PROSECUTION CLOSING SPEECH - Thursday 22nd June 2023
Day 4 - Morning Session
LIVE: Lucy Letby trial, June 22 - prosecution closing speech
10:30am
The trial is now resuming. Mr Johnson says there are four children left to go through - Child I, Child J, Child N and Child Q. He first details the case of Child I.
10:34am
Mr Johnson says evidence had been heard of Child I, that medics do not worry about self-correcting desaturations.
Mr Johnson says having failed to kill Child G and Child H, she turned her attention to Child I, and was designated nurse for two of the four occasions in which she tried to kill the baby girl, and falsified notes along the way.
Mr Johnson says it was important to note from the post-mortem evidence that Child I did not have NEC [a gastrointestinal disease].
10:37am
Mr Johnson says Child I's first collapse was marked with a desaturation to the 30s and had vomited, on September 30.
He says the day before, Dr Lucy Beebe had reviewed Child I. She remembered seeing Child I from memory, as the girl became unwell, was shipped out and recovered well, and came back, which she said was unusual, for her short time at the unit.
Dr Beebe had said she was shocked and frustrated by Child I's death, as she felt there was something going on which they [the staff] were not aware of.
Dr Beebe said the aim for Child I, after the September 29 review, was to continue feeding and growing the baby girl.
10:39am
The day rota for September 30 had Letby as designated nurse for Child I and two other babies in room 3. Mr Johnson says Letby "did not like" being in room 3.
The plan was to give Child I immunisations, as was the case for Child G. He says there was nothing wrong with Child I, who was receiving cares from the mother and a feed.
Mr Johnson says Child I produced a small stool at the 10am feed. The 10am feeding chart note is signed by Letby.
"The doctors were very happy with [Child I]," Mr Johnson says.
10:43am
Dr Beebe's note is shown to the court for September 30. Mr Johnson says it is important to note the reason for the review. It was 'asked to review as reduced temperature'.
Mr Johnson says Child I was taking full bottles, gaining weight, and Dr Beebe recorded that Child I was handling well. Child I, during the examination, produced a yellow, seedy stool, which indicated good gut health, he tells the court.
Dr Beebe said this was not a sign of NEC. Mr Johnson says Child I was "not in distress", the abdomen was the same as yesterday, and the plan was to monitor Child I closely, raise the cot temperature, but Child I appeared clinically well.
Mr Johnson asks what was going on at this stage. Child I's mother, in evidence, said Lucy Letby raised the issue with her about Child I's stomach. Mr Johnson says that was not the same reason Letby gave to Dr Beebe.
NJ: "So what was going on here?"
10:45am
Mr Johnson says no concern was expressed to medical staff about Child I's abdomen by Letby.
"Why was Lucy Letby expressing concern to [Child I's mother] about the abdomen? Why did Lucy Letby not raise the issue with Dr Beebe?"
Mr Johnson says Letby was gaslighting the mother by suggesting a problem with Child I that didn't exist, until she caused the problem.
10:53am
Mr Johnson says "everything was unremarkable" for Child I until 1pm when she was asleep, and fed via a NGT.
The mother said she had gone to meet the family in the canteen at this time.
The feed chart shows a 35ml feed for Child I, which Mr Johnson says would take some time - "about 15 minutes", taking until 1.15pm. He says the nursing notes are accurate as they are time-stamped by the computer automatically.
The note is written between 1.36pm-1.48pm - it was "at most" 20 minutes after the feed ended. Mr Johnson says the details of the feed and review recorded are not correct.
He says the addendum, of a '1500' 'Drs' examination of Child I, is "a complete fabrication".
A male doctor's note records examining Child I at 4.30pm.
Mr Johnson asks who these doctors were who examined Child I at 3pm. He adds the '3pm note' contains: '[Child I] appeared mottled in colour with distended abdomen and more prominent veins.'
Mr Johnson says there is no corresponding doctor's note for this examination of 'mottling'.
Letby's note: 'Full monitoring recommenced'. An observation note records this was done from 3pm.
Mr Johnson says Dr Beebe had advised it at 11.40am. He asks why did Letby only recommence full monitoring after Child I's mother had left the unit.
Mr Johnson says Letby is transposing events, including a note of a yellow seedy stool, from 11.40am to 3pm to an examination - "which never actually happened".
10:59am
Mr Johnson says it is a "very calculated way" of giving the impression a child who had no problem at all, "had a problem".
Child I's mother had a routine for each day, visiting Child I at regular times, and the father would come in from after 5pm. Mr Johnson said the time between 3pm and 5pm was "her window of opportunity" to attack Child I.
NJ: "What are the chances of these things happening at precisely this point?"
Letby had written: 'Mummy present when reviewed by Drs. Had left unit when [Child I] had large vomit and transferred to nursery 1.'
Mr Johnson says Letby had tried to give the impression the Neopuff caused the inflated stomach for Child I.
He says "remarkably", Child I improved, and there were 'minimal aspirates'.
"Yet another miraculous recovery...all good once Lucy Letby had left."
Medical expert Dr Dewi Evans ruled out infection and said the only explanation was a dose of air administered through the NG Tube. Dr Sandie Bohin agreed, and the effect would have been to splint the diaphragm. She discounted the possibility of NEC.
Professor Owen Arthurs said the stomach and almost all of the gut had been distended. Mr Johnson says that was from administered air.
11:01am
The second incident for Child I, on October 13, 2015 at 3.20am, is now detailed by Mr Johnson - the 'see in the dark' incident, he calls it.
He says Child I had been progressing well.
11:06am
The first part of the night shift had Child I being fed normally.
Mr Johnson says the second event was much more serious than the first. Before it, Child I had been in a good clinical condition, Mr Johnson says. He says it was expected she was coming up for discharge from the hospital in a couple of weeks.
Letby was the designated nurse for a baby in room 1. Nurse Ashleigh Hudson was the designated nurse for Child G, Child I and one other baby in room 2.
She left room 2 to tend to another baby in room 1, assisting colleague Laura Eagles, and asked a colleague to monitor Child I - either Caroline Oakley or Lucy Letby. Caroline Oakley had no recollection of being called.
Ms Hudson said she had been in room 1, and some milk needed defrosting for Child I's feed, and when she got back, there were no adults in the room. She started to prepare the milk, with her back to Child I.
The next thing she remembered was Lucy Letby in the doorway, who pointed out that Child I 'looked pale' - she was 'about 5ft-6ft away' from Child I. She said something along the lines of 'Don't you think [Child I] looks pale?"
Ms Hudson said the light in room 2 was low, and the lights were on in the corridor outside room 2.
Mr Johnson reminds the jury what Lucy Letby said about this in interview.
11:15am
Mr Johnson refers to Letby's 2019 police interview, in which she said room 2's light was off, and there was 'an element of light coming from the doorway', and Child I was by the window.
Ashleigh Hudson said Child I had a blanket over her, and a 'tent structure' keeping her secure. She said she could not see Child I due to the canopy and the lighting. Mr Johnson says Letby did not have a better view. Ms Hudson said she switched on the light and looked at Child I, who was 'gasping', 'incredibly pale', and in a 'very bad way'.
Ms Hudson initially thought the deterioration was so rapid she thought she was too late to save her.
She said you "cannot see" a child from the position Lucy Letby was in.
Mr Johnson says we have a "head-on credibility conflict", of two accounts who "don't live in the same world".
Mr Johnson says in cross-examination, Letby was asked about looking from a brightly lit corridor into a dark room would improve her ability to see.
He says her first response was "I don't know".
NJ: "She 'conceded' she would not have been able to see, yet she persisted that she could see [Child I].
NJ: "We had a break, we came back, and I asked Lucy what she had said in interview...
He says Letby had said "Maybe I spotted something Ashleigh couldn't spot."
Mr Johnson had asked Letby: "You don't have better eyesight than Ashleigh, do you?"
LL: "No."
NJ: "The question is, how would you be able to spot the colouring [of Child I better than Ashleigh Hudson from the same point of view]?"
LL: "I had more experience so I knew what I was looking for/at."
Mr Johnson adds: "You will remember the way she corrected herself."
He says there was a very long pause. He added at the time: "Your answer, you explain it."
He said Letby was "finding it difficult to concentrate on all the dates".
Mr Johnson said there was nothing about the dates in this context. He says did Letby make an innocent mistake, or did something else slip out, under the pressure of the witness box?
He says Letby caused the problem for Child I. He says Child I recovered well.
11:22am
Mr Johnson says Letby had timed her note, having seen Ashleigh Hudson's nursing note first, so it appeared she saw Child I first. Mr Johnson says it is another case of 'plausible deniability'.
Professor Arthurs said Child I's large bowel was distended, and the NG Tube was in the curled up in the oesophagus rather than the stomach.
Dr Evans said the only explanation was air administered to Child I via the NG Tube.
Mr Johnson says Dr Bohin explained Child I was sabotaged by air administered via the NG Tube and via and IV line.
Dr Anne Boothroyd's x-ray report on September 30 recorded: 'There is splinting of the diaphragm due to bowel distention'.
11:28am
For the third event for Child I, Dr Ravi Jayaram said there were 'no clinical concerns' for Child I before the night of October 13-14. Mr Johnson says evidence was heard to say Child I was "stable".
This was the second time Letby was the designated nurse. Mr Johnson says this was the second time she had the opportunity to falsify notes.
Dr Matthew Neame's 5.55am note is shown to the court for October 14. Mr Johnson says this is not a retrospectively written note, as it includes a note of a prescription which is timestamped at 5.56am, and an urgent x-ray is timed at 6.05am.
He says Letby's addendum note, made at 8.43am, after Child I had desaturated: 'At 0500 abdomen noted to be more distended and firmer in appearance with area of discolouration spreading on right hand side, Veins more prominent'
Mr Johnson asks why would Lucy Letby do this?
He says to bear in mind what happened the previous night, if these symptoms were shown, then the doctor would be called urgently. He says the absence of a doctor called shows there was no problem at 5am.
11:34am
Mr Johnson says, from the paper trail, if anyone 'puts two and two together' and thinks there is a problem with Lucy Letby, they are "thrown off the scent".
Dr Neame said the mottling was "unusual", which was why he recorded.
NJ: "How many times have we heard that in this case?"
Mr Johnson says the abdomen was distended.
Dr Andreas Marnerides had excluded NEC.
Mr Johnson says the only possibility is pushing air in down the NG Tube.
Dr Neame said Child I looked uncomfortable when examined and "grimaced". He noted the abdominal distention.
Prof Arthurs said, of the x-ray image, the stomach was 'markedly dilated', and the small bowel and the large bowel were also dilated, with 'no symptoms of NEC'. Another image at 8.03am had the stomach decompressed, and a third image the following day showed 'no problems at all'.
Dr Neame recorded a further desaturation for Child I at 7am, and the ET Tube was reintubated. It was noted there was 'good air entry' for Child I, but - as Mr Johnson says, in so many other cases for babies in this trial - Child I was desaturating.
11:38am
Child I had further desaturations on October 14-15, which Mr Johnson said were 'explicable' as there were secretions in the NG Tube. Child I had a 'miraculous recovery' after being transferred to Arrowe Park, and improved, until coming into the "misfortune" of contact with Lucy Letby, he adds.
Dr Evans thought Child I's stomach had been injected with air, and air injected into the intravenous system. There was an "astonishing amount of air" in Child I's stomach.
Dr Bohin concluded Child I had air administered.
11:52am
The trial is now resuming after a short break.
Mr Johnson turns to the fourth and final event for Child I, on October 22-23, 2015, in which Child I died.
11:55am
Mr Johnson says Ashleigh Hudson had given evidence to say Child I was "very easy to settle", and although Child I was in nursery room 1, that was as a precaution given her history of episodes.
Child I was self ventilating in air and her saturations "optimal", and she "looked very well", and "pink, well-perfused" and a "soft, non-distended abdomen".
Caroline Oakley said in a statement Child I's abdomen was "fine" and "soft, non-distended".
Mr Johnson says that is the background to Child I when Lucy Letby came on shift that night.
12:03pm
Letby was designated nurse for a baby in room 2 and a baby in room 3. Ashleigh Hudson was designated nurse for Child I and another baby.
Child I was in a "virtually perfect" clinical scenario, Mr Johnson says. He says Letby "got herself involved".
Child I gave a 'cry that had not been heard before' - 'loud and relentless', according to Ashleigh Hudson, who interpreted it as "distress".
When she was repositioned on her tummy at about midnight, Child I stopped breathing. Resuscitation efforts began and Child I then began to fight the ventilator.
Dr John Gibbs was told Child I had had an abnormal cry. He was 'perplexed' at Child I's rapid deterioration and recovery, which would not show a sign of infection.
Mr Johnson says Letby falsified paperwork for one of her designated babies at this time - the baby to be transferred to Stoke.
Letby recorded a note at 10.50-10.52pm note of a 10% glucose infusion for the 'Stoke baby'. The infusion note is written as starting at '2300', and that writing is changed to '2400'. Mr Johnson says it was changed to give Letby an "alibi" for midnight.
Mr Johnson says further times are overwritten/changed on Child I's infusion chart - from 12.15am to 12.25am, and one to a time at 1.25am, which Mr Johnson says puts it out of sequence between '1.28am' and '1.48am' on the chart.
12:09pm
Ashleigh Hudson said she was alerted to Child I at 1.06am by either the alarm going off or Child I crying. She said, in room 1, Letby was already there at Child I's cotside and "had her hands in the incubator". Mr Johnson says Letby had sabotaged Child I, and caused Child I to cry.
Mr Johnson says Letby 'put Ashleigh Hudson off' by saying: "She just needs to settle".
'Air++' was aspirated from Child I. Mr Johnson asks how that could have got there other than being forced in by Lucy Letby.
Dr Rachel Chang could see air entry and chest movement on Child I, but Child I wasn't recovering. She said Child I's death was "inexplicable".
Dr John Gibbs noted mottling on Child I. He said he "could not understand" why Child I had died and referred the case to the coroner.
The grieving parents agreed to bathe Child I. Mr Johnson said despite having two designated babies to care for, and Child I not being her designated baby, Letby met the parents.
The mother said: "Lucy came back in. She was smiling and kept going on about how she was present at [Child I's] first bath and how much she [Child I] had loved it."
"I wish she had just sopped talking. Eventually I think she realised and stopped. It wasn't what we wanted to hear then."
12:17pm
Dr Evans says this was "another" case, in Child I, receiving air administered. He thought the nature of the collapse, the crying, the prolonged resuscitation, and the purple and white discolouration, were all symptoms of air embolus. There was no account of natural disease.
Dr Bohin said the cause of death was air embolus - from the unexpected catastrophic collapse, Child I being unsettled and agitated, the 'extremely unusual' crying meaning Child I was in excruciating pain.
In cross-examination, Dr Bohin was asked if she had a coherent explanation for an air embolus. Mr Johnson said Dr Bohin's answer, without hesitation, lasted for about 10 minutes. She was asked about Child I's poor weight gain, and Dr Bohin said that did not make her more likely to have a cardiac arrest [as Child I had].
Prof Arthurs said it was 'unusual' to see the amount of dilation in Child I's stomach. He excluded CPAP belly as a cause. He said it was "reasonable to infer" air administered.
Dr Marnerides said at the time of Child I's death, she had no acute illnesses or abnormalities in the bowel, other than presence of air. The presence of gas had "no pathological cause". He said the collapses were air administered from the NG Tube.
Mr Johnson says Child I's case is a "stark one". He says Letby made repeated efforts to kill Child I, and falsified notes both for Child I and another baby. She 'gave herself away' in the event with Ashleigh Hudson.
"Lucy Letby's behaviour in the aftermath [of Child I's death] was bizarre and inappropriate. She revelled in what she had done."
"Her voyeuristic tendencies caused her to look up [Child I's mother] on Facebook."
"Having killed her [Child I], she wrote a condolence card. It was still on her phone when it was seized by the police."
12:23pm
Mr Johnson details the case of Child J.
He says when Letby was giving evidence in this case, she said band 4 nurses [nursery nurses] cannot do intensive care or high dependency babies, or handling of stomas.
Letby said the unit was very busy as an explanation why a band 4 nurse was caring for Child J.
Mr Johnson says the implication of that exchange was to give that Child J received incompetent care, and staffing levels were compromised.
Letby had messaged a colleague on November 19, 2015: "It's shocking really that they are willing to take on the responsibility for things that they have no training or experience etc on. Don't think they appreciate the potential difficulties"
Mr Johnson says the jury will remember witnesses had been cross-examined about nursing guidelines. He says the part that was never quoted was the bit about stomas. The care, shown to the court, says special care day nurses can include care of a stoma.
Mr Johnson says that whole evidence "was designed to mislead you".
"It's the same type of behaviour that Lucy Letby engaged in with her colleagues."
12:26pm
Mr Johnson says Child J had no respiratory difficulties and was being bottle fed, and did not need respiratory support, and was in room 4.
Nurse Nicola Dennison said Child J was 'getting ready to go home' with a stoma by November 26, 2015. She wrote in notes that Child J was 'stable'.
Child J's mother left at the end of the day, intending to return at 8am the following day, but received an emergency call overnight.
Letby was in room 3, designated nurse for two babies that night shift. Nicola Dennison was the designated nurse for Child J and one other baby in room 4.
12:32pm
Child J desaturated at 4.40am on November 27.
Mary Griffiths was working in room 2. She said in evidence Child J was a 'joy to look after', and described the first desaturation, which she and Nicola Dennison dealed with. The desaturation was "alarmingly low".
Ms Dennison said, after cross-examination, Child J collapsed after her feed.
Dr Kalyilil Verghese recorded the shift was busy. Twins had been admitted to room 1 at 6.10am.
He said he reviewed Child J once, and all information was given to him by nursing staff. He noted there had been 'two profound desaturations', timed at 5.15am.
Child J was moved to nursery 2 when the designated nurse was Mary Griffith. Mr Johnson says Letby was then involved in care of babies in room 2, despite her designated babies being in room 3.
12:34pm
Letby had said, in a text, the unit was 'closed' trying to get someone in. At 6.49am she messaged 'It's all a bit t**s up'
Mr Johnson says resources had been diverted to room 1, and this was the "perfect opportunity" for Letby to attack Child J.
At 6.56am, Child J collapsed.
12:42pm
Mr Johnson says Child J's saturations dropped, as did Child J's heart rate.
Mary Griffith noted '[Child J's] monitor went off at 0650 myself and L Letby attended. Found baby with pale hands and baby very rigid. Sats went to 7 and heart rate to 68. [Child J] neopuffed with little improvement....Dr Gibvs on unit and called to help. neopuff continued for 16 mins until sats improved.'
Mr Johnson says this was a serious enough incident for the consultant to be called.
A glucose bolus was started at 7.20am, which Mr Johnson says was administered by Letby. At 7.40am, according to nursing notes, Child J desaturated again, and her fists were clenched, her eyes were rolling to the left, and Letby got involved again.
Dr Gibbs recorded at 7.35am: 'Two seizures' - he said he remembered Mary Griffith and Lucy Letby were there when he arrived. A seizure was 'reasonably long', about '10 minutes'.
Mr Johnson says prior to these events, Child J had never had a seizure, and she had not had one since. She "recovered very well" afterwards. He adds blood tests were normal and showed no signs of infection, and a brain scan showed no abnormality, nor in an x-ray.
Dr Gibbs said an oxygen drop was the reason for the seizure, but could not find a reason for the oxygen drop.
Dr Stephen Brearey said there "was no explanation" for the deteriorations.
12:46pm
Dr Evans said there was no marker of infection for Child J. He said if there had been, the recovery would not have been so quick. He agreed there had been a lack of oxygen, and it had not been an epileptic seizure.
Dr Bohin said babies who are ready to go home do not have collapses which require prolonged resuscitation and a quick recovery.
Mr Johnson says the cause of collapses "bear all the hallmarks" of an attack by Lucy Letby.
He said Child J was "prospering" prior to the attacks, and the attack happened while the unit was distracted by two emergency admissions. He says at that time, when it was 'all hands to the pump', Letby was on her phone.
He says Letby stopped texting seven minutes before Child J's collapse.
Letby's suggestion that she had little memory of the event is "not realistic", Mr Johnson says, as that night was punctuated by two emergency admissions to the unit.
He says Letby "was running with the I don't remember line to avoid answering questions."
He says Letby searched for Child J's parents, which is 'inexplicable', other than through an 'unnatural interest in them'.
12:50pm
Mr Johnson moves to the case of Child N.
He says Child N was sabotaged by Lucy Letby as he was getting ready to go home.
The first incident was "characteristic of Lucy Letby's handiwork", Mr Johnson says.
Dr Christopher Booth had gone on a break.
Mr Johnson suggests Letby was "in her least favourite room" that day, in nursery 4, with 'only' two babies, and had time on her hands by texting about Melanie Taylor's shortcomings and a male doctor.
He says that includes the 'go commando' comment, which he says Letby lied about not knowing its meaning.
NJ: "If she's not even prepared to tell you the truth on something so trivial, what is she prepared to tell you the truth about?"
12:57pm
Mr Johnson says Letby's interviews are "very revealing" in relation to the texts in the case of Child N. He refers to the 2020 police interview.
Letby was asked if she knew Child N had haemophilia. She replied she didn't know. Mr Johnson says that was a lie, as there was a handover sheet in the 'Morrisons bag' at her home which documented Child N had haemophilia.
On June 2, 2016, Letby was recorded caring for two babies in room 4, including giving a feed to one of the babies, a 50ml feed to a baby who was asleep. Mr Johnson says it would take 15-20 minutes. He says the 2030 time could mean any time between 2015-2045.
Mr Johnson says the 'keypad on Lucy Letby's phone must have been hot' as Letby was texting constantly at this time.
He says it is accepted people do text at work, but giving an NG Tube feed is a two-handed process, and "you can't do that if you're texting at the same time".
He says there are 41 text messages in the conversation, and that "cannot be done" if you are giving, "in the proper way", an NG Tube feed.
Mr Johnson says Letby was asked about this, how it could be done: LL: "You can't."
Mr Johnson had told Letby there was one method of administering a feed quickly.
Letby added: "You think I pushed it in?"
NJ: "That's what you were doing, wasn't it?
LL: "No."
1:05pm
Designated nurse Christopher Booth said, for the incident, he went for a break around 1am on June 3. Sophie Ellis was giving a feed at the time and had only a vague memory of child N, and had a number of designated babies that night. Melanie Taylor was making an entry on a fluid balance chart and had no memory of Child N. Valerie Thomas was a nursery nurse who would not have been in room 1. Mr Johnson says the process of elimination was it was Lucy Letby who was in room 1, as she wasn't recorded doing anything at that time.
Dr Jennifer Loughnane noted Child N was 'unsettled' and desaturations had gone to 40%, and he was 'dusky and mottled'. He was "screaming".
Mr Johnson says Dr Loughnane sat back in the witness box when reading the word 'screaming'. Mr Johnson says he asked Letby if she remembered Dr Loughanne doing that, and she said she did.
Dr Evans said the 30-min crying was unusual, as was the speed of decline. He could think of no naturally occurring or innocent cause.
Dr Bohin said the desaturation was 'life-threatening', and there was 'nothing to suggest it was an innocent event', and there 'must have been an inflicted painful stimulus' to cause a life-threatening collapse.
Mr Johnson says that same kind of injury was inflicted by Letby on Child O, 20 days later, causing a liver injury. He says this attack happened on a baby who was perfectly well just after the designated nurse had gone on a break.
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