Count 13: Attempted murder of Baby J on 27 November 2015. Alleged mechanism: Airway Obstruction (NO VERDICT)
BABY 10 SUMMARY [Baby J]
10 was a 32+2/7 week, 1.709 kg birth weight, twin female infant who was born by elective
caesarean section to a mum with twin-twin transfusion/laser treatment, and preterm
prelabour rupture of membranes. She had laparotomy with small bowel resection and stoma
formation of functioning ileostomy and mucous fistula for malrotation/volvulus and necrotic
bowel with perforation and adhesions. She developed stomal excoriation and formation of a
mucocutaneous fistula. At 17 days of age, she developed seizures and was treated with
antibiotics and Phenobarbitone. At 47 days of age, she was found blue and crying, then
became pale and was resuscitated with cardiac compressions and bagging because of low
heart rate (40/min). She recovered quickly and was transferred to Alder Hey Hospital, where
she was diagnosed with sepsis. She had another similar episode of clinical deterioration at
Alder Hey Hospital about 10½ hours after her transfer.
CONVICTION
It was alleged that 10 deteriorated on day 47 of life because of malicious airway obstruction.
PANEL OPINION
10 is a preterm infant with bowel resection and stoma formation with excoriation. She also
had seizures that were treated with phenobarbitone. Following transfer to Alder Hey
Hospital on day 47 of life, she was diagnosed to have an infection and was treated with
antibiotics. She had another similar episode of clinical deterioration at Alder Hey 10½ hours
later.
It is most likely that the clinical deterioration on day 47 of life at the Countess of Chester Hospital (CoCH) was an episode of seizure, apnoea or hypoventilation, which was an early manifestation of the sepsis that was subsequently diagnosed after she was transferred to Alder Hey Hospital. Infection does not just happen suddenly. It brews in the body over time, usually 1-2 days before it overwhelms the body’s defences and clinical symptoms occur. The episode of deterioration in question is most likely part of the same infection episode and cannot be treated as a separate event. The occurrence of a similar episode of deterioration at Alder Hey Hospital supports the diagnosis of sepsis as the cause of the episode at CoCH. The resuscitation with chest compressions seems to be an overreaction from the nurses. Dr Soni, who responded immediately to the crash call, recorded that the heart rate was 46/min on the monitor but >100/min on auscultation and the infant was crying under the mask while cardiac massage was ongoing. The nurses reported that the infant was breathing throughout but laboured. Bagging or oxygen would be appropriate for desaturation but not cardiac compressions because it can cause harm to the infant, including trauma to the heart and other organs, rib fractures and disruption of circulation. Of note, the parents were concerned about the care their baby was receiving in CoCH. They requested to have the Baby 14ot transferred back to CoCH and were successful.
CONCLUSIONS
1. 10’s deterioration on day 47 of life was due to sepsis.
2. There is no evidence to support malicious airway obstruction.
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".
3pm: Intelligence analyst Kate Tyndall has returned to talk the court through events for Child J, who was born at 3pm on October 31, 2015, weighing 3lb 12oz. Child J was admitted to the neonatal unit 10 minutes later. A picture was taken of the baby girl. She remained at the Countess until 4am on November 1, being transferred to Alder Hey, before coming back to the Countess on November 10, being admitted to the neonatal unit by Lucy Letby.
The same day, Letby messages a colleague saying "It's chaos here" and she had had a row with another colleague.
A selection of messages, recovered from Letby's phone, are shown to the court for the period from November 10-26. Letby sends a lengthy message to her colleague explaining why the unit was 'chaos' and why she had a disagreement with a colleague, adding staff were "peeing her off". Her colleague replies: "Nothing like a bit of team spirit eh! x" Letby apologises for her rant, saying: "Just really gets me down sometimes and some...want the easy life"
Letby asks a colleague on November 16 about how often a procedure for the Broviac line for Child J needed to be carried out. She receives a reply that it is carried out weekly. Letby says she had three missed calls on November 25, having been to Las Iguanas and was at salsa, saying no-one at the unit knew how to administer immunoglobin, and they rang her. Her colleague sympathises, saying they should not be ringing staff not on duty, but should be contacting Liverpool Women's Hospital first.
The events of November 26 are now being talked through the court.
At 10.30am, a doctor's note says Child J was 'pink, well perfused, no respiratory distress' 'Abdomen- soft. Mum says mild distention soft abdomen. Stoma looks healthy'. The note adds 'if [increased] distention to inform' as the plan, along with the feed for expressed breast milk and donor.
Letby messages a colleague saying 'staffing really needs looking at', before messaging colleague Jennifer Jones-Key to say 'sounds like you had a mad day'. Letby adds the situation is 'just not manageable'.
Letby adds: "It's a nightmare isn't it...especially with no management x" Jennifer Jones-Key said the staff [on duty] were going to ring Letby or Yvonne Griffiths the previous night [regarding how to administer immunoglobin], but thought that would have been done so sooner.
Letby adds the staff there should not have been in that position. She adds, for her November 26-27 night shift: "Ah well. Hopefully be a bit calmer for me tonight lol x"
5.16pm: A colleague messages Letby at 5.16pm: "U well rested for work? x"
Letby replies: "Yep I've had a chilled day and slept well..." She adds: "Ready to face
anything" with a strongarm emoji, before discussing about being contacted the previous
night, and querying why she had been contacted when staff on duty had other lines of
enquiry, such as Liverpool Women's Hospital or the transfusion department.
Letby, as she sets off to work, messages her colleague: "Off to the mad house x" with a neutral face emoji. Once inside, she messages the colleague to say she is in room 3 of the neonatal unit for the night shift. A shift rota for that night is presented to the court. There are two babies in room 1, two babies in room 2, two babies in room 3 (both designated nurse Letby), and two babies in room 4, one of them being Child J. In addition, there are two babies in transitional care, and two babies whose location could not be confirmed from the records.
7.30-8pm: Nurse Ashleigh Hudson records, for Child J at the November 26 night-shift handover: 'Observations satisfactory as charted...Broviac remains in situ...[Child J] appears to be in no pain or discomfort.'
7.36-10.53pm: Letby received and sent messages between 7.36pm and 10.53pm, but not related to Child J.
1.57-4.29am: At 1.57am on November 27, swipe data shows Letby recorded as entering the neonatal unit, at 3.47am and at 4.29am.
At 4.40am, an apnoea/brady/fit chart records Child J having an episode of apnoea, heart rate down to 100, lasting for three minutes.
At 5.03am, a desaturation to '30s' is recorded, heart rate to 100, lasting two minutes. In each event, a Neopuff device is administered. Nurse Nicola Dennison records Child J looking unwell at 4.40am. In an untimed note [written retrospectively at 7.37am], Child J is moved from nursery room 4 to room 2.
Letby says, in a message to a colleague, she had not had a good shift, as Child J had '2 profound desats' and there were 'only 5 staff' on duty. The colleague replies: 'We closed again then? x' Mr Johnson explains to the court 'closed' by this definition means the unit would be closed to new arrivals, not closed entirely. Letby confirms the unit is closed until they can get someone in.
6.56am: There is an event timed as 6.56am which marks Child J's desaturation. A retrospective note created by Mary Griffith, referencing Lucy Letby, is made at 7.11am. The note says '[Child J's] monitor went off at 6.56 myself and L Letby attended. Found baby with pale hands and baby very ridged...'
7.15am: A note is made at 7.15am recording that the parents of Child J are informed of the collapse and to come to the hospital as soon as possible.
7.24am: Child J had a further collapse at about 7.24am. Dr John Gibbs records the event in his notes. Resuscitation efforts are made and a range of medication is administered, while observations are recorded and an x-ray made.
8.55am: Letby is recorded as using her swipe card at the neonatal unit access door at 8.55am.
10.30am: Lucy Letby messages Jennifer Jones-Key just before 10.30am: "Wow it
turned manic - left at 9.15 but others still there."
The reply: "Warned you..don't know what it is", adding that things seem to go
"pear-shaped".
Jennifer Jones-Key messages Letby saying, of the staffing situation, 'more staff will just go off sick'.
Afternoon: A colleague of Letby messages her on the afternoon of
November 27 to say: 'Oh and Tony Chambers n some woman turned up earlier! x'
Letby replies: 'Gosh it's mad. At least things are moving in right direction. Is it bit
calmer now? Still only 5 tonight? Hope Tony got stuck in and helped!!'
Night Shift: Letby is on a night shift on November 27-28. She recorded Child J's
vital signs and her fluids. Nurse Mary Griffith messages Letby to say she had left the
hospital at 9.45am, getting back home at 10.30am, adding she hopes Letby has a better shift
tonight.
Letby replies: "You must be tired. Thanks for staying....still busy as only 5 on. [Child
J] quiet hasn't done anything else abnormal and xray etc ok..."
2.30am: Notes from a doctor on November 28, 2.30am, for Child J record '...no respiratory distress...' The plan was 'continue to slowly increase feeds...to achieve full feeds by 1800 today'.
5.06am: Letby records further observations for Child J at 5.06am on November 28, with 'shallow breathing observed at times' and, in a family communication note, Child J had been 'out for cuddles' with parents, who 'seemed happier' that Child J was recovering and feeds were gradually being increased.
3.30am: Child J continued to be cared for at the Countess of Chester Hospital's neonatal unit until 3.30am on December 18, 2015, when she was transferred to Royal Manchester Children's Hospital.
Mr Myers moves on to the case of Child J, a baby girl born on October 31, 2015 at 32 weeks + 2 days gestation, at the Countess of Chester Hospital. Mr Myers says there were a "number of problems in pregnancy" and Child J was diagnosed with a necrotic and perforated bowel (NEC), and required transfer to Alder Hey for a stoma to be fitted. Child J returned to the Countess of Chester Hospital on November 10. Mr Myers refers to the events on the night shift of November 26-27. Mr Myers says Child J had desaturations at 4.40am and 5.03am on November 27. The designated nurse for Child J that night was Nicola Dennison. Child J had further "low desaturations" at 6.56am and 7.24am, with "eyes deviated to the left", "stiff arms" and "clenched fists".
Letby tells the court she had "very little experience" with stomas,
having seen a couple at Liverpool Women's Hospital during training. Other staff at the
neonatal unit had no relevant recent experience of stomas, Letby adds, saying stoma surgery
would only be carried out at a tertiary centre such as Alder Hey [the Countess of Chester
Hospital was a level 2 centre]. Asked if Countess staff would regularly handle babies with
stomas, Letby said: "No."
"I don't recall anybody being overly confident." She adds Child J's parents "took the
lead" as they had the relevant experience from what they had been told at Alder Hey.
Letby messaged a friend on November 19: "It's shocking really that they are willing to take the responsibility for things that they have no training or experience etc on. Don't think they appreciate the potential difficulties X" Asked who she means by 'they', Letby says "the band 4 nurses". Mr Myers asks who would ask them to do it. Letby says it would be up to the shift leader to allocate them. Asked why they would be asked to look after a baby with a stoma, Letby tells the court: "the unit was so busy at the time". Letby messaged the same friend at November 25: "Went to las iguanas was really nice. At salsa. Had 3 missed calls they don't know how to give immunoglobulin and I was last person to give so just phoned and told them. [Nurse] said it's mad. Ravi is there. What a nightmare it's all getting they'll have to send babies out?? X" Letby tells the court it was "mad busy" on the unit, and the staff numbers were not at the level required for the number of babies on the unit. The night shift rota for November 26-27 is put up. Two band 4 unit nurses are named in the rota. Child J was in room 4. The designated nurse was Nicola Dennison, a band 4 nurse also looking after one other baby in room 4. Letby was the designated nurse for two babies in room 3 that night.
Letby tells the court she had no involvement in Child J prior to her
first desaturation. A rota of the end of the shift is shown to the court, with Letby having
taken on a new arrival to the unit as their designated nurse during the night. She said that
night was "very busy". Nicola Dennison's nursing notes are shown to the court. they include:
'Shortly after the feed at 0400 [Child J] became unwell and desaturated to the 30s. Initially
not apnoeic but then did require some Neopuff to recover. Colour looks pale and mottled...' A
doctor records two 'profound desats', the 1st to 30s, the 2nd to 50s. Both episodes required
bagging. 'Since then pale + mottled'. The apnoea/brady/fit chart is shown to the court,
recording two events at 4.40am and 5.03am. The 4.40am event lasted three minutes, the second
lasting two minutes.
Mr Myers: "Did you have any idea this was happening at the time?"
Letby: "No." Letby is asked if she has recollection of the second pair of events. "Yes."
She adds she has independent recollection of those events. She said, for 6.56am, she heard the
monitor alarm in room 4 and Child J was "fitting", "She wasn't breathing properly...her eyes
were rolling to one side of her head."
"We both heard the monitor and we [Letby and Yvonne Griffith] went in." Letby said no-one
was in room 4 at the time the alarm first went off. Dr Gibbs arrived "very quickly" and Child
J was transferred to room 2. Letby says for the second event, she was called to help, but does
not recall who. Letby is recorded on the chart subsequently administering an infusion with
Mary Griffiths. Letby says she stayed "a little later" on the unit that day for the end of her
shift, but cannot recall when that was. Letby tells the court she was unaware of the first
pair of events for Child J that night, but was aware and involved in the care during the
second pair of events.
Lucy Letby was the designated nurse for Child J for the following night
(November 27-28), the court is shown. A nursing note for Child J written by Letby from that
night is shown to the court.
Mr Myers: "Any issues for [Child J] from that night, in your care?"
Letby: "No." Letby messages a colleague about the shift of November 27-28 being "much
better". Mr Myers asks what she means by that. Letby replies the workload on the unit was much
more manageable than the previous night. Mr Myers asks if a 'nicer,' lighter workload would be
what she wanted.
Letby: "Yes."
Mr Myers: "Would you want things to be going wrong?
Letby: "No."
Mr Myers: "Would you want babies to be hurt?"
Letby: "No."
The trial has had a short break, and will be resuming shortly with Mr Johnson cross-examining Letby in the case of Child J.
Copies of Letby's defence statement, edited to the relevant parts in the case by agreement, are handed out to members of the jury. Mr Johnson moves to the case of Child J, a baby girl born on October 31, 2015. Letby, in her defence statement, said she had never seen a baby with stomas before at the Countess, and other doctors were "equally unsure about stomas", and the parents were "more proficient" than the Countess staff at dealing with stomas. A handover sheet was taken to Letby's home, the defence statement adds, unintentionally.
The night shift rota for November 26-27 is put up. Two band 4 unit nurses are named in the rota. Child J was in room 4. The designated nurse was Nicola Dennison, a band 4 nurse also looking after one other baby in room 4. Letby was the designated nurse for two babies in room 3 that night. Letby rules out staffing levels as a contributory factor in Child J's collapse, nor medical incompetence, nor staffing mistakes. She says the unit was busy at the time, but was not a contributory factor. She adds she does not know how Child J collapsed.
Letby accepts the evidence from Child J's mother that Child J was well and "about to go home in a day or two".
Letby adds there was an issue with Child J's stoma care, as it had
been discussed among the nurses that they had little experience. She adds she does not
"want to name names" on any specific nurses' lack of experience. Mr Johnson refers to
Nicola Dennison's previous experience with stomas, which she said in evidence she had
experience of it. Letby says over the years, she did not recall any other babies with
stomas. Mr Johnson says band 4 nurses, as said by Letby in evidence on May 16, should not
be involved in stoma bag care, as they would be unfamiliar with the procedure. Letby said:
"The unit was very busy and we had to use staff where we could." Letby says she was not
referring to Nicola Dennison specifically, but the nursing situation overall. She says
there was not an issue over staffing levels at the time of Child J's collapse. Asked to
explain a text message she had sent to a colleague Letby tells the court: "Sometimes I
felt nurses would take on roles which I didn't think they were trained enough in". The
next message adds: "It's shocking really that they are willing to take the responsibility
for things that they have no training or experience etc on. Don't think they appreciate
the potential difficulties X" Letby agrees she believed it was "potentially dangerous". Mr
Johnson says the impression of the court was that band 4 nurses were not qualified in
stoma care, and the hospital was 'cutting corners' by assigning such nurses to those
tasks. Letby agrees. The court is shown a document about the duties for special care
babies [such as Child J], which includes stoma care.
LL: "You need to appreciate the context that the unit was not familiar with stomas."
NJ: "This nurse was familiar with stomas, wasn't she?"
LL: "In her opinion, yes." Mr Johnson says Letby was deliberately creating the
impression to the jury that the care for Child J was deficient.
LL: "I do think that. I don't think she had a high standard of care. "I don't think
anyone was overly confident in saying 'I know what to do with a stoma'. We were led by the
parents..." Mr Johnson asks why Nicola Dennison was not challenged about this.
LL: "I can't answer that."
Letby denies not being happy in nursery room 3, or being happier in nursery room 1. Letby accepts the evidence of Nicola Dennison that babies in room 4 should have the light off overnight, as they are due to go home.
Mr Johnson says two pairs of events for child J happened; one pair in room 4, one pair in room 2. The room 4 incidents happened at 3am and 4.57am, and the room 2 incidents happened either side of 7am. Letby accepts this was the case.
The court is shown a night shift staffing rota at the end of the night, in which Child J was in room 2. Letby is asked if she has any memory of the earlier pair of incidents. She says she does not have a recollection. She says from her memory, Child J had a seizure and was moved to room 2. She says she could be mistaken in her memory.
The court is shown an apnoea/brady/fit chart for Child J on November 27, recording events for Child J at 4.40am and 5.03am, recorded by nurse Nicola Dennison, in nursery 4. The desaturations are recorded by Dr Kaliyilil Verghese. Letby recalled when she was called in to room 4, Child J was 'fitting', not desaturating. Letby accepts that by 6.28am, Child J had been moved to room 2, as a text message written by her to a colleague had said that was the case.
Letby says she cannot recall where she was when she sent the 6.28am
message, whether she was in room 2 or not. The message added: 'only 5 staff!'
Mr Johnson: "So it was all hands to the pump then?" as twins had been admitted to room
1 as an emergency.
LL: "Yes." Mr Johnson says all staff would have been concentrated in room 1. LL "Not
all, but most, yes."
NJ: "You were not involved in that, were you?"
LL: "Not from memory, no." Mr Johnson says the message sent at 6.31am would have meant
Letby would not have been in room 1. Letby agrees. Letby says Mary Griffiths would not
have been in room 1 as she was not an intensive treatment unit-trained nurse. She denies
she would have been the last nurse for room 2. Letby accepts, from looking at the neonatal
schedule, she would have been in room 2 when the emergency twins were admitted to room 1.
NJ: "There would have been a lot of distractions...wouldn't there?"
LL: "I don't know what you're implying."
NJ: "The medical staff would have their attention focused on the twins, and any help
that could be spared would have gone on the twins.
NJ: "Do you accept that a lot of help was needed?"
LL: "It would be normal practice to get in the consultant when we only had the
registrar, yes." Dr John Gibbs arrives at 6.34am, earlier than normal for his shift, to
assist.
The last message Letby sent to her colleague was 6.49am. The
colleague sent three messages which were not replied to in the following minutes.
NJ: "That's because you were in nursery room 2, sabotaging [Child I], weren't you?"
LL: "No, I wasn't."
Letby accepts that, on the neonatal schedule, she is not recorded
doing anything in the half hour prior to Child J's collapse at 6.56am. Mr Johnson refers
to Dr John Gibbs's notes of 'sudden desats (to unrecordable levels) at 6.56 and at 7.24
and bradycardia. Both associated with clenching of hands, stiff limbs, and on second
occasion, eyes deviated to left.'
NJ: "This was your doing?"
LL: "No, it wasn't." Letby accepts it was an emergency situation and Dr Gibbs had to
be called away from room 1 to Child J in room 2.
NJ: "You took your opportunity, when all the resources at the NNU were concentrated on
the twins who had been admitted as an emergency."
LL: "No." Letby accepts evidence had been heard saying there was no known cause for
Child J's deterioration. Letby had care of Child J the following night, which the court is
shown, from Letby's notes for that night, 'nothing happened'.
See also: Dr John Gibbs' oral testimony at the Thirlwall Inquiry
Giving evidence on Monday, February 13, consultant paediatrician Dr John Gibbs said two "profound" desaturations around 5am on November 27, 2015 were "alarmingly low".See also:
INQ0103104 – Thirlwall Inquuiry Witness Statement of Dr Stephen Brearey - various pages, dated 12/07/2024
Dr Stephen Brearey's oral testimony at the Thirlwall Inquiry
See also: INQ0101331 – Witness Statement of Mary Griffith, dated 06/06/2024
Earlier, nurse Mary Griffith – who worked more than 40 years at the Countess of Chester before retiring in 2016 – agreed with Mr Myers that Letby was "knowledgeable", "caring" and "thorough" in her job.