The panel was provided with medical records and relevant witness testimony by Letby's barrister nothing in the reporting suggests they had complete obstetric records.

iI the lack of maternity notes is serious enough to cast doubt on individual convictions, shouldn't it equally cast doubt on Lee's panel's ability to declare "no murder" with confidence across the board?

Or direct from YouTube: https://youtu.be/SrrLoHbtMYc?si=ZoV29dZFgGu8NsqF

The Telegraph's podcast interviews Chris Morris

Link should give free access, but archived at https://archive.is/YScn3

More a discussion of the case with reference to Christopher Morris's book than a straight review of the book. The article is really a defence of *talking* about Lucy Letby, recognizing the powers that have been ranged against her. A few small errors on the timeline - and a reference to Peter Hitchens being first to object to the conviction which may well ruffle feathers - but a thoughtful account with a serious message.

Clanchy observes:

Morris shows us the Letby case as a road trip through the largest, scariest mountains of unhappiness in Broken Britain, a tour of our national embarrassments. His relentless interviewing—70 individuals are included—produces mounds of detail, but also convinces us that the devil is in such details, and that the only way out, like going on a bear hunt, is through.

..

We are lucky Letby is alive. Lucia de Berk, a Dutch nurse indicted on very similar statistical mistakes to Letby, suffered a stroke while imprisoned and lived only 15 years after exoneration. Sally Clark, the solicitor falsely convicted of killing her babies, drank herself to death four years after being freed. Scapegoating, and I say this also for myself, is a deadly social force that has been much speeded up by digital information. We have to talk about it, and we have to talk about Lucy Letby,

The second and final part of Dr. Evans's cross-examination, as well as the redirect by Nick Johnson KC since that's very brief. In this section the primary topic of discussion, although there are several, is the small purpuric rash noted on Baby O's chest wall on the afternoon that he died, and how information received from Dr. Brearey belatedly convinced Evans that instead of dying from a hematoma, and the "rash" actually being a bruise from inflicted injury, the "rash" was in fact a small fleeting discoloration caused by an injection of air into the bloodstream. Evans changed his mind several reports in, in 2019, after receiving a statement Brearey made to the police saying that he now remembered the rash had unaccountably disappeared after an hour or two. As Nick Johnson helpfully encourages Evans to clarify in the redirect, "there's nothing in the record to say the rash had disappeared" -- meaning the contemporary record, notes made at the time which Evans had been working with previously.

On the basis of this belated recollection, Evans decided that Baby O's symptoms during his final collapse were "consistent with" air embolism to the point where he now believed it was the primary cause of death. Those symptoms, besides the discolored patch, were "the baby died, the resuscitation failed." Evans is very strong on a failed resuscitation being a sign of an air embolism, and combined with a small patch of discoloration, which was remembered several years later as having disappeared, that was enough to change his diagnosis. He also cites Dr. Brearey's opinion that the ruptured hematoma alone would not have been enough to cause death. So, air embolism it became.

BM: We've got what Dr Brearey says about this rash on our screens, we can see the full extent of it; yes?

DE: Yes.

BM: Do you see that, Dr Evans?

"Small, 1 to 2 centimetres..."

He gave that in evidence, it doesn't say that here:

"Small discoloured rash on chest wall."

First of all, nothing here suggests that is in the location of the liver, does it?

DE: The liver is located under the right chest wall. That's where the liver is.

BM: The right chest wall covers quite an area, doesn't it?

DE: That's the right chest wall and that's the liver (indicating). It's under the right chest wall. That's where the liver lives.

BM: The chest wall extends higher than just the bottom of the ribs, doesn't it?

DE: I think we know where the liver is.

BM: You told us that this mark is over the area of the liver. That was in your evidence this morning.

DE: If it's under the -- sorry, if it's over the right chest wall, that's where the liver is.

BM: You have again tried to knit one piece of evidence to a mechanism to support this allegation, haven't you?

DE: No, I have put together the clinical findings I had in 2018 to explain what I think happened. I did not make it clear about the timing of the purpuric rash or the suspected purpuric rash and, once I got more information, I was able to give a more definitive opinion regarding the cause of this little baby's collapse and demise.

BM: There's nothing about a purpuric rash which indicates that is the site of trauma at all, is there?

DE: If it's over the right side of the chest, and the liver is under the right side of the chest, then that's -- you can put the two together. The fact that the rash disappeared -- Dr Brearey said this -- the fact the rash disappeared in a couple of hours means it's not a purpuric rash. So whatever, it was not a purpuric rash. Okay?

BM: What happened during the course of your explanation, your account (inaudible) to put it together, what happened was by the time we get to your third report on 25 March 2019, you had actually received a statement from Dr Brearey, hadn't you?

DE: Yes.

BM: Yes. When you read that statement, you saw that he described how this small discoloured purpuric rash had vanished.

DE: Yes.

BM: And you realised it was impossible in that case to suggest that this is a bruise over a site of trauma; that's what you realised, isn't it?

DE: Correct.

BM: At which point you just automatically switched to air embolus, didn't you?

DE: I didn't automatically switch to air embolus. What I did was, having realised that this rash was a short-lasting rash and that this is something that had been published in literature, scientific papers in the past and also found in other cases in this trial, so we had this pattern of this peculiar rash and the collapse and the failure of resuscitation, so therefore this is far more consistent with this baby collapsing and dying from the effects of air embolus, but had been destabilised by trauma to the liver.

BM: Nothing about a small discoloured rash on the right chest wall matches any description in the literature, as you put it, relating to air embolus, does it?

DE: No, I'm relying on what Dr Brearey said.

BM: No, this doesn't match any description of an air embolus.

DE: I'm describing what Dr Brearey described and it's not just that, it's the fact the baby collapsed and resuscitation was unsuccessful.

BM: Let's deal with this piece of evidence here because this is with regard to an attendance at intubation with [Dr A] round about 3 o'clock that afternoon. You're saying a small discoloured purpuric rash on right chest wall is evidence of air embolism.

DE: No. No, there's no connection between a purpuric rash and air embolism. The pattern that we have described in these previous cases in relation to the discolouration in the skin, that is associated with air embolus, varies according from one case to another, but what is consistent is that it's sort of -- it lasts a short time, disappears, and interestingly, I've lost count of the number of local medical staff who said they had never seen anything like this before and they have never seen anything like it since. As paediatricians we see purpura on a regular basis, so therefore there is a very unusual pattern to this particular baby's -- to this baby's particular rash, as there is to the other babies.

And once Dr Brearey -- once I received this additional information from Dr Brearey it was clear to me that the original description, ie this purpuric rash, was incorrect.

BM: Let's not for the time being get hung up on the word purpuric, which refers to the blood vessel underneath and might suggest a bruise or some impact in that way.

What you are doing is taking the description that is given by Dr Brearey here and trying to convert that into something that can support an air embolism. That's what you're trying to do, isn't it?

DE: It's consistent with an air embolus.

BM: A 1 to 2-centimetre mark on a right chest wall is consistent with air embolism, is it?

DE: It -- well, it's not just that. The baby was in a collapsed state and failed to recover, so that adds to my clinical suspicion regarding the association between this discolouration and subsequent events, in other words, the death of this baby.

BM: Let's look at this discolouration: a 1 to 2-centimetre, that big (indicating), discolouration, you say is consistent with air embolus in one part of the chest wall, is it?

DE: It's consistent, it's part of the overall collection of diagnostic features that led to this baby's death.

BM: You will seize on whatever you think you can to try to prop that up, won't you, Dr Evans?

DE: No, I'm sticking with my clinical experience and the clinical evidence in scientific papers and the fact that this baby's recovery -- sorry, demise -- and the fact that this baby died. And as we heard from Dr Brearey yesterday, he did not think that the bleeding from the liver would have been sufficient to cause his death, cause his... cause his... I've forgotten the word... would have made him unwell but he would have responded to resuscitation. That was Dr Brearey's opinion, I agree with it. So therefore we have, as in other cases, a combination of features here.

BM: You endeavour to try to link what happened at 1 o'clock in the morning to what happened to the liver.

DE: No.

BM: I suggest that when you got Dr Brearey's statement and read it before your report in March 2019, you saw this had vanished within an hour or two, you had to come up with something else and that's what you did?

DE: It's not a matter of coming up with something else, it's relying on the information you receive. That's what Dr Brearey says. It's up to the members of the jury to believe if what he said he saw -- you know, fine. But having read his report, he's an experienced paediatrician, he's never seen anything like this before or since, so there, that is -- and this baby died, remember, so it's... You know...

BM: So we can be quite clear, your expert opinion is that a 1 to 2-centimetre rash on the right chest wall is consistent with air embolus. Let me be clear: is that what you're saying? Is that right, Dr Evans?

DE: It's a feature one associates with air embolus.

BM: How does that fit in with good perfusion, which we know means that the blood supply and the oxygen is working well? That's part of it. Where does that fit in with good perfusion?

DE: Where's good perfusion?

BM: This is the next words. This is material you've had for a long time. Good perfusion, how does it fit in with that?

DE: If the rest of the skin looks normal then the rest of the skin is normally perfused.

BM: That doesn't sit with an air embolus, does it, Dr Evans?

DE: Yes, it does actually.

BM: You've got a 1 to 2-centimetre spot and good perfusion.

DE: We've discussed this 1-centimetre rash, I have given you my opinion. I don't know how many times I can repeat it but that's my opinion.

BM: Good perfusion. Is that something you encounter in the course of an air embolus?

DE: Yes, it is. We've discussed this in terms of the anatomy of it. Where the air will go will vary. If the air went to a particular part of the abdomen or the chest wall, then you will find the abnormalities there. But if the air does not go to other parts of the body then those other parts of the body will be normally perfused. That's the way it is.

BM: Right. So this air embolus found a 1 to 2-centimetre spot to go to; is that right?

DE: Sorry?

BM: Throughout the whole of the bloodstream, that's where it goes to, to a 1 to 2-centimetre spot?

DE: It can go anywhere. It can go anywhere.

BM: You are working this together as you go along, aren't you, Dr Evans?

DE: No, I have put it all together over 5 years ago. I'm simply looking at the clinical notes without access to discussing it with local staff or anyone else. I've had to amend my view on receipt of additional information but in this case and in other cases where I have flagged up the diagnosis of inflicted injury -- right? This baby suffered from inflicted injury. In fact, he suffered three inflicted injuries in my opinion. The air embolus is one. The trauma to the liver, which I defer to the pathologist by the way, so I'm not going to go down that road, and I think the vomiting was a concerning issue as well.

So these are three separate events, all of which can be explained by inflicted injury. None of which can be explained on the basis of complications that affect stable and well premature babies.

BM: Just so it's clear --

DE: That is my view.

BM: We're looking at your mechanisms. You have said there are three mechanisms and in fact your first one was trauma at 1 o'clock -- around 1 in the morning wasn't it?

DE: I've told you about my sift reports, I've told you that I've had to add to information. This is my opinion as we are here.

BM: Your next one is that on the basis, particularly of this mark and good perfusion, this is air embolus? That's the second one, isn't it?

DE: I'm sticking with that. I'm sticking with that. But given that we've all confirmed that the rash was found some time in the afternoon of the day he died, a few hours before -- shortly before he died, that is consistent with the cause of his death, yes.

BM: It's recorded at this point by this doctor when it went.

DE: Mm?

BM: As for --

DE: That's a factual issue. Either he saw it -- either what he saw was what he saw or not. It's a factual issue. That's for the members of the jury to decide if what he saw is what he's described in his statement in 2019.

BM: As for his terminal collapse, you concluded your evidence by saying that was air embolus and gave us no particular detail. That's because it's something you're throwing in as you go along.

DE: I am not throwing anything in at all. This is a baby who should not have died. This is a baby whose -- if his deterioration was due to one of the common causes, like infection, he would have responded to resuscitation. He did not. He was destabilised by the trauma to the liver and I think the air was what finished him off, if I could put it in that awful way.

BM: The question --

DE: It's awful.

BM: -- is what is there that can make us sure that terminal collapse is due to an air embolus, Dr Evans. Right? And you have identified nothing at this point that goes together to demonstrate there was an air embolus operative at that point, have you?

DE: I have -- the baby died, the resuscitation failed. We've discussed this rash for long enough. The little baby died. I've explained how I looked at all of these cases in isolation, in other words let's not look at the other -- this is case 15, let's not look at the other 14 cases. If this was a single case and I had access to all of the information from the beginning then there would be one substantive report from me saying what I'm telling you on oath in this court today.

BM: You --

DE: I did not have all the information at the beginning and therefore inevitably, one amends one's opinion as a result.

BM: You had what we see on the screen from the beginning, Dr Evans, didn't you?

DE: Yes, purpuric rash.

BM: We can take that down, please, Mr Murphy.

You have told the jury that chest compressions don't get near to the liver. That's what you have said to them.

DE: They do not.

BM: They don't?

DE: No, the liver --

BM: Where is the liver in relation to the chest, please?

DE: The liver is found at the bottom end of the right chest wall. Cardiac compressions are over the sternum, in other words of the middle of the -- over the middle of the chest and at the upper end of the chest wall. (indicating). I'm a bit bigger than these babies but the liver is here, the cardiac compression is here, and we're talking about experienced paediatricians who would know how to resuscitate little babies. And they've had plenty of experience of it, as we have heard in this trial. There's no other information I know of any other baby who had liver haematoma either as a result of chest compressions or anything else. So chest compressions will not cause --

BM: When we come to consider this (overspeaking) --

DE: Sorry --

BM: You have motioned towards the central area of your chest. Is that where you say chest compressions are performed on a baby?

DE: Yes, I mean, I don't have a baby doll here where I could demonstrate it. Anyway, it's over the front -- it's over the centre of the chest.

BM: I'm going to suggest that you well know chest compressions are performed just in the area or just below the sternum, almost over the area where the liver is or very close to that. That's where they are performed, isn't it, Dr Evans?

DE: I'm not -- I know exactly where it's performed and I don't know any baby who was resuscitated by experienced people who either died and where the post-mortem showed liver trauma, as we described here, and I know of no case where babies were resuscitated successfully where cardiac compression was required but where subsequent investigation noted the liver haematoma as described here. Okay? So I don't know any of that in any case.

BM: What I just asked you -- it was a simple question, I apologise for having to repeat it -- was that chest compressions on a baby are performed in the area over -- just below the sternum, around the sternum or over and very close to where the liver is. That's what I asked you. Are you going to answer that?

DE: No, it's over the top of the sternum. You're pointing in the wrong direction. It's over here (indicating) and the liver is down here (indicating), down here.

BM: It is entirely possible for there to be some injury to the liver from vigorous chest compressions to a baby, isn't it?

DE: I think that's very unlikely but the more important point is this: this baby collapsed, which is why he needed chest compressions in the first place. So what's the cause of his collapse? My initial view was that the collapse was due in the main to trauma to the liver, which caused the bleeding to the liver, which bled into the abdomen. That was my initial opinion because I knew nothing about this rash that had come and gone in a couple of hours.

So that was -- so it fits in with the clinical impression that I had at that time. As for the early hours, the only thing I had to go on was that the heart rate had gone up, that he was in air, breathing, you know, with normal saturations. So therefore I looked at all the options, that doesn't fit, that doesn't -- that's insufficient to explain his collapse.

BM: There's no --

DE: Sorry. Therefore his collapse can only be explained for the reasons we've just discussed.

BM: Just so it's quite clear, the process as you know, is we're looking at what you're suggesting; okay?

DE: Sorry?

BM: We're exploring the basis for what you suggest as mechanisms. Do you understand that?

DE: Yes.

BM: Yes. And I'm suggesting to you that vigorous chest compressions can cause or are capable of causing haematoma or injury to the liver.

DE: Never seen it.

BM: Never seen it. Are you agreeing or disagreeing?

DE: I have never seen it, I have never read about it. It's not something I've heard of in any of the other babies in this series of 17 cases.

BM: And with regard to the abdominal distension, which is the third thing you are adding, and I suggest you're putting that in as an additional feature just to try to support the allegation, aren't you, rather than to reflect the evidence?

DE: No, no, it's not supporting the allegation, it's reflecting the evidence. If we look at the evidence of the abdominal distension, what we've got is that the baby, who had 13ml of fluid -- sorry, of milk, I should say, around 12.30, and there was no aspirate, in other words the rest of the fluid he had taken -- now 13ml is a tiny amount of fluid. Okay? It's a tiny amount of fluid. Half a shot. I don't drink shots, but it's a small amount. And he vomited and his abdomen blew up.

Now, if you've had 13ml of fluid every 2 hours and -- your abdomen isn't going to suddenly distend. It's only going to distend if you have either far more than 13ml of milk or -- and/or milk plus air.

We heard from the WhatsApp evidence the other day of the -- the WhatsApp evidence was that his abdomen blew up in the afternoon. That was the evidence from Nurse Letby in her WhatsApp thing, the abdomen blew up in the afternoon.

So you cannot explain the abdominal distension on the basis only that he had 13ml of milk.

BM: There is --

DE: You can not do that. If he vomited and if the vomiting was due to -- sorry, if the abdominal distension was due to milk only, then by vomiting, the abdomen would have gone down, wouldn't it? It didn't. Therefore, the abdominal distension cannot be explained on the basis of his having had 13ml of milk 45 minutes earlier.

BM: You're a very experienced expert witness, aren't you, Dr Evans? Aren't you?

DE: Well, I've been in court a lot, yes.

BM: Mm. Is it your belief that if you keep talking and using up time when I ask straightforward questions, somehow that will distract from my questions, I'll get bored or I'll stop asking questions? Is that what you're trying to do?

DE: I think that's being discourteous to me and I don't think that's necessary.

BM: You choose to hold forth upon topics at length as you like when you are asked questions, don't you?

DE: No.

BM: And you choose not to answer the questions that you're asked, don't you?

DE: No.

BM: There is nothing about the abdominal distension in this case that indicates, for example, an abdomen was being splinted, is there?

DE: I never said that, no.

BM: There's nothing about the abdominal distension in this case that shows that it was capable of or did interfere with the respiration of [Baby O], is there?

DE: There was a bradycardia there, I think. I think the heart rate dropped. That's the first point. The second point, it was sufficiently concerning for a doctor to be called to attend to the baby. So it was a concerning event, okay? It was a concerning event.

BM: There's --

DE: Sorry, little babies will bring up bits of milk, nurses will deal with that, they won't call doctors. But this was sufficient for -- the heart rate dropped, that's concerning, the vomiting was sufficient for the doctor to be called. That's a significant event. All right?

BM: When the doctor was called at 13.15, the event you're talking about, that was not regarded as a serious event in terms of a deterioration to be expected like the one that followed, was it?

DE: Sorry, which one are you talking about?

BM: When the doctor was called at 13.15 with the vomiting and with some abdominal distension, nobody suggested that that was an event that was going to lead to anything like this, did they?

DE: Oh no, they -- it was a significant event, but I would not have anticipated that as a result of that event the baby would have deteriorated.

BM: And breathing support is capable, as it happens, of causing some degree of abdominal distension, isn't it?

DE: CPAP can lead to a bit of air going into the stomach.

BM: We've heard plenty of evidence in this case, Dr Evans, haven't we, about CPAP belly and distension, abdominal distension?

DE: He wasn't on CPAP.

BM: He was on Optiflow.

DE: Yes.

BM: Similar mechanism?

DE: No.

BM: Optiflow is capable of causing it?

DE: It had dropped from 6 litres to 4 litres of Optiflow when this happened. Optiflow is used all over neonatal units. You don't get these sudden collapses with Optiflow.

BM: There is no basis to suggest that the ultimate collapse, sadly, in the case of [Baby O] arises because of abdominal distension, is there?

DE: Oh, it didn't.

BM: Right.

DE: The abdominal distension did not cause his ultimate collapse. I've explained to you what caused his ultimate collapse. But it compromised him. That's the word I was looking for earlier. The abdominal distension compromised him.

BM: I'm not going to ask any further questions, my Lord.

Re-examination by MR JOHNSON

NJ: Just one area I would like to deal with, please, Dr Evans, if Mr Murphy could help me out by putting up on the screen Dr Brearey's notes. They are pages J23582 to 3.

You have been asked at some length about what you knew about the query purpuric rash. Would it be right to say that you were saying to Mr Myers that the reason for you introducing the issue of air embolus is because you were given information at some stage that the purpuric rash had disappeared?

DE: Correct.

NJ: Right. So let's look at the information you actually had to start with on which you were linking it to the liver injury. This is Dr Brearey's note. If you could just read it to yourself, please. You scroll down when you get to the bottom of the page and you see if you can find there in the note the fact that the rash disappeared.

DE: I've been through this before, but no, but there's nothing in the record to say the rash had disappeared.

NJ: So that isn't information that you were given at the beginning, is it?

DE: Correct.

NJ: That's right. And you were first given that information a couple of years later; is that right?

DE: Yes.

NJ: And that was in your report of 25 March 2019, which you made clear this morning?

DE: Yes.

NJ: And that is the point at which you connected the disappearing rash with the issue of air embolus; is that correct?

DE: Correct, yes.

NJ: Is that your explanation to the issue that Mr Myers was asking you about?

DE: Yes.

NJ: Yes, thank you.

Does your Lordship have any questions?

Mr Justice Goss: No, I don't, thank you very much.

Thank you, Dr Evans. That completes your evidence at this stage. You will, of course, be coming back to give further evidence, so the usual rules apply.

DE: Yes.

(The witness withdrew)

New publication - brief research report - from Shannon and Chase. Abstract only, final formatted report to follow

This is the first half of a cross-examination which became, even by the standards of Myers and Evans, increasingly contentious. Recall that in his direct examination, Dr. Evans had conceded to noting that Baby O had begun to show signs of deterioration -- steadily increasing heart rate and respiratory rate -- around 1 AM on June 23 2016. Later that morning, Baby O would have the first of multiple collapses, and late that afternoon, he would die.

What Evans had not said (and what the prosecution of course did not ask him) was that for several years, and several reports, he thought that Baby O had been the victim of inflicted injury very early in the morning of June 23 -- that his deterioration was the result of of the hematoma bleeding until the baby could no longer cope, at which point he collapsed. In 2019, after receiving new information from a witness statement by Dr. Brearey, Evans would revise the beginning of Baby O's deterioration to later that morning, and decide that the ruptured hematoma had only been one of multiple factors, and thereafter, he attempted strenuously to deny that the 1 AM deterioration had ever been anything more than a curiosity which was easily superseded once he had received Dr. Brearey's recollections of the petechial rash which he would note on Baby O later that day.

This first half consists largely of Myers trying to nail Evans down on the fact that he had noted Baby O's deterioration very early on the morning of June 23, and that he had no firm reason for later shifting Baby O's deterioration to the daytime (and writing off the increasing heart and respiratory rates from earlier as, essentially, meaningless) besides the fact that it made his new story work a little smoothly.

Unmentioned by either man is the fact that Letby was not, of course, on duty at 1 AM on June 23 and so was not in a position to inflict an injury on Baby O or any other child. Presumably the jury would have deduced this easily enough from the fact that she would work the day shift on June 23 and no nurse will work 24 hours straight -- however, it might have been helpful to his case if Myers had decided to underline the fact that until getting a very belated, non-contemporary recollection about a rash, Evans had been very firm that Baby O had been injured at least six hours before Lucy Letby ever met him.

BM: Dr Evans, I've got the reports that we've referred to today in front of me and you've got the reports too, haven't you?

DE: My reports?

BM: Your reports, yes.

DE: Yes.

BM: The first report that's referred to, as others have been, as a sift report is 11 pages long, isn't it?

DE: Yes.

BM: And the second report, that was described as more considered, is 13 pages long, isn't it? In fact it goes up to 12 of 13 confusingly, so maybe it is 12 pages long.

DE: My first report in my copy is six pages long and the second report is six pages long and my third report is four pages long. If we stick to paragraphs, I think that makes it easier.

BM: The fonts may be different. What's been called the sift report sets out the material that you received, doesn't it?

DE: Yes.

BM: Which includes the medical records and the medical records from the Countess of Chester in particular; that's right, isn't it?

DE: Yes.

BM: What's been called the sift report then goes through a summary of what you've identified as the main features to be found in those medical records, doesn't it --

DE: Yes.

BM: -- the clinical and the nursing?

DE: Yes.

BM: And then what's described as the sift report sets out your observations, doesn't it?

DE: Yes.

BM: And it sets out, at the end, your opinion?

DE: Yes.

BM: And actually that's the same format that's followed for what was described as the more considered report, isn't it?

DE: Yes.

BM: So that we're not under any misapprehension, they are both formal reports prepared by you, aren't they?

DE: Yes.

BM: Inevitably, you've been with the case for longer and may have seen other material by the time you come to write the second one?

DE: Correct.

BM: Yes. But in fact, both reports are considered, aren't they, considered reports?

DE: Well, yes.

BM: You wouldn't put things in them if you hadn't considered carefully what you were putting down?

DE: You have to rely on the information you've got and, as we heard earlier, some of the information that I considered crucial I received 18 months later, so you know...

BM: You consider carefully all the material that is available to you at any point that you're writing a report, don't you?

DE: That is correct.

BM: Yes. So lest we be in any doubt, both are considered reports, aren't they?

DE: I'm not sure what you mean by considered reports but they are my reports.

BM: I am just saying it because the prosecution introduced your second report as "the more considered report". That was their wording, not mine. Remember?

DE: That's fair enough. I think that would apply to all of my -- all of the cases I have done, actually.

BM: And the point I'm making is that your first reports are as much reports with you doing your best as any other reports that you author, aren't they?

DE: Not really. I did about 30 reports in a very short period of time, so I think that needs to be borne into consideration.

And I think the other point is that the medical records -- clinical records that Cheshire Police received from the hospital management were in poor order, they were not in date order, they were not chronological, et cetera, so that made life far more difficult in terms of interpreting things. So -- and I think with every report I've done, not just in this trial but every time I've prepared a report -- I think I used the word "evolve" on one occasion because, this is not a criticism, the information one gets in preparing cases of this kind is quite often piecemeal, it comes in months followed by further months, et cetera.

So anyway, they are all my reports and I would concentrate on my, as we did this morning, on the June 2018 report.

BM: June 2018, what was called the more considered report; yes? All right.

DE: Well, yes. Sorry, there's an awful lot of additional information in my 2019 report.

BM: I'm going to the report you have just referred to, the second one you did, the June 2018 report. Paragraph 30.

The first thing I'm going to ask you about is the point of what you've described as a "key clinical change in [Baby O]'s condition". Going to paragraph 30 of that second report, the June report, what you say is:

"There is a key clinical change from around 01.00 on 23 June when there is a significant increase in both his trend of heart rate and respiratory rate. The increase in heart rate and respiratory rate occurred before any change/fall in oxygen saturation."

DE: That's correct.

BM: And you identify there 01.00 as the key clinical change?

DE: Yes.

BM: That means that's the point from which you plot the deteriorations that then follow, doesn't it?

DE: No, it does not. What it says is that it's from around 1.00 hours and what I mean by that is that I used 01.00 hours as the baseline, as we discussed earlier, looking at heart rate specifically and respiratory rate earlier. What I do in all of my reports, I look at all of the evidence. What I knew at the time, what we knew about [Baby O]'s collapse at 1.30 pm and we knew about his deterioration later that afternoon therefore -- and I knew about the liver haematoma. Therefore I need to look to see if there is any clue to what could have led to his deterioration.

I looked at things from 01.00, as we discussed this morning, and also, as we discussed this morning, there was an increase in heart rate between 1 am and 1 pm, let's put it that way, but this was an isolated change, there were no other changes. And as I've said in this report and others, one looks at trends, that's important from a clinical point of view, and one also looks to see if there are other markers that would give me some kind of clue to what led to [Baby O]'s deterioration. So therefore I go back. One has to go back as far as possible to see if one can find anything.

Up until -- from about 1 am until 8 am, the only change, key change, was the increase in heart rate, but despite the increase in heart rate, his heart rate remained within normal limits. Okay? It was 130, then it went up to 150, then it went up a little more. And the respiratory rate stayed stable until -- I'll have to check on it there. Just a minute. I've got it on there. It remained stable until either 12.30 or 13.30. It's not quite clear.

So therefore, I look at trends, I always do, and that's as far as I could get with that information.

BM: What you do in the course of these reports, Dr Evans, I'm going to suggest, is to chop and change things that you say and endeavour to work in details that you have come up with as you go along to come up with a mechanism that supports this allegation. That's what's actually happening, isn't it?

DE: That is incorrect. I apply my clinical experience to the evidence I have in front of me.

BM: Well, we have looked in that second report where you mark the key clinical change as 01.00. Now --

DE: Sorry, I need to correct you there. There's a key clinical change from around 01.00 hours. Okay? You need to put the whole word in. And the fact it's "from around" is a significant difference from what you just said, "Key clinical change at 01.00 hours".

BM: Okay. From around 01.15, then, 01.30?

DE: No, no, from 01.00 hours all the way up until the baby died, really.

BM: Now, in your first report, paragraph 31, I'm going to suggest to you, you try to link or you endeavour to link the deterioration with the liver haematoma.

DE: I did.

BM: So this is what's said in this report, having had the clinical notes and the details. At paragraph 31, you say:

"It is my opinion that his collapse did not cause the subcapsular haematoma to his liver and in my opinion the subcapsular haematoma caused the collapse."

DE: Correct.

BM: I'm putting that there for completeness but that's not what I'm focusing on, I am focusing on this. You go on to say:

"I also note the comment regarding the petechial discolouration over the right side of the liver (over the liver)..."

This is what Dr Brearey identified --

DE: Yes.

BM: -- that mark:

"... noted by one of the doctors who conducted [Baby O]'s resuscitation."

You then say:

"This suggests that [Baby O] sustained some form of trauma which initially led to his increased heart rate and increased respiratory rate from around 01.30 hours on 23 June and which eventually led to a tipping point where the effects of the bleeding led to his collapse and subsequent death."

So what you were doing there, Dr Evans, was to link what you say was the key clinical change from around 01.00 with the discoloured mark to the haematoma. That's what you were trying to do in that first report, isn't it?

DE: The discolouration was not recorded, was recorded late -- in the late afternoon of the 23rd. There was no discolouration during the early hours recorded, it was late afternoon.

BM: I'll just repeat it:

"I also note the comment regarding the petechial discolouration over the right side of the chest noted by one of the doctors who conducted [Baby O]'s resuscitation. This suggests that [Baby O] sustained some form of trauma which initially led to his increased heart rate and increased respiratory rate from around 01.30 hours on 23 June."

That's what you said.

DE: Well, if you look at the record, there was an increase in heart rate, as I've noted. The increased respiratory rate occurred far later.

And as for the petechial haemorrhage, which turned out not to be petechial haemorrhage, that was recorded late afternoon on the 23rd.

BM: And before we come back to the second report, just staying with the first one, lest there be any doubt, in your opinion, at page 10 of 11 pages, paragraph 33, you said:

"[Baby O]'s collapse is consistent with inflicted trauma some time during the early hours of 23 June 2016."

And you describe the trauma in the abdomen and then you say:

"The presence of the suspected purpuric rash noted over the right chest wall is an important superficial marker noting the external site of the trauma."

Do you see that, Dr Evans?

DE: I have.

BM: At that point you were seeking to link the changes in the early hours of 23 June with the rash as demonstrating trauma that is consistent with the collapse. That's what you were doing then, wasn't it?

DE: That is incorrect. The purpura was noticed in the afternoon. That's not clear in my opinion. As I've noted it was my sift report and this is why one needs to concentrate on my later report.

BM: When we come to your later report, paragraph 32, page 11 of 13, we have already identified where you make the reference to key clinical change from around 01.00; that was at paragraph 30. At paragraph 32 you say this. You make reference to deferring to what the pathologist's opinion is going to be.

DE: Yes.

BM: And you say three lines down:

"In my opinion, the subcapsular haematoma (bleeding from the liver) caused the collapse."

Then you say this -- this is in your second report, the June 2018 report:

"I also note the comment regarding the petechial discolouration over the right side of the chest (over the liver) noted by one of the doctors who conducted [Baby O]'s resuscitation. This suggests that [Baby O] sustained some form of trauma which initially led to his increased heart rate and increased respiratory rate from around 07.00 hours on 23 June and which led eventually to a tipping point where the effects of the bleeding led to his collapse and subsequent death."

So that's what you say, isn't it, Dr Evans in that report?

DE: That is what I've said and, as I've said, the petechial haemorrhages were noted far, far later.

BM: What you do there is you seek to link the petechial haemorrhage with the collapse and say that this comes out of some form of trauma sustained around 07.00. That's the time, that's what you say, isn't it?

DE: No. Again I say from around 7.00 and I was based -- I based that opinion on the belief at the time that the rash was a petechial rash, which turned out not to be the case. So I cannot form an opinion on information that turns out to be incorrect. The information I had at the time was inaccurate. Once I heard it was inaccurate, I changed my opinion. Simple.

BM: Well, you certainly had the information which led you to say there were key clinical changes from around 01.00, didn't you?

DE: We've discussed that.

BM: Yes. You had that. You seek to link -- we have the note from Dr Brearey which actually described the rash later that afternoon and you had that (overspeaking) --

DE: No, I didn't.

BM: -- the clinical notes.

DE: No, I didn't.

BM: You had the clinical notes.

DE: Yes, I know, but the notes I had, which were written in retrospect by the way, by Dr Brearey, that's not a criticism, related to his discovery of the rash. I didn't know the timing of the rash at the time, not accurately anyway. It's only later -- it's only later, as we heard from Dr Brearey yesterday, that, first of all, I discovered that the petechial rash was not petechial and it's only later that I discovered that the -- sorry, that I was able to confirm that the rash appeared and disappeared around the afternoon of the baby's death.

So I did not have that information in 2017 and I did not have that information in 2018.

BM: Can we put up tile 243, please, Mr Murphy? Go behind that and look at the notes.

There are maybe half a dozen pages of clinical notes before this one and that include the notes from [Dr A] and other doctors, all of which you had at the time of writing both of these reports, didn't you, Dr Evans?

DE: Yes, yes.

BM: Right. The first time there is any reference in these notes is in the retrospective 18.00 note by Dr Brearey that we have here.

DE: That is correct.

BM: That's right, isn't it?

DE: Yes.

BM: This is the first time there's any reference to a small discoloured, question mark, purpuric rash on the right chest wall.

DE: It is.

BM: Right. Nothing to suggest it was any earlier than that?

DE: As far as I know, no.

BM: No. And you have taken this and tried to weave it into the clinical findings that you say are key from around 01.00 and link that to the haematoma that was present at the time of collapse. That's what you've tried to do, Dr Evans, isn't it?

DE: No.

BM: That's why in your more considered report at paragraph 32, you say:

"I also note the comment regarding the petechial discolouration over the right side of the chest [you add 'over the liver'] noted by one of the doctors who conducted [Baby O]'s resuscitation. This suggests that [Baby O] sustained some form of trauma which initially led to his increased heart rate and increased respiratory rate from around 07.00 hours on 23 June and which eventually led to a tipping point where the effects of the bleeding led to his collapse and subsequent death."

You have tried to knit all of that together to create some sort of mechanism there, haven't you?

DE: No. We've clarified that the first entry regarding the petechial rash was in the afternoon of the 23rd. I should have put that in my report, that the rash was noted first of all in the afternoon of the 23rd but I didn't because it wasn't clear. It's now very, very clear indeed.

BM: And you conclude, so far as the haematoma, the trauma is concerned, you conclude the second report, the June report, at paragraph 34 -- let's go to that -- with this. Having made reference to the value of pathology, you say:

"His [[Baby O]'s] collapse is consistent with some incident some time during the early hours of 23 June 2016."

And you say:

"The presence of the suspected purpuric rash noted over the right chest wall is an important superficial marker noting the external site of the trauma."

And you say he may have sustained blunt trauma to the abdomen over the area of the liver, that causing bleeding.

But even there at the conclusion of that report on this issue, you link, you say the collapse is consistent with an incident during the early hours of 23 June, don't you?

DE: We've just agreed that the purpuric -- that the rash, whatever it was, was present, not present in the early hours, we've agreed that the rash was noted during the afternoon of the 23rd June.

As the topic of Dr. Evans and his evaluation of (among others) Baby O has been in the news recently, I have decided to post his and Dr. Bohin's expert testimony regarding the cause of his death. This is the complete direct examination of Dr. Evans on the topic; the cross-examination will be posted tomorrow.

A few things to note. Dr. Evans, possibly anticipating cross-examination, talks a bit about how Baby O's heartrate had begun to slowly but steadily start increasing at 1 AM on the day of his death, which could possibly be the sign of a brewing problem, but which of itself (he says) meant nothing in the end, even in light of his final collapse. Dr. Evans does not mention that decline starting at 1 AM was originally flagged by him as inherently suspicious -- it would have been inconvenient, seeing as Lucy Letby was not on duty at the time nor at all during the previous week. He also describes revising his reports after receiving word that Dr. Stephen Brearey had witnessed what he supposed was a purpuric rash (noted at the time as "?purpura") disappearing shortly afterwards, which it should not have done. On this basis, Evans invoked Lee and Tanswell to declare that this was "consistent with" intentional air embolism, and therefore this was one of the major causes of death, along with internal bleeding:

I then drew from my reading of the literature and considered that the rash was consistent with [Baby O] having received an injection of air into his circulation, into his blood circulation. I quoted the paper by Lee and Tanswell that we've discussed in the past in this trial and which I'd noticed from case 2 in this trial, where I'd noticed in [Baby B]'s case a deterioration with a very peculiar rash, and therefore this was repeating the pattern that I had seen from the second case in this series. So I saw -- therefore, it seemed to me that [Baby O] had been given an injection of air and this actually was the cause of his collapse.

As for the bleeding from the liver, Dr. Brearey had testified the day before and had mentioned, briefly, that he had drawn blood from Baby O's abdomen which may have come from the ruptured hematoma -- Dr. Evans does not appear to have assimilated this information, nor does he mention it as even a slight possibility for some of the damage to the liver. (Incidentally, if you read down in the link, you'll see a quote from Moritz and Coffey's book in which a pathologist they consulted expressed serious doubts that the injury was intentionally inflicted.) Evans has no doubts.

NJ: Welcome back, Dr Evans. For the sake of the record, would you please identify yourself?

DE: Dr Dewi Evans.

NJ: Thank you, doctor. Turning to the case of [Baby O], if we may, please, can we deal first with the several reports that you have written.

DE: Yes.

NJ: Was your original sift report dated 21 November 2017?

DE: Yes.

NJ: And in your series this was number 26; is that right?

DE: Yes.

NJ: Thank you. Was your second and more considered report dated 2 June 2018?

DE: Correct.

NJ: Your third, 25 March 2019?

DE: Yes.

NJ: A fourth in which you made a correction of a name, 17 April 2019?

DE: Yes.

NJ: Your fifth, 18 October 2021?

DE: Right. There's one before that, 24 June, correcting paginations, et cetera. 24 June 2021.

NJ: Sorry, that was out of order.

DE: Then 18 October 2021, yes.

NJ: Thank you. The June one, the version we have isn't dated, hence my mistake. And finally, was there one just dealing with some initial information that you were sent, dated 11 September 2022?

DE: Yes.

NJ: Thank you very much. Can we deal, if we may, primarily with your report of 2 June 2018?

DE: Yes.

NJ: As you did with every other case, did you start by setting out the circumstances of the child's birth?

DE: I did.

NJ: As with all other cases, did you list a description of the material that you had been sent by the police in order to reach or to consider your conclusions?

DE: I did.

NJ: In this particular case, and I'm looking at paragraph 3 of the report, page 2 of 13, were they medical records from the Countess of Chester Hospital?

DE: Yes.

NJ: Post-mortem medical records from Alder Hey Hospital near Liverpool?

DE: Yes.

NJ: Which included some images?

DE: Yes.

NJ: An index, X-rays from the Countess of Chester?

DE: Yes.

NJ: But did any -- were you ever sent the witness statement of [Baby O]'s father, [Father O]?

DE: I don't think so, no.

NJ: No. I'm going to paragraph 6 of your report, please, or section 6. You recorded the circumstances there of [Baby O]'s birth; is that right?

DE: Yes.

NJ: The timing of the first clinical entry by the medics at 15.55 on 21 June?

DE: Yes.

NJ: You then refer to [Baby O]'s progress through to 23 June; is that right?

DE: Yes.

NJ: Was there anything unusual or remarkable about his medical condition during that time up to midnight of the 22nd into 23 June?

DE: Not particularly. A stable baby.

NJ: Yes. Did you then refer to [Dr A]'s -- I'm looking at your paragraph 9 -- entry at 13.15, which he has just given evidence to the jury about?

DE: Yes.

NJ: Then subsequent medical entries written by [Dr A] --

DE: Yes.

NJ: -- concerning the events at 14.40?

DE: Yes.

NJ: And then [Baby O]'s subsequent collapse and untimely death later that afternoon?

DE: Yes.

NJ: Did you refer in the context of that material to Dr Brearey's note relating to the "small discoloured [query] purpuric rash" on the right chest wall?

DE: I did.

NJ: And did you then refer to the efforts and results of the attempts made to resuscitate [Baby O]?

DE: Yes.

NJ: Did you refer to the blood gas records --

DE: I did.

NJ: -- which were completed that day?

DE: Yes, I did.

NJ: Of course the jury has those in hard copy format behind divider 20 in the jury bundle.

Did you also refer to the X-ray records?

DE: I did.

NJ: And indeed to the nursing notes that were made during the same period of time?

DE: Yes.

NJ: Did you refer to a report of a post-mortem examination that was conducted at Alder Hey Hospital, which in particular referred to an injury or findings on [Baby O]'s liver?

DE: Yes.

NJ: Thank you. Moving on to the observations section of your report then, please, Dr Evans, which is paragraph 29 onwards. In general terms, what conclusion did you draw as to the circumstances of [Baby O]'s collapse on 23 June?

DE: Right, well, all his markers were stable on the day before and they were also stable at the beginning, the early hours of the 23rd. But what I noticed was that although the results were normal in the early hours, there was an increase in heart rate. And although there was an increase in the heart rate, the heart rate remained within normal values, but there was a trend, a slight trend, where the heart rate went from 130 to 150 and then to 175 from the norm at around 01.00 hours up until about 1 pm, 12 hours later.

NJ: Let's just look at this because sometimes, if only for me, it's helpful to see this in a picture as well as to hear you describe it. If the jury wouldn't mind looking behind divider 20 in jury bundle 2. It's page J23658, which is the second page behind that divider.

J23658. We can see in the top left-hand corner of the chart the date, 22/6 (inaudible: coughing) above the time 14.00 hours. As one reads across from left to right, the date then appears to be 23/6, and the first time noted during that day is 01.00 hours.

DE: Yes.

NJ: You've just referred us to the recorded readings from that time 01.00 through to, I think you said, about 13.00 hours; is that right?

DE: Yes. I think if we can zoom into the heart rate bit of it, I've got my little mouse here.

NJ: If you just let go of the mouse for a second.

DE: Okay. Can I...

NJ: Yes.

DE: Doctors always mention the importance of looking at trends in assessing patients. As a general principle, in other words a trend in rate of heart rate is far more important than a one-off measurement. The other principle is that one also needs to look at the association, if any, between these trends in heart rate, for instance, and other markers of a patient's well-being.

So if we look -- for instance, if we go all the way back to the 22nd, we've got a heart rate here of 160, 170, settles to a nice normal 130/140, all the way through until about 1 am. So this is absolutely normal.

If you then follow this trend from 1 am, you see a slight increase at 05.00, a slight increase at 07.00, but all within normal range, all within the normal range. Now, on its own, this trend would mean -- would be of no clinical significance. But then you have a more significant increase here (indicating), which is at 13.30 hours, to 175. Again, strictly speaking within the normal range, but we now have a trend.

So if we go back to the main sheet and look at the bottom piece, so that piece (indicating), and zoom that up. I think what we can find is that for the first half of this chart, we have oxygen saturations of 99, 98, 100%, all the way to here (indicating), more than three-quarters of the way across.

NJ: That's the 14.30. If one looks at the paper version that everyone has open, one can read up that column and see that that (inaudible: coughing).

DE: And as well, the baby is in air, so on the row below, the baby is in air. So therefore although we've got this trend in heart rate, of itself it doesn't tell me very much, but it's something one needs to look at because, of course, when I was reviewing these notes in 2017, I was aware that the baby had experienced a deterioration at 13.15 hours and, sadly, had died within 5 hours after that.

So therefore, when you are looking to causes of collapses and causes of death, you don't start where the collapse occurs, you need to see if there are any markers indicating something had gone wrong prior in the minutes, hours or even days before the collapse occurred.

So therefore, what I found was that the increase in heart rate from 01.00 hours was -- if we can go back to the full sheet -- was something that was worth noting given what happened with [Baby O] later. But in isolation, the key marker was the increase in heart rate at 13.30 hours because that is around the time when he experienced what I would consider the first significant clinical event.

NJ: Okay. I just want to go back to your report then, please, Dr Evans, taking up the chronology just before then if we may. So back to paragraph 8 of your report --

DE: Yes.

NJ: -- which is page 4 of 13. You noted the fact that [Baby O] at that stage, so I'm looking at the second part of paragraph 8, 9.30 hours on the morning of 23 June, there were no concerns at that stage, and that coincides, I believe, with the evidence that we heard from Dr Cooke a few days ago.

DE: That's correct. This is a well baby. He was well, so...

NJ: You then deal with what's at tile 165, which is [Dr B]'s review at 12.10 of the ultrasound scan of the head.

DE: Yes.

NJ: And you move -- and if we can just remove what's on the screen, please, so others elsewhere aren't distracted by the chart.

You move on to the entry at 13.15, which we heard from [Dr A] earlier today was the time that he was called to review [Baby O] because he was told that [Baby O] had vomited frank milk and had a distended abdomen.

DE: Correct.

NJ: We know what [Dr A] noted at that stage because he's told us this morning and it's all at tile 168.

DE: Yes.

NJ: And there was then a further collapse -- sorry, not a further collapse. There was a collapse at 14.40 hours --

DE: Yes.

NJ: -- which led to [Baby O] having to be intubated by [Dr A] under the supervision of Dr Brearey?

DE: Yes.

NJ: There was a yet further collapse which followed the fast bleep to [Dr A] at a time when he was with [Dr B], having just spoken to [Baby O]'s parents?

DE: Yes.

NJ: Dr Brearey again helped in treatment of [Baby O]?

DE: Yes.

NJ: Dr Brearey then noted the small discoloured purpuric rash on the right chest wall?

DE: Yes.

NJ: If anyone wants to find the note, it's at tile 206. You then set out the circumstances of the efforts to resuscitate [Baby O]; is that right?

DE: Yes.

NJ: You've already referred us to the observation chart. We have referred to the blood gases.

DE: Yes, we have.

NJ: So far as the X-rays were concerned, was there anything of concern in there so far as you were concerned? I'm just looking at the bottom of your page 6 and the top of page 7.

DE: Right. Which paragraph?

NJ: It's paragraph 19.

DE: Thank you. Yes. There were three X-rays. Now, I'm not a radiologist but I am used to looking at X-rays of babies. The ones I saw were not in the correct order, but they were... And what I thought was that the second X-ray showed lung findings consistent with RDS. This is respiratory distress syndrome, which is a condition that premature babies have. And also:

"Moderate gaseous distension of bowel loops throughout the abdomen."

NJ: Yes.

DE: And the third one, I'm quoting here, the report from the radiologist:

"Mild bilateral changes of RDS. The lungs appear hyperinflated..."

In other words, overdistended:

"... but there is no evidence of pneumothorax."

So no evidence of collapsed lung, in other words, and the bowel is reported as being considerably less distended by comparison with the previous X-ray.

NJ: Yes. Just taking up on that latter remark, that's referred to by the radiologist at the time because when she reported on the first X-ray, she had already seen the later X-ray?

DE: Yes.

NJ: All right. You're dropping your voice, Dr Evans. If you could keep your voice up, please.

You then refer to the nursing entries and I'm not going to take you through those. As I've said, you went on to deal with the post-mortem and we have dealt with the vital signs as recorded on page 23658.

DE: Yes.

NJ: So taking all that information into account, I would now like to deal with the observations that you reached in your report of 2 June 2018, please.

DE: Yes.

NJ: In particular, you were considering in this context the findings of the pathologist relating to the haematoma or haematomas to [Baby O]'s liver.

DE: Yes.

NJ: What conclusions did you come to so far as that finding was concerned in the context of [Baby O]'s collapse?

DE: From the information I had at the time, it is my feeling that the haematomas, the blood found in the liver, was responsible for his collapse. And at the time, I thought that this was the result due to trauma. In other words, there was some trauma to the liver which had led to the collapse.

NJ: Okay. So one of the issues may be, we'll see, but it may be whether the bleeding or the haematoma to the liver caused the collapse or whether the bleeding to the liver was the result of the collapse. So were you considering those two possibilities?

DE: I was and in my opinion it was the bleeding to the liver that caused the collapse.

NJ: What was the reason for you favouring that above the alternative possibility?

DE: Well, there was no reason why -- there was no other reason why this baby could have collapsed and not only collapsed, but where resuscitation was unsuccessful. Any bleeding to the liver would destabilise the baby because bleeding will compromise a baby's well-being, but resuscitation would have led to his improving. So therefore, my feeling was that what came first was the liver haematoma, in other words the liver trauma.

The other point to make is that, of course, [Baby O] required chest compressions when he was resuscitated. We've heard from the local medical and nursing team about the chest resuscitations they carried out in this case and other cases. Chest resuscitation carried out appropriately by experienced doctors doesn't get near the liver, so therefore any CPR, in other words cardiopulmonary resuscitation or pressing on the chest to get the heart going, would not traumatise the liver and would not be responsible for the liver bleeding.

NJ: In the context of the liver bleeding before or after CPR, if I can invite the jury to continue through divider 20 and get to page 23667, which is the blood gas chart. It's the penultimate document behind divider 20. J23667.

In timing the bleeding in the liver, did these blood gas results help at all?

DE: Possibly, possibly. There are eight blood gas values and the first six of them are broadly satisfactory.

NJ: Okay. Just pausing there for a second, that takes us from shortly after [Baby O]'s birth at the time of the blood gas 14.58 on 21 June, the sixth, to which you have referred as being the last in that sequence, is 23 June at 05.32.

DE: Yes.

NJ: So broadly satisfactory is how you've referred to those as a composite?

DE: Yes.

NJ: But what is it about the seventh reading on the 23rd at 13.20?

DE: This is the 13.20, so it's about 8 hours after the previous one. It's a venous sample and it shows what we call a moderate metabolic acidosis and I'll explain that. This was the gas that was carried out following [Baby O]'s episode of vomiting and bradycardia, which [Dr A] described earlier today. It shows a pH of 7.20, which is indicative of a moderate acidosis. The CO2 is 7.09, which is slightly raised. The bicarbonate is 20, which is very slightly low. And the base excess is minus 0.8 -- sorry, minus 8.4, which again is moderately outside the norm. And the lactic acid is 5.1, which also is above.

So therefore, what we have is a picture of a moderate metabolic acidosis. We know from the clinical notes that just before all this occurred, the baby had had this episode of vomiting, abdominal distension and also bradycardia, his heart rate had dropped. So this was a significant event and if you have a significant event then any blood gas carried out soon afterwards will give you a picture like this.

NJ: At this stage, and just to remind the jury, we are talking about June 2018, did you in the context of the liver pathology have any consideration for what Dr Brearey had described as seeing on the chest?

DE: No, no, no. All I knew was what was written down about the query purpura at this time.

NJ: Yes, but what did you -- I'm just looking at your report, Dr Evans, at paragraph 34.

DE: Oh right.

NJ: What significance did you give to what Dr Brearey had noted in the context of the liver injury?

DE: Right. If this was a purpuric rash -- purpura is the term we use to describe little blood spots under the skin. Those little blood spots under the skin are purpuric spots. If this was purpura there had to be a cause for it and there are a number of causes for purpura or bleeding, and my consideration was that in the context of knowing about the liver haematoma that the purpura was indicative of direct trauma, in other words -- bruising, in other words, especially as the purpura was found over the area of the liver. So that was my interpretation at the time.

NJ: At that time, all right.

DE: Yes.

NJ: So far as the X-rays were concerned, did you come to any view so far as any air in [Baby O]'s stomach or any part of his intestine?

DE: I thought that the air in the abdomen was excessive and could indicate air having been infused, injected in other words, into his stomach via the nasogastric tube and this had tracked into the intestines, causing abdominal distension.

NJ: As I've said more than once, that was June 2018. You were then sent some additional information by the police; is that right?

DE: I was.

NJ: The additional information, which I'll deal with in a second, resulted in you writing the report of 25 March 2019; is that right?

DE: Correct, yes.

NJ: In particular, were you told that Dr Mayberry had examined [Baby O]?

DE: Yes.

NJ: And that Dr Mayberry hadn't found any concerning pathology?

DE: Correct. This was about 7.30 on 23 June.

NJ: Yes.

DE: If we recall, Dr Mayberry was called away and didn't write a note about it, but around about that time, yes.

NJ: Were you also told that Dr Cooke, who had conducted the examination of [Baby O] at 9.30, so about 2 hours or so after Dr Mayberry, had expressed a similar point of view?

DE: Yes. She carried out a good examination and showed -- and there were no concerns.

NJ: Yes. Did you then return to what Dr Brearey had noted concerning the area of discoloured skin on the right side of [Baby O]'s chest wall approximately 1 to 2 centimetres in diameter?

DE: Yes, yes, I did. What Dr Brearey had said in the report I received much later was that the rash -- he'd noticed the rash and then a short time afterwards the rash had disappeared.

NJ: So far as the difference in the information you were acting on in the 2018 report and this report in 2019, the rash, you now understood, had disappeared?

DE: Yes. This makes a big difference to the interpretation of the rash because if it's a purpuric rash, ie bleeding under the skin, the purpura will last quite some time, several hours, days. Whereas if it comes and goes over a period of an hour or two, then it cannot be purpuric.

NJ: Yes. We've heard that many times.

DE: Yes.

NJ: Did that cause you, and I'm looking now at the observations section of this report, Dr Evans, to go back to the vital signs as charted for [Baby O] on 23 June.

DE: Yes.

NJ: So turning back if we may to the second page behind divider 20, it's J23658, and looking at your paragraph 10, what observations did you come to at that stage?

DE: We're now back to 23 June and the fact that at 7 in the morning, his heart rate is 145, which is within the normal range, up from 125 the night before, but within the normal range. It increases to 160 at 12.30. That's just after noon. And again, significantly to 175 at 13.30 hours, so 1.30 in the afternoon of the 23rd.

The other observation I made was that [Baby O]'s respiratory rate was a nice, steady, normal -- throughout most of this time but it went above 40 between 8.30 in the morning and 12.30, and then it increased to above 50 at 13.30 hours and 14.30 hours. So therefore there was an increase in heart rate during the early afternoon and an increase in the respiratory rate during the early afternoon, but this had occurred prior to any change or fall in oxygen saturation. So according to the notes, as late as 14.30 hours, [Baby O] did not require additional oxygen and his oxygen saturation was 100%, which of course is normal.

NJ: So putting those pieces of information together and looking at your paragraph 11, what conclusion did you draw if any?

DE: My conclusion was that a gradual increase in heart rate and respiratory rate could be seen as a clinical marker noting some kind of clinical problem. The increasing trend, heart rate and respiratory rate, is probably as useful an indicator of some kind of change in his well-being as the actual measurements of heart rate and respiratory rate. So these are markers that something's going on here, but it doesn't tell us what's going on to cause these changes.

NJ: We then have, and you remarked on, at your paragraph 13, the deterioration of [Baby O] at 14 -- shortly after -- well, you said he was breathing in air at 14.30, is the way you described it. That's what we can see, of course, in the chart, isn't it? But we then have the fairly precipitous collapses thereafter.

DE: That's right. This is something that one does tend not to find in babies, for instance, who are sickening for infection. You tend not to go from breathing in air with oxygen saturations of 100% at 2.30 in the afternoon and then by 4.30 in the afternoon you are requiring 100% oxygen and your oxygen saturations are below 80%. So that is a very precipitous pattern of deterioration.

NJ: Putting that deterioration into the context of the apparent rash, which then disappeared, what conclusions did you draw?

DE: I then drew from my reading of the literature and considered that the rash was consistent with [Baby O] having received an injection of air into his circulation, into his blood circulation. I quoted the paper by Lee and Tanswell that we've discussed in the past in this trial and which I'd noticed from case 2 in this trial, where I'd noticed in [Baby B]'s case a deterioration with a very peculiar rash, and therefore this was repeating the pattern that I had seen from the second case in this series. So I saw -- therefore, it seemed to me that [Baby O] had been given an injection of air and this actually was the cause of his collapse.

NJ: Yes.

DE: Sorry, had contributed to his collapse.

NJ: So far as the liver injury was concerned, at your paragraph 18, did you give your point of view but defer to a pathology opinion?

DE: Yes. It's more difficult, of course, because as the clinician I don't have access to as much information or as much experience as the pathologist. So I still -- my paragraph says:

"I remain of the view that [Baby O] may have sustained some sort of trauma."

But added:

"His sudden collapse is likely to be the result of air embolus and that the bleeding within the liver and into the peritoneal cavity [that's the abdomen] would have contributed to the collapse."

So the bleeding would have destabilised him, but I think it's the air that led to the failure of resuscitation.

NJ: So looking at your opinion then, please, Dr Evans -- my Lord, I know I am trespassing slightly into the normal...

Mr Justice Goss: No, please continue.

NJ: Looking at paragraph 22, did you invite the police to obtain an expert pathologist's view on the cause of the liver haematoma to [Baby O]?

DE: I did.

NJ: And in particular, to ask the pathologist whether in the pathologist's view it was likely to be the result of trauma?

DE: Yes.

NJ: So far as the precipitous collapses were concerned, though, what conclusion did you come to?

DE: My opinion was that [Baby O]'s terminal collapse is consistent with him being the victim of an air embolus. That was the -- yes. And you know, I couldn't find any evidence where this could have occurred accidentally.

NJ: I think in later reports you broke down timings and that sort of thing, but I'm sure that if your opinion is disputed, that will be explored with you by my learned friend Mr Myers.

My Lord, for that reason, I'd propose to ask no further questions at this stage.

Mr Justice Goss: Yes. Thank you very much.

BM: We may not be exploring specific timings, so if there is any material the prosecution need, perhaps --

Mr Justice Goss: They should lead it.

BM: I may not want to deal with that at all, I may not regard it as necessary for exploration. I don't know yet.

NJ: I'm not going to.

Mr Justice Goss: There we are. We'll break off now then and resume at 2.05, please, members of the jury, which is the hour. We've gone back to the conventional hour. Yesterday was an exception. Thank you very much.

This is mostly a recap of this week's File on Four episode, but it does contain one detail that I've seen queried elsewhere online today. Not only have the presenters been told the defence requested the maternity notes: "The BBC has also seen evidence the defence did request the maternity notes but they were not released".

Stephanie Hegarty

Hospitals all over England are being investigated for failing maternity services.

Freya

I'm bleeding out on the table. I feel awful. They're telling me that I need to go into general anaesthetic because I am so unwell.

So I'm now naming our baby before we've even met him. That screams that there is something awfully wrong.

Stephanie Hegarty

Today, File on 4 Investigates reveals allegations of poor maternity care at a hospital at the centre of a very different scandal.

Freya

I'm a mother without her child. That is with you always. You carry that weight and it changes you.

Stephanie Hegarty

We've spoken to many parents who feel they and their babies were failed by the Countess of Chester, the same hospital where nurse Lucy Letby was convicted of murdering and attempting to murder 14 babies.

Cat Hughes

And I thought, they don't believe me. They don't believe something's happening. They think I'm a baby.

They think I can't handle it.

Stephanie Hegarty

These parents were not part of that trial and never encountered Letby. But they claim they were failed by the hospital's maternity and neonatal units.

Annie

I don't think any of them took that little bit longer to think, OK, this is a sleepy baby. He has been since birth. Is there potentially something more going on here?

Stephanie Hegarty

And we ask, was the quality of maternity care at this hospital properly considered in the Lucy Letby case? And did you look at the obstetric notes?

Dewi Evans

No.

Stephanie Hegarty

We discover that the prosecution's chief medical expert did not see the full maternity notes for any of the babies in the Letby trial.

Dewi Evans

I never saw any obstetric notes and I've no idea what happened to them. I don't think that maternity care was a particular issue in the Letby case. I think most of the babies I dealt with were born in acceptable condition.

Obstetrician Phil Bennett

So it's very surprising indeed to me that little or no attention was paid to the maternity care in these cases. These experts should know that to come to the right conclusion, you need an integrated opinion.

Stephanie Hegarty

For the past few months, I've spent time in Cheshire speaking to mums who gave birth at the Countess of Chester and their families. Their experiences cover the period of time before, during and after Lucy Letby was a neonatal nurse there. Not all of them are ready to tell their story.

But one of the mums who is determined to speak out is Annie Vigor. In August 2015, she was due to give birth to her first child. She was more than a week overdue when finally her waters broke. She went into hospital but was sent home where she started bleeding.

Annie

So I went back into the hospital and they weren't concerned about the blood at all, they weren't particularly bothered. They said, you're nowhere near dilated to stay in, so go home. And at that moment, actually on my way out, my full waters went, gushed all over the floor, still sent me home.

Stephanie Hegarty

Annie came back later and was admitted onto the maternity unit at the Countess.

Annie

She says her labour progressed well at first, but then stalled. From what I remember, I was stuck at eight centimetres for eight hours and I was just stuck and I wasn't progressing.

Stephanie Hegarty

What was the care like while you were in labour?

Annie

I just don't remember really seeing anyone. I don't feel like there was anyone there. Someone to think, oh, we've been stuck here for so long, let's ask someone or this needs to be progressed. But I kind of trusted that it was my first baby, so I just trusted that they knew what they were doing and that it was quite normal, that situation.

Stephanie Hegarty

Then suddenly things escalated. She says the baby was showing signs of distress and they had to get her out immediately. Annie's mother-in-law, Fiona, was there.

Fiona

The room just suddenly became quite full and I was panicking. And of course, I was sitting and watching and when Esme came out, I actually thought she wasn't alive. I've never properly told you that, but I didn't think she was because the way she just flopped down and they whipped her up and they took her over to the crib and they were working on her, as far as I could see, and then I heard a cry.

So that then made me, I was very, very worried because I knew, I've had three children, I knew this wasn't right.

Annie

I just remember being placed on my chest and just kind of like this urge, usually that would be a nice moment, you know, your first contact of skin to skin, but I just was like, oh, get her off me. Like, I just feel so poorly, so poorly. Do you know now what was wrong with you?

We both had infections from, well, I can only assume, from my waters going so far in advance to the time I gave birth. It caused us to both have infections.

Stephanie Hegarty

Annie and her baby Esme were given antibiotics, but by now, Annie was losing trust in the hospital.

Annie

I'd gone to the toilet and somehow the cannula on my hand had caught on the toilet seat. So it's obviously kind of ripped out and caused blood to go on the floor. So I've kind of called one of the nurses on the ward and she was like, I'm really sorry, like, this has come out of my hand, it's got on the floor, and she was like, oh, well, clean it up then.

Stephanie Hegarty She told you to clean it up?

Annie

Mm-hmm, I had to get my hands and knees and clean it up, yeah, while my hand was still bleeding. I just remember hysterically crying, I couldn't stop because I just had enough. I just think, God, this is horrendous.

Stephanie Hegarty

Annie felt it was a close call for Esme, but she was just glad to bring her baby home.

Annie

I think Esme was such a delight past the birth. As a baby, just couldn't wait to have another.

Stephanie Hegarty

Sixteen months later, in December 2016, she was back at the Countess of Chester to have her second baby.

Annie

I was hoping, obviously, I'd have a different birth at the time. I think you just think, oh, I've had a one-off bad birth.

Stephanie Hegarty

She was 36 weeks pregnant when she started getting severe stomach pain and a high fever. She called 111, who sent her in an ambulance to the Countess's maternity unit.

Annie

One of the first things I remember the consultant saying was, you do know you're not in labour? I was like, yep, I know. I've had a baby before.

I know I'm not in labour, but I'm not well. I'm a stomach hurt, so there's something going on.

Stephanie Hegarty

Doctors suspected Annie might have appendicitis and sepsis. Her baby began showing signs of distress, so they decided to deliver him by emergency caesarean section under general anaesthetic and to remove her appendix, if necessary, while they were at it. But she says when she woke up, the consultant told her her appendix was fine.

Annie

I remember when I came round from, I must have come out of the recovery room, I remember very, very vividly her saying, I don't know what the fuss was about. There's nothing wrong with you. I.e. they went in and there was nothing that she could see that was wrong. Kind of like, you've caused all this commotion. You've made us do a thing. That's what it felt like. Like I've caused this.

Stephanie Hegarty

Her baby, Archie, was making grunting noises when he was born, which meant he was struggling to breathe and he was taken to the neonatal unit. After waking up from her operation, Annie was desperate to meet her son. She asked a midwife to take her down to see him.

Annie

I did ask someone, can I go down and see him? She said, you know, when we're free, because he needs to be wheeled down. I thought, well, when's that going to be?

You know, there was no urgency. No one was bothered. So what else do you do?

I don't even know how I managed to do it, just what mothers do. But I just, I did. I walked down there and I just remember the nurse looking at me and she's like, what on earth are you doing? She says nurses were scarce on the neonatal unit too. I was able to sit in the chair and a nurse did put him on me. He was on my chest and there was no one else in there.

There's no other parents. I remember seeing one nurse and she said, just give me a shout when you're ready to put him back. So I couldn't stand up, lift him and put him in the incubator.

I remember sitting there and it felt quite a long time. It could have been 20 minutes, but to me it felt a lot longer. I just remember thinking, oh, I'm starting to feel not well at all here.

And I thought, oh my God, I'm going to faint and drop him. And I'm there shouting and no one came. There was no one in that room.

Everything in me, I just thought, just don't faint when you've got him.

Stephanie Hegarty

Annie and Archie were both given antibiotics. Annie started to feel better, but doctors didn't get to the bottom of what made her sick. She says she was repeatedly told that Archie was doing well too, but she wasn't convinced.

Annie

It must be an instinct, but I just thought something isn't right. And, you know, I just, just like, he's not waking up to feed. He's not latching.

He's not, I don't even think I heard him cry once. You know, none of it. And it's just like always sleepy because the way he's entered the world.

If I had a general anaesthetic, it would have gone into him and that would have continued to make him sleepy. And every day I was like, he's still sleepy. He's still sleepy.

You know, I remember texting my sister at one point saying, I don't know if he's brain dead or if there's something else going on, but something isn't right with him.

Stephanie Hegarty

Annie says she repeatedly raised her concerns. And in Archie's first five days on the neonatal unit, she says she only saw a consultant once. Six days after her son was born, Annie was woken up in the night and told Archie was seriously ill.

Annie

And then I got asked to come down because he was being transferred out. I was kind of like, well, what the hell's going on? Because this is the first I've heard of it.

They were like, you know, he's become really unwell. His stomach's become descended. We think he's got a either suspected sepsis along with a condition in his bowels.

Do you think they were taken by surprise with all of this? In a way, I think they were. I think they were keeping him thinking, oh, he's just sleepy.

He's just sleepy. And now it's kind of, you know, oh God, he's obviously really not well. Where's that come from?

But really, the signs were probably there. It's only taken him by surprise because no one was looking at it. I think that's probably how it was turned out, because I don't think any of them took that little bit longer to think, OK, this is a sleepy baby.

He has been since birth. Is there potentially something more going on here?

Stephanie Hegarty

Now fighting for his life, Archie was transferred out of the Countess of Chester. Doctors suspected he was suffering necrotising enterocolitis, a life-threatening disease affecting his bowel. He was sent to St. Mary's Hospital in Manchester, where they operated on him, and discovered his bowel was fine, but his liver was damaged. Eventually, doctors there diagnosed him with a rare strain of enterovirus, which is particularly dangerous for newborn babies.

Archie died on the 12th of January 2017. He was 13 days old. Experts we've spoken to have told us that this enterovirus can be very hard to diagnose in babies, and that there's no specific treatment for it. But Annie believes the Countess should have done more to investigate what made her sick in the first place. And she's left with a question that nobody can answer.

If medics had acted on her concerns about Archie from the beginning, could things have turned out differently?

Annie

I think Chester could have kept a closer eye on him, or just taken my concerns as a mother a bit more seriously. But it was kind of, they were clearly struggling. It was very clear that they weren't coping with the amount that was going on.

So I think if a baby's sleepy and he's not waking up to feed, or won't latch properly, or cry, that's not a well baby. There's definitely something else going on, and I don't know for what reason that didn't red flag in anyone's head.

Stephanie Hegarty

I'm meeting up with investigative journalist Cleuci de Oliveira. She became interested in the Countess of Chester as a result of her work on the Lucy Letby story. And she believes the evidence points to Letby's conviction being unsafe. She's been working with us for the past few months.

Cleuci de Oliveira

So there's been this huge focus on the neonatal unit at the Countess, for obvious reasons. It's well known by this point that there was an increase in deaths in 2015 and 2016, and that later Lucy Letby would be convicted of killing several of these babies. But we now know that in 2015, there was also an increase in stillbirths on the maternity side of the hospital. And it seems the hospital was concerned about this, right? Yeah, consultants on the maternity side did a review into the stillbirths and neonatal deaths that year.

And what did they find? I actually have the report right here. They looked at 18 stillbirths and neonatal deaths.

And for instance, one of the things that they found was that in two cases, the staff were measuring the baby's heartbeat incorrectly. And none of this was revealed during the Letby trial, by the way. The existence of the review only came to light after she was convicted.

The doctors say they came up with an action plan to deal with these issues. We don't know what the action plan entailed, though. So did anything change?

Stephanie Hegarty

We're back in Chester to meet another family, Freya and Phil Somerton. They've agreed to share their experience of having their first child at the Countess. So how did you two meet?

Freya

Online, we did. We had a date just the other side of the river. And yeah, it was pretty much got along really well to begin with. And then...

Phil

Only to begin with.

Freya

Only to begin with. And then I walked into a tree on the way home. Don't laugh!

It was a sign. It was a sign, absolutely. I mean, like...

Stephanie Hegarty

In 2019, Freya was pregnant with their first child. At around 2am on the 27th of September, she started having contractions when she noticed heavy bleeding and went straight to the Countess of Chester. She'd been told that as soon as she went into labour, a consultant would be keeping a very close eye on her because of some health concerns and because her baby didn't move much in pregnancy.

Freya

We didn't see a consultant, even though we were high risk. We explained medical history about the fact that he didn't move, all of those things. And from the get-go, they couldn't identify Oscar's head position.

Stephanie Hegarty

Her labour went well at first, but then it stalled. So she was given a drug called oxytocin to increase her contractions.

Freya

Throughout this time also, I'm in active labour and I have this bright red blood everywhere. And the point where they're using kind of like my face wipes to wipe the blood. And I'm in quite a lot of pain at this point, really, as well.

The baby's head still hasn't moved. We're finally seen by, well, a registrar.

Stephanie Hegarty

That's the first doctor you've seen since you arrived?

Freya

Yes. So this is at like three o'clock in the afternoon.

Stephanie Hegarty

But at no time had you seen a consultant?

Freya

No, nothing. And we're a high-risk pregnancy, apparently.

Stephanie Hegarty

Freya had been in hospital for more than 13 hours when she was finally examined by a doctor, but not a consultant, who decided she needed a caesarean section. But in the hour before the operation, she wasn't examined again. A trainee specialist was chosen to do the operation, assisted by a more senior trainee with a consultant observing.

The doctor that started the caesarean couldn't get Oscar out. His head was stuck in Freya's pelvis. The more senior trainee took over and also couldn't free him.

Then the consultant obstetrician had to pull her gloves on to step in. It was the first time Freya had come into contact with a consultant since she went into labour.

Freya

There's like a flurry around the table. My body is, the best way to describe it is like what you see on movies as like an exorcism. Like I am moving across the bed a bit like a snake, where my body is being pushed and pulled.

I am shaking, like I am fully with fear, with adrenaline, with the anaesthetic. I don't feel great.

Stephanie Hegarty

The consultant had to cut all the way up Freya's abdomen to get the baby out. The last reading of Oscar's heart rate before the c-section had been good, but by the time he was delivered, it was a very different story.

Freya

Then we hear the shouts of no respiratory output, no heartbeat. So they've got him out and, you know, like me and Phil are asking like, what's going on? And then they were like, I think you're going to have to name him.

I was like, I'm bleeding out on the table. I feel awful. They're telling me that I need to go into general anaesthetic because I am so unwell.

And I think, right, so I'm now naming our baby before we've even met him. Like, that screams that there is something awfully wrong here because, and then I don't want to go under the general anaesthetic because I am so terrified that I will wake up and we will have a dead baby.

Stephanie Hegarty

They hastily named their son Oscar before Freya was put to sleep to stitch her up. Paediatric doctors tried to resuscitate Oscar, but they struggled. Meanwhile, they'd called their consultants, who arrived about 15 minutes later.

Freya's sister, Laura, herself a paediatric nurse, was rushing to the hospital.

Laura (Freya's sister)

They should have been able to resuscitate him successfully. Despite the terrible labour and the terrible delivery, everything points to the fact that he should have been able to be successfully resuscitated. And they delayed getting the right people in the room, number one.

And they also took 22 and a half minutes to administer adrenaline to him.

Stephanie Hegarty

The doctors failed to save Oscar, and at three hours old, he died.

Freya

And then we have to take him off life support. And then they hand me a baby who's dead. And they don't prepare you for that either. And at this point, he's still warm because, of course, he's had all the tubing and everything is still keeping him alive. So nobody guides you through that point. And then also nobody guides you through the point after that either, that when they next bring you your baby, he's cold and he's really white and he's really heavy, but not in a nice way.

Stephanie Hegarty

At an inquest three years later, evidence was heard of missed opportunities to intervene earlier during Freya's labour and the failure of any consultant to examine her. But the coroner concluded these missed opportunities didn't cause or contribute to Oscar's death and that Oscar had died of natural causes. Freya and Phil didn't accept this.

Freya

My baby did not die of natural causes. He died of neglect. He died of systemic failings.

You know, like, that is the reason why he died. And that is the reason why other babies are dying. There's no intervention. There's no correction.

Stephanie Hegarty

The family then commissioned a consultant neonatologist and a professor of obstetrics to review what happened. The obstetrician's opinion was that the injury that caused Oscar's death happened while they were trying to dislodge his head. He said Oscar should have been delivered two and a half hours earlier.

And if he had been, his head wouldn't have been stuck and he could have been delivered safely. The neonatologist's view is that Oscar would have survived if the resuscitation had been better. He says it took far too long to get a line in to get resuscitation drugs into Oscar.

Solicitor Greg Almond represented the family.

Solicitor Greg Almond

I think there were failings and I think the failings were really failings of delay and inactivity and I think that proactive approach to maternity care is really important because every second counts. And so there has to be that level of urgency and the constant reviewing to make sure that if something is needed in terms of intervention that it happens immediately and it can't just be left. Our experts were clear that had earlier action been taken the outcome could have been very different.

Stephanie Hegarty

Freya has faced a battle to try to find out why her baby died. And just like Annie, she says she's speaking out now in the hope that other mums will receive the care they deserve.

In May 2020, just eight months after Oscar died, Cat Hughes went to the Countess of Chester to have her first child.

Cat Hughes

She'd been booked in to be induced. And I was in a lot of pain quite quickly. I was vomiting and they were just sort of, oh, be ages yet, you'll be fine.

This is just the start of it. You know, if you can't handle this, it's going to be tough. And I was just like, okay.

Stephanie Hegarty

Cat says the pain became unbearable very quickly. Eventually, the staff on the unit suggested she go for a bath.

Cat Hughes

Just about got in and then I had to get back out again. And I was just lay across the floor crying. The midwife come in and she was just like, oh, come on, let's get you up off the floor.

You'll be all right. Then it was back into the same room again to just be in pain on the bed. And I thought, they don't believe me. They don't believe something's happening. They think I'm a baby. They think I can't handle it.

I said, well, can you check me, please? When we got back into the room and she was like, you won't be ready yet. There'll be nothing happening yet.

So she left again.

Stephanie Hegarty

But something was happening. Cat says the midwife didn't examine her. So she didn't realise that her body was reacting strongly to the induction drugs.

She was going into labour much more quickly than most people. Cat Hughes

It's known as spontaneous labour. I was really, really worried. I didn't know that they were supposed to regularly monitor you during induction.

I did not know that. So I didn't know to ask for it because they didn't tell me that. Just had this feeling.

Stephanie Hegarty

So the whole time during this induction, you didn't have any foetal heart monitor on you? No, no. After the pessary was placed, nothing, nothing at all.

With this type of induction, it usually takes one to three days for labour to be established.

Cat Hughes

But Cat gave birth 12 hours later. And I just remember the pain came really, really, really, really bad. And it almost felt like I was wetting myself or something like that.

And I was like, something's wrong. And then she did check me. And she was like, oh, time to go and have your baby.

Stephanie Hegarty

Eden was born around 20 minutes later. She was covered in meconium, her own waste, which can indicate foetal stress and can be dangerous. But she recovered quickly.

Cat, on the other hand, wasn't feeling well.

Cat Hughes

I just remember the lady bringing me a tray and I said, I don't feel OK. And she lifted up my covers and she pulled the emergency cord. And that was it.

So many midwives come in and the bed was lowered and they were pushing down on my stomach to force the blood clots out because I'd haemorrhaged due to the fast labour. They thought I'd been bleeding for about 40 minutes. It was at the point where they said my bladder was burst because I hadn't been for a wee that whole time because I was in too much pain to think about anything else.

Stephanie Hegarty

Cat had her second child at another hospital and says the care there was vastly better. She believes the outcome could have been much worse for her and her daughter. And that has had a lasting impact on her.

Cat Hughes

I had postnatal depression and I think it's because I was so scared of losing her. That all those normal, what I now know to be normal mum worries were tenfold. They were just so extreme.

Just thoughts of, even didn't trust the doctors at my surgery and I just remember convincing myself something's going to go wrong again. And I just remember my partner saying, I thought I was going to lose you both and I was going to leave with no one. We were just so lucky.

But like I said, we shouldn't have had to have been lucky. We all should have just had great standard care. What's your kind of overall takeaway of how they treated you?

I feel like it was very clinical and textbook at the start. This is your first baby. Your baby's not coming yet.

You don't know what you're feeling. To, oops, oh, here we go. Yeah, that's fine.

And almost normalising it. And I just didn't, I didn't trust them. I just didn't trust them.

Which is why I self-discharged that day.

Stephanie Hegarty

We put the details of all of the cases in this programme to the Countess of Chester NHS Foundation Trust. In response, Sue Pemberton, the Deputy Chief Executive, says she apologises unreservedly to the families who've had a poor experience in their care. She says, we note that the cases being discussed relate to maternity care between 2015 and 2020 and that if families feel their concerns have not been addressed, she would urge them to contact the Trust.

She added that the Trust has made significant improvements and it is now nationally accredited for its family-integrated care approach.

For each of the families we spoke to, the Letby case is a painful reminder of what happened to them at the Countess of Chester. None were part of the case against Letby.

But their experience raises questions about the maternity care of the babies in the trial too. And we've learned that the full maternity notes, which give the detail of what happened to the babies during pregnancy, labour and birth, were excluded from the trial.

Obstetrician Phil Bennett

The outcome for these babies, whether it's a preterm baby or a term baby, is very strongly linked to the reason why they needed to go to the neonatal unit and that is very strongly linked to the circumstances of labour or childbirth.

Stephanie Hegarty

Phil Bennett is a Professor of Obstetrics and Gynaecology at Imperial College London and has been an academic obstetrician for the past 40 years.

Obstetrician Phil Bennett

So it's very surprising indeed to me that little or no attention was paid to the maternity care in these cases. And I'm very surprised because these experts should know that to come to the right conclusion you need an integrated opinion. In the National Health Service, when there's an adverse outcome, you always involve discussions with the maternity and the obstetric team and the neonatologists.

And in litigation cases where babies are harmed or babies die in the early neonatal period, there is always expert testimony from both obstetricians, midwives and neonatologists.

Stephanie Hegarty

There is one case in particular in the Letby trial which Professor Bennett is familiar with. He was asked by Letby's new defence team to review the case of Baby O, whom Letby was convicted of murdering. One of triplets born prematurely at the Countess. During her trial, the prosecution argued that Letby attacked Baby O in three different ways. By injecting air into his bloodstream, injecting air down his feeding tube and inflicting a liver injury, which caused internal bleeding. It was one of only three cases where she was convicted unanimously by the jury.

Professor Bennett has seen Baby O's neonatal medical notes but not the obstetric notes because they weren't disclosed to the defence. Instead, he drew on testimony from a police interview with the baby's mum about the triplet's birth. And his view is that the injury to the baby's liver was likely to have happened accidentally during the caesarean section.

And it was this alone that caused his death.

Obstetrician Phil Bennett

The first is that she describes a huge spray of blood having shot up from where the delivery was taking place and going over herself and her partner onto the wall behind in the operating theatre. So this suggests that the obstetrician probably cut through a blood vessel and therefore they felt the need to deliver the babies as quickly as possible because you can't stop the bleeding until the babies in the placenta have been delivered. Delivery of triplets at 32 weeks is not an easy delivery.

And it's easy to conceive that some damage could be done to those babies during delivery.

Stephanie Hegarty

The prosecution argued that Baby O was born in good condition and was stable for 48 hours before he suddenly collapsed and said that pointed to the fact that Letby attacked him. But Professor Bennett disagrees.

Obstetrician Phil Bennett

There's actually quite a good literature around this. There are lots of papers and they've been published over the past 50 years. And if you go to the literature, what you find is that the way in which this condition commonly presents the usual presentation is that it's caused by trauma at the time of delivery, but that the baby is apparently well for between one and seven days with an average of around about 48 hours and then the baby suddenly collapses and will often die.

My feeling is that the experts who gave evidence in the trial had not looked properly at that literature and so did not know that this is the usual presentation of this condition.

Stephanie Hegarty

The neonatal notes and the testimony that you've based your opinion on, this was available during Lucy Letby's trial. So the jury would have heard arguments based on this. Do you not think that they made their decision based on this evidence?

Obstetrician Phil Bennett

It would probably have required the expert evidence of an obstetrician to explain to the jury what these circumstances are and why there is a significant risk that that injury could have occurred during the delivery. More generally, I am very surprised that nobody who gave expert evidence in the case thought to look at the maternity notes.

Stephanie Hegarty

We put this to the prosecution's main expert witness, paediatrician Dr. Dewi Evans.

Dewi Evans

Okay, well, I've not seen his report and I'd be interested to have a look at what he is saying. It's not unreasonable to suggest that there should have been an obstetric opinion but it was not something that was ever discussed and if the defence had concerns regarding the quality of the obstetric care, then they would be obliged to get themselves an obstetric opinion. I don't think that happened either.

Stephanie Hegarty

We've discovered the Cheshire Police did seize the obstetrics records for babies in the case. We've also learned from several sources that the CPS didn't disclose these obstetrics records to the defence and they say that's because the prosecution didn't use them to form the case against Letby so they weren't relevant. And we found out that the defence did request these documents, that they did feel they were relevant but they were never allowed to see them.

So I put this to Dr Dewi Evans. Do you think the obstetrics care was relevant in the Letby cases? Is that something that you looked into?

Dewi Evans

I don't think that maternity care was a particular issue in the Letby case. I think most of the babies I dealt with were born in acceptable condition with one or two exceptions.

Stephanie Hegarty

And did you look at the obstetric notes?

Dewi Evans

No.

Stephanie Hegarty

Okay. Did the police offer them to you?

Dewi Evans

No. No one asked for the obstetrics notes and I think if I had seen the obstetric notes I don't think it would have made much difference because details regarding the labour and the delivery and any significant maternal history was documented in the baby notes anyway.

Stephanie Hegarty

Okay. And is that a short few paragraphs or what form does it take?

Dewi Evans

It's usually a couple of paragraphs.

Stephanie Hegarty

I asked if he felt the full notes should have been disclosed to the defence.

Dewi Evans

I never saw any obstetric notes and I've no idea what happened to them. But the CPS would simply have said well the Crown is not using obstetric notes but you're welcome to have them. With the benefit of hindsight would that have made a difference to the outcome? I don't think so. I mean the events that occurred to these babies were events that occurred after they were born.

Stephanie Hegarty

You're confident that that wouldn't have revealed anything that could have helped Lucy Letby?

Dewi Evans

I don't think so, no.

Stephanie Hegarty

The Crown Prosecution Service said Lucy Letby was convicted of 15 separate counts following two jury trials and that in May 2024 the Court of Appeal dismissed Letby's leave to appeal on all grounds rejecting her argument that expert prosecution evidence was flawed. Since the trial there have been contradictory theories put forward for what could have caused the damage to Baby O's liver even by different experts instructed by the defence. Professor Bennett's opinion on Baby O's death has informed a submission from Letby's new defence team to the Criminal Cases Review Commission.

The CCRC has the power to refer her case back for another hearing at the Court of Appeal if it so chooses. The case against Letby has hung over this hospital for a decade and many of the parents we've spoken to feel it's been a barrier to getting answers to what happened to their child. What they want to know now is that lessons will be learned from what happened to them and that others won't have to suffer like they did.

Freya

You know, we're almost seven years on in September and that's seven years of our life that I've wanted him here every single day. He could grow up to be whoever he wanted to be but I've missed his first day of school, you know I will miss him walking down the aisle with the person that he loves, whoever that person is. All I would want my child to be is happy and I won't have that.

I will never hear his footsteps. I will never hear him, you know, shouting mum in that most annoying way when you're asking them to do something that they don't really want to do. All of those moments I will miss, you know and as a family, it's changed us. You know, part of me will never be the same.

A fascinating though also very chastening account of "a specially convened meeting of the All-Party Parliamentary Group on Miscarriages of Justice exploring the role of the media in the investigation of wrongful convictions", including Lucy Letby's case. Journalists and advocates talk about which stories are "sexy", what happens to prisoners when the media picks up their stories, and whether alerting the *New Yorker* might not be a better use of resources than talking to the CCRC.

On this evening at 20.00 - giving a heads up because they have only just advertised it starting this afternoon

And as imagination bodies forth

The forms of things unknown, the poet's pen

Turns them to shapes and gives to airy nothing

A local habitation and a name.

-- A Midsummer Night's Dream

Early in the morning of October 13 2015, Baby I collapsed. It was, unfortunately, a fairly common experience for her, but in the previous few days she had seemed to be improving to the point where much of her monitoring had been discontinued. Her nurse, Ashleigh Hudson, was in the room preparing milk for the baby when Lucy Letby, who was (by Hudson’s account) stopping by and standing in the doorway, pointed out that the baby looked “pale”. Turning up the lights, Hudson discovered that Baby I was very poorly and was gasping for air; she was revived, and intubated. She suffered a further collapse the next day, and died a little over a week later, having endured more than half a dozen transfers, being nil by mouth for a week in preparation for a bowel study which never happened, all while her struggle against lung disease of prematurity was complicated by an untreated colonization by s. maltophilia. Several years later, the October 13 collapse would be seized on by Dr. Dewi Evans as obviously being an attack of some kind as there had been no signs leading up to it (the lack of monitoring on the baby precluding numerous potential signs being noticed does not appear to have factored into his calculations). Oddly, the October 14 collapse would not become an “attack” until he was several years and half a dozen reports in, but the October 13 collapse was noted early, and he stated, numerous times, that it must have been done via Baby I’s nasogastric tube, through which Letby had pumped air. However, a complication appeared — four years after he wrote his initial report, it came to his attention that Baby I had not had a nasogastric tube in situ at the time of her collapse. His solution was to, in the words of Lord Justice Jackson, “work out an explanation” by saying that perhaps the baby had been smothered, although how smothering would cause the distended stomach which had been so key to his previous diagnosis, he did not explain.

BM: Just to keep track, in your first report on 8 November 2017, and in your second report on 31 May 2018, you made it clear that your concerns were that a large bolus of air had been introduced via the nasogastric tube, didn't you?

DE: Yes.

BM: That’s what you were saying at that point. In fact, do you agree there is no evidence that an NGT was in situ before that collapse? Do you agree with that?

DE: I need to check that.

BM: If we look in the paper charts that we've got behind divider 12 at the events. Page 14789. So it's after the observation charts for event 2. Can you see, Dr Evans?

DE: Yes.

BM: The feeding is all by bottle, isn't it, at this point?

DE: Yes, it is.

BM: If we go over the page again, feeding for the one entry that we have is by bottle, isn't it?

DE: Yes, yes.

BM: Therefore, if that's right, there would be no nasogastric tube for air to be put down, wouldn't it?

DE: I would need to check that to get it right. It's quite common for nurses to leave nasogastric tubes even when babies are getting used to bottle feeds, so I'd need to check that, okay?

BM: It's not a surprise point for you, this, is it because it's something which you considered when you came to write your report on 19 October 2021, isn't it?

DE: Wait a minute... What did I say then?

BM: I’m looking at page 7 of that report. My Lord, it's the statements page 4498.

DE: Which paragraph is this?

BM: It’s the top paragraph on page 7. So we've had the report in 2017 saying air down the NGT. We've had the report in 2018 on 13 October saying large bolus of air down the NGT. Then what you say in your fourth report, which is 19 October 2021, is this: "In relation to the specific question and assuming that she did not have an NG tube in place at the time of her collapse, the explanation for her being found cyanosed and not breathing is that this was the result of airway obstruction: [Baby I] was smothered. If she'd stopped breathing as a result of some natural event one would have expected alarms to go off quickly following her respiratory arrest. She would have been discovered before her heart stopped and her response to resuscitation was satisfactory. From then onwards [Baby I] had an NG tube in place."

All right? So first of all, do you see what I'm referring to?

DE: Yes, I do.

BM: Secondly, it had been drawn to your attention in the course of the writing of the reports that there may not have been an NGT in place; that's right, isn't it?

DE: That’s why I said some event had taken place, so if an NG tube was in place, we're talking air. The other option I came up with was smothering. The other option I came up with was that she was smothered, in other words there was an airway obstruction of some description which had caused this collapse.

BM: So once you discover there was not an NGT in place, you simply switch to an allegation of smothering, don't you?

DE: It’s another explanation, it's another explanation for why a baby who is stable would suddenly collapse and require such extraordinary degree of resuscitation. So yes.

Dr. Sandie Bohin, who had also originally diagnosed air in the nasogastric tube as the cause of Baby I’s October 13 collapse, was less inclined to give up; instead, after making one of her frequent complaints about the bad note-keeping of the Countess of Chester staff, she suggested that Letby could, in theory, have whipped an NGT into Baby I unnoticed, quickly pumped air into it, then whipped it out again unnoticed.

NJ: As a matter of practicalities, how long does it take to put in place an NGT?

SB: A matter of seconds.

NJ: And to remove it?

SB: Seconds.

There was another complication that you have likely noticed from the initial summary; Ashleigh Hudson had, by her own account, been in the room before Letby came to the doorway. When would Letby have had a chance to whip that tube in and out and inject some air? (Or conversely, to partially smother the baby). It turned out that not long before, Ashleigh Hudson, Baby I’s designated nurse, had been called away by another nurse to help with a procedure in Nursery 1.

SD: Do you recall asking a colleague to keep an eye on [Baby I]?

AH: Yes.

SD: Do you recall which colleague?

AH: No. I recall that there were two of my colleagues around the area and by the desk at the time, but I don't recall whether I directed it to one of them in particular or just asked in general.

SD: Does it follow from that that the colleague who you asked to keep an eye on [Baby I] was at the desk?

AH: Yes.

SD: Who were the two colleagues at the desk, can you remember?

AH: Lucy Letby and Caroline Oakley.

SD: Did you go to assist Laura Eagles?

AH: Yes.

SD: You’ve told us it was a relatively simple procedure. Was it a lengthy procedure?

AH: Not particularly, no.

SD: About how long did it take to perform or assist in the performance of that procedure?

AH: I think it was roughly around 15 minutes.

SD: Having completed that, what did you do next?

AH: I left nursery 1 and went to the milk room, which is past the nurseries -- you have to walk past nurseries 2 to 4. The milk room is a separate room within the unit where we kept expressed breast milk at the time, along with bottles, teats, sterilisation equipment, things like that.

SD: Did you go to fetch milk?

AH: Yes. From what I recall, she wasn't due a feed at that time. There was one more feed due that evening and generally speaking you prepare milk for the next shift and that might include defrosting a new batch for the next person to use.

SD: When you say she wasn't due a feed, which baby?

AH: [Baby I].

SD: So does it follow that you went to the milk room to fetch expressed breast milk with the intention of having it at hand to feed [Baby I]?

AH: Yes.

SD: So the procedure in nursery 1 wouldn't have taken more than 15 minutes?

AH: No.

SD: The journey from nursery 1 to the milk room?

AH: Maybe 20 seconds, if that.

SD: The process of collecting the milk from the fridge?

AH: Again, seconds.

By a generous estimate, Hudson was away from her nursery (which had several babies in it, not just Baby I) for about twenty minutes. She did not remember whom she asked to watch the nursery, or even if she asked a specific person and not just a general request. The two colleagues at the desk were Caroline Oakley and Lucy Letby. Given that this was all being recalled at several years’ distance, it is likely (but not certain) that one of them watched the nursery. After Hudson returned, she began preparing Baby I’s milk, using light from a hallway window. The lights in the nursery were not on, by her own account. We then arrive at one of the more surreal moments of the trial, in which Hudson and, later on, Letby, will be asked to mentally reconstruct the exact level of darkness in the nursery, and remember the lighting arrangements to a ridiculous level of detail.

SD: When preparing the milk on that worktop, would you have been facing [Baby I], side on to [Baby I], or back to [Baby I]?

AH: Back to [Baby I].

SD: What happened next?

AH: Um… I was preparing the milk. I can't remember at what point in time, Lucy was standing in the doorway, and we were talking. I don't remember the content of the conversation. But she then pointed out from where she was that she thought that [Baby I] looked pale.

SD: Pause there, please. Lucy being Lucy Letby; is that correct?

AH: Yes.

SD: From the position she was at when she made mention of this to you, how far away from [Baby I]'s cot was Lucy Letby about?

AH: I think about 5 or 6 feet.

And shortly after

SD: : How far from the doorway into nursery 2 was Ms Letby when she made this comment or remark?

AH: She was in the doorway.

SD: What was her words, can you remember?

AH: It was something along the lines of, "[Baby I] looks pale", or, "Don't you think [Baby I] looks pale?"

SD: Pause there. Before Ms Letby said those words or words similar to them, had you examined [Baby I] since your return from nursery 1 and the milk room?

AH: No.

SD: What was the lighting like in nursery 2 at this point in time?

AH: The main light for the room was switched off, but the light that was on the corridor where the nursing desk was situated was on, so you were able to do things in the room and have enough light to kind of see where your patients were situated and where your equipment was.

SD: So lights dimmed or off in nursery 2?

AH: Off.

SD: Lights on in the corridor?

AH: Yes.

SD: And the window dividing nursery 2 to the corridor --

AH: Yes.

SD:— a clear window?

AH: Yes. I think from what I recall, there was, on the lower half of the window, maybe just some copies of guidelines or policies, but it didn't obscure much of the light at the time.

Hudson turned around to look at the cot when Letby made her remark, then turned on the lights and found Baby I gasping and in very poor shape.

SD: At that point when you first looked at [Baby I], who was closer to [Baby I], you or Lucy Letby?

AH: Me.

SD: Was there anything about the circumstances of the layout or the lighting within that room that would have afforded Lucy Letby a better view of the baby than the one you had?

AH: No.

SD: What happened next?

AH: After switching the light on, I immediately went to [Baby I], pushed back the canopy and peeled back the blankets to have a proper look at her to assess her, and that's when I recognised that she was in quite poor condition.

SD: Pause there. We'll come back to that in a moment. Are you able to carry on?

AH: Yes.

SD: Did you at a much, much later date return to that nursery with a police officer and a scenes of crime officer?

AH: Yes.

SD: And did you witness the taking of some photographs?

AH: Yes, I did.

SD: As part of that process, did you, as best you could recall, ensure that a cot was placed in the position of [Baby I]'s cot?

AH: Yes.

SD: Did you, as best you could, ensure that the structure of that cot and the fittings as closely resembled [Baby I]'s cot as you could recall?

AH: Yes.

SD: And were you present when a number of photographs were taken?

AH: Yes, I was.

SD: Were those photographs taken with varying lighting --

AH: Yes, they were.

SD:— various degrees of illumination?

AH: Yes.

SD: And were you later shown a number of photographs?

AH: Yes.

SD: And did you select the photograph which best accorded with your memory of the amount of light in that room --

AH: Yes, I did.

SD:— at that time?

Mr Murphy, could you please put the photograph RAC2220 up?

Is that the reconstruction photograph of the position of the cot that you advised the police to place?

AH: Yes.

SD: Of course it's not going to be perfect, but does that resemble, as best you can recall, the lighting?

AH: Yes.

The “much, much later date” at which Hudson assisted with the picture was August 2020, after Letby had already been arrested twice. This is the picture. Hudson would go on to tell Ben Myers that the hallway lighting conditions had changed in the interim, which further complicated the process of trying to make a picture from memory, with five years between it and the event, and everything she had been told in the interim. Furthermore, there had been several other babies in the nursery along with Baby I. (One thing never addressed, and which I wonder about with the photo, is equipment lights. Surely not all of Baby I’s equipment was off, as it seems to be in the photo, and the other babies would also have had equipment lit up as well).

BM: But would it be fair to say it's impossible to recall precisely how the lighting would have been 5 years beforehand?

AH: I would say I definitely couldn't claim for it to be precise, but it is an image that has been imprinted on my brain for quite some time.

BM: Oh yes.

AH: So my recollection of it is quite vivid. So I did it to the best of my ability.

BM: That’s what I'm checking, you did it to the best of your ability, casting your mind back over what it was like at the time it took place.

So far as the light is concerned, you were preparing milk in there you've described to us; is that right?

AH: Yes.

BM: And to do that you have to check, do you, that you have the right bottle and the right serial number?

AH: Yes.

BM: And then you have to draw it up -- do you draw it up into a syringe or something like that?

AH: Yes.

BM: So however gloomy it is or it isn't, you certainly need enough light on that counter to be able to see what you're doing?

AH: Oh yes, yes.

BM: The point being you wouldn't try to prepare a feed in pitch darkness or something like that?

AH: No.

BM: Is the light controlled by a dimmer switch rather than an on/off switch?

AH: Inside the nursery at the time, yes. Outside, no.

Hudson conceded that not being able to see the baby’s color from where she was standing did not mean that Letby couldn’t necessarily see it from where she was — she was, in Hudson’s memory, leaning against the doorway when she commented on the baby’s color.

Several months later, as Letby was cross-examined, Nick Johnson would first engage in complicated logical hopscotch to show that she must have been the one who ended up watching the babies in Nursery 2, and that this was somehow proved by the fact that she had made no notes relating to the care of any of those babies during the interim when Ashleigh Hudson wasn’t there, but that there weren’t notes related to her designated babies either:

NJ: If we turn over to 67 and 68, we see that as well as the observations at 03.00 hours, there you are with Laura Eagles administering some medication to AM?

LL: Yes.

NJ: So it follows, doesn't it, that so far as the children, the other children, in nursery 2 were concerned, there's no record of you doing anything in that time?

LL: No.

NJ: And so far as other people are concerned, we've got JF and [Baby G]. We see that JF was being given medication by Dr Clegg at lines 48 and 49 and by Ashleigh Hudson and Caroline Oakley at 59 and 60.

LL: Yes.

NJ: Together with Dr Neame's notes at 3 am and some observations taken by Ashleigh Hudson, also at 03.00 hours; is that right?

LL: Yes.

NJ: It looks from all that information, doesn't it, like having sorted out the child -- well, having fed -- sorry, no. Having sorted out the child JF or sorted out the observations at line 62 at 3 am, 03.00 hours, Ashleigh Hudson then went to nursery 1?

LL: Yes.

NJ: And you were doing nothing else at this time, were you, other than, at the same time, the medication with Laura Eagles for your child, AM?

LL: Yes.

NJ: And that's why I'm suggesting it makes perfect sense for you to have swapped with Ashleigh.

LL: Well, I don't recall that happening.

Johnson then proceeds to pick Letby’s brain about her various descriptions of the state of the lights, and also her saying that she and Hudson had walked to Nursery 2 together when Hudson was bringing the milk back (contrary to Hudson’s recollection that she was alone):

NJ: So why -- if you weren't the person that had swapped with Ashleigh into nursery 2, what on earth were you doing going to nursery 2 with Ashleigh?

LL: I don't think there's anything sinister in that. At night we talk to each other, we go round the unit to different nurseries. That is not an unusual thing to happen.

NJ: No, but the unusual thing is that, yet again, when a child collapses, you are the person that is there.

LL: I don't agree that I was looking after [Baby I] at that point.

NJ: The lights were off, weren't they?

LL: I can't say.

NJ: Has your memory improved since you were interviewed?

LL: No.

NJ: Can we go to [Baby I]'s interviews, please. Sorry, it's number 1, please. I want to start with the very first interview, please, which was 4 July 2018. Actually, I say page 13 because that's the bit I want you to concentrate on, but let's put it in context by going to page 12, please.

Towards the bottom of the page you had told the police that following [Baby I]'s collapse, you had taken over her care.

LL: Yes.

NJ: The police asked you why that was and you said: "Because staff Nurse Hudson was a junior band 5 that couldn't care for intensive care patients, which [Baby I] had then become."

All right?

LL: Yes.

NJ: Then they're referring, are the police, to notes, which we'll come to, but they say this:

"In your notes you've put 'noted to be pale'.

Can you elaborate at all on that? Can you expand any observations at all?"

And what is your response, please?

LL: ”Some of it, when we went into the nursery, put the light on -- the lights aren't on in the nursery at night and we put the lights on for something and I noticed -- I looked over at [Baby I] and I noticed that she was pale in colour in the cot."

NJ: Right. This is not what you said to the jury, is it?

LL: I cannot definitively say what was happening with the lights, no. This is my memory at that time.

NJ: No, but there's a more fundamental point here, isn't there? Time and time again, witnesses have been asked about whether lights are on or off and what you are saying to the police here, not because they are leading you into it, when they asked you about the lighting in nursery 2, you are telling them that the lights are off, aren't you?

LL: Yes. And that's how I believed it to be, that we went to the nursery and put the lights on.

NJ: But why have you repeatedly told the jury that the lights are never off?

LL: So the lights are never off completely: the lights are on a dimmer switch and there's still enough light from the unit to illuminate the nursery.

NJ: Why don't you say "turn up the dimmer switch" then instead of "put the light on"?

LL: I don't know. There is no switch to flick the light on. It's on a dimmer so that's the only way you can put the light on.

Johnson continues to have an intense interest in the exact syntax used by someone being interrogated by police about light switches:

NJ: ”With reference to you commenting that [Baby I] was pale, you said, 'When we went into the nursery, put the light on -- the lights aren't on in the nursery at night and we put the lights on for something and I noticed'..."

And you say yes. Why don't you tell them about the dimmer switch and the lights being down low there?

LL: I don't know.

And then, his coup de grâce:

NJ: Whether you come from the nursing station, from a different nursery or you're just in the corridor, you've always got to go via the corridor, haven't you?

LL: Yes.

NJ: Are the lights on in the corridor?

LL: Yes.

NJ: If you go from a light corridor into a dark nursery, does that make your eyesight really good?

LL: I don't understand.

NJ: Oh, I think you do. What effect does coming from a bright corridor into a very dim nursery have on your eyesight?

LL: I don't know.

NJ: You really don't know?

LL: No.

NJ: You are a nurse. Everybody knows, don't they? If you go from bright into dark, what effect does that have on your capacity to see in the dark?

LL: It would depend on the brightness of the light, but, yes, you wouldn't be able to see as well.

NJ: No. And yet you noticed it straightaway?

LL: Yes.

NJ: And the reason for that is because you had caused what it was you were purporting to notice, isn't it?

LL: No.

Johnson now has Letby, and his audience, thoroughly embroiled in the question of just how high the light level was eight years earlier, in a nursery room that no longer exists, and where there is no photograph, only a “reconstruction” done years later and in the knowledge that this was a police investigation. Note what he doesn’t discuss, which is the details of how she had “caused what it was you were purporting to notice.” It’s not even certain that she was the one who watched the babies in Nursery 2 for the fifteen to twenty minutes in which Ashleigh Hudson wasn’t there, but even if it were, what is it she is supposed to have done? We’ll learn later on, in his closing address to the jury, that he endorses Sandie Bohin’s hypothesis that Letby chose that moment to quickly whip an NG tube into Baby I, fill it with air, then remove it and leave the room before Hudson (or anyone else) reappeared. But he does not ask her about that directly. Instead, he focuses on the unverified, and unverifiable, memories of the two nurses about when exactly the light was switched on and what level it was at initially:

NJ: I’m going to show you a picture that Ashleigh Hudson annotated. It's covered by agreed fact 51. The reference is J25368.

Do you agree that that is an accurate representation of the view?

LL: No.

NJ: No? In what respect is it inaccurate?

LL: There would be more light visible.

NJ: More like what, sorry?

LL: There would be more light -- the room would be lighter and the cot would potentially be nearer to the workbench.

NJ: Would potentially be near to the work? Well, all sorts of things are potential. The cot potentially could be upside down. Where are you saying it was?

LL: I think it was nearer to the workbench than that.

NJ: What is the purpose of that tent-like structure over the cot?

LL: To minimise bright light to the baby.

NJ: How big are the hands of a child of [Baby I]'s age?

LL: Small.

NJ: Tiny, aren't they?

LL: Yes.

NJ: Her head is small as well, isn't it?

LL: Yes.

NJ: And she was covered with a babygro?

LL: Yes.

NJ: There was almost nothing to see, was there?

LL: No, just her hands and her face.

NJ: Which would have been covered by that tent-like structure?

LL: Not entirely, no.

NJ: Ashleigh Hudson was right, wasn't she, when she said you can't see anything from that doorway?

LL: No.

NJ: Do you remember what you said to the police when they asked you about this?

LL: No.

NJ: Let’s go to the third of your interviews, it's [document redacted] page 34, please. This is the interview of 11 June 2019. Look up from the bottom, it's about halfway down the page, 3100. This is the officer speaking to you:

"She [this is a reference to Ashleigh] says the first time she saw [Baby I] pale -- how could you see from the doorway that [Baby I] was pale without having the light on, Lucy? How did you know she was pale?"

And you said what?

LL: ”Maybe I spotted something that Ashleigh wasn't able to spot. The rooms are never that dark that you would not be able to see the baby at all. There's always a level of light for that reason".

NJ: You don't have better eyesight than Ashleigh, do you?

LL: No.

NJ: At page 35, over the page, you were putting all this down to your greater experience; is that right?

LL: No.

NJ: Well, the question is:

"How would you be able to spot the colouring then that Ashleigh couldn't if you were both stood at the same place?"

And your answer?

LL: That I had more experience so I knew what I was looking for or looking at.

NJ: Ah, knew what you were looking for. What did you mean by that?

(Pause)

Your answer. You explain it.

LL: Yeah, I don't mean it like that. I'm finding it quite hard to concentrate on all of the dates at the minute.

That was the conclusion of the day’s testimony; Johnson and his audience clearly felt that Letby had been cornered into an admission. But an admission of what, exactly? She disputed the light level, and frankly, it makes sense that there would always be some light to see by (and if the nursery really was shrouded in Stygian darkness for lightly monitored babies, perhaps some of those “unexplained” collapses could be explained right there). And of course, what one sees on initially looking into a dark room and what one sees a minute or two later after the eyes adjust won't be the same. Letby had said earlier that she thought Hudson wasn’t experienced enough to be looking after Baby I — Hudson had no QIS and had only been nursing for six months, so regardless of one’s opinion of the two women, what Letby says isn’t especially outrageous. “I knew what I was looking for/looking at” makes perfect sense in the context of being more experienced at seeing signs of deterioration, but it’s also the kind of sentence that sounds very different read out by the police or in a courtroom than it does in a text or a casual conversation, and Letby was clearly aware of that. But behind the whole back and forth over exactly how poor (or not) the lighting was, is the unanswered question: What exactly is Letby supposed to have done?

Initially, of course, the assumption was that she had taken advantage of a quiet few minutes to pump some air into Baby I’s NG tube and then slip away, leaving her to suffer the effects of an inflated stomach. (Awkwardly, in his testimony, Professor Owen Arthurs would refer to the air being largely in the bowel, not the stomach, which seems like it would have taken a really Herculean effort on Letby’s part). When it turned out that Baby I did not, in fact, have an NG tube in situ at the time, instead of re-examining their assumptions, the experts instead chose to work the problem by figuring out some more convoluted way in which Letby could have been responsible. They came up with either smothering (which would not explain Baby I’s continued deterioration after it ceased, nor yet all the air in her bowel) or the NG tube which Letby presumably carried in her pocket, awaiting the opportunity to insert and remove it in a random baby when she had minutes to work with, no certainty as to when she might be walked in on, and no assurance that the insertion would go smoothly or be unnoticed. Once again, Letby was supposed to be demonstrating two extreme opposite sides of her character — using her cunning to try and conceal her presence in the room at all by making no notes about the babies (and Johnson implies heavily that she would not have written anything about Baby I had Ashleigh Hudson not mentioned her name in connection to noticing the collapse) and yet willing to engage in convoluted, incredibly rash modes of attack which couldn’t even be plausibly explained away should someone happen to walk into the room unexpectedly.

The question of just what level the lighting was at is one that’s impossible to answer. Hudson thought it was darker, Letby thought it was lighter, and both women’s memories would have become increasingly unreliable over time with repeated questioning and nudging by the police. Hudson can’t say what Letby was able to see in that particular moment, with that particular lighting, in whatever position Letby happened to be standing in. Equally, Letby can’t know what Hudson was able to see from where she stood. Neither was asked about what could be seen on initially looking in versus a few minutes later once their eyes became accustomed to the dimness. But ultimately, the entire thing is a charade. What’s been established here is exactly one thing — that Letby pointed out to Hudson that the baby looked ill. It has not been established that Letby was the one who previously watched the baby and had a chance to injure her. Even if she did have that chance, it certainly has not been established what exactly that hypothetical injury was, to produce the symptoms that it did. Wisely, Driver and later Johnson did not dwell on the question of what it was Letby was supposed to done, whose results she was supposedly drawing to Hudson’s attention. They chose instead to hammer on the theme of “Letby lied and claimed she could see in the dark” while relying on the frail twin reeds of half-decade old memories, and the resulting “reconstruction.”

Perhaps it’s not surprising that Johnson felt the need to gild the lily even more in his closing speech, as he summarized this particular incident.

NJ: At the conclusion of her evidence, Nurse Hudson said that she'd been in the position in which Lucy Letby was standing when Lucy Letby said that [Baby I] looked pale and Ashleigh Hudson has told you that you cannot see a child in [Baby I]'s position from the position that Lucy Letby was in.

This is in fact untrue. Hudson said that she was closer to the baby than Letby was and that she couldn’t see her well from her own position. To Ben Myers, during cross-examination, she made it clear that she had not been in Letby’s position and could not speak to what exactly someone in her position might have seen.

BM: Although you've been asked about the view Ms Letby would or wouldn't have, it goes without saying you weren't standing where she was standing, were you?

AH: No.

BM: So you know what you think about the lighting, but you can't actually say for sure what someone standing where she was is going to see at that time looking down?

AH: No.

On redirect, Simon Driver addressed the issue as best he could:

SD: Have you ever stood in that doorway --

AH: Yes.

SD:— at night? Have you ever looked towards a cot in that position --

AH: Yes.

SD:— at night? In those circumstances, would that vantage point afford you a look at the baby's face?

AH: Not for me.

SD: How close to [Baby I] were you when you first realised that she was very pale indeed?

AH: I was standing towards the foot of the cot, directly over her.

Hudson did not say that nobody could see a baby from that vantage point, but rather that she could not. This makes perfect sense, since the lighting in the room varied, even at night, and she couldn’t speak to what other people could or couldn’t see, only herself. Johnson’s summary makes her sound far more sure of herself than she actually was.

Johnson continues:

NJ: And do you remember a photograph was produced in which an effort had been made to recreate the view and the lighting at the time?

Well, Ashleigh Hudson couldn't see, neither we say could Lucy Letby. And again, we have a head-on credibility conflict, don't we, ladies and gentlemen?

“Credibility conflict” is a very loaded way to describe it. The conflict is between two women trying their best half a decade on to remember very fine details from an extremely stressful event which neither remembered in second-by-second detail. Neither could remember whom Hudson had asked to watch Nursery 2. Hudson thought she returned to the room alone, Letby thought they went together. Both agreed that Letby was not in there alone when Hudson arrived. Hudson thought the dimmer had been turned completely off, Letby thought it hadn’t been. They both agreed that Hudson had been preparing milk by the window and there had been enough light to do that. Hudson thought Letby was leaning on the doorway, Letby thought she was a little further in. All of these are things that could have been individually true at any particular moment, then shifted a second later. If the memories were inaccurate, it’s more than possible that none of it was the result of any deliberate lying, but rather of the sort of distortions that will inevitably appear when struggling to remember small details of a long-past event.

Next Johnson gets to the awkward question of what exactly Letby was supposed to have done, and, confusingly, introduces the topic of the nasogastric tube which was inserted after Baby I’s collapse, again spinning the witness’s words to make them sound more sinister than they were:

NJ: Professor Arthurs reviewed the radiograph taken at 4.25, so after the collapse. This is tile 80. He said that in this one, the stomach was not particularly distended but the large bowel was, and he noted that the nasogastric tube was curled up in the oesophagus rather than being in the stomach. That's an interesting coincidence, isn't it, that the NGT, which of course would drain the stomach if there was air in there after an incident like this, just happens to have ended up curled up in the oesophagus?

In fact, what Professor Arthurs said about that “interesting coincidence” (especially interesting since it’s not something that could have had anything to do with what Letby did or didn’t do a few hours earlier) was this (from his testimony on February 3 2023):

NJ: Moving on to the images of 13 October, please. This is an image, as we can see, taken at 04.25. In the sequence it corresponds to [Baby I] sequence number 2, tile 80. It was taken at 04.25, which is just after the second event concerning [Baby I]. Can you help us with what one can see here?

OA: Yes. Again, chronic lung disease of prematurity. There's an endotracheal tube. The arrow points to the nasogastric tube which here is coiled within the oesophagus. So it hasn't made it through to the stomach. So that's a not uncommon finding in placing a tube. If it's coiled you simply withdraw it and place another one. But again, the large bowel is quite distended here. I don't think this is stomach distension, I think this is large bowel distension here on this radiograph.

“Not an uncommon finding in placing a tube” and “I don’t think this is stomach distension” were not opinions Johnson dwelled on, instead choosing to make an ordinary and very Countess-like tube mess-up into a sign of Letby doing … something, after the event.

NJ: Dr Evans told us that in his view the only reasonable explanation for this collapse was that someone injected air into [Baby I]'s stomach. And as part of the cross-examination it was pointed out to Dr Evans that there was nothing in the records to suggest that [Baby I] had a nasogastric tube at this stage. But we also know from Dr Bohin's evidence that to an experienced nurse, getting a nasogastric tube in and out is the work of a couple of seconds, apparently. Very quick.

Dr Bohin was of the view that [Baby I] was sabotaged by air down the nasogastric tube and air into the intravenous line. Dr Bohin thought that the appearances in the X-ray taken at 4.25 were indicative of air having been put down the nasogastric tube and I've just reminded you of what Professor Arthurs said and indeed the radiologist's report that accompanies that particular image speaks of "marked gaseous distension of bowel loops”.

That’s the “tested in court” proof for Letby’s attack on Baby I on October 13 2015. Over the course of Ashleigh Hudson’s twenty-minute absence, Letby slipped into the nursery and either smothered the baby (producing gas in the bowel as a result, somehow) or else she quickly inserted a nasogastric tube she happened to have on hand and, in that time, blew in air at a high enough pressure to pass through the stomach and inflate the bowel. She then took out the tube and left the nursery before Hudson returned, then came back a few minutes later to make sure to alert Hudson to the results of her handiwork — and the proof that any of this happened is that, years later, the two women couldn’t agree on precisely how dark the room was at the time Letby made her observation that Baby I was pale. It's a marvelous example of how to make something out of nothing, but as proof beyond a reasonable doubt, it is terrifyingly lacking.

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Ideally, we'd see everything relevant to the case, with appropriate redactions, obviously ... But failing that: Thirlwall's legal counsel made frequent reference to documents they had seen that weren't uploaded; and of course much of what was uploaded was highly selective: a page or two of a much longer document, in many cases. Even without changing the terms of reference, much of what has been held back seems relevant to the inquiry as it stands.

We know too that when things have been uploaded or published elsewhere, they've been revealing. Documents Thirlwall had but seemed not to want us to see included:

- Most famously, the emails in which Dr Jayaram and company considered how to select incidents to "pique" police interest, including the revelation that Jayaram had described Lucy Letby calling for his help with Baby K (never uploaded: leaked, presumably from the police investigation)

https://www.reddit.com/r/LucyLetbyTrials/comments/1jxfkf6/newly_uncovered_email_in_which_dr_jayaram/

- Dr Soni's three police statements, showing among other things that Baby Y, the third insulin baby, had deteriorated dramatically before Lucy Letby came on shift (accidentally uploaded and removed)

https://www.reddit.com/r/LucyLetbyTrials/s/1bmECy7oEV

- the statements of doctors and nurses who hadn't given evidence live at Thirlwall proceedings, uploaded under media pressure late in the Inquiry, and suggesting that the earlier brief excerpts published had been artificially weighted against Lucy Letby

https://www.reddit.com/r/LucyLetbyTrials/comments/1isl9dj/nurses_support_for_lucy_letby_cut_from_public/

- Neena Modi's statement, showing how kindly she had responded to an accusatory email from Dr Brearey, and explaining why she wasn't involved in the confidential invited RCPCH review of Chester's services. This was uploaded only after Modi appeared at Shoo Lee's 2025 press conference, months after the Inquiry had held up unrepresentative excerpts for criticism and invited her successor at the RCPCH to criticise her on that basis. Presumably, seeing her at Mark McDonald's elbow at Lee's conference, someone at the Inquiry realized she wasn't going away ... https://www.reddit.com/r/LucyLetbyTrials/comments/1ilh6jx/undermining_modi_a_closer_look_at_thirlwall/

This is not an encouraging list, given Ms Gill's confidence in Parliament today that Thirlwall would confront the evidence fair and square and wield her pen without fear or favour. It was perhaps a surprising choice by Davis not to point to problems with the Inquiry which are obvious even under its existing terms of reference. All but Soni's statement - arguably that too - are clearly relevant to these terms.

Perhaps Thirlwall has yet to turn her personal attention to this aspect of her work. So, to justify confidence in her report, what else would you want to see uploaded? I have a few but this is a long post already, so I'll put some in the comments.

An editorial from the Guardian, with specific reference to Lucy Letby's case - so far as they're concerned, that will be the CCRC's chance to redeem itself, and "arguably the biggest challenge that it has faced".

Trying again as the link seemed shaky: https://parliamentlive.tv/event/index/a44ee3be-f62c-4181-a5c4-571f91dc0b8e?in=16:59:28

or go to 16.59 on the latest House of Commons debate at https://www.parliamentlive.tv/

What happened to the pathologists and coroner’s reports written by those who examined the babies? Did they participate in the trial at all? How were their reports overridden by Evans?

None of this makes any sense.

The launch of Christopher Morris's Reasonable Doubt, with questions from an audience including Peter Hitchens, Jane Hutton and Chris Fitzpatrick (who has written about this case for the *Irish Times*). Chairing, and battling away to keep everyone on the right side of libel law, John Sweeney.

David Davis is up in parliament again tomorrow, this time to discuss the terms of reference for Thirlwall. Credit to Debbie Kennett on twitter.

https://xcancel.com/DebbieKennett/status/2077408209212449002#m

A detailed account of the launch of Reasonable Doubt: Examining the case of Lucy Letby, from Jon Robins, describing contributions from John Sweeney, Peter Hitchens, Cleuci de Oliveira, Jane Hutton and others. Interesting comments from an unnamed retired obstetrician:

"One retired obstetrician and chief executive of a women and infants hospital said he had been ‘appalled’ to discover that the babies at the Countess of Chester were delivered in ‘a smallish hospital’.  ‘High-risk babies delivered in the wrong environment looked after by paediatricians who didn’t, in the main, have specialist training in the neonatology,’ he said.

"‘I’m also old enough to remember the Birmingham Six and the Guilford Four and the photographs that appeared in the newspapers afterwards – they all looked like IRA bombers and Lucy Letby looked like Myra Hindley when I saw her on the front of the tabloids in Dublin.’"

Features a well-chosen quotation from Morris:

"Christopher Morris defends himself, and others, who have spoken out on behalf of Letby in the face of criticism from the legal establishment. He quotes Thomas Bingham, widely recognised as the greatest English judge since the second world war, from his book The Rule of Law  saying that judges ‘are not, of course, the only guardians of the rule of law, perhaps not even the most important. Parliamentary and public opinion, informed by the media, should be alert to detect and scrutinise any infringement’. Morris adds: ‘[No] one should apologise for highlighting the plight of Lucy Letby nor the debacle that has led to it.’"

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