of Child B.
She confirms she has examined medical records, case notes and photographs for Child B, and peer-reviewed Dr Dewi Evans's report for her non-fatal collapse in June 2015.
Child B collapsed at 12.33am on June 10, 2015, at the neonatal unit. She later recovered and, four weeks later, was discharged from the Countess of Chester Hospital.
Dr Bohin says Child B was "compromised" at birth, and required respiratory support, which was "not that unusual" for someone of her prematurity.
"She stabilised very quickly," Dr Bohin added, and was "in air" with "normal" blood gases, and "stable enough" to have skin to skin contact with her mother and for feeds to be started.
Dr Bohin said the circumstances of Child B's collapse were not normal, but "very concerning".
She said: "Despite being on CPAP, she was otherwise normal."
If such babies deteriorate, there is normally "prior warning", but there was "nothing to suggest she was going to collapse in this way".
The prosecution refer to an event where the nasal prongs were dislodged, prior to the collapse.
Dr Bohin said the prongs can be "misplaced", and the babies are "probably quite uncomfortable", and if left for a prolonged period of time, there would be a desaturation, with prior warning.
She added: "It was noted, the prongs were replaced, and everything went back to normal".
Dr Bohin replies to the question if the misplaced prongs had anything to do with the subsequent collapse: "No, none at all".
Dr Bohin said other factors, such as infection or cardiac arrhythmia, could be discounted, and the only conclusion left was "air embolus".
She refers to the skin colour changes seen on Child B, and how "florid and different it was from anything they had seen before".
"It just didn't fit with any other potential different causes".
Dr Bohin said she looked at Child B's case "on its own merit", as with any other, when coming to a conclusion.
Ben Myers KC, for Letby's defence, is now asking questions to Dr Bohin.
Mr Myers asks if it is important that medical experts have current day-to-day experience in a medical environment.
Dr Bohin: "Not necessarily no - what you can't do is dispel the exerience they have had over many years."
She adds it is not "crucial" they have on-the-job current day-to-day experience. After further questions, she said such experience would be "advantageous".
Mr Myers refers to GMC guidance in giving evidence as an expert witness, and asks if someone who retired from clinical practice is still in the same position to give evidence for events which happened in 2015.
Dr Bohin says comeone does not lose their knowledge after retiring from on-the-job clinical practice, but if they keep up to date with clinical practice, they are not at a disadvantage.
Dr Bohin said the first time she had contact with other medical expert Dr Evans was earlier this year, to discuss one of the cases in the trial, via a telephone conversation, as there had been a difference of opinion.
Dr Bohin said she had previously seen one example of an air embolus, and it was in a neonatal case, but was "very long ago". She said she could not recall the specifics of the case, but the air bubbles seen in the imagery were "very striking".
She said she had formed her views after excluding other possibilities.
Dr Bohin said she is unaware of any genetic condition which would cause a baby to collapse and die within 24 hours.
She said genetic screening would only be done if staff had a suspicion the baby had a genetic condition.
Mr Myers says Dr Bohin said Child A was "extremely stable" prior to collapse.
She said there was "nothing which was cause for concern".
The blood gas record for Child A is shown, and Dr Bohin says the lactate number of 2.6-2.7 is 'slightly elevated' (a normal reading at the Countess was '2'), but has to be taken in context with other parameters which were normal.
The NICU Observation Chart is shown to the court for Child A.
Mr Myers says the respiration rate is "not stable".
Dr Bohin says it's above the normal rate, but "is stable". She said the range is 60-80 breaths, which is outside the normal range, but with CPAP breathing support, and 'in air'.
She said during the afternoon there would have been interventions which would have caused the respiration rate to rise.
She said the respiratory rate, in conjunction with other factors, would have been something staff "would have been aware of".
Mr Myers: "Would you say this was an alert?"
Dr Bohin: "Yes, but there was nothing else that needed to be done. He wasn't having a lot of desaturations.
"The next step would have been to ventilate him...and he didn't require that."
Dr Bohin: "Handling in a baby with respiration support can make the respiration go up."
Mr Myers asks if the heart rate would also go up.
Dr Bohin: "It can do...but not necessarily."
Mr Myers refers to the insertion of the UVC and long lines.
Dr Bohin said the long line was not in the "best" position, but was in a "fine" position that was "safe" and would not cause problems with the heart.
Dr Bohin said a long line can move if left in "for two weeks or more".
She said the long line would not have moved in the space of a day, and the recommendation is not to x-ray every day.
Mr Myers refers to Child A's lack of fluids for four hours.
Dr Bohin says it was "not ok", and "would not be optimal care", but he had "no IV access" and the doctors had to prioritise other matters on duty, and adds "it wouldn't cause a sudden collapse like with [Child A]."
"The only deterioration he could possibly have would be to drop his blood sugar."
Mr Myers: "Would you agree the whole situation is sub-optimal at that moment?"
Dr Bohin: "No."
Mr Myers asks if the lack of fluids means the whole situation is sub-optimal for Child A.
Dr Bohin: "No."
Mr Myers refers to the skin discolouration.
Dr Bohin explains there is a difference between a rash, such as chickenpox, and changes to colour in the skin, where it can go blue, or pale, or mottled.
Mr Myers refers to a paper published by the International Journal of Critical Illness and Injury Services on air embolisms, which reports air can enter via the UVC during negative pressure in the vessel systems.
Dr Bohin says she knows this sort of thing can happen, but in adults, and is not aware of any neonatal cases.
Mr Myers now refers to the case of Child B.
He says the UVC procedure had to be repeated with her. He asks if that was "sub-optimal". Dr Bohin replies: "No. Ideally you would want it in first time."
A clinical note refers to Child B not getting fluids "for a couple of hours".
He asks if that was "sub-optimal".
Dr Bohin agrees.
Mr Myers refers to a clinical note showing it took five attempts to insert a long line for Child B, and asks if that was sub-optimal.
Dr Bohin: "Five attempts is what it took - it's incredibly difficult to site these - they are a millimetre wide. At times it just won't thread for you.
"If it won't thread for you...you are very aware you are handling this baby and the easier thing is to take it out and reinsert it," she adds, rather than "fiddling about with it" in the baby's body.
Mr Myers: "[Five attempts to insert the long line] This is standard, is it, in practice?"
Dr Bohin: "Yes, it is."
Referring to treatment, Dr Bohin said "nothing can ever be done immediately" in the hospital, but the size of the neonatal unit care was standard for a unit of that size.
Dr Bohin agrees there were breathing problems for Child B at birth.
Mr Myers: "Do you agree that Child B could deteriorate without deliberate harm?"
Dr Bohin: "It is a possibility."
Mr Myers: "Air embolus is usually fatal, isn't it?"
Dr Bohin agrees there is a risk.
Dr Bohin says a small quantity of air could create an air embolus. She said it is the volume and speed which are the factors.
Mr Myers says it is "almost always" fatal.
Dr Bohin replies that can be the case with adults [to which there have been medical reports published].
A clinical note refers to the "purple blotching...pink and active" for Child B, and is shown to the court.
Mr Myers asks if 'pink and active' refers to the baby.
Dr Bohin: "Yes."
The prosecution, led by Nicholas Johnson KC, is clarifying a few matters from Dr Bohin's evidence.
Dr Bohin said she needs to be "completely independent" and base her conclusion on the evidence presented to her.
The blood gas record is shown to the court.
One of the parameters from a blood capilliary reading, a 'PO2' recording, is typically "disregarded" as it is not reliable, Dr Bohin says.
Dr Bohin presents a UVC to the court, and explains how it is administered and left so there is no air left in the tube.
She explains a long line looks similar, but has a wire inside it.
Dr Bohin clarifies she has never heard of a case, in clinical experience or in educational courses, or in published literature, of a neonatal having an air embolus as a result of negative air pressure, as described in the medical paper concerning air embolisms in adults.
Dr Bohin is asked if there is any link between Child B not getting fluids and the collapse which happened 28-30 hours later.
Dr Bohin: "No."
A note, dated July 14, relays a progress report for Child B.
Mr Johnson asks if there is any evidence of breathing problems in that note.
Dr Bohin says there isn't.
Dr Bohin says the colour change 'on its own' is not diagnostic of an air embolus, but needs to be taken into context with the sudden and unexpected collapse.
Prof Sally Kinsey (child a and b)
Professor Sally Kinsey, a blood expert, is going to give evidence in relation to a number of the cases so far in the trial.
Professor Kinsey confirms she was approached by Cheshire Police to look at several cases in the course of this trial. One is yet to come, while the other three are the cases of Child A and Child B (both twins) and Child F.
She also confirms she has looked at the records of Child F's twin brother, Child E, for the purpose of her investigation.
She has written reports for each case and set out the relevant backgrounds for each child, the court hears.
Her first report is dated March 4, 2020, relating to Child A.
The court hears the conditions that Child A and Child B's mother had before her birth, and the decision to deliver the twins by C-section in June 2015.
The events of Child A's treatment at the Countess of Chester Hospital neonatal unit, subsequent collapse and death, are relayed in court.
Child A's blood count was considered 'normal' for his age.
She said she had considered whether Child A's mother's auto-immune disease could have been a significant factor in the death of Child A.
Said auto-immune disease was a rare condition (affecting about 50 in 100,000 people) which affected the mother, which can cause increased blood clotting.
It is "well recognised" that pregnancy can cause issues, which can cause nutritional problems for babies in the womb, and a C-section can be required "to save the life of the mother and the child".
The court hears it can cause premature birth and blood clotting for the mother.
Nicholas Johnson KC, for the prosecution, asks: "Did the...syndrome pass on to [Child A or Child B]?"
Professor Kinsey: "No, that is not the case."
Mr Johnson says there was concern the condition had passed from mother to son, but says Professor Kinsey is sure it did not.
"It didn't," Professor Kinsey replies.
Prof Kinsey says, for the conclusion of air embolus for Child A, the doctors' descriptions of skin discolourations on the baby had "cemented" her concerns.
She adds it is very "rare" and has not seen it in her experience, but she says she has read it from literature, and the skin discolurations are a "stark" feature.
Prof Kinsey says she is sure the cause of Child A's death does not have a haematological origin.
The case of Child B, a baby girl, is now being discussed.
The events of Child B's treatment at the neonatal unit and her collapse are relayed to the court. The jury is being shown clinical records which have previously been shown as part of the sequence of events and from doctor/nurse witnesses.
Prof Kinsey confirms she had noted what was written for Child B's skin discolouration on June 10 - the 'purple blotching'.
For all the blood results Prof Kinsey had seen, she said they were 'normal' for her age and the time the tests were taken.
There was, like Child A, no passing on of the mother's auto-immune disease to Child B, she adds.
The question of air embolus is raised. She said she had made similar observations to Child A.
The professor says there was no haematological evidence that could have caused Child B's collapse, and wanted to draw attention to the skin discolouration in the area around the chin, which she said was most likely a 'rash' caused when medical staff were trying to administer air.
Ben Myers KC, for Letby's defence, is now asking Prof Kinsey questions.
He says his questions are more concerned on the nature of an air embolus.
Mr Myers asks about the principle of experts giving evidence, and their areas of expertise.
He refers to Prof Kinsey's expertise in haematology and certain paediatric specialisms, and her reports. They include focus on cancers and blood disorders.
Mr Myers: "Air embolus does not feature in your expertise, does it?"
Prof Kinsey: "No."
Mr Myers refers to the diagrams of gas exchange, which are 'standard images' in the way gas exchange works in the body.
Mr Myers: "In no way are they designed to explain an air embolus."
Prof Kinsey: "They were produced to explain the gas exchange and circulation."
Mr Myers: "What you are doing in your evidence is to take that understanding of circulation and gas exchange and use it to explain how an air embolus is displayed."
Prof Kinsey: "Yes."
Mr Myers says Prof Kinsey has, at times, commented on the issue of air embolus in her reports for Childs A, B and E.
Prof Kinsey: "Only in the changes to the colour of the skin, very impactful."
Mr Myers refers to the summary/opinion for Child A, and whether there was any haematological significance for Child A. He says that is not in dispute.
He refers to the conclusion, which he says relies on comment from [medical experts] Dr Dewi Evans and Dr Sandie Bohin, and the description from [Countess of Chester Hospital consultant] Dr Ravi Jayaram of the skin discolouration for Child A.
Mr Myers refers to the 1989 medical journal review: "mentioning a particular case - 'blanching and migrating areas of cutaneous pallor were noted in several cases and, in one of our own cases, we noted bright pink vessels against a generally cyanosed...background."
Prof Kinsey confirms she is drawing a parallel between the 1989 journal review and what had been observed by doctors and nurses.
She tells the court she was "shocked" by Dr Jayaram's description of skin discolouration for Child A, which she said came before she had considered the possibility of air embolus.
She said she knew this is what air embolus was like, and knew from her own education, before seeing that description matched what was said in the 1989 medical journal review.
Mr Myers says Dr Jayaram's clinical note - 'legs noted to look very white and pale before cardiac arrest' does not contain the full details from her report. Dr Jayaram did not add anything further to the skin discolouration observation in the report to the coroner, Mr Myers adds.
Mr Myers: "The description you read came from his statement [to police] two and a half years later."
Prof Kinsey agrees.
Mr Myers refers to the case of Child B, and the summary/opinion Prof Kinsey made in her report.
He says, for air embolus, Prof Kinsey again draws parallels between the 1989 medical journal and the skin discoluration observations seen for Child B.
The clinical note of 'widespread purple discolouration with white patches' for Child B, made at the time, is shown to the court, along with a subsequent 'improvement in skin perfusion'.
A doctor's note on June 10, shown to the court: 'suddenly purple blotching of body all over...upon my arrival purple blotching...[later] purple discolouration almost resolved'.
Lucy Letby's note on June 10 is also shown to the court: 'Cyanosed in appearance...colour changed rapidly to purple blotchiness with white patches'.
Mr Myers: "In none of those is there any description of a bright pink or red feature?"
Prof Kinsey: "No."
Prof Kinsey's report, dated November 1, 2022, is referred to.
Mr Myers says Prof Kinsey was asked to give further consideration as to how an air embolism worked.
She says she was asked to give further explanation on the features of an air embolism. She said she was not an expert in such mechanisms, but has provided an explanation.
Mr Myers says the report notes there is very little medical literature in relation to air emboli.
Mr Myers: "You have used your knowledge of blood and circulation to assist this?"
Prof Kinsey: "Yes."
Mr Myers says part of the limited medical literature relates to decompression in deep-sea divers, colloquially known as 'the bends', and that in those circumstances, nitrogen bubbles would be in the circulation longer than oxygen bubbles. He asks Prof Kinsey if that is the case.
Prof Kinsey: "I don't know the answer to that question."
Mr Myers says the research paper in question [for 'the bends'] dealt with four overweight deep-sea diving adults.
Prof Kinsey: "Yes, there were many limitations to their findings."
Mr Myers said the results were "very specific based to the people [in that study]."
Mr Myers asks if the symptoms of decompression sickness would always result in skin discolouration. Prof Kinsey said it would not.
Mr Myers asks if that can be applied to babies - if an air embolus could always lead to skin discolouration observations. Prof Kinsey said it would not.
Prof Kinsey says the problem with decompression syndrome, in comparison to air embolus in infants, is the bubbles get larger as the deep-sea diver returns to the surface.
Mr Myers says that is another limitation of the available medical literature for air emboli.
Prof Kinsey says the reason that study was used in her report was that skin discolouration had been an observation in that study, as it had been in cases of air embolus.
Prof Kinsey says the scale of the air embolus problem would depend on the size of the air bubble and the type of vessel that it is in.
Upon a question from the judge, Prof Kinsey says she has never encountered any discussion about nitrogen bubbles in the system, other than in deep-sea divers.
She says the biggest factors for any air embolus would be the size of the air bubble and the vessel that it is in.
What was not a factor in her discussions was the quantities that made up the air [ie what amount was nitrogen, what amount was oxygen, carbon dioxide, etc].
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.
Dr Marnerides said it appeared Child A, a twin boy, died as a result of an injection of air into his bloodstream.
From Dan O’Donohue Twitter (29/03/23):
He reviewed tissue samples from Child A. The medic says from his review, he found 'globules' in the veins in the lungs and brain tissue that were most likely air, he said this air 'most likely went there while this baby was alive'
From Dan O’Donohue Twitter (30/03/23):
Mr Myers is now taking the medic back over the cases he has reviewed, starting with Child A. Mr Myers quotes his review, in which Dr Marnerides said the cause of death was 'unascertained' and that there was no 'convincing indication the death was due to an unnatural cause'
Mr Myers asks the medic if he agrees, he responds: 'Yes, I wrote it'
Police Interview Summary
The wording of the summary has been agreed between the prosecution and defence.
For the case of Child A - the first interview took place in July 2018.
Letby was allowed to look through the case notes, and was asked if she remembered the specific shift. She replied: "Yes."
Letby gave details of the handover and the long line administration.
She said she checked the fluids and a nurse colleague "had the bag out".
She said they noticed Child A was "pale and mottled", and a crash call was put out.
She said full resuscitation attempts followed.
She said Child A had been "a little bit jittery in appearance" and believed that was due to low blood sugar levels.
She said a colleague was there with the fluids at the handover.
She was asked why the fluids were a priority, and Letby explains Child A had gone 'a few hours' with a lack of fluids.
She said that "wasn't ideal".
She said Child A had a rash-like appearance, which Letby put as being the result of an infection, or being cold.
"He was more pale than the areas of the mottling."
She was asked if anyone had seen the mottling. Letby replies: "Yes."
She said they were advised to stop administration of the fluids.
Child A was then not breathing, and Dr Harkness was called over.
Letby said she could not recall Child A's resuscitation, but recalled Dr Jayaram had entered the room.
She said the death of Child A "had been difficult" for her, and said there was a support network among the nursing team.
She said she could not recall who attached the fluids line, but believed it was her nursing colelague Melanie Taylor who had connected the fluids.
She said photos were taken of Child A in accordance with the parents' wishes on their phone, along with a lock of hair and hand/footprints.
She agreed she had been taught to prime lines so air could not get in them.
She denied having done so via Child A's long line or UVC.
She said she didn't know exactly what an air embolism was.
She said her relationship with the child's parents was "strictly professional" and could not explain or remember why she had searched the mum's name on Facebook several times in the following weeks.
She explained, for a later search, she may have been searching for their names for an update on Child B.
For Child B, Letby explained the discolouration was a different appearance to that of Child A.
Child B's appearance was observed before resuscitation attempts began.
She did not recall having had any concerns for Child B, or any alarm going off for her.
She confirmed she would have handled Child B to an extent for medication and to attach lines.
She said she did not recall how upset Child A and B's parents were at the time.
(End of reporting)