UK - Lucy Letby Trial - Media, Maps & Timeline *NO DISCUSSION*

[Tortoise]

JUDGE'S SUMMING UP - Monday 3rd July 2023

Day 1- Morning Session

LIVE: Lucy Letby trial, July 3 - judge's summing up

8:36am

Today, trial judge Mr Justice James Goss is expected to begin his summing up of the case, a process which is expected to last this week. Members of the jury have already been told they will not be sitting on Friday, July 7.
The judge has already given his preliminary directions of law to the jury. These were given prior to the prosecution and defence closing speeches, the latter of which concluded last Friday.

10:26am

The trial is now resuming.
The judge, Mr Justice James Goss, is beginning his summing up.
He says the prosecution case is there was deliberate harm at the Countess of Chester Hospital neonatal unit, sometimes repeated attempts on the same infants, and some of those babies died.
He says after Child O and Child P died, and Child Q collapsed on successive days in June 2016, Lucy Letby was confined to clerical duties.

10:29am

He reminds the jury of the background to the offences alleged on the indictment.
He says the Countess of Chester Hospital is, and was, busy.
He says the jury are now familiar with the tertiary system of hospitals, with the Countess a level 2 unit, routinely providing care to babies of 27+ weeks gestation. The jury have been provided with a guide, and walkthrough recordings, of the unit.
One room, 'room one', the ICU room, had four incubators and two computers plus other pieces of equipment. Room two was the HDU, rooms three and four were special care babies rooms.

10:31am

He says the last evidence heard was from Lorenzo Mansutti, an experienced plumber at the Countess of Chester Hospital.
The Women's and Children's building was built in the 1960s and there were issues with the plumbing, and there was an incident between 2015-2016 where the hand basin backed up with foul water. There was another incident where room 4's floor flooded after a back-up sink overflowed. None of the incidents reported happened on the days when the alleged offences took place.

10:34am

Consultant Dr John Gibbs had said in evidence it would have been better if there were more consultants, but refused to say the staffing level at the time compromised the care of neonatal infants.
He says every year, up to 2015, the number of deaths at the neonatal unit was within the number to be expected, and less than the national average.
Between 2015-2016, the number of deaths "increased significantly", including the number of "unusual" events. The defence said this was a consquence of higher admissions and a higher number of infants with more complex needs.

10:37am

In evidence, Letby was asked about her relationship with other staff. She said she had "no problem or issue" with any of the doctors and had a "normal working relationship" with them "at the time", except for one female doctor she did not get on that well with.
She said she "loved one [male] doctor as a friend", but there was no loving relationship between the the two.
She later said four doctors had "conspired against her falsely" - Dr Stephen Breary, Dr Ravi Jayaram, Dr John Gibbs and one other.

10:40am

The judge says the evidence given by witnesses behind screens, or from remote locations on videolinks, should not be diminished in any way. He adds their evidence should be judged in the same way as any other witness in the case.
He says established BAPM 'gold standard' guidelines had one designated nurse to one ICU baby, one nurse to two HDU babies, and one nurse to four special care babies.
He says nursing notes would be written retrospectively on computers. They had an accurate electronic timing of the start and completion of the note.

10:44am

He says nurses were asked about staffing levels.
The court had heard from one nurse: "Sometimes there were more babies [on the unit] than there were meant to be". 2015-2016 "was a busy period" with more babies with higher acuity.
Staff "were giving up breaks" to provide care.
"It was always quite busy," said another nurse.
Dr Stephen Breary accepted nursing levels were lower than the gold standard guidelines. He added their levels were similar to other neonatal units, and staffing levels were better than those around Cheshire units. The court heard the other units did not have the mortality levels.

10:48am

The judge says the jury should consider if sub-optimal care was a factor in the collapses of the babies. He says in a few cases, it is accepted there was sub-optimal care.
He said Letby accepted herself that sub-optimal care played little or no part in most of the babies' cases.
He says [defence barrister] Benjamin Myers KC repeatedly suggested that doctors "had gone out of their way" to "damage" the defendant by blaming her for sub-optimal failures in care. He says she "did nothing to harm any baby".
He says it is up to the jury to find who is telling the truth and who is "reliable".
He adds he is not going to put a single document up for the jury to look at, as they have all the documents.

10:51am

He says in two cases, two babies received insulin when it was "wholly inappropriate" to do so. Each of them - Child F, Child L - was a twin. He says the prosecution say there is "no doubt" it was added intentionally.
He says the prosecution say the chances of more than one person acting in that way [administering insulin] is not realistic.
He adds the defence invite the jury to question the samples, and the "lack of harm" caused by the infants if they had been poisoned by insulin.
He says the prosecution say the intention was "endangering the lives" of the two babies.

10:55am

The judge says the prosecution referred to a list of reoccurring factors for babies in the case.
He says for the defence, they say Letby was a committed, hard-working nurse, and if there was someone intent on harming children, it was not her.
The judge now gives the background to Letby, starting as a nurse at the Countess of Chester Hospital in 2012 as a band 5 nurse.
The court had heard Letby "always strived to go on every course she could".
In March/April 2015, Letby had completed a six-month course - including a placement at Liverpool Women's Hospital - she qualified in the speciality of caring for intensive care babies. She was the only band 5 nurse [along with colleague Bernadette Butterworth] to have that qualification.

11:02am

The judge says Letby has no previous convictions. He says it is entirely for the jury to attach the weight of the defendant's previous character.
Letby had said she had cared for hundreds of babies, and that hurting a baby was completely against everything a nurse is.
Colleague Christopher Booth "confirmed" she was "conscientious, hard-working, and willing to help", and another colleague said Letby would "remain friends" with the parents of babies on Facebook.
Eirian Powell said Letby was "an exceptionally good nurse".
Letby had a "passion" for working in the intensive care side, and "staff knew" she enjoyed that side of care.
The judge says Letby's health was good, and she did not take time off work in 2015-2016. She was "flexible", living at Ash House [accommodation at the Countess], then at a flat between 2014-2015, then back to Ash House until April 6, 2016, to Westbourne Road, Chester.
Letby was "often asked to do more" than the required number of shifts per month.
She was "devastated" when taken off clinical duties in 2016. She had "prided herself" on being very competent.
Letby registered a grievance in September 2016. It was at that time she learned she was being blamed for the deaths, and that that was "sickening", and her mental health "deteriorated".
She was arrested at her home in July 2018. She was interviewed, then moved to Hereford to be with her parents. A search was conducted of her Chester home.

11:06am

The arrest "traumatised" Letby, she said.
A defence statement was confirmed by her on February 11, 2022. The judge says some of it differs from the police interviews.
He refers to his next legal direction, on the defence statement.
He says if the jury find "a material difference" between the two statements, the jury are entitled to ask themselves why.
He says the defence say the task was made more difficult by the delays in bringing the case, and the volume of evidence served.
He says if the jury are sure there is a 'material difference', and they do not believe the defendant is telling the truth on the reason for those differences, then that should be in support of the prosecution case.
He says the jury must not convict on the basis of those changes alone.

11:08am

The judge refers to delays in the case.
He says the jury should take into account the passage of time since the events, and the impact that might have on the witnesses and the defendant in recalling them.

11:15am

The judge refers to expert witnesses who have given evidence in the case.
He says the jury would expect to hear evidence from experts with relevant expertise. Their role is to be a witness, not an advocate.
He says the defence have criticised that evidence, and will come to that when going through the relevant cases.
He says the jury are entitled to consider their opinions when coming to conclusions on the case. It is up to them to consider some or all of their evidence.
He says their evidence is part of the case, and the jury should not consider it in isolation, and should be considered in the context of expert, clinical and relevant circumstantial evidence.
The experts did exclude some reasons for collapses based on their own knowledge and expertise.

11:17am

He says he will turn to the relevant cases. He says the material is dense, and is conscious of the circumstances in which they happened, and does not intend to be insensitive. He reminds the jury of his initial direction for the jury to treat the case on the evidence, not on emotion.
He adds he is conscious the jury has already heard nine days of closing speeches.

[Child A]

11:22am

He refers to the case of Child A - the twin of Child B.
He recalls the events of their birth and the collapse.
Child A's cause of death was "unascertained". The prosecution case is Child A did not die of any natural cause, but instead had air deliberately injected intravenously system with the intention to kill.
The defence say Letby did nothing to harm Child A, and raised issues with the long line.

11:35am

The judge details what neonatal unit staff were recorded, and recalled, doing for Child A before the collapse. He says there were issues siting a cannula "as can happen".
A long line was later inserted by registrar Dr David Harkness.
Nurse Melanie Taylor came on duty. Child A was "stable and satisfactory", and the nurse "had no concerns". She ended her shift at 8pm, and handed over to the defendant, who had come in at 7.27pm. She confirmed a 10% dextrose bag had been prescribed, to be given via the long line.
All three babies that night in room 1 required long lines - Child A, Child B and one other.
Dr Harkness was unsure if the long line was in the perfect position. He believed it was "imperfect", but good enough to be used.
Dr Dewi Evans said the position was not a problem, and there was no evidence of the end of the line puncturing the heart lining. He said if there was, it would show up on a post-mortem examination. Dr Sandie Bohin said it was "not in an optimal position" but "safe to use".
Melanie Taylor said she was sitting at the computer in room 1 when Child A started to deteriorate.
The alarms sounded, and Melanie Taylor went over, thinking the baby was going to recover. She said Letby was administering Neopuff. She says it "was a bit of a blur".
Letby said she was not initially intending to work that night shift, but was "happy to help" after being asked to work. "There was a lot going on", and she said Melanie Taylor, "being the sterile nurse", was administering fluids.
Child A's hands and feet were "white" at the time of the desaturation - 'centrally pale and poor perfusion'.
An emergency crash call was put out.

11:42am

Dr Rachel Lambie had said Child A 'looked like Child B', pale and blotchy all over. The defence said her original police statement referred to Child A being pale, with white hands.
She thought there was a "lot of discussion" over the rashes. She said no-one had told her what to say on them.
The defence "draw your attention" to the difference, the judge says.

11:42am

The judge's next legal direction is on differences in evidential statements.
He says what a witness says in the witness box is all evidence for consideration. He says where there are, or appear to be, differences in accounts, it is for the jury to decide how different those accounts are, and how important they are.
He says if there are important differences, they should consider them, and the explanations given. He says if the jury do not accept their explanations, they should treat the witness' evidence with caution. If the explanations are accepted, then the evidence can be treated as such.
He says it is "really no more than a common-sense approach" "to see where the truth lies".

11:48am

Dr Harkness had given a description of the 'blotchy' rash, saying it was only seen again by him in the case of Child E. The defence criticised him for not including the description in medical notes at the time or in notes to the coroner.
Dr Ravi Jayaram had said it was "highly unusual" in the way that Child A was deteriorating and his heart rate fell even after intubation. At the time, he noted Child A's pale skin.
His explanation for not including the 'pink patches' skin discolouration to the coroner - mentioning it to the police later - was "he had not considered it clinically relevant" at the time. He said it was "a matter of regret" he had not mentioned them.
He says he could not explain how Child A collapsed.
He said he read a document in a medical paper about skin discolouration in a case of air embolus. He said he had not been influenced by that paper when it came to that explanation.

12:14pm

The trial is resuming after a short break.
The judge is continuing the summing up, in the case of Child A.
He recalls what Letby had said in police interview, and recalled 'red, purple blotchy markings' on Child A, which she thought were signs of an infection.
She believed there was an issue with the long line, and Melanie Taylor had connected the fluids to Child A.
Child A's death was not expected or anticipated. She said she thought the bag of fluid was 'not what they thought it was', but they had checked it afterwards.
She said she did not keep in touch with the parents, and did not recall what she did with the handover notes.
She said she did not know much about air embolisms, and all staff were "meticulous" about precautionary checks to prevent that happening. She denied pushing air through the line.
She could not recall using social media to search for the mother of Child A, and when asked to explain searches for the mother on Facebook, said she could not do so.
Letby said the fluid bag should be contained and put in the sluice room for checking.
She said staffing levels contributed to the death of Child A, citing difficulties with the long line and Child A's lack of fluids for several hours.
She said if air embolus was the cause, Melanie Taylor was responsible. She disagreed with the descriptions of skin discolouration given by a nursing colleague and Dr Harkness.
She said searching for the parents was a "common pattern of behaviour" for her.

12:25pm

The judge says Mr Myers "repeatedly expressed his opinions" on the merits of the expert evidence, questioning and challenging them. He says that is his right, but it is up to the jury to determine the reliability of the expert evidence.
The judge refers to Prof Owen Arthurs' evidence, who "considered each case on its own merits".
Prof Arthurs was provided with radiograph images of Child A. He noted the umbilical catheter was "slightly in the wrong place", and there was "a line of gas in front of the spine" on one of the images, which was "an unusual finding". He said it was "so unusual", he reviewed other cases at Great Ormond Street Hospital, to compare for a similar images. He said such gas would normally only be seen in heavy impacts such as road traffic incidents - this could obviously be discounted.
The other usual case would be "overwhelming infection" in organs of the body, such as sepsis, but Child A did not have any such identifiers.
He said he had "not seen this much gas" in any baby, other than in the case of Child D. He said it was 'consistent with air administered' to him, but 'not diagnostic' of it.
In cross-examination, he said he found no unexplained cases, and accepted this was an observational study, not a controlled study - the judge says for obvious reasons, the latter could not be carried out.

12:29pm

Prof Arthurs said radiographic evidence of air embolus was "rare", and in suspected cases, seeing anything on the radiograph was "rare". He said the absence of it on the radiograph did not rule that cause out.
He said one of the reasons is the imaging of the event is not important, the main priority is to save the life. An x-ray taken an hour later "wouldn't show anything".

12:41pm

The judge refers to expert witness Dr Andreas Marnerides' evidence.
His expertise, the court is told, is on the pathology of conditions on those who had died.
He said there was "no evidence of infection" or "any other abnormalities".
He said he could see, from his study, "empty structures" of fat or air in Child A - after testing, he ruled out the former.
He said he could see evidence of air in the brain when the baby was alive.
The findings "could not be taken as absolute proof of air embolus".
He said there was "no evidence of any natural cause of death", or any of natural disease.
He took the view that Child A's death was of air embolus via injection.

12:54pm

The judge refers to Dr Dewi Evans, and his role in providing background evidence for Child A.
He said: "On the whole, babies don't suddenly collapse".
He said Child A was the fifth case he looked at, and the cause of the collapse was "unusual". He said as he looked at further cases, he noticed a "pattern", as he received more evidence.
He said Dr Evans' evidence came for criticism by the defence. He had not been in practice since 2009, and the defence said he had "constructed theories" and "acted as an investigator" and was "biased", " putting himself forward...at the outset".
The judge says the prosecution point to a large number of incidents for review with "no apparent reasons for an event or death". They point to Dr Evans' long experience in neonatalogy, and provided "clear evidence" in Child F and Child L that identified two babies on the unit were being poisoned. The prosecution say Dr Evans was not handed other potentially incriminating evidence, such as shift patterns for staff.
Dr Evans said Child A was "stable" and "as well as could be expected" before the collapse. Repeated attempts to insert a UVC or long line may have caused upset to Child A, but would not have caused the collapse, he said. The lack of fluids "would not make a material difference".
'Bright pink' skin discolouration would be unusual in a baby's collapse - but skin discolouration is "not diagnostic" of an air embolus alone, Dr Evans said.
He denied he had been "influenced" in reaching his conclusion by a 1989 medical paper. He said in Child A's case, there had been colour change, sudden and unexpected collapse, air in various parts of the body, and no explanation for death. He said it was probably an air embolus intravenously.

1:02pm

The judge refers to Dr Sandie Bohin, and her evidence for Child A.
He says the defence accused her of lacking independence, and "enthusiastically supported" Dr Evans' evidence. She repeatedly denied this assertions, and said her views were her own. The judge says it is up to the jury to assess the validity of the defence's assertions.
Dr Bohin said neither the UVC or long line contributed to Child A's collapse. She said Child A was "so well", that there was consideration to giving him feeds, and babies doing well do not develop pink fluctuating rashes that come and go.
She said, excluding other possibilities, air embolus was the "only plausible explanation", and believed air getting in accidentally "was extremely unlikely".
Studies on air emboli should be "treated with caution" as they are on adults or animals, she said.
In cross-examination, she said she did not know of any genetic condition that would cause a collapse and death within 24 hours of birth.

 

[Tortoise]

JUDGE'S SUMMING UP - Monday 3rd July 2023

Day 1- Afternoon Session

LIVE: Lucy Letby trial, July 3 - judge's summing up

[Child A continued]

2:14pm

The trial is resuming following its lunch break.
The judge describes Prof Sally Kinsey's evidence, in which she had concluded, from the descriptions by dctors and nurses of skin discolouration, that Child A had had an air embolus. The court had been told of how an air embolus affects the body. She confirmed she had not seen one in her experience, but the descriptions provided were "pretty stark".

[Child B]

2:14pm

The judge turns to the case of Child B, and relays the care and events leading up to and the time of her collapse.

2:22pm

A nurse colleague said she had her gloves on, and was drawing up medication, when Child B collapsed at 12.30am. Letby had said Child B was apnoeic [not breathing].
The nurse said Child B 'looked like Child A', with blotchy discolouration; a 'cyanosed appearance' was recorded in the nursing notes. The notes added the colour changed rapidly, to "purple blotches with white patches."
Letby said she had accepted being in room 1 at the time of the collapse. She said the colleague had alerted her to Child B's collapse. Child B had a 'dark mottling', a 'general mottling'. Child B was 'more purple' and she did not see what the nursing colleague had seen.
Letby had accepted she would have had access to the IV lines prior to the collapses of Child A and Child B, but said she did not do anything with them.
Letby, in police interview, said Child B's mottling 'purple, red, rash-like appearance' was more extensive than with Child A, but was "similar".
She recalled Child A and Child B's parents being very upset. She said, in a 2019 police interview, she accepted she may have taken blood gas readings prior to the collapse, but did not do anything to harm Child B. In a 2020 police interview, she said she did not know how Child B collapsed.

2:27pm

Dr Rachel Lambie said the most unusual observation for Child B was a 'dusky, pale grey colour - then developing widespread blotches of a purple/red colour - they would flush up, then disappear, then appear elsewhere - they were flitting all over'.
It took about 90 minutes for the grey colour to disappear and be replaced by pink, she added.
She said this "was a very unusual event" which she had not seen before or since, and Child B recovered quickly.
Blood gas results came back as normal.
Letby said she had been asked to get a camera to get a photo of Child B, but when she had returned, the discolouration had gone.
A female doctor recalled 'purple blotching to the mid-right abdomen and right hand', which she was "puzzled" by.
The rash was "so florid" and "so very unusual", she said, and its quick disappearance was not normal.

2:33pm

Dr Evans said Child B was "stable" prior to the collapse, and prone to desaturations. The collapse was either the result of smothering or air embolus. He said if the cause was hypoxia or infection, the effects would stay.
He said the fact Child B survived meant it was likely less air was administered, or it was administered more slowly.
Dr Bohin said Child B was compromised at birth, but responded very well to resuscitation and breathing support measures.
The circumstances of the collapse was "very disturbing" and there were no other warning signs. The dislodging of the nasal prongs for Child B had been resolved.
She based her air embolus conclusion on 'florid' skin colour changes and ruling out other causes.

2:33pm

The defence say it cannot be excluded that Child B's collapse was a natural event.

[Child C]

2:36pm

The judge refers to the case of Child C.
He says medical experts found it difficult to conclude the cause of death, but Dr Marnerides said it was air administered into his stomach via the naso-gastric tube.
Letby said she did nothing harmful to Child C, and a cause such as a gastrointestinal blockage cannot be excluded, that Child C should have been treated at a tertiary unit, and there was a failure to react to bile aspirates, vomiting, and an overall lack of care.

2:47pm

Child C was "born in good condition" and was 'on the margins' of being treated at the Level 2 Countess of Chester Hospital neonatal unit, the jury is told.
The judge recalls the events leading up to Child C's death on the morning of June 14.
"Nothing stood out as worrying" for Child C from observations, but there was caution for his care.
Prof Arthurs said radiographs for June 12 showed left-sided chest infection, and marked dilation of the bowel. Symptoms of this included CPAP belly, NEC, sepsis or air embolus.
Bile was later noted on Child C's blanket on June 13, and 2ml of black-stained fluid was obtained on aspirates. No desaturations were observed.
Bile aspirates was a "concern" in neonates, but not that unusual for them, and "not a major cause of concern", the court had heard.
Dr Gibbs said the bile for Child C was "a worry", but the aspirates "were not increasing", and "his overall observations were satisfactory". An obstruction would have been found post-mortem.

2:52pm

"Black bile was not normal, but not unknown in premature babies", the court had been told.
Dr Sally Ogden said the bilous observations were a "concern", and the x-ray showed a "loopy bowel". Child C was still pink and well perfused and he had "no concerns with breathing" and the abdomen was soft to touch, which was "reassuring".
Dr Gibbs had "no particular concerns" about Child C that day on June 13. Babies with [gastrointestinal disease] NEC develop a hardened abdomen, the jury was told.

3:06pm

Messages showed Letby wanted to 'throw myself back in' to the neonatal unit - She said that meant getting back in to looking after babies as that was what she was taught at Liverpool Women's.
The messages included Letby saying: "From a confidence point of view, I need to take an ITU baby soon."
Sophie Ellis, a band 5 nurse - not intensive care unit trained - was supported by a band 6 nurse that night shift to be the designated nurse for Child C that night in room 1.
At the start of the night shift, there was a hope to start Child C on feeds. He was "pink, well perfused, active and alert".
At 10.34pm, Letby said she had 'done a couple of meds in 1', and believed Sophie Ellis didn't have the skill in caring for premature babies.
Sophie Ellis was alerted to Child C's desaturation. She said she had been alerted to the desaturation by Letby, who had said 'he's just dropped his HR and saturations'. This was something she had not put in the nursing notes, but something she said to police. She said she did not do so at the time as it was ultimately a traumatic event.
She said she didn't do anything to Child C, and didn't see anything being done to him. Letby was "stood at the incubator at the far side".
A nursing colleague said she believed she saw Melanie Taylor and Sophie Ellis by Child C. Child C was not breathing, "very blotchy", and was not aware if Letby was in the room.
Melanie Taylor said in evidence when she approached the incubator, Letby was already there. She said in police interview, she was in room 1 feeding another baby, and was called over by Sophie Ellis, not mentioning Letby.
Letby said she had "very little independent memory" of events. She said she had given evidence on Child C's collapse having been "placed" there in the room by Sophie Ellis' account.

3:17pm

The trial is resuming after a short break. The judge says we will finish before 4pm, at the conclusion of the case of Child C. The case of Child D will be referred to tomorrow.

3:27pm

Dr Gibbs said efforts to intubate were unsuccessful due to swollen vocal cords.
Sophie Ellis said she got upset at the situation, after Child C's mother arrived, as it was "overwhelming" and she had not been in that kind of situation before. Lucy Letby said to her: "Do you want me to take over?" Sophie Ellis said yes, left room 1 for a short break, then went to look after babies in room 2.
Dr Katherine Davis said "even the smallest, sickest babies" would respond to resuscitation, but Child C did not. Dr Gibbs said he could not find anything that would allow to restart long after resuscitation had stopped, and could not understand that from a natural disease process.
The mother said, in an agreed statement, she recalled CPR being performed on Child C, and the heart rate had fallen unexpectedly and rapidly. She says she did not grasp the gravity of the situation and was shocked when asked by a nurse if she wanted a priest. She asked if Child C was going to die - the nurse, described to be in her mid 20s, replied "Yes, I think so".
The father of Child C said a nurse, who he later believed to be Letby [based on her picture appearing in the newspaper] had said to the parents in the family room 'you've said your goodbyes now, do you want to put him in here?', referring to a basket for Child C. He said Child C's mother said "He's not dead yet", and the nurse then backtracked.
Letby had accepted she had made searches for Child C's parents on Facebook 10 hours after, but could not remember doing so, or why. She questioned whether she was the nurse who said the 'you've said your goodbyes...' comment, and did not recall saying it. She said she was very sad for the parents.
In evidence, she said she did not recall any specific contact with the parents. She said the search for the parents were as they were 'very much on her mind' at that time, as 'you don't forget' events like those which had happened to Child C.

3:35pm

The nursing colleague recalled asking Letby "more than once" to look after her designated babies that night, and it was not part of her responsibilities to be in the family room, as that was for Melanie Taylor.
Dr George Kokai carried out a post-mortem examination for Child C. He noted a distended colon, which Dr Marnerides said was "not an abnormality". He said the potential complication was a twisted colon that would lead to "obvious" symptoms of pain.
There was evidence of "acute pneumonia". Dr Marnerides said one could die of pneumonia or with pneumonia. He said the former was plausible, but upon hearing further clinical evidence, he reviewed his opinion. He said babies dying of penumonia experience gradual deterioration, which was not the case here. He said he revisited the cause of death, viewing images of a distended stomach, and no evidence of NEC.
Prof Arthurs said the small bowel was dilated. Dr Marnerides observed a dilated stomach and bowel, and noted Child C had been off CPAP for over 12 hours. No air had been obtained from aspirates before the collapse. He had never known CPAP belly being the cause of an arrest in a baby in his years of experience.
He said, in his opinion, the cause of Child C's collapse was of excessive air administered into the stomach via the naso-gastric tube.

3:44pm

The judge says Dr Evans said the pneumonia infection did not cause Child C's collapse.
The cause was "difficult to explain". Initially, he said it was unexplained. He said excessive air in the stomach can cause 'splinting of the diaphragm'.
The judge [said] he had not given that conclusion before giving evidence, and it was not advanced in his eight reports. Dr Evans denied he was 'coming up with things now to support an allegation of harm'. Dr Evans said from an academic point of view, air embolus could not be excluded. The judge says Mr Myers was critical of this late conclusion.
Dr Bohin had said her conclusion of the 'bubble in the stomach' was if the NGT was not on free drainage, then it could have been accumulation of gas by CPAP. The alternative was the deliberate administration of air via the NGT.
She said Child C died with pneumonia, but not because of pneumonia, and that would have made Child C less responsive to resuscitation. In reaction to questions about bowel obstructions, she said Child C would have had a distended abdomen, and normal bowel sounds would not have been heard. The judge said Dr Bohin had added: "There were no clinical indicators of obstruction".

 

[Tortoise]

JUDGE'S SUMMING UP - Tuesday 4th July 2023

Day 2

LIVE: Lucy Letby trial, July 4 - judge's summing up

10:30am

The trial is now resuming.

[Child D]

10:41am

The trial judge turns to the case of Child D. He recalls the baby girl's birth, and that she died 36 hours later on June 22, 2015. The prosecution's case is air was administered intravenously.

He says the guideline was for Child D to be given antibiotics at birth, due to the gestational age, and this had not been done. The prosecution said while Child D died with pneumonia, not of pneumonia. The defence said you cannot be sure of that, and the cause could have been infection.

Dr Sandie Bohin said Child D should have been screened at birth due to her low temperature, which was a sign of infection.

Child D was placed on CPAP. Her heart sounds and capillary refill were normal, abdomen was soft and non-distended, and the chest was clear. The parents were informed it was likely sepsis.

Child D stabilised on CPAP.

10:44am

Child D was intubated and ventilated, after showing signs of acidosis. An x-ray showed 'very little abnormal', according to Professor Owen Arthurs. Child D was given the protein surfactant.

Child D was weened off the ventilator and extubated. Dr Elizabeth Newby said Child D was a little stiff and hard to handle, and felt there was an element of infection. Dr Bohin said Child D had signs of pneumonia, but was recovering.

10:47am

Child D's mother recalled an event when she arrived on the unit and Letby was 'hovering round [Child D], not doing much, holding a clipboard', and she asked if everything was ok. Letby replied everything was "fine".

The mother added: "She just stuck around".

The mother said Letby was told to go away, or words to that effect.

Child D's father did not recall this event. He recalled he was given a Father's Day card on June 21 by the staff. He said nurses were "friendly and warm" and was made to feel welcome when he went to the unit.

10:51am

Prof Arthurs said a radiograph of Child D from the afternoon of June 21 showed the catheter was in the wrong position, and there was a sign of infection, but nowhere near as prevalent as that seen for Child C.

Child D showed 'big improvements' and 'good progress' on June 21 in relation to blood tests and respiratory efforts, although she was 'not stable enough' to have a lumbar puncture. She was 'responding well' and her tone was reasonable. Child D desaturated to the 80s when attempts were made to take her off CPAP. Dr Sarah Rylance was 'happy' with Child D's clinical condition by this stage, 'stable and making good progress'.

11:02am

The judge says shift leader and designated nurse for Child D in room 1 on June 21-22, was Caroline Oakley. Letby was designated nurse for two other babies in room 1.

Child D was on 'nasal CPAP in air', with 'satisfactory' gases. The readings for 7.30pm-12.30am were all normal and she was 'happy' with Child D, who was "breathing beautifully in air".

Aspirates found had 'minimal importance to them' as Child D was not being fed at this time.

Caroline Oakley said she assumed she began an infusion at 1.25am, being the designated nurse, but the writing on the infusion note was not hers.

One of the nurses on duty was aware Caroline Oakley had been on her break, and checked Child D, who was fine.

While she was at her computer, she was alerted to alarms, and found the monitor was showing Child D was desaturating at 1.30am. She recalled Letby was there.

She noted Child D had a rash on her trunk and arms, and was 'not a normal rash' - like a 'mosaic', like 'vessels of blood meeting with each other'. She had not seen anything like it before, she said.

She said 'her trunk and legs went a mottling colour, and it was odd'. She discussed it with Dr Andrew Brunton.

Child D settled and discolouration 'seemed to disappear and dissipate'.

Caroline Oakley said the rash was 'different to mottling' and it was 'an unusual rash'. She "had an episode but responded very quickly".

Another senior nurse said she had a limited memory of events. she remembered Child D being stiff and having a rash on her trunk, which was an 'odd, unusual rash'.

11:11am

The judge says at 3am, there was a second event. Caroline Oakley said Child D was crying and desaturating, and the skin was discoloured, but less than before. Dr Brunton recalled Child was agitated and upset, and thought it was something to do with the face mask. He saw skin discolouration, but this was 'not as obvious' as before.

A prescribed saline bolus was signed for Child D at 3.20am by Caroline Oakley and Lucy Letby.

Nurse Oakley said they were happy with Child D, and she would be provided with expressed breast milk. She said if Child D was unstable, she would not have changed Child D's nappy. Observations were 'fine' by 3.30am.

At 3.45am, Child D's monitor was alarming. Caroline Oakley found Child D had stopped breathing and was apnoeic. Dr Emily Thomas heard the call for help. She asked a nurse to put out a crash call for Dr Brunton. He ran when he was crash called.

Full resuscitation was carried out on Child D with the assistance of doctors and nurses, including Lucy Letby. There were 'secretions+++' from the nose and mouth. The parents were informed and went to the unit.

After 28 minutes of resuscitation attempts, it was decided to stop.

At 4.50am, Dr Newby had a discussion with Child D's parents on the 'sudden collapse'. She agreed babies can suddenly collapse, but was "surprised" Child D did. She "did not appear to be a baby in extremis".

A nurse had a conversation with Lucy Letby about the drugs administered during resuscitation. Letby asked the nurse how she knew the doses to give. The nurse replied she knew them from her years of experience, and recommended Letby learn them as well.

11:25am

Dr Andreas Marnerides said pneumonia was likely to be present at birth for Child D.

Professor Arthurs talked of a 'black line' in front of the spine indicating gas in the great vessels, which was "unusual" in children who had died without an explanation. It was present in "two other children", one of whom was Child A. There was "more air" in Child D than Child A. One explanation was someone was injecting air into the child, and the radiograph images were consistent with, but not diagnostic of, externally administered air to Child D.

Dr Marnerides said the presence of air in such a vessel was "significant". He said from a pathology point of view, air embolus could not be proved. He said there was "no other natural disease" that could explain Child D's death. He said in his opinion, Child D died with, not from, pneumonia. He concluded the 'likely explanation' was air embolus.

Dr Dewi Evans said the 1.30am episode was "very surprising and unusual" as Child D had been responding to treatment and was "a stable baby". He said Child D had symptoms of early onset pneumonia and had developed that before birth, but was making a recovery. He said he could not think of any events which would end with unsuccessful resuscitation, and the cause was an air embolus.

Dr Bohin peer-reviewed Dr Evans' reports and conclusions. She said the striking feature of all events was they were sudden and unexpected, and came with mottling of the skin. She said it was a concern that Child D was crying in the second event. She said although antibiotics were given late, there was nothing, clinically, to suggest Child D was going to collapse. "This was not a picture of a baby with pneumonia severe enough" to collapse. She was "clear" infection did not cause the "sudden" collapse. There were episodes of discolouration which was consistent with the limited recorded events of air embolus. She concluded air had been administered intravenously, causing an air embolus.

11:28am

The judge says Lisa Walker, a band 4 nurse, talked about an event of being in room 3 - a special care unit - where Letby was feeding babies via a naso-gastric tube. The alarm on the portable monitor was going off - the desaturation alarm.
Lisa Walker went over to help. Letby stopped the feed and began stimulation for the baby, but was not getting a response.

She saw colleague Kate Bissell walking past, and shouted for help as the baby was not picking up. A doctor working on a computer went over to help.

The baby was given gentle stimulation and picked up.

Lisa Walker said Letby asked her, "quite firmly", why she asked for help. She said Letby was "quite cross" and the band 4 nurse didn't respond.

She said Letby's demeanour was that she would have been fine and didn't need any help.

11:32am

Letby, in police interview, denied doing anything deliberately harmful to Child D. She said she could not remember doing Facebook searches for the parents of Child D three days after Child D's death.

She said she could not recall why she said Child looked like having 'overwhelming sepsis' or that there was 'an element of fate' in babies.

In evidence, Letby said she "didn't really remember" the night shift. She said she would have been caring for her designated babies and assisting colleagues with other babies.

She did not remember being called in to room 1 at 1.25am, Child D desaturating at 3am or Child D collapsing at 3.45am.

[Child E]

11:33am

The trial judge refers to the case of twin boys Child E and Child F, dealing with Child E first.

11:39am

Both twins were born "in good condition", the jury is told. Child E died less than six days later.

The court had been told Child E was very premature. A doctor agreed Child E was capable of dramatic changes in his condition.

The day after Child E was born, the mother went to cuddle Child E, as he was on CPAP.

On July 30, the boys were 'progressing really well', and due to a high blood glucose level, Child E was given a low dose of insulin.

The twins were 'doing well' and stable on August 1, with time out of his incubator.

On the day of August 3, a nurse said the mother was on the unit with long periods of skin-to-skin contact, and Child E could have 'as many cuddles' as he liked. Child E was 'pink and well perfused' with regular circulatory system and a cautious feeding regime. "Everything remained well". Intravenous caffeine was given as prescribed.

11:50am

The trial is now resuming after a short break.

11:56am

The judge says Dr Emily Thomas said she had examined Child E and there were no signs he was unwell, and observations were normal, with a soft, non-distended abdomen and no suspicious aspirates. He was "well and stable".

A nurse noted Child E's blood sugar was higher than normal, and his insulin infusion was restarted at a lower dose. Antibiotics were given as prescribed.

A doctor said the observations were normal and not a cause for concern, and the high blood sugar level was relatively normal for a neonate and would not lead to the sort of collapse seen hours later.

12:06pm

Child E's mother recalled giving cares to Child E, then going upstairs to provide milk between 7pm-8.30pm, the latter being the time of the night shift handover.

Letby was the designated nurse for Child E and Child F in room 1. Letby said the 9pm feed was omitted because of 16ml mucky, bile-stained aspirate, discarded, and the SHO was informed, and told to omit the feed. She said the doctor's name was not always made on nursing notes.

She accepted she got '15ml fresh blood' from Child E at 10pm. She denied she had got Belinda Williamson [Simcock] to write in the 10pm entry.

Dr Christopher Wood was the on-call SHO and was asked if he recalled receiving a call about an aspirate. He said he didn't recall it, and didn't definitely rule it out. He said if he had received a call, he would make his assessment, and make it in clinical notes, and seek advice from a registrar.

Dr David Harkness said it was his recollection that during the review, there was a fresh blood vomit and 14ml aspirate. He says there was a discussion with a doctor about a blood transfusion.

12:18pm

Child E's mother recalled going to see Child E and Child F, at 9pm.

Letby was there at the workstation, the mother said. She added child E was crying like nothing before - 'horrendous', and saw 'blood coming out of his mouth'. It was 'not on, or going on to anything else', 'like a dribble pattern - it was blood'.

"It was smudged, and didn't look completely dry, it was darker [than normal]."

The mother said she was panicking and asked Letby why Child E was bleeding, She said Letby said the NGT had been rubbing at the back of the throat.

Letby did not recall saying this. In cross-examination, she said she did not tell the mother and would not tell parents to go away. She accepted that in the interview for Child N, she had said an NGT could cause bleeding.

The mother said she accepted what Letby had said, and did as she was told to go back to the post-natal ward as Letby was an authority figure, but she was concerned. She said she made a call to Child E's father. The judge refers to phone call data at 9.11pm. The father said the mother was upset at the time of this call.

Midwife Susan Brookes recalled Child E's mother had said to let her know if there were updates overnight from the unit, as one of the twins 'had deteriorated slightly'.

She had recalled at 11.30pm the neonatal unit rang to bring Child E's mother to the unit in 30 minutes, as Child E had a bleed.

Letby said in police interview, she could not recall the events with Child E's mother, and could not remember any specific bleed. She said the 14ml bleed later, after 10pm, was "very concerning" and, in evidence, that was when she said she first saw bleeding on Child E.

The judge says there are "significant conflicts" between Letby's evidence and that of the parents. He says the defence say the mother's evidence is "unreliable" in relation to timings.

12:30pm

The judge says Dr David Harkness noted, at 11.40pm, Child E had a desaturation, with colour changes on the abdomen - "a strange pattern over the tummy which didn't fit with poor perfusion" The legs and upper arms were 'pink in normal colour'. he said the only other time he had seen this was with Child A, and not since. The patches were 1-2cm big, and he carried out an emergency intubation.

Letby said there was a 'purple block' on the abdomen for Child E at 11.40pm. She said it was not like Dr Harkness had described. She said she found Child E's death "very traumatic", and filed a Datix form. She said the medical team were late administering a blood transfusion.

The defence challenged the decision not to give a blood transfusion earlier. A doctor had said she did not believe the collapse was due to blood loss, and that blood transfusion had its risks. She said she did not believe, "even with hindsight", Child E should have had a blood transfusion at that point.

The mother had contact with Letby after Child E died. She said Letby bathed Child E. In Letby's evidence, she said the parents bathed Child E.

A doctor said at the time, she believed Child E had died of NEC, and that a post-mortem examination would not tell the parents any more, and would delay their transfer back home. She had said NEC was the most likely cause of the gastro-intestinal bleed. No post-mortem examination was carried out.

She completely agreed, that with hindsight, she should have requested a post-mortem examination. She apologised to the parents for not pushing for that, having wanted to avoid further distress for them.

Letby said in messaging with Jennifer Jones-Key, in response to the unit being 'on a terrible run', that Child E had a haemorrhage, and could have happened to anyone.

She said the searches for the parents of Child E and Child F more than once on Facebook was part of a normal pattern of behaviour for her, as was taking a picture of the card for the parents. She said it was something for her to remember, as was a photo of her shift pattern.

12:44pm

The judge says Prof Arthurs said there was no evidence on the radiograph image for Child E of an air embolus, but that did not exclude it may have happened. He said there were no features of NEC on the x-ray.

Professor Sally Kinsey said Child E did not have a blood clotting problem.

Dr Evans said Child E was "incredibly stable", at increased risk of NEC, but suitable treated. He said if a baby had NEC, they would become "gradually unwell" and Child E would not have coped with handling in any way, and have a distended abdomen, along with other observations. He said NEC was not a viable explanation.

He said there was a significant haemorrhage and something must have caused this. He noted the 'unusual' discolouration, which prior to this case he had only seen in literature as evidence of an air embolus. He said there must have been some sort of trauma caused by a piece of equipment, such as an introducer. He said there was no "innocent explanation" for it. He said he has never seen an ulcer cause this type of bleed. He said the haemorrhage was caused by trauma.

Dr Bohin says she formed her opinion on the case, and refuted 'going along' with Dr Evans' conclusions. She said the decision not to hold a post-mortem examination was "a poor decision".

Dr Bohin said babies with NEC do not go from being well one minute to very unwell the next. The 16ml aspirate before the 9pm feed "struck her" as being odd, and did not match Child E's clinical picture at that point, and was "at a loss" to describe where that had come from.

She said the NGT insertion can sometimes cause "very minor bleeding" in a baby, but not a haemorrhage. The blood vomit was "an extremely unusual feature". Dr Bohin had never seen a baby have a gastric haemorrhage in this way, the court is told.

She believed Child E died of an air embolus.

[Child F]

12:53pm

The judge refers to the case of Child F.

On July 31, 2015, Child F was given a dose of insulin to treat high blood sugar levels, and he stabilised.

On the day of August 3, other than a minor respiratory issue when Child F was taken off CPAP, all was well, and he was tolerating feeds.

The prosecution allege Child F was given insulin via a nutrition bag hung up on August 4-5, and that the next bag hung up at noon on August 5, a stock bag from the fridge, had a similar amount of insulin put in it.

The jury is reminded of the relationship between insulin and insulin c-peptide levels, naturally occurring in the body, and the relationship between those two in synthetic insulin.

The defence say the proof is on the prosecution, that the jury must be sure that Child F and Child L received synthetic insulin, and that it was Letby who administered that. They ask if Letby was intent on harming Child F, why she did not attack that baby on subsequent shifts.

1:01pm

A new TPN [fluid nutrition] bag was hung at 12.25am on August 5 for Child F.

Yvonne Griffiths said the fridge contains stock bags for Babiven and start-up Babiven, and insulin. That fridge was kept locked, with one set of keys, initially in the hands of the shift leader but available on request. There was no system for signing the keys in or out.

Child F was the only baby on that night shift of August 4-5 who was receiving TPN.

2:09pm

The trial is now resuming following its lunch break.

2:20pm

The trial judge clarifies a matter from this morning, and says during the cross-examination of Prof Arthurs, it was said that gas could be recirculated in the body in the event of vigorous resuscitation.

He continues with the case of Child F.

He says a nurse was "really happy" with Child F from 10pm-1am. There was "no way of knowing" who had got the bags out of the fridge.

Prof Peter Hindmarsh says the bag administered at 12.25am had insulin in.

Dr Harkness attended the unit that night and noted Child F had vomits and tachycardiac, with a heart rate of 200bpm, but otherwise well. Prof Hindmarsh said these were signs of hypoglycaemia.

Doses of dextrose and salt water were administered.

2:32pm

Kate Bissell and band 4 nurses said they had never added anything to a TPN bag.

Dr Gibbs said the fall in Child F's blood sugar level was 'unexpected'.

At 10.30am, a new long line was to be inserted in Child F, as instructed by Dr Satyanarayana Saladi, with the removal of the old one.

The fluids were stopped while the line was replaced, and Child F's blood sugar level rose. A new TPN bag, from the stock bags in the fridge - of which there were about five - was hung up at noon. Fluids resumed.

Child F's blood sugar levels remained low in the afternoon after dextrose boluses at 3pm and 5pm.

The TPN bag was stopped at 7pm.

2:40pm

The judge details how the insulin blood sample was taken to the laboratory in Liverpool and analysed, and the results came back showing an 'undetectable' level of insulin C-Pep compared to a high level of insulin.

It was suggested that the sample be referred for further tests, but Child F had recovered by this stage, so the sample was stored for seven days before being disposed of.

Prof Hindmarsh said the increased blood sugar readings for Child F during the afternoon were consistent with them following fresh bolus administrations of dextrose.

The blood glucose had 'started to rise spontaneously' between 10.30am-noon, Prof Hindmarsh said, during the time the fluids were not being administered.

He said the difference between the blood glucose levels on a heel prick and a plasma sample would be about 10-15%. He said the dangers of low blood sugar include confusion, seizures, brain damage and in serious cases, death.

2:52pm

The judge says the court had heard the most likely cause of insulin administration was for it to be administered intravenously. Prof Hindmarsh says the most likely way for this was via an infusion, at a rate of 1.2 units per hour, and calculated that 0.6ml of insulin - a clear fluid - was added. He says the same amount would have been needed to have been added to the stock bag.

He concluded that the only explanation was for Child F to have received bags contaminated with insulin.

Dr Evans concluded Child F had received exogenous insulin via the TPN bag from before 01.54am to before 7pm. Dr Bohin agreed, and said two bags must have been contaminated with insulin.

When interviewed, Letby remembered Child F as the surviving twin of Child E. She agreed her signature was for a TPN bag, and could not remember if she had administered the TPN bag or not. The bags were kept at the top of the fridge, the insulin at the bottom.

Letby said medication would not be added to a TPN bag. She agreed the blood sugar level for Child F at 1.54am was "dangerously low", and denied harming Child F or giving him any insulin.

Letby, in evidence, said she believed her nursing colleague had hung up the TPN bag. She confirmed she did not know about c-peptide at that time. She knew adding insulin was "life threatening" to a child like Child F.

She said Facebook searches for the parents was because the twins were on her mind.

[Child G]

2:59pm

The judge refers to the case of Child G, born in a tertiary unit, and was "very premature", weighing just under 1lb 3oz. She was "at the margins of survival" when born. On August 13, Child G was transferred to the Countess of Chester Hospital, and was "stable".

Letby said she remembered Child G, who had "a lot of problems". The prosecution case is Letby deliberately overfed Child G.

Dr Stephen Brearey first reviewed Child G on August 22, and the general trend was one of improvement for the baby girl. She was "stable and well", with desaturations self-correcting. The oxygen requirement was "continuing to come down".

For September 6-7, the night shift, Child G was the only baby in room 2, and Letby had a baby in room 1.

3:10pm

The prosecution case is after the 2am feed for Child G, administered by a colleague, Letby deliberately injected milk and air afterwards.

3:17pm

September 7, 2015 was Child G's 100th day of life, and a banner was prepared to celebrate that on the unit.

Child G was still on nasal prongs and some oxygen, and was "stable".

A nurse said she usually completed the chart after the feed. The 2am, 45ml feed was given via an NGT. Letby agreed the readings were good at this time.

The nurse said an aspirate was taken from Child G for a pH check, this level being 4. She then went on her break at 2.05am-2.10am. When she returned, she found Child G had deteriorated with a projectile vomit. The deterioration had come as a surprise to her.

3:25pm

Shift leader Ailsa Simpson said she was at the nursing station with Letby when she heard Child G vomit - when they went over, the alarm for Child G went off, and there was "a large amount of milk" fed, and the vomit was on the cot, on the floor and on the chair adjacent to the cot.

Respiratory support was given via Neopuffs.

Letby had said, in evidence, she had no contact with Child G prior to the vomiting episode. She said she was aware Child G had a lot of ongoing issues, but the observations were good up to that 2am feed. She said she had been with Ailsa Simpson when they heard Child G vomit, and the alarm had gone off. She said when they arrived, no-one else was in there. She said they immediately started to give Child G Neopuffs. She identified a possible problem of the nursing colleague overfeeding Child G, but did not believe that likely.

In police interview, Letby said it was a "shock" for three deaths in June-September 2015, and "didn't feel there was anything to need to look into". She said the nursing colleague was on a break when the vomit happened. She said sometimes babies vomit, but did not often projectile vomit. She said when babies vomit, they can taken on air when gasping. She added she was not sure of the cause of air in Child G's abdomen.

In a separate police interview, Letby said Child G had either received more than 45ml milk, or had undigested milk from a previous feed. She said it was an oversight from a previous interview that she had not mentioned the vomit going on the floor and the chair by the cot.

3:35pm

Dr Alison Ventress said the vomit had been reported to her. For a description of Child G being in distress, and the abdomen purple and distended, she could not recall if that was something she had seen or was told, and the same went for Child G's watery stool, and a subsequently improved abdomen.

Dr Ventress was then called urgently to theatre. She said by this time, Child G was looking better. She was called out of theatre before 3.30am as Child G was apnoeic and had desaturated, and it took five minutes for the saturations to pick back up. Child G went to room 1, and had a further profound desaturation. At the time of insertion of an ET Tube, blood-stained fluid was noted beneath the vocal cords, which Dr Ventress noted was "unusual".

Dr Brearey said he had not seen a projectile vomit in a pre-term baby like Child G.

There was a further profound desaturation at 6.05am, and the decision was made to reintubate Child G. 'Thick secretions++' in the mouth and a blood clot in the breathing tube was noted. The NG tube was aspirated and 100ml was aspirated. Dr Ventress said she was not sure it was air, as that was not documented, as it would be noted otherwise. Dr Brearey took the '100ml' reading to be fluid or milk.

Letby's case, the judge says, is she did nothing wrong, and did not falsify notes. She accepted air or milk could have been pushed from the feeding syringe into Child G's throat. She denied doing so.

3:53pm

Child G was readmitted to Arrowe Park Hospital on September 8, 2015 with presumed sepsis. She was very unwell on arrival, with severe hypertension. A radiograph, Prof Arthurs said, was not a sign of NEC.

The baby girl gradually improved to the point of returning to the Countess of Chester Hospital on September 16.

Dr Evans said Child G was compromised by receiving a large volume of milk and air, and this was not unique to babies. He proceeded on the basis the stomach of Child G was empty prior to the 2am feed, and a pH reading of 4 was indicative of an empty stomach. He said babies fed by NGT "do not vomit". He said Child G suffered significant oxygen deprivation which caused irreversible brain damage. He concluded Child G must have had more than 45ml of milk.

Challenged on this, he said this was the first case he looked at, and reached his conclusion without looking at any other cases.

Dr Bohin said the vomit was "extraordinary", and said it was impossible to say how big Child G's stomach was, but the excess volume of milk would not be much to compromise the lungs. She detailed a number of desaturations and events for Child G in June-July 2015.

She concluded that it was "clear" by September 7, Child G was tolerating feeds. A pH reading of 4 was not consistent with there being a large amount of undigested milk in the stomach - she said if there was, the milk would have neutralised the pH reading [to 7]. She concluded Child G's stomach was empty.

It was put to Dr Bohin that she was modifying her opinion based on the accounts of the nurse and Dr Evans. She refuted that, and said she based the level of milk on the pH reading, not anything Dr Evans had said. She concluded Child G must have had a large amount of milk and air administered after the 2am feed.

4:01pm

The judge refers to the events on September 21 for Child G, during the day shift, at 10.20am and 3.40pm.

Child G was, the court is told, in a "satisfactory" condition.

He says there was an event at 10.20am had two projectile vomits and went apnoeic, colour loss, and desaturation to 30%. Letby, the designated nurse, said she remembered the incident, and Child G was due to receive immunisations.

The event had happened after a 40ml feed at 10.15am. Child G was being treated as 'a term baby'.

Dr Peter Fleming recorded the projectile vomits, and that Child G went apnoeic for '6-10 seconds'. He discussed the case with Dr Rachel Chang, and the course was to leave the NGT on free drainage, as the abdomen was distended. Child G was to be transferred to room 1.

4:13pm

Care had been transferred to a nursing colleague on September 21. She said Child G's heart rate was high when she first took over, but had settled by 12.45pm.

After the vomits, Child G was 'nil by mouth'.

Dr Chang noted Child G was pale and had a feed delayed, and the baby was "not herself". The tummy was "soft and distended" so a screen for sepsis was planned.

Child G needed to be cannulated, and this required seven attempts, successful on the seventh attempt by Dr Gibbs, by which time Child G had been without fluids for six hours.

A nursing colleague remembered Dr Harkness and Dr Gibbs arriving, and believed Child G was behind screens and on a trolley. She said when the doctors finished the procedure, they would let a nurse know, and the baby would be put in the cot. She next saw Child G when Letby called her for help.

She saw Letby providing breathing support for Child G, and the nurse could see Child G was 'a poor colour'. The monitor was switched off. She shouted for nurse Caroline Bennion, and Child G responded to treatment, and was transferred to room 1. Child G was placed in an incubator.

Letby, in evidence, said screens were put up for the procedure for Child G. She said it was 'common practice' for nurses to look behind screens, and said she saw Child G behind the screen, alone, on a trolley, blue and not breathing, and the monitor was switched off. She said she was keen to put a Datix form about the incident. She said she did not take it further as the nursing colleague said the situation was in hand.

She said in police interview, it was 'bad practice' for the monitor to be switched off and 'somebody had made a mistake' in leaving Child G unattended behind screens on a trolley with the monitor off.

She did not remember making numerous searches for Child G's mother on Facebook. She had no comment to make about them.

Dr Gibbs accepted the monitor should not have been switched off. He admitted he had no recollection after the cannulation, and accepted it was possible, and said if the nurse said it had happened, then it happened, and he apologised for doing so.

Dr Harkness said he did not recall the monitor being detached, and would probably have told a nurse when they were finished. He said it was "possible" Child G was behind a screen unattended.

Caroline Bennion recalled Child G needed to be cannulated. Eirian Powell had no recollection of anything untoward clinically being brought to her attention.

4:23pm

The prosecution say Letby was incorrect when she messaged a colleague to say Child G 'looked rubbish' when she took over care for her that morning. Letby accepted she made an error on recalling the timing of the vomit, but said Child G looked pale on handover.

Dr Evans said he had 4,000 pages of material for Child G alone, and concluded the episode of projectile vomiting was "life threatening", and said Child G had been given far more milk than intended, more than 40ml. He accepted the events on September 21 were not as serious as those on September 7.

Dr Bohin said the "feeds didn't add up" and the events of September 21 were "strikingly similar" to September 7, but the consequences were not as serious for the September 21 event.

Prof Arthurs said if a baby had been deliberately overfed, that would not necessarily show up on an x-ray.

 

[Tortoise]

JUDGE'S SUMMING UP - Wednesday 5th July 2023

Day 3 - Morning Session

LIVE: Lucy Letby trial, July 5 - judge's summing up


[Child H]

10:46am

The trial is now resuming. Trial judge Mr Justice James Goss will continue his summing up of the case, referring to Child H.

10:52am

Child H was born in good condition on September 22, 2015 at the Countess of Chester Hospital, weighing 2.33kg (5lb 2oz), and was admitted to the neonatal unit.

Child H was very unstable into September 24, suffering desaturations, bradycardia and pneumothoraces. Dr Dewi Evans and Dr Sandie Bohin agreed Child H should have had surfactant earlier, and the judge says it is accepted that care was sub-optimal. There was also "an unacceptable delay" in intubation. They said although the pneumothoraces were a complication, and some of the sub-optimal care may have led to later pneumothoraces, none led to the later collapses of Child H on September 26-27, for which neither could find a cause.

10:57am

Child H was later transferred to Arrowe Park Hospital, where she improved, and had no further cardiac arrests. She returned to the Countess of Chester Hospital on September 30.

The prosecution say, acknowledging the sub-optimal care and challenges Child H faced, the coincidence of the collapses when Letby was present and being involved in Child H's care, the unexplained collapses, and Letby's interest in the family and other events, that she was responsible, by whatever method, for the collapses by deliberate harm on two occasions.

Letby denied harming Child H. She raised the issue of sub-optimal care, issues with the chest drains, and said there was a 'cumulative effect' for Child H which led to her collapses. The defence say an innocent explanation for the collapses cannot be ruled out.

11:05am

The judge details the events for Child H prior to September 26-27, which involved two chest drains being put in place in response to desaturations Child H had. The tip of the second chest drain moved around. In cross-examination, Dr Ravi Jayaram said the second chest drain tip would not come into contact with the heart, and it was "very unlikely" it would come into contact with the sac around the heart, and he had not heard of any event where that had happened.

Letby had messaged Sophie Ellis on September 25 saying it was 'pretty bad so far' how busy the unit was. In evidence, she said she had come across chest drains in Liverpool where the drains were stitched in, but not in Chester, and no-one seemed familiar, and a third chest drain had to be obtained from a children's ward.

11:12am

Dr Alison Ventress said the second chest drain on September 25-26 had 'almost fallen out', and Child H's oxygen requirements gradually increased.

Dr John Gibbs said "unusually", Child H had developed another tension pneumothorax, and the two chest drains were blocked with serous fluid, and a third chest drain was inserted. Both Dr Gibbs and Dr Jayaram said drains can become blocked. There was then "a marked improvement", the judge tells the court, for Child H.

Letby said, in evidence, ruled out staffing levels as an issue, but said there was "potential incompetence" in relation to where the chest drains were located. She recorded at 2210 Child H had a desaturation at the time of the heel prick, and serous fluid++ was recorded on the drains. She added the SHO was informed. There was no note by an SHO. The prosecution say Letby falsified notes, and there was an error on the timing on the blood transfusion note. Letby, in evidence, said these were mistakes, and she was not deliberately fabricating them. She denied sabotaging the drains, and said they had not been stitched in place.

11:26am

At 3.22am on September 26, Child H collapsed, and full resuscitation began. Child H quickly improved and resuscitation was stopped.

The cardiac arrest had 'no obvious pneumothorax' and there was no evidence of fluid around the heart, a blood clot, and Child H's temperature was normal. Dr Gibbs concluded the event was caused by hypoxia (lack of oxygen), but the explanation for that was not clear.

Child H had chest drains and was deemed 'unstable' for transport, so remained at the Countess of Chester Hospital on September 26-27, when she collapsed at 12.55am on the latter day.

Dr Matthew Neame said his recollection was when Child H collapsed, Letby was Neopuffing her, and assumed she was Child H's designated nurse that night [Shelley Tomlins was the designated nurse for Child H that night]. He noted thick secretions blocking the ET Tube.

Shelley Tomlins had noted Child H had a 'profound desaturation to 40% despite equal bilateral entry and positive capnography.'

Letby, in cross-examination, was referred to text messages of her involvement with Child H that night. She said she had been assisting that night.

Child H had another collapse at 3.30am and Dr Neame responded, and believed Letby was present. Child H was reintubated and her oxygen level and heart rate remained low.

Dr Satyanarayana Saladi had been called to assist with the resuscitation, and contacted a consultant at Arrowe Park as there was no explanation for the collapse.

A blood test revealed a raised result for an infection marker [CRP levels], and Child H was transferred to Arrowe Park.

11:29am

Letby, in police interviews, recalled caring for Child H as she had chest drains in. She did not recall where she was when the first profound desaturation took place. She thought the cause could have been some form of airway problem. She was unable to explain the collapse and denied deliberate harm. She agreed she had searched for Child H's mother on Facebook, but did not know why.

Letby, in evidence, denied she was 'bored' on her shift, and said the timing of her messages could have meant she was on a break. She denied having interfered with Child H's tubes on any occasion.

11:36am

Dr Evans said it was unusual for a baby to have three chest drains. He said the deterioration of Child H would have been much more gradual if she had had infection.

He said a pneumothorax was a complication of Child H's clinical condition. He said the overall picture for Child H was that she 'improved significantly and quickly' when responding to treatment.

Dr Bohin noted the presence of respiratory distress syndrome, and that had surfactant been given earlier, that would have reduced, but not removed, the likelihood of a pneumothorax developing. There was an 'unacceptable delay' in the first intubation, and a needle 'may have punctured lung tissue'.

The collapses on September 26 and 27 mirrored each other in having no obvious cause and were not quickly resolved, Dr Bohin had said. She could not identify any cause for these "significant collapses".

Prof Owen Arthurs said the radiograph images showed a recurrent pneumothorax. He said there was 'no ideal position' for a chest drain. He said there was movement of the second chest drain. He said they are not known generally to cause bradycardias, particularly in neonates.

[Child I]

11:41am

The judge refers to the case of Child I, born on August 7, 2015 in Liverpool Women's Hospital, before being transferred to the Countess of Chester Hospital on August 18, "where she was expected to improve with no ongoing concerns".

Child I died on October 23 in the hospital. The prosecution case is on four occasions, Child I suffered sudden and unexplained episodes, and a consequence of deliberate harm by Letby. They say the final event caused her death, and Letby is responsible for murder.

Letby says she did not harm Child I on any occasion, and whatever the causes of her deteriorations, she was not responsible. She said there were periods when Child I desaturated and was being treated for infection, suspected infection and suspected NEC.

The prosecution say for three of the four events, Child I rapidly recovered, and the other desaturations and infections are explicable.

11:49am

The judge refers to an event in late August 2015, when Letby was not on duty, when Child I had a distended abdomen and an NG Tube dislodged. Dr Bohin, in cross-examination, said this decline differed from later events, and Child I had slowly deteriorated due to signs of infection and needed the use of a ventilator. Child I was returned to Liverpool Women's Hospital with suspected NEC. While there, she had a profound bradycardia, with her airway found to have large secretions in the ET Tube. Child I recovered from the episode.

11:56am

The judge refers to the first of the four events, on September 30, when nursing staff were "very happy" with Child I at this point.

Lisa Walker carried out a skin patch test on Child I that day, which she would not have done if Child I was not well.

On September 30, Letby was the designated nurse for Child I and two other babies in room 3 for the long day. Letby said, in evidence, she did not do anything to cause the event for Child I.

Dr David Harkness said in agreed evidence, other than being pale and a slightly enlarged abdomen, there was "nothing to worry about". Dr Elizabeth Newby said they were at a plan of establishing feeds.

The judge refers to the target weight gain for babies. Child I was at the lowest percentile end. Dr Newby said Child I's weight was low, and dropped down the percentile guidelines, but there had been numerous events in life when they had been unable to feed Child I due to abdominal distension. Dr Bohin said it was "no surprise" Child I's weight was low, and Child I was unable to be fed as she had been ill.

12:09pm

The trial judge says he will not be going beyond 4pm today or tomorrow on his summing up, and apologises to the jury for the late finish yesterday. He says he will confirm timings next week when, it is expected, the jury will go out to consider verdicts.

12:20pm

The judge says Letby had noted, of Child I's abdomen: "mum feels it is more distended to yesterday and that [Child I] is quiet". In evidence, she said Child I waking for feeds was for the 10am feed. At an addendum, Child I was 'reviewed by Drs at 1500 as she was mottled and monitoring was recommenced'. There was no corresponding doctor's note. In evidence, Letby said she believed it had been a male doctor, and it was the same name given when she was interviewed by police.

She denied force feeding and causing a vomit for Child I. The mother of Child I had, by the time of the desaturation, left the unit and the father was at work. Child I desaturated and had a large vomit at 4.30pm, after a feed recorded by Letby of '35ml via NGT' at 4pm.

A doctor had made a note for Child I's event, where Child I had dropped to 30% saturation, but by the time he arrived, Child I was breathing well and was pink, and the chest signs were clear. The abdomen was a little distended.

Bernadette Butterworth recalled Child I's heart rate dropping and she desaturated, and required Neopuff. She saw Child I's stomach distending, and milk and 'air+++' aspirated.

Letby said she did not know why so much air was aspirated. She said, in evidence, she had not pumped Child I full of air.

Dr Harkness saw Child I that night, and Child I was breathing well for herself, and a blood test showed no obvious signs of infection. She did not like being handled.

Nurse Ashleigh Hudson noted Child I was stable on October 1.

12:23pm

By October 12, Child I's feeds and weight were up, with feeds given every four hours of about 55ml of milk.

At 1.30am on October 13, she took a 55ml bottle feed.


12:31pm

For the second event, the judge says Ashleigh Hudson noted Lucy Letby saying Child I looked quite pale. When the light was turned on, Child I looked very pale, and the monitor was not sounding. Neopuffing was established, heart rate in 50s.

Letby wrote her note later, and the judge says she would have been able to see nurse Hudson's note at the time of writing. Letby: 'Child I noted to be pale in cot by myself...SN Hudson present. Apnoea alarm in situ and had not sounded...minimal shallow breaths followed by gasping observed'.

Child I was given a blood transfusion. An x-ray showed "marked gaseous distention of bowel loops." A blood test showed no bacterial growth after 5 days.

Ashleigh Hudson confirmed she had given Child I a feed at 1.30am, and Child I 'seemed very stable' and her waking for feeds was "really encouraging".

She had assisted Laura Eagles with a procedure for about 15 minutes. She would not have left Child I alone if she was unstable, and would have asked a colleague to keep an eye on the baby. The other colleague on duty, Caroline Oakley, has no memory of being asked to do this.

In evidence, nurse Hudson said Letby was standing in the doorway, standing 5-6ft away from the cot, the light was switched off, and the corridor light provided some illumination. There was a canopy over the upper part of the cot, and blankets were on Child I. She switched the main light on, and was closer to Child I than the defendant, and could see Child I was pale. She pushed back the canopy and blankets to tend to Child I. The apnoea alarm had "not sounded" and the deterioration was "very surprising".

12:35pm

Letby, when interviewed, remembered the event. She said when she and nurse Hudson went into the nursery room, they put the light on, and saw Child I was pale.

She denied injecting air into Child I's stomach. She thought they were at the doorway and had just put on the lights, and the nursery "was never that dark that you would not be able to see the baby".

In second interview, she said "maybe I spotted something that Ashleigh wasn't able to spot". She said from her position, she noted Child I was pale.

In her evidence, she was asked how she could spot Child I - 'she knew what she was looking for', which she corrected to 'at', the judge says.

In evidence, she said she could not recall looking after Child I prior to this event. She recalled herself and nurse Hudson going into room 2 together, and could see Child I's face and hands. Child I was 'gasping and shallow breathing', so the alarms didn't go off. She remembered telling nurse Hudson was 'a little pale'. She said room 2's lights were on a dimmer switch, and it was not as dark as a photo identified by Ashleigh Hudson in evidence.

12:39pm

Dr Elizabeth Newby said she was called to the room. As she arrived, she passed Letby in the corridor.

Resuscitation took place on Child I, and it took 12 minutes before signs of life were detected. She said it was "definitely a serious state of affairs".

The ETT was seen, by Dr Matthew Neame, to be too far in, and the NGT was also not in the right position.

By the following day, Child I was seen by Dr Harkness and assessed to be 'sick but stable'.

12:47pm

The judge refers to the third event for Child I on October 13-14.

Child I was in room 1.

Dr Neame reviewed Child I, who was 'settled and pink', with breathing 'a bit squeaky' - normal in ventilated babies, the abdomen distended but soft.

Letby noted for Child I on October 14: 'At 05:00hrs abdomen noted to be more distended and firmer in appearance with area of discolouration spreading on right hand side. Veins more prominent'. The judge says there are no corresponding medical notes for this.

Child I 'grimaced' on Dr Neame palpating the abdomen, which was noted to be mottled and distended. His impression was that the increasing abdominal distention caused the lungs to be "squashed". The increased tenderness and skin discolouration stood out to him. He consulted Dr Jayaram, who was told of the distention, and it was decided to continue with the ventilator settings. After Dr Jayaram consulted Alder Hey Children's Hospital, they said they would contact the Countess of Chester Hospital with a plan in the morning.

12:50pm

Child I had a cardiac arrest at 7am. Shelley Tomlins noted Child I was pale and veiny, with 'slightly greyish discolouration', and Dr Neame thought the swollen abdomen was squashing the lungs. By the time Dr Jayaram arrived, Child I was stable. An x-ray showed no evidence of a pneumothorax.

Letby, in evidence, said she did not have any recollection of the shift, other than from the notes. She agreed the signs were initially good for Child I. She said she had not inflated Child I with air or sabotaging her.

12:55pm

Child I 'responded very quickly' to treatment, and stabilised after being transferred to Arrowe Park on October 15. She returned to the Countess of Chester Hospital on October 17.

12:56pm

The judge reminds, and stresses, the jurors of their obligation not to research the case, and not to discuss it among themselves before their deliberation.

 

[Tortoise]

JUDGE'S SUMMING UP - Wednesday 5th July 2023

Day 3 - Afternoon Session

LIVE: Lucy Letby trial, July 5 - judge's summing up


[Child I continued]

2:00pm

The trial is now resuming following the lunch break.

2:08pm

The trial judge is resuming the summing up in the case of Child I, and refers to the fourth and fatal event.

Child I was pronounced dead on October 23, at 2.30am.

Child I was not an intensive care baby but was in room 1 as a precaution, the court is told.

Designated nurse Ashleigh Hudson had agreed Child I was 'settled and stable' the night of October 21-22. The following day, Child I remained nil by mouth, and was unsettled at times - as recorded by Caroline Oakley - but settled with a dummy. Her cares were attended to by Child I's mother.

For the night of October 22-23, Ashleigh Hudson was again the designated nurse for Child I. Letby said she did not recall, in evidence, much of the night shift when Child I died. She said staffing levels might have played a part.

2:15pm

The judge says just before midnight, Ashleigh Hudson said Child I became unsettled and had 'very loud crying' - 'relentless', something she had not heard before from her. Child I was put on her tummy and she became quiet, and there were gaps in the breathing. Child I was turned over again and nurse Hudson called for help.

Letby said, in evidence, she had not heard Child I 'cry like she had not heard before'. She was 'quiet' and 'apnoeic'.

Dr Rachel Chang and Dr Gibbs were called and CPR began on Child I. She was ventilated and recovered - she was pale and mottled (blue) in her trunk. The colour "steadily improved" over five minutes and Child I became pink all over.

It was decided to extubate Child I as she was fighting the ventilator - "a good sign".

Dr Gibbs was unsure what had caused Child I's rapid deterioration. He said he could not understand what natural disease could have caused it.

A 'large stomach bubble' was seen in an x-ray for Child I.

Letby, in cross-examination, was asked about a record for one of her designated babies that night [the Stoke baby]. The baby was noted by Dr Chang to be safe for transfer. Letby had noted, between 10.50pm-10.52pm, to commence 10% glucose for transfer. The IV fluid chart showed the start time altered from 11pm to midnight. In response to the allegation of falsifying records, Letby said the 11pm was an error which she had corrected.

2:19pm

Nurse Hudson said Child I was behaving normally prior to the final desaturation. She did not recall how she was alerted. She said when she arrived at Child I, Letby was already there at the incubator, 'with her hands in, with a dummy, trying to settle [Child I]'. Child I's crying was "loud and relentless" and nurse Hudson was concerned Child I was going to collapse.

The nurse recalled she said something along the lines of 'She's going to do it again, isn't she?' and that Letby replied: 'She just needs to settle, she just needs to settle'.

Child I then collapsed.

Dr Chang arrived at 1.12am and was joined by Dr Gibbs in trying to resuscitate Child I, who had 'mottling of purple and white all over'. Efforts to resuscitate were unsuccessful.

2:23pm

Melanie Taylor said they were all devastated, and it was "pure shock", and this was the second death she had been directly involved in. She was never concerned about the treatment/care that babies received. Ashleigh Hudson was supported by Letby.

The mother of Child I recalled Letby: 'was smiling and kept going on about how she was present at Child I's first bath and how much Child I had loved it'.

Letby had said she was 'trying, in that awful situation', to create a positive memory for the parents.

2:28pm

Letby was asked about a sympathy card she had taken a photo of for Child I's family, on the day of Child I's funeral. She searched for the mother on Facebook on October 2015 and May 2016.

Letby said she did not remember if she was present when Child I collapsed, and 'maybe she had gone to her after hearing her crying'. She said the transfer process would have been 'stressful' for Child I, and believed the process was done too quickly.

She said it was "upsetting" losing Child I, and said she regularly took pictures of cards she sent. She did not know why she had searched for Child I's mother on Facebook.

She recalled settling Child I after crying, but did not know if this was after the first or second collapse.

2:52pm

Prof Arthurs reviewed all the radiographic material. He said lungs were normal prior to the final collapse, and it was quite unusual to see 'massive dilation of the stomach', which could cause splinting of the diaphragm. The post-mortem imaging showed dilation in the bowel, and he said that was present before she died.

He said there are not many conditions which cause dilation of all the bowel. He said one of the explanations was air deliberately administered down the NG Tube, and that was his inference.

Dr George Kokai carried out a post-mortem examination of Child I. Dr Andreas Marnerides was dependent on the report.

Dr Marnerides said Child I did not have NEC. He was "very sceptical" that Child I died of natural causes.

He said the collapses were more likely to be excessive air administered to the stomach, via the NGT.

The defence say a similar event happened for Child I on August 23, a day when Letby was not on duty.

Dr Evans said Child I's weight gain could have been better, and attributed that to her illnesses. He formed the view Child I had received a large volume of air down the NGT. He said it would have had to have been sizeable to cause splinting of the diaphragm. He refuted suggestions he had taken events from September to support a prosecution case, saying at the time of his reports, no-one had been arrested.

Dr Bohin said she, too, thought abdominal distention had splinted the diaphragm in the first event. She discounted NEC.

Dr Evans said the second event was more serious. He refuted suggestions he had been 'looking for evidence to support the prosecution'.

Dr Bohin said she was not sure if an NGT was in place at the time - there was no clinical need for one, but it was practice to keep one in place 'just in case'. She accepted in her report that she said Child I did not have an NGT. She considered air in the vein was a possibility, due to the subsequent discolouration findings. In cross-examination, Dr Bohin was accused of 'backing up' Dr Evans. She refuted that, saying she was independent and had disagreed with Dr Evans on some conclusions. She said she had seen air embolus twice in babies in her career, and explained what the symptoms were, saying the clincial presentation was 'wide and varied'. She agreed there was nothing specific about discolouration that made it diagnostic of air embolus, but it was consistent with air embolus.

3:03pm

Dr Evans said for the third event, he came to the conclusion of a large volume of air administered via an NGT into the stomach. The response to Child I's resuscitation was not what he would expect. In cross-examination, Dr Evans said this was a separate event, not a continuation of an existing event.

Dr Bohin concluded it was an air embolus caused by excessive air administration.

For the fourth event, Dr Evans said Child I was 'a stable baby' prior to the collapse. He said he thought air was administered, on this occasion, via the blood. He thought the relentless crying, as described, was of a baby in pain and distress, and there was no explanation. In cross-examination, he denied he was 'gonig for whatever mechanism that could support his explanation'. He said if air was injected in the stomach as well, that was something he could not rule out.

It was at that point, the judge says, Benjamin Myers KC, for Letby's defence, cross-examined Dr Evans on a family court judgment's report which criticised the medical expert, with "strong views" by Lord Justice Jackson. The defence said the 'inconsistencies' in Dr Evans' evidence undermined his case and the judge's criticism was 'relevant'.

The judge says it is up to the jury to consider the evidence, and they know no more about that case - and the judge's summary report - than the agreed evidence which was presented to them.

[Child J]

3:14pm

The trial is resuming after a short break.

The judge refers to the case of Child J, born at the Countess of Chester Hospital on October 31, 2015.

3:17pm

After a short time, Child J produced some brown bile, and was transferred to Alder Hey Children's Hospital for surgery. She had a perforated bowel and was fitted with a stoma.

She returned to the Countess of Chester Hospital on November 10, and progressed well, moving into nursery room 4 (special care). She had issues with gaining weight, but hospital staff were not overly concerned. Nursery nurse Nicola Dennison said babies with stomas don't tend to grow very well.

Child J's mother had stayed with Child J, giving cares, prior to leaving on the night of November 26-27.

3:20pm

Letby was messaging a colleague, prior to this night shift, about how nursery nurses should not be caring for babies with stomas, and there were issues with staffing, saying they would have to send some babies out [to other hospitals].

During the shift, Child J had two sets of sudden and unexpected desaturations, which required resuscitations, and in the latter, there were symptoms of a seizure, something Child J had not had before or since. Dr Bohin said there was no cause for the events. Dr Evans said infection could not be ruled out.

The prosecution said Letby did something or things to cause deliberate harm. The defence say in the absence of any identifiable cause, the jury cannot be sure Letby did anything to harm Child J.

3:30pm

Mary Griffith recalled an event at 5-6am when she heard an alarm go off in nursery 4. She saw nurse Dennison had Neopuff on Child J, as she had desaturated.

Dr Kalyilil Verghese recalled attending once, at 5.15am. Swipe date showed him entering the unit at 5.03am. He said he was told what had happened, that Child J had two 'profound desaturations', the first to the 30s, the second to the 50s. In the later, Child J was pale and mottled. He said at least one of those events was "significant".

Apart from Child J's increased efforts to breathe, Child J had recovered well.

Child J was moved to room 2, where Letby was.

Letby said it was 'widely talked about' that nursery nurses were doing stomas when they shouldn't. She said it was a very busy time.

She said she had no idea these events were happening.

Dr Gibbs was on the unit when Child J desaturated again, this time with a falling heart rate. He said he assisted nurses Griffith and Letby.

Dr Gibbs noted Child J had desaturations to 'unrecordable levels', the first at 6.56am, the second at 7.24am, plus bradycardia - they were associated with stiff arms, clenching of hands, and on the second occasion the eyes deviated to the left; these were symptoms of seizures. The first took 10 minutes to settle, and the perfusion was poor. The second took five minutes to settle. Both events required ventilation.

Dr Gibbs could not explain the desaturations, and Child J had not presented with these symptoms before. He would say there were caused by a drop in oxygen, but the cause of that was not known.

3:38pm

Prof Arthurs reviewed the images for Child J. After the last collapse, the image was unremarkable - it could not assist in an explanation for this event.

In police interview, Letby recalled Child J as she had a Broviac line and stoma. She thought she only treated Child J after the collapse. She said she had administered medication as Nicola Dennison was a nursery nurse, and not qualified to administer such medications.

She accepted searching for Child J's parents, but could not recall doing so.

In evidence, she said she was aware of the second pair of events, that she and Mary Griffith heard the alarm, and saw Child J fitting when they arrived. No-one else was present.

Child J recovered. Dr Stephen Brearey noted no blood glucose abnormalities to explain the seizures, and there was nothing of concern in blood results. Abdominal x-rays did not raise concerns. He had no concerns, and said it was a "remarkable recovery" for her. He did not understand why Child J had been hypoxic.

Letby was the designated nurse for Child J the following night and there were no concerns raised.

3:43pm

Dr Evans said the collapses were unexpected, the second pair were more serious, and 'indicative of something wrong with the brain', and indicative of loss of oxygen to the brain, and could not explain any natural process that had caused that hypoxia.

Dr Bohin said infection was not responsible for Child J's collapses, and did not come to any major conclusion other than the deteriorations were sudden and unexpected.

[Child K]


3:48pm

The trial judge begins referring to the case of Child K, born at 2.12am on February 17, 2016, weighing 1lb 8oz. She was transferred to the neonatal unit prior to transfer to a tertiary unit - Arrowe Park Hospital, where her condition continued to deteriorate, and the mother agreed, in the "most heartbreaking decision" of her life, to end life support for Child K on February 20.

The prosecution say Letby attempted to kill Child K within two hours of her being born, interfering with the breathing tube, causing her to collapse. There were two further collapses and the prosecution allege there was sabotage by Letby, but they are not the subject of charges.

There is no expert opinion in Child K's case, and the evidence is circumstantial, the judge says. The prosecution urge the jury to rely on inferences. The defence, the judge says, point to Child K's extreme prematurity, and no 'direct evidence' of harm caused. Child K was given surfactant late, and witness Dr Ravi Jayaram's evidence is "tainted and unreliable".

Letby had no recollection of events, but believed the ET Tubes were not secured correctly.

3:52pm

The oxygen saturation of 85% was 'good' for Child K minutes after birth, for a baby of her gestational age, and good enough to attempt intubation.

Dr James Smith said if he had seen any evidence of trauma or bleeding, he would have asked a consultant to step in and carry out the procedure.

Nurse Joanne Williams said a team would carry out the procedure, and the ET Tube would be secured so the tube does not slip.

Child K was transferred to the neonatal unit on a Resuscitaire, with the plan to transfer to a tertiary unit.

3:56pm

Mr Myers referred to a leak on the ventilator in his closing speech. An Alder Hey consultant said the air leak numbers "did not tally" with the high oxygen saturation readings for Child K. Joanne Williams said if Child K was not receiving the oxygen saturation required, the alarms would have gone off.

Surfactant was administered, which Dr Smith agreed was "late" by 13 or 18 minutes, but would not have compromised Child K.

4:00pm

The trial judge confirms the jury will not be starting deliberations on Thursday, as he will not have completed his summing up until Monday. He says that will happen 'earlier rather than later' on Monday, July 10.

He says the court will resume 10.30am-4pm tomorrow.

 

[Tortoise]

JUDGE'S SUMMING UP - Thursday 6th July 2023

Day 4 - Morning Session

LIVE: Lucy Letby trial, July 6 - judge's summing up


[Child K continued]

10:31am

The trial judge, Mr Justice James Goss, continues with the summing up in the case of Child K.

10:39am

Joanne Williams was Child K's designated nurse and left the neonatal unit at 3.47am - an hour and a half after Child K was born - to update the parents. She said she would not have left Child K if she was not stable, or had someone to look after her in her absence.

Dr Jayaram and nurse Williams were "happy" Child K was "quite stable".

Joanne Williams said in cross-examination the morphine infusion for Child K, timed at one chart for 3.30am, could have been at 3.50am.

Dr Jayaram said he was aware Letby was alone with Child K, and thought he was being "irrational", but went to check on Child K as a precaution.

Dr Ravi Jayaram said he walked in to the nursery room and saw Letby by Child K's incubator, and saw Child K's saturation levels dropping to the 80s. The monitor alarm was not going off. He said: "What's happening?" Letby said something along the lines of: "She's desaturating."

Dr Jayaram ascertained the ET Tube was not working as it should, and Child K was ventilated. He said babies usually desaturate after about 30-60 seconds, so the cause of the desaturation would have started before he went into the room.

Dr James Smith saw Dr Jayaram on the right side of the incubator as he walked in. He reintubated Child K.

The court had heard it was possible for a user to pause the monitor alarm sounds for one minute.

10:48am

Dr Jayaram was challenged about why he had not confronted Letby about her behaviour. He said it was "not appropriate" to raise concerns in medical notes. He said concerns were raised after this incident, and faith was put in senior management, and they were told it was unlikely anything was going on, and to see what happens. He said in hindsight, he wished they had bypassed management.

He could not remember the transport team note where he had written 'baby dislodged tube'. He said it was "highly unlikely" Child K had dislodged the ET Tube.

He accepted the note Child K had been sedated after the desaturation, but denied altering his account to fit the evidence. He said he had not seen the swipe data for timings.

Letby, in interview, said she could only remember Child K because of her size. She did not recall Child K's tube slipping or any collapse. She agreed she thought Joanne Williams would not have left Child K alone if Child K was not stable. She could not remember if the alarm was silent, but agreed it should have sounded if Child K was desaturating.

She thought it possible she was seeing if Child K was self-correcting.

In evidence, she said she did not have independent memory of Child K other than her being a tiny baby.

She said although she had no memory of it, she said she would have waited 10-20 seconds to see if Child K self-corrected, as that was "common practice".

Elizabeth Morgan said, in agreed evidence, it was possible for an ET Tube to be dislodged in an unsedated and active baby, and a nurse would not leave the child alone in this situation if the baby was not settled. She said it would be 'good practice' to observe the baby immediately and take corrective action if necessary if a baby of this gestational age had begun to desaturate. She believed it would not be normal practice to 'wait and see', in a child of this gestational age, with the lungs so underdeveloped.

10:53am

At 6.15am and 7.30am, Child K desaturated again, and it was noted the ET Tube had dislodged again in the second event. Letby was on duty.

The transport team arrived for Child K, who required several rounds of treatment to stabilise her. She left, having been stabilised, at 12.50pm. The prosecution say Child K was a settled baby who would not dislodge the tube.

There was no record of an ET Tube dislodgement at Arrowe Park.

Child K died on February 20, 2016. The cause of death was extreme prematurity with severe respiratory distress syndrome.

10:58am

Letby, in further interview, said she had no memory of Child K's ET Tube slipping, and suggested it had not been secured initially. She accepted searching for Child K's mother's name, but could not recall why.

In evidence, she said she had nothing to do with the events at 6.15am and 7.25am. she agreed she had no reason to be in room 1 at 7.25am.

She said she looked up the name for the mother as "you still think of patients you care for".

She said the night was a "busy shift".

The judge says the prosecution accept they cannot prove Letby's actions caused Child K's death, but say she attempted to kill her.

[Child L]

10:58am

The judge refers to the case of Child L and Child M, and their birth on April 8, 2016 at the Countess of Chester Hospital.

11:05am

The judge says it is alleged Letby tried to kill Child L by putting insulin into bags of dextrose.

Professor Peter Hindmarsh said the hypoglycaemia episode for Child L lasted from April 9-11, and multiple bags had insulin added. He said a 'not noticeable' amount of insulin, 0.1ml, would have been added to the 500ml bag, which would not change the colour.

He was of the opinion that two or three bags - depending on how many were hung - had insulin added. He said while 'sticky insulin' would account for some of the hypoglycaemia, over time more insulin would have had to have been added via a bag, he said.

Letby worked four long day shifts from April 6-9, and had moved house during that time to Westbourne Road, Chester.

She said April 9 was still "fairly busy" on the unit.

11:10am

After birth on April 8, Child L's blood sugar was "a bit low" at 1.9. The court had heard this was normal for premature babies, so he was started on glucose.

Reference to hypoglycaemic pathway was mentioned, that milk should be given to infants before an infusion of glucose. Neonatal practitioner Amy Davies said she had "no concerns" for Child L regarding putting him on an alternative pathway.

Dr Sudeshna Bhowmik wrote the rate of the glucose infusion. Letby said glucose bags were kept in room 1, and insulin was kept in the equipment room. She could not recall if any of the bags were kept under lock and key.

The first bag was 10% dextrose at noon on April 8.

Colleague Amy Davies denied administering insulin, saying that would only be given to babies with blood sugar levels over 12, and would be prescribed by a doctor.

11:16am

This was the 60th case Dr Dewi Evans looked at, the court is told, and saw the relation between insulin and insulin c-peptide in the blood plasma laboratory result for Child L.

He suggested to police a specialist should be approached to review his findings.

Prof Hindmarsh said neonates have higher glucose requirements, and any blood sugar level under 2.4-2.6 is a "cause for concern", so it was appropriate for the initial dextrose infusion.

For the night of April 8-9, there were "no concerns" for Child L, and all the blood glucose readings were above 2.

No fluid bags were changed during the night shift.

For the day shift of April 9, Mary Griffiths was the designated nurse for Child L. She said he was "stable".

11:25am

Prof Hindmarsh says Child L was hypoglycaemic by 10am on April 9 and insulin "must have been added" between midnight and 9.30am. He said it is "fairly easy" to insert insulin into the portal of the bag via a needle.

The judge says Prof Hindmarsh says "at least three bags contained insulin" to maintain the low blood sugar levels for Child L. The insulin could have been added to the bags at the same time, he added. He said once it was in the bag, "it would not be known by smell or appearance".

The type of insulin used was 'fast-acting', the court was told.

Mary Griffiths said it was "quite a shock" the blood glucose levels for Child L dropped after the dextrose was administered.

Letby said, in evidence, said she had nothing to do with insulin in the bags, and could not assist with an explanation why the blood sugar level was low. She said she had nothing to do with the bags, prior to changing them. Mary Griffiths could not recall if the bag was changed.

A plasma blood sample was taken, but podding was "late", the court had heard, due to the collapse of Child L's twin, Child M.

The evidence, the judge says, is the blood sample was taken between noon (when Child L had a 1.6 blood sugar reading) and 3.35pm.


11:31am

The blood sample 'passed all the quality control tests' and 'performance checks' at the Royal Liverpool Hospital.

The judge tells the jury: "In short, there is no evidence to doubt the reliability of the test results, you may think."

The insulin and the insulin c-peptide results were the 'wrong way around' from what they should have been. Child L's insulin level of 1,099 should have meant an insulin c-peptide of 5,000-10,000, but it was 264. The court had heard said it was therefore synthetic insulin, administered exogenously, and to do so was "dangerous".

Clincial biochemist Dr Anna Milan said there was not anything that doubted the accuracy of the results. In cross-examination, she explained in the case of insulin, if the sample had not been treated appropriately, the insulin level would have been even higher, and insulin c-peptide was stable.

Prof Hindmarsh said the '1,099' reading was a minimum, not a maximum.

11:42am

Letby, in interview, said the original blood sugar levels for Child L were not a huge surprise for a neonate. She said very prolonged low blood sugar levels can cause brain damage and even death. She said it was not common for babies to be given insulin.

She said they had access to the hypoglycaemia pathway on the unit. She said any addition to an infusion bag would be "very rare" and have to be prescribed by a doctor, and would have to be administered via a syringe on the bag port.

She replied "That wasn't done by me" to the accusation the bags had been sabotaged. She said an explanation would be insulin would be in one of the bags, and denied responsibility.

The prosecution say there is "uncontrovertible evidence" Child L was poisoned with insulin before 10am on April 9, and accounted for 'persistent' low blood sugar levels. They say this happened when Letby was on shift.

Blood sugar levels improved on April 11. The prosecution says from the second 15% dextrose bag on that day, Child L was no longer being infused with insulin.

Letby said the initial low blood sugar levels for Child L on April 8 showed naturally resolving hypoglycaemia. She accepted only she and Belinda Williamson [Simcock] had been on duty for the Child F and Child L events when the babies first had serious low blood sugar readings.

She denied doing anything to harm Child L.

[Child M]

11:58am

The judge refers to the case of Child M, who the court had heard was "not an intensive care baby" but put next to Child L on April 9.

At 11am, he had a "small possit", as noted by Mary Griffith, and 1.5ml of bile-stained fluid was aspirated at 12.30pm. Child M was to be 'nil by mouth', a decision made by a registrar.

12:02pm

At 3.45pm, Child M received antibiotics, the prescription by Letby and Mary Griffith, and administered by one of the two nurses.

At 4pm, Mary Griffith had been preparing a 12.5% dextrose infusion for Child L. The parents had left a few minutes earlier. Child M collapsed at this time. Letby said: "Yes, it's an event, it needs to be sorted." and the resuscitation call was put out. Dr Jayaram was crash bleeped.

A nurse colleague said her role was to draw up the resuscitation drugs. She was shown a piece of paper towel referring to entries on clinical notes, for times and medications administered. She recognised her handwriting of adrenaline made. That note was subsequently recovered from a Morrisons bag in Letby's bedroom at the time of her arrest in July 2018, along with a blood gas record for Child M.

The nurse said the practice was to put the note in the confidential waste bin or the clinical waste bin, where it would be incinerated. the judge says it is the prosecution case that Letby recovered the note from the bin afterwards.

12:16pm

Child M was not breathing for himself and required doses of adrenaline in the resuscitation, which lasted under 30 minutes. They reached a point, the judge said, where Child M "might not survive", then Child M suddenly picked up his breathing and heart rate.

Dr Jayaram said he saw pink patches/blotches on the abdomen of Child M that moved around. He noticed that He said it was similar to what he had seen with Child A. He first mentioned it in his witness statement. He said his priority at the time was communicating with parents and post-resuscitation care.

He said [he] and his colleagues sat down on June 29, 2016 to discuss the findings. Dr Jayaram said someone mentioned air embolus. He researched it in literature, and he shared that research the following day with colleagues.

In cross-examination, he said he had not appreciated the clinical significance of the skin discolouration at the time. He rejected the assertion he did not note it at the time because it did not happen, or that omitting it was 'incompetence'. He said at the time, "there were other events going on". He agreed that after Child D had died, Dr Stephen Brearey had carried out an informal review of events at that time, and that Letby was associated with those events.

In police interview, Letby denied doing anything to harm Child M. She did not know why Child M desaturated. She said she had been drawing up medications at the time of the collapse. She thought she had taken the paper towel home 'inadvertently', not emptying her pockets. She said the paper towel might have been put to one side. She denied she had kept it to keep a record of the attack.

In evidence, she said Child L and Child M stood out as she had been the allocated nurse for when they were delivered. Child M was not in an allocated space on the nursery, she recalled, and maybe things would have been different if he had been in an allocated space. She did not recall seeing any discolouration, did not recall having any description of skin discolouration being mentioned to her, and any discolouration would have been difficult for her to see.

Letby said her taking home the notes was an "error" and denied taking them from a confidential waste bin. She added she cared for the twins on subsequent days "quite frequently", during which time there were no adverse incidents.

12:33pm

Paediatric neuroradiologist Dr Stavros Stivaros provided agreed evidence in which he said Child M had shown signs of brain damage, likely caused by the collapse on April 9, 2016.

Professor Owen Arthurs viewed radiographic images for Child M and said they could not support or refute an air embolus.

Dr Dewi Evans concluded there were no concerns for Child M prior to the collapse, save for one bilous aspirate for which he was put nil by mouth. He did not believe that caused the collapse, as Child M's stomach was empty. He believed a noxious substance or air was administered to Child M's circulation [ie intravenously], and could not explain a natural cause for Child M's rapid recovery, ruling out infection.

He said, taking into account Dr Jayaram's description of the skin discolouration, the cause for Child M's collapse was an air embolus.

In cross-examination, he accepted there was no empirical research for how air dissipated in the body following a collapse, and based it on physiology, that cardiac massage would dissipate it. He said if the air goes around the abdominal area, it would result in skin discolouration, and if it heads towards the brain, it can cause neurological damage. He said 'very little air' is required to cause collapse.

Dr Sandie Bohin said Child M had no markers of infection. She had to find some way to explain how a baby previously well suddenly collapsed, and had prolonged resuscitation for which he almost did not make it, then recovered rapidly. She said the skin discolouration seen by Dr Jayaram was "compatible" with air embolus.

She said the actual volume to cause a baby to collapse and die is unknown. She said if it was a small volume, it would "take some minutes" to get to Child M in this case, as he was on a slow infusion.

In cross-examination, Dr Bohin accepted most babies die in the case of air embolus, but it was "not inevitable". She could not think of an alternate medical cause from her differential diagnosis. She said the type of cardiac arrest suffered by Child M was "incredibly unusual".

[Child N]


12:36pm

The judge refers to the case of Child N, born on June 2, 2016 at the Countess of Chester Hospital.

He says the prosecution case is Child N had three unexpected collapses in June 2016, that are all attributable to inflicted trauma by Letby, and were acts carried out with the intention to murder him. The defence case is Letby did not harm Child N, that there are inconsistencies in the accounts, and the jury cannot be sure Letby intended to murder Child N.

12:39pm

Child N had 'intermittent grunting' and it was recorded at 3.10pm on June 2 that he had a desaturation to 67% for a minute, and was crying, as recorded by nurse Caroline Oakley. He was placed in a hot cot and reviewed by Dr Anthony Ukoh.

The nurse said she had no recollection of events other than that in her notes. There was nothing to suggest the naso-gastric tube was moved after it was placed, or that there were difficulties placing it on Child N.

12:46pm

For the night of June 2-3, Christopher Booth was the designated nurse for Child N. Letby had messaged a colleague to say they had a baby with haemophilia, and in evidence, said staff were panicked by this.

The prosecution say Letby was messaging a colleague 'constantly' from 8pm while feeding a baby in a nursery which was a two-handed job.

She refuted a suggestion, in cross-examination, she had force-fed her designated baby at the time, saying the note of the feed must have happened at a different time.

Dr Jennifer Loughnane reviewed Child N and saw he was 'pink and well perfused', and consideration was given to starting enteral feeds. Christopher Booth had no concerns as he went on his break. He handed over care to a nurse when he went on his break at 1am, but cannot remember who.

The other colleagues cannot recall caring for Child N.

Child N had a deterioration to 40% at 1.05am - "a significant desaturation", and Child N was "screaming", Dr Loughnane had noted. She said she had no direct recollection of that, and said she would not usually have written that word.

At 2am, Child N had recovered was settled, and was asleep.

12:48pm

Christopher Booth recorded there had been no further episodes for Child N following that desaturation. The baby remained nil by mouth.

The prosecution case is Letby sabotaged Child N in some way to cause the collapse. Letby said she had no memory and did not know Child N had collapsed. She said she did not believe it was a collapse which required resuscitation. She denied using the absence of Christopher Booth as an opportunity to sabotage Child N.

12:56pm

Letby referred to an "active life" in messaging on June 13, planning a holiday.

The prosecution say the second and third events for Child N happened on June 15, 2016.

There had been no concerns for Child N on June 14 at handover for the night shift, by nurse Jennifer Jones-Key. At 1am, Child N was 'pale, mottled and very veiny', with slight abdominal distention. He was reviewed by a doctor, who observed mottling, a potential sign of sepsis, but was otherwise normal. On further observation, Child N had five minor desaturations which had resolved, and the mottling had gone. Child N's oral feeds were stopped, and he was given antibiotics and glucose. The defence say these were signs of Child N deteriorating.

At 7.15am, Child N had another desaturation. The prosecution say Letby, who had arrived early for her day shift, did something to cause the collapse. Letby said she had gone to see Child N as she had had him for the previous day shift.

The 'profound desaturation' caused Child N's heart rate to be affected.

12:59pm

A male doctor had been called to attend Child N and recorded a desaturation to 48%. He decided to move Child N to nursery room 1, and attempted to intubate. He saw blood which prevented him from seeing the airway. The back of Child N's throat "looked unusual" with swelling, and he was not sure where the blood was coming from.

He made three unsuccessful attempts to intubate, and suction 'did not clear the view enough', and he said he did not want to inflict mechanical trauma. He remembered Letby was helping with the attempted intubation.

A chest x-ray confirmed no pulmonary haemorrhage.

 

[Tortoise]

JUDGE'S SUMMING UP - Thursday 6th July 2023

Day 4 - Afternoon Session

LIVE: Lucy Letby trial, July 6 - judge's summing up

[Child N continued]

2:05pm

The trial judge says Letby, in police interview, she remembered Child N had an 'unusual air way issue', and was 'very difficult to intubate'.

She was asked about intensive care charts, and references to blood. She said if the NGT had been inserted forcefully, it could cause about 1ml of blood. She did recall Child N bleeding at the time of intubation, but was not sure why.

In her second interview, Letby said she would arrive prior to 7.30am for her day shift. She went to talk to Jennifer Jones-Key, her colleague, on this day. She referred to her colleague's note of Child N being pale and veiny overnight. His condition "deteriorated".

In cross-examination, it was put to Letby that observation charts showed nothing deteriorating for Child N.

Letby said she was stood at the doorway, and Child N's deterioration happened "within minutes", was "blueish and not breathing".

For the intubation, Letby recalled blood being seen, and her interpretation of the note was blood was seen once intubation had been attempted. In the family communication note, Letby wrote parents were contacted, phones were switched off, and message was left. In cross-examination, Letby agreed she had written out the 7.15am incident as she had taken care of Child N from 7.30am.

The first time she recalled seeing blood was after the second desaturation at 3pm for Child N.

2:12pm

The judge says there was a dispute over previously agreed evidence on who made a call to Child N's parents.

A further desaturation happened at 2.50pm, after the parents left the ward.

Dr Huw Mayberry was crash-called to Child N, who had desaturated. He could see vocal cords, but there was a "substantial swelling in the airway", and did not recall seeing any blood.

Dr Satyanarayana Saladi recalled seeing blood in the oropharynx and blood in the NG Tube.

Child N was later intubated successfully by the Alder Hey transport team.

Child N continued to have episodes of apnoea, but they were less serious, and recovered at Alder Hey.

Letby noted: 'approx. 14:50 infant became apnoeic, with desaturation to 44%, heart rate 90 bpm. Fresh blood noted from mouth and 3mls blood aspirated from NG tube. Neopuff commenced and Drs crash called...unable to obtain secure airway'.

She said after the 3ml aspiration of blood, she had some memory of events, and there was "a sense of panic" on the unit, and it was "chaotic". She said there was no factor 8 left, so some was brought over from Alder Hey. She said Child N was the "focus of the whole unit at that point". She said she was stressed and anxious as they couldn't get an airway.

2:18pm

Professor Sally Kinsey gave evidence on haemophilia, and the purpose of Factor 8. Child N had 'moderate' haemophilia, and would need Factor 8 when it was required, not on a regular basis. She did not see any issue with Child N's blood which caused the collapses.

She said a spontaneous bleed could not be explained by haemophilia, as a baby could not damage themselves in the throat, and any instrumentation could "potentially" cause bleeding. A pulmonary haemorrhage was "not a viable" explanation.

The defence do not suggest it was spontaneous bleeding or pulmonary haemorrhage - they point to when witnesses saw the bleeding.

Child N was the 29th case Dr Evans looked at. The event on June 3 was unusual, particularly the screaming and crying. He said something must have been done to him - and this was not an air embolus.

For June 15, Dr Evans said the bleed was a consequence of trauma.

Dr Bohin said the June 3 desaturation was 'life-threatening' and she had never experienced a baby crying for 30 minutes, or screaming. She said Child N had received a painful stimulus.

For June 15, she believed the bleed was a consequence of trauma.

[Child O]

2:24pm

The judge refers to the cases of Child O and Child P, two of three triplets born on June 21, 2016 at the Countess of Chester Hospital.

Child O died on June 23, and Child P died on June 24.

Child O weighed 2.02kg and was admitted to the neonatal unit. From about 5pm on June 21 and through June 22, there was 'nothing remarkable' about Child O's condition.

Letby was on holiday from June 16-22, during which time she had gone to Ibiza.

In text messages, Letby enquired with a male doctor about the triplets, and said she felt at home in ITU, and 'the girls' knew she was happy to be in room 1 of the neonatal unit.

Child O was moved from room 1 to room 2 during June 22, and had 'a good day' and was 'very stable', the court is told.

Overnight on June 22-23, Child O was recorded as having partially digested milk in aspirates, which was 'normal', and a 'stable night', with a full abdomen at 7.30am showing 'no concern'.

2:30pm

Letby accepted that Child O was fine on June 22 and the night of June 22-23. She was the designated nurse for Child O and Child P on June 23, along with another baby, all in room 2.

In police interview, Letby said the babies were in the 'high dependency' room and the ratio should have been one nurse to two babies - Letby was the only designated nurse in room 2 for that day, plus supervision of student nurse Rebecca Morgan. In cross-examination, she accepted staffing levels or competencies contributed to the collapse of Child O, and that Child O was not a high dependency baby.

Nurse Melanie Taylor confirmed there were no issues for Child O at the beginning of the shift.

A doctor noted Child O's abdomen was 'full but not distended, soft, non tender', and he was 'making good progress' at 9.30am.

Melanie Taylor said Child O, prior to his collapse, asked Letby if he should be moved to room 1 as he looked unwell. Letby did not agree, and he should stay in 2. Melanie Taylor said she was 'put out' by this. Letby did not recall being dismissive.

2:38pm

Letby recorded feeds for Child O at 10am and noon.

A note by a male doctor at 1.15pm recorded a distended abdomen and a vomit after a feed, and ordered an x-ray.

Letby noted Child O, reviewed by the registrar 'had vomited (undigested milk) tachycardic and abdomen distended. NG tube placed on free drainage … 10ml/kg saline bolus given as prescribed along with antibiotics. Placed nil by mouth and abdominal x ray performed. Observations returned to normal'.

An entry on the blood gas record by Letby said Child O was on CPAP, when he was not. Letby said she meant CPAP via Neopuff. Dr Bohin said she could find no record of Child O being on CPAP for this time.

In interview, Letby recalled Child O's abdomen becoming distended and him being intubated. She did not recall who was present when he vomited.

Melanie Taylor said Child O collapsed at about 2.40pm. When she went to nursery 2, Letby was already there, and a doctor arrived after. Letby said she discovered the collapse after hearing his monitor alarming, and he had a 'blotchy, purpley-red rash' kind of 'mottling'. She said mottling could be a sign of infection or cold. Child O was moved to nursery 1.

The doctor's note of the event was a 'desaturation and bradycardia'. He was 'mottled' and skin looked 'unusual'. Child O was bagged and transferred to room 1. He was intubated at the first attempt and connected to a ventilator. The doctor went to speak to the parents.

Letby noted Child O was 'mottled++ with abdomen red...poor perfusion'. She said she did nothing to Child O to introduce air, and said two prescriptions on the neonatal schedule with her co-signature were for after the collapse.

The doctor noted a 'very very rare' purpuric rash, and 'good perfusion' and Child O appeared to stabilise. Letby said she did not see the type of discolouration the doctor did.

2:44pm

At 3.51pm, Child O desaturated again, to the 30s. 'Chest movement and air entry observed, minimal improvement.'

Doctors were crash-called and Child O was reintubated on the first attempt. He had another desaturation at 4.15pm, and resuscitation efforts were made. There was 'no effective heartbeat' and the abdomen was 'still distended', and the rash had disappeared, which 'perplexed' the doctor, who had not seen that kind of rash before or again.

Care was withdrawn and Child O died.

Dr Brearey said it was "deeply distressing for all involved" as Child o's deterioration "came out of the blue" and they "excluded all natural causes". He later held a debrief at which he said Letby 'did not seem upset'.

Letby said she was "shocked and upset" at Child O's death, which was "unexpected", and there was an 'element of delay' when getting a registrar called to the room.

She remembered Dr Brearey inserting a drain into Child O's abdomen, which was swollen and red, and she had not seen that procedure before.

She said everyone was "completely flat" after Child O died. She said she wanted to save 'every baby in your care...you are not supposed to watch a baby die".

3:06pm

Child O's father described the stomach, swelling up, and 'looked like he had bad prickly heat - like you could see something oozing through his veins'. Letby said she had not seen anything like that.

A female doctor was quite upset and very apologetic at Child O's death, and could not explain it.

Dr Brearey told the court senior people at the hospital 'could not believe' someone was trying to harm babies. He said there had been a meeting and, when it was put to him about Letby's association with the events, he had said something along the lines of 'it can't be Lucy, not nice Lucy'.

He said senior clinicians 'were becoming increasingly concerned' about the deaths. It was his opinion, that there was not an increasing range of acuity of babies being treated, and was wary it was a 'chicken and egg' situation where, because of the unexplained incidents that were happening on the unit, the babies' care needs became more acute.

He said he had wanted to escalate the situation properly in the hospital, rather than by going to the police.

He said Letby rejected his suggestion to take time off after Child O's death.

The Countess of Chester Hospital was redesignated as a Level 1 unit, by its own decision, on July 7, 2016. The number of cot spaces was reduced from 16 to 12, and the gestational age limit was raised from 27 weeks to 32.

Dr George Kokai carried out a post-mortem examination. Dr Andreas Marnerides reviewed, and said injuries to the liver were the result of impact trauma. He said during treatment, small bruises could be caused to the surface of the liver, and would not be extensive. He says the liver is not in an area where CPR is applied. He has only seen this kind of injury to the liver before in children, not babies, from accidents involving bicycles. He did not think CPR could produce this extensive injury to the liver, and has never heard of this sort being accepted as such. He also found internal gastric distention, and concluded there had been an air embolus.

Prof Arthurs also referred to radiograph images, taken post-mortem. He said the gases were an 'unusual finding'.

Dr Evans said the air was "excessive" and could have been administered via the NGT, and the skin discolouration was symptomatic of that. He said the bleed in the liver would also have contributed to the collapse. He could not find any evidence where the air embolus came accidentally.

Dr Bohin said the cause was excessive air down the stomach via the NGT, causing an air embolus, and could not see any innocent cause for that. She refuted the accusation from the defence that she was striving to support the case against Letby by supporting Dr Evans.

The prosecution say the jury can exclude natural causes, and Letby caused deliberate harm to Child O. The defendant denies wrongdoing, and the defence say it was a natural deterioration, and the liver injury was caused during resuscitation.

[Child P]

3:26pm

The judge refers to the case of Child P, born "in very good health".

The triplets had been on CPAP and antiobiotics as a precaution.

At 10am on June 23, Dr Kataryna Cooke recorded no concerns.

Dr Gibbs recorded Child P had active bowel sounds, and a 'full...mildly distended' abdomen. He said Child P appeared very well, and should continue on NGT feeds, and if there were any concerns, for him to be fed intravenously. There was no suggestion of infection for Child P.

Sophie Ellis was the designated nurse for Child P on June 23-24. She had learned that Child O had died on June 23. Child P's observations were in the normal area, and Sophie Ellis recorded a desaturation which resolved, and a low lying heart rate.

For feeds, Child P was on two-hourly feeds up to 8pm on June 23, with trace aspirates. At 8pm, Sophie Ellis aspirated 14ml milk aspirates, with a pH of 3. She fed him a further 15ml milk feed, and placed him on his tummy.

At the midnight, a further 20ml acidic milk aspirate was taken. Feeds were stopped and Child P was put on 10% dextrose infusions.

She said if any of the aspirates were bilous, she would have noted it.

The last update on the night shift was 'abdomen soft and non-distended' for Child P.

3:34pm

Nurse Percival-Calderbank had said Letby found working there was 'boring' and she tended to move back to the other nurseries, and colleagues were concerned for her mental health, as those units could be distressing and exhausting.

Letby, in evidence, said she never found nursery work 'boring' and did not recall having a conversation with Kathryn Percival-Calderbank to say otherwise.

In interview, Letby said she wanted to be designated nurse for Child P that day to provide continuity of care.

Full blood tests were ordered for Child P. Dr Ukoh said Child P was to keep an eye on, as he had a distended abdomen. 20 minutes later, at about 9.50am, Child P desaturated. Rebecca Morgan said she recalled all the alarms going off, and she helped Dr Ukoh taking the top of the incubator off. Dr Ukoh said he and Lucy Letby were in the room when Child P collapsed. Letby said she was in the room when Child P collapsed.

Arrowe Park provided advice for treatment of Child P. A poor blood gas result showed Child P had respiratory acidosis. He had a poor heart rate and poor perfusion.

Child P was sedated and paralysed, which Dr Bohin said was entirely correct.

3:41pm

At 11.30am, Child P desaturated again, and he was given CPR. Spontaneous circulation was restored. A female doctor could not understand what was going on.

Upon saying the transport team from Liverpool were arriving to transfer Child P, Letby had said words to the effect of: “he’s not leaving here alive is he?”

The female doctor replied "Don't say that" - she thought they were 'winning' at that point.

In evidence, Letby said she could potentially have said that at that time, and both she and the female doctor were stressed at that time.

Letby said from her recollection, there was no reference to a tube dislodging for Child P. There is no evidence of anyone checking if it was blocked when it was removed.

A radiograph image taken at 11.57am had showed a pneumothorax, which was not a tension pneumothorax.

A male doctor's recollection from 12.50pm was that it was "very very busy" for Child P, and the plan was to insert a chest drain.

There was no apparent cause for what was going on clincially, the judge tells the court.

3:49pm

Letby said she recalled the pneumothorax, and there was a "general decline" for Child P.

A miscalculation had been made where the adrenaline doses were higher than they should have been, but a doctor from the transport team had previously told the court they found no sign of Child P being impacted by that.

Child P's mother said Child P's stomach looked the same, but not as swollen. The father said the scene in the unit was one of pandemonium. "It was the same again". A female doctor was very apologetic to them, saying they would get to the bottom of what had caused the collapses.

The third triplet, who was stable, was taken to Liverpool by the transport team.

A female doctor denied she was trying to dramatise anything, in cross-examination. She said the situation was traumatic enough as it was.

In evidence, Letby said she had been involved with administering a lot of medication, and did not recall seeing any discolouration. She said there was 'relief' on the unit when the transport team turned up.

She said there was discussion if there had been a 'bug' on the unit.

4:01pm

After the deaths of Child O and Child P, the consultants 'insisted' Lucy Letby was removed from the unit, and 'resisted' attempts to bring her back, the court is told.

Dr Marnerides said he had no evidence to indicate a natural disease that would account for Child P's death. He thought small haematomas to the liver were potentially the result of CPR, or as a result of prematurity, and did not have enough to say it was an impact injury.

He said there was no clinical evidence for a natural cause. He said having considered other accounts, he concluded there was gastric distention caused by excessive air injected into the stomach.

Prof Arthurs reviewed radiographic images for Child P. He said the gases shown were 'unusual' for baby who did not have natural diseases. He said it was consistent with air administered.

Dr Evans was "at a loss" to explain how Child P had collapsed. He had believed the cause was complications from the pneumothorax. There was no credible natural cause. In cross-examination, he said an experienced or competent nurse or doctor would not cause a liver injury in resuscitations.

He said Child P could have collapsed from doses of air administered, and denied shifting his account to fit the evidence.

Dr Bohin was concerned about the x-ray for Child P on the night of June 23, and the air present there. Overnight, Child P became intolerant of feeds. She said attention should have been paid to the x-ray, which showed a pneumothorax, earlier. She said the air in Child P's abdomen from the night before was abnormal, and had been introduced at some point or points via the NGT, splinting the diaphragm. She could not think of any natural occurring phenomena that accounted for the subsequent collapses.

4:02pm

The trial judge says the case of Child Q will be referred to on Monday at 10.30am.

The jury "will be beginning their deliberations" before the lunch break on Monday. He says he expects that to be after an hour's court sitting. He urges the jurors to bring their refreshments with them on that day.

5:33pm

The trial will not be sittig on Friday. It is expected to resume on Monday, when the jury will retire to consider verdicts.
The Standard will continue to provide live updates on Monday.

 

[Tortoise]

JUDGE CONCLUDES SUMMING UP AND JURY RETIRES TO CONSIDER VERDICTS - Monday 10th July 2023

LIVE: Lucy Letby trial, July 10 - judge's summing up


10:31am

The trial judge, Mr Justice James Goss, has entered the courtroom.

10:32am

The 12 members of the jury are now coming into court, and the trial will resume with the judge's closing section of his summing up.

10:36am

Before the judge resumes, the jury is presented with a final selection of documents, which are for reference purposes, to add to their jury bundles.

[Child Q]

10:40am

The judge now refers to the case of Child Q, a baby boy born on June 22, 2016 at the Countess of Chester Hospital. He weighed 2,076g at birth, and required breathing support - he was taken to the neonatal unit.
There were no signs of infection, the judge says.
Three days later, on June 25, Child Q had a profound desaturation and vomit. the prosecution say this was liquid, and possibly air, being forced down the NGT. They say possible mild NEC would not account for the type of desaturation and recovery. The defence say developing NEC cannot be excluded.

10:43am

For June 23-24, Tanya Downes was designated nurse for Child Q. She noted 'coffee ground' style amounts of bile in Child Q. 1.5ml of bile was aspirated at 4am.
The nurse recalled Child Q had to be readmitted in July 2016 with gut problems, at the out-of-hours clinic.

10:50am

Child Q was tolerating feeds and there were "intermittent, moderate acidic" aspirates, a sign the milk was being partly digested, by the early hours of June 25.
Blood gas readings showed a drop in pH results, and nurse Samantha O'Brien noted, after the doctor's review, was for the current plan of care to be continued.
She said Child Q had been stable, and the reviewing doctor had no concerns.
Letby, designated nurse for Child Q on the day of June 25, said she was informed Child Q had large aspirates overnight, so he was not in good condition.
At about 9.10am, Child Q's alarm sounded, and he desaturated. Nurse Mary Griffith had been giving cares to another baby in the room with Letby and Child Q, with her back to Child Q.
Shortly after Letby left the room, Child Q's alarm went off. Nurse Griffith was mid-feed and could not go over immediately, and Minna Lappalainen was called over to Child Q, and began Neopuffing the baby.
Nurse Lappalainen recalled the alarm going off and could see Child Q had been sick, with mucus coming out of his mouth. She filled in the apnoea/fit/brady chart, a desat of 68 and brady of 98. "brady 98; desat 68; fit ?; baby found to be very mucousy, clear mucous from nasopharynx oropharynx removed clear fluid +++. O2 via neopuff given post suctioning...NGT used to aspirate stomach by Nurse L Letby"

10:51am

Letby noted: '[0910 Child Q] attended to by SN Lappalainen – he had vomited clear fluid nasally and from mouth, desaturation and bradycardia, mottled ++. Neopuff and suction applied...reg attended. Air++ aspirated from NG Tube'

10:55am

Letby said, in police interview, she had returned to nursery 2 to see Child Q being tended to by nurse Lappalainen. When asked about the air in Child Q's stomach, she said sometimes babies gulp when they vomit, and there could have been a blockage in the bowel.
She said she would not have left room 2 if Child Q was not stable. She denied causing Child Q harm, or leaving the room so she had an alibi from the incident.
In evidence, she said Child Q had a low temperature, and was concerned about that. She said she arranged with nurses Lappalainen and Griffith for when she went to nursery 1 and was there for a few minutes.
For the 9am feed for Child Q, the Oxygen and saturation levels are missing. She said those omissions were "a mistake".
She said the baby in room 1 was an intensive care baby, so she could not have left that baby for too long.
She said she had no part in giving Neopuff after Child Q needed oxygen. She said she was told air++ had been aspirated from the NG Tube. She said the collapse, relatively, was 'not serious'.

11:03am

A male doctor was called to the unit. He noted as a result of the Neopuffing, Child Q's saturations returned to 100%. The baby was moved to room 1 and put on CPAP, and given antibiotics as a precaution.
He was presumed, at this time, to have sepsis. A blood test could not give a reason for the vomit, the judge says.
A chest x-ray showed a 'trace of fluid', and 'no suggestion of a large amount of foreign matter' or a sign of infection.
Dr John Gibbs said the collapse did not fit with a baby who was tired.
It was decided to intubate Child Q and put him on a ventilator.
A female doctor examined Child Q noted the blood gases were acceptable. Child Q was 'very unsettled at times' but there were no signs of concern, she recalled. She saw a sign of respiratory acidosis, and the ventilator settings were changed. Amy Davies said Child Q was restless at times.
On June 26, Child Q showed a loop in the bowel. Arrangements were made to transfer Child Q to Alder Hey Children's Hospital. A consultant there stated in agreed evidence that Child Q had been admitted due to concerns over his deteriorating condition. When assessed, Child Q was stable and his abdomen 'very slightly swollen'.
By the night of June 26, he was assessed as 'very stable', with 'subtle signs of NEC', and was taken off the ventilator by June 27. The decision was made to transfer Child Q back to the Countess of Chester Hospital on June 28.

11:18am

The judge says the mother of Child Q said the baby was in and out of hospital about three times a year, and had a weakened immune system, and was diagnosed with developmental delay, and would require appropriate support.
Professor Owen Arthurs reviewed radiograph images for Child Q. A single loop of dilated bowel was seen in the first, which was 'slightly normal', and gas in the bowel which had gone to the bowel wall. They were 'signs of NEC', but 'not diagnostic' of NEC.
"Things were settling" at the time of the third x-ray, taken at Alder Hey.
Dr Dewi Evans and Dr Sandie Bohin had considered the possibility of NEC.
Dr Evans said although there were markers of Child Q having infection, from the bile aspirates and 'not really tolerating feeds', it did not explain the 'sudden collapse' at 9.10am, with a 'very significant deterioration', and it was 'not clear how to put it all together'.
The suspicion of NEC was 'perfectly reasonable', as was putting Child Q on CPAP.
He said Child Q would not have vomited anything at all, unless 'a lot' of clear fluid had been forced down the NGT, possibly with air as well.
He said once Child Q had vomited, he recovered. He said in relation to the air+++, there was very little Neopuffing taking place. He said when babies vomit, they do not swallow air.
In cross-examination, he accepted he had initially concluded Child Q had received air, and not fluid. The air++ was 'noteworthy'. Dr Evans refuted he had 'added' the liquid element to support the case. He said the evidence he had heard from the people looking after Child Q had been "a great help" in forming his opinion. He said the presence of NEC or otherwise could not be discounted, but that would not cause a sudden collapse, and noted the rapid recovery of Child Q, and no further gastro-intestinal problems until his discharge from the Countess hospital in July 2016.
Dr Bohin noted the aspirates were 'not uncommon' for Child Q prior to the collapse. She did not know where the fluid+++ came from for Child Q, from the notes. Child Q's intermittent air was unlikely to cause the 'air++' aspirated. She concluded Child Q had been given air down the NG Tube, which had distended the abdomen so much, squashing the lungs, causing mottling. In cross-examination, she agreed 'mucus+++' being aspirated could cause problems with breathing. She said there was not a cause of where the 'mucus+++' would have come from.
She refuted the possibility of any baby sucking in air during a vomit. She added aspirates was a sign of NEC, as well as other factors. She said it was not a diagnosis of NEC. She said Child Q 'got better too quickly for it to have been mild NEC'.

11:20am

Letby was enquiring with a male doctor about what Dr Gibbs had been saying about leaving Child Q unattended. The doctor reassured Letby.

[POST-JUNE 2016]

After Letby was taken off nursing duties, she filed a grievance with the hospital in September 2016. She said that time was emotionally difficult and had left her feeling isolated.

11:22am

The judge says agreed evidence says searches of Letby's home in Chester and Hereford were carried out in 2018 and 2019 respectively.
He said there were various papers collected, including 'NOT GOOD ENOUGH' and 'I am a horrible evil person'.
The defence says these were notes written by someone who was 'distraught' at what was happening and was being 'unfairly targeted'.
The prosecution say the notes are by 'a troubled person' who was 'in part confessing to what she had done'.

11:24am

257 handover sheets were found at Letby's Chester and Hereford homes, 21 of which in relation to babies in the indictment.

11:29am

In relation to a note filled in on both sides, Letby said she had written it as 'everything had got on top of her', and 'it made her feel guilty and isolated' and 'she was blaming herself'.
She thought the police would be involved and she would lose her job. She thought she was being victimised by Dr Ravi Jayaram and Dr Stephen Brearey. She said despite what she had written, she 'had not killed them on purpose'.
She said she was 'career focused' and the note 'I AM EVIL I DID THIS' was how the situation had made her feel. She said that year was difficult as there were more babies being admitted to the neonatal unit, with more complex needs such as chest drains and stomas, and staffing levels were 'quite poor at times', and she was doing a lot of additional shifts and overtime, and did not believe there was much support on offer.
She said the handover sheets she had taken home in her pocket, were kept 'for no particular reason' and she 'did not know how to dispose of them'.

11:42am

Letby had said 'ideally', handover notes should be put in the confidential waste bin. She said she 'hardly ever looked at them'.
In evidence, she confirmed she had bought a shredder, and 'only shredded bank statements', and the handover sheets and notes were 'insignificant'.
When asked about Child M's blood gas records, the note taken home was 'an error on her part', and said the sheets had 'no meaning to her'.
In a 2019 police interview, she identified a 'support network' of three nurses and a doctor she had after being removed from nursing duties.
She had she was 'not really aware' of air embolisms, and could not recall any specific training in that.
In her 2020 interview, Letby was asked about the diaries. She said she thought she started documenting names amid concerns of the rising number of babies dying.
In evidence, she said she had liked all doctors at the hospital. She said she was worried she was in trouble as she may have made a mistake in the care of Child Q.
She accepted, in an email she had written, she was 'having a meltdown++' as noted.
In messages to a colleague, she accepted reference had been made to air embolus, and had filed a Datix form on July 1, 2016 in which she cited an open port had a potential risk of air embolus.
She denied she was 'covering herself' for a cause of accidental air embolus or 'getting her defence in with friends'.
Asked about a series of Facebook searches for parents' names of babies, she had they were for babies who had died or were seriously unwell. She denied she was 'checking up on her victims', but that they were 'on her mind'.
She said she could not recall why she had written a sympathy note for all three triplets [Child O, Child P and the surviving triplet], when one of the triplets survived.

11:49am

The judge says the jurors have to be sure of the defendant's guilt, her character, and any inconsistencies between evidence given by the defendant and any witnesses.
The judge says if jurors are sure that two babies had insulin administered to them, deliberately, they have to consider whether that was a coincidence, or whether it was done by one person, and if so, who.
He says there were 'certain common features' among the cases, that the defendant was on duty for each event. He refers to the note that Nicholas Johnson KC had referred to, which was a list that included five babies had unusual bleeding, eight had discolouration. The defendant said she did not see discolouration or there was no discolouration to be seen. Five babies' collapses happened within moments of a nurse going on break. Four of the babies were 'screaming/crying uncharacteristically'. Four babies recovered after being taken to another hospital. Three cases were where Letby was accused of behaving inappropriately after the baby passed away.
The prosecution say these are not unconnected events, and say the insulin, air embolus and post-mortem findings can make the jury sure of Letby's guilt.
Letby denies doing any harm, and the searches and keeping of confidential documents had nothing sinister. The handwritten notes were 'a product of despair'. The defence say the jury cannot be sure in any event of Letby's guilt.

[PREPARATIONS FOR JURY DELIBERATIONS]

11:51am

The judge says a 20-minute process will now commence where jurors will affix their name labels to all the confidential documents they will have for their deliberations, to begin soon. He says there will be a few more things to be said to the jury once this process is completed, before the deliberation process can then begin.

11:54am

The judge says the beginning of the deliberation process is a 'strict procedure', and after the 20-minute break, he has a few words, but 'important words', to say to the jury.

11:55am

The members of the jury are now leaving for a 20-minute break, during which time their name-labelled bundles of documents will be taken to the deliberation room.

12:49pm

The trial will resume shortly - trial judge Mr Justice James Goss has returned to the courtroom.

12:50pm

The 12 members of the jury have now returned to the courtroom.

12:56pm

The judge apologises for the delay, saying the process took longer than anticipated.
He says in relation to the lists the prosecution submitted, that the defence say they did not establish patterns, and there were dissimilarities.
He says there will be two additions to the evidence bundle for the jurors - they had already been heard in evidence.
Benjamin Myers KC says the two additions to the bundle are photographs of Letby's house, and a schedule of social media material which had been served.
The judge says an iPad has been linked to a large screen in the room, so evidence for group discussion can be presented on a big screen, for convenience. There will be spare iPads [which contain the evidence stored electronically in the case].

1:00pm

He says the deliberations are confidential to the jury, and there is no disclosure of them to anyone, including any court bailiffs when they are present in the deliberation room.
He says the jurors should respect each others' opinions, everyone should be listened to, and no-one should feel pressured, including on time.
Deliberation times will be between 10.30am-4pm. At 4pm, the jury will be brought back each day and then sent home. When they are not deliberating, the deliberation room will remain locked.
The judge urges jurors to not, under any circumstances, discuss the case with anyone outside of all 12 jurors in the deliberation. They are not allowed to discuss the case with each other in the absence of any juror.
Two five-minute 'smoke breaks' will take place during each day, one in the morning and one in the afternoon. For each of those breaks, a bailiff will escort the juror or jurors outside and remain with them. Another bailiff will remain with the jurors inside the deliberation room.
A man or woman will be selected as the jury foreman. That person can be changed in advance of a verdict for any reason, the judge advises.
Any questions on the case are to be written on a note, not communicated verbally to the court bailiff, for presentation to the court.

1:01pm

He says verdicts should be unanimous on each count. He says if, after a certain length of time, jurors are unable to agree unanimous verdicts, then they will be brought back to court and further directions will be given.

1:02pm

The court ushers are now being sworn as jury bailiffs.

[THE JURY RETIRES TO DELIBERATE]

1:03pm

The jury is now being sent out to consider verdicts.

1:20pm

Here is the story from today, as the 12 members of the jury have now gone out to consider verdicts in the trial of Lucy Letby: Jury out in trial of baby murder-accused nurse Lucy Letby

 

[Tortoise]

4:01pm

Legal teams, members of the public and press, and Lucy Letby have returned to court, along with the trial judge.

4:03pm

The trial judge informs the jurors they can go home for today, and will resume deliberations at 10.30am.
The jurors are urged not to discuss the case with anyone, including each other, until they have returned to the deliberation room tomorrow.

Recap: Lucy Letby trial, July 10 - judge's summing up, jury out

The trial of Lucy Letby, who denies murdering seven babies at the Countess of Chester Hospital neonatal unit and attempting to murder 10 more, is…

www.chesterstandard.co.uk

 

[Tortoise]

On Monday, July 17, trial judge Mr Justice James Goss said only 10 of the 12 jurors were present, and that meant no deliberations could take place.

He said it was not yet known when the next day of deliberations would be able to take place.

Lucy Letby trial jury deliberations adjourned

THE jury in the trial of baby murder-accused nurse Lucy Letby has been adjourned due to juror absences.

www.chesterstandard.co.uk

 

[Nanna2Lily]

On Monday, July 17, trial judge Mr Justice James Goss said only 10 of the 12 jurors were present, and that meant no deliberations could take place.

He said it was not yet known when the next day of deliberations would be able to take place.

Lucy Letby trial jury deliberations adjourned

THE jury in the trial of baby murder-accused nurse Lucy Letby has been adjourned due to juror absences.

www.chesterstandard.co.uk

Thank you for all the hard work you’ve put into this case. It’s much better to understand the way it’s all laid out. So much easier to spot all her lies and there are many of them. Hope we get verdict soon. My opinion after following since beginning and from what has been reported so far, she is guilty.

 

[Tortoise]

"Ultimately, no deliberations took place last week.

However, on Monday, July 24, the trial judge allowed deliberations to resume at 10.30am."

Lucy Letby trial jury sent home after resuming deliberations

THE jury in the trial of baby murder-accused nurse Lucy Letby resumed deliberations today (Monday, July 24).

www.chesterstandard.co.uk

 

[Tortoise]

"...with deliberations continuing until 4pm.

During the day, a question rose from the jury, asking for clarification on how long it would take for insulin and insulin c-peptide levels to return to normal in a baby after manufactured insulin is stopped.

The judge replied there had been no evidence heard in respect of that. He said the recordings of the insulin and insulin c-peptide ratio were from blood samples analysed and the results were relayed to the hospital days later, when the babies' blood sugar readings had returned to normal.

The jury is expected to continue deliberations on Tuesday."

Lucy Letby trial jury sent home after resuming deliberations

THE jury in the trial of baby murder-accused nurse Lucy Letby resumed deliberations today (Monday, July 24).

www.chesterstandard.co.uk

 

[Tortoise]

The jury resumed deliberations on Tuesday at 10.30am and concluded for the day at 4pm.

Lucy Letby trial jury sent home after seventh day deliberating

THE jury in the trial of baby murder-accused nurse Lucy Letby has been sent home following deliberations for a seventh day today (Tuesday, July 25).

www.chesterstandard.co.uk

 

[Tortoise]

"At about 3pm, a note from the jury requested copies of agreed statements in respect of the charges for Child H.

Trial judge Mr Justice James Goss replied that copies of the transcripts were not possible to be delivered to members of the jury, but he could re-read, on request, which of those 12 agreed statements as they had been heard in court.

The jury retired for a few moments to indicate which agreed statements they wished to hear again.

Upon their return, the trial judge re-read agreed three statements; one from Child H's father, and two doctors who had been involved in the transport and care of Child H to Arrowe Park.

After the judge had finished reading the statements, the jury was sent home shortly before 4pm."

Lucy Letby trial jury sent home after deliberations for eighth day

THE jury in the trial of baby murder-accused nurse Lucy Letby has been sent home after deliberating for an eighth day today (Wednesday, July 26).

www.chesterstandard.co.uk

 

[Tortoise]

On Tuesday, August 1, the jury of 12 resumed deliberations just after 10.40am, and concluded for the day at 4pm.

The jury is expected to resume deliberations at 10.30am on Wednesday.

Lucy Letby trial jury sent home after deliberating for 11th day

THE jury in the trial of baby murder-accused nurse Lucy Letby has been sent home after deliberating for an 11th day today (Tuesday, August 1).

www.chesterstandard.co.uk

 

[Tortoise]

The jury resumed deliberations yesterday and at 10.30am today, and concluded them for the day at 4pm.

Trial judge Mr Justice James Goss reminded jurors not to discuss the case with anyone until they resume deliberations on Thursday at 10.30am.

Lucy Letby trial jury sent home after deliberations for 12th day

THE jury in the trial of baby murder-accused nurse Lucy Letby has been sent home after deliberating for a 12th day today (Wednesday, August 2).

www.chesterstandard.co.uk

 

[Tortoise]

After 13 days of deliberations, and after deliberating for 66 hours, the court was brought back in at the end of Thursday, August 3.

Trial judge Mr Justice James Goss said "for good personal reasons", it was "not possible" for one of the 12 jurors to continue.

He added that further directions would be given on Friday morning to the remaining 11 jurors.

Lucy Letby trial juror discharged after 13th day of deliberations

THE jury in the trial of baby murder-accused nurse Lucy Letby has been sent home after deliberating for a 13th day today (Thursday, August 3).

www.chesterstandard.co.uk

 

[Tortoise]

On the morning of Friday, August 4, the judge told the jury that some of them had been operating under a "false premise" that the court would not be sitting next week, with three of the jurors having made appointments or commitments for that time.

He said he would not be "unsympathetic" if rearranging those appointments was "impossible", but those jurors should make efforts to do so at the earliest opportunity.

He added the jury should continue as a jury of 11, and give unanimous verdicts at this stage.

Lucy Letby trial jury sent home after 14th day of deliberations

THE Lucy Letby trial jury has been sent home following the 14th day of deliberations (Friday, August 4).

www.chesterstandard.co.uk

 

[Tortoise]

The jury was sent home for the weekend at 4pm on Friday, August 4, with the jury having deliberated for more than 71 hours.

The 11 jurors are expected to resume deliberations on Tuesday, August 8, with the judge telling the jury that, "for good reason", the court cannot sit on Monday.

Lucy Letby trial jury sent home after 14th day of deliberations

THE Lucy Letby trial jury has been sent home following the 14th day of deliberations (Friday, August 4).

www.chesterstandard.co.uk