LADY JUSTICE THIRLWALL: Good morning.
Mother A&B, I know I'm going to refer to you by that description, but I do know that underneath that description is a real person, and I won't forget that.
Thank you very much indeed for coming to give evidence this morning. I know you'll be nervous, and I think the best way of dealing with that is just to get on with it, so that's what we'll do.
THE WITNESS: Yeah.
LADY JUSTICE THIRLWALL: First of all, then, I'll ask Tim Suter to do the affirmation with you.
THE WITNESS: Okay, thank you.
MOTHER A&B (affirmed)
Questioned by MS LANGDALE
LADY JUSTICE THIRLWALL: Thank you. Ms Langdale.
MS LANGDALE: Mother A&B, as you know, I'm Counsel to the Inquiry, and I'm going to be asking you questions. If at any time the wi-fi or signal means that you can't hear me, or I can't hear you, please just put your hand up, and we'll know straight way.
MOTHER A&B: Okay.
LANGDALE: If you want a break at any point, put your hand up, and we will know straight way.
You provided a statement to the Inquiry dated 17 July 2024. Can you tell the Chair whether the contents are true and accurate, as far as you're concerned?
MOTHER A&B: Yes.
LANGDALE: I'm going to take you through that statement, and I'm also going to take you to some documents. I know you would prefer me to read those documents, rather than you finding those electronically, and I'll do that or read parts of it as we go through your evidence.
The first thing I'm going to do at your request is to read your victim impact statement that you gave at the end of the criminal trial.
MOTHER A&B: Okay.
LANGDALE: And you said this:
"2015 was going to the best year of our lives. We were going to become parents to a little boy and a little girl. Everything was perfect. Our babies were doing well in the neonatal unit. We were told that [Child B] needed a little bit of extra help but was doing well, and that [Child A] was very strong and doing really well. Never could we have imagined that the most precious things in our lives were placed under the care of an evil monster. We never got to hold our little boy while he was alive because you took him away. Our minds are traumatised that it won't let us remember most of the night where you killed our child. What should have been the happiest time of our lives had become our worst nightmare.
"After losing [Child A], not only were we absolutely traumatised at what had happened, we were riddled with fear for our baby girl, [Child B]. We weren't there when [Child A] collapsed, and by the time I was brought through to him, he was gone, despite all the efforts to revive him. You had been successful in your quest to cause maximum pain and suffering. We are so thankful that we had that fear for [Child B] as it saved her life, not allowing you to fully do the same to her as you did to [Child A].
"After losing [Child A], we made sure that there was always a member of family at her side watching. However, we made a mistake. We started to believe that what happened to [Child A] was a tragic event that we couldn't have stopped. We trusted that [Child B] would be given extra special care. It had certainly appeared that way. Little did we know that you were waiting for us to leave so you could attack the one thing that gave us a reason to keep going on in life. We are forever grateful that you wasn't able to take [Child B] away from us that night.
"Although our family has a gaping hole where [Child A] should be, there is a constant shining light in [Child B]. You tried to take everything away from us. You thought it was your right to play God with our children's lives.
"Our lives are tough. We struggle with anxiety, depression and PTSD and sometimes we almost want to give up, but we never will. We have a duty to our children. We have a duty to keep [Child A]'s memory alive for generations to come, and we have a duty to give [Child B] the best life possible, and we will spend our lives doing that.
"You thought that you could enter our lives and turn it upside down, but you will never win. We hope you live a very long life and spend every single day suffering for what you have done. Maybe you thought by doing this you would be remembered forever, but I want you to know my family will never think of you again. From this day, you are nothing. I hope they lock you up and throw away the key."
LANGDALE: I'm going to move to paragraph 7 of your statement and begin to ask you about your experiences at the Countess of Chester Hospital.
So you tell us in these paragraphs, and perhaps tell us in your own words now, what treatment you received when you were pregnant at the Countess and moving towards when you had your caesarean section and the birth. What was it like, your antenatal care and generally? How did you feel?
MOTHER A&B: The antenatal care was -- I mean, I had a couple of specialists who realised it was a high-risk pregnancy, so the antenatal care was good. I was being looked after by another consultant at a different hospital for my condition.
LANGDALE: Yes. And do you --
MOTHER A&B: But the antenatal care with the consultant was good.
LANGDALE: And you had some care at the Countess, didn't you, and some consultant care, so split care type of arrangement.
And how did you feel, knowing you were expecting twins?
MOTHER A&B: Really excited. Even more so when I found out it was a boy and a girl, and I sort of got one of each.
LANGDALE: And you actually spent some time in the Countess of Chester before the caesarean section, didn't you?
MOTHER A&B: Yeah.
LANGDALE: And how was that, that period of care?
MOTHER A&B: The only time that I didn't feel very comfortable was the day that I was admitted, and somebody from the neonatal unit came and told me about -- that they were going to show me around and things and basically how high risk it was and how, you know -- because, at the time, I was 29 weeks and basically put the fear of God in me.
LANGDALE: You actually --
MOTHER A&B: But other than that, the actual care on the maternity ward was really good.
LANGDALE: And you had -- you tell us at paragraph 20 of your statement you had -- you were 31 plus two weeks, and you had a caesarean section; yes?
MOTHER A&B: Yeah.
LANGDALE: And [Child B] and [Child A] were delivered at 8.30 and 8.31 pm. [Child A] weighed 3 lbs 12 ounces, and [Child B] weighed 3 lbs 11 ounces; yes?
MOTHER A&B: Yes, that's correct.
LANGDALE: And when you came round, what do you remember? You set out from paragraph 21 what you were told about the babies and how you felt. How was it?
MOTHER A&B: That [Child A] needed a little bit of extra -- no, [Child B], sorry. I'm getting them mixed up. [Child B] needed a little bit of extra help.
LANGDALE: Yes.
MOTHER A&B: But that [Child A] was doing really well for a premature baby. Really well.
LANGDALE: And you'd had a general --
MOTHER A&B: In fact one of the nurses -- sorry.
LANGDALE: No, no. Go.
MOTHER A&B: One of the nurses actually told my partner that she'd never seen a pre-term baby doing as well as he was.
LANGDALE: And you'd had a general anaesthetic, so what happened to you after you had had the babies?
MOTHER A&B: Well, it was in the evening, so I was just encouraged to rest.
LANGDALE: So --
MOTHER A&B: I remember being really thirsty, but I was on low [fluid?] restriction, so I was kind of only allowed to have a certain amount of fluid per hour. So I was sleeping and then waking up at every hour to have the amount of fluid that I was allowed. The neonatal unit brought through, because I asked -- because obviously I was going to be under a general anaesthetic, I did ask to have photos taken so that I could see them as soon as I woke up. So they brought through, like, two little cards with a photo of each.
LANGDALE: So did you see them in person that first night or not?
MOTHER A&B: No.
LANGDALE: But you tell us your partner went into the unit and had taken some photos and you saw them?
MOTHER A&B: (Witness nodded) Yeah, on the photos, yeah, but not physically saw them.
LANGDALE: The next morning, you asked if you could go and see your babies first thing. Were you aware able to do that?
MOTHER A&B: No.
LANGDALE: Why not?
MOTHER A&B: Because they told me that they were trying to insert long lines and that I would need to wait. I also asked several times throughout the day and was told that exact same thing. I was only allowed to go through when the consultant that was looking after me came through, and I actually complained to her and told her that I hadn't seen them yet and that I really wanted to, and it was quite distressing that I wasn't allowed to go through.
And that was only then that that consultant went through and told them that I was able to go through and see them, but even then, I had to wait about two hours.
LANGDALE: At paragraph 26 of your statement, you say this:
"When I first went to the neonatal unit, I went to see [Child B] because I'd been told she'd had breathing difficulties at birth and had needed medical assistance to start her breathing. I was told by a nurse that she needed a little bit extra help. I took the nurse's comments to mean that there was now nothing to be concerned about."
Do you remember that?
MOTHER A&B: Yeah, that's true.
LANGDALE: You tell us in your statement, from paragraph 30 onwards, later that day you were in your room, and you heard nurses discussing [Child A], or you -- or Father A&B --
MOTHER A&B: My partner.
LANGDALE: Yes, father heard. And what are you aware that he heard being said, then?
MOTHER A&B: He heard them say there's something wrong with [Child A], and discussing whether they should come and get me and my partner.
LANGDALE: Did someone come and get you? And what happened next?
MOTHER A&B: They came to get me when he'd already crashed and there was nothing more that could be done.
LANGDALE: You say you were wheeled down to the unit by a staff member or Father A&B -- you can't remember now -- but what scene did you come across? What did you arrive to?
MOTHER A&B: It was chaos. Absolute chaos. I couldn't even actually -- there was that many people, I couldn't even actually see [Child A].
LANGDALE: You say there were many people around his cot, and one nurse asked if you were religious and if you'd like her to say a prayer. Do you remember that now?
MOTHER A&B: Yeah, I do.
LANGDALE: What did you make of that? What did you think of that?
MOTHER A&B: Well, I'm not religious myself. My partner is. So I felt like I sort of had to say yes, even though I wasn't ready for -- to let go. So she was asking me to say a prayer, and I had got to accept that my child died before I even got to know what was going -- what was happening, or anything like that. And I understand she was probably just trying to make me feel better, but it made me feel so much worse. Sorry.
LANGDALE: Dr Jayaram spoke to you and said he needed permission to stop CPR. Was it him who asked you about that or spoke to you?
MOTHER A&B: Yes.
LANGDALE: At this point, had you ever had a chance to hold [Child A]?
MOTHER A&B: No. No. The only contact that I had with him before he died was -- he was crying when I went into the neonatal unit, so I went over, and I put my hand in and put my hand on his stomach, and that's the only time.
LANGDALE: Shortly afterwards, you were asked if you wanted the hospital chaplain to come to see you. What in fact was your need at that time? What did you want to do?
MOTHER A&B: To find out what had happened. I'd been told that my baby, for a pre-term baby, was in one of the best conditions that they'd ever seen, and then hours later, he died.
And I was told I need to go and get rest because I'd had major surgery, when what I actually needed was an answer. I was told that: we had to stop CPR because he was gone, and even if they managed bring him back, he could have been severely disabled, although I wouldn't have cared. I would have preferred to have him, disabled or not. But they still said that they needed to stop.
LANGDALE: Shortly afterwards, you were told they'd need to take [Child A] to Alder Hey Hospital for a post-mortem, "and he had to stay in a hot cot while we waited for transport to take him there."
You say you were asked, at that time, to speak to the coroner. Were you asked to do that, and how did you feel about having to do that?
MOTHER A&B: So the -- the time that it happened to [Child A], it was the evening, and my concern went straight away to [Child B], and I didn't want to leave her. I didn't want to talk to anybody. I just wanted to be there with my child. I'd already been told for nearly 12 hours, maybe even longer, that I couldn't see them. I got to see them for maybe half an hour, so if he'd been alive -- so half an hour is all I got to see my child before he died. And there was no way that I wanted to leave [Child B]. Why would I want to leave her? I only got half an hour with my other child. But they kept coming through: "You need to talk to the coroner. You need to talk to the coroner," and it was the last thing I wanted to do. And in the end, my partner got so sick of them pestering us, that he went and spoke to the coroner, just so that they would leave us alone.
LANGDALE: Father A&B remembers that it was Letby who brought [Child A] in to you.
MOTHER A&B: Yes, I --
LANGDALE: Do you remember anything --
MOTHER A&B: Yes, I remember vividly that it was her. I didn't remember at the time when I was first -- when the police were brought in and I was told her name, but as soon as I saw the picture of her face, I remembered straight away.
LANGDALE: We have seen the medical records and the conversations that Dr Brearey, Dr Saladi and others are having in the next few days, and to quote, for example -- my Lady, it's page 63 -- Dr Saladi: "cause of death is unknown", and Dr Brearey also saying to you -- sorry, it's Dr Saladi: "We don't have an explanation for the cause of death of [Child A]. We're waiting for the full post-mortem report."
Is that what they were saying to you? They did not know why --
MOTHER A&B: Yeah.
LANGDALE: -- he had died?
MOTHER A&B: Not only did they not know, they didn't expect it.
LANGDALE: They didn't know, and they didn't expect it. And we see that in the medical records, that they didn't know and they didn't expect it.
The Inquiry also has the Datix form, it's called a Datix form, which is filled in around Serious Incidents or deaths, or should be. Were you ever shown that Datix form before it was sent to you by the Inquiry?
MOTHER A&B: No, never. I wasn't even aware that a Datix form had been completed.
LANGDALE: And we know -- and my Lady, it's page 28 -- the Datix form says:
"Sudden and unexpected deterioration and death of a patient on the neonatal unit after full resuscitation requiring post-mortem."
So it sets it out. And there's also a section,
"Duty of Candour, Assessment, Patient and Family", and
"How the Patient and Family Have Been Treated" that has to be completed.
You hadn't seen the Datix form, but had Dr Brearey, Dr Saladi -- you'd understand that it was unknown or unexplained, from their point of view, at this point?
MOTHER A&B: Yes.
LANGDALE: [Child B] -- you set out in your statements how you wanted to be with [Child B] afterwards, and was that -- was it possible? Were you able to do that? Could you sit with her?
MOTHER A&B: Yes. Yeah. The night that it happened, they were very good at letting us stay and letting us sit there, but towards the afternoon of the second day was when they were telling us that they would allow it for now, but we would need to go back to the rules, basically.
LANGDALE: You say also in your statement -- how did hearing alarms on the ward generally make you feel, having lost [Child A] and when you were with [Child B]? What was that time like for you on the ward?
MOTHER A&B: Unbearable. Even now, if I visit family or anybody in hospital and I hear those beeps, it makes me want to cry. It is something that we -- both myself and my partner -- we cannot deal with, hearing that noise, because that's obviously the noise that indicates something is wrong.
LANGDALE: You also tell us at paragraph 57 that the nurses would try and encourage you to go and rest when you were sat with [Child B], but unless the father was there -- or you found that really difficult to do.
I think the screen is frozen.
MOTHER A&B: -- and when I was sat by -- oh, sorry.
LANGDALE: That's okay. We lost you for a moment. I don't know if you heard the question, but it was: how you were feeling at that time, sitting with [Child B].
MOTHER A&B: The only time that I felt relaxed or comfortable was sat by [Child B]. And every time I had -- because I'd just had major surgery, so moving around was not easy, you know. It took me a while to get out of bed to get into the room when they were resuscitating [Child A]. So I didn't want to leave the room with [Child B] because it might take me too long to get back. And it was the only time that I felt comfortable.
I actually had -- my consultant came on to the unit to check my blood pressure, and it was the only time that it was stable, was when I was there with [Child B]. But they kept telling me that I needed to rest.
LANGDALE: And you say: during the night, you set your alarm on your phone for every two hours, and you'd call the unit.
MOTHER A&B: I would, yeah.
LANGDALE: One night, you rang at about 4.00 am, and there was a bit of a confusion about whether the call -- well, do you want to tell us what happened?
MOTHER A&B: So I called every two hours, and me and my partner would sort of take it in turns, but most of the time it would be me because I couldn't sleep properly. I called, and I said: I'm just calling to check on [Child B], which is what I did every night every 2 hours, from when I left the hospital. Normally, they would just put me through to the nurse, so they told me: "I'll put you through,"
and the next thing, I was on the phone to -- I don't know whether it was a consultant or a registrar, but it wasn't a nurse, and there was a child crashing, and he asked me -- he told me he'd given them a certain CCs of adrenaline, am I coming in? So naturally, panic, because in my brain: why hadn't they rang me if something was happening with my child, like I asked them to do every night? Even though I called every two hours, I asked them to call me if there was anything.
LANGDALE: Then the next day, was it explained to you that that should have been a conversation with somebody else?
MOTHER A&B: It was, but I was made to feel like I'd done something wrong. When I walked in that unit, everybody turned their head to look at me, and I was taken off into a room to be explained that to. They did apologise, but the atmosphere when I walked into that unit was as if I'd done something wrong.
LANGDALE: Turning now to the cause of the death of A and the deterioration of B. I'm going to read some documents here to help remind you of what they say, rather than you have to turn them up, if I can.
The first one is a letter, it's at page 25 in our bundle, and it's a letter dated 29 January 2016 to Yvonne Williams at the Countess of Chester, and it's from you, Mother A&B, and you wrote this:
"Hi Yvonne. Sorry for the delay in getting this to you. Here's the issues regarding [Child A]'s care that we have.
"1. As we were told [Child A] was so well, why was his long line not put in straight away?
"2. While myself and my partner were on the unit, we noticed the SATS monitors are not checked straight away by a nurse or doctor when they beep, so how many times was [Child A]'s monitor allowed to beep without being checked? How long was it beeping before the medical staff attended to him?
"3. Why, when we were told the doctors were struggling to put his long line in, was a more senior doctor not called to assist?
"4. Why were we allowed to believe [Child A]'s initial post-mortem showed nothing, when in actual fact he had a condition?
"5. Why were we not informed straight away that his long line had been put through his liver? We were told it was taken out straight away. Is this the case? And if not, why not, and why were we not informed of this?"
So this is you writing in January 2016. What was it that made you write that letter to Yvonne Williams?
MOTHER A&B: Because we had no answers. Nobody had told us. And I understand that they were -- when we were on the neonatal unit, they were telling us they didn't know and they'd never seen anything like this before, but that doesn't help us as parents. And why was nobody looking for an answer? So I was trying to get some clarification as to what happened, because as I said to you, I was only brought into the room when it was too late, so I didn't see what they actually did or what had happened beforehand, or anything like that. I was brought into the room when it was too late. So I was trying to get some answers as to what had led for, in one of the nurse's own words, a perfectly well pre-term baby to suddenly die.
LANGDALE: We've got in our bundle at 26 and 27, my Lady, a two-page letter from Dr Jayaram dated 10 February 2016. And he has taken all your questions, and they have been answered. I'm not going to read all of the answers to the various points out now, but at paragraph 4, where you had said:
"Why were we allowed to believe [Child A]'s initial post-mortem showed nothing, when in actual fact he had a condition?"
Dr Jayaram replied:
"I'm not sure who fed back the PM results to you, but having read the report, the only abnormality described by the pathologist was a crossed pulmonary artery. This is a rare variant where the left pulmonary artery that carries blood from the heart to the left lung starts to the right-hand side of the right pulmonary artery. However this should not cause any problems with the function of the heart and lungs and the post-mortem report suggests that there was no issue with the heart and lungs as a result of crossed pulmonary arteries."
What did you make of that? Did you think he was saying that there was a condition or no condition that was relevant to the death of A?
MOTHER A&B: To be honest, that part of the reply made me feel better, because we thought if he'd had this condition, that could have possibly contributed to it. And as I explained, I'm very nervous -- was very, very nervous about [Child B], and I have been -- even now, I'm still very nervous about [Child B] and her health. So for me, the fact that it was sort of insignificant made me feel better.
LANGDALE: And similarly, when he's talking about the long line:
"Why were we not informed straight away?" you'd asked; that it had been put through his liver, he makes the points that he would not normally expect paediatricians to keep parents informed at every stage of the procedure, but he does also say:
"The UVC entered one of the liver veins but did not puncture the vein or enter the liver itself. The PM showed a tiny clot on the end of the line which would be expected, but the liver itself was normal, suggesting that the UVC did not cause any damage to the liver. As above, this is not an uncommon event in UVC insertion."
So how did that make you feel about the long line point?
MOTHER A&B: Well, to be honest, it didn't really -- he's put that he didn't expect to inform parents of everything, but it took him all day, so you would have thought that somebody would have given a bit more of an explanation because I was desperate to see my children but I had to wait because of these long lines. So I would have expected that it was more than normal for somebody to come and explain to me that maybe they're difficult to place, because I don't even know what -- at the time, I didn't even know what a long line was. So if they'd have come and told me what it was, what the function important that it would stop me from seeing my children? So I understand maybe that he doesn't feel that he needs to explain every detail to parents, but when something is taking that long and a parent is missing out on meeting their children for the first time ever and they've been born the night before, to me, that's just something that you should do. Because if I hadn't -- you know, if I'd have had a caesarean and I was awake, I would have saw them there and then, but I didn't because I was under general anaesthetic, so that was going to be my first chance to see them. And that was what we were told was causing the delay in us going through, was the long line insertion. It should have been better explained to us.
LANGDALE: You then had instructed solicitors, hadn't you, and we have seen a letter written on your behalf by solicitors dated 28 September, and it was sent to coroner Mr Nicholas Rheinberg. My Lady, it's page 37 of our bundle. And the letter is dated, as I've said, 28 September, Mother A&B, and what it says is:
"Dear Mr Rheinberg. Inquest concerning the death of [Child A]. I write further to the disclosure of the one-page summary regarding [Child A]'s death which was today provided by the Countess of Chester Hospital. We were of the understanding that a full investigation was taking place at the Trust regarding [Child A]'s death which would result in a report detailing the chronology of events, the issues involved, whether any errors were made, whether such errors could have caused or contributed to [Child A]'s death, and the lessons learned.
"We were told in August 2016 that this investigation was ongoing and we would be provided with a Serious Untoward Incident Report. We therefore expected to receive prior to the inquest hearing a fairly lengthy and comprehensive document dated August or September 2016. We are therefore very surprised that the Trust has now provided such a short document describing only the most superficial investigation and one that bears the date 1 July 2015. Clearly, this document is not the result of the major and detailed investigation we were told was still ongoing only a few weeks ago.
"We are very concerned that, with less than two weeks until the inquest hearing, no proper investigation report has been provided which is arguably the most crucial piece of evidence in the inquest. Without it, we and the Family's counsel are quite simply unable to prepare sufficiently for the inquest. If we do not have such a report by Monday 3rd October, we will very regretfully have to ask you to adjourn the hearing until the report has been provided and all parties have had a chance to consider it. We therefore respectfully invite you to revert to the Trust to see whether the full SUI report can be disclosed as a matter of urgency, if indeed that investigation is yet complete."
We also know, Mother A&B -- it's at page 66 -- what that one-page report was that was signed by S Brearey and dated 1 July 2015, contained a summary of your case, and learning from these changes. And underneath
"Learning from these cases", it said:
"There was notable excellence in practice and record-keeping, [it says in all three cases] although the following points are unlikely to have influenced the outcome, the following points for discussion improvement in practice were noted: no record of capnograph used following intubation. However, doctor recorded see ETT pass clearly through cords and good chest movement, verified by consultant. ETT left in for PM - no comment that was incorrectly placed on preliminary PM report. Delay in debrief."
Do you remember that one-page report that you were sent, a one-page typed report, or not now?
MOTHER A&B: To be honest, I don't, no.
LANGDALE: Fair enough.
MOTHER A&B: I don't remember that.
LANGDALE: What we know -- and, my Lady, we see at page 38 in our bundle -- the reply from the coroner to your solicitors:
"Thank you for your letter which arrived whilst I was attending a conference. I too was disappointed with the brevity of the report which I received. However, I have no power to order a hospital to conduct an investigation and still less give directions as to the nature and extent of any investigation that is undertaken."
Later on, it continues:
"I'll not be adjourning the inquest next week; it would be inappropriate for me to do so. As you know, the Consultant Paediatric Pathologist was unable to determine the cause of death. It is to be hoped that the Pathologist with the benefit of hearing the clinical evidence may be able to give an opinion as to the cause of death, although we will have to wait and see whether this turns out to be the case."
You attended the inquest, didn't you?
MOTHER A&B: I did, yes.
LANGDALE: And we've got your solicitors -- there's no publicly available record now, my Lady, of the whole hearing, but we do have a detailed file note from your solicitors, page 49 onwards in our bundle, of that inquest.
What are your -- before -- I'm going to take you to a couple of extracts of it, but just standing back, what's your memory of that inquest? What did you learn from it? How did you feel when you left it? What was the impression that you had gained from it?
MOTHER A&B: Well, it was -- the whole day was an absolute nightmare.
It started off with a big crash on the motorway, so we were running really late, which was like mass panic for us that they would start without us. It was very uncomfortable. Again, it was a situation where there was people from the hospital and everything like that, and when we walked into the room, it was that feeling of: we've done something wrong. I felt like it was a waste of time, if I was being completely honest, because nothing came of it.
I don't feel it was sort of thorough as it should have been. It seems to have been -- it was just a case of: this was unexplained, and that's that. And as hard as it is to take, me and my partner on that day, although we were very upset, what else could we do? It just seems to be that throughout this whole process, it's been forgotten by the Countess that we are people and they're our children. And it just -- that's how it feels.
LANGDALE: I'm going to read to you now from page 49, the first one, some of the evidence that Dr Saladi and Dr Jayaram gave and ask you if you remembered that.
If we look at page 49 of our bundle:
"Mr Rheinberg asked [that's the coroner] Dr Saladi whether he had any worries about [Child A], and Dr Saladi confirmed he had no worries at all. After his breathing had become regularised immediately following birth, all was looking well, and he would not have anticipated any complications. Mr Rheinberg then touched briefly on Mother A&B's condition, and Dr Saladi confirmed that this would not have had any impact on [Child A]."
Do you remember him giving that evidence?
MOTHER A&B: Not really, to be honest.
LANGDALE: Fair enough. Then if we go to page 53, Mr Rheinberg moved on to questioning Dr Jayaram. He confirmed that he was handed over to from Dr Saladi:
"[Child A] was very stable when he came on shift, and he knew about the need for gaining central access."
If we go over the page, 54:
"Dr Jayaram saw the X-ray after the line had been removed, and [in his opinion] the line again was in an acceptable position. He did not think the tip of the line was in a position which would have caused problems."
And if we go over the page to page 56:
"Dr Jayaram was then brought in to try and assist with his paediatric knowledge of the circumstances... Mr Rheinberg asked Dr Jayaram whether or not he'd seen anything similar. Dr Jayaram confirmed that normally death in neonates is the end point in a cause of events and normally they can be resuscitated. He confirmed that there had been similar cases of neonates dying in similar circumstances on the unit which they've not been able to explain. He confirmed that they have therefore downgraded the unit so that they do not care currently for preterm babies, and they have also requested an independent review, and they are still awaiting the formal report.
"However, the initial feedback from this is that nothing can be found that is wrong with any of the training, any of the practices, or any of the equipment. However there is a potential issue with staffing. As far as Dr Jayaram is aware this report is then to go back to the Executive Board, and they decide whether or not to release it to the public. Mr Rheinberg asked whether or not it would be possible for the family to receive a copy. Dr Jayaram said he's of the personal view that it should be made available for the public and he would have no issue with a copy of it being provided to the family, however as he pointed out it is the Executive Board's decision. He has to confirm however that the events that happened to [Child A] do not make any clinical sense to him at all."
Do you remember Dr Jayaram giving evidence?
MOTHER A&B: I remember him being called, because obviously he was the one that was there on the night, so we were quite interested to see what he had to say. And I remember him saying that he couldn't understand and that there was -- he couldn't find a reason.
LANGDALE: So Dr Jayaram was clear about that with the coroner or in the hearing. I've read that note of the evidence, but you remember him saying he couldn't understand it and didn't have a reason for it?
MOTHER A&B: Well, I don't know the exact words, but that was what he alluded to, yeah.
LANGDALE: We now know, of course, the report they're talking about there that they'd gone to get is this RCPCH report. Did you understand at the time of the inquest about that report or what that meant?
MOTHER A&B: We thought the report was going to give us some answers, and we were very, very disappointed when we were given a copy of it because it left us no better off. There was no answers in it at all.
LANGDALE: Moving forward in the chronology, it looks as though you phoned and spoke to a Sian Williams in February 2017, can you remember that, trying to follow up the report? We've got notes, they're her notes, of conversations about the report and whether people had it. Do you remember that or not, or do you think you did speak to --
MOTHER A&B: I remember trying -- I remember trying to get our copy and find out when we would get it, but I couldn't tell you who I spoke to.
LANGDALE: Right; so you did phone the Countess. You had solicitors, as well. So you remember that, trying to get hold of that report?
MOTHER A&B: Yeah.
LANGDALE: There's a letter -- again, it's in the bundle, my Lady, at page 40 -- 8 February 2017, from a Mr Harvey. And you tell us you don't remember receiving that letter.
This letter says, I'll read it to you, 8 February:
"Following on from your conversation with our Deputy Director of Nursing Sian Williams on Friday, please find enclosed a copy of our report. During this telephone conversation, it was explained to you that we asked for this external assessment from the Royal College of Paediatrics and Child Health and the Royal College of Nursing. This step was taken because we wanted to better understand why there had been a greater number of deaths than we would normally expect on our neonatal unit between January 2015 and July 2016. In the report, it describes no single cause or factor to explain the increase we have seen in our mortality numbers. The review makes a total of 24 recommendations across a range of areas, including compliance with standards, staffing, competencies, leadership, team working and culture. We are already working to implement these recommendations."
And it continues. And it says at the end:
"We would really encourage you and your family to have a meeting with us to discuss anything from the report that you need further clarity on."
Do you remember getting any correspondence from Mr Harvey or not?
MOTHER A&B: I don't. I remember that we were supposed to have a meeting with him but that it didn't happen. And I think that was because that -- the police were brought in and he was then not allowed to talk to us.
LANGDALE: So how did you get that report? Because you did get that report in the end, didn't you?
MOTHER A&B: Yeah. I got it through the post.
LANGDALE: So you were going to have a meeting but you couldn't have. Why did you not have one, as far as you were aware?
MOTHER A&B: Because the police were called in, and we don't think he was allowed to talk to us after that. I'm not certain that that's the reason, but --
LANGDALE: You didn't have one?
MOTHER A&B: No, we didn't have one.
LANGDALE: There's also a letter, 28 April 2017 -- page 46, my Lady -- to Mother A&B, writing to pass on the results of the independent external review regarding the care of your baby.
Do you think that's the one that was sent, that you got -- the report -- in April, or did it get it before then, or you can't remember now?
MOTHER A&B: I can't -- I remember we received it, but I couldn't tell you when, to be honest.
LANGDALE: What appears -- and again, do you remember this or not, say if you don't -- attached to that letter is a one-page typed notes of [Child A] and with cause of death unascertained. Do you remember getting that, a summary --
MOTHER A&B: No.
LANGDALE: -- in any report?
MOTHER A&B: No.
LANGDALE: And it may be that you did, you just don't remember now.
MOTHER A&B: It may be that I did, but I don't remember.
LANGDALE: You were, we can see, with the instruction of your solicitor and your attendance at the inquest, trying to find answers as to why [Child A] died. Did you feel at any of these moments getting the report or communicating with the hospital you got any answers?
MOTHER A&B: No. It feels as if the more they tried to sort of -- like I say, with Dr Jayaram's reply to me and everything, it just felt really half-hearted, and that's why I wanted to say: we are human beings, and we'd lost our child, and at no point did I think that anybody was trying. I think it was just a case of: he was a patient. He died. That's the end of it. Move on. I don't think that they ever tried to understand how it was affecting us, and the fact that we never had a reason -- to me, it was really important for them to try and do everything they could to give us a reason, and to me, they just didn't care. They just did not care. We weren't even -- I just didn't even feel like they thought of us as people, that they thought of [Child A] as an actual baby that had died. It was just a patient.
LANGDALE: When you say "they didn't care", you obviously spoke to Dr Saladi, Dr Brearey and Dr Jayaram at the inquest.
When you say "they", who do you mean by "they"? Do you think -- do you include everyone at the hospital, or do you think the doctors were talking with you and showed care?
MOTHER A&B: At the inquest, Dr Jayaram was -- approached us and was very nice, and, you know, but just, in general, when we were on -- I mean, what you have to understand is: I had to walk through them doors and sit there all day every day to visit my child who was still alive. That was also the same place that I had to walk past where my other child had died. And I remember we were in the nursery once, and a new baby had been put in the incubator space where my little boy had been, and you can't help but look. You can't help it because there's now -- and he's a little boy. You can't help but look, and one of the nurses basically sort of said, "What are you looking at?" You know, it's just -- we are human beings, and we were looking because that is the space where our child was. And it's a human reaction, I think.
I had to go on to that unit for four weeks after I'd lost my child to try and care for my other child, and I don't think that they understood that. I just think that they just thought, like a conveyor belt, we're just a patient; we're not a person.
LANGDALE: Did any of the nurses have a conversation with you about how that felt?
MOTHER A&B: A few of the nurses were brilliant. I can't lie. A few of them were brilliant. But I was being told to rest all the time. And I remember there was an incident where I actually shouted at one of the nurses because she'd -- every night when I would leave -- so I would wait until the night shift took over so I would know who was looking after [Child B]. And every night, they would say, "Why don't you try and sleep tonight?" And as I -- I just would sort of say, "I'll see. I'll see."
But then there was one night -- I can't remember even what had happened that day, but I was obviously not feeling good, and the nurse said to me, "Why don't you just sleep tonight?" And I turn around, and I shouted at her, and I said, "If I had my baby at home, I'd be awake every two hours. I need to do what I feel is right." And to me, to call and check on my child when I would have been awake feeding her, if she was at home with me, is the least I can do. And just because she's in hospital doesn't mean I'm not her mother.
But it was hard having people tell me what I should do. It was as if people forgot that they are my children. That's my child. And I know what's best for my child. But I was constantly being told what I should do, what I shouldn't do. There was just so many things, and you were made to feel -- you're not -- so we were told that we're the parents. We're the parents. It's up to us. But they were just words. We were never actually given any respect as the parents.
LANGDALE: You mention in your statement -- it's paragraph 44, my Lady:
"At [Child A]'s inquest, I heard for the first time staff had witnessed blotching/mottling, travelling across [Child A]'s chest and body. I was not aware of this at the time of [Child A]'s death. When [Child B] collapsed, I saw mottling/blotching on her, as did the doctor, but I was not told, either then or subsequently, that the same or similar had been seen on [Child A]."
Can you tell us a bit more --
MOTHER A&B: No, so I was told that he -- that she collapsed in the same way that he did.
LANGDALE: Right. So do you --
MOTHER A&B: But not as -- [audio disruption] Sorry, can you repeat that? I didn't catch that.
Did I see ...?
LANGDALE: You say there, you saw mottling/blotching on her. Did you see that? Can you remember that for [Child B]?
MOTHER A&B: Yes. I even took a photo of it a day later, and you could see -- not as -- it wasn't as prominent, but I did take a photo the next day, and it was still there slightly --
LANGDALE: Did anyone ever discuss that with you at any stage, the rashes?
MOTHER A&B: No. Well, at the time, the on-call consultant asked me if she could take a photograph of it because they hadn't seen it before. So I said yes. And by the time the nurse had gone to get the camera to take the photo, it was resolving, so they didn't bother, which to me is only half a job because they should have took a photo of it, especially knowing what we know now.
That could have been anything. That rash could have been absolutely anything. It could have been a deadly virus that was going to spread throughout the whole hospital, and it was just a case of: oh, it's gone now. Never mind. Which is why I took the photo the next day when I could still see it a bit.
LANGDALE: Moving on now to suspicions and concerns regarding Letby. When did you first know or have any indication there was suspicions about either deaths at the hospital or Letby's care of children?
MOTHER A&B: When the police called me.
LANGDALE: And what did they tell you when they called you?
MOTHER A&B: That they were brought in to investigate the number of deaths over the neonatal unit. They didn't tell us that they suspected a person. We thought that they were being called in because there'd been, you know, negligence, not enough staff or something wrong with the equipment, or ...
LANGDALE: And then --
MOTHER A&B: They just told us they were going to investigate.
LANGDALE: You say in your statement at paragraph 91 -- that was December 2017 time that they first contacted you.
MOTHER A&B: No, they contacted me before that.
LANGDALE: Right, okay, so it was earlier.
MOTHER A&B: Yeah, it was earlier.
LANGDALE: And were you assigned a police liaison officer?
MOTHER A&B: Yeah.
LANGDALE: From that point onwards, did you ever have any correspondence from the hospital or not, when the police were involved?
MOTHER A&B: No.
LANGDALE: Right. Did you --
MOTHER A&B: The only time that I had anything to do with the hospital was: [Child B] had to have follow-up appointments, as pre-term babies do, up to two years.
LANGDALE: Yeah.
MOTHER A&B: But that was the only time. And while I was there, I would visit the nurses because, as I say, some of the nurses were absolutely brilliant. So I would take her in to see them so they could see how she was doing.
LANGDALE: Bereavement counselling and support now. You tell us in your statement you were asked shortly after [Child A]'s death if you wanted to speak to a bereavement counsellor, but your full focus was on the health of [Child B]. You told us that earlier as well.
MOTHER A&B: That's right.
LANGDALE: Do you want to expand on that? What was the role, as far as you were concerned, of counselling at that point for you in your specific circumstances?
MOTHER A&B: To me, counselling just -- I couldn't even -- I couldn't be away from [Child B], so how could I go and leave and have counselling? And if I opened the floodgates as to what happened [Child A], I would be no good to [Child B].
I needed to be there for [Child B]. She was my main focus at that point. And that's the only reason that I kept going, was because of [Child B].
LANGDALE: And did you find yourself more anxious about her health, given what had happened?
MOTHER A&B: Very. Very, very, very anxious. Even now, I'm still very anxious about her health.
LANGDALE: The Inquiry has asked you about your views on recommendations or what might have prevented crimes of Letby being committed. You refer to CCTV, and you say you'd like to see it used. What's your thinking about that? How could that have assisted you?
MOTHER A&B: Well, I think that it would have been a bit of a deterrent, or if not, we would have had a much clearer view of who was there and what happened at the time, without just people's statements or things like that. You would be able to see it for yourself who was there and what was happening, and it might never have happened again.
I understand that [Child A] was the first one, and maybe they couldn't have stopped her for that one, but they most certainly could have for the rest of them, if they'd have had that CCTV in place.
LANGDALE: You also give thought to the distressing situation when, effectively, you were phoning up about [Child B] and got information about another child's collapse, and you speak about the pragmatics of phone lines. How do you think that could be improved?
MOTHER A&B: It needs to be a separate number. It was the same phone number for consultants, for staff, for parents. And we were given the number -- it was called the parent line, which was supposed to be a separate line. But if that one wasn't answered, it would go straight to the other line. And that's how the mix-up with putting me on the phone to -- in a distressing situation with a child collapsing happened. It should be something completely separate.
LANGDALE: You also mention that you always spoke to clinical registrars about your babies. We know you had some conversations with consultants, we've seen them in the notes.
MOTHER A&B: (Witness nodded).
LANGDALE: But having more time with consultants --
MOTHER A&B: They only came because we caused a scene, and we shouldn't have to do that. You could never imagine what we were dealing with. We'd just lost one of our children, and nobody was telling us why, and then very shortly after, we very nearly lost our second child.
And to me, the least that they could have done was set up a separate room for me and my partner and our child's consultant to sit down while we threw as many questions as we needed to them. And they didn't do that. It would be a case of: we would catch them on rounds, and it would always be the registrar. And it was only after I think they got sick of us that we managed to speak to a consultant.
LANGDALE: You have already mentioned the mottling on the baby's skin never seen before. You say:
"If it was an unprecedented presentation, it should have been investigated more thoroughly earlier on."
MOTHER A&B: Well, when I think about it, if you look at what happened with Covid, Covid spread worldwide, and lots of people lost their lives because of it. Nobody knew that that wasn't a disease that was going to kill thousands and thousands of people. And it seems like nobody cared. It should have -- the amount that came through, sitting through the trial, I know that there was -- I don't think there was a single member of staff that was called in the trial that said they'd seen it before, apart from other children related to this case. So why was that not treated as something urgent that needed to be looked into? It could have been something wrong with the hospital equipment that was poisoning them, but nobody checked. And for everybody to be so shocked and never ever seen this before, why was something more not done about it? Because it wasn't just [Child A] and [Child B].
LANGDALE: You --
MOTHER A&B: They could have maybe stopped this sooner if they did look into it properly.
LANGDALE: You also comment that the approach of staff on the unit was to ask for your input on simple things like if they could give your babies a dummy, but when it was bigger issues such as the condition when they were born, or cause and collapse, you didn't feel there was proper consultation or discussion?
MOTHER A&B: No, there wasn't. We -- as I said to you, they explained to us: "Well, you're the parents, you know. These are your babies," but it never once felt like that. It was almost as if we were sort of -- they were in control, and we were just there to visit.
LANGDALE: One of the recommendations you suggest, you say:
"I would hope psychological screening process is implemented to assess any staff treating vulnerable patients in the future. This would be screen of their mental state to confirm they are fit to be treating patients."
MOTHER A&B: Yes, I agree with that.
LANGDALE: You suggested that. Why do you think it's important to know something about the psychology or wellbeing of people dealing with patients?
MOTHER A&B: Well, because if there was an assessment done, or if counselling was mandatory, whoever was talking to these staff might have seen some red flags. Something might have shown up in a discussion with these people, or in an evaluation, that might have needed more monitoring or maybe further assessment.
LANGDALE: You remember from the criminal trial learning that Letby had texted her friends stating that Father A&B had collapsed to the floor when she had taken [Child A] for the post-mortem. Was that true, that that had happened?
MOTHER A&B: No, it's not true. And this is what -- this is why my point about psychological evaluation is very valid. That's not normal. It was -- there was several text messages that came out through the trial that were lies, and it was -- to me, it was attention seeking, and I think that that would have -- that should really have been a red flag. And if somebody had been checking in with her and assessing her, maybe that would have come up sooner.
LANGDALE: You mention you'd like to see better reporting on the administration of medication; at least one child harmed by unapproved administration of insulin.
MOTHER A&B: Yeah.
LANGDALE: So that concerns you, the access to that drug and how it can be used?
MOTHER A&B: Well, it's not -- it's not necessarily just that. Like, through sitting through the criminal trial, it came up that there was -- one would sign and one would administer, but they didn't necessarily go and stand there while it was administered. And I understand that that is supposed the rule, but it needs to be more -- it needs to be better policed. It needs to be made sure that that happens in a hundred per cent of cases. And, again, that might have stopped what was happening, because nobody could have done anything to a child if there was another person stood there right next to them while they were doing it.
LANGDALE: And finally, you say in your statement:
"I'd hoped that a formal process is implemented to thoroughly investigate any unexplained death" carried out by independent professionals not associated with the staff involved.
Why do you think it's important that they're independent and not from the same hospital if they're investigating something at the hospital?
MOTHER A&B: Well, because the staff at the hospital have a relationship with each other. And obviously, it's going to -- as it did with the criminal trial, it took a long time before people even suspected because she was their friend. And if you're an independent person, you've got nothing to do with any of the people, including the bosses. The bosses could be covering. Friends cover for each other. If you're an independent person, you don't care about any of that; you're just looking at facts and finding out what really happened. And if somebody impartial who had nothing to do with anybody on that unit had have come in sooner, who knows.
LANGDALE: Mother A&B, they are all my --
MOTHER A&B: I just think it needs to be -- sorry?
LANGDALE: Finish what you were saying. You think it needs to be someone...?
MOTHER A&B: Independent, who's not associated. I mean, I'm not saying that it's somebody from completely outside of the hospital, necessarily, but the doctors and nurses and consultants on the neonatal unit work with each other; they have relationships. And I just think if it's somebody that is not involved in that, there's no emotion to it. It's just strictly looking at what happened.
LANGDALE: They are all the questions I have for you, Mother A&B.
Is there anything you would like to add that I perhaps haven't asked you about, or something else that you would like the judge to know about?
MOTHER A&B: Just on the -- you know how I was saying about the independent review, I also think that there needs to be given more information to the parents, because as I've stressed the whole time, we are people, and that is our child. That's our world. And I was never given an opportunity to sit in an official setting and ask questions that I wanted answered. It was almost -- and they didn't -- they didn't roll their eyes, but you know that's how I felt. Like: "Here comes this woman again asking the same questions that we can't answer" and never even tried to answer. And we were just supposed to accept that one of the most important things in the world to us was gone, and that's it.
So I think, in hindsight, there needs to be more emphasis on treating parents as individuals. As I said, some of the parents on the neonatal unit probably had a great experience, but I didn't. I lost a child on that unit. And there was never any thought given, when I walked through them doors every day, that I had lost a child on that unit, you know. There was never any thought given to that. And I just think, instead of treating me as this hysterical woman, put yourself in my shoes. How you would feel if you had to walk into the place every day where your child died. And I would have done it because obviously [Child B] was there, so nothing would have kept me out of that unit, but it was hard. It was really hard.
And I just think, treat us as people because that's what we are. And not everybody is under the same circumstances. And if I'm asking a question over and over again, it's because I need an answer. I need you to -- I need to know that you care. I need you to know that [Child B] and [Child A] are people. They're the most important people in my life. And I just think that that is something that's been overlooked through this whole process, in the press, in the trial. We had to act a certain way in the trial. We couldn't just be the parents of these babies. And all we want to do -- all we want to do is find out what happened, and we never ever want it to happen again.
And it just feels like we have been given no power throughout this whole process, throughout all this time. We've got no power. And I just think that this Inquiry is finally the chance that we are listened to, and we can give our side of things. And my side of it is: I am a person, and they are my babies, and I've lost one of them, and I very nearly lost one of the others. And that's what needs to be at the focus of everything, not Lucy Letby. Why is anybody talking or thinking about her? We're human beings, and that's how we should have always been treated.
LANGDALE: That concludes your evidence from my perspective. What we're going to do is, we're going to stop now, the Chair is going to leave the room, your lawyers will have a conversation and may have some more questions or may not. But if you maybe go and have a cup of tea or something and come back in ten minutes, the link will still be here, and we'll know if there's more questions or if we will be concluding. Does that work for you?
MOTHER A&B: Okay.
LANGDALE: Does that work for you?
MOTHER A&B: Yeah. I'll go and grab a drink and have a walk around the house.
LANGDALE: Yes, exactly. Okay, see you shortly.
MOTHER A&B: Okay, thank you.
(11.17 am) (A short break) (11.40 am)
LADY JUSTICE THIRLWALL: Welcome back Mother A&B.
I understand there are going to be some more questions for you, so I hope you've had a drink and a chance to relax insofar as anyone can do that.
MOTHER A&B: Okay, thank you.
LADY JUSTICE THIRLWALL: Now, Mr Skelton?
Questioned by MR SKELTON
MR SKELTON: Mother A&B, may I ask you just briefly about [Child B] again.
In your statement, you describe wanting to stay with her after [Child A] had died.
MOTHER A&B: Yes.
SKELTON: And could you describe what happened the first time you left her.
MOTHER A&B: She collapsed and had to be resuscitated and was attempted to be murdered.
SKELTON: What did you feel about the fact that that occurred the only time you weren't there?
MOTHER A&B: It was an absolute nightmare. I just -- my brain -- my first thought was: "Not again", and that night, I refused to leave the bedside all night. And the whole time that [Child B] was in hospital, that is the best night's sleep I'd ever got because I was right there with her.
SKELTON: You mention in the statement at paragraph 52, and you have mentioned in evidence in answer to Ms Langdale, that you recall her having a particular rash that you took a photograph of.
MOTHER A&B: Yes.
SKELTON: What had you been told about [Child A] and whether or not he had had a rash of a similar type?
MOTHER A&B: I was -- all I was told in the similarities between [Child A] and [Child B] was the way that they collapsed. The only difference between [Child A] and [Child B]'s collapse was her -- I can't remember if it was her oxygen rate or her heart rate didn't drop as rapidly, so they were able to bring her back --
SKELTON: If you --
MOTHER A&B: -- but I was not told about [Child A]'s rash.
SKELTON: If you had been told about the similar-type rash, what would you have done?
MOTHER A&B: Well, I would have demanded that something was done. I understand that there was a lot of discussion about my condition, but for some -- a consultant to tell me they had never seen this before, that indicates that something is seriously wrong. Seriously wrong. And for it -- it wasn't just a one-off; it happened with [Child A] and then the very next day with [Child B].
SKELTON: So would it be --
MOTHER A&B: That, to me, indicates that something is wrong and it should have been looked into.
SKELTON: I'm going to turn now to a wider issue. When did you first become aware that there had been an unexpected increase in mortality in the neonatal unit?
MOTHER A&B: When the police were called.
SKELTON: Would you have wanted to know about that increase in mortality much sooner?
MOTHER A&B: Yes, because maybe then it would have been easier for us as parents to push for something more to be done.
SKELTON: Would you have expected to have been told about it in 2015 when it became a concern internally within the hospital?
MOTHER A&B: Well, we attended an inquest in 2016, and it was not even mentioned then, and it had clearly -- it clearly had been an increase of a lot by then, and it still was not mentioned.
SKELTON: I'll come on to the inquest in a minute, but just focusing on 2015, if you had been told that there'd been an unusual spike in the deaths on the unit in 2015, what would you have wanted to have happen?
MOTHER A&B: The same as I would have wanted to have happened as soon as it happened with -- twice with [Child A] and [Child B]: an investigation. A thorough investigation. Not just looking into the unit as a whole; looking into those deaths. I understand that there was a report given to us that was an independent review, but it was not a review into those deaths specifically; it was a review into the neonatal unit, and there should have been a review of those deaths.
SKELTON: Over time in --
MOTHER A&B: Not just of the unit. Sorry.
SKELTON: It's quite all right. Over time in 2015, the doctors begin to suspect that one member of staff is connected to the deaths and collapses, and as you now know, that's Letby. Would you have wanted to know about their suspicions about that connection sooner than when you were first contacted by the police?
MOTHER A&B: Definitely.
SKELTON: Again, if you had been told that they thought a member of staff was responsible and possibly even harming the babies deliberately, what would you have done?
MOTHER A&B: I'd have been on the phone to the police every day asking what was happening. When was somebody going to be charged? You have to understand, we have been told -- we were told and made to believe that there was -- it was unexpected and unexplained. But it wasn't unexpected or unexplained. It was a person. And I have lived with guilt that it could have been my fault or that we should have done more for years. And it wasn't until we were told it is -- somebody is responsible. As heartbreaking as that is, it's an answer, which is something that we were never given.
SKELTON: Many months after those suspicions arose, the inquest took place into [Child A]'s death on 10 October 2016. Are you surprised now that that -- the concerns that the consultants had about a particular member of staff, Lucy Letby, weren't raised with the coroner?
MOTHER A&B: Very concerned. Very, very concerned. At the inquest, we had no idea, and from the trial we know that by that time they did suspect her, but nobody mentioned it, not once, and they should have.
SKELTON: The note that's made of the inquest records that Dr Jayaram mentioned an independent review. Was that the first you'd heard about that?
MOTHER A&B: Yes.
SKELTON: Again, and I know I'm repeating this question, but had you been told the hospital were conducting or asked for an independent review to have been conducted, what would you have wanted to have said or done?
MOTHER A&B: I'd like to have been more involved. I'd like them to have spoken to us. Because maybe we could have shed some more light on it. We could have brought [audio disruption] just would have liked to have been more involved, rather than -- as I say, there's records of me trying to chase up the review and was just told: well, that's important document that I would have got some answers as to what would have happened to [Child A].
SKELTON: Can you remember when you first got a copy of the report from that review, which was undertaken by the Royal College of Paediatrics and Child Health?
MOTHER A&B: I can't remember the exact date, to be honest.
SKELTON: It might have been in about February 2017. Do you remember seeing that document?
MOTHER A&B: I do remember seeing it, yeah. It was like a booklet.
SKELTON: Did it make any mention of concerns or suspicions about any particular member of staff?
MOTHER A&B: No.
SKELTON: Have you since --
MOTHER A&B: The only concern that was raised was staffing levels.
SKELTON: Did you subsequently become aware that there was another version of the report that did have a section on those concerns about that member of staff?
MOTHER A&B: No.
SKELTON: How do you feel about the fact that there were two versions of the report, one of which was given to you and others parents which didn't mention concerns about Nurse L, as she is termed in the report, and then another version which does deal with those concerns?
MOTHER A&B: We had a right to know. As I explained before, they are our babies. We had a right to know. And we were being -- well, I was made to believe that that report was the report. I never knew that there was another version of it that explained concerns.
SKELTON: The report that you didn't see contains a section, as I've mentioned, on Nurse L in which it's said that the consultants had made allegations about her resulting in her being removed from the unit and that they had a gut feeling that she was involved with, and linked to, the deaths, but they hadn't found evidence to demonstrate that. What's your response to that?
MOTHER A&B: It's mixed feelings, because I'm forever grateful because the consultants did speak up and did say something, but it's also very sad that nothing was ever shared with us.
SKELTON: Thank you, Mother A&B. Is there anything you'd like to add or ask arising from the questions that I've just asked you?
MOTHER A&B: No.
MR SKELTON: Thank you, my Lady.
LADY JUSTICE THIRLWALL: Thank you, Mr Skelton.
Mother A&B, that's the end of your evidence.
I can't thank you enough for coming and giving your evidence today. And you've helped me really begin to get to profoundly understand your experiences and that of your partner.
There is just something I'd like to say to you, though, because towards the end of your evidence you said that you and he felt powerless during the whole of the experiences you have described, and that's a very interesting and I'm sure accurate observation.
But what I'd like you to know is that your evidence today is amongst the most powerful I have ever heard.
I'll just say a little bit more because you caused me to reflect a bit.
Obviously, the love that you and your partner have for your children shines through, as is your -- as does your determination to make a difference to people in the future. And you've really reflected on what happened to you and how it could and should have been very different. The expression you used was: "They should have put themselves in our shoes". And that obviously is an insightful observation and one which I thought I would consider as people explain to me in due course how they behaved at various stages.
I'll give very careful consideration to all your practical and thoughtful suggestions for change that already you have made a difference and you will achieve change. Thank you very much indeed.
(11.52 am) (The Short Adjournment) (2.00 pm)
MS LANGDALE: May I call Mother C.
LADY JUSTICE THIRLWALL: Yes, please.
MS LANGDALE: And may the witness be sworn.
MOTHER C (affirmed)
Questioned by MS LANGDALE
LADY JUSTICE THIRLWALL: Thank you very much indeed. Just before we begin, I am conscious that there is an audio link this afternoon, so I just want to make one thing very clear. The accredited media and the Core Participants have an audio link to this afternoon's hearings. There is no delay on the link. As a result, we must all be scrupulous to avoid any reference and any inadvertent breach of the orders of the Crown Court.
The media knows which people must not be identified, and if there is any breach the information which has been referred to in error must not be reported. This includes, of course, information which may lead to a jigsaw identification of the people named in the orders. All such information will be removed from the transcript before it goes up on to the website.
Thank you.
Ms Langdale.
MS LANGDALE: Mother C, you have prepared a statement dated 4 July 2024 for the Inquiry, and can you confirm the contents are true and accurate, as far as you are concerned?
MOTHER C: Yes, they are.
LANGDALE: I am going to take you now, if I may, through that statement and take you to some other documents that you refer to in the statement as well.
MOTHER C: Okay.
LANGDALE: You begin by setting out your baby's delivery and your pregnancy. Can you tell us about the circumstances of your pregnancy, how it was going, and the care you received there?
MOTHER C: Yeah, so my pregnancy with [Child C] was my first pregnancy, and it wasn't going very well, unfortunately. I went for my routine 20-week scan at the Countess of Chester Hospital, and we were told at that scan that my baby was measuring much smaller than would be expected, and so from that point on, we were very closely monitored under the care of foetal medicine, that was predominantly Jim McCormack, and the foetal medicine midwife at the time was Jill Ellis. They saw us very regularly and gave us really excellent support, we were very grateful for that, but the pregnancy was very precarious, really. The scans were to monitor growth but also to monitor blood flow to weight, up until the point where the situation was critical and the baby would need delivery. So it was made very clear that my baby was going to be born early and that that would have to be by caesarean section. So I felt the communication and the support was really excellent, to be honest, but it was a very scary time.
LANGDALE: And it was a day in June 2015 when you'd been in for a scan, in fact, with Mr McCormack that the delivery ensued; is that right?
MOTHER C: Yes. So I -- in these kind of routine -- well, in these monitoring appointments that I was having -- I'd been for one on 5 June -- Mr McCormack was actually on holiday. It was Sara Brigham that I saw that day, and she felt that I needed admission to hospital for the remainder of my pregnancy because some of the parameters had worsened. So I was admitted on that day, and it was the following week that things had become critical. Mr McCormack was seeing me daily, things had become critical, and he said that delivery needed to happen that day.
LANGDALE: Was there any discussion about where the delivery should take place, which hospital, and why?
MOTHER C: So prior to my admission to hospital -- so I couldn't tell you exactly when, but during that pregnancy, I did ask Mr McCormack at one point whether I needed a transfer to somewhere like Liverpool Women's or a different unit, but he didn't feel that that was necessary. He said that he would monitor things closely and that if that changed then we would change the plan, and I completely trusted him and his judgment.
LANGDALE: When [Child C] was delivered by caesarean, when did you see him, and where did you go next?
MOTHER C: So when he was delivered, I heard him cry, so I knew that he'd been born, you know, breathing and screaming, like I had hoped. But I didn't see him when I was in theatre. He was sort of whisked off to the neonatal unit. And my caesarean was completed, and then I was taken up to the postnatal ward where I was told that I was not allowed to go down and see him until I was able to stand unassisted. I'd had an anaesthetic into my spine, so my legs were numb, and I was in pain and recovering.
I hadn't anticipated that I wasn't going to be able to see him, so this was really upsetting. My husband was up and down to the neonatal unit sort of seeing him and taking photographs and bringing the photographs up, but it was quite a difficult kind of disconnecting experience to be not allowed to see him in person for some hours. So it was later on that day, I would estimate maybe six or seven hours after his birth, that I forced myself to stand because I needed to go and see him. The neonatal unit was on a different floor of the hospital, so it did represent some challenge with that.
LANGDALE: And how did you hear how your son was in those few hours? Via his father, or via a doctor, or did anyone talk to you about how he was?
MOTHER C: Yeah, so my husband was up and down, so he was kind of updating me a little bit, but we had some updates from Dr Sally Ogden, who was the registrar, so she came and spoke to me in theatre a couple of times to sort of say where things were up to, and she let me know that he was doing really well, he was born in good condition, and that he had had a brief period where he was ventilated so that he could have surfactant, which helps the lung development, but that he was fighting it so much and that he was so lively that they didn't feel that ventilating him was necessary, so this was only for a brief period, so he was breathing by himself.
LANGDALE: You say in paragraph 6 of your statement that Dr Gibbs was present a lot on the ward and spoke to you a number of times over [Child C]'s short life. What did he say to you about how he was?
MOTHER C: So I don't recall seeing Dr Gibbs on the day that he was born, but in subsequent days, certainly we saw him a number of times on the ward, and we felt that he was very open and honest with us, that [Child C] was very small for his gestation and that that represented certain risks such as an increased risk of developing infection and an increased risk of a particular bowel complication called necrotising enterocolitis, but that he was born in very good condition, he was making good progress, and he was doing well.
He expressed to us that although babies of that gestation and that -- well, that size at that gestation -- were at risk of these complications that his prognosis was good and that he was not expected to die, certainly, and he made that very clear to us.
LANGDALE: I think it was on the second day of his life that you were able to hold him for the first time?
MOTHER C: Yes.
LANGDALE: How was he, and how was that?
MOTHER C: We've got sort of videos and photographs of that day. It was -- it was really overwhelming, actually, to hold him in. We'd had a very difficult pregnancy, and there were times in that pregnancy that I didn't know whether he would be born alive, you know, so to hold him was a really big thing for us. It was very emotional, and I -- you know, I hadn't had a baby before, and I didn't really anticipate all the feelings that I would have when I held him, and that immediate bond that you feel that, you know, I couldn't describe now but I certainly didn't anticipate. It was a really amazing feeling.
LANGDALE: Was there a time when it was decided he was able to have his first milk feed?
MOTHER C: Yes. So we'd had a few days where he was nil by mouth and receiving nutrition via his lines. Because of his sort of size and gestation, they felt that they needed to rest the bowel to reduce his risk of complications. So it was on 13 June so his (redacted) -- (redacted) day of life that he was given his first milk feed. We'd had a really good day that day. We'd spent a lot of time holding him. My parents had come in to visit, which -- we'd not had anybody in to visit until that point because we wanted to kind of settle in ourselves, and we wanted our privacy, but because things were going so well, they'd come to visit that day. John Gibbs had come to see us and had said, you know, if this day continues to go well, then we'll give him his first milk feed this evening, which is what happened.
LANGDALE: And then on the evening of 13 June, your husband set off home, and you went to express some milk.
MOTHER C: Yeah.
LANGDALE: What happened later that evening?
MOTHER C: So I'd been expressing since he was born, so I'd gone to express before going to bed. So having expressed the milk, I went down to say goodnight to him, and then went back up to go to bed. You know, I was actually quite exhausted. We'd spent all day on the unit, and I was still recovering from my surgery. So I would estimate I went up to bed shortly after ten o'clock, maybe half past ten, and I was asleep. And shortly after 11 o'clock, the door to my room was flung open by a midwife on the postnatal ward who was really panicked and was telling me that I needed to come immediately because my son had become unwell really quickly.
And I remember the absolute shock that I felt at that time. I was really disoriented. I'd been woken up from my first sleep. I assumed -- my first assumption was that perhaps she'd got the wrong room because this was so out of the blue, so unexpected. I was kind of trying to get my bearings. I remember saying to her, you know: "Do you mean me? Are you sure you're talking about my baby?" And she said, "Yes," and that I needed to come. So we made our way down to the unit. I was in a lot of pain, but the adrenaline sort of took over at that point.
LANGDALE: And when you went back to the unit, you say you walked straight into the intensive care room where [Child C] was. What did you find there?
MOTHER C: I'd phoned my husband on the way to the unit, but when I walked in, I think -- I didn't really know what to expect because I'd had this sort of panicked midwife waking me up from sleep, but what I was faced with was -- it just -- it was awful, and it took me completely by surprise, you know. There were medical personnel everywhere. There were numerous doctors and nurses. Where [Child C] had been, in an incubator with the glass sides up the whole time that we'd visited him, the sides were down. They were doing CPR on him. And it was extremely -- it was extremely busy, you know. Alarms were going off. And I really struggled to take it in.
So I was ushered to a seat several feet away but within the same room by a nurse, and I sort of sat down there because I was aware that I was in a lot of pain as well.
LANGDALE: When you went down and were met with that scene, you say a nurse came and asked you if you wanted the priest.
MOTHER C: Yeah.
LANGDALE: Tell us about that.
MOTHER C: So when I was sat on this chair several feet away, a nurse I hadn't seen before, who I'd had no previous interaction with, just asked me, you know, "Would you like me to call a priest?" And even though I was faced with a situation where my son was having CPR, I was still quite confused and disorientated as to what was going on, and until I was asked that question, it really didn't hit me that there was a chance he was going to die, which sounds probably quite strange, but I just -- my thoughts hadn't kind of caught up yet. So I asked her. I said, you know, "Do you think he's going to die?" And she said, "Yes, I think so." And at the time -- you know, as I say, I didn't know this nurse's name, I hadn't seen her before, but I believe this was Lucy Letby.
LANGDALE: And when she said, "I think so", how did you feel?
MOTHER C: I completely shut down, to be honest, at that point.
From then on, that evening, I struggled to absorb a lot of what was going on, you know. I just went into complete panic mode, you know, I couldn't -- I just couldn't take things in properly. None of the medical personnel there, apart from John Gibbs, were people that we'd met before, you know. We hadn't been on the unit for very long, and at this point, I was still waiting for my husband to arrive, so I was on my own. It wasn't a question that I'd ever thought about being asked, so I struggled to know how to really answer it. So the rest of the evening really is fractions of memory, and then lots of blurred feelings of panic, really.
LANGDALE: After [Child C] was baptised, resuscitation efforts ceased, didn't they?
MOTHER C: Yes.
LANGDALE: Tell us about what happened then.
MOTHER C: So there was quite a long wait, actually, for the baptism, and during this time, the type of resuscitation that was being performed was sort of slowed down so that it was more what John Gibbs has described as a token resuscitation, which I would agree with. It wasn't something that was actually meant to resuscitate him any more because they'd tried everything that they could up until that point.
And after he'd been baptised, he was handed to us, and I remember my husband holding him, and I sort of put my hand on his arm, and I could feel a pulse at his elbow, and I thought, you know, he's not -- he's not died, you know. He's still alive. But he was obviously not the same baby that he'd been some hours before. He was, you know, floppy and grey and not responding in any way.
And John Gibbs had a conversation with us about, you know, what we would like for him. What would be our thoughts and feelings about what happens next. And we'd had this very difficult pregnancy, followed by this really sudden, awful situation, and we'd witnessed this very long period of attempts at resuscitation, and we all felt that everything reasonable had been done and that there'd been such a significant amount of time where he hadn't had any oxygen that, you know, we just wanted him to be kept comfortable at this point.
LANGDALE: And did -- was he made more comfortable?
MOTHER C: Well, we contacted our parents, who came in and sat with us. We were sent to a family room, and we were all getting quite upset, obviously, because of the situation anyway, but because [Child C] was making some kind of noises, some distressed, whimpering noises that were really difficult to witness and to hear, so I went to the nurses' station and asked the registrar, Dr Davies, whether something could be given to settle him because I felt that he was in pain. You know, he'd had resuscitation for around an hour, you know. That would be painful for anybody. And I was told that that isn't something that they usually do for neonates. And I sort of felt I had to push it a little bit because I didn't want my son to die in pain, and I felt that he was in pain, and there was no -- there was nobody that was going to tell me that he wasn't. You know, that's how I felt as his mother. So she said she would speak to Dr Gibbs, and shortly after, one of the nurses came and gave him some morphine, and that did work, and that did settle him.
LANGDALE: You're in a family room at this point --
MOTHER C: Yes.
LANGDALE: -- are you, together, and you say:
"Two nurses were in and out to see us, one called Melanie Taylor, and the other being Lucy Letby."
MOTHER C: Yeah.
LANGDALE: What were they doing?
MOTHER C: So there were various things that they were involved with, so one of them being the administration of morphine when it was needed, another being creating things for a memory box. So taking [Child C]'s hand and footprints, taking a bit of his hair, and checking on us. So my understanding at that time was that they were designated to do that, and it was only at the criminal trial that I realised that that was not the case, that Lucy Letby was specifically designated not to do that, and she was supposed to be somewhere else and was repeatedly told to be looking after a different child.
So that's been quite a difficult thing to learn through this process that, you know, that was something that was not supposed to be happening at that time.
LANGDALE: Had you seen Melanie Taylor before, either of the nurses before, or not?
MOTHER C: I don't believe we had met Melanie Taylor before that night. I don't think we had, no.
LANGDALE: Was that the first time you heard that, at the criminal trial, that she wasn't supposed to be looking after [Child C]?
MOTHER C: Yes.
LANGDALE: Your husband has said in your joint statement:
"At some point while [Child C] was dying, I remember a nurse plugging in a 'cold cot', a ventilated moses basket, in the corner of the room ..."
And he said this:
"I vividly remember when Lucy Letby prompted me to place [Child C] in the cold cot. At the time, I reacted curtly to her suggestion, and she promptly removed herself from the family room. My mother-in-law also recalls this incident. Reflecting on it now, I believe she wanted to savour my son's dying moments for herself, which fills me with both emotion and anger. Had I not challenged her, she would have further intruded on our private goodbye to [Child C]."
MOTHER C: Yeah.
LANGDALE: Do you have any recollection now of her presence and doing that?
MOTHER C: I do. It's not something that I recollected at the time of my police statement spontaneously, but when I read Father C's police statement, I do have memories of that. They are not as clear as his. I remember the cold cot being plugged in, and it was actually next to my mother's legs, and she complained about it because it sort of makes a noise, and it's very cold, and we were in this really difficult situation where, you know, our son was dying, and it was certainly jumping the gun to bring that in and plug it in. And I remember snapping at one of the nurses, but I couldn't give any more specific detail than that. I do know that my mother made a complaint to the Bereavement Office, I think just a verbal one by phone call, to say that that must never happen to anybody else, that, you know, when a child is dying, you shouldn't come in and plug in a basket for when they are deceased to put them in it.
LANGDALE: After [Child C] died, you were given a memory box. Tell us about the memory box and how that was put together, what was in it, and who was doing that.
MOTHER C: Yeah, so that memory box was put together by Melanie Taylor and Lucy Letby, and it consisted of hand and footprints that were sort of ink on paper. It had some clay hand and footprints. It had a little box with some of [Child C]'s hair and some water from the baptism. It had a teddy with it, as well, and the blankets that had been used during that evening, a hat and a little dummy.
LANGDALE: So all of the physical memories of your son in that.
MOTHER C: Yes, so I haven't got any physical memories of my son that were not packed in that box by Lucy Letby.
LANGDALE: You say at paragraph 16 of your statement:
"During the events of this night Dr Gibbs had advised us of the need for a post-mortem examination due to the sudden, unexpected and inexplicable nature of [Child C]'s collapse, and that we would hear from the coroner's office with regards to this."
MOTHER C: Yes.
LANGDALE: So Dr Gibbs told you that immediately, in effect?
MOTHER C: Yes. Yes, he did. One thing that I remember that night was him sort of running through a list of causes of collapse out loud and sort of stating each one that wasn't applicable, and he sort of ran out of things in the list. So he was very, very clear on that night that this was not something that had been expected, and that he had no explanation, and that he was perplexed as to how [Child C] hadn't responded at all to very vigorous resuscitation and then had these signs of life later.
LANGDALE: Well, he wrote to you, didn't he? If we look at page 23 in this bundle, on the 20 July 2015, Dr Gibbs writes to Mother and Father C. It says at the beginning:
"I expect you are still coming to terms with [Child C]'s sad death ..."
And invites a meeting.
MOTHER C: Yes.
LANGDALE: If we go over the page at 24, three paragraphs down, he explains:
"You might be aware that in addition to any sudden and unexpected death needing to be reported to the Coroner, there is also a separate investigative process that needs to be undertaken for every sudden unexpected death in infancy. This is known as the SUDI (Sudden Unexpected Death in Infancy) process."
He sets out:
"I'm afraid that one important aspect of the SUDI process is to consider whether an infant's (or older child's) death could possibly have been due to child abuse and also whether there are safeguarding implications for any other children in the family. Clearly, there are no child protection or safeguarding concerns related to [Child C]'s death, but the SUDI process, albeit in an abbreviated version, has to be followed for every sudden and unexpected death in an infant."
And he goes on to say at the end of that page that it was a sudden and unexpected death, again.
MOTHER C: Yes.
LANGDALE: So when you read this letter, what messages did you take from this? It was the invitation to the meeting, but what was being said in this letter, as far as you were concerned?
MOTHER C: I was still very much deep in grief when receiving any of the correspondence, really, that we're going to talk about. But this supported what we'd been told in person, you know, that this was unexpected and unexplained. So I just took from this that this was the process that was kind of expected following that, really, just the meetings that were going to happen that were sort of standard meetings in these kind of circumstances. So I didn't think too deeply, really, about the fact that these -- what sounded like fairly standard routine meetings for unexpected events were going to happen.
LANGDALE: And we know from your statement that in fact you had two meetings on 21 August 2015. One was with Dr McCormack, and another one with Dr Gibbs.
MOTHER C: Yeah.
LANGDALE: You set out at paragraph 17 the one with Dr McCormack, and if you want to -- I'm not suggesting you need to -- the notes of that meeting are at 27 and 28 in the bundle. But what did Dr McCormack say to you in that meeting?
MOTHER C: So as I've alluded to already earlier on, you know, he was always a great support to us, and when we met with him at this point, it was no different. He expressed his shock at what had happened and his surprise, really, that this had been what had occurred, that [Child C] had collapsed and died very suddenly. He was much more concerned with, you know, what had happened in pregnancy and why [Child C] had been born prematurely, so that was very much his focus of that meeting, was to understand the pathology that had caused that and to look at ways of preventing that problem in a future pregnancy.
But he was very supportive. He offered to refer us for some counselling. He made a plan for any future pregnancy. And, yeah, we knew we could contact him at any stage if we needed to or wanted to discuss things further. He had a very approachable manner.
LANGDALE: And then you saw Dr Gibbs, and a summary of that meeting we see at page 30. Thirty onwards is Dr Gibbs's letter to you.
MOTHER C: Yeah.
LANGDALE: He sets out a number of things in that letter. It's a fairly lengthy letter.
MOTHER C: Yeah.
LANGDALE: But if we look at page 2, he sets out at paragraph 2:
"Although there were several risk factors in [Child C], that increased the probability of death following his delivery, it still was not expected that he would die (at least until a severe complications, such as NEC had developed), and it certainly was unexpected when he experienced a cardiorespiratory arrest at the end of the (redacted) day of life."
In the paragraph above that, he refers to what you referred to earlier and says that when the resuscitation efforts were being made, he says:
"By that stage, a little surprisingly, [Child C] did have a weak pulse and was making gasping respiratory efforts."
MOTHER C: Yes.
LANGDALE: What did you make of that at the time? You know now of the significance of that. When you read that, what did you understand by that?
MOTHER C: I wasn't really in a position to consider anything we were being told in great depth at that point because I was trying very much to deal with this intense grief. I felt that Dr Gibbs was quite perplexed as to what had happened and why. I feel this letter reflects that, reflects the fact that he couldn't explain or didn't understand why [Child C] had collapsed in the first place but also then didn't respond as expected but then showed signs of life later. He made it very clear to us that he found that very unusual, but I didn't really think anything deeper than that at the time.
LANGDALE: On page 32, the last paragraph, he refers to this and says:
"I was sorry to learn of your negative experience with the Bereavement Office at Alder Hey Children's Hospital. I do hope you're able to go ahead, as intended, to feed back on your experience to the staff in that office."
What was the experience that you had there?
MOTHER C: So when [Child C] was having his post-mortem over at Alder Hey, I received a phone call from the Bereavement Office, and the lady that spoke to me was obviously trying to be lovely and supportive and kind, but she made a comment about how they had dressed [Child C] and that he looked beautiful. I found this comment particularly difficult because in his life he had never been dressed and he had never been dressed by me. And if anyone was going to dress him, it should have been me, as his mother. So at that time, you know, I know that there was no malice in that at all, but I found that really difficult, that my son was elsewhere, and he'd been dressed by somebody, and it wasn't me.
LANGDALE: In the conversations you had with Dr Gibbs around that time about [Child C], did you know if there had been any other deaths or unexpected deaths recently, or not?
MOTHER C: No, I didn't. He did sort of mention that. I remember him making a comment about how it's very rare that they had unexpected or unexplained things happening on the ward, but there was certainly no talk about numbers of deaths that year or anything of that nature, no.
LANGDALE: You say at paragraph 21 in your statement, after meetings in August you were:
" ... trying to process everything that had happened and looking towards the future as best as [you] could."
In November 2015 while you were at work, you received a phone call from the Coroner's Office. Can you tell us about that.
MOTHER C: Yeah. So when we had met with John Gibbs, he had said that he had had discussion with the Coroner's Office about the cause of death, so we were expecting a phone call at some point or a letter to say what the post-mortem had concluded. This was several months after [Child C]'s death, and that would enable us to then go and register the death. So it was a kind of -- it was a shock on the day that it actually happened because, as I say, I was in work when I received the phone call. But the Coroner's Office has said that the cause of death had been concluded as diffuse myocardial ischaemia and that we should now go and register the death and that I would be getting a letter with the relevant details on it.
LANGDALE: And did you go and try and get the death certificate, and what was that experience?
MOTHER C: Yeah, I did go and get the death certificate, and it was another upsetting and difficult experience for anybody to go and register the death of their child. I chose to go on my own because I didn't want to put anybody else through having to do something so awful. And when I got there and I'd gone through all of the paperwork with the registrar, she asked me if I would like a copy of the death certificate, which of course I did want a copy of it because it's a formal document, I felt it was important to have, and she told me that there was a charge of £4, which I didn't have. I hadn't taken any money with me. I wasn't expecting to be charged for anything. And this certainly set me into a panic at the time because I thought: I can't face coming back here to do this all again just to pay £4 for something that's so important. So I got quite upset because it was a big thing in my life going and doing that, and the thought of leaving without one was unbearable. So she did actually waive the charge, but I was quite shocked that there was a charge for something of that nature, to be honest.
LANGDALE: Indeed, it's one of the things you mention at the end, when you suggest recommendations -- you don't think there should be a charge for something like that.
MOTHER C: No, not for something so essential.
LANGDALE: Paragraph 22. You refer to a friend of your husband sending him a WhatsApp message. What was that about?
MOTHER C: So I'm fairly sure now that it was July 2016 that my husband's friend sent him a WhatsApp message which contained a picture of an article from the Chester Chronicle, and the message was to ask whether we were involved in the investigation that was going on at the Countess of Chester, which covered the period of time during which [Child C] had died, and it was relating to an investigation of increased deaths on the neonatal unit. And up until this point, we had absolutely no idea that there was any kind of concern or investigation taking place, or even that there had been an increased number of deaths, so this was extremely distressing to find out, and especially to find out in this way.
LANGDALE: Would you have been easy to contact?
MOTHER C: Yes. I was -- at that time, I was a patient of the hospital. I was heavily pregnant. I was being seen regularly at foetal medicine. We had not moved house. I had not changed my mobile phone number. I had not changed my email address. So I would have been extremely easy to contact.
LANGDALE: You say you were furious, distressed and anxious in your statement.
MOTHER C: Yeah.
LANGDALE: And you turned up unannounced at the Bereavement Office at the Countess of Chester Hospital, having read the article.
MOTHER C: Yeah.
LANGDALE: What happened when you did that?
MOTHER C: So when I turned up, I didn't really know who I was asking for or what to do. So I remember knocking on the door of the Bereavement Office and being met by presumably one of the clerical workers from the Bereavement Office, and I said that I needed to speak to somebody as a matter of urgency about the article that had gone in the Chester Chronicle, and the first question that I was asked was whether I was from the press, which was an awful question to be asked at that point. And I said no, that I was a bereaved parent, and I wasn't leaving until somebody had the decency to talk to me about the article that had gone in the newspaper.
So this lady went and got Sian Williams and Alison Kelly, who came down and spoke to me. It was a fairly short meeting, to my recollection, where I was told by them that there was an investigation being done by the Royal College that was more of a formality because there'd been a very small increase in number of deaths, that it was looking at various sort of logistical things like staffing levels and that sort of thing, and that they weren't really expecting anything to come from it, that they had tried to contact me, which I challenged because, you know, I'd gone in there and said, "How can you let me read this in the newspaper? I think that's absolutely outrageous." I was really upset. They said that they had tried me on my landline once, and I challenged this as well. I said, you know, "Do you really think that that is acceptable to just try somebody once?" And the response was that they didn't know whether parents would want to know, so they didn't know how far to take the attempts to contact parents to let them know that this was happening.
And I was quite taken aback. I didn't see any sort of malice in the way that they'd behaved, but I saw absolute breathtaking ignorance. And I said, you know, "That is not your choice to make, who would want to know, when you're talking about the death of people's children."
I asked them if they knew that I was a patient under Foetal Medicine, and they knew that I was one of Jim McCormack's patients and actually used this as further justification for not contacting me. They said that if I had any questions, they knew that I could ask Jim McCormack. And, again, I challenged this, and I said, "Well, how on earth could I ask him about something that I didn't know was going on?" I don't remember them having an answer to that, but they were apologetic at the lack of information that we'd been given. They said that they had nothing really that they could tell me until the report had been done that was expected to be a few months down the line, but that they would keep me informed from that point.
LANGDALE: You say in your written evidence:
"They did apologise and said that they would ensure better communication in future."
MOTHER C: Yes.
LANGDALE: So when you left there, what was your expectation around communication?
MOTHER C: I expected that when the report had been done by the Royal College that somebody would contact me to discuss that with me.
LANGDALE: You also spoke to Mr McCormack about it, didn't you? Told him?
MOTHER C: Yes, I did. So as I've mentioned, I was having regular appointments with him at that time, and when I had my next appointment with him, I told him how distressed I'd been to read this in the newspaper and how let down I felt and how upset I was. And then he advised me that the consultants had been told that all patients had been informed, which obviously was not the case at all. So, you know, he was not very happy that we had had to learn it in that way.
LANGDALE: You then heard nothing from the Countess until January 2017, you say, when you received a phone call on holiday. Can you tell us about that?
MOTHER C: Yeah. So several months had passed, and in this time, we had welcomed a baby, and we were very much trying to look forward. Although we were very disappointed by the lack of communication, we felt in some ways reassured that nothing could have been found that, you know, the report must have been done or, you know, that there was nothing of note, why we hadn't heard anything. So we didn't contact to push for anything.
And then out of the blue, I got a phone call, I think it was a Friday evening -- it was into the evening, anyway -- from Sian Williams, telling me that the Royal College review had been done and the report had been leaked. She said that the Sunday Times was going to print something, and she just wanted to let me know.
So obviously this prompted lots of questions, you know. What on earth were the Sunday Times interested in? What had the report shown that would interest the media? What is this leak? And she said she couldn't tell me. So I pushed her again, and I said, you know, "Well, what has the report shown?"
And she said, you know, "Well, there was some mention about staffing levels, but, you know, I can't discuss the report with you, but you can have a copy of it."
So I asked her to email it to me because we were abroad at the time, and she said she couldn't. So she gave me the option of collecting it when we returned from holiday, so that's what I did. But in the meantime, we were expected to just wait and see if something went in the newspaper about it, once again, without knowing what to expect or what had been found.
LANGDALE: Can you have a look at page 54 in the bundle, please. These are Sian Williams's notes to be confirmed in evidence, but that's what they appear to be. If you look at 6 February 2017:
"Call from Father and Mother C enquiring about the two cases unexplained."
Did you turn up and collect the report on 6 February?
MOTHER C: Yes.
LANGDALE: Do you think this might be then?
MOTHER C: Yes, so I'd been on 6 February and collected that report. I don't recall ringing Sian that evening, but I obviously did, because the report threw up a number of new questions, that being one of them -- you know, was this the end of the investigations for us, or was there something further that was going to happen?
LANGDALE: So you physically collected the report.
MOTHER C: Yes.
LANGDALE: There's a note -- if you look above "Actions agreed",
"Send report in the post".
MOTHER C: Yeah.
LANGDALE: Is that a conversation you had?
MOTHER C: I remember asking Sian if she could email it to me because I was away. Now, from memory, I think the day that she rang me was a Friday. We were returning from holiday on the Sunday, and so I went to collect the report on the Monday. It may have been -- because I've thought about this, I've read these notes -- it may have been that she had offered to post it but that it was going to be quicker for me to collect it in person if she wasn't going to post it until the Monday, so I think that's possibly what's happened there, because as soon as I was told that there was a leak to the press, I wanted to know what on earth was so interesting about it that people were not telling me. So I wasn't willing to wait a second longer than I needed to.
LANGDALE: If you look at paragraph 26, going back to your statement, you say there, as you just have, that Sian Williams, when you collected it, advised you that:
"Some parts of the report had been removed as it contained information about the babies and that a plan was going to be made to meet families individually to discuss each case".
MOTHER C: Yes.
LANGDALE: Did she tell you that some babies needed further investigation but she had been told that [Child C] was probably not one of them?
MOTHER C: That's correct, yes.
LANGDALE: That's what you were told.
When you were sent the RCPCH report, if you look in the bundle, there's a copy that's grandly described as
"Final copy for dissemination" at page 101. Is this the copy you had at paragraph 4 -- if you go to page 109 -- where at paragraph 4, "Findings", it simply has underneath it:
"Recommendation: Conduct a thorough external, independent review of each neonatal death between January 2015 and July 2016 to determine any factors which could have changed the outcomes. Include obstetric and pathology/post-mortem indicators, nursing care and pharmacy input."
And then "Recommendation":
"Ensure there are clear, swift, and equitable Trust processes for investigating allegations or concerns which are followed by everyone."
Did you see just that piece underneath there?
MOTHER C: So I don't remember reading that particular paragraph, and that doesn't fit with my recollection of being told that there were two that required further investigation. So I couldn't be a hundred per cent sure, but I don't believe that that paragraph was in the report that I was given, because I think that would have made me realise that there had been, you know, a recommendation of further investigation into our son's death.
LANGDALE: If you go to page 76 in the bundle, this is a confidential copy of the RCPCH report.
MOTHER C: Yes.
LANGDALE: At paragraph 4, "Findings: the individual nurse" -- I'm not going to read them now -- it'll be available later on in the evidence -- but if you look at those paragraphs, three large paragraphs, and over the page?
MOTHER C: Yeah, that was definitely not in the report that I was sent. There was no mention of any individual of concern at all. All of that had been removed from the report.
LANGDALE: So any allegations about Nurse L or being moved to an alternative position, that wasn't shared with you?
MOTHER C: No.
LANGDALE: Or the comment:
"In the light of information shared with the Review team, the RCPCH advised the Trust to follow corporate processes in responding to allegations of misconduct by opening an investigation. It was also recommended a full and detailed independent casenote review was required on the deaths, prioritising those that were unexpected."
So that bit was not in the material that was sent to you?
MOTHER C: No, it wasn't. No.
LANGDALE: And what do you make of that now?
MOTHER C: I think, you know, we were in a very vulnerable position as bereaved parents who were very much being kept in the dark about what had happened to our child. We were being given no information whatsoever without being -- without finding it out almost by accident, and these are serious suggestions in that report, that there was serious concern about this nurse, that were being hidden from us. They were deliberately removed from the report that we were given.
LANGDALE: Going back to what you knew at the time, we see at page 37 of the bundle a letter you wrote to Mr Harvey as Medical Director on 7 February 2017.
MOTHER C: Yeah.
LANGDALE: Would you like to read that letter in now, either all of it or parts of it --
MOTHER C: Yeah.
LANGDALE: -- which set out clearly what your views were at the time and what you were thinking.
MOTHER C: Yeah, I will read it. So I wrote this letter the day after receiving the copy of the report that we were given, which as we mentioned, did not contain everything:
"Dear Mr Harvey. I am writing as a bereaved parent following the recent Royal College review of the neonatal services at The Countess of Chester Hospital. I suffered a complicated pregnancy in 2015 and was under the care of Mr McCormack in Fetal Medicine. Due to problems with my son's growth, I had a caesarean section at 30 weeks on (redacted) June 2015 and our son, [Child C], was transferred to the NICU for support.
"He was born in good condition (all things considered), although very small, having suffered severe IUGR due to placental insufficiency. It was felt by the paediatric team that he was high risk but had a very good chance of survival. On 13th June whilst on the postnatal ward I was called down to the Neonatal Unit urgently as [Child C] had suffered a very sudden and unexpected cardiac arrest. Although an output was regained after what I understand to be around 50 minutes of resuscitation it was clear to us that [Child C] was not going to survive. With our families we spent several hours holding him as he died in the early hours of 14th June 2015.
"Due to the unexpected nature of his death, he was referred for a post-mortem, the results of which took five and a half months to come to us. I am aware that this was a delay at the coroner's office. It was a very difficult wait for us. It was concluded that [Child C] died of severe myocardial ischaemia despite normal coronary arteries - a rare cause of death in a neonate for which there was no explanation.
"It is very hard to explain what this tragedy has done to us and our family. The effect it had at the time was devastating and the impact it will have forever is impossible to put into words. Losing [Child C] changed our perspectives on almost every part of life.
"Six months later, in December 2015, I was re-referred to Foetal Medicine with a positive pregnancy test. We had been warned that any pregnancy I had would likely be complicated and would result once again in premature birth. This was clearly a stress to us. However, we felt that the support of the Foetal Medicine team was truly outstanding. It gave us the strength to go ahead. Without the support of Mr McCormack and Jill Ellis and the Foetal Medicine team, I do not think we would have the happiness that we have found since having our baby, who is now six months old.
"Jo Gwinn provided me with counselling for several months, which got me through this stressful pregnancy and helped tremendously with my grief. In amongst the things that went wrong, I feel it is important to acknowledge those things that went right. Mr McCormack, Jill Ellis and Jo Gwinn deserve high praise and we will forever be grateful to them for what they did for us.
"Although my pregnancy was progressing well, we were truly horrified when, in July 2016, we read an article in the Chester Chronicle detailing that an investigation was taking place into deaths on the Neonatal Unit covering the period during which we lost our son. This article stated that support was being offered to the families involved. At no point had anyone contacted myself or my husband to inform us of this investigation into our son's death - the only way we knew about it was to read it in the newspaper. I am sure you would agree that this is a significant failure of the Trust and, quite frankly, a disgrace.
"I met with Sian Williams and Alison Kelly when I turned up at the Bereavement Office really quite distressed following this publication. It was explained to me that an attempt had been made to contact us on our landline number on [Child C]'s records (which was our previous landline number). It was known that I was a patient under Fetal Medicine but no other attempts to contact us were made, eg, by mobile or letter. In an already stressful situation, coping with our loss and dealing with a new pregnancy, we were put in a position where we felt that the Trust did not respect our grief enough to go to every possible length to inform us about this investigation. More effort should have been made. This caused a significant setback for us when we were trying to focus on remaining positive about my pregnancy and our future.
"Sian Williams and Alison Kelly were very pleasant during this meeting and I was told I would be kept informed from there on. I was surprised following this that I did not hear anything from the Trust until Friday 3 February 2017 (seven months later) when I was called by Sian Williams whilst on holiday in Lanzarote. She informed me that there had been a leak of the Royal College report and that an article would be going in the Sunday Times. I understand that this leak was not internal.
"She offered me the option to collect a copy of the report, which I did, on Monday 6th February. When I met Sian to pick up the report she advised me that there was a plan to meet families individually to go through the case reviews as these did not feature in the report.
"The report from the Royal College opened up questions that I had already asked myself. I am fully aware of the fact that sometimes there are questions that do not have answers. I have asked myself over time whether it would be helpful for us to know what, if anything, went wrong, or whether that would just cause us further distress.
"I have asked myself whether someone may have acted negligently, whether the respiratory support [Child C] was given was sufficient, were his blood gases, electrolytes and blood glucose monitored closely enough, and, indeed, was he in the right unit in the first place, or should he have been transferred to a more specialised centre?
"The report does strike me as having some suspicion that there were some unusual features of the deaths of the babies on the unit and that perhaps there was something going on on the unit that caused or at least contributed to the increase in mortality.
"I am unsure where the Trust is planning to take this, or how this will be concluded. I have not had a definite answer as to whether any further investigation into [Child C]'s death is planned. Sian felt that [Child C]'s case was probably not one of the cases that required further investigation but she was not certain. This is something that we need to know for definite. An investigation into the death of our son is the last thing that we want or need, unless it is deemed necessary or features of concern have been identified.
"Having suffered terrible grief, nine months of counselling, and having had a healthy baby in 2016, we need this chapter of our lives to be concluded so that we can focus on creating a happy, positive future for our baby.
"Every time another article is printed, or piece of information comes to light, it takes us back to the worst time of our lives, when all we want is to continue moving forward. The handling of this investigation and lack of communication has added to the distress of my family and I'm sure the distress of other families who have already suffered enough. We are trying to move forward after our indescribable trauma but this is hindering us.
"I would be grateful for any planned meeting to go through a review of our son's case to take place as soon as possible. We need closure on this. Although our grief will be lifelong we do not need any further prolongation of our suffering or further turmoil that delays in further investigations and poor communication will bring.
"I hope that the handling of this investigation is reviewed so that the Trust can learn from the mistakes made here and that any further action required off the back of these case reviews is undertaken promptly. That really is the least that bereaved families such as us deserve.
"Yours sincerely."
LANGDALE: The message couldn't have been clearer, could it, at the end of that?
MOTHER C: I don't think so, no. I was really angry, upset, disappointed, but also felt completely in the dark as to what was going on.
LANGDALE: We see, just for your reference, page 58, it's a note from Debbie Dodd -- I think that's the secretary to Mr Harvey -- but either way, an agreed meeting with Ian Harvey, Monday 20 February 2017, 10.00 am.
MOTHER C: Yes.
LANGDALE: And someone was going to collect you from the main reception and take you to Ian's office, it records there.
Who went to that meeting, as far as you're aware? Who was present?
MOTHER C: So it was myself and my husband, Ian Harvey and Alison Kelly.
LANGDALE: Was Mr Cross there, another male there, or not?
MOTHER C: No.
LANGDALE: So you're very clear, it was just the four of you?
MOTHER C: Absolutely. Mr Cross was not there. I've never met Mr Cross.
LANGDALE: Tell us what was discussed at the meeting. You deal with it at paragraph 31 of your statement.
MOTHER C: So at the meeting, Mr Harvey did apologise to us for the lack of communication. He acknowledged that us learning things from the newspaper was not satisfactory.
LANGDALE: Pausing there. Did he give a reason for it?
MOTHER C: No.
My main aim and agenda from that meeting was to understand what had been found with regards to the care of our son. And my fear, in some way, from that meeting would be that we would hear something that would have changed the outcome for him. For example, deficiencies in care so severe that, had they not occurred, he would have survived. So I had a very clear worry in my head.
So during the meeting, Mr Harvey told us that there had been some minor learning points noted when [Child C]'s care had been reviewed, that there were some things that could have been done better. And I specifically asked him: was there anything that would have changed the outcome for [Child C] -- because that was really my agenda in that meeting -- to which he said no, nothing had been found that would have changed the outcome.
LANGDALE: When you were asking that question, what were you driving at? Was it equipment failure, or a human being's failure, or action? What were you getting at there?
MOTHER C: I didn't really know, in honesty. I think, at that point, we still weren't really clear on why an investigation was even happening. The impression that we'd be given by Sian Williams and Alison Kelly was that this was more to look at staffing levels and that sort of thing.
LANGDALE: What does that mean, though, "staffing levels"? I mean, the number of people on a ward, or what?
MOTHER C: Well, exactly, really. You know, to make sure that they were meeting all of the standards that they should have been meeting, that sort of thing. So my mind didn't really go there, in terms of there being something worrying. I was more thinking, you know: was the standard of care sufficient? Was he in the right place? Was there anything that was missed that should have been acted upon that contributed to his death? So they were the things that were on my agenda that I was concerned about.
So, in honesty, when we were told that none of those things were the case, we were relieved, because so far as we were concerned at that time, we were hurting so much from everything that had happened that anything that was going to add to that was something that we were going to really struggle with. But at that point, we needed to know, as I said in my letter to Mr Harvey. You know, we couldn't face hearing about something else to do with our son's death being printed in the newspaper before somebody had told us. So that was really what we wanted to get out of that meeting, and we left that meeting feeling like we did have some answers, that there had been some minor problems with the care, nothing that had affected the outcome, and we were satisfied with that. You know, if you look properly at any case, at any care, you should find things that could have been done better, so that was no great surprise to us.
But I asked Mr Harvey at the end of the meeting for a copy of the report that was specific to [Child C], because I was aware that that was not enclosed in what we had been given, and he said he was not able to give us a copy of the report at the time because there were some more meetings to follow before he would be able to release that information.
And I didn't push this at the time because I was quite happy with what I had heard, and I believed what I had heard, that me having a physical copy of that report was more for my own records and more of a sort of formality in that sense. So we left there feeling more comfortable that we were going to get the full report, that the full report would not contain any surprises, because we'd had a discussion about it, and there wouldn't be anything in there that was going to make us more upset, really, than we already were.
LANGDALE: So you left the meeting with the impression that there couldn't have been anything changed about his care that would have affected the outcome and prevented his death?
MOTHER C: Absolutely, yes.
LANGDALE: Mr Harvey, you say, also told you you had another meeting to attend before the full report could be released.
MOTHER C: Yes.
LANGDALE: You've said that now, and you also say that in your statement. What was that about, as far as you were aware? Did he tell you?
MOTHER C: I can't remember what he told us about that meeting.
LANGDALE: You use a -- you say in your statement:
"He was reassuring and said that after that meeting a line would be drawn under the investigation."
MOTHER C: Yes.
LANGDALE: Did he say a line would be drawn?
MOTHER C: Yes, he did. He said that they were going to draw a line under the investigation after the meeting that was to come in -- I think he said it was in the following week.
LANGDALE: What did you understand, if anything, from that phrase, "a line would be drawn under the investigation"?
MOTHER C: That it was finished. That they investigated things thoroughly. That nothing of concern had been found, so they were closing it, you know. That was the end of the investigation. So from that end, I didn't expect to hear any different or new information.
LANGDALE: When you learned that, in fact, full, in-depth case review of the babies was recommended, what did that make you think about this meeting?
MOTHER C: Well, I didn't actually learn that for years after that meeting. That absolutely horrified me, how misled we'd been in that meeting and how untrue what we had been -- how untrue the information was that we'd been told. I felt completely betrayed on every level, to be honest, you know, as a human being sat with another human being who knows the pain that we've suffered. You know, it's evident in the letter, it's evident from the facts of what we'd been through at that point that someone could sit with you and tell you something untrue about the death of your child is something that I cannot believe happened even now. I cannot comprehend that someone could do that.
LANGDALE: We see a letter to you from Mr Harvey, page 41 in the bundle. Next correspondence is 3 March. I'll read that to you:
"Dear Mother C.
"Further to previous correspondence, our recent meeting, and the completed Review of the Neo-Natal Unit carried out by the Royal College of Paediatrics in Child Health at the Countess of Chester Hospital, I am writing to appraise you of our current progress. You will have seen within the Review that one of the recommendations was that a separate independent review of the care of each of the babies should be carried out. This review has now been completed but has, in turn, indicated that a small number of areas of investigation are required and I aim to undertake this as quickly as possible. I will, in due course, be sharing the findings of this further review in relation to [Child C] with you and will be offering to meet with you to discuss any concerns or issues that you may have arising from both the College Review and the subsequent review.
"I apologise for the length of time that this whole process has taken. This reflects the depth to which we have carried out the whole Review process. I want to make sure that I can confidently respond to any concerns you have in an open and transparent manner.
"Unfortunately, due to the depth of investigation, I am not in a position to give you a definitive date for any meeting but will be endeavouring to make this as soon as possible and would certainly aim for this to be within the next six weeks. I apologise that I can't have all the details to facilitate a meeting before your return to work as had been hoped."
What did you make of that letter?
MOTHER C: When I received that letter, I was absolutely devastated because it was completely contrary to what we'd been told in the meeting. We were told that -- the thing we were discussing in that meeting was the case review, for a start, whereas this letter says, you know, that they've now been completed. Well, we were under the impression that they'd been completed when we were speaking to Mr Harvey. And we were told that a line was being drawn under the investigation, that it had been completed. So what on earth were they investigating, and why were we just getting this very sort of generic letter that didn't give us any sort of real information? So the final line that says about, you know, "not having all the details to facilitate a meeting before your return to work", when we had met with Mr Harvey, I made it clear that I was due to return to work, following maternity leave, and that I was eager to have the physical copy of the report before then, and he'd assured me that I would have it.
So I was really upset because this came sort of around the time that I was returning to work. I wanted it all concluded. I wanted all of the information in my possession before then. So this just told me that this was still hanging over and there were still things that we were not being told and that we didn't know, despite meeting face to face.
LANGDALE: You then wrote to him again on 19 April. My Lady, that's at page 43 of the bundle. I'm going to read that extract or parts of that:
"Dear Mr Harvey.
"Thank you for your letter dated 3rd March. I am sure you are aware that being informed that there were areas of further investigation required regarding our son's case was a surprise to us given the information we had been given by yourself and Sian Williams up to this point. Whilst I am aware that things don't happen instantly and reports and results take time, I really would like to point out how awful this is for us."
You then set out the periods of delay, and you then carry on:
"I really cannot tolerate any further delays. I have never wanted to seek legal advice over all of this because, as I said in my original letter, we want to move forward. However, this really is prolonging our suffering. I would be grateful if you could send me a copy of the report from the Royal College of Paediatrics review and a copy of subsequent investigations regarding [Child C]. This really is the least we deserve at this stage."
You then gave an email address and suggest it could be posted to you; you don't mind. You say:
"I need to see them in advance of any meeting anyway to gather my thoughts and any questions I may have. If for some reason this is not possible, I feel we will have no choice but to seek legal advice."
Again, very clear, what you're saying it there.
MOTHER C: Yeah.
LANGDALE: What happened subsequently? Were you sent a copy of the report, or anything about [Child C]?
MOTHER C: No, I was not. I think I was then sent -- so I think I sent that via email to the personal assistant of Ian Harvey, Debbie Dodd, and I received an acknowledgement of that email saying --
LANGDALE: That's at page 45, I think, in the bundle, is it?
MOTHER C: Yes. 46. And her response says that she has spoken to Mr Harvey, he sends his apologies for not getting back to me before now but assures -- :
"[He] assures you that he will have the information for you by the end of next week."
Was the reply to that letter. But that was not the case at all. So I received a subsequent letter. I received it on 25 April, and I emailed Debbie Dodd again.
So the follow-up letter that he'd sent did not contain the information that I'd requested, did not contain the full Royal College report, did not contain the report into the investigation into our son's death. And at this point, I really felt that there was something significant going on that we were not being told about.
I had thought it was quite unusual that, following our meeting with Ian Harvey, we never received a letter detailing what we'd discussed in that meeting. That, to me, is quite standard. You know, we'd seen John Gibbs, and he'd sent us a letter that detailed everything we'd discussed. We'd seen Jim McCormack, and he'd sent us a letter detailing everything we'd discussed. We saw Ian Harvey and discussed details about the death of our son and did not get any kind of summarising document, which I thought was unusual, but at this point, I started to think: well, why have we not received any kind of summary of that discussion? Why are we not allowed a physical copy of the report that he's told us apparently says that there were only minor criticisms of our son's care? What on earth is actually going on here?
So my reply back to Debbie Dodd was getting increasingly frustrated and annoyed, and I suggested that really if we didn't get the information within the next couple of days, then I suggested that the Trust itself sought its own legal advice because I was really suspicious that there was something here that we weren't being told that was much more significant than we'd been led to believe.
LANGDALE: And then if we look at page 48, there's a letter to you from Mr Harvey, dated 28 April 2017.
MOTHER C: Yeah.
LANGDALE: "Dear Mother C.
"Further to my letter of 21st April 2017, I am writing to you again to pass on the results of the independent external review regarding the care of your baby. I appreciate that, by its nature, this report will contain some technical terms, but I felt it was important that you saw the original report. Once you have had the opportunity to read and consider the contents of this latest document, together with the previously sent copy of the Royal College of Paediatricians and Child Health report, please contact me if you wish to meet to discuss these documents and any other issues you might have in greater detail. We will then also be in a position to explain any of the terminology that might be unclear."
If you look at the next two pages, did they come with that letter?
MOTHER C: They did. The next three pages came with that letter. But they were not these exact pages that are shown in evidence here. They had "Draft" written across them in capitals, like a watermark on the page. But the contents, the sort of layout of it, is otherwise the same as what we'd received.
LANGDALE: So you now know this is an extract of Dr Hawdon's report, this one.
MOTHER C: Yes. I know that now, yes.
LANGDALE: When you got it, did you know who the author was? Well, tell us what you did and didn't know, receiving that information.
MOTHER C: So when I received this, I was struck by a number of things. I was struck by the fact that the information that had been sent to us started at page number 27, so it was page 27, 28 and 29. There was no introduction to the report, who had written it, what date it was written on. It wasn't signed and dated by anybody. There was no context. And it's, you know, like a bullet-pointed list.
So when I received it, I was struck by how superficial it looked. That, you know, we'd been told that these in-depth investigations had taken place and not revealed any cause for concern. Yet, we were sent a couple of pages of a report that didn't look at all in-depth to me, but also, where was the rest of it? You know, this report starts at page 27. Where's page 1 to 26?
So it was very evident when we received this that, again, this was not the complete information. We still had not received the full Royal College report, and this certainly could not possibly have been the full investigation into the death of our son. Or, if it was, then it was woefully inadequate to call that a thorough investigation.
So I was upset, distressed, extremely annoyed, perplexed. Lots of different emotions as to what on earth was going on that led somebody to think that that was acceptable.
LANGDALE: You say in your statement:
"I felt at the time - and still feel now - that we were being told that there was nothing to be concerned about, were not being adequately informed, because the Trust management did not want to deal with difficult questions."
MOTHER C: Yeah.
LANGDALE: Can you just expand upon that for us?
MOTHER C: I think telling a bereaved parent that there is going to be an investigation into the death of their child would bring up a lot of questions as to why and what you are investigating, and potentially, I suppose, open the doors to various other things like litigation. So I felt very much that they didn't want us to know anything because they didn't want to be faced with questions that maybe they didn't have the answers to, or maybe they did, but that those answers were going to hurt them in some way. So I felt very much at the beginning, when I'd met Sian Williams and Alison Kelly. I felt very much, as I said before, that there was a breathtaking ignorance; but my thoughts and feelings turned into this being something much more deliberate than that, by this point.
LANGDALE: Now you say in your statement that you lost every ounce of trust you could possibly ever have in the management, so you didn't request any further meetings?
MOTHER C: Yeah.
LANGDALE: Why didn't you request any further meetings? Trust was one factor, but why else?
MOTHER C: I think, after all the pressure that I had put on to receive the thorough information -- and still, I had not received the thorough information -- I felt quite frankly like I was banging my head against a brick wall, that nothing was going to get me that information now, because I'd put it in writing, I'd followed it up with emails, I'd met in person, and still there was a report somewhere on somebody's desk about my dead son, and they were not letting me have it. So I felt that all of the morals that underpinned that decision, there was nothing that I could do to persuade them that the right thing to do was to be transparent and open with me.
So at that point, you know, against all of my previous instincts, against all of my previous wishes, we then felt we that no choice but to seek legal advice, to actually get the full reports and to get the truth of what actually had happened to our son. We hadn't been looking to blame anybody. We hadn't been looking to make any accusations to anybody. We just wanted the truth about what happened to him, so that we could grieve properly and move forward with our lives.
LANGDALE: Did you ever receive a full copy of the RCPCH report from the Trust, from the hospital?
MOTHER C: Not from the Trust, no. We received a full copy when the Inquiry was started in 2023; I asked for the help of Steve Barclay, the Secretary of State for Health at the time, to get the full report for us. And that was when we got the full reports, finally.
LANGDALE: Eight years after his death?
MOTHER C: Yeah, eight years after his death.
LANGDALE: And what did you learn the first time you read that report?
MOTHER C: So in terms of the Royal College report, I learnt that the suspicions about Letby were written within it. That was the main difference. The report that we'd originally been sent didn't have any appendices in them, but actually, the appendices were not particularly relevant to us. But the main difference was this concern about the nurse, and the concern from the consultants that had been raised.
In terms of the Jane Hawdon report, that was really quite different to what we had been sent. So when we received the full Jane Hawdon report, it was evident that she'd written a cover letter that, you know, explained about the report, and that on the pages pertaining to our son there were a couple of boxes that had been removed when the report had been sent to us by Ian Harvey. One of those boxes detailed the post-mortem results for our son, and one of the comments in one of those boxes said that the post-mortem result was agreed, but that it didn't explain the cause of his deterioration.
So it was good to finally have the full information, but so many years after and so much had happened since then, it really added to the feelings of betrayal that we were being told very superficial parts of what was a much more suspicious investigation.
LANGDALE: I'm going to move on to suspicions and concerns regarding Letby. I don't know if you'd like a break for five or ten minutes or --
MOTHER C: Maybe five minutes, if that's okay.
LANGDALE: Shall we have a break?
LADY JUSTICE THIRLWALL: So five minutes. If you want ten, just say.
THE WITNESS: Thank you. I think five will be okay.
(3.22 pm) (A short break) (3.27 pm)
MS LANGDALE: Suspicions and concerns regarding Letby.
You referred to it earlier in evidence, but I'm going to quote it in full here, your husband's recollection of Letby in the family room and you set out here a quote from your husband's evidence:
"Although I initially had uncertainties, I am sure that Lucy Letby was the person I encountered in the Family Room at [Child C]'s death. My initial uncertainty stemmed from the fact that the only image of Lucy Letby I had seen at the time of my police statement was in the newspaper, where she appeared differently to her work appearance, particularly regarding her hair colour. When she prompted me to place [Child C] in the cold cot, I responded with surprise, saying, 'He is not dead yet.'
"This reaction was uncharacteristic of me, but her comment caught me off guard. She seemed taken aback by my response and promptly left the family room, as my mother-in-law recalls. I distinctly remember saying goodbye to the nursing staff as we left the family room; she was among them."
You described that earlier, but when you look back with what you know now, what do you make of that?
MOTHER C: It's horrendous. You know, knowing what we know now, it took us aback at the time because it just didn't fit with the context of what was happening. You know, we were having this very private, sort of difficult time that went on for several hours. And, you know, my concern now is that she wanted us to leave him there, you know, which just doesn't really bear thinking about, to be honest. It just adds an extra horror to what we already have to think about.
LANGDALE: You say you were never given any information or indication by the hospital that there was any individual linked to [Child C]'s death, or the wider cluster of neonatal deaths?
MOTHER C: Yeah.
LANGDALE: Did that remain the case?
MOTHER C: Yes. The first time that we knew that there was anybody linked to our son's death was on 3 July 2018, when we were phoned by Cheshire Police to inform us that somebody had been arrested on suspicion of murdering our son. That was the first time that we had any information linking an individual. Although we knew there was a police investigation, we thought that was purely to rule out foul play, rather than that they would actually name an individual.
LANGDALE: Where do you think the transparency should have been? At what stages do you think you should have been told these things?
MOTHER C: I think, in terms of the Royal College investigation, we should have been told that as soon as it was decided that our son's death was going to be looked into by anybody, and definitely before any press release was made. In terms of suspicion about an individual, I do think that this is more difficult but, you know, to not inform us at all until somebody is arrested is unforgivable. We had absolutely no idea that there had been layer upon layer upon layer of concern voiced by various people within the hospital about the conduct of Lucy Letby and her association with these deaths, and to not inform us of any of this, and for us to get a phone call out of the blue from a police officer in the early hours of the morning to tell us that they were arresting somebody, you know, it was an absolute shock that day. We hadn't anticipated that that was what was going to happen.
LANGDALE: Medical records. When did you first get access to [Child C]'s medical records, and do you know when you requested them?
MOTHER C: I'm not sure when I requested them, but certainly, in amongst the time that we've been talking about, I did do a request. I think there was an email address on the website. I can't be a hundred per cent sure, but I certainly emailed to ask for a copy of medical records and I didn't get any reply. But then, obviously, we'd appointed a solicitor and then, you know, there was a police investigation. So, you know, it became almost academic for me to read his medical records, you know, they were going to be looked at elsewhere.
LANGDALE: So you certainly, at no point before the police investigation, had looked comprehensively at his medical records and been given them?
MOTHER C: I'd never seen them. No, I'd never seen them before.
LANGDALE: But, through the criminal trial, you'd learnt what you learnt?
MOTHER C: Yes.
LANGDALE: What kind of evidence did you hear in the criminal trial that you didn't know before that was relevant to your child or the care it provided at the hospital?
MOTHER C: In terms of the medical care I felt, and I still feel, that John Gibbs and the medical team were transparent with us about the medical care that he'd received. So there wasn't any sort of great shock there. In terms of the fact that there had been other deaths that -- well, that there had been another death that week, I had no idea until the criminal trial. I had no idea that there were various text messages flying around about the death of our son and the other collapses and things that had happened. I had no idea about the fact that there had been other internal meetings to discuss his death until the criminal trial. But in terms of kind of his medical condition, I felt that we had been given accurate information.
LANGDALE: Paragraphs 43 and 44 of your statement raise concerns in getting answers.
MOTHER C: Yes.
LANGDALE: By the time the police investigation had commenced, what was your view about those issues? Did you look for answers or did you wait and see? What was the position?
MOTHER C: We were very much not asking questions because we were not in a position to receive difficult answers, is probably the best way to describe it at that time. Certainly when the police investigation was launched, we had several visits from liaison officers to support us, but they couldn't actually really give us much in the way of information at that point, with it being a criminal investigation. So it was more kind of -- it was just more support, rather than information. It was kind of telling us that we needed to do a police statement, and how would we like to do that, and planning for that sort of thing.
But in terms of asking any further questions to the Countess following our meeting with Ian Harvey, it felt completely pointless to do so, so we didn't.
LANGDALE: In terms of the impact upon you and your family, at paragraph 45 you set out further comments about rebuilding lives and impact.
MOTHER C: Yeah.
LANGDALE: Would you like to describe that now?
MOTHER C: Yeah. Can I read them? That's probably ...
LANGDALE: Yes, of course.
MOTHER C: So I made an impact statement to the Criminal Court, and, you know, that is still completely accurate. But there are some further comments.
"Following on from the criminal trial, we have had to try to rebuild life and regain some normality for ourselves and our family, which has been very difficult. As a family, we have endured years of anxiety and stress, from the initial arrest of Lucy Letby to her conviction. The events of that night and everything that has happened since have left an indelible mark upon us, one that will stay with us for the rest of our lives. Returning to our everyday lives post-trial has proven more difficult than expected. Despite the support we received during the criminal trial, the knowledge we gained about the events leading up to our son's murder and the methods that were used by Lucy Letby has been indescribably traumatising.
"We have had multiple unannounced visits to our home address by members of several media organisations wanting to speak to us. This has been distressing, intrusive and anxiety provoking. We have had to increase security at our home, at great cost, in order to feel protected, and that we can protect our family from this as much as possible. The impact and trauma of the events at the Countess of Chester will be lifelong for us.
"The impact statement gives details of the impact of losing [Child C] but, for obvious reasons, did not touch upon the impact that the initial investigation at the Countess of Chester in 2016 and the lack of transparency and communication with regards to this. We have suffered immeasurably from the moment our son collapsed. The trauma that we faced from then until now is thoroughly incomprehensible to anyone who has not endured it. I have been truly horrified as we have learnt more and more detail of the extent of information that was withheld from us by the management at the Countess of Chester.
"A duty of candour is something I believe should be inbuilt in to all those working in healthcare. Sitting with a patient and discussing the truth when something has gone wrong is such an integral part of the trusting relationship medics should have with their patients. To find out now that at the time Ian Harvey met with us in February 2017 he was well aware both: of concerns about Letby; and that the report about our son's death did contain criticism, is an absolute disgrace. I cannot understand this (redacted) on any human level whatsoever.
"We continue to feel thoroughly betrayed by this. It has affected our grief, compounded our distress and given us a general sense of distrust which we didn't have before."
LANGDALE: Suggestions and recommendations. You say you think that there should have been greater analysis of unexpected deaths where no clear cause had been found on post-mortem.
MOTHER C: Yeah.
LANGDALE: Have you given any further thought to how that can be ensured that that takes place, or whether patients should have a voice in seeing whether that's taken place, or anything like that?
MOTHER C: I think it's difficult to say, without knowing the ins and outs of all of the specific processes that exist at the moment, but what I will say is, you know, there was some discussion and debate at the time between the pathologist and John Gibbs as to whether the findings on the post-mortem were the cause of the collapse, or the consequence of it. And with there being several strange answers on post-mortem reports, or unusual answers such as "unascertained" or, you know, prematurity being given as a cause, I feel like there should have been something that tied all these together as being an unusual collection of events, rather than looking at each one individually; looking with greater scrutiny at the picture as a whole, however that can happen.
LANGDALE: You also say:
"I do not understand why the coroner's office did not recognise the increase in deaths as being an unusual peak, especially when taken in the context of post-mortem findings that were not 'typical' and clinical details that showed the sudden and unexpected nature of the deaths. When someone dies in hospital the post-mortem is conducted to establish a natural cause of death even in cases of unexpected death. I feel this needs to change to include toxicology and a greater index of suspicion for all unexpected deaths in hospital."
MOTHER C: Yes.
LANGDALE: Would you like to add to that all, or does it speak for itself?
MOTHER C: I think it speaks for itself, really. You know, I think it's very sad that we have to consider that somebody could come to deliberate harm in a healthcare setting, but unfortunately this isn't the first, and it won't be the last, time that that occurs. So the index of suspicion needs to be higher.
LANGDALE: You also say:
"I also feel that different medical personnel being on duty for the deaths prevented her from being caught sooner."
Do you think there's merit, then, in consistency of staff on units and on wards to see what's going on?
MOTHER C: Yes, I think so. I think patterns would be recognised much quicker.
LANGDALE: CCTV. Would you like to see that on wards, or not?
MOTHER C: I think this is a difficult -- it's a difficult subject, isn't it? I don't think it's very clear-cut, and I think there are lots of privacy implications. But in terms of knowing which staff are where, I know that some places have CCTV in hospital corridors, for example, but not in bays, and that helps to identify who is where and when, and who's accessing drug cupboards and, you know, what they're carrying. That sort of thing. So I think careful thought needs to be given to it. I understand that it's not a straightforward thing to implement, though. But I think things like electronic swipe data on fridges would be fairly easy to implement, and would give accountability to people. You know, you use your swipe card to get into the fridge that controls, you know, where the medication is kept, rather than there just being a bunch of keys that's passed around a group of nurses on the ward and nobody knows who has got them, and who is accessing what and when. So I feel like that would be a more straightforward thing to implement, in comparison to CCTV.
LANGDALE: You were also relying on photos, weren't you, when you couldn't first see your son, or having to look at images. Would it have helped then, to have some kind of viewing of him when you couldn't physically get up and get to the unit?
MOTHER C: Yes. And I think there are some countries where they have cameras in the incubators so you can do constant monitoring of your baby, and that certainly would have helped me following my caesarean section when I couldn't go down there.
LANGDALE: You say you'd like to see drug fridges locked electronically and opened using swipe cards unique to individuals so there is clear evidence available when you access them.
MOTHER C: Yes.
LANGDALE: You'd like to see a better regulation of NHS managers?
MOTHER C: Yes.
LANGDALE: And greater accountability for patient safety. Would you like to expand on that?
MOTHER C: I think it sort of speaks for itself, really. I think, you know, there is a feeling, I suppose, that NHS managers can go under the radar, easily move from one place to another, and perhaps aren't held to account in the same way that doctors would be referred to the GMC, nurses could be referred to the NMC. There is no body to refer an NHS manager to, to my knowledge. And I think something with a clear structure would potentially help, and then those who were not getting the support from management would have somewhere to go.
LANGDALE: You say:
"I would like to see the formation of an independent body to whom clinicians can raise patient safety concerns without fear of repercussions within their workplace."
MOTHER C: Yeah.
LANGDALE: How do you think that would assist them?
MOTHER C: I think -- and I'm sure that there will be evidence heard about difficulties in raising concerns and concerns about being reported themselves for raising concerns -- I think there needs to be somewhere clear that clinicians can access that's actually outside of their hospital Trust. You know, because often the concerns will be being raised about somebody within that Trust, and what if that concern is being raised about the person that you need to speak to within the Trust? You know, just somebody completely external to provide support and guidance, and to help people's concerns be taken seriously.
LANGDALE: Do you think -- I mean, clearly all patients require safety in hospital, but do you think there's argument for an elevated level of reporting and assistance where it is child protection concerns, in effect, the most vulnerable neonates?
MOTHER C: Yes.
LANGDALE: Where they can't even have their mother, in this case, near them at the time --
MOTHER C: Yeah, absolutely. When you have your child in hospital or in a neonatal unit, you know, you're not there to advocate for them. You are very much leaving your child in the care of other people, and you have to be able to trust them to do the right thing.
LANGDALE: You have said already in evidence you would like to see bereaved families not charged for death certificates, and you've said:
"On a personal note, I would like a personal face-to-face apology from Ian Harvey."
MOTHER C: Yes.
LANGDALE: Do you wish to say any more about that?
MOTHER C: I feel very strongly. I felt at the time that we were being misled, that we were being kept in the dark. I feel very strongly now that Ian Harvey was desperately trying to stop us from asking further questions by providing a whitewash gloss-over of a report and hoping that we would just take his word for it and not ask any more questions. I feel that we were treated extremely disrespectfully, and I think it's added hugely to our distress at what was already a distressing time.
MS LANGDALE: I have no further questions, my Lady. I don't know if Mr Baker, King's Counsel, has now, or if he'd like to consider a moment.
MR BAKER: I'd like a short break, my Lady.
LADY JUSTICE THIRLWALL: Yes, of course. We will leave so you can discuss.
MS LANGDALE: I think you have to leave, as well as the witness.
(3.46 pm) (A short break) (3.53 pm)
LADY JUSTICE THIRLWALL: Mr Baker, I was looking for you in the wrong place.
MR BAKER: Yes, I had moved.
LADY JUSTICE THIRLWALL: Very wise.
MR BAKER: Thank you, my Lady.
Questions by MR BAKER
BAKER: Mother C, can I first of all take you to a document called a Datix report and, if I can, give the INQ number. Would it be possible to bring that up on the screen? So it's INQ0000111.
I don't know if you can read it from there, but it's described as a Datix Admin and Management Form. Have you seen this document before?
MOTHER C: No.
BAKER: Okay. If we scroll down on to page 2, towards the bottom, you can see here an entry dated 29 June 2017:
"Potential claim - neonatal."
MOTHER C: Okay.
BAKER: Do you know anything about potential claim?
MOTHER C: No.
BAKER: If we go on, then, to page 5. There's a reference here to a Serious Incident Panel, SI Panel. Date of meeting, 2 July 2015. Here attended by Alison Kelly. Were you aware that a meeting had taken place on 2 July 2015 relating to [Child C]?
MOTHER C: Not to my recollection, no.
BAKER: And if we could go down, please, to the "Meeting Discussion Points", and the reference beginning
"Coincidental Findings". It says here:
"Delayed cord clamping at delivery (not hospital policy yet for pre-term babies).
"No recorded use of CPAP in delivery room.
"Small delay in intravenous antibiotics (one hour delay) and TPN commencing.
"Glucose high on one occasion, above 10, however delay in repeat monitoring the glucose levels.
"AXR [abdominal x-ray] equals nasogastric tube not in place. Baby lively and pulling at lines. Only settled in kangaroo care.
"Intravenous Ranitidine prescribing.
"24-hour consultant to consultant discussion for babies on ventilator.
"Learning point for when non-ventilated babies are not improving."
Were you made aware of any of those concerns at all in relation to [Child C] in July 2015 or afterwards?
MOTHER C: No. I wasn't made aware of any of those, no.
BAKER: Thank you. And if we could go then finally on to page 7, we have here a section entitled "Duty of Candour Assessment". Can you see that?
MOTHER C: Yes, I can see it. Thank you.
BAKER: There are a series of prompts in the left-hand column:
"The patient and family have been supported to deal with the consequences and have a key named contact.
"The investigation has been appropriate to the incident.
"The patient/family have been informed once it has been known that a moderate/severe incident has occurred within ten working days.
"The initial notification provided face to face.
"The verbal notification was accompanied by an offer of written notification ..."
Boxes to the right of that are all blank. Were any of those steps taken in respect of you?
MOTHER C: No.
BAKER: If we could go back now, my Lady, into the paper bundle, I think it may be slightly easier to orientate.
LADY JUSTICE THIRLWALL: Yes, thank you.
MR BAKER: If you could look, please, to the paper bundle you see in front of you, and to page 30. We have here a letter from John Gibbs to you dated 24 September 2015. If you turn over the page, please, to the bottom of page 31, we can see here at the paragraph that begins
"The pathologist was impressed". Can you see that?
MOTHER C: Yes.
BAKER: It says:
"The pathologist was impressed by the patchy myocardial ischaemia in [Child C]'s heart and, until I have discussed the PM with him by phone, he had felt that this could have caused [Child C]'s collapse. He based this assumption on the fact that when there is a sudden cardio-respiratory collapse this will lead to myocardial ischaemia but it takes some hours for the cellular changes (histological changes) to become apparent. Therefore, because [Child C] has clear signs of patchy myocardial ischaemia the pathologist had assumed this problem must have developed during the few hours before he suddenly collapsed, because if he died at or shortly after the resuscitation this would not have allowed time for the ischaemic changes as a result of that collapse to have become obvious when later examining the heart. However, when I pointed out to the pathologist that because of the slightly unusual, prolonged nature of [Child C]'s resuscitation (even though the latter part of the resuscitation was only intended to be a relatively token effort pending the baptism), some signs of life had returned and it was some hours later that [Child C] finally died. This would probably have allowed the myocardial ischaemia that would have been expected at the time of [Child C]'s collapse (and during his resuscitation) to have become established histologically since [Child C]'s death did not occur for some hours after his collapse and resuscitation."
You saw that paragraph in the letter to you. How did you interpret it?
MOTHER C: What Dr Gibbs was saying in that paragraph completely fitted with my understanding as well, you know, that we'd had this collapse with this sort of prolonged period where [Child C] was dying. And what he was saying made sense to me, and it fitted exactly with what he had discussed with us as well, that he very much felt that the findings at the post-mortem were as a consequence of the collapse and not the cause of it, and that nothing had been found that explained the cause of [Child C]'s initial collapse.
BAKER: So you understood him there to be expressing uncertainty about the recorded cause of death within the -- following the post-mortem?
MOTHER C: Yes. So at the time of this letter, the official post-mortem hadn't been concluded. This was a discussion that he'd had with the pathologist in the August, and it was the November that we got notification of the conclusion of the post-mortem, and the conclusion was -- myocardial ischaemia was put as the cause of death, but these discussions were happening in the run-up to that period of time.
BAKER: You were shown the letter -- and it's at page 30 -- forgive me; it's bundle-page 48. You were shown the letter from Ian Harvey enclosing sections of what you now know to be Jane Hawdon's report --
MOTHER C: Yes.
BAKER: -- and those sections on page 49, 50, and 51.
MOTHER C: Yes.
BAKER: There is, in fact, a copy of the full report included -- I will give my Lady the INQ number in a moment. It's INQ0006862, and it's at page 31. Now, it may be helpful if you just look for a moment at the Datix report at bundle-page 48, if you still have it in front of you, and page 49 in particular, and compare it with the document that's on screen now.
We can see at page 49 under "Child C" -- it begins with "IUGR [intrauterine growth restriction], reverse EDF [end diastolic flow]". And the box we can see on the screen is missing from the version that you have in front of you.
MOTHER C: Yes.
BAKER: Now, when you said in response to questions from Ms Langdale, King's Counsel, that you had since seen a form that had boxes on it --
MOTHER C: Yes.
BAKER: -- is that the form you were referring to?
MOTHER C: Yes.
BAKER: And when did you first see this document that has the box on it?
MOTHER C: As part of disclosure for this Inquiry.
BAKER: And you were giving evidence a moment ago about discussions regarding the post-mortem report.
MOTHER C: Yes.
BAKER: At the end of the box there, it says:
"Agreed PM report but no cause for deterioration identified."
MOTHER C: Yeah.
BAKER: Again, when -- were you made aware of that at the time of your discussions with the Countess of Chester Hospital in 2017?
MOTHER C: When we met with Ian Harvey, no. And when we received this heavily redacted, if you like, copy of the report, then no, it was not featured in the information that we were given.
BAKER: Thank you. And my Lady, if we could go, then, to page 32, the following page. You can see obviously at the bottom of that page there's another box which talks about "Delayed cord clamping policy. Confirm with staff".
When was the first time that you saw that box?
MOTHER C: As part of disclosure for this Inquiry.
BAKER: Finally, in relation to this document, the conclusion section of this report, which includes a summary of cases, beginning on page 55. Now, this version of the report omits reference to [Child C], whereas other versions of this report include [Child C] within this first box, this first section here under paragraph 1.
MOTHER C: Yeah.
BAKER: When did you first see the summary of case section of Jane Hawdon's report which sets out that [Child C]'s death could have been prevented with different care?
MOTHER C: As part of disclosure for this Inquiry.
BAKER: Finally, then, in relation to your meeting with Ian Harvey, if you could look at your witness statement, please, first of all, at paragraph 31, you say in that paragraph that you were not absolutely sure that Alison Kelly was present at that meeting.
MOTHER C: Yeah.
BAKER: Whereas in evidence before the Inquiry, you said you were now sure --
MOTHER C: Yes.
BAKER: -- that she was present.
MOTHER C: Yeah.
BAKER: What has caused you to change your mind?
MOTHER C: At the time that I wrote this statement for the Inquiry, I was relying on my memory now, and my memory -- my sort of spontaneous memory now is that I believed it to be her, but I couldn't be a hundred per cent sure. Since writing this statement to the Inquiry, I have re-read my police statement that was written a number of years ago, and in that police statement, I state that it was Alison Kelly, and I would not have said that if I was not a hundred per cent sure.
BAKER: And then finally on paragraph 23, this section is actually on the following page, page 10 -- 23 carries on to that page -- you are here describing a discussion between yourself, Alison Kelly and Sian Williams.
MOTHER C: Yes.
BAKER: About ten lines or so from the bottom -- seven lines from the bottom, you say:
"They advised me that the investigation was just a formality to check staffing levels because there had been a small increase in the number of deaths, but they didn't think that it was significant."
What was your recollection about what they were communicating to you in this particular meeting about the reasons for the investigation?
MOTHER C: There was absolutely no indication of anything criminal being investigated, that it was more a kind of review of their services to make sure that they were meeting appropriate guidelines. There was nothing that they said that made me think that there was anything more to it than that.
MR BAKER: Thank you.
My Lady, I don't have any more questions, thank you.
LADY JUSTICE THIRLWALL: Thank you very much indeed, Mr Baker. So, obviously, that concludes your evidence.
Before you go, I just wanted to thank you and your husband for coming to the Inquiry this afternoon. You were asked in your evidence to give a description of your experiences, and you've done so with enormous clarity and great eloquence. You give reflective and insightful suggestions for change. I don't underestimate the effort and the huge emotional toll that this has taken upon you both, on top of everything that's gone before, and I just want you to know that your contribution to this Inquiry is very, very significant, and I wanted to thank you.
(The witness withdrew).
(4.11 pm) (The hearing adjourned until 10.00 am the following day)
LADY JUSTICE THIRLWALL: Just before we start, there's something I just want to say because it's so important. These proceedings are being linked on an audio link, and they are of course subject to the orders of the court that were made by the Crown Court some months ago. The link is a live link, and it means if anyone inadvertently breaches the order, it is absolutely essential that no reporting is made of any breach. I'm sorry to repeat that, I know I said it at great length yesterday and I'll probably say it again tomorrow, but it's important to understand that nothing must be reported which would be a breach of the order. Thank you.
Now, good morning, Mother D, very good to see you and thank you very much indeed for coming to give your evidence today. I know you'll be feeling nervous so rather than say anything else, I think it's probably best if we just get started. Ms Langdale.
MS LANGDALE: May Mother D be sworn?
LADY JUSTICE THIRLWALL: Thank you.
MOTHER D (sworn)
Questioned by MS LANGDALE
MS LANGDALE: Mother D, you have prepared a statement dated 30 August 2024 for the Inquiry. Can you confirm the contents are true and accurate, as far as you're concerned?
MOTHER D: Everything is true and accurate, yes.
LANGDALE: You begin your statement by saying this:
"[Child D] died on 22 June at 4.25 am in the neonatal unit at the Countess. She was attacked three times during the night and died after the third attack. She was murdered by Lucy Letby."
MOTHER D: Yes, that's correct.
LANGDALE: Can I ask you firstly broadly about the impact that has had on you: first of all the loss of your child; and secondly, learning that she was murdered by Letby?
MOTHER D: Immediately, I could not stay in the room, so my husband wheeled me out of the room where she passed away and everything crumbled in. It was just a whirlwind of emotion and disaster, and I had loads of questions straight away.
It's not until the police called us at 6 am to tell us that they were about to arrest someone that has murdered [Child D] and other babies that it hit us, yes.
MS LANGDALE: When the police called you that morning, what did they say to you? Can you remember?
MOTHER D: Richard, the detective, called us, and I was with my husband. That woke us up, and we -- he just said, "I'm letting you know, this is the Police, Cheshire Police, I'm letting you know that we're about to arrest a person that has allegedly murdered your daughter and other babies. I can't go into it too much now. I know it's very abrupt, but we will call you back". And this left us in shock because we'd just never expected something of that nature.
As much as I had questions, and I was questioning people at the Countess and wanted the police to get involved, I did not expect this to turn out this way. So we were just shocked, and we were trying to understand what was going on. And until we were getting a callback, because we didn't have any way of contacting anyone, we were just questioning things starting to try to understand: how does that work? What happened? There's more people? Just more and more and more questions. I already had thousands and now we were just confused how serious this was turning out to be.
LANGDALE: We're going to go through this morning some of the questions you had at the time, but just focusing now on after you'd been called by the police, did you attend the criminal trial? Did you listen to the evidence of the criminal trial?
MOTHER D: Not until I was called as a witness. So until I gave my evidence, I did not listen, hear or know about anything that was being said. If anything, during the investigation, I had many questions, and the police were just very firm in not sharing any information, any contact with the parents, I've never met anyone. I only knew what I knew of my story. So when the trial started, my husband did attend every day. But I was clear that I was going to stay in a bubble. I didn't -- I wanted to be integral and I wanted to make sure that I didn't get impacted or influenced by anything I hear, and I knew absolutely nothing. I just knew my husband coming home upset. Sometimes he came home he was whitewashed, but I didn't know how to support because I didn't know what he's heard.
On the morning of giving my evidence, I was still isolated, you just go through a different entrance. You're kept in that bubble I'd been keeping myself in. So I gave my evidence and then I got 10, 15-minutes' break and it all started then. I was listening about everything to do with my daughter and my case, and I was trying to catch up every evening on what's been said the past weeks, how much I-- everything was a surprise and a shock because I knew nothing about all that was revealed.
LANGDALE: What did you learn when you caught up with what had happened in the criminal trial and what had been said about your daughter? What did you learn that you did not know before in that process?
MOTHER D: So much. Well, first, that everything I knew was not the reality. There's a lot of things that happened before the birth, my daughter's birth, that I wasn't aware of. Because all throughout my searches for the truth, I was never told there was anything suspicious with anyone else before, after. So going to the trial, I knew there was going to be things coming out but I didn't know the nature and what I didn't start convinced that Lucy Letby was guilty, because -- not that I didn't want to accept, but I just didn't know what they had on her. I just needed to hear for myself, I needed to understand. It needed to make sense.
And so yes. I went thinking: let me find out what's the truth, what you've got on her, why this is the reality of what's happened, and then learn what I need to do with this. I understand that it was a lot of failings, and some I understood already because I requested my notes, but I didn't know all the meetings that took place. I didn't know all the times they failed. On top of the ones I've already identified, there was other times, other conversation, all the messages and the interest Lucy Letby had in our family, I didn't know.
LANGDALE: Just pausing there, so you say in your statement one of the things you found hard to digest in the criminal trial was how Letby could say she didn't remember your daughter. What did you find out -- first of all, how did you find that, and what did you find out in terms of her conducting searches on you and your husband?
MOTHER D: I ... I didn't realise how much of a mess this was. I -- in my head, I could picture her in my story. But I didn't know everything else that was happening. I found out that she looked us up, both my husband and I, which I clearly know the mother's name does not appear where she would be looking at a baby's notes. So she would have had to consciously go and look for the notes. Even more, for my husband. She -- I never spoke with her in conversation to know her name. I -- she shouldn't have known about us and she should have had no reason to go and look us up. And the conversations she had by text message with colleagues about my daughter and how she called this "fate", and that "sometimes things happen", this I found shocking, because after what she's done, this is disgusting. I don't know if that answered the question. Sorry.
LANGDALE: You say at the beginning of your statement you continue to struggle psychologically. How difficult has it been for you dealing with all of this?
MOTHER D: There's not many words to explain, because not only this situation is thankfully not common, you start ...
I first found -- I thought, during labour, for things to go okay, and they didn't. And then she was fighting for her life. She was doing it well. I was promised that I would be okay to go to sleep that night, and I will wake up and I'll be able to feed her and hold her. And we got woken up in the morning to be told: no, this is not happening. And things turned around. I did not pick myself up and I still haven't picked myself up, because everything just crumbled. Everything -- nothing made sense. I mean, there is the grief side of things, but you're having to completely turn things around so you're going home without your baby. But you know things aren't right. There's accepting things sometimes happen and but nothing made sense. So to try to get myself together and move on, it was impossible. So psychologically, it was hard to have people understand what I was trying to do. Because clearly, I think my husband and I were each other's rock because we could not allow anyone else in that little unit, only our daughter and she wasn't there, so we were the only people in each other's life but we weren't dealing with things the same way so it was extremely difficult. I know my husband was worried because I was asking too many questions, and I was requesting notes and I was talking about -- I'm investigating and going to the police, and I thought maybe I was losing my mind and I didn't think people understood why I was pushing and everything that I identified, no one seemed to have paid attention to.
So it was hard to keep saying, because I -- I just didn't know if what I was doing was right but I kept thinking: this is my -- I can't -- this is my daughter's voice. I can't give up here. So I will carry on even if I'm on my own. And I did. So throughout doing that, any energy and strength I had was going into pushing, reading the notes, getting clued up, and anything else was getting drained in my emotions. I was just losing myself, I was no longer a friend or a daughter or a wife. I know I was losing myself, but that was my sacrifice.
LANGDALE: Let me ask you now, under "Experiences at the Countess of Chester Hospital" from paragraph 16, you talk about when you were pregnant, when you learnt you were having your daughter, tell us about that period.
MOTHER D: Well, that was happy. I mean, we never tried. That was pretty straightforward. We ... I mean, we met, we fell in love, we enjoyed life and then when we decided to try for a baby, it happened naturally, in love, and all sounded perfect. My pregnancy was smooth, apart from the odd pain that people get. There was no concern, no issues. I was towards the end of my pregnancy just over three weeks, so my daughter was a good size baby. She was pretty much -- I was almost full term so everything for me was in place. Everything was ready. The nursery was sorted. I crafted everything in the room. I painted, I decorated, I made everything. Only we knew the name, so we had like a little reveal ready. Everything was ready in the house. So we were just on the little cloud nine.
And then when my water went, I -- I can't say I felt concerned, but obviously you're anxious because you're not sure what's going on, but that's when things changed. But up to then, everything was fine. No complication, no issues.
LANGDALE: And when your waters had gone, you tell us that you were told to go into the hospital, and what about the delivery? Tell us about the delivery.
MOTHER D: So it's not a straight delivery because there's the pre -- should I go into this? Because when the water went, I knew it was a water, but when I called the hospital they said, "Well, just wait a bit, see how it goes." And then a few hours later, I called again and they said, "Well come in, you know, we'll check". And that is when I trusted the hospital.
And the midwife checked everything she needed to check and I said, "But the water went and now it's been a little while, what's the protocol? What are we doing?" And she said, "Well, you know, you have -- labour hasn't clearly started so you're going to have to go home and wait", and I thought this was risky. But she sent me on my way, so I went home. I think we were more excited at that stage because we thought that's it, she's -- because they did tell us, "We will induce you tomorrow if it hasn't started on its own" and there was nothing to worry about, unless labour started clearly, had come early, otherwise I was coming the next day.
I came the next day, and when we arrived it was a really quiet place and we were the first in the waiting room, and we waited in a waiting room, and then another couple arrived, and they went before us, and that's when I started to feel uncomfortable because I thought: okay, this has been over 24 hours now, I'm still losing water. Is there any water left? I didn't understand enough and I didn't have anyone to ask questions to. So I was concerned. At that stage I was clearly tired already because I haven't slept through the night. And when we first got put into a room, we were waiting for more hours, and they said, "Well, we won't start just yet, you know, we're still observing what's going on, is the baby moving?" And I thought: everything seems okay. I'm still not comfortable; I feel this is all open to infection. And they just dismissed my concern.
And a day went by, and still no one really pushing for the next stage. And this built up to a second day, and then a third day. I was all that time in hospital and all throughout. We went through so many different shifts and handovers and every time I said, "Have you paid attention that I am not" -- they made a mistake on the notes on the gestation age and I said, "This is relevant, you need to pay attention." "Yeah, don't worry, we know what we're doing" and I said, "Okay, but, you know, this doesn't seem right, and you're saying this is still not progressing, and you induced me now, still no progress. When are we talking the next stage?"
And I kept being dismissed because they were busy and they weren't worried. It came to a point when I -- all this time I didn't rest, pretty much, and I went to the bathroom and I have seen a bit of blood but they said this is not concerning, we'll just move you on to the next stage of induction now, and they said, "Now things will go a lot faster".
It didn't.
LANGDALE: Did there come a time when you were asking for a caesarean section?
MOTHER D: So that's when, when we got moved to another room which -- that's what they called the Labour Ward and that's where things will get started. That's when I was seeing more of the consultant, and I felt there was a bit more attention given to me. I was no longer very patient and maybe I was a bit abrupt. My husband was saying, "You know, you're tired, they know what they're doing". And I said, "I think they don't and they think because I'm a first time mum they don't know what's going on but I said I feel things aren't going well, and my body is clearly not wanting to do this like that so I'd like a C-section".
The consultant said, "Well, we need to review because, you know, you're still fairly early in the labour process."
And I said, "It's not early, it's over two days. My water has gone".
I wasn't full term, I was past. I mean, I'd just made it to 37 but when my water went, I wasn't. This is not correct. I still -- "What about the risk of infection? What about this?"
And they just -- I felt dismissed, and so I waited and the consultants were generally coming every four hours-ish, and there seemed to be always a delay, because they were very busy. Then another person came, and that's the doctor that delivered my daughter.
When he came, I mention that I wanted a section a bit more firmly, and he smiled and he said, "That's what people tend to think these days, this is the easy option". I said, "This is not the easy option. I'm petrified of scars." And I know that's not -- but the after -- the healing part, I'm scared of. So this is not my option. That's not my first choice, that's my last option, and I'm not doing it for me, I'm doing it for the baby because at this stage I don't -- I can't tell that I'm feeling the baby or not. I'm completely exhausted. I haven't slept for three days. And all this -- because one of the midwifes was lovely but probably a bit too soft. She just kept coming to me and giving me a hug and saying, "Oh it's going to be fine". "It's not going to be fine. I want you to listen. I want you to pay attention to what I am saying. I want C-section and I want it now".
Because by that time they've turned the monitors away from me and I couldn't see any more what was going on with the movements. They tried to give me gas and air. Nothing was working. I was starting to panic, clearly. And I said, "I want someone to listen". I was getting very upset and a bit rude, probably. But I said, "I'm sorry but I need you to listen".
And he said, "Well, can we wait another four hours?"
I said, "I don't want to wait". But we still had to wait. And then, when he came back, and because I said, "Why would I wait?" And he said, well -- he went into the technical and he said, "I'll exam, I'll do the exam". And he said, "You're not dilating."
And I said, "Exactly. I've been here for almost three days now. We need to do something, get the baby out".
And when -- "How do we know the baby is fine? Because I can't see the monitor and there seems to be a lot of activity. What's going on?"
He went anyway, and I was just told to just try to keep calm and deep breath and all that. I just felt completely dismissed and not cared for and not looked after, and I was just dismissed, I felt. And I was getting very scared. And then he came back for the four hours check, he did the exam, and he said, "Actually, it's gone back. There was a one centimetre thing" and he said, "It's gone back now".
And I said, "That's it. I'm not asking you; I'm telling you. C-section now".
And he said, "Okay, just one sec" or whatever.
He went outside speaking with people. They came back, and it seemed like an urgency then. Everything turned round. They got my husband to scrub up and they say, "Okay, we're going to take you to theatre now". And it's as if all of a sudden they realised that there's a rush.
I've read the notes and it doesn't say that it's a rush, but it felt like a rush and a panic. And they obviously had to top my epidural up and the -- the spinal, sorry, and do everything they needed to do to prep me for theatre. And I was warned that it would be overwhelming because there's a lot of people for an operation, and it was overwhelming.
LANGDALE: When your daughter was born, you and your husband were there. How was she?
MOTHER D: So when -- so that was obviously my first time. I didn't really know. There's a sheet in front of -- between me and the delivery part so I can't see a thing. I was just crying and upset and the baby came and I couldn't hear the baby. And I thought: what's going on? And my husband was also upset. And then the nurse had my daughter in her arms and she took her to the side and you can't really see because of the way it's set up. So [redacted] went straight there and she was probably weighing the baby and doing the check they need to do. There was still no sound and the room was very quiet. So I just was not -- I didn't understand what was going on.
And then they said, "She's fine" and they put her on my husband's chest and he came next to me, and I looked, and I thought: she does not look fine. I mean, she's very quiet and she looked a bit purple. And they took her back and then they sort of, they came and speak to me then. So I couldn't see what was going on. And I know they called my husband to be with the nurse and my daughter. But I was just -- I didn't really know what was going on. There was a whole rush and they were talking to me and they were, "How are you feeling?" And this and that and checking on me. So there was one part looking after the baby, one part looking after the mum and that was it. And then they finished the C-section. I don't know what was happening in the background. Took me back to the room, and then that's when --
LANGDALE: Let me ask you another question.
Eventually she was taken, wasn't she -- your daughter was taken to the neonatal unit and you were told she required antibiotics and she required some ventilation --
MOTHER D: So not straight away.
LANGDALE: When were you told that?
MOTHER D: Well, I ordered them to take her, because -- so they brought her back to the room, and they put her for skin to skin on me, and she didn't feel right, she didn't feel lively or with me. And I could see I wasn't connecting with her; I could feel she wasn't there, and was asking, I could see there was plenty of nurse coming in and out and I was saying, "Can you please come and check?" And they were saying, "Oh no, she's fine, can you try to feed her?" And she was not interested in feeding. I said, "She seems very floppy and she's doing that noise". I didn't know what it was called but she said, "Yes, it's grunting. She's come three weeks early so the lungs sometimes don't quite work as well as a full-time baby and you've given birth through C-section so, you know, she's a bit shaken, that's nothing to worry about".
And I said: "Well, she does not look right so can you please ask the doctor to check on her"? A doctor came and I was very annoyed because he had that smirk on his face, and very dismissive, and he's just like, "Oh, no, the baby's fine, there's just nothing odd here". And I wasn't happy and I said, "I want a second opinion. I want you to go and ask another doctor because this is not right. She's not responding like she should".
LANGDALE: You say in your statement at paragraphs 42 and 43 that after you had first been able to visit her, you say there:
"[Child D] looked better and was a better colour. Father D took me back to my room and Dr Brunton went to see [Child D]. She was doing much better. I was told to continue to express milk. At about 7 pm, I understood that [Child D] was doing well and she was improving and was responsive on handling."
You say here:
"I know that ventilation was removed and she seemed to be making a good recovery. I was told if everything continued to improve I'd be able to hold her the next day."
Do you remember being told that?
MOTHER D: Yes, very clearly. So that time between when she went to intensive care and then, there was, at first they weren't so sure of her condition or how she will do, and but there was never a concern for her life. They just say, you know, she's just born, and it was a bit of a shaken start so she just needs a bit of care, she's a bit vulnerable, but she'll be fine. They said that they started the treatment, just watching her obs and that was that throughout the day, and my husband has been with her most of the time.
And during that day, that was when we spoke the first time to Dr Brunton and he came to us, and he reassured us he said, "Listen, everything's fine, she's much better. She's come off the light therapy. She's picking up. She seems to be more lively". She seemed to react as she should react. All the obs and the readings were going better. And they said: if all carries on, continue expressing milk, and if all carries on, tomorrow morning you can breast feed her and you can have a cuddle and that's that. She's on her way to recovery. She's -- full recovery".
LANGDALE: You say that the about 2 am in the morning you understand Dr Newby was called urgently to see [Child D] because of an unusual area of mottling. How do you -- were you told about that first time --
MOTHER D: No.
LANGDALE: -- that Dr Newby was called? No. So you know that from the notes?
MOTHER D: Yeah.
LANGDALE: You say:
"I found out afterwards this was across [Child D]'s abdomen and was said to be because of sepsis, something I could not understand."
Then you say:
"At 3.15 am, a second call was made because [Child D] was very upset and crying and at 3.45 am her alarm sounded."
And you say it was at 4 am that you were woken up by one of the nurses?
MOTHER D: Yes.
LANGDALE: So tell us about how you were woken up and what was said to you?
MOTHER D: It was the first night since my water broke that I let go, and I thought, "I will rest, because things are okay. She's going to be okay, and we can rest". The same for my husband. We were together in the same room, yes, we were sleeping. Someone came to the room, a nurse, and she said, "You need to come now, your daughter is very poorly" and we just said -- and she said, "You need to come now". And I couldn't get out of the bed on my own so my husband got me on the wheelchair and she was rushing us, and when we arrived, that's when there was the scene. I couldn't see my daughter. I could see Dr Brunton holding her, and trying to save her. There was a lot of people. One that was doing nothing useful, that was Lucy Letby. And she was just looking at us crumbling and crying and Dr Brunton was trying to save my daughter, and he was trying really hard. He was just -- someone -- well, Letby was holding the phone to his head and I was saying "What's going on? Why has he got -- he's busy, why is there a phone?" And he kept shouting, "No, this is" -- and he was saying my daughter's name and he was saying, "This is not someone else, this is this baby", and shouting, and then Dr Newby tap on his shoulder and she said, "You need to let her go. She's gone".
So he didn't want to let her go. But then as soon as she said that, they said the time of death, and that -- I couldn't stay in the room. We completely broke down and I said, "Get me out, I can't believe this". He was still holding my daughter; I couldn't even see her. And we were rushed out. We went back to the room. The door closed, and it was just us crying, thinking: what just happened? We didn't even know what time it was until they said the time, and then that just kept going over in my head. And I -- yeah. That just -- that's how ...
LANGDALE: Pausing there on the phone call, you found out later there'd been a mix-up and it was the parents of Baby B [Child B] that Dr Brunton was talking to --
MOTHER D: Yes.
LANGDALE: -- when the phone had been put to his ear so talking about your baby to a different parent?
MOTHER D: Not only this, I found that out later by piecing things together that that was the first time the parents of Baby B [Child B] left her after what she's gone through and her brother died and they got a call in the middle of the night to say that their baby was not going to make it but really in fact it was my daughter.
I don't know how; to me this is not just a mistake. It's malicious. And I don't know how it was allowed, but -- and why would you need to put a phone on to someone who is trying to save a baby? It's completely ridiculous.
LANGDALE: Yes. You say in your statement Dr Newby was there and she was clearly upset.
MOTHER D: She was upset.
LANGDALE: And you say it was all so unexpected?
MOTHER D: And shocked. I can't say how long, but pretty quick after we went back to the room she came to see us, and she just was upset and she said, "I don't know what to say. I don't know what happened. I don't know why it happened. I can't explain it. We're going to speak to the Coroner we always have a briefing so we'll speak. I will tell you what I can when I can but at the time now, I don't know what's happened. I can't explain it".
LANGDALE: You say she told you that they'd need to inform the Coroner.
MOTHER D: Before that, they asked us if my daughter would be an organ donor, which is something I did not think about. But we were pretty much put on the spot, and I said, "Yes, if this is going to save another baby". And the nurse said, "Well, there's a baby that need a heart" and that just made us even more upset, because -- and I said, "Yes, if her heart can" -- but it was very rushed but I understand the medical reason, it needs to be rushed in this situation. But within a matter of minutes someone came back and they said, "Well, actually, your daughter -- there's going to be a post-mortem so she can't be an organ donor" and then I felt guilty. And because I thought: what if the other parents have just found out that they've got someone to save their baby and now they haven't and why does my daughter need a post-mortem? And that's when we were told that's because they don't understand what happened, and why it happened. So they need to investigate.
LANGDALE: You were asked if you wanted hand and footprints taken, and you say you did, but you couldn't do it, but fortunately your husband's mother had the strength to do so?
MOTHER D: Yes, she did. Yes.
LANGDALE: You say you were then sent for an MRI scan; yes?
MOTHER D: Yes.
LANGDALE: Then you were moved to the Lavender Suite. Can you tell us about that?
MOTHER D: That's very -- another shocking way of dealing with grieving parents. Once it was -- after my daughter passed, they offered us to come back and see her. So we went to see her, and then they said, "We're going to move your room now, it's a better room, you're going to have more space, more privacy". It turns out that room is in Labour Ward so you go past people who are giving birth in good or bad situation. You -- they are seeing you completely destroyed and you're seeing them smiling and there's balloons around and it's very bad taste, the way it's located. And when you are in that room you can hear everything that's going on outside. It's very traumatising. Very traumatising. You feel you're stuck because if you get out, you're just going to be facing all this, and it's just feel like you're stuck in time because this is you two days ago and you just keep thinking: this is torture. What should I have done? What's happened? What's going on and why are we here?
And I also felt for the other parents because I would be very distressed if I seen someone like they would have seen me. Yes, it's bad.
LANGDALE: You were given a memory box when you left. What did you have when you left?
MOTHER D: Ha. Well, nothing. I know it comes from a good place, but they give you a box and it's got two little teddy bears in it. The idea of the two teddies is one goes with your baby and one stays with you. And I mean maybe if your baby has been alive for a little while you might have some memories, but there wasn't any. I did ask, when my daughter was born, they give the babies a hat and a blanket and I did ask to have these two. They brought a blanket that was not hers. It made me very upset, and they said, "That is hers". And I said, "I'm telling you I know what her blanket was and that was not her blanket". I don't know where the blanket ended up but the box had nothing in it. They gave the bracelet with her name on it. That was that. An empty box.
LANGDALE: I'm going to come now to the questions you were asking and the cause of her death and deteriorations and we know you had a meeting with Dr Joanne Davies and you said Joanne Davies and nursing staff on 24 June 2015. Do you know what nursing staff or who was there or not?
MOTHER D: Sorry, can you repeat?
LANGDALE: You say in your statement at paragraph 59:
"We had a meeting with Dr Joanne Davies and nursing staff on 24 June 2015."
MOTHER D: Yes. That was more to do with my -- although I had questions about what happened, it was more about my condition, because I wasn't recovering as expected. This is why I had an MRI and --
LANGDALE: Don't worry about that. We don't need to go into that.
A. Yes, okay.
LANGDALE: If you go to page 45 of the bundle, we see there a letter from Dr Joanne Davies to, I assume, a GP. You don't need to give a name of the GP. But I want to look at some of what she is saying in this letter, at this time. She says:
"I saw Mother and Father D today in the Pregnancy Risk Clinic following the sad loss of Baby D [Child D]. As you know, Mother D had spontaneous rupture of the membranes at 36+6 weeks gestation and after an emergency caesarean section for failed induction of labour.
"Baby [Child D] became unwell and subsequently died on the neonatal unit hours later. Since then, we have had the post-mortem back which essentially has shown acute pneumonia."
It says at paragraph 2:
"We had a very long and detailed discussion about her antenatal and intrapartum care. I explained there had been an obstetrics secondary review and also a multi-disciplinary perinatal mortality review to discuss the case.
"Following these case reviews, I explained to them that the findings were that we had missed an opportunity in giving Mother D both oral antibiotics and IV antibiotics as per the premature rupture of membranes policy below 37 weeks. I apologised for this missed opportunity."
It goes on:
"I explained that when she was initially seen at 36+6 weeks, the decision was made to induce her the following day and therefore manage her as a term rupture of membranes. The main difference in this management is that oral antibiotics are not started, intravenous antibiotics in labour are only started if there is evidence in a change in maternal observations or fetal observations. Neither of these occurred in Mother D's labour and therefore she was never given intravenous antibiotics. I apologise for this.
"We had a long discussion about the possible implications of not having these antibiotics. I have explained to her that we can never know that if she had got these antibiotics we would not have had the same outcome. We also had a long discussion about NICE and college guidelines around premature rupture of membranes and term rupture of membranes and the arbitrary cut-off of 37 weeks, and if Mother D had been only one day further on in her pregnancy and had followed the term rupture of membranes guideline, this management would have been correct."
Over the page at the top:
"This was obviously very difficult for them to take, and I agreed with them, if the guideline is in place then it should be followed. In this case it was not done so."
And at the end of the letter the same page it says:
"They were both keen to know the processes that had taken place after the review in this meeting. I explained to them the reviews have produced an action plan. The main actions are around learning for the individual members of staff involved in the team but also review of the term 'Premature Rupture of Membranes guidance" and the timing of induction. I reassured them that all members of the team, both obstetrics and paediatrics, took any poor outcome very seriously and at all times wanted to learn to improve practice.
"As far as what happened from now for them I explained to them the complaints process and if they wanted to go forward with that."
So discussion there around antibiotics, and we know you had another meeting on 17 August when you asked Dr Newby lots of questions. And if we turn to page 23 in the bundle, we see that letter. It's page 23.
A letter to Mother and Father D, and Dr Newby is thanking you for coming in and she summarises the details of the discussions.
At the first point she says:
"We discussed that paediatric involvement started from the time of [Child D]'s birth and therefore these are the aspects of care which we discussed at the meeting. We discussed that a Neonatal Morbidity and Mortality Meeting had taken place on 29 July 2015, at which we discussed in detail [Child D]'s care as a department. Present at that meeting were myself and my consultant colleagues including our Neonatal Lead, Junior Doctors, some of whom were involved in [Child D]'s care and our governance facilitator."
Did you know at the time those meetings were happening and did anyone ever ask your view or thoughts in respect of that meeting?
MOTHER D: No, which I commented on that.
LANGDALE: Over the page at paragraph 4, page 24, paragraph 4:
"We discussed that unfortunately the post-mortem results are as yet unavailable but we felt as a department that the most likely diagnosis was one of sepsis, ie overwhelming infection, and we discussed the signs that led us to this diagnosis."
And at bullet point 6 on the next page, 25:
"We discussed the aetiology of the rash which is documented to have appeared during [Child D]'s first episodes of deterioration. This appeared to look like bruising under the skin and we discussed that this was likely a sign of the effects the infection was having upon [Child D]'s circulation."
Do you remember the post-mortem results and sepsis being discussed with you at this time?
MOTHER D: No, and I -- as much as she was a doctor, I clearly said, "I disagree". And I asked -- so at the meeting I said you had -- so when my daughter was born and started on antibiotics they said, "We will run the tests but it takes a few days". She passed before the test results. But when the test results -- and when we left the hospital we still didn't know. When we finally got to meet with the doctors, I said, "What were the test results? Did she have an infection?" She said, "No, she did not".
And I said, "Well, you explain this to me because if an infection is that overwhelming that it will kill a baby but doesn't show on the reading, this does not make sense. She was getting better. Not getting worse. Again, explain". She couldn't explain.
They had to write a report. They had to put something together because that's what they do; they can't leave things unresolved and that's what they did. But that was unsatisfactory for me. I said, "I'm not accepting your finding. I'm not accepting your reasoning. It doesn't add up or doesn't explain, and you have to do better than that".
LANGDALE: We know you wrote to the Coroner on 23 September 2015. That letter, my Lady, is at page 48 of the bundle. Page 48 to 50, Mother D.
You say to the Coroner:
"As discussed over the phone with Yvonne Williams, my husband and I would like you to start a complete inquest following our daughter [Child D]'s death."
You set out a number of matters. You set out how you were induced. You set out how handover and communication failed, as you were induced as being full term where in fact the membranes ruptured prematurely, this being a high factor for infection.
You set out over the following page:
"Taking into consideration all of the above, [Child D], a greater risk for infection should have been taken straight to Neonatal Intensive Care."
You set out Apgar scores. The last but one paragraph, you say:
"Post-mortem confirmed pneumonia. I believe it is known by the doctors that early onset pneumonia in newborn are due to bacteria, most commonly Strep B, that same bacteria being the most common reason for Premature Rupture of Membrane. Placenta could have provided more accurate data."
Were you all looking all these things up for yourself? How were you questioning these things that --
MOTHER D: That's when I felt there was half of me that stayed sane to try to understand and get clued up with what needs questioning. When I requested the notes, I knew nothing I was getting myself into. So nothing was in order. Everything was a mess. So I tried to put it in an order that made sense. And then there were lots of words and initials and things noted so I had to understand what they mean. I had to understand the NICE Guidelines, the College of London, the protocols, and what should have been done, in my case whether my daughter was fine or not. At birth she should have automatically gone to Intensive Care just to be watched, because of all the prebirth, which is another massive failure. And they should have kept the placenta because of all the labour's situation. They didn't.
LANGDALE: And you say at the end of the letter at page 50:
"Could you please look into the post-mortem conclusions, following notes, reports and statements and review whether [Child D]'s death was of natural causes or not."
You say in your statement going back to paragraph 71, you carried out your own research, considered data on cases. And you carried on having an exchange of correspondence, didn't you, between -- I don't want to take us to it all -- September and October between the Coroner and the Coroner's Office, and asking for certain things to be addressed?
MOTHER D: Yes. By then I have contacted a solicitor and I had someone supporting my actions. The first decision of the Coroner was not to have an inquest and to just draw things as whatever they seemed to be. I asked for the post-mortem to be reviewed and I asked for an inquest but I had to point out to him why what it was saying did not add up with what happened. There was clearly -- the Countess has not provided all the information. For what they proved, it was half a lie, half, I don't know how to describe the other half. It was clearly not -- they weren't giving all the information and what they were giving wasn't true or accurate. So it was upsetting that I had to do their job for me.
LANGDALE: Why did you want an inquest?
MOTHER D: To find out the truth because nothing that's said added up with what they were saying. Nothing -- it didn't match up.
LANGDALE: Let's look at two pieces of correspondence briefly. At page 51 that's your solicitor's letter, Gamlins Law, to the Coroner --
MOTHER D: Yeah.
LANGDALE: -- asking for an inquest, and making submissions what the family say and what you were saying about the circumstances, including NICE Guidelines, how they were identified, how they weren't followed, not prescribed antibiotics, et cetera. A list of issues relating to your treatment. And then we see at page 54, 11 January 2016 the response from Mr Rheinberg who says:
"Thank you for your letter of 23 December 2015. Your further submissions have been very helpful and I have decided on reflection not to discontinue the investigation but to hold a full inquest into the death of [Child D]. During the course of your letter you submit that the evidence suggests that had different courses of treatment been employed, [Child D]'s death would probably have been avoided. That in my view overstates the existing evidence which only suggests that death might have been avoided.
"However, I am now satisfied that this is an area that needs to be explored in detail at a full inquest and my intention is to instruct an independent gynaecologist and an independent paediatrician. The gynaecologist will be able to give expert evidence as regards the treatment of Mother D. I'm afraid it will take a little time to obtain expert reports but I will list a full inquest hearing as soon as possible."
How did you feel when you knew that was going to take place?
MOTHER D: At that stage, finally because they weren't joining the dots, they were just taking things out of context and just taking things to fit whatever they were trying to, to just -- it felt like they were just trying to file my case, and I was not having it. So for me, I kept saying, "You can't just look at the treatment in intensive care or look at the pre birth -- both sides are related and are important and failings happened with me and my daughter". So that, for me, was going to be thorough and I was being heard.
LANGDALE: One of the reports obtained of course was from the consultant paediatrician, Dr Mecrow, and he concluded that your daughter's death was disturbing because the collapse was so sudden and unexpected. When do you remember seeing that report from Dr Mecrow? When did you first see that?
MOTHER D: I don't remember the date. I do remember that when I got it, I got on the phone with my solicitor and I thought: this is more -- again, more evidence. There's -- now when people are actually looking into things, we need to do more. And I mean, I wanted to complain against the Countess, but I was obviously told not to.
LANGDALE: The Coroner sent -- you say at paragraph 81 of your statement:
"The Coroner sent us the service review that was completed by the Royal College of Paediatrics and Child Health in 2016. I think we received it in about April 2017."
So you remember receiving that before the Inquiry. We saw it back in April 2017, around then?
MOTHER D: Yes.
LANGDALE: What did you make of that report insofar as your child was concerned? Did it help you understand anything about --
MOTHER D: I did. It didn't seem to. It seemed like an overview. It seemed like just a tick in the box, no, they haven't actually looked into -- that was just a tick in the box. They did call someone, or a team of people. They reviewed some things. They identified. They didn't identify anything to me. It was just very vague and we still weren't talking about my case in particular. At that time I was only aware and interested in my case but I also did mention the fact that what happened if the mistakes happen again? If you're not allowing me to report this, how do we know this doctor or this nurse or anyone who makes a mistake won't get away with it again? Because we don't know where the mistakes are or why they happened. Clearly, we don't. So this is -- this didn't -- that was just brushing the problem away, but it wasn't -- it didn't address the issues.
LANGDALE: There's a letter at page 55 of the bundle, if you could have a look at that, please, 3 March 2017, addressed to "Mother D", from Mr Harvey.
"Further to previous correspondence and the completed review of the Neonatal Unit carried out by the Royal College of Paediatrics and Child Health at the Countess of Chester Hospital, I'm writing to appraise you of our current progress. You will have seen within the review that one of the recommendations was that a separate independent review of the care of each of the babies should be carried out. This review has now been completed but has in turn indicated a small number of areas of investigation are required and I aim to undertake this as quickly as possible. I will in due course be sharing the findings of this further review in relation to [Child D] with you and will be offering to meet with you to discuss any concerns or issues you may have arising from both the College review and the consequent review.
"I apologise for the length of time this whole process has taken. This reflects the depths to which we've carried out the whole review process. I want to make sure I can confidently respond to any concerns you have in an open and transparent manner. Unfortunately due to the depth of investigation, I am not in a position to give you a definitive date for any meeting but will be endeavouring to make this as soon as possible and will certainly aim for this to be within the next six weeks."
Did you receive that letter?
MOTHER D: Yes.
LANGDALE: And what did you make of that?
MOTHER D: That was a cop-out. It was just not good enough. That was just again trying to say, "Well, we've addressed the situation". I wasn't -- they weren't getting rid of me then. For me, I've had many exchanges, and every time, it was just trying to keep me at bay. That just doesn't address anything. It doesn't answer any of my questions. It doesn't go any of the specifics of what I was pointing out. It was just not good enough.
LANGDALE: If we turn over the page at 56, there's another letter from Mr Harvey dated 21 April to you:
"Dear Mother D,
"I write further to our letter of 3 March and would like to thank you for your continued patience in this matter. I can confirm that further investigation work has been undertaken, however, we have been advised by the independent external case reviewer to consult with the Pan Cheshire Child Death Overview Panel, CDOP, which has been arranged for next week. It is important we take this step to complete the reviews so that we can conclude this matter as soon as possible.
"Once this consultation has taken place, I'll make arrangements as soon as possible to meet you to discuss all the review findings. I appreciate this provides for a further delay for which we are sorry and recognise it is a really distressing time for you but it is important we complete our reviews."
Did you receive that letter?
MOTHER D: Yes.
LANGDALE: Did you know what the Pan Cheshire Child Death Overview Panel was or did?
MOTHER D: No, and that's another frustrating part of the process, because it was really hard to communicate with anyone and get answers to any question, because I was just always told "They will get in touch, someone will get in touch, and we will answer to you as soon as we can". But there was never -- I am being told something is being done, okay, but that is after something else was done. What happened to the something else? What was the finding? What's relevant to my story, to my circumstances? Nothing. This is just a lot of rubbish. There is nothing in this letter that answers any of my questions or my concerns.
LANGDALE: You comment that you read a news article on the BBC website on 8 February 2017 in which Mr Harvey had said the Trust had acted swiftly and reviews had been completed. You say that at paragraph 85 of your statement. Do you remember what you read at the time?
MOTHER D: Yes, yes, I do. Well, what was being said did not match with what was being said to us.
LANGDALE: And your solicitors -- at page 57 of the bundle, my Lady -- sent a letter to the Coroner on your behalf.
MOTHER D: Yes.
LANGDALE: "We write further in respect of the inquest touching upon the death of [Child D] due to take place on 25 May. We enclose copies of letters sent to our client from Mr Ian Harvey, Medical Director, dated 3 March and 21 April, regarding independent reviews to be undertaken by the Trust on each of the babies identified within the Royal College of Gynaecologists and Obstetricians' Review. The letters indicate that the review upon [Child D]'s death have been undertaken but a small number of areas of investigation are required and in the most recent letter that a consultation was needed with the Pan Cheshire Child Death Overview Panel.
"However, in a news article published on the BBC website, Mr Harvey indicated to the BBC that the Trust had 'acted swiftly' and that the reviews had been completed. Furthermore, he indicated to the BBC that 'When we speak with parents we can now share full and accurate information on an individual basis and we are now able to share everything that we understand about what has happened here'.
"Mother and Father D [the letter continues] are concerned that despite indicating to the BBC that all information was available and ready to share with the parents in February 2017, that it is still not the case now. Furthermore, Mother and Father D are extremely eager for the review and its findings to be released to them in advance of the inquest."
And then the letter continues with observations about witness statements, and it says also:
"We confirm we have sent a copy of this letter to the solicitors acting for the Trust."
You were asking for all of the information about your child that was available by then, weren't you, very clearly?
MOTHER D: I was very specific and still they wouldn't comply. I remember calling because when I got the notes I was asked: 'is that because you've got something, are you bringing a claim against the Countess'? And at the time I was not. I just wanted to understand for myself what there was to understand. Then when there was more reports and reviews and I was asking, they said at the time, "You're not allowed to have access to these".
So I don't know what was being discussed, what was being answered. I kept asking, every time I could, and I'd speak to someone at the Countess, no transparency. I don't know what was being done, when it was being done, what came of those conversations, what improvements were -- nothing. Nothing was -- it was very blasé and no information was shared. Nothing.
LANGDALE: At paragraph 89 of your statement you say:
"It was clear that the Trust was not being open and honest with us. It seemed to me they were trying to cover something up. We finally received a copy of the review on 29 April 2017."
That's the Royal College review.
Do you remember now when you got that report, did you see a section in the report with comments about Letby, a Nurse L, described as "Nurse L"? You know there's two copies of the --
MOTHER D: No, there was not. No.
LANGDALE: So have you seen them since and --
MOTHER D: And it was not mentioned, it was not written. It was not something that existed. It wasn't. No. At no point when I spoke to people face-to-face, Ian Harvey and all the doctors, no one ever mentioned anything. It was just "We're sorry what happened", you know, nothing. Nothing else. No transparency. I was very precise and direct with my question. I was straight to the point and I was getting no answers.
LANGDALE: How often did you -- you say you spoke with Mr Harvey. Did you meet him how often?
MOTHER D: Face-to-face, once. But I think we had about five exchanges. And with people from the Countess, many, over a dozen between everyone I spoke to. Even over 20.
LANGDALE: Have you now read the full version of the Royal College report with the paragraphs about Letby and the need for an investigation or an HR processes? Have you read that?
MOTHER D: No.
LANGDALE: If you had been aware that there were concerns about a member of staff being present at a number of deaths, what would your response have been to that around this time?
MOTHER D: I think I would have gone to the police myself regardless of what anyone advised or -- I mean, when I first mentioned involving the police, everyone thought -- this is bonkers. There's nothing to do -- it's not criminal. There's nothing more to it. It's sad, but your baby passed because she was poorly but if I knew everything there was to it, I would have gone myself.
MS LANGDALE: My Lady, I'm moving to a different topic and I wonder if that's a good point for a morning break?
LADY JUSTICE THIRLWALL: Thank you very much indeed Ms Langdale.
So, Mother D, we are going to take a break now. So if we can be back ready to start, if you're ready, at 11.30. If you're not, we'll wait for you.
THE WITNESS: Thank you.
MS LANGDALE: And you must not discuss your evidence with anyone in the break.
THE WITNESS: Okay.
(11.14 am) (A short break) (11.30 am)
MS LANGDALE: We're going to pick up from paragraph 95 in your statement, "Suspicions and concerns regarding Letby".
Did you have any concerns about Letby at the time or with the benefit of hindsight? If you have any recollections of your dealings with her, then tell us.
MOTHER D: With the benefit of hindsight and what I know, I had what someone would call instinct. I felt very uneasy in her presence. When I went to visit my daughter, she was there, I did not know her name, Lucy Letby, and she was just there in the room, and she had no reason to be there because she didn't clearly do something. She was just around waiting, and I told my husband: why is she here? Can we tell her to go? And he was just trying to keep me nice and sweet but I was uncomfortable. She just was watching us, and there was no reason for her to be there. So I did question her presence. I did question why she was there and I remember seeing that same person again at the time of death so as soon as I could I mentioned that person again because I did think -- I don't know why she stood out. I didn't catch her doing anything in particular. I just remember thinking: this person does not belong in those situation, why is she here? Yes.
LANGDALE: You tell us at paragraph 98 you didn't know of her involvement at all until you were informed by the police. Did the hospital at any time let you know whether there were concerns at all about her?
MOTHER D: No, in fact no one has ever made a relation between what I was saying and what they knew. So at no point had anyone ever asked: is there anything I've noted? Is there anything on a particular person? It's only when I spoke to the police that I made a point -- not knowing who they were referring to, I made a point that there was a nurse who stood out to me and I explained why, and they took note, obviously, and they weren't aware. They went back asking me more and if there was anything in particular and I said I can't explain this feeling, I just -- sometimes you can't exactly understand, about things don't add -- don't -- seem odd, or doesn't -- an odd presence, and especially, I think it stood out even more because at the time of death, it was -- I don't know, it seemed maybe ten people, and that's one person stood out for me as odd. I wouldn't know why, because I didn't see her in other situation to think. I didn't -- I never exchanged conversation or any other moments with her. So yeah, that person did stand out to me.
LANGDALE: And when you say at the time of death, was that when she was holding the phone for Dr Brunton?
MOTHER D: Yes.
LANGDALE: Medical records.
From paragraph 100, we ask you about medical records, and when you requested them. Can you tell us about that, when you asked for them, when you got them? I don't need to ask you about the details of them, we've gone into that already.
MOTHER D: Well, when I requested them it wasn't straightforward. But when I got to the right person I was sent a form that I needed to fill in to explain why I wanted the records and I questioned that because I said I shouldn't have to exactly justify it, but I did. I said I wasn't understanding the circumstances and I needed to go over now that I have -- I wasn't -- at the time, I was obviously tired and sad and everything. So I just thought: let me go back. Maybe now I'm calm, I've slept, maybe I will read through and maybe things will make more sense. But yeah, this is why I wanted the notes. I got the notes, but it wasn't easy.
LANGDALE: But it was in 2015, was it, that you got them?
MOTHER D: Yes.
LANGDALE: So you asked for them and there's a process to go through, but you did get the records to go through?
MOTHER D: Yes, and not long after, I required something else. I can't remember exactly, but I asked for some other notes, and they said, "Well, you shouldn't have actually had access to those notes in the first place".
So, um ...
LANGDALE: But you had the notes that enabled you to go off and consult the NICE Guidelines and look for the other information around prescription of antibiotics and you did that when you got them?
MOTHER D: Yes.
LANGDALE: You also saw a case review, if we turn to page 28. It begins at page 27, Case Review Admission to NNU.
"This report is made following review of the clinical notes by each speciality in relation to care provided to Mother and Baby."
And this relates to you and your daughter. Is this part of the notes that you got at an earlier stage or do you know when you got this?
MOTHER D: No, there was -- I don't believe that was part of the original notes, no.
LANGDALE: At some point you've obtained this and look at what it says on page 28 at the top:
"Actual effect on patient and/or service."
It says:
"A term baby has died within the first week of life.
This will have a severe impact on the parents and family."
Then it says:
"The Trust also recognises the potential psychological impact to the staff directly involved, and this, in conjunction with the potential impact to the reputation of the Trust, is considered severe harm."
MOTHER D: Yes.
LANGDALE: You comment on that in your statement. How do you view the way that is described, the second sentence I've read out?
MOTHER D: That troubled me. I didn't understand why this is what was concerned -- this -- it was out of order for me to mention anything to do with the reputation and that's one of my concerns because that's when exactly I was trying to push and ask questions, where I felt there was resistance, where things were trying to be played down and clearly I know by the reports and everything I read, that things weren't -- if I didn't request the notes and get clued up as much as I did, I would never have got the Coroner to get involved. I would have never known everything that was missed, and everything it shows not to share with the Coroner. So it was clear they were trying to hide things.
LANGDALE: When you looked at the detail of this case review you were also concerned to the reference to you as being a PRoM case, ie, a Premature Rupture of Membranes when in fact you were a Pre-term Premature Rupture of Membranes?
MOTHER D: Yes.
LANGDALE: So you were looking at all of the details, weren't you, and seeing whether there were inconsistencies? Whatever they did or didn't mean, you were looking and seeing them?
MOTHER D: But this is to my point. They were dismissing exactly what I was pointing out, and it was not innocent, I don't believe, because it just added up with what was being shared with the Coroner, what was being shared with the information in the review of the conversation. Any meetings they were having, they kept dismissing the details, which is -- I mean even the mottling on my daughter, you -- they told me clearly they don't understand, they've never seen this, they don't know what's going on. So then, look for answers. Don't tell me this and then leave it at that. This is not good enough. I need to understand. I can't accept when I don't understand what happened and why it happened. And they didn't either, so I don't understand why they wouldn't push more.
LANGDALE: Bereavement counselling and support.
You tell us at paragraph 117: "Shortly after Baby D [Child D]'s death, a lady from the Bereavement Department came to see us."
MOTHER D: Yes.
LANGDALE: What did she offer and tell us about that service?
MOTHER D: In all honesty, from my experience, she came far too early. I haven't yet wrapped up my head around the fact that my daughter has passed. I just -- things were going far too fast, and when she came and I just felt -- it was just inappropriate that someone would come straight away. I mean, we knew if we wanted to go and ask for someone we could ring a bell, we could ask, we wanted just some space and to gather our thoughts and some privacy. We weren't given that. And I told the lady I wasn't being rude but she could leave now because she wasn't really welcome and I will contact her when I need -- yeah, I just think it's a bit inappropriate to push the service on to someone who doesn't want it.
LANGDALE: You say:
"Sometime later [you] were referred to the hospital's Bereavement Counsellor, Jo Gwinn", and you undertook bereavement sessions with her.
Did you find that helpful?
MOTHER D: Very. She was exceptional. She was brilliant. But from her own -- my understanding, she pushed for me to have more sessions, otherwise I was only going to get given a few, maybe four or six, but I came to a point where I begged for more. And she said, "Well, no, the people above me believe that you've had more than enough and now it's time, you know, to go about your life, or whatever", and I was highly disappointed, and especially since by that time I still haven't had answers. I still was asking around, yeah. But for what -- for the job she did, she did a brilliant job. She was very supportive.
LANGDALE: And you had a number of sessions, roughly how many, did you have?
MOTHER D: It was 24.
LANGDALE: And they stopped at that point?
MOTHER D: Yeah, because she was told that's it, she can't -- she kept pushing but she was told that's it, no more.
LANGDALE: Raising concerns and getting answers.
You told us that in September 2015 you made the decision to instruct a solicitor and pushing for the things that you had been asking for and that solicitor contacted both the Trust, we know, and the Coroner's Office, don't we? During that process -- and this isn't obviously a reflection on the lawyers -- how frustrating was that in terms of trying to push for the Trust and also with the Coroner for answers, from your perspective?
MOTHER D: Well, there was two aspects. There's the emotional one, because I didn't feel I was supported around by people. I think people just thought because I was grieving, I was transferring my sadness on to other avenues and that I needed to just accept what happened.
So there was my heart and then there was my head that told me: no, there are things that need investigating and I need answers. And thankfully, the solicitor was supporting me, but it wasn't straightforward either because it was the neglect side of things where I thought there was more to it, which was not easy. She said, you know, you're not up against --
LANGDALE: Don't worry, you don't have to tell us what your solicitor said to you.
MOTHER D: Okay.
LANGDALE: I don't need to ask that.
So you were still looking for answers and it wasn't easy because you weren't getting any, is that --
MOTHER D: No, because you can't just put a complaint against a nurse or a doctor or -- yeah, it's not that straightforward at all.
LANGDALE: You had no involvement with PALS, you say in the statement. Did you know what they were, this Patient Advisory Liaison Service?
MOTHER D: No.
LANGDALE: Okay. You tell us that you travelled on 16 May with your husband to have a meeting, on 16 May 2017 you were supposed to be having a meeting with Mr Harvey and your solicitor but you received a telephone call earlier that day from the police telling you that the investigation was taking place. So those two things coincided.
When you got to the hospital, did that meeting take place or not? Or what happened when you were there?
MOTHER D: So when we arrived, as far as we knew, it was still happening. We'd been waiting for a while and the secretary, there seemed to have been a mix-up because she said, "You should have been contacted because this has now been cancelled". And I didn't care. I said, "I'm still here, and Ian Harvey is still here and I want to see him. I came here today and he can speak to me, he can tell me to my face that he won't answer my question or he will. He promised me he will give me answers. There's no reason, if there's nothing to hide, nothing to worry about. He can speak to me face-to-face". I wasn't going away until she was getting him so I did see him but he didn't want to speak. He didn't have anything to say. He said it wasn't up to him to speak any more. So ...
LANGDALE: Your solicitor in this period also received a telephone call from the Coroner's Office to say the inquest hearing had been adjourned due to the police involvement.
MOTHER D: Yes.
LANGDALE: How did you feel about that?
MOTHER D: Very upset. It was upsetting that Ian Harvey was not answering any question at all. So that's -- that was worrying and then the police being involved made things more worrying and more serious. But I thought, even though this is happening, we'll still be able to have some answers, and when that got cancelled, it was very upsetting because we weren't going to get any answers and with now the police being involved it was going to be years before anyone tells us anything.
So everything got put on hold, and I then decided to give up the notes because it was making me very poorly, and I was just constantly knocking on doors and asking people and I just thought now I've got the police doing that job I have to stop and they're going to take over and I have to trust that they will do a thorough job and I mean I passed on all the questions I had, all the notes I had. I had hundreds, thousands of pages and letters and exchanges. So I had to trust that they were going to do everything and then I had to accept that I was going to stay in limbo for a while because now we -- we were very close to getting answers and it was all stopped again. So very hard.
LANGDALE: Were you involved at all in any capacity with any reviews in respect of your baby that were conducted by the hospital, or asked by anyone --
MOTHER D: Not at all. And it's not for me now asking to be, but not at all, no.
LANGDALE: Did you know when Serious Incident Meetings or any other meetings were taking place in respect of your daughter?
MOTHER D: No. It was very vague. No, never.
LANGDALE: You say, "My husband and I are owed an apology"?
MOTHER D: Yes.
LANGDALE: From the hospital generally? What do you mean, "owed an apology"?
MOTHER D: So we had to piece the whole picture together pretty much during the trial. That's when we were finding out information. And that's when things started to make sense. But to me, if I wasn't failed in the first place by the Countess in dozens of way, and all against the protocols and the guidelines they should have followed, my daughter wouldn't have ended up in intensive care. I wouldn't have ended up poorly and destroyed, and she wouldn't have been in a place where someone is preying on babies. So they owe the strict minimum, they owe us an apology, the babies an apology, and all our family that have suffered apologies.
LANGDALE: Moving to suggestions and recommendations.
And you say you've given careful thought over the years to this. Firstly, CCTV. What do you say about that?
MOTHER D: My recommendation would be that it is different to an adult having CCTV in the rooms or in the corridors, because the babies, every parent that can't be at the hospital want to know what's happening to the baby, to the babies, to their baby. It should be -- there should be no reason why this is not safeguarding. There's no -- there's nothing that could be bad about this. All this is watching someone caring for the baby. So --
LANGDALE: Would it have helped you the first night when you couldn't be with her, would it have been nice just to be able to see her in the incubator that if there is a little camera --
MOTHER D: If I knew she had one collapse I would have stayed there all night. If I had access because there was a CCTV or because we were being kept aware of what was going on, she wouldn't have died. I would have been there. So it wouldn't have happened. So yes.
LANGDALE: Communication.
What did you think the level of communication was and what change do you think there should be around communication with parents?
MOTHER D: So I understand they don't -- communication is poor. I appreciate there's a level of information they can share sometimes or they choose not to because they don't want to worry. Maybe we are not as informed or understanding, but there should be no second-guessing. No parents don't want to know. If there is any risk, any problem, anything, we want to know. We want to know for all the reasons that could exist. We need to know. For understanding what happened, for understanding how to address the future, anything, it's -- the communication is power.
LANGDALE: You also speak in your statement about the need for investigations into deaths when they unexpectedly die, when babies die. And you say you question and don't understand why the investigation process is not carried out by independent investigators. Do you want to say a bit more about that?
MOTHER D: Well, why they don't go into it further? Is it because no one takes accountability, and no one thinks it's their job to pick up or point out anything that seems unusual is beyond my understanding. The fact that me, I'm not trained, I could identify a few failings and they did not is shocking. So I imagine anyone that's outside that has no interest in defending or the opposite would be the right person. They don't join the dots between shifts and between what happened to one baby the day before, anything. There's no -- there's nothing to lose to say something wasn't right, we need to report this. There should be one place where it's clear, it's spotted as a separate way of looking at things. Is there a pattern here? Is there a train that it keeps -- something keeps happening? Whether it's the mottling, whether it's anything that's unusual or whether parents keep reporting the same issues, there should be a unit just for that, investigating. Because whether it's someone that is harming babies or it's a virus that's just broke out from nowhere, how are they going to join the dots when they decide not to?
LANGDALE: Accountability.
You say:
"Throughout the years I've come to appreciate that what we were told may not in fact be correct or accurate. For example, Mr Harvey's false reassurance to the media when in fact he would not disclose the investigation findings to us. How do we hold board members to account?"
Why do you think that's important to hold them to account?
MOTHER D: That's their role, safeguarding, that's their role to communicate. That's -- they should have -- they lied to the public, they made it sound like they did their job and they communicated right, and they didn't. So they're all -- every single one is responsible. It's not just one person; it's all of them.
LANGDALE: And you say:
"It would urge consideration of independent oversight and regulation for management teams at hospitals."
MOTHER D: Yes.
LANGDALE: What about the role of the Coroner in that? You were pushing and you got an inquest was going to be held, until the police became involved. Do you think that is a process that gives an independent overview?
MOTHER D: Over the years I think I understand that they don't -- when -- in the process of that, the post-mortem involvement, the Coroner won't be looking at something suspicious. That for me is a failing in the first place, because you're here to identify what's happened. But at the same time, if they're not fed all the information, or the correct information, they can't do the correct job. So in my case and in my daughter's case, it's ... the Coroner was responsible to review the case, and for me, I don't understand how I had access and the knowledge, he didn't. Is it a failing on his part because he didn't dig enough or his team didn't look for more? Or is it all on the Countess because they didn't share all the information? I think it's on both sides.
LANGDALE: You finish your statement with an area for recommendation heading "Compassion". What do you think is important for other bereaved parents, as you were in the Countess of Chester, to understand in providing an environment for those parents after the death of a child?
MOTHER D: You should not be in the same building as other families having babies once your baby has passed. That is first. It goes without saying. I don't know if that's been -- that's something I asked that should change. I don't know if it has changed but it's shocking that someone thought that was a good idea. And this should be not just one person that is ... out to help families. There should be a team of people on hand. There's not thankfully hundreds of deaths so there should be people there for the parents.
LANGDALE: And you also say that whilst you did obtain [Child D]'s medical records, it was difficult and sometimes met with some resistance. Surely that should be offered to parents that they can see the records in their own time and see for themselves what's recorded about their child?
MOTHER D: Not everyone realises that is even an option, that there is ways they can get informed if they want to. So I think some people don't realise also that they can question things. So it should be transparent. It should be clear. It shouldn't be a matter of looking to be courageous or strong and find the time or the energy, and it should be just an open and simple option where the parents should be allowed to review and be made aware and be part of -- when there's the reviews that happen after death, where they review mortality, they review actions, what happened then? Even when you ask, you don't get the answer. I still don't know what was said. I still don't know what they decided. The only thing I got told is: well, I think we will retrain some of the staff. They don't all know about the NICE Guidelines. That's not just the NICE Guidelines. That's everything. There's dozens. I mean, I'm not working with them day-to-day, and I can name many. So they should, for working there, know what should be done.
LANGDALE: Mother D, those are all the questions I have for you.
Is there anything you'd like to add or state that I haven't asked you about that you think is relevant to do so?
MOTHER D: No, I trust in the process. I just want the truth to come out. So no, that's it for me. Thank you.
MS LANGDALE: Thank you.
My Lady, this might be a good moment to break again so Mr Baker can consider if he has any further questions to ask.
MR BAKER: I have a couple of questions. I just need to take instructions.
LADY JUSTICE THIRLWALL: Very well. Let me know when you're ready.
(12.01 pm) (A short break) (12.10 pm)
Questioned by MR BAKER
LADY JUSTICE THIRLWALL: Mr Baker.
MR BAKER: Thank you, my Lady.
Mother D, you gave evidence describing how unwell [Child D] was when she was first born, and how she was then taken to the neonatal unit.
MOTHER D: Yes.
BAKER: Did her condition improve after she was taken there?
MOTHER D: Yes.
BAKER: If you look at your witness statement, please, at paragraph 107, you can see there you're describing in this witness statement extracts that you subsequently read in the clinical notes; is that correct?
MOTHER D: Yes.
BAKER: And you say:
"At 9.25 on 21 June 2015 Dr Newby reviewed [Child D] and noted good condition and improvement. Dr Rylance reviewed [Child D] at 7 o'clock [7pm], noting that she was much improved but that her breathing still needed assistance but I expected that for a newborn three weeks early born by caesarean section."
First of all, those entries that you read in the notes, are they consistent with what you were told by members of medical staff?
MOTHER D: Yes.
BAKER: And are they also consistent with what you observed when you visited [Child D]?
MOTHER D: Yes. She was good colour, she looked full size baby. Yes.
BAKER: And the time of the second entry is described, the Dr Rylance entry is 7 pm. And you have given evidence that you visited the neonatal unit around 7 pm?
MOTHER D: Mm-hm.
BAKER: So presumably a little bit more or after this point?
MOTHER D: Yes.
BAKER: And that was a point where you saw Letby?
MOTHER D: Yes.
BAKER: And you described how she made you feel uncomfortable?
MOTHER D: Yes.
BAKER: Was that the same night, and I appreciate it was the early hours of morning that you were called back, but was that the same night that you were called back unexpectedly because [Child D] had collapsed?
MOTHER D: Yes.
BAKER: If you could then go on to a slightly different topic, it's at paragraph 81. Here you say that you received a service review completed by the Royal College of Paediatrics and Child Health. You think you received it in about April 2017 from the Coroner?
MOTHER D: Yes.
BAKER: Did you receive a copy of that report from the Trust?
MOTHER D: I believe, through my solicitor.
BAKER: When you received the copy from the Coroner in or about April 2017, was that the first time that you had seen that report?
MOTHER D: Yes.
BAKER: And the version of the report that you received, did that refer to suspicions regarding Letby?
MOTHER D: No.
BAKER: You also gave evidence that you had one conversation with Ian Harvey. Did he or anyone from the Trust say to you at any time that there had been failings in the care provided to [Child D]?
MOTHER D: Yes. He knew there was failings.
BAKER: Did he communicate those failings to you?
MOTHER D: No.
BAKER: Did anyone from the Trust communicate to you there had been failings in the care provided to [Child D]?
MOTHER D: Well, Dr Davies, in her conversation with colleagues, she said that I was treated as PROM, but being so close to being PPROM, they did fail in doing the right -- taking the right action. But I was very close so it's almost as if it wasn't so much of a failing.
BAKER: When did you first discover that there were suspicions regarding a nurse?
MOTHER D: The police contacting us.
BAKER: That was on the day of Letby's arrest?
MOTHER D: Yes, yeah.
BAKER: You prepared a Victim Impact Statement for the Crown Court trial, and it appears at page 59 of the bundle that you have. You may feel that you've already said everything that you want to say about impact so there's no obligation to read it, but if you would like to read it, it's there to be read out. Don't feel you should have to.
MOTHER D: I would like it to be read, but not by me.
BAKER: Would you like me to read it?
MOTHER D: If that's okay, please.
MR BAKER: Is that okay?
LADY JUSTICE THIRLWALL: Of course.
MR BAKER: It says:
"Victim Impact Statement dated 5 July 2023 anonymised but signed by Mother D.
"My name is Mother D. I am [Child D]'s mum. Lucy Letby had a chance to say something to us all parents of the victims and she only had one word: 'unimaginable'. Her wicked sense of entitlement and abuse of her role as a trusted nurse is truly a scandal. Lucy Letby, you failed God and the plans he had for [Child D]. You even called it fate. You were clearly disconnected with God. After today, I hope to be free of this limbo state I've been stuck in. The heavy load constantly on my mind has deeply changed me. My heart broke into a million pieces the second [Child D] lost her battle against evil and that is when hell broke loose for us. Those lives were not yours to take, and although I am torn with sadness, anger and unanswered questions, I cannot forgive you. There is no forgiving, not now, not ever. After [Child D] passed, we were asked if we would like her to be an organ donor. This was a very difficult question to answer but we thought if she could be a baby's saviour, as painful as it felt, it felt right to say yes. We were told the baby needed a heart. I can't explain how I felt then, but very soon, they came back to us and said that a post-mortem has been ordered as they couldn't explain why she collapsed and died, therefore she could not be an organ donor, which broke my heart even more.
"I stayed a few more days in hospital to recover, then Father D and I went home, just the two of us, instead of a family of three. We were given [Child D]'s hand and footprints and also a memory box with two tiny teddy bears, one to go with [Child D] and one for us to keep. Our family cleared all traces of baby stuff around the house, removed the baby seat from the car, took [Child D]'s hospital bag home. All was stored inside her bedroom and the door remained closed for many months. We had to organise her funeral. You don't choose the date. The service took place the day before her due date and her ashes were buried in a tiny box on her actual due date.
"Those weeks were particularly difficult. I couldn't rest or stop thinking about all the little things I should be doing instead. My arms, my heart, my life, all felt so painfully empty. I miss [Child D] so much. I was desperate to feel her, smell her, cuddle her. I needed to be her mum in every way to look after her and keep her safe. I felt so guilty and questioned if any of this was my fault. Did I miss something? Did I do something wrong? Did I fail my daughter?
"When I left the hospital, I requested [Child D]'s medical notes and mine. I got clued up on medical terms, neonatal death statistics, guidelines protocols. I was knocking on doors asking questions, meeting with doctors from the Countess and even the Management Team. We got a solicitor and I wanted the police involved. At that stage, I was told that this was not a criminal matter so the police were out of question.
"We got the post-mortem report and even the Coroner ordered an inquest. Things just didn't add up. A week before we were due to go to court and face the Coroner, we got a call at 6 am from the police telling us that they were about to arrest someone on suspicion of [Child D]'s murder and also other babies. This was something else to overcome. We knew nothing during the whole time of the investigation or what has happened to [Child D].
"I became obsessed and this took over my life, fighting for [Child D] and justice. I wanted to know everything. I was told by someone once not to expect too much, and that it wouldn't change anything, nor bring [Child D] back. Thank God the police started their investigation. Now the why and never knowing will keep this wound forever open. The following year I gave birth to [Child D]'s brother, such a gorgeous boy, and it was all those first times. The first time we held our baby boy, the first trip in the car to come home, first bath, first cuddle, first smile, all those moments were filling my heart with happy memories. I love being a mum and at the same time struggle with grief and depression. I have disconnected from many people around me. I lost my confidence as a friend, a woman, a mum, a wife. I never feel good enough. I felt I'd let myself go. My marriage is also scarred by all the hurdles we went through. At first, we were each other's rocks but as challenges were met, we found ourselves dealing with them in different ways, not at the same pace, and it has been hard to keep strong together at times.
"I feel not only I lost [Child D], but lost all those years of my life too. Since [Child D] passed away I live beside my own shadow. I have had multiple therapies, panic attacks, dark thoughts plus many struggles to overcome. I used to cry every day, felt so empty, had a car accident and crashed into a wall. After a nervous breakdown I took time off work and started antidepressants. I guess it was time, but I felt so scared I would never recover.
"I gave up, then tried again but it became a rollercoaster and I was mentally exhausted. I did feel very lonely. At the time it felt I was losing my mind, my sanity, my worth, myself. I considered ending it all. I couldn't continue and didn't really want to. I was hoping so hard that maybe if I went to the other side I would see my daughter and be with her. Now whether this is true or not, I now find comfort thinking that my prayers brought me the strength and courage to stay.
"Fast forward to the trial. This was a long time coming and I knew it would be really hard to stay in a bubble until I gave my evidence. My husband went to court every day. I listened to the opening statements and the evidence from first victims. He would come home but not allowed to speak to me about any of it. He was so strong, and I had no idea what he was taking on. I believe that part of the trial was harder on him than me.
"When I finally gave my evidence and sat on the public gallery to listen to all the facts the prosecution team had gathered, it was clearly overwhelming. It felt invasive having [Child D]'s short life exposed to the public and sit through listening to all the babies' tragic stories. At the same time, I found comfort getting some answers, being able to ask questions and finally meet other families.
"In preparation for the trial, we also had to consider what we would tell [Child D]'s brother about his sister. I explained that [Child D] died because someone hurt her. He asked where that person was, and when I said 'prison', he didn't ask any more until a while after. Then one day he asked me who had the keys to the prison and if there was any chance the person that hurt [Child D] could get the keys and get out. He got upset and worried she might get out and hurt other babies, including his cousin. I had to reassure him there was no chance of that happening.
"We still have [Child D]'s death to declare officially and this could not be done until the cause of death has been agreed. This is going to be another difficult thing do not, going to the registrar and declare our daughter's death eight years after her birth. We wanted justice for [Child D] and that day has come."
Thank you, my Lady.
LADY JUSTICE THIRLWALL: Thank you very much, Mr Baker.
Mother D, that's the end of your evidence. I just wanted to say that from when all this began, you looked for answers and explanations about what happened to your daughter, and we can all see and hear that at great personal cost you have never given up, and your evidence to the Inquiry this morning leaves everyone listening in no doubt of your determination and persistence on behalf of your daughter and for you and your husband. You've done everything that you could have done, and all of that evidence is of great help to the Inquiry. It's made my task easier, as do your thoughtful suggestions about recommendations.
I do know just how hard this process has been for you and for your husband, and I would like to thank you both for all you've done for the Inquiry. Thank you very much indeed.
THE WITNESS: Thank you.
LADY JUSTICE THIRLWALL: I think that's the end of this session this morning. We'll start again at 2.00.
(12.26 pm) (The short adjournment) (2.00 pm)
LADY JUSTICE THIRLWALL: Good afternoon. Welcome.
I understand Mr Sharghy is going to read your statement for you. You don't need to answer, if you just nod if you hear what I said, all right? (The witness nodded)
LADY JUSTICE THIRLWALL: Mr Sharghy.
MR SHARGHY: "I, Mother I, the mother of [Child I], will say as follows:
"I am the mother of [Child I]. I have (redacted) and I live with my husband, the father of [Child I], in Cheshire. I've referred to [Child I] as 'my baby' or 'our baby' in this witness statement, rather than using her name, to protect her identity.
"This witness statement was made following several telephone discussions with my legal representatives.
"My experience at the Countess of Chester Hospital:
"In April 2015 it was confirmed that I was pregnant with my child. I was sure that I was pregnant prior to taking any test because I was really sick. Once I took an at home test, I rang the midwife and she arranged a 12 week scan. This was the first time I was seen by anyone. My sickness continued up until around 13 weeks; it was horrible. I'd never been that sick with any of my previous pregnancies. After 13 weeks the sickness and tiredness continued, it just wasn't every day. Then after 20 weeks, I felt normal again.
"All of my scans came back normal. I had a 12 week scan at the Countess of Chester Hospital and then attended Eye of the Lens in Bromborough to have a 16-week scan which was to determine our baby's sex. We were told we were having a girl.
"Then at 21 weeks we had our last scan at the Countess of Chester Hospital. At no time during any of my scans were any concerns raised. Our baby was developing as I'd expected. I didn't have any antenatal appointments as I breezed through my last pregnancies and there were no areas of concern.
"I did not get to the stage of agreeing a birth plan as my waters broke early, at around five months. As I'd had other children already, my plan was to 'go in, give birth and go home'. I'd never needed to stay overnight with my other children. The previous labours were quick, probably around 3 hours.
"My waters broke about 5 weeks after my last scan. I remember prior to them breaking I felt stressed. I was panicking over many different things. We were due to go on holiday on 28/08/2015 and I was stressing because I didn't have a hospital bag and I really needed my hospital bag to be in the car. In the end it didn't matter because my daughter arrived early.
"On 31/07/2016 I went to the Labour Ward at the Countess of Chester Hospital as I felt something wasn't right but I was reassured and sent home. That night, my pyjamas were soaked in bed. I went back to the Countess of Chester Hospital on 01/08/2015 and was admitted to the Labour Ward. Initially, they tried to tell me that I could have just leaked but I knew my waters had broken. There was water everywhere, plus it wasn't my first baby, and I knew what it felt like when your waters break. Looking back maybe the staff were just trying to calm me down. I remember they conducted some checks which confirmed my waters had indeed broken. This resulted in me being transferred that night to the Manchester Royal Hospital by ambulance and my husband followed me by car.
"When I arrived at Manchester Royal Infirmary, they conducted blood tests, and I was regularly monitored. I was kept there over the weekend, during which time I remember a nurse from the neonatal ward giving me a tour around and they showed me where my baby would be if she was born in the near future. They told us what to expect and explained that if I didn't get an infection, they wouldn't leave me past 34 weeks so no matter what, she would be born prior to 34 weeks.
"The medical staff kept telling me that our baby was safer inside me at this time. However, if she was still inside after 34 weeks, she would then have to be delivered due to the risk of infection.
"My waters breaking so early was completely unexpected. I had expected to walk in and walk out with my new baby a few hours later. I had just had my 20 week scan and everything was fine so I hadn't even seen anyone since when my waters broke. My other children did not need special or intensive care so it was never something I had ever considered.
"By Monday 03/08/2015, due to there being no sign of infection, I was sent home, with the agreement that I would go to the Countess of Chester Hospital every two to three days for blood tests.
"I only got to the first appointment which was on the following Wednesday 05/08/2015 because when the nurse took my bloods, she informed me that I'd have to stay in as my blood levels were slightly abnormal and that they'd like to keep an eye on me. Plus, they were waiting for my blood test results from Manchester Royal Hospital to be sent through so they could compare them and see how much they'd risen.
"I'd asked if I could go home and collect some things as they'd wanted me to stay. Initially I was told 'Yes' but prior to me leaving, the results from Manchester Royal Hospital were received. After they'd compared my two sets of results, I was told I couldn't leave and my levels appeared to have significantly increased. I believe these results referred to my infection levels and there was concerned that an infection had developed, even though my temperature was okay, and I didn't have any other symptoms.
"The Countess of Chester Hospital then transferred me that day via ambulance to the Liverpool Women's Hospital. On arrival I was booked in and given a room on their maternity ward, whilst my bloods were checked again. Over the next few days, I was continuously monitored.
"By (redacted) August 2015, I was still leaking amniotic fluid, however, my waters had started to change colour. Usually amniotic fluid is clear, but it had started to turn a yellowy/greeny colour so everyone was worried about infection. Due to this change in colour, I had a further scan. After I was informed by a female doctor (name unknown) that there was still some fluid left and that my baby was still safer in than out.
"The doctor continued to say that I would become poorly before my baby did, so my blood pressure and temperature were continuously monitored. I remember telling them that I don't really show signs, I just crash, but they were adamant that I would show signs of an infection before it affected my baby. They instructed me that if I had any pain I should say so immediately, as I wouldn't have a normal delivery and that she may come very quickly.
"Later the same day I remember my children had come to visit me and I was sat with them in the hospital canteen when my back started to ache. I recall telling my sister that she should take them home as it was getting late. I said goodbye to them and my husband asked if I was coming out to the car. I said that I thought I was in labour and that I needed to get back upstairs to the ward.
"When I got back onto the Maternity Ward a midwife came and I was attached to a monitor. She informed me that I wasn't in labour and then left. I told my husband that I thought I was having contractions, go and get the midwife. She returned and gave me a couple of paracetamols and left again saying I wasn't in labour. As I wasn't happy, I spoke with a friend of mine, who is a midwife at the same hospital; she went to get a male doctor (name unknown). This doctor instructed the staff to remove me from the monitor and he physically checked me. After his examination he said for me to go straight to the Labour Ward as I was 6cm dilated.
"When I got to the Labour Ward, I was told that I needed to be connected to a drip which would help my baby's brain to which I told them it was too late. I asked the midwife 'How important is it that the team are here', to which she said it was very important. So I said 'Get them in here then' and she buzzed down.
"A further midwife and the neonatal team arrived shortly afterwards. During this time, my contractions just stopped (I think it was out of fear as I was too scared to push) so the staff checked the monitors and from there they were able to see my contractions and they'd tell me when I needed to push. At some point they informed me that my baby was becoming distressed, so I pushed harder and she came out.
"Our baby who we named [Child I] was born at 9.02 pm on the evening (redacted) August 2015 weighing 2lbs 2oz. I was only in the labour room for around an hour. I didn't have any pain relief, nor did I need any intervention.
"Prior to my baby's birth, I had been told that she would immediately be removed to the Neonatal Ward and I would be able to see her later. In fact, when she was born, she was doing really well and they kept her in the room with me for a short time. They brought her over to the bed for me to see her and she was put in an incubator for a while. They took her upstairs saying she needed to go to the Neonatal Unit for 'long lines'. I really appreciated I was able to see her even if it wasn't for long.
"My husband was present during the birth, and I remember him saying 'She's not as small as we thought she would be'. I freshened up and went back to the Maternity Ward where we had a private room which had two beds so my husband could stay. We then just waited and waited for hours. My husband was becoming extremely anxious and frustrated and was not happy as they weren't telling us anything. I kept reassuring him saying 'If they're not saying anything she must be doing okay'.
"Eventually, at around 2am or 3am, a nurse came down and told us that as our baby only weighed 2lb 2oz they were struggling to get her lines in. They had to scan her each time to see if the line had been inserted correctly and on several occasions it hadn't been. At around 3am we were allowed to see her for around 10 to 15 minutes; she was on an incubator on a ventilator.
"The ratio at Liverpool Women's Hospital was one nurse to two babies. Our baby was covered in a sterile tissue-like cover as they didn't want her to get an infection from where they'd entered/attempted to secure her lines. We then returned to the Maternity Ward, and stayed overnight.
"Later that morning around 6.30 am, Father I (my husband) and I went back up to see our baby who was still on the Neonatal Ward (Room 7) and still in an incubator. She wasn't on a ventilator; she just had a BIPAP mask. Her nurse told us this was due to the fact that our baby had fought the ventilator so they removed it and placed the BIPAP mask on instead. I was told that sometimes it can do more harm than good to use the ventilator if the baby didn't need it and not to panic.
"I was told that our baby would need to go to the Neonatal Unit because she was premature and that meant she couldn't breathe unaided and would need constant monitoring and medication for apnoea. It was explained to me that she would be doing the growing she would normally do inside me, albeit in the incubator.
"On that first morning, (redacted) August 2015, one of the nurses then asked if we'd like to get her out of the incubator. At first we were reluctant, but they confirmed that it would be okay. However, as soon as she was placed onto my chest her saturation levels dropped so she was put back into the incubator where her levels improved. The nursing staff said that it might have been just a bit too soon to remove her. My baby appeared fine whilst in the incubator as she was kicking, and her hands were going everywhere. It was just us that were scared to touch her.
"During that day, Father I (my husband) and I spoke to one of the male neonatal doctors and were informed what to expect. We were told that our baby would likely be with them for a long time, but she was doing really, really well and that there were no complications, and the next weeks would indicate which way it was going to go for her. The doctors told me she was doing really well and just needed to avoid getting an infection and to keep growing. On hearing this, I was initially petrified as I didn't know if she was going to come through, but she was fine and eventually all my fear just went away.
"Our baby was just small; the nurses kept telling me that I must have really looked after myself for her to come out as she had. I could see other babies on the ward that had been born of a similar age to our baby and they were struggling, but she wasn't.
"Our baby was then taken off CPAP. I was told she was doing fine on the machine and she wasn't being tired out, so they were going to put her on four hours of oxygen followed by four hours off. I initially raised some concerns, but they said she was healthy enough to do it the old-fashioned way. They did that for a couple of days and it was again all good news; she didn't need the oxygen all of the time. We were really positive at this point.
"Around this time, we were asked if they could run some tests on our baby for training purposes. My husband didn't want them to do the testing, but I did, so we agreed it could go ahead. How I looked at it was if people didn't get this opportunity, our baby wouldn't have had the care she'd received. If she'd been poorly or on a ventilator, I would have said 'no'. The tests only consisted of some probes on her chest, gel in her hair and checking the artery to her heart.
"All of [Child I]'s tests results came back fine and were reassuring as expected -- we were told she was doing well. When [Child I] was approximately (redacted) days old, we were told that [Child I] was going to be moved into Room 2 on the NICU (Neonatal Intensive Care Unit). Babies in Room 2 do not require as much intensive care as those in Room 1; it was more like a HDU (High Dependency Unit) room, although it was still within the NICU. We thought that was brilliant news. However, the next day another doctor came in and said that our baby didn't need to be at Liverpool Women's Hospital any more, and that she was going to be transferred back to the Countess of Chester Hospital because she didn't need intensive care any longer and that all our baby needed was to keep growing, there wasn't anything wrong with her except that she was so small.
"On hearing this we initially panicked as we didn't want her to go back to the Countess of Chester Hospital. Liverpool Women's Hospital was spotless, the floor shone and our baby was settled there. The doctor again said that she didn't need to be there any more. We had been feeling really safe at Liverpool Women's Hospital, but around the same time, we'd also heard that a virus had broken out on Ward 2 there, so I agreed for my baby to be moved back to the Countess of Chester Hospital to reduce the risk of my baby catching anything.
"On 18/08/2015, my baby was transferred back to the Countess of Chester Hospital by ambulance. My husband and I followed with our other children but when we arrived at the Neonatal Unit they wouldn't let us in. Our other children weren't allowed to enter the ward without their red books being shown; they were really strict. I didn't think badly of the hospital as I was glad that they were being so fussy.
"I remember being introduced to a lady called Berni. Berni was a senior nurse on the ward. I don't know her grade but she wore a dark blue uniform and had long dark hair. She took us aside and was very firm in telling us exactly what we could and couldn't do and that if we didn't adhere to these rules, we would be asked to leave. At first, I didn't like her. I thought she was rude. However, as time went on, I started to like her; it was what the ward needed. She was very strict and to the point.
"The Neonatal Ward was located at the rear of the hospital by the Maternity Ward. It had four separate rooms, numbered 1 to 4. Each room cared for babies who needed certain levels of care and were at different levels of health.
"Room 1 -- this was an intensive care room and it could accommodate up to eight babies with a ratio of one nurse to four babies.
"Room 2 -- this was the HDU. The room could accommodate five babies. The nurses from this room would also care for babies in either Room 3 and 4 as well.
"Room 3 -- this was the room before you go home. It could accommodate six babies; again the nurses were shared between the other rooms.
"Room 4 -- this was the nursery. It could accommodate up to six babies. This room was the room which prepared babies for going home.
"Our baby was placed in Room 1. At first, I had reservations about her care. I felt they didn't have time for our baby at Chester. Berni was looking after her, but they were so busy, I remember on one occasion we asked if we could get her out of her incubator but Berni told us 'No' as she just didn't have the time to do it. I remember ringing my mum in tears saying 'I don't want her here, they're not giving her enough time'. Room 1 was also very busy; they even had babies in the corner, and I was very concerned they would not have time for my baby.
"I also queried my baby's oxygen intake as they kept putting her on oxygen if her saturations dropped lower than 96. I had heard previously that too much oxygen was bad for babies so I wasn't very happy. At Liverpool Women's Hospital they would alternate between having my baby on oxygen and taking her off, but they just didn't have the time to do this at the Countess of Chester Hospital.
"Then a couple of days later, Dr V came and informed us that our baby had had a scan and from this scan they could see that she had had a small bleed on her brain. The doctor then went on to say that this could have been caused by a lack of or too much oxygen. I remember thinking: 'They've caused this by putting her on the oxygen'.
"I felt that the Countess of Chester Hospital and the Liverpool Women's Hospital had different methods. The Countess of Chester Hospital was more concerned about feeding and growing as opposed to Liverpool Women's Hospital who wanted to get the babies off oxygen. They just had different methods and over time the nurses would explain why they were doing certain things.
"I also remember my baby continued to wear a CPAP mask. The problem was it was too big for her face. Staff at the hospital used cotton buds to try to pad it out but this just caused her face to be marked. I remember going home one night and asking Jo (who was another senior nurse but I do not know her full name) if she could please just lift it or move it slightly as it was marking my baby's face. The following day when we returned my baby no longer had the CPAP mask on, and I was informed that she didn't need it anymore. I remember feeling annoyed because if she didn't need it, why hadn't they thought to remove it and prevent her face being marked without having to ask?
"When my baby was around (redacted) weeks old, she was moved to Room 2, and it was good in there. I met other families, one of them being Mother G, whose daughter, [Child G], had also been born prematurely at 23 weeks but she was now (redacted) months old. When in Room 2, my baby received her first bottle.
"A nursery nurse called Nicky (I do not know her full name) came in. I remember this Nicky was sneezing and coughing whilst putting her hands in our baby's incubator.
"I was fuming, absolutely fuming, because we were doing everything to stop our baby from getting an infection. I was so annoyed that I had to go outside and phone the nursing desk. I told them that under no circumstances was anyone with a cold or cough to come near my daughter.
"I had to phone them because if I'd seen someone in person I would have lost my temper, and to top it off whilst Nicky was in the room with a doctor, the doctor asked Nicky if she was full of cold, to which she said 'Yeah, I've been full of it for days', so even the doctors were aware and didn't do anything.
"On 5 September 2015, I helped give my baby her bottle, to which she took well. She was then placed back in the incubator. I went home to see my other children and came back just as the nursing changeover was going on.
"My husband asked if he could hold our baby which Berni agreed to but said it could only be for ten minutes as they were changing over staff, so we were made to go to the parent room. This again annoyed me because had he waited a further 30 minutes until the staff changed over to the night shift, we could have held her for a couple of hours instead of just ten minutes. This was due to the fact that that they limited our baby's movements and now that my husband had moved her we wouldn't have been able to hold her again for some time. I left the ward at this point.
"When I returned, my baby's oxygen saturation levels had dropped so either the morning or night nurses had called the doctor. When the doctor arrived, I realised it was Dr Matt from Liverpool Women's Hospital. I was so relieved it was someone we knew. He's not actually called Dr Matt; we just called him that because we knew his first name was Matt. Dr Matt informed us that the nurses had noticed that our baby had been desaturating during changeover, so they were giving her oxygen. He said that she probably just needed a little bit of help. He then did a lumbar puncture to check her bloods just to see if she had picked up an infection.
"I was told that our baby might just be tired as she had had a big day. I had given her a bottle that day so it was a big day for her. I was learning that with a premature baby, ('premmie'), it was often a few steps forward then 100 steps back.
"As our baby's oxygen saturations had settled, Dr Matt returned to the other ward, and I felt comfortable going home for the evening -- around 10 pm or 11 pm. I thought everything was going well again. After we arrived home however, we received a phone call asking us to go back in as they'd had to put our baby onto a ventilator due to her becoming poorly again. I can't say which nurse rang me; I didn't know them too well at the time so I don't know who it was.
"The following day, on 06/09/2015, our baby was sent back to Liverpool Women's Hospital. She was (redacted) weeks old, and this was the start of her becoming poorly.
"On the morning of 06/09/2015, a doctor had told us that they suspected our baby had NEC (necrotising enterocolitis) because her stomach had swelled up and her veins were visible. We were also told that she needed to go to Liverpool Women's Hospital so she was close to Alder Hey Hospital just in case her bowel ruptured and they needed to operate.
"The doctors were adamant that it was NEC and they told us that all of our baby's symptoms pointed towards this. They were working on 'worst-case scenario' to rule it out.
"When we arrived at Liverpool Women's Hospital, they immediately said that our baby didn't have NEC and within 24 hours she went from being fully ventilated (at the Countess of Chester Hospital) to no ventilation and starting back on her feeds (at Liverpool Women's Hospital).
"Our baby was still unwell and weak because she had been resuscitated and so they kept her there and put her on antibiotics just in case. She remained in Liverpool Women's Hospital for a further week but she was in the HDU not the Neonatal Unit (NICU). During this time, the medical staff did not check our baby's stomach or bowels and I think if they had just checked, it could have influenced her future care and I'm not happy about that.
"Whilst at Liverpool Women's Hospital, I remember phoning the Countess of Chester Hospital's neonatal ward and asking the nurses to pass a message on to [Child G]'s mum. I just wanted to tell her that our baby had turned a corner and that she was doing okay, but they informed me that they couldn't as [Child G] had been transferred to Arrowe Park Hospital with a similar medical condition as our baby. On hearing this, I put our baby becoming ill down to a bug that they both had picked up. I thought that it might have been Nicky's fault and that she had passed on her cold to our baby and [Child G] as she had been coughing on the ward just before her collapse. Staff at Liverpool Women's Hospital and the Countess of Chester Hospital said this was not the case as our baby didn't have a cold because she would have been sneezing.
"On our return to the Countess of Chester Hospital, our baby was placed in Room 3. This meant that, in a matter of a week she had gone from being critically ill on a life support machine and being rushed to Liverpool Women's Hospital, to now returning to the Countess of Chester Hospital and being placed in the room before your baby goes home. In same room was a lady called (redacted) with her baby.
"My emotions had gone from rock bottom to now being positive again. I coped by trying to forget what I'd seen and gone through, and just kept going. I just used to say 'She's just had one of her moments and she was letting us know who's boss!'
"Whilst in Room 3, our baby was being cared for by a nurse called Janet Cox during the day, but I can't remember who it was at night. By now our constant attendance at hospital was taking its toll on our (redacted) year old daughter so my husband and I decided to split our time. I used to go to the Countess of Chester Hospital from 9 am until 3 pm and my husband would go there from 4 pm until 10 pm, as he worked during the day.
"Our baby continued to do really well and we were dressing and feeding her. Then one day I went to the Countess of Chester Hospital, and (redacted) was really upset. I asked her what had happened and initially she said 'Nothing' but eventually she told me that she'd been up all night expressing some milk and that it had been a real struggle. She said that she'd then placed the milk into the nursing fridge and someone gone in and had given it to one of the other babies.
"Obviously she was upset because of the effort it had taken to extract it, but she was more upset due to the fact that she was on heart medication and she was worried that one of the other babies may become sick because of it. She'd asked the nurses which baby had been given it, but they declined to say due to confidentiality but said the baby would be okay because it was being fed through a feed so they could syringe it back out. They wouldn't even tell her which nurse had given it which I think is wrong because the nurse should have at least apologised.
"I also don't believe the baby's parents were told as we saw no angry parents, which I would be if my baby had been given milk containing elements of heart medication. I was concerned that it may have been our baby. I started to become obsessed with handwashing and I wouldn't take our baby out of the incubator because I was concerned that she may pick something up from the room.
"Shortly afterwards, (redacted) was due to take her baby home. Nurse Nicky came in and helped bathe (redacted)'s baby. After she'd finished with (redacted)'s baby she asked me if I wanted our baby bathing, to which I remember asking, "Are we allowed?' and she said, 'Yeah, she's doing well, I can't see why not' so I said, 'Yeah'. I was made up, but before she could, Janet Cox (nursery nurse) came in and said, 'No! You can't bath her, she's not old enough, she can't regulate her own body temperature yet'. Our baby would have been around (redacted) weeks by this time.
"[Child G] returned briefly and moved to Room 4 and after that (redacted) and her baby went home. I recall a doctor telling me that when they were discharging her, and that our baby wasn't that far behind her and was doing really well.
"After they left, another baby was admitted to our room but I wasn't happy with this family as they didn't wash their hands; the dad would touch all of our baby's blankets. I complained to the nurses, and they told him off, which resulted in him apologising. I just explained to him that I was concerned that our baby would pick up a cold from someone which could be extremely dangerous for her. On 30/09/2015 I was changing our baby's nappy before leaving for the day when a nurse called Lucy (at the time I didn't know her surname but now I know it to be Letby) came on duty. It would have been around 3 pm. This was the first time I met Lucy Letby.
"I'd describe Lucy as being around late twenties with shoulder length blonde hair, with a long slim face; her face was always on the babies' fundraising pictures. I say she'd just come on duty because I hadn't seen her earlier and I thought it strange because handover is normally at 7.30 pm so I just put it down to maybe the nurse who was looking after our baby had gone home early.
"Lucy came over and said that she thought our baby's stomach looked swollen, which I agreed with, but I thought that our baby looked okay in herself. Lucy informed me that she'd keep an eye on her and she'd call for the doctor to also check her out. I left at around 3 pm. Our baby had been doing really well and was staying where she was safe. She had been in an incubator since her collapse on 06/09/2015 but had recently been moved to a cot so I was feeling quite relaxed at the time.
"I had just got home and that gone to see a neighbour when I received a phone call (around 4.30 pm) from the hospital. I can't remember who I spoke to, but they told me that our baby had had another turn and I needed to make my way to the hospital. I panicked as my husband was at work and I had to ring him to let him know he had to come to the hospital now.
"I arrived first, and when I got there Berni, or maybe (redacted) was resuscitating our baby by conducting chest compressions in Room 1. I froze. I was on my own as my husband hadn't arrived yet and it was very scary. Our baby's stomach was swollen, she had been sick, and she looked really unwell.
"I can't remember any of the other members of staff who were present but there were other staff there. Berni informed me that the swelling to our baby's stomach had now gone down and that she was doing better. I thought her stomach had swollen up so much that it had crushed her chest which had caused her collapse, but I wasn't told what specifically caused the collapse. I know that the doctors took samples from her spine and checked for infection. The doctors and nurses told us that she was a puzzle and weren't sure why she kept having episodes.
"I now understand that a report called a 'Datix' was created on 01/10/2015 about our baby's collapse on 30/09/2015. I was not told about this at the time and would not have known what a Datix report was. I had no idea there were any meetings or discussions about her collapse.
"The next day, our baby was moved to Room 2. It was a quick change-around, but this time we didn't have to change hospitals as our baby started to improve within hours.
"I also remember [Child G] had been poorly many times around the same time as Baby I [Child I], as they were both back in Room 2 and I was trying to reassure Mother G that it would be okay. The nurses were telling me that our baby was doing well again and that it had been known for babies to be sent home from Room 2 previously.
"As the days went by, I noticed that our baby was starting to be more aware. She was looking around the room taking it all in. I was able to sit her on my knee and I remember looking at her and thinking 'We're going home'. She just looked like a full-term baby. She didn't look frail or small; she just looked like she should be at home. I started to think she needed to be at home so she doesn't get an infection as I'd seen so many people not washing their hands and then touching things in the room.
"I just wanted to take our baby home desperately. I had sent videos home that I'd taken on my phone and I was allowed to bath her which she loved and was smiling. I remember bathing her the first time. I was in Room 2 and Lucy Letby was on duty. I was so pleased to be able to bath our baby. Lucy helped prepare the bath and gave advice as to how to bath our baby. She even offered to take some photos using my mobile phone which I agreed.
"Other than these limited interactions, I didn't really have much to do with Lucy. She always appeared reserved and kept herself to herself. I thought she was a bit miserable compared to some of the other nurses. She never really interacted with the parents.
"When our baby was (redacted) weeks old, I enquired about her getting her immunisations when she returned home but the hospital said that they had given them to her whilst she was in hospital. A female doctor (name unknown) did prepare us by saying that our baby's white blood cells would rise after she'd been immunised.
"Our baby had her immunisations on 05/10/2015 but afterwards Dr Matt told us that her bloods had risen more than they'd expected and that they were going to screen her.
"I understand from my medical records that on 07/10/2015, our baby had a lumbar puncture and was put on antibiotics. Shortly afterwards, I remember the female doctor coming back in and asking why our baby was on antibiotics. I recall telling her that because of our baby's history and because she declined so rapidly, it was done as a precaution. I explained that our baby could go from being perfectly fine to nearly dying within seconds. There was no in between with her. I had been told all along that this was normal for premature babies, that they get infections, that they go up and down, and that they might have to test her for lots of things.
"I remember the staff at the Countess of Chester Hospital kept making a big deal about our baby's stomach swelling. They thought she had NEC, or twisted bowels. They said that she might need a dye test and that perhaps she had an intolerance to milk. At this point the medical staff told me I had to stop Googling everything. I remember a couple of the nurses telling me that sometimes these things happen. I was never led to believe that these collapses were anything to be concerned about or abnormal, or that they were worried about anything out of the ordinary.
"I had been feeling positive at this point. Our baby was doing really well, I thought. I clung to the nurses saying it was fine, that it would be two steps forward, ten steps back sometimes. I know she was on antibiotics after her immunisations but this wasn't a concern as I know they were given as a precautionary measure. Dr Matt wanted to be cautious and I appreciated that.
"I also remember that at some point they tested our baby for cystic fibrosis. I think it was after immunisation but before she got really sick, although I cannot be sure now. I remember being asked to leave the room and when I returned, our baby was screaming. I'd never heard her cry so loudly.
"As time went on, I felt the atmosphere within the hospital had changed. I had gone from feeling that our baby would be coming home to uncertainty. Tubes were starting to go back in, and it just felt like something was wrong. It felt like they were looking for something. I remember asking a blonde-haired nurse (name unknown, but she was in Room 2) if our baby would likely be going home any time soon. She just said, 'We'll see. She comes off her antibiotics Wednesday so we'll see what they say when she comes off'.
"Dr Dave (full name unknown) then came and checked on our baby and I again asked him how long until we could take her home. He just told me she could wake up tomorrow and not need the heated mattress or it could be six months down the line and that's just what it's like for a premature baby.
"Our baby was still feeding and was in a heated cot. She was also wired up to monitors. In the late evening of 10/11/2015, we were sitting there and I remember a nurse called Ashleigh was looking after our baby. Baby G [Child G] was there with her dad and she'd been poorly too. We were all just talking when our baby's oxygen monitor started bleeping. I turned to Ashleigh and asked if it was our baby to which she replied 'Yes, it's nothing to worry about, it's just the signal". Ashleigh then fiddled with the strap which was attached to our baby's foot saying it must be loose, but the bleeping continued. Ashleigh kept reassuring me that everything was okay, however, when I left that night, I didn't feel right. I felt as though it was the start of a pattern for our baby as her oxygen and saturation levels would always start jumping just before she became poorly.
"First thing in the morning of 11/10/2015, I phoned the hospital and spoke with Ashleigh. I asked her if she'd sorted the monitor out, to which she informed me that she'd turned it off, saying our baby didn't need it and for me to stop worrying. When I asked how our baby was, she told me that her temperature had dropped overnight and I remember thinking that's two signs: first the monitors bleeping, and then her temperature dropping. Ashleigh kept reassuring me that everything was okay and that she was fine.
"That day or the next day, which I think must have been 12/10/2015, a new baby joined our room. Again, this caused friction as they weren't adhering to the washing of hands rule and I feared that our baby would catch an infection. Mother G was telling me to calm down, but I feared our baby getting poorly so much that I had to say something.
"Then, later that night whilst I was at home, we received a call from the hospital telling us to come immediately. This would have been the early hours of 13/10/2015. I don't remember much of the call or who it was that rang us. When we arrived, our baby was really poorly. It was the worst she'd ever been. The staff had to resuscitate her at least seven to eight times. She just kept flatlining. I remember the following staff being present: Jo, Berni, Dr Matt and a young nurse who subsequently left to go to Australia. Others could have been there, but I can't remember them.
"Eventually, they managed to stabilise our baby and the hospital staff believed that our baby had a bowel problem. On this occasion she was not found with a swollen stomach, she was found not breathing and my thoughts were had they kept the monitors on her, her condition could have been detected earlier.
"Our baby's stomach did swell in the end, and she had bruising under her left breastbone. It was blue in colour and the bruise was probably a few centimetres in size, which doesn't seem big, but due to our baby's small size, it was quite significant. Our baby continued to be poorly and she was continually being resuscitated.
"By 14/10/2015, the hospital gave us a room to sleep in, but every time we left and started to fall asleep, we'd be woken up with banging on the door telling us to come quickly. This wasn't once, this happened several times. When I look back at it now, it feels like this went on for days but I understand from my medical records it was actually only over two days. Our baby also seemed to deteriorate when we left her alone and it was predominantly at night.
"Eventually, Dr Matt said that he was worried. He said that he didn't know if our baby was going to make it. I recall they phoned Alder Hey Hospital to seek advice. Alder Hey Hospital said that if she stayed on antibiotics for seven days and stabilised, they would be able to give her a dye test to see what the actual problem was but she would need to be on nil by mouth for this. I understand from my medical records that this conversation happened on 14/10/2015.
"I believe that the doctors there at Alder Hey thought our baby had complications or damage from an earlier episode of NEC which could have caused damage to her bowels, which would explain why she'd become poorly as she may have had a build-up in her bowels. I wasn't entirely convinced this was the cause of our baby's problems because on this one occasion Ashleigh (nurse) said that she'd just found her blue in her cot and her stomach hadn't been bloated. I again queried why she'd been taken off her oxygen monitor if she was that poorly, as surely this would have picked up the fact that she was having breathing difficulties. I just couldn't understand why they would continue to do that.
"At this point I felt like our baby was getting worse -- things weren't improving any more. I remember standing outside the hospital and thinking what if she doesn't get home? At this point we couldn't leave hospital at any point because that was how quickly she went downhill.
"At some point between 13-14/10/2015 Belinda (surname unknown, however she was an Australian nurse) pulled me to one side and told me to sit down. She said that our baby's heart rate, even though it had picked up, was still too low and it had been like that for some time, so she suggested that we get our baby christened. She tried to reassure me that our baby could still get better but it was something for us to consider.
"I felt as though by christening her we were giving up, but we did it. I think it was on 15/10/2015. We organised for everyone to come in a rush, and our baby was christened at the hospital. My medical records show that our baby was moved to Arrowe Park Hospital on 15/10/2015 so the christening was held that morning before she was moved. I believe Belinda was there but I can't remember any other staff being present.
"On 15/10/2015, our baby had another collapse in the morning. I was shown a scan of her lungs, and from the scan it looked as though they'd collapsed. Staff at the Countess of Chester Hospital said that our baby had to be moved as they couldn't do any more for her. We were asked where we would like her to go as there was room at Arrowe Park Hospital or Liverpool Women's Hospital. Due to Arrowe Park Hospital having a McDonald's House we decided to go there as we could all be able to go as a family. This decision was also made due to the fact that our other daughter was missing us and she'd started to have nightmares due to our absence.
"However, as our baby was being moved, her oxygen saturations dropped. I remember Belinda used an implement and sucked loads of fluid out of her lungs before she was placed in a travel incubator. Our baby was then transferred by ambulance to Arrowe Park Hospital.
"I now understand that a Datix report was created on 13/10/2015 about our baby's collapses. I was not told about this at the time and have only been made aware of it very recently.
"When we arrived at Arrowe Park Hospital on 15/10/2015 our baby was x-rayed again, and her lungs were fine. They'd blown back up, so now I had Arrowe Park Hospital telling me that there was nothing wrong with her. I felt as though the staff at Arrowe Park Hospital were rude; they were acting as though they were the better hospital. They said to me that they were annoyed that our baby had even been taken there and that there were other babies who were a lot sicker than her and that she didn't need their care.
"I felt I had to defend the staff at the Countess of Chester Hospital. I told them that I'd seen them saving my daughter's life time and time again, but they just kept telling me that our baby was fine and for me to look at the scan. I tried to tell the nurse and the doctor that when she's moved fluid blocks her lungs which then stops her breathing, but the doctor just told me that he couldn't understand what I was saying.
"I appreciate that I may have been upset at the time and not making sense, but I believe the doctor should have listened to my concerns. A nurse then informed me that she was going to give our baby some milk to which I said, 'No, she's nil by mouth'. The nurse stopped and apologised, and said that she'd not read the notes. I was so angry, I didn't want to be there any longer.
"I remember placing my hand on our baby's chest and I could feel her chest bubbling. I told the nurses that she wasn't well and that there was something going on. I asked the nurse to use suction to clear the lungs because I knew as soon as they moved her, she would drop like a tonne of bricks. The nurse just kept reassuring me that they had specialist doctors who were looking after our baby and that she would be okay. I again stressed my concerns saying that she was going to crash again, and she told me that [Child I]'s lungs were fine, but when the nurse turned our baby, she crashed as I had told them she would. A doctor then came over waving his arms in the air as though he didn't know what to do, so I screamed at him to get the ventilator, to which he did. Our baby then started to pick up and her condition improved.
"Our baby was only at Arrowe Park for two days. They said she didn't need to be there and everything was fine. Looking back now, it always seemed as soon as our baby left the Countess of Chester Hospital, her condition would improve but the journey to and from the hospitals would take it out of her. When I was told she could return to the Countess of Chester Hospital, I was pleased and happy to return.
"I was always anxious when our baby was transferred because if she was being transferred it meant she was really poorly. I didn't have any issues with the transfers themselves, but it was always very strange that she improved straight away once at Arrowe Park Hospital or at Liverpool Women's Hospital.
"[Child I]'s deterioration and death.
"Our baby was transferred back to the Countess of Chester Hospital by ambulance on 17/10/2015. The journey was fine and she settled back into the Room 1 on the Neonatal Ward. I understand from the medical records that our baby desaturated during the journey but soon recovered. I remember going home that night and telling my mum that our baby was awake but she just didn't look herself. It was as though she was looking right through me, like she couldn't see me.
"In my mind, it was the following day that I got a call from the hospital. However, I understand from my medical records that it must have been on 22/10/2015. Time sort of stands still when you are in the Neonatal Unit and it can feel longer and shorter. Nurse X, one of our baby's regular nurses, told me that our baby needed some clothes bringing in as she'd taken her out of the hospital clothes and had put her in a babygrow.
"The staff at the hospital continued to remain positive about our baby's condition and I started to believe them. I gained hope that we would bring her home. The staff were also talking about our baby having the dye tests, as she was still nil by mouth at this point. They said that she might be able to go and have this at Arrowe Park Hospital.
"That night we left the hospital around 10.30 pm. I remember Ashleigh was our baby's nurse that night, as was Lucy Letby. We left at this time as my mum had asked us to come home because our other children needed us. I remember leaving the hospital that night feeling lighter because our baby looked alert again, she was looking around and seemed less tired.
"Then at around 12.30 am I woke up having realised I'd slept through a phone call from the hospital. I didn't check to see if they'd left a message, I just immediately phoned the ward. The phone was answered, and I was put on to Ashleigh who informed me that our baby had just had 'a little turn' and they'd had to put her on a ventilator but she was okay now. When I put the phone down I said to my husband that we had to go to the hospital. I wasn't happy with our baby being on a ventilator after all the problems she'd had previously.
"Lots of thoughts were running through my mind. What if they had turned her and blocked her lungs? I needed to remind them, so after I rang my mum to come and look after my other children, I phoned the ward again and someone else answered the reception phone (name unknown). This person went to find Ashleigh but when they returned they told me that we needed to get to the hospital as soon as we could.
"We left home immediately and on our arrival at the hospital we saw Dr Gibbs, Ashleigh and Lucy Letby. They were working to try to resuscitate our baby. They didn't have time to tell us anything but asked me to put my hands on our baby so she could feel us. I remember standing by the incubator with my hand on her foot because there was only room for us at the bottom. I was shaking and I couldn't look at the monitors because I knew she was a lot worse than all the other times. I felt absolutely broken.
"I heard them all counting times, so I asked Dr Gibbs how long they'd been doing this, and he said '20 minutes'. I could see every time they were pumping her chest, her oxygen saturations levels would go up, but when they stopped, she would flatline every time. I remember thinking 'You can't keep doing this to her' and I said to Dr Gibbs, 'You can't do it anymore'.
"My husband couldn't watch. I don't know where he went. I think he was in one of the corridors. Whilst they were working on our baby Dr Gibbs gave her an injection. I don't know why or what was in the syringe, but it was given into her leg.
"When they eventually stopped working on our baby, they passed her to me. I didn't want to let her go and held her so tightly as she was our gorgeous little princess. I cannot even begin to explain the pain of losing her. I feel like a part of us died with her. She didn't die straight away. It was around 2 am or 3 am in the morning on 23/10/2015 when she actually went. I can't be certain as to the exact time as I didn't clockwatch, as too much was going on.
"After she passed away, we were left alone and all of the other babies were moved out from the room. This gave us some privacy. Later on, we were moved to a private room when it became visiting time.
"My husband blamed the hospital; he blamed the staff on duty that night because they'd not been the ones on duty when our baby had been successfully resuscitated before. I felt that our baby had just given up, that she just didn't have any fight left in her. I also wondered if her ventilator had blocked as that would have blocked her airways completely. I blamed Arrowe Park Hospital. They had her nil by mouth for so long and they hadn't even done the dye test. I felt like our baby had been starved for nothing. I thought that if she hadn't been nil by mouth she might have had more energy to fight.
"Ashleigh and Lucy (Letby) asked if I wanted to bathe our baby. My husband initially said no, but I didn't want to look back and regret not doing it, so I said 'yes'. Lucy brought the bath in and said if I could get her ready she'd come in and take some pictures which we'd be able to keep.
"Then, whilst my husband and I were bathing our baby, Lucy Letby came back in. Ashleigh and Lucy would come in and out. She was smiling and kept going on about how she was present at our baby's first bath and how much our baby had loved it. I remember thinking at the time, 'What are you going on about, she's only ever had one bath and my husband never got to bath her'. I just felt so sorry for him because he hasn't got that memory and I wished Lucy would just stop talking. I remember thinking 'Will you just go away'. I was really uncomfortable and I just wanted her to leave. It was also weird that she kept smiling. I had never really seen her smiling before. Eventually, I think she realised and stopped. It wasn't something we wanted to hear right then so I put it down to saying the wrong thing at the wrong time. However, I still thought her behaviour was strange. I mentioned it to my mum who said that maybe Lucy was trying to put a nice mood on it, but there was no nice mood. I just wished she and Ashleigh would go and swap with the next shift. I don't know if Ashleigh was there for all of it.
"I remember it was Lucy Letby who packaged up our baby's belongings for us to take home. Prior to leaving hospital, Father I (my husband) and I were spoken to by another nurse (name unknown) who had blonde hair, and by Dr Gibbs.
"Dr Gibbs said that are baby was basically a full-term baby and that these collapses shouldn't have kept happening. He mentioned about our baby having a post-mortem examination. I said I didn't want her to have one, as I just wanted her leaving alone, but he informed me that I didn't have a say and that she needed to have one as her death had been unexpected and the results would be needed to 'clear the hospital'. In response, I informed him that our baby had been fighting for her life for the past seven days, how was that unexpected and unexplained? He just said she needed to have a post-mortem and that Alder Hey Hospital wanted her there that day. On hearing that, I lost my temper. I told him that our baby had been starved of food for the past ten days at the requests of Alder Hey Hospital so she could have a dye test to check her bowels. I questioned how she could fight anything off that she'd picked up and said something to the effect that 'now she's dead they want her'. I was fuming. I told Dr Gibbs that they were not touching her. I also remember him saying that they couldn't have kept putting our baby on a ventilator. I am still not sure what he meant by this, as [Child G] had been on and off a ventilator for the past three months.
"A short time later Dr Gibbs returned and said that he'd sorted it with Alder Hey Hospital and our baby wouldn't be going until Monday. I remember not liking this doctor. Looking back, I think it was just the circumstances as my mum said he had been lovely.
"We left the hospital that day with some bags which consisted of a box of our baby's belongings, handprints and leaflets, et cetera. I thought it was like a kick in the guts, as you go through all that and you come out with a couple of bags, not a baby. I was never offered any support by the hospital and there was never any follow-up welfare checks. At the time, I was really numb.
"It was my GP who supported me and gave me every test possible to show me that I wasn't at fault for our baby's death, as I wanted to know why my waters had broken early. I blamed myself for our baby's death so my GP arranged for tests just to prove to me that there was nothing I could have done. I was also having nightmares and woke terrified if anyone tried to contact me through the night.
"I really did blame myself. I remember going back to the Countess of Chester Hospital at some point and speaking to Gill Davies, an obstetrician, as I was hoping to get a hysterectomy to make sure that this could never happen again. I thought it was all my fault, that I had done something or given our baby something to make her come out too early. Gill tried to reassure me that what had happened to our baby was a random thing and she promised me that if I had another baby everything would be carefully checked.
"As time passed, my husband continued to blame the hospital for our baby's death, so in a way, I was glad that our baby had had a post-mortem as I felt that it would show if the hospital had been at fault.
"I remember my husband and I got a letter at some point from the Coroner. Looking at the Coroner's bundle, I can see it was dated 28/10/2015. I didn't really know what it meant at the time, but I do remember talking to a family member about what an inquest was as it was mentioned in the letter.
"We had our baby's funeral in early November 2015 and I asked that people didn't buy cards or flowers, that they should donate to the Neonatal Unit at the Countess of Chester Hospital. I can't remember which day I went back to the Countess of Chester Hospital, but I popped in to bring the donations from the funeral in person. I remember bumping into Nurse X. I wasn't necessarily trying to talk to her, but I had just let the Unit I know was coming in and Nurse X happened to be the first person I saw.
"We spoke about our baby, and how shocked she was that our baby had died because she was doing so well. Nurse X had had to ring me just before she died to ask for more baby clothes. I distinctly remember Nurse X saying 'I even had to put clothes on her' during this conversation. Putting clothes on was a big deal in the Neonatal Unit. When babies are unwell or very premature, they cannot hold their body temperature so their incubator had to be set to a certain temperature to keep them warm or cool, and they have no clothes on as a doctor may need quick access to them. The babies just lie in their nappies until they start to get better. By saying our baby needed clothes, I understood this was Nurse X saying that she had been doing well.
"I understand from Nurse X's witness statement that she doesn't remember saying this, and that she remembers me asking why she dressed our baby. I definitely didn't ask Nurse X this. I already knew why she had dressed our baby as she had called me to ask me to bring in more clothes, so I am certain that I didn't ask her anything like that.
"I also understand that Nurse X doesn't recall saying anything about prematurity. It is my recollection that Nurse X said 'I don't think it was prematurity related', as we were already discussing how shocked everyone was that our baby had died. The impression I got was that she thought our baby had some kind of underlying condition or that something had happened to cause her death.
"Around this point in the conversation I remember Dr Harkness approaching. I understand from Dr Harkness' witness statement that he says I came to the Unit a few times. I remember I wanted to drop some things off for another parent once, but I might have even done that when I was dropping the donations off, but I don't recall coming back any other time. I'm not sure where he got the impression that I did but I distinctly remember leaving the Unit after dropping the donations off and thinking 'I can't go in there again'."
"Dr Harkness and I spoke briefly. He gave his apologies about our baby's death, and I changed the subject quickly. We spoke a little bit about how her grave was going to be a castle. In his statement I understand he says that I felt 'fobbed off' by Alder Hey Hospital. I didn't feel 'fobbed off', I felt let down by them. They made her nil by mouth and said they would do the dye test and they never followed through. I was angry at them. I felt our baby had been starved and wondered what if they had done the test and they had found an issue with her bowels? Would she still have died?
"I also understand he says I was annoyed by the transfers our baby had to endure. I was never angry at the transfers themselves, it just meant she was really poorly.
"Dr Harkness and I didn't discuss our baby's possible cause of death and he wasn't there when Nurse X and I were talking about it. Soon after he joined the conversation, I saw Ashleigh approaching and I had too many bad memories wrapped up with her, so I ended the conversation and left.
"I understand that the Coroner sent another letter on 12/10/2016. Thinking back, I must have received the second letter although I don't remember it. It stated that the investigation into our baby's death was being discontinued and enclosed the death certificate. This is because I remember I rang the Coroner's Office when I received the death certificate to ask about a toxicology report. They told me that the hospital hadn't requested one. My thoughts were if she'd died at home, she would have had one so why not when she was in hospital? The fact a toxicology report was not performed had not been explained to us by the hospital. By the time we found out about this from the Coroner, it was too late as our baby had been buried.
"The post-mortem report came back with the cause of death as being prematurity and confirmed that there wasn't anything wrong with her bowels. I have never been happy with this conclusion, as our baby wasn't born a poorly little baby; she just became poorly. I still remember (redacted) telling my mum that I'd been reading our baby's monitors wrong and I put that down to two things: guilt on (redacted) behalf or because she'd turned them off when our baby had clearly been struggling. Had the monitor been on, I believe our baby's condition would have been detected earlier or she had got something to hide. I blamed her, even though she only looked after our baby maybe three times.
"I remember having a meeting with Dr V with the results of the post-mortem. I remember her saying that the hospital may discuss our baby in later meetings. We weren't given the impression that they were investigating anything; we thought it was for training purposes or something like that.
"When I left, Dr V made it perfectly clear that our baby had died from prematurity and she had explained that our baby had damage to the brain, but we knew that before she died.
"I understand that a Datix report was created on 23/10/2015 about our baby's death. As with the other Datix reports, I wasn't told about this at the time. This certainly wasn't discussed during my conversation with Dr V.
"In around January 2016 I started to get nightmares again. I'd wake [up] in the middle of the night dreaming that I was back in the hospital and that the nurses were banging on my door. I also had to turn my phone off at night because if someone texted or phoned me in the evening/night I would panic.
"In April 2016, I was diagnosed with having Post Traumatic Stress Disorder.
"The Royal College of Paediatrics Review.
"I received a letter from the Countess of Chester Hospital asking me to contact them to make an appointment to speak to someone. I thought it was around January 2017, but I can now see it was dated 08/02/2017. Apparently, they had tried to call me a few days before as well.
"Included within this letter was a link to a review the Countess of Chester Hospital had conducted which related to a number of baby deaths during a specific time period. This was the first I'd heard of any review or investigation, so it was a bit shocking. I had no idea that any investigation or review was being conducted by the Countess of Chester Hospital.
"Receiving this letter was the first I'd ever heard of the Royal College of Paediatrics and Child Health Review. I also was never aware of an advisory report prepared by Dr J Hawdon. The first I'd heard of this was when my solicitor mentioned it to me while I was making this statement.
"I went onto their website and read the report. I'll be honest and say I only skim-read it. I did however recognise that our baby's death had been included even though she hadn't been named. I knew they were referring to her because she'd been the only baby who'd died on that ward on 23/10/2015.
"I contacted the hospital on what I can see was 09/02/2017 and asked if the report related to our baby's death, to which the person (I believe was probably a receptionist) said 'Not really, but I can't really go over it over the phone'. I remember telling her that I was pregnant again and unless they had a good reason, I didn't really want our baby's death raking back up and I was trying to keep things as stress free as possible.
"I have seen the note of the telephone call. It is my recollection that when I asked if the Review was important, that she told me, 'To be honest, all this is for us to improve our services, but we'll leave your baby's file open, and you can come and see us after you've had the baby if you choose to', although I see she didn't put that in her notes. I specifically remember her saying this because I rang my mum after telling her that the report was for training. I do remember talking to her about how I didn't have any concern about our baby's care, and how I was frustrated at Alder Hey Hospital. This was the only discussion I had with the Countess of Chester Hospital about the Review.
"Police investigation and concerns over Lucy Letby.
"On 11/05/2017, I was contacted by Cheshire Police who informed me that they'd commenced an investigation into the large number of baby deaths/collapses at the Countess of Chester Hospital between 2015 and 2016. They called me to make an appointment to come and see me the following day. However before they arrived my waters broke. My mum had to wait at the house for them to arrive to tell them.
"I gave birth to my youngest daughter by emergency C-section on (redacted) May 2017 at the Countess of Chester Hospital. By this point the whole world knew there was a police investigation into the baby deaths at the hospital and there was press lining up at the hospital. This was a really difficult time for me. Eventually we were moved to Liverpool Women's Hospital.
"When I did finally speak to the police, I got the impression that they were investigating our baby's death and thought it might be down to hospital mistakes but that they had to look at the criminal side just in case. I was stressed about how I was going to tell my husband as he was always sure something had gone wrong and I was always telling him he was being stupid.
"According to the witness statement I gave to Cheshire Police at 1.05 pm on 20/11/2017, I handed DC Price the following items for their investigation:
"Mother I Exhibit 1: plastic container containing medical equipment used by [Child I] on date of her death (also a separate box which is a memory box which contains clothing worn by our baby).
"Mother I Exhibit 2: personal child health records.
Mother I Exhibit 3: two pictures of our baby, documentation with death certificate.
"Sometime after I was informed of the police investigation and I had given our baby's things to the police, I did try and contact someone at the Countess of Chester Hospital. The police were being very tight lipped about the investigation, and I wanted our baby's things back or some progress or something. I phoned them, but I was told that they could no longer give out any information as it was with the police now. I remember thinking I should have spoken to someone about the Review report earlier.
"Looking back, I didn't have many dealings with Lucy Letby. I have already outlined the ones I remember. I remember thinking she was a bit quiet and a bit odd. She always seemed a bit of a loner. The most interaction I had with her was when she helped me bathe our baby. We saw her around on the odd occasion, but we didn't have much to do with her. She was always the most reserved of the nurses. I remember thinking she seemed miserable compared to the others and I never saw her interact with parents much.
"Now I have seen the medical records, I am absolutely shocked at how much 'care' she provided to our baby. She is all over her notes. I have noticed a lot of the 'care' was when I wasn't present.
"I have been told that Lucy Letby sent us a card when our baby's funeral was held. I don't recall receiving one at all. I did get sent some cards, and I kept them, and I have looked through them, but I haven't found a card from her. For the funeral I specifically requested no cards, so someone else might have opened the card and thrown it away. It wasn't for anything personal that I told everyone not to buy a card -- I felt I didn't want cards for her for this. I had told everyone to buy cards when we brought her home and we weren't going to bring her home. Instead, I told people to donate to the Neonatal Unit. I didn't want sympathies for me. It was never about me, it was about our baby. Knowing what I know now, I am glad I didn't see it and that I don't recall anything about Lucy Letby's card.
"I have been asked if the Countess of Chester Hospital ever said anything or provided any information about concerns over Lucy Letby's conduct. They didn't mention anything to me at all. As explained above, I tried ringing them during the police investigation and they wouldn't speak with me. I certainly was never told of any actions the Countess of Chester Hospital was taking about concerns with Lucy Letby's conduct. The first I heard of anything was when doctors and staff were giving evidence during the criminal trial. The police remained very tight lipped about what or who they were investigating. In March or April 2018 I went to see Dr Brearey at the Countess of Chester Hospital. During this appointment he asked if I had heard from the police. At the time I was annoyed as I hadn't heard from them for months and I couldn't get hold of my Family Liaison Officer. He went on to talk about the nurses on the Neonatal Unit and how they were struggling and how hard it was. I told him my theory that it could have been an infection that had caused Baby I [Child I]'s ultimate demise. If there was an infection on the unit, those nurses should have kept the babies away as an infection could have harmed all of the babies in the Unit. I had many theories at this time as I had been told nothing by the police. Dr Brearey told me that it wasn't an infection, that everything had been tested and our baby was clear. My reaction to that was that if it wasn't an infection, it only leaves that someone tried to hurt my baby. I said 'How can I live with myself knowing that someone would have tried to hurt my baby?'. Dr Brearey said that I would never have known. I walked out of that appointment thinking someone had deliberately killed my baby.
"I was officially made aware that our baby might have been murdered and that an arrest was going to be made when the police phoned me at 6 am on the morning they were making the arrest. When they told me, my whole body started shaking and the thought of having to tell my husband was awful as he wasn't with me when I took the call. This was in July 2018. I was shocked that it was Lucy, but my husband wasn't when I did tell him. He always had suspicions that something wasn't right and now it had been confirmed, although if he had to point the finger at anyone, he had assumed it was (redacted). The police then came to see us later that morning. We were not given any details at all about how or why, only that an arrest was being made and how long they would be questioned before being bailed etc.
"A few weeks after this, we had an appointment with Detective Superintendent Paul Hughes as he had agreed to speak with all the families. I asked if Lucy would be charged and he wouldn't confirm this, but said they were confident that our baby had been deliberately harmed. We were so broken that someone could do something so evil to our precious little girl. It has had a massive effect on our family even to this day.
"I have been asked if I consider that the Countess of Chester Hospital was 'open and honest' with me at the time and after in respect of our baby's death. At the time, I thought they were honest with me. I only had good things to say about them. This is obvious as I collected donations from my baby's funeral and said I was happy with the care our baby received when speaking to the receptionist about the Review report.
"With what I know now, I don't believe that they were being honest at all. I had doctors and staff telling us that our baby's collapses and conditions were 'normal' but it turns out it wasn't normal. Staff at the hospital already had concerns about babies being unwell and about Lucy Letby well before our baby died. I, hand on heart, believed everything they said to me at the time, and now I am so angry they were not being honest. I feel lied to and that they were just covering their own backs. Even the receptionist I spoke to about the Report downplayed it and said it wasn't important and it was basically for 'training'.
"I felt totally blinded by all their lies and cover-ups. My husband isn't surprised though, he always believed something had gone wrong and the hospital was responsible for our baby's death.
"I had never felt the need to request our baby's medical records until I was told that someone was being arrested for her murder but by that time, I had instructed Irwin Mitchell (solicitors) and they had requested them on my behalf. Once they got them, they sent copies to me so I could review them. As I mentioned before, when I reviewed them, I was shocked by how much care was provided by Lucy Letby. She was all over the records. The only overly concerning thing was that there was a note that at some point our baby was given too many antibiotics, and even though there was no harm done, no one ever told me this.
"Knowing what is in the medical records, and after hearing evidence at the criminal trial, I truly believe that our baby was tortured. She died because she had no fight left in her as she suffered collapse after collapse, and in the end was kept nil by mouth for a test that was never done. She went through so much in her short life that was deliberately done by someone who was supposed to protect her and help her come home where she belonged.
"Bereavement counselling and support.
"When I think back, I am disappointed by the help and support offered by the Countess of Chester Hospital after our baby died. I remember I was given a leaflet about counselling services on the day she died. I didn't have any other support. It was just left up to me. They dumped this information on us on the day our baby died, and I had these carrier bags of things that I was leaving with and not a baby. I was expected to reach out for support when we were in the worst pain and emotional state any human can imagine. No one reached out to us to offer support of any kind.
"My real lifeline was my GP. I would sometimes book an appointment to see the GP so I could offload as I was so sad. Eventually my GP booked for me to see a counsellor, but I had to wait months to get an appointment and then it was just to speak to someone to see what kind of counselling I needed. I heard nothing for months after that, and as I had started to pick myself up at that point, I didn't follow it up.
"The first year after our baby's death was a blur and I don't know how we as a family got through it. I wore sunglasses constantly to hide the pain and tears from my other kids as I didn't want to upset them as they were also struggling. I struggled in public, to eat, to sleep, and I would just relive the collapses. My emotions felt like they were happening again. I would have nightmares and night sweats and sank into a black hole, and it was harder and harder to keep going.
"By April 2016 they'd got so bad I asked my health worker and GP for help. I didn't think it was depression, but I just couldn't snap out of it. They arranged for me to see an emergency counsellor who diagnosed me as having PTSD. Once I'd been diagnosed, my symptoms appeared to improve. I think it helped just to know what was happening to me.
"My husband struggled to be around us as a family and went to the pub to try and cope. He wished that he was dead instead of our baby. We even separated for a while as neither of us could deal with what happened. Our other kids also suffered. They gave up things they enjoyed and my older daughter stop speaking.
"Eventually we got back together and I got pregnant again. I don't remember any of the pregnancy really. I put a wall up and blocked it out as we were filled with fear. What if the same thing happened again? Scans were not happy moments -- again, just filled with fear. When our daughter was born, she was born at 34 weeks so I had to go to the NICU again and it was terrifying. We didn't leave her for a second. I couldn't bring myself to breastfeed my daughter as I had a fear that my milk had caused our baby to die.
"My GP prescribed me beta blockers, antibiotics and sleeping tablets. I was having nightmares and couldn't sleep for the first year after our baby died, and then it started all over again after I gave my police statement for the criminal proceedings. When the police got in touch, I went straight back down the black hole of depression. I started counselling in 2018 through the police and Victim Support services and I have been using this on and off ever since.
"I didn't request any additional support from the Countess of Chester Hospital as I didn't know there was anything available.
"Raising concerns.
"As I explained above, I didn't have any concerns about the Countess of Chester Hospital at the time our baby died, but my husband did and was always convinced someone was responsible for what happened. My husband has not spoken to anyone at all; he really struggles talking about anything and I do worry about him. We asked the Countess of Chester Hospital for (redacted) to not come to the funeral as my husband had held them responsible for our baby's death. He blamed everyone who was there for not doing enough. I didn't raise this with the hospital though and neither did he.
"After all my years of counselling, I can see it is easier to be angry than it is to show emotion. That is how my husband goes through all of this, but in the end he was right. Throughout the years after our baby's death my husband has ranged from being convinced that a nurse had 'done something' on the night our baby died to believing our baby had died as the treating doctors hadn't done enough to save her.
"We didn't raise concerns for a few reasons. I believed that the Countess of Chester Hospital had done everything they could. I never imagined that someone would deliberately hurt our baby. I didn't know the doctors had concerns about Lucy, because they didn't tell me and instead told me everything was normal. I didn't know they had been lying at that point.
Secondly, we didn't think anything would be done even if we did report our concerns and I would not have known where to report our concerns. Based on the incident mentioned above when a nurse gave milk expressed by one mother to a different baby, I would not have been confident that reporting concerns would make any difference. That incident was reported and it didn't go any further, the nurse never apologised and the other baby's parents were never informed so what was the point? When it started to become apparent that something was wrong, everyone closed ranks, and no-one would give us any information.
"We did not speak with PALS and the only external organisation we spoke to was Irwin Mitchell (solicitors), who were first contacted in July 2018. I was not aware of any other organisations we could have contacted. I have not been involved in any other reviews concerning baby safety.
"I have seen the witness statement provided by our Family Liaison Officer, DC Griffiths. Our FLO made a statement which I have read and I totally agree with what she says. I often felt alone and completely out of the loop about what had happened to my baby. It feels like everyone else knew and I didn't. I had to find out that someone might have intentionally harmed our baby at a check-up appointment with another doctor. Even when the police did tell me, I wasn't allowed to know how my baby had been harmed. Eventually when I was given this information, I had to sign a non-disclosure agreement and I was told I could not even tell my solicitor or my counsellor. I understand why the police wanted to keep this information confidential, but it was very hard and I spiralled down that black hole again. I believe there was a real lack of transparency thorough this whole process, starting at the Countess of Chester Hospital where I was assured 'everything is normal', to being told that the RCPCH Review was just for 'training', to everyone at the Countess of Chester Hospital closing ranks and not talking to me, to the police drip-feeding me information. I spent years digging for information, and it has taken me to some very dark places mentally.
I believe it would have been easier if everyone was more open and helped a grieving family understand what went wrong, why our baby had died when she was actually progressing well despite being born prematurely, and what support was available for us to access if/once we were ready to confront the horror of losing a baby.
"I have been asked what in my view would have assisted in preventing Lucy Letby's crimes. I believe the doctors and nursing staff should have acted earlier and those in positions of authority at the hospital (ie, the management at the Countess of Chester Hospital) should have listened to them instead of trying to create their own narrative that Lucy Letby was a victim of bullying and harassment. Someone should have investigated the concerns fully at the time. This is what management are paid so handsomely to do. They shouldn't have been concentrating on saving their own skins and jobs and reputations. Babies died because someone in an office being paid hundreds of thousands of pounds didn't want the hospital to look bad if they shut the Neonatal Unit down while they investigated why so many babies were deteriorating when they should have been thriving. Covering up failures, inadequacies and deliberate harm was valued far higher than the life of a baby whom they should have protected unconditionally.
"Even the many doctors who had concerns because they were overworked and understaffed should have spoken up earlier and louder than they did, though, given the way they saw their colleagues who did raise concerns were treated by management and the regulatory bodies, some may be forgiven for believing that speaking up was futile. However, I believe that much more should have been done after the first three babies had died within a short space of time in similar circumstances. Had prompt and effective action been taken at that time, so many other babies would have survived or not have suffered enduring life-changing harm. How many babies needed to die/be seriously harmed for action to be taken to stop Lucy Letby? Sadly, we all now know the answer.
"I understand that complaints were made about Lucy Letby far earlier than when she was suspended. If they had just had someone supervise her work, that might have saved the life of number of babies and the permanent injury of many more. Even if they weren't suspicious of Lucy Letby but they had investigated a potential infection outbreak or faulty machine, it might have been enough to stop Lucy Letby from having the opportunity to harm my baby time after time until she succeeded in killing her.
"I think there are a lot of changes that could be made that can make any and all hospital wards safer. I have heard people mention having cameras on the medication dispensers but I don't think this is enough. In the Neonatal Unit, practically anything at all could be dangerous to premature and sick babies, not just medication, so I think there should be cameras on all the babies. I can't think of anyone that would try and claim it was an invasion of privacy to have their newborn child monitored not just medically but also, actually, to prevent any harm arising or for there to be deniability when things go wrong. If this had been available when our baby was at the Countess of Chester Hospital, Lucy Letby would never have been able to hurt our baby or indeed others.
"I also think there needs to be much more effective oversight at all levels of hospital management and overall at the Trust. People paid huge salaries allowed this to happen. They made doctors apologise to Lucy Letby when she had murdered babies and continued to harm other babies. The Countess of Chester Hospital was totally blinded by self-preservation that they forgot why they exist -- to remain true to the Hippocratic Oath 'I will use my power to help the sick to the best of my ability and judgement. I will abstain from harming or wronging any person by it'.
"Finally, I think all hospitals and Trusts need to have a robust and fast investigation process whereby mistakes, issues with systems, personnel and the like can be looked into and any harm arising stopped as soon as reasonably practicable. The death of one baby in suspicious circumstances should be enough to result in a prompt and robust investigation as, sadly, families cannot rely on the inquest process to look into suspicious deaths as effectively as is expected. For example, the Coroner in our baby's case did not really consider the full facts and medical history to ask the simple question of 'why did this baby appear to thrive but have several serious crashes, one of which resulted in her death?'.
"I absolutely feel that the way information was shared with us was wholly inadequate. The same doctors that gave evidence at the criminal trial and said that they had suspicions of something going on before our baby had even arrived at the Neonatal Unit were the same doctors that told me that these collapses were 'normal'. There was no way I could have made any informed choice about what the best care for my baby might have been, when the key information was being withheld from me. The staff were not telling the truth or being honest while on the ward, but appeared to discover their moral and professional obligations when giving evidence in court. This is where a lot of my anger comes from -- these people were speaking to me, and they had suspicions but told me everything was fine.
"I understand that they couldn't tell me that they had reservations without evidence, but they shouldn't have told us everything was normal. I could have made my own decisions -- I trusted them and believed everything they said, and it was not the truth. I could have made the decision that she was better placed somewhere else, or that they could have had more oversight at the time.
"The Trust could have told me about the RCPCH Review that was going on in 2017 and been honest when I asked if it was important. I had just lost my baby and I was pregnant with my youngest daughter and trying to drag myself out of the black hole of depression, so I relied on them to be honest with me and they brushed it off.
"Finally, I understand the police had to be careful about what was said so not to jeopardise the criminal trial, but they were so closed off and unhelpful and at times it was very isolating.
"In terms of additional support, I think it would be helpful if counsellors and bereavement services reached out to you. When you lose a baby, you are numb for a long time. You are still sad but numb. It doesn't hit you properly, but when it starts to hit -- especially when you have been in a cocoon of a Neonatal Unit -- it could be months down the line and you hit rock bottom and there is no one there or anyone to offer support. When they offer support, you don't feel like accepting anything, but when you need it there is nothing.
"If I had support services ring me and offer help, I might have accepted it earlier, and if they had conducted check-up calls a few weeks or months down the line, I might have been able to access help earlier. When you're in a black hole, you can't always find the momentum to get the help you need but if someone reaches out to you, you might accept it.
"I also think there should be consideration of sanctioning (and where appropriate removing) any manager/person in a position of authority who ignores concerns raised by whistleblowers. At the present time, there appear to be no sanctions against those who lied and kept information whilst babies were being killed/harmed by Lucy Letby. It was only when it became untenable to keep up the pretence that they finally opened up on the scale of concerns raised against her and the number of babies that she had harmed. Yet those managers/people in a position of authority were not sanctioned and continue to work unhindered by their unprofessional and morally corrupt conduct.
"I honestly believe that these people should have to explain why they didn't do something earlier, why they ignored the multitude of concerns raised about Lucy Letby's conduct, why their actions facilitated a mass murderer.
"Our baby would have turned nine this year. We should have been watching her grow and play with her siblings and friends. However, we have to somehow try to live with the fact all this has been taken away from her and us in the cruelest way possible. No parent should ever have to go through what we have been and continue to go through each and every day. To understand how easily my beautiful girl's death could have been prevented hurts even more. Forever and a day, I will continue to ask 'why?'"
Thank you very much, my Lady.
LADY JUSTICE THIRLWALL: Thank you, Mr Sharghy.
Mother I, thank you very much indeed for providing that very frank and detailed statement, and also for inviting us to hear Mr Sharghy read it so that it would be read into the record. As a result, it's there for consideration and inclusion in our review of the Terms of Reference, and I just wanted to thank you for that.
Thank you very much indeed. And also, for being here today, listening. It's very good to see you, and thank you.
(3.42 pm) (The hearing adjourned until 10.00 am the following day)
LADY JUSTICE THIRLWALL: Is the shorthand writer ready? Thank you very much.
I'll just mention one thing which I did yesterday. I know that everyone who is listening online and who is a member of the media is aware of the reporting restrictions which arise out of the Crown Court orders, and this is really by way of a reminder that if there's any inadvertent breach of the order by anyone, it is not to be reported, and obviously it will be removed from the transcript in due course.
Ms Langdale.
MS LANGDALE: Good morning, my Lady.
MOTHER E&F (sworn)
Questioned by MS LANGDALE
MS LANGDALE: Mother E&F, you provided a statement to the Inquiry dated 16 July 2024. Can you confirm the contents are true and accurate as far as you're concerned?
MOTHER E&F: Yes.
LANGDALE: We all know of course that [Child E] was murdered on 4 August and [Child F] attempted murder by insulin poisoning.
Could you tell my Lady the impact that has had on you?
MOTHER E&F: The impact that that has had on us has been enormous. It changed the course of our life completely and we've had to try and grieve in so many different ways. We tried to grieve at the time, and then we had to endure what was going to be happening when that report arrived on our doorstep, and then that brought everything back up. We had to grieve for the life that we thought we were going to have with [Child F], with his learning difficulties. So it was a real mixture of emotions and ups and downs, and it felt like over the course of nine years, a lot of things that have been good and meaningful to us have been very overshadowed by the actions of the Countess of Chester.
LANGDALE: We'll come on to reports and what you did and didn't receive later.
One of the matters you comment at the outset in your statement about is being robbed of expectations of family life and tormenting yourself with thoughts of [Child E] buried in the clothes that Letby picked out and dressed him in. And we have seen a note you have written about that where you say:
"She dressed him in a little woollen gown with blue ribbon around the waist. We buried him in that. She put a small teddy next to him."
Did she have a discussion with you about those clothes or what was being done? Can you remember?
MOTHER E&F: No, so there was no discussion about those clothes. He was bathed by Lucy Letby and he was placed in that woollen gown in his incubator, and when I asked where it had come from, she said that it had come from the unit and she'd picked it out and chosen it for him.
LANGDALE: And you also made notes that she gave you a memory box with his hand and feet prints in it, and taken some pictures and put them on a card, and all his belongings were in that memory box?
MOTHER E&F: Yes.
LANGDALE: Did you know that was being put together?
MOTHER E&F: I did not know that was put together.
LANGDALE: And how do you feel now about having the memory box being put together by her?
MOTHER E&F: I think if that memory box was put together in the way it's meant to be put together by somebody who was, you know, a caring professional who hadn't done harm to our child, it would be meaningful, but everything in that box, absolutely everything, has been created by her. All his belongings were touched by her. His blankets that had the blood on are in the box. His hand and footprints were taken by her. His hair was cut by her, and it's painful. Even one of the pictures that she took of him has got part of her hand in it and for me that hurts because I don't know if it was intentional but it felt intentional, once we knew what had happened.
LANGDALE: You say in your statement you listened to your boy's final hours during the trial. So what did you learn in the criminal trial that you didn't know before?
MOTHER E&F: Everything. We didn't know any information, because the criminal trial was, you know, it was quite rightly so it was protected and, you know, that was important. But the information, you know, about the falsifying of records and the way things were done, and --
LANGDALE: You gave evidence in the criminal trial, didn't you?
MOTHER E&F: I did.
LANGDALE: And just touching upon that, when you knew you had to give evidence, were you able to speak to anyone about the rest of the case or anything like that until you'd given your evidence?
MOTHER E&F: No. So I wasn't able to attend court up until after I had given evidence. So I had to stay away from the media and everything until I'd given evidence. So I couldn't know anything about what was happening in the trial, which was really, really difficult because again, everything felt out of my control.
LANGDALE: We'll come on to that evidence later but for now can I ask you about your experiences at the Countess of The Chester Hospital in the run-up to giving birth and when you were pregnant, and you start at paragraph 19 in your statement.
MOTHER E&F: Okay, so I was under the care of Liverpool Women's Hospital. I was there as an inpatient, there'd been a problem at one of my last appointments, and the Consultant thought it was best that I stayed in hospital. They were trying to get the pregnancy to 30 weeks and they thought that was going to be possible and I was being scanned every day. It was suggested that [Child E] was significantly smaller than [Child F], and there was a problem with the blood flows to the boys.
We knew there was a problem with the neonatal unit at the Liverpool Women's as in capacity and we knew a few days before that it was actually at capacity. And it was suggested that we -- you know, we be transferred to different units and I think one of them was actually Cardiff, and I was quite upset at the prospect of being sent to Cardiff, which is quite --
LANGDALE: Yes. So you ended up having a C-section, didn't you, at the Countess of Chester?
MOTHER E&F: I did.
LANGDALE: And how was that experience?
MOTHER E&F: It was okay. So I arrived in an ambulance and I was taken to a room, and albeit it was -- it wasn't like the Tertiary Centre of Liverpool Women's, it was quite a stark contrast to that. But I was treated well and things were explained to me. And I was about to go into theatre and an emergency came in so they -- the emergency went in and I waited and then I went in and had -- had the boys.
LANGDALE: And you were told there was going to be a team for each of the boys?
MOTHER E&F: Yes.
LANGDALE: And one for you, in the theatre?
MOTHER E&F: Yes.
LANGDALE: You had an epidural?
MOTHER E&F: Yes.
LANGDALE: All of this was explained and went well from your perspective.
MOTHER E&F: (Witness nodded)
LANGDALE: And when were they both born, did they cry on delivery? How was it?
MOTHER E&F: Yeah, so it was explained to me before, before I had my section, that because they were so premature, that they may not cry, but actually both boys did at birth, which was really lovely to hear.
LANGDALE: Where were you taken when you came out of theatre?
MOTHER E&F: I was taken back to the room where I had come from and then, after an hour or so, I was taken up to a ward with other mums and babies. My husband was able to go and visit the boys briefly. I didn't want him to go on his own so my mum actually went with him. They didn't want her to but I insisted that he must have my mum with him.
LANGDALE: So you were effectively on a ward watching other mothers with their babies but you couldn't see yours?
MOTHER E&F: Yes.
LANGDALE: Did you or your husband have to insist that he could see them or how was that or was it just offered? What was the position?
MOTHER E&F: I think it was offered that he could go and see the boys, but that was to take some pictures for me. So I essentially had two pictures of my boys, and, you know, it was really, really difficult when there's lots of other mums on a ward around me with babies, and babies crying, and it -- it all just felt really, really sad and I felt lost.
LANGDALE: Would it have been helpful for you to have a camera in the incubator so you could have at least seen them from where you were even though you were in a different part of the hospital and view them in the way parents sometimes do when they can't be with their children?
MOTHER E&F: Absolutely. I think that would have been really helpful for me at that time.
LANGDALE: You say in your statement you were told you should wait until the morning to see the twins but you insisted you wanted to see them sooner and eventually, at 11 pm, six hours after giving birth, you were able to do so?
MOTHER E&F: Yes. My husband said he wouldn't leave the hospital until I'd seen them and he took me down to the neonatal unit to see them.
LANGDALE: And when you saw them, what impression did you get about how they were and what was happening?
MOTHER E&F: I was actually in shock when I seen the babies because they were so small and [Child F] was actually wrapped in a plastic bag, and it took me by surprise. And I actually said to one of the nurses, "I don't think that these are my babies, they're just so small". And she said they were, "They are, I was here when they came through".
LANGDALE: And at any stage or other, were you led to have any concern that they weren't progressing, getting stronger and doing as they should?
MOTHER E&F: Everybody that we came into contact with said how well they were doing and they were doing way better than what, you know, they were meant to be doing for their gestation that they were born at. [Child E] was actually breathing for himself, he was on no support. [Child F], he needed a little bit of extra support but that was explained to us. It was because [Child E] was ready to be born and [Child F] would have been quite happy to stay in utero a bit longer.
LANGDALE: [Child E]. On the night of 3 August 2015 tell us when you were called to go to the NNU what happened?
MOTHER E&F: Sorry, can you repeat that?
LANGDALE: On 3 August, if you look at your statement from paragraph 46 onwards --
MOTHER E&F: Yes.
LANGDALE: -- you visited [Child E], that evening, didn't you on the ward?
MOTHER E&F: Yes.
LANGDALE: Can you tell us about that now?
MOTHER E&F: In the evening?
LANGDALE: Yeah, in the evening when you went down, what --
MOTHER E&F: So in the evening I went to take some expressed milk. I'd been with him. I'd have been with both of the boys all day. My husband had done skin to skin with [Child E] in the morning and I had done skin to skin in the afternoon with him. He was thriving. He was --
LANGDALE: Tell us what that means, skin to skin?
MOTHER E&F: So it's when baby is placed on mum or dad's chest and then wrapped in a blanket to keep all the heat in, and, you know, the baby can feel our heartbeat and we can feel theirs, and it's just a really beautiful thing to be able to do.
LANGDALE: So you'd been doing that in the day. In the evening, what happened when you took the milk down?
MOTHER E&F: So I went in the evening, I took the milk and as I was -- I was -- I'd come in to the unit in the corridor, I could hear screaming and crying, and it was a shock, because I'd never really heard -- I mean, I'd been on that unit six days and I'd never heard a baby cry like that. And then I walked into the room and I realised it was my baby. And I went to him, and he had blood around his mouth and I was just shocked and I tried to -- I put my hands in the incubator and I tried to do a containment exercise that they'd explained to us, that that makes the baby feel like they're still in your tummy, you put your hand on their stomach and hand on the head, and that is meant to calm the baby down so it feels like it's secure and safe. And that didn't work.
And I asked Lucy Letby why there was blood around his mouth, why he was bleeding. She was quite dismissive and said, "It'll be the feed tube rubbing the back of his throat, and that's where the blood will have come from. But I've contacted the registrar, and, you know, he's on his way. Go back -- you know, you go back to the ward and if there's any problems I'll ring for you".
And I didn't have my phone with me and I wanted to speak to my husband because I knew there was something not right. So I left.
LANGDALE: And did you phone your husband?
MOTHER E&F: I did and he told me that there was nothing to worry about because he's in the best place: he's in a hospital with people that know what they're doing, and if there was a problem, that we would know about it. But I know.
LANGDALE: When you went back, did you get a call later that night to go back to the NNU?
MOTHER E&F: Yes, yes. So I'd had a conversation with a midwife and I was upset, and I told her what I'd found, and I think she checked on me throughout the couple of hours, and she then asked me to -- she'd come in to the room and asked me to contact my husband, and ring him. And at that point I knew something really bad was happening, and she asked to speak to him and she didn't -- she wanted to speak to him and she told him to come to the hospital straight away and not to drive. To get somebody else to drive him.
So at that point, I knew something really awful was happening, but I never for a million years did I think that my boy was going to die. It never entered my head that he was going to die.
LANGDALE: So you go down with the midwife again that evening?
MOTHER E&F: Yes.
LANGDALE: How long after when you first went down are we talking about? Do you remember the timings or not?
MOTHER E&F: A couple of hours. About two hours, I think.
LANGDALE: So you go down, and what situation confronted you? Where were you when you went down?
MOTHER E&F: Sorry?
LANGDALE: Where were you when you went down, where were you taken?
MOTHER E&F: So when I went down I was sat in that same corridor where I could first hear them crying and there were some chairs and the midwife was sat next to me and I think she was trying to talk to me, and I was -- I don't really know what she was saying because I was watching what was happening through the window because I could see his incubator straight from where I was sat. And I could see -- or I couldn't really see -- I couldn't see [Child E], but I could see the team around him working and it looked busy and it looked serious.
LANGDALE: You say in your statement you had to sit outside in the corridor for approximately 15 minutes?
MOTHER E&F: Yes.
LANGDALE: And then:
"A member of staff came out and asked if I wanted [Child E] to be christened and asked where my husband was."
MOTHER E&F: Yes, yes. I've reflected on that. I think it was a nurse. It wasn't Lucy Letby and it wasn't the nurse in charge. It was the other nurse. But in that time, I actually don't believe that I would have -- I don't think I would have been with [Child E] if it hadn't have been for the midwife, because I heard her talking to the staff, saying, "It's not fair, it's not right. She's his mum. She should be there with him. This isn't right. She's sat in a corridor".
LANGDALE: We have, my Lady, the statement from that midwife.
We've seen the statement from the midwife, who says she had taken the decision to take you down to the NNU and indeed she thought you should be there.
MOTHER E&F: Yes.
LANGDALE: Is that what you're telling us?
MOTHER E&F: Yes.
LANGDALE: You remember her saying that?
MOTHER E&F: Yes.
LANGDALE: Were you allowed to go in to be with [Child E] or to hold his hand at any point?
MOTHER E&F: I did, yes. I did, after I was -- I think I was sat outside for a about 15, 20 minutes, and again, a nurse came out and said for me to go in, and to hold him. So I had to kind of go around the back of where they were working and hold his hand, and I was told to talk to him because he could hear me, and I was just talking to him, telling him everything was going to be okay and all the fun that we were going to have when we got home.
LANGDALE: We know at paragraph 60 of your statement you tell us [Child E] was christened and Doctor ZA had said to you they wanted to stop working on him as they couldn't save him.
MOTHER E&F: Yes.
LANGDALE: Did you witness and see how hard they were trying to save him?
MOTHER E&F: I did. I did. I believe that Doctor ZA and Dr Harkness tried everything that they could, and that, you know, I could see their expressions on their face, that, you know, it's -- they were really upset by what was happening, and I think they tried everything they could to bring him back, and I think trying for 45 minutes on a baby that's so small is -- it's testament to how much they wanted to save him.
LANGDALE: What were you told straight afterwards? What can you remember being told about it?
MOTHER E&F: So I had -- we had a conversation with Doctor ZA, and she told us that she believes he had died from NEC, which is --
LANGDALE: Necrotising enterocolitis?
MOTHER E&F: Yes, yes. Which is quite common in premature babies and small premature babies albeit, you know, [Child E] was, from what we were told, he was, you know, a really good weight for his gestation. And she mentioned a post-mortem, and I think it was my husband who asked what would that be able to tell us? And she said well, she didn't think that that would -- she wouldn't be able to tell us anything, because, you know, she believed he'd died from NEC.
LANGDALE: You were asked whether there should be a post-mortem, and Doctor ZA in effect said you weren't going to learn anything different from it.
MOTHER E&F: Yes.
LANGDALE: What do you think about parents' input at that time as to whether there's a post-mortem or not? Do you think it's important you have a say in that? Do you think it should be a final say? What do you think about the role of the parent in that situation, deciding whether there should be a post-mortem?
MOTHER E&F: I think in our situation, I think that decision should have been taken out of our hands, I think. From everything that I've learnt from the criminal trial, it was so unusual for [Child E] to die in that way, that was expressed by all the doctors. I think trying to make an informed decision when you've got your child that's died in your arms on whether you want him to have a post-mortem is -- it's an impossible decision to have to make and I couldn't -- I couldn't make an informed decision at that time. So I feel that it's unfair to ask a bereaved parent whether they want that to happen for their child, because of course you don't.
LANGDALE: You decided, you say, not to have a post-mortem, and Doctor ZA later apologised for her advice on that point during the criminal trial. So tell us about that?
MOTHER E&F: So in the criminal trial, she spoke about not giving enough weight to the X-ray that he'd had that showed no signs of NEC whatsoever, and it was a real emotional moment because it's the first time that anybody from the Countess of Chester has apologised for their, you know, part in what happened, and I think it was extremely brave of her to do so. She actually wrote to us as well back in September 2023 to apologise, which I thought was a really kind gesture from her.
LANGDALE: You then set out in your statement, you touched upon it earlier, that Lucy Letby bathed [Child E]. And you say:
"He was all purple and bruised. It hurt even more seeing him in that state."
MOTHER E&F: Yes.
LANGDALE: So you could see that -- you've described what you see there?
MOTHER E&F: Yes. So at that time, Lucy Letby asked if I would like to bathe [Child E]. And the boys are my first babies and I've never bathed a baby before. I've never bathed a baby that small and I'd never bathed a baby that had died and I just -- I couldn't do it. And she bathed him in front of me.
LANGDALE: Did you get any private time to spend with [Child E], you and your husband, at this point?
MOTHER E&F: We had no private time with [Child E] at all. We had to grieve in Nursery 1 and spend time with him in Nursery 1 with other members of staff.
Mine and my husband's family came that same night after [Child E] died and they had to go and spend time with him in his incubator in Nursery 1, so there was no space to spend any time with him at all, which at the time I didn't question, because I didn't know, I didn't know any better, so to speak. It was -- and that's the thing. It's giving parents choice, because in that moment they don't know what's right, because, you know, it's the first time that that had ever happened for us, and we couldn't even think straight because a couple of hours earlier we had two thriving little boys, and in the space of a couple of hours, it had all been taken. And our world had just spinned upside down and nothing felt right. So it, you know, should be for professionals to guide.
LANGDALE: And you say:
"Myself and Father E&F grieved the loss of our baby in full view of the staff in Nursery 1."
MOTHER E&F: Yes, yes.
LANGDALE: We know that a Datix report was produced in relation to the death of [Child E]. They are reports used by hospitals or made by hospitals surrounding incidents, concerns or risks, deaths.
MOTHER E&F: (Witness nodded)
LANGDALE: If we look at page 63 in the bundle you've got there, there's a handwritten number in the right-hand corner. If you go to 63, this is the Datix form surrounding [Child E] and his death. If you look at page 64, it looks as though people enter information at different times in this reporting system and we see on 2 August 2017:
"Unexpected neonatal death of twin. Baby had a gastric bleed followed by another, but the cause was unknown. The baby had a sudden deterioration after this. The baby suffered cardiac arrest and CPR/resuscitation was attempted. The baby's parents were consulted and the decision was made to stop resuscitation."
Sorry, I should have said the date was 2 August 2017.
Was that information in that way communicated to you around the time or subsequently of his death?
MOTHER E&F: No.
LANGDALE: If we look at the top of the same page, there's an entry by Debbie Peacock, 16 December 2015.
"Summary of Neonatal Review.
"Baby was a 29 week gestation infant at high risk of NEC. His initial condition was good but he showed signs of stress and maladaption to extrauterine life, persistent high blood sugars. He is likely to have died from a perforated bowel secondary to NEC. Neonatal care was appropriate and record-keeping of a high standard. Possible learning points from the case are described but is unlikely any changes in management would have prevented this sad outcome."
So that's the entry for December 2015. Was that what you understood was the position, what was stated in the summary above?
MOTHER E&F: Part of it. I wasn't aware he had persistent high blood sugars, I was told he had high blood sugar at I think it was day (redacted) of life, and with a small amount of insulin -- it rectified itself.
LANGDALE: Sorry, you're talking about Baby F [Child F] now. You're talking about Baby F [Child F], yes?
MOTHER E&F: No, E.
LANGDALE: E, sorry, yes, with the insulin, yes, sorry, carry on?
MOTHER E&F: So it says here, doesn't it, with [Child E], he had had persistent high blood sugars?
LANGDALE: Yes.
MOTHER E&F: That was rectified with a very, very small amount and that was, I think, I think that was -- he'd come off that by the time (redacted) August had arrived so it wasn't persistent, it was -- I think it was a one-off.
LANGDALE: Right, and they'd told you that at the time?
MOTHER E&F: Yes, but we were also told with that it's so common with neonates, and it's them adjusting to being, you know, born.
LANGDALE: When [Child E] had died, how did you feel about being in the same hospital with [Child F]?
MOTHER E&F: We wanted to leave but we were waiting on transport. So every day it was waiting to see if the transport team could have two ambulances available for the boys to move them, and unfortunately for us, that never happened. So after [Child E] died, we were very, very keen to move.
LANGDALE: If you go back to your statement at paragraph 73, following [Child E]'s death, almost exactly 24 hours later [Child F] collapsed.
MOTHER E&F: Yes.
LANGDALE: Can you tell us about that?
MOTHER E&F: So we were in bed in the accommodation on the neonatal unit, because I discharged myself from the Countess of Chester Maternity Services, and me and my husband were staying on the unit until we were able to get [Child F] moved, and we were in bed, and Nurse T come and knocked on the door, and said, "I think you need to come in to Nursery 2, [Child F] is experiencing really rapid, fast heart rate", and in that moment I just thought: not again. This simply cannot be happening to us again.
And I went in there, and I sat in the chair, and I was just willing that his heart rate would come down and he was going to be okay. And I sat all night, and the heart rate didn't come down, and I think it was -- I was told to go back to bed by a nurse. But I wouldn't. There was no way I was leaving him. No way. Not after leaving [Child E] the night before.
LANGDALE: We know that Dr Gibbs came to review [Child F] and what did he tell you about [Child F]'s position?
MOTHER E&F: He told me that [Child F] had an infection in the long line of his leg, and moving the long line in his leg, and setting him on a course of antibiotics would rectify things.
LANGDALE: You now know the day that you left the Countess of Chester Hospital, insulin test results came in for [Child F]?
MOTHER E&F: Yes.
LANGDALE: Did you know about those results at the time and what they showed?
MOTHER E&F: I didn't even know he'd been tested for insulin. Insulin was never mentioned to us at the time. We were simply told he had an infection in the long line of his leg.
LANGDALE: Did you ever know that there were ever any issues with his blood sugar?
MOTHER E&F: No.
LANGDALE: What were you told about any infection or antibiotics? Did you know about anything?
MOTHER E&F: Yeah, so we were told he would be started on a course of antibiotics. I think it was precautionary, because they thought that they had an infection in the tip of the long line of his leg, and they removed that long line, and put him on a course of antibiotics.
LANGDALE: When did you find out about insulin having been given to [Child F]?
MOTHER E&F: So I -- as part of the police investigation, [Child F] was asked to go for an MRI scan, and again, the police did not inform us what that was looking for, but I asked a medical professional who told me what the test was looking for. So with that, I had actually obtained [Child F]'s medical records from our solicitor, and for many, many weeks I combed through all those the best I could with no medical knowledge whatsoever and found the readings, and researched what those meant, and came up with my own conclusions that, you know, they were suggesting that, you know, he'd been given a lot of insulin when he shouldn't have. And I think a month before the criminal trial, the Family Liaison Officers provided us with like a paragraph which set out what the case against Lucy Letby was. Again, it was very brief, and there was no real information behind it but I think that was done so there was no -- I want to say shock but "shock" isn't the right word because the whole thing was shocking. So we knew before we went into the room what was --
LANGDALE: Going to be said about your child?
MOTHER E&F: Yes.
LANGDALE: Were you, in terms of the hospital, ever told about any meetings or investigations into [Child E]'s death and [Child F]'s sudden deterioration? For example, we've seen on that Datix a neonatal unit discussion or meeting.
MOTHER E&F: Yeah.
LANGDALE: Anything like that or a serious incident discussion?
MOTHER E&F: Yes.
LANGDALE: Nothing like that?
MOTHER E&F: No. And I think I never questioned anything, because quite a few people on the unit at that time had actually said to us, "You know, we're never going to forget [Child E] because we don't lose children on this unit. It just doesn't happen", and that was said to us quite a few times. So for us, it wasn't something that usually happened there.
LANGDALE: When did you find out at the time there would not be a post-mortem? There seemed to be no need for one?
MOTHER E&F: That was the next day. So -- well, not the next day. In the day of the 4th --
LANGDALE: 4 August.
MOTHER E&F: -- we were in the family room and I was there with my mum and my husband's mum, and I think it was Doctor ZA came in and said that she'd spoken to the Coroner and the Coroner had said that we don't need to have a post-mortem and they actually arranged for the registrar to actually come to the hospital to register both the boys' births and [Child E]'s death at the same time.
LANGDALE: You -- it's understood you received a letter from the Medical Director, Mr Harvey. If you go to page 73 in the bundle we see a letter dated 8 February 2017.
MOTHER E&F: Yes.
LANGDALE: "Dear Mother E&F,
"You may be aware the hospital asked for an external assessment of its Neonatal Unit from the Royal College of Paediatrics and Child Health and the Royal College of Nursing. This step was taken because we wanted to better understand why there had been a greater number of deaths than we would normally expect on our Neonatal Unit between January 2015 and July 2016.
"On Friday last week we tried to contact you to let you know this report was ready and we are keen to share it with you. You will be able to access this report via the News section on our hospital website from 12 noon on Wednesday 8th February.
"Once you have read the report we would be happy to meet with you. Please contact [number given] between the hours of 9am and 5pm so we can arrange for us to speak with you directly and for the report to be delivered. We are desperately sorry for any distress or upset that news of this review will have caused. We know you will have been through so much already."
Did you receive that letter?
MOTHER E&F: I did. I received that letter by a black taxi knocking on my door about 30 minutes before that report was due to go live online.
LANGDALE: And was the report sent with it?
MOTHER E&F: No, the report was online, so I was having to access that report on their website.
LANGDALE: Had you any warning that was coming or what it was about?
MOTHER E&F: I had absolutely no warning whatsoever. I was absolutely mortified. I was panicking. I didn't know what was going on. I was at home with my son, [Child F], and my daughter, who was a couple of months old at that time, and it beggars belief that a black taxi could turn up at my door with a letter about something that I had no idea about, I had no knowledge that there was any assessment or anything that was going on.
LANGDALE: You say in your statement:
"Prior to this, the only time Countess of Chester contacted me was to ask for a breast pump back. In fact it had already been returned to them on the day we left the NNU."
MOTHER E&F: Yes.
LANGDALE: Were they able to contact you to ask you about that --
MOTHER E&F: (Witness nodded)
LANGDALE: -- and how did they contact you? Don't give --
MOTHER E&F: So I -- the neonatal team loaned me a breast pump for [Child E]'s funeral so I could pump milk whilst I was there.
LANGDALE: Of course.
MOTHER E&F: And I had already taken that straight back because we were actually living on the unit. So I'd given it back on the day. And they actually telephoned me to ask me for it back and I said, "Well, I gave it back".
LANGDALE: So they had a number for you?
MOTHER E&F: Absolutely, yeah, they had a number. They rung me twice for that same breast pump.
LANGDALE: You tell us you called Debbie Dodd, which was the number supplied to you on that letter that was brought to you in that cab?
MOTHER E&F: Yes.
LANGDALE: And you wanted to read the report and try to understand what it meant?
MOTHER E&F: Yes.
LANGDALE: When you phoned Debbie Dodd what did you ask and what happened?
MOTHER E&F: I asked to speak to Ian Harvey, because he'd signed the letter. And she said he wasn't available, and that she would pass any messages on and I said I was concerned because I had no idea that there was ever any issue, and, you know, why was this the first time that I'm hearing about this? And in my mind, I thought it was because we were out of the area, and I felt like we'd kind of been forgotten. And then Ian Harvey never rung me back. And I actually had a conversation, I said, "This letter states that you've tried to ring me". I said, "Nobody's tried to ring me". I said, "I'm at home with my two children. If somebody rings, I answer it".
LANGDALE: Can you go to page 74 in the bundle, and it's another letter from Mr Ian Harvey, 3 March 2017.
"Dear Mother E&F,
"Further to previous correspondence and the completed review of the Neo Natal Unit carried out by the Royal College of Paediatrics and Child Health at the Countess of Chester Hospital, I am writing to appraise you of our current progress. You will have seen within the review that one of the recommendations was that a separate independent review of the care of each of the babies should be carried out. This review has now been completed but has in turn indicated that a small number of areas of investigation are required and I aim to undertake this as quickly as possible. I will, in due course, be sharing the findings of this further review in relation to [Child E] with you and will be offering to meet with you to discuss any concerns or issues that you may have arising from both the College Review and the subsequent review.
"I apologise for the length of time this whole process has taken. This reflects the depths to which we have carried out the whole Review process. I want to make sure I can confidently respond to any concerns you have in an open and transparent manner. Unfortunately, due to the depth of investigation I am not in a position to give you a definitive date for any meeting but will be endeavouring to make this as soon as possible and will certainly aim to make this in the next six weeks."
First of all, did you receive that letter?
MOTHER E&F: Yes.
LANGDALE: What did you make of that?
MOTHER E&F: I -- at the time, it made me panic and it made me worried, because again, up until this point, I had no idea or any clue that there was, you know, an elevated death rate on the unit and I was thinking all sorts of things. I didn't know what had happened. I actually didn't know what happened. I was in the dark. I had no information to go off, and to be honest, it's just a lot of words, isn't it? It doesn't actually mean anything, that letter.
LANGDALE: Did you try and phone Debbie Dodd again or what did you do when you --
MOTHER E&F: I think I contacted Debbie Dodd and I think at that time we contacted a solicitor as well, which ...
LANGDALE: When did you finally receive, first of all, the RCPCH report? Do you know which one I'm referring to then? The external report was by Dr Hawdon, and then there was an RCPCH report?
MOTHER E&F: Yes.
LANGDALE: The first one that was --
MOTHER E&F: So the first one, that was the one that went online, wasn't it?
LANGDALE: Yes.
MOTHER E&F: So we accessed that on 8 February and I had accessed that online.
LANGDALE: Was that -- was that something that was publicly available to anyone who accessed it?
MOTHER E&F: It was.
LANGDALE: Or a few people? So it was a publicly available version of the report?
MOTHER E&F: Yes, but from my phone call with Debbie Dodd on that date, she sent me a hard copy of that as well.
LANGDALE: The Inquiry is aware there are two different versions: a confidential version of that report and one that was disseminated more publicly?
MOTHER E&F: Yes.
LANGDALE: Have you now seen the two different versions of the report?
MOTHER E&F: I have.
LANGDALE: Where there's one with more information about Nurse LL and one with no information about Nurse LL?
MOTHER E&F: Yes.
LANGDALE: So which one did you see at the time?
MOTHER E&F: The redacted version.
LANGDALE: So you didn't see anything about the concerns about LL?
MOTHER E&F: No.
LANGDALE: Or what was said in that section 4 of the RCPCH report?
MOTHER E&F: No.
LANGDALE: Would you like to have seen that at the time?
MOTHER E&F: Yes.
LANGDALE: And what impact, if any, do you think that would have had upon you at the time, to see that section?
MOTHER E&F: I think the Countess of Chester being transparent and open with what they were investigating would have given me peace of mind of, you know, not thinking that I've missed something, and, you know, I blamed myself for a lot of things that happened in that time, and I think, you know, that's my son. I think any information that they have about him should have been shared openly with us. I don't think it should have been held back. I think to do that is, I think it's quite hideous, to be honest.
LANGDALE: If you look at page 75 of the bundle in front of you there's another letter, 21 April 2017, addressed to Mother E&F.
MOTHER E&F: Yes.
LANGDALE: "Further to the letter of 3 March I would like to thank you for your continued patience. I can confirm that further investigation work has been undertaken, however, we have been advised by the independent external case reviewer to consult with the Pan Cheshire Child Death Overview Panel (CDOP) which has been arranged for next week.
"It is important we take this step to complete the reviews so that we conclude this matter as soon as possible. Once this consultation has taken place I will make arrangements as soon as possible to meet you to discuss all the review findings.
"I appreciate this provides for a further delay for which we are sorry and recognise it is a really distressing time for you but it is important that we complete our reviews."
Did you receive that letter?
MOTHER E&F: Yes.
LANGDALE: Did you know what the Pan Cheshire Child Death Overview Panel was or what it did or what that meant?
MOTHER E&F: No, I didn't know anything about that.
LANGDALE: Did that communicate anything effectively to you? What did you take from that?
MOTHER E&F: I took from that that something had gone very, very wrong, and we still had no idea, and I was essentially waiting on other people to tell us what happened to our son.
LANGDALE: If you look at page 76, the next page, another letter, 28 April 2017 to you from Mr Harvey.
"Dear Mother E&F,
"Further to my letter of 21 April I am writing to you again to pass on the results of the independent external review regarding the care of your baby. I appreciate that by its nature this report will contain some technical terms but I felt it was important that you saw the original report. Once you have had the opportunity to read and consider the contents of this latest document, together with the previously sent copy of the Royal College of Paediatricians [sic] and Child Health report, please contact me if you wish to meet to discuss these documents and any other issues you might have in greater detail. We will then also be in a position to explain any of the terminology that might be unclear."
And if we turn over the page, there's two pages of typed notes, medical notes, in respect of [Child E] from this external review. Just looking at those notes, were they sent to you at the time?
MOTHER E&F: Yes.
LANGDALE: What did you make of those notes in relation to [Child E]?
MOTHER E&F: I was absolutely furious when this arrived. It was -- it's just not meaningful at all. And, you know, I felt the times were wrong on this document. I now know that the times were falsified. But that the timings was wrong, and the letter itself is -- why on earth would you sent bereaved parents a letter with documentation in about their child from a medical perspective when the parents have no medical training or any medical background? What was earth was I meant to do with that piece of paper? You know, to say I was furious was an absolute understatement, because the letter, it's careless. It's not mindful of bereaved parents and I'd go as far as to say it's quite sloppy, to be honest.
LANGDALE: Tell us why you challenged the timings and why you say at the time you thought it was sloppy?
MOTHER E&F: So I challenged the timings because it stated that on 03/08, [Child E] had a gastro bleed at 2210 when in fact I know that that was an hour earlier.
LANGDALE: You knew he was bleeding an hour earlier?
MOTHER E&F: I knew he was bleeding just before 9 o'clock and I pointed that out, and that was the time that I was that furious I contacted my mobile phone provider because I knew that I'd had a conversation with my husband as soon as I'd come back up, and I almost thought that I was losing my mind and I was wrong. So I wanted that proof that I was right, and I got that proof. I was right, and I knew what time it was.
LANGDALE: So the time here had been incorrectly stated in the records?
MOTHER E&F: Yes.
LANGDALE: So when you read that letter from Mr Harvey and saw those two pages, what do you think was happening then? This was in April 2017.
MOTHER E&F: I thought that the hospital was really incompetent. That was my overarching thought. I just thought that they just haven't been able to get anything right. And then, for page 79 that we have here, but it was 21 on the report, you know, again I had to take to the Internet to try and decipher what any of that actually meant. But I think the Countess of Chester are dealing with people and to send that report with nothing to back it up or any conversation, or anything, it was actually sent on sample paper.
LANGDALE: On?
MOTHER E&F: Sample paper, so it wasn't -- it was just like it had been -- there's just been no care, I think. And --
LANGDALE: Each letter that we have gone to stated that you could make an appointment to meet with Mr Harvey?
MOTHER E&F: Yes.
LANGDALE: Would you have welcomed that? Did you want --
MOTHER E&F: I tried to, yes. I tried to make an appointment with him and was -- I think I rung quite a few times -- so I know I rung after every letter arrived, and maybe more, more than once. And on one occasion I was told he was on annual leave and I was told that, you know, he would get back in contact with me, and -- and I was actually really upset with Debbie Dodd on the phone at one point. I wasn't upset with her, I was upset on the phone and, you know, she was kind and she was nice and she empathised. But essentially she was just Ian Harvey's shield. And that's how I feel about it.
LANGDALE: And you say in your statement after the commencement of the police investigation you never tried to contact Mr Harvey again?
MOTHER E&F: No.
LANGDALE: You were going to be a witness and your position you've set out earlier?
MOTHER E&F: Yes.
LANGDALE: Moving now to suspicions and concerns regarding Lucy Letby. At the time or subsequently, have you had concerns when you look back about her?
MOTHER E&F: When I look back?
LANGDALE: Yeah, when you look back.
MOTHER E&F: I think her behaviour towards me was very different to other nurses, and that's something that I've reflected on. She was very attentive of me. Whenever she used to see me she would hug me. She was just as upset as me, which, reflecting back on it now, it's very odd, odd behaviour, when none of the other nurses were really like that. They were very professional and cared for [Child F] in the correct way, whereas she was very emotional, and I thought she was being kind.
LANGDALE: This was when the bathing and the dressing of [Child E], you mean, she was upset and tearful?
MOTHER E&F: No.
LANGDALE: No?
MOTHER E&F: No, right up until we actually left the unit she looked like every time she was speaking to me she was on the verge of tears, and very upset.
LANGDALE: When you look back now, the evidence you gave at the criminal trial and now about being sent away when you were concerned about any blood on his mouth, what do you make of that now?
MOTHER E&F: I -- well I blame myself for leaving, and I shouldn't have left him, but I can't turn that clock back, because I did leave him, and that's something that I have to live with. But I think that, you know, she was doing something to him in that moment, and I've -- you know, it's been nine years and I've reflected quite a lot on it, and her behaviour in that moment when I went in, and where she was stood and what she was doing and the lack of eye contact, which was very, very different to what I had known her to be, and that was something that I grappled with for quite some time, in that moment it was -- our interactions were very, very different to what they had been.
LANGDALE: When did you first learn there was going to be an investigation by the police?
MOTHER E&F: So I think it was -- I want to say 17 May. It was definitely in mid-May, and we'd had a phone call off of Family Liaison saying they wanted to come and have a chat with us, and, you know, there was an investigation going to happening with regard to the hospital. But in that moment, and right up until her arrest, I never believed that somebody has maliciously gone out of their way to hurt my baby. Never. I never thought that.
LANGDALE: Standing back now, do you think that the hospital were open, honest, as candid as they could be with you throughout this process of them having investigations, having to conduct them? Do you think more information should have been given to you?
MOTHER E&F: I think more information should have been given. I know it's a fine line of what they, you know, they can and can't give. I think the way things were presented was really, really poor. And I think they had a duty of care, and -- you know, and that candour and openness. I think it just fell short of the mark, didn't it, really? I mean, when we look at and reflect on the letters that were sent, it's just really, really poor.
LANGDALE: Medical records.
When were you given access to your babies' medical records, and did you have to ask for them and do you know when they were --
MOTHER E&F: I never asked for them from the hospital. I obtained both boys' medical records via our solicitor.
LANGDALE: Bereavement counselling and support.
After [Child E]'s death were you offered any bereavement support or care?
MOTHER E&F: No, we weren't offered anything. We were given a SANDS leaflet, but that was whilst I still had [Child E] in my arms. I don't actually know what happened to that leaflet, but in that moment, I wasn't able to think about bereavement support. It was -- I was very much in that moment, and I was in shock, and I don't think that that was quite the right time to be delivering a leaflet to a parent.
LANGDALE: You tell us in your statement that you took a hamper to the hospital to the unit later on. Tell us about that, and how that was received?
MOTHER E&F: Yes. So I believe that was in October. We took a hamper to the Countess of Chester and we went to the ward, and we buzzed the door. And it looked like they were doing some decorating inside in Nursery 1. And two nurses come out that we didn't recognise and they took the hamper from us and then they went back in, and that was the last time that we ever stepped foot in the Countess of Chester.
And we took that hamper because we were so grateful to have a child that was still with us, and from our experiences there, we actually thought at one point that we weren't going to have our family to come home. So we were very grateful. And, you know, I think for me, I mistook people's kindness and, you know, I thought because people were kind and they seemed caring that they had, you know, our best interests at heart, and it turned out that one person didn't, and they betrayed everything and done the most unimaginable thing possible. And for me, my children are not left with anybody. They don't get left in any medical settings with anybody: myself or my husband are always with them.
There's just -- the worst thing happened to us once, it happened to us twice. It wasn't going to happen a third time. It just wasn't happening. And we protect those children with everything. And I ask questions and I don't take people at face value and I think that was part of my naivety at the Countess of Chester. I took people at face value. I took what the consultants said and I took what Lucy Letby said at face value, and I took it for what it was. But a lot of it was lies.
LANGDALE: So your trust has been affected?
MOTHER E&F: Yes, yes. Thankfully, we've never really had many occasions with our children where we have had to leave them unattended in a hospital setting, but again, the one time that we did have to was when [Child F] had to have his MRI scan as part of the investigation and that, for both myself and my husband, felt like torture waiting at the other side of that door because the last time we'd left a child with somebody, something really, really dreadful happened for us. So the children don't get left with anybody.
LANGDALE: You say in your statement you have no experience or didn't experience the Patient Advice and Liaison Service, PALS, and you didn't raise concerns with any external organisations, that's presumably because you told us at the time that you didn't have any concerns that something terrible had happened?
MOTHER E&F: No, no.
LANGDALE: The Inquiry has seen a witness statement from the Family Liaison Officer in the criminal proceedings, and she sets out some of the family's concerns about the provision of information, about hearing things for the first time at court. Was there material you heard when you were able to listen to the evidence for the first time at court that you felt that about?
MOTHER E&F: Yes. All of it, to be honest. The criminal trial was very in-depth and it took us through our children's lives, you know, essentially hour by hour. And to find out that [Child E] had had that significant bleed to the point of it being very, very unusual, and for no post-mortem to be warranted from that made me question why, if it was so unusual, and so out of the blue, why on earth was a post-mortem was not, you know, given any weight to, if there was nothing on [Child E]'s X-ray to say there was any signs of NEC, why was the post-mortem not, you know, mandatory? Why was it left for me to make that decision? Again, I feel guilty for not requesting that, because if that had been requested and that had come back and something -- well, something would have been on it, you know, there's a lot of babies that could have not been involved in this case and it could have stopped there. And that weighs very, very heavily on me, because that decision was ultimately ours, and that's painful to think about.
So I carry our grief, but the sadness of the other families, because it should never have gone past that point. And it's the same when I realised in the criminal trial that the insulin reading was there and it was seen and nothing was done. That could have been an end to this whole horrendously sad turn of events, but it wasn't. And I think, although the doctors and the consultants worked really hard to save [Child E], I think there should have been some curiosity as to why these things were happening. Why he was bleeding, why [Child F]'s insulin was -- it wasn't just a little bit over, I mean it was in the 4000s, it's a lot, you know.
And why was it not investigated? You know, we put our trust in these people. I put my trust in them to do the right thing and the best thing for my children.
LANGDALE: Were you ever asked by any doctor or nurse about what you had seen, the blood on the mouth when you'd gone down to the unit?
MOTHER E&F: No.
LANGDALE: So that discussion didn't happen in the grief and the loss --
MOTHER E&F: No.
LANGDALE: -- and the timings, none of that --
MOTHER E&F: No.
LANGDALE: -- was discussed?
MOTHER E&F: None of it was discussed, and again, I didn't bring that up because I thought the team would have been transparent and I thought Lucy Letby would have ...
LANGDALE: She said she was calling someone, you thought they'd know?
MOTHER E&F: She said she was calling the registrar, so I expected, you know, what I'd seen and what she'd seen, because she was there, to have been reported to him. And in that moment, I don't -- I didn't feel strong enough to even think about that moment. Unfortunately I don't have that -- I don't have that anymore because nine years on, I can still play that night through my mind like I'm watching a film, bit by bit. And that's how I knew that I had my timings right, because I can play that over in my mind.
LANGDALE: I'm going to suggest we have a break now because we're going to move on to suggestions and recommendations.
MOTHER E&F: Okay.
MS LANGDALE: Is that convenient?
LADY JUSTICE THIRLWALL: Yes, thank you very much indeed, Ms Langdale.
Mother E&F, we're going to take a break, it will be 15 minutes unless you want longer, in which case it will be as long as you like. Thank you very much indeed.
THE WITNESS: Thank you.
LADY JUSTICE THIRLWALL: Do feel free to just go.
(11.20 am) (A short break) (11.36 pm)
MS LANGDALE: [No audio feed] ... into insulin levels.
MOTHER E&F: Yes, I think I touched on that earlier on. I found it really difficult to wrap my head round that that could be sent back from a lab of an insulin reading that that high, and absolutely nothing to be done with that, whether a child has recovered or not, you know, I think something should have been you know, investigated. I think in light of what we now know with things that happen prior to my boys being there I actually think that, you know, the Consultant who looked at that should have, you know, maybe been a bit more curious as to why that was and maybe looked at past evidence of other babies and what's been happening. Maybe there would have been a trend there.
LANGDALE: Thirdly, you say hospital management should have been much more responsive to concerns that were raised, both to staff who were raising them, and to parents?
MOTHER E&F: Yes. So I think ...
I think with that it's giving parents a full picture, not half a picture, and having to scramble around and look for answers themselves, and that adds a whole lot of strain on somebody to then they're having to do that, rather than management being upfront and transparent, I think with those letters, for instance, from Ian Harvey, they caused a lot of heartache for me, and because they were very empty. They almost seemed to pay lip service, almost, that -- he had no intention of meeting us and I can really see that now. It was words, almost like a tick-box exercise and I think if that had been done we'd have had a bit more understanding at that time.
But also when it comes to being more responsive, I think from what I've now seen and read, I think the management being dismissive of the consultants when they're on the frontline and they're dealing with things day in, day out, really isn't -- it's not good enough and I think change needs to happen, and I'm not -- you know, I don't think I'm the person to put a suggestion forward for that, because I wouldn't know where to start. But there's someone out there that can put that change in place.
LANGDALE: CCTV. We asked you for suggestions about keeping babies safe in neonatal units. What are your views about CCTV?
MOTHER E&F: I think CCTV is a good idea. I think some people may have reservations about it, with, you know, confidentiality and privacy. But I also think that we've been on the receiving end of the worst-case scenario, and I think it's really important to keep your children safe, and if you can't be there, and you can't be there 24 hours a day, I think having that knowledge that your child is safe is helpful. But then, that being said, if a nurse is accessing a child's line or -- we don't know what to look for, and any parent doesn't know what to look for with unusual activity. So it seems like it's a good idea, but I think more so, I think the CCTV is a good idea so people know where members of staff are on the unit at that time so again, to back up meaningful paperwork, if anything happens again, you can say that this person was in such a place because the paperwork suggests so because they did this, this and this for this child, and also the CCTV places them there, it doesn't place them anywhere else.
LANGDALE: You also refer to swipe data, to be used when accessing medicines such as insulin, so it's immediately apparent who has accessed particular items?
MOTHER E&F: Yes, yes. And I would also say I think a CCTV camera pointing at that fridge as well, so when you've got that swipe data and also when you've got, you know, for instance, with a TPN bag if somebody is going to be putting something they shouldn't in a TPN bag, there's CCTV there in that room that's going to cover that so it will be seen.
LANGDALE: You say:
"... neonatal staff should have monthly/quarterly supervisions with a psychologist/therapist to check staff for wellbeing/warning signs."
A. Yes, yeah. I think that, you know, that happens in a lot of professions in this country and I don't see why nurses, especially in a neonatal unit, would be any different, especially if that mortality rate is high, and, you know, it's -- it must be a difficult job for them if they are, you know, dealing with families and, you know, children that have died, and I think checking in with a psychologist or therapist to ensure that their wellbeing is suitable for them to be working in that kind of environment, I think that would be really, really helpful.
LANGDALE: You mention post-mortems:
"Fourthly, post-mortems should be mandatory and not done by choice."
Is this for neonates or babies, do you think, that die? All babies or unexpected deaths? What is your thinking?
MOTHER E&F: I think all neonatal babies personally and I know that may come as a controversial answer, but again, we've been in that worst-case scenario, and not knowing is really, really hard. It's really hard, because although we have some knowledge, we don't have that full picture, we don't know what happened to our son and I think having that would help. I certainly don't feel that asking about a post-mortem as soon as your baby has died and is still in your arms is the place to be doing that, really.
LANGDALE: You referred to:
"... a protocol should be in place to ensure no staff take sensitive patient information home with them ... Whilst this [might] be the law ... it needs to be set out categorically so staff understand ... and with disciplinary sanctions for breach."
MOTHER E&F: Yes. I don't feel that anybody should be able to take personal information home. It really upsets me that my son's information was kept in somebody's house and transferred from one property to another, in a carrier bag. That should -- if anybody should have that, it should be me.
LANGDALE: Do you want to just expand on that? When you say one person carrying it around in a bag, what did you hear at the trial?
MOTHER E&F: Well, Lucy Letby at the trial, she had [Child E]'s and [Child F]'s sensitive data stored at her home and she actually moved house and actually took it with her in a Morrison's carrier bag.
LANGDALE: So you query how that could ever have been at home with her?
MOTHER E&F: Yeah, yeah. Maybe there should be something in place where the staff should have to maybe come in to the shift in their own clothes and then change into their scrubs once they get to work, and as they're leaving, take their scrubs off, empty their pockets, put things in the confidential waste and then put their own clothes back on. That would be for me the most sensible way of ensuring that nothing goes home in pockets.
LANGDALE: And you also say "No use of mobile phones by staff on duty in wards, even in corridors and nurses stations". Again, was this evidence that you heard in the trial that you're commenting on here?
MOTHER E&F: Yeah.
LANGDALE: So expand on that, if you will?
MOTHER E&F: So I was really shocked at the use of mobile phones on the unit throughout the whole period of the June -- to June, and it wasn't just Lucy Letby; it was doctors, it was other nurses, that contacting each other all the time knowing that they're actually on shift, and these people are tasked with looking after the most precious things that we have, and for them to be distracted by phones and messaging their friends about nights out or messaging about babies on the unit, it just feels very -- it feels wrong, and they're there to work and they're there to look after and care for the babies. I think for me, they need the full concentration on the babies, and if phones are going to be used, have them in their break rooms. They shouldn't be in their pockets. They shouldn't be able to be accessed in non-clinical areas such as the nurses' station because that -- you don't need your phone. So, I mean, I think somebody said: well, they use their calculators. Well, you know, we can have a calculator that's not attached to a phone. I think having a phone is a big distraction, and I think that they should be left in their lockers. And I think that should become common practice, because we haven't always had mobile phones, have we? And ... yeah.
LADY JUSTICE THIRLWALL: What about if somebody wants to contact, for example, a doctor on the ward?
MOTHER E&F: Well, I think they have their phone that's attached to the nurses' stations so they're able to contact different doctors because I think they bleep them. So don't actually think that comes through their personal mobile phones. I think that comes through --
LADY JUSTICE THIRLWALL: It comes through a bleep, does it?
MOTHER E&F: Yes, or I think they do have the landline.
LADY JUSTICE THIRLWALL: And what you were describing about people using their phones, I think, if I've understood this correctly, it's people on the ward at the time on shift texting or messaging each other, but not about clinical matters, but about general chit-chat.
MOTHER E&F: Well, both. So it was of a social nature and on, you know, the babies that are on the unit which, again, that shouldn't really be discussed over text message with somebody who is not on shift.
LADY JUSTICE THIRLWALL: Ah, so that's someone who is not on the shift --
MOTHER E&F: Yes.
LADY JUSTICE THIRLWALL: -- that they're then discussing with. I see. I understand. Thank you.
MS LANGDALE: In terms of sharing information with you, you say:
"Instead of hiding behind his secretary [Mr] Harvey should have spoken to me and my husband and made clear that there were unexpected deaths on the Neonatal Unit and what they were doing about it. This candour was the minimum we were entitled to"?
MOTHER E&F: Yeah.
LANGDALE: When did you first learn that there were a number of unexpected deaths between 2015 and 2016?
MOTHER E&F: It was when that report arrived. And out of the blue, as I said, we hadn't -- we didn't have any idea of anything that was going on. We were trying to get on with our life and then that arrived. And things haven't quite been the same since.
LANGDALE: Moving now, if we may, to bereavement protocols and what should be in place and what should be consistent nationwide, in your view, you deal with it from 169 onwards but can you tell us how you think support should be offered and what is important at the time of bereavement of a child?
MOTHER E&F: I think when you're in that bereavement and it's fresh, and it's just happened, I think you need to be given choices because you don't actually know what's right for you in that moment and having choices, like, for instance, we didn't know that we could -- it never even entered our head to ask for anything, because we were just so distraught. But, you know, having something that's consistent across the whole of the UK is really important.
So, you know, for instance, the memory boxes, they're really important, but we didn't know that that was happening. You know, we hadn't given any consent for that to be done. We didn't have any pictures of both of our boys together. You know, and one of the big things for me is we didn't get to spend any private time alone with our son at all. We weren't able to be with him, we weren't able to hold him. In fact, we went to bed and got up in the morning, and went into see [Child F], and [Child E] was still in his incubator, and I was -- it took my breath away in that moment. And it was actually Lucy Letby, and I said, "He's still here" and she said, "You haven't told us to take him", but then I didn't know that I was meant to -- I didn't know what was meant to happen.
So being clear, I think is really, really important, in that moment, often what, you know, what is happened, what is in our control at that point.
LANGDALE: So clear information at the correct time?
MOTHER E&F: Yeah, clear information at the correct time. I would have really have liked the opportunity to take [Child E] into one of those family rooms and spend some time with him, and we didn't get that.
LANGDALE: And what level -- when you say nationwide -- of bereavement counselling support do you think should be offered or maybe required by people to address grief and loss?
MOTHER E&F: I think every neonatal unit and every maternity suite should have a Bereavement Midwife in place. I think that should be standard. I think they should have an understanding of what it means to lose your child. I also think that counselling should be offered as standard to every parent, not at the moment that the child is in their arms, but a conversation maybe, you know, a debrief afterwards, you know, before you're discharged. Have a conversation, open and honest. And, you know, set out what's in place, you know, give information, you know. There's so many different organisations out there that provided, you know, bereavement care, and I had no idea about any of them. Not one. And I suppose I was made to feel like because I had [Child F], I had to kind of pull myself together and be grateful, and I was. I was very grateful but I was also very, very sad.
LANGDALE: What recommendations do you think this Inquiry should make? You refer to the Inquiry needing to look into the treatment of whistleblowers and how to hold managers accountable.
MOTHER E&F: I think what I mean by that is I don't feel like they should be able to hide behind secretaries or, you know, make decisions to make themselves look good like they've got a clean sheet on their time at the hospital. I feel that, you know, it's -- you know, it's life, isn't it, human life that we're looking at. And I think looking good is nothing compared to saving, and I can't think of the word, I'm so sorry -- protecting life.
LANGDALE: Don't worry.
MOTHER E&F: And I think if there was the slightest, even if it was a hunch from consultants, a hunch should be enough to at least look at what is happening, because we're dealing with --
LANGDALE: Safety of babies?
MOTHER E&F: -- safety of babies and lives. And I don't think -- I don't think anything that I have read by the management is really justified in their actions of what they have done.
LANGDALE: You finish your statement with this:
"I would like to know if it is standard practice to give a nurse another baby straight away in a space a baby has tragically died, in order to get over it. In this is the case, I am horrified and this needs to change."
MOTHER E&F: Yeah, so again that was something that come up in the criminal trial, and it was mentioned that at Liverpool Women's Hospital in the neonatal unit, if a baby dies, they automatically give the same neonatal nurse who has been on shift and looks after a child, that child -- another dying child in the same cot space to get over it. And I was just wondering if, you know, if there is any truth to that because it has come from Lucy Letby.
LANGDALE: Well, let's pause there. We'll perhaps explore that. But you want to know if that's the case?
MOTHER E&F: Yes.
LANGDALE: And if it is the case, why?
MOTHER E&F: Why, yeah, absolutely, because that just doesn't seem acceptable.
LANGDALE: And you comment finally on the duty of candour and what that means and you say:
"I believe [it should] be ... legally enforceable. At the moment it's just words with no legal teeth to back it up."
MOTHER E&F: Yes.
LANGDALE: Would you like to expand on that or not?
MOTHER E&F: Well, again it just comes back to, you know, having something solid in place, and almost those rules for management to follow, rather than them just going off on a whim and doing things that suit them at that time. And, you know, we look at those letters that were sent to me, they don't actually mean anything. They're a lot of words. I mean, to send bereaved parents three pages of a document that have absolutely no meaning, what on earth did the management think was going to -- how that was going to make anybody feel or what we were meant to do with that information? It created a lot of upset, and panic because we had no idea what any of it meant.
MS LANGDALE: Those are all my questions. Is there anything you'd like to add or say or bring to our attention that I haven't asked you?
MOTHER E&F: No.
MS LANGDALE: My Lady, may we have a short break, then, so Mr Baker can consider with his team whether there are any further questions for Mother E&F?
LADY JUSTICE THIRLWALL: Very well.
(11.59 am) (A short break) (12.03 am)
Questioned by MR BAKER
LADY JUSTICE THIRLWALL: Mr Baker?
MR BAKER: Thank you, my Lady.
Mother E&F, if you could turn, please, to your witness statement and to paragraph 18.
MOTHER E&F: Yes.
BAKER: You give some description here of your history, but say that on 14 February you discovered you were pregnant and that you considered this pregnancy to be a miracle?
MOTHER E&F: Yes, yes. We'd actually found out a couple of days earlier that we were pregnant on 14 February and we found out we were having twins, which was -- it was a miracle. To find out we were pregnant with twins on 14 February was just amazing. You know, we were ecstatic. It didn't feel real. We were very, very happy.
BAKER: Having asked you about a very happy time, I'm sorry I'm going to have to ask you questions about a more difficult time.
MOTHER E&F: Okay.
BAKER: Before the early hours of the 4 August, had anyone said to you that your twins were severely unwell or that they might not survive?
MOTHER E&F: No. Quite the opposite. Everybody who came into contact with us said our boys were doing really, really well, and that was why the transfer had been suggested, because if they were unstable they wouldn't have been able to travel.
BAKER: I think you said in response to questions from my learned friend that there was a planned transfer for the twins.
MOTHER E&F: Yes.
BAKER: Why did you understand that that was transfer was considered to be safe?
MOTHER E&F: Because we were told that was the case. Because it wouldn't be -- they wouldn't have been able to travel if the boys, either of the boys were unwell. They had to be in a stable condition to be able to be transported because ...
BAKER: When were you expecting that transfer to take place?
MOTHER E&F: That transfer was, it was mentioned, I think it was mentioned to us on, I want to say on the 30th -- the 31 July, and we were simply just waiting on transport to be available, and that was the only thing that was keeping us at the Countess of Chester at that point.
BAKER: So coming on, then, to the evening of 3 August, you said in evidence that during the day, you'd seen [Child E] and [Child F], and that they were, as far as you were concerned, doing well?
MOTHER E&F: Yes.
BAKER: And you went back during the course of the evening. So about 9 o'clock is what you said in evidence?
MOTHER E&F: Yes.
BAKER: How can you be sure it was 9 o'clock?
MOTHER E&F: Because I was delivering breast milk for my boys' feed, and because, you know, I knew that I needed to do that because it was important because I wasn't able to do a great deal of other things for my boys at that time. I was very reliant upon other people to do things but the one thing I could do was provide them with milk.
BAKER: Was anybody expecting you on the ward at about 9 o'clock?
MOTHER E&F: I'm unsure. I was unsure if anybody was expecting me but other people would have known that the boys' feeding schedules. I had signed a document to say that I consented to giving donor milk to my boys, but the thought of that was ... it just didn't sit right with me. I wanted to be able to do that for them, and I made sure that that happened.
BAKER: And you described how, when you were walking towards the room, you heard awful screaming.
MOTHER E&F: Yes.
BAKER: And then you went into the nursery. Where was Lucy Letby when you went into the nursery?
MOTHER E&F: She was between his incubator and a workstation.
BAKER: Was she doing anything in relation to [Child E]?
MOTHER E&F: No. No, she was doing something with some papers, and kind of shuffling things around and moving them around and she only actually came and stood by his incubator when I had my hands in doing containment on [Child E].
BAKER: And whilst she was stood there shuffling papers, what was [Child E] doing?
MOTHER E&F: Screaming and crying.
BAKER: Now, who was it who told you to leave?
MOTHER E&F: Lucy Letby.
BAKER: And you said in evidence that her behaviour was different. In what way was it different to how it had been before?
MOTHER E&F: She had been kind and looked at me and looked me in the eye, and when I went to give milk she seemed really abrasive and didn't make eye contact with me, and this is on reflection, it felt very different to our other interactions that we had and the interactions that we had after that as well.
BAKER: You said you went -- you followed her instruction and left the unit.
MOTHER E&F: Yeah.
BAKER: And that you then telephoned your husband, Father E&F?
MOTHER E&F: Yes.
BAKER: Do you know what time you telephoned him?
MOTHER E&F: Yes, 21.11.
BAKER: Now you've subsequently seen medical records and you attended the criminal trial?
MOTHER E&F: Yes.
BAKER: What did you later find out about what had been written in the notes?
MOTHER E&F: I found out that the notes had been changed to suit a different narrative of when [Child E]'s bleed started, and that's why the registrar hadn't been contacted, because he didn't know I'd been there and he didn't know that [Child E] was bleeding at just before 9 o'clock.
BAKER: So Lucy Letby had told you that she would contact the Registrar?
MOTHER E&F: She told me that she had, yes.
BAKER: That she had?
MOTHER E&F: Yes.
BAKER: And then when you saw the notes subsequently you saw that the times had been changed?
MOTHER E&F: Yes.
BAKER: With the benefit of hindsight, what do you think you witnessed on 3 August?
MOTHER E&F: An attack on my son. An interrupted attack. I think I caught her off guard. Something had happened to him for him to be bleeding. Stable babies don't bleed.
BAKER: You were taken to a Datix report at page 63 of the bundle that's in front of you. Forgive me, I am going to use the internal numbering. You can see there's page 1 of 9. Can you see that?
MOTHER E&F: Yeah.
BAKER: This Datix, the timing of it, it's completed on 4 August at 5.53 in the morning, so a few hours after [Child E]'s death?
MOTHER E&F: Yes.
BAKER: If you turn on to the second page of the report, page 2 of 9. Can you see there that the incident reporter was Lucy Letby?
MOTHER E&F: Yes.
BAKER: Then if you turn on to page 4 of 9, there is a section there at the bottom called "SBAR"?
MOTHER E&F: Yes.
BAKER: Which is -- Situation, Background, Assessment and Reporting is the acronym. If you go on to page 5 of 9 you can see an entry at 1930 hours?
MOTHER E&F: Yeah.
BAKER: Which refers to improving oxygen requirements, and then the next entry is at 2210 hours and it says ST4, I think my Lady will later find out is a registrar:
"... has asked to review the baby as he had had a gastric bleed at approximately 2140 hours."
MOTHER E&F: Yes.
BAKER: Now, you've already suggested you don't regard that note as being accurate?
MOTHER E&F: It's not accurate.
BAKER: When did you first find out that Lucy Letby had only contacted the registrar at 2210 hours?
MOTHER E&F: At the criminal trial.
BAKER: So that would be about an hour after you phoned your husband?
MOTHER E&F: Yes.
BAKER: If you go on to the next page, 6 of 9, you can see here a reference to an "SI Panel Meeting", and it's dated 13 August 2015. Do you know where you were on 13 August 2015?
MOTHER E&F: Yes. At my son's funeral.
BAKER: So that's the date of [Child E]'s funeral?
MOTHER E&F: Yes.
BAKER: And were you still a patient in the hospital around that time?
MOTHER E&F: [Child F] was.
BAKER: [Child F] was. And it's a meeting that's attended by Ian Harvey, Alison Kelly, and Sarah Harper-Lea. Were you aware of that meeting taking place?
MOTHER E&F: No.
BAKER: And if you were aware of that meeting and had been aware that the notes were recorded that the gastric bleed had occurred at 20 to 10 at night, what would you have said?
MOTHER E&F: I would have corrected them and said that that's not accurate.
BAKER: And finally, before we leave this form, if you look at page 9, this is an entry that is dated 16 December 2015 relating to [Child E]'s care and describing lessons that had been learned from [Child E]'s care?
MOTHER E&F: Yeah.
BAKER: Did anybody ever tell you that the care provided to [Child E] had been such that it was necessary to learn lessons from it?
MOTHER E&F: No.
BAKER: You described also a conversation that you had with Doctor ZA regarding [Child E], where she said that her diagnosis -- that she diagnosed NEC --
MOTHER E&F: Yes.
BAKER: -- and didn't recommend a post-mortem, and that she subsequently apologised to you and wrote to you about that. What did she apologise for?
MOTHER E&F: In the criminal trial she apologised for not pushing and suggesting for a post-mortem. In the letter to us, she apologised for not being open and transparent with what was happening on the unit at the time and she wasn't able to be, and that is not how she works with patients. And she apologised for that.
BAKER: And I think in her witness statement -- and of course the Inquiry will hear evidence from Doctor ZA in due course -- Dr ZA observes that the abdominal X-rays of [Child E] did not show any signs of NEC prior to his collapse, and whilst she notes that children with NEC don't always have positive findings on X-rays, particularly in the early stages of the condition.
"It was only with hindsight that I felt that if NEC was severe enough to cause death, it should have shown on the X-ray findings."
Is that information that she communicated to you as well?
MOTHER E&F: No.
BAKER: And you also were asked questions about [Child F] and being told that he'd had an infection in his long line which had caused him to deteriorate. Do you recall who told you that there had been an infection in the long line?
MOTHER E&F: I believe it was Dr Gibbs.
BAKER: Dr Gibbs. And again, the Royal College report -- and I'm sorry I'm jumping around because I'm trying to not repeat all the questions you've already been asked.
You said that the version of the Royal College report that you saw at the time, so in April 2017, didn't have any references to Lucy Letby in it?
MOTHER E&F: No, that's correct.
BAKER: Have you since seen a version of the Royal College report that does have reference to Lucy Letby in it?
MOTHER E&F: Yes.
BAKER: And when did you see that for the first time?
MOTHER E&F: This week.
BAKER: This week?
MOTHER E&F: Yes, it was shared with us this week, yes. I think it was Monday.
BAKER: Okay. And you described the Jane Hawdon report, which was sent to you in truncated form as being written on sample paper. What do you mean by "sample paper"?
MOTHER E&F: It had "sample" written right through the paper.
BAKER: Okay. Finally, I appreciate that you will not want to say who you work for or where you work, about what is your occupation now?
MOTHER E&F: I am a bereavement counsellor working with bereaved parents.
BAKER: And what prompted you to go into that type of work?
MOTHER E&F: I think the lack of support given to me and way I was made to feel. I didn't want any other parents to feel like that. I so that was one of the reasons why I decided that that was what I wanted to retrain in, and do with, with my career, is to help other bereaved parents, and give them a space where they can speak openly and honestly, and not feel like they're a burden on anybody and they can sit with their own feelings and not have to take into account anybody else.
MR BAKER: Thank you, my Lady. I have no more questions.
LADY JUSTICE THIRLWALL: Thank you, Mr Baker.
Mother E&F, thank you. I know this was the second time you've provided statements and come to give evidence about what happened to your babies and to you. And I do understand the enormous physical and emotional effort that's been required. It's a huge public service, for which I do thank you. And I'd like you to know that as a result of listening to you, everyone listening can all understand the joy of your pregnancy which you described so well, and the joy of the delivery of your two little boys, and also, the harrowing account of what happened to them so soon afterwards, and the lifelong consequences for you and your family.
I realise that this may make no difference to how you feel, but I would like you to know it. I've read many, many documents and I've listened to your evidence very carefully. You have absolutely nothing to feel guilty about. Nothing. And you've nothing to blame yourself for. Nothing at all.
On the contrary, it's we who have everything to be grateful to you for, including the work that you're now doing for bereaved parents. Thank you for all your evidence. Thank you to your husband for being here throughout, and thank you for all the thought that you've obviously given to the question of recommendations and the need for change. I can't thank you enough.
THE WITNESS: Thank you as well for giving me this opportunity to voice some of the things that I have today.
LADY JUSTICE THIRLWALL: As I've said before, you could not be more welcome.
THE WITNESS: Thank you.
LADY JUSTICE THIRLWALL: Everyone is now free to go when they want to.
(12.25 pm) (The short adjournment) (2.00 pm)
LADY JUSTICE THIRLWALL: Afternoon. Now, I know, I can say you're very, very welcome, Mother G and Father G. I am sorry to use the ciphers, I do know that there are real people and real experience underneath those ciphers.
I'm delighted that you've both been able to come this afternoon. How are we going to proceed?
MS LANGDALE: Ms Schermer-Jones is going to read Mother G's statement and Father G will then read his own statement.
LADY JUSTICE THIRLWALL: Very good and thank you for providing both those statements. Ms Schermer-Jones, when you're ready.
MS SCHERMER-JONES: My Lady, I'll be reading the witness statement of Mother G:
"I, Mother G, will say as follows:
"My date of birth is (redacted) January 1973 and I make this statement to assist the Thirlwall Inquiry into the harm caused by Lucy Letby to babies under her care, which included our daughter in 2015.
"This statement has been drafted following meetings and telephone conversations with my solicitor Ms Linda Schermer-Jones from Oliver & Co. I do recall the events set out in this statement but do not recall all the precise dates and times of the events and this statement is therefore based on my recollection and on the records and notes made.
"Our daughter is referred to as [Child G] to maintain her anonymity in the criminal proceedings brought against Letby. We wish our daughter's anonymity to be preserved, so instead of our names, my husband and I will use 'Mother G' and 'Father G' for the purpose of the Thirlwall Inquiry evidence.
"We have been sent a long list of questions by the Inquiry for us to deal with in our witness statements, and I have tried to answer them to the best of my ability.
"Impact:
"The victim impact statement that was provided to the police (Inquiry document number INQ0000387 [not found]) was actually a statement made on behalf of both my husband and myself, even though it was signed only by my husband.
"I feel that Lucy Letby has ruined our lives. She has ruined everything. Our daughter needs 24-hour care because of Letby, we don't know how long she will live and it affects every single minute of all of our days.
"For years we thought that our daughter had suffered from neonatal sepsis and aspirated her vomit, causing her brain damage and making her the way she is now.
"Experience at the Countess of Chester Hospital.
"My care after falling pregnant was provided by our local hospital, the Countess of Chester Hospital, and the plan was for all of my care, including the delivery, to be provided there.
"Nine weeks into my pregnancy I started bleeding, but this stopped. I had further bleeding at 22 weeks but otherwise the baby was fine.
"When I was 23 weeks pregnant, I had a further bleed. When I was seen at the Countess of Chester Hospital, we were told that in addition to blood, I was also leaking liquor (the water that surrounded our baby in my womb). It was explained that this meant I would likely give birth soon. This was a shock as I knew it was too early in my pregnancy to give birth and we were very worried about the baby.
"The Countess of Chester Hospital kept me in and staff told us that they weren't equipped to deal with babies born before 28 weeks and so we were given the choice of going to either Arrowe Park Hospital or the Liverpool Women's Hospital if I gave birth prematurely. We chose Arrowe Park Hospital. I prayed to God for me to continue carrying our baby a little further every day, to give her the best chance of living.
"Birth at Arrowe Park Hospital -- before transfer to the Countess of Chester Hospital.
"I was transferred to Arrowe Park Hospital a few days later having had stomach cramps for a few hours, which I thought was constipation. Upon arrival on the ward there, I was allocated a room. I went to the toilet in my room and was shocked to find that I was in the process of giving birth to our daughter while in the toilet. I screamed for help and banged on the walls of the toilet. When the doctors came running in, I had already given birth to our baby. This was (redacted) May 2015 and I had been pregnant for 23 weeks plus six days.
"Our baby was taken to the intensive care part of the Neonatal Unit of Arrowe Park Hospital. She was ventilated and had several intravenous lines. She was absolutely tiny and her skin was almost see-through, but I felt so much love for her.
"Our daughter had a difficult first few weeks after her birth and needed a lot of support, but she was growing and doing well. She was able to breathe on her own after a few weeks and was making good progress.
"Our daughter had many brain scans at Arrowe Park Hospital, and we were told they were looking good. I could see her growing and made sure I was present as much as possible so we could bond. She was our little miracle, a gift from God. We were so happy to see her improving.
"On 13 August 2015 (at around (redacted) weeks of age), we were told our daughter was well enough to be taken to the Countess of Chester Hospital. We were told that the Countess of Chester Hospital had been calling up to ask the Arrowe Park doctors transfer our daughter to the Countess of Chester Hospital, but until then the Arrowe Park doctors didn't think she was ready. I don't know why the Countess of Chester Hospital was so eager for our daughter to be transferred there, especially as she was doing very well at Arrowe Park Hospital. I would have been more than happy for her to have stayed at Arrowe Park.
"First admission to Countess of Chester Hospital -- 13.08.15 to 08.09.15.
"Our daughter was transferred to the Countess of Chester Hospital on 13 August 2015, to the High Dependency Unit there from the High Dependency Unit at Arrowe Park Hospital.
"At first, our daughter continued to improve. She was doing so well. She was smiling, grabbing her dummy with her hand, drinking from her bottle, recognising and responding to our voices. She had a cheeky little smile which I loved.
"We were coming up to her 100th day since birth on (redacted) September 2015 and the nurses on the Unit had prepared balloons, cake and a banner to celebrate our daughter's 100th day, which was very exciting. We were told that she was doing well and that it wouldn't be long before we would be able to take her home.
"On 6 September, one of the other babies on the Neonatal Unit, Baby I [Child I], as she was referred to in the criminal court case against Lucy Letby, became very ill and was transferred to the Liverpool Women's Hospital. I had become quite friendly with Baby I [Child I]'s parents during the time that both our babies were staying at the Neonatal Unit of the Countess of Chester Hospital. We chatted a lot, supported each other and shared our experiences.
"On the evening of 7 September 2015, our daughter was doing very well. My husband had given her a bottle at around 22.00 and we went home for the night afterwards.
"We then received a call in the early hours of the morning from the nurse on duty, Nurse Z. She told us our daughter had vomited and aspirated her vomit. She said not to worry and for us to take our time to come in. We jumped out of bed and set off straight away to go see our daughter.
"When we arrived, we saw that our daughter was intubated and had lines going into her body. She was not moving. The doctors told us that her oxygen level was low and her blood pressure was low, and that she might need to be transferred back to the neonatal unit of Arrowe Park Hospital if she didn't improve in the next few hours.
"Readmission to Arrowe Park Hospital -- 08.09.15 to 16.09.15.
"Our daughter was transferred to Arrowe Park Hospital on 8 September 2015, where we were told the doctors were better able to look after her when she was so unwell. They told us she was likely suffering from neonatal sepsis, which had caused her to vomit. My husband thought there might have been an infection going around on the Neonatal Ward of the Countess of Chester Hospital because Baby I [Child I] and our daughter fell ill there straight after each other. We were told that no infection was found on the Neonatal Ward.
"Nobody referred to what happened on 7 September 2015 as being a 'collapse' at that time. This happened later. We also only found out years later that the blood tests that had been done at the time showed no evidence that our daughter was suffering from sepsis.
"Our daughter improved quite quickly at Arrowe Park Hospital. She no longer needed to be ventilated and she was given another brain scan while she was there.
"Second admission to Countess of Chester Hospital from 15 September 2015 to 4 November 2015.
"On around 15 September 2015 our daughter was well enough to be taken back to the Neonatal Unit of the Countess of Chester Hospital.
"We had a meeting there with the doctors who told us about the result of the brain scan that had been taken at Arrowe Park Hospital the week before. We were told that she had a small shadow on her brain. This was the first time we were told our daughter had a shadow on her brain. The doctors told us that this may cause our daughter to be a bit 'clumsy' when she grew up but that otherwise her life would not be affected by it and no treatment was needed for it.
"On 21 September 2015 I was coming in to visit my daughter on the Neonatal Unit when her nurse Lucy Letby told me to wait in the parent's room as she had to do some tests on our daughter. I had been waiting for a while when I heard our daughter screaming, so I ran back into her room to make sure she was OK.
"When I went in, I found Lucy Letby standing by our daughter's cot, looking sort of puzzled. There was another nurse in the room as well. Our daughter was screaming and looked very red and I saw vomit on her. I picked our daughter up from her cot to calm her down, which she did. My husband had also arrived by then.
"We were told our daughter was poorly and needed to be taken to the Intensive Care Unit. We weren't told what had happened so I thought she may have become unwell due to having just received her immunisation shots, which made me feel guilty. Years later we found out that our daughter had stopped breathing twice on 21 September 2015. This was at the criminal trial of Lucy Letby. We also never knew that Letby had switched off our daughter's monitor, so the alarm wouldn't be heard.
"It was very hard for us to only find this out in court. There was a lot of stuff that happened to our daughter that we didn't know about and had not been informed.
"Our poor daughter, oh my God. Our precious little fighter, who didn't have much chance being so premature. Then when she was doing well, Lucy Letby made her collapse and caused her brain injury. Both my husband and I stayed in court when the care for our daughter was discussed but it was awful to find out the details of what happened at trial. I was upset, angry, shocked and felt sick to my stomach when we found out in open court, in front of everyone.
"Cause of Collapses and Injury.
"After her collapses on 7 and 21 September 2015, I noticed a marked change in our daughter. She didn't smile much anymore. She didn't react to us like before. She appeared more 'distant' and appeared less connected. She had less of a spark and stopped grabbing her dummy herself. Although this is hard to put into words, I knew even then (without knowing what had been done to her deliberately) that our daughter was no longer the same baby that had left Arrowe Park Hospital on 13 August 2015 and had continued to thrive up to her 100th day hallmark on (redacted) September 2015.
"She also seemed to have more reflux, vomited more and eventually it became clear that she wasn't safe to take oral fluids anymore because she could inhale vomited food and choke. As a result, she now only gets nutrition through a tube directly into her stomach.
"As our daughter grew, she started missing her developmental milestones. In around May 2016, she had an appointment with her regular eye doctor who noticed that she wasn't focusing or reacting to light, despite her eyes themselves appearing okay.
"The eye doctor therefore suggested that she needed another brain scan to look for a cause for this in her brain and this scan was done in around August 2016.
"My husband and I had an initial appointment about the new brain scan with Dr Brearey at the Countess of Chester Hospital in around August 2016. Dr Brearey told us that the new brain scan showed our daughter had very severe brain damage. Dr Brearey showed us the brain scan, which looked all black. We both had tears in our eyes and were very upset. Dr Brearey said that the vomit our daughter had aspirated on 7 September 2015 had caused a lack of oxygen and the injury to our daughter's brain. We had a lot of questions about what had happened and about what this would mean for our daughter.
"Dr Brearey said he could not answer our questions about our daughter's future and said he would arrange another appointment where another specialist from Alder Hey Hospital would be present to help answer the questions we had.
"We then had an appointment with Dr Brearey and a neurology doctor from Alder Hey Hospital at the Countess of Chester Hospital. We were told our daughter had cerebral palsy, wouldn't be able to walk, wouldn't be able to talk, wouldn't be able to eat, wouldn't be aware of her surroundings. She would have spasms in her arms and legs. We were told she had a reduced life expectancy.
"It was devastating to hear how badly our daughter would be affected by her brain injury.
"We asked how this could have happened after just one vomit? My husband was very worried she had been left to drown in her own vomit and asked how long the vomit lasted for and how long it took for the nurses to come to the help of our daughter after her vomit. Dr Brearey said he would arrange another appointment to go through this in more detail with us.
"At the next appointment with Dr Brearey, which was in around September 2016, he went through and showed us the charts that had recorded all that had happened with our daughter in the Neonatal Unit on 7 September 2015. He said that the charts all looked fine up until the moment she had her vomit and there was no reason to think that our daughter had not been helped very quickly after she vomited.
"Dr Brearey told us that our daughter had suffered neonatal sepsis and vomited, and had aspirated this vomit, the combination of which caused a lack of oxygen to her brain, leading to her brain injury. There was no mention of any 'collapse' on 21 September 2015. We weren't told that there was a concern or an investigation into what had happened at the Countess of Chester Hospital.
"At the time we trusted Dr Brearey's opinion and believed what he said. At that point we thought our daughter's brain injury was God's will, we couldn't do anything about it and we just had to accept it.
"Suspicions and Concerns Regarding Lucy Letby.
"In around May 2017 we were informed by the police that they were starting an investigation into the Countess of Chester Hospital. We were not given any details and they didn't say anything about anybody hurting our daughter. We thought that the police were perhaps investigating a cover-up or maybe there had been a virus going round the Neonatal Ward at the Countess of Chester Hospital.
"Eventually we were asked to provide a witness statement to the police which took us a while to arrange as our daughter was in and out of hospital for treatment all the time.
"The police did come to our house to take our statements, but they didn't mention Lucy Letby by name or any involvement of nurses in their investigation. I still thought this was an investigation into a cover-up of a bad virus on the Neonatal Ward.
"In around July 2018, my husband got a call from the police to say they were coming to the house that morning to speak with us about an arrest that had been made, which they wanted to tell us about as it would be all over the news soon. My husband was in work and was told to come home to meet with the police.
"The police came to our house and told us they had arrested Lucy Letby as they had some evidence that Lucy Letby had attacked our daughter. They did not mention more than one attack on our daughter and they didn't mention any other babies being involved. The police told us they couldn't comment any further as it was an active investigation and it might jeopardise the court case against Lucy Letby.
"I couldn't breathe and was in shock. It was extremely hard to hear this, and it broke my heart. I had to leave the house and just walked outside. This was the first time we became aware that someone may have hurt our daughter.
"I received a further call from the police shortly thereafter, to tell me that Lucy Letby had been released on bail.
"Because I was visiting our daughter daily, spending as many hours as possible with her on the Neonatal Ward, I did interact with Lucy Letby a few times but she didn't really talk to me much: less than other nurses.
"While I didn't particularly like Lucy Letby, I had no inkling that she was hurting our daughter on purpose. To me, she looked miserable; like she didn't enjoy her job. I just thought she wasn't very good at her job but never thought she would intentionally harm our daughter.
"I thought I could trust all the hospital staff to look after our daughter. Of course, my views have changed since then and it is fair to say that I now have bad trust issues and I find it very hard to talk about what happened. At the same time, I can't forget what happened.
"The Countess of Chester Hospital never once told us they had any concerns about Lucy Letby and we didn't find out until we were informed by the police in 2018 -- but even then, we knew no details of what precisely Lucy Letby was accused of having done to our daughter. We only found this out just before the criminal trial of Lucy Letby, which was harrowing.
"I feel that the Countess of Chester Hospital have covered up what happened to our daughter for years, telling us all this time that our daughter suffered neonatal sepsis, despite there not even being a marker for sepsis in her blood tests at the time.
"Medical Records.
"We didn't get the medical records ourselves. The police requested them with our permission. Later on, our solicitors also got a copy of the medical records.
"Counselling and Support.
"We were not offered any help or support by the Countess of Chester Hospital or by anyone else, and I didn't request any myself.
"I did go to see my GP. I was hoping to be referred to a specialist, but this didn't happen.
"Reinforcing Concerns and Getting Answers.
"The Royal College of Paediatric and Child Health review into neonatal services at the Countess of Chester Hospital and the advisory medical report prepared by Dr Hawdon are things I first heard about at the criminal trial of Lucy Letby. We have never received a copy of either report.
"Dr Brearey never said anything about an investigation at the Countess of Chester or about concerns over Lucy Letby's care of our daughter. It really upset me to think that he might have helped cover it all up. Our daughter continues to be treated by him, even now.
"I did receive a call from Dr Brearey on the day when the police came to see us in July 2018. He apologised and said he had been unable to tell us about any of the concerns while the police were investigating.
"As set out before, we only became aware of a police investigation in around May 2017 when we were told this by the police themselves, albeit without providing us with any detail of what happened.
"We were also not given any opportunity to meet with anyone at the Countess of Chester Hospital to discuss our daughter's care in 2015 or any investigations.
"I feel the information given to us by the Countess of Chester Hospital is totally inadequate. We only ever had clinical meetings with the Countess of Chester Hospital staff about ongoing care for our daughter but concerns about Lucy Letby were never mentioned at all.
"As we did not have any idea about our daughter being hurt, we didn't raise any concerns with the Countess of Chester Hospital, with PALS or with any external organisations. We have also not been asked nor have taken part in any wider review into the safety of babies under the hospital's care.
"Suggestions and Recommendations.
"After four babies had already died on the Neonatal Unit of the Countess of Chester Hospital, they still wanted our daughter to be transferred there from Arrowe Park Hospital. She was doing well at Arrowe Park Hospital and was developing and growing stronger there.
"In my view, the Countess of Chester Hospital should have taken Lucy Letby off the ward and investigated her much sooner. Concerns had been raised by Dr Brearey, which the Countess of Chester Hospital just left be.
"The number of babies dying on the Neonatal Unit at the Countess of Chester Hospital was higher than at the Neonatal Unit at Arrowe Park Hospital where babies were more premature and more ill. This was another reason to start an investigation.
"An investigation should have been carried out by an external body, independent of the Countess of Chester Hospital, and a full report prepared.
"During the investigation, no further babies should have been admitted to the Neonatal Unit. This would have saved more babies' lives. To my mind, the Countess of Chester Hospital was more concerned about their reputation than about our daughter's life.
"I think this Inquiry should recommend that there should be increased protection for whistleblowers. Also, I feel there should be a recommendation that hospital leaders should be held personally responsible when things go wrong after they have had a report about problems and did nothing about it."
LADY JUSTICE THIRLWALL: Thank you very much indeed, Ms Schermer-Jones and Mother G.
Now, Mr G, when you're ready, please start.
FATHER G: I, Father G, will say as follows:
"My date of birth is (redacted) December 1978 and I make this statement to assist the Thirlwall Inquiry into the harm caused by Lucy Letby to babies under her care which included our daughter in 2015.
"This statement has been drafted following meetings and telephone conversations with my solicitor, Ms Linda Schermer-Jones from Oliver & Co. I do recall the events set out in this statement, but do not recall all the precise dates and times of the events and this statement is therefore based on my recollection and on the records and notes made.
"Our daughter is referred to as '[Child G]' to maintain her anonymity in the criminal proceedings bought against Letby. My wife and I wish our daughter's anonymity to be preserved, so, instead of our names, my wife and I will use 'Mother G' and 'Father G' for the purpose of the Thirlwall Inquiry evidence.
"We have been sent a long list of questions by the Thirlwall Inquiry for us to deal with in our witness statements, and I have tried to answer them to the best of my ability.
"Impact.
"The Victim Impact Statement I provided to police (Inquiry document number INQ0000387) was actually a statement on behalf of both my wife and myself. I do not wish to add anything to it.
"Experience at the Countess of Chester.
"Birth at Arrowe Park Hospital -- before first transfer to the Countess of Chester Hospital.
"Our daughter was born on (redacted) May 2015 at Arrowe Park Hospital because my wife had gone into labour prematurely. Our daughter was conceived using IVF and antenatal care was provided at the Countess of Chester and we were expecting all care to be provided by the Countess of Chester, including the birth of our daughter.
"At 23 weeks of pregnancy, when it came apparent that our daughter might be born prematurely, my wife was transferred from the Countess of Chester Hospital to Arrowe Park Hospital. We understood that, while the Countess of Chester did have a Neonatal Intensive Care Unit, they were not capable of providing the very specialist care needed by babies who were born at less than 28 weeks, while Arrowe Park was capable of doing this. Our daughter was born at Arrowe Park Hospital after only 23 weeks plus six days of pregnancy.
"We were happy with the care given to our daughter at the Neonatal Intensive Care Unit of Arrowe Park Hospital, and while she was there, she had a rocky start and needed a lot of support being ventilated for the first few weeks of her life. Our daughter is clearly a fighter and we could see her growing and improving week upon week.
"My wife was at the hospital every day, for most of the day, to be with our daughter and she expressed breast milk to feed our daughter through a tube via her nose into her stomach. I went back to work after a few weeks after her birth and would visit when I was not in work.
"Doctors and nurses at Arrowe Park told us that the staff at the Countess of Chester Hospital were always ringing them to push for our daughter to be transferred to the Countess of Chester. I got the impression this was a financial issue, with the cost of looking after our daughter at Arrowe Park Hospital coming out of the budget of the Countess of Chester Hospital.
"At that time, our preference was for our daughter to stay at Arrowe Park Hospital as we could see her improving there. She had regular brain scans and we were told that her brain looked good and was developing well.
"Initially the doctors at Arrowe Park Hospital didn't think she was well enough for our daughter to be transferred to the Countess of Chester Hospital, but on 13 August 2015 she was transferred to the Countess of Chester Hospital.
"First admission to the Countess of Chester Hospital -- 13.08.15 to 08.09.15.
"The Neonatal Unit at the Countess of Chester Hospital had three parts: namely, the Intensive Care Unit (ICU) for the babies needing the most support; the High Dependency Unit (HDU); and the Nursery. In total there were approximately 16 cots. Our daughter went from HDU at Arrowe Park Hospital to HDU in the Countess of Chester Hospital on 13 August 2015.
"At that point, she had improved enough to only need a little bit of oxygen (via nasal prongs) and was in an open cot. She did not need any of the intravenous lines anymore. She recognised my voice and turned her head to me and smiled whenever I talked to her.
"On 26 August 2015, our daughter was strong enough to drink her first bottle, even if it was only a small amount to start with. She continued to improve and was able to grab hold of the bottle with her tiny hands when being fed. We were told by staff on the Unit that our daughter just needed to grow bigger and then we would be allowed to take her home.
"Because my wife spent most days on the Neonatal Unit, we got to know some of the parents of the other babies there and on around 6 September 2015, we became aware that Baby I [Child I] ('I' referred to the cipher given to her as part of the criminal trial against Letby), who had been on the Unit for (redacted) weeks, had suddenly become very unwell. She was transferred to Liverpool Women's Hospital Neonatal Unit.
"In the early hours of 7 September 2015, I received a phone call from Nurse Z on my mobile. She told me that our daughter had had a vomit and had aspirated the vomit, meaning the vomit had gone into her lungs, and that she would need to be put on the ventilator.
"Nurse Z said not to worry, she wanted to let us know. While we were told to take our time to come in, my wife and I jumped in our car and raced to the Countess of Chester Hospital. We arrived at the Neonatal Unit within 20 minutes of receiving the call.
"When we arrived, we went straight to the Intensive Care Unit and saw doctors working on her. She had been intubated and looked very still. Multiple lines had been inserted into her little body and it was awful.
"When we spoke to doctors, they told us again that our daughter had had a vomit and she had aspirated it.
She required ventilation to help her to breathe and to get her sats (the oxygen levels in her blood) up.
"Readmission to Arrowe Park Hospital -- 08.09.15 to 16.09.15.
"All that day and into the next morning, the doctors tried to get our daughter's sats up and to get her blood pressure up, which was also low. From what we were told, the Countess of Chester could only provide intensive care to our daughter for 24 hours, after which she would need to go to a more specialist unit, and so on 8 September 2015 she was transferred to Arrowe Park Hospital again.
"We were happy she was taken to Arrowe Park Hospital as the doctors there had made our daughter better before, and we thought their care of her was very good.
"At Arrowe Park Hospital, the doctors said it was suspected that our daughter was suffering from sepsis caused by some sort of virus.
"At Arrowe Park Hospital, our daughter had an MRI scan of her brain on around 15 September. We didn't get the result from this scan until after she was taken back to the Countess of Chester Neonatal Unit once more.
"Second admission to the Countess of Chester Hospital -- 15.09.15 to 04.11.15.
"Our daughter was taken from Arrowe Park Hospital to the Countess of Chester Hospital on around 15 September 2015. We were told that she was fine to go back, she was off the ventilator and didn't need much oxygen at all.
"My wife and I then had a meeting with a consultant and a nurse (whose names I don't remember) on the Neonatal Unit of the Countess of Chester Hospital to discuss the outcome of the brain scan of 15 September 2015. They said that they could see some small amount of damage to our daughter's brain on the scan.
"They said these might cause her to be a bit 'clumsy' when she grew up, but that was all. The consultant said she had seen worse scans and those babies grew up to be okay, so we felt positive for our daughter.
"I did ask the consultant about a potential virus going around the Unit. I asked her about it because Baby I [Child I] had also fallen ill, just a day before our daughter became very ill on 7 September 2015, and so I thought a virus might have caused both babies to have become very ill in quick succession. The consultant told me there had been no virus.
"On 21 September 2015, I arrived at the Neonatal Unit for a normal visit of our daughter after work.
I had not received a phone call about her being unwell, and when I went in, I found that she had been taken to the intensive care room and was being worked on by doctors. Our daughter was screaming and clearly in pain.
"I asked what was going on and was told again she had a viral infection and was poorly. Eventually, they let my wife hold our daughter, upon which she calmed down and then the doctors were able to put a cannula in her. We were not told that she had a collapse and not told that she had stopped breathing that day, only that she was poorly.
"Cause of Collapses and Injury.
"Nobody mentioned anything about the investigations taking place at the Countess of Chester Hospital into our daughter's illness or the care given to her at the time. We were not even told she had suffered a 'collapse' or 'collapses' on 21 September 2015. We were told she had a vomit on 7 September 2015 and was 'poorly' with neonatal sepsis. We were simply told on 21 September 2015 that she was 'poorly' with no further details of how or why our daughter became ill.
"As to the cause of our daughter being poorly on either date, we were always told by the hospitals (both the Countess of Chester Hospital and Arrowe Park Hospital) that our daughter had neonatal sepsis, nothing else, that had caused her brain damage. I had nightmares about our daughter not being attended to quickly enough by the staff after her vomit of 7 September 2015 causing her to aspirate her vomit, which was very upsetting.
"Then a concern was raised by the ophthalmology doctor at a routine check-up of her eyes, when our daughter was around one year old, in May 2016. We had some concerns about her vision and about not meeting her milestones and we were told that her eyes appeared to be okay and that she needed another scan to check whether there was a problem with her brain. Our daughter's last brain scan had been done the year before and no scans had been done since.
"The new brain scan was done around 12 August 2016 and some weeks later we had an outpatient appointment at the Countess of Chester Hospital where the Consultant Paediatrician, Dr Brearey, had asked a neurology doctor from Alder Hey Children's Hospital (whose name I don't remember) to join the consultation we had with him and to explain the outcome of the brain scan and the extent of our daughter's brain injury. There were also two junior doctors present at this appointment.
"We were shown the recent MRI scan and we could see for ourselves that it looked black, which was not something that had been seen on her previous scans. Seeing this image was absolutely horrendous. We were told that our daughter would be very disabled for the rest of her life and that she would not be able to do much.
"We were told that our daughter could choke in her sleep. We were very worried about this happening and kept our daughter in our bedroom to sleep at night so we could keep an eye on her. In around 2021/2022, we had a bedroom fitted downstairs for our daughter, including a hoist, and my wife started sleeping in the downstairs bedroom with our daughter to be able to look after her during the night and make sure she didn't choke.
"Dr Brearey told us again (at that appointment in 2016) that the cause of our daughter's brain injury was neonatal sepsis and a vomit resulting in a lack of oxygen to her brain. I was very upset and said to Dr Brearey that all this happened after our daughter came to the Countess of Chester Hospital, that nothing had been wrong with her brain until after her transfer there.
"I didn't understand the diagnosis that Dr Brearey gave us, namely that our daughter's prematurity and neonatal sepsis had caused her brain injury, as her brain had been developing well, and she had been improving before going to the Countess of Chester Hospital. I therefore raised a question that I had been very concerned about, namely of our daughter vomiting on 7 September 2015 and asked whether she had been left to drown in her vomit. At that time, and due to the scarcity of information that we had been given, my wife and I did not fully appreciate or understand the seriousness of the two further 'collapses' that our daughter suffered on 21 September 2015. In response to my question, Dr Brearey said he would arrange a new appointment to go through all our daughter's charts and her stats (like blood pressure and oxygen levels) with us.
"My wife and I did get another appointment with Dr Brearey on 28 September 2016, where he showed us our daughter's stats on a computer screen. He went through all her charts and told us that he could see that all our daughter's stats were fine, right up to her sudden vomit on 7 September 2015 and that it didn't look like there had been any delay in attending to our daughter after her vomit. Dr Brearey didn't say anything about investigating or reviewing why she vomited or why she became unwell. He also did not mention the two collapses that we now know our daughter to have suffered on 21 September 2015 and how they might have affected her.
"The doctors didn't tell us that on 7 September 2015 our baby daughter in fact had a projectile vomit, with the milk coming out of her tiny little body with so much force that it reached the chairs opposite her cot. They also didn't tell us that upon aspirating the contents of our daughter's stomach after her projectile vomit on 7 September 2015, they found she still had around 45 millilitres of milk in her stomach, which was an enormous amount of milk and more than her feed. We only found this out at the criminal trial of Letby in 2023. Moreover, they didn't tell us that she had stopped breathing (twice) on 21 September 2015. We were also not told that there were concerns about an increasing number of babies dying on the Neonatal Unit, nor that they were looking at the standard of care given to our daughter. It truly came as the biggest shock of my life when I found this out years later.
"We put our trust into the doctors and believed them after they told us time and again that the cause of our daughter's brain injury was her prematurity and subsequent neonatal sepsis, resulting in aspiration and lack of oxygen to her brain on 7 September 2015. It was set out in all her medical notes and in the clinic letters that we received/read. I thought it had just been bad luck for our little girl.
"It was only when the police said they were starting investigations in around May 2017 that we first became aware that the police were looking into the Countess of Chester Hospital. However, even then, I still thought that there may have been a degree of malpractice and that perhaps a doctor had been useless -- it never occurred to me that someone had intentionally harmed our baby.
"In around July 2018 I had a call from the police Family Liaison Officer (FLO) at 06.30 am when I was in work, to tell me that they had arrested Lucy Letby. The FLO said they wanted us to know before we read about it in the press. The FLO asked me to go home and they would come to speak to my wife and me about it and explain things to us.
"When the police came round, they told us that Letby was accused of hurting our daughter. We were both in shock. We weren't told what Lucy Letby had been accused of, in terms of how or when she had hurt our baby daughter -- we only found this out much later, a few months before the criminal trial started in 2023.
"Later that day, my wife told me she had also received a phone call from Dr Brearey, who apologised to us. He said he had been unable to tell us anything about their concerns while the police investigation was ongoing.
"We subsequently received a letter from the police that set out two charges against Lucy Letby: namely, one of attempted murder on 7 September 2015 and one of attempted murder on 21 September 2015. Then, just before the start of the criminal trial in 2023, we were told by the police that a third charge had been added to the list; namely, of a second attempted murder on 21 September 2015 and we were told what it was alleged Letby had done.
"We didn't know that our baby had stopped breathing twice on 21 September 2015 until evidence was given during the criminal trial of Lucy Letby in 2023, which made an anxious and difficult situation worse for us.
"We now know that the attacks by Lucy Letby caused a lack of oxygen to our daughter's brain resulting in a massive brain injury. Prior to the attacks, our daughter's repeated brain scans looked OK and her brain was seen to be maturing well. After the attacks, her brain scans changed and clearly showed a brain injury which had wiped out most of her brain. As a result, our daughter is severely disabled and will remain so for life.
"Our daughter cannot talk or sit up by herself. She cannot walk or swallow -- she is fed by way of a tube directly into her stomach. She is blind and can't reach to grab things on purpose with her hands. She has very little understanding and needs help with everything, including feeding, bathing, dressing, and moving. She has a normal size body for a nine year-old so we have had to install hoists as lifting her has become more difficult. She can't be left unattended due to the risk of her choking. My wife and I provide the majority of her care and do so lovingly. She is our little girl, our fighter and our star. I have been besotted with her ever since the day she was born.
"Suspicions and Concerns Regarding Lucy Letby.
"As to my interactions with Lucy Letby, I only briefly spoke to her once or twice during our daughter's stay at the Countess of Chester Hospital. Implicitly trusting the medical and nursing professionals at the hospital, I had no concerns about Letby or her work at the time.
"We were not given any information about the concerns regarding Lucy Letby's conduct by the Countess of Chester Hospital at all. They didn't tell us about any concerns, nor did they tell us they were looking into concerns.
"We only found out about concerns regarding Lucy Letby from the police when she was arrested. We had to learn further details about the case by reading newspaper articles after Letby's arrest, which set out that concerns had been first raised as far as back as June 2015 or thereabouts, ie, before our daughter was attacked by Lucy Letby.
"When the police said they started investigations in around May 2017, we first became aware that the police were looking into the Countess of Chester Hospital, but, even then, I thought there may have been a degree of malpractice and that perhaps a doctor had been useless -- it never occurred to me that someone had intentionally harmed our baby.
"In around July 2018 I had a call from the police Family Liaison Officer (FLO) at 6.30 am when I was in work to tell me they had arrested Lucy Letby. The FLO said they wanted us to know about it before we read about it in the press. The FLO asked me to go home and tell my wife about it, and explain things to her as well.
"When I told my wife about it, we were both in shock. We weren't told what Lucy Letby had been accused of in terms of how or when she'd hurt our baby daughter.
We only found this out much later, around the time the criminal trial started in 2023.
"Medical Records.
"We didn't get the medical records ourselves. Our solicitors did.
"Counselling and Support.
"We were not offered any support by the Countess of Chester Hospital and I didn't request any myself.
"Raising Concerns and Getting Answers.
"I was not aware of the Royal College of Paediatric and Child Health review into neonatal services at the Countess of Chester Hospital until the trial, and did not receive a copy of their report.
"I was also not aware of the advisory medical report prepared by Dr J Hawdon until the criminal trial of Lucy Letby. We were also not told that the Countess of Chester Hospital was investigating or reviewing our daughter's collapse and only became aware of the police investigation in around May 2017, when1 we had had an email from the police to tell us that the police were investigating the Countess of Chester Hospital -- not that they were investigating Lucy Letby in particular. At that time, I didn't think anyone had intentionally harmed our daughter and I didn't think anything would come from the police investigation that would have particular impact on our family.
"Save for the meeting with Dr Brearey in September 2016, the only meetings we had with the Countess of Chester Hospital were about our daughter's ongoing care and treatment, not about concerns relating to the care given to our daughter previously. Even then, the information we were given wasn't the full story, as we later found out.
"In my view, the information given to us by the Countess of Chester Hospital was completely inadequate. We were never told about concerns relating to the care given by Lucy Letby to our daughter. All the clinical letters we received referred to her being premature and suffering neonatal sepsis as the cause of her brain injury.
"The hospital letters about our daughter have only recently changed to remove the reference to neonatal sepsis as a cause of her brain injury. The Consultant Community Paediatrician from (redacted) has started referring to, in their letters, the fact that our daughter is a victim of Lucy Letby instead.
"It has been very important for us to see this in writing, to have this confirmation and acknowledgement in black and white. Moreover, it is important for the other doctors who treat our daughter to know this, because it avoids us having to explain time and again how our daughter did not suffer neonatal sepsis but was intentionally harmed by Lucy Letby (which is upsetting to talk about) and it also avoids awkward assumptions about what happened to our girl being made by those who treat her.
"I did send an email to the Chief Executive of the Countess of Chester Hospital after Lucy Letby's criminal trial because the Countess of Chester was still denying they had caused an injury to our daughter. In her reply, she apologised to me for the delay and offered a meeting, but I was then asked to go through the solicitors instead of writing to the hospital directly. I didn't contact any external organisations.
"We did have big concerns about being left in the dark about what precisely happened to our daughter. It was horrible to only find out these details at the criminal trial of Lucy Letby, particularly so in relation to our daughter's projectile vomiting on 7th September 2015 and her stopping breathing twice on 21st September 2015.
"I was present for part of the criminal trial of Lucy Letby. During the trial, we were unexpectedly shown a photo indicating the distance between our daughter's cot in the Neonatal Unit and the chairs. It was calculated that her projectile vomit of 7 September 2015 that had reached the chair in her room was a distance of 3-4 feet away from her cot, indicating the force of her vomit and the pain she must have felt with the pressure building up in her tiny little body. We had not known about this and hadn't seen it before. It was an absolute shock to hear it for the first time during the course of the trial.
"I have not taken part in any wider reviews relating to the safety of neonatal babies and have not been asked to do so by anyone.
"Suggestions and Recommendations.
"In relation to my views as to what could have assisted in preventing Lucy Letby attacking our daughter, I think Lucy Letby should have been taken off her job straight away (when suspicions or concerns were raised) until a full investigation had been concluded.
"At the time, Lucy Letby was left to continue to care for (and as it turned out, harm and even kill) babies who were physically vulnerable due to their prematurity and medical concerns, and were unable to speak up for themselves if untoward events had occurred. Parents could not stay with their babies 24/7 and relied implicitly and entirely on (what they thought were) the best and most professional care that their babies needed and deserved.
"The Countess of Chester Hospital should have acted more quickly and taken her off the front line straight away.
"It would also help to have CCTV cameras in each baby's room and in the corridors, for the safety of children and staff alike.
"There should be a locked door at the entrance of the wards, only accessible with a personal key fob with logged entry/exit times. At the criminal trial, Lucy Letby admitted having been let into the Neonatal Unit regularly by others on the Unit, even when she had no reason to be there. 'Tailgating' should not be allowed. These things stop there being an accurate report of who is and who isn't on the ward at any given time. I worry that Lucy Letby might have been present when more or other babies had 'collapsed' because no one knew she was there at the time and therefore no investigations took place.
"Also, access to all drugs should be digitally monitored by use of a personal swipe card. This way, it won't be possible for anyone to get away with taking and using medications without there being a record of the same.
"Lastly, I am of the view that protection for whistleblowers should be improved. Whilst there are supposed to be rules in place to make sure whistleblowers are taken seriously and can speak freely so as to prevent harm being caused, these rules do not seem to give enough protection to the whistleblowers and as a result, tragedies continue to happen. It is not enough to simply have written policies regarding protection of whistleblowers. For the policy and self-regulation/monitoring to work effectively, the culture on hospital wards has to be such as to promote and safeguard reporting of concerns, no matter how trivial it might first appear. Any reported concerns should also be investigated by an external body/person who has no direct interest and/or involvement in the operation of the hospital/ward. The findings of such investigations should be recorded. There should also be a mechanism to audit past reports of concerns and subsequent investigations, such that it will be obvious when a pattern starts to develop which might warrant further action.
"About support to parents, in my view, there should be more funding in the NHS for psychological assistance and treatment."
LADY JUSTICE THIRLWALL: Thank you very much indeed, Father G and Mother G.
I mentioned at the beginning, I was very pleased that you felt able to come today, and I would just like to repeat that. I don't underestimate -- and I've said this to other parents -- how much it takes out of you to write these statements and then to come and speak to them, or have them read. And you've done that with great courage today, and great dignity, and I am grateful to you.
Just so you know, these statements, which give such a clear and detailed picture of your long experience at the Countess of Chester Hospital and then beyond, really do help me answer the many questions that are set out in the Terms of Reference.
We now have a really clear image of the 100th day celebration and then of the change in your daughter which I think you, Mother G, particularly noted, and then learning what had happened to her and coming to terms with that. But what absolutely shines through in the most extraordinary fashion is your profound and enduring love for your daughter, and your care for her is quite extraordinary. And as you would say, it's nothing more than you would have wanted to give your child from the moment she was born.
You've done this for her, and for other parents, and the Inquiry is very, very grateful to you for being so generous. Thank you.
That concludes proceedings for today. Thank you all very much.
(3.01 pm) (The hearing adjourned until 10.30 am the following day)
LADY JUSTICE THIRLWALL: Good morning, Mother H.
Thank you very much for being online to give your evidence this morning, I know it won't have been easy to arrange and I'll very grateful to you. You'll be wanting to get started so I'm going to invite Ms Langdale to do that.
MS LANGDALE: Thank you, my Lady. May the witness be sworn.
MOTHER H (affirmed) (By videolink)
Questioned by MS LANGDALE
MS LANGDALE: Mother H, we're doing this over a link, and if at any point you can't hear me, raise your hand, I'll do the same if I can't hear you, and we'll see that if we can't see each other or hear each other saying it.
You provided a statement on 16 July 2024 to the Inquiry. Can you confirm the contents are true and accurate, as far as you're concerned?
MOTHER H: Yes.
LANGDALE: I'm going to begin by asking you about your experience at the Countess of Chester Hospital and your experience through pregnancy and any treatment that you were having there. Can you tell us about that?
MOTHER H: Yes. So [Child H] was my firstborn child. I didn't know what to expect in terms of hospital care throughout pregnancy or birth because I had no experience so I didn't know what was to be considered normal. And I am a diabetic so I had a lot of hospital involvement with my pregnancy journey at the Countess of Chester Hospital, which is where I received my diabetes care and --
LANGDALE: What was that care like?
MOTHER H: The diabetes care was good because they had regular appointments, regular scans, and, you know, just making sure that everything was okay. So the before birth appointments seemed to all be quite intense in that, you know, you had to go regularly, there was a lot of tests and checks and things like that, but it showed that they were monitoring things, and I was told what the plan would be for a diabetic mother that they always aimed to induce you early, but the plan is to get to 38 weeks because there is a risk of the placenta not working at the end of the pregnancy if you go to full term.
So it was always expected, I suppose, that she would be born earlier, but the aim was to not have a premature baby and to try to have a have as healthy a pregnancy as possible. And they provided a good care and at that point it seemed to have been good care --
LANGDALE: So the antenatal team dealt with your diabetic issue and explained things to you and you felt that was good and clear care?
MOTHER H: Yes, I had no concerns during that pregnancy at all in terms of the Countess of Chester in terms of the diabetes care and the antenatal appointments there.
LANGDALE: In the antenatal phase was there any discussion or not about whether [Child H] would need some extra care when she was born or not? What did you think the position was?
MOTHER H: At the time of sort of when it was just a case of planning during pregnancy and all the scans and things, there was no indication that she would need extra care, but I was told that if she came earlier, there is always a chance that, you know, she could have been born earlier and therefore then that runs the risk of needing some extra assistance. But they said that can vary greatly and it depends on how early it is that the pregnancy goes to.
LANGDALE: You were induced, weren't you, at 34 weeks and four days?
MOTHER H: Yes. Yeah.
LANGDALE: Tell us about your experience of that and the C-section?
MOTHER H: So I was ... I'm trying to think how to word this. I was not having a good end to the pregnancy at this point in that I was having a lot of low sugars and it had got to the point then when I was having to go in a lot more regularly for checks and there were some concerns. Everything from the scans I suppose seemed to be okay but at this particular point in time when I got to 34 weeks and four days it got to a point where it was really quite bad so I had to phone and go in sort of as an emergency. At that point they had decided to give me steroids to try and help control blood sugars and to help develop the baby's lungs because it was earlier than the 38 weeks that we planned for, and I was admitted to hospital and given another dose of steroids the next day and told that at this point she could be delivered earlier. But there was no indication that she would need a lot of extra care or that she would be particularly poorly. And in fact from the day she was delivered there was -- they told me there was a chance she might not even need to go to the neonatal unit and it was just a case of seeing how she is when she's born.
The next day after I'd had the second dose of steroids, they decided that because the blood sugars hadn't improved there were concerns that maybe the placenta was failing and so the safest option was to deliver her and not run the risk. So I was told that they'd perform a caesarean. However, then it came to my attention that there was actually a shortage -- they said because she is early, she would need -- she may need some checks from the neonatal care team and we need to make sure there's a bed if she needs to go there. And they said it's exceptionally busy and there were no beds available in the Countess.
They explained to me that they couldn't move me because I wasn't well enough, but that if it came to the case where they'd have to deliver her, it may be that she would have to be transferred to another hospital and I would have to follow.
LANGDALE: How did that make you feel, the thought of that, that your baby would be taken to another hospital but you were effectively confined to the one you were in?
MOTHER H: Terrified. I didn't want that to happen at all, and at this point I was really beside myself thinking no, no, I don't want that to happen, I thought being separated at all from your baby when they're born was enough. Everybody goes on about, you know, this golden hour and have this golden hour, you know, with the baby afterwards, and you have these visions of how it would be and then to be told that actually she could be taken completely away to another hospital. And it got more complicated than that because then they said there was no beds in the near vicinity and, you know, it could be as far as Birmingham that she could be transferred to and they were even contacted to try and find an available bed, and that brought a lot of panic just before her birth as to what was going to happen.
They had decided then at 6 o'clock that evening or around about then that they were going to do the caesarean and it wasn't until I was on the operating table that they came over to say that it was good news, and a bed had become available, there'd been a discharge, and a bed had become available in the Countess on the neonatal unit, and at that point I thought: great. Yeah, that means that at least, you know, we can be in the same hospital. With hindsight it would have been far better if she'd been transferred to another hospital, but at the time, I thought that it was really good because we could be together.
LANGDALE: In terms of --
MOTHER H: I didn't have --
LANGDALE: Sorry.
MOTHER H: I was just going to say I didn't have any issues, though, with the caesarean or anything.
LANGDALE: So the obstetric care you received was good. You felt that you were looked after?
MOTHER H: Yes.
LANGDALE: And communication was good?
MOTHER H: Yes. Yeah, because they kept me informed over the situation with the beds and with the hospitals and what was available and, you know, what was going to happen in terms of that. So from that side of things, yes, the only issue was that it was a busy time, it seemed to be, but that was a case of that was something that obviously couldn't be helped.
LANGDALE: How was [Child H] when she was born?
MOTHER H: She was in really good condition. I remember them saying she had like an Apgar score of 9, she came out and she was crying, she was pink. She was slightly smaller but she was still a good weight. And they were really pleased, and they let us hold her sort of straight away, as much as you can when you're having a caesarean but they placed her on my chest and my husband was able to hold her, and, you know, we could have that bit of time with her.
However, after a little bit of time holding her I noticed that she started to sort of grunt a little bit and the doctors said they would just take her to check her over. And at that point they said, "Because she is early, I think it's best if we take her for some monitoring on the neonatal unit".
So they took her to the neonatal unit, and my mother was in the hospital at the same time so she went down with her, as did my husband. I asked him to go there also.
LANGDALE: Where were you? Which ward were you on? Where were you staying?
MOTHER H: I was on the -- still on the Labour Ward at this point, in the recovery. They told me because it was quite late at this point that, you know, obviously I wanted to go straight away to go and be able to see her, and I didn't know what the expectations were in terms of the set-up with neonatal units and how that worked, it was something I had no experience of at that time.
So I really wanted to go and they said it would probably be the next morning before I could go and I said no, I really wanted to go and they said, "Well, if you're able to get up and get dressed and walk, as long as you've got somebody with you, a nurse with you, or somebody, then you can go to the neonatal unit."
So I did that, so that I was able to go and see her that evening. But it was much later in the evening at this point.
LANGDALE: Were you able to walk to get there or did you need to be in a wheelchair? What happened?
MOTHER H: I had to go in a wheelchair because I'd had the anaesthetic so I had to go in a wheelchair but I was able to go with a nurse from that ward and my husband. And when I got to the unit she was on CPAP, and I was told that she was struggling a bit with her breathing and needed a little bit of extra support and --
LANGDALE: What's CPAP?
MOTHER H: It's a positive airway pressure just to provide some extra air. I think it forces sort of like the oxygen through to sort of keep the airways open, because they said, you know, even after a C-section and when a baby is early, you know, the lungs can be a bit sticky. So it's to keep that, the -- everything open.
LANGDALE: Was that explained to you?
MOTHER H: It was explained why she needed it, but there was sort of a very vague then explanation of: but it's normal, she probably won't need it for long, it's okay. At this point I said, you know, it was quite a shock to see her like that. I didn't know what this was beforehand. I'd never seen CPAP or had any experience with it. But she said, "It's okay, you know, you can still hold her," and the nurse at that time had arranged for us to be able to hold her while she was on the CPAP for a little while, and we stayed there for as long as we could.
But I wasn't given any indication that her health was going to get worse and they didn't seem to have any concerns at all. It was like this is fairly normal, you know, and it can happen, and they need a little bit of this, a little bit of extra support, and, you know, it tends to, you know, just be a case of they have that bit of support and then everything's okay. You know, there was no concerns and no indication that this could get worse or any extra support might be needed.
We had a lot of questions at the time because this was all completely new to us and very unexpected --
LANGDALE: Can I just pause there.
I'm going to ask you now about some deteriorations of Baby H [Child H] on September 24 and 25 September.
To be clear, my Lady, these are not deteriorations Letby was charged in respect of.
I'm going to ask you about the care and what happened and what you saw. So you say at paragraph 28 of your statement:
"On the morning of the 24th, I wanted to go back down from the maternity ward to see [Child H] ... there were no midwives available and I was not allowed to go on my own as I was in a wheelchair."
That's what happened on the 24th, was it?
MOTHER H: Yes, because I was still an inpatient I had to stay for a bit longer to make sure that my sugars were stabilised, post-birth, and because of the C-section there was a time limit, and it was sort of like the ward -- I wasn't allowed to just get up and go on my own to go down the stairs because the way it is in the hospital is the ward I was on after I'd come from the Labour Ward is upstairs, the sort of maternity ward, and the neonatal unit is downstairs. So you have to go up the ward and go down the stairs and it's along the corridor and then out the back.
So I wasn't allowed to go on my own and I always had to let the midwives know if I was leaving, and there were certain times I had to be back as well for doctors and nurses and checks and things like that to do things and you didn't always know when that was going to be so sometimes you'd end up waiting longer for that. So on that morning I was very eager to go down and see her.
I was finding it very hard being on the ward which was a ward full of people with their babies with them, and I was on the ward, and I'd asked to go down early in the morning to see her. I was told there were no midwives available because again, it was a very, very busy time and the ward was exceptionally busy at that time. They were helping people as well with their babies and I felt at that point like I wasn't really a priority because it was just me, you know, waiting, and I was at this point sort of just trying to get in the process of getting discharged, and it was a case of I had to wait, you know, I wasn't, you know, they had other things that they had to deal with, and it kind of felt like it was a bit of an inconvenience for me to ask somebody.
LANGDALE: So was it Father H who came in and took you down that morning?
MOTHER H: Yes, yes.
LANGDALE: So tell us about that?
MOTHER H: So he was on his way in, and it's -- a little bit of a drive to the hospital, so it's not quite as easy as getting there, getting back and things like that.
LANGDALE: Yes.
MOTHER H: And I'd come in that morning, then and he took me down to the unit and we went to go and see our daughter. When we got there, I noticed that she'd been put on a different machine. She was in the first room as you sort of walked through the door from the corridors. I asked the doctor what was going on and I was told that she had been put on a ventilator. I really couldn't understand why I'd not been informed of this earlier because we were told that she was okay. You know, I'd always check and would always ask how she was, and we were told that she was okay, you know, that she was okay.
I was only upstairs. I knew they were busy but if it was something that significant to me, a ventilator sounds like a really scary and a really big change and there was no indication that that was going to happen that we were told of. You know, they never said, "Oh she's going to need maybe, you know, more breathing support or to need extra care".
LANGDALE: What did the ventilator look like when you walked in? What does that --
MOTHER H: It's -- it was sort of like she had sort of almost like tape or screens around her mouth with a big breathing machine and the machine itself was on the outside of the incubator. That was big. But you could tell it was -- it's different, and you could tell it was more intense, and there was quite a lot ongoing there. But I was very distressed at the situation, and I was also just really upset that I had not been informed considering I was upstairs. But regardless of that even if I wouldn't have been upstairs and I would have been discharged, if I wouldn't have been able to have been there because they were always telling me to take breaks, you couldn't come in at handover, you'd always have to avoid handover time. You were not allowed to be there at times of handover. Then, you know, the --
LANGDALE: Who told you that, that you couldn't be there at times of handover?
MOTHER H: The nurses. It was sort of the rules, that you weren't allowed to be there at handover times. And, you know, and the people would always tell you to go and take a break, you know, and go and -- so I spent an awful lot of my time sat by the incubator and being told "Go and take a break, go and take a break." But I didn't ever want to. I didn't ever want to leave her for as much as possible and I was very keen to get discharged from the hospital in one way so that I didn't feel like I had to keep going back there to have things, but then in another way I was worried about being separated from her and being at home and not able to get in as much.
LANGDALE: When you saw her with the ventilator, did you ask doctors and nurses about it, and --
MOTHER H: Yeah.
LANGDALE: And what were you told?
MOTHER H: So I asked them what had happened, how had this happened, and, you know, why weren't we told? And we were told -- their response is that they need to deal with what's happening at the time and to look after the child. And I said okay, I get that and of course I want you to deal with the situation and look after my child first but there are other nurses, there were other midwives upstairs, there were other doctors, could somebody not have phoned simply or phoned my mobile, you know, even just to say, especially considering that she'd been checked on and I was told she was fine, you know, and it's a case of why could nobody have done that? And what had happened? Why did she all of a sudden, I was told that she'd need the CPAP, and that she'd be on that for a bit, and a bit of extra support and that this was another step now which meant that obviously she had deteriorated and I don't remember anyone giving me a clear explanation as to why she had deteriorated. It was a case of, "Sometimes they just need a little extra support, that her breathing had got worse and we needed to give her some extra, more intense, breathing support". We weren't happy about the situation so we spoke with PALS.
LANGDALE: Just pausing there, what is PALS and how did you know what PALS was?
MOTHER H: It's the Patient Advice Liaison Service. I knew what PALS was.
LANGDALE: So you knew of the service generally?
MOTHER H: Yes.
LANGDALE: So what did you do in terms of communicating with them?
MOTHER H: So we made a complaint to say that we weren't happy about the situation because it worried me then, you know, if something else happened, were we going to be informed? And what did this mean? You know, I felt like we'd not been given a proper explanation, and it was really -- everybody had been really reassuring that "This is fine, this is normal, it's all just going to, you know, be a bit of time and it will, you know, sort of get better". And at this point now I was really starting to worry, is something more going to happen? And we told them that we weren't happy, you know, and that especially that we'd not been informed, because we didn't know then and we couldn't have been there. And --
LANGDALE: So you spoke to -- the Inquiry has seen a record so you spoke to a woman from PALS on the same day, on the 24th, when that had happened when you saw the ventilator?
MOTHER H: I believe it was the same day, yes. I'm sure, from my memory, I'm sure it was later on, on the same day.
LANGDALE: And how was the person who received the complaint? Was she helpful? Did she record it? What was your view?
MOTHER H: She said she would speak with Dr Gibbs because it was Dr Gibbs who was the doctor who was there at the time for the care. She said she would speak to Dr Gibbs and then we were told that Dr Gibbs would come and speak with us. So we went into -- there's another room on the ward where the parents sort of -- or a meeting room, and we had a meeting with Dr Gibbs, and he apologised about the delays and he just reiterated that, you know, there was a need to deal with the situation at the time, and that it had happened at handover, so there just hadn't been the time before we got down there ourselves to be able to inform us. He said they would have informed us, but it happened and that we were there basically at the point that they'd managed to stabilise her and therefore it was just a case of they hadn't had time to be able to inform us as of yet but their intention would be that they would try to keep us informed in the future and there was discussion there over if I got discharged, over us staying on the unit in the parents room at the back of the ward.
The parents room however was full for that night, so they said to us about another room which was connected with the children's ward where we could potentially stay, looking into some options over how we could be near, especially with her, because at the point then that the baby was on a ventilator, they said then they tried to make that also a priority.
LANGDALE: Were you satisfied with Dr Gibbs' response and his apology to you? Did you think that was an appropriate response?
MOTHER H: I was upset. I was very upset still and I was very worried. I think it certainly made me a lot more worried of what was going to happen and I realised that it wasn't going to be a case of this journey was going to be quite how it was portrayed to us in terms of, you know, a simple and short stay. And I was concerned. Which is why, then, at this point we said we don't want to be too far away. We don't want to leave. And I made sure as well from that point onwards that even if they were telling us to go and take breaks, that I stayed as much as I possibly could by her side, and I was a lot more cautious over things.
I still, however, did not have any prior experience or any, you know, medical knowledge so I didn't always know the questions to ask or what things meant, and it was very hard to get an understanding of that. I don't think that it was well explained to us, and it was very hard. So we weren't entirely satisfied with Dr Gibbs' response at the time, and we appreciate that they were busy, but to us it's our child that, you know, this is all completely new to us. This might be everyday to them to some degree, but it's not for us. And, yeah, we felt more could have been done.
LANGDALE: Just so I'm clear, Mother H, in terms of you getting down to the unit and seeing your baby, and how long it took you to do that, can you just clarify what the practical difficulties were about getting there?
MOTHER H: Yeah. So because I was an inpatient on the ward, they have doctors around up there on the morning, as they do as well in the neonatal unit. So you couldn't go to the neonatal unit, as I say, during handover times, which were set times. I can't remember what they were off the top of my head now but I know that they were morning and evening. You know, the morning shift handover and the evening shift handover. So you couldn't be there during those times.
And the same, they had ward rounds upstairs, and you had to wait to see the doctors because, you know, the doctors couldn't always come back to see you at other times. So the practicalities of actually getting downstairs after having had a caesarean, there is lifts and things like that, but it was still a fair walk. And you had to have somebody with you, because I was an inpatient with diabetes issues, you know, and sugars issues, so it wasn't safe as such for me to just be able to wander around the ward on my own. And I had asked to have been discharged so it could have made it easier for me to get there, because my priority at that time was getting to my daughter. And they said, "Well, you can discharge yourself but we'd rather wait for you to do this". So I followed the doctor's advice -- my diabetes doctor, that is -- to give it "at least this amount of time for the recovery, let's get in a situation where me feel that you're more stable, and then we'll go with discussion". And they tried to put it from the point of view of at least you're closer being up here, but then in some ways I felt like I had less freedom and less ability.
Obviously parents or mums who have had a baby or have got their baby there can come and go a bit more freely because there's other things there and I know every situation is different but that was the situation for myself at that time so it felt very restrictive. So I had to wait. Most of the time I just had to wait for my husband to be able to get in to come to take me --
LANGDALE: And did you have a mobile phone with you?
MOTHER H: I did, yes.
LANGDALE: Is that a number that you were happy to leave? Would the hospital have that number or wards have that number?
MOTHER H: Yes, they did.
LANGDALE: On the maternity ward as far as you're aware is there a landline, calls at the nurses stations that can be taken?
MOTHER H: Yeah, I'd asked a few times if, you know, it could be phoned to check. But especially to begin with, when we didn't have access to be able to get to things as easily when I was -- at that very first night I'd asked in the night, you know, to phone to check on her, but they were always just too busy, was the response, you know, a lot of the times. So I had my mobile, which I did use to be able to check if I couldn't get down there, because your thoughts are constantly on your child and how they're doing, and it's really heartbreaking to know that they're downstairs, they don't feel like your child because they're in a completely separate room and you can't be there with them and especially when you're in a ward where it's full of people who have just had their babies to the most part, and you can't be doing those things. It's very, very hard. So I would always check in by phoning, if I couldn't be there.
And my husband would do the same, or he would check with me, "Have you checked, you know, to see how things are?"
LANGDALE: Paragraph 38, you tell us, you were told:
"... [Child H] had pneumothoraxes ... hospital staff had told me that this was due to her being on breathing support as it can sometimes cause damage."
Can you just tell us what your understanding was at that time? You've already covered that a bit, but just set out what you thought was happening.
MOTHER H: So they told us initially that because she was on the ventilator, they were going to put something called surfactant which is to help the lungs with that stickiness, which they do give to babies that are premature and it helps them give them a bit of a break, it's something that is naturally produced usually but they said they'd give it manually or synthetically, I suppose, when a baby is early because sometimes they don't produce enough of it when they've been born early and we knew that she'd gone quite quickly from being fine to having deteriorated at that point and needing a ventilator, and they said because of the pressure of the air that's being forced through the ventilator, it can be quite a common problem that the air pressure can sometimes cause leaks in the lung. But there was no indication that the incident had a classification of, you know, particular seriousness in terms of the fact that -- they didn't say there were more of these events that could happen, they didn't say that she was going to become seriously ill or that, you know, she could be at risk of dying or needing, you know, resuscitation and things like that. There was no indication of that whatsoever. We were just told that it was due to her being on breathing support and it can sometimes -- whilst it's needed to help, it can sometimes cause damage because of the pressure of the air going through the lungs.
LANGDALE: If you look at page 22 of the documents you have with your statement, you will see a Datix incident report for 25 September?
MOTHER H: Yes.
LANGDALE: When did you first see this Datix report?
MOTHER H: I saw this only during the Inquiry. Oh sorry, this -- sorry, this one.
LANGDALE: 25 September. Take your time.
MOTHER H: Sorry, which Datix, this one is, because I know there's a couple of Datix --
LANGDALE: Yes, there's a couple. This one is 25 --
MOTHER H: -- I'd seen this during the criminal trial.
LANGDALE: Yes. So we see here 25 September:
"1.30: infant required emergency needle aspiration of a large tension pneumothorax. Required x3 further needle aspirations. X2 butterfly needles used from Resus trolley. No further needles available on the unit leading to a delay in treatment of approx 10 mins.
"Action taken: Butterfly needles obtained from Children's Unit because no stock items available on Unit for use."
So there looks as though there has been some delay in treatment there. Were you aware of that at the time or of any issue?
MOTHER H: No. We were not told anything about that whatsoever. We were not told that there were no needles available. We were not told that there had been a delay. As I say, this was something that was all completely new to us. The first time we saw this particular incident was in the courtroom during the criminal trial and it really, really made us very upset that we had not been told this. Especially as it said that the risk grading was that there was a high potential, you know, for harm from that, I feel that it's something that should have been informed to us, even if it was a case of, you know, it was a mistake and, you know, we didn't expect this, it still should have been -- we still should have been told that, you know, there's been a report made to say that this was an issue and an error, and we weren't told about it at any point from the hospital.
LANGDALE: Turning to your statement at paragraph 48, we to move additional collapses in early hours of the 26 September and 27 September.
My Lady, to be clear about these, the prosecution didn't specify a precise mechanism but said there was no obvious explanation for these deteriorations in the early hours of the 26th or on the 27th and cardiac compressions and adrenaline was required to resuscitate Baby H [Child H]. Letby was found not guilty on 26 September of attempted murder and the jury could not agree in relation to 27 September.
LADY JUSTICE THIRLWALL: Thank you.
MS LANGDALE: Mother H, tell us about -- at paragraph 48 you begin -- the first collapse, the one on the 26th, what happened and how you came across that?
MOTHER H: So at this point I was still up on the ward. I'd been moved to a side room because I was finding it quite hard and upsetting, especially with the fact that she had deteriorated, and we were now concerned, getting concerned about her care and about us being informed of things, and the situation was getting (unclear). So they'd moved me into a side room. I did feel that the midwives were still very busy, because the ward -- it was a busy time. And I remember it being late in the night, because I'd not long, really, left the ward because as I say, I was spending as much time as I possibly could down there and I'd had to go back up to the ward to get my nighttime medication, which was already late at this point.
I'd gone back up and I remember it being early on, and I'd only really just got back into bed. And I'd -- when I'd got into the bed, I just remember hearing like a knock on the door because, as say, I was in room at this point, so I just remember hearing a knock on the door, and one of the midwives had come in, and she'd come in and she'd said, "You need to come quickly" and I remember being in quite a shock and thinking: what do you mean? And she told me just to get my slippers and my dressing gown and I needed to come to the neonatal unit urgently. She didn't say why and she didn't say what and I remember feeling in a panic and feeling, you know, do I need to let my husband know? And I remember rushing and she said, "Phone him on the way". So I remember grabbing my phone and trying to phone him on the way and just saying, "Just come, just come quickly".
The midwife took me through -- the normal way you'd go out is to walk all the way through the ward, to get to the main entrance doors and go down the lift, as I say, and round that way, but she took me an opposite way out here and there was a little door at the back of the ward which I had no idea what that was for, but it had stairs, and those stairs went directly down into the neonatal unit. So she took me down those. We ran down those stairs out the back of the ward upstairs to get into the neonatal unit. She said it was a shortcut that they had for emergencies.
When I got there, towards the room, I could see the lights were on, and the lid was off her incubator, and that was like one of the first times that I'd really seen that. And I remember thinking: what is going on, because at this point still nobody had told me. And I was also panicking that this situation was not looking good, and I did not know where my husband, you know, was up to, in terms of being able to get there.
And Dr Gibbs was doing chest compressions, and asking the nurses to get medicine. And I remember one of the nurses saying to me, just because I was stood in the corner of the doorway because I didn't want to get in the way, because there was a lot going on, I remember them saying to me, "It's okay, you can go in". And I remember walking in, and I remember Lucy Letby was there during the resuscitation. I don't remember anybody actually telling me, "She's being resuscitated" but there was a lot happening at the time and as I say, I could sense the urgency, and I didn't want to stop them from taking care of our daughter.
I remember one of the nurses telling me to go over and hold her hand and talk to her. And I remember just going over and holding her hand, and just talking to her. And the nurse just said, "Just talk to her about anything. Anything at all", she said, "Just let her know that you're here, let her know that she can hear your voice".
And I remember talking to her and, you know, making promises, you know, that all the things that she was going to do, and then I heard Dr Gibbs mention something about Atropine, and I didn't know specifically what that was, but it sort of made it an alarm bell go off in my head, and I remember thinking: that doesn't sound good. And so I asked him, I said, "How long has this been going on for?" And he told me that it had been 20 minutes, and that to me felt like a long time.
And I was looking up at the doors and the entrance to the neonatal unit at this time thinking: is my husband going to be able to get here? And I remember he then came running through the doors, and just sort as he came back through the doors I was still speaking to her at this point. I was holding her hand, and I was talking to her and I remember him coming through the doors and then sort of as he got to her cot-side, I just remember coming back all of a sudden, and everybody seemed to just sort of step back a little bit, and the other drugs which Dr Gibbs had in his hand at that time, he didn't, you know, put through and he didn't do and, you know, she seemed to be starting to improve. And after they'd sort of stabilised her again at this point because you could see her heartbeat and everything had come back up, I remember speaking with Dr Gibbs as to why it had happened, and we asked why she needed to be resuscitated, because, you know, that's a major thing. And I just remember him saying to us he didn't know. And, you know, why weren't we told that this could potentially happen? And he said he didn't know, and they didn't anticipate it to happen. And I remember him telling me he didn't anticipate it to happen again, but we were worried obviously then about the situation.
He also asked us, though, if we -- of our religious beliefs and if we wanted to have her christened, and I felt almost like the urgency to get her christened implied that she might die. So even though she's stable now and they're, like, "She's doing perfectly fine on the ventilator, she seems to have come back through this, we don't know why it's happened, we don't anticipate that it will happen again, she seems to be good again now, but because we don't know why it happened, you know, if that is something that you'd like to do, it may be worth getting her christened while she's still in hospital".
So we arranged that and that happen on the morning of the 26th.
LANGDALE: And that night again there was another collapse, wasn't there?
MOTHER H: (Witness nodded)
LANGDALE: Tell us what happened?
MOTHER H: So we stayed with her all of that day and other family had been allowed to come in as well, because normally you're only allowed a certain limit of people at the cot-side but other family had been allowed to come in for the christening and between us all we all spent a long time at her cot-side, and she was perfectly, you know -- she was on the ventilator still and obviously not perfect, but there was no issues, no deteriorations, no -- she seemed stable for being on the ventilator, and it was just a normal course of care throughout that day. But we weren't given any explanation as to why it had happened, and we were just sort of told that "She's come round, she's okay now, and we don't anticipate it to happen again".
But we were really reluctant to leave her so they'd arranged for both me and my husband to stay in the family room, and a nurse on the shift that day told us she was having a good day, she was stable, and she said it was difficult to believe that she'd just been resuscitated a few hours earlier. And her nurse then for that night, by the time we'd got to the night point, because we'd stayed again until very, very late in the evening at her cot-side told us she'd had a really good day considering, and we should go and get some rest and that there were no issues and no concerns. This is the nurse that was caring for her on that night.
However, then it felt like basically minutes after we'd got back or when we'd only just got back, really, to the parents' room, again just putting head on the pillow to maybe get some sleep, again, there was a knock on the door and it was the same situation again and this time we were a lot closer to get there a lot quicker so we literally just had to come out of the parents room and round to the room where she was and the lid was off the incubator and the doctor was giving her chest compressions again.
And it was what -- like watching a replay of the first incident. I asked how long they'd been doing the chest compressions this time, and they said it had only been for a couple of minutes and I went over to hold her hand again, and this time she came around a lot more quickly, but we were very concerned at the fact that this had happened again, and at this point my main concern was: was she going to make it? And I remember she just -- she didn't look a good colour at all, and it's a very scary situation when you see your child, we didn't know to question that, you know, because I don't know what somebody looks like after they've been resuscitated, but both me and my husband remember that she was, you know, not looking good, and we were really concerned at this time.
They decided as well then that they were going to transfer her then at this point to Arrowe Park who they had been keeping in touch with throughout her care.
LANGDALE: We know she was transferred on the 27th to Arrowe Park so how did you think -- how had that decision been arrived at? What did you know about the transfer or reasons for transfer?
MOTHER H: As I say, once she'd been on the ventilator, they said they had to have contact with a higher level unit. So there was doctors in Arrowe Park that they would speak to after each of the ward rounds and things like that, or any changes to sort of relay or ask about her care. That was apparently normal practice when a baby is on a ventilator. So they were in touch with Arrowe Park anyway about her care, and they'd said they felt it best to transfer her over there because it had been the second collapse and they didn't know why it had happened.
There, was, however, concerns with the difficulties of transferring a baby on a ventilator, and they'd said that it was something that is quite intense, especially if a baby is very vulnerable, and it was set out as we couldn't go with her because of all the equipment that needed to be done, there was a team that would have to come to arrange all the equipment and transfer her over and that we would have to follow behind, but they would phone us if during the journey there were any issues, and it was very much a case of sort of saying goodbye to her before she goes and, you know, all of this, and, you know, have some time with her as well, you know, before she's going on her journey but "We will keep you informed throughout". And it was very, very hard to have that situation. It took a little bit of time as well, but a doctor came over first of all from Arrowe Park, he checked her over and again at this point she was stable again, as stable as she could be on a ventilator, and they were asking lots of questions about things, trying to work out as to maybe why this had happened, talking about tests, talking about all kinds of weird and wonderful conditions, talking about what had happened, talking about what they might be doing, their own checks and their own observations and things, and when she was ready to be transferred, they moved her over into the transfer incubator, and we were told to give her a few minutes and then to follow behind.
LANGDALE: And was there a handover? Did you see doctors and nurses from the Countess talking to Arrowe Park Hospital doctors?
MOTHER H: (Witness nodded)
LANGDALE: You've described that, but did you see that?
MOTHER H: I remembered the doctor there, yes. Yes, they were involved with asking because they were asking questions. Arrowe Park were asking questions to them. They were letting them know of certain -- handing over certain like documents and things, and they did a discharge sort of summary to hand over to them to take with her because then we'd be under the care of Arrowe Park, so it was like we'd been discharged from the Countess to go to Arrowe Park and at that point they just -- they'd said that they didn't know, this was the second in two nights, and they didn't know why it had happened so even though she was stable again now, they felt it was for the best.
LANGDALE: So the plan was, [Child H] went in the ambulance and you and your husband were going to follow in a car?
MOTHER H: Yeah.
LANGDALE: Or something like that?
MOTHER H: And the nurse that was her nurse for that night before, I remember telling us that her being transferred was the right thing for her, and I remember the doctor who resuscitated her was also keen for that to happen.
LANGDALE: Why was the nurse keen for that to happen?
MOTHER H: I don't know. I do remember that that particular nurse, when we had come in, because she had come back into the room later on in the resuscitation, I don't remember when. I just remember her being there at the end and there was a desk with a chair on it and I remember her sitting at that desk at one point with her head in her hands and she seemed quite shocked, and to me, I thought -- I just remember that image of her sitting there and thinking why, you know, if this is something that you deal with, why is -- I thought maybe she's tired and obviously it's very distressing, but I felt almost like I had to reassure her a bit, in terms of, you know, things. And she said, "Oh, you know, it's the right thing for her". But I remember just feeling that sort of atmosphere of her being quite shocked that it had happened, the same shock as I think what it was for us. And that sort of stuck with me, then, as to why. Why did this happen? And the doctor was the same, because this was obviously the second time it had happened now and we were told they didn't anticipate it would happen again, and we were sort of just trying to ask why? Why has this happened again? What is it? And is this going to happen again? You know, are we going to lose her?
LANGDALE: When you -- [Child H] was taken into the ambulance, you say Letby handed you a red box. Can you tell us about that?
MOTHER H: Yes. So literally as we're leaving the door, they gave us a box. It was just like a red box, and it had a teddy bear on the top and inside the box was a cot card and her wristband from the Countess of Chester but then there was also in a plastic bag with a white sticky label on the front that said, "For my Mummy and Daddy, xxx" and it had her CPAP hat in it, the CPAP hat and things. To me it almost seemed a bit like a memory box. I remember thinking that it was quite morbid. You know, because she was not dead, and yeah, I did ask about that during the criminal trial and I was told it wasn't a memory box as such, that was something that they did, but I remember not feeling entirely comfortable about that. And especially the fact that the writing on that label of the CPAP hat says, "For my Mummy and Daddy" with a "xxx" on it from Lucy Letby, you know, and the fact that she handed that over to us, yeah. I do struggle with that.
LANGDALE: When Baby H [Child H] was at Arrowe Park, you say they'd taken a detailed family history and did tests. Did you see her being treated at Arrowe Park when you got there?
MOTHER H: (Witness nodded). When we arrived there we saw that they were doing, yeah, lots of tests that they did so heart, checks on her heart. They asked again really like detailed family histories, loads of blood tests, they did a lumbar puncture, you know, for concerns maybe over infection, they did ECGs they did x-rays, they did ask, you know, about incidences of what happened at the time. They did lots of tests. And we were there for many of them.
The unit itself was a very different set-up in that it was a very busy room, and there was lots of incubators in this room, whereas our daughter had been in a room on her own at the point of these two resuscitations in -- and the room was completely separate. It's off to the side. So very isolated, really, in the Countess. So this -- and almost very quiet. And it was very busy in Arrowe Park so it was harder to almost sit there with her more often, but there was a lot of tests and it was a very different atmosphere.
But they did a lot of thorough checks, and we watched the doctors remove the chest drains within hours from [Child H] because she'd stabilised that much and they said that, actually, she'd stabilised in the ambulance, you know, and they said that that was not usually what happens. They said she's had a really, really good journey, they said. Usually it puts them through a lot of extra pressure because they're so unwell and so unstable but they said, actually, she'd done really well on the ambulance journey, and so then by the time she'd got there within a few hours, after doing the tests and they'd removed the chest drains, and she was like a completely different baby.
We spent just two nights at Arrowe Park and during that time she had the chest drains removed, she'd come off the breathing support, she was able to go back on to feeds, because she'd been on parenteral nutrition before through a drip because she was so unwell so she was able to go back on to starting to have feeds through an NG tube, but, you know, she was starting to be able to have that. You could hold her. You could pick her up. She was a completely different baby.
However, they couldn't give us an answer still as to why it had happened. We had to just sort to leave it there, and have that concern still in the back of our head as: was it going to happen again? Could she have some really, you know -- condition that, you know, could cause something to happen again, or could she have problems? And also, the concern over whether the length of time of the resuscitation would have any impact on her. They did do brain scans but they said it wouldn't be something that they would know until she grew, because of the lack of oxygen. So it would be --
LANGDALE: So she had two nights at Arrowe Park and then went back to the Countess of Chester to make sure, you say, she was able to feed properly?
MOTHER H: And put weight on, yeah.
LANGDALE: So tell us about when she went back, and what ward and cot she was in when she went back?
MOTHER H: So when she went back, we were put back into that same first room to begin with, and I remember not feeling -- they said, "That's normal process, when you come back in, you go back into that first room for the first few hours and we do some observations and then we move her over to one of nurseries which is less intense because she doesn't need to be in this intensive care room now, but we've put her in here for monitoring to begin with".
And I remember them saying, "But we'll put her in this cot this time because we don't want to put her into the --" and I remember thinking it was a really strange thing to say -- "We don't want to put her back into the cot of doom". And I thought that was just such a really odd thing to say, and just put it down to the fact that she'd been resuscitated in there, and they didn't want to put us back in the same place.
We were in there for a few hours and then we moved into one of the other nurseries which was the first time that we'd been in those nurseries, and she was able to just to concentrate on being fed, had less intense monitoring but still a little bit of monitoring and checking that she was gaining weight.
LANGDALE: And how many days or how long did she have to be there before discharge, roughly?
MOTHER H: We left -- in total, we were there for 21 nights. In total. That was the length of stay from when she was born until when we got to go home. She made very quick improvements after that. It was just a case of the normal checking she was gaining weight and feeding, which took a little bit of time but not very long and then it was just checks to be able to go home. And yeah, we were able to go home then but still we'd no explanation as to what had happened.
LANGDALE: Medical records. Did you ever have access to her medical records at the time?
MOTHER H: No.
LANGDALE: Or when did you first see them?
MOTHER H: No. During the court case.
LANGDALE: So during the criminal trial, you saw her records?
MOTHER H: (Witness nodded)
LANGDALE: Had you ever asked for them or did you not do that earlier?
MOTHER H: No. We always still felt uneasy with the fact that obviously this had happened and we didn't know why, but we'd kind of taken it as a miracle that she'd come through this. Nobody anticipated that it would happen again. They couldn't find the reason for it. They had done a good job and she seemed to be doing so much better that by the time we'd got home with her and we were busy with her, concentrating on her, and as she grew, you know, she seemed to be reaching her milestones, there was less concern as well over there being any other issues which could be going on. We didn't feel it was worth going through that trauma again of bringing it all back up again, or trying to find out what had happened, and we just sort of took it as a miracle as that she survived this and she's a miracle that she's here, you know, kind of thing. So we didn't ever go back. We considered making a complaint or trying to dig further but we felt at the time that it was better to concentrate our energy on her.
So we didn't go back into that but the thought was always there still in the back of my mind as to why did this happen? And for a long time, I was still worried, could it happen again? You know, I was still concerned over things, and protective of her. But we didn't -- there was nothing to indicate that there was anything wrong and -- with her. She was doing great, and we didn't feel it was worth going through the pain of going through it all to try and find out why or what had happened. And we didn't know that there were things that could have been done differently, because that was our first experience. So we didn't, at the time.
LANGDALE: In terms of Letby, did you have any suspicions or concerns about her while you were at the Countess of Chester? Did you have many dealings with her?
MOTHER H: No, she -- some of the nurses you could that have like a chat with or a laugh and, you know, you'd get to know them because you're there a lot, and you're there for quite a while. But I don't -- Lucy Letby didn't really register much with me. She was pretty unmemorable, to be perfectly honest. I do remember her being present during that first collapse, but on the whole there was very little conversation between us. She was very quiet in terms of that, and there was no particular dealings or connection that I recall us having with her. So other than knowing that she was there, no.
LANGDALE: When did you learn that there were suspicions and concerns about her and her conduct?
MOTHER H: May 2017. I got a phone call from the police. We'd seen the newspaper articles at the time that said there were investigations into baby deaths and collapses on the neonatal unit, and they would determine if it was medical negligence or somebody, you know, could have caused harm. But at that point when we were told by the police, we were sort of given the impression that the fact that somebody could have caused deliberate harm was very much a worst-case scenario. And we didn't expect that to happen. I mean, you don't, you just can't imagine that somebody would do that. So we just didn't for a second think that but we did think, you know, we never knew why these collapses happened.
LANGDALE: Did you get a telephone call before she was arrested from the police?
MOTHER H: Yes, yes.
LANGDALE: What were you told then?
MOTHER H: So we were told then that they were going to be making an arrest, because prior to that, we were told that they had -- were going along the route of that somebody that caused harm, and that was quite a shock to take. They couldn't tell us who it was until they were making the arrest, and I remember them saying -- phoning to say they were going to be arresting Lucy Letby. And I remember thinking: how could this -- you know, how could this have happened? It didn't feel real. But at the point that we were told that somebody had caused harm, and there was a high probability, they said that somebody would have caused harm and that's what they were looking into now, the police said. At that stage I didn't know that Lucy Letby was under suspicion. So to get that phone call and say that it was her was definitely a shock, and it was very hard. I remember it being very early in the morning.
LANGDALE: When were you and how were you told that Letby was suspected of causing injury to your child, [Child H]?
MOTHER H: Well, during that call, because we knew -- well, we knew that somebody -- that there was a high probability that somebody was causing harm because at the first point it was a case of looking at all the options and then we were told that it was a case of -- it was a high probability that they were -- somebody had caused the harm was the reason that they were now looking into. So we knew that there was a potential that somebody had caused the harm. But it still didn't seem definite at that point. And then it was the point that, "We're arresting somebody because -- we have Lucy Letby, who we believe has caused the harm."
And it was that morning of the --
LANGDALE: Did you ever have any dealings with the hospital management or anyone from the hospital about your child and her treatment and what was by then suspected?
MOTHER H: No. Nothing at all. Absolutely nothing from the Countess. And we were told obviously because of the investigations that we couldn't do anything at that time; we had to wait for the criminal proceedings to take its course. And so we couldn't contact the hospital at that point to ask or to see anything further. But we had nothing at all from them. And, you know, she was cared for under the paediatric -- the same neonatal doctors, but the paediatric team until she was nearly two because that's the normal process when you have premature babies, they like to monitor to make sure they're developing and regular checks, you know, and things like that. So we were at the hospital still for outpatient appointments and we saw, you know, the doctors still as an outpatient, and at no point were we told anything, you know, about these other meetings and things that -- reports that had been done. Nothing at all.
LANGDALE: So the Royal College report, you didn't know about that one --
MOTHER H: No --
LANGDALE: And there was a report from Dr Hawdon -- so that's been through the Inquiry.
MOTHER H: (Witness nodded)
LANGDALE: Did you listen to the criminal trial?
MOTHER H: Yes.
LANGDALE: Parts of it? What did you hear? Did you hear material for the first time in that trial that you'd like to have known before?
MOTHER H: Yes, a lot. There was basically nothing from, in terms of the medical side or things like that that we knew beforehand, because we hadn't gone down the route of making a complaint, or asking for further information after we'd been discharged, because as I say, we were concentrating on her. But nobody told us, still, about this. You know, if we'd have been told this, then we'd have known that actually, there was something there that could have been looked into further. And I suppose we were just clinging to the fact that she was a miracle, that she pulled through. And I was also dealing with the fact that I was feeling the guilt over the fact that because I'm a diabetic, that was essentially the reason why she was born early. And, you know, and I was thinking: is this a normal course for a premature baby? I didn't know any differently at the time because, again, it's not something you often hear of.
LANGDALE: More generally in your statement dealing with PALS, you say:
"On this occasion [ie, in relation to Child H] PALS did what they were supposed to do and informed the doctors so they could answer my questions."
MOTHER H: (Witness nodded).
LANGDALE: Did you feel that it was a route for raising your concerns and the questions were answered and you had a meeting with Dr Gibbs?
MOTHER H: Yes, yeah, because he came to meet us, as I say, and talked us through, and acknowledged, you know, our complaint and our concerns and said that they would try, you know, to better keep us informed. So yes, yes I did.
LANGDALE: And were they easy to find in the hospital, the person you needed to speak to? Did you know where to find them, or just ask somebody to know where to find them?
MOTHER H: It was an email that was sent, because there was a number. There are leaflets as well with it on. I can't remember where exactly I got the email address from at this point or whether I phoned the office on the number and was given the email address or whether I got it off a leaflet. I can't recall exactly, but I don't remember -- I don't remember particularly it being a case of being hard to find or to get hold of. But I suppose we had the advantage of knowing that that service was there. So we were looking for it.
LANGDALE: You tell us with a subsequent child you didn't want to go to the Countess of Chester Hospital?
MOTHER H: Yes. Yes, I think it was the memories of what had happened and also at this point we knew there was an investigation happening. We had not really planned on having another child and I struggled with it a lot because of what happened with our firstborn and I was terrified throughout the whole pregnancy. The whole pregnancy was completely different. It was an awful lot of tests, and I didn't want to go back to the Countess and I especially didn't want to go back to the neonatal unit. But all my diabetes care was there, and I needed their input from that team for both the safety of the baby and for me, and I needed something that was close by. So the plan was always going to be that I'd have the diabetes care there during this pregnancy and then I would be transferred to another hospital for her birth.
But it came to -- we also had a meeting with Dr Brearey to discuss my feelings of going back to the Countess of Chester, and what had happened with our firstborn, and I remember him saying to us that sometimes the safest place to be is the warzone after a war. And also trying to reassure us that there had been no incidences of anything since, and that, you know, they would do anything possible, if we decided that that's what we wanted. It was completely understandable if we didn't, but if that's what we wanted, to go back there, then they would do everything possible to make it as comfortable for us as they could.
And obviously the hope was at that point that that wouldn't even need to happen, and that she wouldn't need to go to a neonatal unit. However, it was the case again, unfortunately, that she had to arrive early, and because of the situation at that time, it was again an emergency situation and she did have to be born in the Countess, and at this point I was very clear in the fact that she was never to be left alone, you know, without one of us there. I couldn't -- I couldn't do that. And I made sure that there was somebody who was going to be there with her as much as physically possible.
LANGDALE: I don't want to ask you any more about your other child unless you want to share that information. You've set out your position there.
Shall we move on to suggestions and recommendations?
MOTHER H: Yes. Yeah.
LANGDALE: What, in your view, would have assisted in preventing the crimes of Letby? You set out a number of things. Would you like to expand on any of them? You say,
"A clear contract between parents and staff". What are you thinking about there?
MOTHER H: Well, I think it's important to be able to have an input on the child's care, and to know exactly what's happening with her condition so that you can feel like they are your baby, that they are yours, and you have the ability to be able to make the most important decisions, that you don't have to hand everything over to them. The communication should certainly be a lot better. There should be ways in which, you know -- in no other situation, you know, after a baby is in the neonatal unit, you know, if you had a baby that was born and was only, you know, a few weeks old and had to go back into the hospital, you'd have to be there with them all the time. The same for a child. You know, kind of thing. They're your responsibility. But that's sort of taken away from you a bit when you're in the neonatal setting because you have to rely on other people to care for them and you can't physically be there all the time. You can't sleep by their -- the cot-side. You can't be there. So there needs to be the way to keep fully informed and to have so that access and that ability to be able to know that they are being cared for and clearly.
LANGDALE: You say there should have been staff training around dealing with concerns and a protocol for reporting concerns, and transparent systems.
MOTHER H: Yes. So if there was a case of -- there should have been enough well-trained staff because obviously we were getting told quite a lot that it was busy, and there wasn't enough staff. That seemed to have always been a reoccurring theme or excuse. And we were -- if there would have been more around suspension and things like that, the minute that any concerns came in, then, you know, a lot could have been prevented, I feel.
So people who maybe work, you know, that might have -- nobody ever wants to suspect, I suppose, that somebody that they work with is doing something wrong. I suppose it was just not in your nature, but if you have any concerns whatsoever, there should be a way for that to be reported and reported without any consequences.
LANGDALE: You say there should be respect between managers and senior medical staff?
MOTHER H: Yes, because they're the ones who are there on the wards, the senior medical staff, and the managers are people who aren't involved in that. So they should be able to take on board what they're saying without there being a case of: well, this is protocol, this is how it works, you know, kind of thing. There should be a case of, "This is what's happening, we need you to do something more about that."
You know, it should be a case of there should be more safety measures in place to prevent things like this happening, and if somebody is saying they've got issues, then they should be listened to and dealt with. Even if the outcome is that's not the case, then great. There shouldn't be a case of: well, we'll, you know, we'll ignore that until we know for sure.
LANGDALE: You say:
"A system of senior nursing staff having responsibility for safety, with regular spot checks to ensure staff are adhering to good practice."
MOTHER H: Yeah. So if they have people who are coming in to assess, I suppose it's the same with anyone, if you've got somebody from the outside coming in to check what you're doing without it being a case of a pre-arranged check, or, you know, things like that, then you're more likely to get an accurate picture of what is happening.
And information should be shared, such as the CQC, and should have been shared widely, and highlight any unusual features or statistics that were in the case. So if there was a problem concerned a trend then it was known about. Because, as I say, when you're a parent going into that, you don't know. I didn't look up statistics before I went into any hospital to see what were the average statistics of a baby being born early, how many -- how common is it for a baby to be resuscitated? You take what they're saying, you trust what they're saying and you sort of believe that's the case. But obviously they know, because they work in that situation all the time, that that wasn't usual. So if there were these unusual features and statistics, then that should have been picked up. If nobody was raising that at that point from within, because they just didn't want to believe that anybody did it then there should have been a way for there to have been checks from the outside that would know about that, and have picked it up sooner.
LANGDALE: You raise CCTV, and we can see how clearly CCTV images would have made crimes visible. But another aspect of CCTV, for you when you had to be separated from Baby H [Child H], would it have been helpful to just see in the incubator, see how she was without having to ask people to take you down or try and rely on others, to see for yourself?
MOTHER H: Yes, that would have been -- there was -- you almost have this constant state of stress when you're away from them. It's probably a lot of hormones as well, you know, after you've had a baby, but it's like -- it's a real stress, not being there with your baby. So to be able to see them would be massively reassuring, you know, and it would help massively for those times when you couldn't be there.
LANGDALE: You also mention proper monitoring and strict security on storage and use of drugs, including ensuring anyone accessing storage would be identifiable afterwards, so the swipe card data.
MOTHER H: (Witness nodded)
LANGDALE: We asked you whether you had received any support or offers of support, and you hadn't, at the time, when your baby was in hospital?
MOTHER H: (Witness shook head)
LANGDALE: Can you tell us now the impact of all of these events on you, in so much you would like to share that?
MOTHER H: Yes. The impact has been overwhelming. What happened has affected every aspect of our lives, and it really isn't easy to put into words to truly convey the enormity of it. It is also deeply personal, and there is a limit to what I want to say here.
LADY JUSTICE THIRLWALL: You don't need to say anything that you don't want to. Please don't.
MOTHER H: Thank you. But ultimately, it has changed me fundamentally as a person. Among other things, it has really affected my ability to trust people, especially when it comes to anyone taking care of my children. You know, they -- the people in the neonatal ward, you put your whole trust into them to take care of your baby, and that has been completely abused. It's affected my trust in hospitals and the health service very, very deeply, and unfortunately that's something that I still have to have ongoing, is contact with hospitals. So it's not something that I can easily walk away from, and it's very, very hard to have to go back into a hospital setting. I know a lot of people say, "I hate hospitals", but I really do find it very traumatic to have to go back to a hospital. I just -- because I don't have the trust.
I feel that the changes as well will be lifelong. Time does heal, but I can't now un-know what I know, and I can't change what happened. I do try not to dwell on it but it's impossible not to think about it much of the time. The impact is wide as well as very deep. And it has also affected our wider family.
Another big concern for me is the fact of I'm extremely grateful that she did survive, and that I tried to focus on the positives of the fact that I have her and cherish that. But then another concern for me is, at the moment, she doesn't know. And one day, I will have to tell her. And I don't know how it will affect her when I do, if it's something I can't deal with, how is she going to deal with it?
I suppose, thankfully, not many people have to cope with something like this, but I do worry a lot of the time how I'm going to tell her and navigate that the best I can, so that she can understand. And another issue, particularly, for us, is the fact that unfortunately with the criminal trial, for that first count, they had found or come to the conclusion that they could not decide beyond reasonable doubt that she was guilty. They were -- obviously many of them did not feel that for the second count, and I know now, throughout those trial, that beyond reasonable doubt that she did do it, and I know a lot more detail and a lot more information than I knew beforehand. You know, ignorance is bliss, in a way, because had I have never have known any of this, then I would have just been going along with the fact that she'd had these awful events, there's a miracle that she survived them, and I would have just never have known the other side of it. But now I do know, I can't forget that. And there is still as well just the trauma of the actual nights of what happened coming back, with those knocks on the door and seeing your daughter being resuscitated, and that, you know, they were the worst moments of my life and thankfully, something that I have never had to deal with before or again since.
But how I explain that to her and obviously now she's a lot older she has a lot more questions about things. It's very hard to answer her, because I feel like I have to come up with a bit of a story. And she almost has a bit of an admiration for hospitals in a way that she goes, "Oh, you know, I'm going to go back one day and I'm going to help babies". And she said, you know, "I'd one day like to be able to be a nurse and to help people".
And I find that in a way very hard, because I think what will her opinions be when she knows the truth over what happened? And I suppose it's just how is she going to deal with that. You always want to protect your children, but one day -- I know this is something I can't keep from her forever, and I hope that I'm going to be able to deal with it the best that I can, for her, so that she knows what happened or she knows that she's safe, and that she may not have the justice for that first count, but she certainly -- we know, and a lot of other people know, what happened, and that Lucy Letby is in prison and will never be coming out, and that is the best outcome that can possibly be, out of all the options that are available.
MS LANGDALE: There's no further questions from me, Mother H.
There will be a short break and your barrister might have some questions for you after the break. Thank you.
LADY JUSTICE THIRLWALL: Thank you very much. We're going to take 15 minutes to give the shorthand-writer a break.
If you need any more, Mr Baker, just say.
MR BAKER: Thank you.
THE WITNESS: Thank you.
LADY JUSTICE THIRLWALL: So we'll take a break now.
(12.07 pm) (A short break) (12.22 pm)
LADY JUSTICE THIRLWALL: Mr Baker, thank you.
Questioned by MR BAKER
MR BAKER: Mother H, I'm just going to begin by asking you to go back to paragraph 30 of your witness statement, please so this is a section of your evidence where you are dealing with finding out that [Child H] had been put on to a different machine, a ventilator.
MOTHER H: Yes.
BAKER: Prior to that she'd been on a CPAP machine which you describe --
MOTHER H: Yes.
BAKER: -- as a mask which provides positive pressure, a Continuous Positive Airway Pressure.
MOTHER H: Yes.
BAKER: Is CPAP. In what way was the ventilator different to that?
MOTHER H: It was doing the breathing for her. So they said that in terms of to give her a break or to give her a rest, but she had to be -- have medication. So to be sedated to be on that, so that she didn't fight back against it. And in terms of its looks, I suppose it looked a bit different because it's a tube down the throat. Not that you could actually see that, but you could see the outside of it on there as opposed to just a sort of a mask, a little small mask over the sort of nose and mouth area. But yes, it's a machine that was doing the breathing for her.
BAKER: So --
MOTHER H: So it's a lot more intense ...
BAKER: So rather than being a mask that was helping her to breathe, she'd now been sedated, had a tube put down her throat, and the machine was breathing for her?
MOTHER H: Yes.
BAKER: And that's why you gave evidence to say that you found this quite shocking and different?
MOTHER H: Mm-hm, yes. Yeah. It was a big step, and it's a significant deterioration, you know, that -- I don't think you can get much more breathing support, really, than a ventilator. There's nothing else that I'm aware of that there is for that.
BAKER: You go on in your witness statement to describe how you spoke with PALS, to Dr Gibbs, and that you raised a complaint about not having been told about this change and having to come on to the ward to discover it.
MOTHER H: Yes.
BAKER: There is, in your bundle, an email from Eirian Powell to John Gibbs. Have you seen that?
MOTHER H: Yes, I have.
BAKER: If you could just turn to it, please.
MOTHER H: Yes.
BAKER: So it begins with an email from Brenda Hooley, but the Eirian Powell email is towards the bottom of the first page. And there is a reference to your complaint:
"Brenda from PALS came to speak to me this lunchtime."
Did you formulate your complaint through PALS?
MOTHER H: Yes, yeah.
BAKER: And there is a comment from Eirian Powell in the penultimate paragraph to that email which begins: "My question as an addendum ..."; can you see that?
MOTHER H: Yes, I can.
BAKER: "... is why it had taken mum so long to come to the unit when she was aware of how poorly her baby is. (just a thought) especially as she is an inpatient, or even ask a midwife to ring/use her mobile for an update. I have spoken to Belinda and Nurse W, and as you can imagine Nurse W is upset that she had tried her best, only to receive this complaint."
First of all, what sort of interactions, if any, had you had with Eirian Powell prior to this point?
MOTHER H: I don't recall many, if I'm being honest, many interactions with her. So I didn't know of her and I certainly don't remember her being involved in our daughter's care at any point. So I know who she is, so now I know she was there and around on the wards at the time, but I certainly don't remember her having any involvement in the care of our daughter at that time.
BAKER: Had you had any conversations with Eirian Powell before you discovered that [Child H] was on a ventilator?
MOTHER H: No.
BAKER: Reading that comment now, how does that make you feel?
MOTHER H: Very, very upset, and I am shocked that that is even part of a conversation between the nurse and the doctor, because she hasn't got the full story there at all. And, you know, I am deeply offended by that. You know, like how dare she make a comment on that at such a difficult time? Because in actual fact I was an inpatient on the ward, I had asked many a times for the people up there to phone, to phone down. I had used my mobile to ring to check that she was okay, and I was told that she was stable, and I was trying my best to get down there. I wasn't allowed to just go down on my own, so I couldn't get down there easily.
And I wasn't aware of how poorly she was because I wasn't told how poorly she was. So to have been told that she was stable only just before, to then go down and find this situation, and you think: well, what has happened, you know, in the meantime? And to then have somebody comment on it, to say, "Why did it take so long?", when in actual fact I was trying my best to get down there, and nobody had informed me. So if somebody would have told me, I would have been able to have got down there, as well, much quicker. And if the staff weren't so busy up on the ward, then more people would have been able to helped to get down there.
There's a massive assumption, I think, being made on her behalf there, but why that even comes into a conversation with regards to a PALS complaint, or it's felt as being appropriate, is deeply upsetting, if that's the view that they're taking of parents.
And if she felt like that, as well, why didn't she come to talk to me, to say: "Look, your baby is really poorly, you know, maybe you should spend a bit more time here?" When in actual fact all the nurses were doing was telling me to take more of a break because I was spending so long next to her cot-side, you'd get the impression.
So I can't understand how they can say something like that in an email between each other, and have a very different outlook, especially for the fact that I had not spoken to her, she didn't know the situation. And that was exactly our problem: was that we weren't being communicated with to be told how poorly she was.
BAKER: Thank you. And just for clarification, when was the first time you saw this email?
MOTHER H: Yesterday.
BAKER: Going back to your witness statement at paragraph 72, this is a section where you're describing [Child H]'s condition during the collapse on 26 September, which was the second serious collapse that you'd witnessed, and it's asking, actually, a question of Father H in the bold section above about the --
MOTHER H: Yes.
BAKER: -- about the baby being very mottled during the collapse on 26 September 2015. But you then describe in the following paragraphs what you saw, and what Father H reported that he saw, as well.
Could you just explain what you mean by what you say at paragraph 73?
MOTHER H: Yes. She was very, very pale, and had sort of blue-purple marks, like a mottling, all over her body. But we didn't know, I suppose, that that was anything different, because we'd never seen anybody being resuscitated on the brink, you know, of death, really, before. And it is something, though, that stuck in our minds, and I remember when she came back, it was almost like that just disappeared. You know, she sort of came back to. It's almost like, you know, when you just wake up from a sleep. It was like, you know, her heartbeat came back, she came back. And it was just very, very quickly, then, that she came back.
But at that point, looking at her, we thought that it doesn't look good.
BAKER: Shortly after this episode on 26 September there was a discussion that you witnessed regarding transfer to Arrowe Park Hospital.
MOTHER H: Mm-hm.
BAKER: And you described in evidence before the Inquiry a nurse saying that it was the right thing for Baby H [Child H] -- [Child H] -- to be transferred to Arrowe Park.
MOTHER H: Yes.
BAKER: And the doctor also being keen. You give that nurse's first name at paragraph 86, but I don't think -- you didn't say it in evidence. Can you recall the name of the nurse who was saying it was --
MOTHER H: Yes.
BAKER: -- it was right for a transfer?
MOTHER H: Sure. Sorry, I wasn't sure whether I was -- whether I should say her name or not. It was Shelly. Shelly Tomlins. And I remember she was actually shortly due to be finishing at the Countess. And yeah, she was taking care of our daughter on that night that that had happened. And I just remember her saying, you know, that's the right thing to do, but I do remember the image of her sitting at the desk behind the back of the cot-side with her head in her hands. And the best -- the interpretation I got from that was it was, like, shock. And it was hard, because I do always remember thinking: why is this something that you're -- it's a hard thing to go through, but I do remember thinking: why, as the nurse, do you look like you're struggling with this, you know, so much? And that it was so unexpected.
Especially for the time that I'd seen her before then, you know, she was saying, "Oh she's had a really good day, you know, she's been really stable." And she was. We had been having a laugh, we'd had a joke and a talk together, you know, because at that point our daughter was doing fine. So we were sat by her bedside, but we were just -- we were able to have a conversation because there wasn't anything, you know, happening.
So we remember speaking with her and, you know, being there. And yeah, it just -- I just recall that image. It was like something that she hadn't seen, she hadn't expected to happen and, you know -- or that she hadn't seen before.
MR BAKER: Thank you, my Lady. I've no more questions.
LADY JUSTICE THIRLWALL: Thank you very much indeed, Mr Baker.
Mother H, thank you very much indeed for being here online to give such a clear and detailed account and a very thoughtful account of your experiences at the Countess of Chester Hospital. I hope you'll understand, in light of some of the evidence you gave towards the end of your evidence with Ms Langdale that it's not for this Inquiry to review the jury's verdict in any of the counts, and I won't be doing that in the case of Baby H [Child H]. You're nodding. I'm glad you understand that. But I would like to thank you for the great assistance that you've given to me in coming to my findings and recommendations in the rest of your evidence.
I know that it's not been easy for you to arrange to do this, because you have so many very real calls on your time, and so I'm particularly grateful to you for making yourself available and giving so generously of your evidence. Thank you. And you're free to turn us off now, if you'd like to.
THE WITNESS: Thank you.
LADY JUSTICE THIRLWALL: Now, Mr Baker, I think there's something else you want to deal with.
Statement by MR BAKER
MR BAKER: Yes, there is indeed. It's a correction in relation to the evidence of Mother E&F from yesterday, so I'm asked to read a short statement:
"For the purposes of clarification in respect of evidence given yesterday in answer to questions from Mr Baker, I confirm the date of [Child E]'s funeral was 12 August 2015 and the date of [Child F]'s transfer from the Countess of Chester Hospital was 13 August 2015."
LADY JUSTICE THIRLWALL: Thank you very much indeed, Mr Baker.
Ms Langdale, I think that concludes the evidence we're going to hear today.
MS LANGDALE: It does, my Lady.
LADY JUSTICE THIRLWALL: So we'll resume in this room next Monday at 10.00. Thank you all very much. I'll rise now.
MR BAKER: Thank you.
(12.41 pm) (The hearing adjourned until 10.00 am on Monday 23 September 2024)
LADY JUSTICE THIRLWALL: Just before we start, I will remind those people listening online that the feed is going out live. If there are any breaches -- probably inadvertent breaches -- of any of the restriction orders, they must not be reported and any references will be deleted from the transcript before it is issued. Thank you.
Can I just say thank you very much for coming today to see me. I know that you will be nervous, so rather than keep you waiting any longer, I'm going to ask Ms Langdale to begin.
MS LANGDALE: Thank you, my Lady.
Mother J and Father J have provided to the Inquiry a joint written statement. They are both going to give oral evidence. I'm going to invite Mr Suter to have both witnesses sworn and I'll direct questions to Mother J and Father J as appropriate and occasionally they may defer or Mother J may defer for an answer to some questions. So if that meets with your approval, that's the way we propose to deal with the evidence.
LADY JUSTICE THIRLWALL: That seems very sensible. Thank you, Ms Langdale.
MOTHER J (affirmed) FATHER J (affirmed)
Questioned by MS LANGDALE
MS LANGDALE: Mother J, can you confirm that the statement provided to the Inquiry is true and accurate as far as you are concerned?
MOTHER J: It is.
MS LANGDALE: Father J, can you confirm likewise?
FATHER J: Yes, I can.
MS LANGDALE: Mother J, you provide various observations about the care provided to your child, [Child J], both at the Countess of Chester and at Alder Hey Hospital. As a preliminary question, how did experience of both hospitals inform your understanding of the level of care that she was provided in each hospital?
MOTHER J: Sorry, can you repeat the question?
MS LANGDALE: If you look at paragraph 7, when you set out your experiences of the one hospital, how did experience in another hospital assist you in doing that?
MOTHER J: So we saw different standards in the care that the two hospitals -- Alder Hey Hospital had a very consistent team of nurses that looked after our daughter and at the Countess there were quite a different number of nurses involved in her care which meant that when things were changing, the nurses didn't see -- the same nurses weren't seeing those changes and picking up on those changes.
LANGDALE: Let's look now, if we may, at your background before having [Child J]. How was your antenatal care and treatment generally at that point?
MOTHER J: We had very good antenatal care with the Countess of Chester Hospital and also Liverpool Women's Hospital. We were cared for by their Fetal Medicine Team. I think it's -- which section is it in the -- I just refer back to the statement. Yes, number 10. We felt that we were in very good hands with the Fetal Medicine Team. They communicated the various concerns with the pregnancy and looked after us incredibly well.
LANGDALE: You refer there to Mr McCormack. He is of course the Consultant Obstetrician and Jill Ellis, is that a senior midwife?
MOTHER J: Yes, it's the late Jill Ellis, sadly. She was present with the majority of the scans with Mr McCormack.
LANGDALE: So you were very satisfied with that care?
MOTHER J: Yes, absolutely. It was a difficult pregnancy but we were well informed and when things were changing in the pregnancy. The team -- the people around us acted quickly and communicated really well with us, so we understood the decisions that we had to take and we felt informed and we were making them based on their experience and scope.
LANGDALE: You had to have laser ablation surgery, didn't you?
MOTHER J: Yes, I did.
LANGDALE: Would you like to tell us what that was about?
MOTHER J: Yes, so with twin-to-twin transfusion syndrome there was an issue with the blood supply to the two babies, so one baby gets far more blood than the other and then that obviously has an impact on the growth and survival, so it was picked up quite early by Mr McCormack and Jill Ellis and they had suspicions around week 13 that that could be something in the pregnancy and it did deteriorate really quite quickly.
They were keeping a close monitor on it and we were sent over to Liverpool Women's Hospital to the expert Surabhi Nandha to review us and they said that we would need to have the laser ablation at King's College Hospital in London which was a laser treatment to divide the blood vessels and to resupply the blood to both babies.
LANGDALE: Moving forward in time, you had a caesarean section, didn't you, in October?
MOTHER J: Yes.
LANGDALE: Tell us how that came about and from your perspective how that all went?
MOTHER J: Yes, the plan from Mr McCormack was to try and get us to 34 weeks with a caesarean section because of the complexities in the pregnancy. So we knew that that was what we were aiming towards but unfortunately that didn't happen and we got, you know, 32 weeks and two days so fairly close.
LANGDALE: How was [Child J] when she was born?
MOTHER J: Yes, she was -- she was breathing. They showed her to us. There didn't seem a great deal of concern and, yes, she seemed fine after the delivery. We knew that she would go to the neonatal department because of her prematurity but there didn't seem any alarm bells going off immediately after the birth.
LANGDALE: Were you prepared for what happened with her twin at that point?
MOTHER J: Not really. I think on reflection the pregnancy had been so difficult, with lots of uncertainty on whether my daughter would survive, that it was very difficult to think about already carrying a child that had died in the pregnancy.
LANGDALE: The initial neonatal care. [Child J] we know was taken to Nursery 1 in an incubator on the neonatal unit. When did you first get to go and see her and how easy was it to do that?
MOTHER J: So I think we can refer to paragraph 16 ... yes, we -- we went to see her. I think it was around about 6 o'clock in the evening that we actually got to see her in the incubator and that process was quite easy. I think I went off to the maternity ward and then came back down to see her once I had had my things in there.
LANGDALE: Sorry, I didn't quite catch -- once you had had --
MOTHER J: My things in the room. So I think I went up to the room for a short period of time and then came down to see her in the neonatal unit.
LANGDALE: You went together to do that?
MOTHER J: Yes, yes.
LANGDALE: What were you told about her when you got there, if anything?
MOTHER J: I don't recall having a conversation.
LANGDALE: You make reference to her bringing up some brown fluid. Was the conversation about that?
MOTHER J: Yes, so we had a conversation about that. So I just remember that not long after I arrived and saw her in the incubator, she just all of a sudden started to bring up some brown fluid and I called the nurse or my husband and said "Oh, she has got some brown fluid coming out of her mouth" and I was handed a tissue or something and just -- I think I wiped her mouth, or I think one of the nurses perhaps wiped her mouth and that was the first sign that something wasn't quite right.
LANGDALE: You said you had been told about necrotising enterocolitis, "and we knew it was potentially very bad but the neonatal team did not know for sure" if she had that, and in fact she didn't turn out to have that, did she?
MOTHER J: Difficult one to answer that, really, because I think they had mixed views on it maybe.
LANGDALE: At the time was that being expressed to you, mixed views about whether she did or didn't? Don't worry if you don't know the answer.
MOTHER J: Maybe Father J could answer that question.
LANGDALE: Do you remember that, Father J?
FATHER J: Yes, because I was up and down to the unit between my wife and our daughter. Initially they weren't sure whether it was NEC. However, that did come up as a possibility when they looked at x-rays and I can remember them showing me the x-rays. They were also concerned that if it was NEC they wouldn't be able to deal with it, so they worked on the assumption that it could be NEC and therefore they referred to Alder Hey at that point. It was already quite late in the evening so I remember there was a lot of phone calls and activity and they did keep us updated and then the decision was to take our daughter to Alder Hey, which they said was a precaution but if there was a problem, Alder Hey was the right place to be. So it seemed like -- so it was extremely stressful. It felt like the right decision to us and turned out to be the right decision.
LANGDALE: Mother J, you say:
"A little later ... a neonatal nurse visited me on the ward and asked what we would be calling [Child J]'s sibling on her death certificate."
You say that hadn't been discussed with you before and you think it probably should have been, looking back.
MOTHER J: Yes, we weren't aware that -- because our other daughter had been born into the world that she would be given a name and I think the only way that I could deal with the situation the day after the surgery was to think of it like a miscarriage because it was incredibly painful to carry on a pregnancy whilst carrying a child that had died, so I wasn't really prepared for that situation, which, you know, you can look at things in hindsight, can't you, and perhaps we could have asked some questions around the births, but we were so concerned that our other daughter really wasn't going to make it into the world that we felt it quite difficult to be dealing with that as well.
LANGDALE: In fact you say you were asked if you would like a priest to visit so you could have [Child J] christened prior to transfer and surgery?
MOTHER J: Yes.
LANGDALE: You say "well-meaning", but that was quite stressful?
MOTHER J: Yes, because I think when you're in that stressed state and, you know, our daughter was going to surgery, that you're into a world that is very unknown, uncertain situation and probably your mind goes to the worst case scenarios and, you know, at that point I was thinking that she probably wouldn't make it through the surgery and that's why they were asking whether we would like to get her christened. So that made me feel very stressed and worried then that the outcome wasn't going to be a positive one.
LANGDALE: You say at paragraph 18:
"We are sharing this information in case it helps the NHS to prepare parents going through a similar pregnancy to ours so parents can make some decisions earlier in the pregnancy to remove making important decisions so soon after giving birth when they could be experiencing extremely stressful circumstances and uncertainty."
The transfer team then, so we know [Child J] was transferred to Alder Hey in the early hours. Who is best able to say how it was with the transfer team?
MOTHER J: I think Father J.
LANGDALE: Father J, how did that work?
FATHER J: The transfer team, if I remember correctly was a regional transfer team who came with their own equipment and then our daughter was prepared for the transfer which takes some time. The transfer team seemed extremely professional and -- but it's quite a daunting experience because they come with -- they come with a special incubator which just -- even now we struggle to look at the photographs, but they were supremely professional and they took their time, they were very calm and our daughter was finally transferred.
It's quite a stressful experience and especially in the situation that we were in as parents in that I had to leave my wife in the Countess of Chester and follow the ambulance to Alder Hey and try and collect some clothes and we had other things that we needed to organise at home and that you're not prepared for in these situations, so I followed the ambulance on my own with -- neither of us really had any sleep, I didn't have any sleep for a couple of days, but they were -- they were extremely professional when we got to Alder Hey as well so that was very comforting, that aspect of it.
LANGDALE: How did you feel, Mother J, that you weren't able to go to Alder Hey with your daughter?
MOTHER J: Well, incredibly upset and isolated and just removed from something that was so serious and our daughter is so precious that I felt pretty helpless.
LANGDALE: What did you hear about how her operation had gone?
FATHER J: If it's okay for me to answer. I was staying in a room at Alder Hey, so the surgeon -- I was getting some information back but of course during surgery I didn't get any information back so it was just a case of waiting. The only way we could get information is I was contacting my wife to update her which was quite a difficult experience because I was in a hospital setting at Alder Hey that was -- I wasn't really getting a great deal of information because of the nature of the fact that we were in surgery. So I think neither of us really knew what was going on but we understand that that's probably part of the process that you have to go through, but it was quite difficult to contact each other.
LANGDALE: You -- we know that [Child J] was in Alder Hey for ten days at that time. At paragraph 24 you set out some examples of excellent care or positives that you noticed about Alder Hey. Would you like to tell us what those were?
FATHER J: Yes. I will refer to my statement and read some of them, if that's acceptable.
LADY JUSTICE THIRLWALL: Yes, of course.
FATHER J: So the main positives that we noticed, they had the meticulous record-keeping, attention to detail. They were happy to explain what was happening and answer questions. They were very willing to communicate with us and understood we felt more at ease when we understood the detail, and we felt like they were very good at adapting their communication style based on the parents' style of communication. So just to elaborate there they treated us quite collaboratively. They realised that we liked to know what was happening and the Consultant -- the surgeon, the Consultant Surgeon and the nursing staff would hold their discussions in front of us, which was extremely helpful so we could understand the flow of information between them and it was clear that the nurses that were very, very skilled and knowledgeable as well which gave us comfort.
LANGDALE: Sometimes they describe it as "a huddle" when they are all grouped together. Was that the kind of situation and you could be part of it or what?
FATHER J: Yes and one feature of the new Alder Hey was that you had a relatively large room for each baby, which had a sliding door which could be shut, so the people who needed to be in there would come in there and you would -- you were all involved in the same discussion, which was -- which seemed very -- a great way of dealing with parents, to us.
They also had -- as my wife mentioned before -- the same staff care for the same baby, so they knew the patient history, so they tried quite hard to keep -- to keep the same nurses on whilst not -- whilst -- hard to explain. They would make sure that other nurses were involved so there wasn't just single nurses who knew what was going on but they tried to keep the main nurse the same all night, for example.
They also recognised that we had lost our daughter's twin and they were extremely empathetic about that and very sensitive around it.
They encouraged us to take breaks and stressed the importance of looking after ourselves so we were fit and healthy to look after [Child J] because that's something that as scared and worried parents, it's very easy to not look after your own health in those situations, for example, not eating, not sleeping, not wanting to go to sleep because you're worried about what might happen.
They gave us reassurance it was okay to go and leave [Child J] and rest and that we felt she was safe with them. They also made sure that we knew when the consultant or surgeon was coming round so we could ask questions so that was quite a formalised process and the consultants and nurses, as I said before, openly discussed things in front of us and included us in the conversations.
LANGDALE: Training of care.
So you had to have some stoma care training, didn't you, in readiness for transfer back to a district hospital and then ultimately to home? Can you tell us about that, how you received that training and how you were facilitated in that process of care for your daughter?
MOTHER J: So the nurses at Alder Hey took us through the process and we watched them and then we would take part in the process and they would then check what we were doing and they were just very patient and encouraging and recognised that it wasn't an easy process to do to a child but they reassured us that we were taking the right steps and doing the right things.
LANGDALE: How difficult did you find it emotionally and physically, the first time doing it?
MOTHER J: Yes, the first time we did it, it was incredibly emotional. We were obviously parents and we're not nurses and the process of putting a small tube into her bowel and being concerned it might hurt or damage -- hurt the child or damage the stoma was incredibly stressful and I think we were obviously quite anxious at that time because we had just been through so much during and then after the pregnancy.
LANGDALE: At this time we understand from paragraph 28 the plan was to try and get you back to the Countess of Chester to be nearer home. Was there any indication that there was concern at Alder Hey that, for example, there wouldn't be an ability to manage the stoma or the care required for your daughter at that point?
MOTHER J: No, no concern. Alder Hey said they would contact Chester and check that they could do the recycling which is quite an important part of the process, so they made the contact and Chester said that they could do that and they were comfortable with that decision, so plans were made to return to Chester.
LANGDALE: Did you understand they had a stoma team at the Countess of Chester who would be responsible for her care, effectively?
MOTHER J: That wasn't shared with us.
FATHER J: Shall I answer that?
LANGDALE: Sorry, can you say that again?
FATHER J: Is it okay if I answer that question?
LANGDALE: Yes.
FATHER J: Yes, they told us that they -- my understanding was that they did have a stoma team and that there were nurses who were sufficiently trained in stoma care and we didn't discover what that meant until the trial in fact in terms of what level of staff and according to the NICE guidelines who should and shouldn't be able to look after stomas. That wasn't explained to us at the time but we learned that later.
LADY JUSTICE THIRLWALL: Sorry, Ms Langdale, just for clarification, you say they told us that they did have a stoma team. Was that Alder Hey or the Countess?
FATHER J: At the Countess. So at Alder Hey, the process was that Alder Hey had called the Countess of Chester. They had confirmed to them and then they subsequently confirmed to us that they had a stoma team. It wasn't clear to us at the time that it was an adult stoma team, however, and that they didn't have a specialist neonatal stoma care team but the nurses were supposedly trained at stoma.
LANGDALE: When you were still at Alder Hey discussing the transfer back to the Countess of Chester, what was the overall plan? What were they telling you in terms of how much weight she needed to gain, whether you would get to the stoma reversal point, what was the big picture thinking at that point?
FATHER J: There was a plan for her to gain around a kilo in weight and the reason for that was it makes the reversal operation easier and there was a number of other aspects, one of those was that the stoma recycling from the bag was a key component in this, make sure there's a regularity of feeds and that the volume was increased over time and this was explained to us that by transferring from one stoma to another it allowed the lower part of her intestine to also grow which would help later on when we reconnected. They gave us an indication of around 9 to 12 weeks although they did say that was something they would have to review depending on progress.
LANGDALE: How much did they want her to put on weight per week?
FATHER J: Yes --
MOTHER J: A pound a week.
LANGDALE: So the expectation was a pound a week, milk volumes presumably having to increase for those purposes?
FATHER J: Yes. I mean the correlation between pound a week and the total amount that they said was the minimum amount they needed was significantly different, so we weren't concerned at that point that we wouldn't achieve the minimum weight gain.
LANGDALE: Did you speak with a dietician at Alder Hey, and whichever one of you did answer the question perhaps?
MOTHER J: Yes, we did speak to the dietician.
LANGDALE: What was the dietician's advice?
MOTHER J: The dietician said it was really important to monitor the output from the stoma because the consistency -- any changes in consistency should be reported, colour should be reported, and yes, she was -- I think she did refer to the weight gain side of things as well. If our daughter wasn't putting on weight that should also be a red flag and raised.
LANGDALE: Did the dietician say you could get in touch with her if you needed follow-up or information?
MOTHER J: She did.
LANGDALE: Did you ever do that?
MOTHER J: We didn't because we mentioned that to the team at the Countess and they said they had their own dietician and they would get their own dietician involved so that then puts us in a little bit of a difficult situation then because we didn't want to reach out to the Alder Hey dietician based on that information.
LANGDALE: No. So you go back to the Countess of Chester on 10 November, Baby J [Child J] goes back. Did you have any discussions with the dietician there subsequently?
MOTHER J: No.
LANGDALE: They didn't identify themselves to you or you didn't --
MOTHER J: We didn't -- we requested to see the dietician on a couple of occasions and that never happened.
LANGDALE: You say in your statement, at paragraph 36, that the physical infrastructure was very different when you got back to the Countess. Baby J [Child J] had come back in an ambulance. You are there, you say, standing at a desk in front of two nurses. What was obviously different about the two places?
MOTHER J: I think the style of communication was very different to what we had experienced at Alder Hey, so Alder Hey was very professional, but very empathetic, just -- I feel like they put themselves in the shoes of the parents. I think they understood that being in hospital is a stressful experience and an unknown environment to go into. It felt like they were very sensitive, whereas I felt like when we arrived at the neonatal unit at the Countess it wasn't such a warm reception, but it was a professional reception, so I guess it's -- when you're going from one place to another and transitioning it's about making everybody feel at ease and familiar because we knew that our journey with them was going to be for some time.
LANGDALE: Paragraph 41 you say in the statement:
"We tried to let them know what [Child J]'s routine had been whilst at Alder Hey and reiterated the things that had been stressed to us as important before we left but they seemed quite disinterested in this information. The feeling we got from the nursing team was that there was a Countess of Chester way of doing things and that was the way it would be done regardless of what had been said to us at Alder Hey."
Can you elaborate on that?
MOTHER J: Sure. So it felt like when we left Alder Hey we were in a very positive position, with a good plan that was clear. Our daughter had been -- she made excellent progress despite the adversity against her, surgery, stomas, all of those things, but she was progressing really, really well, so we felt comfortable with the information that they had given to us and that we were planning on following that because we knew that we would be doing this process at home, that had been the expectation that had been clearly set to us, so when we started to share that it wasn't really taken in the way that we expected, which was that would just continue. It was very much "Well, you're here now so" --
LANGDALE: So when you arrived, did they do more of the stoma care initially than you had been allowed to be part of at Alder Hey, or how did it work?
MOTHER J: Yes. There was a 48-hour period of infection control where our daughter remained in an incubator so they were involved in the care then. We didn't get involved in the care for the first 48 hours but we were monitoring what -- closely what was happening because we had seen what had happened at Alder Hey and seeing how they measured everything that was going on and --
LANGDALE: Do you mean the measured outputs and inputs?
MOTHER J: Yes, outputs, inputs, consistency, colour, of the stools, you know, everything that was done there wasn't immediately done at the Countess and that straight away made us concerned because we had left with having a conversation with the dietician saying that these are the things that should be closely monitored.
LANGDALE: So were they measuring fluid in and fluid out or --
MOTHER J: It will probably be best that my husband answers that question because that was a conversation that took place.
FATHER J: They weren't measuring in the same way that Alder Hey was, that's for certain. There was a later interaction that I had with one of the Registrars where we had a basic disagreement which was slightly later in our journey about that specific lack of measurement and not following the same procedure where I questioned why it wasn't standard procedure and didn't -- and felt brushed off and quite honestly slightly condescended, in a case of "You just don't understand", which is frustrating when it's your child because --
LANGDALE: What was it suggested you didn't understand?
FATHER J: Just -- the actual phrase -- I remember the phrase being used: "that's not how babies work". I distinctly remember the phrase because it really stuck with me because I was quite irritated by it. What was happening is we were finding there was -- the weight gain wasn't at the rate we were expecting and it started -- this is slightly later, a few weeks into the journey with them, we were monitoring carefully feeds, we were giving a lot of the feeds ourselves and one of the things they did at Alder Hey would be for example measure fluids in, weigh nappies out and then we would know how much had been recycled of the stoma so it was a fairly simple concept, but they weren't following it with the same -- with the same attention to detail.
LANGDALE: Paragraph 43 you say:
"Although [Child J] was recovering well she wasn't gaining weight at the rate we were told to expect by the Alder Hey specialist. We know retrospectively from the records that they were noting that weight needed to be reviewed and there was suboptimal weight gain, but we didn't see any positive actions to address this. We couldn't access the donor milk to top up feeds for [Child J] feed her ourselves on time. We could only access our own milk from the communal fridge which contained boxes labelled with the child's name."
Would you like to expand on that, Mother J?
MOTHER J: Sorry, I think ...
LANGDALE: Don't worry, paragraph 43.
LADY JUSTICE THIRLWALL: Just take a minute to have a look. There's no rush.
(Pause)
MOTHER J: Yes, so there was a weekly weigh-in. It was on a Thursday and for us that was a particularly important day of the week because you're doing all of these things to make -- really the goal is to take your child home and at the right time, but as quickly as possible because a hospital setting is not a home setting and we were really keen to be able to get her home as quickly as possible, so I just remember being quite disappointed when we had had that weigh-in and it would be, you know, tiny, tiny weight gains that we were seeing which was frustrating but also it felt like going home was being pushed further away from us and then surgery, reversal surgery, you know, who knew how long that was going to be then. So I think there's quite a focus on the weight gain because we knew really that that would get us to a point where we could have the reversal surgery and hopefully life would be a little bit different after that, so it was frustrating that when there were busy times on the ward that we were waiting to get the donor milk and then -- I recognise that every place of work gets busy and it can be very challenging at times and people are trying their best to split their time and manage their priorities, but for us I think it's just -- it was quite frustrating because we knew that the weight gain was such -- would change, you know, the time we would be in hospital and getting our child home.
LANGDALE: You say in that paragraph:
"There were days when the feeds and medication would be so delayed she essentially missed that feed. We were monitoring this in the daytime and trying to keep her on track but could not influence this at night."
So what were you doing in the day? Either or both of you can comment on that.
MOTHER J: So I would arrive on the ward about 8 o'clock in the morning and stay there until 6 to 8 o'clock at night.
LANGDALE: Were her feeds late when you were there in the day?
MOTHER J: Yes, on occasions the feeds were late.
LANGDALE: Why was that?
MOTHER J: I think pressure on resource, is what I was hearing at the time.
LANGDALE: You say:
"Whilst this was unlikely to be endangering her health it was slowing down her weight gain."
MOTHER J: Yes, well, you know, when a child is hungry, they want their food now and, you know, waiting 5, 10, 15 minutes is probably acceptable. An hour on a child that's very premature is not an acceptable time to wait.
LANGDALE: Father J, you were working with nurses to create templates to get a better fit underneath the stoma bag. Tell us what you were doing?
FATHER J: Yes, we -- because there were a lot of aspects to both the feeds and stoma care which were -- the feeds not being particularly unusual, but important and the stoma care being, you know, quite challenging, we were basically monitoring everything and trying to help where we could, not only because we wanted to help but because we knew this was something we would have to do at home, or was likely to be something we would have to do at home. The original plan was that our daughter would gain sufficient weight and be stable such that we could take her home. That was expected to happen within weeks, not months, so we were conscious that we needed to know exactly what we were doing as well.
So we were monitoring the feeds, which at that point -- were two hours originally and we were also helping with the stoma care and to do that we were making templates for the stoma bags. The stoma bags were probably not at that time appropriate for neonatals because they just weren't small enough, so you had a stoma bag that was probably too large and it took quite some skill to make it stay on, it took quite some skill to cut it so that no skin was exposed because the output from the stoma was actually -- very easily irritates the skin so it was necessary to make sure that the stoma bag was cut in such a way that only the stoma trickled through, and as you can probably imagine on a busy ward with babies crying, needing feeding and, you know, pressures on the staff constantly, we were making templates for the bags such that when we weren't there the nurses didn't have to necessarily think about what they were doing in terms of cutting the bags, they could just cut them to a template and stick them on which was intended to save them some time.
LANGDALE: So it was fair to say that you were both very involved in the feeds and care of Baby J [Child J] at this time?
FATHER J: In the daytime we were extremely involved, yes.
LANGDALE: You say at paragraph 47 on 23 November Baby J [Child J] was moved to Room 4, the room requiring the least observations, and you were told to prepare to go home and how this would work.
Mother J, what was your expectation around this time?
MOTHER J: That there was a process that was in place for actions that would be taken in order for us to complete the discharge process.
LANGDALE: How was she at this time, how well did she seem?
MOTHER J: Yes, she was incredibly well. I was very keen to breast feed so we had had one of the nurses from the Breast Feeding Team come down to see us, try to breast feed which was a little bit of a challenge because of the situation with the stoma but she was, you know, feeding well. There were -- yes, just seemed to be quite happy, just the challenge of the weight gain really but still, you know ...
LANGDALE: You say in this paragraph:
"[Child J] had been taken off the monitor and we were told she would not be put back on it. However, the notes collected by our solicitors say the staff put her on the monitor at night on 23rd to 24th. On the evening of the 24th I stayed over and did cares and feeds to practice for being at home and to prepare [Child J] for this also."
Do you remember whether she was on a monitor at any point at this time? Would you have been told whether she was or not?
FATHER J: I think --
LANGDALE: Father J?
FATHER J: Yes. We were told that she wouldn't be on a monitor but we did know that other babies were sometimes put on monitors. Why that was -- and this is probably just pure speculation -- was that the Room 4 -- they would often leave the babies in Room 4 and it would be lights off and, you know, they -- because they were essentially on their way home, they were kind of left on occasions at nighttime and I suspect that sometimes they put them back on monitors if they were leaving for a long time. I don't know if that's the case, however, and we only know that we were told our daughter wasn't going to be on a monitor because we had some anxiety over that initially because when you have had a child that's been on a monitor for weeks and weeks and suddenly isn't, that gives you some --
LANGDALE: What kind of monitors -- I suppose we should be clear what kind of monitor?
FATHER J: This is a sats monitor and heart rate monitor. Yes, so we were told she wouldn't be on a monitor at night but the notes have told us that she was on the monitor on occasion.
LANGDALE: You say at paragraph 49:
"By 25th November she had been increased to larger four hourly feeds and her stoma was healthy, and she had a soft abdomen which was a healthy sign."
Thursday 26 November you have pictures of her looking well and taking full bottle feeds and you had messaged friends and family saying her NG tube had been removed as she no longer needed it. What were these things all being done in preparation for?
MOTHER J: For taking her home.
LANGDALE: At that time did she seem stable and ready enough to go home?
MOTHER J: Very, yes.
LANGDALE: You say one of the discharge readiness check items, Mother J, was for the baby to be bathed. How was that handled? Obviously she had her line, she had her stoma, Broviac line in situ, wearing the stoma bag. How was that handled?
MOTHER J: Yes, there was a lot going on with her, with the Broviac line and the stomas, so I was a bit concerned about her having -- or being bathed and the nursing assistant at the time didn't really -- couldn't really see that I was feeling quite stressed about that because we were informed all along the way that infection was the biggest threat to these neonates.
LANGDALE: To be clear, did she ever get an infection?
MOTHER J: On the -- later on in the journey, before we left the Countess, when she was very poorly.
LANGDALE: At this point -- carry on, at this point you have the bath, you have the conversation about the bath?
MOTHER J: Mm-hm.
LANGDALE: Does she have one?
MOTHER J: She did have a bath in the end but the nursing assistant said to me at the time that she wasn't any different to any other babies on the ward and that, you know, she should have a bath because that's part of the process. I still didn't feel comfortable with the way that that was put across and one of the more senior nurses got involved and she did bathe her, but I just feel that that could have been handled a lot differently.
LANGDALE: That night and over the early hours of Friday 27 November 2015 you now know that that's when [Child J] collapsed on a number of occasions. We know, of course, my Lady, Letby was charged with an attempted murder of [Child J] but the jury could not agree on that count.
What and who first heard about [Child J] collapsing that night? Who is best able to tell us about that?
MOTHER J: My husband can probably answer that question.
FATHER J: Yes, so we were planning on going in as normal because at this stage we were expecting to take our daughter home imminently. We had basically performed most of the tasks and procedures that they wanted us to do before we took our daughter home, so we got a call in the morning and one feature of the calls from the hospital was that they often came from a withheld number, so I answered the call. It wasn't a long discussion. They said we had to come straight in because our daughter had been resuscitated. It was -- it wasn't a long discussion. We just got straight in the car and left. We later discovered that actually they didn't tell us at the time the full details. They told us that she had had a collapse and been resuscitated. There was a series of collapses, we discovered later in the court case, so obviously we had been called at the end of that process and not at the start -- and not nearer the start of that process.
LANGDALE: Just dealing with what you were told at the time, not what you learned subsequently, so you go to the hospital, do you see any medical records at that point?
FATHER J: No.
LANGDALE: So you're having a conversation with a doctor, a nurse, who tells you about it?
FATHER J: I don't remember specifically which doctor or nurse told us at the time when we arrived. I think there was quite -- it was quite a stressful situation, there was quite a lot of people running around. There was a conversation later on with Dr Gibbs. It wasn't a formal debrief as such. He told us what had happened. I understand there were some other things happening on the unit as well at the same time which was causing quite a bit of stress for the staff which had happened after our daughter's collapse, so it was understandable that -- they were clearly quite busy.
LANGDALE: Paragraph 62, if I can take you to that, Father J. This is a record of messaging friends about the discussion, so, first of all, are these notes here what you said at the time in messages? Can you see?
FATHER J: Yes, so --
LANGDALE: So see what you told -- what you said about that.
FATHER J: Yes, so I had messages to friends and family describing the conversation with Mr Gibbs and he had said that they were investigating the possibility that it could be sepsis, it could be an epileptic seizure or it could be sleep apnoea and those were the three primary areas that they were going to investigate.
He explained that when he attended for the -- he had attended personally for the desats at 06.56 and 07.24 where our daughter -- you will have to excuse me. It is quite difficult, this.
LANGDALE: Shall I read the message?
FATHER J: No, it's fine. She went stiff and her eyes rolled back and she was clenching, I remember that description, and once they brought her back she took a very long time to settle. He -- that's why Dr Gibbs said he thought potentially seizure and Dr Gibbs had a specialty in epilepsy and he said it looked very similar.
He seemed quite distressed but we knew also there was an emergency with twins on the ward that morning, so we put that down to having a difficult morning. Dr Gibbs was usually very calm and collected so we were actually very concerned at this stage that he couldn't explain what had happened but they did then go on to perform a number of tests on our daughter to try and get to the bottom of what had happened.
LANGDALE: So just -- I can pick up, if I may, Father J, paragraph 62 Dr Gibbs had said:
"... he didn't really know what the problem was and why [Child J] had collapsed but he had said they were investigating" -- you have already set that out -- "the possibility it could be sepsis, an epileptic seizure or sleep apnoea."
So he wasn't sure why she collapsed. You learned in the trial further details about the final -- or the collapse, the muscle spasms and the collapse. Is that when you also found out the records that there were, earlier records and notes about --
FATHER J: Yes, and we discovered about the -- there was actually a series of collapses and not just the collapse that we were told about. We learned a little bit more about the type of collapse. We also learned that, by listening to the other cases, that the length and duration of a collapse like that had resulted -- the description had been very similar to the collapse of other children who had very sadly had been left with permanent disabilities, so that was quite a shocking and distressing thing to hear.
We also never -- Dr Gibbs -- Dr Gibbs was always somebody who we found to be very easy to communicate with and extremely professional. Even by his own admission later on when we had contact with him he was never able to explain the collapse to us and his -- the subsequent investigations had ruled out pretty much all the things that he suggested it could be.
LANGDALE: You say at paragraph 64:
"They gave [Child J] a blood transfusion and antibiotics in case there was an infection but after tests they ruled out sepsis and the records show there was no sign of infections in bloods as the CRP was zero and so they stopped the antibiotics."
FATHER J: Yes, so they were adamant that it wasn't an infection. That was one thing which was clear which is why we were very concerned for years afterwards that our daughter had -- would potentially have another seizure at some point because they said it wasn't -- it absolutely wasn't sepsis, that was clear, and it wasn't just a generalised infection, they made that quite clear, from the tests.
LANGDALE: Was there any formal debrief later on, so not just on the morning, but later on with you or any of the nurses and doctors about that collapse or what had happened or not?
FATHER J: There wasn't. We didn't ever have a formal debrief and, as I understand it, I don't think there was ever a formalised review or record made or we have yet to be made aware of one.
LANGDALE: [Child J] was moved from Room 4 back to Room 2 for closer monitoring, you say at paragraph 68 and [Child J]'s father and you, Mother J, stayed in the parents' room on the ward that night and the next day. How did [Child J] do then?
MOTHER J: Yes, she made quite a quick recovery, was keen to start her feeds, we could tell that she was very hungry and that process was always quite slow because they were being cautious but she -- from seeing her in one situation 24 hours earlier where she looked dreadful, she came back to how she was before really quickly.
LANGDALE: We see from paragraph 70 Letby writing up [Child J]'s notes that night along with [Child J]'s observation, says:
"Parents had [Child J] out for cuddles and pleased that she is starting feeds. Appeared happy this evening and understands care being given to [Child J] resident on the unit overnight."
In terms of the night before, you make an observation about CCTV at paragraph 65, going back in your statement, and say:
"We will never know the truth. It is for this reason we believe babies should be monitored using technology such as CCTV."
What's your view about that?
FATHER J: Yes, I believe that generally in this period CCTV would have answered a number of questions and that that probably will remain unanswered forever for a number of parents. I think one thing that's become clear is that note-taking I personally believe wasn't as accurate as it could or should have been. There are a number of areas where CCTV could have helped, for example, even where nurses -- who is covering who during the breaks, because that didn't seem to be noted. It would have been much easier to know who was where when.
I think there's -- there's a concern generally in society about the amount of CCTV we have but this is the most vulnerable members of our society, our babies and the elderly, and in those cases I personally believe they deserve the right to be protected in any way that is necessary and people who are working in those settings, that should be part of that -- they should accept that as part of them wanting to do the right thing and be in an environment that is 100% dedicated to the patients and their safety.
LANGDALE: You say -- going back to 71 -- this is how she is at the end of November. You say: [Child J] underwent tests on her heart, brain and bowel to check for underlying conditions, chest, abdominal x-rays, cranial ultrasound, ultrasound scans of her abdomen and a blood transfusion. You message friends on 30 November saying she was fine and handling well, pictures of her out of her cot with no NG tube and yet here she was being put back in a cot and taking full feeds again.
At that stage what did you think that had been, the collapse on 27th or -- did you think it was a blip or a condition, what were you thinking?
MOTHER J: It just never really made sense to us. We just really couldn't understand how a child could go from being so well to then not breathing and requiring resuscitation. It just didn't sit well with us at all.
LANGDALE: By 8 December, you record here that she was weighing 5 lbs 1 oz, which was increasing but not at the weight you were told to expect and it's at this time, Father J, that you have the conversation about the meticulous or not recording of fluid in and out. Were you worried about that at this time?
FATHER J: I was, mainly because we had become -- we had become hypervigilant at this point because we had -- we had an unexplained collapse. We were concerned that something wasn't going right and probably quite naturally we were looking at everything that could be improved upon to try and help our daughter's journey.
One thing that had happened at this point was we were expecting to go home and we had had a sudden unexplained collapse and we were obviously at this point I think scared is a fair phrase to use. We were scared that we would take our child home and she would have a collapse at home and we would be unable to deal with it, knowing what they had had to do to keep her alive, you know, we were really frightened of taking her home and her not surviving being at home with us.
One -- I think this is the type of scenario where you feel quite helpless and do everything that you can to try and -- in your power to try and improve things, so we were asking questions about why -- you know, why certain methodologies weren't being followed, we were monitoring, we kept a notebook of the times of feeds, we kept a notebook of the times of supplements being delivered. We noted that some nurses had missed some supplements and again whilst these weren't in any way life-threatening actions, to us it demonstrated a lack of attention to detail which perhaps not only affected care but could have been helpful in highlighting issues for other parents later.
LANGDALE: You say in the statement at paragraph 78 that, Mother J, you knew you could contact PALS but despite you having these concerns, both of you, you didn't contact PALS. You were aware of who they were but you didn't pass your concerns about the inattention to detail around feeding to them. Why was that? Why didn't you choose to do that?
MOTHER J: I think we felt at the time that if we had shared our concerns with PALS that with being on the ward for such long periods of time that we were working with the nurses and if they felt criticised then we thought that that would damage the relationships further and we didn't really want to do that, so we were trying our best to maintain relationships and work with them but there seemed to be a bit of an uneasy atmosphere, is the only way I can describe it at the time.
LANGDALE: You say here:
"It just wasn't that type of environment that you risked criticising the nursing care."
MOTHER J: Yes, and what I mean by that is I think if you shared an observation or you weren't happy with something then there was a defensive response to that rather than a "we're invested in our daughter's care and we're trying to help you here, we can see that you are busy", so it was the response to the communication and we were trying to communicate in a way which was respectful to their priorities and the needs of the other babies on the ward.
LANGDALE: If you were asking for swabs or care kits or anything like that, what kind of reaction would you get to those requests?
MOTHER J: I would generally ask my husband a lot of the time to communicate with the nurses with those things.
LANGDALE: Pausing there, that speaks for itself, really. Why would you ask him to do it and not feel able to ask for yourself?
MOTHER J: Because it just felt like it was met with -- I don't know what the right word is, reluctance or just another thing to do perhaps is the better way to describe it really --
LANGDALE: And Father --
MOTHER J: -- they were a busy team but, you know, the response was like a roll of the eyes, you know.
LANGDALE: So Father J, how did you find it when you asked for those kinds of routine kits?
FATHER J: I think we were both very focused on making sure that what was supposed to happen did happen and I was -- as time had gone on, my approach had certainly changed and I was much more prepared to challenge and I think we made -- whether it was a conscious or unconscious decision that I would challenge when necessary any staff actions and, for example, I would ask -- if they were late with cares or we had asked for the equipment -- there was a kind of care pack that you needed and if they weren't giving that to us I would just simply ask "Can I go and get it myself?"
In the end, actually, a number of times I was given permission to go and collect it myself which in itself is slightly strange, but we were very focused on making sure that what needed to happen, happened on time.
LANGDALE: Paragraph 79, we see there was communication between the Countess of Chester and Alder Hey in relation to the appearance of the stoma at one point and getting assistance from Alder Hey about whether anything needed to be done. Who can address that? Father J, thank you.
FATHER J: Yes, well, the stoma -- the stoma started -- one stoma started to protrude slightly more and have what is called a fistula in it, which is a small hole inside.
Alder Hey were not particularly concerned about it, however it was something that needed to be monitored and it was information that Alder Hey needed in order to help them assess when surgery would need to take place because, as with everything, they had surgical lists which only occurred every so many weeks so it was a question of which list our daughter would get on for reversal surgery. This was obviously an important piece of information that may mean she needed to go in earlier, get on an earlier list.
The -- we were more concerned in that this fistula was causing the bags to wash off and that made changing the bags even more frequent than they were already which made the whole care for our daughter even more challenging which meant for us we knew that we were going to have an even -- a more difficult time, let's say, on the ward.
We were getting to the point where we didn't feel like the communication levels between Alder Hey and the Countess were sufficient and that perhaps information wasn't getting passed through quickly enough, or at all, and we never -- we don't know yet whether all the things we brought up were passed on to Alder Hey, but certainly it was getting to the point where we had the surgeon's mobile phone number, again unusually, and we were considering --
LANGDALE: The surgeon from which hospital?
FATHER J: Alder Hey, yes. Considering contacting directly, which again was probably outside protocol.
LANGDALE: Then the stoma bags were getting more difficult, you say that clearly. What did you come to find in December, on 14 December, 15 December, with the stoma bag? Paragraph 81. Who was the one who came in --
MOTHER J: Oh, so that was me.
LANGDALE: Right, so tell us what you found when you came in on the 15th?
MOTHER J: Yes, so I walked into Room 2 and our daughter was in her hot cot at the time and she was just in a small towel, just put across her bottom area, and just over the stoma so the stoma bag wasn't on there and just sort of loosely covered is the way I would describe it and she has a Broviac line in place, so I just took one look at her and was just -- well, I was just disgusted really to see her in that situation and also incredibly saddened being a mum and thinking: what's happened here, and there were two nurses in the room at the time and they could see that she was in that situation and I just said, you know -- I think one of them was pregnant and I knew the other one had children and I said "You are mums, what would you do in this situation? Why has she been left like this?" They didn't really engage in discussion and we made a complaint on that day. I think my husband then came in shortly afterwards, saw her in that situation as well and then we took the address they gave us --
LANGDALE: When you say made a complaint, Father J, who did you complain to or speak to about it or was it you, Mother J?
MOTHER J: I spoke to one of the nurses and said that we wanted to see one of the Consultants about that situation and that it was just unacceptable.
LANGDALE: Did you speak to a Consultant?
MOTHER J: Yes.
LANGDALE: Who did you speak with?
MOTHER J: Dr Saladi.
LANGDALE: When did you speak to him?
MOTHER J: I think that was in the afternoon on the same day.
LANGDALE: Did you both speak with Dr Saladi?
MOTHER J: Yes, one of the nurses, Eirian --
LANGDALE: Eirian Powell*? [see correction below]
MOTHER J: Yes.
LANGDALE: So who wants to tell us about that meeting? Who is best able to tell us about that?
MOTHER J: Probably me again. So we were just in a small side room and explaining that seeing our daughter in that situation was very upsetting and just couldn't understand how that could happen really, but the conversation quickly sort of turned towards ourselves and more about they were seeing that we were tired and stressed and that we should perhaps consider going home, spending some time recovering and that, you know, sort of didn't really address what had happened so that's quite frustrating really that it got turned that it was us that were the challenge.
LANGDALE: Can you just expand for me? Who said something to the effect that if you were tired you should just go home and rest and was it expressed like that or in a different way? Because of course if you go home and rest, you're not there to monitor and look after your baby yourself, are you, so how was this put to you?
FATHER J: Yes, I will answer that if that's okay. Yes, Eirian Powell* [see correction below] -- in fact Eirian Powell and Saladi both agreed that we should have some rest, however it was Eirian Powell's suggestion that we should go home initially. It was very frustrating and again quite condescending that we were making a complaint about finding our child with a Broviac line under a towel covered in her own faeces and the conclusion was that we should have some rest and it wasn't the conclusion that I was expecting to hear and certainly I was quite annoyed by the answer, I remember.
MOTHER J: I think as well, on reflection, we weren't informed who left her in that situation and that I think would be the first thing that you would share with somebody and then -- so you could address that with that person and take the appropriate actions. We understand that there are emergencies that happen in these neonatal wards, but, you know, on reflection now it's only recently come to light who was caring for her and that wasn't shared at the time and at that meeting we were saying -- you know, we were really concerned that she was -- we had already had one collapse and we were -- which was unexplained, so we were really concerned that she was going to get poorly again without -- you know, with the same situation and we were trying our best to obviously make sure her care was at the highest level, so I kept saying to them "I'm really concerned that she is going to get poorly, we're going to be in the same situation again" and literally 24 hours later we were.
*CORRECTION: During the hearing on 24 September 2024, Ms Langdale KC stated: "we understand from the solicitors representing Mother and Father J that Mother and Father J would like to correct something they said in evidence yesterday. Their meeting to raise concerns about Baby J [Child J] was with Dr Saladi and a nurse, but that nurse was not Eirian Powell as stated. We will explore in oral evidence, my Lady, which nurse it was in due course".
LANGDALE: You say on the same day of that experience, Father J, you had messaged the Alder Hey surgeon asking about the surgical date, saying there were some bag issues and trying to see if she could get an earlier surgical date and you received a reply that they had a list for January 14 and [Child J] was on it although also they would try to get an earlier list if possible.
FATHER J: Yes.
LANGDALE: What was your view about her being in the Countess of Chester at this point?
FATHER J: At this point we were already extremely anxious. We wanted to be out of the Countess and it's hard to describe the stress of any parent on a neonatal unit when they've got a sick child and when things aren't quite happening in the way you expect them to happen and then you have an unexplained collapse, that stress is almost incomprehensible.
We sensed things weren't right. We felt the culture was a difficult one and we were taking it upon ourselves to try and basically kick-start the communication that should have been happening anyway. Fortunately the surgeon was extremely approachable and very helpful which was our general experience of Alder Hey and she started to communicate with us directly about her surgical lists and telling us when we could get on that list.
LANGDALE: You also had been told that a Consultant from Alder Hey held a stoma day clinic at the Countess of Chester where she would come and see children who had had bowel surgery. Did you ever ask for Baby J [Child J] to be seen in that day clinic at any point? Did that ever happen?
FATHER J: Yes. We weren't initially aware that this stoma clinic occurred. We found out that the surgeon would come. We assumed, possibly wrongly, that as the only neonatal stoma baby in the Countess of Chester we would automatically be on this list for review. However, it was clear that wasn't the case and we were very surprised by that and when we requested to go on the list we were told they would see what they could do, which seemed almost incomprehensible to me at the time.
We did -- because we had a -- because of our daughter's fistula, particularly we knew that it was important for her to get reviewed to see which surgical list she would go on and we were having problems with the bags coming off. It seemed obvious to us that the best -- the best outcome would be for her to have a stoma reversal as quickly as possible and we did get seen eventually, once the -- once Alder Hey were aware that we were wanting to be seen, they said of course we can be seen and when the Consultant saw her daughter she said, "Well, yes, you should be on the next list".
LANGDALE: So you did finally see that Consultant at the Countess of Chester on the day clinic --
FATHER J: Yes.
LANGDALE: -- having requested that and when she saw [Child J] you, I understand, have messaged a friend to say:
"The Consultant took about 10 seconds to come to the conclusion the quicker [Child J] has her stomas closed, the better for everyone."
FATHER J: Yes. That was a text message to a friend.
MS LANGDALE: My Lady, I think that's a good point to stop. The stenographer will need a break. I'm sure you both do as well. If you can avoid talking about the evidence in the break.
LADY JUSTICE THIRLWALL: So we will break for about 15 minutes unless you would like any longer, in which case just say.
MOTHER J: Thank you.
LADY JUSTICE THIRLWALL: So quarter of an hour.
(11.29 am) (Short Break) (11.48 am)
MS LANGDALE: So we were in mid-December 2015. You have just told us, Father J, that Baby J [Child J] was seen by a Consultant who recommended progressing to reversal of stoma. On 17 December one of you received a call heading to the hospital. Who is best able to deal with that?
MOTHER J: That's me.
LANGDALE: Would you like to tell us what happened on the 17th?
MOTHER J: So I was in the car and the phone rang and it was a withheld number and at that time the only withheld numbers that were calling were from the hospital, so I knew it was the hospital that would be calling as the other call that we had had was -- the emergency call was from the hospital, and I just recall that the nurse said that our daughter had had another collapse.
LANGDALE: Did you go into the hospital? Paragraph 92 and 93 in your statement.
MOTHER J: Yes, so I -- yes, the nurse on the phone said that she had had a collapse and to come quickly to the hospital and she did say at the time that she had let out a big scream and then suddenly collapsed, so I carried on with the journey, got to the hospital as soon as possible and she was in the intensive care room when I arrived.
LANGDALE: Were you given any cause or reason for the collapse?
FATHER J: I will address that, if that's okay. At that point, no, we weren't. Again, there was -- as they tended to do in these cases, we understood the risk perhaps that there could be for example an infection, so they tended to have a kind of clear checklist of things that they would go to, first infection being one of them, so they would have needed to take bloods and measure things like CRP, and even basic things like pressing her abdomen, simple tests, in order to try and understand what was going on. So at that point they said they wouldn't rule out infection, they wouldn't rule out sepsis and they wouldn't rule out an issue with her bowel, so those were the three things that they were looking at.
LANGDALE: Was there a plan to transfer her to Alder Hey then?
FATHER J: Dr Brearey was involved and he decided as a precaution it was best to transfer her to a surgical hospital, either -- they said it would -- primarily they would try and get her back to Alder Hey but if not we would go to St Mary's, depending on who had a bed available.
LANGDALE: You got -- we see at paragraph 99 -- confirmation from Alder Hey that [Child J] could go on a surgical list for 30 December and you, Father J, told the Consultant that [Child J] was seriously ill?
FATHER J: Yes.
LANGDALE: You say you both sat next to [Child J]'s incubator during the time after the collapse until the early hours when transfer to St Mary's Hospital arose?
MOTHER J: So I was so concerned and obviously upset seeing her in such a severe situation that I couldn't leave her, so I just sat next to the incubator and I think maybe, you know, took a few comfort breaks, five-minute comfort breaks, and just waited for the team to come and transfer her.
LANGDALE: You tell us she was given broad spectrum antibiotics at this time:
"They couldn't explain with any certainty what had happened."
She had been doing so well and it was unexpected.
In the early hours of 18 December you left the Countess of Chester to go to St Mary's Hospital in Manchester. Did you have any other further discussion about that second collapse or not with the Countess of Chester or anywhere else at the time?
FATHER J: We -- at that time we didn't and because we had left the Countess by the time it would have come to having a discussion because we weren't there any more. St Mary's -- obviously we then had discussions with St Mary's about what they believed it was. As we understand, our daughter had some infection markers and it was assumed that she had had an infection, although we never had -- we never had a full debrief. We certainly didn't have anything written and there was no formalised meeting afterwards, so everything that we learned pretty much on the whole of our daughter's journey, in fact, was verbal.
LANGDALE: There came a time she had a cranial ultrasound on 21 December which appeared normal and St Mary's told you that she was well enough to be discharged back to Chester. What did you think about that?
MOTHER J: So we were both deeply concerned about returning back to Chester given the experiences that we had had there.
LANGDALE: So did you in fact stay at St Mary's until the transfer to Alder Hey?
MOTHER J: Yes, we refused to go back to the Countess of Chester and were quite firm in saying that we either have the surgery at St Mary's Hospital or it would need to be Alder Hey but we couldn't return back to Chester because at that point we had lost confidence really.
LANGDALE: It says -- you say:
"We know now from records St Mary's noted our concerns with regards to Countess of Chester's stoma care and we didn't want [Child J] to go back there."
So you go to Alder Hey Hospital on 23 December and you describe the reception when you arrived there from the nursing team. What was that like?
MOTHER J: Like stepping back into a warm family, familiar faces, they knew us, they knew [Child J].
LANGDALE: Sorry, you might have to speak up slightly.
MOTHER J: They knew us, they knew our daughter and we felt we were in the right place then for the path to recovery.
LANGDALE: You say:
"... the nursing team hugged us ... We felt at ease and safe again."
MOTHER J: Yes. That's exactly how I felt.
LANGDALE: She had her surgery on 30 December and you say made a quick recovery and by early January you had returned home with her.
MOTHER J: Yes.
LANGDALE: In the immediate aftermath obviously she was recovering well, you say that, but were you left -- physically she was recovering well. Were you worried about any aspects, or that there might be anything else that lay ahead given what had happened?
MOTHER J: Yes, just having those experiences of the collapses and not having any explanation of why they happened, it was always there at the back of our minds that at some point that could reoccur.
LANGDALE: You also had experience, didn't you, of the Countess of Chester children's ward, as you had an issue with milk intolerance as you moved forward. What was your experience of the children's ward and the staff that you dealt with there at the Countess of Chester?
FATHER J: We were dealt with by Dr Gibbs and he remembered our daughter from the NNU and they diagnosed us -- they had diagnosed the issue really quickly. They switched our daughter to a non-dairy milk supplement and resolved the issue really quickly and we felt we had been given really great care, which -- again our experience of the Countess of Chester was that we had had really fantastic care by the Fetal Medicine Team. We had a great experience in the children's ward and it seemed to not fit with our experience with the NNU.
I think I would like to point out as well that Dr Gibbs -- we had a lot of contact with Dr Gibbs and Dr Brearey and both of them came across as extremely knowledgeable and professional and caring and empathetic towards us as parents. The main issues seemed to be that they were just overstretched in their roles.
LANGDALE: When you received discharge letters -- presumably you received discharge letters from the hospital relating to your daughter's care. Did they mention the collapses you have told us about?
MOTHER J: No. I have looked back at those letters because I kept them over the years and none of them mention anything about the collapse. It was almost like it didn't happen. Other things are documented there but none of the collapses.
LANGDALE: You tell us you were invited to a workshop at Alder Hey to help them understand the experience of babies and parents moving from a specialist surgical hospital to a district hospital. What were your contributions to that? What's your thinking about that?
MOTHER J: So -- I will just refer to my statement there, so:
"We were invited to a workshop at Alder Hey to help them understand the experience of babies and parents moving from a specialist surgical hospital to a district hospital. They were aware of potential challenges when babies transfer to district hospitals and wanted to try to ensure continuity of care. There were lots of suggestions from families who had been negatively affected by these moves and not just the Countess of Chester Hospital. Alder Hey were keen to use the parents' experiences to find a solution on how to monitor the progress of babies after surgery within the district hospitals, they were considering ideas such as a trained Alder Hey nurse would visit once a week. It was clear at this meeting that the other parents had challenging experiences at other district hospitals. It left us feeling that the care at Countess of Chester Hospital was similar to the care given at these other district hospitals across the region and none of them were able to reach the level of care of a specialist surgical hospital. Despite comparable experiences across the region, no other hospitals had the same problem of deaths and collapses."
LANGDALE: Medical records. When did you first see [Child J]'s medical records?
FATHER J: We didn't see any records until we had appointed a solicitor. As I say, apart from the discharge letter I don't think we received any other letters about specific things such as collapses, or -- and nor was it recorded that we had made a complaint about finding our daughter in a towel -- faeces covered towel, so those were things we would have expected would have been recorded but in fact as far as we know at this time there were some notes made but there was never any formalised response to much of our feedback.
LANGDALE: Back in paragraph 81 of your statement, in relation to your daughter being found in the towel, you say:
"There was no record of Letby or other staff having issues with bags on the shift, however, on 15 December, at the handover from Letby's shifts, when I came in at around 8 am and found [Child J] in her cot ..."
That's when you have given the evidence earlier about what you found.
So when you saw the records was that the first time you could see whether there had been any issues or who was there on the shift before you found her?
FATHER J: The first time we asked who had left our daughter in a towel, this faeces covered towel with nothing else on her. We never got an answer at the time. We never got an answer afterwards. It wasn't until our solicitor looked at the records that she discovered that the designated nurse on that shift was in fact Lucy Letby who was responsible for looking after our daughter when she was left in this particular state, so that was a big shock to us. It is something we have only found out recently.
LANGDALE: You also at paragraph 91, describing the second collapse, make the point that Letby was on duty again that evening, the 16th through to the 17th. Is that something you asked about at the time, who was around, or would it not have occurred to you to ask about that?
FATHER J: At the time it didn't occur to us to ask and again it wasn't something that we discovered until the police involvement with the case and I'm not sure of the exact time that we found that out but it had been investigated by the police and not taken to -- not taken to trial, so at that point they were able to give us further information.
MOTHER J: However, what I would like to just add there was the nursing staff at the nighttime -- we didn't know who the nurses were at the nighttime looking after our daughter at the Countess of Chester. At Alder Hey we were told who was responsible for their care, so I would say in the daytime it was very clear but at the nighttime not so clear and consistently shared with us.
LANGDALE: So how many years after these events and your daughter's time there do you feel you got further knowledge around who was looking after her and where and what happened potentially?
FATHER J: It's been in the region of probably -- some information had been eight years almost before we discovered what is actually quite important information to us.
LANGDALE: In terms of impact what would you like to say about impact? You say a couple of things at paragraphs 116 and 117.
MOTHER J: I will refer to my statement.
LANGDALE: Yes.
MOTHER J: "I cannot emphasise enough the impact of this on our whole family. Who we are as people, parents, work life, spouses, children. We went through this at the time with minimal written explanation. We then discovered about the investigation into deaths and collapses via the newspaper and read that the hospital and Police had supposedly contacted all parents involved. My husband contacted the Police to check if they had looked into [Child J]'s collapse and they said the hospital had not passed on our records despite us never getting an explanation as to the reason for the collapse and Letby being the designated nurse. We then quickly found ourselves part of the investigation once the police had looked at our records. For nearly ten years we have been on a challenging journey. The last five years have been especially difficult, enduring the investigation and trial and hearing new information in terrible detail about the other children on the same ward. This has cast a shadow of sadness over every part of our lives."
FATHER J: I would like to read 117, if that's okay:
"By the time [Child J] was on the ward I now know that the consultants had already reported their concerns about Letby and an independent report had potentially told the Executive Team to investigate it further. I don't understand how in the light of this more action wasn't taken. It is almost inconceivable that, even when they did move her for a short period, they moved her to a patient safety admin role. When someone is accused of causing harm to patients, to move them into a role focused on safety seems ludicrous and inconceivable."
LANGDALE: I'm going to move now to recommendations and I don't know, Father J, shall I ask you first to deal with some of these points? Point one, as far as Baby J [Child J] is concerned you say missed opportunities to intervene and protect Baby J [Child J]. What would you seek to highlight?
FATHER J: We -- I believe here that we're talking about potentially not -- about protecting all the children on the neonatal unit and I believe in terms of our daughter there were some opportunities missed, for example immediately after Baby J [Child J]'s collapses there appeared to be no investigation which seems to be a missed opportunity. On discovering Baby J [Child J]'s mother's milk was missing, which is a topic we haven't --
LANGDALE: Actually we haven't, perhaps we should pause there and Mother J, would you like to tell us about that? So there was an occasion, wasn't there --
MOTHER J: Yes.
LANGDALE: Set that out for us.
MOTHER J: So it happened on the first collapse. We -- the milk was obviously an important part of the journey in helping our daughter recover, so when we received the call at home we just took the expressed breast milk from our fridge but we didn't have any labels at the time because we were obviously just rushing to get into the hospital as fast as possible, so when we arrived on the ward my husband -- I went straight to our daughter in the HDU and my husband said "You need to -- we've got some milk here but it is unlabelled. Do you have any labels?" and they didn't have any labels at the time so he said, "Well, I will place it in the box of our daughter in the communal fridge" which was just for expressed breast milk and "Could you please get us some labels so we can label it?" because we knew that that was the process that we had to follow.
So shortly afterwards -- I can't remember, I think maybe my husband went to get the breast milk because we were allowed to start giving small feeds and the milk wasn't in the box so we asked the question "Where is the milk?" and I remember there was quite a few nurses around the area and I think my husband was asking pretty much everybody, you know, "Where has this milk gone?" you know and there wasn't any explanation, nobody owned up to removing the milk from the box in the fridge, disposing of it. The milk never turned up. We never had an explanation as to who had taken it and, you know, what had happened really and I remember my husband at the time was just really -- just perplexed that this could happen and there didn't seem to be too much seriousness attached to that.
LANGDALE: The importance of it?
MOTHER J: Yes, absolutely, the importance of it and we -- you know, we didn't ever get an explanation of what had happened, so yes, that just remained as is.
LANGDALE: So you make the point there then, Father J, that in terms of recommendations, picking up on that and the importance of that, for the child, for the mother, for the safety generally of children being fed on the units, did you ask anybody about that at the time, any of the nurses?
FATHER J: Yes. It's one event that still stands out quite clearly in my mind. I was adamant at the time, despite the fact that that was the day of one of the collapses, that I went around to all nursing staff and to the nursing station and said "Look, we're going to have to put some milk in the fridge that's unlabelled. As soon as you get labels, we need a label to put on it. Don't throw it away". Then when I returned and then it was missing I then asked everybody again "Where is it?" My concern at that point was that it's a -- you know, it's expressed milk and shouldn't be given to anybody else. Certainly I was quite shocked that they didn't take it particularly seriously and my question was "Well, if somebody has thrown it away, that's fine, we just need to know that it has been thrown away and not given to somebody else", because whilst my wife wasn't taking any kind of medication, you know, she could have been, so that was quite concerning and they didn't treat it very seriously at all and the reason I referred to it in the missed opportunities was that again Letby was on duty and to me it seems as if there was some concerns going on, these types of events were opportunities to, for example, do a little bit more investigation and perhaps start to manage situations and ask questions, so if I may, if I return back to those recommendations, and immediately after Baby J [Child J]'s collapses and immediately after discovering that my wife's milk were missing, they were opportunities to start asking questions.
Even things like minor care errors such as missing feeds and supplements, I would have thought there would be generalised questions asked about why things weren't happening in the way they should be. That in itself is an opportunity to look into any individual's activities and certainly after finding our daughter wrapped in a towel with her stoma bag off and then now that we know that the nurse at the time was Letby, that was most certainly a missed opportunity to investigate or begin an investigation into opportunities.
LANGDALE: You also say there was a reluctance, or appears to be a reluctance to accept the seriousness of incidents and an omission in recording them or follow-ups to them. You refer to the unrecorded meeting with Eirian Powell* [see correction above] and Dr Gibbs, is that the one you mean?
FATHER J: Dr Saladi.
LANGDALE: Sorry, Dr Saladi.
FATHER J: Yes, so that meeting was effectively a complaint and whilst we didn't formalise a complaint I'm not even sure that we knew how to make a formal complaint. I think we had made a verbal complaint and one would have assumed at the time that that would be recorded as such as followed up as such. We didn't have any formal or written review after the collapses. In fact, we don't know what level of review, if any, occurred internally, even if there was kind of a stand-up discussion anywhere. We didn't get -- we didn't get all of the details in any case ourselves until after the police investigation and the solicitor review and in fact the police investigation information didn't come until the trial.
There were also, I would highlight, facts that recorded events were only recorded -- for example when feeds were missed that wasn't recorded, so they only recorded times when feeds were given rather than -- they didn't record what was essentially a failure to feed on time and I would have thought those were opportunities for just basic improvement in their own processes.
There was incomplete records of when our daughter was put on and off monitors which were discovered by our solicitor and I think those things personally should be basic, basic data recording, and those things would have helped actually in the ensuing investigations.
It also wasn't recorded when we as parents were performing stoma care and giving feeds versus nurses doing stoma care and feeds, which again I would have expected to have happened.
We didn't get any follow up at any points about any of the collapses even though for the first collapse we had no explanation whatsoever and for the second collapse we had an incomplete explanation.
LANGDALE: You make a point around attitudes and behaviours of some nursing staff and a cultural issue. Would you like to tell us what you raise there?
FATHER J: Yes. One of the -- one of the questions which is still being answered now by the records is we didn't know if any of our messages or questions were passed to Consultants, so where we had queries about care we never knew to what level that was referred to because we never got any full feedback.
We had a perception that some of the nursing staff -- and this was perhaps a perception because we didn't know their individual levels of training, but some of the nursing staff and Registrars seemed to us overconfident about their competency, particularly around issues like stoma care, but that was based on our experience of Alder Hey who were extremely competent and I think it's fair to say that as Alder Hey are a surgical hospital it's probably unfair to compare directly.
We did, however, find that we did get some dismissive responses by some nursing staff and Registrars. When we questioned their approach and their answer was "This is the way we do it here" rather than addressing our concerns and there was a reluctance, we noticed, to defer to Alder Hey surgical hospital when the care didn't align with the plan that had been explained to us.
LANGDALE: How did that manifest itself?
FATHER J: We were asking -- we thought initially the appropriate way to deal with issues was to deal with the Countess of Chester staff and that they would escalate when requested or when appropriate. That didn't seem to happen and that became a growing frustration and -- which ultimately -- which ultimately resulted in us dealing directly with Alder Hey which I'm pretty sure was not the accepted protocol, but in this situation our main focus was to make sure our daughter (a) survived and (b) thrived and when we didn't -- when we finally realised we weren't getting the progress that we needed, we took that into our own hands.
We only discovered the level to which information has or hasn't been between Alder Hey and the Countess of Chester very recently in the last probably 6 to 12 months.
LANGDALE: In terms of communication in its various forms but particularly staff communicating with you as parents, how would you assess that and how could that have been improved?
MOTHER J: At the Countess?
LANGDALE: (Nods)
MOTHER J: So the style of communication in Alder Hey worked really well for us where their nurses were present and the Consultant would be present, perhaps the surgeon and the parents and we would have just a quick review of what had happened today, what happened that week, any significant things that needed to be focused on and then there was sort of like a collective agreement on next steps and that worked really well because it just felt like we were part of the journey, we were informed and it helped us to relax and feel that things were happening as they should be happening and at the Countess it was a -- it was more of a kind of reactive communication as opposed to proactive communication, so we would sort of hear, you know, the Consultants would be coming along to do their review, but we wouldn't know when that was happening. It was sort of by chance if you were there or not there and I think for us and the way we were as parents, we would like to be included because we needed to know what was happening and how our daughter was progressing, so that may not be perceived by the hospital as an important thing to have the parents involved because the care is in their hands, but actually for us to be present and so heavily involved I think it would have helped if everybody, the nurses and doctors, were there at the time.
LANGDALE: Were you offered any counselling or support at any stage in this journey of care with Baby J [Child J]? You're shaking your head --
MOTHER J: Sorry, yes. So the first offer of counselling came from the police when I first met with the detective and he suggested that we had been on quite a journey and perhaps I should seek out some counselling, but prior to that we hadn't had anything.
LANGDALE: When did you first become aware that there was an investigation being undertaken in relation to the neonatal services at the Countess of Chester in respect of deaths and unexpected collapses?
FATHER J: It was actually I read an article in the newspaper, in the local newspaper. Prior to that we weren't aware of any of the reports. We hadn't been copied any report and in fact we have recently discovered that there was no informal notes made about the collapses anyway.
LANGDALE: So you weren't aware of the Royal College report, Dr Hawdon's report or anything like that?
FATHER J: No.
LANGDALE: Until the police told you or --
FATHER J: None of it and in fact we didn't -- the police didn't give us very much information at all. That was understandable because they were talking about a murder trial, couldn't tell us anything and that was again a difficult situation -- yes, so we were unaware of all -- and in fact we are still learning about the reports at this time, what reports -- in fact the opening statements of the Inquiry enlightened us further about what reports were written and when.
LANGDALE: So you have never been invited to any meetings or discussions at the Countess of Chester Hospital about Baby J [Child J] at the time or subsequently?
FATHER J: No.
LANGDALE: PALS. Have you had any experience of PALS, the Patient Advice and Liaison Service, ever tried to use it, thought of using it? You said earlier why you didn't actively want to make a complaint, but did you ever actively think about PALS?
MOTHER J: We thought about PALS but we didn't make contact with them because we were concerned then about what impact that would have on the relationship with the nurses and the doctors.
LANGDALE: So it wasn't that you had a lack of confidence in the service, it was that you didn't want the effect of it to be transmitted to the nurses?
MOTHER J: Yes, yes.
LANGDALE: Did you ever raise any concerns with any external organisation about your experiences at the time?
FATHER J: If I may answer that?
LANGDALE: Yes, please.
FATHER J: We didn't raise any concerns. However, we did raise concerns when we were part of a working group set up by Alder Hey, so it wasn't something that we actively pursued. Our main focus was to get our daughter home. I think there was a huge amount of relief to get home and our main focus after that was to look after her.
LANGDALE: That was parents such as yourselves trying to help understand where improvements could be made to help babies recover from surgery in district hospitals?
FATHER J: Yes, we realised we had been on quite a journey and also potentially had some useful feedback for that group and wanted to be part of trying to improve things.
LANGDALE: In terms of suggestions and recommendations, one of the issues you raise is an annual "Fitness to Manage" test for Executives to ensure they understand duties in key areas such as patient safety, safeguarding, response to complaints and accusations of wrongdoing, whistle-blowing, both legal and moral aspects. Would you like to expand on that a bit?
FATHER J: Yes, I don't claim to understand what tests or qualifications are required to be an Executive at the Trust. However, it does seem clear to me that there should be a standard below which nobody sitting in one of these positions should fall and that should be something which is tested and checked on a regular basis to understand that those people -- to make sure that they understand their duties, that they are regularly reminded of their duties and that they have the knowledge and understanding of what those requirements are, such that they cannot (a) hide behind ignorance or (b) pretend that it's not something that they have a duty to make sure they have all the information about. So in this case having already seen the initial submissions to the Inquiry, listened to the opening, it does seem clear to me that this type of annual fitness to manage test would have resolved at least some of the problems that have been discussed.
LANGDALE: Reporting of deaths and collapses you say should immediately go to a centralised reporting system with a strict set of guidelines, meaning Executives can't influence the reporting or under-report. What do you think the issue might be if there's under-reporting? Why might that be the case?
FATHER J: Well, it seems clear that in order to compare performance you have to have all of the information and if that information isn't presented in the correct way in a formalised manner and understood by the people receiving that information, it's almost impossible for them to see things such as outlying statistics. There's a lot of talk about statistics around this case so it's not a word I want to particularly use in this case, but it is very important that the people who understand what they are looking at get all of the information and there should be no way that any Executive Team in any Trust should be able to influence what is reported. The facts should be reported and nothing else.
LANGDALE: You say when collapses and deaths occur there should be:
"Immediate review straight after [an] incident including witness statements taking a true account at the time ... in the same way accident reporting occurs in the workplace."
FATHER J: Yes, it seems -- and I understand that the Datix system, I assume, is actually that appropriate system, but it appears to me that this hasn't happened and certainly in our case that didn't happen and of course we have contact with other parents and we know that that hasn't happened in their case. It seems to me that this type of process is one that's extremely well-known, well understood in many walks of life and industries and it just doesn't seem to be working, or certainly was not working at the time that we were at the Countess of Chester and that's something that if it isn't working now then it needs to be immediately addressed.
LANGDALE: You say:
"Technology for Automatic incident data analysis flagging up data such as staff/team attendance v incidents over a time period."
FATHER J: Yes, it seems to me that technology has significantly moved on since even this time and it would appear to me that it should be relatively easy for information to be automated such as, you know, if a child is put on a monitor in a crash situation, a button can be pressed and that data sent somewhere to be recorded and, you know, for example with recording -- there was a tendency in crash situations to write things on the nearest piece of paper like a towel, like a paper towel. To me that just seems so archaic. Why -- for example, police have an open channel they can press in an emergency situation. Why that couldn't be simply implemented in the case of hospital crashes, I would think these types of use of technology should be more than achievable now.
LANGDALE: You have covered, both of you, CCTV earlier on, saying it should be there for each cot space or incubator. You also suggest here areas such as the drug store, storage areas and milk fridge and monitoring of drugs such as insulin with either swipe card systems or facial imaging systems?
FATHER J: Yes, again it seems remarkable that even the basic things like the milk fridge were accessible to anybody who came onto the ward. We know about the insulin cases and it seems fairly clear again that CCTV and the use of swipe cards, or even facial recognition systems which are commonplace in a lot of workplaces, would allow -- or would prevent the misuse of drugs, either accidently or intentionally.
LANGDALE: You have already referred to monitor readings being transmitted to an independent body with the press of a button, but you refer here also to automatic audio recording being available to staff so they can make voice notes rather than writing on paper towels to get a realtime record of actions.
FATHER J: Yes. I think it's quite important that realtime records -- realtime records are much better than retrospective records. One thing that became clear in the criminal trial was that there were a number of retrospective records made which may or may not have been wholly accurate and in the case of being able to make verbal notes whilst also in this case if you're attending to a crash, it would seem quite sensible that somebody who needs to use their hands could also make voice notes at the same time.
LADY JUSTICE THIRLWALL: Would do you mean, like sort of recording what they're saying to each other while they're doing it?
FATHER J: An audio recording of what is being said, yes, yes, you could even make notes of observations at the time. For example, skin discolourations seems a very relevant observation that could be made by an audio note.
LANGDALE: You go on to set out in the same part of your statement where you think the information was not shared with you adequately. We have covered most of those points in evidence already, but one point you make is Consultants' and Registrars' rounds times were not readily transmitted to parents and you say later "We never knew if requests to speak with Consultants were transmitted to them by the nursing staff." And you referred earlier to Alder Hey and the "huddle" and being there and set times, so what was different about the Countess of Chester in terms of not knowing when you could speak to a doctor or being able to speak to one?
MOTHER J: I think the nurses at Alder Hey were aware of the timings of when the Consultants were going to visit and they were -- they would just come to us and say "Such Consultant will be here around about this time if you would like to be present for the discussion", whereas at the Countess that just didn't happen. It was more that, you know, we were hanging around and making sure that we were there to try and be involved in that discussion and sometimes we just missed that opportunity, you know, we popped to the kitchen to have a quick cup of tea and then, you know, that had happened and we weren't there then.
LANGDALE: Frustrating?
MOTHER J: Yeah, it was frustrating and, you know, disappointing because things were happening that we wanted to discuss directly and we couldn't, we missed the opportunity. We understood that, you know, their time is very precious but we just felt like that communication could have been a lot better.
LADY JUSTICE THIRLWALL: Can I just ask a supplementary about that. I understand the point you make about not knowing when they were coming but when you were there and they came, what was that like? Were you involved in the discussion then?
FATHER J: Can I answer that? It was very specific to whichever Consultant or Registrar came.
LADY JUSTICE THIRLWALL: Right.
FATHER J: So both Brearey and Gibbs we had contact with and they were very -- quite communicative with us and quite helpful. The Registrars, they changed quite frequently and so it was very difficult to build any kind of relationship with them, so they tended to just be in and out and gone, so it was very much dependent on which Consultant or Registrar did the particular round.
LADY JUSTICE THIRLWALL: I follow.
FATHER J: As opposed to Alder Hey which was much more structured and it was the same surgeon who was your Consultant who came to see you every time.
MS LANGDALE: One of the recommendations you think the Inquiry should make surrounds continuity of care and you say limiting the number of nurses that look after a child over a period of day-to-day or over a longer period presumably.
FATHER J: Mm-hm.
LANGDALE: Was that -- you gave evidence about that earlier, but was that frustrating for you as parents that it did change so much?
MOTHER J: Yes, it was frustrating. I think that when the nurses are dealing with your child on a daily basis they get to know the small signs of -- and get to know the -- you know, the way that they are behaving. They just get to know them.
LANGDALE: To know the patient?
MOTHER J: Yes, absolutely, and because she had complex needs with the stoma care you sort of -- the more a nurse worked with her, the easier it was then to make her comfortable and know if she was in any kind of discomfort and at Alder Hey they did that very, very well. It was just a small number of nurses that were caring for her, whereas at the Countess it sort of went in -- how to describe it, like -- one period of time it could be the same nurses and then a couple of weeks later it might be different nurses and if they were short-staffed -- I remember somebody came on -- they had like a bank nurse and I don't think that bank nurse had any experience of stoma care but then the next time was a bank nurse from Alder Hey which was reassuring, so it was just that inconsistency that made you feel a little uneasy really because she was being dealt with by so many different people.
LANGDALE: You have raised the need for stoma care at both hospitals and you say here:
"Alder Hey spoke to the Countess of Chester about [Child J]'s complex needs and were told the Countess of Chester had the necessary experience in recycling bowel contents and neonatal stoma care."
You say:
"I am not sure how this was checked [though], whether it was just a question on the telephone or by email or some more formal means of checking."
Father J, would you like to expand upon that?
FATHER J: Yes, I would. We still don't really understand how the process worked in terms of what proficiency, skill and training looks like in this case, ie somebody can be trained but not have the proficiency because they haven't had the practice or experience and others could have -- not be trained to the same level but actually have had quite a lot of experience. I'm not sure how that's measured. I'm not sure how it was measured then and certainly we're not sure how either of those things, both the competency and skill level, were checked. We know there was a telephone conversation but we don't know if there was either the passing of training records, for example, to demonstrate that certain members of staff were able to perform stoma care and I think that's something generally -- we're talking about stoma care here, but generally should be more formally checked, if it isn't.
LANGDALE: You say:
"Weekly review with surgical hospital of the progress of surgical babies at district hospitals" would be a good idea "in order that they are fully aware of progress and what's happening."
FATHER J: Yes. I mean I think perhaps -- we're talking about nearly years ago now. Things like video calls were obviously not as prevalent, but certainly now I would think that would be quite an easy thing to perform, to have a weekly review, even if it's only a remote one, in order to allow the surgical hospitals to have more involvement with the local hospitals.
Certainly at the time there was definitely a feeling when we had these feedback meetings with Alder Hey that this wasn't an issue specific to the Countess of Chester, it was an issue that was quite well-known around local hospitals and integrating surgical babies back into local hospitals and we didn't feel as though the involvement from Alder Hey was great enough and whether they even knew really what was going on, and I think by formalising some kind of weekly, that that would have helped them to understand what was going on and would have taken a huge amount of stress off us as parents.
LANGDALE: You say also:
"Consider an additional ward at Alder Hey for babies recovering from surgery rather than local hospitals. This may help speed up the time taken to get babies home." With that level of expertise.
FATHER J: Yes, one of the things that was a big focus was to get babies well enough to go home because there was two aspects: one, they thrived better at home. Certainly our daughter did when she got home. She put on a huge amount of weight when she came home. So there is one aspect which is, you know, blocking beds and the other aspect is that they seem to improve when they got them home. However, if the local hospitals just aren't able to handle certain types of surgical babies it seems sensible to us that some other method is used in order to help them get home.
LANGDALE: Finally from me, you say, in terms of recommendations that this Inquiry should consider, parent liaison support but not only of a religious nature. I don't know if you would like to expand upon that, Mother J, or whether you would like to --
MOTHER J: I think it's important to check in with the parents on how they are mentally when they're going through such a process of change. Some of the things that you see are not things that you are prepared to see and just having someone that can maybe sit down and just ask that question of "Are you okay?" to then open up a conversation, may just help people to, you know, to just be open about what they're experiencing.
I think when you're involved in the care of a child that's had surgery it really does touch every part of your life and it's important that the parents feel physically, but also mentally, strong to deal with the things that they're seeing.
MS LANGDALE: Thank you. Those are all my questions.
Is there anything either of you would like to say that I haven't asked you about, or would like to bring to the Chair's attention? Your counsel will have an opportunity in the next ten minutes to have a look if there's anything else that he would like to ask you after a short break.
MR BAKER: The short break is not necessary from my point of view, I'm ready to start now, but if the witnesses would prefer to have ten minutes then I'm happy to --
FATHER J: No.
LADY JUSTICE THIRLWALL: I think they're probably ready to continue. Very well.
Questioned by MR BAKER
MR BAKER: I just want to go back, first of all, to 15 December. It's dealt with at paragraph 81 of your witness statement and that's the date when you went in and found [Child J] without her nappy on.
Now, your evidence was that it was first thing in the morning, it was -- Lucy Letby had been the nurse over the course of the preceding night, so it was the end of the shift.
What was it that particularly concerned you about finding Baby J [Child J] wrapped in a towel without a stoma bag on?
MOTHER J: Just a lack of care and humanity really, towards a child that was recovering from surgery and here was at a high risk of catching an infection because she had a Broviac line.
BAKER: What is a Broviac line?
MOTHER J: It's a line that goes into the -- so it's a quick access point into the aorta, the main artery into the heart.
BAKER: So it's a central line?
MOTHER J: A central line.
BAKER: What had you been told about managing the Broviac line?
MOTHER J: That it needed to be flushed every seven days to keep it sterile and to make sure that it was clean and free of infection.
BAKER: Did it concern you then, with regard to infection, that the stoma bag had been left leaking?
MOTHER J: Well, the stoma bag was off, so yes, it was very concerning.
BAKER: When you spoke to Mr Saladi and Eirian Powell* [see correction above], did you raise that issue with them, about the risk of infection?
MOTHER J: Yes. I mentioned the risk of infection quite a few times and that I was concerned that she was going to, in my words, "get poorly", which was my way of saying that she was, you know, at high risk of infection and we still hadn't had an answer on why she had collapsed the first time and I was just so afraid that that was then going to happen again. It was trying our best to mitigate against that, even though it was an unknown -- unknown collapse.
BAKER: Do you think they took that seriously, that complaint or concern?
MOTHER J: Not as -- not as seriously as I would have expected. I think they listened to us, but I didn't see any actions after that conversation.
BAKER: But you weren't aware at that time that Lucy Letby was the nurse?
MOTHER J: No, we weren't aware at that time.
BAKER: Finally, on page 32 of the bundle, which is also page 32 of your statement, you have a concluding comment. First of all, how is [Child J] doing now?
MOTHER J: Yes, she is doing very well now, very healthy.
BAKER: I don't know if you want me to ask you questions about the concluding comment section, or if you would just --
MOTHER J: I would like to read that out:
"This journey has severely impacted our lives even though we have a healthy and happy child. We recognise that we haven't suffered the terrible loss and sadness and ongoing lifelong challenges of many of the other families. They have lost babies who would normally have gone on to live happy lives in loving families. Having a healthy child has given us the strength to keep moving forwards during many of the dark days, and in particular during the trial. Despite our involvement, we can only imagine the strength, courage and dignity the other parents needed to summon to function over the last ten years. We have given this statement to stand in solidarity with them. At the end of this process there must be accountability and there must be permanent change."
MR BAKER: Thank you, my Lady. Those are all my questions.
LADY JUSTICE THIRLWALL: Thank you, both of you, and, Mother J, thank you in particular for your remarks which I know you wrote together at the end.
You mentioned a number of times during the course of your evidence how important it is to be empathetic and to walk in the shoes of someone else. You mentioned it principally in relation to the care you had at Alder Hey, in fact, but what you have demonstrated and I think will be very important to the other parents is your willingness to do this for them, as well as for yourselves, and I'm very grateful to you for doing that. I also know that it's much harder to do than you think it's going to be because it brings back a lot of memories.
Your evidence was thoughtful and detailed, some of it very personal, but all of it very helpful for me in looking at Part A of the Terms of Reference and a little bit about Part C also.
I was struck by your comparison between different hospitals, but also between different wards of the same hospital and the difference that individuals make to how a ward feels and how you felt as parents, so thank you for that.
Finally, the thought that you have put in to the recommendations is very striking and you have given a number of suggestions which will be considered and tested against the views of others, but I am grateful to you for all of that. Thank you very much indeed for coming.
MOTHER J: Thank you.
FATHER J: Thank you.
LADY JUSTICE THIRLWALL: So that concludes the proceedings for this morning. We will start again at 2 and you are free to go whenever you want.
MOTHER J: Thank you.
FATHER J: Thank you.
(12.52 pm) (The luncheon adjournment) (2.00 pm)
LADY JUSTICE THIRLWALL: Mr and Mrs K, thank you very much for coming to give evidence. It's very good to see you. I know that you will be nervous, so we will crack on. Ms Langdale.
MS LANGDALE: Mother K, may you take the affirmation?
MOTHER K (affirmed)
MS LANGDALE: You have provided the Inquiry with a statement.
MOTHER K: Yes.
LANGDALE: Can you confirm that the contents are true and accurate as far as you are concerned?
MOTHER K: Yes, I can.
LANGDALE: You tell us about your pregnancy with [Child K]. Can you tell us something first about your expectations for family life and moving into your pregnancy with [Child K]?
MOTHER K: Yes. So obviously my husband and I had met, we had moved out, got a house and things, careers were going well and we found ourselves in that space where we were wanting to start a family. It was a little bit of a long road to get there but we did, and we found ourselves pregnant in 2015 and we were obviously thrilled and happy and over the moon with it.
We generally didn't foresee any issues with the pregnancy or anything like that. I kept myself very fit and well, but yes, we went, you know, to the 12-week scan --
LANGDALE: Before we get to the scan, can I just ask you this: was your care shared between the community midwife based at your GP surgery and with the Countess of Chester?
MOTHER K: It was, yes. Obviously the normal process is you contact your doctor locally and that then kind of kicks in the process to arrange scans and things like that.
LANGDALE: And you both attended all appointments at the Countess of Chester Hospital?
MOTHER K: We did, yes.
LANGDALE: And you would go to the midwife appointments?
MOTHER K: That's right, yes.
LANGDALE: So you had your first scan. Tell us about that. I think you were going to move on to that?
MOTHER K: So yes, we had the first 12-week scan booked in at the Countess. Both of us attended and during the scan you could tell that they started to look a little bit concerned as they were obviously working through the scan and the details. At the end of the scan the midwife did say "Right, I'm going to go and have a conversation with one of my colleagues" and then came back into the room and advised us about the little pocket of fluid around the back of our daughter's neck.
From that we went into a separate room where more discussions were had around what does that mean for my daughter and mean for us and decisions that we would have to make. They alluded to the fact that this could be a potential sign of Down's syndrome and a couple of other conditions as well.
So obviously we were pretty devastated. They gave us some options of what we could do next and one of those was the amniocentesis. We did have to wait a couple of weeks so we were at the right gestation for that to happen, and, again, we were told that carrying out that procedure would tell us if our daughter had a condition or not, but also it did carry a risk of miscarriage as well.
LANGDALE: Was it Mr McCormack who was advising you?
MOTHER K: So at this point it was the lady -- the senior midwife -- that was going through the options with us and then once we decided the route that we were going to take, we then got put under the Consultant, Mr McCormack.
LANGDALE: And how did you find that antenatal care provision or obstetric care for you generally from Mr McCormack and the senior midwife?
MOTHER K: We couldn't have faulted them. They were brilliant. They were so supportive. They spoke about all the options very clearly, precisely; you know, let us ask the questions that we wanted to ask, everything like that. They were very reassuring through the process.
LANGDALE: And you had an amniocentesis?
MOTHER K: We did.
LANGDALE: You had follow-up scans then, you tell us?
MOTHER K: Yes, we did.
LANGDALE: At paragraph 17 you talk about some of the follow-up scans?
MOTHER K: Yes, so once we had the results back that actually everything was okay with our daughter, the pregnancy was continuing but now they needed to monitor the fluid, so pretty much every two weeks we were in for a scan. These were carried out by Jill Edwards. She was a senior midwife there and she was fantastic. We built up a really good relationship. You could tell the amount of experience she had but also just on a personal level she was very connective. Mr McCormack would then obviously review the results. He would have conversations with us that the fluid was starting to clear on its own and that that was a good sign and that by the time baby arrives, fluid should all be cleared up and no issues and they were happy with the development of the baby.
LANGDALE: I think at this time you were buying some items in preparation for your baby's birth for home?
MOTHER K: Yes.
LANGDALE: And decorating a nursery?
MOTHER K: Yes, so because obviously we had had the great news about, you know, baby is completely fine, things are all going in the right direction with her development and things like that, we, yes, allowed ourselves to then go into the mode of preparation and purchasing some items and family wanted to get involved -- they were excited as well and purchased a few things for us -- and, yes, moved naturally down that route.
LANGDALE: Then at about 25 weeks you woke up with some niggly stomach cramps and ended up going into hospital, didn't you --
MOTHER K: That's correct, yes.
LANGDALE: -- with those and you were examined and they thought you were in pre-term labour?
MOTHER K: Yes.
LANGDALE: So what happened then? What were you told? Were you kept in the picture? What happened?
MOTHER K: So we arrived at the hospital, generally under the impression that we were just going to be sort of checked over, baby was going to be checked and it was going to be fine, a bit of growing pains and sent on our way. We took no preparation bags or anything like that with us. We waited in the waiting room for about half an hour or so, taken through to a side room, examination, and then they said "Well, you're in pre-term labour". Obviously we were very shocked at this point, as in "Well, what does that mean? What's going to happen?"
They quickly sort of advised that really their next step would be to look into transferring us out because their unit, you know, doesn't cover that gestation. They also advised very quickly about the steroid injections that we would be receiving to boost her lung capacity and we were just then sort of obviously left while they did their investigation work, I'm assuming about the transfer.
LANGDALE: Let me just ask you for a moment about the transfer. I think you now know it was a Dr Ford and Dr Brigham that you spoke with?
MOTHER K: Yes.
LANGDALE: And your medical records indicate you would need to be transferred to a Level 3 centre?
MOTHER K: Yes.
LANGDALE: But you were told, were you, that you were just going to go to another hospital. Is that the position?
MOTHER K: Yes, they didn't call it "Level 3". They just said "You need to be transferred out because we don't deal with babies of your gestation; you need a little bit more special care than what we can provide at the Countess".
LANGDALE: So then steroid injections were discussed and what happened then?
MOTHER K: They were discussed and obviously we agreed and the first round was given and then from that point they were looking to transfer us into a room then; to be fully admitted and put into a labour suite I suppose.
LANGDALE: So you were in fact admitted to the Countess of Chester. Did the issue of transfer ever come up again, either from you or from them about going somewhere else or not?
MOTHER K: Not -- from memory. All we can remember is the transfer conversation. Obviously that was quite nervous for both of us to be taken out of your support area and then they came back in. They did say a name or so of a hospital. We now know it was Preston. Thinking back, we thought it was a little bit further away from that -- the first one that they mentioned to us -- just because we were aware of the surrounding areas and the timeframes it takes to get there. So when they said it the first time, it was more of a shock then of "Well, how are you going to do this? How are we going to get there?" With the one that actually came out, we knew where that was a little bit more, but actually after that point nothing else was said about the transfer.
LANGDALE: You say that you learned in the trial the reason you weren't transferred was because it was too risky to transport you and in fact your labour had progressed?
MOTHER K: Yes.
LANGDALE: Dos that fit with your recollection now that your labour in the afternoon had progressed?
MOTHER K: Yes, they had obviously continued to examine and they said "it's now progressing". I suppose the effort that they tried to slow it down didn't quite work and that, yes, this baby is coming, type thing.
LANGDALE: And at some point they discussed with you whether or not a caesarean would be necessary or a good idea. Do you remember that?
MOTHER K: So yes, this was a late-night discussion. Now through the criminal trial we're aware that it was Dr Ford that had had this conversation with us and it was a conversation where it was myself and Father K and then it seemed like a team of people because quite a lot of the interns had come in to see these discussions, be part of them. We had sat down -- and his demeanour and that was great -- and, he sat on the edge of the bed and really spoke to us on quite a personal level and he just described the fact that he couldn't tell -- he couldn't give us like medical advice of which way to go because the research that's out there around the 25 week gestation was quite limited, so he could just tell us what he knew and then basically it was our decision of what we need to do.
He described the fact that it wouldn't be a normal C-section because of obviously Baby K [Child K]'s gestation and that that would then affect potentially future pregnancies.
MS LANGDALE: So Father K and yourself were having that discussion with Dr Ford?
MOTHER K: Yes.
LANGDALE: And you were faced with an unknown situation really and not one where there was a lot of medical expertise to back it up from what you are saying?
MOTHER K: Yes.
LANGDALE: It was unclear what the route was forward?
MOTHER K: Yes.
LANGDALE: You say your feeling at that point was if she could have a few more hours where she was basically to do what she needed to do in there --
MOTHER K: Yes.
LANGDALE: -- was where you landed.
MOTHER K: Yes.
LANGDALE: So how did that go?
MOTHER K: Yes, they were very accepting of that. It was our decision to make. They were like "Fine". He was very confident in the fact that he could deliver our daughter. He made us very comfortable that if we wanted to let things progress naturally and as they should that he will be there and will be able to deliver.
LANGDALE: In fact is that what happened?
MOTHER K: Yes, that's exactly what happened, yes, and he was very confident and delivered her.
LANGDALE: You say at paragraph 35:
"... other than the baby being only 25 weeks old, the doctors said there were no clinical concerns or signs that the baby was distressed. I had been monitored since my admission to the labour ward, and the baby's heart rate and all other signs were good."
MOTHER K: Yes.
LANGDALE: Is that your recollection of it?
MOTHER K: Yes.
LANGDALE: You say at paragraph 36:
"[Child K]'s heart rate was listened to every hour."
You were scanned a few times during the delivery but there was nothing that led you to worry.
MOTHER K: No, no.
LANGDALE: You woke up at midnight with further pains.
MOTHER K: Mm-hm.
LANGDALE: Tell us as much as you would like about the actual delivery.
MOTHER K: So, yes, I had been getting niggly pains throughout the day but then it had woke me up at sort of midnight as stated. Obviously I nudged my husband just to say "Oh, kicking in a little bit now" and he pressed the button on the wall. As what we were advised to do, if we felt we needed any assistance and then that's when obviously everybody entered the room, examined me, scanned me and then prepped for delivery basically.
LANGDALE: Dr Ford was there?
MOTHER K: Yes.
LANGDALE: You say he calmly stepped forward to help to deliver [Child K] naturally.
So she is born at 2.15 am or 2.12 am in the morning?
MOTHER K: Yes.
LANGDALE: She is immediately taken to an incubator on the other side of the labour room where the staff are with her.
MOTHER K: Yes.
LANGDALE: So was it what you had been told to expect, in effect?
MOTHER K: Yes, it was, yes. We were told that the Neonatal Team had been contacted, they are aware of her delivery, that they would obviously need to be present for her delivery and that's what happened as soon as they knew that it was imminent. The Neonatal Team was also there and stood there prepped ready to take her.
LANGDALE: We know she weighed 692 grams. If you look at that bundle in front of you at page 68 we can see recorded the condition at birth.
MOTHER K: Yes.
LANGDALE: "Dusky and floppy with no respiratory efforts." Then if we look at the APGARs at 1 minute 4, 5 minutes 9 and 10 minutes 9. Do you see that?
MOTHER K: Yes.
LANGDALE: How did you understand she was at birth and what was happening? How did you feel around that?
MOTHER K: To be honest, it was a bit of a blur because obviously they're still sort of working on myself. Baby was just taken straight over to the Resuscitaire and they were completely around her; you couldn't see her. You just kept sort of, you know, looking over but at the same time, I'm being asked sort of questions and things to do as well. We weren't expecting a cry or anything like that; we were prepared for the fact that they were going to have to help her so we did know that. Then it must have been maybe 20 minutes, half an hour when they sort of reverted back and said "We have stabilised her" and that's also when we learned whether it was a daughter or a son, so yes.
LANGDALE: So up until that point then the antenatal care and the care on delivery, how would you describe your experience of that?
MOTHER K: I had no questions around it. I felt very informed. They were, as I said, very attentive. They answered our questions well. There was a plan of what was going to happen and that happened. There was no criticism from our perspective at that current time over any care that I had received and, as far as we were aware at that point, that our daughter had received.
LANGDALE: About half an hour after she was born the Consultant Paediatrician -- I think you now know that was Dr Jayaram -- came over to speak to you, advised you that the baby was stable and ready to be transferred to the NNU.
MOTHER K: Yes.
LANGDALE: And she was.
MOTHER K: Yes.
LANGDALE: Which of you were able to go down and see her first? What happened in terms of seeing her?
MOTHER K: So before she was transferred obviously my husband was offered to obviously come and see her before she was transferred out of the labour ward, so my husband went to see her first. Obviously I was still being treated and then she was transferred down.
My husband then had walked down before myself again that evening but the first time we had gone together was early hours in the morning when we had been told by the midwife looking after her that she was okay and due a visit.
LANGDALE: When your husband went down to see her, did he come back and tell you how she was? Were you relying on him to tell you how she was because you couldn't see her yourself at that point?
MOTHER K: Yes, very much so but at the same time more so on the medical staff to be honest because while my husband went down to see her I had gone off to sleep, so he had left obviously to go and see her while I was resting, so I didn't hear about him coming back or his renditions of things until I was awake. So actually we were still very much reliant on the medical team to tell us how she was doing.
LANGDALE: You say that at about 4 am a nurse came in to you to take you down to see her as well --
MOTHER K: Yes, yes.
LANGDALE: -- with your husband. Tell us about that?
MOTHER K: So the nurse came in and she just said "Hi guys", you know, "I have been with your daughter, she is now stable, she is doing okay, she is doing all right and she is well enough for you to come and have a visit", so we were like "Yeah, brilliant, we want to go down." From my recollection I don't think we went back with that actual nurse. I believe that -- because I had to get into a wheelchair and things -- the nurse left and then another midwife from the ward actually wheeled us to see her but it was a very short conversation. "She is doing good, come see her", basically.
LANGDALE: You describe seeing her so tiny and so precious.
MOTHER K: Yes, she was just a dot, that's all she was. It's such a strange feeling because the first thing you obviously want to do is pick her up and give her a cuddle, but at the same time you don't want to touch her because you don't want to disturb her. You don't want to disrupt the treatment. It's a really torn way that you go about it because I can't help her so you don't want to get in the way of anybody else helping her, you don't want to interrupt the process that's happening and, so you're very tentative with it. It's a really strange, feeling but yes, she was this little dot with a little white hat on, yeah.
LANGDALE: And she had a breathing tube?
MOTHER K: She had a breathing tube and tubes everywhere else.
LANGDALE: What did you think the breathing tube was helping her with?
MOTHER K: Obviously breathing and respiratory. As I said, we had been told by the Consultant before she arrived that she is going to probably need that with her being the gestation she is and it was tied to a little bonnet and, yeah, and she had obviously all the monitors on her and the monitors had little animals on them and things like that, so yeah.
LANGDALE: What was the atmosphere in the unit as far as you were concerned when you went in?
MOTHER K: Very calm. Very, very calm. There was no hustle and bustle around. To be honest I can't recall any other babies at that time being in the unit. I suppose you just focus on, you know, your own baby but it was very calm, yes, very calm.
LANGDALE: You say you stayed for around 20 minutes and you both returned to the labour room where you slept. When you can't see your baby in that situation, do you think it would have been comforting to see them via a CCTV or --
MOTHER K: Yes.
LANGDALE: -- on your phone in the way that we can see images over our phones these days?
MOTHER K: Yes, 100%. As you said, you were reliant on a third party to come and tell you how they're doing, whereas if you could literally have something where you could just look, you can check, she is fine, the reassurance that that would give you is overwhelming really and actually address some of your anxieties and things like that and enable you probably to start that recovery process as well and things like that because you know she is okay, you can see her at any moment you want to.
LANGDALE: You referred a moment ago to wanting to leave people to do their job, the staff to do their job, and that you couldn't do that job --
MOTHER K: Yes.
LANGDALE: -- because at this point she needed the assistance. Would it help with that if you're not having to pester and ask for information, if that's how it feels like when you are asking for it?
MOTHER K: 100%, yes. I felt very conscious that you just didn't want to get in the way. She needed their 100% focus and their dedication and I didn't want to take any of that away, so you massively let them do their job in that time. So yes, being able to see what they were doing, or even the fact that actually the midwives that come round and check on you, you could actually ask them "What are they doing now?", so again you're not taking away that concentration and dedication from your baby but you can get the information you need elsewhere, so it would be massively reassuring.
LANGDALE: You say that as far as you knew [Child K] was stable, they were good at that point?
MOTHER K: Yes.
LANGDALE: At that point was there an expectation in your mind that there would be a transfer if she was stable?
MOTHER K: Yes.
LANGDALE: Again, why did you think that was necessary or was going to happen?
MOTHER K: Because it had been explained pretty much from the outset -- again, from the time that we were admitted -- it would have been ideal that we were both transferred out and that if both of us weren't going to be transferred out, she would be. She needed to go to a tertiary centre and that's what would happen and when she is born that's the process that then would kick in to find that transfer, so we knew it was going to happen.
LANGDALE: So you tell us you got some sleep and then you were ready and you went back to the NNU when the transfer team had arrived?
MOTHER K: Yes.
LANGDALE: You also tell us that you learned subsequently that while [Child K] was on the NNU there were three separate incidents when the breathing tube became dislodged and she required resuscitation. Was any of that said to you at the time?
MOTHER K: No.
LANGDALE: When did you discover that?
MOTHER K: In the criminal court proceedings.
LANGDALE: Taking you back to the time, you go back to the NNU, the transfer team have arrived. Did you meet with any of the transfer team?
MOTHER K: Yes.
LANGDALE: What was that experience?
MOTHER K: They came to see us first before they went down to see our daughter. They introduced themselves, where they were from and obviously the purpose is to transfer her. That they would obviously go down to the unit, they would transfer her over to a travel cot that would be suitable for the ambulance, and obviously they would make her secure and safe before they did that, and then before they left the hospital they would be back in touch with us for updates as to how that was going and let us know. So we were like "Brilliant, yeah, great".
LANGDALE: If you had been told about desaturations at the time they were happening, or as soon as possible thereafter, what do you think you would have done?
MOTHER K: Sat there at the side of her cot. Well, my husband would have sat by the side of her cot, or we would have took it in turns, took it in shifts. You would have questioned "Well, how has that happened?" You know, like, "How does this dot do that if that's what you're saying happened, that she sort of did it herself, or did it just slip?" You would ask the questions of "How has that happened?" and then for it to happen again and again, but you would hope that if we were told about the first incidents she just wouldn't have been left on her own.
LANGDALE: To be clear: if she is not breathing as well, you would have wanted to have been there; to be with her if that was happening?
MOTHER K: Of course, yes, we should have been told; while that was happening, we should have been told that this is happening and been called to her, in my opinion, and then from that we would have understood and asked the questions "Well, how, how has that happened?", you know, that type of thing and then from that point she wouldn't have been left on her own. One of us would have been there.
LANGDALE: You had been contacted before, hadn't you? Someone had come up to get you to come and visit her?
MOTHER K: Yes.
LANGDALE: Did you have a mobile phone with you?
MOTHER K: Yes, we would have had our mobile phones, yes, 100%.
LANGDALE: And you were nearby in any event?
MOTHER K: Yes.
LANGDALE: How far away?
MOTHER K: About five minutes, if that. It's literally just through the corridor.
LANGDALE: So around midday the transfer team tell you that [Child K] is stabilised and a doctor says to you the transfer is going to happen. What was his expression, what did he say to you?
MOTHER K: "It's now or never."
LANGDALE: What did you take from that?
MOTHER K: That was one of the first times I suppose that we both had the thought of maybe this isn't as plain sailing as what it was being made out or that we were aware of because we hadn't been told any different at that point. All it was was that she was stable and she was doing okay. We had probably already maybe had the conversation about "It's taking up quite a long time" because they must have got there about 8 o'clock, 8.30 or something like that, so it's now midday, but, yes, that was the first time we had that inkling of maybe this is not where she should be right now.
LANGDALE: The transfer team are going to take her to Arrowe Park Hospital, aren't they and you say the team at Chester completely took their direction from the transfer team. In what way?
MOTHER K: They just took over her care. They instructed what needed to happen and that's what the Countess team around assisted with and helped with and so from the moment they arrived, her care was under them.
LANGDALE: Did the team introduce themselves, who they were, when they took her?
MOTHER K: Yes, so it was the same team that came in the morning and then, as I said, it was the same Consultant that came back to see us to say "We're taking her now, we can't do any more for her at Chester, we've got no more additional facilities to help her, so we're going to take her".
LANGDALE: At that point had you agreed a name for her?
MOTHER K: Yes, we did. Obviously we didn't even know whether it was a boy or a girl until she arrived, so yes, we had the conversation and I said "I think we need to give her a name before she leaves" and we, yes, agreed a name.
LANGDALE: When she left with the transfer team, you hadn't been discharged from the Countess of Chester?
MOTHER K: No.
LANGDALE: What did that feel like when she was going somewhere else?
MOTHER K: Probably a little bit frustrating by now because they knew this was happening and they knew that I needed to go. I was actually quite fortunate as in I had no complications so I can go -- I was physically fine to go -- so it was frustrating that we're still waiting now for paperwork when they knew the importance of it, I suppose, and they knew that this was going to happen but they obviously got the paperwork together and then discharged me probably about two hours afterwards, I think, once she had left.
LANGDALE: Did you get a telephone call when she was safely there?
MOTHER K: Yes, we did.
LANGDALE: Who phoned you?
MOTHER K: The Consultant that took her phoned us and said "She is here, she did great in the trip", so I'm assuming by that that obviously there was no drop of her condition while she was being transferred and that they had managed to then obviously transfer from the travel cot into the Resuscitaire within Arrowe Park and they had settled her, yes.
LANGDALE: I think you were able to discharge yourself about 2 o'clock, weren't you?
MOTHER K: Yes, yes.
LANGDALE: Then you both went over to Arrowe Park?
MOTHER K: Yes.
LANGDALE: How was she when you first saw her there?
MOTHER K: Again, very much like what we had seen her in the Countess. The set-up was very similar. Obviously she was in the incubator and the tubes and, you know, all the wires hooked up to the machinery and things like that, but yes, as soon as you walked in through the door she was right there in front of you so yes, I remember well.
LANGDALE: You said the transfer team had prepared a certificate for her.
MOTHER K: Yes, they had.
LANGDALE: Tell us about that?
MOTHER K: Once we got there, they passed us over a certificate to say congratulations on your transfer from Chester to Arrowe Park and when you receive things like that you just -- it's heartwarming really -- think how sweet that they thought of that and obviously now it's a keepsake. Because in those moments you don't think about sort of collecting memories, if that makes sense, but that was a lovely touch, a great touch, yes.
LANGDALE: You say when you arrived it said Baby K [Child K] with her name --
MOTHER K: Yes.
LANGDALE: -- on the board?
MOTHER K: Yes.
LANGDALE: So again tell us how that felt?
MOTHER K: That's obviously the first time we have now seen her name because she left without a name, so actually we both commented on it. We were both like "Oh, they wrote her name" and, again, in the normal process of things, that wouldn't be something that you probably would hold on to, but it means a lot in those circumstances, a lot, that now she has got that identity and that she is here, she is cemented, so yes, it means a lot.
LANGDALE: You say:
"The feel of Arrowe Park was very different to Chester. They have an open-door policy so, as a parent, you can go whenever you want. There are no time restrictions."
MOTHER K: Yes, so the staff, the nurses that worked there, the Consultants that worked there, encouraged you to come whenever you wanted -- 24 hours, around the clock -- and because of that, those initial feelings of not sort of wanting to get in the way or you didn't want to interrupt something that they were carrying out or anything like that kind of did subside a little bit, because as soon as they caught your eye they were like "Oh, yeah", and they would invite you into the process so yes it had a slightly different feel and you were engaged a little bit more.
LANGDALE: Was that the case even when it was busy? Presumably that had a busy ward as well. Would it still be the same?
MOTHER K: Yes, 100%. So obviously the dedicated nurses are there one-on-one with your little one but in the mornings, there was always a ward round and you were asked to be there on those mornings when they would discuss the condition of your baby, what the treatment is going to be that day, what the plan is. You were part of it, which was lovely; quite hard to sometimes grasp and understand exactly what they were talking about in their terminology, but by the same token they would -- especially the nurses -- then try and re-explain it, I suppose in a little bit more layman terms for us, but you were always encouraged to be part of those conversations. It would be busy then where they're moving everybody around, but you were, yes, massively encouraged --
LANGDALE: If the terminology was difficult to understand did you have any hesitation about asking for clarification or anything?
MOTHER K: No and they even gave you the option, you know, "Do you have any questions? Do you have any concerns? Do you want to ask us anything?" They gave you those opportunities to do that within that meeting, but not obviously solely within that meeting. As I said, once you came down and the nurses were about they would explain what they were doing and why they were doing it and answer any questions that you had.
LANGDALE: You say you were told about the room at Ronald McDonald House when you first arrived at Arrowe Park.
MOTHER K: Yes.
LANGDALE: Tell us about that accommodation and how supportive that is or can be for parents in your situation?
MOTHER K: I don't think we could have done it without that support and without that option. They had already set that up for us. We weren't aware that that was something that was available and when we got there they said "We have already set you up to meet with one of the ladies that run Ronald McDonald" and they had already put a room aside, so again very proactive, you know, with what they knew that we would need but yes, again it also allowed you to sort of be with your baby as much as you wanted to be and then also have that breathing space of being able to go and change, shower, food, or even as well when you have family you've got somewhere to sit with your family and have discussions with your family and things and it hasn't got to be all around the cot, so, yes, we couldn't have done it without that.
LANGDALE: Whilst she was at Arrowe Park she also required the breathing tube, didn't she?
MOTHER K: Yes.
LANGDALE: Were there any incidents with that when she was there?
MOTHER K: No, or through transfer.
LANGDALE: You tell us at paragraph 68 that there was a change within the 24-hour window and that she looked different?
MOTHER K: Yes.
LANGDALE: Again, only sharing as much as you would like to, but how did she start to appear?
MOTHER K: She just become very swollen; very swollen, very bruised. She just looked very tight, her skin had gone very tight and, yes, she looked full. You would just look at her and you would think -- all I kept thinking was "How much more can you pump into her", because that was the impression that she gave you when you're looking at her, is how much they had put into her that caused it, so yeah, she was very swollen.
LANGDALE: You say at paragraph 73:
"Outside of the huddles information was passed on at the cot-side. Some mornings we would walk in and a nurse may be changing the lines and they would tell us that [Child K] had had a good morning. At one point [Child K] had her first wee and everyone was pleased. It was a good sign as it meant that everything was working as it should. A positive step."
So they were telling you along the way how she was?
MOTHER K: Yes.
LANGDALE: But you also say at paragraph 74:
"The team had started to explain what the meanings on the monitors were and I knew they were having difficulty keeping [Child K]'s sats within the range that they would like."
MOTHER K: Yes.
LANGDALE: So was that being explained to you as well as seeing the sats? What did you think the issue was?
MOTHER K: Yes, so they were struggling obviously to try and keep her oxygen levels up and she would fluctuate so much through the day; within one hour they would all be sat within the good range and then the next hour they would have all dropped again. As I said, they would explain as much as what they could around everything and where they would like them to be and that they were trying -- they tried everything to help her. They transferred her to a different ventilator that increased the rapidness of her breathing because some babies preferred that. She didn't like that, so she went back to the other ventilator.
There was a young doctor -- I don't think I actually mentioned it in here -- but there was a young doctor there and she had been sat there for hours working out this next medication that they were going to try and again you could tell that it was kind of like the last chance but they literally were trying everything that they could come up with and every single person in that unit tried as much as they could to do what they could for her.
LANGDALE: The day before she passed away, you say it's the first time you realised just how poorly she was. Was it something that someone said to you or something else that made you realise that?
MOTHER K: I think, again, I don't know whether it's just a parent thing, you sort of grab on to the little things like she has had a wee and that's kind of what you focus on so you're like "Okay, so it's all working and it's good and". But obviously alongside that, there's other things that you can see that they're fighting with and it was just you could start to see it in their demeanour as well, I suppose a little bit and how it came across and, as I said, the change in her body and you just got a sense of it. It wasn't necessarily what somebody actually said. It was the collective feeling.
LANGDALE: Did somebody raise with you whether you would like her to be baptised or advise that?
MOTHER K: Yes, they did. So they asked us if she would like to be baptised and we said yes, we would, so a couple of family members also came in and she was baptised and again I suppose just you're holding on to hope, I think, that's what you do and everything else might be pushed to one side a little bit to sort of get you through the next couple of steps. Looking back now and learning what we have learned, normally they ask you that question if things aren't going great but when you're in that situation and we were obviously first time parents, we had never been in this situation before, we just thought "Oh, that's a lovely thing to do". Naivety and, as I said, maybe a bit of hope, but now we're aware of the fact that they actually did it because they probably knew what was coming and the person that carried it out and the words and the reading of how they did it was not so positive.
LANGDALE: Do you mean the experience wasn't positive?
MOTHER K: Not the experience, the words that he was using as in like this was her last way out, if you know what I mean, rather than the celebration, it was a goodbye. But the experience of it and the process of it 100% we would do it again, but yeah, you are just a bit naive and hold on to the hope, I suppose.
LANGDALE: So the following day you say you had an overwhelming feeling in the early hours that you needed to go and see her.
MOTHER K: Yes. I've never felt anything like that before or since. I just woke up and I was just like "I need to go", just needed to go, and obviously nudged my husband and he was half awake and I was like "Can we just go see her" and he was like "Yeah", I was like "okay", in our pyjamas and we went and, as I said, you turn the corner and she was right in front of door and I knew. I just knew without even anybody saying anything.
LANGDALE: Shall we take a break? Would you like a break?
MOTHER K: I'm sorry.
LADY JUSTICE THIRLWALL: We will leave the room.
The shorthand writer will stop making notes and we will come back when you are ready.
(2.46 pm) (Short Break) (3.00 pm)
LADY JUSTICE THIRLWALL: Ready to start?
THE WITNESS: Yes.
MS LANGDALE: Mother K, we know you and your husband were shown to a family room with your baby and you set out in your statement what happened next, and you say here that the staff gave [Child K] dignity with the way they handled her.
MOTHER K: Yes.
LANGDALE: Can you just expand upon that, the care or the assistance you got with that difficult time?
MOTHER K: Yes, so as we walked into the room, there was a Consultant -- which we now know is Dr Gardner -- and she was sat at the bottom of [Child K]'s cot. That was the Consultant that we had a conversation with and she had actually said that she had been debating about phoning us for a couple of hours during that night because of how much [Child K] was struggling. So we had that conversation and frankly sort of said, "She's not going to get better"? To which the response was, "No, she's not going to get better, it's a matter of time", and we said, "Well, we want time with her, quality time with her. We don't want the machines to be telling us that it's over". She had gone through enough by this point. There was no more that they could do so we requested to have that time with her, so, as you said, we got taken to a family room literally just outside the unit, and they said that then they would fetch our daughter into us once we were in the family room and they did, and they wrapped her up in a blanket, fetched her in with a NeoPuff and handed her over to my husband first and then explained that obviously they would take the NeoPuff away when we had enough time to spend with her and they would come back and check within ten minutes or so on her and that's what they did. It was very peaceful, it was very calm and, as I said, they were just very gentle on how they handled her and how they handled us.
LANGDALE: You say,, on reflection, that in the back of your mind at the time there was concern about what you should be doing in that situation.
MOTHER K: Yes.
LANGDALE: Because obviously you had never dealt with that situation.
MOTHER K: Yes.
LANGDALE: So what would your advice be to people dealing with that situation? I don't mean the parents, I mean the people -- nurses, doctors -- who may not have had that experience advising on what to do in that situation.
MOTHER K: Emphasise that time is on your side; that you haven't got a time limit with your baby. There's no pre-conceptions of what you should be doing. There's no right thing; there's not a wrong thing. Every family is different. The time that they spend is different. There's not going to be a knock on the door and that's it, you've got to leave, or --
LANGDALE: Did you find yourself worrying about that "Am I supposed to be here for a long time?" or not?
MOTHER K: Yes, 100%. You're sat there and then you just don't know what to do, which was a very strange feeling for myself and for my husband. We are in careers where we do make decisions, we manage people and we're very capable of that but we just weren't at that point. It had just gone and I needed somebody to do that for me and I think some parents would be still fully, you know, "This is what I want to do and this is how it's going to be" and that's perfectly fine and I think other parents need a little bit of coaxing and help and reassurance that it's okay to sit for hours with your little one and, you know, little things like taking pictures and things like that would never have crossed my mind as such. Just that type of assistance and creating that environment for you to find your way a little bit.
LANGDALE: The Consultant who did the transfer did come in to see you?
MOTHER K: He did.
LANGDALE: Which you appreciated. Tell us about that.
MOTHER K: Yes, obviously the morning shift had come on and we got a knock on the door of the family room and it was the Consultant that had transferred her and he said "I had obviously just started my shift and I have just learned that she has passed and I just wanted to come and pass on my condolences", which we thought was lovely. He didn't have to do that, you know, he had sort of moved on with his day, but he didn't, he took the time to come and just say "I'm sorry and I hope you're all okay". It was just a really nice gesture in that moment.
LANGDALE: When you first arrived at Arrowe Park you say they had given you contact details and a little booklet about Bliss, the charity for premature babies.
MOTHER K: Yes.
LANGDALE: Did you ever look at that?
MOTHER K: Yes, I had flicked through it. I can't say I sat there and read it cover to cover, but I had sort of flicked through it. There were numbers in there for assistance and help and it explained a little bit about the process and the procedure of taking care of a prem baby and sort of what's to be expected, so yes, you had a little bit of a reference material to look at.
LANGDALE: So did you feel you were given some information at least about bereavement counselling, if you wanted to obtain it then?
MOTHER K: Yes, yes, it was in the back of the book.
LANGDALE: Moving forward from that time, now, we know you had subsequent pregnancies, children. I'm not going to ask you about the details of those, but at paragraph 98 of your statement you refer to an appointment you had with Mr McCormack, the Consultant Obstetrician at the Countess of Chester focusing on you and your obstetric history, not about [Child K]'s treatment or health.
Again, going to the antenatal care and then the discussion of future pregnancies for you, did you feel that aspect of care from the Countess of Chester was a positive experience generally?
MOTHER K: Yes, so again Mr McCormack and Jill Edwards, who was our lead midwife through it all, we had met with both of them and again it was to discuss anything that they thought the reason why we would have gone into premature labour and from their side of things, there was nothing that would stand out to them as to why that happened and no reasons why for future pregnancies it would happen again, but obviously the reassurance of the fact that though it has happened, future pregnancies would be monitored closely. Obviously they then took the time out to talk about our daughter and what had happened in the weeks prior to meeting them and, yeah, they wanted to know the whole story from a personal perspective so, yeah, we felt very comfortable in their care and very confident in their care.
LANGDALE: You did have children under their care, the same joint arrangement with your GP and the hospital?
MOTHER K: Yes, we did, yes.
LANGDALE: There's just one event at paragraph 119 in relation to one of your children that was delivered there and when you say at paragraph 119 with this child:
"[You] were reviewed by the midwives before [you] were discharged and the Paediatrician completed the new baby check. Everything seemed to be fine and the baby was feeding great. I questioned whether we needed to be seen by the Neonatal Team before we were discharged because the baby had been under their care with having borderline oxygen levels and we had been advised that the baby would need to be seen before they were discharged."
And you were told that wasn't necessary. In the next paragraph you tell us that you were in fact called back. So tell us what happened there?
MOTHER K: So with that pregnancy when our baby was delivered, they were delivered very, very quickly and his oxygen levels kept dropping so the neonatal team was called in at the same time as delivery and the baby was passed over to the Neonatal Team obviously to be assessed because of the oxygen levels dropping.
They stabilised our baby. The baby didn't have to go into the Neonatal Unit or anything like that. The baby was fine, but because they were borderline on the oxygen levels as to whether they would make a decision to move into Neonatal or not, they said to us, "Before you are discharged we would like to review the baby as well", so the baby was, you know, perfectly fine overnight and everything like that, as you said, all the checks were done, the baby was fine, and we had no concerns, it was just the fact that they told us that the Neonatal Team needed to see the baby, so I had asked the midwife that was arranging discharge. They said "No, no, it's fine, the normal doctor has been round, checked the baby all over, they are fine" and then she came back later on and I said "Have you double-checked, are you sure because we were under the impression that they wanted to review the baby before we left?" "No, no, you're fine, you're fine". We were like "Okay". So we went home and literally it must have been within 10, 15 minutes of walking in through the front door the phone went and it was the Neonatal Consultant who said "You need to come back, we needed to monitor the baby for 24 hours because they were such a borderline case it runs the risk of them having seizures" and so the baby needed to be under their care for 24 hours.
So obviously my next question is "Well, the baby is not staying on their own, I'm coming back with them" and to be fair she was like, "Don't worry, we've got you a side room on the maternity ward, you will both be staying". She was very apologetic "I'm sorry", so obviously we changed a few things over in the bags, turned round and went straight back to the hospital.
As soon as we got onto the ward they called down to the Neonatal Unit and that Consultant came up to see us. As you can appreciate, my husband was a little bit angry and annoyed by this point and sort of expressed our concerns over it and, to be fair, she was also very frustrated that it had happened and she expressed the fact that she had already been looking at the process, she had already made suggestions for changes for this not to happen again. It shouldn't have happened and obviously my baby then had two-hourly monitoring and was perfectly fine and we went home the following day.
I've got to say, it would have been very easy for that Consultant not to have phoned. She could have very easily have thought "Well, they have discharged now, any issues they will come back", but she didn't, she did the right thing, which would have caused her, you know, headache, workload, paperwork. She did the right thing and picked up the phone and asked us to come in. It shouldn't have happened. However, the implications that followed were very correct.
LANGDALE: You say in your statement regardless of what negative backlash might have come, she did the right thing.
You applaud that she telephoned you and got you back?
MOTHER K: Yes, 100% and you could see that she was pretty annoyed that it had happened, yes.
LANGDALE: Moving now to paragraph 122 and counselling and support that you have received. You say you received counselling support from a bereavement midwife at the Countess of Chester Hospital and also received occupational health support via your employer. How did you find -- without going into the details of it -- the value of the support from the bereavement midwife at the Countess of Chester Hospital?
MOTHER K: She was lovely actually and I think sometimes you don't realise you need it until you're sat there. It was a space that you were able just to talk about how you felt, what anxieties were building up within you and it was a chance just to release that pressure that sort of builds and builds and builds, so it was very useful, yes.
LANGDALE: For what period of time was that offered to you through the NHS service?
MOTHER K: There was no time cap put on it from memory. It naturally came to conclusion through having my next child really and actually as we were walking out with our child, our next child, we bumped into her so it kind of rounded the situation off, but no, there was no time cap that I was aware.
LANGDALE: The other observation you make here is one you made earlier in your oral evidence, that that time with [Child K] in the family room -- it would have helped you to realise that there genuinely wasn't a timeframe and you didn't have to do anything straight away, practicalities can wait, just that little bit of extra reassurance about that?
MOTHER K: Yes, that's it, that you've got a little bit of time to process and I think, you know, it depends what type of person you are. We are practical people and sometimes it's easier to deal with practicalities than emotions -- so to have somebody maybe say "You've got the time, don't rush, you haven't got to rush" would help.
LANGDALE: Medical records. At paragraph 155, you say you never asked for [Child K]'s records because you had no reason to ask for them, so when was the first time you heard and saw medical records about her?
MOTHER K: At the criminal trial.
LANGDALE: You also say here:
"There was a moment of realisation during the re-trial of shock and realisation as I just didn't know how poorly [Child K] was when they got to Arrowe Park."
MOTHER K: Yes, so, again, when you're going through the emotions, as you described before, you hold on to the hope aspect of things and you probably resonate with that more than you do with the negativity side of things and in the stark light of a trial and it being read to you what medication she was on, what they tried, what was actually wrong with her in their terminology, was quite hard to digest. I fully appreciate that that isn't what would happen at the cot-side to parents in that detail, but we just didn't know. As I said, I don't know whether we were just holding on to the hope, but in that stark light of day, I just remember sitting there thinking how poorly she was and what they had done. I didn't know that at the time in Arrowe Park to that level.
LANGDALE: You say, going back to paragraph 140 you only became aware of any concerns regarding [Child K]'s treatment when you were contacted by the police by telephone in May 2017.
MOTHER K: Yes.
LANGDALE: Who took the call from the police?
MOTHER K: I did.
LANGDALE: And what did they tell you?
MOTHER K: So at this point -- you know, roughly a year on -- I was at work and I took the call as kind of scooting out of the office to a side room. Obviously she introduced herself as a Family Liaison Officer with the police and our daughter was part of an investigation that they were carrying out at the Countess of Chester Hospital as her care was within the time limits that they were looking at. It very much felt at that stage -- again, because we didn't really view her care as Countess of Chester Hospital because she was transferred out to Arrowe Park; she was only there hours -- and in our mind it was a little bit of process of elimination and she had just fallen inside that timeframe and so they were obviously just going through what they had to go through. Not for one minute did we ever foresee any of this at that time.
LANGDALE: You say:
"We were only told that [Child K]'s treatment definitely formed part of the police investigation in July 2018."
MOTHER K: Yes.
LANGDALE: So did you get another telephone call or a visit about that?
MOTHER K: It probably would have been both. So they would tend to phone to give you, I suppose, the high level overview of where they were at and what was going to happen and then they would come out and sort of sit with you and go through it into the detail of what they would be allowed to explain to you, so from how the experiences go -- I can't say 100% they -- but I would assume they would have done both at that time.
LANGDALE: When were you told of the mechanism of harm that was alleged in respect of Baby K [Child K]?
MOTHER K: That was maybe a couple of months before the criminal trial started. We were told by our counsel team what had happened because, by the same token, we had asked quite a few times for us not to learn it while we're sat there in the court proceedings; that it would obviously be helpful for us if we were aware of what had happened and be told as much as what we could be told to some extent before we were sat learning it at the same time as everybody else, so we had a meeting. That was worked on by the counsel teams and agreed what we were able to be told and it was at that meeting that we were told what had happened.
LANGDALE: Did you ever have any contact with the Countess of Chester Hospital about Letby's involvement in [Child K]'s care or anything about Letby?
MOTHER K: No, nothing, no.
LANGDALE: One of the matters you say you learned at the trial in particular was, as reflected in Mr Justice Goss's summing up, the impact it might have had were Baby K [Child K] cared for in a tertiary centre, in a better centre. Can you tell us about that? What did you hear about that?
MOTHER K: No, basically what was said and we were told was that if our daughter had been born in a tertiary centre she would probably still be here and that's the hard sort of fact of it; that she needed that specialised care and you generally just didn't understand the need for that and we were aware of the fact that she needed to be transferred but also aware of the fact that she -- they were equipped to stabilise her -- in Chester to be transferred, but yes, it was the fact that she would probably be here.
LANGDALE: Or with improved outcomes, I think it said, with improved outcomes for her?
MOTHER K: Yes.
LANGDALE: You didn't make contact with PALS or any other organisation, but from what you're saying at the time you didn't have concerns?
MOTHER K: We were completely oblivious. As I said, to even class her care under the Countess we didn't because she was there for hours; for us, she was cared by Arrowe Park, so yes, we had no reason to follow up with anything.
LANGDALE: Recommendations that you invite the Inquiry to consider.
You say, first of all, at paragraph 166:
"A simple flag on medical records to alert and assist medical staff quickly to your history and that a baby loss has occurred ..."
MOTHER K: Yes. So it would be very useful if people were aware of your circumstances quite quickly and it would alert them to the fact that maybe they need to delve a little bit deeper into your medical history before they have initial conversations with you. You found like you were repeating yourself quite a lot sometimes with whenever you were speaking to people or anything like that which was unnecessary really if they had actually read your medical records -- so just having that quick way to recognise -- especially when you're going through your next pregnancies -- you're very heightened with what the outcome can be and your reactions might be slightly different to, a mother that hadn't gone through that and that flag would assist the staff to be able to accommodate maybe, you know, that little bit of extra anxiety that you might carry or that little bit of extra support that you might need, or, you know, little things like for example when we had our daughter's eldest sibling, they had to have the same glasses on as what our daughter did. They were the baby didn't leave my side, the baby was there with me. But just reseeing that again, you go into overload with it and, you know, to be fair the midwives were a little bit like -- you could see them looking at you thinking "Where has this reaction come from?" I was just upset, and so with that flag it might have made them look at your history to sort of understand and appreciate that a little bit.
So for me that would have helped and just alleviated some of the questions and conversations.
LANGDALE: You also refer to the need for accurate recording of information and, on transfers, CCTV which we have discussed, but you say changing attitudes and relationships between clinicians and management teams within the NHS is a concern for you.
MOTHER K: Yes. I think that you can put these mechanisms in place that will assist and help and alleviate anxieties and pressures. However, through a lot of this, which I am assuming will come out later down the line and conversations, my understanding is there's such a disconnect between those clinicians that are on the floor and the management that sit at the top. They have different roles to play and I understand that, but that connectivity should be there and that mutual respect and understanding should be there.
These clinicians had raised concerns that were very hard for them to understand and get their head around and I don't feel like they were listened to. There's actions that could have been put into place by management a lot sooner to alleviate some of the next steps that have happened and my biggest thing as well is they need accountability. There's no accountability for anybody in a senior position to make -- if they don't make the decisions based on information that they're given, they need to personally be accountable for it. There's many organisations out there that have that in place. They're not dealing with lives but they are held personally accountable, they will be fined, they can be put into prison, because they haven't followed processes and procedures that are put in place to safeguard against these issues.
That's exactly the same as what happened in the Countess, but they're dealing with people's lives and the impact of that is forever. It doesn't stop. It doesn't stop. For myself and my husband, the ripples are unbelievable and I never appreciated that and, you know, you're around and you hear it but you don't appreciate it until you're in it and it's scarred your life, it's changed you. You look back and you don't only just grieve your daughter, you're grieving who you were. I grieve who we were as a husband and a wife.
It just completely destroys what's around you and you have to pick yourself up and find out who you are again in this new world and it just doesn't stop, it doesn't go away and we live with it every single day and for nobody to take accountability for that or ownership for that is not right. It can't continue to be like that because this will happen again because what's the reason to stop them? There is no reason. They just protect themselves.
LANGDALE: You conclude your statement, Mother K, at paragraph 173, with some acknowledgement of the people that have helped you along the way in all that you have experienced. I don't know if you want to reflect some of that now, read that, or parts of that; however you choose to complete your evidence, or at least your questions from me.
MOTHER K: "Finally, I would like to say that along with this unthinkable and stressful process I have met some of the most amazing and caring people which I'm so thankful for. They have touched my life in many ways and somewhat restored my faith in humanity that was not present at the start of this ordeal. We have all been fighting our own battles but have also managed to support and care for each other along the way. I believe this has enabled some healing to take place as you've discussed your thoughts and feelings with people that have been going through the same as you. We have a long road to go but evil will not prevail. I hold on to the faith that we will make it, our children will make it and know that life can be good and filled with adventure and surrounded by people that will care, support and love you each and every day."
MS LANGDALE: That concludes my questions, my Lady.
LADY JUSTICE THIRLWALL: Thank you, Ms Langdale.
Mr Baker.
MR BAKER: I don't have any questions.
LADY JUSTICE THIRLWALL: No, thank you.
MR BAKER: If we could have a short break so we can just review Mr K's witness statement before it is read out.
LADY JUSTICE THIRLWALL: Of course. There is no need for you to leave the room, we can leave the room.
(3.32 pm) (Short Break) (3.57 pm)
MS STANGER: "I, Father of [Child K] will say as follows:
"My personal details are duly removed from this witness statement to protect my identity and I can be identified as the father of [Child K] who died aged (redacted) days old.
"I make this statement at the request of and to assist with the Public Inquiry to examine the events at the Countess of Chester Hospital and the implications following the trial and subsequent convictions of former neonatal nurse Lucy Letby of murder and attempted murder of babies at the hospital, of which my child was one.
"My wife, Mother of [Child K], and I have spent many years involved with the investigation into the actions of Letby and the subsequent criminal trial. At the criminal trial which took place between October 2022 and August 2023, the jury were unable to reach a verdict in respect of [Child K] and as such, a re-trial specific to our baby took place commencing on 10 June 2024.
"As part of the initial police investigation named 'Operation Hummingbird', my wife and I both provided our witness statements. However, since that date further evidence has come to light through our involvement in the Inquiry and more recently the re-trial has alerted us to the full extent of Letby's actions and the concerns that had been raised as to her involvement in the deaths of a number of babies.
"I take this opportunity to provide my statement to the Inquiry as to my own experiences and my concerns regarding the care afforded to my baby at the Countess of Chester Hospital.
"With the exception of the statement I provided to the police and one session of counselling in around 2022 this is the first occasion that I have discussed the events surrounding [Child K].
"Background.
"I grew up with my mum, my dad and sisters. My dad worked whilst my mum stayed at home. After I left school, I went straight into employment. My sisters both have their own children with my eldest sister being very young when she first had children. I've got a large extended family and I see a lot of my cousin as we have children of a similar age.
"I first met my wife at a local pub when I was a teenager. Although we were young, we wanted to start our life together. We bought our first house when we were in our early 20s. We both worked full-time in demanding jobs.
"After a few years, we decided that it was time to start our family. My wife always wanted four kids. I was happy with one of each but welcomed more. I always knew when we first got married that we would have children and that, when we did, they would come first.
"I wanted to have children before my wife. I always wanted to have them young and be an engaged dad. All I want to be is out and about with the children. I love being with them.
"I knew as soon as I had any children, girl or boy, that I wanted them to learn to swim early as I love the water. I wanted that to be our thing that we did together along with teaching them to ride a bike once they could walk.
"In 2015 my wife found out that she was pregnant with [Child K]. We were delighted but it was massively tempered due to (redacted). I can't remember now when we told people, but I think we held back a little because my wife wanted to wait a while.
"I went to all of the appointments with my wife at the Countess of Chester. After the first scan we were told that there was some fluid on [Child K]'s neck and we had some tests done. We had tests for Down's syndrome and they came back clear. My wife's midwife, Jill Edwards, has passed away now but she was a fantastic woman. It was a bit of a worry because I didn't know what was going to happen but the more and more scans we had, we believed it was getting smaller. I was starting to think that it was going to be okay. As the weeks went on, I started to get more excited. I could see on the scans that the baby was getting bigger, the fluid is getting smaller and I was happy.
"Jill and my wife's obstetrician, Mr McCormack, seemed to be very good friends. She always referred to Mr McCormack if there was anything. We didn't find out if we were having a boy or a girl. I wanted to but my wife didn't.
"I went with my mum and we bought the Moses basket in preparation for baby's arrival.
"We were told that there was a little bit of fluid on [Child K]'s lungs but no one seemed to be concerned. Everybody was telling us that the baby was okay.
"A few weeks later in the morning my wife said to me that she felt a bit off. To start with it didn't seem too bad, but she had a shower and was getting ready for work and it hadn't gone away. She seemed a bit uncomfortable and she had had some spotting. I said she needed to call the midwife and let's just go in to be checked.
"After some calls, we went to the Countess of Chester Hospital just after 9 am. I had contacted my employers to tell them that I would be late. When we arrived, we were taken to a side room and my wife was examined. We were told she was progressing with labour. I didn't have a clue what was going on. I had to ask my wife what was happening and she told me it meant that the baby was starting now. We had only gone in to get checked over and the next minute we were having the baby.
"My wife was admitted onto the labour ward and we were told that they would try to slow it down. One of the injections was for [Child K]'s lungs to try and bring them on a bit. I was concerned for my wife because she was lying there uncomfortable and I felt so useless. I didn't know what to do or say. At that time, I wasn't concerned about my wife or [Child K]'s care. They know best. [Child K] was the first child we had. I had never been in that process before so I didn't know what was happening.
"All we were told was that they were going to transfer my wife. We didn't know why. I know now as part of the lengthy investigation process that Preston was mentioned but I don't think that Preston was mentioned at that time because I knew where that was. I believe it was somewhere else that was mentioned first.
"It could have been Bristol or Stoke that was mentioned. I cannot be sure now.
"Our view at that time was that we would do what we had to do. We would go wherever we needed to go and I would have got there. Eventually we were told that my wife couldn't travel because it wasn't safe any more. At that point I thought, 'why are we staying here now? You told us that you were looking for another bed in a hospital because that was a better hospital.'
"We were expecting [Child K] to arrive soon and at one point a youngish male came down to speak to us. This is Dr Ford, who also provided a statement to the police. He said that [Child K] was going to be breach, they were premature and that they were monitoring the baby. I wasn't sure at that time whether he was an Obstetrician or from the Neonatal Team. I was just focusing on my wife and my baby and I understood that the labour was moving.
"I remember that there was a conversation about a caesarean section but all I remember is that it was an option. I don't really remember much more because it was such a blur. Everyone was in the room with us.
"I knew that there would be a Paediatrician when [Child K] was born and they said that we wouldn't be able to have a cuddle. They wanted to get [Child K] to the cot and stabilise them as quickly as possible.
"My wife was given a second dose of steroids and during another ward round in the morning [Child K] had turned round again. I think that my wife wanted a natural birth but I don't think that we ever refused a caesarean section. There was just too much going on in there to listen and take it all in. My focus was on my wife. I didn't need to worry because the doctors were doing what they needed to do. I just had to make sure that my wife was okay. I was just holding my wife's hand and letting the midwives and doctors get on with it.
"My wife was the active one in the discussions with the doctors and midwives. We were having the injections for [Child K]'s lungs to try and push them along. Again, if [Child K] needed it, they needed it.
"I thought that we were in the safest place and I was relieved that we didn't need to travel but would have done it if that was the best thing for [Child K]. They explained that it wasn't a good thing to move my wife because it was a lot safer to have the baby born in Chester. The labour room was only small and it was constantly black in there. There were people in and out all of the time so it was hard to know who we spoke to and what was said.
"In the statement I gave to the police I refer to a conversation I had with the midwife about fostering because she was adopting the boys that she had been fostering. She was a short-haired woman.
"Delivery.
"Before [Child K] was born, I stayed with my wife the whole time. Around midnight on the day [Child K] was born, we had fallen asleep. My wife woke me up and said that she was in pain. Her mum and sister were with us. I panicked and pressed the buzzer. The room was filled with people as I held my wife's hand.
"I always refer back to the young white male Consultant I refer to in my statement to the police. He had short dark hair and was wearing glasses. At the time I thought maybe it was a trainee, but I now know him to be Dr Ford who provided a statement to the police. When he was in the room everyone was doing everything around him but it got to a point and he stepped in. My wife screamed as he did whatever he needed to with Childs K's foot, unhook it, I think, and the next minute I saw him pass [Child K] to another doctor.
"When [Child K] was born, she was a reddy purply colour. They asked whether I wanted to have a quick look at [Child K]. To be honest I wanted to see [Child K] with my wife but she said to go and have a quick look. I wanted to know she was really here.
"Even after I looked at [Child K], I didn't have a clue whether they were a boy or a girl. My wife asked me and I couldn't tell her. Then one of the doctors said, 'Oh, sorry, it's a little girl'. I was over the moon. [Child K] was here. [Child K] was okay.
"[Child K] was tiny -- really, really small. I know now that the medical records say [Child K] was floppy. I didn't even hear [Child K] cry. I could see the cot but couldn't see into it. There were too many people.
"It felt like a long time that the Paediatrician was with [Child K] but it's going to seem like a long time when you're waiting to hear a cry. My expectation was I was meant to hear a cry but it never came. There was no cry.
"When [Child K] was taken to the Neonatal Unit, I let my wife go to sleep and then I phoned my mum to tell her that [Child K] was here.
"Neonatal care.
"I went to the Unit by myself at first. I couldn't sleep because I was so excited. I have a baby girl. I just wanted someone to come and say that everything was okay. I was over the moon. [Child K] had just been born. I didn't feel worried because we were in the hospital; we were in the right place so I thought that whatever needed to be done for [Child K] was going to be done. I wanted to know that [Child K] was okay.
"My wife was absolutely exhausted because of what she had been through, so as my wife slept, I decided to go and see [Child K]. I knew I couldn't get through the double doors to get onto the Unit but walking to the Unit really wasn't far and there was a window into the nursery which I could look through. I can't recall the exact time I went.
"I was looking through the window and there was somebody with [Child K]. I couldn't say if it was Lucy Letby; I couldn't say it was anyone, it has been nearly nine years. But there was someone standing by [Child K] and I felt uncomfortable. I'm not sure if uncomfortable is the right word, but I didn't want to get in their way. I know I couldn't be in the way because I wasn't in the room but I didn't want to distract them from what they were doing. I can't remember if there were any other babies in the room. My focus was on [Child K]. I was so excited. I wanted to tell people that the baby had arrived and was okay.
"Now, I feel guilty that I didn't stay and watch for that little bit longer.
"We couldn't get onto the Unit without a member of staff. We didn't see [Child K] being resuscitated and we were not told that this had been needed. If I had known then I would have asked why, and I never would have left [Child K]'s side. If we had known and asked questions maybe Dr Jayaram would have taken it further at that stage because we would have demanded answers.
"I now know that it was Joanne Williams that told us we could go to see [Child K]. She came into the room on the Labour Ward. I don't know now if my wife had woken up or whether it was the door opening and the conversation that woke her, but Joanne said that [Child K] was stable, [Child K] was fine. She asked if we wanted to come and see [Child K]. Of course I did.
"We jumped at the chance to go and see [Child K]. My wife got into a wheelchair and someone took us into the Unit because you had to be buzzed through the double doors to get into the nursery. We sat on the left-hand side of [Child K]. [Child K] had all kinds of tubes attached to her which obviously needed to be there. I just couldn't take my eyes off [Child K]. She was so tiny, so small. Her whole hand sat on my thumb. A photograph was taken of us while we visited. I thought that they were doing their job. There was nothing to make me worry. All I was told was that [Child K] was doing okay. I knew that [Child K] was small and we knew that [Child K] was going to be poorly, but she was stable and here. We spent maybe 15 or 20 minutes with [Child K]. My wife put her hand into incubator and I think I did too. We knew that [Child K] would need to be transferred to Arrowe Park but we didn't know when so we should rest before the transfer.
"We went back to the Labour Ward and my wife got back onto the bed. She needed some clothes so she told me to go home, get a shower and collect our things. I can't remember exactly but I think I went to my mum's first just to say that [Child K] was here, then went home. I know that we would have been told that [Child K] was stable, as, if not, I never would have left.
"[Child K]'s Breathing Tube and Desaturations.
"While [Child K] was on the Neonatal Unit there were three separate incidents when the breathing tube had become dislodged and [Child K] required resuscitation. Nobody told us about these episodes whilst we were in Chester. We only became aware of these facts when we had a meeting with the Crown Prosecution Service at Knight's Court just before we went to trial for the first time when we were also told that the murder charge would be dropped. It was only then that we were told what had happened.
"I now know that there were three episodes when [Child K]'s breathing tube moved: at 3.50 am (which is before we first visited the Neonatal Unit); at 6.30 am and 7.30 am on (redacted) February 2016. If I had known, I would have asked questions. I would have asked what they were doing. Dr Jayaram would have had to explain to me there and then why [Child K]'s tube had moved and how it had moved.
"I now know that the first episode took place before we went onto the Neonatal Unit because my statement to the police confirmed that the photographs we took of the three of us were at 4.31 am. I can't help but wonder whether I was looking through the window of the Neonatal Unit around the time that this episode took place but I didn't see anything that made me worry for [Child K]. I would have been back at the hospital with my wife by the time the second episode took place. From what I have been told, the last episode took place at the end of Letby's shift.
"Transfer to Arrowe Park Hospital.
"The transfer team arrived in the morning of (redacted) February 2016. I expected this to happen. I remember them saying that they were struggling to stabilise [Child K]. All that went through my mind was 'Why was someone stabilising [Child K] when these doctors have already done that?' We were waiting a long time, a couple of hours I think. My statement to the police confirms that the transfer team arrived around 9 am. They came and introduced themselves and told us what was going to happen with [Child K].
"[Child K] didn't look any different from their birth at this stage. [Child K] had been moved into a transport incubator. At some point whilst the transfer team were with [Child K], me and my wife talked about naming [Child K]. My wife had always liked the name, and it was one of the names we had, so I said to my wife that if she wanted to call [Child K] that name, we would do.
"At one point Dr Kamalanathan, the specialist transport Paediatrician, said "Come on, we've got to go, it's now or never, we're going to go". My statement to the police confirms that it got to around midday when the transfer team told us that it was now or never. All I can remember is saying goodbye and walking out behind [Child K] as she went into the ambulance and the ambulance left. We went back to the Labour Ward where we showered and changed ready to follow once my wife was discharged. Once this happened, we went straight to Arrowe Park.
"Care at Arrowe Park Hospital.
"We got to Arrowe Park and went straight to the Neonatal Unit. I feel like to start with [Child K] looked a better colour. I have photographs of [Child K] in both Chester and Arrowe Park. There was a certificate for [Child K] for making the journey. Nobody told us anything that made us worry for [Child K], so we drove home and gathered more clothing as we were going to stay at the hospital. We weren't at home for long before we just wanted to be back there with [Child K].
"We were given a room to stay in at the Ronald McDonald House. To get to the Neonatal Unit from the room you had to come down in the lift, come out through the corridor and then went round a corner. Then you came into the Neonatal Unit and [Child K] was right there as soon as you walked through the door. She was in the end cot.
"To start with there was nothing that looked unusual about [Child K]. A little bit later, [Child K] started to swell and she was a different colour. Towards the end, [Child K] looked very swollen and bruised.
"At Arrowe Park, [Child K] dropped her oxygen support and I remember saying that it was good that they weren't on 100%, but then it went back up to 100% shortly afterwards.
"The doctors talked to us at [Child K]'s cot every day. They always started with [Child K], perhaps because she was the poorliest. There was always a nurse with [Child K]. They were doing what they could for [Child K].
"My mum, dad and sisters came to visit [Child K], along with my wife's family. We showered, slept and ate but the rest of the time we were with [Child K]. We didn't leave their side.
"The night before [Child K] passed away, we spoke to one of the doctors, Dr Barbarao, and he said that [Child K] was very, very poorly. I can't remember his exact words but it frightened me and that is probably the reason why we didn't really sleep that night. It would have been late when we left [Child K] to get some sort of sleep.
"I thought that my wife was asleep and she thought that I was asleep and I just remember her asking if I was awake. We decided to go down and sit with [Child K].
"[Child K]'s Last Moments.
"The doctors on the Unit had previously told us what the numbers on the machines mean and where they would like [Child K]'s reading to be so when I walked in there I knew things weren't good, especially from the night before. No one needed to tell us. They were too low. I knew from the look on the doctor's face, that we now know was Dr Gardner, that [Child K] had deteriorated and she was about to call us. My wife said '[Child K] is not going to get better, is she?'
"[Child K] had swollen up. She was a normal colour but had bruising around her chest and tummy.
"We spoke to the doctor and I said that I didn't want to hear the noise of the monitors any more. I felt it was the right thing to do to turn the machines off. It wasn't fair to continue.
"They took us to a little room outside the Unit. I wasn't in there long -- literally a couple of minutes -- and they brought [Child K] in. They brought our baby in and handed her to me as she took a breath. That was it. [Child K] only took one breath on her own in my arms.
"My wife sat with [Child K] and had cuddles. The doctor came back in to check on [Child K] and confirmed that she had gone.
"[Child K] had to go into a little cold bed. I couldn't understand why they had to go in there so quickly but, again, it was one of the things that if that's what needs to happen, then that's what needs to happen. I wish I could have held [Child K] for a little bit longer. Maybe I should have asked to hold them for a bit longer.
"During the course of drafting our statements with our solicitors my wife and I have spoken. She asked me if we should have stayed with [Child K] for a little bit longer. Maybe we should have done but we had to leave [Child K], didn't we?
"The drive home was so horrible. I couldn't leave the carpark at first. I was leaving my first born. I went to drive off and my wife asked me if I was okay and I wasn't. I didn't want to leave, but at the same time I just wanted to go home. My mum wanted to come round but I said no. I didn't want to see anyone or anyone to be there. I couldn't believe that this had happened to us.
"Police Investigation.
"We didn't know anything about Lucy Letby or issues with [Child K]'s treatment until my wife received a phone call from the police in May 2017. I was in work and my wife rang me very upset. She said she had had a phone call from the police and that there was an investigation on a nurse in Chester Hospital. They were looking into all the deaths within a timeframe so [Child K] fell into this. I was at work at the time of the call, so I went straight home.
"The police came round in the evening to discuss further. One of the Family Liaison Officers and a male officer visited. Again, they said that they couldn't say for definite that [Child K] was one of the babies involved but they were looking into [Child K] because she fell within the timeframe. We were just told that it was an investigation into a nurse in Chester Hospital. We didn't know if it was a man or a woman and we weren't told Lucy Letby's name. I asked why they couldn't tell us more and was just told that they can't. I can't remember if we were offered any support at that stage.
"I was in denial at that stage. I thought [Child K] had passed away because she was early and because she was so sick. You would never think in a million years that something would happen to your baby in hospital. Knowing that the police can't give you any information didn't make it easier for me. I was running wild in my head about what might have happened to [Child K].
"I don't remember when I first saw Lucy Letby's picture, but when I first saw it I couldn't say I recognised her, in the same way I wouldn't recognise Joanne Williams who came and got us to visit [Child K] for the first time. I wouldn't have noticed her because my focus was on my wife and [Child K]. When we first saw the picture I asked my wife if she recognised her but neither of us could be sure. There's one picture where she might have been more recognisable for my wife but even then we cannot be certain. I didn't even recognise Dr Jayaram and he was at the Resuscitaire with [Child K].
"Subsequent Pregnancies and Experiences.
"After [Child K] passed away, we had an appointment with Mr McCormack to discuss my wife's pregnancy and why she went into premature labour. This appointment didn't involve a discussion about [Child K]'s care once born.
"When I found out my wife was pregnant in 2018 I was over the moon, but I was also petrified. We knew about the investigation and that [Child K] might be one of the babies involved whilst my wife was pregnant. I remember asking my wife whether we were going to go to Chester still with all that was happening. However, she was happy with her midwife, Jill, and the support she was receiving at this time.
"With all of my wife's later pregnancies we didn't tell anyone for a long time. Even after the first three months we didn't tell anybody or buy anything. My wife had extra support from her midwife, Jill, for the pregnancies with [Child K]'s elder siblings.
"When [Child K]'s eldest sibling was born the baby was given the same type of little black glasses that [Child K] had worn for her treatment for jaundice. I was petrified seeing that again. They were kept on them for a couple of days until the jaundice improved.
"When we had our youngest child, the Countess of Chester Hospital discharged the baby before they should have been seen by the Neonatal Consultant. We got back home and had to take the baby back to hospital. I was so angry. They discharged my baby and they should never have been discharged. I told her what we had been going through with Letby and she was so apologetic. I only tell people occasionally what's happened because I don't want to tell anyone but that time I was so angry. They were not watching what they were doing.
"With [Child K] I stepped back and let the doctors get on with their job, but with each of my wife's other pregnancies I have asked more questions which carried on when they were born. When [Child K]'s eldest sibling needed the glasses I asked why and they told me it was jaundice, so I asked what jaundice was and what it meant. I was involved with conversations and asked over and over until I was happy.
"[Child K]'s siblings never left our side whilst we were in hospital. The children have had nights away from us with both of our families. When my wife went back to work full-time they went to our childminder who was and is brilliant with all of our children. I felt okay leaving [Child K]'s eldest sibling with the childminder but only because my cousin's little girl had been there too and I asked my cousin if our eldest would be safe. Our childminder knows what has happened so is extra thoughtful with messages and photographs throughout the day.
"The children have stayed at their nan's house a couple of times and they have been to my mum and dad's caravan a few times but I can count on one hand the number of times they have been.
"Counselling and Support.
"I can't talk about what happened to [Child K], it scares me to remember and I don't want to think about it.
"I have been offered bereavement support and counselling but I never wanted to speak to anybody.
"My wife spoke to the bereavement midwife but I didn't want to. My wife said I should have had some counselling and encouraged me so I went to one session a couple of years ago. I said I didn't think I needed to because I didn't want to go through it all again but she said that it had really helped her. So I thought I'd try it. I didn't like it, so I said at the end of the session that I was going to be honest, that I didn't want to do it again. I just felt uncomfortable, it was nothing to do with the counsellor, they were lovely and they made it a lot easier for me. But for me, it just made me relive it. Later down the line I might think,
"Do you know what? I'm ready to speak to someone now, I'm stronger and could cope better with it", but at the moment, it's hard to say. I feel like right now I'm just putting one foot in front of the other.
"Medical records.
"We never asked for [Child K]'s records because we didn't know the truth. I had no reason to ask for her records. The first time I heard about our medical records was during the criminal trial. In the re-trial they went into more detail.
"Experience with the Press.
"We have only been visited by a couple of people at home. One guy gave me his number and I just shut the door and on another occasion a workman called me because he had answered the door to the press.
"Information sharing.
"According to the witness statement I provided to the Police, the photographs we took on my phone were taken at 04.31 am on the morning of (redacted) February 2016. They were saying that the first time with the tube was around the 03.45 am or 03.50 am mark, that means it was before we visited. Why weren't we told? There were another two episodes, why weren't we told? Without a shadow of a doubt I would have stayed with [Child K] if I had known.
"At the time I did not know that there were different levels of hospitals; I thought that one hospital was the same as any other.
"We only found out about the three desaturations just before the first trial when we met with Pascale Jones and Nick Johnson at Knight's Court and heard Dr Jayaram's evidence during the re-trial. Up until this meeting, no one had sat us down to explain what had happened to [Child K]. I now know that her three desaturations were due to her breathing tube being moved. If we had been given this information it would have stopped all the running around in my head. Like with [Child K]'s pictures, when I used to look at them I saw the bruise and I thought that maybe it was something Lucy Letby had done to [Child K].
"I did not know about the report of the Royal College of Paediatrics and Child Health into neonatal deaths and the NNU at the Countess of Chester Hospital or the Advisory Report of Dr Hawdon until my solicitors made me aware of them during the disclosure process relating to the upcoming Inquiry hearings. We had no idea about any of the investigations into neonatal services and unexplained collapses until we were contacted by the police. I believe we should have known about these investigations sooner.
"If we had been given this information earlier, I would have asked questions. If I had known about the first desaturation, then would the second one have been able to happen? I would have pushed for answers as to how and why they were happening. It was such a long time afterwards that we have been given this information; they should have shared it. It's obvious to me that they were hiding it and it makes me angry.
"As detailed above, we have not been in contact with the Trust about [Child K], which includes PALS. We didn't think that there was a problem until the police contacted us. We haven't been contacted from any other organisations about neonatal care.
"The Trust haven't been open and honest with us about any suspicion of harm caused to [Child K]. We were never told about the desaturations.
"Recommendations.
"When we met for the public inquiry, one of the mums mentioned about a flag for medical records of bereaved parents. Just recently, I heard my wife on the phone trying to get a sick note and they asked why. So it feels like we have to explain what's happening again and again. I don't know how everyone else feels, but for me it would help to have this flag because the doctors have to read their notes before they speak to us so they would know what's going on without me repeating myself.
"If there had been CCTV that was being monitored that would have prevented some of the deaths. I think it's a good idea to put CCTV in the nursery but can't help but think it's only being looked at now because of what's happened. It's a massive cost to put it in, but it's about keeping children safe. It shouldn't just be in the Neonatal Unit, it should be for all children.
"There should be one person to sign drugs in and out and confirming which baby it's for and why. It needs to be more regulated, perhaps even a swipe operation to open up these cabinets that contain medications.
"Information should be given to patients or their parents there and then. Whether that's to an old-age pensioner or a baby, they should be told so they can make their own decisions about what happens next and what impact that has in their lives."
LADY JUSTICE THIRLWALL: Thank you very much indeed, Ms Stanger.
Mother K, Father K, I know that underneath those names there are real people. Thank you very much for coming today and for giving your evidence. You have absolutely perfectly communicated, both of you, your profound love for your daughter and there's a really very vivid description of inexperienced new parents dealing first with the joy and then the huge loss and how it changes everything and you, Mother K, rightly said people just don't know if they haven't experienced, so thank you for sharing that so generously with us.
You have really well described what your experiences were, which, as you know, I'm looking at in Part A of the Terms of Reference and thanks also for the thoughtful observations about what helped and what didn't, and also your very frank acknowledgement of when there was good care and kindness shown to you by the many people who were involved in looking after you, Mother K, and your daughter, and it was interesting to learn of the help that you derived from the contact that you had with the bereavement midwife. I had not heard of that before, so it is particularly useful to me and thank you for your suggestions in respect of the need for accountability and much more besides.
I do know how difficult the process of this Inquiry has been for you. Thank you both very much for giving your evidence today and that concludes the need for you to be here. Obviously, you can come back at any time that you wish to, but no one is going to ask you any questions any more.
THE WITNESS: Thank you.
LADY JUSTICE THIRLWALL: So we will finish now and we will start tomorrow morning at 10 o'clock.
MS LANGDALE: 10 am.
LADY JUSTICE THIRLWALL: Thank you all very much.
(4.33 pm) (The Inquiry adjourned until 10.00 am on Tuesday, 24 September 2024)
LADY JUSTICE THIRLWALL: Good morning, Mr Skelton.
I understand we've got Father L&M on the line --
MR SKELTON: Yes, my Lady.
LADY JUSTICE THIRLWALL: -- listening and I understand that he can see us, so thank you very much indeed for being here, Father L&M. I understand Mr Skelton is going to read a statement on your and Mother L&M's behalf.
MR SKELTON: Thank you.
MS LANGDALE: My Lady, before we do that --
LADY JUSTICE THIRLWALL: Thank you. Sorry, Ms Langdale.
MS LANGDALE: -- and before we turn to today's evidence, we understand from the solicitors representing Mother and Father J that Mother and Father J would like to correct something they said in evidence yesterday.
Their meeting to raise concerns about Baby J [Child J] was with Dr Saladi and a nurse, but that nurse was not Eirian Powell as stated. We will explore in oral evidence, my Lady, which nurse it was in due course.
LADY JUSTICE THIRLWALL: Thank you very much indeed, Ms Langdale.
Mr Skelton.
MR SKELTON: Thank you. Witness statement of Father L&M dated 17 July 2024.
"I, Father L&M, will say as follows.
"I am the father of [Child L] and [Child M]. I make this statement on behalf of myself and my wife, Mother L&M.
"I make this statement in relation to the Inquiry into the events on the neonatal unit at the Countess of Chester Hospital. As the Inquiry knows, Lucy Letby has been found guilty of causing harm to and the death of several children at [the hospital]. She was found guilty of attempting to murder both of our children in April 2016.
"The contents of my statement are accurate and derive from my own knowledge. Where the contents are not from my own knowledge, I have specified where the information came from. This statement has been prepared following discussions with my solicitor taking place on the telephone. I have also relied on information contained in the statements my wife and I prepared in the criminal proceedings.
"Impact.
"As stated, Lucy Letby was found guilty of attempting to murder both [Child L] and [Child M]. The babies were born [in April] 2016. Lucy Letby tried to murder [Child M] on 9 April 2016 and [Child L] from 9 April 2016.
"We are asked by the Inquiry about the impact of events at the [hospital] and subsequently on our family. My wife and I have already provided statements to the police and a victim impact statement. My wife's statements are dated 27 March 2019; and dated 17 April 2023. My statements are dated 5 March 2019; and 17 April 2023. I would ask that the Inquiry read those documents alongside this statement, but also here set out below are some extracts from these statements.
"In my wife's police statement she wrote:
"'Being involved in this case has taken its toll on our family and seeing my husband suffer throughout the last five years has been heartbreaking for me to witness. The doctors told us that the whole events that took place in 2016 surrounding my children were normal for premature babies and we believed what the doctors were telling us at the time. Little did we know that a year or so after their birth the Police would come knocking on the door and break the news that this could be an attempted murder case.
"'I was second on the scene when [Child M] had his collapse as I was still on the ward at the time. My mental health has suffered as a consequence of this case and I have some good days and some bad, especially as the trial was about to begin and anxiety levels increased.
"'The boys had to witness their dad suffer a seizure for the first time in their life which was traumatic for them and I believe this would never have happened without the enormous amount of stress and anxiety this has placed on us as a family and I have also suffered from restless sleepless nights throughout this five-year ordeal waiting for the case to come to court'.
"To be clear, the reference above to being told by doctors that the events in 2016 were normal for premature babies refers only to [Child M]. As I explain below, at the time we were not made aware of any concerns about [Child L]'s condition.
"In my statement to the police, I wrote:
"'The whole event surrounding this case has taken its toll on me both physically and mentally ...
"'I was first on the scene when [Child M] had his collapse, and that image has been forever etched in my mind and this case has been going on for five plus years (it is obviously longer now). The stress and strain has been unbearable at times and my mental health has suffered as a consequence of this case.
"'I had to take time out of work and seek counselling. I have also had to take a course of anti-depressants to help me cope with this. Even though they have helped they can never take away the feelings I have as a parent knowing now what truly happened at the Countess of Chester in 2016 and it doesn't make it any easier to cope with over time ...'
"I had a seizure for the first time in my life as we approached the criminal trial. This happened in front of my children and was very distressing for them. The doctors attributed this to the stress and the pressure of what had happened to our children.
"I cannot get the image of the doctors and nurses trying to do CPR on [Child M] out of my mind or being told we needed to come quickly to the neonatal unit. Even to this day I get flashbacks to what I saw on the unit. I get chest pain, have trouble sleeping and struggle to manage my diabetes sometimes. I used to think I was a very happy-go-lucky guy but now I find myself struggling with my patience which has naturally affected my relationship with my children.
"[Child L] is very clingy to his mother and neither [Child L] nor [Child M] would sleep in their own beds. We had some concerns about [Child L]'s behaviour as he grew up but now we know it is just his personality. [Child L] also had some minor speech problems but we have been reassured by the doctors that he is fine.
"I explain below that [Child M] had a brain scan after his collapse. This was reported as normal but we still have concerns that there may be a problem as he grows up but for now we are happy the twins are fine and healthy. In the evidence at the criminal trial Professor Stivaros noted that there is damage to [Child M]'s brain which will not rectify itself and, over time, [Child M] may deviate from his peers in terms of attainment and cognitive and motor function. It still haunts me to this day that we do not know what the future might hold.
"Experience at the Countess of Chester Hospital.
"Delivery of our Babies.
"Our twins were born by caesarean section [in] April 2016 at 33 plus 2 weeks gestation at [the hospital].
"We knew early on that we were having twins and, up until March 2016, my wife had a routine pregnancy and the due date was (redacted) May 2016. In March, I took the day off work to take my wife to the hospital because she was not feeling well. Her doctor explained that she would need to be admitted straight away and I understood this to be because of the position of the babies in the womb. She had to be kept in hospital to be monitored for about two weeks. The plan, which my wife agreed with, was to deliver the twins with a caesarean section.
"[In] April 2016, I was at work and my wife rang me to tell me that the doctors at [the hospital] wanted to deliver the twins the following day due to the position they were both in inside the womb. My wife had remained in hospital until this time. I went home and packed a bag for her, taking it to the hospital that night so that everything was ready for the next day.
"The twins were delivered the next morning at 33 weeks and 2 days, by caesarean section. ... I was with their mother when they were born and I was allowed to see them both straight away. Lucy Letby and a nurse called Laura were present and took the babies to the neonatal unit. We were told they were fine and healthy. My wife was taken to a ward upstairs.
"I was able to go to the neonatal unit to see them again a few hours later and they both seemed fine, they just seemed like babies. They were in Nursery 1. I cannot recall who was looking after them when I went to the neonatal unit but they both seemed fine.
"I understood they were on the unit because they were small and they did not weigh very much - they each weighed just over 3lbs. I understood that we would be able to take them home within a few weeks.
"I have since learned that [Child L] had periods of low blood sugar which required treatment, but we were not aware of this at the time.
"[Child M].
"... the rest of our family came to see the babies. We all went together down to the neonatal unit, as did the mother of Child L&M. We were very happy and proud parents. All seemed well and no one spoke to us about any concerns.
"We had been back on the maternity ward for about ten minutes (having left the neonatal unit) when a nurse came rushing in to tell us we needed to come back to the neonatal unit immediately because something was wrong. I do not remember this nurse's name or what she looked like. However, in my wife's statement to the police she said that she thought the nurse was called Yvonne but we cannot be sure. This nurse did not give more detail at this time about what was wrong. I am advised by my solicitor that Nurse Belinda Simcock's police statement says that she sent a nurse called Ashleigh Hudson to get us.
"I arrived on the neonatal unit before my wife as she was in a wheelchair and needed to be pushed. When I got there, I remember seeing one of the doctors doing chest compressions on [Child M]. It was such a horrible image and has stuck with me forever.
"My wife arrived shortly after I did. She remembers that the nurse said that they would explain what was wrong when we got to the neonatal unit.
"In my wife's statement to the police she recalled that Lucy Letby was there, with the nurse called Laura, and another nurse wearing glasses and with a bob haircut, as well as a doctor.
"I do not remember much about what we were told or who was there on the unit. My head was just spinning at the time and my focus was only on [Child M]. I was just crying and crying and could not speak.
"In my wife's police statement she said:
"'When we got there one of the doctors was just pressing [Child M]'s chest. People were saying the boys were healthy yesterday and they didn't know what had happened today. One of the nurses with glasses and a bob haircut said she had done everything with him and he was absolutely good and she didn't know what had happened. I don't know her name but it sounded like she was the nurse in charge of his care. She was short and fair'.
"I remember the doctors trying to help [Child M] for about 30 minutes. They told us afterwards that his heart had stopped. I recall there was a conversation with me about withdrawing treatment for [Child M] because they had been working on him for so long and he was not coming back, but then he managed to recover.
"During this time one of the male doctors, who I now understand to be Dr Ravi Jayaram, took me and my mum into a side room on the unit. My wife was not present. He explained to us that these things can happen with premature babies. I understood that he was referring to [Child M]'s collapse and the need for resuscitation. I saw no reason to question that at all, it seemed to make sense.
"At the criminal trial into Lucy Letby's actions, Dr Jayaram explained that he had been involved in the resuscitation of [Child M] and had seen weird patches and discolouration on [Child M]'s skin when they were trying to resuscitate him. I also understand now that this would have been very rare and highly unusual. At no point was this mentioned to us as parents. We had no idea that anyone thought anything about [Child M]'s condition or presentation was unusual or suspicious. We were first time parents and had been told that this could happen with premature babies and so we had no reason to question anything or raise any concerns. Essentially we were given a reason for it which we accepted at the time. [Child M] was then not unwell again, so the explanation made sense to us in the circumstances.
"The Inquiry has referred me to the police statement of Dr Jayaram, dated 7 March 2019. I am informed by my solicitor that in this statement Dr Jayaram says that, during the resuscitation, he saw patches of pink flitting on [Child M]'s abdomen, which appeared to come and go a little bit. He says he remembers the patches being quite clear as [Child M] has quite dark skin and it was 'very unusual' to see these patterns. He then says that he saw very similar observations with [Child A] and that, as a result of his observations with [Child M] and [Child A] and conversations with colleagues, he carried out some research.
"Dr Jayaram's statement to the police also says that [Child M]'s resuscitation was done correctly but he did not respond as expected, but then suddenly and quickly recovered. He writes, 'these facts, combined with the pink blotches I saw, later made me question whether an air embolism was involved after reading the paper I found on the subject'. The statement also says '[if] [Child M]'s collapse had been a one-off, even in view of all I have stated above, I may not have thought anything more of it, however, this happened at a time when other incidents were occurring, a time when realisation was beginning to dawn on me and so I added [Child M] to my list of suspicious incidents'.
"The Inquiry has asked us what Dr Jayaram told us about [Child M]'s collapse. I have explained this above. We were not given more information about his collapse or the reasons for it until the police spoke with us in 2019. Blotches on [Child M] were not mentioned to us by Dr Jayaram or others at the [hospital]. We were not made aware by Dr Jayaram or others at the hospital that [Child M]'s collapse was being viewed as suspicious. The information set out above from Dr Jayaram's statement was not discussed with us by the doctor or others at the [hospital].
"The Inquiry has also provided the police statement of nurse Laura Eagles dated 27 February 2018. I am informed by my solicitor that in that statement Nurse Eagles says that she was made designated nurse for [Child M] on the day shift on 10 April 2016, starting at 07.30. Her statement refers to the handover notes stating that [Child M] had suffered a collapse the day before and was being treated for necrotising enterocolitis. We did not know that [Child M] was being treated for necrotising enterocolitis.
"My wife stayed in hospital for a further two weeks. She would visit [Child L] and [Child M] on the neonatal unit during the day, she would stay with them for a good few hours each morning and then when I finished work at about 4 pm I would go and spend the evening with them along with her. Once she was discharged, she would go every day to spend time with them just as before. The boys seemed perfectly well and, as far as we were aware, there were no incidents in that time or concerns about their condition. We were aware that [Child M] had a brain scan to make sure there had been no damage from his collapse. We were told that came back fine so we were really happy.
"[Child L].
"The Inquiry has referred us to our police witness statements in which we both recalled only [Child M] had issues early on. We are then asked if anyone at [the hospital] told us there were concerns about [Child L]'s condition while he was in the neonatal unit.
"The answer is no, no one told us there were concerns about [Child L]'s condition while he was in the neonatal unit.
"No one told us that [Child L]'s blood results had been abnormal and had shown there was far too much insulin in his blood stream. It was never mentioned to either of us as parents. In fact, my wife's statement to the police says that, after Saturday 9 April 2016, the boys were really stable and there were not any other problems. That was our understanding of the position. My wife was there every day. My statement to the police says there were not any other issues with the boys and 'it was actually only [Child M] who had the problem early on'.
"The Inquiry has asked us about evidence from Nurse Belinda Simcock has contained in her police statement dated 16 February 2018. I am informed by my solicitor that in this statement it says 'I would say that I was surprised that [Child M] suffered such a collapse as it was [Child M]'s brother [ie Child L] who had been more of a concern to us than [Child M]'. We were asked whether anyone said anything to us to indicate concern about [Child L] and whether we knew if there were any concerns about [Child L] at the time. As indicated above, the answer is no. We were not told about any concerns about [Child L].
"The Inquiry has also referred us to the police statement of Dr Stephen Brearey dated 16 April 2019. I am informed by my solicitor that this statement sets out when he first became aware of the possible administration of insulin to [Child L]. That statement refers to [Child L]'s hospital discharge letter, which stated: 'in his first 72 hours of life [Child L] did have notable hypoglycaemia requiring high concentration dextrose (up to 15%) via UVC. A hypoglycaemia screen at this time revealed normal cortisol and appropriately low insulin/C-peptide supporting a diagnosis of hypoglycaemia secondary to small size and prematurity rather than [any] other underlying pathology'.
"At the time, we were not informed that [Child L] had notable hypoglycaemia requiring high concentration dextrose.
"Dr Brearey's statement also says that in February 2018 he was asked to review the care of a number of babies, including [Child L]. He read the discharge letter referred to above and says 'I took this statement at face value which I recognise as an error of judgment'. He then says that in August 2018, the laboratory was asked to send insulin and C-peptide results and, on reviewing [Child L]'s results, it became clear his insulin and C-peptide results were abnormal and 'suggestive of exogenous insulin administration'.
"We were not told about this by staff at the [hospital] at any time. It was the police that first informed us in 2019 that they thought insulin had been used to harm [Child L]. It was not until we heard the evidence at the criminal trial that it was first explained about how this was likely done. The suggestion was that this excess insulin had been added to a number of fluid infusion bags for him.
"We were able to take the twins home after about three to four weeks.
"Causes of collapse or deterioration.
"The Inquiry has asked us a series of questions going to what we knew about concerns or investigations at [the hospital] and how we became aware that investigations were being undertaken in relation to neonatal services there in respect of neonatal deaths and unexpected collapses.
"We are specifically asked what, if any, investigations into [Child M]'s sudden deterioration we understood were going to take place at the time and whether we thought there was any investigation in relation to [Child L]. We did not know that [the hospital] was doing or going to do any investigation into [Child M]'s collapse. As explained above, we did not know there were concerns about [Child L] and so did not think there was any investigation into him.
"We heard nothing from [the hospital] about the events on the neonatal unit once we took the twins home. The first we ever heard about anything of concern was when the police knocked on our front door in 2019 telling us they wanted to speak to us about an attempted murder case.
"We are asked if we were aware that the Royal College of Paediatrics and Child Health undertook a review into neonatal deaths and the neonatal unit at [the hospital]. I am informed by my solicitor that this review is dated November 2016. We were not aware of that. We are also asked if we were aware of an Advisory Medical report prepared by Dr Hawdon dated 1 October 2016 in relation to babies who died or had cardiorespiratory collapses in the neonatal period at [the hospital]. We were not aware of that. I do not recall receiving any copies of the report from the Royal College of Paediatrics and Child Health.
"Suspicions and Concerns Regarding Lucy Letby.
"The Inquiry has asked if we had any dealings with Lucy Letby. I have already explained above that Lucy Letby was present at the delivery [in] April 2016. My wife recalls her being present after [Child M]'s collapse on 9 April 2016.
"My wife also recalls one occasion where she went into the unit, Lucy was in the room with Child L&M. This was after my wife had been discharged from hospital. [Child M] was being monitored by a machine that showed his heartbeat. It stopped working and my wife said 'Lucy, something is wrong with your machine?' Lucy could hear her but she did not respond, she was just looking at the machine and then she went outside. There was a loose wire on the machine but there was no alarm sounding, it was just showing all zeros. Then after a few minutes she came back in the room and she checked the wire, and said 'Now it's okay'. Then it started making the noise it made when it worked properly.
"Lucy Letby took a real shine to [Child L]. She would feed him while my wife was feeding [Child M]. She would talk to us about him all the time and she said he was her favourite. When it came for us to take the babies home, Lucy asked if she could get [Child L] ready. We have been asked by the Inquiry whether we had any suspicions or concerns about her. We did not.
"Raising Concerns and Getting Answers.
"The Inquiry has referred us to the statement of DC Griffiths, a police Family Liaison Officer in the criminal proceedings, dated 16 December 2021. In this statement DC Griffiths sets out some of the families' concerns about the provision of information and about hearing things for the first time at court. We are asked if we have these concerns.
"The answer is yes. There are two parts to this. First, we did not receive anything from the Countess of Chester Hospital about concerns on the unit, or concerns about what had happened to our children. It fell to the police to have to relay that information to us. Secondly, we heard abundance of information and evidence at the criminal [trial] and much of this was new.
"We certainly did not make any use of the Patient Advice and Liaison Service (PALS) as we were new parents and did not think anything unusual had happened.
"Suggestions and Recommendations.
"Lucy Letby is responsible for giving [Child L] excess insulin. We understand that if small amounts of insulin were being used, this would not be noticed, eg if adding insulin to a dextrose infusion bag then 1% of a bottle would not be noticed. However, healthcare professionals at [the hospital] had [Child L]'s blood results on (redacted) April which showed excessive insulin. We think that this should have raised - including with us -- and investigated further. Perhaps [Child L]'s lines and equipment could have been changed and then the insulin prepared by a Consultant to ensure it was correct. Maybe the contents of the bags should be checked with some kind of test before they are administered?
"It is not for me to advise a hospital as to how this should be managed. That is a recommendation for those in practice who know how to implement proper safety and monitoring system but, for us, without doubt, it is a drug that needs tighter control and supervision given the harm it can cause.
"I believe that the whole management team, above the consultants, need to be held accountable for their actions. From our perspective, they allowed a nurse who was causing harm to babies to continue working after concerns were raised by Consultants about her potential involvement in babies dying or deteriorating. If they had listened sooner, fewer babies would have died or been harmed. Fewer families would have been bereaved and damaged. It is not enough to just say sorry to the families now.
"I understand a rash, similar to that seen on [Child M], had been seen before in another baby on the unit. However, it was extremely rare and very unusual. Dr Jayaram said that he had done some private research about the cause maybe being an air embolism but that his concerns were not taken seriously. Given the rarity of skin discolouration, I do not understand why more steps were not taken to consider the cause, or a discussion about it amongst the doctors, or with other doctors on a wider scale. If it had been, there may have been more weight to the suspicion that it had been purposefully caused. Given how unusual it was, I really do not understand why it was not taken further by the clinical staff.
"Unusual, rare or unexplained symptoms in a baby should be discussed openly with all the team on the unit and research taken further if the cause remains unexplained. At the criminal trial, Dr Jayaram gave evidence that he had emailed a medical paper he had found about air embolism to his colleagues. But was this ever taken any further?
"I am aware of a book which the BBC are planning to release in the autumn titled 'Unmasking Lucy Letby'. I do not think it is fair that this book and other publications are allowed to be released without first consulting the families. This will further add to the pain each family is suffering."
My Lady, that concludes the statement.
LADY JUSTICE THIRLWALL: Thank you very much indeed, Mr Skelton.
Father L&M, thank you very much for providing your statement. You will have heard me say to other parents that I do know that underneath the letters L&M there are two boys and I know that under Mother L and Father L and Father M and Mother M there are real people and I do take account of that at all times.
The statements are enormously helpful, firstly about the facts and your experience, and I will be referring to them as I go on to consider what is going to go into my report, but I do recall that it was very early on, before the Inquiry had been set up, that you raised the suggestion that there should be CCTV on neonatal units and you will know that others have agreed with you and it is for that reason that we were able to ask the corporate witnesses to deal with that suggestion and we will have in due course evidence from them about using CCTV in hospital wards.
The same applies to your observations which we heard in your statement about the need to scrutinise access to insulin, so thank you for the whole of your evidence and in particular what you have said in respect of recommendations.
I am grateful to you for being here today and for listening to Mr Skelton read out your statement. Would you be kind enough to pass on all of what I have just said to the mother of the children, your wife. Thank her very much too.
THE WITNESS: Thank you, very much, and to Peter.
MS LANGDALE: My Lady, may we now rise, not least to check the quality of the audio link, I think there are some difficulties with it.
LADY JUSTICE THIRLWALL: Okay, I'm sorry to hear that. I will rise briefly and will someone just say when we are ready.
(10.37 am) (Short Break) (11.03 am)
LADY JUSTICE THIRLWALL: Mother N, I understand that you are online with your camera turned off, which is of course absolutely fine. Thank you very much for being with us this morning and I understand Mr Skelton is going to read your statement on your behalf.
Mr Skelton.
MR SKELTON: Thank you, my Lady.
Witness statement of Mother N, dated 17 July 2024.
"I, Mother N, will say as follows:
"I am the mother of [Child N].
"I make this statement in relation to the Inquiry into the events on the neonatal unit at the Countess of Chester Hospital ... for which Lucy Letby has been found guilty of the murder and attempted murder of several children.
"[Child N] was born [in] June 2016. Lucy Letby was found guilty of attempting to murder him on (redacted) June 2016. She was charged with two further counts of attempting to murder him on (redacted) June 2016 but the jury was unable to reach a verdict in relation to those counts.
"The contents of my statement are accurate and derive from my own knowledge. Where the contents are not from my own knowledge, I have specified where the information came from. This statement has been prepared following discussions taking place on the telephone.
"I have previously made a statement to the police in relation to these events, dated 19 December 2018 and would ask that this be read in conjunction with this statement. I have also included some information from that statement in this document.
"Impact.
"I prepared a victim impact statement for use in the criminal proceedings, dated 21 June 2023. Again I ask for that impact statement to be read alongside this statement but I have also included extracts here ..."
LADY JUSTICE THIRLWALL: Mr Skelton, just before you continue, may I just check, Mother N, that you can see Mr Skelton?
MOTHER N: I can, yes, thank you.
LADY JUSTICE THIRLWALL: Thank you. Sorry, do continue.
MR SKELTON: "'When we received the phone call (on (redacted) June 2016) to say that [Child N] was poorly and that he wouldn't be coming home as expected, it just didn't feel real. The day we were called to the neonatal unit was the worst day of our lives, from waking up that morning being prepared to take home our son to the utter catastrophic scene we arrived at has left a lasting imprint on us, seeing our tiny baby fighting for his life, medics doing CPR on his tiny body and not knowing if he was going to live or die with no obvious cause. We have often heard of people dying from a broken heart, this is how we can describe how we felt that day the pain was immeasurable and we didn't want to leave that hospital without our son, we both relive this every day because not a day goes by without thinking about that day. Then he was transferred to Alder Hey which was even further away from home and we were often doing a two-hour round trip twice a day to see our son in-between looking after two other children, we did this for a month after his transfer.
"'Financially this was difficult as Father N was self-employed, we were exhausted both emotionally and physically and the additional driving didn't help. We felt guilty leaving [Child N] in hospital, but we also felt guilty leaving our other children at home.
"'I honestly knew [that] [Child N] had been deliberately harmed. I felt like there wasn't a natural explanation but that someone was responsible for [Child N] being poorly. I don't know whether this was common sense, or a mother's instinct but I just knew and I said this to Father N at the time. I just kept questioning why our healthy baby boy was fine one minute and then bleeding from the mouth and needing CPR the next.
"'This caused massive trust issues which have remained with us to this day and we don't think will ever leave us. I only trusted Father N and me to be there and I didn't want [Child N] to be left alone and Father N agreed, so this created additional pressure for us all.
"'When [Child N] eventually came home, I only wanted it to be me or Father N who took him for his medical appointments. This makes life difficult if I am ever poorly, as I am the only person trained to provide [Child N] with his medication in respect of his blood disorder.
"'My mum used to care for our two eldest children overnight, but I can count on one hand the number of times I've allowed [Child N] to stay at his grandmother's. My mum is completely capable but it is our trust that has been broken.
"'I think there has only been one occasion when me and Father N have been out, just the two of us, since [Child N] was born. As that would involve asking someone to look after [Child N] for what I would say was social but not essential.
"'[Child N] slept in with me and Father N until he was two and a half, as we wanted to be able to hear him breathing and feel his presence. We had an 'Angel' monitor in [Child N]'s bedroom which was an alarmed mat. This was meant for babies but he actually slept on it until he was four/five years old.
"'We knew the alarm would activate if [Child N] stopped breathing, we still have a camera so we can watch him whilst he sleeps and check he's okay even though he has just turned seven years old, we are both extremely over-protective, making sure everything is perfect and everything is done right. It made me feel good, but looking back I don't know whether we functioned on adrenaline because we certainly didn't sleep. I wanted to be the one who did everything.
"'Now as [Child N] gets older, he is a free spirit. We wanted him to be home schooled as we didn't want anyone else looking after him as our trust in people in a position of trust has been completely broken. All the other impacts; emotional, financial, anything else doesn't matter much to us [as] our son being here today is more important than anything else and outweighs the burden of all other impacts. We couldn't keep [Child N] safe in hospital, as a parent it's your duty to protect your children and this was taken away from us when he was in a place where he should have been at his safest, so we do everything possible to keep him safe now and if that means wrapping him up in cotton wool, then that is what we will do.
"'We know he that we smother [Child N] with love and affection ... after everything that has happened in his early life we don't give him boundaries, as we never want him to feel sad.
"'When we were informed that [Child N] was a part of the police investigation, we weren't sad - we were happy and relieved. We would describe it as a feeling of a mixture of emotions, both shock and it being surreal. We felt like we were being listened to and that finally we would receive some answers as to why and what happened to [Child N] that day happened.
"'We didn't want to burden our eldest children with all of the information and the police investigation as all we ever want is for our children to be happy and content. They had been through enough when [Child N] was poorly and having to see me and Father N upset.
"'We have discussed having another baby since [Child N] was born but the fear of witnessing what happened repeat itself and having to go back into the hospital setting and the possibility of going back into the neonatal unit has stopped us from doing so.
"'The worst part of going to [the criminal] court is being away from [Child N] and the other children. It disrupts their routine and their home life - everything that we try our hardest to protect and preserve, having to listen to what she did to the other babies weighs heavy on the mind because you know exactly the hurt each of those parents felt you carry that also ...'
"Experience at [Countess of Chester Hospital].
"[Child N]'s antenatal care and delivery.
"I had my antenatal care at [the hospital] and had a normal pregnancy with [Child N] up until about 24 weeks. At that point I attended for a scan and to check on his growth as there was a concern that [Child N] was not growing properly.
"I recall that the plan was that I delivered at 32 weeks by a caesarean section because he was small and the consultants wanted him delivered as soon as possible in order to make sure the placenta did not fail.
"I have a blood clotting disorder. We knew [Child N] was a boy and were aware there was a 50% chance he would be born with a blood disorder. We understood that, because of this, extra staff would need to be present in theatre for safety and to check [Child N] over once he was born. I initially expected [Child N] would be on the maternity unit with me, but once he was delivered we were told he would need to be admitted to the neonatal unit for a few weeks before we could take him home. I recall finding this out on the evening of his birth.
"The Inquiry has referred me to the police statement of Dr Sudeshna Bhowmik, who was a trainee paediatrician. In this she describes meeting me on the morning of (redacted) June 2016, before [Child N] was born. She says she explained various things about his delivery and that [Child N] would be admitted to the neonatal unit for observation, respiratory support and feeding support as needed. I am asked if this accords with my memory but I do not recall a tour of the unit and in my original police statement made in December 2018, I stated that 'No one actually sat us down and told us anything about [Child N] and I felt there was a lack of information throughout the whole process in the neonatal unit. We actually ended up having a few words with one of the nurses about this and the fact that there were parents who had come onto the unit after us who had been given booklets on premature babies whereas we didn't get given anything until we raised the issue'.
"[Child N] was born at [the hospital] in June 2016 by caesarean section. He did not have a bleed during the delivery but he was small, only 3 lbs 11 oz and he was also jaundiced. He was taken to the neonatal unit straight away.
"It was not until very late that night that I got to go and see him on the neonatal unit. One of the midwives took me down there. He was in Nursery 2 and I was surprised that he was just in the incubator on his own.
"While I was there, I was not introduced to any staff on the unit and no one came to introduce him or herself. The first time I interacted with the nursing staff and they spoke to me was when I needed to ask questions about [Child N]. Nobody from the neonatal unit proactively came to speak to us about him, about his condition, or his treatment. No one gave us information about caring for a premature baby.
"We did see parents come onto the neonatal unit who were given booklets about premature babies, but we were given nothing.
"I also did not get daily updates from the nurses on the unit. I would take it upon myself to look at [Child N]'s charts and try to speak with the consultant who I recall was there each day. I was trying to get more information and find out how [Child N] was doing (I explained this in my police statement). I understand that staff were working with Alder Hey Hospital on a plan in case [Child N] had a bleed while he was so young.
"As far as I was concerned, [Child N] was only on the neonatal unit because he was premature. It was not until (redacted) June, so (redacted) days after he was born that I was made aware there had been problems with [Child N]. I was informed that doctors had been trying to keep his temperature stable and also that he had a feeding tube in, but they were trying to establish a feeding regime for him. There had been nothing to make me think his condition was not normal.
"However, even at this point I was not made aware there had been any problems with [Child N]'s condition in the early hours on (redacted) June 2016.
"The Inquiry has asked me for my views on the adequacy of the information on the neonatal unit at [the hospital]. It should be clear from what I have said above that I considered the information to be inadequate, in terms of the processes on the neonatal unit, how to care for a baby there, and also information about [Child N]'s condition. I thought that was the case both at the time and after.
"In the first days of [Child N]'s life, I remember Lucy Letby, along with nurses called Catherine and Bernie, helped to look after him.
"[Child N]'s Collapses.
"The Inquiry has asked me about [Child N]'s deterioration in the early hours of the morning of (redacted) June 2016 and what I was told about this deterioration and its cause. I am now aware that [Child N]'s oxygen saturations dropped very low overnight on (redacted) June to 40%. I heard about this profound desaturation around a month before the criminal trial. Lucy Letby was convicted of attempting to murder him on this date, but I knew nothing about this deterioration at the time. I was not told that a crash call had been put out or that [Child N]'s oxygen saturations had dropped to 40%. I was not even told [Child N] had had problems that night until shortly before the trial.
"On (redacted) June 2016, I was told that [Child N] would be able to come home the following day. By this point he was in Nursery 4.
"However, at around 8 am on (redacted) June I got a phone call from [Child N]'s father. He said there had been an issue at the hospital and that [Child N] had a bleed but there was nothing to worry about. I then rang [the hospital] to ask them if I should bring the car seat in with me to take [Child N] home that day. However, I was told by a lady called Grace that [Child N] was in fact really poorly and be had been since 4 am that morning. She said that they had caused the bleed. By this I understood she meant healthcare professionals had caused a bleed. She told me I had to get in there as soon as possible.
"I do not know why I had not been contacted earlier, if the bleed or the problem had happened during the night and several hours earlier.
"I got to the hospital at about 9 am. Father N met me at the hospital. [Child N] was now in the intensive care nursery. I had never been in that nursery before. I saw lots of people gathered around him. It was a very emotional time and I just remember consultants trying to keep him stable at this point. I remember being told he had some apnoeas since the morning but they did not know why.
"I recall that Lucy Letby was there and another nurse, possibly called Mina.
"I was told that the doctors had tried to intubate him at some time between 4-8 am and that he had had a bleed when they were trying to do it. Dr Saladi said he had let a registrar try to intubate [Child N] which had resulted in a bleed (or that was our understanding). We did not really get an answer as to what had happened or why and were just told that it was essential to intubate [Child N] at the time.
"They carried on trying to intubate him while we were there. I believe an anaesthetist tried and could not, and Dr Saladi also tried and could not. It was a long, drawn out process. During this time he had two further collapses.
"During the day on (redacted) June, Lucy Letby was our main point of contact as she was tending to [Child N] in between the doctors being with him. She recommended that we have [Child N] baptised, and for some reason we did. I think we just wanted anything that might possibly help. It was a spur of the moment decision. It was only that evening that they managed to intubate [Child N], when doctors from Alder Hey arrived.
"On the evening of (redacted) June, Father N and I were sitting outside the intensive care nursery when the night duty shift nurses arrived on the neonatal unit. One of the nurses ... came to speak to us. She had been looking after [Child N] overnight on (redacted) to (redacted) June. She said she had been caring for him when he became ill. We found her to be cold and dismissive. I also felt like everyone was staring at Father N and me. In hindsight I think this is probably because [Child N] was yet another child who had collapsed in the neonatal unit. I felt like it was so inconsiderate of the nurse to think that this was the right time to talk to us about the fact that she had been looking after [Child N] given all the events that had happened that day.
"After this approach from the nurse I immediately said to Father N that she had harmed [Child N]. In retrospect I was wrong that she had been responsible, but I just knew there was something not right about him being so well and then suddenly becoming so ill. A child does not go from being fine and healthy to being gravely unwell.
"In addition, [the hospital] had no Factor VIII in stock to give to [Child N] so a haematology nurse from Alder Hey Hospital had to bring this over to [the hospital] in a taxi. I found this extremely upsetting as they had known there was a risk [Child N] had (redacted). I am informed by my solicitor that [Child N]'s medical records at 1.45 am on (redacted) June 2016 state 'presumed (redacted)'.
"That night [Child N] was transferred to Alder Hey Hospital where they stabilised him. After he was transferred, we were approached by a nurse in the intensive care unit there who told us that, after reviewing [Child N]'s notes, there were discrepancies. I do not recall the nurse explaining what discrepancies these were.
"No one, either at Alder Hey Hospital or from [the Countess of Chester Hospital], expanded on this further. We just had that little bit of information and nothing else. We have never been told what the discrepancies in the notes were.
"Causes of Collapses.
"Once [Child N] had left the care of [the hospital], we did not hear anything from the hospital about the causes of the collapses or any investigation into them. When [Child N] was a few months old we attended a paediatric appointment at [the hospital]. I saw Dr Murthy Saladi, a consultant paediatrician, and began to question him on what had happened to [Child N] on (redacted) June 2016 and what had caused it. Initially, Dr Saladi began to speak about the registrar who attempted to intubate [Child N], but upon further questioning was unable to give a reason for why the collapses had occurred. This is the conversation with Dr Saladi that I refer to in my police statement.
"I think it is ingrained into you that, when you go to hospital and something happens, the doctors always provide a medical reason, but they seemed not to be able to provide a reason to me.
"The Inquiry has asked me what, if any, investigations into [Child N]'s sudden collapses I understood were taking place at [the hospital] at the time or were going to take place. I was not told about any investigations that were being done or would be done. As I explained above, when I tried to understand more about what had happened and why, it seemed that Dr Saladi did not have any answers, but no one suggested to me that an investigation could or would be done.
"Suspicions and Concerns Regarding Lucy Letby.
"The Inquiry has asked me about any dealings I had with Lucy Letby. I have set this out above.
"I am also asked what, if any, information I was given by [the hospital] about concerns about Lucy Letby's conduct; and if I was given information, when and how that was provided. I am also asked what I was told [the hospital] were doing about any concerns about Lucy Letby. [the hospital] did not inform me of any concerns about her conduct or that it was doing anything about such concerns. I learned from the police that a nurse at [the hospital] had been arrested, as I explain below.
"The first I heard about the police investigation into unexplained collapses on the neonatal unit was on a phone call with the father of [Child N] in or around mid-2018. He told me that he had received a phone call from the police and passed my details over to them. I received a call from Cheshire Police not long after in which I was informed that they were investigating some of the unexplained collapses at [the hospital]. When the police came to visit me at home, they told me that the hospital had referred itself to the police regarding unexplained collapses and the police believed [Child N] may be one of the suspicious or concerning collapses.
"Shortly before Lucy Letby was arrested I received a phone call from Cheshire Police informing me that they would be making an arrest. I was not told if this person was employed by [the hospital], or whether this particular person had any part in [Child N]'s care.
"I am informed by my solicitor that Lucy Letby was arrested on 3 July 2018. Around 6 am on the morning of her arrest, I received a call from the police to say that they had arrested a nurse who had worked at the [hospital]. I cannot recall when I was told it was Lucy Letby.
"Counselling.
"The Inquiry has asked about any help and support I was offered by the [hospital], the Trust or any other organisation.
"I received the offer of counselling during the criminal trial. I had just one session and hated the awkward silences in which I was expected to speak so I did not go back. My counselling session was with the therapists provided by the Police Service. It was held by Microsoft Teams. I would consider now having more counselling if it would be face-to-face.
"Raising Concerns and Getting Answers.
"The Inquiry has asked me a series of questions going to my knowledge of investigations at [the hospital], the police investigation, communication from [the hospital], and the adequacy of information provided by [the hospital]. I did not think to request [Child N]'s medical records. Some of the evidence I have given above is relevant to this topic.
"I am asked if I was aware that the Royal College of Paediatrics and Child Health undertook a review into neonatal services at [the hospital]. I am informed that this review is dated November 2016. I was not made aware of this report and was not provided with a copy of it.
"I am also asked if I was aware of an Advisory Medical Report prepared by Dr J Hawdon, dated 1 October 2016, in relation to some babies who had died or had cardiorespiratory collapses, in the neonatal period at [the hospital]. I was not made aware of this either.
"I have explained that I tried to have a conversation with Dr Saladi about what had happened to [Child N] on (redacted) June. This was when he was a few months old and I took [Child N] to a paediatric appointment at [the hospital]. But I was not invited to a meeting at [the hospital] to discuss his care or any investigations.
"As I have explained above, Lucy Letby was charged and tried for three counts of attempting to murder [Child N]. The first attempt was in the early hours of (redacted) June 2016. As is clear from this statement, I had no idea there had been an issue with [Child N] prior to (redacted) June other than he had experienced some episodes of apnoea. I was not aware of anything significant or sinister that had occurred prior to (redacted) June. We were essentially kept in the dark about this. It is in relation to this attempt on [Child N]'s life, that we knew nothing about, that Lucy Letby was found guilty.
"We were aware there had been collapses on (redacted) June 2016 but were told that the cause was uncertain. Although Lucy Letby was charged with two counts of attempted murder in relation to events on (redacted) June, the jury was unable to reach a verdict on either count. Therefore, it remains the case that we have no clear explanation for [Child N]'s collapses on this date.
"At the criminal trial we heard evidence that Doctor U had tried to look into [Child N]'s throat when his desaturations occurred on the morning of (redacted) June and thought he had seen blood in [Child N]'s throat.
But we also heard that there was swelling and Doctor U could not see where the blood had come from. I still don't understand the sequence of events. Did [Child N] have blood in his throat before he needed to be intubated, or was the bleeding caused by the numerous attempts to intubate him? If the blood was there first, what caused it? [Child N]'s medical records describe it as being already there when Doctor U looked in his throat but elsewhere the records seem to state it was intubation that caused the bleeding. I still do not think I know for certain why [Child N] needed to be intubated, all we were told when we arrived at the hospital on (redacted) June was that [Child N] had a bleed and that was why they needed to intubate him. They were very vague about what was happening, like no one really knew.
"In my police statement I referred to three concerns I had with the neonatal unit at [the hospital]. These were the staffing levels, the nurse that looked after [Child N] the night he fell ill and the discrepancies in his notes regarding the reason for him deteriorating on (redacted) June. These are concerns I had at the time, and still have today. I did not raise these concerns with anyone at [the hospital] as I had already left their care and was under the care of Alder Hey Hospital.
"On staffing, the whole time that [Child N] was in the neonatal unit at [the hospital], they seemed very understaffed. There was a board on the wall that said how many staff should be on duty, and how many staff were actually on duty. The board said that five or six should be working, but there were usually three or sometimes four.
"I lodged a complaint against Doctor U. I made this complaint when it was revealed at the criminal trial that he had discussed [Child N] with Lucy Letby on Facebook and by private text message, even referring to [Child N] by their surname. There were several grounds to my complaint. One was his disregard for, and blatant breaches of, patient confidentiality. In addition, he shared emails that had been exchanged between Consultants in regard to Lucy Letby's conduct with her, and should not have done that. I made this complaint as the evidence was heard at trial but was asked by the police to put the complaint on hold due to the reporting restrictions. I made the complaint formally at the end of the trial. I raised the complaint with PALS and received a response from (redacted), explaining they would be overseeing the complaint response. This acknowledgement was received about a month after the trial finished in 2023.
"I have had a number of meetings about this complaint. At a recent meeting I was told by an anaesthetist that consultants now use an encrypted 'chat' service such as WhatsApp to communicate outside work. I am yet to receive the formal outcome of the investigation.
"I know that the evidence presented at the criminal trial showed that a number of nurses on the neonatal unit did the same thing as Doctor U. They would share and discuss the medical conditions of patients on their private mobile phones. No record of those conversations would have been available unless there was police involvement. Though I do not object to nurses and doctors discussing patients, it is the method of communication by insecure means, and the risk of a breach of confidentiality, that was so wilfully ignored and commonly used by a number of staff.
"Recommendations.
"The Inquiry has asked me if I have any recommendations or suggestions to help prevent crimes like Lucy Letby's in the future and keep babies safe on neonatal units. While I include some information in this statement, it may be that I have further thoughts and wish to say more as the Inquiry continues, possibly through my lawyers.
"Firstly, I would like CCTV to be mandatory when vulnerable patients are being cared for.
"I would hope that the managers of the Trust are held accountable for failing to investigate the whistleblowing allegations. A lot of the harm that Lucy Letby caused could have been avoided if a thorough and prompt investigation had taken place after the whistleblowers raised concerns. The managers should be listening to what is reported to them. Ignoring these allegations, or not giving them proper weight, makes these people complicit in the harm that was caused. I feel that they should be held accountable, they should not be able to continue in their roles and should face criminal action.
"I do not think that the NHS is fit for purpose as it stands. There have been many issues in the past, such as Harold Shipman and Beverley Allitt, and nothing effective has been done to prevent this from happening again. It should start with the people at the top, they should listen to the Consultants who work, day-in day-out, in the wards as those who experience and know about the day-to-day running of the NHS. It should not be someone sitting in an office making decisions.
"Reflecting on what has happened, I find that the staff were too involved with each other, and had too much of a focus on their friendship rather than their job and what was going on in the unit and with the babies. I now know that they were texting each other outside of work about the babies. I feel that they need to be more professional and there should be a clear line set in place to prevent this in future. If they paid more attention to their patients, rather than gossiping, things might have been different."
My Lady, that concludes the statement.
LADY JUSTICE THIRLWALL: Thank you very much indeed, Mr Skelton.
Mother N, thank you very much indeed for providing us with your statement and allowing Mr Skelton to read it. It is a very helpful and a very focused statement which sets out very clearly what your experiences were and will undoubtedly be of great assistance to me when dealing with the issues raised in the Terms of Reference.
Thank you also for your observations on what would be good recommendations and your other views on other aspects of the care that you received in the hospital and also your general observations about other matters. Thank you very much indeed.
MOTHER N: Thank you.
Thank you, Peter.
MS LANGDALE: My Lady, may I ask that we resume at midday.
LADY JUSTICE THIRLWALL: Thank you. So 12 o'clock.
(11.34 am) (Short Break) (12.03 pm)
LADY JUSTICE THIRLWALL: Mr Skelton, I understand that Father N is not dialling in, or has not dialled in?
MR SKELTON: I think that's right, my Lady.
I understand he is self-employed and it was always a possibility he wouldn't be able to attend today.
LADY JUSTICE THIRLWALL: Very well, but you are content and you have instructions to continue to read his statement?
MR SKELTON: I do, thank you.
LADY JUSTICE THIRLWALL: Thank you. I will invite you to do that now then, please.
MR SKELTON: Thank you.
Witness statement of Father N, dated 17 July 2024.
"I, Father N, will say as follows:
"I am the father of [Child N].
"I make this statement in relation to the Public Inquiry into the events at Countess of Chester Hospital for which Lucy Letby has been found guilty of murder and the attempted murder of a number of children.
"[Child N] was born in June 2016. Lucy Letby was found guilty of attempting to murder him on (redacted) June 2016. She was charged with two further counts of attempting to murder him on (redacted) June 2016 but the jury was unable to reach a verdict in relation to those counts.
"The contents of my statement are accurate and derive from my own knowledge. Where the contents are not from my own knowledge, I have specified where the information came from. This statement has been prepared following discussions taking place on the telephone.
"Impact.
"The Mother of [Child N] has already prepared an impact statement, dated 21 June 2023 and I would request that this be read alongside my statement.
"In particular her statement describes '(We) ... kept questioning why our healthy baby boy was fine one minute and then bleeding from the mouth and needing CPR the next. This has caused us massive trust issues which have remained with us to this day and we don't think will ever leave us'.
"Both myself and [Child N]'s mother have made previous statements surrounding the events on the neonatal unit at [the hospital]. My statement is dated 14 November 2019 and [Child N]'s mother's statement is dated 19 December 2018. I ask that those police statements are read in conjunction with this statement, but have also included here some information from my police statement:
"'Since [Child N] was born, Mother N and I went to see [Child N] in the neonatal unit every day. Mother N stayed in hospital for about a week after the caesarean. She was initially in a private room, upstairs on the ward. Once Mother N came home we both went to see [Child N] every day. We usually went along in the morning at about 9 o'clock after the other kids went off school. At the weekend we also took Mother N's children in to see him. I never went to see [Child N] by myself. I was a bit scared to be honest. We tended to stay with [Child N] for a couple of hours then we would go home for a while and go back later. Sometimes Mother N would go back later by herself and I would look after the other kids. As I said, I was self-employed and we were juggling the other kids, [Child N] and my work. There was plenty of time that neither Mother N nor I were able to be with [Child N] on the neonatal unit.
"' ... when I went to visit [Child N] I remember looking at the staffing board on the wall of the neonatal unit. It seemed to me that a lot of the time there were less nurses on duty than there should have been. When we were in the neonatal unit at [the hospital] I got the impression from the nurses that it was like [Child N] wasn't our son. I didn't get a good vibe. I felt like I should not be touching him. We were not encouraged to handle him by the nurses. I didn't hold him until he went to Alder Hey when he was about three weeks old.
"'Every time you went into the unit it was someone else looking after him. You might have the same nurse for two days and then someone else. It was a weird situation in the neonatal unit. I felt like we were not entitled to hold our own kid. You did not feel welcome. One of the nurses, Mina, was all right. She interacted with people. It might be that they were old school, I don't know.
"' ... on the day [Child N] was due to come home from the Countess of Chester Hospital (I am not sure of the day or date but [Child N] was (redacted) or (redacted) days old), I was at work ... first thing in the morning. I then received a phone call from [Child N]'s nurse, Lucy. Lucy said that [Child N] had been a bit unwell in the night but she said he's okay now. About ten minutes later Mother N rang me crying her eyes out as she had had a phone call from another nurse who had said that [Child N] was really not well and we needed to go to the hospital. I can't remember who Mother N said it was that phoned her but I remember that it was not Lucy. Mother N told me that the nurse said he had a bleed.
"' ... during the first day we were at Alder Hey we were trying to get answers about why he was there and what had happened. We spoke to a nurse and she said that she would have a look in [Child N]'s transfer notes. She told us that there was a conflict in the notes as to what had happened. I think one set of notes said that they had caused the bleed and another set said he had had a bleed. I found it really hard to come to terms with what had happened or make sense of it. I thought that something usually happens for a reason. We could not get an answer from anywhere we looked what had actually happened or why'.
"Experience at the CoCH.
"[Child N]'s Antenatal Care and Delivery.
"I was self-employed when Mother N was pregnant so I could not attend all the scans with her at the [hospital]. I am not sure of the date but at one appointment Mother N informed me that the doctors were concerned that [Child N] was not growing normally so he would have to have steroids to help develop his lungs.
"As a result of these concerns about his growth, the plan was that he would be delivered by caesarean section several weeks earlier than normal. We were both aware of this and the reasons for it.
"As [Child N]'s mother has (redacted), we knew that the delivery would require a number of extra people in the operating theatre in case there was excess bleeding. Everyone was very aware of this from the beginning of the pregnancy.
"I do not recall although I am almost certain that we did not meet with Dr Bhowmik or Dr Jankee for a tour of the unit. I have no recollection of Dr Bhowmik talking to me about [Child N] being on the unit. Across all the statements I have given in relation to [Child N]'s time on the neonatal unit, I have always said that we were given no introduction to the unit but we did see that some other parents were.
"The caesarean was planned for June 2016 and I was there when [Child N] was delivered in June at 13.42. He was just over 34 weeks. I remember he was very small and weighed only 3 lbs 11 oz.
"We knew there was a risk he would need Factor VIII at birth but learned later on, due to the subsequent events on the neonatal unit, that [the hospital] did not have any in stock for him. This was a surprise as the caesarean had been booked in advance, the date set and the doctors had warned that he might need it. Luckily, there were no issues with [Child N] bleeding on the day he was born.
"Events Post [Child N]'s birth - Neonatal Care.
"[Child N] needed oxygen when he was born and this was a bit scary. I knew he would need to be cared for on the neonatal unit because he was premature. Other than that, we were told he was fine and there were no issues.
"Mother N was not allowed to go and see him after he was born as she needed to wait for the epidural to wear off. I sat with her before going to see [Child N] alone.
"I was only able to stay for five minutes as I had to get home to collect our other two children from school.
"[Child N] was on the neonatal unit for about 14 days. As far as we had been aware, the only issues he had in that time were that his bilirubin levels were high and he received some light therapy for this. As I explained below, we were not made aware at the time of the significant drop in [Child N]'s oxygen saturations overnight on (redacted) June 2016.
"We saw [Child N] every day on the unit. I never went by myself as I was a bit scared to go there alone as he was so small and vulnerable. We would stay with him for a couple of hours and I knew that Mother N would go back later in the evenings by herself to see him. I would stay at home to look after our other children. I was juggling work and the children and visiting the hospital.
"No one ever sat us down and explained anything about the neonatal unit. I had understood that [Child N] had to be there because he was premature but we were not given any information about why he really needed to be there and what treatments he would have or how we should be caring for him. We noticed some parents were given a booklet about premature babies but we were not.
"I got a sense from the nurses on the neonatal unit that it was like [Child N] was not our son. We were not encouraged to handle him and it felt like they did not want us to touch him. The Inquiry has referred me to my police statement in which I said I ' ... got the impression from the nurses that it was like [Child N] wasn't [our] son' and I 'didn't get a good vibe'. It felt like they were the ones looking after him and that they knew best. I felt removed from him a little bit because they were feeding him and caring for him but I was not told if I could pick him up or how to handle him. It felt like they acted like the parents and they knew best.
"It was not until he was transferred to Alder Hey Hospital at three weeks old that I got to hold him for the first time. No one told me if I was allowed to take him out of the cot or how to be safe with him. I was given no information at all.
"I remember when [Child N] was about 10 days old Lucy Letby said to me 'Hold him! He is your son'. She was very abrupt and short with me. I did not say anything in reply. [Child N] was just lying happily in his cot and he was settled and not crying. She did not hand him to me and I did not pick him up.
"Every time I went into the neonatal unit there was a different member of nursing staff looking after him. There was a sense that you were not welcome there because they were looking after the babies and not you.
"[Child N]'s Collapse.
"We now know that [Child N]'s oxygen saturations dropped very low overnight to 40% on (redacted) June 2016. Lucy Letby was convicted of attempting to murder him on that date. The Inquiry has asked whether we were told about this deterioration at the time and how and when we were told about it. We were not told about this deterioration. We did not know [Child N] had had problems overnight on (redacted) June. I find this disgusting. As parents we have an absolute right to know what was happening to and with our son.
"[Child N] was due to come home from hospital on (redacted) June 2016. By this point he was in Nursery 4. As it turned out this was also the first day on which we were aware of any problems with his condition, other than that he had issue with his bilirubin levels and the fact that he was premature so needed support with feeding.
"On (redacted) June 2016 [Child N] had three episodes of deterioration. I am informed that the medical records show that [Child N] was unwell during the night on (redacted) June and had a mottled appearance and then his oxygen saturations dropped around 08.00. We were not present and were only contacted in the morning as I set out below. The next deterioration was at around 14.50. We had briefly left the hospital to get something to eat. Then there was a further drop in his oxygen saturations that evening. I set out more detail below.
"On the morning of (redacted) June I was at work and I received a phone call from Lucy Letby. She said that [Child N] had been a bit unwell in the night but that he was okay now. I told her that [Child N]'s mother would be at the hospital soon and would see him then as usual. There was no other information, no detail as to what 'a bit unwell' meant but I did not get the impression that [Child N] was still unwell or that I needed to be concerned.
"About ten minutes later I got a call from [Child N]'s mother. She was very upset and explained that a different nurse had called her and told her that he was very unwell and that we had needed to go to the hospital. Mother N told me that [Child N] had had a bleed but I understand her police statement said I had told her that [Child N] had a bleed. It has been so long since these events it is difficult to remember who it was that was first told he had a bleed.
"I rushed back home and then we went straight to the hospital. It was about 9~am when we arrived at the neonatal unit.
"When we got there, [Child N] was now in the intensive care nursery. Lucy Letby was by [Child N]'s cot and there was no one else around him. Occasionally a doctor would pop in and out of the unit but there was no rushing and no sense of urgency, which I didn't understand given the urgency of the phone call to Mother N.
"Lucy Letby told me he had been a bit unwell in the night but did not explain what that meant or what was wrong with him. No one did. We had not received a call in the night to alert us to any problems or that anything had happened.
"However when I saw [Child N], I was shocked. He was blue in colour and had traces of blood around his lips like he had coughed up blood and it had splattered on him. The blood was dry and dark in colour. I remember feeling really confused because the machines monitoring him all looked normal but clearly something had happened. However, no one told us what had happened or why.
"Once [Child N] appeared settled for a bit, we decided that we should go and get some food as neither of us had eaten all day. We felt guilty about leaving but we had nothing with us. We went to a McDonald's drive-through as it was less than five minutes away in the car. We were probably gone from the hospital for around 20-25 minutes in total.
"When we returned to the neonatal unit, the parents whose baby was also in the intensive care nursery were sitting outside the unit. They said to us 'your lad is unwell again' and I thought there was why they had been made to sit outside and I apologised to them.
"We were buzzed back into the neonatal unit and all the blinds were down which I felt meant that something serious was happening. I didn't want to go into the intensive care nursery room where [Child N] was because I was worried.
"A nurse came to speak to us, I think it was Beth or Kath. The nurse said that [Child N] was now really unwell and if we wanted we could see a priest.
"Mother N went into the ITU and the priest arrived to talk to us. I was shocked by this as I am not religious and we had not asked for him. I remember exclaiming 'what the fuck are we doing here with a priest?' It felt really inappropriate because he was a stranger and I had the impression that we were being ushered out of the way. We made chit-chat with him and then after about ten minutes [Child N]'s mother went back into ITU and I waited outside.
"I asked Nurse Beth if [Child N] would be all right and she said 'I don't know'. I stayed sitting outside on the chairs as I was struggling and very anxious.
"Lucy Letby recommended to us that we have [Child N] baptised so we made the decision to do that on the evening of (redacted) June. We did this out of desperation as we would have tried anything for him to be okay.
"I only entered the ITU room when the situation seemed to have stabilised. I was told that by the doctors very quickly that they had attempted to intubate [Child N] but that he had bled when they tried to do so and that this is what the problem was.
"As I remember it now, at some point we were told to go outside and get some fresh air. During this time [Child N] had another collapse, needing CPR again. We therefore did not see that collapse but it became clear once we were back on the unit.
"When we got there I was aware they were doing resuscitation. At this point I was also aware that a team from Alder Hey Hospital had been called and were present. I recall that a woman in a green cardigan was present and I believe she was a haematologist. The male doctor from Alder Hey assisted with trying again to get the breathing tube in and this time he was successful. After that [Child N] stabilised and everything seemed to calm down.
"The doctors then prepared him to transfer him to Alder Hey Hospital.
"After [Child N] had stabilised, we spoke to a haemophilia nurse, Kathy, who had come to the [Countess of Chester Hospital] from Alder Hey Hospital. In my police statement I say that she had come over in a taxi with some 'Factor'.
"I know that Alder Hey staff had to bring extra Factor VIII with them. Despite [the hospital] knowing that [Child N]'s mother is (redacted) and knowing that [Child N] may need Factor VIII, [the hospital] did not have enough in stock.
"A nurse came to speak to us as we waited outside the intensive care nursery. She was very cold and stern. She told us she had been taking care of [Child N] the night before and he had been fine.
"There was no reason for her to come and speak to us like that and impart that information in that moment, particularly given our child was being resuscitated at the very same time and we did not know what was wrong with him.
"Just before we left [the hospital] to go to Alder Hey Hospital, Lucy Letby came up to us. She said that she hoped [Child N] would be all right and hugged Mother N. She may have even kissed her but I cannot be sure.
"Transfer to Alder Hey.
"[Child N] was transferred to Alder Hey in an ambulance and he went into intensive care.
"When we arrived at Alder Hey Hospital I overheard a conversation between the staff about a discrepancy in [Child N]'s notes. I do not know if they were describing his bleeds or what happened when he had collapsed as they did not say anything else about it.
"I tried to understand from the staff at Alder Hey what had happened to [Child N] and why he was there. A nurse said she would look in his medical notes and she told us there was a conflict about what had happened and what had caused his bleeding. I think one record said the bleed was caused by trying to place the breathing tube but it might also have said he needed the breathing tube because he had had a bleed. It was impossible for her to tell us. I do not feel that we ever got an answer to our questions.
"[Child N] was at Alder Hey for about two weeks before he came home. He would occasionally have little spasms and vomit but it was not clear why.
"The Inquiry has asked if I feel I was kept sufficiently informed about any deteriorations in [Child N]'s condition. The answer is no. For a start, we were not informed at all about his deterioration overnight on (redacted) June 2016. Then when he had had his deteriorations on (redacted) June we did not really know what was going on, what had happened or why. This was then made worse when we were told and heard about the discrepancy in [Child N]'s notes about what had happened.
"Cause of Collapse.
"The Inquiry has asked me what, if any, investigations into [Child N]'s sudden collapses I understood were taking place at [the hospital] or were going to take place. Once we took [Child N] home from Alder Hey, and he had left the care of [the hospital] that was the end of the contact we had from, or with, the [Countess of Chester Hospital]. No one contacted us about any internal investigation into what had happened to [Child N]. Therefore, we did not think any investigations were being done or would be done. It was just not something that was mentioned to us.
"The Inquiry has asked me about a conversation or meeting that Mother N's mother had with Dr Saladi about the difficulties intubating [Child N]. This is referred to in both Mother N's police statement and my police statement. During a routine paediatrician appointment, Mother N had asked Dr Saladi why [Child N] could not be intubated and why he was bleeding from his mouth. He did not know. We had tried to find out what had happened from him but never got an answer.
"The Inquiry has also asked me if we were given any further explanation by [the Countess of Chester Hospital] about [Child N]'s collapses. Other than what I have set out above, the answer is no.
"Additionally, no one ever told us we could raise concerns about [Child N]'s care or complain about it. It felt like once he was at Alder Hey Hospital what had happened was just brushed over.
"When I prepared my police statement (dated 14 November 2019) I included:
"'To this day I still do not know what happened to [Child N] at [the Countess of Chester Hospital], whether someone had tried to put a tube in him, or who that person was or whether he had had a bleed'.
"That demonstrates that even in November 2019 I had not had any proper explanation of what had happened.
"I was never comfortable with the care [Child N] received on the neonatal unit at the [Countess of Chester Hospital]. We felt the care was good when he moved to Alder Hey Hospital.
"Suspicions and Concerns Regarding Lucy Letby.
"I have explained above my recollection of our contact with Lucy Letby.
"It was only after Lucy Letby had been arrested that we were informed she was being charged with the attempted murder of [Child N]. We were told about this by the police.
"I remember getting a call from the police around the time they had arrested Lucy Letby to let me know.
[Child N]'s mother had a knock on the door at home from the police. This was the first time we were told there was an investigation into or a suspicion about Lucy Letby. It was also the first time we were aware there was an investigation into [Child N]'s collapses or suspicion that she had been involved.
"The Inquiry has asked what information we were given by [the hospital] about concerns about Lucy Letby's conduct. As is apparent from the above, we were not given any such information by [the hospital].
"When we were told, it actually did not come as a surprise that something untoward had happened on the neonatal unit. In my police statement (November 2019) I said, 'personally, ever since we left [the hospital] I have said something was not right in that hospital. Something happened, the conflict in the notes, something did not add up'. I had felt that [Child N] was fine and healthy and then suddenly very unwell and given there was some debate about when he had a bleed, ie if it was caused by poorly intubating him or not, I suspected they were trying to cover up an error.
"However, while I thought [Child N] had perhaps received negligent care, I did not think anyone had intentionally or maliciously harmed or tried to harm him.
"No one contacted us about any internal investigation on a wider scale about the neonatal unit and no one mentioned to us again anything about what had happened to [Child N]. We were not invited to the hospital to have a meeting or to discuss what had happened to [Child N].
"Raising concerns and getting answers.
"The Inquiry has asked a series of questions going to what I knew about concerns about or investigations into [the Countess of Chester Hospital], and what information was provided to us about [Child N]'s care.
"I did not make a complaint about his care, nor was I offered any counselling or support in relation to the incidents at the time.
"I did not think to request his medical records.
"The position is quite straightforward. After [Child N] was discharged from hospital, no one from [the Countess of Chester Hospital] or elsewhere contacted us about an investigation into [Child N]'s care or collapses. No one contacted us about any investigation on a wider scale into the neonatal unit. I am aware that Mother N had asked Dr Saladi to try to find out what happened but we never got an answer.
"We were not invited to any meetings with [the hospital] about any investigations into [Child N]'s care.
"Until we were contacted by the police out of the blue, no one had mentioned anything about what had happened to [Child N], or discussed any concerns with us.
"To date we still have not had an acknowledgment from [the Countess of Chester Hospital] about what happened. We have had no indication from [the hospital] that they have even reflected on what happened or taken any steps to make changes. There have been no meetings with [the hospital] to discuss what happened; nothing at all.
"The Inquiry has asked for my views about the adequacy of information and communication from [the hospital]. It follows from what I have said that the information and communication was not adequate. At the time I was angry, confused and suspicious but knowing what I know now and after the information I heard at trial I am shocked and disgusted with [the hospital] to know that complaints and concerns had already been raised well in advance of what happened to [Child N] and that these were brushed under the carpet.
"We also never got to the bottom of what it was that Alder Hey thought was a discrepancy in [Child N]'s notes. No one has ever answered this question for us when we asked the staff.
"The Inquiry has referred me to a Royal College of Paediatrics and Child Health investigation report into neonatal services at [the hospital], which I understand is dated November 2016. I am asked when and how I came aware of this investigation report and whether I received a copy of it. I was not made aware of this report and was not provided with a copy of it.
"I found out that there had been an investigation and a report when I read about it on the BBC website.
"It was not until about a month before the start of the criminal trial that I was told about the collapse on (redacted) June 2016. We were called into a meeting with the police and the CPS and they informed us as to what had happened because they wanted us to be aware of it before the trial started and so we did not get a shock in Court.
"The Inquiry has also asked if I was aware of an Advisory Medical Report prepared by Dr J Hawdon in relation to some babies who died or had cardiorespiratory collapses, in the neonatal period at the [Countess of Chester Hospital]. I was not made aware of this.
"Other Comments.
"I remember going to collect some of Mother N's breast milk for [Child N] from [the hospital] so we could have it at Alder Hey Hospital for him. The fridge where the breast milk was kept could be accessed by anyone. There was no lock on it.
"When I was there, I met one of the nurses and again she was quite dismissive of me, and cold. She just had a very brisk attitude and like I was intruding.
"I also recall being telephoned by the unit many months after [Child N] was discharged to tell us that there was still some breast milk there and we had to go and collect it.
"I did get the impression that things were quite understaffed at Chester. The board that showed which nurses were on duty had 5-6 slots but only ever 3-4 names.
"Recommendations for Change.
"I can only make recommendations for change at this stage that are based on the 11 months I sat through the criminal proceedings and the things I heard in Court during that time. It may be that I have further thoughts and wish to say more as the evidence in the Inquiry is heard.
"I know that clinicians had raised concerns with their management in 2015 and that these were not taken seriously. This feels like such a kick in the teeth, those missed opportunities to take action that could protect the children who were harmed or killed after these concerns had been raised (like installing CCTV).
"I believe the use of CCTV on a neonatal unit can only be a good thing. I recognise there are privacy issues, but really, it is for the benefit of everyone: babies, parents and also staff. I believe it can protect babies from harm and protect staff from allegations of harm (if mis-founded). I do not think there is much that could be seen as inappropriate or unhelpful about having CCTV. For example, babies in cots or women breastfeeding can be seen when visiting a unit or when someone is breastfeeding outside of hospital.
"During the criminal proceedings, I was horrified to hear that staff had been using platforms like Facebook or private text messaging to send messages about babies. It cannot be that doctors and nursing staff believe this is an appropriate thing to do and I am disappointed that no action has been taken by [the hospital] to reprimand those that did this as soon as it became evident that this had taken place.
"The general attitude and complacency to this conduct (which was part of the evidence in the criminal trial) is shocking. Staff should only talk about babies, or patients more generally, on work phones or electronic methods where it is recorded and traceable."
My Lady, that concludes the statement.
LADY JUSTICE THIRLWALL: Thank you very much indeed, Mr Skelton.
Would you be kind enough to convey my thanks, please, to Father N for providing the statement and for inviting you to read it on his behalf. Please explain to him that it now forms part of the evidence to the Inquiry and it will be for me to consider it in due course when preparing my report.
MR SKELTON: I am grateful.
MS LANGDALE: My Lady, we resume at 10 am tomorrow.
LADY JUSTICE THIRLWALL: Thank you very much indeed. We will rise now.
(12.30 pm) (The Inquiry adjourned until 10.00 am on Wednesday, 25 September 2024)
LADY JUSTICE THIRLWALL: Good morning.
MR SCORER: Good morning, my Lady.
LADY JUSTICE THIRLWALL: I understand we have Father O&P&R online?
MR SCORER: That's right, my Lady.
LADY JUSTICE THIRLWALL: I understand you are going to read both statements, starting with Mother O&P&R?
MR SCORER: That's correct.
LADY JUSTICE THIRLWALL: Thank you very much. When you're ready.
MR SCORER: This is the witness statement of the Mother of Children O&P&R.
"I, Mother O&P&R will say as follows:
"I make this statement in response to the Inquiry's Rule 9 request. This statement should be read in conjunction with my police and Victim Impact statements.
"Experience at the Countess of Chester Hospital.
"My first child was born at the Countess of Chester Hospital. This was a normal pregnancy, there were no complications, and the care was good.
"Initially I did not realise that I was pregnant with triplets. When I went to a booking appointment at the Countess of Chester Hospital I thought that my stomach was bigger than in my previous pregnancy but I didn't think anything of it.
"My first ultrasound scan took place at about 12 weeks gestation. It was then that we were told that I was having triplets. Father O&P&R and I were both quite worried about how we would cope but our family was very supportive and we knew we would get through it together.
"The Consultant at the Countess of Chester Hospital referred me to the Liverpool Women's Hospital for a second scan. However, he told us that he was happy to care for me at the Countess of Chester Hospital and they could refer back to Liverpool Women’s Hospital if there were any problems along the way.
"The Countess of Chester Hospital was more convenient for us so I was happy with this plan.
"At Liverpool Women’s Hospital I was told that one of the triplets was a little smaller than the other two, and as all three triplets were sharing one placenta, I was given the option of having the smaller triplet's heartbeat stopped to give the two others a better chance of survival. We decided against this and to let things be.
"At the Countess of Chester Hospital I had scans every two weeks initially, but this increased to weekly as the pregnancy progressed.
"At around 23 weeks I was given steroids so that if the babies arrived early their lungs would develop more quickly. We desperately wanted the babies to get as close to 34 weeks as possible. Every scan was fine, and we were told that the babies were growing well.
"We decided to find out the sex of the babies and we also named them early on.
"At around 30 weeks I had some tightening. I was very large and I went into the the Countess of Chester Hospital as a precaution. They did a swab and said that everything was fine, and that they did not expect the babies to arrive early.
"I did not actually expect our babies to be born at the Countess of Chester Hospital, I was explicitly told throughout my pregnancy that they would be born there only if there was a nurse and a bed for each baby. I was told that for this reason, it was very unlikely that I would actually have them at the Countess of Chester Hospital. I was warned by Consultants that it was likely that we would have to travel to another hospital. We were told that this could be Birmingham or London but we had to be ready to go anywhere.
"It was only when I went into labour that I was told I was going to be giving birth at the Countess of Chester Hospital. I was told that there were enough nurses and beds to deliver the babies there.
"Going into hospital to have the triplets was a different experience from having my first child. Ahead of giving birth, I was told by Jim McCormack that we would be able to look around the Neonatal Unit at the Countess of Chester Hospital. In the event, this was put off and I was not given the opportunity to look around and see the Unit. We were told that the probability of us being there would be low. That said, we had not experienced a Neonatal Unit before so we had nothing to compare it with anyway.
"I was given to understand throughout my pregnancy that on delivery the babies would need to go to the Neonatal Unit as a precaution due to the risk factors that come with a triplet pregnancy and them having to be born at 34 weeks.
"On an evening in June 2016, I was at home. I started to get contractions at around 2300 hours. I called the Countess of Chester Hospital to let them know and they told me to come in straight away. I was in a lot of pain.
"When I arrived, the contractions were strong but they said that my cervix was not dilating so they didn't consider me to be in active labour. A nurse from the Fetal medicine unit popped in to see me and expressed surprise that I hadn't been moved towards a caesarean section, given my state.
"The next day, they reviewed me and decided to do the section.
"I had diamorphine injected into my leg. I cannot remember how long it was before this wore off.
"On a date in June at approximately 1.30/1.45 pm, I was sent to theatre. Despite being 33 weeks pregnant with triplets, I had to walk from the observation room on the Labour Ward to the theatre. This was a few rooms down from the Neonatal Unit.
"I was told to climb onto the bed and sit on the edge ready to be given a spinal block.
"Father O&P&R was not in the theatre with me at this point. He was getting his gown on.
"My hope and expectation was that Jim McCormack was going to deliver the babies as he had scanned me every week and reassured me that everything was going really well. Unfortunately, he had booked annual leave. It was very disappointing for me that he wasn't there. I don't know the doctor that did the C-section.
"After receiving the spinal block, my legs started to go numb and I was told to 'quickly' put my legs on the table. My stomach was big as I was having triplets; it was not easy for me and throughout the delivery I felt very rushed. I was laying on the table and being operated on when I felt pain; I was opened up at this point. I was given further medication.
"When they started the surgery and I was opened up, blood and fluid splattered up and over the screen and onto the wall behind me. This also went onto my face. I was told this was due to the pressure in my stomach.
"I had never experienced a C-section before. I was told I would feel some pressure and pulling but that I would not feel any pain. At one point I was in pain and I said 'That's hurting'. The anaesthetist said 'I don't think that is hurting, it's pulling' and then he gave me more medicine.
"When the boys were delivered,, I could hear them crying. One of the nurses brought [Child R] over to me for a few minutes. I was told that [Child P] and [Child O] needed a little bit of oxygen but that this was not unusual for babies born that early.
"The boys were then taken to the Neonatal Unit, and I was taken to recovery.
"After being sewn up, I was taken to the recovery suite opposite the theatre. Father O&P&R followed the boys to the Neonatal Unit and was there for around an hour before coming back to the recovery suite to check on me.
"Whilst in recovery, I was shown some photos of the boys so I could see them as I wasn't allowed down to the Neonatal Unit until 1900 hours.
"At 1900 I went from the Maternity Ward to the Neonatal Unit.
"When I arrived on the Unit, Father O&P&R had to go home. I remember being with the boys on my own.
"I had a catheter in from the surgery. I remember needing to go to the toilet. In the room there were six bays and one bathroom. I was at the end of the ward and had to walk to the other side where the toilet was.
"I could not physically get out of bed and walk because my stomach was burning. The pain was so bad. I called for someone to help but they took a while to come.
"The stitches used for my C-section scar were not dissolvable. I was told that I needed to air the scar out. I went for a shower.
"I had never experienced a C-section before. Later on, having experienced a second one, I can compare the two. The C-section at the Countess of Chester Hospital was a lot more painful. I wanted the midwife to help me and apologised that I could not shower by myself. I was made to feel that I was putting them out, as if they did not want to help.
"Father O&P&R came back to the hospital and brought our first child. I think this was in the morning before lunch. I saw the boys on the Neonatal Unit twice this day and I was there for around an hour each time.
"The boys were in separate rooms on the Neonatal Unit. I was reassured that everything was fine, they had no concerns. I cannot recall the precise date but Lucy Letby was looking after two of the babies. She showed Father O&P&R how to feed them. She told us how lucky we were and that their weights were great.
"Father O&P&R changed [Child P]'s nappy and took pictures.
"Father O&P&R and I were told that they were going to brain scan all three boys. Doctor V said this was routine for all babies. After the scan results came back, we were told everything looked fine and they had no concerns.
"I wanted to express milk and Lucy Letby, who was present on the day shift (I cannot recall the precise date), showed me how to do this and gave me a leaflet.
"On a night in June, my mum came to visit during the evening visiting times. The lights were low. Two of the babies were in one room and one on their own in another. Father O&P&R asked the nurses if there was an issue with one of the babies and asked why they were separated. He was told this was because of a lack of space, so I was not concerned.
"We were told that [Child P] and [Child O] needed a little bit of oxygen, but this was not unusual for babies born that early. Otherwise, we were told that they were healthy.
"Father O&P&R was asking the nurses if the babies had come out fine, and if their weights were okay. We were reassured that their weights were better than expected and that they had been born healthy. I cannot remember who reassured us, but I think that someone from the Neonatal Unit would have been in the theatre so it could have been that person.
"I was expecting my boys to go to the Neonatal Unit due to the high risk of my pregnancy because we were having triplets and they were premature.
"Throughout my pregnancy, I was told how well it was going, so I did not expect the babies to need actual treatment in the Neonatal Unit. The term 'feed and grow' was used, and I expected the babies to go to the Unit to feed and grow and then we would go home. So, we basically understood their going to the Neonatal Unit to be essentially precautionary.
"I was never given a specific timeframe as to how long they would be in the Neonatal Unit. We assumed that this would be dependent on their progress.
"I was not expecting the babies to need any special treatment as we were told when they were born that they were healthy -- there was nothing medically wrong with them.
"Before birth, Father O&P&R and I were expecting the babies to be 3lbs each at most. In fact they were considerably bigger than we expected, reinforcing our belief that they were in good health.
"On a date in June, Father O&P&R's dad was coming to visit. You were only allowed to have one visitor with one parent, so Father O&P&R was going with his dad to see the boys and I stayed on the Maternity Ward.
"Around ten minutes after Father O&P&R had left the Maternity Ward to go to the Neonatal Unit,, Father O&P&R and Doctor U (who was the main Consultant) arrived at my bed side. This alarmed me straight away because I didn't why they were there. This was around 3 pm in the afternoon.
"Doctor U assured me that there was nothing to worry about, but that [Child O] needed some extra breathing support so they had administered a breathing tube. He told me this was not uncommon for babies in the Unit and it was a regular occurrence. Despite this reassurance, I wanted to go and see [Child O] for myself.
"Doctor U, myself and Father O&P&R got in the lift to go down to the Neonatal Unit. I was in my wheelchair. Doctor U walked us onto the Unit.
"We were confronted with a scene of complete chaos. It was madness.
"Nurses were running around left and right grabbing medicines and IVs. As soon as I went in, I knew it was an issue with one of the boys.
"When Doctor U saw what was going on, it was obvious he didn't have any idea what was happening and I could see in his face that he was panicked and shocked.
"I was left in my wheelchair and had to stay outside the Unit in the hallway because it was so small that there was no space for me. Doctor U didn't say a word. Father O&P&R went over to ask what was going on. He pulled Doctor U aside, but he didn't know what was going on and he simply told us to give the staff space to do their job.
"It was clear that [Child O]'s collapse was a complete shock to them.
"The Neonatal Unit staff were doing anything and everything; there were IVs hooked up. I don't remember the exact amount of IVs, just that he was given a lot of different medications. Lucy Letby was on the ward at this time; she was passing medicine to the doctors. It looked like they didn't really know what they were doing and were just trying anything they could think of.
"I called my mum and asked her to come straight away. She arrived quite quickly.
"[Child O] passed away at 5.47 pm. I was there when he died. He was passed over to me so I could hold him.
"As this was happening, and before [Child O] died, Dr Brearey was called onto the Unit. At this point, I was in a wheelchair in the corridor of the Unit. He told me that [Child O] had been starved of oxygen. My mum was present during this conversation. He told me that it might be better if [Child O] didn't pull through because the damage caused to his brain would be life-changing.
"No one seemed to know how this had happened. Everyone was in shock and disbelief.
"I thought that [Child O] maybe had something wrong with him that went undetected like a disease or a virus. This was just my assumption, however, as I wasn't told.
"The other boys were in a separate room to [Child O]. I was told that the staff were going to do extra tests on them.
"I am not sure which tests, but I understood they wanted to check if they had picked something up. They assured us they weren't looking for anything in particular and it was just routine.
"I felt maybe I had passed something onto the boys.
"I felt the nurses and doctors didn't have a clue what they were doing during the collapse. At the time, as a parent, I felt like they were doing an inadequate job.
"Much later, when we eventually went to Liverpool Women’s Hospital, some of the staff there said they had heard on the phone that there was a problem with his liver. However, there was nothing concrete so we remained in the dark.
"We didn't learn anything further until just before the criminal trial.
"Father O&P&R and I were taken to the family room on the Neonatal Unit. A nurse whose name I don't remember asked if we wanted to dress [Child O] but I was too traumatised. I couldn't do it, so the nurse dressed him.
"They allowed any family to come onto the Unit to say goodbye. I remember there were quite a few family members present at this time.
"The nurses took [Child O] and I into the room where [Child R] and [Child P] were, and they took them out of their cots so I could have a photo of them all together. This is the only picture I have of all three boys together. We could have had professional photos done but we didn't know if [Child O] had an undiagnosed illness that could be passed on to his brothers, so we didn't want to take any risk.
"On this night, I was given my own room with [Child O] and Father O&P&R stayed with us.
"I was very worried about [Child R] and [Child P]. I asked the midwife to phone down to the Neonatal Unit to see how they were doing.
"On a date in June, at about 6 am, I went down to the Neonatal Unit. This was before the night shift staff changed over.
"I was told by the nurse that the boys were 'little angels' and that she had no concerns. She told me to go and have some breakfast and to have a shower because everything was okay. At the criminal trial I found out that [Child P] had, in fact, been very unwell overnight but at the time I wasn't told this -- in fact I was told the exact opposite.
"I went back to the Maternity Ward to have some breakfast. After this, I went to have a shower.
"Whilst I was finishing showering, a nurse ran in and told me that [Child P] was really poorly and I needed to get downstairs to the Unit right away. I went down in a wheelchair.
"As soon as I got to the Unit, I was confronted with the same chaos and panic as the day before. It was all happening again. They had pushed [Child R] to the back of the room and [Child P] was in real trouble.
"I phoned my mum to get her to come quickly.
"As soon as they managed to stabilise [Child P] and his stats were improving, he would deteriorate again. This went on for hours.
"We were given the family room for the day and went in and out, as [Child P] was being pumped with drugs and resuscitated over and over again. Father O&P&R and his dad stayed to watch as much as they could.
"In this period, I was just forgotten. I felt entirely forgotten and ignored. I had no medication or pain relief, and my mum had to get me some food so I could eat. If my mum hadn't been with me, I would not have thought about food or medication. No one was looking after me, and I had just had major surgery (redacted) days before.
"Lucy Letby was involved in the attempts to stabilise [Child P]. She was rushing in and out getting things on the instruction of the doctors.
"I think Dr Brearey was on shift. I remember him saying things looked more hopeful than they did with [Child O]. [Child O] did not recover from his collapse, whereas [Child P] came back round a few times.
"Before [Child P] died, the team had called for a transport team to take [Child P] to Liverpool Women’s Hospital. The team eventually arrived, and the Consultant, Dr Rackham, took over. He seemed to be more senior. He was very calm. Other people seemed to listen to him, and he took control.
"Eventually, however, he said that he didn't know what had happened and could not believe what was happening, but that he could not do anything else for [Child P].
"[Child P] passed away during late afternoon. I was holding him whilst he passed away.
"Father O&P&R begged Dr Rackham to take [Child R] to Liverpool Women’s Hospital. Dr Rackham told us that he didn't know if he could due to space because he had come to take [Child P]. I thought if we didn't get [Child R] out, he was going to die. Father O&P&R and I did not know what was wrong at this point but I just knew we needed to get [Child R] out of the Countess of Chester Hospital. I didn't think anything malicious had happened at the time, but I did feel that something had gone wrong in the Unit. I thought that possibly the hospital staff had done something that they shouldn't have. But we had no information as to what had happened and why, and no one tried to provide any.
"Dr Rackham said that because the transfer had already been arranged, they could take [Child R] instead. I asked to be transferred to Liverpool Women’s Hospital to be with him, but I was told it wasn't possible. The only way I could be with him was to discharge myself. I wasn't willing not to be with him, so a doctor checked my stitches and I signed the paperwork to confirm self-discharge.
"Whilst this was happening, Lucy Letby dressed [Child P] in the clothes we set aside for him and put his memory box together. She made a big deal about taking photos and seemed quite upset. I remember my mum thanking her for everything she had done.
"Our experience at Liverpool Women’s Hospital was completely different from the Countess of Chester Hospital. When we got to Liverpool Women’s Hospital, I was in agony from my C-section. Father O&P&R got me a wheelchair and we went to reception. Someone came to meet us and we were buzzed into the ward. The nurse looking after [Child R] was called Leah Murphy. She took us to go and see him.
"They put us in a family room on the Neonatal Unit and we slept there for a few nights. They made sure that we were settled.
"On the ward, Father O&P&R and I noticed a different level of cleanliness compared to the Countess of Chester Hospital. There were clear hygiene protocols. For example, we were told to wash our hands before entering the Unit and then again before entering the room. The nurse said that this was standard procedure. Father O&P&R informed the nurse that they didn't do this at the Countess of Chester Hospital.
"The room that [Child R] was in was huge; there was enough space either side of his cot for any machines or screens that were needed.
"The nurse asked if I had done skin-to-skin contact with [Child R]. She couldn't believe that this hadn't been offered to me at the Countess of Chester Hospital. She took [Child R] out of his cot and put him on my chest for the first time, which was really special.
"We stayed at Liverpool Women’s Hospital for around three weeks. This was mainly because they were being extra cautious given the unexplained deaths of [Child O] and [Child P]. I was very grateful. They said that [Child R] was the only child in the Neonatal Unit who didn't strictly need to be there, but they would keep him there anyway as long as they had space.
"I think the nurse had been told that [Child R]'s siblings had passed away.
"They made the decision not to give milk to [Child R], but rather to give him nutrients down a line, as the cause of what had happened to [Child O] and [Child P] was unclear.
"The staff on the Unit were so thorough. [Child R] had every organ checked.
"The nurse told me I could get [Child R] out of his cot and I was scared, but she told me that skin-to-skin contact was the best thing for a baby and they should have done this at the the Countess of Chester Hospital.
"I was aware of postmortems. When I was waiting to be discharged, the nurse said these would be done.
"Criminal Trial.
"As I was originally on the list to be a witness, I didn't really know anything that was going on during the trial itself. It was February when our part of the trial started, and this was the week before I was taken off the list. I therefore went to Manchester for most of that part. If I couldn't make it to Manchester - for example, on one day, there was too much snow -- I watched it from the video link in Chester Court.
"I found the trial extremely difficult. It was so intense at Manchester being there in person. The Defence were just doing their job, but they were saying things like the doctors were lying about what had happened and that was really hard. There were some points when the Defence were questioning witnesses that I had to leave the room as I couldn't cope with listening.
"Father O&P&R and my mum also went every day and stayed to listen to everything.
"I seem to remember speaking to a counsellor at some point in Manchester to help me cope with listening to the trial.
"When it came to the verdict, Father O&P&R didn't feel able to go as it was too much for him mentally. It also meant a lot of sitting around and doing nothing just waiting for a decision to be made, hoping something would happen.
"Instead, as it was over the school summer holidays, Father O&P&R stayed with our children at home and I went to the Court. I felt I had to be there. I felt torn between the children I had at home and making sure that someone was there for [Child O] and [Child P].
"I spent almost all of the summer holidays just waiting and waiting for answers and coming back with nothing. However, I was there the day that the verdict was given.
"I remember that day very clearly. I was sat next to a police officer who was holding my hand, and I just sat and looked at the floor waiting for them to come in. We were at the end as there was a list of names to go through.
"When it finally came to us, I was relieved that they had made the right decision and reached a guilty verdict for both [Child O] and [Child P]'s deaths.
"The police officer called Father O&P&R to let him know the outcome.
"I had a sense of relief that we hadn't gone through that very distressing process for nothing and relieved that we had justice for our sons, but it suddenly made everything very real.
"Impact.
"I went to see my GP for the first time at some point in 2017 about the impact that everything had on my mental health. Although things were bad after we lost the boys, I think giving my statement in November 2017 was what pushed me into significant anxiety. I really struggled.
"My GP prescribed me with anti-depressant medication, but I wasn't offered any counselling or other mental health related treatment through the NHS at all.
"Once the police investigation had started I was offered counselling with them and they put me in touch with someone in Homicide Support who came to see me at home and also arranged a counsellor. This was all before the COVID pandemic. The counsellor was a trauma counsellor and she came to see Father O&P&R and I together at home.
"However, once the trial was starting, I was originally going to have to give evidence and this meant I couldn't see anyone at that stage. Eventually, at the last minute, I was taken off the list and I didn't have to give evidence. I don't know why this happened.
"The events we went through have impacted my faith in the medical profession in a very big way. I found out about the pregnancy with my youngest child before the police made contact. At this time we had already made the decision to never return to the the Countess of Chester Hospital, I therefore chose to have my youngest child at Arrowe Park Hospital as I couldn't bear the thought of returning to Chester. I ended up having another caesarean section as I wasn't in labour and the child didn't want to arrive naturally. My experience in theatre that day was very different to when I was at Chester. The surgeon even told me that the caesarean scar from Chester was 'so bad' he had taken it away and 'thrown it in the bin'. After my child was delivered, they was given straight to me for skin-to-skin contact.
"The team at Arrowe Park were very sensitive to our needs and put a butterfly sticker on my file to indicate our previous loss.
"Throughout the criminal trial, I had support from a team called Aspire who were at the Court all the time. I was also given five after-care sessions via the police which I took up, however these have now ended. A referral was done via my GP for counselling, however the appointment that was booked for me took place while I was away so they just discharged me without even contacting me to rebook. That was around October 2023 and I have had nothing since.
"There are also really small things which are a constant reminder of the children we have lost. For example, I had to call 111 when [Child R] had come home because he had a temperature. When I spoke to them, it meant I had to go through the whole process of explaining that he was a triplet and born prematurely and this meant the call handler had to ask me about his brothers and how they were. There are constant reminders all the time.
"I no longer trust any medics and I find this really difficult when any of the children get ill, as children often do. A few years ago, [Child R] got his finger trapped ... and had to go for a x-ray. I was so anxious about this and worried about the doctors that I wouldn't allow him to go in on his own, as I just don't trust anyone.
"Since the end of the criminal trial, things have not really got any easier. We have children at home that need us, so we just have to carry on, but it is never ending. It feels like every time I pick myself up, there is something else that comes along to knock me back down.
"We now have to face the Inquiry, which is taking place, and although we know it is important, it will drag lots of very difficult memories up for us again.
"Further Questions in Rule 9 request.
"As far as the Datix reports are concerned, I did not know they existed until we saw them in the criminal trial.
"As to when I was first made aware of the number of Neonatal deaths at the Neonatal Unit between 2015 and 2016, I think I first learned about this from a phone call with the police. In the phone call I was told they needed to speak with me and that they were investigating the boys' deaths. The police officer then came round to the house to speak to us. I think this must have been around April/May 2017.
"Before that, all I was aware of was that the boys would have a postmortem. From that, we got our first explanation of how they had died. We had a phone call from the Coroner and were told they had put the deaths down to the boys being premature.
"In the report we received, the names and the dates of the boys were wrong. I feel they did not give us a good enough explanation. The health of the boys and how well they were doing did not match what they were saying.
"We found out about the wider problem when the police came to our house; they said that they were looking into the deaths. I thought it was something to do with medical negligence. I didn't think it was going to be murder. The police asked us to tell them what had happened.
"On 3 July 2018, Father O&P&R got a call from our Family Liaison Officer and they informed us that they had arrested someone on suspicion of murder. This is the first time we ever knew about this. Father O&P&R got the call before we saw it on the news.
"Our Family Liaison Officer then came to the house that morning and told us that Lucy Letby had been arrested.
"We were devastated and in a state of disbelief because Lucy Letby was the one who was looking after the boys.
"When we had been in the Neonatal Unit, Lucy Letby did not stand out more than any of the other nurses. She was visibly upset when the boys died. She put both boys in the cot together and she was crying.
"It was Lucy Letby's idea to take photos of the boys. She dressed them and then took photos of them together.
"I was never told anything about Letby by the Countess of Chester Hospital. It was only during the trial I found out that she had been suspended and taken off the ward. I think I may have also seen this on the news.
"I do not believe that the Countess of Chester Hospital were honest with us at any stage. In my view, they never should have taken on our care in the first place. We were not made aware of the higher mortality rate in the Neonatal Unit - which we now know they were aware of at that stage. I think as parents we should have been informed of this.
"They knew that something untoward was going on and continued to take on my care, even though we could have been sent to a Neonatal Unit elsewhere.
"As far as medical records are concerned, I did not know that we could ask for them, and if I had we would have requested them.
"Father O&P&R and I were not offered any support or counselling by the Countess of Chester Hospital. The possibility of support was never even mentioned. The first time we were offered support was through Homicide Support and then at the criminal trial.
"I spoke to the Honeysuckle Counselling Team at Liverpool Women’s Hospital a few times; they gave me some leaflets and arranged for Father O&P&R to see the boys in a room, and they did a professional photo for us.
"The Honeysuckle Team was not full counselling; it was more just being made aware that there was support available. Because of what I had been through, I needed someone to give me support and push me because I could not do it myself, but nobody did.
"Myself and Father O&P&R were only fully offered support when we went to the criminal trial in 2023; this was seven years after this happened. We were also offered support through Homicide Support.
"I do not know what PALS is and have no experience of it.
"Suggestions and Recommendations.
"I believe that the Countess of Chester Hospital knew much more than they have admitted to publicly about Letby's crimes and I understand from my solicitors that by the time my children were born there, there were already serious concerns about Letby. Obviously, we want to see what evidence comes out about this in the Inquiry, but clearly, hospital management should have been much more responsive when concerns were raised, rather than ignoring or covering up concerns to protect the reputation of the hospital and the Neonatal Unit.
"The information sharing with us was not adequate. It was worse than that - it was basically non-existent. Everything I have since found out about what really happened I have learned through the police, through the trial and through my solicitors. Within the NHS there is supposed to be a duty of candour. Nobody at the Countess of Chester Hospital was candid with us. The duty of candour needs to be made legally enforceable.
"I believe that there should be CCTV in every Neonatal Unit, so that what happens to babies is recorded on camera and can be checked.
"I also believe that there should be proper monitoring of access to medicines, so it can be checked who has accessed particular items.
"Finally, there should be clear protocols to provide support, (to include counselling), full information and guidance to parents who have been bereaved or whose children have been harmed."
That concludes the statement of Mother O&P&R.
Thank you, my Lady.
LADY JUSTICE THIRLWALL: Thank you very much, Mr Scorer.
Father O&P&R, I think we're going to have a short break. If you just let us know when you are ready.
MR SCORER: Thank you, my Lady.
(10.37 am) (Short Break) (10.44 am)
LADY JUSTICE THIRLWALL: When you are ready.
MR SCORER: My Lady, I will now read the statement of Father O&P&R.
LADY JUSTICE THIRLWALL: Thank you.
MR SCORER: "I, Father O&P&R, will say as follows:
"I make this statement in response to the Inquiry's Rule 9 request. This statement should be read in conjunction with my police and Victim Impact statements.
"Experience of Countess of Chester Hospital.
"Before Mother O&P&R became pregnant in 2015, we already had one child who was born at the Countess of Chester Hospital. The birth went fine, there were no complications and we considered that the care provided was good.
"When Mother O&P&R found out she was pregnant again, I went to the booking appointment and all scanning and medical appointments at the Countess of Chester Hospital with her, as it was important for me to be involved in the process and to support her.
"I remember the day we found out we were having triplets really clearly. It was at the 12-week scan and while the sonographer was checking the imaging I was sure I could see two heads on the screen. I told Mother O&P&R what I could see and she thought I was being silly, but the sonographer replied that she thought that there were more than two. We then found out there were three babies.
"We were so shocked that Mother O&P&R burst into tears; partly from surprise/excitement and partly because it suddenly hit us both that we would need to find a way to (redacted) support three babies as well as ourselves and our oldest child. It felt like a once in a lifetime opportunity to welcome three children at once. I felt really blessed in that moment.
"After we spoke to the Consultant at the Countess of Chester Hospital we were referred to Liverpool Women's Hospital the next day to make sure everything was okay. We had to deal with a difficult conversation about potentially stopping one baby's heart to help another thrive, but Mother O&P&R and I both agreed that we wanted to let things progress naturally. We had a big talk about it but we were both on the same page and wanted the best for all three children. Looking back, the babies' heartbeat Liverpool Women’s Hospital wanted to stop was in fact [Child R], so if we had gone ahead with this we could have lost all of our boys.
"After that difficult conversation, things got better and better. I recall all the doctors and midwives being really surprised that Mother O&P&R was doing as well as she was. It did feel at times like they were all waiting for something bad to happen, but everything was fine all the way through her pregnancy.
"As she got bigger, we made jokes about how she would make it through the scan because the three growing babies put so much pressure on her abdomen, that applying the scanning equipment made her feel faint. On one occasion she did actually pass out, but everyone was delighted with her progress.
"However, we were told that the likelihood of Mother O&P&R delivering at the Countess of Chester Hospital was quite slim as they thought it unlikely that they would have enough beds and nurses available to care for them. We were warned that we would probably need to travel some distance to go to another hospital for delivery - Birmingham and London were mentioned but we were told to expect to go anywhere. So I did not expect our babies to be born at the Countess of Chester Hospital. Myself and Mother O&P&R were explicitly told throughout her pregnancy that they would only be born there if there was a nurse and a bed for each baby. I was told by the Consultants, Jill and Jim McCormack, that it would be very unlikely that we would have them at the the Countess of Chester Hospital.
"We had no set plans for our future working arrangements once the babies had arrived, but our loose idea was for Mother O&P&R to go back to work after about nine months and for me to take over, and I would eventually also go back to work once we were all in a comfortable routine.
"Mother O&P&R had scans every two weeks at the Countess of Chester Hospital except for a couple which were performed at Liverpool Women’s Hospital.
"We decided to find out the sex of the babies and to figure out who was who, to make it easier to identify them all. The babies stayed in the same position throughout her pregnancy, so this made it easier to keep track of them. I cannot be certain, but I think we found out that they were all boys at around 20 weeks. We named them.
"Mother O&P&R and I expected the boys to go onto the Neonatal Unit due to the fact that we were having triplets and this was high risk. I was told by Dr McCormack that myself and Mother O&P&R would be able to go and look around the Neonatal Unit at the Countess of Chester Hospital but this was put off and we did not end up going. The tour was supposed to put our minds at rest and give us reassurance as we had never experienced a Neonatal Unit before.
"Mother O&P&R started to have some tightenings at around 30 weeks, so we thought it best to go to the Countess of Chester Hospital to make sure that everything was okay. When we got there, I really got the impression that they weren't very happy that we had come in, because Mother O&P&R wasn't ready to go into labour. We knew that to be the case, having been through this before; we went out of caution and concern, but it felt as though caring for Mother O&P&R's pregnancy was a little too much for them.
"While Mother O&P&R was admitted to the Countess of Chester Hospital as a precaution, my family had to help us with child care for our eldest child as I spent as much time in the hospital with Mother O&P&R as I could, in case something happened. Mother O&P&R was eventually discharged home as she wasn't ready to go into labour.
"On an evening in June 2016 Mother O&P&R started having contractions late at night, at home. We called the hospital, and they told us to come straight in because she was high risk.
"Again, it felt like they didn't really appreciate us being there once we arrived - a date had been booked for Mother O&P&R's caesarean section and we got the impression that going in early was a big inconvenience for them, even though she was obviously not in control of her contractions starting.
"The first doctor we saw was really young and this made me feel a little nervous.
"The Countess of Chester Hospital confirmed that in fact, contrary to expectations, they did have enough beds for all three boys if they did arrive and they therefore agreed to keep Mother O&P&R in overnight. They eventually confirmed that she would have the caesarean section.
"The following day, Mother O&P&R was taken down to theatre for the procedure and I went into the operating theatre with her. It struck me how cold looking and dingy the room felt, and it didn't fill me with confidence. The state of the theatre was like something out of a horror film, ;when I walked in there I immediately felt uneasy. It was very cold and unhygienic. When you go to a dentist, it is all clinical and clean, but this was not the case with the theatre. The room was really small with half a dozen doctors. I was standing by Mother O&P&R's head but I could also see the other side of the screen.
"My first impression of the lead surgeon was that she was very young. The surgeon was of a slim build, tall with curly hair; I cannot remember her name. I remember asking Mother O&P&R if she was the person who was going to be delivering the babies. It was my expectation that Dr McCormack would be delivering the boys but he had booked annual leave. We had put our trust in Dr McCormack and he was there through the pregnancy reassuring us that everything was going so well. It was disappointing for him not to be there at the end.
"As the boys were being delivered, I watched the whole process including the first incisions being made and the boys being pulled out. I was warned that I might not want to watch but I did.
"The first incision they made caused a big spray of blood to go across the room. It went so high, it reached the wall behind Mother O&P&R and I and a small amount landed on her head. Again, this left me feeling somewhat nervous. I watched the boys come out one by one and saw that they were all being checked over.
"It was a huge relief to see all of them come out safely.
"When the boys were delivered, they were crying. The nurses brought [Child R] over to see Mother O&P&R for a few minutes. Whilst Mother O&P&R was being sewn back up, I went over to see the boys to see if they were doing okay. I was told one needed some assistance. I asked the nurse if they were okay and she told me everything was okay and he just needed some oxygen. They assured me that all boys were born sound and healthy with very good weights. After [Child P] had some oxygen, he perked up. I asked lots of questions, if they had come out fine and if their weights were okay. I was reassured that their weights were better than expected, they had been born healthy and normal. I cannot remember who was specifically reassuring me. I think it was someone from the Neonatal Unit who was in theatre with us, so it could have been them.
"I was expecting the boys to go to the Neonatal Unit because they were premature triplets. Due to how well the pregnancy went and the reassurance we had, we did not expect them to need any treatment. The doctors used the term 'feed and grow'. Mother O&P&R and I expected the babies to go to the Unit, feed and grow and then go home. We did not expect them to need any special treatment; there was nothing actually wrong with them. The doctors and nurses reassured me that the boys were healthy. I was expecting them to be less than 3lbs at the biggest. In my eyes, they were considerably bigger than what everyone expected.
"I believe that Mother O&P&R only saw [Child R] immediately after the delivery, because [Child P] and [Child O] needed some initial support. Because he was more stable, a few photos were taken of [Child R] being held next to Mother O&P&R by one of the nurses.
"After the boys were delivered, Mother O&P&R was taken to the ward so she could be looked after, and I went down to the Neonatal Unit to see the boys. I was down there for around 45 minutes and was able to have some skin-to-skin contact with [Child R]. After that, I went upstairs to see Mother O&P&R.
"The following day we had lots of family members visiting that day, but Mother O&P&R was in a lot of pain and she needed help with showering and her personal care, so although I did try and spend as much time as possible with the boys, I also had to balance this with making sure Mother O&P&R was looked after and seeing family.
"That night, I left the hospital and stayed at home with our eldest child and then returned to hospital the next day.
"On the following day, my dad came to the hospital to see us and to meet the boys. You are only allowed one parent plus one visitor on to the Neonatal Unit at a time, or both parents, so Mother O&P&R and I agreed that I would meet my dad and take him down there.
"I think I met him at the hospital reception, as I recall that he didn't really know where to go, and we then walked to the Neonatal Unit together.
"On the way down, I bumped into Dr U who was coming to speak to Mother O&P&R. He didn't seem panicked, he was calm. He reassured me that everything was fine and there was no reason to be alarmed, but [Child O] needed some help and they had put a breathing tube in. This was around 3 pm.
"Dr U, my dad and I got into the lift and came down to the Unit. When we walked through the doors you could see Dr U didn't have a clue what was going on; I could see in his face that he was panicked and shocked.
"Everything had been fine when I left to go and meet my dad, but when we got back there it was absolute pandemonium.
"Doctors and nurses were all running around and it was extremely busy and overwhelming with the number of doctors and nurses packed into the room. No one told me what was happening, and they were all just rushing around. There were lots of different things being put into lines and tubes.
"All I got told was that there was a problem with [Child O] and then I got ushered to one side and told a doctor would come and see me.
"I went up to the ward to go and get Mother O&P&R. I told her there had been a problem and she needed to come down to the Unit.
"Mother O&P&R needed to be in a wheelchair because of her surgery so I wheeled her down to the Unit. The journey down there was agonising for her because every time the wheelchair went round a corner, or over a threshold or bump it caused her a lot of pain. When we arrived, I couldn't get her close enough that she could see [Child O] or be near him because of the wheelchair and volume of people in there. She ended up having to wait in the hallway.
"I was able to get back into the Unit and went to try and find out what was happening. Mother O&P&R had called her mum to come to the hospital and she arrived and waited with Mother O&P&R.
"We didn't get any explanation of what was happening even though I was standing close to what was going on. We had no idea what had gone wrong. I know that somebody mentioned swelling on his abdomen, and this was something I could see for myself; his stomach had popped out almost like a pot belly. His skin was a different colour and it looked almost like there was something pulsating through his veins.
"The doctors seemed as baffled as we were, and no one could tell us why things had suddenly gone so wrong. It was really shocking. I have no medical training and it felt like the doctors were essentially in the same boat as me.
"Shortly before we were given the news that they would have to stop trying to resuscitate [Child O], they asked whether we wanted to have him christened. We both did, so me, Mother O&P&R and her mum were present when the priest came down and christened him.
"Shortly after he was christened, [Child O] passed away.
"After he was gone, he was passed to Mother O&P&R so that she could hold him. I was devastated.
"We were given sole use of the family room, which was usually for all Neonatal Unit families to use. We were conscious that there were other families on the ward at the time that all of this was happening, so we were grateful for a space where we could try and take stock of what had happened and have some privacy.
"Mother O&P&R and I spent some time with [Child O] in the family room before I had to deliver the awful news to my mum.
"Someone suggested that we get a camera and take some photos and they would give us a blank SD card so we could keep them. I tried to dress [Child O] but I couldn't bring myself to do it. He was cold and so still and I just couldn't do it.
"Someone else dressed him and we took some more photos and I also brought my mum up to see him. We were in the room for a while and just sort of sat in there for the evening.
"We took a photo of all the boys together on this day and this is the only picture we have of the three of them together.
"That night, Mother O&P&R was moved off the ward and into a separate room which meant I could stay there with her.
"I couldn't let [Child O] out of my sight. I wasn't ready to be away from him, so he stayed in the room with us all night in the cold cot. Neither Mother O&P&R nor I slept that night. I knew it would be the last time that I would see him. A nurse came and collected him in the morning.
"Overnight, Mother O&P&R called down to the ward a few times to make sure that [Child P] and [Child R] were okay and each time they said everything was fine.
"On the following day, Mother O&P&R and I both went down to the ward to see [Child P] and [Child R] first thing in the morning. The nurse we saw at first was lovely and said they had both been little angels. She said they had been feeding well and opening their bowels as normal and there was nothing to worry about.
"It later came out as part of the criminal trial that there had been some minor issues to do with the numbers on their charts, but I don't really recall what this was, and it was apparently nothing significant.
"Mother O&P&R went back up to the ward so she could have a shower and I stayed down on the Unit and, similarly to the previous day, I had planned to go and meet my dad.
"Literally just before I was due to go and collect him, it all happened again.
"I had to go and get him and when he arrived I said 'Dad, it's all happening again'.
"We rushed back to the Unit, and it was like déjà vu. It was almost an exact repeat of the day before.
"Everyone was running around like headless chickens looking like they had no idea what was wrong. I asked one of the doctors what was going on and said 'it's happening again, isn't it'. Nothing was said to me; no one could explain it, again.
"They couldn't tell me what was happening, just that they were doing everything they could for him. In my mind, I could already see it was the same. [Child P] had the same mottling on his skin, the same distension on his belly and I just knew it was the same thing, even though I didn't know what that thing was.
"I can't be sure, but I think there were doctors there that day that hadn't been present the day before, perhaps even more Consultants. I remember watching as an incision was put into [Child P]'s chest to help his lungs and because there was no space, they had to put a screen up in the hallway.
"Mother O&P&R was, again, stuck outside in her wheelchair, also with no idea what was happening.
"There was another doctor at what looked like a makeshift desk using a screen to look up how to perform the chest drain and where the incisions and tubes should go. It looked as though they were following a tutorial and not as if they really knew what they were doing. His resuscitation went on for a really long time and we were eventually told that they would arrange to transfer him to Liverpool Women’s Hospital. However, they needed to wait for transport to come and get him. That wait felt like it was hours, although, in reality, it was probably much shorter.
"While all of this was happening, Lucy Letby was involved in [Child P]'s resuscitation.
"I saw a nurse Googling a procedure; she was youngish. She had a PC screen in front of her and as soon as I saw this come up on the screen I panicked. I was confused as to why she was Googling this. The procedure was a lung drain. On the screen there was an image of a person with an arrow pointing to where the incision should be. It was a medical diagram. I think the staff heard me talking about it; I was angry at this point. I can remember other staff coming over to the computer to look at it; they all had a word with each other and did the procedure. This was worrying me because it is an everyday procedure, one that hospital staff must do day in and day out.
"When the Consultant from Liverpool Women’s Hospital Dr Rackham arrived, there was such a shift and change in the atmosphere. He was so good. He was calm and confident and gave clear instructions to everyone about what they should be doing. Despite how calm he was I could sense how shocked he was that nothing they had tried was working.
"Dr Rackham eventually came over to us and he said they had tried everything and there was nothing more they could do. They asked if we wanted him to be christened, which we did. His support was stopped shortly after he was christened.
"I remember Dr Rackham passing [Child P] to Mother O&P&R and saying he didn't know what had happened and that he couldn't believe it. He said that they had done everything they could have done.
"Mother O&P&R was holding [Child P] as he passed away. It was heartbreaking.
"I remember feeling quite angry at this stage and I felt as though the hospital could have done more to help the boys. I just felt that something wasn't right, and I knew that if they didn't take [Child R] to Liverpool Women’s Hospital, he wouldn't survive.
"Mother O&P&R felt the same and I remember her saying to me 'take my boy out of here now'. I approached the Consultant from Liverpool Women’s Hospital and said that we weren't happy leaving [Child R] in the care of the Countess of Chester Hospital, knowing that something had gone really wrong with both our boys in just 24 hours. I told him I thought that if he stayed there, he would be next and I genuinely felt that to be true.
"In not so many words, he indicated that he agreed there was a risk to [Child R] and that because they had agreed to take one baby back with them, he made some calls to try and arrange it. He spent about 10-15 minutes making calls and explaining to the hospital what had happened, and it felt like he was having to fight for us. When we found out that he had managed to get it agreed, we were delighted. We really felt that [Child R] would be safer there.
"Shortly after this, I was out in the courtyard with Dr V. She gave me a hug and told me that they had tried everything. She couldn't believe that this had happened to both boys so quickly. I recall Dr V pulling me to one side and asking if we wanted there to be a postmortem report for [Child P]. She said that they don't always do one, but this can be arranged sometimes. I said we definitely wanted one done as I knew something wasn't right and I really pushed for this to be done. She said it wasn't up to her to make the final decision, but she would try to keep us updated. Dr V was very upset and kept apologising to us, but it just felt like a lot of sorrys were given which didn't really help us because we didn't understand how it had happened. She told me that they would get to the bottom of it, she took me into her private office and explained a postmortem or autopsy might be needed and in this case we should argue one be done. I told her we needed answers and it needed to be done.
"Mother O&P&R and I were then taken to another family room at the other end of the Labour Ward. [Child R] and [Child P] were brought in together with [Child P] in a cold cot. Lucy Letby was present in that room, and she had dressed [Child P]. We took some photos of the boys together. Lucy Letby made a very big deal about taking photos of the boys and making memory boxes.
"In order for Mother O&P&R to be able to go with [Child R] to Liverpool Women’s Hospital, she was forced to discharge herself. She still needed care and medication after her surgery and we asked several times for her care to be transferred, but they said this wasn't possible. We were never told why. This meant she had to sign paperwork to discharge herself even though she still needed support.
"[Child R] was then transferred in an ambulance and we were encouraged to go home in between to get some fresh clothes and to avoid following the ambulance, so we didn't panic if they had to pull over for any reason. The transfer team were brilliant and even texted us once [Child R] had arranged, so we knew he was safe and we could start our journey to the hospital.
"We drove to the hospital once we knew [Child R] had arrived. Mother O&P&R was in agony. Every time the car went over a bump, she was in a lot of pain and this was only adding to her upset.
"When we arrived at Liverpool Women's Hospital, I got Mother O&P&R a wheelchair and we went to reception. Someone came to meet us and we were buzzed in. They put us in the family room on the Neonatal Unit and we slept there for a few nights. The staff made sure that we were settled.
"Leah Murphy was the nurse looking after [Child R]; she came to see us and took us to see him.
"As soon as I arrived on the Unit, I noticed a different level of cleanliness on the Unit compared to the Countess of Chester Hospital. We were told to wash our hands before entering the Unit and the room. The nurse said that this was standard procedure. I told her we were never asked to do this at the Countess of Chester Hospital. The room [Child R] was in was huge; there was enough space either side for any machines or screens that were needed.
"Every detail was explained to us. The nurse told Mother O&P&R and I about the monitors and what it means when they go off. They said not to worry unless we see them worry. They were really reassuring as we were already panicked. I think the nurse must have been told that two siblings had passed away.
"We were there for three and a half weeks. We did not need to be there; we were there as a precaution. The staff made the decision to starve [Child R] as there was no evidence from the Countess of Chester Hospital of what had happened to his brothers. They said that they would not feed him for now as they needed to take precautions. They were so thorough. [Child R] had all his organs checked. I felt like they knew more; they handled situations so much better. We had seen a few very poorly babies in there and not one of them died; every baby pulled through and we knew that [Child R] was in safe hands.
"The nurse told Mother O&P&R she could get [Child R] out of his cot and she was scared. The nurse told us that skin-to-skin was the best thing for a baby and that we should have been doing this before. Mother O&P&R had never had skin-to-skin contact with [Child R] before this. She was scared that she would pass something on to him. The staff said [Child R] was the only child in Intensive Care who did not need to be there. During the three and a half weeks, he moved down the rooms in stages.
"Before the boys were born we rented an old house that had issues with damp and mould. It wasn't something that bothered Mother O&P&R and I, but we didn't feel comfortable taking [Child R] back to the house, particularly because we still didn't know what had happened to [Child O] and [Child P]. We couldn't take any risks.
"We therefore stayed with our families initially. [We were very grateful to be put up but it wasn't really] the ideal situation.
"Mother O&P&R was very distressed and couldn't deal with anything which meant I had to try and sort everything out with the house, but it was difficult for me, so I ended up asking my dad to arrange everything for us.
"After we left hospital with [Child R] and were more settled in our home, we just tried to cope with day-to-day life as best we could. I was trying to work but I was struggling emotionally. We received no help from the Countess of Chester Hospital or the NHS. Then we found out that the police investigation was starting, and this really changed things.
"I had always known that something wasn't right in what happened to the boys and although the police involvement was some validation of my concerns, it was also overwhelming.
"It sickened me to think that the police had to be involved in a hospital investigation and as we weren't told about the nature of the investigation, it made it really difficult to understand and cope.
"There were so many different scenarios and possibilities going through our heads about what might have happened and why the police were involved. Mother O&P&R blamed herself for what had happened to the boys, thinking she had done something wrong during pregnancy or passed something on to them. I blamed myself and thought I might have passed something on to them. We both blamed ourselves, although Mother O&P&R felt this more strongly than I did. It was hard to try and tell her it wasn't her fault; anything I told her she just didn't want to hear.
"My gut feeling had always been that something medically had been done wrong to the boys because of the way their abdomens had been swollen and I just knew something was not right. I didn't always think it was malicious, but I thought something had been given incorrectly with the amount of medicine they were pumping into the boys, or even that CPR had been done too vigorously. Mother O&P&R didn't really vocalise any theories as much as me; she is much quieter and tends to just keep to herself. It was only when the police had shed light on the events that everything fell into place with what I was thinking, and it all made sense from what I had seen.
"Mother O&P&R was particularly anxious about being kept in the dark and couldn't understand why we weren't being told anything. It was very frustrating and made us both really nervous.
"As time went on, the police started asking us more and more about specific shifts and specific members of staff and, over time, Lucy Letby's name came up more frequently. Mother O&P&R and I both remembered her from our time at the hospital.
"I remember the day they told us that she had been arrested, and our hearts sank. It was so difficult to understand at first because she had been so visibly upset when [Child P] passed away. When she was working on a shift she came across as quite robotic and cold, but after [Child P] died, she appeared to be devastated.
"Criminal Trial.
"At the start of the trial, Mother O&P&R was a potential witness, so she wasn't allowed to watch or listen to anything relating to the proceedings. She took herself off of all social media platforms and avoided the news. I followed everything for the first week religiously. I was glued to my phone and texting my parents any developments that happened. It was a strange time because Mother O&P&R and I couldn't discuss any of it and we were very strict about this as we were not willing to risk jeopardising any conviction.
"After around a week, I stopped following what was happening because of not being able to speak to Mother O&P&R about it. It was more important to me to support Mother O&P&R than follow what was happening and I was worried about slipping up.
"I started re-following events once Mother O&P&R found out that she was no longer going to be a witness, which was towards the end. That's also when the police disclosed more information to us about what had happened and the rest of the trial.
"A Family Liaison Officer came over to our house, and Mother O&P&R's mum came too and that's when we got all the information about what had happened to [Child O] and [Child P] and how it all happened. This was the first time we knew or had any idea of why the boys had died.
"We were given lots of paperwork to read, which explained all the medical terms and what had happened, but it was really hard to see it all written down. We had spent all those years making up scenarios about what might have happened and blaming ourselves and seeing it there in black and white was devastating. Once we knew what had happened, in a way, it seemed quite obvious. We both used to watch medical dramas and have seen episodes before where similar sorts of things happen, and they always talk about how difficult it is to detect.
"After we knew what had happened, we did start to attend the trial -- either in person or by video link at Chester. Both Mother O&P&R and I only attended anything to do with our family. I didn't want to read into what happened to the other children. I didn't feel I could cope.
"It was a nightmare for us to get to Manchester Crown Court to attend any of the Court days. We didn't have a car which meant relying on a Family Liaison Officer -- the children would have to go to our family so they could be taken to school, we attended a full day in Court and then it sometimes took us (redacted) hours to get home because of traffic. Some weeks it was like that for days on end.
"The verdict arrived during the school summer holidays, but we didn't know when it could come and no one could give us any idea of timescales for the decision. We could either go there every day and wait all day long, or chance it and not go. The children were off school, so I stayed at home with them and Mother O&P&R went to the Court every single day and waited all day on her own, while I looked after the kids.
"This was tough for me as I had been at the Court all the way along for our parts, and then couldn't be there for the most important bit.
"The day that the verdict was given Mother O&P&R was at the Court. A police officer called me once the decision had been read out. By this point, there was no doubt in my mind that Lucy Letby was responsible, so I ended up just finding it reassuring that the right thing had been done.
"Mother O&P&R and I have both lost a lot of faith in the medical profession now and this has only been made worse by my experience of trying to get mental health support.
"When it comes to our children and getting medical treatment, I would say that Mother O&P&R and I are both now quite anxious about them. We are very alert to any health issues they might have and probably overly anxious about them getting unwell. I am fine taking them to the local doctor or GP but it's another issue if we have to take them to hospital.
"I still have very vivid nightmares and don't sleep well. Even at the weekend, I still cannot really sleep. I am often sat up until 1 am unable to switch my brain off and when I go to bed, I still about everything that has happened.
"I have visions and nightmares approximately every other night, of being back at the hospital. They tend to be about the boys and are a mix of specific things I remember happening at the time; the colour of their veins and their veins pulsating is something which comes up a lot. I also have angry dreams where I tell myself I should have done more. I have also had angry dreams about Lucy Letby.
"I cry a lot more than I used to before all of this happened. I never used to cry about anything, only at something like a family funeral. But now, I get upset easily. I am more affected by emotional situations generally if I see something sad. There was an incident a while ago where I witnessed an older lady fall and hit her head. I called an ambulance for her, and I think she was okay. I wouldn't usually have been affected by it, but I found it really harrowing to deal with and remember the sound of her head hitting the floor.
"I am also now far more emotional when I think about life in general. I often think about sad things like my dad getting older and that worries and upsets me, whereas I would usually just get on with things.
"The Inquiry's Further Questions.
"The Inquiry in its Rule 9 request has raised various detailed questions concerning our dealings with the Countess of Chester Hospital after our children's deaths, particularly in the period 2017-18.
"I would like to answer these questions but I need to explain that, unfortunately, I cannot add much to the information already set out above, and set out in my police and Victim Impact statements and in the documentary record. I wish to help the Inquiry as much as possible, but the simple fact is that as a result of everything we went through, much of what occurred in the period 2017-2018 is now a blur. As a result, I am struggling to answer the Inquiry's detailed questions.
"When these events happened, all my instincts were that something in the hospital had gone badly wrong. I found it impossible to believe that these things could happen without some serious mistake, failure or culpability on the hospital's part. But I am obviously not trained in science or medicine, so I was not in a position to know what might have gone wrong, or even where to start looking. More than that, I had lost two children and was utterly devastated. My life had fallen apart.
"Following the deaths of our children, we did not receive any support or counselling from anyone. Had we received some support, we might have been in a better position to try to act on what our instincts were telling us, which is that something had gone badly wrong. As it was, our lives had been devastated, but got no support and we had to fend for ourselves. Moreover, even with counselling, we did not know how to navigate our way around the system. We did not understand how the coronial system worked, for example. We had no idea where to start when it came to getting hold of information and answers. We were in no fit state mentally to take on a hospital which had no interest in trying to help us or be honest with us.
"We only started to get meaningful information when the police investigation got underway and we gradually learnt more. Until then, we had been completely unaware that there had been an abnormal number of baby deaths at the Countess of Chester Hospital Neonatal Unit in 2015-16. The hospital knew, but didn't tell us. Then we learnt a lot more at the trial. For example, we had never seen the Datix reports before the trial. I didn't even know they existed until the trial. The trial was the first time we saw them.
"I confirm that we received some letters from Ian Harvey. I am aware that there is a record of me calling the hospital and that I was very distraught. I have no memory now of making that call. Of course, I entirely accept that I did make it, and that I would have been very distraught. I simply have no memory of it. It was such a traumatic time, and I have probably pushed things out of my conscious memory in order to cope.
"I hope the Inquiry will recognise that very few parents who experience the sort of trauma that we did are realistically going to be in a position to take on the system and get answers. Every parent in this situation should be properly supported and given access to high-quality counselling. But even with that, most parents in this situation are not going to be able to push for answers. We can only get answers if those in positions of authority, who have information, are required to be candid and honest. This simply did not happen. I have heard talk about the duty of candour but it was certainly not honoured by the Countess of Chester Hospital in this case.
"Suggestions and Recommendations.
"I believe that the Countess of Chester Hospital knew much more than they have admitted to publicly about Letby's crimes and I understand from my solicitors that by the time my children were born there, there were already serious concerns about Letby. Obviously, we want to see what evidence comes out about this in the Inquiry, but clearly, hospital management should have been much more responsive when concerns were raised, rather than ignoring or covering up concerns to protect the reputation of the hospital and the Neonatal Unit.
"The information sharing with us was not adequate. It was worse than that - it was basically non-existent. Everything I have since found out about what really happened I have learned through the police, through the trial and through my solicitors. Within the NHS, there is supposed to be a duty of candour. Nobody at the Countess of Chester Hospital was candid with us. The duty of candour needs to be made legally enforceable.
"I believe that there should be CCTV in every Neonatal Unit, so that what happens to babies is recorded on camera and can be checked.
"I also believe that there should be proper monitoring of access to medicines, so it can be checked who has accessed particular items.
"Finally, there should be clear protocols to provide support (to include full counselling), full information and guidance to parents who have been bereaved or whose children have been harmed."
My Lady, that concludes the statement of the Father of O&P&R.
LADY JUSTICE THIRLWALL: Thank you very much indeed, Mr Scorer.
Father O&P&R, thank you very much for being present today online and for providing the statement and allowing Mr Scorer to read it on your behalf. I don't underestimate for a moment how difficult it has been to prepare the statement and then to hear it read again.
Would you please pass on to Mother O&P&R my thanks for what she has done in preparing and providing the statement.
FATHER O&P&R: Of course.
LADY JUSTICE THIRLWALL: I completely understand why she is not online with you today and I am grateful to her for what she has done, as you have, on behalf of the Inquiry.
FATHER O&P&R: Okay, thank you very much.
LADY JUSTICE THIRLWALL: Can I just say to you that both of you have really explained very vividly what your experiences were in the Countess of Chester Hospital in 2016 awful experiences as you have described them -- and yet thanks to your quick thinking, at a time when you were devastated, you insisted and managed to achieve [Child R] being transferred to Liverpool Women's Hospital, where he seems to have thrived from the moment he got there, being skin-to-skin with his mother very early on.
FATHER O&P&R: Yes. We thank our lucky stars for getting him moved.
LADY JUSTICE THIRLWALL: Yes, yes. There's no question that that made a huge difference to him.
What comes across so well in your statements is your love for all of your children and I know that you still live and always will live with the loss of two of your children, but the love for all of them shines through in everything that you have done.
Can I also, on a practical note, thank you for the suggestions for recommendations that you have made. They are characteristically thoughtful and ones that are already being tested by the corporate witnesses. They are being asked what their views are about these very practical suggestions, so thank you both very much for making a significant contribution to the Inquiry. Thank you.
FATHER O&P&R: Thank you.
MS LANGDALE: My Lady, that concludes the evidence in Part A.
LADY JUSTICE THIRLWALL: Thank you very much indeed, Ms Langdale.
We will adjourn now and we will begin evidence tomorrow morning at 10 o'clock. Thank you all.
(11.25 am) (The Inquiry adjourned until 10.00 am on Thursday, 26 September 2024)