A critical machine to monitor babies in the neonatal unit at Lucy Letby’s hospital was broken during the time when infant deaths spiked, a leaked document shows.
The Telegraph has seen a risk register report from the Countess of Chester which shows that between March 2015 and until at least June 2016, the blood gas analyser was faulty.
The machine is used to monitor the amount of oxygen and carbon dioxide in the blood and was “the first port of call” for measuring blood glucose levels, according to the hospital risk register.
However, the document warns that readings were “not accurate” and that they were having to use heel prick blood tests to provide temporary readings while waiting for laboratory tests to come back with true results. The report warned it was a potential patient safety issue.
The jury at Letby’s trial was not told about faulty equipment.
Commenting on the revelation, Michele Worden, a former advanced neonatal nurse practitioner at the Countess of Chester neonatal unit, said: “The blood gas machine is a vital piece of kit.
“A blood gas result will enable a clinician to make decisions about increasing/changing respiratory support and oxygen levels.
“If it is a resuscitation situation it will help clinicians make difficult decisions such as whether to continue etc. Most intensive care units, whether it is adult paediatric or neonatal, will have their own machine.
“If no machine is available then the blood gas has to be packed in ice and rushed to a biochemistry lab to be processed. The longer this takes the more the sample degrades so you can get incorrect results which may undermine or increase risk of wrong clinical decisions being made, according to experts.”
The machine is often used when babies are receiving respiratory support to help doctors know when to vary oxygen levels. It is also used to monitor blood sugar and if the results are wrong experts said that it could lead to “the wrong clinical decisions or treatments”.
During the Letby trial, the jury heard how babies would often collapse unexpectedly or without warning. But experts said that warning signs may have been harder to pick up with faulty equipment.
Several of the deaths in the Letby case involved babies whose blood oxygen levels had suddenly dropped.
One Cambridge professor told The Telegraph that “any trained medical doctor” would know that a broken blood gas analyser “would be of considerable concern”.
“A drop in blood oxygen is a critical sign of deterioration,” the expert warned.
In August 2023, Letby was convicted of the murders of seven newborns and the attempted murders of six other infants. A retrial in July also found her guilty of the attempted murder of another child.
Since the conviction, numerous scientists, statisticians and doctors have expressed concern about the evidence presented to the jury regarding shift patterns, medical conclusions and the standard of care at the Countess of Chester.
The Telegraph has previously disclosed how at the time when infant mortality rates spiked at the Countess of Chester hospital between 2015 and 2016 – the years in which Letby was convicted of killing the infants – the bacterium Pseudomonas aeruginosa had colonised a tap in the nursery of the neonatal unit.
Pseudomonas is known to be lethal to vulnerable babies. In 2012, a premature baby died and 12 others needed treatment at Southmead Hospital in Bristol after an outbreak of a water-borne bacterium.
David Livermore, professor of medical microbiology at the University of East Anglia, said: “The monitor, along with sewage leaks and a Pseudomonas-colonised tap, is more evidence of malfunction in this sub-optimal unit.”
Issues of faulty equipment and infections on the ward are expected to be raised at the ongoing Thirlwall Inquiry, which is looking into how the deaths at the hospital could have been prevented.
A spokesman for the Countess of Chester said: “Due to the ongoing Thirlwall Inquiry and police investigations, it would not be appropriate for us to comment at this time.”
