2. The babies

Baby A

1. Baby A was born, with twin Baby B, at the Countess. Baby A and Baby B were delivered at 31 weeks and 2 days’ gestation by caesarean section. They were taken to the neonatal unit shortly after their birth. Baby A weighed slightly over 1.66 kilograms and was described to Mother A and B by the hospital staff as “in one of the best conditions that they’d ever seen” for a pre-term baby.
2. Baby A remained stable, after a period of respiratory support. During the day, an umbilical venous catheter was put in place but was not correctly positioned. It was replaced but still did not sit correctly, so a long line was then inserted at about 7pm to administer fluids. Letby was Baby A’s designated nurse for the nightshift. Shortly after 8pm, Baby A began to deteriorate. The deterioration happened suddenly, over the course of a very few minutes. Baby A’s heart stopped beating and Baby A required resuscitation. Within half an hour of this sudden collapse, Baby A died.
3. During this period, Father A and B overheard staff discussing whether to come and get Baby A’s parents as there was something wrong. Mother A and B explained that the hospital staff “came to get me when [Baby A had] already crashed and there was nothing more that could be done”. As a result, the first time Mother A and B held Baby A was after Baby A had died. Mother A and B described feeling “traumatised” and that there was “a gaping hole where Child A should be”.
4. Baby A’s sudden collapse and death were unexpected and unexplained. Nurses and doctors were shocked. The speed and severity of the collapse were exceptional in their experience. The nurse in charge of the shift remarked in evidence that, “in what’s now 25 years of neonatal nursing experience, I have never witnessed a deterioration in that manner that fast”.

Skin changes

5. Before Baby A died, a number of people noticed an unusual rash across Baby A’s body. It was a “blotchy pattern of well perfused pink skin … coupled with patches of white and blue skin”. The rash disappeared and reappeared. It was not static. The rash was not properly recorded by Dr Jayaram, and Baby A’s parents were not told about it.
6. All the records were provided to the coroner’s office. A post-mortem was carried out by a consultant paediatric pathologist. He expressly found that Mother A and B’s blood disorder had not contributed to Baby A’s death. He identified a structural anomaly in the aorta, but did not consider it to have had any role in Baby A’s death. He considered the placement of the long line and the umbilical venous catheter and, after research, concluded that neither had contributed to Baby A’s death. He concluded that the cause of death of Baby A was ‘unascertained’. An inquest into Baby A’s death was opened in December 2015. Following an inquest hearing in October 2016, the Senior Coroner for Cheshire, Mr Nicholas Rheinberg, found that the cause of death was ‘unascertained’. I return to this later in the Summary report.
7. Letby was convicted of the murder of Baby A.

Baby B

8. Baby B was a similar weight at birth to Baby A, at a little over 1.66 kilograms. After the collapse and death of Baby A, Parents A and B were “riddled with fear for our baby”. On the night shift that followed the death of Baby A, Baby B also collapsed and required resuscitation. Baby B survived.
9. Observations of Baby B by the designated nurse at 20:00 noted Baby B as active. Just prior to midnight, an alert sounded as Baby B’s oxygen saturation had dropped. Baby B had knocked out the continuous positive airway pressure (CPAP) prongs. They were put back into position and Baby B was checked by paediatric registrar Dr Rachel Lambie. Baby B seemed to recover. Shortly afterwards, there was a further alert. The prongs had come out of Baby B’s nose again. Baby B’s nurse was drawing up antibiotics, and so Letby attended to Baby B. Letby called her colleague over saying that Baby B looked just like Baby A. Baby B had the same rash and had collapsed in the same manner.
10. Dr Lambie attended to Baby B, who was ventilated. She recorded in the medical notes that Baby B had “acute apnoea with no warning. Widespread purple discolouration of skin with white patches.” Dr Lambie described the collapse as “so acute and so unusual”. The rash covered Baby B and was moving. A nurse commented at the time that this was the same thing that had happened to Baby A the day before. Dr V, the consultant who was on call and attended Baby B, recorded a florid, widespread and blotchy rash. The cause of the rash was unclear. At the time, Dr V’s differential diagnosis was that the rash was caused either by Mother A and B’s blood disorder, or by an infection. It was later found to be neither.
11. The unexplained presentation of both Baby A and Baby B and the very sudden deterioration of both babies were the subject of discussion amongst staff. They were concerned by the unexplained rash on both babies; no one had seen it before.
12. Mother A and B saw the blotchy rash when Baby B collapsed. She recalled that a consultant told her that the rash was extremely unusual. She did not know at that time (nor did the consultant) that Baby A had the same rash when Baby A died. If she had known about the rash on Baby A, she “would have demanded that something was done”.
13. Letby sent a series of text messages to colleagues discussing the collapses of Baby A and Baby B. She expressed a desire to get back into Nursery 1, where the most unwell neonates were cared for. She sent detailed accounts of what had happened to other colleagues. She fabricated parts of those accounts. This included making up that Father A and B was on the floor crying when Baby A was taken to the mortuary. This was not true. In Mother A and B’s view, these messages were “attention seeking” and a “red flag”.
14. Letby was convicted of the attempted murder of Baby B.

Baby C

15. Baby C weighed 800 grams when he was born by caesarean section at 30 weeks and 1 day’s gestation. His growth in the womb had been slow, hence his relatively low weight. However, Baby C was in good condition. No resuscitation was required; on the neonatal unit he was ventilated for a short period and then began breathing by himself.
16. Mother C, who was on the post-natal ward, was told by a midwife that she had to be able to stand up unaided to go and see her baby on the neonatal unit. Mother C had had an epidural and a caesarean section. She was desperate to see her baby. She should have been taken to see her son. After six or seven hours, she forced herself to stand “because I needed to go and see him”.
17. Dr John Gibbs, a consultant paediatrician, was very involved in the care of Baby C. He told Parents C that, although there were risks for a baby born at that gestation and weight, Baby C was making good progress and was doing well. Dr Gibbs said that the “prognosis was good and that he was not expected to die”.
18. That evening, Letby made it clear to Nurse W, a neonatal nurse (band 6) and the shift leader, that she would rather be in Nursery 1 than in Nursery 3, where she was assigned. When an alarm sounded for Baby C in Nursery 1, and his allocated nurse entered, Letby was already by his cot. Baby C had entered a prolonged period of bradycardia and desaturation. Resuscitation was started. Letby was heard to say: “He’s going.”
19. Dr Katherine Davis, a paediatric registrar who attended Baby C in response to a crash call, could see no obvious explanation for Baby C’s collapse. She described it as unusual. It was her experience that most neonates in need of resuscitation usually had a slow heart rate but Baby C’s heartbeat was completely absent and did not respond to the administration of drugs or other resuscitation techniques. She had not seen that before and has not seen it since. Dr Gibbs attended ten minutes into the resuscitation efforts.
20. At approximately 11pm, Mother C was woken by a midwife and informed that she should come to Nursery 1 immediately. She did so and arrived as CPR was being administered to her son but he was not responding. Dr Gibbs was involved in Baby C’s care. A nurse (Mother C believes it was Letby) asked Mother C whether she would like a priest to attend. Mother C asked whether she thought her baby was going to die. The nurse said: “Yes, I think so.” During the prolonged wait for the arrival of the priest, limited resuscitation was continued. After Baby C was baptised, he and his parents were transferred to the family room and at his mother’s insistence pain relief was given to him. He settled peacefully for his final hours in the arms of his family.
21. During this time, Ms Melanie Taylor, the neonatal nurse (band 6) to whom Baby C was allocated, and Letby were coming in and out of the family room making preparations for a memory box, taking handprints and footprints and some of Baby C’s hair. This was not Letby’s responsibility, and she had not been asked to be involved. Nurse W had told her repeatedly that she should be looking after the child for whom she was the allocated nurse. Nurse W explained that Letby kept trying to be in the room with Baby C, and to help Ms Taylor, despite this being unnecessary. Nurse W reported this to Ms Powell, who told her to complete a Datix form (Datix is a web-based risk management system). Ms Powell did nothing else about Letby’s conduct.
22. Before Baby C’s death, Letby brought in a ventilated Moses basket, known as a cold cot, and plugged it in. Father C was curt with Letby, who left the room. In the parents’ joint statement, he said: “Reflecting on it now, I believe she wanted to savour my son’s dying moments for herself, which fills me with both emotion and anger. Had I not challenged her, she would have further intruded on our private goodbye to Child C.”
23. Dr Gibbs’ evidence was that the collapse and death of Baby C were unexpected and unexplained. In his 21 years’ experience, such deaths were very occasional. Baby C had been breathing well. In the time leading up to his collapse, he did not seem unwell. In that context, the lack of response to resuscitation was very surprising. It may have been expected from a baby who had been ill for a while and had no reserves left, but that was not Baby C, Dr Gibbs said.
24. A post-mortem was conducted, which concluded that Baby C had no signs of infection but that there were signs of heart damage – which was given as the primary cause of death. Dr Gibbs thought this view “didn’t quite fit together”. He wondered whether the heart damage had occurred after the collapse rather than before. The second cause of death was ‘prematurity of the lung’, which Dr Jane Hawdon, a consultant neonatologist from a London hospital who reviewed the death in late 2016, would later say in evidence was unlikely given that Baby C was born at 30 weeks.
25. Letby was convicted of the murder of Baby C.
26. Mother C told the Inquiry that the “events of that night and everything that has happened since have left an indelible mark”.

Baby D

27. Mother D attended the maternity unit at the Countess at 11:30 on 18 June 2015 after her waters broke. At 37 weeks and 1 day’s gestation, her pregnancy was close to full term. She was advised to go home until her contractions started. She returned the next day because she was concerned that there was a risk of infection since it was now 30 hours since her waters had broken. She was admitted and the following day was started on intravenous induction. Labour did not progress. She was anxious about her baby and repeatedly asked for a caesarean section. She felt her concerns were dismissed and she was not listened to. Her daughter, Baby D, was delivered by emergency caesarean section just after 4pm. Baby D was born in good condition, with Apgar scores of 8 after one minute and 9 after five minutes, and weighed 3.13 kilograms. However, her mother noticed she was beginning to grunt and seemed floppy. After a prolonged period of observation, she was transferred to Nursery 1 in the neonatal unit, where she was given antibiotics and light therapy for a period.
28. Dr Andrew Brunton, a paediatric registrar, reviewed Baby D at the start of the night shift. He had no concerns. He told Mother D: “[E]verything’s fine, she’s much better. She’s come off the light therapy. She’s picking up. She seems to be more lively.” Mother D could see her daughter looked better and so went back to bed. Letby was on shift in the neonatal unit.

Skin changes

29. At 01:30, Baby D collapsed. Dr Brunton attended quickly. He noted that there were areas of “light brown/dark brown and black lesions tracking across the trunk” and that she needed extra support with her breathing. Dr Brunton contacted Dr Elizabeth Newby, the consultant paediatrician on call. An attending nurse noted that the rash was similar to the others seen on the unit at that time. Dr Emily Thomas, then a junior doctor and now a consultant paediatrician, said in evidence that she had never seen anything like the rash and has not seen such a rash since. Mother D recalled that “they told me clearly they don’t understand, they’ve never seen this, they don’t know what’s going on”.
30. Baby D stabilised by 02:35. At 03:15 she deteriorated again, but subsequently stabilised. However, at 03:45, Baby D collapsed for a third time and stopped breathing. Letby was present for the resuscitation. Dr Thomas assisted, as did Dr Brunton and Dr Newby. Dr Brunton was concerned by the unusual pattern of collapses followed by periods of stability. He said: “It was completely unclear to me as to why Child D had suffered dramatic deteriorations in her clinical condition punctuated by periods of being completely stable.”
31. Mother D was woken up by the nurses. She was told her daughter was very ill, and she needed to attend the neonatal unit. When she arrived, she saw Dr Brunton holding Baby D, trying to save her. At 04:25, Baby D died. Her death shocked staff. Her designated nurse called her death “unexpected”. She remembered “feeling happy with [Baby D] at the start of the shift” and “thinking she looked well”.
32. Dr Newby could not explain why Baby D had died. In evidence she referred to the lesions on Baby D’s abdomen and said she could not fully explain Baby D’s death. She still had a clear and independent recollection of the death of Baby D because, as she explained in evidence, “[I]t’s very unusual to get a death on a neonatal unit, particularly a child that’s not known, for example, to have significant congenital abnormalities.” She described Baby D’s death as “very difficult and traumatic” for staff.
33. Mother D felt that Letby was observing her and her husband when they were with their daughter after she had died. Letby was out of place. Her presence made Mother D feel uncomfortable. She subsequently found out that Letby had “looked us up, both my husband and I … she should have had no reason to go and look us up”. She was also shocked to learn of Letby’s text conversations with colleagues about Baby D, and attributing her death to “fate”.
34. Dr Newby reported Baby D’s death to the coroner. She described the death as sudden and unexplained. She reported the rash that had been seen on Baby D and the fact that this was the third death in a short period on the neonatal unit. A post-mortem was conducted. The cause of death was recorded as ‘pneumonia’ and ‘acute lung injury’. This contradicted the theory of Dr Newby that Baby D had acute sepsis, which was not borne out by blood cultures.
35. Letby was convicted of the murder of Baby D.

Baby E

36. Baby E, and his identical twin Baby F, were born by caesarean section at 29 weeks and 5 days’ gestation. Baby E was born in good condition, at 1.327 kilograms. Mother E and F said that she and her husband considered having twins to be “a miracle”. They were told repeatedly how well the twins were doing. They were doing better than could be expected for babies born at their gestation. Baby E was breathing for himself.
37. On 3 August 2015, Parents E and F spent all day with their newborn sons. They both had skin-to-skin contact with Baby E. Mother E and F described him as “thriving”.
38. That evening, Mother E and F took expressed milk for Baby E to the neonatal unit. As she approached, she heard screaming and crying of a type she had never heard before. She realised it was Baby E. She went to him and found him with blood around his mouth. Letby was in the room with Baby E. Mother E and F asked her why there was blood around his mouth. Letby was dismissive, abrasive and avoided eye contact. She said the blood would have been caused by the feeding tube rubbing on his throat. She told Mother E and F to go back to the ward and that she would be called for if there were any problems. Mother E and F followed Letby’s instructions. She told the midwife what she had seen, and phoned her husband as she “knew there was something not right”.
39. It is Mother E and F’s belief that, when she went down to the nursery with the expressed milk, she witnessed “[a]n interrupted attack”. In her view, she “caught her off guard. Something had happened to him for him to be bleeding. Stable babies don’t bleed.”
40. Dr David Harkness, the paediatric registrar, was on the night shift in the main children’s ward. He was bleeped by Letby and went across to the neonatal unit. Letby asked him to review Baby E as he had vomited with flecks of blood, thought to be from irritation from the feeding tube. Dr Harkness prescribed medication and Baby E was relatively settled. Approximately half an hour later, Baby E developed sudden, substantial bleeding. Dr Harkness thought that this was unusual. There was then a subsequent episode of bleeding, which Dr Harkness described as “‘out of nowhere’ and something I had not seen before or since”. Baby E suffered a further sudden collapse. Strange patches appeared and disappeared across his abdomen. The only other time Dr Harkness, who is now a consultant, had seen such patches before was in the case of Baby A.
41. Dr ZA, Dr Harkness and the nurses began resuscitation. The midwife Mother E and F had spoken to earlier asked her to contact her husband and tell him to come to the hospital. Mother E and F then went down to the neonatal unit and could see the team working on Baby E. Without the intervention of the midwife, Mother E and F does not think she would have been with Baby E. She overheard the midwife explaining to staff that Mother E and F should be there. Mother E and F sat in the corridor for a while and was then invited to go in. She explained: “I was just talking to him, telling him everything was going to be okay and all the fun that we were going to have when we got home.” Baby E was christened. He died at 01:40 on 4 August 2015.
42. Baby E’s death was very sudden. Dr Christopher Wood, a GP trainee on the unit, said: “‘[I]t really seemed to come out of the blue’ – Child E had seemed well leading up to this and wasn’t ‘on the radar’ as a child of particular concern.” Mother E and F described how earlier she had “two thriving little boys”, but that “in the space of a couple of hours, it had all been taken”.
43. Letby omitted from the nursing notes any reference to the episode described by Mother E and F. Mother E and F stated that those records had been “changed to suit a different narrative of when Child E’s bleed started”. However, at the time, Parents E and F considered Letby was doing all she could. After he had died, Letby bathed him and chose the clothes that he was buried in. Letby made a memory box, without Mother E and F’s prior knowledge or consent. It is “painful” for Mother E and F to know that the contents in that box were created or touched by Letby.
44. At the time of Baby E’s death, Dr ZA believed he had died of necrotising enterocolitis (NEC). There was, however, no sign of the condition on Baby E’s abdominal X-ray, a factor she missed.
45. Parents E and F decided against a post-mortem, in conversation with Dr ZA. Baby E’s mother explained that making an informed decision at the time when your child had just died was “an impossible decision to have to make and I couldn’t — I couldn’t make an informed decision at that time”. She asked: “[I]f there was nothing on Child E’s X-ray to say there was any signs of NEC, why was the postmortem not, you know, mandatory? Why was it left for me to make that decision?”
46. After Baby E’s death, Parents E and F went to see Baby F. Baby E was still in his incubator. Mother E and F was shocked and said to Letby: “He’s still here.” Letby replied, “You haven’t told us to take him.” As Mother E and F said, she did not know what she was supposed to do. Letby’s remark was cold and unfeeling, at best.
47. Letby was convicted of Baby E’s murder.

Baby F

48. Baby F was 1.434 kilograms at birth, slightly heavier than his brother. When he was admitted to the neonatal unit, he had a low blood glucose of 1.9 millimoles per litre. This rose dramatically the following day to a very high level of 15.1 millimoles per litre. At 03:40 on 31 July 2015, manufactured insulin was administered. Baby F responded well to this, and his blood glucose level dropped to 8.7 millimoles per litre. No more manufactured insulin was prescribed or administered to him.
49. During the night of 4/5 August, Dr Harkness was called to attend Baby F. At this point, Dr Harkness was concerned about Baby F’s increased heart rate and low blood sugars. He discussed this over the phone with Dr Gibbs, the on-call consultant. Dr Gibbs examined Baby F at around 8.30am the following morning and noted he continued to have low blood sugar. Dr Gibbs also suspected that Baby F had an infection. The low blood sugar levels had persisted, despite the fact that Baby F had been given extra sugar. Dr Gibbs described this as “unusual”. Blood samples were taken at 17:56 on 5 August, while Baby F had low blood sugar levels, and were sent to Liverpool Clinical Laboratories at Royal Liverpool University Hospital for analysis. He was taken off the intravenous feeds, and the total parenteral nutrition (TPN) bag – a feeding bag – was taken down. His blood sugar levels began to increase.
50. Parents E and F were asked to come into Nursery 2. They were told that Baby F was experiencing a “really rapid, fast heart rate”. They were understandably scared. Mother E and F reports thinking: “[N]ot again. This simply cannot be happening to us again.” Dr Gibbs explained to Parents E and F that Baby F had an infection in the long line of his leg. The long line was moved, and he was given a course of antibiotics. Baby F’s parents were told this should rectify things. They were not told that he had been tested for insulin.
51. Baby F recovered and his parents were waiting for a move to a hospital nearer their home. The blood test result came back from Liverpool Clinical Laboratories on 12 August. It showed there was low C-peptide to insulin. Baby F had an insulin level of 4,657 picomoles per litre and insulin C-peptide levels of 169 picomoles per litre. This does not happen when insulin is being produced naturally in the body. The result showed that the blood sample contained insulin from an external source – that is, exogenous insulin. Baby F had been given insulin, which had not been prescribed to him.
52. Dr ZA realised that the results made it look as though Baby F had been given exogenous insulin as a medicine, which he had not. She checked to see if another baby in the unit had been prescribed insulin. They had not. This significantly reduced the likelihood of insulin having been accidentally administered. However, Dr ZA did not interrogate this further. She found “the idea that someone could be doing it deliberately … so fantastical and unlikely that that couldn’t possibly be what had happened”. Dr ZA did nothing to check that her conclusion was correct. She did not speak to the laboratory, nor did she speak to colleagues. With hindsight, Dr ZA considered that she had “made the wrong decision” and reflected: “I deeply regret that that is how I interpreted things both for Child E and F’s parents and for all the babies that happened subsequently.” Long before the Inquiry, she had apologised to Parents E and F for her mistakes in respect of both babies.
53. Mother E and F said that what happened to her sons has changed the course of her family’s life completely. She said: “[W]e’ve had to try and grieve in so many different ways. We tried to grieve for Child E … We had to grieve for the life that we thought we were going to have with Child F, with his learning difficulties.”
54. Letby was found guilty of the attempted murder of Baby F.

Baby G

55. Baby G was born in Arrowe Park Hospital at 23 weeks and 6 days’ gestation. She weighed 535 grams. After 11 weeks, she was transferred to the Countess in a stable condition. Throughout this time, at both hospitals, Baby G continued to improve. She was, in her mother’s words, “our little miracle, a gift from God”. As she neared 100 days of life, the nurses at the Countess prepared balloons and a banner. Parents G were told that they would soon be able to take her home. She was reviewed by Dr Brearey on 6 September 2015. He confirmed that she was stable and improving. Preparations for her discharge continued.
56. In the early hours of 7 September, Baby G suffered repeated collapses. Letby was on the night shift and allocated to a baby in Nursery 1. Baby G, in Nursery 2, vomited at around 2.15am. This was substantial, and projected across the room away from her cot. During subsequent attempts to resuscitate Baby G, 100 millilitres of milk was aspirated from her stomach. This volume, combined with the amount vomited, was much more than Baby G should have been fed. In the words of Father G, this was “an enormous amount of milk and more than her feed”. He said that the initial vomit was calculated as having travelled 3 or 4 feet away from Baby G’s cot, which indicated “the force of her vomit and the pain she must have felt with the pressure building up in her tiny little body”.
57. Parents G were called and told that their daughter had vomited and aspirated her vomit. They were told that blood tests had confirmed neonatal sepsis. They were not told that Baby G had collapsed. Baby G was treated for presumed sepsis with antibiotics. However, the blood test results recorded at the time were not consistent with that diagnosis. Dr Brearey accepted during his oral evidence that, whilst at the time it had been thought that the blood tests were indicating an infection, he now accepted a different cause of collapse. Mother G informed the Inquiry that Parents G “only found out years later that the blood tests that had been done at the time showed no evidence that our daughter was suffering from sepsis”.
58. Baby G was transferred to Arrowe Park Hospital on 8 September, where she improved. She moved back to the Countess on 16 September. During the day shift on 21 September, Baby G was being cared for in Nursery 4 by Letby. Shortly after a feed at 09:00, Baby G projectile-vomited twice and stopped breathing temporarily. Mother G had come to see her daughter that morning. Letby told her to wait in the parents’ room as she needed to carry out some tests. Mother G heard screaming. She ran back in to make sure her daughter was okay. She found “Letby standing by our daughter’s cot, looking sort of puzzled”. She continued: “Our daughter was screaming and looking very red and I saw vomit on her.”
59. Baby G was moved to Nursery 1 and Nurse W took over her care. She collapsed again at 15:30. Again, this episode was put down to sepsis. There was not sufficient evidence that this was the cause. It has subsequently been accepted by Dr Brearey that the large volume of gas and liquid that needed to be aspirated from Baby G’s stomach should have been seen as significant and unusual at the time. Parents G were not told about it. They should have been.
60. The effect of the repeated collapses has been profound for Baby G. She has suffered a brain injury with lifelong consequences. Mother G described the impact of the collapses: “I feel that Lucy Letby has ruined our lives. She has ruined everything. Our daughter needs 24-hour care because of Letby, we don’t know how long she will live and it affects every single minute of all of our days.” The hospital’s concerns about Letby were not shared with Parents G. They found out from the police during their investigations in 2018. They did not know what Letby was accused of doing to Baby G until just before the trial.
61. Letby was convicted of attempting to murder Baby G on two occasions: during the night shift of 6/7 September and on the morning of 21 September. She was found not guilty of a further charge of attempted murder, relating to the afternoon of 21 September.

Baby H

62. Baby H was born at 34 weeks and 4 days’ gestation. She weighed 2.33 kilograms. She suffered a number of collapses between 24 and 27 September 2015. During her time at the Countess, Baby H had a recurring pneumothorax and three chest drain procedures.
63. On 24 September, Mother H was in a wheelchair, and waited for Father H to take her downstairs to see their daughter in the neonatal unit. Mother H noticed that Baby H had deteriorated since the previous evening. She was now ventilated. No one had informed anyone in the family about this change. Mother H told the Inquiry:

    “I asked the doctor what was going on and I was told that she had been put on a ventilator. I really couldn’t understand why I’d not been informed of this earlier because we were told that she was okay. You know, I’d always check and would always ask how she was, and we were told that she was okay, you know, that she was okay. I was only upstairs.”

64. Mother H made a complaint about the lack of communication. An apology was offered by Dr Gibbs. However, in an internal email, Ms Powell’s first response was to criticise Mother H. She asked: “[W]hy had it taken [Mother H] so long to come to the unit when she was aware how poorly her baby is.” Ms Powell’s loyalty was to the nurse. It led to unjustified criticism of a mother who had proper cause to complain. Mother H described feeling “deeply offended” by the comments.
65. Baby H suffered a collapse in the early hours of 26 September. She was resuscitated. Mother H described Baby H as very pale. She had “sort of blue-purple marks, like a mottling, all over her body”. It was not clear to the clinicians what had caused this collapse. In the evidence of Dr Matthew Neame, a registrar who cared for Baby H, this collapse “needed some further assessment and further investigations in order to try to identify the cause”.
66. Baby H collapsed again in the early hours of 27 September. She needed resuscitation and, unusually for a neonate, also required the administration of adrenaline. Again, it was not clear why Baby H had collapsed. Dr Murthy Saladi, a consultant paediatrician, stated in his written evidence: “[I]t was not clear why Child H had deteriorated … Any [unexpected] deterioration in a child is worrying.” Baby H stabilised.
67. Baby H was transferred to Arrowe Park Hospital on 27 September.
68. Mother H remembers Letby giving her a box. She described it as “a red box, and it had a teddy bear on the top and inside the box was a cot card and her wristband from the Countess of Chester”. She said: “[T]here was also in a plastic bag with a white sticky label on the front that said, ‘For my Mummy and Daddy, xxx’ and it had her CPAP hat in it, the CPAP hat and things. To me it almost seemed a bit like a memory box.” Mother H recalled: “I remember thinking that it was quite morbid. You know, because she was not dead … I remember not feeling entirely comfortable about that.”
69. Mother H described the impact of the events at the Countess as “overwhelming”. She said: “What happened has affected every aspect of our lives … it really isn’t easy to put into words to truly convey the enormity of it … It’s affected my trust in hospitals and the health service very, very deeply … I really do find it very traumatic to have to go back to a hospital.”
70. Letby was charged with two counts of the attempted murder of Baby H: the first relating to the collapse in the early hours of 26 September; the second in the early hours of 27 September. Letby was found not guilty of the first count, and the jury could not agree a verdict on the second.

Baby I

71. Baby I was born at Liverpool Women’s at 27 weeks’ gestation. She weighed 970 grams. She was transferred to the Countess on 18 August 2015. When she arrived, she was placed in Nursery 1. After a period of deterioration, Baby I returned to Liverpool Women’s. She was cared for on the Level 3 neonatal unit between 6 and 13 September, before being transferred back to the Countess.
72. Mother I gave evidence that she felt there was a difference in care between the two units. Staff seemed stretched at the Countess, with one nurse refusing to help Mother I get Baby I out of her incubator as she was too busy. Mother I also said that, despite being told on 6 September, just before her return to Liverpool Women’s, that Baby I had NEC, later that day staff at Liverpool Women’s told Parents I that Baby I “didn’t have NEC and within 24 hours she went from being fully ventilated (at the Countess of Chester Hospital) to no ventilation and starting back on her feeds (at Liverpool Women’s Hospital)”.
73. When she was returned to the Countess on 13 September, she was placed in Nursery 3. In the words of Mother I: “[I]n a matter of a week she had gone from being critically ill on a life support machine and being rushed to Liverpool Women’s Hospital, to now returning to the Countess of Chester Hospital and being placed in the room before your baby goes home.”
74. On 30 September, Letby told Mother I that her daughter’s stomach looked swollen and that she would keep an eye on her. Mother I agreed that it did look swollen, but that Baby I was doing really well. Mother I left the neonatal unit at about 3pm. At 16:30 she was called to come back. Baby I had collapsed. Her blood oxygen levels had fallen, as had her heartrate. Mother I saw Baby I receiving chest compressions. Mother I said: “I wasn’t told what specifically caused the collapse … The doctors and nurses told us that she was a puzzle and weren’t sure why she kept having episodes.” Baby I was then moved to Nursery 2 and quickly recovered.
75. By mid-October, Mother I began to feel a sense of unease: “I had gone from feeling that our baby would be coming home to uncertainty.” On 13 October, Parents I were called to the hospital in the night. Baby I was very unwell. “The staff had to resuscitate her at least seven to eight times. She just kept flatlining.” This was the worst she had been. The following night, on 14 October, Parents I slept at the hospital. Mother I felt that just as they were starting to fall asleep, they’d be woken up to come and see their daughter. In her words: “Our baby also seemed to deteriorate when we left her alone and it was predominantly at night.” Dr Neame was working on both 13 and 14 October. He described Baby I’s collapses as “unusual”. It was a challenging week. It was “far more challenging than a typical week on a neonatal unit”.
76. On 15 October, Baby I was transferred to Arrowe Park Hospital and remained there until 17 October when she returned to the Countess.
77. On the night shift of 22/23 October, Ms Ashleigh Hudson, a neonatal nurse (band 5), was Baby I’s designated nurse. Letby was also on shift and caring for other babies. Parents I left the unit at approximately 10.30pm. Just prior to midnight, Baby I collapsed. A crash call was made, and help was sought. Letby came to help. Dr Rachel Chang (a paediatric specialty trainee) attended, and Dr Gibbs was called. Baby I was ventilated and stabilised. At about 12.30am, Mother I woke up and realised she had missed a call from the hospital. When she phoned, she was told Baby I had collapsed. Parents I set off for the hospital. Just prior to their arrival, Mother I phoned again and was told to get there as soon as they could. Ms Hudson entered the nursery and saw Letby there with Baby I. Just after Ms Hudson arrived, at about 1am, Baby I collapsed again. The team attempted resuscitation and Parents I arrived to see these efforts. After 20 minutes of attempted resuscitation, Baby I died. She was handed to Mother I. She told the Inquiry: “[A] part of us died with her.”
78. Ms Hudson was worried about Baby I’s aftercare. She asked for help. Letby volunteered. Mother I recalled:

    “She [Letby] was smiling and kept going on about how she was present at our baby’s first bath and how much our baby had loved it. I remember thinking at the time, ‘What are you going on about, she’s only ever had one bath and my husband never got to bath her’. I just felt so sorry for him because he hasn’t got that memory and I wished Lucy would just stop talking. I remember thinking ‘Will you just go away’. I was really uncomfortable and I just wanted her to leave. It was also weird that she kept smiling. I had never really seen her smiling before.”

79. Letby was convicted of the murder of Baby I.
80. Mother I reflected that, at the time of the Inquiry, Baby I would have turned nine years old. She said: “We should have been watching her grow and play with her siblings and friends. However, we have to somehow try to live with the fact all this has been taken away from her and us in the cruellest way possible.”

Baby J

81. Baby J was born by caesarean section at the Countess at 32 weeks and 2 days’ gestation. She weighed 1.709 kilograms. She was initially transferred to Alder Hey for an operation, before being returned to the Countess on 10 November 2015. She progressed well and was eventually moved to Nursery 4.
82. Parents J gave evidence to the Inquiry about the marked difference in the quality of communication they experienced at the two hospitals. Alder Hey was proactive and included parents in decision-making meetings. The Countess was reactive and less transparent. This meant that, at the Countess, Parents J were not as clear about how their daughter was progressing.
83. Baby J had a stoma and a Broviac line – a central line – which needed to be kept clean. There was a risk of infection, which could have serious consequences. On 15 November, Mother J went into Nursery 2 and saw her daughter covered with a small towel and her stoma bag detached. She was covered in faeces. Mother J was “just disgusted” and “incredibly saddened being a mum and thinking: what’s happened here, and there were two nurses in the room at the time and they could see that she was in that situation”. Mother J asked the nurses but they did not engage with her. Letby was Baby J’s allocated nurse.
84. Parents J made a complaint. This led to a meeting with Dr Saladi and a nurse. Parents J were told to go home and rest; they must be tired. This was not an appropriate reaction to their justified complaint. The parents’ complaint should have been accepted, and a Datix report should have been completed. At the Inquiry, Dr Saladi apologised for his response to the parents’ justified complaint about poor care.
85. During a night shift on 26/27 November, Baby J had a series of sudden and unexpected desaturations which were associated with seizures. She required resuscitation. Letby was on shift and assigned to care for two babies in Nursery 2. She assisted with the resuscitations. Dr Gibbs was called, and Baby J was moved to Nursery 2. Father J said: “[W]e were expecting to go home.” He described it as a “sudden unexplained collapse and we were obviously at this point I think scared”.
86. Some time after these collapses, Parents J spoke to Dr Gibbs. Father J relayed that:

    “[Dr Gibbs] had said that they were investigating the possibility that it could be sepsis … epileptic seizure … sleep apnoea … Even by his own admission later on when we had contact with him he was never able to explain the collapse to us and his — the subsequent investigations had ruled out pretty much all the things that he suggested it could be.”

87. Speaking about the impact of Baby J’s collapses, the lack of information from the Countess and the criminal trial, Mother J said in evidence: “I cannot emphasise enough the impact of this on our whole family. Who we are as people, parents, work life, spouses, children … [it] has cast a shadow of sadness over every part of our lives.”
88. Letby was charged with the attempted murder of Baby J. The jury were unable to reach a verdict.

Baby K

89. Baby K was born at the Countess at 25 weeks’ gestation. She weighed 692 grams. She was taken to the neonatal unit. She was small, and Parents K knew that she was poorly, but they were told by Ms Joanne Williams, a neonatal nurse (band 6), that “Child K was stable, Child K was fine”.
90. Father K told the Inquiry how he felt when Baby K was born: “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.”
91. On the night shift of 16/17 February 2016, Ms Williams went to the delivery suite to update Parents K. She told Dr Jayaram that Letby, who was on the night shift, was “baby-sitting”. While she was away, Dr Jayaram went into Baby K’s nursery. He saw that Baby K’s endotracheal tube was dislodged and that her oxygen saturation was dropping. Letby was not doing anything. Dr Jayaram and the nurses successfully resuscitated Baby K. She collapsed again at 06:15 and 07:25. Nurse W, who took over from Ms Williams as the designated nurse for Baby K in the morning following her collapses, told the Inquiry it was “highly unlikely” that a premature baby could have pulled out its own correctly secured endotracheal tube. In an email in 2017, Dr Jayaram said that Letby had alerted him to Baby K.
92. Baby K was transferred to Arrowe Park Hospital. She died some days later.
93. Parents K were never told about the incident with the dislodged tube and that she required resuscitation later that night. Father K told the Inquiry that they only learnt of Baby K’s collapses when meeting the Crown Prosecution Service. Furthermore, the Countess was not open with Parents K (or any other parents) about any of the concerns about Letby. By the time Parents K were informed by the police that there was a suspicion of deliberate harm to their daughter, they had been grieving the loss of their daughter for over a year. Mother K told the Inquiry that the information was a complete shock. They were in denial when they heard. She said: “Not for one minute did we ever foresee any of this at that time.”
94. The impact of Baby K’s death was felt keenly by both parents. Mother K said: “[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.”
95. Letby was tried for the attempted murder of Baby K. The jury were unable to reach a verdict. The case was re-tried. Letby was convicted.

Baby L

96. Baby L and his twin brother Baby M were born at 33 weeks and 2 days’ gestation. Baby L weighed 1.465 kilograms. In Father L and M’s words, “they both seemed fine”. It was his understanding that, whilst they were small and needed extra care, he and his wife would be able to take them home within a few weeks. Baby L’s parents did not know at the time that Baby L was experiencing periods of low blood sugar levels.
97. A blood sample was taken from Baby L on 9 April 2016 while his blood glucose levels were low and was sent for testing at Liverpool Clinical Laboratories. The sample was tested on 11 April. The test results showed that Baby L had an insulin level of 1,099 picomoles per litre and insulin C-peptide levels of 264 picomoles per litre.
98. A call was made by the laboratory to the Countess on 14 April, to discuss this result. This would happen when an external laboratory considered that the results were urgent, unexpected or unusual. A contemporaneous note of this call, made by Dr Shirley Bowles, a consultant chemical pathologist who took the call, stated that the test result was “[d]ifficult to interpret without the concurrent glucose but may be inappropriate if patient was hypoglycaemic at the time of collection”. Baby L’s medical records show that he had low blood sugar on the date of the blood test. Dr Bowles gave evidence that she concluded: “[I]t looks like there is external administration of insulin.”
99. Dr Bowles agreed, in oral evidence, that the most likely scenarios that could have produced the blood test results were: first, that the child was hyperglycaemic but was given too much exogenous insulin and therefore almost became hypoglycaemic; second, that exogenous insulin was given in error; and third, that exogenous insulin was given to the child deliberately. Dr Bowles did not consider the last option likely at the time. It was “unthinkable”.
100. The evidence suggests that Dr Bowles called the neonatal unit to flag the surprising results. It also suggests that she was not able to speak to any clinical member of staff. She then verified the results and placed them on Baby L’s electronic medical record. A day later, they were transcribed by hand into Baby L’s notes by a junior doctor. These highly unusual and concerning blood test results were missed repeatedly by treating clinicians and, in particular, by Dr U, a paediatric registrar who was responsible for Baby L’s care. Dr U died in July 2026.
101. Parents L and M were not told of the blood results until the police informed them in 2019. They told the Inquiry: “[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.”
102. The events at the Countess, and the subsequent police investigation and trial, caused an enormous amount of stress and anxiety for the family. Father L and M 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.”
103. Letby was convicted of the attempted murder of Baby L on the day shift of 9 April.
104. In evidence, Mr Harvey said that the blood test results of Baby L should have been cross-referenced with those of Baby F. He said: “I think if this had been identified and reported, it would have influenced our decision to go to the police.” Had the results been put together, the police should have been contacted. That did not happen.

Baby M

105. Baby L’s twin brother, Baby M, weighed slightly more than Baby L at 1.705 kilograms. Like his brother, he was doing well.
106. At about 4pm on 9 April 2016, Baby M unexpectedly collapsed. Letby requested that a crash call be put out. Nurse W assisted with the resuscitation until the doctors arrived. Three clinicians attended, including Dr Jayaram. After half an hour of resuscitation, they were considering whether to withdraw support, at which point Baby M recovered.
107. Nurse W was in the room at the time of the collapse. She reported that Baby M had been stable during the day. She said: “I did not think what happened on that day would happen.”
108. Parents L and M were on the maternity ward when they were told they needed to come quickly as something was wrong. They arrived on the neonatal unit and saw one of the doctors carrying out chest compressions on Baby M. Father L and M 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.”
109. An echo scan was carried out to ascertain whether there was an underlying cardiac condition that had caused the collapse. The scan was normal. Dr Jayaram confirmed to the Inquiry that he had seen an unusual blotching during the resuscitation of Baby M, which was similar to what he had seen on Baby A. There was some discussion among the consultants about the sudden collapse, and some discussion of the presence of the rash. They did not act upon any concerns they had at this time.
110. Parents L and M were not told about the blotchy rash by Dr Jayaram when he discussed the collapse with them. They learnt about it at the criminal trial. Dr Jayaram told Parents L and M at the time that he could not explain the collapse but did not tell them about his suspicions that Baby M had been harmed deliberately.
111. Father L and M was candid with the Inquiry about the effects of witnessing his son collapse. He said: “Even to this day I get flashbacks to what I saw on the unit.”
112. Letby was convicted of the attempted murder of Baby M.

Baby N

113. Baby N was born at 34 weeks and 4 days’ gestation. He weighed 1.67 kilograms. On the night of 2/3 June 2016, Baby N was in Nursery 1. His designated nurse was Mr Christopher Booth, a senior neonatal practitioner (band 6). Letby was on shift that night, despite a decision having been taken in May to leave her on day shifts for another two months.
114. While Mr Booth was on his break and another nurse – he could not remember who – was looking after Baby N, there was an episode of sudden brief collapse. The nursing notes record that Baby N was “crying ++ and not settling. He became dusky in colour, desaturating to 40’s. Responded to facial oxygen within 1–2 minutes … No further episodes occurred.”
115. The Countess did not tell Parents N about this collapse. They were not informed that Baby N’s oxygen saturation dropped significantly. In the words of Father N: “We did not know Child N had had problems overnight … I find this disgusting. As parents we have an absolute right to know what was happening to and with our son.”
116. Baby N suffered further collapses during the day shift on 15 June. The prosecution case at trial was that these collapses were the result of an inflicted injury, which resulted in heavy bleeding in the throat area. Baby N had begun to deteriorate from 1am. The first collapse occurred just before the day shift began. Letby had arrived early and was already on the unit. The second collapse happened at about 2pm. Letby was his allocated nurse.
117. Parents N were called to attend the neonatal unit. Mother N told the Inquiry that it “was the worst day of our lives, from waking up that morning being prepared to take home our son to the utter catastrophic scene we arrived at has left a lasting imprint on us, seeing our tiny baby fighting for his life, medics doing CPR on his tiny body and not knowing if he was going to live or die with no obvious cause”.
118. Mother N told the Inquiry she kept asking herself how he could have gone from being healthy one minute and then bleeding from the mouth the next. When Father N saw Baby N, he said: “He was blue in colour and had traces of blood around his lips like he had coughed up blood and it had splattered on him. The blood was dry and dark in colour.”
119. A nurse explained that Baby N was very unwell and asked if Parents N wanted to see a priest. A priest arrived to talk to them. Father N described that he was “shocked by this as I am not religious and we had not asked for him … It felt really inappropriate because he was a stranger.” Father N stated that it was Letby who recommended they get Baby N baptised. They ultimately did so out of desperation.
120. Dr U was the night-shift registrar on 14/15 June 2016. Letby worked the day shift on 15 June. Dr U and Letby were both involved in Baby N’s care. They messaged each other several times during the night, sometimes about Baby N, sometimes on personal topics. Mother N was understandably upset by this and made a formal complaint about Dr U.
121. Both Dr Brearey and Dr Saladi reported to the Inquiry that Baby N’s collapse was very unexpected. The damage to Baby N’s throat was such that it was difficult for clinicians to intubate him. Staff from Alder Hey attended to assist with the intubation. Baby N was subsequently transferred to Alder Hey and survived.
122. Letby was convicted of attempted murder in relation to the collapse on 3 June. The jury could not agree a verdict on either of the two counts of attempted murder relating to the collapses on 15 June.

Babies O, P and R

123. Babies O, P and R were triplet boys. Their father described the prospect of their birth as “a once in a lifetime opportunity to welcome three children at once. I felt really blessed.”

Baby O

124. Baby O was born by caesarean section at the Countess alongside his brothers, Baby P and Baby R. They were born at 33 weeks and 2 days’ gestation. Baby O weighed 2.020 kilograms. Mother O, P and R had received her antenatal care from Dr Jim McCormack, a consultant obstetrician and gynaecologist at the Countess. He was on leave when the babies were delivered, but reported to the Inquiry that all three were born “in excellent condition”. Mother O, P and R said that they were “reassured that their weights were better than expected and that they had been born healthy”.
125. Letby returned from holiday on 22 June. She was on duty the next day. She messaged Dr U and asked: “What gestation are the trips?”
126. During the day shift on 23 June 2016, Baby O was initially in Nursery 1. Letby was his designated nurse, and Ms Taylor was also working the day shift. He was subsequently moved to Nursery 2 to be with his brothers. In Nursery 2, Ms Taylor felt uneasy (she described it as a ‘gut feeling’) about Baby O’s condition and suggested to Letby that they move him back to Nursery 1, which she felt was better equipped if he continued to deteriorate. Letby said she wanted him to stay in Nursery 2.
127. Dr Brearey was on the neonatal unit and was asked by Dr U for assistance in intubating Baby O. Dr Brearey described the intubation as uneventful but noted a purpuric rash on Baby O’s chest. Dr U informed Parents O, P and R that Baby O needed some extra breathing support. They were told this was not uncommon. Mother O, P and R wanted to see her son. She went down to the neonatal unit. Baby O had deteriorated and had been moved to Nursery 1. Baby O’s mother described the scene that greeted her as “complete chaos”. In her words, Dr U looked panicked and the staff looked like they did not know what was going on. She said: “It was clear that Child O’s collapse was a complete shock to them.”
128. The neonatal unit did not know why Baby O had collapsed. It was an unexpected event with an unknown cause. They contacted Dr Oliver Rackham, a consultant paediatrician for the neonatal transport team at Arrowe Park Hospital, seeking to transfer him to an intensive care unit. Baby O died before this could happen.
129. Dr Brearey assisted with the resuscitation of Baby O. He did not see Letby do anything untoward. He had noted the rash earlier and connected this to the rashes that he knew had been seen on other babies. The rash was unusual. Father O, P and R described it as follows: “His skin was a different colour and it looked almost like there was something pulsating through his veins.” He also described his son having a swollen abdomen “almost like a pot belly”.
130. Parents O, P and R told the Inquiry just how confused the clinicians appeared to be about the sudden collapse. Baby O’s father described the doctors as seeming to be “baffled … no one could tell us why things had suddenly gone so wrong. It was really shocking.” This was supported by the evidence given to the Inquiry by doctors and nurses who had cared for Baby O. Dr Huw Mayberry, a paediatric registrar, and Ms Taylor both told the Inquiry how shocked they were that Baby O had died. He had been stable. According to Ms Taylor, there had been “no clinical recordable signs that I could have said this baby is deteriorating. So his observations, such as his heart rate, breathing, stayed the same or stable as he was previously.”
131. Dr U and Letby exchanged messages about the resuscitation and the debrief about Baby O. Dr U described the debrief as “good – we didn’t come up with anything missed or delayed”.
132. Letby was convicted of Baby O’s murder.

Baby P

133. At birth, Baby P weighed 2.066 kilograms. Like his brothers, he was born in good condition.
134. On 24 June 2016, Mother O, P and R was very worried about Baby P and Baby R, after the tragic loss of Baby O. She told the Inquiry that she went down to the neonatal unit at around 6am and “was told by the nurse that the boys were ‘little angels’ and that she had no concerns”. She did not find out until the criminal trial that Baby P had been unwell in the night, as he had aspirated milk from his nasogastric tube. Mother O, P and R left the unit, having been reassured. Later, a nurse came to get her and told her that Baby P was very unwell and she needed to come to the nursery now.
135. Baby P had collapsed. He was administered adrenaline and CPR was performed. He seemed to have improved initially, but remained unwell. When she arrived at the nursery, Mother O, P and R was confronted by the same panicked scene as the day before, when Baby O had collapsed. She told the Inquiry that, while Baby P was being resuscitated, “I felt entirely forgotten and ignored.” When Father O, P and R arrived, he had the same experience. He found staff panicking, and nothing was explained to him. He saw that Baby P “had the same mottling on his skin, the same distension on his belly [as Baby O] and I just knew it was the same thing, even though I didn’t know what that thing was”.
136. Arrangements were made to transfer Baby P to Liverpool Women’s. Just when Dr Rackham arrived to facilitate the transfer, Baby P collapsed. Dr Rackham led the resuscitation attempt. Sadly, Baby P did not recover and he died. Dr Rackham affirmed what he wrote in his statement to the Inquiry, that “there was no identifiable cause of death at that time, so I was surprised at the collapse and the death and unable to explain what happened”. At the time, Dr Rackham told Parents O, P and R that he did not know what had happened, and could do no more for Baby P.
137. Dr V, a consultant involved in Baby P’s care, told the Inquiry that she overheard Letby commenting, after Baby P’s first resuscitation, “He’s not leaving here alive, is he?” Dr V said she was taken aback by what she considered an inappropriate comment. She told Ms Powell about it.
138. Dr V also noted that, prior to his collapse, Baby P had appeared stable and in reasonably good condition. His deterioration was very unexpected. There was no evidence at the time that suggested a reason for Baby P’s sudden collapse and death. Dr Mayberry, who arrived in the evening of 24 June for his night shift, having cared for Baby P the night before, was “devastated, shocked and bewildered” to learn that Baby P had died.
139. Father O, P and R remembered that Letby was involved in the aftercare of Baby P. He recalled that Letby had dressed Baby P. She had made a “big deal about taking photos of the boys and making memory boxes”. Letby’s approach to this solemn and difficult task was described by Dr V as “very inappropriate” as there was an “inappropriate jolliness, brightness to it”.
140. Letby messaged Dr U with a running commentary about caring for Baby P after his death. When one of her nursing colleagues came onto the ward, Letby was heard to say something like, “You[’ll] never guess what’s just happened!”, a very disturbing way to refer to the death of a baby.
141. Letby was convicted of Baby P’s murder.

Baby R

142. Baby R weighed 1.865 kilograms at birth. Like his brothers, he was in good condition.
143. After the deaths of Baby O and Baby P, Parents O, P and R were extremely concerned for Baby R. Mother O, P and R recalled that:

     “Father O, P and R begged Dr Rackham to take Child R to Liverpool Women’s Hospital … Father O, P and R and I did not know what was wrong at this point but I just knew we needed to get Child R out of the Countess of Chester Hospital. I didn’t think anything malicious had happened at the time, but I did feel that something had gone wrong in the Unit.”

144. This fear for Baby R was shared by some of the clinical staff. After helping to care for Baby P, Dr V recalled “begging in my head” for Dr Rackham to take Baby R, because she feared that he would die next.
145. There were no medical concerns regarding Baby R, but Dr Rackham agreed to transfer Baby R to Liverpool Women’s out of caution, because of the deaths of Baby O and Baby P. He explained his rationale: “The child was well but was a triplet and the other two triplets had died without any explanation … in case there was some underlying condition in that family, such that that baby was also going to have a collapse, it would be more sensible for him to be in an intensive care unit when that happened.” The post-mortem reports made no reference to any underlying conditions, nor did the mortality reviews of either Baby O or Baby P. Baby R thrived in Liverpool Women’s and remained well.
146. During the Inquiry, at the close of Dr Rackham’s evidence, Parents O, P and R expressed their view that Dr Rackham had saved Baby R’s life. They expressed their “profound gratitude” to him.

Baby Q

147. Baby Q was born at 31 weeks and 3 days’ gestation. He weighed 2.076 kilograms.
148. On 25 June 2016, Baby Q collapsed unexpectedly. The nursing notes for Baby Q record: “09:10 attended to by S/N [senior nurse] Lappalainen – He had vomited clear fluid nasally and from mouth, desaturation and bradycardia, mottled ++. Neopuff and suction applied. Doctor U attended. Air++ aspirated from NG [nasogastric] tube.” Letby was Baby Q’s designated nurse on the day shift.
149. Letby was charged with the attempted murder of Baby Q. The jury were unable to reach a verdict.
150. Mother Q did not know that her son had suffered a collapse at the Countess. She was told by the police when they had opened their investigation. Mother Q said of the way that the hospital managed information: “I think that they played everything down to protect the parents and prevent panic, but I feel that this was not fair to us as we needed to know what was happening to our child.”
151. In Mother Q’s victim impact statement to the criminal trial, she wrote: “One thing that I really struggle with is, this had been going on for such a long time and Child Q was the last one if she would have been caught before, this wouldn’t have happened to Child Q.”
152. As is plain from the accounts above, it was not just the number of deaths in 2015 and 2016 that caused concern. It was the fact that the babies collapsed suddenly and unexpectedly, and often without explanation. The consultant paediatricians and Ms Powell all said at the time that often the babies who collapsed unexpectedly did not recover as they would have been expected to. These were striking and unusual concerns, as were the skin changes/mottling/rashes.
153. For the parents, the worst imaginable event had happened. Over the following two years, information was withheld from them by the Countess. Even when the police were brought into the hospital in 2017, they were not aware of it. For most, the first they knew that the deaths of their babies may not have been of natural causes was at the time of Letby’s arrest in June 2018. The lack of candour from the hospital was lamentable.