Lucy Letby: Baby monitor at hospital 'was broken' when babies died on ward

A vital piece of equipment used to monitor babies in the neonatal unit at Lucy Letby's hospital was broken at the point when there was a surge of infant deaths, during a period when infant deaths surged, a leaked document has revealed.

A risk register obtained from the Countess of Chester Hospital showed that between March 2015 and June 2016, and possibly later, the blood gas analyser was faulty.

This equipment is crucial for monitoring oxygen and carbon dioxide levels in the blood and, in accordance with the hospital's risk register, was the "first port of call" for measuring blood glucose levels.

However, the report - shared with the Daily Telegraph - suggested the readings were "not accurate", forcing staff to instead depend on heel prick blood tests for temporary readings while waiting for more reliable laboratory results.

The document raised concerns about patient safety due to the faulty equipment.

The jury at Letby's trial was not informed about the malfunctioning machine.

Commenting, Michele Worden, a former advanced neonatal nurse practitioner at the Countess of Chester neonatal unit, said: "The blood gas machine is a crucial piece of equipment.

"A blood gas result enables clinicians to make critical decisions, such as adjusting respiratory support or oxygen levels. In resuscitation situations, it helps determine whether to continue intervention. Most intensive care units, whether for adults, children, or newborns, have their own machine.

"If a machine isn't available, blood samples must be packed in ice and rushed to the biochemistry lab. The longer this takes, the more the sample degrades, leading to potentially incorrect results that could increase the risk of wrong clinical decisions."

The machine is especially important for babies on respiratory support because it enables doctors to decide when to adjust oxygen levels. Inaccurate results could lead to incorrect treatments or decisions.

During Letby's trial, the jury heard that babies frequently collapsed unexpectedly. Experts have suggested that faulty equipment may have made warning signs harder to detect. Many of the deaths involved babies whose blood oxygen levels had dropped suddenly.

In August 2023, Letby was convicted of the murders of seven newborns and the attempted murders of six others. A retrial in July also found her guilty of attempting to murder another infant.

Since she was found guilty, numerous scientists, statisticians, and doctors have raised concerns about the evidence presented to the jury, including shift patterns, medical conclusions, and the quality of care at the Countess of Chester.

During a spike in infant mortality between 2015 and 2016 - the years in which Letby was convicted of killing the babies - a bacterium called Pseudomonas aeruginosa had colonised a tap in the neonatal unit's nursery. The bug is deadly to vulnerable infants and has been linked to previous outbreaks in hospitals.

David Livermore, professor of medical microbiology at the University of East Anglia, said: "The faulty monitor, along with sewage leaks and a Pseudomonas-colonised tap, provides further evidence of serious issues in this underperforming unit."

A Countess of Chester Hospital spokesman said: "Due to the ongoing Thirlwall Inquiry and police investigations, it would not be appropriate for us to comment at this time."

The inquiry will continue to examine events at the Countess of Chester Hospital, at Liverpool Town Hall today.