Jabe

Not only did Cheshire police get the door swipe data wrong but analysis indicates that in the case of Baby E they got telephone call log times wrong too. 

When the events are examined in detail the only possible explanation for discrepancies in the evidence is that calls made to Baby E's father were actually an hour later than the Police and Prosecution stated.

Could it be that the calls were logged in GMT and never adjusted for British Summer Time? You wouldn't think that this oversight would be possible but it seems to be the only explanation.

(Please note I am in no way critical of Baby E's parents because what they went through is unimaginable)

This was crucial evidence because Baby E's mother says she saw blood around her baby's face at around 9pm. She was understandably panicked and after going back to the ward she called her husband who was at home an hour away - the call log showed her call placed at 9.11pm, which was used supporting evidence.

But Letby's notes recorded this event as happening at around 10pm and Dr Harkness's notes were recorded at 10.10pm having arrived a little before.

The testimony given by Baby E's mother must have had a powerful effect on the Jury as she described horrendous crying (like screaming) from the corridor before entering the room and seeing blood around her baby's mouth. 

The Prosecution made the extraordinary allegation that Letby had attacked the baby before 9pm causing this bleeding and then sat on the situation for an hour whilst he suffered. In hindsight, the mother thought she had interrupted Letby in the process of murdering her baby, which is too awful to contemplate. It seemed the Jury believed this.

After Baby E's condition worsened there was a later call from the midwife to the father logged at 10.52pm telling him "Don't panic, but get over here now." He testified that this call was split between the midwife and his wife, though his wife didn't remember it.

From trial reporting of the mother's testimony:
She was later told by the midwife and to ring her husband. The midwife called the husband at 10.52pm, telling him to come to the hospital, after the neo-natal rang the maternity ward.

But clinical notes recorded that Baby E's condition didn't worsen until after 11pm and it was at 11.30pm that the midwife received the call from the neonatal unit at the time they were preparing to intubate.

The midwife's statement from 2019 was read out in court. From trial reporting:
"At 11.30pm on August 3 she had a call from the neonatal unit to ask Child E's mother to go down in 30 minutes as Child E had a bleed and required intubating - 'very poorly'. "
"At midnight, the midwife stayed with Child E's mother for 10 minutes in the corridor outside the neonatal nursery room."

The midwife was called by the neonatal unit at 11.30pm and was with the mother at midnight.

The only way to reconcile the call log times with medical & midwife records is to shift the call log times 1 hour forward meaning that the mother's call to her husband was at 10.11pm rather than an hour earlier.

Lucy Letby did not wait and do nothing while Baby E suffered but did everything correctly as she was supposed to and told the truth about it.

Source of the above information was from the http://tattle.life website and also cross-checked with other trial reporting.
https://tattle.life/wiki/lucy-letby-case-5/

#LucyLetby

From the Thirlwall Inquiry we find out that Baby E's mother contacted her phone company in 2017 to get the call log times.

Mobile phone companies usually report call logs in UTC (= GMT).

Did Cheshire Police ever verify these call times?
https://x.com/mucha_carlos/status/1838034145202634940

This information was taken from the Daily Mail podcast from a few days ago as the relevant Inquiry  transcripts haven't yet been published:

https://youtu.be/dzJBFBMUTjY?si=jwpRg5-kvwealTTz&t=1356

"In the end, she got the medical records for her children from her solicitor and started reading up on medical terminology and blood readings herself. She told the inquiry she soon realized Lucy Letby had falsified entries in baby E's notes on the night he died. Lucy Letby had written that it was 10 PM when she'd come down to the unit with the breast milk and found her son in distress. But she was sure it was an hour earlier because of the call she'd made to her husband immediately afterwards. So baby E's mom called her phone company herself to double check. She told the Inquiry, 'I needed the proof and I got the proof.'"

0/8
This is a thread on Baby C. I've posted most of this before in one form or another but this rounds it all up into 1 thread.

Key Points:

1. Dr Dewi Evans changed his opinion about Baby C's cause of death, both before and during the trial (and after - see point 4).

2. The pathologist for the prosecution, Dr Andreas Marnerides, drew his conclusions about the cause of death from an x-ray taken on 12th June 2015, a day when Letby was off work.

3. @stephHegarty on BBC Radio 4's File on 4 programme exposes the x-ray dates mix-up, and Professor Colin Morley says the baby died of natural causes.

4. 1st October 2024 - @sarahknapton of the Telegraph reports that Dr Dewi Evans has changed his mind again about Baby C's cause of death.

5. 10th October 2024 - @lawrencefelic of the Guardian reveals that 2 months before the trial, prosecution expert witnesses had jointly agreed that the 12th June x-ray was evidence of air being injected into the nasogastric tube.

6. Dr George Kokai, the official pathologist, concluded that Baby C had died of ischaemic heart damage, but Dr John Gibbs didn't fully agree, and said so.
 
7. Dr Jim McCormack, Mother C's obstetrician, says that Baby C's death was neither unexpected nor unexplained.

8. Nurse witness testimony supports Lucy Letby's defence that she was outside the room before Baby C collapsed.

#LucyLetby

1/8

Before the trial, Evans concluded that air had been deliberately injected air into Baby C's nasogastric feeding tube. His evidence was an x-ray taken of Baby C on 12th June 2015 showing a distended stomach with an abnormal amount of air.

Evans admitted in court that this x-ray helped him form the conclusion that someone had deliberately harmed Baby C which result in their death.

But Letby wasn't at work that day and hadn't yet had any contact with the baby.

At some point in his series of 8 reports on Baby C he changed his 12th June x-ray diagnosis to "CPAP belly" (air in the stomach caused by pressurised breathing support) which is common and not considered a problem.

But he still insisted that the cause of Baby C's collapse on 13th June was due to injection of air into the nasogastric tube even though there was no objective evidence of this. Letby was working on this day though assigned to other babies in a different nursery.

At the trial he unexpectedly added to his diagnosis: now there must have been a splintering of the diaphragm caused by pressure of this excess air, something which he'd never mentioned before. Again - no objective evidence for this.

Ben Myers KC asked him what evidence he had that air had been injected into the stomach on 13th June and his curt response was: "The baby collapsed and died".

Trial reporting of Evans' cross examination from https://tattle.life/wiki/lucy_letby_case_3/#dr-dewi-evans
Mr Myers refers to a 'massive gastric dilation' was 'most likely' due to an injection of air on June 12.
Dr Evans: "That was a possibility, yes."
Mr Myers says in that report, there was no suggestion the diaphragm had been splintered since, and if he wanted to say so in that report, he could have done so.
"If it wasn't said, it wasn't said."
Dr Evans said what was being discussed, on June 12, there was a "distinct possibility" Child C had excess air in the stomach from CPAP belly.
He was "still stable" from a respiratory point of view.
He tell the court: "However the air went in, it would have been insufficient to splinter the diaphragm on the 12th, as he would've collapsed and died on the 12th."
The air which had gone in was 'insufficient' to cause a collapse. There was 'nothing to suggest' the excess air was enough on June 12.
He says the two events on June 12 and 13 "are quite different" in the way they happened.
Mr Myers said that it was Dr Evans's view, a couple of months ago, there was deliberate harm on June 12.
"That was a possibility, yes it was."
Mr Myers: "What you have done today in your evidence is introduce something supporting the allegation."
Dr Evans: "That is incorrect."
..
Mr Myers asks Dr Evans what evidence there is to support that air had been injected into the stomach on June 13.
Dr Evans: "The baby collapsed and died."
Asked to explain further, Dr Evans says it was part of a differential diagnosis.
He said there were three clinical scenarios - injecting air into the stomach that interfered with his breathing, or that air was injected intraveneously, or from a combination of the two, which Dr Evans says "sounds awful".
Dr Evans says, from his perspective, from an academic point of view, he would not be able to rule out any one of those three scenarios.

#LucyLetby

2/8

Dr Andreas Marnerides, the expert witness pathologist used x-rays taken on 12th June 2015 in his testimony that Letby had injected air into Child C's nasogastric tube, which directly caused the baby's collapse and death on 14th June 2015.

Letby wasn't working on 12th June, the day the x-ray was taken, and hadn't ever met the baby.

Marnerides has effectively testified that someone - not Letby - injected air into Child C's feeding tube. The 2 doctors have got themselves in a complete muddle about what happened when.

This is from the Prosecution's closing speech as described by the Chester Standard live reporting:

 "He [Marnerides] added: "I have never in the past 10 years, come across even a suggestion that 'CPAP belly' would lead to the deterioration of a baby, let alone this gastric distention that would lead to [a baby's death]." 
...
"Dr Marnerides described "massive" gastric distention, using the word "ballooning"."

In an earlier report in 2019 Dewi Evans had described a "massive gastric dilation" seen on 12th June x-ray (see previous post).

Marnerides used a very similar term: "Massive gastric distention" and referred to it leading to the baby's death. There can't be any doubt that he's drawn this conclusion from the 12th June x-ray.
#LucyLetby

Prosecution's closing speech, screenshot from:
https://www.chesterstandard.co.uk/news/23603440.recap-lucy-letby-trial-june-21--prosecution-closing-speech/

3/8
On 1st October 2024, BBC R4's File On 4 programme "Lucy Letby: The Killer Questions" was broadcast. The reporter was @stephhegarty. 

It included a section on Baby C and featured Professor Colin Morley, a world-renowned neonatology scientist and researcher.

The programme is still available to listen to on BBC Sounds:
https://www.bbc.co.uk/sounds/play/m0023vnp

Professor Colin Morley is certain that a bowel obstruction was the cause of Baby C's collapse and that he died of natural causes. He suggests that the doctors were out of their depth in treating Baby C and that the baby should have received a higher level of care.

But Dr Dewi Evans insists that the biggest concern was "that the x-ray showed a huge great bubble in the stomach". He's still referring to that x-ray on 12th June when Letby wasn't there.
 
Transcript of this section of the programme:

Reporter:
We've been looking at the case of Baby C, a boy who was born in June 2015, 10 weeks premature and weighing just under 2lb. Letby was found guilty of deliberately injecting air into the child's stomach via his feeding tube. Key to the prosecution's case was that Baby C was stable and that his collapse at almost 4 days old had been unexpected. But 5 different neonatologists have told File on 4 there were signs Baby C was in trouble before then.

Professor Colin Morley:
I'm Colin Morley. I've been a paediatrician for about 50 years, 45 years, and specialized towards the end, in the care of sick babies, particularly premature babies. I worked in Addenbrooke's Hospital and the University of Cambridge, done quite a lot of research related to breathing problems, and I went to Melbourne for 10 years as professor of neonatal medicine.

Reporter: 
Professor Morley is a world-renowned expert in neonatology. This is the first time he's spoken about the Letby case. He didn't attend the trial, but he's reviewed the evidence heard in court about the care that Baby C received.

Professor Colin Morley:
Baby C was [an] extremely small baby, so this baby really needed intensive care. The baby was not in the right hospital. The baby started vomiting black fluid, bile probably with digested blood. That's a very serious sign, although they didn't seem to appreciate that.
And the x-rays showed dilated bowel with a lot of gas, particularly in the stomach and the upper intestine. I think they failed to recognize that the baby had a bowel obstruction which was causing the problems. And that needed urgent surgical opinion and probably surgery to save the baby's life.

Reporter:
You're saying quite clearly here you believe this baby died of natural causes. How confident are you of that?

Professor Colin Morley:
I'm very confident because of what I've read. Bile stained vomiting, that means intestinal obstruction until not proved. The x-ray showing distended bowel, that means bowel obstruction. And, I don't see any reason to come up with a very strange hypothesis that somebody forced gas into the stomach through the nasogastric tube enough to kill the baby. There was plenty other things going on that would mean the baby wasn't gonna survive if he didn't have the proper treatment.

Reporter:
Baby C's size and prematurity put him at the limit of what the Countess of Chester could care for. Professor Morley says a consultant should have been examining this child several times a day.

Professor Colin Morley:
I've spent a lot of my time working in intensive care units, and this baby certainly should have had [a] higher level of care. They're tricky and they deteriorate, and you need to be able to keep an eye on things to see what's going on. The consultant didn't see the baby for the first 3 days. He was seen by nurses and trainee doctors.

Reporter:
It was in the middle of Lucy Letby's night shift that Baby C collapsed. Doctors tried to resuscitate him, but they couldn't.

Professor Colin Morley:
This and other cases to do with Lucy Letby I've looked at, I got the feeling that the resuscitation was suboptimal. The people's skills were not up to the job of resuscitating a tiny baby like this. And that's not surprising, I mean it sounds very critical but this was a hospital that wasn't really set up for a baby as small and sick as this baby. They had a bit of equipment called a neopuff, which is designed to help inflate the baby's lungs. People find it very difficult to get a good seal between the mask and the baby's face on little tiny babies like this. By the time the baby was intubated 20 minutes later, it would have deteriorated significantly.

Reporter:
This medical evidence was reviewed and peer reviewed by a team of medical experts, paediatricians, radiologists, and a pathologist. And it was considered in great detail, so it's quite a statement for you to make that they've simply got it wrong.

Professor Colin Morley:
Looking after and diagnosing [a] very premature baby, 800 grams is extraordinarily tiny. They just were out of their depth. And instead of going for the diagnosis which was, you know, just: bile stained vomiting, the baby's got intestinal obstruction, don't need much more than that. The x-ray was absolutely classical of a baby who'd got a lower bowel obstruction.

Reporter:
The pathologist who took the stand for the prosecution said there was no bile obstruction found in the post mortem.

Professor Colin Morley:
Well, clinically, the baby did have a bowel obstruction. I'm devastated for the families, there's absolutely nothing worse than losing your precious baby. And they've been told that the baby was murdered by Lucy Letby, which is awful. But, you know, my job is to tell the truth about what I think has happened. I just don't believe this wild hypothesis based on no evidence whatsoever that somebody inflated the stomach enough to kill the baby.

Reporter:
Letby's defence team did argue that Baby C could have been suffering from a bowel obstruction, which doctors had failed to spot. But this was rejected by the prosecution's expert witnesses, including Dewi Evans.

Dr Dewi Evans:
No, I don't think his collapse was a result of a bowel obstruction. What Baby C did have was an infection, and the blood markers were consistent with infection. His case from a clinical point of view was the most difficult because he was very small. But he was doing satisfactorily as well as could be expected, and therefore his collapse and failure of resuscitation was unexpected.
But the biggest concerns was that the x-ray showed a huge great bubble in the stomach and also far more gas than I would expect.

Reporter:
This X-ray was one of the key pieces of evidence in this case. In pretrial reports, doctor Evans and other expert witnesses said it was evidence that air had most likely been pumped deliberately into the baby's stomach via his feeding tube. Pathologist doctor Andreas Marneridis told the court these reports, which reference the x-ray, helped him form his opinion that Letby killed the baby using this method. But during the trial, it transpired that Lucy Letby wasn't working on 12th June when the x-ray was taken.
She hadn't been on shift since before Baby C was born. In his summing up, the judge made it clear to the Jury that this x-ray had been taken the day before Baby C collapsed, though he didn't remind them that Letby hadn't been on shift.
I think it's clear that Letby hadn't met the baby by that stage, had she?

Dewi Evans.
I don't know. She was certainly there when he died. 
#LucyLetby

4/8
On 1st October 2024, @sarahknapton at the Telegraph reported that following the BBC's File On 4 programme, Dr Dewi Evans had changed his mind about Baby C's cause of death.

But he still believed that Letby murdered Baby C, though using a different means.

From the article:
Dr Evans told The Telegraph he no longer believed air injected into the stomach was the cause of the death.
“The stomach bubble was not responsible for his death,” he said. “Probably destabilised him though. His demise occurred the following day, around midnight, and due to air in the bloodstream.
“Letby was there. I amended my opinion after hearing the evidence from the local nurses and doctors. Baby C was always the most difficult from a clinical point of view. So I understand the confusion.”
Dr Evans has not changed his view that Letby was responsible for the death of Baby C, only how she murdered the infant.
His comments come amid ongoing concern about how the evidence in the case against Letby was presented to the jury.
At Letby’s trial, Nicholas Johnson KC, prosecuting, said that Baby C had been killed “by air inserted into his stomach via the nasogastric tube, not into his bloodstream”.
In an interview for File on 4, Dr Evans said the “biggest concern was that the X-ray showed a huge great bubble in the stomach and far more gas than I would expect”
However, it then emerged that the X-ray had been taken on June 12th 2015, when Letby was not working, and had not been in the hospital for two days.
#LucyLetby
https://www.telegraph.co.uk/news/2024/10/01/lucy-letby-witness-changed-mind/

5/8
10th October 2024 - @lawrencefelic reported on the case in the Guardian.

Amongst other things, it's revealed that 2 months before the trial the prosecution experts had jointly agreed that the 12th June x-ray was evidence of air having been injected into the nasogastric tube.

From the article:
The charge regarding Baby C relied on a joint experts’ report signed by Evans in August 2022, two months before the trial. It stated that the evidence for air having been injected into the stomach could be seen on an X-ray of the child taken on 12 June 2015.
Evans gave evidence in the trial when it had already been established by earlier witnesses that Letby had not worked with Baby C before the X-ray was taken. In the witness box, he departed from his written report and proposed two new possible causes of the child’s collapse. He said a large volume of air caused the diaphragm to splint on 13 June, when Letby was on duty, and that air may have been injected into the bloodstream.

Challenged by Letby’s barrister at the trial, Benjamin Myers KC, Evans acknowledged he had never mentioned either of those potential causes of death throughout five years of working on the case, and in nine written reports. “Sorry,” Evans said, explaining his change of evidence, “this baby was put in harm’s way.”

Johnson maintained in his closing speech that Letby killed Baby C using air down the feeding tube as her method, saying she did so on 13 June, and that the prosecution based the allegation on Evans’s evidence.

And on Evans' changing testimony, she writes:

 Evans has completed a new report on Baby C.
In response to questions from the Guardian, Evans said he had now completed a new report for the police on Baby C’s medical condition, based on “corrected” medical notes. He explained he changed his opinion at the trial after hearing staff give their evidence. Evans said Letby murdered Baby C during her night shift of 13 June, but he declined to say whether he maintained this was by injecting air down the NGT. This month, the Telegraph reported that Evans had said he now believed the cause of death was air injected intravenously, not down the NGT.

“Last week I carried out a detailed review from the corrected case notes, only received by me in June 2022, and have now worked out what led to Infant C’s death in more detail, and have completed my report,” Evans told the Guardian. Asked for his current opinion on the baby’s cause of death, he replied: “I think that in my evidence I said that it was the result of air into the bloodstream (but I have not seen the transcript).”

Asked to clarify further, Evans said Cheshire police had now told him not to discuss Baby C in the press.

#LucyLetby
From the Guardian article at:
https://www.theguardian.com/uk-news/2024/oct/10/lucy-letby-police-cps-handling-case-raises-new-concerns-about-convictions

6/8
1st October 2024 - Dr John Gibbs was questioned at the Thirlwall Inquiry

He testified that he had disagreed with the pathologist's report on Baby C's cause of death.

Dr George Kokai, the pathologist, reported to him verbally in August 2015 that the cause of death was "widespread hypoxic ischaemic damage to the heart". 

Gibbs was skeptical about this: he believed the heart damage was caused after Baby C's collapse and was not the cause of it. He queried that with Kokai.
 
Gibbs spoke to the parents face-to-face and also sent them a letter on 29th September 2015 expressing doubts that the pathologist was correct.

The letter can be seen here:
https://thirlwall.public-inquiry.uk/evidence/inq0008978-pages-4-and-5-of-letter-from-dr-john-gibbs-consultant-paediatrician-countess-of-chester-hospital-to-mother-father-c-regarding-child-cs-death-dated-24-09-2015/

When the Coroner did release the pathologist's report later in the year, the official cause of death remained unchanged. 

See screenshot, which is taken from consultant neonatologist Dr Jane Hawdon's report, which can be found here:
https://thirlwall.public-inquiry.uk/evidence/inq0006862_0031-report-from-dr-j-m-hawdon-consultant-neonatologist-royal-free-nhs-foundation-trust-titled-advisory-medical-report-dated-october-2016-page-31-relating-to-child-c-only/

Over 2 years later in November 2017 Dr Gibbs would again contradict the pathologist's official cause of death. 
In his police statement he said: "In my opinion it is more likely that the ischaemic heart changes noted at post mortem were a consequence of, rather than the cause of his collapse and subsequent failure to respond to the initial vigorous resuscitation efforts."
From: 
https://thirlwall.public-inquiry.uk/evidence/inq0001993-page-14-of-witness-statement-of-dr-john-michael-gibbs-former-consultant-paediatrician-countess-of-chester-hospital-produced-for-the-criminal-re-trial-of-r-v-letby-dated-20-11-2017/

This is part of Dr Gibbs' Inquiry testimony which is taken from:
https://thirlwall.public-inquiry.uk/transcript/01-10-2024-transcript-of-week-4-day-2/

Q. But following your conversation with Dr Kokai were you satisfied at that time that Child C's death had been adequately explained or did you still have concerns? 
A. I was satisfied that the death had been partly explained. 
...
I wasn't sure whether the damage to the heart that was noticed on this post-mortem would have all happened at and after the resuscitation or whether it happened before.
It was Dr Kokai's view that the damage to the heart had happened before the resuscitation and therefore caused the collapse but it didn't fully explain it because I then asked "but why did the damage occur to the heart?" So you keep going back one more step.
But with Baby C being an at-risk baby, very small, growth retarded, difficulties with perfusion from the placenta, the afterbirth, before the baby was born possibly that might have explained why the heart was -- had suffered this insult. But it didn't quite fit together. 
..
Q. At that time [Aug 2015] you were not suspicious of any deliberate harm being caused by anyone? 
A. Yes, because sadly it had been my experience even after post-mortem it is not always possible to explain a death and that is occasional. When that situation keeps arising, something very strange is happening. 
..
Q. But looking at heart failure as a potential cause of the collapse, would you say that improving a normal lactate is inconsistent with heart failure as a cause of collapse? 
A. Probably. It's not that common to encounter heart failure in little premature babies. It does occur obviously, so I don't have a good understanding of the relationship between lactate and heart failure.
Q. It's extraordinarily unusual for a baby to -- 
A. Yes, yes --
Q. -- die of myocardial ischaemia? 
A. -- so I am not confident with answering that, you know, improving lactate means you can't have heart failure because we don't see heart failure that much -- I don't see heart failure, I haven't recognised heart failure that often in babies.
Q. So two factors here that were unusual about Child C. First of all, his observations were stable or improving and, secondly, he couldn't be resuscitated? 
A. Yes.
Q. These were two unusual features. 
A. Yes, but the unusual feature of not being resuscitated might have been explained by his post-mortem report because Dr Kokai felt that myocardial ischaemia, the heart damage, had predated his collapse.
Q. Yes. 
A. In which case that could have caused the collapse.
Q. So you had a conversation with Dr Kokai, who was a pathologist, before you spoke with Mother C? 
A. Yes.
Q. Which I think you concede in a letter was a slightly irregular thing to do, but you wanted to be able to explain this to her? 
A. Yes, yes, and Dr Kokai, like the other pathologist, was quite helpful in giving preliminary results of post-mortems. ..
Q. It was something done so that Mother C might have answers? 
A. Yes..
Q. ..Mother C's recollection of the meeting is that you said the following: 
that Child C was not expected to die, his collapse at the time and in the way that it happened was not expected, that you found it unusual that Child C had not responded at all to vigorous resuscitation but had later shown signs of life, that the post-mortem had not revealed an obvious cause of death, but that there was an unusual finding of patchy myocardial ischaemia, which you thought was more likely to have been the consequence of the collapse but not the cause of it, and that Mother and Father C were left with an uncertainty about what had happened..
A. Yes, and I think, maybe I didn't, I thought I had indicated the pathologist felt that myocardial ischaemia explained the collapse and death.
Q. Yes. 
A. He thought it was likely to have occurred six to eight hours before the death, which would have been an hour or two before the collapse.
Q. ..What you say in your witness statement.. you refer here to the post-mortem results and you say that it was shown that: "~... Child C had died of myocardial ischaemia, damage to heart muscle from a lack of blood and oxygen. This provided a reasonable explanation for Child C's death, although later as I became concerned about deliberate harm on the NNU in 2016 I wondered if the PM had revealed the true cause of death." 
I appreciate it's semantics, but I want to be clear about whether you thought that the myocardial ischaemia provided an explanation for the collapse, a reasonable one, rather than the death? 
A. For the collapse, I wasn't sure that it did. But I knew it might, if Dr Kokai was right, and knowing that Child C had had a raised lactate and very poor perfusion before birth, that might have damaged the heart.
Q. So I -- 
A. But I did tell the parents I didn't think that was the likely explanation, but I wasn't sure and when we have all the mortality reviews the results of the post-mortem are given there and the death certificate quotes myocardial ischaemia as the cause of death.
Q. So I accept that you may have felt that perhaps the pathologist knows better. But what you said to the parents, and I suggest it's what also you felt at the time, was that this explanation didn't seem to make sense as a cause for the collapse to you that the -- 
A. Yes, I wasn't sure that it did explain the collapse.
Q. And if we look back -- 
A. I don't think I was explicit -- I don't think I was adamant it does not explain the collapse. I wasn't sure it did explain it.
Q. And also, if we look at INQ0001993.. We can see here this is a section of your police statement..
"Nevertheless these residual signs of life for several hours prior to the eventual death would have been associated with extremely poor blood supply to Child C's heart muscle ..." And then finally: "~... taking Child C's unusual circumstances into account related to prolonged but mild resuscitative efforts pending his christening in my opinion it is more likely that the ischemic changes noted at post-mortem were a consequence of rather than the cause of his collapse ..." 
And that's a position you had reached in 2017? 
A. Did I, in this -- just if we go on a little bit. Did I then explain that Dr Kokai disagreed or was it not in this statement?
Q. It's not in this statement certainly in this section. 
A. Oh.
Q. It's perfectly reasonable. I mean, what I am suggesting to you is that when you were discussing with Mother and Father C you explained to them what Dr Kokai had said but expressed scepticism as to whether -- 
A. Yes.
Q. -- that was the cause of death, do you agree? 
A. Yes.
Q. ..If we can go mean to INQ0005449. So this is the neonatal perinatal morbidity and mortality meeting record and we can see that your name is fifth in the list of attendees. Can you see that? 
A. Yes.
Q. The first child who is discussed within that list is Child C and we can see the third line down in the middle box discussion and learning from the case. It says, "Sudden collapse ? cause." 
A. Yes. 
..
Q. Yes. So the actual cause of death is recorded and it has "PM" for post-mortem before it, so indicating where the source is -- 
A. Yes, yes.
Q. -- but the narrative section to the right of that puts "sudden collapse ? cause", which suggests a degree of scepticism as to the cause of the collapse? 
A. Yes.
Q. And -- 
A. Can I add also, sorry, there was a letter I sent to the parents in December.. once the final post-mortem report had come through and that was after my discussion with Dr Kokai, who was going away to discuss with colleagues, and knowing what I told him about my scepticism, well, the question to him about: did the ischaemia really start before the collapse? And I don't know what discussion he had with which colleagues, but that's what he was going to do.
His subsequent formal death certificate, well, I'm sorry, his subsequent post-mortem report then said -- he presumably discussed it or thought about it -- myocardial ischaemia was the cause of death.
Q. Yes, I don't think there is any doubt that that's what Dr Kokai felt. But you I think you have agreed were sceptical about that as the cause of collapse? 
A. Yes.
Q. Dr Brearey in his evidence says that at this meeting, and he says it in a police interview, he says that you presented the circumstances of Child C's death to the group. 
A. All right, okay.
Q. And that you put up a slide, or at least otherwise showed the group Child C's observation charts preceding the collapse, which were all stable and normal. 
A. Yes and that's why it surprises me Dr Hawdon in her report says his observations weren't normal, but...
Q. But certainly, can I suggest this; that by 11 February 2016, there were audible noises being made within the group of Consultants that somebody may be deliberately harming patients? 
A. Yes.
Q. At this meeting, you held up a slide of Child C's observation charts to show the sudden and unexpected nature of the collapse because of a concern that Child C may be one of the children who was deliberately harmed? 
A. It wasn't expressed like that at the meeting as far as I remember. Sorry, I held up a chart saying that he was one the children that we were concerned about deliberate...? Because I didn't think we discussed deliberate harm to patients in a forum with the junior doctors. That had been discussed with the ward manager by Dr Brearey as the neonatal lead and then with more senior managers.
Q. But here we have a meeting occurring after a point where I think you would accept that you had been concerned about deliberate harm whether or not you could identify the individual? 
A. Yes, at this point I was wondering could Baby C have been harmed, that's correct.
Q. Yes. 
A. I don't remember expressing that in the meeting. I wouldn't normally do it in a meeting with junior doctors and midwifery team and the obstetric people that are mentioned in the attendee list.
Q. Okay, so -- 
A. I would discuss that with the other consultants. Dr Brearey was discussing it with the neonatal ward manager and then shortly after this date in February he was escalating it to senior managers in the hospital.
Q. But certainly by this time, you were concerned that the sudden collapse against a background of stable or improving observations -- 
A. Yes, we were concerned about that from when he -- yes, right from his death.
Q. But to be precise, had been caused by somebody rather than being some unknown natural process. That was what was concerning you as of certainly by February 2016? 
A. Yes. Baby C and Baby I - I started to worry about were those natural deaths, that's correct, yes.
#LucyLetby

7/8 
At the Thirlwall Inquiry on 8th October 2024, Dr Jim McCormack, Mother C's obstetrician, says that in his opinion Baby C's death was neither unexpected nor unexplained.

From the transcript at:
 https://thirlwall.public-inquiry.uk/transcript/08-10-2024-transcript-of-week-5-day-2/

Q. With Dr Gibbs. If you wouldn't have said it to Mother C, would you have said it to Dr Gibbs, "Who are you going to get to investigate the death?" Just look at the -- to see what's being done around finding out, or did you think that was not a matter for you?
A. Well, it -- it -- it was a matter for our learning and, and I -- I can't actually remember but I think it was George Kokai that did the pathology report who would have been most likely at the perinatal meeting. And I think there would have been less of that discussion because, certainly from my perspective when I saw the post-mortem result and the immaturity of baby's lungs, like, I presumed that this was a death entirely consistent with prematurity. And I knew that this baby was very sick. I knew that it had abnormal doppler. I knew there was no (inaudible). I knew that the growth of the baby was very abnormal, it was small, and that is a baby for me that when I saw that post-mortem I would have said to myself, "Right, well, that's typical with my experience with that sort of mother -- with that sort of outcome."
Q. It's a requirement, isn't it, not to apply general principle looking at patients whether they're babies, whether they're the elderly? You could say old people die but they don't always die unexpectedly or in an inexplicable fashion, do they? The fact as a group they're vulnerable to death doesn't mean we say they're old, they've died. You need to examine the cause of deaths particularly if they are unexpected and unexplained, don't you, whatever the age of the prematurity or the age?
A. I --
Q. You're not the only one to express that view, Dr McCormack, but I'm challenging the view if you're a premature baby you are more likely to die, therefore I'm not going to scrutinise when there's a death of a stable baby that wasn't actually very sick -- premature but not very sick.
A. And I accept what you say. I'm only saying that in -- in Baby C's case there was a post-mortem report that actually had a cause of death. So -- and I know there's some debate about the interpretation of it, but to look at it, it's not as if the pathologist is saying this is unexplained --
Q. I was challenging your -- sorry, pausing there, Dr McCormack, we'll deal with that later -- I was challenging your assertion because the baby was premature. But you agree with me that's a generalisation and there is a need to be more specific?
#LucyLetby

8/8
Nurse witness testimony supports Lucy Letby's defence that she was outside the room before Baby C collapsed.

Nick Johnson KC asserted that Lucy Letby was alone with Baby C in nursery room 1 when he collapsed at 11.15pm on June 13th 2015. But witness testimony overall indicates otherwise.

The context:
June 13th/14th was a very busy night shift with the following nurses on duty:
1. Sophie Ellis, a newly qualified nurse, was assigned to care for Baby C in nursery room 1 under Melanie Taylor's supervision.
2. Also in room 1 was another baby who was assigned to Melanie Taylor. (Room 1 was for the most acute cases usually requiring 1:1 nursing care).
3. Lucy Letby was caring for 2 babies in room 3. One of them needed close attention because he had shown early signs of breathing difficulty.
4. The shift leader Nurse B and 2 other nurses were also working that night.

Nurse Sophie Ellis' testimony:
from:
https://tattle.life/wiki/lucy_letby_case_3/#nurse-sophie-ellis)
[Sophie Ellis was noted as administering a feed to Baby C at 11pm. She said after this that she left the room for a short time and heard the alarm going off. She went back into room 1 and saw Lucy Letby.]

"I saw Lucy standing at [Child C's] incubator. She said he had just had a Brady and a desaturation. I can't remember what she was doing at the time."
It resolved but while she sat at the computer and Letby was still there, he had a serious collapse requiring resuscitation which began his deterioration, sadly leading to his death some hours later.

[But Letby could not have been there on her own]

"Miss Ellis said there was 'always a nurse' in the room looking after Child C, even when she left the room briefly."

[So when she left the room who did she leave looking after the 2 babies in there? If it had been Letby she would have said so. It's highly likely that Melanie Taylor remained in the room as she was looking after the other baby there as well as supervising Sophie Ellis in the care of Baby C]

"She said she did not know whether Melanie Taylor was in the room at the time of the collapse."
"She said she became upset herself as this was 'the first time something like this had happened in her experience, and she found it 'overwhelming'.
Lucy Letby said to her: 'Do you want me to take over?' to which she said: 'Yes."
[But Nurse B said it was her who said this to Sophie Ellis - see below]
 
"Miss Ellis said she then left the room, taking a minute to compose herself, before returning to the unit to look after other babies.
The nursing note says care for Child C was handed over to senior nurse Melanie Taylor following the collapse."

Nurse Melanie Taylor's testimony:
From:
https://tattle.life/wiki/lucy_letby_case_3/#nurse-melanie-taylor)
"She says: 'She [Sophie Ellis] would not have been left alone.'
Mr Myers: 'It was a very busy shift, wasn't it?'
Ms Taylor: 'Yes.'"

[Melanie Taylor didn't think she was in the room when Baby C collapsed, that Letby was there and possibly also Sophie Ellis. But this was 7-8 years after the event and this account differed from that she gave in her police statement much earlier in 2018.
When cross-examined on this by Ben Myers KC for the defence, she admitted her memory had deteriorated, that the police statement was correct, that she was already in the room when Baby C collapsed, and that she was called over by Sophie Ellis. 
There was no mention of Lucy Letby in this statement but she still insisted that she was there and that the police hadn't asked her specifically about Letby.]

"Mr Myers says Ms Taylor, in her police statement, said she was 'pretty sure' she was 'already in nursery room 1', feeding another baby, at the time of the collapse.
Ms Taylor says her memory has deteriorated since then, and what is in her police statement is correct.
Mr Myers says Ms Taylor's police statement said she was called over by Sophie Ellis, and there is no mention of Lucy Letby.
Ms Taylor: 'No, but she was there.' "
"Ms Taylor said she read her police statement for the first time this morning and had not memorised everything from it.
She added: "I didn't say Lucy Letby called me over. I likely wasn't asked [by police] if Lucy Letby was there. Now I have been shown that [statement], I can remember Sophie called me over. Years have passed since this has happened.'"
"Ms Taylor said she has not changed her mind about who was present there.
'I tell you now, when I approached the incubator, she [Lucy Letby] was there on the other side.'"
"She added she remembered how 'cool and calm' Lucy Letby looked at the time.
Ms Taylor said she hadn't said Lucy Letby was not in room 1 at the time of the collapse.
Ms Taylor tells the court said she didn't think it was necessary at the time to include that information [of Letby's presence] to police."

[It seems very unlikely that the police wouldn't have at least asked her who else was in the room and would probably have asked about Letby specifically as well.]

Shiftleader Nurse B's testimony:
From:
https://tattle.life/wiki/lucy_letby_case_3/#shift-leader-unnamed)

[Nurse B testified that she entered room 1 when Baby C collapsed and saw Melanie Taylor and Sophie Ellis there and that Lucy Letby came in later.]

"The nurse also recalls Lucy Letby was on duty that night, looking after 'at least' one different baby, in room 3."  [it was 2 babies]
"The prosecution asks the nurse about Child C's collapse at 11.15pm.
'I do not remember where, but I was not in nursery room 1.'
She recalls 'a shout for help', but does not remember who called it.
She entered room 1 and saw Melanie Taylor and Sophie Ellis, and a Neopuff device was being administered."
"She noticed Child C was not breathing and the heart rate was very low.
The Neopuff gave Child C chest movement, but he did not breathe himself.
Child C had a 'mottled' skin appearance, the nurse recalled."
"She remembers a crash call being put out, and recalls Lucy Letby being present, but does not recall when Letby entered the room."

On Cross-examination:
"The nurse says she was not in room 1 at the time, but saw Sophie Ellis and Melanie Taylor in that room, attempting to assist Child C's breathing with the Neopuff device when she arrived.
The nurse says an initial crash call was put out, followed by one for a consultant."
"Mr Myers says the police statement refers to 'I think Lucy Letby was in the room by now'.
The nurse said she made the statement three years after the incident, and could not recall precisely when Letby had entered."
"Mr Myers asks the nurse if she was the one to take an upset Sophie Ellis aside and get her to step down from duty for that time. The nurse agrees."

Lucy Letby's testimony:
(Quotes from https://tattle.life/wiki/lucy_letby_case_3/#defence-lucy-letby-evidence)
"She says she became aware of Child C at the time of his collapse, and her being called to help. Prior to that, she says she was not aware of his events, and was not in room 1.
She says she was called over by nurse Sophie Ellis and asked her to put out a crash call. Melanie Taylor was 'in the nursery when I arrived [in room 1]', with Child C.
He was 'apnoeic and needed respiratory support'."
"Another nurse was present in the nursery at the time. [Nurse B?]
Sophie Ellis put out the crash call.
Letby says she was involved in chest compressions as part of resuscitation efforts."
Letby says she can recall alarms going off, but not standing cot side, or saying anything regarding Child C's observations to Sophie Ellis. "

Conclusion
I'm sure the other nurses were being truthful as far as what they could recall but that their memories had deteriorated over time and that they were perhaps influenced by what else they were hearing in the trial.
I can't see anything in their testimony which reliably places Lucy Letby in room 1 before Baby C collapsed and therefore she could not have done anything to cause the collapse.

#LucyLetby

Also see @TriedByStats excellent &amp; comprehensive analysis of this case which contributed to the BBC's File On 4 programme.

There really can't be any doubt that Lucy Letby is completely innocent of this charge, and the others too.
#LucyLetby

https://x.com/triedbystats/status/1840865071469379848

Here I'm focussing on the events later in the evening of 3rd August 2015 including Baby E's mother's 10.52pm call to her husband.

From the timeline you can see that the timing of this call is out of sync with other event records but putting it an hour later at 11.52pm would reconcile that.

Timeline summary:

1/ Dr Harkness was initially called to Baby E at around 10pm. 
 
 He told Letby to keep close observation on Baby E, and logged a medical note at 10.10pm. He doesn’t believe he would have left the unit after that.

2/ Dr Harkness was called for the 2nd time at 11pm.

He was worried about Baby E’s condition, spoke to the consultant and they decided to intubate. Preparations for this were being made at 11.30pm. The nursing team decided to contact Baby E’s mother who was in the maternity ward.

3/ The midwife received a call from the neonatal unit at 11.30pm asking for the mother to go down

She went to ask the mother to contact her husband.

4/ Mother calls her husband and Midwife asks him to come to the hospital due to baby’s worsening condition.
 
Call log shown to court & mother’s testimony puts this call at 10.52pm but that doesn’t fit with rest of timeline.

5/ At 11.40pm Baby E suffered a sudden desaturation.

6/ Mother went to the neonatal unit with the midwife – they were both there at midnight
 
The midwife stayed with her in the corridor for 10-15 mins at around midnight while doctors and nurses were working on her baby. The father hadn’t yet arrived.

#LucyLetby

This is the same timeline as above but I've added in more details and links to source material.

1/ Dr Harkness was initially called to Baby E at around 10pm. 
He told Letby to keep close observation on Baby E, and logged a medical note at 10.10pm. He doesn’t believe he would have left the unit after that.

Dr Harkness – medical notes:
Dr David Harkness records readings from 9.40pm, written at 10.10pm, 'asked to see patient re: gastric bleed' [note he wasn’t there personally for the 9.40pm readings]
https://tattle.life/wiki/lucy-letby-case-5/#sequence-of-events-from-records

Dr Harkness – trial testimony:
He says for this night he was called over at 10pm, having been called over because Child E had blood in his vomit.
The note 'close observation' is made, emphasising the designated nurse - Lucy Letby - was to monitor Child E closely in room 1.
Dr Harkness says, from his recollection, he does not believe he left the unit as the bleed was 'something unusual' in Child E so he does not believe he went very far.
https://tattle.life/wiki/lucy-letby-case-5/#dr-david-harkness

2/ Dr Harkness was called for the 2nd time, at 11pm.
He was worried about Baby E’s condition, spoke to the consultant and they decided to intubate. Preparations for this were being made at 11.30pm. The nursing team decided to contact Baby E’s mother who was in the maternity ward.
Dr Harkness – trial testimony:
For the 11pm note, he says Letby called him into room 1, where 'Further GI blood loss and desaturation to 70%' is noted.
Dr Harkness says he is planning to intubate Child E…
Dr Harkness says he would discuss the result of the x-ray with surgeons at Alder Hey and seek advice from them.
Dr Harkness said he would then have been preparing to intubate and get the equipment ready.
Prescriptions are made from 11.28pm-11.30pm for a number of drugs.
https://tattle.life/wiki/lucy-letby-case-5/#dr-david-harkness

Daily Mail podcast:
But doctor Harkness was called back again around 50 minutes later around 11 PM by Lucy Letby. When even more blood came up the tube, the court heard that the blood loss by this point was significant, and it amounted to a quarter of all the blood in his body…
Doctor Harkness was worried, and he decided to call the consultant … to discuss baby E's worsening condition. They both agreed that doctor Harkness would give the baby fluids to help replace the blood loss and prepare to ventilate him.. The idea was to get him stable enough to see what was causing the problem. And the nursing team also decided at this point to contact baby E's mother upstairs. She was asked to call her husband.
https://youtu.be/kO9sC8Nz4EI?si=ZpnwQwRcyD2uMyS2&t=1373

3/ The midwife received a call from the neonatal unit at 11.30pm asking for the mother to go down
She went to ask the mother to contact her husband.

Midwife – statement as read out in court:
Her 'midwife notes' are presented to the court, showing the mum of Child E was 'post-natal well', and one of the twins had 'deteriorated slightly'.
At 11.30pm on August 3 she had a call from the neonatal unit to ask Child E's mother to go down in 30 minutes as Child E had a bleed and required intubating - 'very poorly'.
She said the mum was very upset and she thought the 30-minute was 'unreasonable' and asked to go sooner.
https://tattle.life/wiki/lucy-letby-case-5/#midwife-susan-brookes

4/ Mother calls her husband and Midwife asks him to come to the hospital due to baby’s worsening condition.
Call log shown to court & mother’s testimony puts this call at 10.52pmbut that doesn’t fit with rest of timeline.

Mother - trial testimony:
She was later told by the midwife and to ring her husband. The midwife called the husband at 10.52pm, telling him to come to the hospital, after the neo-natal rang the maternity ward.
She said she does not know why the midwife rang, but assumed it was because she was "very upset" and "knew there was something wrong".
https://tattle.life/wiki/lucy-letby-case-5/#family-mother

Father - trial testimony:
‘The second phone call was split between the midwife and his wife. He was told: "Don't panic, but get over here now.’
https://tattle.life/wiki/lucy-letby-case-5/#family-father

Father - on Panorama:
Quickly followed up by a second phone call with a midwife saying, you need to get here now. And there was a 3rd phone call telling me, where are you? The priest has been called. And I just knew. I knew at that point, you know, you don't call a priest unless someone's dying.
https://youtu.be/yo13E3YwvBg?si=IziSqRaran8TP-tn&t=309

Mother - Inquiry Testimony :
Q. When you went back, did you get a call later that night to go back to the NNU? 
A. Yes, yes. So I'd had a conversation with a midwife and I was upset, and I told her what I'd found, and I think she checked on me throughout the couple of hours, and she then asked me to -- she'd come in to the room and asked me to contact my husband, and ring him. And at that point I knew something really bad was happening, and she asked to speak to him and she didn't -- she wanted to speak to him and she told him to come to the hospital straight away and not to drive. To get somebody else to drive him.

Page 11 line 9 of:
 https://thirlwall.public-inquiry.uk/wp-content/uploads/2024/09/Thirlwall-Inquiry-18-September-2024.pdf

5/ At 11.40pm Baby E suffered a sudden desaturation.

Dr Harkness – medical notes:
Dr Harkness records, in clinical notes at this time, written retrospectively, 'Sudden deterioration at 11.40pm, brady 80-90bpm, sats 60%, poor perfusion, colour change over abdomen purple discoloured patches'.

Lucy Letby – medical notes:
Letby recorded, retrospectively: "11.40pm became Bradycardiac, purple band of discolouration over abdomen, perfusion poor, CRT 3secs.
"Emergency intubation successful and placed on ventilator..."
https://tattle.life/wiki/lucy-letby-case-5/#sequence-of-events-from-records

6/ Mother went to the neonatal unit with the midwife – they were both there at midnight
The midwife stayed with her in the corridor for 10-15 mins at around midnight while doctors and nurses were working on her baby. The father hadn’t yet arrived.

Mother -  Trial Testimony:
The mum was taken to the neo-natal ward and the medical team were 'working on Child E' and were unsuccessful in their resuscitation attempts.
 
 https://tattle.life/wiki/lucy-letby-case-5/#family-mother

Mother - Inquiry testimony
Q. So you go down, and what situation confronted you?Where were you when you went down?
A. Sorry? 
Q. Where were you when you went down, where were you taken?
A. So when I went down I was sat in that same corridor where I could first hear them crying and there were some chairs and the midwife was sat next to me and I think she was trying to talk to me, and I was -- I don'treally know what she was saying because I was watching what was happening through the window because I could see his incubator straight from where I was sat. And I could see -- or I couldn't really see -- I couldn't see Child E, but I could see the team around him working and it looked busy and it looked serious. 
Q. You say in your statement you had to sit outside in thecorridor for approximately 15 minutes?
A. Yes. 
Q. And then: "A member of staff came out and asked if I wanted Child E to be christened and asked where my husband was." 
 
 Page 11 line 25 of:
 https://thirlwall.public-inquiry.uk/wp-content/uploads/2024/09/Thirlwall-Inquiry-18-September-2024.pdf

Midwife – statement as read out in court:
At midnight, the midwife stayed with Child E's mother for 10 minutes in the corridor outside the neonatal nursery room where Child E and Child F were, and the mum was eventually allowed in once medical staff had stabilised Child E.
https://tattle.life/wiki/lucy-letby-case-5/#midwife-susan-brookes

#LucyLetby

@JabesAllowed What has his later arrival got to do with this? Baby E needed a bloodtransfusion &amp; someone saw baby's death immanent. Why, wasn't it diagnosed yet or had "bloodbank" gone home?