Benjamin Myers KC, for Lucy Letby's defence, begins his closing speech
He says he has been sitting next to the jury for nearly nine months, and can hazard a guess at what they may be thinking - 'five days' [for the expected length of his speech]. He says he is grateful for their presence and the material they have had to listen to, and its 'distressing' content.
He says what struck him when listening to the prosecution, was that what Letby has done/not done, said/not said - that 'made her guilty'. He says it's "as if the prosecution have a theory" and no matter what the evidence is, or isn't, is treated as to keep that theory going. He says it "doesn't matter how inconsistent that theory is" and that "different standards are applied to Lucy Letby". "Everything is treated as evidence of her guilt".
He cites examples by the prosecution case - her presence when something happens, or not being present, or just leaving the unit, or just turning up for her work. Her making a note, or not making a note - 'guilty'. He says if she signs for medical records, or signs for others - 'guilty'. A baby in her care doesn't show signs of deteriorations - guilty. A baby does show signs of deteriorations - guilty. He says it is "twisting and turning". She cries when giving evidence - guilty. She doesn't cry when giving evidence, or doesn't cry at the right times - guilty.
He says there is 'not one occasion of Lucy Letby doing one of the harmful acts alleged against her.' Mr Myers: "Not guilty." He says "just about everything became an allegation against Lucy Letby". He says what is really at work is "the presumption of guilt", and the prosecution case is "fuelled" and "riddled" by it.
He says he would ask the jury to look at the "presumption of innocence", which is "like a bucket of cold water over everyone at this point". He says "that's the way it works" - "that someone is innocent until proven guilty", that the jury consider the evidence is "fair and balanced". He says "five days is a lot to listen to" - today and into tomorrow is an overview of the defence case, then he will go through the counts individually in the closing speech. He adds he recognises the "enormity" of what the jury have to go through.
He says the information presented has been a "spaghetti soup" of data and evidence, some of which "carries little weight at all". He says the jury must look at the detail presented. He says it is the jury's views that matter on the evidence.
He says that Letby being drawn into agreeing with things in cross-examination that she could not have known cannot be conclusive. He cites Letby being asked about staffing pressures, or the unit taking on too many babies. He says the jury can draw "common sense conclusions" over all the evidence presented. He says Letby is "in no position to settle the issues" [on the unit]. He adds the issues in the trial being discussed are "harrowing and heartbreaking", and cannot be more serious, and 'nothing he says is to diminish the loss' suffered by parents. He says the defence feel upset and "overwhelming sympathy" for them.
He says the emotional reaction to such serious, upsetting and sensitive charges "is to convict". He says the jury have to be "very careful" on the conclusions reached. He says the prosecution "characterise" Letby, which "they are entitled to do", and he says the jury "must be alert to that". He says the language of 'attack', 'gaslighting', 'sabotage', 'you're enjoying yourself', 'your favourite way of killing', playing god', 'calculating', 'manipulative' was sometimes "on the thinnest of evidence...or no evidence at all". Mr Myers says Letby was in 2015: "She's a 25-year-old band 5 nurse, an excellent one - that's what she was, looking after dozens, if not hundreds of babies...day after day." He says "you saw the real person" in her evidence and cross-examination, that she could "remember pieces of evidence" in the years she has been waiting for her trial: "There's little else to do in prison, isn't there?" She was also "scared, anxious and struggling to hold it all together".
Mr Myers cites "plausible deniability" as "if it was a done deal", "setting up cover". He says the prosecution set up questions and answered them as "Lucy Letby", without referring to evidence. He says the way Letby was dealt with in cross-examination was "bad".
He says Letby has been in prison, and in the dock, surrounded by 'commendable' prison dock officers, "standard measures". He says to 'look how this looks' for her in comparison to the witnesses who have come in. He says this is presented as an "inherent disadvantage".
He says the jury must "get past the emotions" and "look at the evidence". He says there are two possibilities of what happened between June 2015-June 2016. He says one of the possibilities is the result of a medical condition, and a condition of the unit - the clinical fragility of the unit, and failings in care at the unit. He says is the other is a nurse who "decided to kill children" or "tried to kill them" for reasons "which make no sense" and "out of the blue".
He says there was a "marked increase" in the number of babies taken on in the unit during that year. He says it was "too many" babies being admitted to the Countess of Chester Hospital neonatal unit with "too many" high requirements. He says the babies were vulnerable as they were in the neonatal unit. He says what some people have said during the trial in evidence, that the babies were "doing brilliantly" there, "boggles the mind". He says it is "no good brushing aside" the issue of sub-optimal care for the babies.
Mr Myers says "the stand-out point" is "not once is there any evidence" of the acts of harm being done. He says this is "the first time" the defence case has been set out. He says the "suspect account" of Dr Ravi Jayaram "doesn't come close" to an account of an attack in progress, nor does the mother of Child E's account. He says there are 22 counts, and 30 events, over 12 months, and "nothing" in evidence of Letby carrying out an attack. He says that was despite Dr Jayaram saying it was "all eyes on Letby" after Child D. Mr Myers adds the jury can use "circumstantial evidence" to highlight sub-optimal care.
He says: "We are the only people who will stand up for Lucy Letby - no-one else." He says the defence case being at the end of the trial is "not an afterthought", and is "so important". He says the prosecution "are not in any special position" with this - they have brought the evidence, "but it does not mean they are right with this". He says there is a suggestion there has been a "hostile reaction" that Letby has "dared to defend herself" and disagree with the prosecution. He says the prosecution "have gone out of their way" to present some aspects as "smoke and mirrors" and evidence by Letby in cross-examination and her evidence was "gaslighting". He says it is "unjustified" and "unfair". Mr Myers says the jury can judge the staffing competencies. He says the prosecution "don't want you to think" about doctors Ravi Jayaram and David Harkness's inconsistent accounts on skin discolouration, that it was a "stunning omission" for them not to put the skin discolouration in notes or in their reports for inquests. He says that point was only uncovered in cross-examination. He disagrees with the suggestion the defence were "gaslighting" the jury. He says it was "not smoke and mirrors" or "gaslighting". Mr Myers says the unit did face "unusual and increased demand" over the 12 months. He says the trial is not about the NHS, or doctors/nurses in general. He says the defence are entitled to be critical of the neonatal unit. He says there is a suggestion there is an "outrage" the defence have "dared" been critical of it.
Mr Myers says it was accepted by the prosecution there was sub-optimal care in the cases of Child D and Child H, but in the latter they did not give much more detail. He says for Child A, there was a 'four-hour' "delay in fluids", and the "line was placed too close to his heart" and was 'not in the optimal place'. "There is plenty of sub-optimal care knocking about in this unit". He says some of the sub-optimal care is 'more contentious than others'. He says there is a "list" for Child H, including the second chest drain for Child H. 'Poor management of stomas' for Child J, and not moving Child K to a tertiary centre, a failure to have factor 8 ready for Child N, 'mistakes in ventilation' and 'getting the doses of adrenaline wrong' for Child P. Failure to react to 'dark bile aspirates' for Child C for 24 hours. He says Child Q was moved to a tertiary centre after three bilous aspirates. He says that is on top of 'babies not being in the right place'. He says babies like Child G and Child I were "prone to serious problems" and "not always" looked after sufficiently qualified staff. He says 'with one exception', senior consultants refused to accept anything was wrong in the 12 months, except for one doctor who failed to attend an emergency as quick as she should have been in the case of Child E.
Mr Myers says evidence presented on October 25 by Dr Dewi Evans: "One tends not to spread news about the mistakes we make", in reference to doctors. He says that is a piece of evidence 'to keep in mind'. He says that was "one of the many things" that came out of his "relatively lengthy" evidence. He says: "In a way, haven't we seen that in this trial?" He says that in relation to doctors being resistant to criticism. He adds no-one, including Letby, is immune to criticism. He says doctors would come with 'prepared speeches'. He says "don't think the senior doctors came here without motives of their own". He adds: "however you look at it, there was a terrible failing of care" at the unit.
He says senior doctors have 'in various ways' suspected Letby was doing something 'for months and months'. He says those doctors 'said/did nothing to raise the alarm...when nothing prevented them from doing so.' He says if they were right, that failure to do anything right was "staggering". He says whichever way, it was a "terrible failing in care".
Mr Myers: "You will understand the stakes [in this trial] are very high. "We don't say 'doctors bad'. We say for those senior consultants who presided at that unit...Lucy Letby getting the blame matters." He says the prosecution used the expression, the 'gang of four' consultants of Dr Jayaram, Dr Stephen Brearey, Dr John Gibbs and a female doctor [who cannot be named]. He says the doctors 'have an interest in what happens here' and each of them 'had gone out of their way to damage Lucy Letby' in their evidence. He cites an example on pneumothroaxes presented by Dr Gibbs which he says was "unneutral". He says "one way or another" the unit "failed". He says this case is a "prime opportunity" to "hide" bad/poor outcomes.
He says the unit was "noticeably busier" than it had been in previous years, and there was "no change in the staffing levels". He says doctors are "running to and from the neonatal unit" in emergencies. He cites an example in the final collapse of Child I.
He cites Dr Sally Ogden's evidence that June 2015 was a "particularly busy" time at the unit, and that was a combination of factors, including the complexity of the babies' needs, the number of staff, and total unit admissions. He says the increased busyness increases the likelihood of mistakes and the chances of missing developing problems in babies. He says the Countess was designed to look after babies of 27 weeks + (gestational age), and there were babies in this case who would be "far better" cared for at a tertiary centre, and evidence had been heard that for Child K's case, the tertiary centre care could have made a difference.
He says between June 2015-June 2016, the unit was "under a much greater burden". He says during this time, whatever the hospital had to "deal with changed". He says after the Countess neonatal unit became a 'level one unit' after June 2016, two more consultants were added. He says that is indicative of staffing pressures prior.
He says the single most important direction in the trial is the burden of proof, which is on the prosecution, and it "never shifts" to the defence. He says the prosecution "have to make you sure", and there are so many areas where the evidence "is not clear".
He says the jury have to be "sure of deliberate harm" and "with the intent to kill", and the jury must assess the "quality of evidence". He says the "medical evidence is the foundation of this case". Mr Myers says Lucy Letby denies all the allegations. He says it must be identified harm being done, and being sure there was an intent to kill at the time. He repeats that Letby denies doing anything like that on any occasion. He says the case is "about an insistent intent to kill". He says that much be considered in the context of Letby 'raising the alarm' for some of the babies, or looking after some of the babies 'before and after their events'.
Mr Myers refers to the theory of air embolus, and if that 'works' each time, why would someone change it up to administering insulin. He says it is 'awful' to think about it, but to go with the prosecution case, he asks why the methods used varied. He says the prosecution referred to levels of insulin were doubled for Child L than for Child F. He says for Child F the level of insulin, from the lab result, was 4,657, whereas for Child L it was 1,099, and the insulin/insulin c-peptide ratio was lower, and 'must be a quarter of the strength'. He says "that was evidence, it was wrong". He says if there was an intent to kill, then the dose wouldn't be a quarter of the strength second time round. He says whatever happened, "that wasn't an intention to kill".
Mr Myers says "various factual allegations" came across Lucy Letby which amounted to 'wholescale document fraud', referred from 'page 34,536 of the evidence', he says, including children not on the indictment - such as 'the Stoke baby'. He asks why witnesses were not cross-examined about such incidents, on 'falsely identifying names' on paperwork, over the months. He says the "prosecution have been looking for things...so they can shore up". He cites a piece of evidence from the case of Child H, a note by Alison Ventress about a chest drain. He says she gave evidence, and she was cross-examined about it, about chest drains moving. He says that was no part of any allegation, and "it came out of nowhere" in cross-examination, "it suddenly became part of an allegation". He refers to a note about blood-stained secretions for Child H, made by Letby. He says the prosecution used that note as an opportunity "to bolster their list" by asking her if she had altered Child H's ET Tube.
Mr Myers says Letby was asked about how long she had been on the phone when feeding a baby not on the indictment, and how long she was spending texting. Letby had said: "You think I pushed it in, didn't you?" Mr Myers said Nicholas Johnson KC, for the prosecution, replied: "I do." Mr Myers asks where had that come from, and "there was no evidential basis" for that. He says it was "an allegation on the hoof". He says no-one suggested that baby had a vomit was unwell. He says that allegation was "made in passing".
Mr Myers moves to the issue of 'delay'. He says there is an issue with missing door swipe data between July-October 2015, and allegations are made against Letby during that time, such as during the case of Child I. He says the prosecution had accused Letby of 'making up a note' for September 30, 2015. Mr Myers says the prosecution can make that allegation as the door swipe data is missing for that date. Another note is referred to for October 14, 2015. He says Dr Matthew Neame's note, timed at 5.55am, is used as evidence there was a delay in reporting the issues. Mr Myers says it is their case 5.55am was when the note was written, not the time he attended. He says there is no door swipe data for that day to say when that doctor arrived.
Mr Myers says there is missing post-mortem examination evidence for Child E, which allowed the prosecution to present evidence of 'bleeding from the throat'. He says that allowed the prosecution to provide linked evidence. He says there is no evidence to show it, post-mortem.
The staff rota and missing events
Mr Myers moves to the topic of 'lists'. The 'staff presence' of when staff were on shift during the times of the 25 events for the babies. He says it is a "major part of the prosecution case" that Letby is present "far more often" than other staff. Mr Myers says it "doesn't show fault". He says "one thing that is striking about this chart" is having focused on it in the opening, there has been no reference to it at the end. He says the jury might wonder why that is. Mr Myers says it is "obvious now" that the list isn't complete. It is "missing two or three events" which could be considered "harm events". He points to Child N's case at June 14, 'night', for Child N's second event at 7.15am. Mr Myers says that is correct, and evidence had been heard Child N was unwell that night. He says Dr Sandie Bohin identified that in her evidence. He says Letby wasn't on duty for the night shift. He says the prosecution say Letby 'did something' before she left her shift the previous night - "what, we don't know". He says the point is that Letby 'wouldn't be in that shift' and the note would be blank.
Mr Myers says there is a 'harm event' for Child C, as identified by experts, on June 12, 2015, which is not in the sequence of events, and is not on the list. He says Letby was not on duty at that time. He says the prosecution are "not that bothered" for that one as Letby "wasn't on duty". For Child I, there was a 'harm event' identified which is not included on the chart, and says the table 'doesn't look so good'. He says there was a third 'harm event', not featured on the indictment, for Child G. He says Dr Sandie Bohin had said there were no further projectile vomits. Mr Myers says he referred to a third event happened on October 15, 2015 by Ashleigh Hudson, at 7.20pm...'one vomit, projectile, quite large in size'. Dr Bohin said if she had missed it, she missed it, Mr Myers tells the court. He added that was her attitude. He says there are 'at least two, maybe three events' which happened for the babies when Letby was not on duty. Child C on June 12, 2015; Child I, August 23; and Child N, June 14, 2016, night.
The Prosecution's list of similarities
Mr Myers refers to the 'list of similarities' that Mr Johnson used at the close of his speech. He says the lists are "not similar" and "how on earth" they are supposed to show a pattern of criminal behaviour. He says they are "masses of lists of differences" He says it is "dead right" they are a list of "dissimilarities". He says Child I features on eight of the lists. Child J is on 'none of them'. Child K is on one of the list. Child A and Child B on two, Child N, six, out of '11 similar features'.
He says the alternate reading is that for the babies a list does apply to, the remaining are for which they didn't. He says there is a 'mirror image', that a list which features seven babies, means that 10 babies did not have that similarity, and for one which features three babies, means it didn't happen for 14 babies. "These lists mean nothing...unless it is linked to the harm alleged." He says the list 'presumes a lot', that the defendant is guilty. He cites the list of discolouration features for some of the children, which staff had not seen before or since. He says each discolouration has to deal with individual babies, whether there was sub-optimal care, and on the quality of the evidence featured. He says for Child A, the descriptions given were 'relatively poor'. He says for Child M, one witness saw a discoluration - Dr Ravi Jayaram. He says the basis of Child H's discolouration was a father's account for a description of the fingers. He says the approach of the list is 'prejudged', 'misconceived and unfair', and the evidence is "very variable" and "create a fundamentally unfair situation". Mr Myers says the jury have to be "very careful" to look at a "short-cut" approach.
About Lucy Letby
Mr Myers says he will refer to 'brief looks' at Lucy Letby, the person she was and is, and documents, and the subject of 'experts', this afternoon. He says who Letby is, and was, is at the "heart of this case". He says she had "never been in trouble before". He says the jury will have formed an impression from her giving evidence of a "serious" person. A photo of a noticeboard from her home, taken at the time of her arrest, "is a good snapshot of who she is, and was". The noticeboard includes a photo of Letby smiling. The noticeboard photo isn't conclusive but "isn't unimportant" - "this is the person we were dealing with at that time". He refers to the "commitment" Letby did in training to care for "hundreds and hundreds" of babies. He says it is "important of the type of person she is". He says it makes the allegations "all the more unlikely", and medical professionals had spoken "highly" of Letby. He says nurse Christopher Booth agreed she was 'conscientious and excellent', and it was "not unusual" for her to work overtime. He agreed she was a "hard worker". He agreed she would be "upset" by the events which unfolded, as it was a "harrowing time".
He says it does not automatically make someone a murderer because of their behaviour after a baby has died, that it can be a misjudgment, although that was how it was presented by the prosecution. Mr Myers says Letby was "committed to her work" and evidence showed "how much she wanted to work". He says she was "young, keen, flexible". He cites agreed evidence from one of Letby's nursing colleagues: "I also remember...we had massive staffing issues, where people were coming in and doing extra shifts. It was mainly Lucy [being a band 5 nurse]. Lucy was young, living in halls, saving up to buy a house, single, willing to do extra work shifts..." Mr Myers says that would explain Letby's increased presence on the neonatal unt.
Mr Myers cites evidence from Eirian Powell, ward manager, in which he says she talked about Letby's importance on the unit, and said Letby was an "exceptionally good nurse" and had "known her since she was a student". She said Letby was "very upset" when she was removed from the unit. Mr Myers says that upset was "no act". He says Ms Powell said Letby was "distraught". Ms Powell said Letby was distraught as 'she thought she caused the deaths of the children'. Mr Myers says there is no doubt Letby was "very upset at the time" and this was "genuine distress".
The post-it notes and social media
Mr Myers refers to the 'striking' notes. He says they demonstrate the "anguish caused to Lucy Letby by what was happening". He refers to the 'not good enough' note. He says Letby wrote that not to the court, not to the police, but to herself, plainly "showing how she feels". He says that was "utterly consistent" of Letby being distraught about being taken off the unit. He says Letby wasn't 'pretending to need anti-depressants' for years, and wasn't 'pretending to be suicidal'; "the impact was immense".
He refers to the social media evidence. He asks what did the evidence give a false impression of - "that she dared to have a social life [in those two years before her arrest]?" Mr Myers says Letby, in cross-examination, had agreed she would go to the races, and have 'fizz', and go on family holidays. He says the photos show Letby having a "conventional social life". He says photos like that rarely show what is going on inside. He says there is nothing shown from the social life which runs contrary to the distress she was suffering. He tells the jury: "If you look in the dock [at Lucy Letby], you can see the effect of years of this."
Medical records and timings
Mr Myers refers to the documents, such as the neonatal schedule, which have 'limits to what they show', as they "only show activity". He says they cannot pin down a nurse's time at a precise time, at a particular location. He says the computer-timed prescriptions are not 'definitely precise.' He says the times are often made "retrospectively". The review does not mention how long an activity takes - which can vary, Mr Myers adds. He says the schedule provides a guide to timings, and does not show what somebody is doing when there is no record. He says it shows that nurses may be shown to do more than one activity at a time. He adds many of the events have someone to assist, and says other nurses assist colleagues. He says when that has been the case for Letby, she has been treated in "the most prejudicial way possible".
Text messages & Facebook searches
He refers to the subject of the text messages, which are "normal". She was a "young professional woman with a life", and the messages contain "social activity and banter". He says only when "you start with a presumption of guilt" can be taken as different. He refers to the 'go commando' message. He says a young woman, being cross-examined, being "humiliated" about something 'completely unrelated to what we were talking about', in front of the public, in front of her mum and dad, was inappropriate. He says "You saw me raise to my feet more than once" about the style of questioning, and the comment about 'running out on your boyfriend [doctor colleague]' was inappropriate. He adds the messaging was "unremarkable". He says the basis of Letby being 'bored' was used as the basis of an allegation she went out to kill a baby. He says "others were doing it at work" [text messaging in the workplace]. He cites four work colleagues who did so, and they were "normal...what you might expect". He says there is "work, gossip, there is winning at the Grand National, there is salsa dancing...normal things."
Mr Myers refers to Facebook searches. He says those familiar with social media will look up people for all sorts of reasons at any time of the day or night. He says it may be "no more than a handful of keys". He says the prosecution identified a number of messages, and there were more messages than that, Mr Myers says. He says the jury may agree Letby was a regular user of Facebook, and "rattle through searches". He says the prosecution draw the jury's attention to the searches for parents, in connection with the allegations. He says that would be a pattern in line with the theory. He says some of the parents names of babies on the indictment are missing from the Facebook searches. He says there are no searches for the parents of Child L-Q. He says the searches by Letby also demonstrate an interest for parents of babies not on the indictment. Mr Myers says that is "important", and Letby is seen as somebody who looks up names regularly.
He says of Letby's 2,318 Facebook searches, "only 31" related to parents' names on the indictment. Mr Myers says Letby has not searched for things on 'air embolus', or 'forcing in air', or any 'fascination with what's alleged here'. He says there is no evidence found Letby Googled 'haemophilia' following a conversation between a colleague nd Letby on Child N.
Diaries and Handover Sheets
Mr Myers refers to the 2015 and 2016 diaries found at Letby's home. He says there is nothing in the 2015 diary which is relevant to the indictment. He asks, if the diaries are relevant, why there is no reference to Child A-K in them.
Mr Myers refers to handover sheets. He says it is "not difficult" to see why Letby would have handover sheets in the first place. He says the issue is why she would keep them in such quantities. He adds if that is evidence of her intention to kill. He says Letby's position is she "didn't throw things away". He says Letby had a "habit" of retaining pieces of paper. He says Letby was 'collecting' in the style of 'accumulating', not as in "collecting stamps". Letby had said, in cross-examination, she accumulated the paperwork, not its contents. Mr Myers asks if the jury don't think this accumulation is "random", what is the prosecution's case for them? He says if Letby had handover sheets and only handover sheets relating to babies on the indictment, that would be significant, but a total of 257 handover were found, with 21 relating to babies on the indictment - "less than 10 per cent". He says there are no handover sheets for Child A, C or D.
Mr Myers says for the 21 handover notes relating to babies on the indictment, '9 or 10' do not refer to dates on which events for the babies happened. He says "they don't do what they should do if the prosecution are right".
He says they do show someone who hangs on to paper "compulsively". He refers to the shredder, and what Letby didn't shred. He says if Letby had thought there would be a police investigation - as written on one of her notes - she would have shredded the handover notes.
Expert Witnesses
Mr Myers refers to the subject of 'experts'. He says the prosecution medical evidence is 'central' to their case. He says it is crucial to show the jury that there is no medical cause for the collapses of babies, and that substandard medical performance is ruled out, and that the alleged harmful acts took place.
Mr Myers says experts should be assessed as other witnesses. He says they don't decide the case, and their assistance is needed to explain how the babies collapsed. He says the jurors should take their evidence into account, but "you don't have to accept them". He says there are 'certain features which are important', that the witnesses in their field "must be an expert" and the "expert is an expert on their topic", and that was something, he said, was recognised by Prof Sally Kinsey, an expert in haematology, who "acknowledged frankly" she was "not an expert" on air embolus.
Mr Myers says theories on air embolus were cited by one expert in 'pigs and rabbits', not neonates. He says expert evidence should be 'independent and objective', 'neutral - just stating it as it is', and 'not an advocate for one side or the other'. He asks if Dr Dewi Evans, Dr Sandie Bohin and Dr Andreas Marnerides gave impartial, objective evidence. He says if the experts do not come out to that, it is "game over for their opinion on that topic".
The judge, Mr Justice James Goss, brings the jury's attention to a matter raised in their absence earlier today. He refers to a matter of the chart presented earlier today, to a list of events and which staff were on duty, presented in court on screens. The judge says he and the jury had 24 events listed on their bundle of evidence, whereas the screen had 25 events listed. The 25th event was irrelevant to the point raised by Mr Myers, and was from an earlier version of that document.
Dr Dewi Evans
He says, in reference to Child Q, he had omitted a reference from Dr Evans's report on Child Q vomitting. He says he accepts that was a mistake. He says Dr Evans had been criticised "in scathing terms" by a court of appeal judge. He says Dr Evans is the prosecution's 'lead expert', and the prosecution not referring to that criticism in the closing speech is "appalling", and his evidence 'underpins' their case. He says Dr Evans is 'not a neonatologist - and that matters'.
He says Dr Evans hasn't got current clinical practice, and "a good deal of his knowledge is historic" and he is "an expert at being an expert", and "his focus is on that, and not in clinical practice". Mr Myers said Dr Evans had accepted his principal role in recent years was of being an expert, and attended a course on having to 'avoid pitfalls'. Mr Myers: "We say he should have been taking a lot more notes at that course". Dr Evans said he had called himself a medical independent witness, not as an expert, and he had come to assist the court on challenging medicla issues. Mr Myers: "There you have it from the horse's mouth. He is meant to be an expert." "You may think that frank assessment was more revealing than you can imagine." He says Dr Evans' evidence is the starting point for the other experts. "He has led the way on medical opinion."
Mr Myers refers to how Dr Evans came to be involved in the case. Dr Evans said he had been contacted by the National Crime Agency. The court is shown an email from Dr evans: 'Incidentally I've read about the high death rate for babies in Chester, and that the police are investigating. Do they have a paediatric/naeonatal contact? I was involved in neonatal medicine for 30 years, including leading the intensive care set up in Swansea...' Mr Myers says the email concluded 'interested to help. Sounds like my kind of case'. He says Dr Evans 'Did not like' the suggestion he was "touting" for work. Mr Myers says his credibility was affected. He "touted for work on his kind of case" created a "misleading impression". He says Dr Bohin was given a reference and Dr Marnerides has relied "heavily" on Dr Evans's opinions. Mr Myers: "He is a full member of the prosecution team from the very start. He is not neutral. He is not independent in any way."
Mr Myers says he had, in evidence, asked Dr Evans if he had come up with air embolus first. He said he'd had. Mr Myers refers to the chronology. He says doctors including Dr Jayaram were suggesting air embolus from July 2017. Dr Brearey said there were two meetings with police, including one on May 15. At that meeting, Dr Jayaram raised concerns with police about air embolus. Mr Myers says this is before Dr Evans got in contact after that point. Mr Myers says Dr Evans was "very keen to get involved" and "unless they [Dr Evans and the police] met in silence" in July 2017, then Mr Myers says Dr Evans would have been informed about a theory of air embolus after being relayed suspicions by the police.
Mr Myers says Dr Evans was cross-examined "for months" about his 'lack of independence'. He says Dr Bohin "has done the same thing but with rather more subtlety". He refers to agreed facts, of December 5, 2022, of a judge's ruling in a court of appeal, in which there had been a report of Dr Dewi Evans. Included in his reasons for refusal, the judge said: "The report is worthless and shows no support whatsoever for an appeal. “No attempt has been made to engage with the full range of medical information or the powerful contradictory indicators. “Instead the report has the hallmarks of an exercise in ‘working out an explanation’ that exculpates the applicants. “It ends with tendentious and partisan expressions of opinion that are outside Dr Evans’ professional competence and have no place in a reputable expert report. “For all those reasons, no court would have accepted a report of this quality even if it had been produced at the time of the trial.” Mr Myers says those comments are "appalling". He says the language from the judge "resonates very uncomfortably" with the evidence presented in this case. "Those comments paint a disgraceful picture". Mr Myers says those comments were put to Dr Evans. He said Dr Evans the Lord Justice of Appeal had got it wrong. Mr Myers "the worrying thing" is "he wouldn't really accept the criticism at all". Mr Myers says that decision "coincides with the months we have spent complaining about [him]".
Dr Sandie Bohin
Mr Myers says Dr Bohin hasn't 'peer reviewed' Dr Evans, but "supported him as far as she can", and "is every bit as much a part of the prosecution team [as he is]." Mr Myers says Dr Bohin has "worked" to agree where she can. "We do say she has been doing her best to shore up the allegations as far as she can." He says of Dr Andreas Marnerides, a pathologist, "is not a clinician, is not a paediatrician or a neonatologist", which "puts some limits [on his expertise]". He says his expertise is on what happens following a death, not in life. He says Dr Marnerides is "reliant" on the evidence of others, something which he agreed. He says he made a lot of reference to Dr Dewi Evans, and it is "too late in the day" to "insinuate" it is someone else.
The trial is now resuming.
Child A
Benjamin Myers KC is referring to the case of Child A. He says there was sub-optimal care in that case. He says on a neonatal unit, babies "are there for a reason" and many of the babies have "signficant problems" and are "at risk of deterioration"
He says Melanie Taylor was designated nurse for Child A and Child B. They were both intensive care babies. He says the prosecution have relied on nursing guidelines for some of the children, but not on the "fundamental issue" of staffing numbers. He says there "should not have been just one nurse" looking after Child A and Child B. He says if there was one nurse for each, they would be "more confident" the issue of lines and nursing care was resolved. He adds Dr David Harkness was stretched between a number of babies for the shift on June 8, 2015.
The respiration rate chart for Child A is shown, with what Mr Myers says is "escalating up to the point of collapse", and is in a yellow bracket (ie elevated above normal). He says [medical expert] Dr Sandie Bohin would not accept that, saying it was stable. Mr Myers says the defence wonder how much attention was paid to Child A, with Melanie Taylor looking after two babies. Mr Myers says Child A received no fluids for four hours, and Dr Bohin agrees it was "sub-optimal". He says the long line was "in the wrong place" for Child A. He said the records show it was not correctly sited. He refers to an x-ray review on June 8: 'Long line...to be pulled back'. Dr David Harkness put in 9.20pm he was unable to move the long line as he had been called to another patient. Mr Myers says Dr Harkness had a review with colleagues the following day and they agreed it was in a 'perfect place'. Mr Myers cross-examined Dr Bohin on the long line position, which she reported was 'not in the best position'. He says Dr Bohin didn't mention it in her evidence. Mr Myers says the line 'was too close to the heart', and fluids were put down it, and Child A had a fatal collapse within 20 minutes of that. He says Dr Harkness removed the line as soon as the collapse happened.
He says Letby helped a nurse with sterilisation. He asks when was she supposed to have done what she was alleged to have done, and next to Dr Harkness and Melanie Taylor. He says there is "nothing to support" that Letby got a syringe and injected some air. He says "no-one could access" the lines without opening the incubator first.
Letby said it was Melanie Taylor who set up and connected the line and put up the fluids. Melanie Taylor "couldn't remember which way it was". Mr Myers says that is something the prosecution would have "absolutely slated" her is she was the one accused. Mr Myers says another nursing colleague gave "lots of evidence", but "could not remember", in evidence, who connected the line. He says in cross-examination, from her January 2018 police interview, the colleague said: "it appears I was able to say then it was Mel who did it". Mr Myers says on the evidence, there is "no basis" of Letby being guilty of any offence for Child A. He says this account is "firmly based on the experts" who agreed on air embolus.
Mr Myers refers to the 'overarching theory of air embolus'. He says "at the heart of it" are Dr Dewi Evans and Dr Sandie Bohin, 'neither of whom are experts on air embolus'. He says they relied on a research paper written over 30 years ago. He says he asked them the clinical signs of identifying an air embolus. They both said a sudden and unexpected collapse. They said a skin discolouration, and the presence of air in the great vessels. Dr Evans added 'resuscitation is unsuccessful'. Mr Myers not one of those criterium have been applied consistently across the trial, and they have been 'chopped and changed' to suit the evidence, with 'extraordinary contortions' to fit. "My word, it changed", he adds.
Mr Myers says the research paper from 1989 identified 5 out of 53 infants with skin discolouration, and one had a rash, of 'bright pink vessels against a generally cyanosed cutaneous background'. He says it is a very specific description, of one case study. He says as the basis of convicting someone of murders and/or attempted murders it is "tenous in the extreme", but Dr Evans and Dr Bohin have made reference to it. That "meagre" research has "carried into pure guesswork", he adds. Professor Sally Kinsey, a professor of haematology, had also given evidence. She had said in cross-examination, she was not an expert in air embolus. She agreed she hadn't seen it herself, and that air embolus did not feature in her expertise. She said she had given evidence because "she had been asked to". Mr Myers said she had relied upon Dr Evans and Dr Bohin, which he adds was a "big mistake".
Mr Myers says there are many causes of discolouration to a baby, and there isn't a precise description as there is no photograph of any. He says the descriptions vary between the witnesses. He adds sometimes the descriptions have come months or years afterwards, after people have listened to other people's descriptions, and the dangers of recollection being 'contaminated or influenced are obvious'. Mr Myers says 'unexpected collapses' can happen to neonatal babies. He says Child D had pneumonia and was at risk of collapse. He says for 'resuscitations unsuccessful', the proportion of babies who recovered in this case "doesn't make sense". He says the air is 78% nitrogen and "doesn't just go". He says it is "static, it is a blockage", and would be found post-mortem. He says the jury won't find air in the heart, post-mortem, in any of the cases.
Mr Myers says the jury know what an air embolus looks like, from how Professor Owen Arthurs described it, and a radiograph image was supplied with the research article. He says it looks "nothing like" what was shown in this case. He says for Child G, the image looks "nothing like", and the UVC is "misplaced" to the lower liver. A second image for Child G shows the baby 'in life', with an air embolus. He says an air embolus can happen "by accident" in legitimate medical treatment. He says Dr Bohin "reluctantly" accepted that could be the case. He says Dr Evans refused to accept it. Mr Myers says the scientific evidence "falls short" on air embolus in this case, with background research "poor", and the guidance has been applied "inconsistently". He says the evidence "is so poor" it "cannot be used" to back the allegations.
Mr Myers refers back to the case of Child A. He says there was a 'failure to read subtle signs'. He says the "crucial" element is there is no evidence of air embolus. He says the prosecution have gathered witness accounts from this trial of the skin discolourations. He says those recollections can change over the years. He says there is no reference to discolouration in the contemporaneous notes for Child A, which he says is "extraordinary". He says nurses Caroline Bennion and Melanie Taylor didn't note anything remarkable. He cross-examined Dr Harkness on the description, who was "very animated" on the "striking" discolourations and "unexpected deterioration", but did not note it at the time, or in a statement to the coroner. He says the evidence by a nursing colleague noted, in a 2018 police interview, Child A was 'centrally pale', with limbs 'white'. Mr Myers cross-examined her on it, and asked her about 'blotchiness', and where that had come from. She agreed the description was different between police interview and evidence. Dr Jayaram said Child A was 'pale blue', with discolouration 'flitting around'. Mr Myers says the description he gave from the interview was 'very similar' to the one from the research paper. My Myers says the description does not appear in his clinical notes at the time, or in the "lengthy statement" to the coroner. Mr Myers says it is a "remarkable coincidence" that two doctors did not give evidence of discolourations to the coroner in a statement, or note it at the time.
My Myers says there is "no fair or proper basis" for an air embolus for Child A, and sub-optimal care, with the "long line in the wrong place".
Child B
The trial is now resuming following a short break.
Mr Myers refers to the case of Child B. He says Child B's deterioration on June 10 was "relatively brief", and didn't involve her being intubated. He says the defence accept there is no obvious medical condition or obvious evidence of sub-optimal care. He adds the evidence of an injection of air for Child B's deterioration "is so weak" and "unclear". He says: "If it isn't clear, therefore not guilty."
Mr Myers says there can be deteriorations for which the cause cannot be identified. He said there had been a number of attempts to insert a line - five by Dr David Harkness - for Child B, when the guideline was a maximum of three. He says the difficulties of inserting lines can put a baby under stress. He says Dr Evans, in cross-examination, went through all the potential causes. He says it was suggested Letby had moved the nasal prongs, or that Child B had been "smothered" - Mr Myers says there was no evidence of that, and it was 'abandoned'. He says the conclusion was of air embolus. A nursing note by a colleague said the prongs had been moved, and "it was not unusual" for the prongs to be moved out by a baby. On air embolus, Mr Myers says nursery room 1 "is a busy nursery" with staff coming and going. Belinda Simcock [Williamson] said, to police, there are 4 drugs cupboards and a sterile fridge, with keys held by the shift leader or a band 6 nurse. "It was constantly busy - I would liken it to a bus station," she said.
Mr Myers says for this allegation, Letby would have to be close to Child B - "and of course, she is not". He said it was "normal" for her to be assisting a nursing colleague in room 1, in assisting putting up the TPN bag at 12.05am. He says the nursing colleague is "not going to miss that" if air is injected, and it would not take 25 minutes for it to have an effect [when the deterioration takes place]. Mr Myers says at the time of deterioration, Letby was with the nursing colleague and not with Child B. He says the nursing colleague had said she was "keeping a particularly close eye on [Child B]", given the prongs had been dislodged and what had happened to Child A.
Mr Myers says the deterioration was not rapid in this case, and resuscitation was successful. A radiograph was taken 40 minutes after the deterioration. He says 'no-one is suggesting air' is present. He says that is different from the radiograph image for Child G, which was taken at Arrowe Park, where the air was still there. He says for discolouration, there was contemporaneous notes at the time. He says the defence are not disputing these discolouration descriptions at the time. He says none of the descriptions match that from the research paper.
My Myers said a doctor who had been present for Child A and Child B said what she had seen on Child B was something she had "not seen before", Mr Myers tells the court. He says it is accepted the skin discolouration is 'striking', but what happened was 'not air embolus'. He says it is not a particularly nice detail [to point out in comparison to other cases], but there was 'no screaming or distress' for Child B. He says that detail of 'screaming/crying/distress' was 'worked into the theory' by medical experts later in the case.
Mr Myers refers to a text message sent by Letby on June 12: '...They are querying a clotting problem [for Child B].' He says the prosecution said Letby was 'introducing cover' for events that had she had caused, "seizing on comments". Mr Myers refers to a text message conversation on June 10, in which the colleague reported: '[Child A's] prelim report - no gross abnormalities. So now bleeds, clots or line issues.' He says this is something Letby is talking about after being informed about it by another nurse, and is "unremarkable".
Mr Myers refers to a note by a female consultant, and suggests Dr Evans 'grabbed at' an explanation of 'pink and active' to describe a rash on Child B. Dr Bohin, cross-examined on it, had said it was "a mistake". Mr Myers says it was "not an innocent mistake".
Child C
Mr Myers refers to the case of Child C. He says Dr Evans identified no cause for the collapse in his report, but identified air embolus in evidence. He says a number of things are "wrong and unfair" about this case from Letby's perspective. He says if Child C was 1g lighter, he would have been treated at a different hospital. He was very premature, poorly and had pneumonia when he died, and had black bile aspirates in the final 24 hours of life. He says the medical experts refused to acknowledge Child C was more poorly than they said he was. He says Letby is being blamed for something when 'on the evidence she wasn't even in the room when alleged harm was done.'
Mr Myers says there were "failures by the neonatal unit", and he should have gone to a tertiary unit for investigation, and there was no examination by a consultant at an earlier stage, or a sufficiently early response to the black bile aspirates, and there was a "general failure" to document things properly. He says that was "circumstantial evidence" of sub-optimal care.
Mr Myers says the prosecution case was to minimise the problems for Child C. In cross-examination, Letby said she could not recall if Child C had prior issues. Mr Myers says Letby was 'manoeuvred' into saying that was the case, and the defence do not accept Child C had no prior issues. He says one of the notes had been put in the wrong patient's file, which was 'poor record keeping'. "Imagine if it was found Lucy Letby had done that? 'Plausible deniability'."
The note recorded bile on a blanket and black-stained fluid for Child C. He says nurse Yvonne Griffiths hasn't signed for a 9am reading on June 12, and something was entered for noon and not signed. He says bile on a blanket and black fluid is recorded in the nursing note at 6.30pm, but is not noted on the fluid chart. He says a radiograph was taken at 12.36pm. Dr Evans, Dr Bohin and Dr Andreas Marnerides had all regarded the image as a 'suspicious event' of harm. He says Letby was not on duty. Dr Anne Boothroyd recorded 'marked gaseous distention of the stomach'. Mr Myers says the jury should take this as "proof" the experts can "get it wrong". He says if this event happened when Letby was on duty, Letby would be accused of causing it.
Mr Myers says futher bile aspirates recorded are a concern for Child C. Dr Sally Ogden had confirmed that could be serious, Mr Myers tells the court. He says when cross-examined, Dr Ogden said it was "a worrying sign", and agreed it could be a sign of some gut obstruction. Mr Myers says on all the evidence, Child C 'merited closer care and attention than he received'. Dr Gibbs said, in cross-examination, intestinal obstruction 'could be one explanation'. He agreed bilous vomits were a 'red flag' for such an infant.
Mr Myers says Child C's bowels did not open throughout. He says Dr Bohin was 'firmly against' suggestions Child C was not doing well, and that it was not relevant he did not leave intensive treatment unit. He says she had the "gall" to imply that where nurses recorded dark bile, it "could have been blood". BM: "How is that better?...What a thing to say - she wasn't there." He says it is an "extraordinary dismissal" of the evidence of "experienced nurses".
Mr Myers says Dr Bohin, for Child Q, bilous aspirates could indicate gastroenterology problems. He asks why that could not be highlighted as a problem for Child C. Mr Myers says it was a "lack of care" that was a potential factor that led to Child C's collapse. He says Professor Owen Arthurs was asked about the radiograph image for Child C on day three of life on June 12. He says if Child C had not opened bowels, it could be indicative of an obstruction. Mr Myers says Prof Arthurs was not aware the bowels for Child C had not opened, and there was no clinical record they had.
Mr Myers says, for the case of Child C, he looks at the post-mortem evidence of whether there was a gastrointestinal blockage. He refers to the agreed evidence by the pathologist, Dr Kokai, who conducted the post-mortem examination, who recorded a 'distended colon' for Child C, which was not normal. He says Dr Marnerides refused to accept this evidence, who said the bowel was 'normal'. The stomach contained 'a large amount of air'. Mr Myers says Dr Evans was prepared to accept air being forced down the NG Tube on June 12 - when Letby was not on duty - but 'just came out' with air being forced down the tube, and an air embolus, in evidence for June 13, when he had not mentioned it in his pre-trial reports. Mr Myers says that was "without any evidential basis at all". He says Dr Bohin agreed that pneumonia was a contributory factor for Child C's death. He says the defence's position is that pneumonia made Child C more vulnerable, and Dr Bohin 'refused' to consider a combination of pneumonia and something else - such as an abdominal blockage - caused the collapse. He says Child C was a "very poorly little boy" who "should have been transferred out of [Chester] with the problems he had", and had "sub-optimal care".
Mr Myers says Sophie Ellis "should not have been looking after" Child C, as she was "inexperienced" and put in charge of a "fragile little boy". He says the collapse of Child C follows "the one and only feed" he received. He says Sophie Ellis "didn't see Lucy Letby do anything wrong". Mr Myers says the evidence of Melanie Taylor "contradicts" in court to what she said to police in 2018, "swapping Lucy Letby for Sophie Ellis". He says she was "utterly brazen about this" in cross-examination. He says the account changed so it put Lucy Letby in the room. He says a female nurse colleague said in evidence was consistent with what she told police. She had been dealing with a different baby, in a different room, with Lucy Letby. She said between 10-11pm, she was called to assist Child C. She 'went to nursery 1, where Sophie Ellis and Melanie Taylor were Neopuffing [Child C]'. Mr Myers says Letby is "nowhere near nursery room 1" at the time of the collapse.
Child D
Mr Myers moves to the case of Child D. He says the "evidence is very clear" that Child D was "very unwell" at 12 minutes of age, but she wasn't given antibiotics for four hours, and Child D was born with pneumonia, and required ventilation, and was on it for 11 hours, and there were continuing signs of respiratory difficulties, requiring the use of CPAP. He says after Child D's first collapse, it was discussed what to do, and there woul 'be a low threshold to intervene from a respiratory point of view'. He says after the second collapse, Child D was taken off CPAP, and Child D later collapsed fatally, and post-mortem was found with acute lung damage. He says Child D was "very ill from the outset". He says it is "a very unfortunate decision" after the second collapse that Child D was taken off CPAP after a discussion of a 'low threshold to intervene'.
Mr Myers refers to the pathologist's report for Child D, recording damaged lungs, "continuing respiratory problems". Presence of infection is "not ruled out" following negative microbiology tests, as Child D had been on antibiotics. Mr Myers said despite that, Dr Marnerides "preferred" air embolus as a conclusion. He said he had taken into account clinicians' views of how well Child D was doing. Mr Myers says Child D was not doing well on respiration. He says Dr Bohin had 'revealed' 'distress' was a sign of air embolus, for the first time in the case.
Mr Myers refers to nurse Caroline Oakley's notes of skin discolouration for Child D at the time. He says there is nothing there to identify a discolouration that matches air embolus. He says in cross-examination, she began to give colours such as 'red-brown', and "ended up saying 'I remember an unusual rash'". He says Kathryn Percival-Ward [Calderbank] had said in 2018 police interview that [Child D] changed colour, was mottled, and had seen it before, but...it looked unusual'. He says her memory had developed by the trial, calling it a 'mosaic' and giving a more detailed description with 'oval markings meeting up with each other'. He says "five years later we have a lurid description". He says he is repeating himself by witnesses giving more detailed descriptions five years later. Mr Myers suggests staff had met up in the meantime to 'share recollections', and this 'almost certainly' happened. He says for Dr Bohin, there had been lengthy cross-examination on air embolus, and it went 'increasingly circular' and 'self-feeding'. He says Dr Bohin had said Child D had two non-fatal collapses by referring to research in dogs, pigs and rabbits, and the results were "variable". Mr Myers says those "vague assertions" does not give confidence as to what happened with Child D. He asks why the descriptions of discolourations vary each time, and why Child D was not seen to be in distress before the final collapse [having been in distress prior to an earlier collapse].
Mr Myers says doctors had agreed blood gas test results for Child D had declined - and Caroline Oakley agreed they "were not as good as they had earlier" on June 22, 2015, at 1.14am. He refers to the 3.45am note by Caroline Oakley: '[Child D] desaturated and then became apnoeic. Called SN Letby to help.' He says "yet again" Letby was being held responsible for an event where she did not have responsibility for that baby at that point. He says there is nothing linked to doing any harm. BM: "Again - what is meant to have happened?" He says the jury have to be sure of what.
He says there is "such a blunt point to be made": "We are looking at intentions to kill, from somebody whom the prosecution allege knows what they are doing [as it has already happened by this point, in their view]. "It's not going to take three goes is it? It would be one shot, sudden, and fatal." Mr Myers the suggestion Child D did not die of pneumonia, as opposed to with pneumonia, is "unrealistic". He says the case against Letby is "incoherent".
Child E
The trial is resuming after a short break.
Mr Myers is turning to the case of Child E. He says there is a lot of pressure with all these events, and it is traumatic for the parents of Child E. He says it is important to look at the evidence as objectively as the jurors can. He says the defence will look at the evidence of Child E's mother as 'sensitively' as they can.
He says it is important to note there was no post-mortem examination - "in this, of all cases", and that absence has 'allowed the prosecution to make all sorts of suggestions'. He says doctors failed to deal with a bleed for Child E which was identified or suspected at 10.10pm on August 3. Mr Myers says it was "obvious" a transfusion would be required. He says a further note by Dr David Harkness at 11pm recorded a further gastrointestinal blood loss. He says "even here, no action for a transfusion". He says it was "delayed a further 45 minutes". A female doctor said it was a "serious situation" at 10pm and a "very serious situation" by 11pm, and she agreed she wished she had got there sooner, as it was a medical emergency. He says this is "obviously sub-optimal care".
Mr Myers it may not have been anyone's fault that Child E was at the Countess, but Liverpool Women's was 'full'. He says it is "not extraordinary" that Child E became unwell, and one of the nurses suggested that stress could have caused acidosis and, as a consequence, bleeding. Mr Myers says Dr Bohin would not consider bleeding as a cause of death. He says he knows it is distressing to talk about, and Child E did bleed to death. He says "everybody here could see [Child E] needed a blood transfusion".
Mr Myers refers to the allegation Letby attacked Child E at 9pm. He says Child E's mother's account was she walked in and Letby was not near the incubator at the time. He says the prosecution's statement was a "highly charged" statement. He says "that is the evidence", that Letby was "not causing harm". He says he is sympathetic with Child E's mother. He says the prosecution have "done their best" to turn this "into a binary choice" - that 'either Lucy Letby is lying or [Child E's mother] is lying'. He says the prosecution have done that deliberately. He says the question is what degree of accuracy has each said. BM: "Perhaps can we take the heat out of that?"
Mr Myers recalls Child E's mother's statement. He says there is no basis for what happened here to the bleed later, as Dr Harkness reviewed Child E later and found him to be 'stable'. Mr Myers says the record of Child E's "horrendous" screaming, as recalled by Child E's mother - "cannot be like that". He says the unit would have been "full of people coming and going". He asks "how on earth" would that not raise the concerns of people nearby? He says it is "unrealistic" it can be "in the way she described".
Mr Myers recalls Child E's mother's statement on the 'bleed coming out of the mouth.' A description was made around the mouth and the chin. He says on cross-examination, it was "agreed it was not completely fresh". He says he suggested it could have been aspirate. The mother disagreed. Mr Myers says there is no suggestion by any doctor/nurse of Child E screaming. The neonatal schedule for Child E on August 3 is shown. He says Caroline Oakley is involved in giving medication to Child F at 9.13pm, with Child F 'being near Child E at the time'. Mr Myers says it isn't about lying, it is up to the jury to draw "a fair conclusion". He says no-one else had seen anything that coincides with this.
Mr Myers refers to the phone call at 9.11pm, and the defence say they don't doubt Child E's mother was distressed at that time. The defence suggest the details from the later phone call were moved to the earlier call, something which is not accepted by either parent. Mr Myers says Child E's mother spoke to the midwife, Susan Brooks, which was agreed evidence. The midwife notes: 'Care since 2000hrs...[Child E's mother] asked me to let her know of any contact overnight from NNU as one of the twins- had deteriorated slightly...' Mr Myers says this is the best, and maybe only, independent guide, for the event, and if the situation was more serious, it would have been noted as such.
Mr Myers refers to the expert witnesses' evidence. Dr Evans and Dr Bohin referred to Dr Harkness's description of discolouration as background for 'air embolus'. He says Dr Harkness gave more detailed descriptions in police interview and in evidence than he had in clinical notes, including the 'mobility' of the colours of the discolouration.
He says at the time of the collapse, no-one was seen interfering with Child E, and Dr Harkness said Child E 'collapsed in front of our faces'. He asks where the attack is supposed to have happened. Mr Myers says he is not going to go into detail of Child E's bleed after the collapse, "as it is awful". He says Dr Evans had said, in his third report, an NG tube being forced in was the cause of the bleed. He added that was withdrawn a few weeks before the start of the trial. Dr Evans said it was 'an option worth exploring' that a tube introducer had been used. Mr Myers says Dr Evans had taken up a role of investigator and hunting up ways to find a conviction. Mr Myers says Child E's bleed "ran out of control and he died". He says there is no post-mortem examination, and Letby is getting the blame, and no "realistic opportunity" of air embolus.
The courtroom at Manchester Crown Court is filling up. Lucy Letby has arrived, as has Benjamin Myers KC, who has been delivering the closing speech for the defence the past two days. The trial is now resuming.
Child F
Mr Myers refers to the case of Child F. He discusses the counts of insulin in general - for Child F and Child L. He says the prosecution referred to Letby's 'concessions' of the insulin results. He says the defence reject she has committed an offence for those two counts. He says the jury 'may well accept' the insulin results. He says it is insufficient to say Letby's concessions that the lab results are accurate when she cannot say otherwise. He says the defence can't test the results as they have long since been disposed of. He says the evidence at face value shows how the insulin results were obtained. He says it is not agreed evidence.
He says 'it seems', insulin continued throughout, and Letby 'cannot be held responsible for, realistically'. He says Letby was accused of adding insulin to bags already put up [for Child F], or 'spiking it three times' for Child L. He says these explanations are "contrived and artificial".
Mr Myers says a 'striking' matter that neither Child F or Child L "come close" to exhibiting serious symptoms as a result of high doses of insulin. Child F had a vomit. Child L "only ever seemed to be in good health", other than low blood sugar levels.
He says for Child F, if accurate, received exogenous insulin administered, according to the laboratory result. He says it was 12.25am when a TPN bag is put up for Child F by Letby and a colleague, and that was changed at noon by two other nurses as the cannula line had tissued. He says the lab sample came at a time when Letby was not on duty, and was after the second bag had been put up. Mr Myers says the readings of blood glucose found for Child F and Child L are not that different for their respective days, but the levels of insulin found in the lab sample differ [Child F had a reading of 4,659; Child L had a reading of 1,099]. He says Professor Peter Hindmarsh was asked to describe the signs of high insulin/low blood glucose. He said there was the potential for brain damage in low blood glucose levels. The other symptoms in serious cases include death of brain cells, seizures, coma, and even death. He says "fortunately", "neither of these babies" exhibited the serious symptoms. He says that is surprising if both babies had the high levels of insulin alleged.
Mr Myers says it is "a strange intent to kill" when the person with intent would know a remedy would be available - a solution of dextrose. He says Letby helped administer that dextrose. He says it is "interesting" the proseution did not ask doctors to rule them out of involvement with insulin. He adds he is not making an allegation.
He says there is "no evidence" Letby interfered with any TPN bag. He says the fridge is used by "all nurses" on the unit, and the "risk would be obvious" that someone could be caught interfering with a TPN bag. He says there are "lots of reasons" to show Letby would be noticed if she were to carry the act of administering insulin.
Mr Myers says the defence make the "obvious" explanation that there is nothing to say Letby exclusively was responsible for the insulin being in the bag. He says insulin continued to be given to Child F after Letby had left the unit, via a maintenance bag. He says it is "incredible" that Letby is held responsible for this.
Mr Myers says the evidence is the stock [replacement] bag must have been contaminated with insulin. He asks how can Letby can be responsible for that bag, as no-one could have foreseen it would have been needed? He says the first bag was replaced as the cannula line had tissued. He says it is like "Russian dolls of improbability". He says a TPN bag lasts 48 hours. He says there are a number of stock bags kept, not kept in any particular order. He says there is no evidence no other babies subsequently displayed symptoms of high insulin from the other bags. He says unless Letby had a "Nostradamus-like" ability to read the future, in the event of a targeted attack, a stock bag would not be contaminated with insulin on the off-chance it would be needed, and the bag was the one chosen 'at random' by a colleague.
Mr Myers says Letby believed she had a good relationship with Child E and Child F's mother. He says there is an entry in Letby's diary on Child E - the only entry for any child in the indictment in the 2015 diary. He says there is no entry for Child F. He says the photograph of the sympathy card for Child E's parents, taken by Letby at the hospital, has no relevance. Mr Myers says it was a photo taken while she was at work.
Child G
Mr Myers refers to the case of Child G, for which there are three allegations. He recalls the key events during her care at the Countess of Chester Hospital's neonatal unit in September 2015. Mr Myers says there are many areas to this case which are "upsetting", and the brain injury Child G sustained is "deeply upsetting- heartbreaking". He says whatever emotions that may be felt as a result, that does not establish what Letby is alleged to have done.
Mr Myers says the case against Letby - the allegations - are "weak", and "demonstrate shortcomings in this case". He says it is "shameful" that Letby was being blamed for the monitor being off on one of Child G's incidents, and it was only from one of the nurse's accounts in evidence that showed it was not the case.
Mr Myers says Child G was very premature, and her transport to the Countess of Chester Hospital was delayed as she had an event where she desaturated to 42%. He said there were also events of blood-stained secretions and an event described in the notes at Arrowe Park as a "pulmonary haemhorrhage". He says for 2.15am on September 7, the allegation is Letby force-fed Child G. He says there is no evidence she did so.
The trial is resuming after a short break.
Mr Myers says Dr Evans and Dr Bohin, before the trial, said air and milk had been forced down the NG Tube, and that a colleague of Letby had aspirated Child G's stomach before the 45ml feed [ie the stomach was 'pretty much empty']. He says that was the assumption. He says the assumption was wrong. The nurse said she would have taken enough aspirate to assess the pH level of the stomach, but not enough to empty the stomach. She had said that would have been done with bigger babies who were stable. He says the evidence "all falls apart". He says the nurse said there could have been undigested milk in there. He says this "created a fundamental problem for the experts". He says the defence was critical of how the allegation "morphs", and focused on the description of the pH level. He says the judge, Mr Justice James Goss, asked about that, and the nurse replied the pH level would not give an indication of how much milk was in the stomach. Mr Myers says Dr Evans and Dr Bohin said low pH levels meant acid, and no milk in the stomach, and had "changed their lines of attack". Dr Bohin was "particularly vigorous" about it, saying pH of 4 was "very acidic" and milk would "neutralise" that reading. Mr Myers says the nurse "did not get that wrong". He says in the case of Child P, there can be a low pH reading with a lot of milk in the stomach. He says 14ml of milk was aspirated, and a pH reading of 3, and a later reading gives 20ml aspirate and a pH reading of 3.
Mr Myers says Child G's CRP rating [a test to diagnose conditions which cause inflammation] had risen in the 24 hours after the projectile vomit, from 1 to 218. He says that is a sign Child G was developing an infection. He says what Letby is alleged to have done is "incredibly speculative".
He says there are "vanishing amounts of time" for Letby to have done what she is alleged to have done, given how long the 2am feed takes to be administered and how long Letby had been with colleague Ailsa Simpson before they were both called over for the projectile vomiting incident at 2.15am.
Mr Myers refers to the 6.05am 'profound desaturation' for Child G. 'NG aspirated as abdo appeared v large, ~100mls aspirated'. He says the presumption of guilt is Letby did this. Dr Alison Ventress had said, in cross-examination, this was most likely to be air. He says Dr Stephen Brearey first gave evidence in the trial at this point. He said he "assumed it was fluid". Mr Myers says that is "extraordinary" and there's "no basis" for that.
The note also refers to 'ETT removed at 0610. Thick secretions++ in mouth. Blood clot at end of ETT...Reintubated at 0615'. Mr Myers says Child G was not getting air in due to a blood clot. He says Alison Ventress had agreed in cross-examination the blood clot had interfered with the ETT. Dr Bohin had agreed, in evidence, blood clots can cause a desaturation, when describing a desaturation event for Child G on a different occasion. Mr Myers says there was a failure to ventilate Child G for hours.
Mr Myers refers to the second event for Child G on September 21, 'At 1015 x2 large projectile milky vomits....desaturation to 35% with colour loss. NG Tube aspirated - 30mls undigested milk discarded.' He says if Letby is alleged to have attempted to kill Child G, 'what a thing to put it in a nursing note'. He asks where the 'document fraud', or 'cooking the notes' is. He says it is "an incredibly weak basis" that the only two events of milky vomits on September 7 and September 21 are suspcious. Mr Myers says "we don't know" how much of the 45ml feed at 6am is still in the stomach by the time of the following feed. He says for September 21, Child G recovered quickly, unlike the September 7 event.
Mr Myers says, for the allegation Letby 'cooked the notes', he refers to Child G's temperature reading on the observation chart, that there are 'two dots' on the 9am reading. He says there are multiple dots recorded on other hours on the same chart by other nurses. He adds the dots are both in the 'white' area [ie normal]. He says it is "not a good point".
Mr Myers adds Child G had a further projectile vomit on October 15, when Letby was not on duty. He refers to the third event for Child G, the second on September 21, 2015. He says the prosecution opening in October last year said somebody had switched off the monitor. He says it was the evidence of a nursing colleague who said what did happen. He said the nurse recalled there had been seven attempts to insert a cannula. Mr Myers says that could have caused a desaturation for Child G. Mr Myers said the nurse's "crystal clear evidence" said the doctors left Child G behind screens and the monitor was switched off. He says Dr John Gibbs had said if that was what the nurse had said, then that was what had happened. Dr David Harkness said he could not recall. Mr Myers says it was "very poor treatment" for Child G.
Child H
Mr Myers refers to the case of Child H. He describes the events for Child H, including the insertion of chest drains. He says the evidence reveals "serial, sub-optimal care" and "no evidence" of Letby "doing any wrongdoing at all", but "she gets the blame". Mr Myers says late provision of surfactant would have made the pneumothorax worse for Child H, as Dr Bohin said. He says Dr Bohin also wrote in her report there was an "unacceptable delay" in intubating, and leaving a butterfly needle in the chest was 'sub-optimal practice as it is hazardous'.
He adds there was a delay in inserting the second chest drain, and Child H had not been sedated. He says the issue of the 'moving second chest drain' is "hotly contested". Highlighting the 'sub-optimal care', Mr Myers says there is "a very good reason" why babies got better when transported to a tertiary centre, and it 'wasn't because of Lucy Letby'.
The trial is now resuming following its lunch break.
Mr Myers says it occurs to him they are halfway through the material, and appreciates it is very detailed. He says it is important and necessary to go through the detail. He continues with the case of Child H. He says the defence suggests a 'build-up' of what had gone on, and a poorly positioned chest drain, caused the collapse at 3.15am, after a third chest drain was put in. He said it must have been "a huge stress on a baby".
Mr Myers says the second chest drain "may be another aspect of poor care". He says it was put in the 'wrong position' for Child H by Dr Jayaram. Two x-rays are shown. He says Dr Bohin accepted, in cross-examination, that the position of the chest drain was not in accordance with guidelines. She said the position of the tip was sub-optimal. Mr Myers says the tip also moved around. A number of x-ray images for Child H are shown for the positions of the chest drain tip. He says it is shown to have moved, and says the tips of the other ones had not.
Professor Owen Arthurs was asked, Mr Myers said, about the position of the tip of the needle [from a radiograph image for Child H on September 26, 2015], and whether it was touching the heart. He replied he could not tell - it could be several centimetres away, it could be touching. A doctor wrote for Child H on September 26: 'Possible cause for cardiac arrest could be that a drain is too close to heart and touching pericardium...' A nursing note: 'At 16.21 [Child H] started to desaturate, no air entry heard, ET Tube suctioned and help summoned from colleague. Crash call... 'Second chest drain noted to be in a different position and 'holes' close to chest wall. Further tegerderm applied and chest drain tubing position altered. Both chest drains bubbling ++ during reintubation...' Mr Myers says the chest drain was "not well secured and this can't be blamed" on Letby. He says a desaturation to 56% at 7pm 'should be included in the list of events, but this wouldn't fit as Letby isn't on it'.
Mr Myers says the key event for Child H happens at 3.20am, hours after the parents left before midnight. He refers to the second event, the following night, in which he says Letby has "no opportunity to be involved in this". He says Child H had a 'profound desat' at 2030 and a further 45% desaturation at 2145. He says the 'profound desaturation to 40%' at 0055 is the one Letby is blamed for, "randomly". There is also a desaturation at 0330, which Letby is not linked with. Mr Myers says the desaturation at 12.55am is part of a series Child H had been going through that night. Mr Myers said no cause was identified for the collapse of Child H. He says there were "very serious failings in care".
Child I
Mr Myers refers to the case of Child I, which he says has a lot of detail to it. He says Child I was very small and "fragile" and "capable of deteriorating from almost nothing". He says this was evidence heard from her time in Liverpool. He says nurses would talk of Child I 'having a big tummy', and Dr Bohin agreed there were multiple occasions noted of a distended abdomen. He says Child I regularly presented as "mottled".
Mr Myers refers to an event of 'abdominal distention' on August 23, which experts had agreed was 'consistent of harm', but is not on the sequence of events and Letby was not on duty. He says there is an 18-hour period from September 5-6 where Child I deteriorated from being a well baby, to the point she was transferred to Arrowe Park Hospital. Mr Myers says it shows how quick Child I could deteriorate, and "she was not doing well".
He says, for the first event [that Letby is charged with], the cause of the collapse on September 30 was said by Dr Evans and Dr Bohin to be air down the NG Tube. Mr Myers says this is the event with Letby's note which the prosecution took issue, that there was 'no doctor review', and she was 'lying about a fictional review at 1500'. He says the agreed evidence by Child I's mother said she was changing Child I's nappy when a nurse she later found to be Letby said Child I's stomach appeared swollen. In a second statement by Child I's mother, she said the first time she saw Letby was 3pm, and remembered Letby 'I'll go and get the doctor to come and check her.' The mother said she agreed, and a female doctor went and checked Child I.
Mr Myers says for the 4pm event, Letby calls for the doctors "in good time", and 'that is all'. He says for 7.30pm, nurse Bernadette Butterworth had said Child I's air in the tummy increased from Neopuffing, and that can push the diaphragm up. He says breathing support can cause abdominal distention, and that can be applied from as little as Neopuffing.
He says for the second event of Child I, this event is the 'what could Lucy Letby see or not see?' He says one of the issues in this case, staffing experience levels are a factor. He says Letby had said nurse Ashleigh Hudson was 'quite inexperienced'. He says Child I was on antibiotics up to a few hours before the collapse, not 48 hours as the prosecution had said. He says as there are no heart rate or respiration observations being recorded, it could not be said how stable Child I was before the collapse.
The trial is resuming following a short break.
Mr Myers says Ashleigh Hudson had been away from nursery room 2 'for about 15 minutes', and when she comes back, no-one is in the nursery. He says Letby is in the doorway of 'a small room'. He says there was 'certainly enough light' for nurse Hudson to feed Child I. He says she 'embarked on a lighting reconstruction' five years later, with the lighting level 'made for the purpose of this investigation'. He says the light would be 'so dark' to 'put the milk in the bottle'. He says Nicola Dennison said the babies were arranged so you can look at them. He says the defence case is that is at odds with what Ashleigh Hudson had given.
Mr Myers says Letby had, in cross-examination, said she had more experience what she was 'looking for - at.' He says this was the fifth day of cross-exmanation, when Letby was increasingly tired and finding it difficult to concentrate. He says there is no meaningful difference between the words 'for' and 'at'. He adds room 2 has a window between the corridor and the nursery. He says it is "unrealistic" to say the room was "impossible" to look in and see babies.
Mr Myers asks what evidence there is for air embolus, as there was no NG Tube. He says Dr Bohin relied upon discolouration of sternum. He says extensive CPR took place on Child I after this collapse, and there was bruising as a result. Mr Myers says there is no clear basis as to what have happened, unless someone had used a 'mobile NG Tube in the most improbable of circumstances'.
Mr Myers says abdominal distention is a running theme for Child I, and while that does not mean harm was not done, it does not alone form the basis of an intent to kill. He says: "we keep having incidents where Letby isn't doing anything she shouldn't do". He says the defence are critical of the theory of air down the NG Tube. He says it is a theory that has been done to support the prosecution. He asks how much air is needed, and how long it takes.
He says for the final event, there are two signficant desaturations, one just before midnight, seen by Ashleigh Hudson, who is not sure why. He says there is a similar event at 1.06am the following morning, on October 23, when Child I does not recover and dies at 2.30am. He says the difference with the latter is Lucy Letby is there. He asks what the difference is between the two events. He says Child I was a very poorly baby before this night, and Child I "would have been under terrible stress".
Mr Myers says Dr John Gibbs noted: 'Poor response to second resuscitation might have been to heart being compromised by previous...collapses'. He says the evidence was the abdomen became distended in response to the first collapse, as Ashleigh Hudson had noted the 'abdo soft' at 23.57pm. A radiograph after the collapse showed a distended abdomen. He says Dr Evans and Dr Bohin 'made a lot' of Child I's crying at the time. He says the experts had worked this symptom in during the course of their evidence as a sign of air embolus. He asks whether there was supposed to be an air embolus at 11.57pm, at 1.06am, or both.
Mr Myers asks about the allegation Letby amended a time on a document: "So what?" He asks about the relevance of it. He asks what is meant to establish that it was done deliberately, rather than a mistake.
He refers to the sympathy card Letby had sent for the parents of Child I, a photo of which was taken while she was at work. He says another photo was taken of a card she had sent to some friends. He says it had been heard this was something she did. He said the sympathy card was sent as she could not go to the funeral of Child I. Mr Myers says evidence had been heard by Lucy Beebe saying Letby was 'crying' after the death of Child I, saying: 'Why is it always me?' He says that was a genuine response by her.
The trial is due to resume at 10.30am.
Benjamin Myers KC, for Letby's defence, will continue giving the closing speech for a fourth
day. He has previously told the jury his speech will last five days.
The trial judge, Mr Justice James Goss, says to accommodate timetabling issues, the court will be sitting until 3pm today. To make up for lost time, the lunch break will be shorter than usual, and the court will begin at 10am on Friday.
Child J
Mr Myers refers to the case of Child J, and outlines the events which happened to the baby girl in November 2015, and what is alleged. He says Child J's mother is "a fairly neutral witness on this topic". He says she said she drew comparisons betwen the care at Alder Hey Children's Hospital and the Countess of Chester Hospital, and the latter was 'not favourable'. She says the staff at the Countess relied on them to sort stoma care. She says they were left to "feel unwelcome", and asked about that, she said she felt their concerns "were not treated seriously". She says the staff there "did not have the same confidence and ability" in dealing with stoma bags. Mr Myers says this statement is used as the basis for their argument that the Countess was receiving too many babies with complex needs.
Mr Myers says the mother had said the concerns were met with "pushback". He says nurses, including Nicola Dennison and Mary Griffiths, had said dealing with stoma bags was "unusual", and Dr John Gibbs said it was a "challenge".
He says this case is evidence "beyond doubt" that serious deteriorations can come out of nowhere, as there are two desaturations for Child J, a well baby generally, which are serious and "cannot be blamed on Lucy Letby". Dr Kalyilil Verghese had considered the first was a 'false desaturation'. Mr Myers says Nicola Dennison had given evidence to say the first "serious desaturation" is a real one "which comes out of nowhere", with Child J desaturating to the 30s [of oxygen saturation levels]. He says Dr Stephen Brearey said he could not find a cause for those two desaturations, and agreed they were unexpected. Mr Myers says it is "clear unfairness" that the latter desaturations, when Letby is present, are an allegation of harm, as opposed to the first two desaturations when Letby is not present. He says there is "no evidence" that can be linked for Letby causing harm to Child J.
Mr Myers says the experts do not identify any physical harm for Child J. He says Letby is being left to explain something for which she probably wasn't present for. He says Dr Dewi Evans, when cross-examined, could not rule out infection in his report. He says this is not attempted murder, and the prosecution case is "empty".
Child K
He turns to the case of Child K. He outlines the events and allegation. He says the allegation "illustrates a good deal wrong with this case". He says Child K "should not have been at the Countess of Chester Hospital", but should have been treated at a tertiary unit. He says arrangements were being made post-birth. He says a review carried out at Arrowe Park Hospital said care at the Countess was "sub-optimal". He says the defence acknowledge there is a question whether transporting the mother before birth was possible. He says Child K should have received surfactant.
Mr Myers says Child K was a tiny baby needing complex care. He says Dr James Smith agreed in cross-evidence that an experienced neonatalogist at a tertiary unit would have had more experience than him in looking after babies such as Child K. A mortality review at Arrowe Park Hospital said Child K's death was "avoidable", Mr Myers says. He says surfactant, to allow babies to breathe properly, should have been administered "straight away" to Child K. He says Child K could not breathe without assistance and it was "inevitable" she would need intubation. He says the "air leak" recorded "cannot be ignored". He says staff at the Countess "did not seem concerned". He says the defence acknowledge the oxygen saturation was high. He says a tertiary unit consultant had said the pressure [VTE reading] was "too low" and the oxygen saturation reading was "not consistent" with the air leak and pressure readings.
Mr Myers says the count is Letby "deliberately did nothing to help" when confronted by Dr Ravi Jayaram, and that by implication, she had harmed Child K. He says Letby did not recall what had happened. He says the allegation "relies on the credibility and reliability" of Dr Jayaram. He says the allegation had "morphed" against Letby. He says tubes can dislodge. He says Dr Sandie Bohin agreed tubes can dislodge even if a baby is sedated. He adds nurse Joanne Williams said Child K was an "active baby".
Mr Myers says Dr Jayaram had said Child K was sedated, and that was "a prime basis for blaming" Letby. He says Child K was not sedated until after the tube was dislodged and she was reintubated.
Mr Myers says Letby's presence on the unit allows the prosecution to "say what you like". He says if it is alleged she was 'caught in the act' by Dr Jayaram, she would not have gone back to dislodge the tube twice more the same morning, as is alleged by the prosecution. He says if Dr Jayaram had seen things in the way he told them, he would not have taken his eyes off Letby for the rest of the shift. "He would have been watching her like a hawk". He says the allegation is "not worthy of belief". He asks why Dr Jayaram, if he had seen what he had said, did not contact the police or 'whistleblow', or file a Datix report. He said he did "nothing".
Mr Myers says nurse Joanne Williams recalled Dr Jayaram had asked her what had happened, and who was in the room when the alarms went off. He asks why Dr Jayaram would ask her that if he had been in the room at the time, seeing Letby in there. He refers to a note on the transport team: "Call received from Dr Jayaram baby dislodged the tube and had to be re-intubated".
Child L
Mr Myers refers to the case of Child L. He says it is the second of the two insulin counts, where Child L had low blood sugar for a period of 53 hours, as identified by Professor Peter Hindmarsh. He says the laboratory result, if accurate, shows artificial insulin administered exgoneously.
Mr Myers says Letby was seeing friends, going on holiday, enjoying salsa, a win at the Grand National. He says it is important to keep in mind the person who these allegations are aimed at. He says at this time, her main concern was moving house "and this was on her mind". Text messages are shown to the court showing conversations with Letby about her new home in Chester, having been at hospital residence.
Mr Myers says it is important to consider each count separately. He says it is not accepted Letby has committed this offence. He says there was a delay in getting the sample taken from Child L sorted, and was outside the 30-minute guidance, whether it was taken at noon or 3.45pm. He says the Countess of Chester Hospital Pathology department records the lab specimen report notes it was received at 6.26pm. He says Dr Anthony Ukoh says the sample was taken at noon.
Mr Myers says nurse Mary Griffiths had said there was a delay in podding the blood sample due to what happened with Child M. He says it is a "point of contention" that the delay in processing the sample is "one thing to keep in mind" when processing the results. He says apart from the "apparently" low blood sugar level, there was no ill effect observed on Child L, which he says is "extraordinary". He asks how that is evidence of poisoning. He says the blood sugar level reading in the sample, was 2.8, a "relatively healthy reading". would be inconsistent with the insulin and insulin c-peptide. Professor Hindmarsh said it was a plasma reading, so would give a different blood sugar level reading than a heel prick, and it was said it would be more like '2.4'. He says the heel prick tests showed a blood sugar level reading of 1.6 at noon. The ones at 3pm and 4pm are 1.5. He says it does raise a question on the accuracy of the blood sugar readings.
The trial is resuming after a short break.
Mr Myers says there was one detail he had omitted before the break. He says at 3.40pm, bolus of 10% dextrose was administered for Child L. He says the prosecution says that would account for the higher blood glucose reading. He says the problem of a 1.5 [heel prick] reading at 4pm still remains, as does the 3pm 1.5 reading. He says it is difficult to work out what effect it would have.
He says Letby cannot have interfered with the bags in the way it is alleged. He says the bags are changed during the 53 hours Child L was recorded to have low blood sugar readings, during which five bags were used. He says a number of bag changes took place for which Letby was not involved in. He says the prosecution alleged Letby was 'setting up an issue' of hypoglycaemia for Child L. He says it does not follow as Child L would be a focus on blood sugar levels, and someone with harmful intent would not identify an issue that was going to be detected anyway. He says Letby would be drawing attention to it. He says Child L's designated nurse was recorded on the neonatal schedule as being a co-signer for 9.25am-9.29am prescriptions. He says that is when the electronic prescriptions are inputted. He says Dr Ukoh would also be in room 1 that morning (where Child L and Child M are) as part of his ward round. He says there is no record of him outside of room 1 during the time Letby was alleged by the prosecution to administer insulin in Child L [about 9.30am].
Mr Myers says the theory Letby spiked the various bags with insulin is "contrived and arfiticial", and the mechanics of it are "unrealistic". He asks how Letby could predict to add insulin to the dextrose bags in storage, which would be used for all babies on the unit, only for Child L. He says the theory of 'sticky insulin' is "mixed". He says there is a lot of bag changes over 56 hours. Prof Hindmarsh was cross-examined about it, if the 'sticky insulin' would run out at some point. He said it would. He said over time, additional insulin would be required to maintain the levels [of low blood sugar levels].
Mr Myers says whatever the reason for Letby accumulating paperwork [at home] in the case of Child L, it does not provide sufficient evidence of an intent to harm the baby.
Mr Myers says Letby subsequently cared for Child L after April 9-11, and it is "utterly inconsistent" with someone wanting to target that child to harm or kill them.
Child M
Mr Myers refers to the case of Child M, and outlines the events that took place. He says it was established he was in a corner of room 1 on April 9, which "wasn't ideal" as the unit was busy. He says Letby was "doing nothing" to harm Child M, and had participated in giving antibiotics 15 minutes prior. He says Dr Evans and Dr Sandie Bohin had worked in a theory of how slowly air embolus could take effect. He says that theory is "unbelievable".
Mr Myers said Letby, on April 9, had other babies to look after that day, with their own issues. He refers to a note by Mary Griffith on April 9 for Child M to say there was an underlying problem prior to the 4pm collapse. He says by 3pm, Child M was made nil by mouth, and says it can be argued that was 'not a great direction of travel for him'. He says if it is accepted that the 4pm event is a signficant escalation, it does not show Letby caused harm at that time.
The trial is now resuming after its lunch break.
Mr Myers is continuing to deliver the closing speech in the case of Child M. He says air embolus was the mechanism proposed by medical experts as the reason for collapse. He says Dr Evans and Dr Bohin referred to discolouration. He says the only witness for that was Dr Jayaram. He says the description is not made in the contemporaneous notes, as they were not there for Child A.
Mr Myers says none of the other staff, including Dr Ukoh, give a discolouration description for Child M. He says Child M did make a good recovery, gradually, from the collapse. He says the significant issue is Letby's last contact with Child M is when she is involved with administering antibiotics at 3.45pm, and if air has been administered at that time, he says it would not take 15-16 minutes to have effect. He says air embolus is fast acting. He says the amount of air alleged to be administered in this case is 0.5ml. He says if there was an intention to kill, it would have been larger. He asks how someone would measure 0.5ml or calculate it. He says even a minute quantity would have a quick impact. He says fortunately, neither twin of Child L or Child M appeared to have suffered harm as a consequence. He says the theory of air embolus is "utterly unrealistic" for Child M.
Child N
Mr Myers refers to the case of Child N, for which there are three counts alleged against Lucy Letby. He outlines the events for Child N, who had haemophilia. Mr Myers says Professor Sally Kinsey said Child N was more likely to suffer a bleed from trauma than babies who do not have haemophilia, and the amount of blood would be larger. Prof Kinsey had said the process of instrumentation had the potential to cause bleeding, such as a naso-gastric tube. Mr Myers says the Countess of Chester Hospital did not have Factor 8 for Child N at birth. He says for the first Child N event, for which it is alleged there was trauma and/or an air embolus, he asks if Letby was even there.
Mr Myers refers to Dr Jennifer Loughanne's note for the Child N event - 'asked to see - desat - unsettled - got upset - looked mottled, dusky, sats [down to 40%] [moved to] 100% O2 'On my arrival, 40% O2, screaming'. Mr Myers says it is "plainly not an air embolus", disagreeing with Dr Evans. He says Dr Bohin said it was a painful stimulus. He said there was no sign of injury or blood.
Mr Myers says both experts put "poor opinions" forward. He refers to the first event of June 15, 2016, in the morning, at 7.15am. He says there is no evidence of anyone seeing Letby coming in and causing harm to Child N. He says the prosecution created the narrative Child N was sabotaged in advance the previous night by Letby before she left at the end of her shift. He refers to nurse Jennifer Jones-Key's note for the June 14-15 shift. He says in evidence, Jennifer Jones-Key said Child N first deteriorated at 1am, and remained at that condition through the rest of the night. Mr Myers says that "is an end to the sabotage theory", as Child N became unwell several hours into that night shift.
Mr Myers says Dr Bohin did not accept that from 1am to 7.15am, there had been a gradual process of deterioration. He refers to the 7.15am event. He says Jennifer Jones-Key referred to more desaturations 'from 7am'. He say she remembered being in the nursery, feeding a baby, and Letby came in for her shift, and Letby came into the nursery, the alarm sounds, and Letby walks over. He says there is "no indication or sensible opportunity" for Letby to cause this collapse for Child N. He says it is a continuation of the "mounting problems" for Child N which began at 1am.
Mr Myers says there is a question for when the blood is seen on Child N, before or after intubation. He says it is hard to see that if the attack happened at 7.15am, that blood would only be seen by a doctor at 8.05am. Mr Myers says it would be "reckless" if a doctor embarked on intubation for Child N while seeing there was blood in the way.
Mr Myers refers to the third count for Child N, later in the day at 2.56pm on June 15, 2016. He says the details of the event are clear, and while most of the five or six doctors described swelling, 'only' Dr Satyanarayana Saladi noted blood. He says it is right that a 3ml blood aspirate is collected. He says the defence observe it's surprising, given Child N's haemophilia, there is not more. He says it is "unclear" what the cause of the swelling is, and could be a consequence of what had gone on that morning.
Mr Myers says there are no signs of a wound found on Child N, and he was "well inspected" by doctors. He says at 7.40pm, Child N desaturated when medical personnel arrived to transport him, and he was prepared for theatre as doctors had been unable to intubate. Mr Myers says it was not surprising Child N's condition was poor given the 'long day' he had had. He says a tertiary unit doctor was able to intubate first time successfully after Child N's desaturation. Alder Hey consultant anaesthetist Dr Francis Potter was asked to give evidence. Mr Myers said he had told the court his interest was paediatric intensive care, and he had experience with airway problem resolution. He said the intubation was managed with 'relative ease'. He said Dr Potter had been "surprised" there had been difficulties in intubating Child N as he said the Countess of Chester Hospital team was "pretty competent". He says Dr Bohin "comes to the rescue [of the prosecution]" by not agreeing with the opinion of Dr Potter. He said Dr Bohin said the drugs given to Child N would have reduced the swelling. He said it was a disagreement between the two prosecution witnesses.
Child O
Mr Myers says he will begin the case of Child O in the remaining 10 minutes [to be continued tomorrow]. He outlines the events for Child O. Child O was one of three triplet brothers - Child P being another of the triplets. Mr Myers says he will start with June 22-23, for the night shift with designated nurse Sophie Ellis. The final note 'Abdo looks full slightly loopy. Appeared uncomfortable after feed.Reg Mayberry reviewed. abdo soft, does not appear in any discomfort on examination.' He says an examination took place, but no note was made by Dr Mayberry He asks why Letby is blamed for Child N being unwell at 1am after Letby had finished at 8pm the previous night, whereas for Child O Letby is blamed for Child O being unwell at 1pm when Child O had been unwell at 8am. He asks why there was no record of a doctor's examination after Sophie Ellis had noted a doctor reviewed Child O, when Letby was blamed for noting a doctor review for Child I when there was no record of a doctor's examination.
Child O cont.
Mr Myers is on his feet, he's continuing to take the jury back over the evidence for triplet brother Child O.
The court heard he was stable up until 23 June 2016, when he suffered a "remarkable deterioration", he stabilised but later suffered a further fatal collapse. Mr Myers says the explanation of the experts - that there was an assault which resulted in a trauma to the liver and air embolus - is 'confusing'. He invites the jury to consider 'how, where and when' this things happened. He said it's 'very unclear'. Mr Myers says the prosecution has not identified a time or place where these alleged offences took place.
Mr Myers has pulled up the neonatal review - which has been pulled together by police analysts and is a timeline of events - it shows that Child O was given medicines by two other nurses at 14:39. Ms Letby is seen as doing an infusion at 14:40, just before the collapse
Mr Myers notes the door swipe data which shows Ms Letby only arrived at 14:39 on the unit. He drills deeper into the clinical notes which show Child O collapsed at 14:40 and then Ms Letby, on instruction from a doctor, began an infusion in response at 14:40 ie after the event Mr Myers says 'it's important to keep this in mind, the suggestion has been made that at 14:40 somehow Ms Letby was involved in what took place before the collapse, she was not'
Mr Myers picks up on the evidence of an independent pathologist, who reviewed the case. He said the boy suffered an "impact injury" akin to a road traffic collision - which caused bruising on his liver Mr Myers says 'the truth is' we 'don't know' how much force it took to make those bruises. He says the pathologist picked 'graphic examples' but cannot say how 'little force' it would take to cause those injuries in a neonate The barrister says it is a 'possibility' that the bruising was a result of CPR during the failed resuscitation attempts on Child O
Mr Myers is pulling up messages sent between Ms Letby and a doctor who cannot be named on 1 July 2016. They were talking about the events surrounding Child O's collapse The doctor tells Ms Letby that one of his doctor colleagues was 'was upset' as the boy's liver issue 'may have been cause by her chest compressions'. He said he had to reassure the doctor for 20minutes Mr Myers says this 'raises the possibility that injury can be caused by CPR, plainly this was something she was concerned about'. He invites the jury to keep this in mind
Mr Myers notes that the prosecution have made much of Ms Letby's Facebook searches for the parents of Child O. He says 'nothing about those' searches establishes guilt and says 'how is that meant to indicate she had done something to harm' him
Child P
Mr Myers now turns to Child O's triplet brother, Child P. At 09:35 BST on 24 June 2016, a registrar found he was "self-ventilating in air" and stable, but 15 minutes later, he collapsed and required breathing support. He collapsed several more times, before being pronounced dead at 16:00. A medical expert for the prosecution said the collapses were consistent with an "additional amount of air being given to this baby"
Mr Myers says this case is another example of the Crown trying to 'shunt blame Ms Letby's way', he says the management of Child P's care was 'poor'. He notes that the baby had a pneumothorax and a X-ray which would have shown this was delayed Mr Myers says Child P's 'death was in all likelihood a consequence of poor medical procedure' after his 09:40 collapse. He says this case is 'a prime opportunity to hide poor performance and bad outcomes' and blame Ms Letby
A registrar Dr Ukoh recorded that at 09:35 on 24 June that Child P was self-ventilating in air. 15 minutes later, he suffered an acute deterioration at 09:50 hrs. Mr Myers says the Crown's case is that at some point between 09:35 and 09:50 Ms Letby injected the child with air He says 'whatever has happened, there is no opportunity' for Ms Letby to do this and says given the cast of doctors and nurses in the room it is implausible in the extreme
Mr Myers is taking the jury back over medical notes for Child P from the early hours of 24 June. He says they show the 'direction of travel', he says he was nil by mouth at this time. The senior nurse on duty said the child's abdomen appeared distended at 04:00 Mr Myers is going over the evidence for Child P final and fatal collapse when medics were waiting on a transport team from Arrowe Park to take him. A doctor who cannot be named recalled Ms Letby saying 'he's not going to leave here alive is he' The doctor gave a vivid account of how she felt this was inappropriate and that Child P had just had a good gas was okay. But Mr Myers has said the clinical evidence shows Child P had an undiagnosed pneumothorax He also notes that the doctor had said by this stage she was aware of rumours about Ms Letby - but he said 'there’s not even a datix report, not in the notes, no complaint, no issue raised about' what Ms Letby is alleged to have said
Mr Myers says the evidence does show the child was unwell and the doctor, in charge of his care, 'felt out of her depth' - she said in evidence how she was counting down the minutes waiting for the transport team to take him Mr Myers says if Ms Letby did make the remark alleged it may have been out of 'social awkwardness' and does not prove murder He says the allegation here against Ms Letby is 'utterly implausible'. He also cites the fact a senior doctor was seen by the mother of Child P 'googling' how to insert a chest drain - he says that is 'indicative of the level of care at the Countess of Chester'
Child Q
Mr Myers is now on Child Q - the last child on this indictment. He was born in late June 2016 and was "initially stable" after his birth, but jurors heard he deteriorated and needed breathing support shortly after 09:00 on 25 June. The prosecution said Ms Letby injected air and fluid into the boy's stomach via a nasogastric tube. A medical expert for the prosecution said vomit found on Child Q was evidence that liquid had been given to him and his respiratory problems were likely caused by the fluid
Mr Myers says there's 'no evidence of her having done anything at all' to cause Child Q's collapse Mr Myers says the clinical evidence is 'consistent with early stage Necrotising enterocolitis (NEC)' - this is a serious condition that can affect newborn babies Mr Myers says 'what an earth is (Ms Letby) meant to have done, there's no evidence of an attack'
Final section
We're back after a break. Mr Myers is now on the final section of his defence closing speech
Mr Myers thanks the jury for their attention to the evidence. He says it 'isn’t difficult for someone to pick up one item or another and give prominence to one or another depending on which position you're coming from' 'The decision on what evidence is important and where it takes the case is for you', he says He warns of the dangers in this case of 'emotion, suspicion and judging Ms Letby by standards that are not applied to anybody else, unrealistic standards, there's a reliance on the fact she was on the unit as proof for far more than that fact can possibly amount to'
Mr Myers says the consultants who have accused Ms Letby 'are not neutral' he says they are 'deeply involved in what happens, we say at times they have said things deliberately to prejudice Ms Letby's position' He also says the experts - in particular Dr Dewi Evans - are 'highly partisan'
Mr Myers says 'we say there were terrible failings in care on that unit that has nothing to do with Lucy Letby' He notes that 'between June 2015 and June 2016 the neonatal unit at the Countess of Chester took more babies than it would usually care for and took babies with greater care needs' He said 'in that same year there was an increase in the number of deaths and the types of collapses we're looking at in this trial, those two facts are connected we would say' 'What didn’t change was Lucy Letby, she had been a neonatal nurse for years, she was dedicated, she cared for hundreds of babies, she suddenly didn’t change her behaviour in 2015, what changed was the babies on the unit and inability of this unit to cope'
Ms Letby appears to be crying in the dock as Mr Myers continues to wrap up his closing speech.
He says 'it is easy to lose sight of the reality of the person at centre of this' and asks the jury not to focus on the 'picture conjured' by the Crown of the nurse Mr Myers invites the jury to 'apply a presumption of innocence and not a a presumption of guilt, if you do that you will reach the right verdicts, verdicts of not guilt and those are the verdicts we ask you to return'.
That completes the defence closing speech.