Count 16: Attempted murder of Baby M on 9 April 2016. Alleged mechanism: Air Embolism
BABY 13 SUMMARY [Baby M]
Baby 13 was a 33+2/7 week, 1.703 kg birth weight, twin 2, preterm male infant, with severe
intrauterine growth restriction (IUGR) who was delivered by elective Caesarean section for
oligohydramnios and IUGR of the first twin. He was born breech and bagged at birth for
being slow to pink. He was plethoric (Hb 190), jaundiced (serum bilirubin 57, above
phototherapy threshold), hypoglycemic (blood sugar 1.9) and was treated for possible sepsis
with antibiotics and phototherapy. His white cell count and CRP were not raised. At 1215
hours the next day, he developed fever which subsided with change in environmental
temperature, increased work of breathing, distended abdomen and bile stained nasogastric
(NG) aspirates. The nurse was concerned enough to call the registrar, who stopped feeds and
put the nasogastric tube to free drainage. Four hours later, Baby 13 developed apnoea with
desaturation and low heart rate. He was resuscitated, given cardiac massage, adrenaline X6
doses, bicarbonate X2 doses, saline X2 doses, intubated and ventilated. Strangely, 2 doses of
adrenaline were given before his airway was secured. He stabilized and was extubated the
next day. A Eustachian valve was detected on cardiac echo. He improved and was discharged
at a month of age.
CONVICTION
It was alleged that air was injected into the intravenous system, causing air embolism and
collapse.
PANEL OPINION
Baby 13 had signs of possible sepsis from birth, including jaundice requiring phototherapy
and hypoglycemia, and was treated with antibiotics. The next day, he clinically deteriorated
for 4 hours prior to collapse, with abdominal distension, increased work of breathing, raised
temperature, and bile-stained NG aspirates, and which were of concern to the nurse and
registrar. The acute episode of desaturation and bradycardia was likely triggered by apnoea
from sepsis, abdominal distension with ileus, and prematurity. It could also be due to the
cardiac Eustachian valve, which can cause episodes of desaturation and bradycardia due to
intermittent right to left shunting of blood through the foramen ovale. The resuscitation was
chaotic, with adrenaline X2 doses given before the airway was secured. Air embolism is
sudden and catastrophic and does not present over 4 hours with gradual deterioration, and
the infant would not recover quickly. Patchy skin discolorations are caused by dilation and
contraction of small blood vessels in the skin in response to hypoxia, which can occur in many
conditions and are not diagnostic of air embolism. Non-specific localized patchy skin
discolorations have not been reported in infants with venous air embolism, including IV air
injection, and only Lee’s sign and Liebermeister’s sign are diagnostic of air embolism (Zhou Q,
Lee SK. Am J Perinatol 2024 Dec 27. doi: 10.1055/a-2508-2733). If air was deliberately
infused through a central venous line to cause air embolism, the line will have to be reinfused
with fluid to prevent detection. Collapse from air embolism occurs instantaneously. It is
doubtful this can be achieved quickly enough before other staff in the unit respond to the
collapse.
CONCLUSIONS
1. Baby 13’s desaturation and bradycardia was caused by apnoea from sepsis or the
Eustachian valve.
2. The resuscitation was suboptimal.
3. There was no evidence of air embolism
Mr Myers refers to the case of Child M, and outlines the events that took place. He says it was established he was in a corner of room 1 on April 9, which "wasn't ideal" as the unit was busy. He says Letby was "doing nothing" to harm Child M, and had participated in giving antibiotics 15 minutes prior. He says Dr Evans and Dr Sandie Bohin had worked in a theory of how slowly air embolus could take effect. He says that theory is "unbelievable".
Mr Myers said Letby, on April 9, had other babies to look after that day, with their own issues. He refers to a note by Mary Griffith on April 9 for Child M to say there was an underlying problem prior to the 4pm collapse. He says by 3pm, Child M was made nil by mouth, and says it can be argued that was 'not a great direction of travel for him'. He says if it is accepted that the 4pm event is a signficant escalation, it does not show Letby caused harm at that time.
The trial is now resuming after its lunch break.
Mr Myers is continuing to deliver the closing speech in the case of Child M. He says air embolus was the mechanism proposed by medical experts as the reason for collapse. He says Dr Evans and Dr Bohin referred to discolouration. He says the only witness for that was Dr Jayaram. He says the description is not made in the contemporaneous notes, as they were not there for Child A.
Mr Myers says none of the other staff, including Dr Ukoh, give a discolouration description for Child M. He says Child M did make a good recovery, gradually, from the collapse. He says the significant issue is Letby's last contact with Child M is when she is involved with administering antibiotics at 3.45pm, and if air has been administered at that time, he says it would not take 15-16 minutes to have effect. He says air embolus is fast acting. He says the amount of air alleged to be administered in this case is 0.5ml. He says if there was an intention to kill, it would have been larger. He asks how someone would measure 0.5ml or calculate it. He says even a minute quantity would have a quick impact. He says fortunately, neither twin of Child L or Child M appeared to have suffered harm as a consequence. He says the theory of air embolus is "utterly unrealistic" for Child M.
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.
Nicholas Johnson KC is continuing to cross-examine Lucy Letby, turning to the case of Child M. Letby confirms there is nothing she wishes to change in her evidence given in cross-examination so far.
Mr Johnson says for Child M, Letby - in her defence statement - said Child M 'was slotted into a space' in nursery room 1 which was 'full'. Child M was 'apnoeic', and it was not known if he had a desaturation. A crash call was put out, and Child M was turned around in an incubator by a nursing colleague, to get him on to a monitor. Letby added she did not notice any skin colour changes in Child M at the time.
Letby said in her statement she had written notes on Child M's resuscitation on a paper towel which ended up in her pocket and were taken home with her. Letby tells the court it would have been used to write up [nursing] notes. Letby says Child L and Child M 'stood out' in her mind at the time, as they were the first twins delivered where she was the allocated nurse. Letby agrees Child M was 'not an intensive care baby' and had been doing well.
Asked if staffing levels were a contributory factor in Child M's collapse, Letby says the "unit was very stretched" during the April 9 shift. She adds she does not know what caused Child M's collapse. Asked to clarify by Mr Johnson, she says it "was a potential" factor. Letby tells the court Child M had been in a corner unit in a full nursery, and "as nursing and medical staff we were very stretched that day". Staffing "was not at a great level". Letby says she "does not know" what caused Child M's collapse, so rules out a mistake by staff. She says it is "hard to say" if staff competencies were a factor in the collapse.
Mr Johnson says Dr Ravi Jayaram observed skin colour changes in Child M at the time of the collapse. He says "because [Child M] was darker skinned, it was more obvious." He said Child M was pale with pink 'blotches' on the torso that would 'appear and disappear'. He said he noted the most 'obvious' patches on the abdomen. "I noted them when I got there at the start of the resuscitation". He added he had only seen that once before, in the case of Child A. Letby says "I did not see anything like that, no".
Letby is asked if the lighting was an issue in nursery room 1. Letby had told police in interview the lighting was "poor" in room 1, and she tells the court she has an independent memory of that event. Child M was "in a darker corner of the nursery", Letby tells the court. She added to police: "I do remember his [Child M] colour being harder to assess as he was an Asian baby." Letby tells the court the colour change, if any, was more difficult for her to see.
Mr Johnson asks why was it necessary for Child M to be in a corner of room 1 if there were four babies in there for a capacity of four. Letby says there always needs to be an incubator free for emergency admissions in room 1. There were four babies in nursery room 2, three in nursery 3 and four in nursery 4. The court hears the neonatal unit was "at effective capacity".
The court is shown a clinical note by Dr Anthony Ukoh, made at 10.25am on April 9. Letby says she does not remember if she had involvement with Child M at this time. Child M was not Letby's designated baby on this day. A neonatal schedule for Letby on April 9 shows a number of duties Letby had for her designated babies in room 1 between 9am-9.11am. Letby says one of the designated babies was "not a low-maintenance baby", with complex cannulation issues, and was on the ward for a long time. Mr Johnson says Letby has an "extraordinary memory" for this baby, seven years on, but not for Child D, who had died.
The court is shown a 1.5ml bile-stained aspirate is recorded for Child M, following which Child M was nil by mouth, and the nasogastric tube was put on free drainage. Mr Johnson says at 3.30pm, a 10% dextrose fluid bag is started for Child M. Letby agrees with Mr Johnson there is nothing to suggest insulin was put in this bag. Letby says she cannot recall what Mary Griffith was doing at this time. Mr Johnson suggests this was when Ms Griffith was collecting a blood sample for Child L to be 'podded' and sent to a laboratory for analysis.
Letby says she "couldn't say" how long it would take to draw up a 12.5% dextrose solution, which in this case was for Child L, the twin of Child M. Letby agrees it would have been after 3.45pm that that process would have started. Letby denies that it was around 3.45pm that she "sabotaged" Child M.
Mr Johnson says the twins' mother said in an agreed evidence statement, she had to be taken back to the unit in a wheelchair, having been alerted by nurse Yvonne Griffiths, and she observed "one of the doctors was pressing [Child M's] chest." Mr Johnson says this is another case where a baby collapsed when the parents were away. Letby says she was with Mary Griffith at the time of Child M's collapse.
Letby agrees Child M recovered quickly following the collapse. Letby says she did not see skin discolouration, and it was not discussed at the time.
A colleague had previously told the court Child M's blood gas record sheet was disposed of in a confidential waste bin. Asked how it had ended under Letby's bed at home, Letby says she has never taken anything out of the confidential waste bin. Letby says she does not know how many blood gas records she has taken home. She says it has been put in her pocket and taken home with a handover sheet. She says she "probably" put it in her pocket, and put it under her bed. Asked why, Letby replies: "Because I collect paper".
Letby says household bills and bank statements would be shredded as they were 'there and then'. Other sheets such as handover sheets were not thought about.
Dr Ukoh's records on the resuscitation for Child M are shown to the court. Mr Johnson says the record is "meticulous", including six adrenaline doses. Mr Johnson says the data for the resuscitation efforts is on the paper towel [that Letby took home], which Mr Johnson says he must have had in his hand at some point. Letby agrees. Mr Johnson says that was in his hand at 8.25pm when he wrote up his notes.
Letby said she had to stay late that shift for the handover and writing up medical notes for Child M. She denies "waiting an hour and a quarter" to write up those nursing notes or "hanging around" to get the note Dr Ukoh had when writing up the note. Letby denies "rooting around in the bin" for the blood gas record for Child M to take home. She also denies sabotaging Child M.
See also: Nurse Ashleigh Hudson's oral testimony at the Thirlwall Inquiry
Taken from Dan O’Donohue Twitter (22/02/2023)See also: INQ0101331 – Witness Statement of Mary Griffith, dated 06/06/2024
Taken from Dan O’Donohue Twitter (21/02/2023)See also: Nurse W's oral testimony at the Thirlwall Inquiry
Taken from Dan O’Donohue Twitter (21/02/2023)See also: INQ0106972 – Witness Statement of Dr Anthony Ukoh, dated 20/07/2024
Taken from Dan O’Donohue Twitter (21/02/2023)See also: INQ0107824 – Witness Statement of Belinda Williamson (nee Simcock), dated 19/08/2024
Taken from Dan O’Donohue Twitter (21/02/2023)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