Chapter 8. February to April 2016: Baby K, Baby L and Baby M

Baby K

Mother K: “[W]e found ourselves pregnant in 2015 and we were obviously thrilled and happy and over the moon with it. We generally didn’t foresee any issues with the pregnancy or anything like that.”¹

Baby K was born at the Countess at 25 weeks’ gestation, weighing 692 grams. She was taken to the neonatal unit. Parents K told the Inquiry that they were aware that she “was small and we knew that Child K was going to be poorly, but she was stable”.² They added that Ms Joanne Williams had told them that “Child K was stable, Child K was fine”.³
Father K told the Inquiry that, when Baby K was taken to the neonatal unit, his wife, who was exhausted, went to sleep, and he phoned his mother “to tell her that Child K was here”. He then went to the neonatal unit: “I went to the Unit by myself at first. I couldn’t sleep because I was so excited. I have a baby girl. I just wanted someone to come and say that everything was okay. I was over the moon. Child K had just been born.” He did not go into the unit but walked to a window onto the nursery. There was someone standing by Baby K. He stated: “I didn’t want to distract them from what they were doing … My focus was on Child K. I was so excited. I wanted to tell people that the baby had arrived and was okay.” He continued: “Now, I feel guilty that I didn’t stay and watch for that little bit longer.”⁴
In his oral evidence, Dr Jayaram said that, by February 2016, he had “significant discomfort” about Letby.⁵ On 16/17 February 2016, he was working on the night shift. At about 3.50am (and after Father K had gone back upstairs to Mother K in the post-natal ward), Dr Jayaram was outside Baby K’s nursery when Baby K’s designated nurse (Ms Joanne Williams) told him that she was going to the delivery suite to update Baby K’s parents on her progress and that Letby was “baby-sitting”. Dr Jayaram said he “felt uncomfortable knowing that Letby was in the room”.⁶ He said that he walked into Baby K’s nursery to check everything was okay and saw that Baby K’s endotracheal tube was dislodged and her oxygen saturations were dropping but Letby had not flagged the deterioration. His thought process was: “[H]ow has that happened? … was it just coincidence that this baby who had been stable to this point in the period where the nurse looking after the baby and Letby was supervising the baby, this event happened?”⁷
Parents K came down to the neonatal unit with Ms Joanne Williams who took photographs of them with Baby K. The photographs are timed at 04:31. No mention was made to them of the incident with the tube. They were aware that Baby K would be transferred to Arrowe Park Hospital at some point.
Dr Jayaram confirmed that, after Baby K collapsed, he was involved in her successful resuscitation.⁸ He called the transport team to organise Baby K’s transfer to Arrowe Park Hospital.⁹ Baby K collapsed again, at 06:15 and 07:25.
Baby K was handed over to Nurse W on the day shift of 17 February 2016. In answer to questions from Mr Baker KC, Nurse W recalled that, during the handover, she was informed that Baby K’s endotracheal tube had previously been secured before it became dislodged. Nurse W commented that it is “highly unlikely” for a premature baby to pull out its own correctly secured endotracheal tube.¹⁰
Baby K was later transferred to Arrowe Park, where she died some days later.
Letby was tried on one count of attempted murder of Baby K. The jury were unable to reach a verdict in the first criminal trial and the case was re-tried. Letby was found guilty of the attempted murder of Baby K. It was the prosecution case that she had deliberately dislodged the endotracheal tube.
On behalf of the senior managers, Ms Kate Blackwell KC pointed out to Dr Jayaram that the record of his call to the transport team refers to Dr Jayaram saying, “baby dislodged the tube”. Dr Jayaram accepted that “that is what was recorded” and said: “[T]he person I spoke to wasn’t a clinical person. It was an administrative person.” Dr Jayaram said: “I would almost certainly have said the tube was dislodged.” He accepted in oral evidence that he had not made any medical notes of his own about the incident, did not mention it to anyone at the time and had not submitted a Datix report. He also accepted, in retrospect, that even situations of accidental tube dislodgement should be Datixed.¹¹
Asked by Counsel to the Inquiry whether he had mentioned this event to Dr Brearey, he said: “I can’t remember in detail. I think I sort of mentioned it in the sense another event had happened and Letby was there but I don’t think I specifically articulated the thought processes I was having at 3 o’clock in the morning.”¹² Dr Brearey did not recall Dr Jayaram mentioning this incident which would, in my view, have been memorable.¹³ Given Dr Jayaram’s recollection that he “sort of mentioned it”, whatever Dr Jayaram said to Dr Brearey, if anything, was not an account of his suspicion about what he had seen in the early hours of 17 February 2016.
Dr Jayaram spoke to the Inquiry at length about the thoughts and worries he had at the time of this incident and in the months thereafter. He was, he acknowledged, at fault for not raising this with anyone else, not Baby K’s family, nor the Local Authority Designated Officer (LADO) nor the police (see Chapter 12). Amongst other things, he explained: “There is a fear because it’s such a seemingly outlandish and unlikely thing that someone is causing deliberate harm, it’s the fear of not being believed, it is the fear of ridicule, it is the fear of accusations of bullying” that prevented him from raising it.¹⁴
Dr Jayaram said that, by the time of Baby K’s collapse, he had seen a draft version of the Thematic Review and was aware of “the staffing mortality analysis that had been done had already flagged up Letby”. He said that, “in the context of those, I should have been braver, I should have had more courage because it wasn’t just an isolated thing, there was already a lot of other information”.¹⁵ I agree. In the event, he told no one for over a year. I shall return to the circumstances of his disclosure in Chapter 26.
Father K told the Inquiry in his written evidence that the Countess did not tell them about the episodes when Baby K’s breathing tube became dislodged and she required resuscitation:
“Nobody told us about these episodes whilst we were in Chester. We only became aware of these facts when we had a meeting with the Crown Prosecution Service … If I had known, I would have asked questions. I would have asked what they were doing. Dr Jayaram would have had to explain to me there and then why Child K’s tube had moved and how it had moved.”¹⁶
Furthermore, the Countess did not inform Parents K of any concerns about Letby in relation to Baby K. Father K’s written evidence was: “We didn’t know anything about Lucy Letby or issues with Child K’s treatment until my wife received a phone call from the police in May 2017.”¹⁷ He asserted: “The Trust haven’t been open and honest with us about any suspicion of harm caused to Child K.”¹⁸
By that stage, the parents of Baby K had been grieving the loss of their baby for over a year. They had no idea what had been observed and what the consequences of it might have been. Father K told the Inquiry that he was in denial when the police called and told them they were investigating Baby K’s death. He commented: “You would never think in a million years that something would happen to your baby in hospital.”¹⁹ Mother K echoed his words: “Not for one minute did we ever foresee any of this at that time.”²⁰

Email May 2017

After the evidence hearings were completed, an Inquiry document – disclosed to all Core Participants in September 2024 – was put into the public domain. It is an email dated May 2017 from Dr Jayaram to the consultants on the neonatal unit. It includes the following passage in respect of Baby K: “Staff nurse Letby at incubator and called Dr Jayaram to inform of low saturations. Endotracheal tube had been secured properly and baby not over-active. No obvious reason for tube to have dislodged.” That Dr Jayaram had gone into the room because he was called by Letby was different from what he had said in evidence. No questions were asked about that. In their judgment on the application for leave to appeal against conviction in respect of Baby K, the Court noted that legitimate criticism could be made of Dr Jayaram’s evidence at trial – including the length of time before he reported the event and the inconsistencies between his evidence and contemporaneous documents, all of which, with other matters, were before the jury. As set out earlier, the focus of the questions in the hearing was not about why he had gone into the room, but about what he had seen when he was in the room with Letby and Baby K and whom he had told about it (question asked by Counsel to the Inquiry), and what he had said to the team collecting Baby K (question asked by Counsel for the senior managers). Dr Jayaram made clear in his evidence that he had not seen Letby doing anything. His concern was that she was not responding at all as Baby K deteriorated.²¹
The impact of Baby K’s death on her parents was expressed by Mother K: “[Y]ou don’t only just grieve your daughter, you’re grieving who you were. I grieve who we were as a husband and a wife.”²²

April 2016: Letby moved to day shifts

On 7 April 2016, Letby was moved to day shifts.²³ This was Ms Powell’s decision.²⁴ By this stage, there had been deaths that did not feature on the indictment – in December 2015, and January, February and March 2016.
One of the themes Dr Brearey had identified in the Thematic Review was that most of the babies had died at night.²⁵ In her evidence, Ms Powell said that the decision to move Letby to day shifts was made by herself, Ms Griffiths and Ms Farmer. The evidence of Ms Farmer,²⁶ and that of Ms Griffiths,²⁷ suggests they were not instrumental in making the decision. In any event, as the Manager of the neonatal unit, it was Ms Powell who was responsible for this decision, which was then implemented by Ms Griffiths on the rota. Ms Rees and Ms Anne Murphy were also made aware of the move. Ms Powell did not tell Dr Brearey or Ms Kelly that she had done this.²⁸ She said that the decision to change Letby’s shifts was driven by a “well-being approach”.²⁹ She explained:
“[Letby] had been involved in so many of the recent deaths that that must have a profound effect on her well-being.
And, therefore, we felt that there would be more support on the days, on the day shifts, and also able to see how she was in herself because we would be there to — to monitor.”³⁰
Ms Powell said that she told Letby that she was “a commonality within, within the deaths”. She did not tell Letby that more eyes would be watching her on the day shift. She explained to Letby that she was changing her shifts for her well-being and “to ensure that she had a respite from all the events that were happening as [they] appeared to be happening at night”.³¹
Ms Griffiths told the Inquiry: “I was asked if I could allocate, take Lucy off the night shift and then allocate two months’ worth of day shift.”³² She understood the rationale for this to be “because of the thematic review, I think it was highlighted that a lot of the incidents occurred during the night shift and so just to look at that commonality I think the decision was to move her onto days”.³³
Ms Farmer confirmed that she was aware that Letby had been moved from night to day shifts in early April 2016, and that six out of the nine deaths examined in the Thematic Review had occurred at night. Speaking to the Inquiry about the rationale to change Letby’s shifts, she stated: “[I]t was discussed with me that that was the plan; that because of all the recent incidents, deaths, that they had occurred during the night, so that’s why she was being moved on to days as support for her. If, if it was a training issue or if she needed emotional support, then there were lots of people around, the managers were around.”³⁴ Ms Farmer said that no part of the explanation to move Letby to day shifts concerned keeping babies on the unit safe.³⁵ I accept her evidence about that. They were not thinking about the safety of babies. Ms Farmer talked about a training issue even though it was being said that Letby was an excellent nurse.
In evidence, Ms Rees said she had asked Ms Powell what the rationale was for the decision to move Letby from night to day shifts. She told the Inquiry that Ms Powell’s response was:
“that it was a neutral act to bring her on to days. It wasn’t deemed as a punishment or a finger-pointing exercise. It was because there are more staff on days than on nights and because of what you alluded to earlier about predominantly a lot of these mortalities were happening on the night shift, she wanted to check her competencies and bring her on to days so she could be more supervised.”³⁶
Ms Powell was consistent in saying that there were no training issues with Letby, and yet her competencies were to be checked and she could be better supervised on the day shift. It is likely that part of the reason for moving Letby to days was to see whether anything changed – specifically, whether or not the deaths continued at night. Ms Rees, like everyone else, seems to have accepted this approach.
Ms Murphy said in evidence that she was aware that Letby was moved to day shifts at the beginning of April 2016. She stated: “[I]t wasn’t done because people were pointing the finger per se, that she was the person causing these babies to deteriorate”. She explained: “Eirian and I had discussed that because she had been involved with so many of the deaths that it would be better for her mental health really to come on to days for a period of time. But because there were also more staff around during the day she would then not necessarily have to look after the sickest babies.”³⁷
Dr Brearey learnt of the decision to change Letby from night to day shifts in May 2016.³⁸ So did Ms Kelly.³⁹ This is an indication of Ms Powell’s confidence in her own judgement and her desire to keep this matter at the lowest possible level – that is, the unit. It is surprising that she did not inform others of this decision.

Baby L and Baby M

Father L and M: “We knew early on that we were having twins and, up until March 2016, my wife had a routine pregnancy … The plan, which my wife agreed with, was to deliver the twins with a caesarean section.”⁴⁰

Twin boys, Baby L and Baby M were born by caesarean section at 33 weeks and 2 days’ gestation. Baby L weighed 1.465 kilograms. Baby M weighed 1.705 kilograms. Father L and M’s evidence was that “they both seemed fine”. He said:
“They were in Nursery 1 … I understood they were on the unit because they were small and they did not weigh very much – they each weighed just over 3lbs. I understood that we would be able to take them home within a few weeks. I have since learned that Child L had periods of low blood sugar which required treatment, but we were not aware of this at the time.”⁴¹
Letby was convicted of the attempted murder of Baby L and Baby M on the day shift of 9 April 2016.

Baby L

A blood sample was taken from Baby L on 9 April 2016 while he had low blood glucose. As with Baby F (see Chapter 5), it was sent to the Liverpool Clinical Laboratories at Royal Liverpool University Hospital for testing. The laboratory received the sample on 11 April 2016 and it conducted various tests, including a C-peptide and insulin test. The results were:
- Insulin: 1,099 picomoles per litre
- Insulin C-peptide: 264 picomoles per litre.⁴²
In her oral evidence, Dr Shirley Bowles, a consultant chemical pathologist, confirmed that she was the person referred to in a screenshot of the Liverpool Clinical Laboratories system, which recorded a call made to “Shirley” at “Countess of [Chester] Biochem” on 14 April 2016 at 09:38:23. The call was about Baby L’s insulin and C-peptide result.⁴³ Dr Bowles told the Inquiry that an external laboratory would “ring through results that they felt needed someone to look at and possibly act upon”⁴⁴ or if the results were “urgent or unexpected or unusual”.⁴⁵ She could not recall the conversation; however, she assumed that “the thrust of the conversation” was in line with the contemporaneous record.⁴⁶ The note records that the advice given was “[d]ifficult to interpret without the concurrent glucose but may be inappropriate if patient was hypoglycaemic at the time of collection”.⁴⁷ Baby L’s medical records confirm that he was hypoglycaemic on the date of the blood test request.⁴⁸ Dr Bowles accepted in evidence that: “The glucose was low, it was 2.8, not quite within the definition of hypoglycaemia, but certainly low.”⁴⁹
Dr Bowles entered the results onto Baby L’s electronic laboratory record at 09:38 on 14 April 2016. She gave oral evidence that she regarded Baby L’s insulin and C-peptide result as a “puzzling result in a patient on the neonatal unit”. She concluded: “[I]t looks like there is external administration of insulin.”⁵⁰
Baby L’s medical records suggest that Dr Bowles made a call to the neonatal unit. Dr Bowles’ name “CON/BOWS” appears on Baby L’s records at 09:38.⁵¹ At 09:40, the results were verified; the results would then have been on Baby L’s electronic case record and thus visible to the clinical team involved in the care of Baby L.⁵² Dr Bowles explained: “[If] there’s nothing untoward about [the] result, it’s an instantaneous process … So the fact there was this two-minute gap was what made me think that … that I tried to telephone someone at that stage.”⁵³ She could not recall if she managed to speak to someone, however, but reflected: “I obviously felt the need to ensure the tests were communicated rapidly.”⁵⁴
At the criminal trial, Professor Peter Hindmarsh, Professor of Paediatric Endocrinology at University College London Hospital, gave expert evidence that Baby L’s hypoglycaemic event continued from 9 April 2016 until about 3pm on 11 April 2016, with the insulin being infused intravenously, having been added to the TPN bags that had been made up. Letby was convicted of attempted murder by adding insulin to Baby L’s TPN bag.
In oral evidence, Dr Bowles agreed that the most likely scenarios producing the blood test results were: (a) the child was hyperglycaemic but received too much exogenous insulin and thus almost became hypoglycaemic; (b) exogenous insulin was given to the child in error; or (c) exogenous insulin was given to the child deliberately.⁵⁵ She went on to explain: “I can’t say whether I thought through that clearly at the time about the possible scenarios. I possibly just thought this is something I need to convey and find out a bit more about.”⁵⁶ However, it is clear that Dr Bowles did not consider whether someone was deliberately harming babies. She described that as “unthinkable”, saying: “I suppose you always tend to think [of] those as being one-offs and you don’t expect them to be in your own institution.”⁵⁷ In that respect, her response was exactly the same as those of the doctors, nurses and managers. This could not happen here. But she had in front of her clear evidence that something had (or at least may have) happened there. That is why she rang the ward.
Dr Bowles was critical of the consultant paediatricians’ failure to share their concerns with the Blood Sciences Department. She said:
“[I]f I — I had been aware that there had been problems with babies on the unit, then obviously this would have been a huge red flag, but at that stage I had absolutely no knowledge of any problems on the unit. So it was like having a piece of a jigsaw but I didn’t actually know there was a jigsaw. So, you know, it was standing alone as an isolated result, and obviously looking at it now it’s very obvious what it was saying, but at that time I — I guess I just didn’t — it didn’t fire that suspicion.”⁵⁸
This was not a piece of a jigsaw. It was a self-contained piece of hard evidence, which showed, on its own, that exogenous insulin had been administered. That was why the Liverpool laboratory had contacted her. It is why she contacted the ward. Having attempted, and it would appear failed, to contact a clinician on the neonatal unit, Dr Bowles verified the results, so that they appeared on Baby L’s electronic case record, visible to the clinical team. Following that, she took no further action.
Dr Bowles made the point that, as duty biochemist, she looked at 200 to 300 sets of results a day.⁵⁹ I accept that, but this was a telephone call about “urgent or unexpected or unusual” results.⁶⁰ When asked whether she had an obligation to complete a Datix form for potential clinical issues that needed further investigation, she agreed that she did and reflected that “in retrospect it may have been a reasonable thing to do”.⁶¹ She confirmed that she had access to the Datix system in 2016. She stated that Baby L’s C-peptide and insulin result “may have merited a Datix”, but said: “I probably felt I didn’t have the complete picture at that stage.”⁶² She had enough of the picture to sound the alarm but that did not occur to her.
Dr Bowles said that it was standard practice for a paper copy of results to be sent to the neonatal unit via the internal mail. The insulin and C-peptide results were written by hand by a junior doctor into Baby L’s medical records at 09:30 on 15 April 2016, a full day after the electronic record was updated.⁶³ However, the significance of the results was clearly missed.
It was Dr Jessica Burke who recorded Baby L’s insulin and C-peptide results in the ward round at 09:30 on 15 April 2016. At the time, Dr Burke was a junior doctor completing her paediatric training. She informed the Inquiry she copied Baby L’s insulin results from the computer and wrote them into the paper notes. She said that she did not expect to transcribe abnormal results from the computer because her experience was that abnormal results were usually called through by telephone from the laboratory to the clinical team.⁶⁴ This supports the conclusion that Dr Bowles probably telephoned the ward but did not speak to anyone.
Dr Burke told the Inquiry: “At that time as an ST2 [specialty trainee], my experience of hypoglycaemia screens was limited.” She was candid, saying, “I would not have been familiar in 2016 with the units or ranges used for these values” and “I do not remember understanding the significance or interpretation of the insulin and C-peptide results on Twin 2 at that time.” She “noticed that the computer displayed what the expected ranges were for the results and that the insulin reading was flagged by the computer system as being high and out of range”.⁶⁵
Dr Burke recollects that she “approached the middle grade (registrar) that day on the NNU [neonatal unit] who I think from memory was Dr U to ask him about the results … I cannot remember if I read the results aloud to the registrar, or if I showed him the results … but I do remember flagging these results to him.” Dr Burke stated that Dr U’s advice was that the insulin and C-peptide result could not be interpreted without the glucose results.⁶⁶ Dr U was a registrar.
Dr Burke reflected:
“I now understand with the benefit of hindsight from the trial and also from my greater experience with hypoglycaemia screens that it was highly unusual for the blood glucose result to not yet be available when the insulin and C-peptide were resulted and that actually the blood glucose result may have been missing rather than not yet available. I also now understand, with the years of experience I have gained since both clinically and through the police investigation and trial, that a high insulin and a low C-peptide result indicate exogenous insulin administration and that in the context of an NNU patient who has never been home and is not prescribed insulin for any reason, that deliberate harm on the part of a healthcare professional is a possible cause.”⁶⁷
Dr U cared for Baby L during a night shift on 9 April 2016. Despite giving evidence that it was common for him to look back 24 hours in a patient’s medical records, he stated that he had not seen that a hypoglycaemia blood test had been ordered for Baby L earlier that day. He later gave evidence that he had understood the tests were ordered; however, the results had not yet been received by the time of the night shift. In fact, Baby L’s results had been entered onto Baby L’s electronic laboratory records at 09:38 on 14 April 2016 (see above).
Dr U worked on the neonatal unit on 14 and 15 April 2016 and made entries in Baby L’s medical records. Dr U accepted that Baby L’s blood test results were handwritten in the medical notes during a ward round at 09:30 on 15 April 2016. Shortly before the afternoon shift handover, Dr U attended Baby L to conduct a cranial ultrasound and recorded this in Baby L’s notes at 16:00.⁶⁸ He accepted that he did not look at the entries in Baby L’s medical records made earlier that day to see what had been recorded or if the hypoglycaemia results had been received.⁶⁹ He should have looked for – and at – them. His failure to do so meant that no one picked up this second example of insulin poisoning on the neonatal unit.
In Dr U’s evidence to the Inquiry and in his statement to the police, he made no reference to Dr Burke flagging with him that Baby L’s insulin results were high. His evidence was that any abnormal results from the morning ward round would be discussed with the consultant responsible for the week. He could not recall who that was.⁷⁰
About Baby L’s insulin and C-peptide result, Dr U said: “[T]he insulin level is unusually high.”⁷¹ He added: “[T]hey are abnormal results and I would have expected that they had flagged some sort of warning or alert.”⁷² He agreed that the results indicated that insulin was given deliberately or by mistake to Baby L and needed investigation.⁷³ Dr U also agreed that not seeing the test results at the time was a missed opportunity to detect the deliberate administration of insulin.⁷⁴ Dr U died in 2026.
Dr Gibbs explained that he did not care for Baby L when his blood sugars were low and found out about the results two years later when he reviewed the records for a police statement. However, he acknowledged that the result had been recorded by a junior paediatrician in Baby L’s medical records. He stated: “[T]he result was sitting in their [Baby L’s] notes.”⁷⁵ Dr Gibbs conceded: “I think we all collectively have responsibility for missing that.”⁷⁶ Dr Brearey agreed it was a collective failure.⁷⁷ Dr Saladi,⁷⁸ Dr ZA⁷⁹ and Dr V⁸⁰ also agreed. I do not think that this was a collective failure. It was a failure by the doctor who was responsible for caring for Baby L at the time, namely Dr U.
Dr Jayaram told the Inquiry that Baby L’s hypoglycaemia happened on the same day as Baby M’s non-fatal collapse. He was aware that Letby was present but at the time did not have any suspicions about Baby L’s state of hypoglycaemia being unnatural. Dr Jayaram cared for Baby L a few days after his blood test and noted that Baby L’s hypoglycaemia had resolved. He stated that it was handed over to him that the blood test results were back and everything was normal. Thus, he was not prompted to look back in the notes at the results.⁸¹ Had he done so, he would have seen the results. Dr Jayaram was candid about the fact that the significance of the results not being picked up was a missed opportunity.⁸²
Speaking of Baby L’s insulin result, Mr Harvey said: “There should have been cross reference with Child F. I think if this had been identified and reported, it would have influenced our decision to go to the police.”⁸³ Given that exogenous insulin had been administered to two babies when there was no clinical reason to do so, it is incontrovertible that the police should have been contacted.

Parents L and M

Parents L and M told the Inquiry: “[W]e were not informed that Child L had notable hypoglycaemia requiring high concentration dextrose.”⁸⁴ They stated: “[N]o one told us there were concerns about Child L’s condition while he was in the neonatal unit. No one told us that Child L’s blood results had been abnormal and had shown there was far too much insulin in his blood stream. It was never mentioned to either of us as parents.”⁸⁵ Dr U accepted that Parents L and M should have been told and it was a mistake that they were not.⁸⁶
Parents L and M spoke candidly about “the enormous amount of stress and anxiety [the Letby case] has placed on us as a family”.⁸⁷ Father L and M shared personal details about the “toll … both physically and mentally” on him and their family.⁸⁸ He told the Inquiry: “I had a seizure for the first time in my life as we approached the criminal trial. This happened in front of my children and was very distressing for them. The doctors attributed this to the stress and the pressure of what had happened to our children.”⁸⁹
Father L and M observed that Dr Brearey, in his police statement dated 16 April 2019, had stated that in August 2018, after reviewing all the insulin and C-peptide results from babies on the neonatal unit, “it became clear that his insulin and C-Peptide results were abnormal and ‘suggestive of exogenous insulin administration’”.⁹⁰ Despite this, Father L and M’s evidence was that they were still not informed of this by the Countess. Father L and M stated: “It was the police that first informed us in 2019 that they thought insulin had been used to harm Child L.”⁹¹

Baby M

Baby M collapsed unexpectedly at about 4pm on 9 April 2016. At the request of Letby, a resuscitation crash call was put out. Nurse W assisted Letby in giving resuscitation breaths to Baby M until the doctors arrived. Dr Anthony Ukoh (a locum registrar), Dr Cassandra Barrett (a junior doctor) and Dr Jayaram attended. The resuscitation continued for approximately 30 minutes and reached a point where withdrawing support needed to be considered. However, at that point Baby M suddenly recovered.
In oral evidence, Nurse W stated that she was in the room when Baby M collapsed. She recalled that Baby M was “stable in terms of his observations on that day”. Regarding Baby M’s collapse, she stated: “I did not think what happened on that day would happen.”⁹²
Nurse W told the Inquiry that, after Baby M’s collapse, “I was trying to find an answer because it, it was unexpected and I almost needed an answer for what had happened.”⁹³
Parents L and M told the Inquiry that they were on the maternity ward “when a nurse came rushing in to tell us we needed to come back to the neonatal unit immediately because something was wrong”.⁹⁴ Father L and M described arriving on the neonatal unit and seeing one of the doctors doing chest compressions on Baby M. He recollected that staff on the ward thought Baby M’s collapse was unexpected. He said: “When we got there one of the doctors was just pressing Child M’s chest. People were saying the boys were healthy yesterday and they didn’t know what had happened today.”⁹⁵ Father L and M spoke candidly about the impact of Baby M’s collapse and resuscitation on him, saying: “Even to this day I get flashbacks to what I saw on the unit.”⁹⁶
Nurse W recalled seeing Dr Brearey performing an echo scan on Baby M to see if there was an underlying cardiac condition that had caused his collapse. She said she asked Dr Brearey about the outcome of the scan and Dr Brearey reported that it was normal.⁹⁷ In oral evidence, Dr Jayaram confirmed that he was involved in Baby M’s resuscitation and noticed an unusual blotching similar to what he had seen on Baby A. His thought process was:
“[A]lthough myself and colleagues were — had begun to wonder about the possibility of Letby deliberately doing something, we hadn’t really started actively thinking about what might be being done.
And again in these situations Letby was there, it was an unusual, very unusual collapse and this unusual discolouration. Again we are thinking along the lines could this be sepsis? But it doesn’t quite seem to quite fit, could this be some kind of cardiac event didn’t seem to quite fit.”⁹⁸

Skin changes

Dr Jayaram stated that he “discussed with Dr Brearey” that there was another case “with the blotching”.⁹⁹ Dr Brearey recalls Dr Jayaram informing him that Baby M had needed to be resuscitated, although he does not recall Dr Jayaram mentioning any “blotching”. Dr Jayaram also approached Dr Gibbs with his concern that Baby M’s collapse was sudden. Dr Gibbs was asked why he did not do anything at that time when he already held concerns that Letby was deliberately harming babies.¹⁰⁰ Dr Gibbs responded that it still was not clear that harm was happening to the babies. It was pointed out to Dr Gibbs that the Working Together to Safeguard Children 2015 guidelines refer to the safeguarding principles being engaged if there is concern that someone may have harmed a child. Dr Gibbs confirmed that this reflected his state of mind at the time. He reflected: “[W]e should have involved the police earlier some time in 2016 and I feel I was at fault.”¹⁰¹ Dr Gibbs was right.
Acknowledgement of their errors and failings was characteristic of the consultant paediatricians. Acceptance was given without prompting at all stages. The doctors’ reflective and self-critical approach is in marked contrast to that of the managers to whom they turned for assistance.
Baby M had collapsed in the afternoon of 9 April 2016. Dr U worked the night shift later that evening. He gave evidence that, around Baby M’s collapse: “There was discussion about babies with rashes and we I don’t think had been able to come up with a clear reason for why those rashes were occurring and that continued through to the time that I finished at the Countess.”¹⁰²
Dr Jayaram spoke to Baby M’s parents about his collapse. However, he did not inform them about the unusual patches and discolouration on his skin or the possibility of deliberate harm. Dr Jayaram told the Inquiry:
“The discussion that I had with Baby M’s family after he was resuscitated was I — I discussed that again I couldn’t explain it. It didn’t fit with things … at this stage, yes, we were thinking the unthinkable, but it was this issue of not having evidence and I wish I could turn the clock back and wish I could have said it, and I didn’t, or later on.”¹⁰³
Dr Jayaram did not disagree that candour required him to alert the parents of Baby M that one possibility regarding Baby M’s collapse was that it was a result of deliberate harm.¹⁰⁴
Father L and M said, about the discussion with Dr Jayaram: “Dr Ravi Jayaram … took me and my mum into a side room on the unit. My wife was not present. He explained to us that these things can happen with premature babies. I understood that he was referring to Child M’s collapse and the need for resuscitation. I saw no reason to question that at all.”¹⁰⁵
The first time Parents L and M learnt about the discoloration on Baby M was at Letby’s criminal trial. Father L and M told the Inquiry:
“Dr Jayaram explained that he had been involved in the resuscitation of Child M and had seen weird patches and discolouration on Child M’s skin when they were trying to resuscitate him. I also understand now that this would have been very rare and highly unusual. At no point was this mentioned to us as parents. We had no idea that anyone thought anything about Child M’s condition or presentation was unusual or suspicious.”¹⁰⁶
There was no Datix report for Baby M’s non-fatal collapse and resuscitation. Father L and M commented on this in oral evidence:
“Given the rarity of the skin discolouration, I do not understand why more steps were not taken to consider the cause, or a discussion about it amongst the doctors, or with other doctors on a wider scale. If there had been, there may have been more weight to the suspicion that this was purposefully caused. Given how unusual it was, I really do not understand why it was not taken further by the clinical staff.”¹⁰⁷
A paper towel with the drug administration notes relating to Baby M was found at Letby’s home (along with many other documents relating to babies on the neonatal unit), and she recorded in her diary for 9 April 2016: “LD [meaning long day] extra twin resus”.