Count 15: Attempted murder of Baby L on 9 April 2016. Alleged mechanism: Insulin Poisoning
BABY 12 SUMMARY [Baby L]
Baby 12 was a 33+2/7 week, 1.465 kg birth weight, twin 1, severe intrauterine growth
restricted (IUGR) preterm male infant, who was delivered by caesarean section for poor
growth and oligohydramnios at 1013 hours. On admission to the NICU, his initial blood
glucose was 1.9 and he was started on intravenous 10% dextrose at 100 ml/kg/day. The next
day, he was kept on intravenous TPN at 75 ml/kg/day plus 10% dextrose at 1 ml/kg/day plus
nasogastric feeds. His blood glucose was 3.6 at 0054 hours but dropped after that and was
low throughout the day (1.5 to 1.9). Blood tests showed c-peptide 264, Insulin 1079. At 1920
hours, his dextrose infusion was increased to 12.5% and blood glucose improved to 2.0 to
2.4. The next day, his blood glucose ranged from 2.1 to 2.4. The next day, a long line was
inserted and his dextrose infusion was increased to 15% at 0130 hours and fluid volume
increased at 0700 hours. His blood glucose stabilized after that from 2.7 to
3.0. Feeds were increased, the intravenous infusion was weaned off, and he was discharged
home.
CONVICTION
It was alleged that Baby 12 received exogenous insulin which caused hypoglycemia. The
evidence is based on a high insulin to low peptide level ratio (I/C ratio).
PANEL OPINION
It is common for preterm and IUGR infants to have hypoglycemia, due to their limited
glycogen and fat stores, inability to generate new glucose using gluconeogenesis pathways,
higher metabolic demands due to a relatively larger brain size, and inability to mount a
counter-regulatory response to hypoglycemia. Baby 12’s blood glucose dropped from 0054
hours on day after admission but his dextrose concentration was not increased until 1920
hours. This is a long interval without adequate sugar and intervention should have been
earlier. His blood sugar improved in response to 2.0 to 2.4. However, this is still low and
further intervention was necessary. Again, there was delay, and his glucose concentration
was not increased to 15% until the next day at 0130 hours and the volume was not increased
until 0700 hours. His blood sugars improved to normal range after that. The fact that his
blood sugar improved each time the glucose infusion increased indicates that the
hypoglycemia persisted because insufficient dextrose was given for this infant’s needs.
Chase et al reported that premature infants have different normative standards for insulin and cpeptide than adults. The Insulin:C-peptide (I/C) ratio does not prove exogenous insulin was administered because the C-peptide was not low for preterm infants (20-45 percentile), potassium levels were normal (insulin decreases potassium), antibodies can store insulin in the blood, glucose levels should be lower if exogenous insulin was used, the infant’s glycaemic profile was inconsistent with insulin administration but consistent with the delivered IV feeding profile, the I/C ratio was within the expected range for preterm infants, and the immunoassay test is unreliable because interference factors can give false positive insulin readings.
CONCLUSIONS
1. Hypoglycemia was due to preterm birth and severe IUGR; it’s medical management
was inadequate.
2. Baby F’s [sic] insulin level and I/C ratio do not prove that exogenous insulin was used, and
are within the norm for preterm infants. Preterm infants and those will illness have
different normative standards compared to healthy adults and older children.
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.
8th April 2016:
Intelligence analyst is talking the court through the sequence
of events for Child L and Child M, twin boys born on April 8.
10.30-10.59am: Child L was admitted to the neonatal unit at 10.30am, and had observations taken by Lucy Letby, with a blood sugar reading of 1.9 recorded at 10.58am. He was treated with a 10% dextrose (sugar) infusion.
Lucy Letby's note, written in retrospect at 5.42pm, noted the blood sugar reading of 1.9, with the registrar commencing dextrose and expressed breast milk.
At 12.14pm, the blood sugar reading had risen to 2.5.
Lucy Letby records communication with Child L and Child M's parents: "Parents were shown babies in theatre and had a quick cuddle....Photographs given and visiting hours discussed. Daddy visited the unit and had cuddles."
4pm: For Child L, a blood sugar reading of 5.8 is recorded at 4pm.
Letby records for Child L at birth "Initially had some recession with a raised respiratory rate, quickly normalised and remained self ventilating in air. Blood gases good... "2 Hourly feeds, NG/bottle. Minimal aspirates obtained..." Recording communication with the parents: "Parents updated by myself on CLS and photograph taken....fully updated on care by myself and reg Bhowmik. Aware of need for septic screen..."
A 6pm blood gas reading records blood sugar of 3.3
6.15pm: Letby messages a colleague at 6.15pm - "Unpacking! Stuff everywhere lol! May do an extra shift this weekend x" The court previously heard Letby had recently moved into a home near the hospital. Letby messages her mother: "Think Im going to do tomorrow [Saturday, April 9] as an extra but go in a bit later."
9pm: Child L's blood sugar reading at 9pm is 2.3.
Letby's colleague Sophie Ellis messages her: "How's the house pal?
Xxx"
Letby: "Hey, it feels a bit weird having a whole house but it's good thanks, although
stuff everywhere as moved in properly on Tue and been at work Wed, Thurs and today...",
followed by a monkey emoji with its hands over its eyes.
Sophie Ellis: "...it'll feel more homely once you've sorted everything out." She also
asks about how busy the unit is.
Letby: "...Unit is busy, no-one particularly unwell just volume and few people off sick.
I prefer 4 days to 4 nights..." Letby adds: 'We've got nice mix of babies at the mo really.
Shift goes quick anyway!'
10pm-Midnight: Child L's blood sugar reading is 2.2 at 10pm, then 3.6 at midnight.
Further medications are administered throughout the night. Agency nurse Tracey Jones records notes for Child L from the night shift, noting the cannula was knocked out by the baby boy during the night so was reinserted. There had been no contact with the parents during the night.
9th April 2016:
For the day shift on April 9, 2016, Lucy Letby is a designated nurse
for two babies in nursery 1. Mary Griffith is the designated nurse for Child L and Child M,
who are the other two babies in room 1. Four babies are in room 2, three in room 3 and four
in room 4. There are seven designated nurses for the neonatal unit babies in total.
10am: Child L records a blood sugar reading of 1.9 at 10am, pre-feed. Nurse Mary Griffith records notes, written retrospectively, saying the IV dextrose [infusion] was increased for Child L.
10.34am: Letby messages colleague Ailsa Simpson at 10.34am, wishing her good luck at picking the horses at the Grand National that day, and that her feet don't get too sore.
11am: Child L's blood sugar reading is 1.6 at 11am.
12pm: A handwritten entry for hypo screen results at noon, not attributed to a name, record results for Child L. Child L's blood sugar reading is 1.6 at noon, pre-feed. Letby co-signs a 10% dextrose infusion for Child L, around noon.
12.30pm: Notes for Child M record that designated nurse Mary Griffith took a break around 12.30pm.
Letby is engaged in messaging people between 11.12am and 12.33pm. Letby messages Ailsa Simpson shortly afterwards: "Oh good hope you have a fab time. Im in work doing an extra! x" Letby also messages her mother, asking if her father was betting on the Grand National, and if so, to put a bet on grey horses for her. Her mother replies that has already been done.
The court hears Letby continues to be involved in messaging, including a group message to colleagues and friends: "Sorry guys mad 4 busy days in work..." then invites the three people to crash at hers, apologising she hasn't fully unpacked yet. She adds: "Got magnum prosecco and vodka woop. No disco ball but sure we can manage. x"
2pm-3.40pm: Child L's blood sugar reading is recorded as 2.0 at 2pm, and 1.5 at 3pm. Letby is a co-signer for the administration of medication at 3.35pm. Mary Griffith records a blood sample was taken from Child L at this time, which was taken to the Royal Liverpool Teaching Hospital for analysis. The prosecution say the blood sample had a very high insulin level recorded, and a low level of C-peptide. Child L was also given a bolus of dextrose, prescribed at 3.35pm and administered at 3.40pm.
A note from the hospital's pathology department records the blood specimen sample for Child L. The blood was "taken for lab but due to emergency not poded at once", nurse Mary Griffith records. That one emergency identified in the neonatal unit, the prosecution tells the court, was for the twin brother, Child M's "dramatic collapse".
4pm: Child L's blood sugar reading at 4pm is 1.5.
Child M's collapse is recorded at this time. A crash call is put out. Friends message Lucy Letby around this time, saying they can have "an unpacking party". For Child L, the dextrose administration is increased to 12.5%, from 10%.
5pm: Child L's blood sugar reading at 5pm is 1.7, which was "still very low", the prosecution say.
5.28pm: Letby's mother messages Letby at 5.28pm telling her: "You've won rule the world :-D xxx"
6pm: Child L's blood sugar reading at 6pm is 1.9.
Letby responds to a colleague at 6.01pm: "Haha why not!! Work has been s***e but...I have just won £135 on Grand National!!" She also sent a group message: "Unpacking party sounds good to me with the flavoured vodka...Just won the Grand National!"
The pathology records the lab specimen of a blood sample for Child L. Among the blood test results sought for the sample are insulin and C-peptide. The insulin level is recorded as 1,099, and the C-peptide is recorded as 264. These readings are entered into the system on April 14, having obtained the results from Liverpool. The C-peptide "should be 5-10 times the level of insulin", but the ratio is recorded as 0.2.
Child L is recorded to have hypoglycaemia [low blood sugar]. Doctors record the hypoglycaemia continued despite the regular infusions of dextrose throughout the day.
8pm: Child L has a blood sugar reading of 2.0 at 8pm.
9pm: Child L's blood sugar at 9pm is 2.4. Letby records notes for Child M at 9.22pm.
10pm: Child L's blood sugar reading at 10pm is 2.3.
10.11pm: A colleague of Letby,
Belinda Simcock, messages her at 10.11pm: "Thanks for listening, I'm ok x"
Letby: "Don't need to thank me, glad you felt able to tell me..."
10th April 2016:
Midnight-2am: Child L's blood sugar
reading at midnight is 2.1, and remains "low" at 2.1 at 2am. A long line is inserted, with
an x-ray taken, and medication administered.
4am-7am: The blood sugar reading at 4am is 2.3, and 2.2 at 6am. The glucose is further increased, but the blood sugar reading "remains stubbornly low" at 2.2 at 7am.
9am-7am: It remains at 2.2 at 9am.
Letby receives a message from Yvonne Farmer asking if she wanted to do more overtime shifts on Sunday night, Monday day or Monday night, appreciating she may be tired, with Letby responding: "Sorry but need some days off now." She adds she could be on call for nights, and would be free for Thursday day/night shifts.
2pm: Child L's blood sugar reading at 2pm on Sunday had "normalised" at 3.0.
Letby refers to her previous shifts as "not nice" in a message to Jennifer Jones-Key. Jennifer Jones-Key says Letby 'hasn't got many nights' coming up on the rota, adding she likely won't see Letby as she works mainly nights herself. "We never see each other if we do work together as always mad shifts".
Afternoon: Child L was still receiving 15% dextrose through the afternoon of Sunday [10th April]. A nursing note made by Laura Eagles that afternoon records: "Blood sugars maintained...remains on 15% dextrose via long line...very unsettled at times." The family had been kept updated of the situation, according to a family communication note.
5pm: Child L's blood sugar levels were "normal" at 2.8 at 5pm. Samantha O'Brien becomes the designated nurse that night for Child L, and the 15% dextrose administration continues through the night.
9pm-2am: The blood sugar levels are 2.7 at 9pm, 2.9 at 11pm, 2.7 at 2am.
11th April 2016:
Samantha O'Brien, in
her nursing note, records: "...1% glucose infusing via long line in left leg,. 3 hourly
blood sugars, all have been above 2.6 so far this shift. Plan to continue [current
medication administration]... "Baby unsettled at times, settles with comfort measures."
5am: The blood sugar level is 2.9 at 5am on Monday, April 11.
8.45am: Letby messages a colleague at 8.45am, saying: "The unit is in dire way with staff," highlighting which trained staff were on duty and who else was on in the last shift, and who was off at that time. A colleague replies, in her message: "that's terrible" Letby replies the overall situation was "not good", "mad and poor skill mix".
11am: Child L's blood sugar readings are 2.8 at 11am. Dr Huw Mayberry, in a clinical note, records the feeds/fluids for Child L, which were increased due to low blood sugar and falling sodium levels.
3pm-5pm: Child L's blood sugar at 3pm is 3.5, remaining at 3.5 at 5pm. Nurse Belinda Simcock said registrar Mayberry was aware of the 3.5 readings, and if they continued to remain above three, then feeds would be increased.
7pm: The blood sugar increases to 4.7 at 7pm.
3rd May 2016:
Child L continued to be cared for at the hospital's neonatal unit
until May 3, and was then discharged.
Mr Myers moves on to the cases of twins, Child L and Child M, born on April 8, 2016 at 33 weeks and 2 days gestation. Letby confirms she is still working and caring for babies, working a mixture of day and night shifts, at the hospital, during this time. She says, in reply to what her intentions were for the babies: "To provide the best care possible." She estimates she had cared for about "100" babies during these few months.
Child L was born weighing 1,465g. Child L later struggled with low blood sugar. A blood sample was taken for Child L - the insulin level read 1,099, insulin C-Peptide 264. The insulin was "far higher" than the C-peptide reading, indicating, Mr Myers, insulin had been administered to Child L. Child M weighed 1,705g. Child M later had a desaturation, which it is alleged Letby had caused.
On April 8, Sophie Ellis messaged Letby: "How's the house pal? Xxx"
Letby responds: "Hey, it's feels a bit weird having a whole house but It's good
thanks, although stuff everywhere as moved in properly on Tue & been at work Wed Thurs &
today ?. Doing tomorrow as an extra so I'll see you tomorrow night. Won't be such an early
start for you now back in Chester!..."
The reply: "Yeah I bet it does, it'll feel more homely once you've sorted everything
out. Jeeeez 4 [Long Day shifts] in a row, are you ok?! ? I know yay and I don't have to
pay for petrol, it's cost me a fortune ?ﾟﾘﾩ. Yeah they are ? haven't seen them for a
while. What's the unit like? Xxx"
Letby: "Yeah I'll get there in time. Petrol & tunnel soon mounts up doesn't it! Can
you claim travel expenses? I couldn't for 405. Unit is busy, No one particularly unwell
just volume & few people off sick. I prefer 4 days to 4 nights. Least tomorrow is an extra
& Sat pay! ?. Awe that'll be nice hope weather a bit better for you! X"
SE: "Yeah we can. Omg really, how come? That's 7 weeks as well isn't it? Yeah, 4
nights are awful. Ah that's not too bad then. Think I'd prefer to keep busy. I think it's
meant to rain...dammit xxx"
LL: "Eirian said something about the induction being paid for by the trust whereas the
405 comes out of network budget so won't pay as its an expected part of role to progress
etc. Mad really & costs a bomb! We've got nice mix of babies at the mo really. Shift goes
quick anyway! Grr typical April showers haha. [Colleague] is in Thailand & It's been
44degrees today! X" Letby said it was a "massive" life moment for her to move into her new
house, and her main focus was on "sorting out the house". Letby says the unit was "still
fairly busy" at this point.
On April 11, Letby messages a colleague: "The unit is in dire way with staff..." She says the unit had 'banker agency staff' and band 5s who did not have the ITU course. She says the unit being busy was "often discussed by staff".
Letby recalls being involved with the care of the twin boys, and looked after one of the twins in the transfer to the neonatal unit. The twins were placed in nursery room 1, and Letby cared for Child L that first day.
The following day, April 9, Child M was in a different place in room 1, following admission of other babies overnight. Child L and Child M were in adjacent beds in room 1, the court hears.
Letby tells the court a baby's blood sugar levels are checked "within the first hour of life". Child L's first blood sugar reading is "low" - 1.9. The baby would be offered "a milk feed" via a bottle or NG tube, and the blood sugar would be checked after another hour. This did not happen with Child L, and he was administered 10% dextrose [sugar infusion], which Letby says was outside the guidelines, a decision made by Dr Bhowmik. Letby's notes: 'Advised by Dr Bhowmik to commence 10% glucose...' Letby added in the notes that she and the shift leader advised this deviated from the usual policies.
A glucose bag was hung up for Child L. Letby said she cannot recall who hung up the bag - she said it would either have been herself or nurse Amy Davies. Child L had normal blood sugar levels the rest of the day. She tells the court she would have ended her shift at about 8pm.
Mr Myers says for April 9, 2016, there are no recordings of blood sugar for 3am, 4am or 5am. A 10am reading of 1.9 is "too low". It is 1.6 at noon. 2pm it is 2. Letby had come on duty at 7.30am. The infusion rate has been changed at noon. A 10% dextrose bolus is administered at 3.40pm. Letby says she cannot recall who was involved in that administration. At 4pm, the blood sugar level is 1.5. At 4.30pm, a 12.5% dextrose bag is administered by two nurses including Ashleigh Hudson. The readings remain "low" up to midnight. On April 10, at 2am, the reading is 2.1, then a new 15% glucose bag is administered. 4am it is 2.3, 6am 2.2, at 2pm it is 3 - "an adequate level", but then drops for the rest of the day. A 15% glucose bag's rate is changed early on April 11, and a new bag is administered that day. The readings are 2.7, 2.9, 2.8 throughout that morning. At 3pm it is 3.5, and blood sugar is said to have stabilised.
The trial is resuming following its lunch break. Benjamin Myers KC is continuing to ask Lucy Letby questions in the cases of twins Child L and Child M. The infusion therapy prescription sheet is shown for Child L, with prescriptions for April 8-9. The first entry is for April 8, 11am, for a 500ml, 10% dextrose infusion, via the IV line. Dr Bhowmik authorised the prescription and the bag additive. Lucy Letby and Amy Davies set up the infusion. The first two infusion prescriptions have a line through them as, Lucy Letby explains, the rate of infusion was changed twice. It went from 4.2ml/hr to 3.6ml/hr to 4.4ml/hr. The 4.4ml/hr rate was started, using the same bag, at noon. The bags were stored in a cupboard in room 1. This was in a separate room from the insulin bags in a cupboard in a corridor.
Mr Myers asks how commonly dextrose is used on the unit. Letby says "very commonly", adding that a 10% dextrose solution would be administered 'all the time'. They would be used "for generic use".
Letby sent a message to her mother on April 8: "Think Im going to do tomorrow as an extra but Go in a bit later. Extra money and Sat pay xX" This was to be Letby's fourth long day shift in a row (April 6-9), the maximum normally allowed for Countess staff at the unit, the court hears. For the April 9 long day, Letby was designated nurse for two babies in room 1, and Mary Griffith was designated nurse for Child L and Child M, also in room 1.
Child L's 10% dextrose bag was changed on April 9 to a new 10%
dextrose bag, at noon, signed by Letby and Mary Griffith. That bag "would have come from
the generic bags in room 1", Letby says. She does not recall who would have put it up for
Child L. The equipment involved in setting it up would come from nursery room 1. Mr Myers
says prior to this, Child L had a blood glucose reading of 1.9 at 10am. Letby says the
initial infusion bag would still have been in place at this time. She says she cannot
explain why that reading was low, and did not do anything to cause that low blood sugar
reading. She adds she did not do anything to cause the later recorded insulin levels to be
high for Child L.
Mr Myers: "Had you done anything to affect insulin?"
Letby: "No." Letby says as well as herself and Mary Griffith being the two designated
nurses in that day, there were other nurses 'coming and going' in room 1, along with
parents "present throughout the day".
Nursing notes for one of Letby's designated babies - a high-dependency baby - are shown to the court. They include: 'Parents visiting carrying out feeds and cares....At 1600 parents were asked to leave the nursery due to a sick baby needing treatment, parents were understanding of this and left for the evening.' Letby says this was when Child M had deteriorated. She said this would be "common practice" to ask parents to leave in such an event. Letby adds the visiting times were 24 hours and parents would visit throughout the day.
Nursing notes by Mary Griffith record, for Child M on April 9: '...at 12.15 noted that his stomach was a little distended and his work of breathing was increased. Was then sent for my break and [colleague] did the 12.30 feed...had an aspirate of 5mls...temp returned to normal and baby settled.
At 1600 baby went apnoeic and had a profound brady and desat. Full resus commenced at 1602...care handed over to SN L Letby.' Letby tells the court Mary Griffith was, at this point, not trained for the type of intensive care Child M required, which was why care was handed over to her.
A prescription chart shows Lucy Letby is involved, with Mary Griffith, in the administration of antibiotics for Child M at 3.45pm. Letby says the line would also be 'flushed' after this is administrated. Letby says at the time of Child M's deterioration, Child L was requiring further dextrose. A chart shows Letby was involved in administering a 4.3ml, 10% dextrose bolus at 3.35pm, administered at 3.40pm. A 12.5% dextrose infusion is made up by nursing staff "in response to ongoing low blood sugars", which begins at 3.35pm and the infusion starts at 4.30pm. The infusion start is administered by Belinda Simcock and Ashleigh Hudson. Letby says she and Mary Griffith had been "preparing a bag" for Child L. She says Mary Griffith was the "sterile nurse" and Letby was assisting her between 3.45pm and 4pm.
Asked when she first became aware of a problem, Letby said the alarm went off and Child M was "not breathing" and "clearly struggling". Mary Griffith and another nurse were in there. Letby recalls asking parents to leave. Letby says she began initiating Neopuff "straight away", but because it didn't reach, the face mask fell on the floor, and Letby asked for another face mask for Child M. She adds she and Mary Griffith "abandoned" the making up of the bag, and "the focus was on [Child M]". Two other nurses 'started the procedure from the beginning' [of making up a new dextrose bag for Child L]. Letby said that would be "standard practice", to make sure staff were sure the new bag had the correct, required concentrations.
Letby, asked again by Mr Myers, denies doing anything to affect Child L's insulin levels. She agrees Child L's blood sugar levels remained low, and cannot explain why that was the case.
Letby says another nurse and Dr Ravi Jayaram came to assist Child M. She says she cannot recall any observation or discussion of discolouration on Child M's skin.
Letby says she left later than 8pm that night as she had a lot of documentation to file at the end of her shift. A nursing note for Child M by Letby is recorded as being written between 9.14pm-9.22pm on April 9. Letby said this was after attending to the clinical needs of Child M. Letby said she would write contemporaneous notes on the back of handover sheets or on paper towels to keep track during the day.
The court is shown a few notes written on paper towels which were recovered from 'the Morrisons bag' at Letby's home by police. There are also medical notes on sheets of paper. They feature notes in the resuscitation of Child M. Letby says the notes were kept in the pocket of her uniform, and came home in her uniform. She says she did not have any other use for them. Also among the notes is a blood gas printout for Child M. Asked to explain that note, Letby says she had put it in her pocket and taken it home. Asked by Mr Myers why she hadn't binned it: "That is an error on my part." She denies having any use for the notes.
Letby confirms she continued to care "quite frequently" for Child L and Child M following their events, until they were both discharged from hospital on May 3. Nursing and family communication notes by Letby in respect of Child L and Child M are shown to the court on April 16, 17, 24, 25, including when Letby had been their designated nurse. "I did my best for them," Letby tells the court.
Mr Johnson moves to the second insulin case, for Child L, who was a twin to Child M. Letby's defence statement said she had done nothing wrong and had not deliberately harmed either twin. Letby agrees this was a case when she challenged doctors if she believed the course of care being given was not correct. Letby said in her defence statement the unit was "exceptionally busy" on April 9, 2016, the day after Child L and Child M had been born. Letby said, at the time, she "could not understand" Child L's insulin levels at the time and "could not understand" why there was not an investigation at the time.
Letby denies 'using' the hypoglycaemic pathway not being followed as an 'opportunity' to attack Child L.
Letby says she accepts someone put insulin into the dextrose solution for Child L, and accepts there would be "no reason" for doing this, and that it would be "highly dangerous".
Letby accepts the blood results 'prove' insulin was placed in the
dextrose solution. Prof Hindmarsh had previously given evidence to say insulin had been
administered between midnight and 9.30am on April 9.
NJ: "Do you accept that?"
LL: "Yes."
Mr Johnson says the insulin administered to Child L was a 'targeted
attack' as the dextrose bag had been in place since noon on April 8. "It follows that
insulin was administered while the [dextrose] bag was hanging, doesn't it?"
Letby: "I don't know." Mr Johnson talks through the process and repeats that, from
evidence, the bag must have been in place when insulin was administered.
LL: "If that's what the expert suggests, yes."
NJ: "It follows that it was a targeted attack?"
LL: "I can't answer that."
Mr Johnson says the only two staff members on duty for both days, when Child F and Child L were poisoned with insulin, were Letby and Belinda Williamson [Simcock]. A staffing rota for the April 9 day shift is shown to the court. Child L and Child M are in room 1, with designated nurse Mary Griffith. Letby is designated nurse for two other babies in room 1. Belinda Williamson is the designated nurse for three babies in room 3. Four babies are in room 2 and four babies are in room 4.
The neonatal schedule for April 9 is shown. Mr Johnson says it is to
show what Lucy Letby was doing between 9am-9.30am. The schedule shows Letby was a
co-signer for medication for one baby in room 2, and giving a feed to her designated baby
in room 1. Letby was the co-signer for medication for a room 1 designated baby around
9.10am. Mr Johnson says a series of prescriptions for three different babies at
9.25-9.29am, co-signed by a nursery nurse and Mary Griffith, gave Letby the "opportunity"
to administer the insulin for Child L. Letby says: "No, I don't know how the insulin got
there." Mr Johnson says it has already been established the insulin was administered on
the unit, on the bag that was connected to Child L throughout that time.
NJ: "That's what it's a targeted attack, isn't it?"
Letby pauses.
NJ: "What do you say?"
LL: "Not by me it wasn't." Letby says she can "only answer for herself" in relation to
the accusation by Mr Johnson that the insulin poisoning for Child F and Child L "can only
be you or Belinda Simcock".
Mr Johnson says despite the fact the bag was changed at noon on
April 9, the insulin kept being administered to Child L, "didn't it?"
Letby: "Yes."
Mr Johnson says "we know that" because the blood sample taken to the lab
was taken at 3.45pm "contained exogenous insulin".
Letby: "I can't recall."
Mr Johnson says Child L was targeted with a second bag of
insulin.
Letby: "I'd have to be guided by the evidence - the expert evidence."
Mr Johnson says
a third bag is hung up at 4.30pm. The hypoglycaemia "continued".
Letby agrees.
The fourth bag, hung up the following day "when you [Letby] were not working"
was put up, and the hypoglycaemia "gradually resolved".
Letby agrees.
Mr Johnson says the reason for the hypoglycaemia was that someone
had poisoned Child L through 'at least two' bags of insulin.
LL: "Yes."
NJ: "And that was you, wasn't it?"
LL: "No."
See also: INQ0102352 – Witness Statement of Dr Sudeshna Bhowmik, dated 20/06/2024
Dr Sudeshna Bhowmik, who was working as a paediatric trainee at the time in April 2016 at the Countess of Chester Hospital, has been called to give evidence.See also: INQ0017825 – Witness Statement of Amy Davies, dated 10/04/2024
The court is now hearing evidence from Amy Davies, a neonatal practitioner who was employed in the neonatal unit at the Countess of Chester Hospital in April 2016. At the time, she was in Band 6.See also: INQ0106972 – Witness Statement of Dr Anthony Ukoh, dated 20/07/2024.
Dr Anthony Ukoh is called to give evidence.See also: Dr U's oral testimony at the Thirlwall Inquiry
Taken from Daily Mail as more detailedSee also:
INQ0008978 - Pages 4 & 5 of letter from Dr John Gibbs to Mother & Father C re Child C's death, dated 24/09/2015
INQ0001993 – Page 14 of Witness statement of Dr John Michael Gibbs, for the trial of R v Letby, dated 20/11/2017
Dr John Gibbs' oral testimony at the Thirlwall Inquiry
See also: Dr Anna Milan's oral testimony at the Thirlwall Inquiry
From Dan O’Donohue Twitter (20/02/2023)