contains evidence heard for Child C
Lucy Letby Case
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Child CCount 3: Murder allegation (air in NG tube)
Prosecution opening statement
As was the case with Child B, the prosecution say, Lucy Letby was not the designated nurse for Child C, a baby boy. Letby was assigned to look after a baby girl, and the leading nurse had to reinforce this assignment when, the prosecution say, Letby was 'ingnoring her'.
The court has heard Child C was being looked after by a nurse less qualified than Lucy Letby and had been given the responsibility as Child C was stable.
That nurse had left to go to the nurses station in the hospital. While there, she heard Child C's monitor sound an alarm.
Upon her return, Letby was already in the room, standing next to Child C's cot.
Dr Dewi Evans heard that infection was a "significant factor" in Child C's collapse, but could not adequately explain it. He had concerns about Child C's sudden deterioration.
The cause of death was ‘widespread hypoxic/ischaemic damage to the heart/myocardium’ due to lung disease, with maternal vascular under perfusion as a contributary factor.
A medical expert concluded Child C was killed by air "deliberately put into the nasal gastric tube".
The prosecution say this was a "variant or refinement of a theme Letby had started with the twins".
The prosecution added an independent pathlogist said the skin colour changes in Child C were likely caused by prolonged unsuccessful resuscitation.
Child C had pneumonia, but the pathologist concluded Child C died as a result of having an excessive quantity of air injected into his stomach via the nasogastric tube (NGT).
It was the third baby to have suffered a serious deterioration in the matter of a few days, the court heard.
Letby was the only nurse who had been on duty for all three collapse incidents for Child A, B and C.
Mr Johnson, for the prosecution, added Letby would have been the only adult in the room when Child C collapsed, as was the case with Child A, and was one of only two in the room when Child B collapsed.
"What we are going to see as we progress is that Lucy Letby’s method of attacking the babies in the neonatal unit was beginning to develop," Mr Johnson tells the court.
In police interview, Letby denied she had anything to do with Child C, other than with the resuscitation.
She could not remember why she had ended up in nursery 1.
In a second interview, asked about texts which had been found on her phone placing her in that room, Letby said that she might have been sending them from the nurses’ station and then gone into room 1 “to do something else”.
She then agreed that she had been the only person in the room when Child C had collapsed.
After finishing her shift, Letby searched on Facebook for Child C's parents.
The prosecution say this would've been one of the first things she would have done after that night shift ended.
Defence opening statement
For Child C, the defence say it is accepted that someone had injected air as a "theoretical possibility", but that is "a very long way from proving what has taken place".
Mr Myers said the jury would have to look at the practicalities of that, and consider alternative explanations.
Child C was "subject to a variety of complications" due to being born premature, the jury is told.
"We say, for a starting point, he should have been at a unit providing more specialist care."
The defence say pathology identified acute pneumonia in Child C.
The defence suggest a structural blockage could have caused distention.
Defence Lucy Letby EvidenceLucy Letby gave this evidence on 5th May 2023, taken from Chester Standard
Mr Myers now turns to the case of Child C, a baby boy born on June 10, 2015, weighing 800g, at 30 weeks +1 day gestation.
An event happened on June 12 where Child C's stomach was distended, Mr Myers explains.
Child C collapsed after a projectile vomit. Resuscitation efforts commenced, but he died on the morning of June 14.
A note by nurse Sophie Ellis is shown to the court, made retrospectively after Child C died on June 14.
The note provides observations for Child C from the night shift. It adds: 'First feed of 0.5mls given at 23.00...At around 23.15, [Child C] had an apnoeic episode with prolonged brady and desat. Crash call...resuscitation commenced. Resus drugs given...care handed over to senior nurse Mel Taylor...'
Further notes written retrospectively by Sophie Ellis on June 16: 'Had 2x fleeting bradys - self-correcting not needing any intervention'. A feed was taken and bile was aspirated.
Nurse Melanie Taylor's notes, written retrospectively: 'Called to help as baby had brady desat, when arrived to baby, baby apnoeic, loss of colour, Neopuffed, but not able to bag, no chest movement....medical team crashed bleeped. No heart rate heard, started chest compressions...intermittent gasping, continued resus. Intubated....good chest movement and air entry, continued chest compressions. Emergency drugs administered as documented...'
Resuscitation efforts continued.
Child C was later baptised and died that morning on June 14.
An x-ray examination of Child C on June 12 showed 'marked gaseous distension of the stomach and proximal small bowel'.
Letby confirms, as shown from her work shift pattern displayed to the court, she was not in work that day. She worked night shifts on June 8-9, 9-10, 13-14 and 14-15.
Letby had messaged Yvonne Griffiths if there were any spare shifts going on June 11. The response was the unit was ok for staffing levels through the week, but may get busier at the weekend. Letby responded 'Think I need to throw myself back in on Sat x'
Asked to explain that message, Letby says she wanted to get back into the unit, looking after babies. "That was what I was taught at Liverpool Women's, after a difficult shift...to get back in and carry on".
Mr Myers refers to police interviews with Letby regarding Child C. Letby told police she was involved, from her memory, in resuscitation efforts. She told police she thought she did chest compressions.
Letby tells the court she has no recollection of any of the events leading up to Child C's collapse. She says it was "a normal shift" and has "no memory" of what happened until Child C's collapse, which was a "significant event".
She says she has looked after "hundreds of babies".
A shift rota is shown to the court, showing Letby was looking after two babies that night on June 13. She tells the court she was in nursery room 3, with Child C in room 1 that night.
A timeline of staff duties from the neonatal unit is shown to the court for June 13-14. Lucy Letby is recorded as carrying out observations for the two babies she was the designated nurse for in room 3, plus an entry made on a fluid balance chart for one of those two babies.
Mr Myers asks how long those would have taken.
Letby says one of those would have taken "minutes", the other procedure would have taken "a little longer".
Child C's event is listed at 11.15pm.
Letby says her duties were allocated for two babies in room 3. Among her duties, as shown on the timeline chart, are signing for medication for babies in that room between 10.08-10.21pm, making nursing notes regarding grunting for one of the babies at 10pm, and making observations.
She says she became aware of Child C at the time of his collapse, and her being called to help. Prior to that, she says she was not aware of his events, and was not in room 1.
She says she was called over by nurse Sophie Ellis and asked her to put out a crash call. Melanie Taylor was "in the nursery when I arrived [in room 1]", with Child C.
He was "apnoeic and needed respiratory support".
Another nurse was present in the nursery at the time.
Sophie Ellis put out the crash call.
Letby says she was involved in chest compressions as part of resuscitation efforts.
Letby is asked why she can now confirm she was in room 3 of the nursery, having not been able to remember to that in police interview. Letby says she was able to remember being in nursery room 3 after since being made aware of which babies were in room 3 that night.
Letby says she can recall alarms going off, but not standing cotside, or saying anything regarding Child C's observations to Sophie Ellis.
She says she was said to have been in room 1 based on the statement by Sophie Ellis, but she tells the court she had not been in that room prior to Child C's collapse.
She says she had been 'put' in that room 1 based on Sophie Ellis's statement. Letby tells the court she has no recollection of being there. She says she suggested explanations to police in interview of what she was doing in room 1 based on the statement, not on her independent recollection.
Letby says her memory of that night was: "I believe that I had been called to help [Child C following his collapse]".
She says she had assumed what police had told her in interview to be true, based on Sophie Ellis's statement.
Messages between Letby and colleague Jennifer Jones-Key are shown to the court, in which her colleague says: "You need a break from full on ITU. You have to let it go or it will eat you up I know not easy and will take time x"
Letby had initially messaged her about wanting to be in room 1, but a colleague had said no. Nurse Jones-Key replied she agreed with the colleague.
Letby is asked, following a disagreement between her and nurse Jones-Key at 11.05pm, whether those messages had led to her taking any action on Child C minutes later. Letby denies that was the case.
Mr Myers: "Do those messages have anything to do with [Child C]?"
Letby: "Not at all."
Letby says she would have been aware of Child C's family during resuscitation efforts, and that was the first time she had seen them.
Asked why she had searched for the parents on Facebook, Letby says they were on her mind.
She adds: "When you go home you don't forget about the babies you cared for."
She says, about what the parents had gone through: "It's unimaginable."
Lucy Letby gave this evidence on 18th and 19th May 2023, taken from Chester Standard (18 May 23) and https://www.chesterstandard.co.uk/news/23532994.recap-lucy-letby-trial-may-19---cross-examination-continues/]Chester Standard (19 May 23)
Mr Johnson turns to the case of Child C.
Letby is asked to look at her defence statement.
Letby recalls she did not believe she was in room 1, and cannot recall how she ended up in room 1 - possibly it was as a result of Child C's alarm going off.
Letby, in her statement, said she had been involved in speaking to the family afterwards, but not to the extent Child C's mother had said.
Mr Johnson said a nurse had given evidence to say Letby had to be removed from the family room after Child C died.
Mr Johnson says Letby's "vague" recollection of events is untrue.
LL: "I don't agree with that."
NJ: "I'm going to suggest you enjoyed what happened, and that was why you were in the family room."
Letby is asked why she did not remember Child C in police interview. Letby says she remembered once provided with further details.
She adds: "I don't know how [child C] died." She rules out staffing levels, medical incompetencies, or someone making a mistake.
Mr Johnson says this is a case where one of the nursing notes, by Yvonne Griffiths, was 'misfiled' to a different baby, and was, after Child C died, refiled back to Child C.
Mr Johnson asks Letby if nursing notes, timestamped by their start and end, are editable.
The court hears because of this, the note had to be re-entered into the system.
The rewritten note is shown to the court.
The note is for the June 12 day shift. It includes: '...no apnoeas noted and caffeine given as prescribed. Longline inserted by Dr Beech on second attempt...[Child C] unsettled at times soothes with pacifier and enjoyed kangaroo [skin-to-skin] care with parents."
A nursing note by Joanne Williams is shown to the court for Child C on the day shift: '...[Child C] very unsettled and fractious...[Child C] taken off CPAP while out having skin to skin with mummy. Calmed down straight away with mummy...'
Letby agrees this was a "positive picture" for Child C.
Child C was on CPAP breathing support to 10am, then was taken off it for a couple of hours, then was on Optiflow breathing support for the rest of his life.
Mr Johnson moves on to the shift in which Letby was present. A shift rota is shown to the court, showing Letby was looking after two babies that night on June 13. She was in nursery room 3, with Child C in room 1 that night.
Mr Johnson says this was another shift when Letby had "migrated" to room 1.
Letby: "Yes, in response to [Child C's] care needs." She says she has no recollection of going to see Child C prior to his collapse.
Letby says she was unhappy at being in room 3 for that shift - as opposed to room 1 - but that was the decision of the prior shift leader.
Letby's nursing colleague had said Letby's designated baby in room 3 needed attention, after Letby had asked if she could be redeployed to room 1 that night.
Letby: "Yes, [they] did need attention and I gave [them] attention."
Letby had sent a message to Jennifer Jones-Key: "I just keep thinking about Mon. Feel like I need to be in 1 to overcome it but [colleague] said no x"
JJK: "I agree with her don't think it will help. You need a break from full on ITU. You have to let it go or it will eat you up i know not easy and will take time x"
LL: "Not the vented baby necessarily. I just feel I need to be in 1 to get the image out of my head, Mel has said the same and [colleague] let her go. Being in 3 is eating me up, all I can see is him in 1"
"It probably sounds odd but it's how I feel X"
JJK: "Well it's up to you but don't think it's going to help. It sounds very odd and I would be complete opposite. Can understand [colleague] she trying to look after you all"
LL: "Well that's how I feel, from when I've experienced it at women's I've needed to go straight back and have a sick baby otherwise the image of the one you lost never goes. Why send Mel in if she's trying to look after us, She was in bits over it. X
"Don't expect people to understand but I know how I feel and how I've dealt with it before, I've voiced that so can't do anymore but people should respect that X"
JJK: "Ok x
JJK: "I think They do respect it but also trying to help you. Why don't you go in one for a bit. X"
LL: "Yeah I've done couple of meds in 1. I'll be fine X"
JJK: "It didn't sound like you would be? Sorry was eating my tea x"
LL: ...Forget i said anything, I'll be fine,It's part of the job just don't feel like there is much team spirit tonight X"
JJK: "...I'm not going to forget but just think your way to hard on yourself. It is part of the job but the worst part but I do believe it makes us stronger people."
LL: "Unfortunately I've seen my fair share at the women's but you are supported differently & here it's like people want to tell you how to think/Feel. Anyway. Onwards & upwards. Just shame i'm on with Mel & [colleague].Sophie in 1 so haven't got her to talk to either."
JJK: "Work is work.
A lot of the girls say women's don't support and tell them to get on with it. I think they don't mean to tell you thou and were over caring sometimes
Yeah that's not good but you got Liz x"
LL: "Women's can be awful but I learnt hard way that you have to speak up to get support. I lost a baby one day.and few hours later was given another dying baby just born in the same cot space. Girls there said it was important to overcome the image. It was awful but by.end of day i realised they were right. It's just different here X
"Anyway, forget it. I can only talk about it properly with those who knew him and Mel not interested so I'll overcome it myself. You get some sleep X"
Letby accepts there were two babies in room 1, but does not accept she was specifically wanting to look after Child C.
Letby tells the court: "It wasn't about me wanting to get my own way."
Letby accepts she was upset, "just generally", that her feeings weren't being considered by a colleague and Melanie Taylor.
Mr Johnson says if this was the Melanie Taylor who Letby had said "potentially" caused a child's death. Letby: "Potentially, yes."
JJK: "That's a bit mean isn't it. Don't have to know him to understand we've all been there. Yep off to bed now x"
LL: "I don't mean it like that, just that only those who saw him know what image i have in my head X
"Forget it. Im obviously making more of it than I should X"
Letby tells the court she had hoped Jennifer Jones-Key would have been more understanding to how she was feeling, and was frustrated, and the conversation was not going anywhere, so she wanted to "leave the conversation".
Letby says colleague Sophie Ellis was the least experienced member of staff on that shift and "did not have the skills for the job" of looking after small, premature babies in room 1.
"I did not think she was qualified for the job...She did not have the skills for the premature babies [in room 1]."
She denies that Sophie Ellis did anything to cause Child C's collapse.
Mr Johnson: "She had something you wanted?"
The court hears Sophie Ellis's statement saying when she entered room 1, Letby was by Child C's cotside, saying: "He's just dropped..his heart rate/saturations" or words to that effect.
The court is shown the neonatal schedule for the night shift of June 13-14, 2015. Letby is shown recording observations for her designated babies, and made medication prescriptions for babies not in room 1.
Letby says the medications for those babies would have been drawn up in room 1. "They could not have been done in a special care nursery".
Letby says if Sophie Ellis has documented correctly, there would have been no air in Child C's stomach after an aspiration was made for the baby's feed.
Letby denies taking, in Mr Johnson's words: "an opportunity to sabotage [Child C]."
In police interview, it is put to Letby that Child C collapsed six minutes after she sent the last of her text messages.
Letby: "I don't recall where I was at the time" - Letby says she may have been in a nursing station before going into room 1.
Letby said she did not recall being cotside, but accepted Sophie Ellis's account at the time it was put to her by police.
"The death of [Child C] was very memorable, wasn't it?"
From evidence given on 19th May 2023:
Mr Johnson says text messages were exchanged between Letby and Jennifer Jones-Key between 11.01pm and 11.09pm.
Letby says she does not accept she was in room 1 at the time of Child C's collapse. She says she has "no memory" of it.
Nurse Sophie Ellis had said she was in room 1 at the time, and Letby said in police interview, based on that, she was in room 1.
Letby says she "disputes" that, as she has "no memory" of it.
"Do you dispute being born?" Mr Johnson asks.
"No." Letby replies.
NJ: "But you have no memory of it?"
Letby is asked why she let a band 4 nursery nurse look after her designated baby.
Letby says it's "not unusual" for band 4 nurses to assist her in her duties.
LL: "I have no memory of that".
NJ: "Did you have something better to do?"
Mr Johnson says the text at 11.01pm sent by Letby to Jennifer Jones-Key meant she must not have been in a clinical area, and would not have had time to feed her designated baby in room 3.
LL: "I can't answer that."
Mr Johnson says it took her out of the nursing area. Letby said she would have been "in the doorway" of the unit.
Mr Johnson says Melanie Taylor, in evidence, described Letby as "cool and calm".
Letby does not dispute that.
She disputes saying to the Melanie Taylor that Child C had had a brady, as she has no memory of it.
Notes by Dr Katherine Davis are shown to the court for Child C's collapse.
At the time of arrival, "chest compressions in progress"
"Occasional intermittent gasps noted".
"Unable to pass ET Tube as cords++" - the court hears the cords were "swollen".
Mr Johnson asks Letby if it was a "theme" that when doctors went to intubate, they had difficulties, with swollen cords and/or bleeding. Letby accepts that was the case. She denies putting anything down Child C's throat.
Mr Johnson: "Do you agree something caused [Child C]'s stomach to dilate before the collapse?"
Letby says the stomach dilation "could have been caused by the Neopuff resuscitation".
Letby is asked if she had seen the kind of decline as seen by Child C before. Letby says she has, but not the way Child C 'clinged to life'.
NJ: "You enjoyed the aftermath of this, didn't you?"
NJ: "Why were you so keen to spend time with the [Child C] family as they cradled their drying child?"
LL: "I don't agree with that, I wasn't there a lot of the time."
Letby disputes being "repeatedly" in the family room afterwards, adding: "I don't recall [colleague] having to pull me out [of there]."
She disputes the statement made by her colleague.
Letby is asked "what useful function" she was contributing to the family during the "dreadful situation" they were going through.
Letby said she cannot recall, other than gathering the mementos, which is a two-person job.
Letby says she would have to see the bereavement checklist charts to see if there was anything she had co-signed, as otherwise she does not recall and has no memory.
The judge asks if hand and footprints are collected when the baby is still alive. Letby replies they can be, or after they have passed.
Letby denies that she was "enjoying what was going on".
Sequence of events from records
Text messages exchanged following the deaths of Child A and B show Lucy Letby asking if there were spare shifts going, adding: "Think I need to throw myself back in on Saturday."
The response: "Hopefully it might settle down by then."
Letby: "I think from a confidence point of view I need to take an ITU [intensive treatment unit] baby soon."
The response: "It does knock you a bit when things like that happen, but it's ok to have time out as well. Enjoy the sun"
The court is shown the nursing night shift for June 13, with a different nurse identified as the designated nurse for Child C, and Letby being a nurse for two other babies.
13 June 2015
9.48pm: A message sent to Letby on June 13, at 9.48pm, says: "You ok? x"
Letby replies: "I just keep thinking about Mon. Feel like I need to be in [neonatal unit room] 1 to overcome it, but [nursing colleague] said no x"
The colleague responds: "I agree with her, don't think it will help. You need a break from full-on ITU, you need to let it go or it will eat you up..."
Letby responds: "Not the vented baby necessarily, I just feel I need to be in 1, to get the image out of my head."
Letby adds: "It probably sounds odd but it's how I feel x"
The colleague responds: "Well it's up to you but I don't think it's going to help."
After further messages are exchanged, the colleague suggests: "Why don't you go in 1 for a bit?"
Letby responds: "Yeah, I have done a couple of meds in 1."
Letby later adds: "Forget I said anything, I will be fine, it's part of the job. Just don't feel like there is much team spirit tonight x"
The colleague replies: "I am not going to forget but think you're way too hard on yourself..."
Letby referred to previous events she had seen in a women's hospital, and the support available following such events.
11pm: The text message conversation, on Whatsapp, concludes at about 11pm.
11.20pm: Child C collapsed 20 minutes later.
14 June 2015
AM: Text messages and Whatsapp messages sent to and from Letby's phone the morning after Child C died are shown to the court.
Letby messages a colleague: "Sorry I was just off [last night], was not a great start to shift but sadly it got worse."
The colleague responds: "You weren't off, you just were not happy and there is nothing I could say that was going to make it any better."
Letby: "I was struggling to accept what happened to [Child A], now we have lost [Child C] overnight and it's all a bit much."
The colleague replies: "It will be but it does happen to these babies unfortunately."
"It's a very sad part of our job."
The colleague recalls a baby who had previously died in the neonatal unit, but had "overwhelming sepsis" so "nothing would have saved that baby".
Letby: "[C] is the little 800g baby...went off very suddenly. I know it happens but it's so sudden..."
Messages are relayed detailing how nursing staff on the night were upset by what happened.
Letby's colleague messages: "This is where we have to pull together and look after each other."
Letby: "Think we support each other brilliantly...just such a shock especially after Monday."
Letby is advised to "switch off for a bit".
Letby messaged her mum that morning to say: "We lost a little one overnight. Very unexpected and sad xx"
Letby added, in the message to her mum: "He only weighted 800g...new girl was looking after him, she is devastated."
Letby's colleague, in a message to Letby, said: "Hoping you are going to ok, this is not like you. Sending the biggest hugs."
Letby, in her reply, says: "It's heartbreaking but it's not about me."
Letby's colleague, in her reply, says to use a 'northern phrase': "Chin up chuck we will get through it together."
Letby: "It's not about me or anybody else, it's those poor parents who have to walk away without their baby."
Letby messages another colleague asking when she is next work, before adding: "We lost little [Child C] overnight, everyone's devastated."
The colleague responds: "Damn. Infection? Crap week. How is [Child B]?"
Letby gives an update and says, for Child C, "it happened very quickly."
The colleague responds: "Damn. As quick as [Child A]? Yeah, s*** week."
Letby messaged the colleague: "Parents sat with [Child C] in the family room...persuaded them to have hand and footprints but they just wanted to go home."
The colleague responds: "That is so sad, don't know what to say."
Letby: "There are no words, it's been awful."
The colleague: "It's a really tough week, especially for you."
10.12am: The conversation ends at 10.12am.
3.32pm: Letby searched for both the parents of Child C on Facebook later that day, at 3.32pm.
A conversation Letby has with a third colleague, later that day, is shown to the court.
Letby: "I don't really want to go in tonight."
The colleague responds: "I don't particularly but we will get each other through it."
Letby: "We are a good team and we will get through. You did so so well."
The colleague: "We all did - so lucky to work with such an amazing and supportive team."
Witness statements agreedAgreed witness statements read out in court not contested by defence.
Family - Mother
The first 'agreed evidence' statement comes from Child C's mother, dated January 2019
The mum said she had gone for an anatomy scan at the Countess of Chester Hospital.
She was informed, while everything was 'normal', the baby 'looked very small'.
It was recommended a test was to be taken for any genetic conditions that may be present.
The results of the scan showed there were 'no genetic problems'. The baby was small, 'but it was not known why'.
Further scans were held, along with blood flow checks.
Child C's growth then 'began to falter' later on, and it became delivery would take place 'quite soon'. She was being monitored 'twice weekly'.
In June, the mother had raised blood pressure in a test, and she was admitted to the Countess of Chester Hospital as a precaution.
That night, it was found Child C's heart rate had dropped, and she was moved to the labour ward as concerns had grown.
On this occasion, nothing happened, so she was moved back to the antenatal ward.
The following Monday, the dedicated consultant said it would be best to closely monitor the situation.
On June 10, the mother had a scan, and found there was a risk of a still-born birth. The mum was taken to the labour ward and given various drugs to support the baby.
The mum was then taken to theatre and a Caesarean section took place.
"The birth was extremely stressful," the mother recalls.
Child C was incubated and put on a ventilator, but the mum was told the nursing staff "weren't particularly concerned" for his immediate condition.
The mum was unable to see Child C for several hours afterwards.
She said she was able to see Child C - "tiny", weighing "800 grammes", that night.
Child C was given CPAP and had been taken off ventilator support.
On June 11, the mum and dad had "small periods of time" where they could hold Child C.
The nurse Joanne Williams there was "very supportive".
In the following days, Child C was taken off CPAP and was "calmer" on June 13.
He had a gastric tube fitted. When fluid came out, it was a black colour and staff could not explain what that was.
The family had "a cautious positivity" for Child C. His oxygen levels were being weaned down "as he was doing so well".
She was woken up at 11.20pm by one of the nurses, having been contacted by one of the neonatal nurses to go there "immediately".
She arrived to see CPR being performed on Child C. "He had stopped breathing without any warning.
"This was sudden and unexpected."
The mum told her husband to come to the neonatal unit.
She recalls not being able to take everything in, and was asked by a nurse if she wanted to get in contact with a priest. The mum was shocked and asked if Child C was going to die. The nurse replied in the affirmative.
The mum said while waiting for a priest, her husband arrived. They had to wait for 50 minutes until the priest arrived.
She was told Child C, after being baptised, had passed away. Although there was a pulse, there was no brain activity.
The mum said: "It was awful."
After Child C passed away, the mum handled him.
She was asked by a nurse if they wanted a lock of his hair.
On June 15, she was contacted by the coroner's office at Alder Hey, for the post-mortem.
She was advised the conclusion was "natural causes".
Family - Father
The father's 'agreed evidence' statement is read out to the court.
He said the mum's Pregnancy was "highly stressful", and recalls she had elevated blood pressure, requiring a trip to hospital.
He recalls being present for Child C's birth, where the child was placed into an incubator.
He said medical staff were "really pleased" with him, and he followed Child C into the neonatal unit.
He said Child C "was still doing well" in the first few hours, and needed respiratory support, but was "capable of breathing independently".
"At no point did the staff express concern of him not surviving."
He said Child C had contniued to do well, and was at home when he was called by the mum to come to the hospital "right away".
When he arrived, the mum was waiting for her and he was informed Child C had collapsed and stopped breathing.
"She didn't think she could do any more", but they continued trying, until a priest arrived.
Child C then began breathing by himself.
The family were taken into a room, where there were two nurses there, one of whom the father has since been able to identify as Lucy Letby.
The father and mother took turns holding Child C, "as we knew he wasn't going to make it".
He remembers one of the nurses administering morphine to Child C.
At regular intervals, the nurses came in to check on their welfare.
A hand and footprint were taken of Child C, along with toys that were cotside.
The father said he and the mum looked after Child C in that room: "We just wanted to cuddle him and make sure he was pain free."
One of the nurses came in and said something along the lines of 'you've said your goodbyes, now do you want me to put him in here [a basket]?'
The mum said 'he's not dying yet', and the nurse backtracked.
"We remember being really shocked by this."
Dr Andrew Brunton
Nurse Bernadette Butterworth https://www.chesterstandard.co.uk/news/23092103.recap-lucy-letby-trial-tuesday-november-1/
Dr Sally Ogden
The court is now hearing evidence from Dr Sally Ogden, who in 2015 was a paediatric registrar at the Countess of Chester Hospital.
Child C was born at 3.31pm on June 10, 2015, with Dr Ogden confirming she was present at the birth and facilitated the baby boy's transfer to the neonatal unit.
Child C was "smaller than expected for that gestation", with a C-section made necessary.
The birth weight of 800g was within the range for Child C to be allowed to be treated at a Level 2 neonatal facility - the one at the Countess of Chester Hospital.
An 'Apgar score', recording how well the new-born is doing immediately after birth, is noted, rising from 7, to 9 out of 10.
A clinical note showed there were 'no RF [risk factors] for sepsis', and Child C was "born in good condition", "came out crying, good resp[iratory] effort...no resus[citation] needed...pink...well perfused."
The heart rate was ">100", the saturation was "95% air".
Dr Ogden said those latter two readings were what would have been expected.
Upon arrival to the neonatal unit, Dr Ogden noted symptoms Child C was starting to struggle breathing, including grunting and subcostal recessions.
The note added: "Decision to intubate", which Dr Ogden said would have been her decision.
The respiratory signs "can change quite quickly after birth", Dr Ogden says, so such support for babies of Child C's pre-term "would not be unusual".
Ventilator support was set up for Child C, with "standard settings...for the context" set up on the machine.
A note of medical communication with the parents is shown to the court.
Dr Ogden's colleague recorded observations taken by her, relaying to the parents that Child C was born in a good condition with good breathing.
Another clinical note showed a 10% dextrose solution would be administered via a TPN bag, through a UVC.
A note on a discussion between the hospital and the Liverpool Women's Hospital was made - due to Child C's weight. The discussion would have raised the possibility of Child C being transferred to Liverpool.
The clinical note, regarding a possible transfer for Child C, concludes: "Happy for patient to remain @ CoCH [Countess of Chester Hospital] at present. If clinical concern overnight for rediscussion with [Liverpool Women's Hospital]."
A clinical note, dated June 11, 2015 at 11am, is made by Dr Ogden, with a number of medical observations.
They include details of the respiratory support and feeds.
Dr Ogden says Child C was on CPAP support by this time, on 41% oxygen - a "moderate" amount for a pre-term baby, with other readings being normal.
There was an increased breathing rate noted.
A high lactate reading was noted, "which needed to be noted in context" with other readings. It was a "sign of multiple different conditions" and, Dr Ogden says, was a sign to look out for such conditions.
Child C's blood sugar levels were stable.
Child C was screened for sepsis, and placed on antibiotics "as a precautionary measure".
There were "no concerns" on the cardiovascular system.
Another note by Dr Ogden at June 13, 9.30am is made for Child C.
The list of 'problems' is noted, including 'RDS' and 'suspected sepsis'.
Dr Ogden says the oxygen levels had gone down on CPAP to 26%, as had the lactate reading.
Child C's breathing was "stable and possibly improved".
"Very dark bilious aspirates" are noted from the feeding section.
This was "not normal" and "suggested a problem with his abdomen", or a sign of how Child C's bowels were responding to being pre-term.
"That would have been a concern," Dr Ogden said.
Child C was observed to be "active, pink, well perfused", with "chest clear, slight increase in work of breathing".
Other observations were recorded as normal.
The overall picture was Child C was "responding as to be expected".
The prosecution say a 'generic plan' of next steps was put forward for Child C, to which Dr Ogden agrees.
Child C had a long line put in place by this time.
Other observations made included that chest was clear with no increased work of breath.
The abdomen was "soft, not distended", which Dr Ogden said was a "reassuring sign", amid a concern from Child C's aspirates that the gastro-intestinal disease NEC was a possibility.
The reviewing doctor suggested to "hold off feeds" for now and review in the afternoon if the aspirates did not get any worse.
Ben Myers KC, for Letby's defence, is now asking questions to Dr Ogden.
He refers to the decision about which hospital Child C should have been placed in.
Liverpool Women's Hospital offered Level 3 neonatal care, with the Countess of Chester Hospital offering Level 2 care at the time.
Dr Ogden said she "believed" the minimum weight for Level 2 care centres to treat babies was 800g - the birth weight of Child C.
Mr Myers: "He was right on the borderline of what could be accepted at the Countess?"
Dr Ogden: "Yes."
Mr Myers refers to the conditions detected that led to the C-section.
He asks if one of the conditions that could follow would be NEC.
Dr Ogden agrees.
Mr Myers said for such babies, there would be an increased risk of infant mortality. Dr Ogden agrees.
She also agrees that Child C would be a "high risk" baby.
She says that for the context, and taking the considerations for those conditions into account, Child C was in a good condition.
Mr Myers refers to the Apgar score for Child C at birth, with readings at one minute, five minutes and 10 minutes. Child C scored 7/10, 9/10 and 9/10 respectively.
The scores are "subjective" and based on observations.
Mr Myers asks about the clinical note which refers to the discussion between the Countess and the Level 3 Liverpool Women's Hospital.
Mr Myers: "At this early point, your view was that Liverpool Women's Hospital needed some communication [in relation to whether Child C would need to be transferred]?"
Dr Ogden: "Yes, that's right."
Mr Myers says if Child C had other problems, along with a 'borderline' weight, then that may affect the decision to transfer a baby to a tertiary centre.
Dr Ogden: "Potentially, it would depend on the circumstances."
Dr Ogden said the decision to transfer would be a joint one made between the hospitals and made via consultants.
Dr Ogden said if Liverpool Women's Hospital could not accommodate a baby, there would have been other tertiary centres available if necessary.
Mr Myers says the Countess would have required sufficient numbers of staff to care for Child C.
He asks if June 2015 "was a particularly busy time for [the neonatal unit in] Chester?"
Dr Ogden: "Yes."
Mr Myers said with the number of babies, another factor would be the individual care required for each baby, which included a number of pre-term babies in June 2015.
Mr Myers now refers to the case of Child C.
He asks about the risk of infection, which Dr Ogden was "not immediately a concern" at the time of his birth.
Mr Myers says infection "is always a potential risk".
He asks about the breathing issues Child C had at birth, and asks whether such issues could be a "sign of infection". Dr Ogden agrees.
The court is shown an x-ray review in which a staff member had noted "hazy left lung field".
Dr Ogden said she hadn't seen the x-ray, but agrees the note in the review means there could be a sign of infection.
The list of 'problems' in a clinical note is raised, including 'suspected sepsis'.
Dr Ogden says there was a treatment plan in place for 'suspected sepsis'. The 'high lactate' noted is an indicator of a potential, non-specific issue with the baby, the court hears.
The clinical note from June 13 is raised.
Mr Myers suggests there are 'increased issues' for Child C.
Dr Ogden: "It's hard to say."
Mr Myers refers to the 'very dark...black aspirates', and Dr Ogden agrees they are "a cause for concern".
Mr Myers asks if the aspirates are a 'red flag' warning sign.
Dr Ogden: "It's certainly a worrying sign which would need more investigation."
A nursing note is presented which showed Child C's weight, by June 13, had dropped to 717g. The note adds: "Doctors aware."
Mr Myers says if that was the weight of Child C at birth, he would not have been card for at the Countess.
Dr Ogden: "I don't think so, no."
Dr Ogden agrees at this point, there would have been some concerns with Child C, and he would've needed close monitoring care.
That concludes Dr Ogden's evidence.
Dr Gail Beech
In June 2015, Dr Beech was working at the Countess of Chester Hospital as a registrar.
She confirms working day shifts on June 11-12 and had involvement with Child C and his parents.
She confirms she carried out an ultrasound scan for child C on June 11, and the reviewing doctor recorded 'NAD' - no abnormalities detected.
Dr Beech's note made on June 12, 10.15am is shown to the court.
She recorded, from data, Child C was on CPAP, 30-40% oxygen assistance from CPAP, the saturation levels for Child C were '91-98%', with 'no documented desaturations'. Gases were 'satisfactory'.
"It looks like he was pretty stable on those CPAP settings," Dr Beech tells the court. The gases refer to the blood gases.
The urine levels were "slightly high, but not concerning yet".
Under the heading 'sepsis', a CRP reading going up was "something to be aware of" but "not a huge rise", according to Dr Beech, and a note 'awaiting lumbar puncture' was made.
The lactate reading recorded is 1.8-2.8. Dr Beech says 2.8 is "high" but had been falling from a higher number.
Dr Beech said there was "nothing there" on the clinical chart numbers which was "worrying", with a few readings being "something to be mindful of".
He was a "nice stable baby" as he had been allowed out of his incubator to be allowed skin-to-skin contact with his mum, Dr Beech added.
Dr Beech said the UVC had come out of Child C during a previous shift, and a note was made for a long line to be inserted later.
The follow-up note showed Dr Beech had inserted the long line under sterile conditions, and was secured in at the third attempt, with the note 'happy with position', adding 'patient left comfortable'.
An x-ray of Child C, timed 12.36pm on June 12, shows the long line having been inserted.
An x-ray review recorded, in the comments, 'large stomach bubble, gaseous bowel'.
Dr Beech said this "wouldn't be a huge concern" given Child C was on CPAP.
Dr Beech reiterates there were no significant concerns for Child C at that point, but there were "matters to be mindful of".
Mr Myers now asks Dr Beech questions on behalf of Lucy Letby.
The three attempts to insert a long line, from a clinical note, are shown to the court again.
Mr Myers asks if there is a guide to the number of attempts, or who should administer them.
Dr Beech said it would be a procedure by a doctor, not a nurse, and would be done by the most junior doctor present, to get them experience, subject to availability and the complexity of the procedure.
Dr Beech said there was "an unwritten rule" a registrar would have two or three attempts before escalating the procedure to someone more senior.
Dr Beech explains the note 'flushed' is made as confirmation the long line has been 'flushed' to ensure there is no air in it.
The x-ray of Child C with the long line in is presented to the court again.
The dark areas in the stomach and bowel areas refer to air inside the body, the court hears. It is compared to an x-ray taken of Child C at birth, where there was also a pocket of air in the stomach.
Dr Beech noted, from the June 12 x-ray, it was "very gaseous", and the result of CPAP.
Mr Myers asks if that could also be termed 'CPAP belly'.
Dr Beech says it could.
Dr Beech has concluded giving evidence.
Nurse Yvonne Griffiths
The court is now hearing evidence from Yvonne Griffiths, who was the Countess of Chester Hospital neonatal unit deputy manager in June 2015 and a senior nursing practitioner.
An 'admin error' had resulted in Ms Griffiths' notes for child C being written in the file for a different child, but the error was spotted and rectified quickly.
The note is written on June 14 on reflection notes from June 12, with care from 8am that day.
The notes record "assistance with ventilation by NCPAP", with oxygen levels varying from 37% to 25%.
Child C was "unsettled at times". Ms Griffiths said he "only loved to be held by parents in a kangaroo style".
The long line was administered, and at 6.30pm, 'bile noted on blanket'. Ms Griffiths said with any baby there is a worry with introducing feeds too early. On this occasion bile came out "spontaneously".
Ms Griffiths said the naso-gastric tube was aspirated as a matter of procedure and 2mls of black stained fluid appeared.
Child C was "too unsettled" for a lumbar puncture - plan to reassess later".
Ms Griffiths said they would not want to take the risk if the baby was too active, as a lumbar puncture would involve a needle.
Ms Griffiths added she came in the morning after Child C had died, to assist staff.
Mr Myers says Child C was "at the limit" [for weight] for being accepted into care at the Countess of Chester Hospital.
Ms Griffiths had said, in a police statement, the hospital did not often care for babies of that weight.
She tells the court there is a decision to be made whether the baby is suitable to be cared for at the Countess, or risking transfer to a tertiary centre, and that is made following consultation.
Ms Griffiths said, in the police statement, "it was very uncertain" what the outcome would be for Child C.
She confirms she was the designated nurse for Child C on June 12. She also confirms Letby was not in the unit that day.
Mr Myers talks through the nursing notes from the previous night shift, for June 11-12. At that point no bile aspirates had been recorded.
He refers to a note about Child C requiring an increase in oxygen when handling as Child C was desaturating.
Ms Griffiths says, in relation to the air in the stomach, the nurses "did everything" they could through the naso-gastric tube to aspirate air.
The note referring to bile found on the blanket and 2mls of black stained fluid being aspirated from June 12 at 6.30pm is referred to.
Mr Myers asks if dark bile is a matter for concern.
"Any bile is a matter of caution," Ms Griffiths replies, and feeds would be stopped as a precaution.
She added Child C did not desaturate when vomiting a small amount of fluid. She agrees it was important for close monitoring on Child C.
Mr Myers: "It is a potentially serious issue, isn't it?"
Ms Griffiths: "Yes - and I did get the doctor to review."
Ms Griffiths has finished giving evidence.
Nurse Joanne Williams
The first witness to give evidence today is Joanne Williams, who previously gave evidence, in an agreed evidence statement, for the case of Child A and Child B.
The court is reminded she was a neonatal unit nurse in June 2015.
Mrs Williams recalls she was the designated nurse for Child C on June 13, and had cared for him prior to that day.
She said that particular day shift was 'not too busy'.
She recalls Child C was small and premature, and weighed 800g at birth.
A nursing note by Mrs Williams is presented to the court, written retrospectively at 4.19pm on June 13, shows Child C was on NCPAP with 23-26% oxygen - "a minimal amount of oxygen".
Mrs Williams said that was "a good sign".
A blood gas reading was "very good" at 9am, but Child C was noted to be "very unsettled and fractious", which Ms Williams tells the court was not that uncommon for a baby of his size.
The note adds Child C was allowed to be taken off CPAP to have skin-to-skin contact with mum.
Mrs Williams says such contact is "extremely powerful" for a new-born baby and is "really beneficial" for them. The note adds Child C "calmed down straight away while on mummy, just required some facial [oxygen] while out. No signs of increased work of breathing".
Child C was weaned off CPAP for two hours and placed on Optiflow at 1pm as, it was noted, the baby boy was "so unsettled on NCPAP".
The court hears Optiflow is a less invasive form of breathing support than CPAP.
Child C was "very settled this afternoon" with a "slight increase in respiratory rate".
A further blood gas reading was taken later in the afternoon with readings "not quite as good", which Mrs Williams was "something to be taken into consideration" and had followed Child C being placed on Optiflow.
The note adds: "Clinically remain stable but aware do not want to push [Child C]."
Mrs Williams said fluids were increased, with 10% dextrose discontinued as it was day 4, and the dextrose would not have been needed with lipids [fats] increased to support nutrition.
The note adds: "Continues to have dark bile aspirates, frequently this morning".
Mrs Williams says it's "not reassuring" as it could be a sign of NEC [a gastro-intestinal disease].
Philip Astbury, prosecuting: "Was it of concern?"
Mrs Williams: "Yes."
It was escalated to an on-duty doctor that day.
Mrs Williams says Child C was on nil-by-mouth and a cautious feeding regime.
The court hears Child C had pulled out two oral gastric tubes during the morning due to being "feisty" and unsettled.
A naso-gastric tube was "on free drainage" to drain air from Child C, reducing air build-up in the stomach, and check for any aspirates.
The notes adds: "Abdo[men] full but soft". The court hears that was "quite normal for a baby...for [Child C]."
The abdomen had a "slight shine but not veiny or distended".
The court hears a distended abdomen would be a symptom of NEC.
The note adds: "If aspirates improve can start [trophic] feeds this evening".
Rantidine was administered via an IV to counteract the bile aspirates.
The weight of 717g was noted, which Mrs Williams says is not unusual as all babies lose weight in the first few days.
She said doctors were aware of the weight update.
A cranial ultrasound scan was carried out, with 'no abnormalities detected'.
An intensive care unit chart for Child C is now presented to the court, which details the various readings and notes corresponding to Mrs Williams's nursing note.
The aspirates of dark bile are recorded at 9am and 1pm. 0.5ml dark bile is recorded at the latter, which was a "small" amount, but any dark bile was a "concern", Mrs Williams says.
A further 0.5ml of dark bile is aspirated at 4pm.
A nursing note of 'family communications', from June 13, is shown to the court, written by Mrs Williams.
She records: "Mummy and daddy on the unit during the day, both have had skin-to-skin with [Child C]. Pleased to see him more settled this afternoon.
"Appear happy with plan of care."
A further nursing note showed a blood gas reading at 6pm was "improvement from previous CBG", but lactate levels had increased.
Child C remained on Optiflow and was "stable".
The aspirates were "reduced this evening".
The note adds: "?? Commence entral feed tonight"
Mrs Williams clarifies: "Query query."
Mrs Williams said you would "always be cautious of a baby that size", referring to Child C.
Mr Astubry: "How was the progress during that shift?"
"He had done well, weaned off to Optiflow, he had benefitted from time with mum and dad."
Ben Myers KC, for Letby's defence, is now asking Mrs Williams questions.
She agrees that "you can never be complacent" with a child like Child C, and however stable he is, he would require close monitoring.
She said it was important to carry out observations, and look for "subtle signs".
Mr Myers says the observations for Child C need to be taken into context for a baby the size of Child C.
Mrs Williams says that could "potentially" be the case.
She adds she was aware of pre-existing concerns raised at Child C's birth.
Mr Myers asks if Child C still needed breathing support with Optiflow, and would not have been switched if he had been settled on NCPAP.
Mrs Williams says he had good blood gases so was able to "step down" respiratory support to Optiflow.
Mr Myers: "You are documenting all the little changes made [on the nursing notes], because he is such a little baby?"
Mrs Williams: "It is important to be thorough."
The note of 'aware do not want to push [Child C]' is raised.
Mrs Williams: "It's making sure we are doing individual care and very aware of what's happening with [Child C] and what he needs."
Not wanting to push Child C was not to tire him, and/or administer procedures such as a lumbar puncture.
Mrs Williams said not wanting to push Child C, in this context, was in relation to breathing.
Mr Myers: "Could that apply to feeding as well?"
Mrs Williams: "Yes."
The matter of dark bile aspirates is mentioned.
Mr Myers: "We have seen from the chart, that aspirates have been taken throughout the day, and they have been there the day before?"
Mrs Williams: "Yes."
A distended abdomen could be a symptom of other conditions, Mrs Williams adds, but NEC would be one which would be of concern.
The 'trophic feeds', as mentioned on the nursing note, would be via expressed breast milk if the aspirates improved, along with the "overall clinical picture", Mrs Williams tells the court.
The weight of 717g is "a significant reduction, isn't it?" Mr Myers asks.
Mrs Williams says it would need to be taken into context, and it was important to administer feeds safely.
The plan to do so would be, following a discussion, to commence entral feeds that night.
Mr Astbury rises to ask one more question on CPAP: "Would you ever take a baby off CPAP just if they were unsettled?"
Mrs Williams: "No."
The court hears the step down to Optiflow would be done in consideration with other factors.
Mrs Williams has now finished giving evidence for Child C.
Nurse Sophie Ellis
The next witness to give evidence in court is Sophie Ellis, who was working as a neonatal unit nurse in June 2015.
She recalls Child C, and first saw him first when he was delivered, as an observer, learning in the nursing role.
She said she was on duty for the night-shift of June 13, starting at 7.30am, ending at 8am the following day.
She said she was allocated to look after Child C for that shift, on her own, with support from another staff member as she was junior in her role.
The nursing staff roles for that shift are presented to the court, with Ms Ellis the designated nurse for Child C, and Lucy Letby looking after two other babies in the neonatal unit.
She said she was aware Child C had been moved to Optiflow, and knew the subject of feeds was a topic being discussed, that they were "hopefully" going to start feeds.
Her nursing note is shown to the court, showing care taken over at 8pm.
"Safety checks completed and fluid requirements calculated...Optiflow...in 25% [oxygen]. Observations satisfactory...[respiratory rate]...elevated at times as previously been for past few days.
"Pink and well perfused. Active and alert."
The fluids dose is stated "due to birth weight of below 1000g".
The long line site was "satisfactory".
A blood gas reading was to be taken at 2am.
Trophic feeds were agreed to be started.
Ms Ellis said she was not present for the first desaturation as she had left the room.
A discussion on trophic feeds was had "before 11pm", with the feed administered at 11pm.
Ms Ellis said "there was nothing particularly striking" about the care for Child C between 8-11pm, he was "doing well" and was "feisty" at that time.
A retrospective note written by Ms Ellis says: "Had 2x fleeting [Bradycardia]s - self correcting not needing any intervention shortly before prolonged [Bradycardia] and apneoa requiring resus[citation].
She said she had left the room "just around the corner", then the alarm went off. She said she could not recall which type of alarm it was - a lower-level yellow or a more frequent [urgent] red alarm.
She said she went into the nursery, having been out for "not a long" time.
She recalls, upon entering: "I saw Lucy standing at [Child C's] incubator. She said he had just had a Brady and a desaturation. I can't remember what she was doing at the time."
"After that, the 'brady' and the desat resolved quite quickly."
Ms Ellis said she didn't do or see anything being done to correct the desat and bradycardia, as Child C self corrected.
She added she then sat at a computer which faced a wall, with Child C behind, out of view.
She explains Lucy Letby was still in there, but not sure about anybody else.
Child C, Ms Ellis tells the court, had a further 'brady' and desaturation which did not resolve and required resuscitation.
She said when she turned around, Lucy Letby was stood at the incubator.
A nursing colleague had asked her to put out a crash call.
Prior to administering the 11pm feed, Miss Ellis said she had aspirated a tiny amount of 'light green bile' from Child C.
A nursing colleague who was in the room said to put out a crash call, and Miss Ellis left the room, she tells the court.
She said she left the room "not long".
She said when she returned, a nursing colleague was getting ready to administer drugs, and for her to continue chest compressions.
She said Lucy Letby was at the side of the incubator, but cannot recall what she was doing.
Miss Ellis said the medical team of registrars arrived along with a doctor to the unit at some point.
Miss Ellis adds the parents were then informed.
She said she became upset herself as this was "the first time" something like this had happened in her experience, and she found it "overwhelming".
Lucy Letby said to her: "Do you want me to take over?" to which she said: "Yes."
Miss Ellis said she then left the room, taking a minute to compose herself, before returnnig to the unit to look after other babies.
The nursing note says care for Child C was handed over to senior nurse Melanie Taylor following the collapse.
Miss Ellis reiterates that, from memory, there was nothing that concerned her about Child C's condition between 8pm-11pm.
Mr Myers asks how long Miss Ellis had been working at the Countess - she replied it was since January 2015.
Miss Ellis she had not previously cared for a baby as small as Child C.
Mr Myers asks: "How is it that someone as inexperienced as you [was given the responsibility of looking after Child C]?"
"Child C was very stable and I was being supported by Mel[anie Taylor].
"You were very well supported at the Countess of Chester Hospital."
Miss Ellis said there was "always a nurse" in the room looking after Child C, even when she left the room briefly. She said Lucy Letby was in there, and cannot recall if Melanie Taylor was also in there.
Miss Ellis says Child C "could have had" two bradys, as they are quite common.
She said she did not know whether Melanie Taylor was in the room at the time of the collapse.
Miss Ellis tells the court for one of the two bradys, Lucy Letby was in the room for the second one, but not the first.
Mr Myers refers to the 8.46am, June 14 nursing note and said there was nothing prior to the 11.15pm collapse.
He asks why the first bradys are not mentioned.
Miss Ellis: "I would have forgotten to write it - it was a traumatic shift".
Miss Ellis says she would have added the detail of that on her subsequent nursing note.
She says she does not remember if Melanie Taylor was in the room at the start of the collapse.
Mr Myers puts it to Miss Ellis that Lucy Letby was not in there at the time of the collapse, and only arrived later [during the resuscitation efforts].
Miss Ellis: "I don't agree with that."
Mr Myers: "You have placed her there when you spoke to the police several years later."
Miss Ellis: "I don't agree with that."
Miss Ellis has finished giving evidence for Child C.
Nurse Melanie Taylor
The next witness to give evidence in the case of Child C is Melanie Taylor, who has previously given evidence for Child A and Child B.
The court is shown Melanie Taylor's observation chart for Child C on the night shift from June 12-13, where "normal" readings are made for the heart and respiration rate. Two of the readings were "slightly elevated" but were normal given the context Child C was on CPAP at the time.
Temperature readings were "stable and in normal limits - what you would expect".
Other readings were considered to be normal.
Other CPAP readings were "normal".
Fluid readings are recorded on a fluid chart, including the "dark bile aspirate".
Ms Taylor says: "We would be concerned about NEC [with those aspirates]."
Ms Taylor concludes Child C was a "stable baby".
There were concerns over bile aspirates but they were not uncommon in neonatal babies.
She adds the aspirates found were: "Not a major cause for concern"
Ms Taylor says further observations were made to check for symptoms of NEC, but the 'tummy soft, not distended' was a good sign.
The registrar was made aware of the dark bile aspirates.
Ms Taylor: "From what I've written, he was a stable baby."
The handover note for the June 13 night shift is presented to the court, showing Melanie Taylor is one of the nurses on duty that night, and a designated nurse for one of the babies (not Child C) that night.
She confirms she was present in room 1 that night, in the same room as colleague Sophie Ellis.
"Sophie was a very competent nurse. She was completely able to look after [Child C]. I had no concerns [with her], he had been stable. I was there for support if she needed it."
Ms Taylor said her memory of the collapse was that she did not know where she was at the time Child C deteriorated, but when she arrived at the incubator, Lucy Letby "was already there".
She did not know if anyondy else was in the room at that point.
She recalls: "I think also Sophie was there - as she was caring for him."
Ventilation support was provided via a Neopuff device, and Ms Taylor struggled to get any chest movement for Child C.
Ms Taylor said Lucy Letby suggested using a type of ventilation support - a Guedel device - to aid Child C.
The Guedel device was followed by use of the Neopuff.
Ms Taylor said a crash call was put out. She added, from her statement, chest compressions began before the first doctors arrived in the unit.
The on-call registrar was first to arrive, Ms Taylor said.
Ms Taylor recalled the chest compressions and resuscitation attempts went on for some time.
Child C later died, the time of death recorded as 5.58am on June 14.
A retrospective nursing note by Ms Taylor, written a couple of hours later, said: "Called to help as baby had brady desat, when arrived to baby, baby apnoiec..."
The notes describe the resuscitation attempts made.
An addendum made at 8.14am said: "Parents stated with [Child C], they took him round to quiet room...registrar went round to quiet room, as mum concerned he is still gasping and has pulse. Doctor explained that it is a brainstem response following resuscitation, further discussion with parents, parents happy for [Child C] to have IV morphine for comfort.
"Maternal and paternal grandparents present, discussed with parents what they would like to do, and offered that we can do it at their pace when they are ready."
The note concludes that a camera was left with the parents if they wished to take photos of Child C. They declined, and had taken some photos on their phone. Child C's hand and footprints were made for the parents.
Mr Myers is now asking Ms Taylor questions about dark bile aspirates.
He said Child C was "a stable baby", with the aspirates not being "a major cause for concern".
Ms Taylor said:"It's not something we would initially be very worried about, but would take into consideration...and act very cautiously when we find bile.
"I was not necessarily concerned he was unstable."
Ms Taylor: "You have to look at the bigger picture and see what it could possibly be, and see if it could be NEC, and act on that and take it as a consideration."
"We do encounter it [bile] in premature babies. We would have to act appropriately and if there are no other signs of NEC then we would treat accordingly."
Mr Myers asks if there could be other, more immediate problems associated with dark bile.
Ms Taylor said that would be a matter for doctors to examine if there was a possibility of that.
"There is no room for error with a baby like [Child C] is there?"
Ms Taylor agrees, and agrees there are "inherent risks" with treating such a baby.
Mr Myers asks about the experience of colleague Sophie Ellis.
Ms Taylor: "You do have a foundation training in neonatal care and you would look after a baby on CPAP. New nurses have to get experience and I was supervising and she was very competent.
"She would not have been left alone."
Mr Myers: "It was a very busy shift, wasn't it?"
Ms Taylor: "Yes."
Mr Myers says Ms Taylor was not sure she was in the room when the collapse happened.
"The only person you remember [being there] was Lucy?"
Ms Taylor agrees. She adds she assumed Sophie Ellis was also present.
Mr Myers: "It is from your account, Lucy is there, no-one else is present, maybe Sophie?"
Ms Taylor: "Yes."
Mr Myers: "I am going to suggest, you were in the nursery when this happened?"
Ms Taylor says she doesn't believe so.
Mr Myers: "That it was Sophie Ellis who called you?"
Ms Taylor: "It might have been."
Mr Myers: "That Lucy Letby was not there at the start of this?"
Ms Taylor: "I disagree."
Mr Myers says Ms Taylor, in her police statement, said she was "pretty sure" she was "already in nursery room 1", feeding another baby, at the time of the collapse.
Ms Taylor says her memory has deteriorated since then, and what is in her police statement is correct.
Mr Myers says Ms Taylor's police statement said she was called over by Sophie Ellis, and there is no mention of Lucy Letby.
Ms Taylor: "No, but she was there."
Ms Taylor said she read her police statement for the first time this morning and had not memorised everything from it.
She added: "I didn't say Lucy Letby called me over.
"I likely wasn't asked [by police] if Lucy Letby was there.
"Now I have been shown that [statement], I can remember Sophie called me over.
"Years have passed since this has happened."
Ms Taylor said she has not changed her mind about who was present there.
"I tell you now, when I approached the incubator, she [Lucy Letby] was there on the other side."
She added she remembered how "cool and calm" Lucy Letby looked at the time.
Ms Taylor said she hadn't said Lucy Letby was not in room 1 at the time of the collapse.
Ms Taylor tells the court said she didn't think it was necessary at the time to include that information [of Letby's presence] to police.
End of reporting
Shift Leader (unnamed)
The first witness to give evidence to day is from a nurse, who cannot be named due to reporting restrictions, who explains she was a shift leader at the Countess of Chester Hospital neonatal unit in June 2015.
The nurse explains to the court the types of different care that would be provided to babies arriving in the neonatal unit.
The nurse is now being asked questions on Child C.
The nurse said back in 2015, she was not sure she was the one allocating the designated nurses to the babies for that shift, as the allocation system was in the process of changing.
She said she remembers Sophie Ellis was the designated nurse for Child C that evening.
She says Sophie was a "very competent nurse", having come through the neonatal unit as a student nurse.
The nurse remembers there being 'no clinical concerns' for Child C at the start of the shift.
The nurse says she remembers Melanie Taylor also being assigned to room 1, with Sophie Ellis who was looking after Child C.
Melanie Talylor "would be there for support, for Sophie".
The nurse also recalls Lucy Letby was on duty that night, looking after 'at least' one different baby, in room 3.
The nurse said she had 'concerns over respiratory distress' for that baby at the start of that night shift. He was 'grunting', and such symptoms had not been present prior to that.
The nurse asked Lucy Letby to increase the observations for that baby from two-hourly to one-hourly and call the registrar in.
The prosecution asks the nurse about Child C's collapse at 11.15pm.
"I do not remember where, but I was not in nursery room 1."
She recalls "a shout for help", but does not remember who called it.
She entered room 1 and saw Melanie Taylor and Sophie Ellis, and a Neopuff device was being administered.
She noticed Child C was not breathing and the heart rate was very low.
The Neopuff gave Child C chest movement, but he did not breathe himself.
Child C had a "mottled" skin appearance, the nurse recalled.
She remembers a crash call being put out, and recalls Lucy Letby being present, but does not recall when Letby entered the room.
She recalled Sophie Ellis "becoming emotionally upset" and the nurse said she advised her to step outside.
The nurse remembers resuscitation efforts were made, and Child C was baptised, and overseeing palliative care to make the baby boy more comfortable before he died.
The prosecution asks: "Whose responsibility is it to ensure the memory box is made and who takes care of it?"
The nurse: "The designated nurse at the time, if they're able."
The nurse said Melanie Taylor took over as designated nurse and "partly" arranged the memory box.
The nurse explains she asked Lucy Letby to focus back on a baby in nursery room 3, but Letby went into the family room "a few times". The nurse recalled asking Lucy Letby to leave the family to Melanie Taylor.
The nurse tells the court Letby did not have any designated duties to be in the family room, and told her "more than once" not to be in the family room.
Ben Myers KC, for the defence, is now asking the nurse questions.
Mr Myers asks the nurse how busy the unit had been between 2015 and 2016, and from a statement she had made, there were more babies arriving into the unit, and more "intensive unit" babies arriving.
Mr Myers said the number of intensive unit babies arriving seemed more than what Arrowe Park, a tertiary centre, had.
Mr Myers says the nurse, in her 2018 statement, said a ward manager was "fighting" for more nursing staff for the Countess of Chester Hospital neonatal unit. "She still is."
"We sometimes weren't meeting staff guidelines for ratios."
The nurse replies that was the case across the nursing network.
The nurse agrees it was "not an ideal experience for staff."
Mr Myers: "And not an ideal experience for babies? There will be a danger of a knock-on effect."
The nurse replies: "Just because the amount of babies increased does not mean we were not compliant on any shift."
The nurse says she did not say staff were "struggling to cope", after being asked about her statement saying staff were missing breaks during "busy" shifts.
Mr Myers asks about Child C, asking if he was in a "potentially fragile condition". The nurse agrees.
Mr Myers says that due to his size and prematurity, there was a risk he could die. The nurse agrees.
The nurse says she could have changed the staffing allocation for designated nurses for that night shift, had she wanted to.
She says she does not know whether Sophie Ellis had looked after a baby as premature as Child C before, but had confidence in her as Melanie Taylor was there for support.
She says she does not recall if Lucy Letby had asked her to spend some time in that room 1.
Mr Myers asks about Child C's collapse.
The nurse says she was not in room 1 at the time, but saw Sophie Ellis and Melanie Taylor in that room, attempting to assist Child C's breathing with the Neopuff device when she arrived.
The nurse says an initial crash call was put out, followed by one for a consultant.
Mr Myers says the police statement refers to "I think Lucy Letby was in the room by now".
The nurse said she made the statement three years after the incident, and could not recall precisely when Letby had entered.
Mr Myers asks the nurse if she was the one to take an upset Sophie Ellis aside and get her to step down from duty for that time. The nurse agrees.
The nurse said Lucy Letby returned to looking after the other babies "after a number of askings" not to be in the family room, as the nurse and Melanie Taylor were looking after Child C and his parents following the collapse.
Simon Driver, for the prosecution, rises to ask the nurse more questions.
The nurse is asked if, given the busy shift, the quality of care was in any way "diminished" for Child C. The nurse says "no".
The nurse adds she would have allocated Sophie Ellis to look after Child C as the designated nurse, with Melanie Taylor supervising, as she believed her to be competent.
The nurse said she believed another baby on the neonatal unit - the one Lucy Letby was designated to look after that night - should have had more care, including a septic screening, as the nurse believed that child was the most concerning to her that night.
The nurse says, from her police interview, she "believed" Sophie Ellis and Melanie Taylor were in room 1 with the Neopuff device when she arrived.
The court hears the response from police was "ok", followed by the nurse saying: "But I...100 per cent couldn't tell you", which the prosecution say meant she was not 100 per cent sure.
Dr Katherine Davis
The next witness to give evidence is Dr Katherine Davis, who in June 2015 was a paediatric registrar at the Countess of Chester Hospital.
The court hears she had been working night shifts for the night Child C collapsed, and the previous night.
Dr Davis says she does not recall the previous night shift, but from her nursing notes on the night shift of June 12-13 she recalls the observations for Child C at 9.20pm on June 12, 2015.
The notes include "suspected sepsis" and "jaundice" on a list of ongoing problems. The latter is, the court hears, "very common" in premature babies.
Dr Davis added that, at that point, there had been 'no desaturations' or 'bradys' (bradycardia).
Child C was 'NBM' (nil by mouth) due to "billious aspirates".
Dr Davis's notes include simple drawings of the lungs and abdomen. The lungs had "good air entry", with the abdomen 'soft' and 'not discoloured'.
Dr Davis says there was "nothing worrying" about Child C's tummy at the time, noting that there would likely be air in the stomach due to him being on CPAP.
She said she would have received a 'crash call' bleep, and was "relatively close" to the unit when it happened.
She remembers "a lot of activity" when she went into room 1.
She remembers there being a senior nurse present, but beyond that, is not sure of who was there.
Dr Davis's note is presented to the court, written at 1.30am on June 14 and timed retrospectively.
The note said she was arrived at the unit in "less than one minute" after the crash bleep went off.
A 'Guedel airway in situ' was noted, with chest compressions in progress.
Dr Davis noted 'occasional intermittent gasps noted'.
Dr Davis said she believed Child C "looked pale" when she arrived.
Dr Davis explains chest compressions would stop "briefly" to detect if Child C had a heart rate, and if there was no heart rate, which Dr Davis said "was unusual" from her experience.
Chest compressions were restarted and the on-call consultant was called "urgently".
Dr Davis attempted to intubate Child C, but was unable to do so as Child C's vocal cords were swollen. Dr David tried again with a smaller tube, twice, but was again unable to intubate.
A list of drugs was administered, including several doses of adrenaline.
The next note was at 2am, following a "prolonged attempt" at resuscitation.
Dr Davis: "It became obvious that we were not winning, we hadn't got a heart rate".
The failure to resusciate was "very unusual" as premature babies usually had some response to resuscitation efforts, even if it was temporary, Dr Davis tells the court. Child C had no response.
Dr Davis said baptism of Child C took place, and it was noted during the resuscitation attempts that a capnograph on Child C had detected carbon dioxide coming out of the baby boy. The on-call consultant was called.
The baptism and blessing were completed.
"Unexpectedly," Dr Davis said, Child C was gasping and had a heart rate at this time.
A discussion was had at the "appropriate way forward", and "unfortunately", it was concluded Child C would have had a lack of oxygen to the brain for a "prolonged time" which would have left him with significant damage to the brain and potential other issues, such as kidney damage.
Morphine was administered to Child C for pain relief, following a discussion with Child C's parents, as Child C was "unlikely to survive".
Dr Davis said she was later called by a family member of Child C to be informed they had believed Child C had died, and she explains she would have carried out the necessary observations, and verified the baby boy had passed away.
Ben Myers KC, for Letby's defence, is now asking Dr Davis questions.
He says that Child C "was on the limit" of what the Countess of Chester Hospital could treat, being at 800g birth weight. Dr Davis agrees.
Mr Myers is referring to Dr Davis's notes on June 12, where a "raised CRP" reading is noted, which he says is "a potential marker for infection". Dr Davis agrees.
She also agrees Child C is at increased risk of abdominal problems due to his prematurity.
Mr Myers asks about the billious aspirates.
Dr Davis says any such aspirates, of any colour, are a cause of concern.
Mr Myers: "It's a red flag for a problem, isn't it?"
Dr Davis: "Yes."
Dr Davis said she would have examined the "bigger picture", in that Child C handled well, had a soft abdomen, and there were bowel sounds.
"There was no suggestion we should do anything different."
Dr Davis said there were no other signs of NEC.
Mr Myers said the bile aspirates could be a symptom of something else.
Dr Davis says Child C was examined for other symptoms, but was still "well", and his bowels were not yet open.
Dr Davis adds: "He had a lot of challenges, but he was doing well."
Mr Myers: "He had the potential, as a small baby, to deteriorate rather rapidly?"
Dr Davis: "Yes.
Dr Davis said Child C "was not getting sick" despite the readings of dark bile aspirates.
"It is not something we should ingore, it's something we would keep an eye on...but I don't think there was anything else we should have done."
She adds that dark bile is "not normal", but "not uncommon" in premature babies.
Mr Myers said Child C was not seen by a consultant until three days after he was born, on June 13, and "the appropriate step" would have been for Child C to see him before then.
Dr Davis said such a step would have been discussed prior to June 13.
Mr Myers said the collapse of Child C happened before Dr Davis had a chance to review him. Dr Davis agrees.
Mr Myers refers to the circumstances of Child C's collapse.
He asks if a tertiary unit would have had advanced practitioners capable of intubating a baby.
Dr Davis said they would have had more staff available, but cannot comment on Arrowe Park. She says from her experience in a teritary centre, there would be advanced nursing practitioners, but they would not work night shifts.
Dr Davis said there would be a risk-benefit discussion for whether a baby would be in a level 2 unit at the Countess of Chester Hospital, or a level 3 unit such as Arrowe Park.
She said there would be risks in transporting a baby in an ambulance to that tertiary centre.
She adds bed availability would not be an issue as they could always transport out of the region if necessary.
Dr Davis said at the time she arrived in room 1, the nursing staff were doing everything they could do.
She says that the decision to intubate was not necessarily the right or wrong thing to do, but had its advantages.
The intubation period would have lasted about 30 seconds, as during that time Child C would not have had Neopuff bag support. Dr Davis said after those 30 seconds, efforts to resuscitate using the Neopuff would resume.
Dr Davis said despite the resuscitation attempts, Child C would have had a "huge amount of time" without a heart rate.
Mr Myers: "Did the delay in intubation cause any difficulties down the line?"
Dr Davis: "No."
Philip Astbury rises to ask if Dr Davis had seen a collapse that sudden or unexpected in a child like Child C before.
Dr Davis: "Absolutely not."
She adds that from her experience, she had seen a lot of babies with significant abdominal issues, and had dealt with babies with NEC, but they didn't "behave or die in the way that [Child C] did."
Dr John Gibbs
The next witness is Dr John Gibbs, who in June 2015 was working at the Countess of Chester Hospital as a consultant paediatrician, and had been working at the hospital for over 20 years.
He says he had seen Child C a few times during the first few days of his life, and had carried out a review.
"There was no particular concern" about Child C, despite there being gastric aspirates, and while being "small" even for being premature, he was at risk of conditions such as NEC. He said such aspirates were "not uncommon" as gastric acid could accumulate in the stomach, and Dr Gibbs recommended an antacid be given for the stomach.
He says Dr Ogden's note of the abdomen being "soft, not distended" is a "very reassuring sign".
Dr Gibbs said if the aspirates "got steadily larger" that would be a concerning sign, and a symptom of NEC.
It was decided, Dr Gibbs said, to monitor the aspirates and hold off giving feeds at that time.
He said if the aspirates got larger, or came with vomiting, then an abdominal x-ray would be carried out.
Dr Gibbs said he carried out an ultrsound scan of Child C's head, which was recorded as 'normal', a 3.55pm on June 13.
He was next involved with Child C as the on-call consultant, having received an emergency call at about 11.28pm. A note is written, retrospectively, by Dr Gibbs at 12.30am.
He said then when he arrived, efforts were being made by staff to resuscitate Child C.
He said Child C looked "pale and mottled", which he said was "not uncommon" in babies in cardiac arrest.
The notes show Dr Gibbs intubated Child C to provide more effective ventilation.
He adds that ventilation can also be obtained through the Neopuff device.
Dr Gibbs says that babies experiencing a sudden and unexpected collapse would normally be expected to show some signs of responding to resuscitation efforts, and it was "unusual" Child C did not.
The resuscitation attempts were said to have "failed" after 40 minutes.
Dr Gibbs said it was "standard practice" for attempts to cease after 20 minutes, but staff would carry on for a little longer "in the hope" of the baby responding.
Resuscitation efforts continued after the 40-minute point while the priest arrived to baptise Child C.
He said, "surprisingly", there were some "minimal" signs of life in Child C, and he was "not sure what to do" as it was "unexpected".
He was "not sure" why a feeble heart rate, and breathing gasps, were being recorded for Child C.
He relayed to the parents that, due to the prolonged time without oxygen, the chances of Child C being brought back without "profound" brain damage were "extremely remote".
Dr Gibbs said it was planned to offer Child C palliative care for his final hours.
Dr Gibbs said he could not provide a cause of death, so subsequently contacted the coroner's office.
Dr Gibbs said a debrief was carried out for Child C's fatal collapse on July 2, in which the circumstances were discussed.
It was noted, in a summary of the debrief, Child C 'did not seem unwell', was 'active (kept pulling out NG tubes)', an infection was 'suggested' but Child C was on antibiotics.
Dr Gibbs noted in the debrief the collapse was not related to the feed, which was administered shortly before the collapse, as he said he could not see how the administration of a 0.5ml feed could lead to a cardiac arrest.
The resuciation was performed "technically well", and the "team worked well together".
Dr Gibbs explains the context from the notes, was that the staff had done everything they could to save Child C.
Dr Gibbs said it was not possible to rule out a pulmonary embolus - a blood clot which breaks off from another part in the body, blocking lung circulation.
Another theory was toxins from medicine administered.
The post-mortem had been held at this point, but the results were not available.
The debrief noted that Child C's parents were advised that "further life support measures" were "futile".
Dr Gibbs said the notes said for future situations, rather than prolonging a baby's life with 'token resuscitation efforts' for a priest/vicar to arrive, it would be better for a nursing member of staff to carry out the baptism duties themselves. This would be in the event of following prolonged, and ultimately failed, resuscitation efforts which left a baby with no realistic prospect of survival.
Dr Gibbs said he would have discussed this with the rest of his consultant colleagues.
Dr Gibbs said he wants to clarify that he is not blaming the parents for requesting to allow Child C to be baptised, and the wait that followed for a priest and vicar to arrive.
He said the problem was that Child C's heart and lungs restarted following the token efforts to resuscitate, and he could not think why that was the case.
"Whatever catastrophic event that had happened [to Child C] had reversed, or begun to reverse.
"I don't understand that from a natural disease process."
He said it was right the parents requested for a priest to arrive for baptism. He adds the difficulty was that Child C's heart and breathing restarted following that.
Philip Astbury has one more question to ask for the prosecution, about monitors in place at the neonatal unit in June 2015.
He asks Dr Gibbs if such monitors record the displayed readings, for people to look up a potential archive of readings. Dr Gibbs says he isn't sure, but doesn't think they did. He adds he hasn't done so, in his practice.
Ben Myers KC, for Letby's defence, is now asking Dr Gibbs questions.
He asks about the staffing arrangements in place at the hospital at the time.
Dr Gibbs says at the time, he is fairly sure the paediatrician of the week on a rota would cover the children's ward and the neonatal ward. They would not have any planned clinics for that week. Other consultants would cover during the night, as that paediatrician could not cover a 24/7 week, the court hears.
Dr Gibbs said the workload would depend on need, and consultants would spend more time on the paediatric ward as there would be much more turnover there than the neonatal unit.
Mr Myers asks if Dr Gibbs would agree consultant cover was stretched during 2015-2016
Dr Gibbs said more consultants arrived after June 2016, but they had been requested for several years.
The consultant cover at the time was "fairly typical" for a level 2 unit, the court hears.
Dr Gibbs said the addition of two consultants "had been planned" for many years.
He said "every speciality wants more staff", as did a lot of hospitals, given the context of the staffing pressures of the NHS overall.
"We wanted to increase the number of staff so we could reduce the number of hours".
Mr Myers says the two consultants arrived after the Countess of Chester Hospital was reduced to a level 1 neonatal unit in June 2016.
Dr Gibbs says that is the case, but the two were not linked.
Mr Myers asks about Child C being 'on the limit' with birth weight.
He asks whether it would be "almost inevitable" Child C would have faced complications, and asks if in hindsight, Child C should have been cared for at a tertiary unit.
Dr Gibbs: "That depends on what causes sudden and unexpected collapses [leading to his death]."
Mr Myers asks, taking that aside, should Child C have been cared for at a tertiary centre.
Dr Gibbs: "No."
Mr Myers asks about the billious aspirates found.
He says if a baby is producing dark bile, if that is a concern.
Dr Gibbs: "It raises some concern, yes."
Mr Myers: "It's potentially serious, is it not?"
Dr Gibbs: "No - it comes from acid reflux...some normal premature babies [produce bile aspirates]."
He adds that is why an antacid was administered to Child C.
Mr Myers produces a nursing note from Yvonne Griffiths, which refers to, on June 12, 2mls of 'black stained fluid', plus 'bile on blanket'.
Dr Gibbs says he would have been concerned if Child C had continued to vomit bile, and there was a lot of it.
Mr Myers produces the intensive care unit chart for June 12, showing 'vomit dark bile' at midnight.
He asks if it is a matter for concern.
Dr Gibbs says there is one note of vomit, and says that is a worry, but would be more concerning if it was repeated.
The intensive care unit for June 13 is presented, showing more dark bile readings.
Dr Gibbs says there are no more vomit readings, and the June 13 readings are from aspirates, which can be common in premature babies.
Dr Gibbs says the aspirates were not increasing from 0.5ml on June 13.
He said the baby would be examined first, with an examination of the abdomen.
Mr Myers asks if there was a possibility of something other than NEC Child C could have had.
Dr Gibbs says NEC was "a particular risk", but there could have been an obstruction in the body, and medical staff would not have just been focusing on looking for symptoms of NEC.
A diagram of the small and large intestine is presented to the court.
Mr Myers asks about the passage of air, and refers to radiograph images for Child C, one taken on June 12, and the accompanying note refers to 'marked gaseous distension of the stomach and proximal small bowel'.
Dr Gibbs says there is 'not much air in the large intestine' shown.
Mr Myers asks if there is an obstruction.
Dr Gibbs says it is a possibility, and the air seen is common for babies on CPAP ventilation.
Mr Myers asks if there is an intestinal blockage.
Dr Gibbs says it is a possibility.
Mr Myers says a symptom of intestinal blockage is vomiting dark bile.
Dr Gibbs says there is only one recorded instance of that, and the symptom would be 'repeated vomiting'.
He says a sign of an intestinal blockage would be a 'very distended abdomen', and when he examined him on June 13, Child C had a 'soft, not distended abdomen'.
Dr Gibbs adds the amount of dark bile aspirates, in the case of an intestinal blockage, would increase, and that was not the case with Child C.
Dr Gibbs says an obstruction is "a possibility", but "not the explanation".
Mr Myers asks if not looking to see whether Child C had a potential obstuction, in view of vomiting dark bile, was "a potential mistake".
Dr Gibbs repeats there was not repeated vomiting, and dark bile aspirates would be found in normal babies.
The court hears Child C did not have his bowels open during his life.
Dr Gibbs says that was not surprising as he had not been fed.
Mr Myers asks if that was unusual, after three days, for the bowels not to open.
Dr Gibbs said it could be unusual, but Child C had not been fed, so there were not going to be bowel motions.
Mr Myers asks if it would have been preferable for Child C to have been examined by a senior consultant prior to June 13.
Dr Gibbs: "It would have been preferable if there had been significant concerns about him, and he had not already been reviewed by the registrar and junior doctor."
Dr Gibbs said he would have carried out daily reviews, without a full examination, of neonatal unit babies.
Mr Myers asks about Child C's collapse.
He says Dr Gibbs intubated Child C at the first attempt, and said Dr Gibbs had told the court intubation was more effective than Neopuff.
Dr Gibbs said it was more effective during prolonged resuscitation attempts, and Neopuff by itself was effective too.
Dr Gibbs said even if he was unable to intubate Child C, Neopuff administration could have continued.
Mr Myers asks about the debriefing notes written by Dr Gibbs on July 2, 2015.
He says no mention is made about the dark bile aspirates.
Dr Gibbs says that is correct.
Mr Myers asks if if is a consideration on the notes that could later be seen as part of legal action, and would that be something Dr Gibbs would be aware of.
Dr Gibbs said the purpose of the debriefings was for the benefit of future patients, not for lawyers.
Philip Astbury asks about hours worked by Countess staff.
Dr Gibbs said the long hours worked were a "widespread problem" in the paediatric network, but the quality of care for patients was not diminished.
He added: "It would be better for a consultant to be available every day to carry out comprehensive reviews."
He said that was the case in most units in the UK.
Asked about the dark bilious aspirates and the one case of vomiting, Dr Gibbs said Child C was not a cause for concern as the abdomen was soft and the other observations were normal.
Medical Expert Evidence
Dr Dewi Evans
Dr Dewi Evans, independent medical expert, has now returned to court to give evidence in relation to Child C.
Nicholas Johnson KC, for the prosecution, asks Dr Evans to confirm he has made a number of reports for Child C, made between 2017 and September 2022. Dr Evans confirms that is the case.
Dr Evans confirms he was sent records from Alder Hey and the Countess of Chester Hospitals, including images and records taken, after Child C had died.
Dr Evans says Child C was a vulnerable, pre-term baby, with restricted growth meaning he was 800g at birth.
"He had two significant risk factors" that meant admission to a neonatal unit with "careful management" that would have been required of several weeks.
He said Child C would have been at risk of a number of conditions during that time.
The commonest risk would have been to his respiratory system, the second would have related to feeding, as premature babies are not necessarily adapted to receive milk. He would also have been at risk of NEC.
The third would have related to infection.
The fourth complication would have been metabolic, and it was important to maintain glucose levels and be aware of the risk of jaundice.
In relation to the breathing problems, Dr Evans says from the records, Child C's breathing stabilised over the days, with CPAP and oxygen support decreasing. Child C had been taken off CPAP on placed on Optiflow, whichw as "a very encouraging sign" that Child C could begin breathing on his own.
The percentage of oxygen support had decreased from a 'common' support of 40% to 25%, the latter which was 'very low' for breathing support.
"They were good markers of progress," Dr Evans says.
Mr Johnson says Child C also had periods of skin-to-skin contact with his mum without breathing support required.
Dr Evans you "wouldn't dream of doing that" if Child C was unstable on breathing support.
Dr Evans continues to discuss the 'realistic risks' Child C could have faced.
One was feeding; Dr Evans says all premature babies require naso-gastric feeding.
If the babies cannot tolerate that, then it is clinical practice to administer nutrition via TPNs, via IV.
Child C was fed via the latter method, which was "the right thing to do".
Dr Evans said aspirates would be taken from the stomach prior to feeding.
He said dark bile aspirates could be a symptom of NEC or an obstruction, but it would need to be taken in context with other signs such as the baby's abdomen condition, and the general condition of the baby - and signs of a problem would be whether the heart rate would increase, the breathing rate would increase, and/or whether the oxygen would need to be increased.
Dr Evans said medical staff were aware to monitor Child C's abdomen and make regular notes.
He says there is one entry made in the nursing notes of 'black fluid' - not necessarily bile, but discoloured blood. That was to be 'monitored' and to 'keep an eye' on the baby's condition. It would not, in itself, be a concern.
For the 'one-off' vomit reading, Dr Evans says if there was something 'serious' going on, it would happen more often than once.
The four dark bile aspirate readings, each 0.5ml, are 'a tiny amount', Dr Evans tells the court.
"The good news is it's only 0.5ml. The other good news is the bile aspirate is not increasing [per reading].
"That is an indication the baby is not getting worse."
He said increasing readings would point to an obstruction, as would a distended abdomen.
Dr Evans says Child C's status was "under control".
Dr Evans says Child C was well for a '30-weeker' (in terms of gestational age).
A blood test for CRP had increased from 1 to 22-23 - 'not particularly high', the clinical was 'aware of this' and Child C was placed on antibiotics.
Child C's platelet count had fallen - which 'on their own don't tell you very much', but in combination with an x-ray was a 'non-specific marker pointing to an infection'.
Blood gas readings taken were 'within acceptable values', Dr Evans tells the court, and in terms of metabolic readings, Child C was a 'stable little baby'.
Dr Evans said all premature babies develop symptoms of jaundice.
"The good news with [Child C] is the jaundice levels were very satisfactory".
If Child C had signs of severe jaundice, he would have required phototherapy, Dr Evans explains.
Dr Evans says Child C had a lung infection, of pneumonia, which was "very common" in premature babies, and he was placed on antibiotics in advance of any test results.
Mr Johnson: "Did breathing issues have any direct cause for [Child C's] death?"
Dr Evans: "No."
Mr Johnson: "Did any feeding issues cause his collapse?"
Dr Evans: "No, that cannot explain his collapse either."
Mr Johnson: "Did the infection of pneumonia cause it?"
Dr Evans: "No - the infection was under control and being treated."
Dr Evans explains if the pneumonia treatment was not working, a number of markers would be shown. There would be an increase in heart rate (which did not occur, he says), an increase in respiratory rate - but that stayed the same.
Oxygen saturation levels stayed "absolutely where they should be", whereas in worsening pneumonia conditions those levels would fall.
Mr Johnson: "Did the jaundice/glucose issues cause his collapse?"
Dr Evans: "None at all."
Dr Evans says there were "no worrying trends" recorded in the notes.
"What was the cause of [Child C's] catostrophic collapse and death?"
Dr Evans says, initially, he did not have a conclusion to Child C's death.
He adds one complication is if the abdomen is filled with air.
Dr Evans: "If you get a significant injection of air into the stomach, it can cause splintering of the diaphragm."
As a result, a baby could collapse pretty quickly as they would suffocate.
Dr Evans says that was his conclusion for Child C.
Dr Evans says if the diaphragm is unable to move effectively, the lungs are unable to get fresh oxygen, and that causes the collapse.
Ben Myers KC, for Letby's defence, is now asking Dr Dewi Evans questions in relation to Child C.
Mr Myers says Dr Evans has had the case material for Child C for about four and a half years, and has provided such conclusions.
"Beofre today, you have never suggested that [the collapse on] June 13, the splintering of the diaphragm, is the cause of the death, have you?"
"That is correct."
Mr Myers suggests that Dr Evans's opinion alone would not have reached this conclusion.
Dr Evans said the death could not be explained from the usual causes babies get. He said, taking into account all the other evidence and information from experienced medical people's reports, and reading the pathology report, the splintering of the diaphragm was now his conclusion.
He said he was functioning as a clinican. "The fact is this baby has collapsed having previously been stable, and one has to explain that."
Mr Myers suggests Dr Evans had been influenced into supporting this conclusion.
He says Dr Evans had not provided this 'splintering of the diaphragm' conclusion in his eight previous reports.
Dr Evans says while Child C was at 'constant' risk of a number of conditions, he was under continual observation and was in a neonatal unit.
He confirms his initial conclusion from 2017 was 'one may never identify the cause of his collapse'.
Mr Myers said Dr Evans 'could not rule out infection' in his 2017 conclusion.
Dr Evans said infection was "a factor" in Child C's short life.
"It is possible to suggest that...his pneumonia was under control, he was requiring hardly any oxygen. It was my role, investigating this unexpected collapse, to give an impartial view of all the issues. I don't prepare partisan reports."
He says infection was a part of Child C's status. He adds it did not cause Child C's death.
Dr Evans tells the court the process in accumulating information in reaching his conclusions.
He says while Child C had an infection, he was recovering from it, as he had gone off CPAP support, on to Optiflow.
"Respiratory wise, he didn't stay the same, he was improving."
Mr Myers says up until the evidence of today, he had not provided in his reports an allegation of harm.
Mr Myers: "You are coming up with things to support an allegation of harm."
Dr Evans: "I am coming up with clinical evidence."
Dr Evans says he has read varying reports, but had not read a single medical report that said "I'm wrong, [Child C] died of something else."
Dr Evans says this case "will always be a challenging case" for any clinican as it is difficult to separate the pathological problems from an event where Child C "was placed in harm's way by some kind of deliberate act."
Dr Evans: "You can't exclude infection from [Child C]'s general status.
"He's got an infection, but it's under control."
Mr Myers refers to another of Dr Evans's reports, from 2019, referring to infection being 'probable' as a significant cause in Child C's collapse.
Dr Evans says if he receives additional evidence, then he will change his mind.
Mr Myers says Dr Evans has not received any new evidence on Child C's infection since.
Mr Myers says the 2019 report said Dr Evans raised a possibility of deliberate injection of air from June 12 via the naso-gastric tube.
Dr Evans, reflecting on that report, said: "Can't rule it out".
Mr Myers refers to a 'massive gastric dilation' was 'most likely' due to an injection of air on June 12.
Dr Evans: "That was a possibility, yes."
Mr Myers says in that report, there was no suggestion the diaphragm had been splintered since, and if he wanted to say so in that report, he could have done so.
"If it wasn't said, it wasn't said."
Dr Evans said what was being discussed, on June 12, there was a "distinct possibility" Child C had excess air in the stomach from CPAP belly.
He was "still stable" from a respiratory point of view.
He tell the court: "However the air went in, it would have been insufficient to splinter the diaphragm on the 12th, as he would've collapsed and died on the 12th."
The air which had gone in was 'insufficient' to cause a collapse. There was 'nothing to suggest' the excess air was enough on June 12.
He says the two events on June 12 and 13 "are quite different" in the way they happened.
Mr Myers said that it was Dr Evans's view, a couple of months ago, there was deliberate harm on June 12.
"That was a possibility, yes it was."
Mr Myers: "What you have done today in your evidence is introduce something supporting the allegation."
Dr Evans: "That is incorrect."
He adds that in coming to his conclusion for this case he is not relying solely on his opinions, but taking in other clinical evidence and reports.
"That is what doctors do, we do it all the time." in what Dr Evans says is a "complicated case".
Mr Myers has gone back to the case of Child B to discuss the legibility of a nursing note concerning blotchiness of Child B's skin.
The discussion goes on for several minutes.
Dr Evans adds: "This is just making a meal out of something."
Mr Myers: "You're not independent, as a witness, are you, Dr Evans?"
Dr Evans: "I am completely independent. I am not here for the prosecution, I am not here for the defence, I am here...to assist the jury."
The judge interjects to clarify the meaning of the note, before the case resumes on Child C.
Mr Myers asks about the bile aspirates, and asks if the dark colour was additional concern.
Dr Evans says it could be discoloured blood, and the presence of vomit once would be a concern, but would need to be put in context of the baby's condition.
"You can't choose out something that supports your case - you need to look at the big picture."
Mr Myers says the x-ray from June 12 had helped form Dr Evans's initial view that there had been an air injection into the stomach.
"That was an opinion I have expressed, yes."
Mr Myers asks Dr Evans what evidence there is to support that air had been injected into the stomach on June 13.
Dr Evans: "The baby collapsed and died."
Asked to explain further, Dr Evans says it was part of a differential diagnosis.
He said there were three clinical scenarios - injecting air into the stomach that interfered with his breathing, or that air was injected intraveneously, or from a combination of the two, which Dr Evans says "sounds awful".
Dr Evans says, from his perspective, from an academic point of view, he would not be able to rule out any one of those three scenarios.
Dr Evans says none of the normal processes described why a baby collapsed.
He adds, for further medical information, he would prefer to defer the matter to the radiologist and pathologist.
He said he objects to being accused by Mr Myers of making things up, and says he is putting forward the information in this case as a result of his own opinion and that of other people's reports.
Mr Myers says 'never once' is an air embolus mentioned in Dr Evans's reports.
Dr Evans agrees.
Mr Myers suggests that Dr Evans has just made up information as he has gone along.
"You keep saying that, and I keep disagreeing."
"And you're not an independent witness at all, are you?"
"And again, that is just being insulting."
End of reporting
Dr Sandie Bohin
Independent medical expert Dr Sandie Bohin has returned to court to give evidence, this time for Child C.
Dr Bohin confirms, after being asked by Mr Johnson, she has received and reviewed all the case evidence, including from doctors' witness statements.
Dr Bohin says her role was not to 'rubber-stamp' anything, but to come to her own conclusions and see whether they agreed with that of Dr Evans.
She said she set out what she thought were the improtant facts for Child C. They include an x-ray taken on June 12 following the insertion of a long line.
She noted the long line was in a "low position", but in a "usable position". The stomach looked swollen and had a distended bowel.
She said initially she could not see a naso-gastric tube on the x-ray image on her laptop, but from viewing the x-ray image shown in court in higher resolution, she could detect it was present, 'very high', in 'not an ideal position'.
Dr Bohin is asked about her conclusions regarding Child C.
She said it was known Child C was premature, growth restricted at birth, and 'potentially at risk of complications', but 'managed very well indeed' in his early days, improving to being put on Optiflow. He had 'clearly not liked' being on CPAP, and had been put on skin-to-skin contact with his parents, without CPAP for a couple of hours, and had done well during those times.
"This was not a baby who was ill, this was a baby who was improving."
Dr Bohin noted Child C "clearly" had an infection, which was "an alerting feature" and for which the medical team treated him with antibiotics and did an x-ray confirming left lung pneumonia.
Despite that, Child C had appeared to respond to treatment due to the lessening of respiratory support.
Dr Bohin said it was "very clear" Child C had pneumonia, but a baby with pneumonia will "often survive", but a sign of that will be that they would slowly deteriorate, going from CPAP to ventilator support, increased heart and breathing rate.
Child C's breathing rate was "very stable", despite "effectively breathing with one lung".
Dr Bohin's conclusion was that he had pneumonia, but that did not cause the collapse or kill him.
Dr Bohin said pneumonia would be a factor in the difficulties in response to resuscitation.
She tells the court there would be a sign something was "amiss" prior to the collapse, and a sudden unexpected collapse would be uncommon in babies.
Dr Bohin says babies on CPAP can have CPAP belly, and in order to minimise that, they would aspirate the NGT.
"It is usual practice to note down the volumes of air aspirated to give colleagues an idea [of how much air is coming out of the baby]."
"I couldn't find any evidence of that [in the notes]."
She adds that, for babies not fed, the nursing staff would put the tube on free drainage so air could come out on its own, as well as actively aspirate every four hours or so. She says there was only 'fleeting mention' of free drainage.
If neither of those things happen, Dr Bohin said that would lead to gas accumulation in the stomach.
Dr Bohin said it was not clear from the notes how long the 'free drainage' was in place.
She said one conclusion for Child C's collapse was CPAP accumulation of air, the other being deliberate injection of air.
She said the doctors did not appear to have a concern as they had noted the abdomen to be "soft".
Dr Bohin said Child C died "with his pneumonia, not because of his pneumonia."
She added babies such as Child C do not collapse suddenly and without warning.
She said an infection would not be the cause as that would lead to a gradual deterioration in the baby, not a sudden collapse and no response to resuscitation.
There was no live reporting for the remainder of Dr Bohin’s testimony but below is taken from the Chester Standard daily round up (02/11/22)
Giving evidence, expert medical witness Dr Sandie Bohin said Child C was “potentially at risk of complications” after birth.
But she told the court: “Actually, in his early days he managed very well indeed. A couple of times he had skin-to-skin contact with his parents and that is something you would not do if you had concerns.
“He was not only doing well but was actually improving. This was not a baby who was ill.”
She agreed Child C developed pneumonia but said he received the standard treatment of antibiotics.
Dr Bohin said: “My conclusion was, yes, he had pneumonia, but that was not what caused him to collapse.
“I think the pneumonia contributed to not surviving the resuscitation.”
Asked to explain a build-up of gas in Child C’s abdomen detected on a X-ray on June 12 – the day before his fatal collapse – Dr Bohin said air could have accumulated via respiratory support he was receiving. The alternative explanation is a deliberate introduction of air down a fitted nasogastric tube, she said.
Prosecutor Nick Johnson KC asked: “When you looked for a reason for (Child C’s) collapse on June 13, can you find an explanation?”
Dr Bohin replied: “No. Babies like this should not collapse. You get prior warning that something is amiss.
“They don’t go from being stable into a cardiorespiratory situation within minutes. They rarely collapse in this way but they are usually responsive to resuscitation and he was not.”
Mr Johnson said: “In your view, did the infection that (Child C) had, was that the cause of his catastrophic collapse?”
Dr Bohin said: “I think he died with his pneumonia, not because of his pneumonia.”
Ben Myers KC, defending, noted Child C’s markers for infection rose in the last 24 hours of his life.
His blood platelet count fell below acceptable levels, his weight was low and he had not been fed, he said.
Notes were also recorded of dark bile being produced and an incident of vomit with bile, he added.
Mr Myers asked: “If you put things together they might be a matter for concern?”
Dr Bohin said: “I say there was not.”
Mr Myers said: “It’s not a question of you minimising the seriousness of (Child C’s) condition, is it?”
“Absolutely not,” said Dr Bohin.
Mr Myers previously told the jury Child C was vulnerable, especially to infection, and should have been at a specialist children’s hospital rather than the Countess of Chester.
Professor Owen Arthurs
Professor Owen Arthurs has been recalled to give evidence in respect of Child C and Child D.
Nicholas Johnson KC, for the prosecution, asks about Child C specifically.
Pictures are shown to the court, the first are radiograph images for Child C taken on June 10.
He points out Child C is small and can almost fit entirely on the one x-ray image.
The x-rays were taken to check for positioning of the UVC.
He says the tube has been brought in a little too far and should be brought back a little.
He says the problem with x-rays is they are 2D images of a 3D person, so there is difficulty with interpreting the picture 'without the baby in front of you'.
Another x-ray of Child C is shown, taken at 10.38pm, showing the line had been withdrawn. There was 'normal gas' in the stomach and bowel.
He says the most striking abnormality is the right lung on the image (the left lung from the child's perspective) is 'white', meaning there is 'something in the lung' preventing the x-ray light passing through, which would indicate an infection.
A further x-ray image is shown for Child C at June 12 at 12.36pm, which is centred at the child's abdomen.
He says the most striking feature about this image is the dilatation of the stomach, which is 'full of gas'.
He says this is more gas in the stomach 'than you would expect for a child of this age'.
There was a 'small tube' in the stomach taking out air.
The left lung cannot be seen on this x-ray image.
Professor Arthurs says, for his conclusion for Child C, that the 'marked gas dilatation' in the stomach noted at June 12 had several potential causes, including CPAP belly, sepsis, NEC or exogenous administration of air by someone.
An observation was made there was no gas in the rectum area for Child C.
Professor Arthurs is being asked about Child C.
He agrees the left lung infection is a 'significant factor' from the first radiograph image.
He says the second image has a possibility of gas in the bowel wall, which is a possibility of NEC.
He says, as far as he knows, no NEC was found in Child C.
Mr Myers says Child C, at four days old, did not have his bowels open, and a bowel obstruction could be considered.
Professor Arthurs, asked by the prosecution about a bowel obstruction, says if the bowel was blocked at a particular point, it would give a 'marker' of where the obstruction was.
He says the image shows no such marker, and as bowel obstructions are a 'common clinical occurrence', it would be diagnosed and babies would go to theatre for an operation.
He says there is no evidence of a bowel obstruction on the imaging, on the clinical notes, or in an autopsy.
Referring to the possibility of a twisted bowel, which he says 'can happen in small babies' and result in a blockage. He says that is often a surgical emergency, and would be documented as such, and found post-mortem if there is such a finding.
That concludes Professor Arthurs's evidence at this stage.
Dr Andreas Marnerides
The consultant was approached by Cheshire Police in late 2017 to review the deaths of a number of babies at the hospital, the court heard.
He gave his opinion on their causes of death after having reviewed the pathological evidence as well as information received from clinical and radiological reviews.
Child C, a boy, was subjected to an excessive infusion/injection of air into his nasogastric tube, he said.
From Dan O’Donohue Twitter (30/03/23):
Mr Myers has taken the medic back over his evidence for Child C, D and now I. The defence lawyer is focusing his questioning on the fact he has had to rely on Dr Dewi Evans and other medics for his review.
Dr Marnerides earlier said to discount the clinical evidence in forming his reports was akin asking someone to explain physics without using mathematics
Police Interview SummaryThere was no live reporting on the day these were heard in court but below is taken from the Chester Standard daily round up article (02/11/22).
When interviewed about child C, the defendant said she remembered him because he was a small baby.
Letby recalled he deteriorated not long after his first feed by one of the nurses but said she had no involvement in that.
Her only involvement with child C was when she was asked to help with the resuscitation attempt, she told police.
She added she had a “vague recollection” of taking child C’s hand and foot prints for a memory box while the infant was sat with his parents but “couldn’t be certain”.
went on to say she found the boy’s death “quite hard because he lived several hours (after the collapse)” and she had “not seen that before”.
Detectives also asked her about a conversation in which a nurse was said to have asked child C’s parents if they wanted him to be taken away in a ventilator basket while he was still alive.
She replied she had no recollection of making that comment and questioned whether the parents had said she was the nurse who said that, the court heard.
She said it was “very sad” for the parents.
Letby, originally from Hereford, denies administering air to child C.
She accepted she made Facebook searches for his parents about 10 hours after their son died but could not remember doing the searches or why.
The court has previously heard Letby messaged a colleague during the night-shift of June 13 that it was “eating her up” she was not allocated to work in the intensive care unit (ICU) room just days after the fatal collapse of another baby.
Letby told police she agreed she wanted to go the room “as it can be hard to go back into an ICU environment after having a sick baby so she preferred to go straight back in”.