Lucy Letby: The Babies

(All babies involved in the case have been labelled in advance by press as Child A-Q).

Charged with the murder of 7 babies and the attempted murder of a further 15, neonatal nurse Lucy Letby is currently on trial after pleading not guilty to the barbaric acts. But who are the babies behind the letters and what did Letby allegedly do to them?

Baby A: A premature boy born June 2015. The youngest twin of Baby B. Murdered.

Described as being in 'good condition' at birth, Baby A was taken to the neonatal unit at ICU. 13 hours later, it is said he began to 'breathe in air' without the requirement of extra, medically administrated, oxygen. A medical chart recorded. the fluid going in and out of Baby A. The connection of fluids could not have happened until after 8.10pm, however the chart recorded infusion began at 8.05pm. By 8.20pm, Baby A was reported to have white hands and feet, with Letby calling a doctor to the incubator at 8.26pm. Resuscitation began and adrenaline administered to stimulate the heart. Doctors observed "an odd discolouration on Baby A's abdominal skin - flitting patches of pink over blue skin that seemed to appear and disappear". All efforts to bring Baby A back to life failed and he was pronounced dead at 8.58pm- 90 minutes after his care was placed in the hands of Letby. She was recorded as being the only witness associated with Baby A's collapse. The doctor noted: "an unusual blotchy pattern of well perfused pink skin over the whole of his body coupled with patches of white and blue skin … all over his body." The monitors showed Baby A had a normal heart rate and good oxygen saturations, and a normal ECG, but was not breathing. The case was passed to the coroner, with the death labelled 'unascertained' at the time.

Medical expert Dr Dewi Evans suggested Baby A's collapse was "consistent with a deliberate injection of air or something else into Baby A's circulation a minute or two prior to deterioration,". Another medical expert said the cause was "not some natural disease process, but a dose of air "deliberately administered".

When interviewed by police regarding the circumstances over Baby A's death, Letby said she had given fluids to Baby A at the time of the change of shifts. She said within "maybe" five minutes, Baby A developed 'almost a rash appearance, like a blotchy red marks on the skin'. She said she had wondered whether the bag of fluid "was not what we thought it was". In an interview in June 2019, Letby said she had asked for all fluids to be kept from the bag at the end to be checked, but the prosecution said there was was no record of her having made such a request. It was suggested by police that Letby had administered an air emolus. She replied it would have been very hard to push air through the line.

In a November 2020 police interview, police put to her that Letby had tracked the family of Baby A on Facebook. She said she had no memory of doing so but accepted it if there was evidence on her computer doing so.

Baby B: A premature girl born June 2015. The oldest twin of Baby A. Survived. She required breathing support via a ventilator at birth. After attempts to insert a umbilical vein cathete failed twice, a long line (IV) was inserted for fluids to be administered successfully.

Breathing support gradually lessened and Baby B was stable. A designated night-shift nurse was responsible for Baby B. Shortly before midnight, the blood/oxygen levels had fallen to 75% and the Cpap nasal prongs were dislodged from Baby B's nostrils. The nurse repositioned the prongs and the levels recovered. Slightly past midnight, Letby started a bag of liquid feed with Baby B, with the nurse, through an IV line. At 12.16am Letby - while not Baby B's designated nurse - took her blood gases. At 12.30am, roughly 28 hours after her brother had died, Baby B's alarm sounded and Letby had called the nurse to the child's incubator. Baby B was not breathing. At 12.33am, resuscitation began. The nurse noted purple blotches and white patches all over Baby B's body, and the heart rate had dropped. After efforts to resuscitate Baby B, Baby B "recovered very quickly". A doctor subsequently found "loops of gas filled bowel".

Dr Dewi Evans concluded Baby B was "subjected to form of sabotage" that night. A medical expert said a "relatively quick recovery" would "only be explained by a dose of air...deliberately administered in the bloodstream".

In a police interview, Letby was asked about the circumstances regarding the connection of a liquid feed bag at 12.05am. She said she had looked at paperwork for the lipid syringe (an addition to the liquid feed bag to children not being given milk), and said the prescription was "not her writing" but "she had signed for it" and "ideally it should have been co-signed by somebody". The rules are that two nurses have to sign for things administered to a baby. Letby told police she had conducted observations on Baby B, but the other nurse was the allocated nurse. Letby also said it was the other nurse who had alerted her to the problem with Baby B. In a June 2019 police interview, Letby said it was her signature on the blood gas record at 12.15am, just before Baby B collapsed. In November 2020, Letby was asked by police about a handover sheet relating to Baby B found at her home address in a search. The sheet showed she had been the designated nurse for two babies in a different room that night.

Baby C: A premature baby boy born weighing 800g at birth. Murdered. Described as in 'good condition' given the circumstances of his birth, he initially showed signs of breathing distress, after a number of days his respiratory support was reduced and he began to manage to breath independently. 

As was the case with Baby B, the prosecution say, Lucy Letby was not the designated nurse for Baby C. Letby was assigned to look after a baby girl. The leading nurse had to reinforce this assignment as Letby was said to be 'ingnoring her'. The nurse looking after Baby C was less qualified than Letby and so was assigned a baby who was said to be in a stable condition. The nurse headed to the nurses station, where she heard Baby C's monitor sound an alarm. Having entered the room, Letby was discovered next to the incubator already.

Letby denied she had anything to do with Baby C, other than with the resuscitation. 

She could not remember why she had ended up in nursery 1. After finishing her shift, Letby searched on Facebook for Baby C's parents.

The prosecution say this would've been one of the first things she would have done after that night shift ended.

Skin colour changes in Baby C were noted to have likely been caused by prolonged unsuccessful resuscitation. Baby C had pneumonia, but the pathologist concluded Baby C died as a result of having an excessive quantity of air injected into his stomach via the nasogastric tube. A medical expert concluded Baby C was killed by air "deliberately put into the nasal gastric tube".

Letby was the only nurse who had been on duty for all three collapse incidents for Baby A, B and C.

Baby D: A baby girl born full term in June 2015. Murdered. It is important to note that the hospital failed to give the mother antibiotics to stave off infection after her waters broke early. Although born healthy, Baby D "lost colour" and "became floppy" in her father's arms. She was put under observation as she was showing signs of respiratory distress, by grunting, and her temperature dropped. Admitted to Room 1 in the neonatal unit, Baby D was given antibiotics and oxygen therapy. She developed a very high temperature and a rise in her heart rate.

She was inturbated, and ventilated. She improved "significantly, but was still affected by her infection".

Catheters were inserted into Baby D and levels of infection dropped. Letby was not assigned care of Baby D and instead was the designated nurse for 2 other babies in Room 1. Throughout the night, Baby D crashed 3 times and each occasion, those attending were struck by the sight of mottling, poor perfusion and brown/black discolouration to her skin, mainly over the trunk. These collapsed happened at 1.30am, 3am and finally at 3.45am. At 1.15am, the designated nurse checked Baby D, recording observations. At 1.25am, the designated nurse and Letby noted the starting of an infusion. An aspirate - drawing liquid through the nasogastric tube - is noted at 1.30am. At 1.29am a doctor noted "an unusual...spreading, non-blanching rash" on Baby D.

Nursing notes of another baby suggest Letby was engaged in their care at the time, however nursing notes suggest Letby and the designated nurse called the doctor to the room. Baby D was successfully resuscitated. At 2.40am, medication was administered by Letby and the designated nurse, who then left to another room. But Baby D then collapsed at 3am. Letby was in the room, the designated nurse was not, and no-one else had a reason to be in the room. Baby D was successfully resuscitated again.

At 3.20am, there is a record of Letby starting an infusion and Letby appears to have remained in the room, as a record shows her caring for another baby in the room at 3.30am. At 3.45am, Baby D suffered her third and final collapse. CPR began and Baby D was pronounced dead at 4.25am. The coroner gave the cause of death as "pneumonia with acute lung injury."

According to Medical expert Dr Dewi Evans, observed that a baby "exhibiting a window of near recovery on two occasions followed by another collapse was not consistent with the fatal evolution of antenatal pneumonia." He added the "abdominal discolouration was indicative of air embolus". Another medical expert said the clinical status of Baby D the previous night was not that of a deteriorating baby who would be dead a few hours later. She added the injection of '3-5ml per kilogram' of air would be sufficient to kill. Baby D had been observed in distress prior to her death, and the medical expert added this would also be consistent with cases of air embolus (air injected into the system).

No other medical staff member who was on duty that night had been present for the collapses of Baby A, B and C other than Letby. For nursing staff, two of the nurses had been on duty for one each of the other collapses.

Letby, in police interview, said she "cannot remember" how she got involved. She seemed to accept that she had administered medication with a syringe at 1.25am – 5 minutes before the first collapse. In a June 2019 police interview, she said she could not remember calling back the doctor when Baby D collapsed, but it was possible she had.  It was put to Letby, in November 2020, that she had searched for the parents of Baby D on Facebook. She said that she could not recall but accepted she had done so. She said she could not explain why she had done it.

All of Babies A-D were not expected to have serious problems, but only one of them survived - and only Letby was "the constant presence".

Baby E: A baby boy born prematurely alongside his twin brother in July 2015. Murdered. He weighed less than 3 pounds at birth and was given oxygen, then weaned to air, and transferred to nursery 1.

Baby E was at risk of a serious gastro-intestinal disorder, NEC, and was started on antibiotics, IV fluids and caffeine.He had a nasogastric tube inserted. Fluids were inserted the following day via a long line. He had a "mild, transient high blood sugar" was was corrected with "a very low dose of insulin", then given tiny quantities of milk the following day, every two hours. The following day after that, he had two small vomits and air was aspirated, but otherwise the feeds were well tolerated and increased incrementally to 2ml every 2 hours. The nursing notes indicated he was stable, on a tiny dose of insulin to correct high blood sugar.

At 9pm on August 3, 2015, the mother decided to visit her twin sons, and "interrupted Lucy Letby who was in the process of attacking Baby E", the prosecution say, although the mum "did not realise it at the time". Baby E was 'acutely distressed' and bleeding from the mouth. The mum said Letby attempted to reassure her the blood was due to the NGT ittirating the throat.

Letby said the registrar would be down to review Baby E, and urged her to return to the postnatal ward. The mum called her husband when she got to the labour ward, in a call lasting four minutes and 25 seconds, at 9.11pm.

Letby made a note in Baby F's records (Baby F being the twin of Baby E) after the mum had left. The next time the mum visited Baby E, he was in terminal decline.

Two records are made at 4.51am, after Baby E had died. The later note records: "Mummy was present at the start of shift attending to cares. Visited again approx. 22:00. Aware that we had obtained blood from his NG tube and were starting some different medications to treat this. She was updated by Reg xxxxx and contained [Baby E]. Informed her that we would contact her if any changes. Once [Baby E] began to deteriorate midwifery staff were contacted. Both parents present during resus."

The prosecution say 9pm was an important time, as it was the time Baby E was due to be fed, by his mother's expressed breast milk.

The mum said that is why she attended at 9pm. "She was bringing the milk". The phone call at 9.11pm to her husband also fits the mum's timing, the prosecution add.

Letby's notes also show: "prior to 21:00 feed, 16ml mucky slightly bile-stained aspirate obtained and discarded, abdo soft, not distended. SHO [Senior House Officer] informed, to omit feed." These notes are false and fail to mention that Baby E was bleeding at 9pm. They mention a meeting that neither the registrar or the mother remember.

At 9pm, Letby has recorded information to detail the volume of fluids given via the IV line and a line in Baby E's left leg, and the 9pm feed is 'omitted'. In the 10pm column is '15ml fresh blood'. The SHO said he had no recollection of giving advice to omit the 9pm feed. He was on the paediatric ward most of that night, until Baby E entered a terminal decline. He believes the only time he had anything to do with Baby E was in a secondary role to the registrar in an examination at 10.20pm. The registrar recalled being told Baby E had suffered a blood-flecked vomit. He does not recall seeing any blood on Baby E's face, but regarded the presentation as undramatic. But "around half an hour to an hour later there was a large amount of fresh blood which had come up" Baby E's tube. There was a further loss of 13 mls of blood at 23:00 hrs. This was the equivalent to 25 per cent of Baby E's blood volume. At 11.40pm, Baby E suffered a sudden desaturation. His abdomen "developed a striking discolouration with flitting white and purple patches."

CPR was started, but Baby E "continued to bleed". Although Letby was participating in the resuscitation of Baby E, she co-signed for medication given to another baby in room 4.

Baby E was pronounced at at 1.40am. The on-call consultant said Baby E was a high-risk infant who had shown signs of NEC.

Dr Dewi Evans said Baby E's death "was the result of a combination of an air embolus and bleeding which was indicative of trauma".

The air embolus was "intentionally introduced" into Baby E's bloodstream via an IV line "to cause significant harm". Medical expert Dr Sandie Bohin agreed the cause of death was air embolus and acute bleeding. She concluded that the cause of the bleeding was unknown but acknowledged “fleetingly rare” possible natural causes that could not be ruled out in the absence of a post-mortem. Dr Bohin concentrated on the abdominal discolouration and concluded that air was deliberately introduced via an intravenous line.

Lucy Letby was "the constant presence" for all of the collapses in Babies A-E.

In a police interview, Letby said he could remember Baby E and he was "stable" at the time of the handover, with nothing of concern "before the large bile aspirate". She said she and another member of staff had disposed of the aspirate and the advice was to omit the feed. She said Baby E's abdomen was becoming fuller and there was a purple discolouration, so had asked a doctor to review Baby E. She said she had got blood from the NG tube. She was asked about the 10pm note and said if there had been any blood prior to the 9pm feed, "she would have noted it". She said it was after 9pm that the SHO had reviewed Baby E but could not reall if it was face-to-face or over the phone. She said she could remember the mum leaving after 'the 10pm visit'. In a June 2019 interview, she was pressed over a conversation with the SHO. 

She said she had no independent memory of it.

She said she could not remember the mum coming into the room at 9pm with milk, nor Baby E being upset, with blood coming from the mouth. She said she would not have told the mum to go back upstairs. In a November 2020 interview, Letby is asked why she had sent a text referring to Baby E had queried whether he had Down Syndrome. She said she could not remember whether there had ever been any mention of Downs in the medical notes.

Letby "took an unusual interest" in the family of Baby E. She did social media searches on the parents two days after Baby E’s death, and on August 23, September 14, October 5, November 5, December 7, and even on December 25. Further searched were made in January 2016.

Baby F: A baby boy born July 2015, the younger twin brother of Baby E. Survived. After requiring some resuscitation after birth, he was later intubated, ventilated and given a medicine to help his lungs. He was recorded as having 'high blood sugar' so was prescribed 'a tiny dose of insulin'. He had his breathing tube removed and was given some breathing support. Baby F had small amounts of breast milk and given fluid nutrients via a long line. If it is known in advance that a baby cannot have milk and needs to be fed fluids then the TPN bag is prepared by the Aseptic Pharmacy Unit (APU) at the CoCH on receipt of a prescription.

The pharmacy bag is delivered back to the ward and is bespoke, prepared for an individual patient. "If, for whatever reason, there is no need for a TPN bag, there are a couple of stock bags...kept in reserve." "As a matter of practice", insulin is "never" added to a TPN bag.

Insulin is "given via its own infusion, usually in a syringe which delivers an automatic dose over a period of time". Insulin is not added to a TPN bag as it would "stick to the plastic - or bind" to the bag, making it difficult to accurately give a reliable dose.

On August 4th, the same day his twin brother died, the pharmacy received a prescription for a TPN bag for Baby F. A confirmation document was printed, at 12.32pm, for Baby F. The pharmacist produced a handwritten correction to say it was to be used within 48 hours of 11.30pm that day. The TPN bag was delivered up to the ward at 4pm that day.

On that night shift, the designated nurse for Baby F, in room 2, was not Letby. Letby had a single baby to look after that night, also in room 2. There were seven babies in the unit that night, with five nurses working. Letby and the designated nurse signed the prescription chart to record the TPN bag was started and administered via a long line at 12.25am. A TPN chart is a written record for putting up the bags, and was used for Baby F. It includes 'lipids' - nutrients for babies not being given milk. Letby signed for the TPN bag to be used for 48 hours. There are two further prescriptions for TPN bags, to run for 48 hours.

Following the conclusion of a Letby night-shift, after the administration of a TPN bag Letby had co-signed for, a doctor instructed the nursing staff to stop the TPN via the longline and provide dextrose (sugar to counteract the fall in blood sugar), and move the TPN to a peripheral line while a new long line was put in. All fluids were interrupted at 11am while a new long line was put in.

Baby F's blood glucose increased, before falling back. A new bespoke TPN was made for Baby F, delivered at 4pm. This could not have been the same one fitted to Baby F at noon that day which would have been either a bespoke bag which Lucy Letby co-signed for, or a stock bag from the fridge.

Baby F's low blood sugar continued in the absence of Lucy Letby. Baby F's blood sample at 5.56pm had a glucose level was very low, and after he was taken off the TPN and replaced with dextrose, his blood glucose levels returned to normal by 7.30pm. He had no further episodes of hypoglycaemia." These episodes were sufficiently concerning" that medical staff checked Baby F's blood plasma level. The 5.56pm sample recorded a "very high insulin measurement of 4,657". Baby F's hormone level of C-peptide was very low - less than 169. The combination of the two levels means someone must have been given or taken synthetic insulin. All experienced medical and nursing members of staff would know the dangers of introducing insulin into any individual whose glucose values were within the normal range and would know that extreme hypoglycaemia, over a prolonged period of time, carries life threatening risks. To give Baby F insulin someone would've had to access the locked fridge, use a needle and syringe to remove some insulin, or, if they didn't do it that way, go to the cotside and inject the insulin directly into the infant through the intravenous system, intramuscular injection, or via the TPN bag.

Medical experts Dr Dewi Evans and Dr Sandie Bohin said the hormone levels were consistent with insulin being put into the TPN bag prior to Baby F's hypoglycaemic episode. Professor Peter Hindmarsh said the insulin "had to have gone in through the TPN bag" as the the hypoglycaemia "persisted for such a long time" despite five injections of 10% dextrose.

Professor Hindmarsh said the following possibilities happened. That the same bag was transferred over the line, that the replacement stock bag was contaminated, or that some part of the 'giving set' was contaminated by insulin fron the first TPN bag which had bound to the plastic, and therefore continued to flow through the hardware even after a non-contaminated bag was attached. "There can be no doubt that somebody contaminated that original bag with insulin. "Because of that...the problem continued through the day."

Letby was interviewed by police in July 2018 about that night shift. She remembered Baby F, but had no recollection of the incident and "had not been involved in his care". She was asked about the TPN bags chart. She said the TPN was kept in a locked fridge and the insulin was kept in that same fridge. She confirmed her signature on the TPN form. She had no recollection of having had involvement with administering the TPN bag contents to Baby F, but confirmed giving Baby F glucose injections and taken observations. She also confirmed signing for a lipid syringe at 12.10am, the shift before. Disturbingly, the end of this part of the interview she asked whether the police had access to the TPN bag that she had connected.

In a June 2019 police interview, Letby agreed with the idea that insulin would not be administered accidentally. In November 2020, she was asked why she had searched for the parents of Baby E and F. She said she thought it might be to see how Baby F was doing. She was asked asked about texting Baby F’s blood sugar levels to an off- duty colleague at 8am. She said she must have looked on his chart.

It's alleged that Lucy Letby tried to murder Baby F in August 2015, on the day after she had killed his twin, Baby E.

Baby G: A baby girl who was born very prematurely, weighing only 1lb and 2oz. She born in May 2015 at Arrowe Park Hospital. Baby G suffered bleeding on her lungs and had nine blood transfusions, with a number of 'septic' or 'suspected septic' episodes requiring antibiotics, but improved and was transferred to the Countess of Chester Hospital's neonatal unit in August, and was clinically stable, being fed expressed breast milk.

Once again, Letby was not the designated nurse to this baby in Room 2 on the night in question, and was instead assigned a baby in Nursery 1. It was a milestone night for Baby G and nurses marked the occasion with a small celebration. Baby G was being fed every three hours alternately by bottle and naso-gastral tube. At 2am, a feed had shown minimal aspirated of partially digested milk. The nurse took her scheduled one-hour break. During this time, it was not recorded who would take over the care of Baby G until the nurse returned. At 2.15am, the shift leader said she was sat with Lucy Leader when she heard Baby G vomiting, along with Baby G's monitor alarm going off. They ran into her nursery. Baby G had vomited violently and suffered a collapse. The prosecution said medical records suggest the shift leader nurse's memory of being with Lucy Letby for a period of time before this event cannot be accurate. Despite Baby G's stomach being 'pretty much empty' prior to her feed, 45mls of milk was aspirated from her NGT. 45mls of milk had been administered for her feed, which then did not explain what accounted for the vomit. Subsequent x-rays showed air in the abdomen and intestines. Baby G suffered further deteriorations. During intubation, a doctor noticed bloodstained fluid from the trachea. At 6.05am, following a further desaturation, 100mls of air was aspirated from the NG tube. When the tube was removed, the registrar noted thick secretions in her mouth "and a blood clot at the end of her breathing tube". There were also signs of infection. Baby G was transferred to Arrowe Park, before returning to the Countess neonatal unit just over a week later. During that time, Baby G made a remarkable recovery.

Five days after her return to the Countess, Baby G was due to receive her immunisations, such was her improved condition. A team of nurses came on the day shift that day, Lucy Letby being among them. Letby was Baby G's designated nurse that day. Baby G was fed with 40ml via a NG tube by Letby at 9.15am. At about 10.20am, Baby G had projectile vomited twice and went apnoeic for several seconds, the court is told. Baby G's blood saturations fell to 30%. The same problem she had faced two weeks prior. As Letby was looking after two other children in room 4, A nurse took over the care from Letby at 11.30am. The nurse took all the observations and noted Baby G was connected to a 'Masimo monitor' - which measures oxygen saturations and heart rate levels. It is a device which stays on and cannot be turned off by a baby. At 3.30pm a consultant doctor was called to cannulate Baby G. Privacy screens were erected and Baby G was on a trolley, with the monitor still attached.

The nurse went to care for another baby.

The consultant doctor said he "could not recall" if Baby G's monitoring equipment was switched off during the cannula fitting, but "it is his practice to transfer the sensor from one limb to another or if temporary detachment is required to reattach the monitor as soon as possible." He added if Baby G was not stable he would not have left her. After the doctors had gone, the nurse responded to Lucy Letby's shout for help. When she attended, Baby G's monitor had been switched off (power was off). Baby G was struggling to breathe. Letby was giving ventilation breaths. Baby G responded to treatment. A subsequent MRI scan revealed neurological changes and, in August 2016, it was revealed Baby G had suffered "irreversible brain damage". Baby G had vomited because she had been given excessive milk and air.

In a police interview, Letby said she remembered the nurse had been on her break when the incident happened with Baby G in nursery 2. She could not remember who had been assigned to look after her. Letby suggested the excess air in Baby G after the vomiting was the result of some sort of infection, or as a consequence of the vomiting.

She said she had withdrawn the 45mls of milk after that episode, and air had come with it, and she had seen Baby G vomiting. She said she did not know why she had gone into the room, but it was possible it was as a result of hearing Baby G vomiting. Letby 'vaguely' recalled the day Baby G vomited after her return to the hospital, accepting she had been the designated nurse. She had no recollection of Baby G vomiting. In a subsequent interview, Letby accepted there were only two alternatives to the first vomiting incident - that Baby G had been fed far more than should have been, or she had not digested her earlier feed. She accepted that the clear inference to be drawn was that Baby G had been given excess milk and air via the NGT. She denied responsibility for either of those eventualities.

For the second incident, Letby denied either over-feeding or injecting air into Baby G's stomach. In November 2020, Letby denied to police that she had switched off the Masimo monitor. She was asked about Facebook searches carried done on the day of the second vomiting incident that Letby looked up the parents of Baby G. She said "she had no recollection of them". Within a minute or two of looking at the mother of Baby G on Facebook, she then looked at the mums of two other babies listed in the charges. One was the mum who, the prosecution said, "interrupted the attack" by Letby on Baby E.

Baby H: A baby girl born in September 2015. She has breathing difficulties shortly after birth and was transferred to neonatal unit Room 1. Independent experts say there was an "unacceptable delay" in tubating her and administering a protein which helps the lungs. Additionally, Baby H "when was put on a ventilator she was not paralysed; she was also left with butterfly needles in her chest for prolonged periods which may have punctured her lung tissues and contributed to further punctured lungs." The two events - in the early hours of September 26 and 27, were "uncharacteristic" and required CPR.

Letby was on duty for both those night shifts, and was the designated nurse for Baby H.

That night, Baby H was given a blood transfusion. At 2.15am, medical notes by a doctor showed a re-accumulation of her left-sided pneumothorax. A further chest drain was inserted to relieve the pressure. The ICU chart shows that Letby recorded having given Child H a dose of morphine at 1.25am and a dose of saline at 2.50am. The saline bolus was set to run for 20 minutes and would therefore have ended at 3.10am. Lucy Letby would have had the cover of legitimacy for accessing Baby H's lines just before she collapsed again.

At 3.22am, Baby H collapsed and required CPR. The attending doctor said the cause was unclear. He concluded the episode was 'hypoxia' (shortage of oxygen). Letby made notes at 4.14am, recording a lowering of the heart rate at 11.30pm which required treatment. She recorded the additional chest drain and a blood transfusion at 2am.

Of the collapse at 3.22am, she recorded: "profound desaturation and colour loss to 30%, good chest movement and air entry, colour change on CO2 detector, neopuff commenced in 100% oxygen and help requested. Serous fluid +++ from all 3 drains, became bradycardic. Drs crash called and resus commenced as documented" At 5.21am, Letby recorded a conversation between herself, the attending doctor, and Baby H's parents. During the following day, Baby H was relatively stable.

A different nurse was the designated nurse for Baby H, still in room 1, on the night of September 26. Letby was also on duty. The designated nurse 'could not recall' if she had taken a break during the shift, but there would have been times she would have gone out of the room to get a drink or retrieve something from a cupboard. Letby was looking after a child in room 2. Baby H suffered "two sudden and unexpected episodes of profound desaturation at 12.55am and 3.30am." The registrar responded to the emergency calls and on one occasion, saw Letby administering treatment, and took the history from her, assuming she was the designated nurse.

The nurse noted 'pink tinged secretions' around Baby H's mouth. The nurse noted a 'profound desaturation' - a "profound drop in Baby H's blood", despite air going into the lungs and carbon dioxide coming out. Both collapses at 12.55am and 3.30am had "no known cause". Baby H was transferred to Arrowe Park Hospital at 5.25am, and was stabilised en route in the ambulance.

Her mother, who was with her spoke of a "dramatic improvement" as soon as Baby H got to the hospital. Baby H returned to the Countess of Chester Hospital and the rest of her time was uneventful before being discharged. She had not suffered any permanent consequences.

Medical expert Dr Dewi Evans said there was "no obvious explanation" for Baby H's deterioration in those two early-morning collapses. Dr Sandie Bohin "expressed concern" at those events, and the collapses "were more significant than the others, for which there are obvious clear medical explanations". She was also "critical of the way the chest drains were inserted and managed".

Letby was interviewed in 2018 by police. She confirmed she had remembered Baby H because she had chest drains - which the court hears are a fairly rare thing these days. For the second incident, Letby said she had not been the designated nurse so assumed she had not been caring for Baby H. She identified her signatures on two medicine administrations.

In 2019, she identified her signature on more documents. In this interview, she told police she had not been the designated nurse but had been giving her treatment at the time Baby H collapsed.

On October 5, 2015, Letby searched for the mum of Baby H, the father of Baby E and F, and the Baby of Child I. It was her day off.

Baby I: A baby girl born prematurely in August 2015 at Liverpool Women's Hospital. 3 attempts were made to take this babies death, and a fourth that kill her.

Baby I was born, weighing 2lbs 2oz, but in good condition. She was intubated and ventilated, then supported by CPAP, and fed through a nasogastric tube. In the first few weeks, she had "a few problems", but "all were resolved". Baby I, by late September, had diminshed clinical concerns, and no breathing problems.

For the first attempt, Letby was on a 'long day' shift (8am-8pm) on September 30. She was Baby I's designated nurse in room three.

According to Baby I's mum, Letby expressed concern about the child and indicated Baby I would be reviewed by a doctor. When she made a nursing note, Letby "reversed the concern", and said it was the mum who had raised a concern about the abdomen, saying it was "more distended to yesterday" and Baby I was "quiet...not on monitor but nil increased work of breathing”. A review took place at 3pm - over an hour after these notes. Baby I appeared mottled in colour with a distended abdomen and prominent veins. A feeding chart showed 35mls was given to Baby I when asleep, but Letby had recorded Baby I as "handling well and waking for feeds". At 4pm, Letby recorded feeding Child I 35mls of expressed breast milk via the NGT. An emergency crash call was called at 4.30pm as Baby I had vomited, desaturated, her heart-rate had dropped and she was struggling to breathe. Her airway had to be cleared and she was given breathing support, and Baby I was transferred to room 1. An x-ray at 5.39pm revealed a "massive amount of gas in her stomach and bowels" and her lungs appeared "squashed" and "of small volume". Air had been injected into the NGT to give a 'splinted diaphragm'. A doctor recorded Baby I had suffered a 'respiratory arrest' at 4.30pm, struggling to breathe, she was pale and distressed, and the abdomen was 'distended and hard'. The NGT was aspirated and produced 'air+++ and 2mls of milk', after which Baby I improved. This is at odds with the 35mls of milk Baby I was fed with at 4pm. Baby I continued to improve and was in nursery room 2 on the night of October 12 by a designated nurse different to Letby. Letby was looking after a baby in room 1. Baby I was being bottle fed every 4 hours, and at 1.30am took a 55ml bottle of breast milk. At 3am, the designated nurse left the nursery temporarily and said she asked either Letby or another colleague to listen out for Baby I. The designated nurse, records show, helped another colleague with something in room 1. Upon the designated nurse's return to room 2, Letby was "standing in the doorway of the room" and Letby said Baby I "looked pale". The designated nurse switched on the light and saw Baby I was "at the point of death". She later recalled the baby was breathing about 'once every 20 seconds'. Lucy Letby made a note at the end of her shift at 8.10am: '[Baby I] noted to be pale in cot by myself at 03:20hrs … apnoea alarm in situ and had not sounded. On examination [Baby I] centrally white, minimal shallow breaths followed by gasping observed.' The registrar was called to the unit at 3.23am. On arrival, he saw nurses giving Baby I full CPR. The notes suggest he had to reposition the ETT. A consultant doctor administered adrenaline, intubated and ventilated Baby I. An X-ray showed gross gaseous distention throughout the bowel and signs of chronic lung disease of prematurity (CLD). Baby I, had the same problem that she had when Letby had fed her on September 30. The medical team felt that the abdominal distention had affected her ability to expand the chest and in turn caused desaturation. Both nursing and medical staff commented on a bruised like discolouration to the right of the sternum. They assumed this was the result of chest compressions. The category of nursing care was raised a level. Letby was made the designated nurse, as she was more qualified. Medical notes showed the ETT had been "displaced" and, at 4.25am, the NGT was "curled in the oesophagus", which would have prevented release of the pressure created by excess air in the stomach.

For the third attempt, Letby had responsibility for Baby I on the night of October 13.

Both Letby and a doctor recorded Child I had increasing abdominal distension, discolouration to the right and sensitivity to touch between 5am and 5.55am. The X-ray taken at 6.05ams showed widespread gaseous distention sufficient to splint the diaphragm. This prevented her from breathing properly.

Baby I had the same problem as before. At 7am, CPR was required as Baby I had a 'significant desaturation'. The doctor recorded, at 7.10am: "desaturating again despite good AE (air entry), chest wall movement and negative cold light (i.e. no pneumothorax) … at about 7.45am HR (heart rate) below 60. CPR initiated… [various boluses given] … capnography positive. Chest wall movement and equal AE noted…” Baby I was "brought back from the brink of death right at the end of the shift, at 7.58am". Letby noted at 8.43am: "At 05:00hrs abdomen noted to be more distened (sic) and firmer in appearance with area of discolouration spreading on right hand side. Veins more prominent … gradually requiring 100% oxygen. Blood gases poor as charted …. nil obtained from NG tube throughout. Continued to decline. Re intubated at approx. 07:00 – initially responded well … resuscitation commenced as documented in medical notes. Night and day staff members present” Baby I was transferred to Arrowe Park Hospital. She had an episode of bradycardia and desaturations after which she quickly stabilised. The baby recovered quickly, and was transferred back to the Countess of Chester Hospital on October 17.

On the night of October 22, Letby was on a night shift, with a different nurse being the designated nurse for Baby I. Between 8pm and Baby I's collapse, the only entry Letby made in any child's records was those in her charge in room 3. Just before midnight, Baby I became unsettled. Letby and another nurse attended to her but Baby I collapsed and required CPR.

The on-call registrar noted Baby I had a mottled blue appearance of the trunk and peripheries. After 5 minutes of CPR, Baby I's saturation rate returned to 100% and she recovered to the point of 'rooting' - ie a sign of hunger, and was 'fighting the ventilator' - ie trying to breathe independently. The ET tube was removed at 12.45am. At 1.06am a nurse, having left the nursery temporarily, responded to Baby I's alarm and saw Lucy Letby at the incubator. Baby I was very distressed and wanted to intervene, but Letby assured her that they would be able to settle the baby. Baby I then collapsed. The on call doctor arrived and resuscitation attempts were made. Purple and white mottling were noted on Baby I's skin. All resuscitative efforts were unsuccessful and treatment was withdrawn at 2.10am, and Baby I was pronounced dead at 2.30am. In the immediate aftermath, Baby I's parents were taken to a private room. As the mum bathed her recently deceased child, Lucy Letby came into the room and, in the words of the mum, "was smiling and kept going on about how she was present at [Baby I']s first bath and how much [Baby I] had loved it.”

The cause of death was given by the coroner as Hypoxic ischaemic damage of brain and chronic lung due to prematurity and 1b. Extreme prematurity. All loops of bowel showed significantly dilated lumen due to increased air content – in layman’s terms they were expanded like a partially inflated balloon. There was no sign of NEC (bowel necrosis) or any other bowel problem.

Medical expert Dr Dewi Evans said he believed the apnoea monitor might have been switched off on October 13 for Baby I, and the deliberate administering of a large bolus of air into Baby I's stomach via her NG tube on October 22/23.

In police interview, Letby said she could not remember the circumstances of September 30, and had taken over the care of Baby I after the Baby had an "episode". She said she had no recollection of the events surrounding Baby I's death, and said the child had been returned from Arrowe Park Hospital too quickly.

In June 2019, she was asked about a sympathy card she had sent to the child's parents. She said it was not normal to do so - and this was the only time she had done so. She accepted having an image of that card on her phone.

She was asked about the October 13 incident and challenged the nurse's account, adding: "Maybe I spotted something that [the nurse] wasn't able to spot", as she was "more experienced". She was asked why she had searched for the parents' details on Facebook. She said she did not recall doing it.

Baby J: A baby girl who was originally stable, but it was discovered she had a necrotic and perforated bowel. She was transferred to Alder Hey for surgery to fit her with a stoma bag. Baby J 'recovered well' and was taken to the Countess of Chester Hospital on November 10, 2015. She had a relatively rare type of intravenous line fitted, a 'Broviac line'. On November 16, medical notes referred to her as being well. But on November 27, she suffered an unexplained collapse in the early hours. Letby was on duty.

Before she went to work for that shift, Lucy Letby exchanged text messages with one of her colleagues. The prosecution say It seemed that she was not happy with working conditions and she referred to the difficulties of looking after the babies who just needed feeding support. Baby J was one of those. Letby was in a different room to Baby J, and was not the designated nurse, but 'got involved', by co-signing for medication at 12.02am. Letby's colleague was a band 4 nurse and not sufficiently qualified to give intravenous medication. After 4.40am, that nurse thought Baby J became pale and mottled. She left the room for a short time, and upon her return another nurse was assisting Baby J with breathing. The last thing Letby had recorded on notes was at 3am. There is data from the door system showing Letby coming in at 3.47am. Just after 5am, Baby J suffered another desaturation and she was moved to the hugh dependency unit in room 2.

The registrar was called and Baby J was working hard to breathe, but had otherwise recovered well. At 6.56am, Baby J's alarm sounded and Letby was among those responding. A doctor attended and took control. He noted oxygen levels were 'unrecordable' and circulation 'poor'. There were symptoms of a seizure. At 7.20am, Letby co-signed a chart for a 10% glucose infusion.

At 7.24am, Baby J collapsed again. The doctor assisted in resuscitating her. Baby J recovered and the doctor could not explain what happened from the results of various tests taken. He considered the events unexplained.

Medical expert Dr Dewi Evans described the collapse at 7.11am as unexpected without any straightforward explanation. He said that it was “of concern and consistent with some form of obstruction of her airways, such as smothering”.

The symptoms of a seizure suggested oxygen deprived to the brain. Baby J has not suffered a seizure since. Dr Evans added: "Whilst I have concerns...one cannot rule out the presence of infection, despite the normal inflammatory markers… at the time of the two collapse episodes…I note also the presence of the stoma which could be the source of the organism(s) that caused her systemic infections.” Dr Evans, in a follow-up statement, maintained 'airway obstruction' was the most likely cause of Baby J's collapse. Dr Sandie Bohin concluded that the issue was not infection because there were no “soft signs” and the gradual deterioration which might be expected, but the collapse was "sudden" and had caused seizures.

In interview, Letby said she had little recollection of Baby J, but remembered the Broviac line. She confirmed contact with Baby J, but denied doing anything to cause her harm. In 2020, she was asked why she had searched Facebook for Baby J's parents. She replied: "I don't remember doing that."

Baby K: A baby girl born prematurely in February 2016, weighing only 692g. There was no time to deliver at a hospital for this type of maternity delivery care. Dr Ravi Jayaram, paediatric consultant, was present at her birth as a result.

Lucy Letby booked Baby K on to the neonatal unit. Baby K  had required help with breathing, but was stable and in as good a condition as a baby of that prematurity could be. Arrangements were made for Baby K to transfer her to Arrowe Park Hospital. At 3.50am, Dr Jayaram was standing at the nurses’ station compiling his notes. Although he did not have a view into Nursery 1, Dr Jayaram was aware the deisngated nurse was not there, a fact backed up by door swipe data. Lucy Letby was the only nurse in room 1, alone with Baby K. "Feeling uncomfortable with this because he was beginning to notice the coincidence between the unexplained deaths and serious collapses and the presence of Lucy Letby, Dr Jayaram decided to check on where Lucy Letby was and where Baby K was." "As he walked in, he could see Letby standing over Baby K's incubator. He could see Baby K's oxygen levels were falling. However, the alarm was not sounding and Lucy Letby was making no effort to help. "Dr Jayaram went straight to treat Baby K and found her chest was not moving, he asked Letby if anything had happened to which she replied, “she’s just started deteriorating now”. Dr Jayaram found Baby K's breathing tube had been dislodged.

Baby K was very premature, and had been sedated and inactive. The tube had been secured by tape and attached to Baby K's headgear. Dr Jayaram was troubled as the levels were falling and Nurse Letby had been the only person in the room. On these monitors, all readings are set to default values in the neonatal unit. "Saturation levels falling to the 80s, is a serious issue and if the machine is working properly, it would have an alarm if the saturation levels fell to the 80s, as Dr Jayaram noticed. "There is an alarm pause button on the screen of the monitor - if you want to treat the child, you don't want the alarm going away. It will pause for one minute. Bearing in mind the rate displayed on the monitor, Dr Jayaram estimates the tube would have been dislodged between 30-60 seconds, and that is on the assumption the alarm had been cancelled once. Dr Jayaram did not make a contemporaneous note of his suspicions or the alarm failing to activate. Baby K remained unwell and later died.

In police interview, when Dr Jayaram's account was put to her, she said no concerns had been raised at the time. She said the alarm had not sounded. She said Baby K was sedated and had not been moving around. She also did not recall either any significant fall in saturations or there being no alarm. She accepted that in the circumstances described by Dr Jayaram she would have expected the alarm to have sounded. She denied dislodging the tube and said she would have summoned help had Dr Jayaram not arrived, saying she was "possibly waiting to see if she self-corrected, we don’t normally intervene straight away if they weren’t dangerously low". After the interviews - that suggestion made by Lucy Letby was referred to a nursing expert. Her view was that it was very unlikely that a nurse would leave the bedside of an intubated neonate unless they were very confident that the ET tube was correctly located and secure, the baby was inactive and then they would be away only briefly.  The nurse dismissed the idea that a competent nurse would have delayed intervention if there had been a desaturation.

Letby was found to have researched Baby K's parents on Facebook in April 2018 - two years and two months after Baby K had died. When asked about this, she said she did not recall doing so.

Baby L: A baby boy born in April 2016 alongside his twin brother who is also mentioned in the charges. Baby L's blood glucose level was noted to be low and he was treated with a dextrose infusion. His condition improved and he was stable by the day-time shift of April 9. Letby came on duty that day at 7.30am. By this time Letby was supposed only to be working day shifts because the consultants were concerned about the correlation between her presence and unexpected deaths and life-threatening episodes on the night-shifts.

In the hours that followed, Baby L's glucose levels fell abnormally low. He was given additional doses of glucose, but they proved ineffective. The answers to these levels were found after a lab sample sent to the Royal Liverpool Teaching Hospital laboratory came back with results some time later. The results of the test were "grossly abnormal", but nothing was done about it as Baby L had, by the time the results came back, returned to normal. The reading was at the very top of the scale that the equipment could measure. There was no correspondingly high level of C-peptide: it was within the normal range. The only explanation for this anomaly is that what was being measured was synthetic insulin, which had not been prescribed to Baby L but was stored and readily available in the neonatal unit. A written record of the dextrose bag fed to Baby L shows that the bag was running from noon on April 8, when it had been set up an hour earlier by Letby and another nurse. Letby had been present for the birth of Baby L. She cared for him on his first day and the prosecution say would have been aware of his mild hypoglycaemia. Baby L's blood sugar level remained "dangerously low" through the day.

At 4.30pm, a new infusion bag was required and this was being applied when Baby L, the twin brother, was being taken ill.

In police interview, Letby said she was aware of Baby L's low blood sugar levels and knew the insulin was kept in a locked fridge, with a variety of other drugs. Keys were passed around nursing staff and there was no record of who held the keys at any time. She agreed the insulin could not have been administered accidentally, but denied being responsible.

Her explanation was it must have been in one of the bags already being received.

Medical expert evidence is this was a case of insulin poisoning, administered intravenously via Child L's liquid feed.

Baby M: The twin brother of Baby L, Baby M was born in good condition and was assessed as requiring 'special care'. He had an unexpected life-threatening event at about 4pm on April 9, at the same time his twin's blood sugar was gangerously low. He came close to death but within 4 hours, he was able to breathe unsupported with air.

At 3.30pm, a fluid bag was attached to Baby M. At 3.45pm, he received intravenous antibiotics.

The notes showed Letby was one of two to administer the medicine. Digital records show Letby's colleague was using the computer at 3.45pm. At 4pm, Baby M's monitor alarmed and Letby was first to the cot.

The emergency was such that doctors were called urgently. The consultant, Dr Ravi Jayaram attended and noticed unusual patches of discolouration on Child M’s skin which he thought particularly noticeable because of Baby M’s skin tone. He thought the patches unusual because normally, if a baby arrests and there is not enough oxygen moving round the body, the baby is uniformly pale, grey or blue. What he saw he thought similar to what he had seen during the resuscitations of Babies A and B. Baby M did not respond well to resuscitation. Six doses of adrenaline followed in 25 minutes and treatment was "about to be withdrawn", when Baby M "suddenly improved".

Dr Jayaram could not find any cause for the sudden collapse, but the discolouration he saw caused him to suspect an air embolism. At 9.14pm, Letby noted Child M was tensing his limbs, curling fingers and toes and rotating hands and feet inwards - signs of brain damage.

On the following night-shift, Baby M had what the prosecution called a 'speedy recovery', although he did suffer further desaturations.

When Letby's home was searched in 2018, a handwriten log of drugs administered during Baby M's collapse was found, and she had made a note of the collapse in her diary. 'LD [Long day] - twin resus'.

In police interview, Letby agreed she had connected a fluid bag to Child M and had co-signed for medication at 3.45pm but could not be sure if she had administered it. She thought she must have taken the notes home 'by accident', and had simply noted what had happened in her diary. She denied that the notes were a "souvenir" and denied deliberately trying to harm Baby M. She could think of no reason how he would have suffered an air embolism.

The cases of Baby E-F and Baby L-M are similar, in that one suffered an insulin overdose and the other an IV air embolism.

Baby N: A baby born born prematurely in June 2016. He was admitted to the neonatal unit and his clinical condition was described as 'excellent'. Baby N had haemophilia. Subseuqent investigation found him to have a mild version of the disease, and children of his age do not bleed for no reason, particularly in the throat.

On the night of June 2, Letby was on the shift and not the designated nurse for Baby N.

She had earlier texted friends and sent a message to a colleague saying “we’ve got a baby with haemophilia”. She sent a further text saying, “everyone bit panicked by seems of things although baby appears fine”. At 8.04pm she sent a text saying that she was going to “Google” haemophilia. 7 minutes later Letby texted her coleague: “complex condition, yeah 50:50 chance antenatally”. The designated nurse said Baby N was stable and left for a break at about 1am. He would have asked a colleague to look after Baby N, but he could not recall whch one.Letby had two babies to care for, in room 4. At 1.05am, Child N's oxygen saturation levels fell from 99% to 40%. "Unusually", fr a baby, he was described as crying and "screaming". Baby N recovered quickly, while the doctor was then called to another emergency. Medical expert Dr Dewi Evans said he believed the deterioration of Baby N "was consistent with some kind of inflicted injury which caused severe pain".

Dr Sandie Bohin said such a profound desaturation followed by a rapid recovery, in the absence of any painful or uncomfortable procedure, suggested an inflicted painful stimulus. She said – “this is life threatening. He was also noted to be … ‘screaming’ and apparently cried for 30 minutes. This is most unusual. I have never observed a premature neonate to scream.” The designated nurse said Baby N was stable and left for a break at about 1am. He would have asked a colleague to look after Baby N, but he could not recall whch one.

Letby had two babies to care for, in room 4.

At 1.05am, Baby N's oxygen saturation levels fell from 99% to 40%. "Unusually", for a baby, he was described as crying and "screaming". Baby N recovered quickly, while the doctor was then called to another emergency.

Medical expert Dr Dewi Evans said he believed the deterioration of Baby N "was consistent with some kind of inflicted injury which caused severe pain". Dr Sandie Bohin said such a profound desaturation followed by a rapid recovery, in the absence of any painful or uncomfortable procedure, suggested an inflicted painful stimulus. She said – “this is life threatening. He was also noted to be … ‘screaming’ and apparently cried for 30 minutes. This is most unusual. I have never observed a premature neonate to scream.”

12 days later, there were two separate incidents on June 15 for Baby N. Letby had been the designated nurse for the previous day.

Overnight he was in nursery 3. At the beginning of the night shift, Baby N was 'very unsettled'. Letby was to be the desigated nurse for June 15. The use of her phone appeared to show she was awake by 5.10am and in for her shift at 7.12am. She had texted a colleague that she had “escaped [room] 1 [and was] back in 3”. A colleague said Lucy Letby same into the room to say hello, but when the nurse's back was turned, Letby told her Baby N had desaturated before assiting with the breathing. There was no evidence of an alarm sounding or if Letby waited to see if he self-corrected.

Doctors were called and an attempt was made to intubate Baby N. He was “surprised by his anatomy more than anything else … I could not visualise parts of the back of his throat because of swelling”. The doctor saw "fresh blood" in Baby N's throat. The doctor was unable to get the breathing tube down the throat of Baby N as he was unable to visualise the child's tracheal inlet. He attempted to intubate Baby N on three occasions. An intensive care chart which records the amount of dextrose going into Baby N records the following: The bleeding record, of 10am '1ml fresh blood', recording aspirates from the NG tube.

Said bleeding is not recorded anywhere in the medical notes. It was more than 2 hours after the attempts to intubate. At 11.29am Letby sent a Facebook message to the doctor telling him “small amounts of blood from mouth and 1ml from ng. Looks like pulmonary bleed on x ray [i.e. a bleed from the lungs]. Given factor 8 – wait and see”. Other than that phone message, there is no evidence that Lucy Letby brought the bleeding to the attention of any of the medical staff. In an update recorded on the computer notes by Lucy Letby at 1.53pm she wrote that Baby N was “stiff” on handling and extending upper limbs, back arching … settled in between episodes. At 3pm there is a further entry in Letby's writing of '3ml blood', initialled not by Letby and coincides with a second collapse that day. Baby N collapsed just before 3pm and a consultant was called at 2.59pm. While awaiting a consultant, a junior doctor looked into the airway of Baby N and saw a “large swelling at the end of his epiglottis” he could only just see the bottom of the vocal cords. He had never seen anything like this before in a newborn baby. The junior doctor's notes made at 4.30pm recorded: "desaturated this afternoon at 2:50pm with blood in the oropharynx + blood in the NG tube. Improved with bagging. Elective intubation planned following ??? unsuccessful attempts with 2 registrars and 2 consultants cords difficult to visualise …” Letby recorded at 6.30pm: "approx. 14:50 infant became apnoeic, with desaturation to 44%, heart rate 90 bpm. Fresh blood noted from mouth and 3mls blood aspirated from NG tube. … Drs crash called”. Baby N was "so unwell" that attempts were made to reintubate him, but the doctor could not see down Baby N's throat as the view was obscured by fresh blood. A more specialist team was called to carry out the intubation. Baby N continued to be unwell on June 15 and difficulties with ventilation persisted. Eventually he was transferred to Alder Hey, where he recovered quickly.

Medical expert Dr Dewi Evans said the blood seen in Baby N's stomach had originated there, caused not from intubation attempts but "instead some preceding trauma". He suggested that “thrusting” a NG tube into the back of the throat might be the mechanism used to inflict the injury. Dr Sandie Bohin suggested only two possible explanations; either inflicted trauma or a spontaneous bleed. She considers the latter less likely as the haemophilia was 'only moderate'. Dr Bohin’s view was that the likely cause of the bleeding was trauma to the mouth, to the throat or to the oropharynx, most likely from a NGT or suction catheter. Professor Sally Kinsey describes the collapse on June 3 as dramatic with no recognised medical cause. She excluded the possibility of a pulmonary haemorrhage - in other words, bleeding in the lungs, causing the collapse on June 15. In her opinion such bleeding would not have occurred spontaneously in a child with Baby N's degree of haemophilia. It follows, the prosecution say, the bleeding was caused by trauma. Professor Kinsey also ruled out heavy-handed intubation as a cause.

In police interview, Letby had difficulty remembering Baby N. She did recall an occasion when doctors had difficulty intubating him. She agreed that she had seen blood but denied being responsible for causing him harm. She could not explain the entry in her notes timed at 10am on June 15 in which she recorded aspirating more fresh blood which she had not apparently brought to the attention of anyone else.

Baby O: weighing just 2.02kgs at birth, Baby O was one of three triplet brothers. 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.

Baby O's body was examined after his death and an injury to his liver was found. Letby was working the day shift on June 23 and was the designated nurse for Baby O and P, in room 2, with another child. 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 Baby 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'. Baby O was put on to IV fluids as a precaution. Baby 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 Baby 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 - [Baby 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 Baby O's collapse, a colleague said of Baby 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. Letby had taken Baby 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, Baby O suffered his first collapse. Letby called for help, having been alone with Baby O in room 2 at the time. Baby 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, Baby 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. Baby O suffered a further collapse at 4.15pm which required CPR. Those efforts were unsuccessful and Baby O died soon after treatment was withdrawn at 5.47pm. A consultant doctor noted Baby 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 Baby 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 Baby O "had a big tummy overnight but just ballooned after lunch and went from there."

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.

Dr Dewi Evans concluded Baby 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 Baby 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 Baby O's breathing. He could not say whether it was either of these factors in isolation or in combination which caused Baby 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.

In police interview, Letby said she had responded to Baby 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 Baby O was. A year later, on the anniversary of Baby O's death, Letby carried out a search on Facebook on the surname of the child.

Baby P: A baby boy born from the same set of triplets as Baby O. He was murdered the following day from his brother.

Letby was the designated nurse for Baby P.

Letby fed Baby P donor expressed breast milk at 8am, 10am, noon, 2pm and 6pm.

The final feed, if accurately recorded, was about 13 minutes after Baby O had died. All the feeds from 8am-4pm are signed by a student nurse and co-signed by Letby. The 6pm feed is signed only by Letby. on the day shift feeds there is nothing more than a 'trace' aspirate (checking if there is anything in the stomach before the baby is fed), apart from a small amount of vomit at noon. The 8pm feed - the first after Letby's shift, produced a 14ml milk acidic (pH3) aspirate. 

Because Baby O had died in unusual circumstances, Baby P was reviewed by Dr Gibbs at 6pm. The abdomen was “full … mildly distended”. There was no tenderness and he had active bowel sounds – good signs.

He was screened for infection. An x-ray taken at 8pm showed striking gaseous distension throughout the stomach and whole bowel.

Lucy Letby made her nursing notes at 8.24pm - therefore she was still in the neonatal at this time. It is alleged that Letby "deliberately caused the problems" as she was ending her day shift, so she would not be detected, Mr Johnson tells the court. On that night shift, milk feeds were stopped for Baby P on the grounds that a further large part-digested aspirate was drawn up the NGT at feeding time. At 6.39am, a nurse recorded the abdomen was "soft and non distended." 25ml of air had been aspirated by one of the nurses, and the NGT had been placed on "free drainage". When the next day shift happened, Letby was Baby P's designated nurse again.

He was with his other brother - the third of the triplets - in room 2. As events unfolded, while Letby was the designated nurse for the other triplet, care was transferred to another nurse.

Text messages Letby sent to a doctor at just after 8.30am suggest she had sent, or was sending, her student with a baby who needed an MRI scan. A registrar noted Baby P, at 9.35am, had “desat + bradys” and had a moderately distended / bloated abdomen and slightly mottled skin. Letby's nursing notes from that night (9.18pm-10pm) recorded: "Written in retrospect...NG tube on free drainage - trace amount in tube. Abdomen full – loops visible, soft to touch … Reg...arrived to carry out ward round – [Baby P] had apnoea, brady, desat with mottled appearance requiring facial oxygen and neopuff for approx. 1 min. Abdomen becoming distended. Decision made to carry out bloods and gas (approx. 09:30)”. It follows the problem with which Baby P had been handed over by Letby to the night shift, but then apparently reappeared within 90 minutes of Letby taking over again. 15 minutes later, Child P had an acute deterioration. A crash call went out. Baby P was intubated and improved, and efforts were made to transfer him to Arrowe Park Hospital. Baby P desaturated again at 11.30am. He was given adrenaline. His spontaneous circulation improved but he continued to deteriorate through the day. A punctured lung was identified from an x-ray taken at 11.57am, treatment started at 12.40pm. The transport team arrived at 3pm. Just before they arrived, Baby P's blood gases were taken and were satisfactory. A doctor was hopeful of Baby P's prospects. The court hears Letby said to her something like:"he’s not leaving here alive is he?"

Baby P's final collapse came at 3.14pm and, despite resuscitative efforts, he died at 4pm.

A post-mortem examination had the coroner concluding Child P died from Sudden Unexpected Postnatal Collapse but he was unable to identify the underlying cause. He certified the cause of death as “prematurity”.

Medical expert Dr Dewi Evans initially suggested the cause of death was complications from his pneumothorax. He was, however, suspicious of the large volume of air in the stomach and intestines evident on x-ray. In his subsequent reports Dr Evans concluded that excess air in the stomach could have “splinted” Baby P's diaphragm compromising his breathing. Dr Sandie Bohin also concluded that the abdominal distension splinted Baby P's diaphragm resulting in an inability fully to expand his lungs and causing his collapse. Subsequent resuscitation and intubation involved high ventilatory pressures, which together with vigorous resuscitation, can cause pneumothorax. She described the abnormal gas pattern seen in Baby P's stomach through to his rectum which she concluded it was caused by the exogenous injection of air via the NGT – describing that as “the only plausible explanation”. This excess gas splinted the diaphragm, compromised breathing and it caused Baby P's collapse.

In police interviews, Letby said the student nurse fed Baby P at two-hourly intervals on June 23, and she had fed Baby P alone at 6pm.

She said she had agreed to be Baby P's designated nurse because the parents had asked for some continuity. Early in the shift, around 8am, she said could see “loops” in his tummy and brought these to the attention of the doctor, and notes were made later that day.

If what she noted was true, it would say when she took over the care from the previous night, he had a developing problem, but that was not the case. A note by a nurse at 6.39am 'ran contrary' to Letby's note, as the problem 'had been resolved' during the night. Letby denied deliberately causing Baby P any harm.

Baby Q: A baby boy born June 22nd, a day after Babies O and P. He was premature but a good weight, and on CPAP for the first 20 hours.He was admitted to the neonatal unit as he needed breathing support, but was initially stable.He had a catheter in place via his umbilicus for nutrition, however he was well enough to commence feeding via his NGT. Initially he was put into room 1.

Nursing staff noted small amounts of bile when they checked his NGT on June 23-24. These were not of sufficient concern to stop him being fed milk. A different nurse was Baby Q's designated nurse on the night shift for June 24. She monitored him through the night, and fed him 0.5ml of milk every 2 hours at 3am, 5am and 7am. The nurse was content with the condition, although the blood gases deteriorated slightly, so she referred the results to a doctor. The doctor reviewed them and was not concerned. The day shift on June 25, Letby was on duty and was Baby Q's designated nurse. Baby Q had been moved into room 2. Letby made notes on Baby Q's fluid/feeding chart at 8am. baby Q was receiving nutrition Babiven via a UVC. Just after 9am, Letby and the nurse were together in nursery 2, and it was feeding time. The other nurse attended to another baby in the room. According to the record, Baby Q's heart and respiratory rates both increased for a short period of time. However, the feeding chart showed something described as 'unusual'. That chart is shown to the court. The 9am fluid chart, in Letby's handwriting, appears unfinished, with numbers noted for fluids, but no record for the feed or Letby's signature initials at the bottom of the 9am column. Letby signed for medication for another baby at 9.04am. The other nurse agreed to keep an eye on Baby Q at 9am. A few minutes later, Baby Q's monitor alarms activated to alert staff to a deterioration in his condition. The nurse called for help and was joined by another nurse. Baby Q had been sick and nurses used a suction catheter while respiratory support was given. Lucy Letby appeared soon afterwards together with doctors who were responding to the call for help. Medical notes indicates doctors were called to the unit at 9.17am as Baby Q had "just vomited" and oxygen saturation levels were in the "low 60s". Medical staff gave him assistance with breathing using a Neopuff device and applied suction to clear his airways. The records indicate not only had his oxygen dropped but also his heart rate. He is described as “mottled” in appearance and, most significantly, a substantial amount of air was aspirated from his stomach via the NGT. The air is thought to had been put in there by Letby, as if the feeding chart had been followed correctly at 9am, the person feeding - Letby - would have aspirated Child Q's stomach to check there was nothing there before administering the 0.5ml milk feed. Another nurse's medical note on an 'apnoea/brady/fit chart' notes: "09:10; brady 98; desat 68; fit ?; baby found to be very mucousy, clear mucous from nasopharynx oropharynx removed clear fluid +++.

"O2 via neopuff given post suctioning. Dr... emergency called to attend.

"NGT used to aspirate stomach by Nurse L Letby” Given that Letby was Baby Q's designated nurse and she performed the aspiration of air, it might be thought surprising that she did not make the note – yet she did make notes in records of other babies’ notes at about the same time. Computerised nursing notes made by Letby for that morning: "“09:10hrs [Baby Q] attended to by SN... – he had vomited clear fluid nasally and from mouth, desaturation and bradycardia, mottled ++. Neopuff and suction applied. [Registrar] attended. Air ++ aspirated from NG tube”. Following the collapse, blood was taken to test for infection and other parameters. A venous blood gas test showed results suggesting that he was unwell but this had resolved by 11.12am. He was started on a course of antibiotics as a precaution. The doctor's view recorded at the time said Baby Q's collapse was a result of “presumed sepsis with jaundice”. At that stage a chest x ray was taken which showed nothing untoward. The more detailed blood tests were recorded at 1.50pm and showed slightly abnormal results which were treated. Baby Q had made a reasonable recovery through the day and at 7.20pm was "looking tired". Doctors took the decision to intubate him because his respiratory rate was down to 19 (low)and his heart rate was between 160-200 bpm (high). At that stage his blood gas readings were good.

The proseution say Lucy Letby was "worried" when she got home that night. She texted a doctor at 10.46pm and asked "do I need to be worried about what Dr G was asking?" The doctor sought to put her mind at rest and told her that Dr G was only asking to make sure that the normal procedures were carried out. She replied that after Baby Q had collapsed she (LL) had walked into the equipment room and Dr G had been asking the other nurse who was present in the room (when Baby Q had collapsed) and how quickly someone had gone to him because she (LL) had not been there. She continued her texts to the doctor, telling him that she had needed to go to her designated baby in room 1. The following day, Baby Q's gases were unsatisfactory, but he had been extubated 4 hours earlier and was in air with high saturations.  Medical staff noted a 'mildly dilated loop of bowel' on Baby Q's left side and raised the possibility of NEC and surgery. Baby Q was transferred to Alder Hey, where he quickly stabilised and no surgery was required.

Medical expert Dr Dewi Evans said Baby Q's collapse was due to 'inappropriate care', and he had been injected with air via the NGT.

The significant amount of air aspirated from his stomach 'could not have arisen in any other way'. Dr Sandie Bohin noted Baby Q was well up until June 25 and believed something happened between 9am and his collapse.

He was only being fed what Dr Bohin describes as “tiny” amounts of milk yet he had taken in “copious amounts of air” from the NGT. This was abnormal. The effect of a large volume of air in the stomach would “squash” the lungs leading to desaturation and instability. Although a baby may recover quickly after such an event, he may remain unstable for some time thereafter. She agreed with Dr Evans’ conclusion that events were consistent with the introduction of a large amount of air via the NGT. A professor reviewed brain imaging of Baby Q taken in November 2019 - more than three years later. He found evidence of abnormalities which whilst they were not diagnostic of him having suffered a brain injury as a result of being given excessive air and liquid via his NGT, they could be explained.

In Letby's home search, officers recovered the handover sheet from the morning of June 25 whic included Baby Q's name. This was a document which should not have left the hospital. When interviewed by police, Letby agreed Baby Q had been well enough for her to leave him on the morning of June 25.

When asked about the excess air aspirated from his stomach, she suggested babies sometimes gulp air when they vomit. She denied putting excess air down the NGT.

Other than three days the following week, that was the last time Lucy Letby worked in the neonatal unit at the Countess of Chester Hospital.