Baby 8 was a 34+4/7 week, 2.33 kg birth weight, female infant who was born by emergency caesarean section for maternal diabetes type 1 with labile glycemic control. She had respiratory distress syndrome (RDS) with grunting, subcostal retractions, respiratory and metabolic acidosis, and needed oxygen, but continuous positive airway pressure (CPAP) support was not provided until 4 hours later. BIPAP was started the next day as the infant did not improve but chest x’ray was not done. The following day, she was intubated and ventilated for desaturation and gasping. She developed a life threatening tension pneumothorax that was not diagnosed for 2½ hours and was not treated for 1½ hours after diagnosis. She deteriorated and a chest tube was inserted to drain the pneumothorax but a lateral chest x’ray was not performed to check its position. Its malposition led to incomplete evacuation and re-accumulation of the tension pneumothorax. During the next 16 hours, there were 4 episodes of severe desaturations. A second chest tube was inserted but it was not done until 2 hours after a check chest x’ray. The infant was ventilated with high pressures (26/5, rate 40/min, Ti 0.45) and continued to deteriorate over the next day with multiple episodes of desaturations. Despite poor blood gases and re-accumulation of the pneumothorax, it was not drained. Ventilation was further increased to pressure 26/5, rate 60/min, FiO2 100%. A third chest tube was inserted but 3 hours after a check chest x’ray showed re-accumulation of the tension pneumothorax. The infant finally improved and was transferred to Arrowe Hospital
It was alleged that Baby 8’s clinical deteriorations at around 00.55 hr and 03.30 hr on 27/9/15 were the result of deliberate dislodgement of the endotracheal tube.
This is a straight forward case of a relatively large preterm infant with respiratory distress syndrome who developed a tension pneumothorax. The infant had respiratory distress from birth but was not given CPAP until 4 hours later. Without treatment, the infant grunts to exert chest pressure in an effort to keep the small air spaces in the lung open. This can lead to pneumothorax. Tension pneumothorax is life threatening and should be drained immediately. If done promptly and properly, recovery is quick. Unfortunately, that did not happen.
There were repeated and lengthy delays in diagnosis and treatment for the tension pneumothorax, and poor placement of chest tubes with ineffectual removal of air in the chest, resulting in re-accumulation of air in the chest and continuing clinical deterioration. In response, high ventilation pressures were used in an attempt to ventilate the infant but this worsened the situation because excessive pressures compromised venous return to the heart and further impaired circulation and oxygenation.
Baby 8 was subjected to multiple invasive procedures (including at least 6 intubations, 7 chest needles, 3 chest drains, and multiple hand bagging episodes), and prolonged period of illness. There was delay in transferring the infant to a higher level facility. We did not find any evidence to support malicious actions like endotracheal tube dislodgement on 27/9/15.
1. Baby 8’s deteriorations were due to medical mismanagement of the tension
pneumothorax.
2. There was no evidence of intentional tampering with the endotracheal tube.
3. One prosecution expert witness recognized that care of the pneumothorax was sub optimal
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".
Intelligence analyst Kate Tyndall has been recalled to court to talk the court through the sequence of events for Child H, presented as an electronic bundle of evidence. As before, the sequence of events features medical charts, nursing/doctors' notes, significant events, plus timestamped evidence of messages recovered from Lucy Letby's phone.
22nd September 2015
6.40pm: The events show Child H was admitted to the neonatal unit at 6.40pm on September 22, 2015, shortly after being born.
23rd September 2015
Letby sends a message to a nursing colleague on September 23 informing her she's rearranging her shifts, and will be working with her. She also informs her mother she's working that night as an extra shift. She also messages another colleague to say how busy the unit is likely to be that night.
24th September 2015
The following day, Letby messages a colleague to say the "It's completely unsafe", followed by a frowning emoji. She messages a friend that work is "extra mad" so she wouldn't be able to do hula hoop [exercise]. She messages a colleague on the number of babies in the unit, in reference to how busy it was on that shift, and how she had not had chance to 'catch up on Corrie' [Coronation Street].
Letby is then recorded as being the designated nurse for Child H for the night of September 24-25.
25th September 2015
Dr Alison Ventress records clinical notes of a lung issue for
Child H that night.
X-rays at 1.40am and 2.29am on September 25 were taken. Child H was
diagnosed with a punctured left lung. Dr Ravi Jayaram records a desaturation for Child H and
a test was carried out for a collapsed lung.
3.07am: Letby sent a text to a colleague at 3.07am on September 25: "Can I go now??" The colleague responds a few minutes later: "Yes. Let's run off together and rescue [colleague] too."
5am: Letby's medical note for the morning of September 25 recorded the "profound desaturation" at 5am, with the fings on the right hand noted to be white, along with a white patch on the abdomen.
The intelligence analyst continues to talk through the sequence of events, with descriptions of the care being given to Child H throughout the day on September 25, 2015, which includes another desaturation in the afternoon.
4.23pm: The cardiac arrest team is beeped at 4.23pm to attend the neonatal unit.
The sequence goes to the night shift of September 25-26, in which Lucy Letby is listed as a designated nurse in nursery room 1 for Child H. No other babies are in nursery room 1, with four babies (including Child G) in room 2, four in room 3 and four in room 4.
11.05pm: A blood transfusion for Child H is begun at 11.05pm.
11.30pm: A desaturation for Child H is recorded at 11.30pm, with Letby writing the note up retrospectively at 4.14am the following day. Observations are being taken more regularly due to the blood transfusion, the court hears.
26th September 2015
A corrected slide from the sequence of events is now shown to the court, showing that for the September 26-27 night shift, Shelley Tomlins was the designated nurse for Child H in room 1 - the only baby in that room that night. Lucy Letby was a designated nurse for two babies in room 2, with another nurse, Christopher Booth, looking after Child G in room 2. Four babies, including Child I, were being looked after in room 3, and four babies were being looked after in room 4.
1.30am: A morphine bolus is administered to Child H at 1.30am on September 26, and the blood transfusion is recorded by Letby as being completed at 2am. However, a separate, handwritten paper record shows the blood transfusion having been completed at 3.05am. This separate record is not signed by anyone.
2.05am: Letby records 'poor blood gas and 100% oxygen requirement' and a third chest drain was inserted around this time, the court hears. Dr John Gibbs records this as being about 2.15am, as the chest x-ray showed a re-accumulation of Child H's left-sided pneumothorax (ie a collapsed lung). A further, third chest drain was inserted to relieve the pressure.
At 3.22am, Child H suffered a 'profound desaturation and colour loss to 30%'. Letby records: 'Good chest movement and air entry, colour change on CO2 detector. Neopuff commenced in 100% oxygen and help requested.' An intensive care chart for Child H on September 26 records 'blood complete 0324 - RESUS'. The record is initialled by Lucy Letby.
3.24am: Dr Alison Ventress confirms in a clinical record she was crash called at 3.24am as Child H "had desat requiring bagging...Sats 60s then heart rate down to less than 100 so nurses crash called, wasn't being handled at all, no trigger identified.' Upon her arrival, Child H was 'being bagged via ETT, good chest movement, capnograph positive, sats 60%, heart rate 70 down to 50'. A test for a collapsed lung was carried out and air was removed.
3.30am: Dr John Gibbs, consultant paediatrician, records he was called from home at 3.30am and arrived at the neonatal unit at 3.36am. He saw 'CPR in progress', and Child H had no pulse when chest compressions stopped. The sequence of events details the series of medications administered to Child H.
3.46am: Lucy Letby's note records, for 3.46am, 'x3 doses adrenaline and x1 dose atropine given...chest compressions stopped at 0346, heart rate 180, saturations >90, placed back on to a ventilator, 30% oxygen'.
Letby recorded, for the Child H event at 3.22am, 'profound desaturation and colour loss to 30%, good chest movement and air entry, colour change on CO2 detector, Neopuff commenced in 100% oxygen and help requested. Serous fluid +++ from all 3 drains, became bradycardic. Drs crash called and resus commenced as documented'.
4.28am: Letby records a Child H family communication at 4.28am: 'Parents visiting at start of shift. Updated on condition and advised to try and rest overnight. Midwife contacted during resus to [help take mum to the unit].' A follow-up note said parents were concerned about the possibility of brain damage, and Child H remained poorly and could relapse. Dr John Gibbs offered a blessing to be administered and the parents accepted the offer. Child H was then blessed with parents and family members present.
7am: Letby recorded 'good blood gas at 0700 - ventilation reduced to 22/4, and rate reduced...in 26% oxygen. [Child H] appears settled.'
9am: A series of messages recovered from Letby's phone, of messages sent to and from her phone at around 9am on September 26, are shown to the court.
They include Letby's colleague Yvonne Griffiths commending Letby for "all your hard work these last few nights". She says Letby "composed" herself "very well during a stressful situation" and it was "nice to see" her "confidence grow" as she advanced throughout her career. Letby shows this message to a colleague and asks her how she should reply. Her colleague expresses surprise. A series of messages are exchanged between Letby and the colleague acknowledging there had previously been "bitchiness" among staff and there had been "comments" about Letby regarding her role which Letby had found "upsetting".
Medical notes record Child H's parents were present as treatment continued for the baby girl, with further medication administered during the day of September 26.
At this point, Child H was the only baby in room one of the neonatal unit, and for this night shift (September 26-27), Letby was the designated nurse for two babies in room two.
8.49pmThere is a further, profound desaturation for Child H, with a crash call made at 8.49pm. Dr Matthew Neame recorded attending to the neonatal unit.
9.31pm: Letby, on shift, messages a colleague at 9.31pm to give an update on Child H's progress throughout the day. She messages colleague Alison Ventress a couple of moments later to say Child H 'had a stable day', and took out the original drain at 8pm, adding 'just blocked tube, lots of secretions!'.
Letby messages her colleague, for Child H, 'I've been helping Shelley [Tomlins, designated nurse for Child H that night] so least still involved but haven't got the responsibility'. Colleague Alison Ventress messaged Letby: "Never known a baby block tubes so often!! Glad she's had a stable day..."
11pm: Letby messages a colleague just before 11pm, lamenting that she had forgotten to record Strictly that night, and BBC iPlayer doesn't work on her iPad.
27th September 2015
12.45am: Letby then is recorded as being on Facebook at 12.45am and 12.46am, liking a post and photo.
12.55am: Child H then has a 'profound desaturation' timed at 12.55am. Nurse Shelley Tomlins recorded: 'profound desaturation to 40% despite equal bilateral entry and positive capnography'. Staff were crash called to the neonatal unit room 1.
1.07am: Dr Matthew Neame reintubated Child H and chest compressions were started at 1.07am. Child H's heart rate dropped to 40bpm. Adrenaline was administered.
1.13am: Chest compressions were discontinued at 1.13am. A request was made to transfer Child H to Arrowe Park Hospital. "No explanation" could be found for why Child H had had such a profound desaturation, the court hears.
3.30am: Child H had a further desaturation at 3.30am, and medication was administered.
4.10am: The transport team arrived at 4.10am and Child H was handed to the transport incubator at 4.45am and the handover was completed at 5.20am.
6.10am: Child H was cared for at Arrowe Park Hospital between 6.10am on September 27 to 11.30am on September 30.
30th September 2015
12.15pm: Child H returned to the Countess at 12.15pm on September 30 and was discharged at 5.05pm on October 9, 2015.
Further messages found on Letby's phone from that morning are relayed to the court. Letby informed two colleagues what had happened to Child H that night. Colleague Alison Ventress replied: "Think of all the babies you have saved and have gone home happily."
5th October 2015
On October 5, 2015, Letby searched on Facebook for the mother of Child H, as well as two other parents involved in the case, in the space of three minutes at 1.15am.
Intelligence analyst Claire Hocknell has been recalled to talk the court through the neonatal review schedule for Child H.
The case now moves to Child H, a baby girl born on September 22, 2015, weighing 2.33kg. The court hears Child H did not receive surfactant [a protein which helps the lungs] until 41 hours after her birth. Child H required three chest drains, and had a number of desaturations in her first few days. At 3.22am on September 26, Child H had a profound desaturation to 30%. The following morning, Child H had another desaturation to the 40s at 12.55am on September 27. Letby tells the court she remembers Child H and her care needs, but not specific details without referring to the notes. She says for September 2015, the unit "was busy at that time".
A message from Letby on September 24 referred to 'staffing levels on the
unit' as being "completely unsafe", the court is told. In a message to another colleague,
Sophie Ellis, Letby says: 'Oh Soph it was pretty bad - 18 babies, intubating on handover & a
baby with a sugar of 0.1!' Letby tells the court the capacity was 16 on the unit.
Mr Myers: "Had the unit always been this busy?" "No." - Letby said it had been getting
increasingly busier. She adds she had never seen a baby with chest drains at the Countess
until Child H. She adds she had never seen a baby with three chest drains, even at a tertiary
centre. "The most I had seen was two." Letby said during this time, doctors had to 'look
things up' and discussions were held on how to manage the chest drains. She says from her
experience, chest drains were sutured into the skin, so they didn't move. "Very few" chest
drains were kept on the unit. Arrowe Park couriered out some drains, Letby tells the court.
A nursing handover sheet for September 23, 2015, recovered from Letby's
home in the 'Morrisons bag', is shown to the court. Letby is asked why she had that sheet, and
four others with Child H on it. "It has just come back with me inadvertently and was left at
home. "They have not been taken out of my pocket at the end of the shift and I have taken them
home."
Mr Myers: "Did you mean to take them home?"
Letby: "No." Letby adds she did not know she had that many handover sheets at her house.
"I did not keep track of them."
The nursing notes by Letby for September 25-26 are shown to the court. They include: '...x2 chest drains in situ at start of shift - intermittently swinging. Serous fluid++ accumulating. 2330 bradycardia and desaturation requiring Neopuff in 100% to recover. 10ml air aspirated from chest drain...following poor blood gas and 100% oxygen requirement consultant Gibbs attended the unit and inserted a third chest drain. All 3 drains swinging... [Child H] desaturating++ on handling - minimal handling observed when possible. At 0322 profound desaturation and colour loss to 30%, good chest movement and air entry, colour change on CO2 detector...Neopuff commenced...Serous fluid++ from all 3 drains. Became bradycardic. Drs crash called and resus commenced...'
Letby is asked about the chest drains 'swinging' - she says that shows they are working, with fluid moving back and forth the drain as needed. Serous fluid is naturally occurring fluid in the body. For September 25-26, Child H was the only baby in room 1, and Letby was the designated nurse that night. She required two nurses on a high level of care, and Letby had a colleague to assist her with drugs for Child H and maintenance of the chest drains.
Letby refers to a note 'at 0200 blood transfusion completed', saying the timing of that is an error, and should be 3am. A blood transfusion chart shows the transfusion had started at 3pm on September 25, and ended at 3.05am on September 26. The note is co-signed by Letby. A separate chart, with Letby's handwriting, shows 'chest drain 0210' and a bolus at 0250. The 'blood complete' is sometime after 3am, prior to 3.24am, Letby tells the court. Letby says the '2am' note error she made was nothing "sinister", and 'just a mistake', and other accessible notes showed the timing the blood transfusion for Child H stopped at 3am.
A message from Yvonne Griffiths, part of the management team, to Letby is shown to the court, in which she commends Letby for her hard work over the previous shifts. The message is on September 26. She adds: 'You composed yourself very well during a stressful situation' and it was good to see her confidence grow. Letby relayed that message to a colleague. Letby said this message exchange had followed a disagreement over baptism for Child H. Yvonne Griffiths had felt it was 'not appropriate for that time of night' as Child H had stabilised at that point and the shift was busy. Further messages between Letby and her colleague are exchanged. Letby says, for context, she was 'choosing not to have [Child H] due to lack of appropriate support' as she wanted extra staff to assist her in the care of Child H, as Child H had several chest drains for which she had not been familiar with.
Letby's response to Yvonne Griffiths: 'Thank you. That's really nice to hear as I gather you are aware of some of the not so positive comments that have been made recently regarding my role which I have found quite upsetting. Our job is a pleasure to do & just hope I do the best for the babies & their family.' Letby tells the court there had been frustration about comments made by colleagues that Letby and another nurse were being allocated room 1 shifts on the rotas, and there was frustration about the unit being 'busy'. Letby agrees the court the frustration was 'particularly prominent at this time' and did not go beyond this period in September 2015.
The trial is now resuming following its lunch break. Benjamin Myers KC is continuing to ask Lucy Letby questions in relation to Child H. The second event is being discussed. For the night of September 26-27, Lucy Letby was the designated nurse for two babies in room 2. Nurse Christopher Booth was the designated nurse for Child G in room 2, and Nurse Shelley Tomlins was the designated nurse for Child H in room 1. The court is shown nurse Tomlin's notes for that shift, which include: '...around 2030 [Child H] had profound desat and brady, air entry no longer heard and capnography negative therefore ETT removed and Drs crash bleeped. New ETT sited...on second attempt...' This event is something, the court hears, Letby is not being blamed for. 2145 - Desaturation to 40% despite good air entry and positive capnography. ETT suctioned quickly with thick blood-stained secretions noted. [Child H] recovered quickly after...'This was also not an event Letby was blamed for, Mr Myers tells the court.
0055 - profound desaturation to 40% despite equal bilateral air entry and
positive capnography. ET suction yielded nil secretions. [Child H] then went bradycardic at
0107 to 40bpm and required chest compressions and adrenaline at 0108. Saline bolus given at
0112...' Letby is asked if she had any involvement with this event.
Letby: "No."
0330 - profound desaturation to 60s, again requiring Neopuffing with no
known cause for desat....copious amounts of secretions yielded orally, pink tinged. Small
amount of ET secretions gained, again pink tinged. Heart rate mainly normal during desat.
Recovered slowly.' Letby is asked if she had any awareness of any of the events, including at
0055, the event Letby is being blamed for by the prosecution.
Letby: "No."
A neonatal review chart is shown to the court, showing nurses' responsibilities and duties throughout the night of September 26-27. Lucy Letby confirms from the chart she was involved in the administration of medicine and a 'sodium chloride flush', with Shelley Tomlins, on Child H at 10.12pm. This was recorded on the computer the following minute at 10.13pm. The 'flush' was a normal procedure following the administration of such medicine, the court hears. The next recorded involvement Letby has with Child H is at 10.38pm. Letby tells the court that was for a morphine infusion. That was recorded on the computer at 10.39pm. The next recorded involvement on the neonatal chart for Letby is at midnight, when Letby is making an observation for a different baby. Letby says she was not near Child H at this time. Letby confirms to Mr Myers the next involvement with Child H on the chart is from 3.41am, with the administration of prescriptions. She does not recall what those would have been for.
Mr Johnson moves on to the case of Child H. Letby says she does recall Child H, due to the chest drains that were put in place. Letby said chest drains had to be couriered from Arrowe Park Hospital, as it was "unacceptable" they didn't have sufficient supplies at the Countess of Chester Hospital. Mr Johnson asks if Letby filled in a Datix form for that. Letby says she does not recall. Letby is asked about the text message she sent to Yvonne Griffiths on September 26, 2015, which said: "Thank you. That's really nice to hear as I gather you are aware of some of the not so positive comments that have been made recently regarding my role which I have found quite upsetting. Our job is a pleasure to do & just hope I do the best for the babies & their family." The court hears this was with regard to Letby and colleague Shelley Tomlins being allocated shifts in room 1, over other nurses who needed the experience. Letby says she cannot recall which nurses, specifically, had been making those comments, but they were band 6 nurses. Letby agrees this message followed events for Child H. Mr Johnson refers to the staffing rota for September 25-26. Letby says it was not the night staff who were making the comments. Mr Johnson asks if it was the day staff, why did they allocate Child H to Letby? Letby replies the comments had come in recent days prior to this.
Letby, in her defence statement, questioned how familiar the doctors were with chest drains. Letby, when questioned on this, says this would be non-consultants. In her defence statement, Letby said she could not recall the specific details of Child H's collapses.
Letby is asked to refer to her defence statement, in which she said her memory for both nights when Child H's collapses "merged into one". Letby added she was also looking after a severely disabled baby. Letby now accepts the disabled baby was born later in the shift. Letby tells the court staffing levels were not a contributory factor in Child H's collapses. Letby said she would "question whether the [chest] drains were securely put in" for Child H, as a potential contributory factor in Child H's collapses.
Letby accepts Child H was born in a good condition, and that she recovered quickly. She tells the court she cannot comment on her interpretation of the security of the chest drains, from her observations.
Nicholas Johnson KC is continuing to cross-examine Lucy Letby on
Child H. Letby is asked if staffing issues contributed to Child H's collapse. She says
"no", but believes the "management of the chest drains" was a contributory factor.
LL: "I believe it has been accepted throughout the trial that there were issues with
the chest drains". Letby said the location of the chest drains on Child H may have been a
factor, and that Child H's pneumothoraces were not treated correctly, due to a lack of
experience and "nobody seemed particularly confident" on managing the number of chest
drains - she says that was down to "multiple" doctors. Asked who those would be, Letby
said that would include Dr [Ravi] Jayaram, Dr [David] Harkness, Dr [John] Gibbs and "Dr
[Alison] Ventress, even".
Letby says she had dealt with chest drains in Liverpool, but not at the Countess of Chester Hospital. She says she did not have much experience, and had a nursing colleague to assist her in the care of Child H. Letby is asked about the time between 8pm and 2am on September 25-26. She says she cannot recall, specifically, the assistance she had from a nursing colleague that night, but she was there 'on and off', and "gave me a lot of verbal advice that night" in the management of Child H's chest drains, and on baptism after the collapse of Child H. Mr Johnson reads from Child H's father's statement. He refers to being at the unit until "about midnight", and was woken up from home "in the early hours". Letby's nursing note is shown to the court. It includes: '...x2 chest drains in situ at start of shift - intermittently swinging. Serous fluid++ accumulating. 2330 Bradycardia and desaturation requiring Neopuff in 100% to recover. 10ml air aspirated from chest drain by Reg Ventress...inserted a 3rd chest drain...' Mr Johnson says Letby misrepresented the time of this event. Letby tells the court she would have got that time from her notes written at the time. An intensive care chart is shown to the court. It includes, for 2200 - '2210 desat...SHO present...serous fluid++ x2 drain' Letby says she cannot recall which SHO was on duty that night. Mr Johnson says the SHO on duty was Jessica Scott, and she has not recorded a note saying she was present for this. Another note 'Brady desat 2330 10ml aspirated from...drain...' Other details are '+clear [in the OP row]' and '+small blood stained [in the Suction ET row]'. Mr Johnson says this is another child producing blood in Letby's care. Letby says this blood has likely come from the ET Tube in the lungs. She denies moving it around to destabilise Child H.
Letby accepts that a 52% desaturation is a potentially serious
event. She says: "I don't agree" to the suggestion she has "cooked the books" in the
nursing notes. She denies falsifying notes for Child H by giving the impression Child H
was deteriorating prior to the collapse. Letby is asked why the '52% desaturation' is not
in her nursing note. "Not every single thing gets written down...that is an error on my
part." Letby says the SHO was present for that earlier desaturation. Letby denies writing
in the intensive care chart after Child H's collapse.
NJ: "You're making this up as you go along, aren't you?"
LL: "No."
Mr Johnson says Child H's father's statement, which was agreed evidence, did not mention a collapse or an SHO being present. Letby denies lying. Dr Alison Ventress records a note for Child H, timed 11.50pm. It begins 'Several episodes of desaturation in past 2 hours...1st one after gas taken...became agitated...' Mr Johnson says Letby told this information to Dr Ventress. Letby says she did not know if she told her this information, she may have been present in the room.
Dr Ventress adds: 'Further episodes no change in HR recovered with
bagging...[oxygen requirement down] to 30% between episodes'. Letby denies "trying it on"
or "falsely creating the impression to Dr Ventress that [Child H] had been having problems
for a couple of hours."
LL: "No, I don't agree that it was false." Mr Johnson says the notes (on the
observation chart and Letby's nursing notes) don't match. Letby agrees it's an "innocent
coincidence" (as said by Mr Johnson).
An observation chart for Child H is shown for September 25-26. Letby
is asked if the results show any concern up to midnight.
Letby: "This [the observations taken] reflects that specific moment in time" and says
that chart shows no concerns, with all readings in the normal range. Dr Ventress added in
her 11.50pm note: '2nd chest drain advanced back in to 4cm as was almost out. Done prior
to chest x-ray'. Mr Johnson says this was Dr Ravi Jayaram's x-ray. Letby is asked why she
had not noticed that. Letby says medical staff put drains in and managing them was not
part of her nursing role. She accepts she knew chest drains were more secure when stitched
in rather than taped in. She says she was checking the chest drains. She denies removing
the chest drain to cause a desaturation just after Child H's father left.
Mr Johnson asks about Letby's error, as mentioned in her evidence,
about the timing of the blood transfusion being completed. Letby said on May 15 the '0200
blood transfusion completed' should be 3am. Letby says she has "miswritten" it from
looking at the charts. A blood infusion therapy chart is shown, in Letby's writing, which
has in the time ended column what appears to be '0205' corrected to '0305'.
NJ: "The same mistake in two different places?" Letby says she "couldn't say with
clarity" adjusting the time after she had written her nursing notes.
NJ: "What happened after 0305?"
LL: "I don't recall."
NJ: "Really?...[Child H] had a cardiac arrest." Letby is asked "how on earth" she made
the 0205 error.
LL: "Because we're human people, we make mistakes." Letby says the error is "mine" on
the nursing notes, but the timings were otherwise accurate. Letby says she cannot remember
Child H's father being present. The father recalled "mottling running out of her skin
towards her fingers". Letby says she agrees there was mottling on Child H's skin, but not
that it was moving.
A blood gas chart for September 26 is shown to the court for Child
H. Letby agrees the reading at 6.44am is a "good" blood gas reading. Mr Johnson says Child
H had had a "miraculous recovery".
Letby: "Yes."
NJ: "Were you pleased?"
LL: "Of course I was pleased."
NJ: "Or were you frustrated that you had failed in your attempt to kill her?
LL: "No."
The second event is being discussed. For the night of September 26-27, Lucy Letby was the designated nurse for two babies in room 2. Nurse Christopher Booth was the designated nurse for Child G in room 2, and Nurse Shelley Tomlins was the designated nurse for Child H in room 1. Elizabeth Marshall is the designated nurse for four babies in room 3, including Child I. The court hears a seriously ill baby was brought into the unit during the night.
The court hears Letby, in her evidence to defence on May 15, said she did not have much to do with Child H on the night shift. Letby said she was reliant on medical notes as she did not recall "with any great detail" that night for Child H. Dr Matthew Neame was the registrar that night, with Dr Jessica Scott the night SHO. Letby accepts she had got "confused" in her defence statement between the events of this night and the previous night. She rules out staffing levels as a contribution in Child H's deterioration. She says she cannot comment on medical incompetencies as she was not Child H's designated nurse and was not present for much of the shift, and rules out a doctor or nurse making mistake(s).
Letby is asked if she was involved in an event timed 9.15pm for
Child H, who had a desaturation and bradycardia. Letby said she did not remember. Dr
Neame, in evidence, said "ETT removed by nursing staff" and that nurse was Letby, alone.
LL: "Well I don't have any recollection of that." A text is shown from Letby to a
colleague at 9.51pm: "'I've been helping Shelley so least still involved but haven't got
the responsibility..." Letby says she "does not agree" she would have removed an ET Tube
by herself. The neonatal schedule shown for 9-10pm shows no duties for Child H for which
Letby has been named as the nurse for it.
The trial is now resuming following a short break and a short legal discussion. Mr Johnson is continuing to cross-examine Lucy Letby on the case of Child H.
Letby is asked about what she had been helping Shelley with, as per her text message - she says she had been helping with Child H. She denies taking an "opportunity" to "sabotage" Child H.
Nurse Shelley Tomlins' note for 9.45pm is shown: The court is shown nurse Tomlin's notes for that shift, which include: '...around 2030 [Child H] had profound desat and brady, air entry no longer heard and capnography negative therefore ETT removed and Drs crashbleeped. New ETT sited...on second attempt...Copious secretions obtained via ETT and orally, blood stained.' 2145 - Desaturation to 40% despite good air entry and positive capnography. ETT suctioned quickly with thick blood-stained secretions noted. [Child H] recovered quickly after...' Letby denies altering Child H's ET Tube to cause bleeding.
Mr Johnson asks if Letby was "bored" with the children she was
looking after in room 2 prior to Child H's collapse.
LL: "No." She denies she had "time on her hands". At 12.45am on September 27, Letby is
recorded as 'liking' a post on Facebook. At 12.46am, she liked a Facebook photo posted by
a colleague. Letby says she may have been on her break at this point. Mr Johnson says
Letby was involved in a fluid balance chart for one of her designated babies around that
time.
Letby: "Yes, at 1am." Child H's father's statement is read to the court, in which he
said "Quite late on [Saturday, September 26]" he went to rest, and was woken up shortly
afterwards and to get to Child H's bedside. Letby denies using the time the father was
away as an "opportunity" to attack Child H.
LL: "No, I've never attacked any child." Letby says she "couldn't say" if she was
covering for Shelley Tomlins at 1am. An observation chart is shown for Child H for
September 26-27. Hourly observations are made between 8pm and 4am, except for 1am. Crash
call bleep data is made at 1.04am and 1.06am for Child H. Mr Johnson says Dr Neame gave
evidence to say when he arrived, Letby was present.
NJ: "Is that right?"
LL: "I can't say, from memory."
NJ: "You were there, weren't you?"
LL: "I can't say exactly where I was, from memory." Letby denies making an "alibi" at
1am for the fluid balance chart for her designated baby.
LL: "That's me giving cares to the baby I was allocated."
Nurse Shelley Tomlins' record, written at 3.49am, for the 3.30am desaturation: '0330 - profound desaturation to 60s, again requiring Neopuffing with no known cause for desat....copious amounts of secretions yielded orally, pink tinged. Small amount of ET secretions gained, again pink tinged. Heart rate mainly normal during desat. Recovered slowly.' Letby denies "interfering with [Child H's] ET Tube".
Letby says she is helping Shelley Tomlins after the desaturation.
NJ: "Why is it always you that ends up in nursery room 1?"
LL: "I don't agree it is always me."
See also: INQ0014592 – Rule 9 questionnaire response of Deborah Moore, dated 15/03/2024
Prosecutor Nick Johnson is reading a statement (which is agreed evidence) from Countess of Chester Hospital midwife Deborah Moore. She took Child H's mother to theatre for her emergency C-sectionSee also: INQ0018066 – Thirlwall Inquiry Witness Statement of Alison Ventress, dated 26/04/2024.
Giving evidence at Manchester Crown Court on Thursday, January 19, registrar Dr Alison Ventress said she received an urgent bleep call from nurses in the early hours of September 25.See also:
INQ0001986 - Pages 4-6 of [Police] Witness Statement of Dr Ravi Jayaram, dated 10/01/2019
INQ0001982 – Page 11–12 of [Police] Witness statement of Ravi Jayaram, dated 18/09/2017 [?]
INQ0010268 - Page 41 of Transcript of Day 14 of the criminal trial of R v Letby, Dr Ravi Jayaram re Child A, dated 24/10/2022
INQ0107962- Page 121 of Thirlwall Inquiry Witness Statement of Dr Jayaram, dated 30/08/2024
Dr Ravi Jayaram's oral testimony at the Thirlwall Inquiry
See also:
INQ0102740 – Page 105 of Witness Statement of Dr John Gibbs, dated 01/07/2024
Dr John Gibbs' oral testimony at the Thirlwall Inquiry
See also:
INQ0000526 – Pages 10 – 12 of Witness Statement of Matthew Neame, dated 08/11/2018
INQ0102351 – Page 10 of Witness Statement of Matthew Neame, dated 23/06/2024
See also: INQ0017279 – Thirlwall Inquiry Witness Statement of Shelley Tomlins, dated 01/04/2024.
Nurse Shelley Tomlins, Child H’s designated nurse on the nightshift beginning September 26, said she would not have been in the baby’s presence throughout. She said she would have been covered by a colleague while on a break or if she had popped out of the room.See also: INQ0098315 – Thirlwall Inquiry Witness Statement of Christopher Booth, dated 16/05/2024.
Fellow nurse Christopher Booth, who was on duty on both nightshifts, told Mr Myers that Letby had completed an overtime shift that week.