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Baby O

Count 20: Murder of Baby O on 23 June 2016. Alleged mechanism(s): Injury to liver/Overfeeding/Air in NG tube, Air embolism

Dr Shoo Lee's International Panel Summary Conclusions

BABY 15 SUMMARY [Baby O]
Baby 15 was a second triplet born at 33+2/7 weeks gestation, by in-labour Caesarean section at the Countess of Chester Hospital, a District General Hospital. He weighed 2.02kg. He had mild respiratory distress requiring continuous positive airway pressure (CPAP) and oxygen. The triplets were extracted at Caesarean section very quickly, a minute apart. Baby 15’s haemoglobin on the day of birth (day 1) was 168g/l. The next day (day 2), he was changed to Optiflow and started on small amounts of feeds. At 36h he was noted to have a rising heart and respiratory rate, temperature instability and mild abdominal distension. He did not pass meconium until 32 hours of age; meconium is usually passed within the first 24 hours. The next morning (day 3), his abdomen was more distended, with visible loops of bowel, and he was uncomfortable after a feed. By afternoon, he vomited undigested milk, and had high blood lactate (5.4), carbon dioxide (7.09), bilirubin (156) and acidosis (pH 7.2). He was given fluids and antibiotics. At 1440h he developed a profound desaturation and low heart rate (80-90/min) and looked mottled. His abdomen was very distended. He was intubated and ventilated with high pressures (28/5). A small purpuric discolouration was transiently seen on his right chest during the resuscitation. At 1551h he desaturated again and was reintubated, receiving cardiac massage, adrenaline (8 doses), bicarbonate (3 doses), and saline infusions. His ventilation pressures were increased to 32/6 in 100% O2. Dopamine was started and needle aspiration of the abdomen was performed. An intraosseous line was inserted because of poor circulation. At 17.43h blood gas showed marked acidosis (pH 7.014; BE -17) and a haemoglobin level that had halved (Hb 86g/l); no heart rate was heard. At 17.47h resuscitation was stopped after consultation with parents. Post mortem showed a ruptured subcapsular haematoma of the liver.

CONVICTION
It was initially alleged that Baby 15 received inflicted blunt trauma to the abdomen, causing purpuric discolouration and a ruptured subcapsular haematoma of the liver; and that air was injected into the nasogastric tube to cause gaseous distension of the intestines. Later, the accusation was changed to deliberate injection of air into his circulation.

PANEL OPINION
Baby 15 collapsed because the subcapsular haematoma ruptured causing acute major haemorrhage into the peritoneal cavity sufficient to cause a near halving of the haemoglobin level. Subcapsular liver haematoma is the result of “traction” or “shear” forces applied to the thin, fragile liver capsule through the hepatic ligaments. In Baby 15, this was highly likely the result of the extremely rapid delivery, which is a well-recognised cause of birth injury. Bleeding into a subcapsular haematoma is characteristically initially slow because it is contained by the pressure of the enveloping liver capsule; in these early stages the clinical signs are insidious and difficult to recognise. High pressure ventilation decreased venous return to the heart and contributed to liver congestion. The slow, deterioration is then characteristically followed by acute collapse when the capsule ruptures, releasing free blood into the peritoneal cavity. The significance of the rising heart rate and falling pH before the terminal collapse were not recognised. The blind abdominal insertion of a needle during resuscitation may have penetrated the right lobe of the liver, causing further injury, noted by the pathologist as parenchymal haematoma and laceration. Blunt direct trauma to the right abdomen or chest is implausible because it is very difficult to generate the kind of forces required to produce the observed injuries in a liver protected by the lower chest wall. The gaseous distension of the intestinal tract was likely due to air swallowing and insufflation during noninvasive respiratory support. The suggestion of injection of air into the circulation is conjecture.

CONCLUSIONS
Baby 15 died from a subcapsular liver haematoma caused by traumatic delivery, resulting in haemorrhage into the peritoneal cavity, and profound shock. This was not recognised ante-mortem

Prosecution Opening Statement

Background
Child O and Child P were two of three triplet brothers, the court hears.

Child O weighed 2.02kgs, which was good for a premature triplet. He was in good condition and made good progress.

He was stable up to June 23, when he suffered what Dr Evans said was a “remarkable deterioration” and died.

Between June 15 and June 23, Lucy Letby had been on holiday in Ibiza.

Child O's body was examined after his death and an injury to his liver was found.

Incident
Letby was working the day shift on June 23 and was the designated nurse for Child O and P, in room 2, with another child.

The prosecution say this "gave her an open opportunity to sabotage the babies".

The third of the triplets was in room 1, the doctors believing he was the most needy of the triplets.

Letby also had the responsibility of supervising a student nurse that day.

The designated nurse recorded 'no nursing concern - observations normal' for Child O.

There are three records of feeds by Letby, at 8.30am, 10.30am, and 12.30pm - the earliest signed by the student nurse, the latter two signed by etby.

In a note made by the doctor at 1.15pm, there was '1x vomit post feed' with 'abdomen distended'.

Child O was put on to IV fluids as a precaution.

Child O's heart rate was 160-170, blood gases were low, and raised CO2 level.

The doctor recorded the results as 'not normal' for a child breathing on their own and treated for suspected 'NEC'.

It was thought down to Child O's swallowing of air or the passing of a stool earlier.

An x-ray taken at the time showed a moderate amount of gas in the bowel loops throughout the abdomen

Letby noted at 8.35pm - 'reviewed by registrar at 1.15pm - [Child O] had vomited (undigested milk) tachycardic and abdomen distended. NG tube placed on free drainage … 10ml/kg saline bolus given as prescribed along with antibiotics. Placed nil by mouth and abdominal x ray performed. Observations returned to normal”.

Prior to Child O's collapse, a colleague said of Child O: "“he doesn’t look as well now as he did earlier. Do you think we should move him back to [room] 1 to be safe?"

Letby did not agree.

The prosecution say this echoes the final, fatal collapse of Child I.

Letby had taken Child O's observations at 2.30pm as 100% oxygen saturations and normal breathing rates.

From her phone, she was on Facebook Messenger at the time, and at 2.39pm, the door entry system recorded her coming into the neonatal unit.

Within a few minutes of that, Child O suffered his first collapse.

Letby called for help, having been alone with Child O in room 2 at the time.

Child O's heart rate and saturations had dropped to dangerously low levels. A breathing tube was inserted by the medical staff and he was successfully resuscitated. He was kept on a ventilator.

At 3.49pm, Child O desaturated again. doctors removed the ET and replaced it "as a precaution". Letby's written notes suggest she was the one who called for help.

Child O suffered a further collapse at 4.15pm which required CPR. Those efforts were unsuccessful and Child O died soon after treatment was withdrawn at 5.47pm.

A consultant doctor noted Child O had an area of discoloured skin on the right side of his chest wall which was purpuric.

He noted a rash at 4.30pm, which had gone by 5.15pm, and did not consider it purpura, but unusre what it was or what had caused it.

The doctor was particularly concerned about Child O's death as he was clinically stable before these events, his collapse was so sudden and he did not respond to resuscitation as he should have

After the shift, Letby sent a series of messages to the doctor on Facebook, and to her colleague. She suggested Child O "had a big tummy overnight but just ballooned after lunch and went from there."

Medical Experts
A post-mortem examination found free un-clotted blood in the peritoneal (abdominal)space from a liver injury. There was damage in multiple locations on and in the liver. The blood was found in the peritoneal cavity. He certified death on the basis of natural causes and intra-abdominal bleeding.

He observed that the cause of this bleeding could have been asphyxia, trauma or vigorous resuscitation.

The prosecution say no-one would have thought a nurse would have assaulted a child in the neonatal unit.

Dr Dewi Evans concluded Child O's death was the result of a combination of intravenous air embolus and trauma. The liver injury was not in his view consistent with vigorous CPR. His view was that the liver damage would have occurred before the collapse and contributed to it and was probably the reason for his symptoms through the morning. As for the air in the bowel loops, Dr Evans concluded that that was consistent with excessive air going down via the NGT.

Dr Bohin concluded that together with the chest wall discolouration seen by the doctor that was indicative of air having been injected into Child O's circulation. She agreed that the abdominal distension was due to excess gas via the NGT.

Dr Andreas Marnerides, the reviewing pathologist, thought that the liver injuries were most likely the result of impact type trauma and not the result of CPR.

He thought that the excess air via the NGT was likely to have led to stimulation of the vagal nerve which has an effect on heart rate and would have compromised Child O's breathing.

He could not say whether it was either of these factors in isolation or in combination which caused Child O's death.

He certified the cause of death to be “Inflicted traumatic injury to the liver and profound gastric and intestinal distension following acute excessive injection or infusion of air via a naso-gastric tube” and air embolus.

Police Interviews
In police interview, Letby said she had responded to child O's alarm at 1.15pm and found he had vomited.

She responded first at 2.40pm and discovered mottling all over with purple blotches and red rash. She said that his abdomen just kept swelling and suggested thatsometimes babies can gulp air when they are receiving assistance from Optiflow, as Child O was.

Facebook
A year later, on the anniversary of Child O's death, Letby carried out a search on Facebook on the surname of the child.

Defence Opening Statement

For Child O, the allegations are "various". An air embolus is "not accepted" and the defence point towards an infection, along with "CPAP belly".

The "liver injury" was "caused during resuscitation", the defence say. The prosecution "do not accept that", Mr Myers tells the court.

Defence Closing Speech

Mr Myers says he will begin the case of Child O in the remaining 10 minutes [to be continued tomorrow]. He outlines the events for Child O. Child O was one of three triplet brothers - Child P being another of the triplets. Mr Myers says he will start with June 22-23, for the night shift with designated nurse Sophie Ellis. The final note 'Abdo looks full slightly loopy. Appeared uncomfortable after feed.Reg Mayberry reviewed. abdo soft, does not appear in any discomfort on examination.' He says an examination took place, but no note was made by Dr Mayberry  He asks why Letby is blamed for Child N being unwell at 1am after Letby had finished at 8pm the previous night, whereas for Child O Letby is blamed for Child O being unwell at 1pm when Child O had been unwell at 8am. He asks why there was no record of a doctor's examination after Sophie Ellis had noted a doctor reviewed Child O, when Letby was blamed for noting a doctor review for Child I when there was no record of a doctor's examination.

(The court adjourns until the following day.)

Mr Myers is on his feet, he's continuing to take the jury back over the evidence for triplet brother Child O.

The court heard he was stable up until 23 June 2016, when he suffered a "remarkable deterioration", he stabilised but later suffered a further fatal collapse. Mr Myers says the explanation of the experts - that there was an assault which resulted in a trauma to the liver and air embolus - is 'confusing'. He invites the jury to consider 'how, where and when' this things happened. He said it's 'very unclear'. Mr Myers says the prosecution has not identified a time or place where these alleged offences took place.

Mr Myers has pulled up the neonatal review - which has been pulled together by police analysts and is a timeline of events - it shows that Child O was given medicines by two other nurses at 14:39. Ms Letby is seen as doing an infusion at 14:40, just before the collapse

Mr Myers notes the door swipe data which shows Ms Letby only arrived at 14:39 on the unit. He drills deeper into the clinical notes which show Child O collapsed at 14:40 and then Ms Letby, on instruction from a doctor, began an infusion in response at 14:40 ie after the event Mr Myers says 'it's important to keep this in mind, the suggestion has been made that at 14:40 somehow Ms Letby was involved in what took place before the collapse, she was not'

Mr Myers picks up on the evidence of an independent pathologist, who reviewed the case. He said the boy suffered an "impact injury" akin to a road traffic collision - which caused bruising on his liver Mr Myers says 'the truth is' we 'don't know' how much force it took to make those bruises. He says the pathologist picked 'graphic examples' but cannot say how 'little force' it would take to cause those injuries in a neonate The barrister says it is a 'possibility' that the bruising was a result of CPR during the failed resuscitation attempts on Child O

Mr Myers is pulling up messages sent between Ms Letby and a doctor who cannot be named on 1 July 2016. They were talking about the events surrounding Child O's collapse The doctor tells Ms Letby that one of his doctor colleagues was 'was upset' as the boy's liver issue 'may have been cause by her chest compressions'. He said he had to reassure the doctor for 20minutes Mr Myers says this 'raises the possibility that injury can be caused by CPR, plainly this was something she was concerned about'. He invites the jury to keep this in mind

Mr Myers notes that the prosecution have made much of Ms Letby's Facebook searches for the parents of Child O. He says 'nothing about those' searches establishes guilt and says 'how is that meant to indicate she had done something to harm' him

Agreed Facts

Recorded Events and Messages/Facebook

21st June 2016
2.24pm: Intelligence analyst Kate Tyndall is now talking through the sequence of events for Child O, who was born at 2.24pm on June 21, 2016, the second of the three triplets born. Child O was born in 'good condition', 'cried immediately' and had a 'good tone' and a heart rate over 100bpm. He weighed 2.02kg - 4lb 7oz.

22nd June 2016
1pm: The sequence of events then records what happens from 1pm on June 22. Child O had been admitted to the neonatal unit after birth and cared for there. The court hears during this time, Lucy Letby is on holiday in Ibiza. She is informed by a doctor colleague Dr A via Facebook Messenger that triplets have been born and are being cared for at the neonatal unit.

Letby responds to a WhatsApp from colleague Jennifer Jones-Key that she is working Thursday, Friday and Saturday, on her return from holiday. She adds: "Yep probably be back in with a bang lol"

5.13pm: Dr A Facebook messages Letby on Wednesday, June 22 at 5.13pm:
'How was the flight?...Day has been rubbish. Lots of unnecessary stress for nnu and too much work to fit into one day. I may have (over)filled the unit again..."
Letby: "...Oh that's not good back to earth with a bump for me tomorrow then!..."
Dr A: "...Yes, you might be a bit busy..."

6.29pm: A nursing note by Samantha O'Brien at 6.29pm on Wednesday records: 'No signs of increased work of breathing...CBG carried out this AM at 1045, good result....respiratory rate remains stable. Baby nursed in incubator...temp within normal limits.' Fluid requirements checked and correct...10% dextrose infusing via cannula in left hand, site became puffy throughout day....feeds of donor EBM also commenced at 1300hr, currently having 4mls 2 hr...'

Letby messages Dr A:
'Yep just got a few bits for lunch (although maybe I won't have time to eat).
Dr A replies he wasn't sure he'd eaten apart from a cereal bar before the triplets arrived.
Letby asks: "What gestation are the trips? I don't mind being busy anyway..."
Dr A: "33+5 [weeks gestation]. 3x Optiflo..."
After more messages, Dr A asks Letby if she has any choice where she is working.
Letby: "No, not with this new handover. Shift leader of night shift allocates for the day shift and vice versa. If your on a run of shifts you tend to stay with same babies."
Letby adds due to the skillsets, she tends to work in nursery room 1.

Letby adds she feels "most at home with ITU [intensive treatment unit] and the girls know that Im quite happy to be in 1 so works out well most of the time."
Dr A replies: "...I like it when you're in itu - everything feels safe and well organised..."
Letby: "Awe that's nice to hear, Huw often says that too - see what happens tomorrow."
Letby adds there is a potential job opening on the unit which she believes she might be lined up for.

Dr A: 'If you didn't want it now, could you defer?'
Letby: 'Yes good to know and worth thinking about...& yes, I'm sure she would let me defer.'

23rd June 2016
2.19am: Nurse Sophie Ellis records, on the night shift for Child O, in a note written at 2.19am on June 23: '[incubator] temperature reduced due to temperature of 37.3C - to check hourly as appropriate. All other observations stable. Pink, warm and well perfused....abdo full but soft.'

6.41am: A note at 6.41am recorded a TPN nutrition bag was stopped as Child O had reached full feeds of donor expressed breast milk, and was 'tolerating well'.

At 7.32am 'abdo loos full slightly loopy. Appeared uncomfortable after feed.' Child O was checked and settled. The day shift begins at 7.30am. During this shift, Child O died.

A rota for the day shift records four babies in nursery 1, three in nursery 2 - including Child O and Child P, three in room 3 and two in room 4. Samantha O'Brien is the designated nurse in room 1 for the other triplet, Christopher Booth is the designated nurse for Child Q in room 1, Lucy Letby is the designated nurse for Child O and Child P and one other baby in room 2.

Letby records, for Child O:...'Observations within normal range...nil increased work of breathing. Donor EBM via NH tube. Minimal milk aspirates obtained...'

8.30am: Letby messages a colleague after 8.30am to say she had a student nurse in but 'no time to do anything'.
Letby adds: 'She's nice enough but bit hard going to start from scratch with everything when got 3 babies I don't know and 2 hourly. Ah well...'
The WhatsApp conversation continues over the following hour.

Dr Katarzyna Cooke records for Child O: 'No nursing concerns observations normal'. The plan was to continue weaning Optiflo, establishing feeds and prescribing vitamins for Child O.
Letby messages a doctor colleague Dr A to ask if he will be present in the NNU after he has been at the clinic.
Dr A replies he is.
Letby adds the student is 'glued to her'.

Letby messages the doctor:
'I lost my handover sheet - found it in the donor milk freezer!! (Clearly I should still be in Ibiza)'
Dr A adds he 'dropped some sweets off to keep everyone going'
Letby: 'Ahh wondered where they had come from'
Letby adds she had forgotten her sandwich, and jokingly asks if she can go home.
Dr A replies there's a cheese roll going spare, then offers to get her something for lunch.
Letby replies: 'Tapas?'
She adds: 'It's ok thanks I've got a few bits with me'
Vitamins are prescribed for Child O.

12.10pm: Dr A records a brain scan for Child O at 12.10pm, noting normal observations.

12.30pm: Letby records a fluid chart at 12.30pm with 'trace aspirates'. A similar reading was recorded earlier that morning.

1.15pm: A doctor's clinical notes record at 1.15pm, Child O 'vomits and has distended abdomen. 'Trace aspirate...no bile 1x vomit post feed No blood' Unlikely NEC, most likely distention secondary to PMec.' Letby records, for 1.15pm: '[Child O] had vomited [undigested milk], tachycardiac and abdomen distended. NG tube placed on free drainage...blood gas poor as charted...saline bolus given as prescribed with antibiotics. Placed nil by mouth and abdominal x-ray performed. Observations returned to normal'

2.07pm: Letby messages a nurse colleague:
'How's it going have you got some sun?' at 2.07pm.
The nurse replies: '...How's your day?'
Letby: "It's busy!!.."

An x-ray report of 'possible onset of sepsis' by a consultant radiologist said Child O's appearance had improved on a subsequent image. 'NEC or mid gut volvulus cannot be excluded'. The x-ray is not time stamped but is understood to have happened prior to Child O's collapse.

2.40pm: A doctor [Dr A] notes: 'Called to see [Child O] at [about] 1440. Desaturation, bradycardia and mottled. Bagged up and transferred to Nursery 1. Neopuff requirement in 100% oxygen...' Letby records: 'Approx 1440 [Child O] had a profound desaturation to 30s followed by bradycardia. Mottled++ and abdomen red and distended...'

2.46pm:  Shift leader Melanie Taylor is recorded as entering the neonatal unit at 2.46pm.

3.03-3.08pm: The doctor [Dr A] records Child O was intubated '1503-1508' 'at first attempt'.

Dr Stephen Brearey records for Child O at this time: 'small discoloured ? purpuric rash on right wall'

3.44-3.51pm: Child O suffered another event at 3.44pm, the court hears. Bleep data for a crash call is made at 3.49pm. A consultant writes a retrospective note '[Child O] had been intubated about 3pm when [doctor colleague's] fast bleep went off. Arrived to find [Child O] was being bagged. Desat to 35...' Lucy Letby's note 'Drs crash called 15:51 due to desaturation to 30s with bradycardia, minimal chest movement and air entry observed. Reintubated...'

Morphine is administered to Child O.

4.15-4.19pm: A doctor records a further collapse for Child O at 4.15pm, and chest compressions commence. Lucy Letby records, in notes written retrospectively at 8.35pm for 4.19pm: 'CPR commenced 16:19 and medications/fluids given as documented...IV fluids 10% glucose...morphine...'

The trial is resuming following its lunch break. The courtroom is cold today, as Lucy Letby - who has been present throughout this trial - now appears to be wearing a scarf.

Kate Tyndall continues to talk through the sequence of events for Child O.

4.26-4.30pm: Adrenaline is given to Child O at 4.26pm, as well as a prescription for sodium bicarbonate. A consultant records adrenaline and compressions given to Child O. Dr Stephen Brearey records being called back at 4.30pm.

5pm: Lucy Letby records, at about 5pm: 'Placed back on to ventilator. Dopamine commenced....Flecks of blood from NG tube. Discolouration to abdomen. Unable to obtain heel prick...due to poor perfusion.' The records show attempts to resuscitate and stabilise Child O were unsuccessful. Child O was baptised.

5.47pm: Child O passed away at 5.47pm on June 23, 2016. Dr Stephen Brearey records: 'After 30 mins of resus, futility of resus explained to parents. Parents and team agreed to stop CPR. [Child O] passed to mum.'

6pm: Child P suffers an event at 6pm, the court hears.

A post-mortem blood test revealed 'nothing untoward', the court hears.

Lucy Letby records, for the family communication: 'Parents kept updated on events throughout the afternoon - were present for some of the resuscitation and maternal grandmother present for support. ...Time alone [for parents and Child O] given. Photographs taken on mobile. Aware of need to keep lines/ET Tube in at present. [Child O] taken to family room to be with parents. Cooling cot arranged.'

The doctor messages Letby if she is ok.
Letby: 'Think so, just finishing my notes. Can't wait to get home.'
Letby also messages a nursing colleague about how the day had gone badly 'Lost a triplet'.
She adds, in a message to the doctor, she was not going to vote that day.
Letby messages the nursing colleague to say Child O 'went very suddenly' and 'had a big tummy overnight but just ballooned after lunch and went from there'.
The nurse replies: 'Big hugs'.

Letby says the other two babies were being screened, as it was not known why Child O had collapsed. She adds: 'I want to be in Ibiza'
The nurse replies: 'Poor parents'
Letby said Child O had died on the student's first day of a four-week placement. She adds who was on duty that day.
The nurse replies: 'Lots of consultants then'.

The nurse messages:
'We don't have any luck with 33-34wkrs' Never seem b able to tell do u'
Letby: 'No, deteriorate so quick'.
Letby said one colleague was upset about what had happened. She adds: 'Yeah worried she's missed something'
The nurse, in part of her reply, says: 'Wow identical triplets! Didn't know that even happened'

Letby's mother messages her daughter to say it was sad what had happened on the first day back after Lucy Letby's holiday.
Letby replies: 'Yep it's just as well I love my job!'
The doctor messages Letby to say the debrief didn't find anything that was missed for the events of Child O.

Letby messages the doctor to say 'apparently' she had sounded bossy around the time of the baptism call for Child O. The doctor says he would interpret it as being proactive. Letby says she has 'broad shoulders' and had apologised, saying it could have been interpreted as being overly direct. The two agree it had been a stressful situation. Letby said she had been 'blubbering at work' and the doctor replies a cry is needed at times, adding 'You should have seen me at the Hoole Roundabout'.

24th-25th June 2016
4pm: Child P dies at 4pm on June 24, and an event for Child Q happens at 9.10am on June 25.

27th June 2016
The doctor messages Letby on Monday, June 27 about the care for Child Q, and a Facebook conversation takes place. A reference is made to clarify paperwork for a prescription for Child O during the resuscitation attempts.

29th-30th June 2016
On June 29, a Datix form is filed in which Child O 'suddenly and unexpectedly collapsed'. Letby files a Datix form on June 30, in which it was recorded that equipment required for a procedure during resuscitation was not available on the unit. It was clarified in July 2016 Child O did not lose peripheral access.

On June 23, 2017, Letby searched for the surname of Child O, Child P and the surviving triplet on Facebook.

Lucy Letby in the Witness Box

Direct Examination

Lucy Letby gave this evidence on 17th May 2023.

Mr Myers now turns to the case of Child O, one of three triplet brothers born on June 21, 2016, weighing 2,020g, at a gestational age of 33 weeks and 2 days, at the Countess of Chester Hospital. Child P is another one of the triplet brothers. Mr Myers recalls the events for Child O, who died at 5.47am on June 23. A post-mortem examination showed damage to the liver. Lucy Letby says prior to this, she had been abroad on holiday with her nursing colleague and a friend. A rota of Letby's shifts showed she was off June 16-22. The rota shows she was on long day shifts for June 23-25 and June 28-30.

Messages are shown to the court between Letby and Jennifer Jones-Key from June 22, Letby confirms when she is back in, adding: "Yep probably be back in with a bang lol" Asked to explain that, Letby says she would be back in a busy shift. Asked by Mr Myers, Letby denies she was planning "anything terrible". Letby said she was "very available" for work as she had no commitments outside work and lived nearby.

A message from a doctor [Dr A] to Letby:
"How was the flight? Unpacked as well 😉 - it's the only way!! (washing machine on?) Day has been rubbish 😡. Lots of unnecessary stress for nnu and too much work to fit into one day 😣. I may have (over)filled the unit (again) 😱. SHO's have all been fed & watered and the babies are generally ok - so maybe not as bad as I'm thinking!"
Letby: "Glad it's over but flight was & airport was fine thinks (on 2nd load of washing!!) "
"Oh that's not good back to earth with a bump for me tomorrow then!!"
"You seem to be quite good at acquiring babies to fill our empty cots....?"
The reply: "It's a skill I've had for years 😄. To be fair, there wasn't a social admission! Yes, you might be a bit busy. Oh - you're right, I made sure they went first. Just realised when I last ate (oops)"

Letby says it was not unusual for the unit to be busy. She adds there was also discussion, at this time, about removing level 4 unit nurses from the neonatal unit. A shift rota for June 23 is shown. Letby was designated nurse for the triplets in room 2. Mr Myers asked if managing three babies in a high dependency was outside the ratio required for nurses to babies. Letby says it is - it should be one nurse to two babies in that room. In room 1, two nurses are looking after four babies. Letby says the care should be 1:1 [ie one designated nurse to one baby], and the room is full.

Notes by Sophie Ellis are shown to the court for the night of June 22-23, recording observations for Child O. They include: 'TPN stopped as reached full feeds of DEBM [donor expressed breast milk], tolerating well, 12mls 2x12. Antibiotics stopped...blood gas completed at 0532 - lactate 2.3' Letby says that lactate reading is outside the normal range, and she would inform a doctor about that reading. Sophie Ellis adds: 'Abdo looks full slightly loopy. Appeared uncomfortable after feed.' Letby says Rebecca Morgan was a student nurse on her first day of placement on the unit, and Letby was the designated mentor. She tells the court the student nurse would be orientated on to the unit by a senior member of staff, but that was not possible due to the unit being busy, so she carried out the induction process herself. "On top of looking after three high dependency babies?"
"Yes - I didn't know I was going to be looking after a student [until I arrived at the unit]." Letby messaged a colleague: "It's busy but no vents [patients on ventilators] anymore. I've got triplets in 2 all ok. But got a student and first day, 2 hourly feeds etc no time to do anything lol and Yvonne f in but said i can show her sound etc x"
The reply: "What?! That's ridiculous. When r u meant to get time to do a proper induction?"
Letby: "No idea, she's nice enough but bit hard going to start from scratch with everything when got 3 babies i don't know and 2 hourly etc. Ahh well." Letby also messaged a doctor: "My student is glued to me....." Letby's nursing notes for Child O included: '...abdomen appeared full, but soft and non-distended...reviewed by [registrar] at 1315 - [Child O] had vomited (undigested milk), tachycardiac and abdomen distended.' Letby says two-hourly observations were required for all three babies in room 2, and the student nurse would also be involved. A fluid balance chart shows student nurse Rebecca Morgan has completed the reading for 8.30am, and had been doing the feed. For 10am and noon, the court hears Letby has signed the observation, but Rebecca Morgan has filled in the entries for feeds and aspirates. For Child O's observations chart, Rebecca Morgan has signed and filled in the observations at 8.30am and 10.30am. Letby says she has written in the observations for 1.30pm and 2.30pm. Letby says the 12.30pm observations have been filled in by Rebecca Morgan, but were not signed "due to human error". She denies there was anything "sinister" in leaving out the initials on the chart.

For 1.15pm, Letby recalls being outside room 2 and hearing an alarm going off. She went in and found it was Child O's alarm. She does not recall if any other nurses were in the room at that time. She recorded: "at 1315 - [Child O] had vomited (undigested milk), tachycardiac and abdomen distended.'" Letby said it was "not a concerning vomit" for Child O, who was not moved from room 2. The notes add: 'approx 1440 [Child O] had a profound desaturation to 30s followed by brady. mottled++ and abdomen red and distended. Transferred to nursery 1...perfusion poor....Drs crash called at 1551 due to desaturation to 30s with brady...reintubated...CPR commenced 1619...' Letby says, for 1440, she heard "a monitor alarming" and went in, and found it was Child O's alarm. She said she called the doctor who was next door. "This was more significant as [Child O] needed intervention at this point....he looked different...unwell at this point. "He appeared mottled...his abdomen was redder than it had been previously. "Mottling is something we see quite often with babies." Mr Myers asks if Letby had introduced air into Child O, or any baby in the case.
Letby: "No."

The neonatal schedule for June 23, 2016 is shown to the court. The event is marked for Child O at 2.40pm. At 2.39pm, two medications are given intravenously to Child O and the records are made on the computer, by Samantha O'Brien and Melanie Taylor. An infusion for Child O is made at 2.40pm by Lucy Letby and Samantha O'Brien. Letby says the order, as it appears to the court [before the event], is incorrect - the infusion should be listed in sequence after the event, in response to what had happened. She says she cannot comment on the 2.39pm medication as she was not there. Medicine prescription charts are shown to the court for the 2.39pm prescriptions. Swipe data shows Letby has arrived on the neonatal unit from the labour ward at 2.39pm. A doctor's notes record for the event: 'Called to see [Child O] at ~1440, desaturation, bradycardic and mottled. Bagged up and transferred to nursery 1... 10ml sodium chloride bolus already given' Letby says the 10% saline bolus is given, as shown on an IV chart, at 2.40pm, in response to Child O's deterioration. She tells the court that one minute prior, she was not on the unit. Child O was transferred to room 1 and the decision was made to intubate him. Letby says she cannot recall "with any clarity" the events from then on. A note from Dr Brearey is shown to the court at 6pm: 'Assisted with initial intubation...small discoloured ? purpuric rash on right chest wall. Good perfusion.' Letby says this is not something she had observed, or was identified to her at any point. Letby says she could not recall the next few hours as events for Child O merged into one. She recalls CPR taking place and there being two doctors and two nurses present. She does not recall taking part in the CPR. The court is shown there were two episodes of CPR at 4.19pm and 5.16pm. Letby recalls a drain being inserted during resuscitation. Asked about what the atmosphere is like when a baby dies on the unit, Letby tells the court: "It's completely flat, there is a complete change in atmosphere...to me personally, it's devastating, you want to save every baby in your care. "You're not supposed...to watch a baby die." Mr Myers says a post-mortem examination identified an injury on the liver. He asks if Letby knows how that happened.
Letby: "No."

Text messages between Letby and a doctor from June 30-July 1, 2016 are shown to the court, concerning the liver injury. Letby recalls a colleague being "very upset" and "was crying" at what had happened. The doctor had messaged: "I'm not sure where the information has come from. "It seems that on the SHO grapevine somebody at LWH has said that one of the triplets was found to have a ruptured Liver. "[Colleague] was upset that this may have been caused by her chest compressions."
Letby: "Oh no, that's awful. "No wonder she's upset. Were you able to reassure her?" The doctor replied: "We spent 20 mins in a cubicle going over everything. The CPR was all at the 5th rib space - between the nipples. The duoderm on [Child O] was high. If there was anything it will have been due to fluid volume causing Liver distension. "I'm not sure I believe it. "It was a coroners pm. "It usually takes weeks to get any report."
Letby: "It seems a bit like a rumour mill has gone into overdrive - the boys were only returned today, can't see how info would be out that quick?" Doctor: "No me neither."
Letby: "Not nice for [colleague] though, can see how it would play on her mind." Doctor: "This has come at the end of a 7 day run for her. Not a good time."
Letby: "No. It's good that she felt able to tell you"

Cross-Examination

Lucy Letby gave this evidence on 8th June 2023.

Nicholas Johnson KC, for the prosecution, moves to the case of Child O. Letby, in her defence statement, said she did "nothing to hurt [Child O]." She noted a "change in [Child O's] appearance", but it was "not dramatic". He had a deterioration and Letby noted Child O's abdomen was "red and distended". She says she didn't notice a rash on Child O, and no-one mentioned it. She said the abdomen was "very swollen", and there was a struggle to get lines in. Letby tells the court one of the lines had tissued. She said one of the doctors had gone out to smoke a cigarette during the time of Child O's resuscitation, and when that doctor returned, they did not wash their hands.

Letby is asked if there is anything she wishes to change in her account of evidence so far. This is a question Mr Johnson asks at the start of most sessions during the cross-examination. Letby says there is nothing.

Letby agrees with Mr Johnson it was "big news" to see naturally conceived triplets on the unit, as it was a rare occurrence. Child O and Child P were two of the three triplets. Messages are shown to the court between Letby and Jennifer Jones-Key from June 22. Letby confirms when she is back in, adding: "Yep probably be back in with a bang lol" M Johnson says within 72 hours of that, two of the triplets were dead and Child Q had collapsed.

Letby is asked why she was "so interested" in the triplets. Letby tells the court it was "general conversation" between staff colleagues as it was "something unusual on the unit". She accepts that all went well with the birth, and accepts that the triplets had been doing well, with Child O being "fine". Letby accepts that Child O was doing well on the night shift for June 22-23, and had been moved off CPAP on to Optiflo breathing support. Letby accepts Sophie Ellis's description there was 'nothing concerning' about Child O's presentation.

Letby is asked to look at an observation chart for Child O for June 22-23. There is a reading which, the court is told, appears to have been changed from '1430' to '1330'. Letby says Child O's temperature is a little unstable in the hours prior to 1.30pm on June 23, but accepts he was otherwise "stable". The court is shown a lab result, that there was no bacterial infection found in a blood sample taken on June 23 for Child O. A feeding chart showed Child O was "tolerating his feeds very well", Mr Johnson says. Letby agrees.

Mr Johnson asks Letby where the 'problem' is for Child O's abdomen that she had said was not dealt with, as there is no data to show it. Letby says, after looking at the data, she does not know what the problem was. Mr Johnson says there is no problem shown in the paperwork. Letby says there was "no formal note" made. The court is shown Sophie Ellis's note at 7.32am: Abdo looks full slightly loopy. Appeared uncomfortable after feed....reg Mayberry reviewed. Abdo soft, does not appear in any discomfort on examination. Has had bo. To continue to feed but to monitor.' Letby says the doctor did not formally record it. Letby accepts a review was carried out at 9am and Child O's liver was reviewed, finding no injury. Letby accepts the liver injury happened 'on her watch'. She says she accepts it happened on her shift, but does not know how it happened. She denies it happened on her hand.

A shift rota for June 23 is shown. Letby was designated nurse for two of the three triplets in room 2 - Child O and Child P - plus one other baby. The third triplet was in room 1, with Child Q and two other babies. Letby rules out staffing levels as a contributory factor in Child O's collapse or death, or staffing mistakes.

Letby says Rebecca Morgan was a student nurse on the unit. She accepts that the student nurse would not always be in room 2, and would sometimes be chatting to parents. Letby says the two triplets she was designated nurse for were in the high-dependency room, and if she left the room for a period of time, she would ask someone to 'keep an eye' on them. A note by Dr Katarzyna Cooke at 9.30am is shown to the court, which included: 'No nursing concerns, observations normal'. Letby says she left the unit at one point to get donor milk for the babies. Letby is shown a series of text messages between herself and a doctor prior to 9.30am. Letby expresses disappointment in the message the doctor will not be on the unit ['Boo']. Letby says she got on well with the doctor. Letby asks if the doctor would be on the unit in the afternoon in the message. She adds: 'My student is glued to me.....' She adds: 'Bit rubbish that you couldn't stay on nnu'. Mr Johnson asks if Letby was 'missing' him. Letby replies this was the first day back from her Ibiza holiday. Letby sent a message at 9.55am: 'I lost my handover sheet - found it in the donor milk freezer!! (clearly I should still be in Ibiza)' Letby is asked if it was a 'busy' morning for her. She says "reasonably, not exceptionally". Letby is asked how she finds the time to text when at work. She says she would not use her phone at the cotside or a clinical area, but would use her phone elsewhere in the unit.

A feeding chart for Child O is shown to the court. Letby is recorded as signing for feeds at 10.30am and 12.30pm. She says the writing above is not by her, but by Rebecca Morgan. She says if she has signed, then Rebecca Morgan does not need to sign. Letby denies feeding Child O. She denies overfeeding Child O. Nurse Melanie Taylor, at about 1pm, entered room 2 and said 'he doesn’t look as well now as he did earlier. Do you think we should move him back to [room] 1 to be safe?' Letby declined. She said she doesn't remember being very dismissive. Letby says "That's Mel's opinion" to the evidence that Melanie Taylor had told the jury she felt Letby was 'undermining her authority'. She adds that Melanie Taylor had the right to override that and 'take Child O off her'. Letby denies she had sabotaged Child O, or that this would have meant Child O would have 'escaped her influence'.

Letby denies she 'lied' to the doctor colleague about a 'trace aspirate' for Child O at 12.30pm. Mr Johnson says he is mistaken, as a doctor's note records '0 bile' for the 'trace aspirate'. Letby says the 160-170 heart rate for Child O, as recorded by the doctor, is higher than normal, and higher than ideal. Mr Johnson says the abnormal readings start, on the observation chart, 180bpm. Letby had recorded 'tachycardiac' for Child O. Letby tells the court when she reviewed Child O, there was a spike in the heart rate, and in her opinion, Child O was tachycardiac.

Mr Johnson says Letby made a 'false, lying entry' in a different chart. A blood gas chart is shown to the court for Child O. Mr Johnson asks where the lying entry is on the chart.
LL: "I don't know." Mr Johnson points to the 'CPAP' note on a column. Letby says Child O had some CPAP pressure. Mr Johnson says Child O had not been on CPAP breathing support for "hours and hours".
NJ: "You were covering for air you had given him, weren't you?"
LL: "No." An x-ray report for Child O is shown, including: 'Moderate gaseous distention of bowel loops throughout the abdomen.' Letby is asked why she wrote CPAP in her notes.
LL: "I can't answer that now, I don't know." Letby says she does not know if Child O might have been on some CPAP pressure via Optiflo. Letby denies 'forgetting to make a false entry on the observation chart'.

Letby is asked about messages exchanged between her and a doctor when, at 2.30pm, she was recorded as taking observations for Child O. The messages were sent at 2.20pm and 2.23pm. Child O collapsed shortly after 2.40pm. In her defence statement, she said the doctor colleague was on the unit at the time. Swipe data shows Letby has arrived on the neonatal unit from the labour ward at 2.39pm. Letby says she cannot say, definitively, where she was at that time. She denies 'nipping out' of the neonatal unit to make it look like she was elsewhere at the time Child O collapsed.

The doctor's note is shown to the court: 'Called to see [Child O] at ~1440 desaturation, bradycardia and mottled...' Letby says she believes she called the doctor to the nursery room. She denies it was to get personal attention; Letby says it was because he was there to assist Child O.

The trial is resuming after a short break. Letby says a 20ml saline bolus was given to Child O in response to a poor blood gas record. She says there was a delay as there was an issue with getting the line for Child O. She says she believes the bolus, which has 'time started: 1440', was in response to Child O's collapse. A doctor's note recorded for the '~1440' collapse: '10ml/kg 0.9% sodium chloride bolus already given.' Letby agrees the two desaturations for Child O that day were "profound" ones. Letby's note: 'Approx 1440 [Child O] had a profound desaturation to 30s followed by bradycardia. Mottled++ and abdomen red and distended. Transferred to nursery 1 and Neopuff ventilation commenced. Perfusion poor' Letby, when questioned, says babies would "frequently desaturate", to this level, and this happened prior to June 2015, and "often".

Letby says the redness to the abdomen on Child O was abnormal, and the description of mottling was normal. Mr Johnson says during the intubation, Dr Stephen Brearey, in evidence on March 15, said Child O had a rash on his chest, on the right side, about 1-2cm in size. He said it was an "unusual" rash that was initially purpuric, and it later disappeared. Letby says: "I don't believe that's what I saw. I saw mottling. If that's what Dr Brearey saw, then if that's what you could take as being true, then yes."

Mr Johnson says when the doctor went to see Child O's parents, and during that time, Child O desaturated again, for the final time. Letby says she does not remember this declining moment, but said she put out a crash call.
LL: "I remember the death, but not this precise moment where he declined and I put out a crash call." Child O was intubated and efforts were made to resuscitate him. Letby says she did not recall seeing the rash disappear. She says she did not see what Dr Brearey and Dr Ravi Jayaram had seen. Letby says she did not pull an NG Tube out of Child O's stomach. An x-ray report for Child O is made at 4.46pm. It record: 'NG Tube in situ with its tip close to the cardia, this should be advanced by 10-15mm.' An earlier x-ray report said the NG Tube was 'in a good position'. Letby says a dislodged tube would still drain, as it would still be in the stomach. Letby says the tube could be moved during the intubation process at 2.40pm.

Mr Johnson says Child O's mother, in agreed evidence, said her baby was 'changing colour' with 'prominent veins.' She says she later saw that in Child P. Letby says she didn't see that herself. The father of Child O said 'you could see his different veins - it looked like he had prickly heat, like something oozing through his veins'. Letby says she did not see anything like that. She accepts she saw a red-purply blotchy rash and a red abdomen.

In police interview, Letby said she believed she had done chest compressions and drew up some drugs. Letby says after looking at records, she now believes she was just involved in medications. Mr Johnson suggests Letby is distancing herself from the CPR so it could not be said she caused the liver injury to Child O. Letby denies this. Letby says she "does not know" how Child O got the liver injury. Letby denies injecting air into Child O to cause an air embolus, or inflicting a liver injury on him.
NJ: "These things all happened on your watch, didn't they?"
LL: "Yes." Letby says she disputes an account that Dr Brearey told her not to come in after that shift.
NJ: "Were you bothered by what you witnessed?"
LL: "Of course I was bothered."

Messages are shown between Letby and the doctor from 9.14pm on June 23: Doctor: 'Your notes must have taken a long time - Had you documented anything from this morning?'
LL: 'Only a little. Had the other 2 to write on as well and sorting out the ffp etc. Left signing for drugs until tomorrow' A nurse also messaged Letby: 'F***in hell, what happened?'
LL: 'Can't Think straight so took a while'
LL: 'Blew up abdomen think it's sepsis' Letby says it's not a term she uses often, but she had seen it before.
LL: 'Had big tummy overnight but just ballooned after lunch and went from there' Letby tells the court that is what she said, having been reviewed by a doctor and Child O had a loopy bowel. She says she is referring to distention found prior to 8am. LL, at 9.33pm: 'Worry as identical'
Mr Johnson: "Were you setting up a false narrative here?"
Letby: "No, that's not what I'm suggesting at all."
NJ: "You had already set your plan in motion by pumping air into [Child P] before you left."
LL: "No."

Letby is asked to look at a Datix form she had written [a form used by staff when issues have been highlighted, such as clinical incidents], on the documentation ['Employees involved' has Letby's name]. The form said 'Infant had a sudden acute collapse requiring resuscitation. Peripheral access lost.' Dr Brearey said the information in the form was 'untrue', and he said he didn't believe at any point IV access was lost. Asked about this, Letby says: "Well, that's Dr Brearey's opinion." The form adds: 'SB [Brearey] wishes amendment to incident form - Patient did not lose peripheral access, intraosseous access required for blood samples only.' Letby says she does not believe her Datix report was untrue at the time.
NJ: "You were very worried that they were on to you, weren't you?"
LL: "No."

Witness Statements Agreed

Family - Mother

A statement from the mother of Child O, Child P and the other triplet is read out to the court. She says she had a 12-week scan at the Countess of Chester Hospital 'which seemed to take a bit longer than normal', where her partner realised there was more than one baby. It was confirmed she had triplets. The triplets would be identical, she was informed, and she was referred to Liverpool Women's Hospital to see a specialist. She was informed there was an 80% chance one of the triplets would be smaller than the other two.

Two weeks later she went for a follow-up scan, and everything was 'fine', as were further fortnightly scans. She was informed the triplets were 'unlikely' to stay at the Countess of Chester Hospital neonatal unit, as there would not be the space for three nursery beds, and they may have to be treated at Birmingham. On June 21, the mother was admitted to the Countess of Chester Hospital, was assessed, and advised to go for a C-section. She went to theatre at 2pm, and the triplet boys were born shortly afterwards. They had been named in advance, and the babies were named in the order they came out. In recovery, she was brought pictures with the boys and their birth weights recorded.

The mother was taken to see all the baby boys, and handled all of them. On the neonatal unit, there "didn't seem to be any routine for washing hands". All the triplets were in nursery room 1, and they were all brain scanned, with no concerns.

The following day, the mother was taken to see the triplets, and was informed all were doing well. She said she asked on numerous occasions, about expressing milk, but no-one came to help until after Child O passed away, when a nurse called Lucy handed her an information leaflet.

On June 23, the mother was in the ward and still struggling to walk. About 10-15 minutes after the father had been to the unit, he came back with a consultant doctor, who informed her Child O's stomach had swollen and 'needed a little help to breathe, so a tube had been put down his throat'. He was calm and said this was normal. The mother was put into a wheelchair, and upon arrival at the nursery, she said: "By the time I got there, it was a scene of chaos". A lot of doctors and staff surrounded Child O. "I remember nurse Lucy was there, all the time."
"The staff appeared to be in a state of panic, and it didn't seem controlled at all." The mother said she sat outside, and could not bring herself to be too close, as Child O kept arresting and changing colour. "He was swollen all over his body".

At some point, another doctor arrived and told the mother "things weren't looking good" for Child O, and said if he did survive, he would likely have brain damage. Child O passed away at 5pm. Child P and the other boy were in nursery room 2. The mother said: "This whole episode had come like a bolt out of the blue. On the face of it, everything seemed to be going well with the triplets. "As a family, we were naturally devastated. "With hindsight, there were a number of things we found unusual." The mother said she didn't expect a student nurse to be looking after one of the babies. She said they kept seeking reassurance that the other two boys were fine.

A doctor [Dr B], who was "quite upset", said she was very sorry for what had happened to Child O, and photos were taken of the baby boy. The mother said she didn't sleep at all that night. She, at one point, asked the midwife to check if the other two boys were ok. She was reassured they were fine. The following day, they went to the neonatal unit and were informed by a nurse the two boys had "been like angels", behaving all night and feeding regularly.

The mother recalled having breakfast and freshening up. She then heard voices and saw a midwife was present and advised to go to the neonatal unit, as Child P was unwell. "I was devastated. A couple of hours earlier he had been fine. "I called my mum to tell her it was happening again." When she arrived, she said it was "like deja vu" and the situation was "chaotic" with people "running around" in nursery room 2, where both boys were.

The mother said she sat outside "for long periods of time". At one point, a young doctor looked to be Googling 'how to insert a line'. They needed to do this process as Child P's lungs had collapsed during CPR. "This alarmed me". The mother was informed they were looking to transfer Child P to Liverpool, but they needed to stabilise the baby first as he kept collapsing. She was told things were "looking a lot more hopeful" for Child P - he looked veiny, but his stomach was not distended like Child O's was. At some point, the transport team arrived. The reaction from the transport team was "incredible to watch" as "they just took over". Even the consultant took a back seat'. "We were reassured, he seemed calm." Child P passed away. The mother said she and her partner "begged" the transport team to take the surviving boy with him to Liverpool Women's Hospital.

The mother said she had to discharge herself from the Countess of Chester Hospital, and asked for her care to be transferred to Liverpool. "They refused, which was the last thing I needed." The mother travelled to Liverpool, having stopped to pick up some clothes along the way, and were . "We were just made to feel at ease - the two hospitals felt like night and day." The staff said the surviving baby boy could be treated there for as long as there was a bed available, but did not need intensive treatment. The surviving baby stayed at the hospital for three and a half weeks. The mother said she was "surprised" there was not 1:1 nursing care for the triplets, and a student nurse was looking after them, with Lucy Letby 'popping in'. Lucy Letby was "extremely emotional" and "in pieces" after Child P passed away. She was "in floods of tears", the mother said. A doctor also arrived and "was also upset".

Family - Grandmother

A statement from the grandmother of the triplets is now being read out. She said she was aware the triplets were identical and couldn't be told apart, apart from their identity tags, and were in differently coloured blankets, and were all of good weight. "All was well, up until June 23." She was informed "something was wrong" with Child O. She left work and travelled to the hospital, and upon arrival, Child O was being baptised, and the parents were "hysterical" and "at a loss". The grandmother recalls Lucy Letby was there, and was "softly spoken". Child O continued to deteriorate, and a Dr John Gibbs was called to the unit, who asked Lucy Letby how many shots of adrenaline had been administered, and Lucy said she was not sure, three or four. Dr Gibbs replied: "Well, what was it, Three or four?" Lucy Letby appeared to be referring to a scrap of paper for records which had yet to be updated. Lucy Letby was in the unit, and the grandmother said: "I remember thanking her for her assistance during the ordeal." The grandmother said she could not recall what happened with Child O, as she was too busy consoling the parents. When she received the "awful call" about Child P being unwell, the grandmother was at home. She arrived at the hospital and saw a number of doctors surrounding Child P. There had been "a significant improvement" in Child P's condition. His condition 'seemed fine' for an hour or two, but then took a dramatic turn for the worse. Outside the nursery room, a nurse researched a procedure on a desktop computer. "I was a little surprised at this, as I assumed the staff knew what they were doing. I thought they were possibly just confirming the procedure." Child P continued deteriorating and the call was made to transfer him to Liverpool, but Child P sadly passed away. It was decided that as the transport team were already present, they would take the surviving boy to Liverpool Women's Hospital, as they were not sure if there was a congenital condition. A doctor informed the family there would be post-mortems for Child O and Child P to establish the causes of death.

Family - Father

A 15-minute video interview is now being played, as agreed evidence, with the father of the triplets. The video interview was recorded in December 2019. He says, for June 23, the scene was "a mess". He recalls being taken to the unit by a nurse 'asap', "there's something going on". He said he and the mother both "panicked". He recalls there was "definitely swelling" on Child O, but could not recall why, and, getting upset and pointing to his hands, he says there were 'bright blue' veins.

He said medical staff were doing 'not a lot', and seemed to be concentrating on Child O's temperature. He said there were "lots of people, rushing in and out". He recalls seeing a 'pot belly' appearance for Child O, which then had 'gone down'. The ordeal lasted "ages" for Child O. It "seemed like hours". The doctor could offer 'no explanation' for what had happened to Child O which has resulted in him dying, the father recalls.

The interview talks about the events of June 24. The father recalls having spent time with the two boys. He recalls the scene for Child P was "worse than the day before", and was "pandemonium". He said there was nothing of the sign for Child P of a swollen belly. He said the medical staff did not have any explanation for why Child P was unwell. The transport team arrived, but Child P passed away within 10-15 minutes. He recalls he and the mother asked the transport team to take the surviving baby boy to Liverpool Women's Hospital. The father adds: "I am sure it was Lucy Letby who wheeled the two boys to us. She said how sorry she was. "I'm pretty certain she dressed them up." He said it was Lucy Letby's job to do up the memory box, which included an SD card containing memories of Child O and Child P. The surviving baby stayed in Liverpool for 'about 11 days' and there were 'no complications at all' apart from a 'small hole in his heart', and remained stable.

Unnamed Doctor

A statement from a doctor is read out to the court. The doctor said she was aware of the triplets beforehand. She recalled that Child O was a good size for the gestational age, and for being a triplet. His heart rate was "absolutely fine". He was "crying and making good respiratory efforts". The oxygen levels were "just on the low side", so CPAP was supplied and the oxygen levels rose. Child O was "stable and nice and warm", wearing a hat. Child O was shown to the father and the doctor congratulated him.

Child O was given mild breathing support. The doctor explained to the father Child O was "doing really well". The doctor recalled feeling "positive" and it was "a good day", and the triplets "were definitely progressing well". On June 22, no issues were highlighted during her long day shift, and on June 23, she was not in work. She received the news Child O had died on her next night shift.

Nurse Kate Bissell

See also: Nurse Kate Bissell's oral testimony at the Thirlwall Inquiry

Kate Bissell, senior nurse, in her agreed statement, says she was involved in Child O's care from delivery. She recalled all triplets were a good size, and the mum had done well to get to 33 weeks. Child O needed a 'little respiratory assistance', which was 'to be expected'. He was put on antibiotics, which was standard care. Child O 'remained stable' throughout the rest of the shift.

The judge, Mr Justice James Goss, says the courtroom has warmed up this afternoon, having been chilly this morning. Lucy Letby is continuing to wear a scarf as a 10-minute break now takes place.

Nurse Amy Davies

See also: INQ0017825 – Witness Statement of Amy Davies, dated 10/04/2024

Court is currently being read agreed evidence. First statement is from Amy Davies, who was a neonatal practitioner in 2016, she recalls having no concerns about the triplets in the days after their birth in late June 2016

Unnamed Nurse

A statement from another member of the neonatal team, who cared for Child O on the nightshift of 22 June into 23 June. She recalls seeing Child O with a swollen stomach - she was assigned to give him a milk feed via an NG tube

She raised concern over his stomach to nurse Sophie Ellis - she told her that she was aware and that she had flagged for him to be reviewed by a doctor. But she had been told 'to go ahead' with the feed and 'closely monitor' him The neonatal worker said she remembers Child O 'squirming a little' when she began the feed

Witness Evidence

Nurse Sophie Ellis

See also: INQ0017829 – Thirlwall Inquiry Witness Statement of Sophie Ellis, dated 11/04/2024

The trial is now resuming, with nurse Sophie Ellis giving evidence. She confirms she was the designated nurse for Child O and Child P for the night shift on June 22-23, 2016. She recalls Child O was reviewed towards the end of that night shift as he had "quite a full abdomen".

The nurse recalls Child O was "very stable" that night with no concerns, and the only thing to report was a full abdomen at the end of that shift. At one point, nurse Ellis says the temperature is 'a little high', so the incubator temperature is turned down. The oxygen saturation readings were recorded as 'very good - what we would like', at 97% and above. Child O was recorded as not requiring additional oxygen, and was on Optiflo.

Feeds were "gradually increased throughout the day", and administered "every two hours". The nurse's note is shown to the court, made at about 2.30am, and records 'stable' observations for Child O and that the baby boy was 'tolerating feeds well. Part digested milk aspirates, under half of feed volume 4 hourly. Abdomen full but soft'. The recordings were 'reassuring', nurse Ellis tells the court.

The addendum at 7.32am records '[Abdomen] looks full slightly loopy. Appeared uncomfortable after feed. Reg Mayberry reviewed. Abdo soft, does not appear in any discomfort on examination. Has had bowels open. To continue to feed but to monitor' Nurse Ellis says this was something notable for Child O, hence the need for a second opinion. It was not a concern in itself, taking into context other observations, but it was "one to keep an eye on".

Notes show Child O had 'ECG dots' - a way to measure heart activity - removed at 11pm as it was no longer needed. A cannula was removed at 5.30am on June 23, and antibiotics had been stopped at 6.41am as it was understood "everything was ok". Child O's Optiflo was also weaned down at 6.30am as the baby boy was "managing well".

The nurse tells the court Child O had managed feeds, antibiotics were stopped, and he had a "very stable" and "positive" night overall for June 22-23.

The nurse was informed Child O had passed away at the time of her next night shift.

Benjamin Myers KC, for Letby's defence, is now asking Sophie Ellis questions. He asks about the feeds and aspirates for Child O during the night shift. He asks if the feeds of 10-12ml of donor expressed breast milk every two hours is normal. The nurse replies it was normal feeding policy for babies of that weight and gestational age. Mr Myers asks if it is usual for babies to have aspirates of under half their feeds. The nurse replies that reading would suggest Child O was tolerating his feeds that night.

The nurse says she wouldn't always record a full aspirate for every feed, but would do so if there was a concern for the baby.

Doctor Huw Mayberry

See also: Dr Huw Mayberry's oral testimony at the Thirlwall Inquiry

From Dan O'Donoghue on X

First in the witness box is Dr Huw Mayberry, via live link from Australia. He is recalling his night shift of June 22 into 23 2016 and his examination of Child O that night - yesterday we heard from a nurse Sophie Ellis, who told the court he was 'stable' throughout that night

Dr Mayberry agrees with the nurse's observation, he says he remembers coming back on for his second night shift on 23 June and 'was obviously very shocked' to hear Child O had died that day. 'I felt that he was very well', he said

Dr Mayberry is asked if he saw anything to indicate Child O was in discomfort, during the early hours of June 22, he says 'not at all'

Ben Myers KC, defending, is now questioning Dr Mayberry - he says 'do you actually have an independent recollection of how (Child O) was that you saw him?' 'Yes', he says Mr Myers says 'you have no notes of your own to rely on, do you?' 'No', he responded

Dr Mayberry doesn't have any notes as he was crash bleeped away from Child O's cotside in the early hours of 22 June to attend another baby - only record of his examination was recorded by nurse Ellis

Mr Myers notes that between 10am on the morning of 22 and 9.30am on the morning of 23 June there is no clinical notes for Child O, he asks if that is standard practice He responds 'if you have a child were you are not concerned about them then it would not be unusual'

Dr Mayberry does say he was asked by a senior doctor why he had not made a note about his examination in the early hours - he tells the court he should have made one

Mr Myers repeats that without a note, it's difficult for him to recall all details of examination and Child O's condition. Dr Mayberry says 'if I could go back I would write it'

Dr Mayberry says he does remember being 'shocked' at Child O's deterioration the following day

Prosecution are asking Dr Mayberry further questions - they've asked him to spell out his responsibilities for the night of 22 June. He tells the court he was a registrar on call for four different units, neonatal, birthing, general paediatrics and emergency dep

Doctor Katarzyna Cooke

See also: INQ0018069 – Witness Statement of Dr Katarzyna Cooke, dated 30/04/2024

Dr Katarzyna Cooke is now in the witness box - she was a senior house officer at the Countess of Chester from 2015-2017. She is asked if she has an independent memory of her involvement with Child O's care - 'the only thing I remember was it was around Brexit referendum'

She is now referring back to her notes. She went on a ward round on the morning of 23 June - a note on her examination of Child O at 9.30am, shown to the court, state 'observations normal'

The notes state that he was moving onto a lighter form of breathing support, which was a 'positive sign'. Antibiotics were also stopped for suspected sepsis - Dr Cooke says most premature babies are screened for sepsis

Asked for her overall observations about Child O that morning, Dr Cooke says 'from the notes it doesn’t appear like I had any concerns about (Child O) and his clinical course was uncomplicated and he was making good progress'

The court is told that Child O was later found with a hematoma in his liver (which is an accumulation of blood). Dr Cooke is asked whether that could have been present at time of her examination at 9.30am

She says if that hematoma was present her 'review wouldn’t be normal, by which I mean observations would suggest baby is undergoing deterioration as oppose to normal observations and no concerns from night team or nursing team'

The judge clarifies that the hematoma was found post-mortem and that it's not alleged the hematoma was in existence at the time of her examination. Ben Myers KC, defending, agrees - saying they are not alleging it was present at that time

The court has previously heard that on post mortem un-clotted blood was found in abdominal space from a liver injury. There was damage in multiple locations on and in the liver which had bled into the peritoneal cavity

The court has previously heard that in the view of the Crown's medical expert Dr Dewi Evans the liver injury occurred before Child O's collapse and contributed to it

Nurse Melanie Taylor

See also: Melanie Taylor's oral testimony at the Thirlwall Inquiry

From Dan O'Donoghue on X

Nurse Melanie Taylor is now in the witness box recalling the events of 23 June

Ms Taylor was working the day shift on 23 June as shift leader. Ms Letby was Child O's designated nurse that day

Ms Taylor is asked how Child O was on that morning, from reviewing her notes she said 'I had no concerns about him, obviously he was premature....we felt he was stable at the beginning of the shift'

Ms Taylor has told the court that afternoon - around middayish - she recalls seeing Child O. 'I remember I thought I don’t think he looks as well as he did before'. She told the court she suggested to Ms Letby that he be moved to nursery 1 for closer observations

Ms Taylor said that Ms Letby said 'no, she felt he was okay and wanted to keep him in nursery 2 and wanted to keep the three triplets together' - Ms Taylor says she felt she was 'put out' by this

'I couldn’t put my finger on it, I just had a gut instinct I didn’t feel like he was as well', Ms Taylor said. Ms Taylor said she 'felt like (Ms Letby) was undermining my decision'

Child O remained on nursery 2 until he collapsed later that afternoon and moved to nursery 1. He eventually needed resuscitation, which was unsuccessful - Ms Taylor said she was surprised by the severity of his collapse

Ms Taylor has finished giving evidence. Judge has asked the jury to temporarily retire while he 'gets an update on the weather' and whether we can continue this afternoon

Chester Standard article 09-03-2023

A COLLEAGUE felt "put out" when murder-accused nurse Lucy Letby insisted a triplet should not be moved to intensive care, a jury has heard.

Letby, 33, is accused of murdering the newborn boy just hours after the exchange.

She is alleged to have fatally injected air into the circulation of the infant, Child O, during a day shift at the Countess of Chester Hospital's neo-natal unit.

Child O was stable and raised no concerns for doctors on the morning ward round on June 23, 2016, Manchester Crown Court heard.

Letby was caring for the youngster in nursery room two, a high dependency unit, along with one of his brothers, Child P, who she allegedly murdered the following day.

Giving evidence on Thursday, March 9, nurse Melanie Taylor said that at one point she had looked into room two and had a "gut instinct" something had changed with Child O.

The shift leader said: "I can't specifically remember what it was that I was not happy about but he didn't look as well as when I started the shift.

"I can't remember the reasoning behind it. Sometimes it can be just a gut instinct. Sometimes they (the baby) can present very slight things.

"I remember saying it out loud to Lucy.

"I asked whether she felt we should move him into nursery one. She said 'no'. She felt it was OK and wanted to keep him in nursery two and wanted to keep the brothers together.

"I guess it's a joint decision. Lucy was the one looking after him. She knew him and was with him all day."

Ms Taylor went on: "With hindsight, I wish I had been a bit firmer. I remember being put out that she was quite insistent. I think because I felt she was undermining my decision.

"She said 'no'. Quite plainly 'no, I don't feel like he should be moved'.

"I don't think from me it was 'he needs to be moved now'. It was more of a feeling than any hard evidence.

"I had a gut instinct he didn't seem as well."

Philip Astbury, prosecuting, asked: "What was the advantage of room one?

She replied: "Just the ability to have more space if anything was to deteriorate. We have more equipment on hand. We have got the emergency trollies in there.

"The resources are closer to hand and easier to get to."

She said her "gut instinct" came about "an hour or two" before the first collapse of Child O in the mid-afternoon.

Ms Taylor said she could not recall how she was alerted to the deterioration but that Letby was in room two when she attended.

Child O stabilised before he was moved to intensive care room one where he collapsed again about an hour later but could not be resuscitated.

Ms Taylor told the court she was "surprised" at Child O's deterioration.

Ben Myers KC, defending, asked the witness: "Do you recall Miss Letby explained she wanted to keep him (Child O) with his brother?"

"Yes," Ms Taylor said.

Mr Myers said: "All other things being equal, keeping them together as far as you can is desirable, isn't it?"

Ms Taylor repeated: "Yes."

Letby, originally from Hereford, denies the murders of seven babies and the attempted murders of 10 others between June 2015 and June 2016.

Doctor Stephen Brearey

See also:
INQ0103104 – Thirlwall Inquiry Witness Statement of Dr Stephen Brearey - various pages, dated 12/07/2024
Dr Stephen Brearey's oral testimony at the Thirlwall Inquiry

Dr Stephen Brearey, who was head of the neonatal unit in 2015/16, is now in the witness box. He is recalling his memory of the events of 23 June 2016 - the day Child O died

Dr Brearey wasn't the consultant on call that week - but he was in the hospital for a meeting. He passed through the unit and spoke to another doctor, who cannot be named for legal reasons, and was briefed on Child O. He stayed and offered to help

Manchester Crown Court has previously heard that Child O was in good condition and stable up until the afternoon of 23 June when he suffered a "remarkable deterioration" and died.

Dr Brearey has just reviewed a number of Child O's charts from that morning - he said 'none of those results were concerning; and that they were all in the 'normal range' and no evidence of infection

Court has just been shown an X-ray taken that morning, the radiologist notes 'the appearance is nonspecific but necrotising enterocolitis or mid gut volvulus cannot be excluded'

On another X-ray taken later that day, the radiologist notes 'the bowel is considerably less distended by comparison with the previous image, earlier that day' - notes no evidence of pneumothorax

Dr Brearey recalls Child O's first crash shortly after 14:30 on 23 June. He helped intubate the baby boy. He tells the court during this procedure he noticed an 'unusual' rash on the boy's chest

He said the rash was purpuric was 'noticeable'. He tells the court this was 'very, very concerning' in a neonate - his first thought for the case of the rash was infection. He notes Child O was on antibiotics and a blood test ordered

Child O crashed several more times that afternoon. On his last and fatal collapse at 16:15, Dr Brearey says that there was 'years of experience in that resuscitation' and that it was going as he would have wanted. 'But we just weren't getting a response back in terms of what we would normally expect', he said. Resus continued for well over 30mins but no pulse was recorded for Child O

The medic tells the court that by late afternoon the earlier rash noticed had 'vanished', which he found 'perplexing' - he said that ruled out it being a purpuric rash, as they're around for a 'good few days'

He said after 30mins the 'team agreed that to continue resus was going to be futile', this was discussed with parents it was stopped. Child O was then passed to his mum

Dr Brearey tells the court that after the death of Child O's brother, Child P, the following day he attended a debrief with other medical staff. He said Ms Letby was present in that debrief. He said he asked how she was feeling and 'can remember suggesting to her to take the weekend off to recover' 'She didn’t seem overly upset to me in the debrief and told me at the time she was on shift next day which was a Saturday'

He said he was concerned about this because he, along with other consultants, had 'already expressed our concerns' about deaths on unit and a potential link to Ms Letby

He said on the evening of June 24 he called the duty exec senior nurse in the urgent care division. She was 'familiar with concerns'. The doctor told her he 'didn’t want nurse Letby to come back to work the following day or till all this was investigated properly;

He was told 'no' and that 'there was no evidence', the exec was 'happy to take responsibility' for Ms Letby continuing

Dr Brearey told the court that "further conversations" took place the following week and the decision was taken to remove Ms Letby from frontline nursing duties - instead placing her in a clerical role. Ben Myers KC, defending, noted that Dr Brearey had first "identified" Ms Letby as someone of interest as early as June 2015 after the death of the first three babies in this case. Dr Brearey had noted, with colleagues, that Ms Letby was present when those three children died in 2015. Mr Myers put it to the doctor that he was guilty of "confirmation bias" towards Ms Letby and failed to look at "suboptimal care" given to the children in this case. "Absolutely not", he said.

Mr Myers put it to Dr Brearey that if there was a basis for his suspicions, he would have gone to the police. Dr Brearey said he and his colleagues were trying to "escalate appropriately" and needed "executive support" to decide the "correct plan of action going forward". Dr Brearey added: "It's not something anyone wanted to consider, that a member of staff is harming babies. The senior nursing staff on the unit didn't believe this could be true." Dr Brearey said with every "unusual" episode of baby collapse between June 2015 and June 2016 there was "increasing suspicion" about Ms Letby, which led him to eventually escalate his concerns and request she be taken off shift.

Chester Standard article 15-03-2023

Yesterday, the court heard that in June 2015, senior paediatrician at the Countess of Chester Hospital Dr Stephen Brearey conducted a review into the circumstances of the death of Child D that month.

An "association" with Letby and her presence at a number of collapses up to that point were noted, the court heard.

Dr Brearey told the court a meeting followed with director of nursing Alison Kelly in late June or early July 2015.

He said: "I think my comment at the time during the meeting was 'it can't be Lucy, not nice Lucy'.

Ben Myers KC, defending, said: "I would suggest that once Ms Letby had been identified as someone, or a factor, that caused concern there was naturally a bias against her in the way she behaved and the way it was interpreted, do you agree?"

Dr Brearey replied: "I disagree."

A further review of collapses at the unit from a neonatologist based at Liverpool Women's Hospital took place in February 2016, the court was told.

Dr Brearey said he sent a report of those findings to the director of nursing and the hospital's medical director as he asked for another meeting.

He confirmed that during this period there was no formal complaint made to the police.

Mr Myers asked: "If somebody hurt a baby on your unit and you believed you had the identity of the person responsible, you'd report it to the police wouldn't you?"

Dr Brearey said: "I think you are making it a bit more simplistic than it was. It was not something that anyone wanted to consider, that a member of staff is harming babies.

"Actually, the senior nursing staff on the unit didn't believe this could be true up until the point and beyond when the triplets (Child O and P) died.

"None of us (the consultants) wanted to believe it either.

"This all became very exceptional and it took a step back to think about it. The nature of these collapses, the unexpected nature of them, the lack of response to resuscitation, the unusual rash noted on a number of occasions and each time the association with Nurse Letby."

He said he wanted to "escalate" concerns within the hospital management rather than go directly to the police.

He said: "I needed executive support and that was what we were after."

Dr Brearey said there were "no more events" after Letby left the neo-natal unit.

He said: "It was the same staff doing the same job and there were no sudden collapses."

The consultant told Simon Driver, prosecuting, that between the deaths of Child D and Child O he was unaware that two other babies had returned blood results which showed abnormally high insulin levels.

Dr B [Thirlwall: Dr V]

See also: Dr B/V's oral testimony at the Thirlwall Inquiry

A doctor, who cannot be named for legal reasons, is now in the witness box. She is recalling the events of June 23 - when Child O collapsed several times and eventually died

The doctor said she was 'shocked' by the appearance and deterioration of Child O on June 23. She tells the court she had seen him the previous day and was 'progressing very well' When she saw the boy shortly before 4pm, she said she remembers him 'just being lifeless and mottled' and thinking 'what has happened'. She said it was 'completely unexpected'

The doctor said she wondered whether the cause of Child O's collapse had been to do with his heart. She asked Dr Brearey, who specialised in cardiac medicine, whether he should have an echocardiogram - he felt one wasn't required

The medic is now recalling Child O's final and fatal collapse. She tells the court 'whatever we gave him was having no effect', she adds this was 'not something I’d seen happen so suddenly in a baby'

Medical Experts

Dr Dewi Evans

Chester Standard article 15-03-2023

A BABY allegedly murdered by nurse Lucy Letby was injected with air, a court heard.

The infant was said to have been attacked by the defendant during her day shift at the Countess of Chester Hospital's neo-natal unit in June 2016.

Giving evidence on Wednesday, March 15, expert witness Dr Dewi Evans told Manchester Crown Court he believed Child O was the victim of an "air embolus" – in which gas bubbles block blood supply.

The retired consultant paediatrician said a "small discoloured purpuric rash" had been noted on the youngster's chest during his rapid deterioration on the afternoon of June 23.

Dr Evans said: "I considered that the rash was consistent with (Child O) having received a injection of air into his circulation, his blood circulation.

"My opinion was that (Child O's) terminal collapse was him being the victim of an air embolus.

"I couldn't find any evidence where this could have occurred accidentally."

Dr Evans said it "repeated the pattern" seen in the case of Child B, a twin girl, who also had a noticeable rash during her collapse – which she survived.

Jurors were told Dr Evans had concluded in an earlier report, in June 2018, that the cause for Child O's collapse was trauma to the liver.

A haematoma – bleeding – had been found in the liver during a post-mortem examination.

Dr Evans said: "If there was a purpuric rash – little blood spots under the skin – there had to be a cause. It was indicative of direct trauma."

He later learned from the police that the doctor who observed the rash had further explained it disappeared a short time after.

Dr Evans said: "This made a big difference to the interpretation of the rash. If it's a purpuric rash it will last quite some time – days, hours."

Letby is also accused of murdering Child O's newborn brother, Child P, on the following day.

The surviving triplet was later discharged from another hospital after their parents "begged" a doctor to remove him from the Countess of Chester.

Professor Owen Arthurs (Babies O & P)

Chester Standard article 16-03-2023

AN "unusual" amount of gas was detected in a baby just hours after his brother was allegedly murdered by nurse Lucy Letby, a court heard.

Letby, 33, is said to have administered fatal doses of air to both infants who died at the Countess of Chester Hospital on successive days in June 2016.

Child O – one of identical triplet boys – was pronounced dead at 5.47pm on June 23 only two days after he and his brothers were all born in good condition.

Following the death, his brother Child P was reviewed on the neo-natal unit by a consultant who ordered an abdominal X-ray.

The subsequent X-ray, timed at 8.09pm, noted "gas filled loops throughout the abdomen", Manchester Crown Court heard.

Letby was the designated nurse for Child O and P on the day shift of June 23 and continued to care for Child P the following day.

On June 24, Child P collapsed on numerous occasions from 9.35am onwards and required resuscitation after his heart rate and blood oxygen levels plummeted.

Medics, including Letby, were unable to revive the youngster from his final collapse at about 3.15pm and he was pronounced dead at 4pm.

A transport ambulance team had arrived at the Countess of Chester at 3pm in preparation for transferring Child P to a specialist hospital.

When he died, his parents "begged" the team doctor to take their surviving triplet instead, which he agreed to.

Giving evidence on Thursday, March 16, Dr Owen Arthurs, professor of radiology at London's Great Ormond Street Hospital, said the June 23 X-ray of Child P was "very similar in appearance" to one taken of Child O.

He told the court: "This is gas throughout the gut. This degree of gas is quite unusual in a baby like this."

He said potential causes were infection or necrotising enterocolitis (NEC), a common bowel disorder in premature-born babies.

An alternative explanation was the administration of air via a nasogastric tube, he said.

Dr Arthurs came to the same conclusions regarding an X-ray of Child O, captured hours before his death.

He said: "This shows a lots of gas in his stomach, small and large bowel. This is more than what would be expected in a normal baby."

Dr Arthurs agreed with Ben Myers KC, defending, that another possible explanation for Child P's dilation was an "unidentifiable cause".

Dr Andreas Marnerides (Babies O & P)

Dr Andreas Marnerides, Pathologist

From Dan O'Donoghue on X

Jury are currently being read the pathology reports for a number of children in the case - they have been warned that there is a lot of incredibly dense medical detail and will be provided with a glossary of terms afterwards.

Dr Marnerides, who leads the forensic children's pathology service at Guy's and St Thomas' Hospitals, is now in witness box.

To assist the jury with his findings in relation to triplet brother Child O, who died in June 2016, Dr Marnerides presented a photograph of the baby boy's liver, taken at post-mortem, to the court. The court has previously heard that Child O died after suffering "trauma" to his liver and an injection of air into his bloodstream. The images showed a "rather large bruise" to the boy's liver that would have caused an internal bleed, Dr Marnerides said.

Lucy Letby's murder trial continues with evidence from expert pathologist Dr Andreas Marnerides this morning. The medic told the court yesterday that it was 'likely' a number of babies died at the Countess of Chester Hospital as a result of air injection

Dr Marnerides was asked to review the case by Cheshire Police in 2017. He is currently taking the court through his review of Child P, who was one of triplets born in June 2016. Ms Letby is accused of killing the boy the day after allegedly murdering his triplet brother, Child O. The Crown say he was killed by an injection of air into his bloodstream.

Dr Marnerides said in his review of Child P, he could not find anything to 'indicate natural disease for the baby's death'

To assist the jury with his findings in relation to Child P, Dr Marnerides is presenting photographs of the baby boy's liver, taken at post-mortem, to the court. The images show small bruises on the outside of the boy's liver

Dr Marnerides tells the court that the bruising, although a lot smaller, is in the same area that it was found in Child P's brother Child O. The court heard yesterday that Child O suffered a liver injury akin to a road traffic collision.

The medic says the bruising found 'could' be the result of CPR - asked whether it could be another impact injury, he says 'I don’t have enough to say that'

Dr Marnerides says having reviewed all the evidence, it is his opinion that Child P died as a result of 'excessive injection of air into the stomach'

Ms Letby's defence lawyer, Ben Myers KC, is now cross examining Dr Marnerides - he starts by telling the court that there are 'strict rules about the extent to which an expert can give an opinion on matters outside their specialism' - he agrees

The medic accepts he cannot offer a view on day to day care, feeding, breathing support or resuscitation of the babies in this case. Mr Myers says when there is no specific finings 'one way or another' in the pathology, he works on the basis of the opinions of the clinicians 'unless something directly contradicts that' - Dr Marnerides agrees

Cross examination of Dr Marnerides continuing, Mr Myers has taken the medic back over his evidence for Child C, D and now I. The defence lawyer is focusing his questioning on the fact he has had to rely on Dr Dewi Evans and other medics for his review. Dr Marnerides earlier said to discount the clinical evidence in forming his reports was akin asking someone to explain physics without using mathematics

We're back after lunch and have moved to Child O. Yesterday the court heard that the boy allegedly suffered a liver injury akin to a road traffic collision - Mr Myers has been asking Dr Marnerides about the minimum force needed to cause such an injury

Dr Marnerides says there is 'no way of measuring the force in a baby because we cannot conduct such experiments on babies'. He says from his experience, the minimum force required 'would be of the magnitude of forces generated from a baby jumping on a trampoline and falling'

Mr Myers puts it to the medic whether vigorous CPR could have caused the injuries found in Child O's liver - he says no. Mr Myers asks whether it can be categorically excluded as a possibility The medic goes a bit leftfield with his response. He says to the court that if a man is found dead in the Sahara desert with a pot next to him, it could be possible that a helicopter flew over and dropped it on his head - but it's not probable

Chester Standard article 29-03-2023

[Child O] was born in good condition, Manchester Crown Court has heard, until he suddenly collapsed two days later in the care of Letby and went progressively downhill as medics failed to revive him.

On the following day shift, the Crown says she murdered Child P, one of Child O's triplet brothers.

On Wednesday, March 29, paediatric pathologist Dr Andreas Marnerides said Child O died partly due to an "impact-type" internal liver injury – discovered after the baby's death.

Jurors were shown post-mortem examination photographs which showed two separate sites of bruising, as well as areas of a blood clot.

Prosecutor Nick Johnson KC asked the consultant: "How does that injury come to be in a child of (Child O's) age?"

Dr Marnerides, who practises at London's St Thomas' Hospital, said: "The distribution, the pattern and the appearance of the bruising indicates towards impact-type injury. I'm fairly confident this is impact-type injury."

He explained the photograph showed "extensive haemorrhaging into the liver", which he had only seen previously in a road traffic collision and in non-accidental assaults from parents or carers.

Mr Johnson said: "Looking at this sequence of photographs, can you rule out the possibility that these injuries were caused by CPR?"

Dr Marnerides said: "I cannot convince myself that in the setting of a neonatal unit this would be a reasonable proposition to explain this. I don't think CPR can produce this extensive injury to a liver."

Mr Johnson said: "In so far as you have spoken about an impact-type scenario for causing that internal injury, would you necessarily expect to see any outside sign on the skin itself?"

The consultant replied: "You can have the most devastating injury internally and nothing can be observed externally. That is very common."

Mr Johnson went on: "What in your view was the cause of death of (Child O)?"

Dr Marnerides said: "In my view, the cause of death was inflicted traumatic injury to the liver, profound gastric and intestinal distension following acute excessive injection/infusion of air via a naso-gastric tube and air embolism due to administration into a venous line."

Chester Standard article 30-03-2023

Paediatric pathology expert Dr Andreas Marnerides had told jurors he concluded Child O died because of "inflicted traumatic injury" to the liver, as well as receiving fatal injections of air into the stomach and bloodstream.

He compared the extent of the liver injuries to those suffered fatally by children involved in road traffic accidents and non-accidental assaults.

On Thursday, March 30, Ben Myers KC, cross-examining, said: "Can you assist with how little force could be involved?"

The consultant at London’s St Thomas’ Hospital said: "I think there is no way of measuring a force in a baby because we don’t conduct such experiments on babies.

"I have never seen this type of injury in the context of CPR so I would say the force required would be of the magnitude of that generated by a baby jumping on a trampoline and falling."

He agreed that smaller internal bruising to the liver sustained by Child O’s triplet brother Child P – who Letby is alleged to have murdered the next day – could be capable of being caused by CPR.

But asked if "rigorous" chest compressions could be the cause of the internal bruising in Child O’s case, Dr Marnerides said: "I don’t think so, no.

"This is a huge area of bruising for a liver of this size. This is not something you see in CPR."

Mr Myers said: "So you don’t accept the proposition that forceful CPR could cause this injury in general terms, do you agree it cannot be categorically excluded as a possibility?"

Dr Marnerides replied: "We are not discussing possibilities here, we are discussing probabilities.

"When you refer to possibilities, I am thinking for example of somebody walking in the middle of the Sahara desert found dead with a pot and head trauma.

"It is possible the pot fell from the air from a helicopter. The question is ‘is it probable?’ and I don’t think we can say it is probable."

Mr Myers asked: "Is it possible in your opinion for at least some of what we see in the damage to the liver arising from the insertion of a cannula?"

The consultant said: "I would consider it extremely unlikely. I would expect some kind of perforation injury."

Earlier, Dr Marnerides said the most likely explanation for the death of Child P was excessive air injected via a nasogastric tube into his stomach.

Thirlwall Evidence Documents

Description
Source date
Publication date
Download link
INQ0049390 - Pages 3 - 4 of Table prepared by Eirian Powell regarding [Child N], [Child O], [Child P] and [Child Q], dated 15/04/2016.
Source Date:
15 April 2016
Publication Date:
12 September 2025
Link:
Download (663 KB)
INQ0018008 - Pages 9 and 10 of Document titled Level 2 Root Cause Analysis Investigation Report, relating to [Child O], dated 23/06/2016
Source Date:
23 June 2016
Publication Date:
22 October 2024
Link:
Download (606 KB)
INQ0002046 - Page 3 of medical records of Child Q (sic) [Child O].
Source Date:
27 June 2016
Publication Date:
10 September 2025
Link:
Download (122 KB)
INQ0014630 - Pages 1 - 2 of Email from Peter Groggins (NHS England) to Marie Sedgwick (NHS England) and colleagues regarding [Child O]'s Serious Incident report, dated 30/06/2016
Source Date:
30 June 2016
Publication Date:
17 January 2025
Link:
Download (3.8 MB)
INQ0005121 - Page 3 of Report from the Countess of Chester Hospital titled Mortality Review, regarding [Child O], dated 05/07/2016
Source Date:
5 July 2016
Publication Date:
7 October 2024
Link:
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INQ0004891 - Email regarding inquest statement relating to [Child O] and [Child P], dated 06/07/2016
Source Date:
6 July 2016
Publication Date:
2 October 2024
Link:
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INQ0005564 - Pages 1 - 3 of Meeting minutes of Cheshire & Merseyside Clinical Effectiveness Group, relating to neonatal deaths and death of [Child O] & [Child P], dated 26/09/2016
Source Date:
26 September 2016
Publication Date:
17 October 2024
Link:
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INQ0002046 - Pages 82 - 83 - email correspondence between Christine Hurst and Nicholas Rheinberg, titled "[Child O] & [Child P]", dated between 14/10/2016 and 17/10/2016
Source Date:
14 October 2016
Publication Date:
6 December 2024
Link:
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INQ0002046 - Pages 86 and 88 - email correspondence between Claire Raggett and Christine Hurst, titled "[Child O] & [Child P]", dated between 31/10/2016 and 09/12/2016
Source Date:
31 October 2016
Publication Date:
6 December 2024
Link:
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INQ0058202 - Page 3 of email correspondence between Christine Hurst and Claire Raggett, titled "[Child O] & [Child P]", dated between 31/10/2016 and 07/12/2016
Source Date:
31 October 2016
Publication Date:
6 December 2024
Link:
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INQ0008605 - Page 7 of Letter from Doctor V regarding her involvement in the care of [Child O], dated 03/11/2016
Source Date:
3 November 2016
Publication Date:
7 October 2024
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INQ0002046 - Page 91 - email correspondence between Christine Hurst, Nicholas Rheinberg and Claire Raggett, titled "[Child O] & [Child P] (deceased)", dated between 17/01/2017 and 20/01/2017
Source Date:
17 January 2017
Publication Date:
6 December 2024
Link:
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INQ0058202 - Page 1 of email correspondence between Stephen Cross, Christine Hurst and various Countess of Chester staff, titled "[Child O] & [Child P]", dated 20/01/2017
Source Date:
20 January 2017
Publication Date:
6 December 2024
Link:
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INQ0002046 - Page 95 - email correspondence from Nicholas Rheinberg to Christine Hurst, titled "[Child O] & [Child P]", dated 26/01/2017
Source Date:
26 January 2017
Publication Date:
6 December 2024
Link:
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INQ0002046 - Page 77 - email correspondence between Nicholas Rheinberg and Christine Hurst, titled "[Child O] & [Child P] (deceased)", dated 01/02/2017
Source Date:
1 February 2017
Publication Date:
6 December 2024
Link:
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INQ0003395 - Pages 2 and 3 of email chain requesting further reviews of [Child O], [Child P], [Child A], [Child I], [Child C] and [Child D], dated 06/03/2017
Source Date:
6 March 2017
Publication Date:
3 October 2024
Link:
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INQ0008615 - Pages 1 - 2 of Datix form relating to [Child O], dated 08/05/2017
Source Date:
8 May 2017
Publication Date:
17 October 2024
Link:
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INQ0001404 - Pages 3 and 7 of Witness statement of Melanie Taylor, Neonatal Nurse, relating to [Child O]. Produced for the criminal trial of R v Letby, dated 12/02/2018
Source Date:
12 February 2018
Publication Date:
10 October 2024
Link:
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INQ0001333 - Table titled Chronology of Events, in relation to [Child O], [Child P] & [Child R], 08/03/2019
Source Date:
8 March 2019
Publication Date:
29 August 2025
Link:
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INQ0014373 - Report from Dr Jo McPartland regarding a case review in relation to [Child A], [Child I], [Child O] & [Child P], undated
Source Date:
Publication Date:
29 January 2025
Link:
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