Court now sitting. Jury had made a request for notepads, Judge Goss tells them there is none in the building. 'I don't know if you know much about government procurement, but it's not as simple as going the stationary and buying it', he says

Consultant paediatrician Dr Ravi Jayaram is now in the witness box, he is recalling the events of 26 September 2015. Dr Jayaram was called by junior colleague Dr Alison Ventress in the early hours as medics were having trouble with Child H

Child H needed a numerous procedures to drain air from her chest as she had suffered pneumothorax, this is where air leaks into the space between your lung and chest wall. Dr Jayaram is explaining this condition and how it is diagnosed/treated

Jury are being shown X-rays of Child H, which show excess air in the chest cavity. Child H had a chest drain and two needles (to drain air) in a bid to treat this

Dr Jayaram is currently describing in detail the process of inserting a chest drain

X-rays taken in the early hours of the morning of 25 September 2015 show that Child H's lung had re-inflated after the procedures. Lots of the black (air) present on previous X-rays in the chest area had disappeared

Ben Myers KC, defending, is now questioning the consultant. He asks whether the act of fitting a chest drain can cause stress to a baby, he says it ‘can raise heart rate’

Mr Myers is asking whether a drain could come into contact with internal structures like the heart, Dr Jayaram says he has 'never seen that happen' - he says anatomical he can't see it, as the heart is surrounded by the lungs and the lungs would have to be punctured

Mr Myers puts it to Dr Jayaram, that due to improvements in medicine, pneumothorax is less common. He says 'generally speaking doctors now are likely to have less practice on chest drains', Dr Jayaram says he 'wouldn’t disagree with that'

He says that is why such treatments are more often carried out by consultants, as they're from a generation when they were more common

Mr Myers is asking Dr Jayaram where the optimum space is to insert a chest drain, he puts it to the consultant that the fifth intercostal space is the best area and is standard. Dr Jayaram says 'it doesn’t matter…as long as it is in, it is going to drain air'

Dr Jayaram eventually agrees that 'ideally' the fifth intercostal space is where a drain would be fitted

Discussion in court is currently centring on the use of different drains - a pig tail train and a straight drain. Child H has a pig tail drain fitted first, by Dr Ventress and then Dr Jayaram fitted a straight drain a short time later.

Dr Jayaram concedes that it would have been easier to fit a second pig tail drain, but there were none available

Mr Myers shows the jury an X-ray of the two drains in Child H. The first as established was in the 'ideal' fifth intercostal space. The second fitted by Dr Jayaram, is not in the fifth intercostal space (his notes written at the time say it is)

Dr Jayaram agrees it is 'clearly' not in there but says the drain is still in a 'good position'. He says it is in the plural cavity and that it is working

Mr Myers is repeatedly putting it to the consultant that the chest drain is in the wrong place. 'No it’s in the plural cavity, you’re focused on process rather than outcome. It needed to be put in. It isn’t going to have any great effect on heart function'

Mr Myers puts it to the medic that the tip of a drain that close to the heart could cause bradycardia if it moves, 'it could' Dr Jayaram says

Mr Myers says if the baby moves, is handled, when it breaths - can all cause the drain to move. Dr Jayaram agrees, but disputes the inference of the questions. He says any movement would be minimal

Mr Myers puts it to Dr Jayaram that he inserted the chest drain in a sub-optimal position and that this contributed to Child H's desaturations in the hours and days that followed. The consultant rejects this, he says the drain was not in the wrong place

He accuses Mr Myers of being focused on process over outcomes, he says the drain was inserted to drain air which it did.

Dr John Gibbs, who was a consultant paediatrician at the Countess of Chester in 2015, is now in the witness box

Dr Gibbs' notes from around 5pm on 25 September show that the drain inserted by Dr Jayaram that morning had moved. Dr Gibbs fixed the drain more securely to stop it moving any further

Dr Gibbs is asked if there's any consequence to the drain moving, he says: 'The main worry is it moving out completely and falling out and being useless'

Asked if there would be any internal consequence, Dr Gibbs says: 'Not that I’m aware of…you wouldn’t want to keep pulling and pushing, that would be rubbing against the lung. Pushing very far in would push against the heart…

'I wouldn’t expect it to cause any trauma or damage to (Child H)at all', he said

Dr Gibbs is now taking the court back over his notes from the early hours of 26 September, when Child H suffered a serious collapse which required CPR and three doses of adrenaline

Dr Gibbs' notes from the time say that it was 'unclear' why the infant went into cardiac arrest. His notes say the likely cause was hypoxia - low oxygen levels - but not clear what had caused that

Ms Letby's defence counsel, Mr Myers is now questioning Dr Gibbs

Mr Myers puts it to Dr Gibbs that against the backdrop of all Child H had been through - the insertion of multiple chest drains - it was 'no surprise' she had a collapse on 26 September. Dr Gibbs says he 'was surprised' by her collapse as she had been stable