Your Baby's life in their hand: Dr Harkness Baby E.
Jamie Egan
Dr Harkness, a paediatric registrar at the Countess of Chester Hospital in the summer of 2015, is being asked about Baby E on the night shift of August 3. He says they started that shift at about 8.30-9 pm. He explains that working in different hospitals, it is difficult to remember the shift patterns. He explains there would have been a handover period, where he would have read a handover sheet for the various patients and any outstanding conditions those patients had. There would be one sheet for the paediatric ward and one for the neonatal ward. If there were any sick children in A&E, the doctors would have been responsible for attending to them, too. He says the handover period would have lasted about 30 minutes. He says some tasks would have required him to work with Dr Christopher Wood, his colleague, on the night, and some would have been done solo. He says his tasks would have included speaking to nurses and seeing the neonatal unit babies.
He says if there was nothing outstanding happening in the neonatal unit, he would be there at 10-10.30 pm. He says that this night, he was called over at 10 pm, having been called over because Baby E had blood in his vomit. At 10 pm, Letby calls a doctor because she thinks the baby may be vomiting blood. 'Small amounts of blood' - minuscule blood flecks - were spotted when the NG Tube was brought out of Baby E, Harkness recalls.
This was the verbatim message Letby told Harkness at 10 pm. Even if we consider there was blood on Baby E’s mouth at 9 PM, as the mother says, there were no signs of haemodynamic instability at 9 PM, according to the prosecution. “The baby was stable” (TBWS) mantra was in full on mode at 9 PM. Therefore, it was perfectly reasonable for Letby not to overreact at 9 PM. However, at 10 PM, after she removed the nasogastric tube (NG tube) and unequivocally identified blood, she called Harkness.
There is another old saying in medicine: A little blood goes a long way. The saying is to remind juniors of two things: When you see blood, it's likely that you are overestimating the quantity but never the quality. Blood in the wrong place goes a long way to tell you where it's coming from. The over-estimation of the quantity tells you that you still have time to react. If you react on time, you can save a life. Harkness singularly failed to act on time. How do we know this? Because Baby E died not long after that phone call.
The court is shown Dr Harkness's note from 10.10 pm on August 3, which says, 'asked to see the patient (Baby E) regarding gastric bleed.
Harkness assumed that the bleeding was “gastric” (from the stomach). Gastric is his word, not Letby’s.
'Large, very slightly bile-stained aspirate 30mins ago.'
The “aspirate” ( also called residuals) are the contents of the gut drawn from an NG tube. If they are acidic with a Ph of around 4, then they are likely from the stomach.
The note adds: 'Sudden large vomit of fresh blood and 14ml aspirate.'
The doctor is given the opportunity to look through his clinical notes and Lucy Letby's nursing notes from that shift to see the chronology of events that night.
The court is now shown the 10.10 pm note.
He says it is not clear, from his note, how much of the 14ml aspirate contained 'fresh blood'.
It is perfectly clear from his note: “large vomit of fresh blood” and 14 ml aspirate.
He says the fresh blood was what he had witnessed, having been called over to see it. The court hears he did not see the child vomit but saw the fresh blood as a product of it.
This is at 10.10 PM
He notes baby E's blood pressure was 'very good', a CRT (capillary refill time) reading was good, the heart rate was 'normal', and saturation rates were good, with minimal oxygen support.
What does this tell us? If you apply finger pressure to the baby’s toe (usually), the skin will turn white, and as you remove it, the white area will refill with pinkish-coloured blood into capillaries. Hence, capillary refill time. It should be nearly instantaneous. However:
There is little correlation between CRT and blood pressure in neonates. PICU-based studies looking at CRT and central markers of poor cardiac outcome showed a positive predictive value of 93-96% and a negative predictive value of 40-50% to detect a ScVO2 of less than 70%. Blood pressure is a poor marker of outcomes in neonates.
"At that point in time, everything is fine, except for the blood in the aspirate," he tells the court.
Remember? A little blood goes a long way. You have time to stop this Harkness.
Baby E was also 'pink, well perfused', the lungs were 'clear', and the abdomen was 'soft, not distended'.
TBWS. All the more reason, Harkness, to keep it that way.
Dr Harkness notes 'GI bleed? Cause', and tells the court that there is a possible diagnosis for the bleeding, and a plan of action with administration of antibiotics is made.
Antibiotics will make no difference to internal bleeding in the immediate phase.
The note 'close observation' is made, emphasising the designated nurse - Lucy Letby - was to monitor Baby E closely in room 1.
What was there to monitor Harkness? Let’s see if the baby bleeds some more?. Harkness saw blood; He diagnosed a gastrointestinal bleed and called it a large volume.
Dr Harkness says, from his recollection, he does not believe he left the unit as the bleed was 'something unusual' in Baby E, so he does not believe he went very far.
Harkness" presence on the ward will make no difference to internal bleeding in the immediate phase.
For the 11 pm note, he says Letby called him into room 1, where 'Further GI blood loss and desaturation to 70%' is noted.
One hour and still counting. Marking time will make no difference to internal bleeding in the immediate phase.
A '13ml blood-stained fluid from NGT on free drainage' is noted.
Which is catastrophic.
He says he remembers seeing 'fresh, red blood in the tube' with the contents of the stomach. He says the free drainage setup would have allowed the vomit to come out rather than go into the baby's lungs. He says the origin of the blood must have come from somewhere in the oesophageal tract, down to the stomach. It rules out blood coming from the lungs. The saturates 'remained 60-70% in 100% O2', with Dr Harkness saying 'because of Baby E's condition', the oxygen requirement had gone up from 'minimal support'.
Yet more TBWS. The baby was dying
He says baby E was still trying to breathe at this time. The comment 'crying' is added to the note.
Breathing and crying will make no difference to internal bleeding in the immediate phase.
Dr Harkness says the child is still well enough to be awake enough and conscious to cry.
Consciousness will make no difference to internal bleeding in the immediate phase.
He said just the note 'crying' would suggest it was a 'typical cry'.
Another dollop of TBWS.
Dr Harkness says the fact Baby E was crying would mean he would have had to have been taking deep breaths to do so.
Breathing will make no difference to internal bleeding in the immediate phase.
The plan of action was to 'replace losses' - getting fluid back in.
What fluids Harkness? The baby is losing blood. What do we replace it with? Blood.
"Strict fluid balance' - the court hears, 'knowing how much to put back in'.
Cut the crap, Harkness; what about some fresh frozen plasma? O Neg And a cross-match, spun-platelets?
Dr Harkness says he is planning to intubate Baby E and do an x-ray to check Baby E's lungs and abdomen to try to explain why the baby was deteriorating.
Intubation and an x-ray will make no difference to internal bleeding in the immediate phase.
The type of intubation was 'elective', which was not on the level of 'an emergency situation', the court hears.
27 ml of visible GI blood loss and an unknown quantity not visible from a neonate , and it was not an emergency? This sums up the entire culture of the GoGH.
Dr Harkness says he would discuss the result of the x-ray with surgeons at Alder Hey and seek advice from them.
Speaking to surgeons will make no difference to internal bleeding in the immediate phase.
Dr Harkness said he would then have been preparing to intubate and get the equipment ready. Prescriptions are made from 11.28 pm to 11.30 pm for a number of drugs.
A number of drugs will make no difference to internal bleeding in the immediate phase.
A further note, written in retrospect, is made at 1.45 am. He records 'sudden deterioration at 11.40 pm'
One hour and 40 minutes (at least) since Letby called for help.
Prior to that, baby E was still to be 'under close observation' by Lucy Letby.
Blaming Lucy Letby will make no difference to internal bleeding in the immediate phase.
Dr Harkness tells the court he was in the room when the 'sudden deterioration' happened and was there with Lucy Letby and another nurse. Those nurses would have been gathering the drugs to be administered. The notes record 'Brady 80-90bpm, sats 60%, poor perfusion, colour change over the abdomen, purple discoloured patches'.
It hardly matters now what colour the abdomen is because it's too late for Baby E.
He says: "This was a strange pattern over the tummy and abdomen, which didn't fit with the poor perfusion - the rest was still pink, but there were these strange purple patches." He says some of the patches were still pink, but others were purple-blue, which was unusual.
Frankly? Who gives a s**t. Baby E is bleeding out in front of you.
He likens the purple-blue colour to what you would see after going for a swim in cold water and coming out with a 'purple-blue' colour on the lips. Harkness is babbling at this stage. Everyone in the world other than the staff at the CoGH calls that mottling. A clinical sign of shock. The rest of the skin was 'normal colour'.
The abdomen had 'purple patches', which didn't fit with an anatomical part of the body. He says it is difficult to describe in any detail without a photo. He says he has seen this in Baby A before and had not seen it on any other baby outside of the babies in the case. The patches were 'different sizes' and in the region of 1-2cm big - 'not dots'. The areas were 'on the abdomen - not above the chest or below the groin - in the middle section'. The patches 'did not fit with the perfusion' seen. He tells the court if the abdomen was dusky or white, then the whole of the body would gradually take that colour too. He says in the case of an affected blood supply, the blood would be lost from the legs first, and the body would pull the blood 'into the middle of the body'. "But on this occasion, it is the middle where you are seeing these discolouration?"
"Yes."
Dr Harkness confirms he has never seen these discolourations before or since, outside of the babies in this case.
Therefore, Baby A had mottling, a sign of shock. Harkness has never witnessed a mottling before in neonatal shock. Harkness, therefore, has not witnessed shock before, except in Baby A. Harkness clearly does not know what he is doing and certainly shouldn't be in a NICU on his own.
Dr Harkness's notes record 'intubated as an emergency at 11.45 pm'
He says although there were risks associated with this, the 'safer option' for baby E was to do things as an emergency.
Baby E was already in an emergency at 10:10 PM at the minimum, it just that Harkness didn’t know.
An ET tube was inserted, with 'good air and chest movement' recorded, and the tube was recorded to be in the correct place.
Baby E was also 'put on ventilator', with 100% oxygen.
More TBWS.
The saturation readings were '60-70%', and after a morphine bolus was administered, those improved to 80%.
The 'purple discolouration of abdomen remained', it is noted.
Translation: Baby E was still in shock because Harkness did nothing to stop it.
Baby E's blood pressure had dropped but was still in the normal range.
Yet more TBWS.
The plan was to administer further medication, but there was a concern that administering a drug to make the heart beat faster would lead to 'worse bleeding'.
Seriously?
Dr Harkness says 'from his recollection' the blood had settled, and there was no further substantial amount of blood recorded.
Dr Harkness said he and a colleague (Dr Woods no doubt who at least admits he hasn’t a clue) were stood at the end of the incubator, discussing what medication and plans were being put in place for baby E, when Baby E collapsed "in front of our face when we were stood there".
You don’t say?
Dr Harkness recalls the resuscitation efforts began, and Baby E's heart rate recovered at 1.01 am, and the parents had arrived by that time.
He tells the court the blood supply was 'very poor'. He says during CPR, blood was coming out of Baby E's nose and mouth, suggesting the blood pressure was low. He says the sight was "not very nice, particularly".
He’s in the NICU. What does he expect? Disney?
Dr Harkness is asked about the bleeding seen on Baby E.
He says: "I have never seen it in a baby to this extent." He says he had seen the level of blood in a teenager but not relatively, in a baby as small as Baby E.
We already know that.
Dr Harkness is asked about Letby's nursing note made on the night shift of August 3, which refers to Baby E's mum visiting at 10 pm, and she was informed by Letby and Dr Harkness about blood coming from the NG Tube. It refers to 'she was updated by Reg Harkness and contained Baby E'.
The note is shown to the court.
Dr Harkness confirms it was the note shown to him. He does not know what 'contained' meant in the context.
He says he does not remember if the mum was present at that time.
A pathology report for Baby E is shown, with 'PT and APTT readings. Those are two tests for blood clotting measurements. They were 'high, but not enough to be shocked by'.
The readings were 19.5 and 53.6, compared to the normal ranges of '12.5-15' and '26-35' respectively.
TBWS.
News flash: Neonates, especially those born pre-term, are at high risk of bleeding, making this a commonly encountered problem in the Neonatal Intensive Care Unit (NICU).
Standardised PT (prothrombin time) for Small for Gestational age Preterm neonates: 16.60 ± 2.10
And APTT: 51.0 ± 11.0
I agree, not enough for the doctor “to be shocked by” but in a BLEEDING preterm neonate, enough to be shocked by (literally).
Cross-Examination
Mr Myers asks about the sequence of events.
He refers to a police statement Dr Harkness made, where the doctor says: "I was asked to review Baby E by Letby [following the finding of a dirty aspirate].
'Looking at the notes, it was 10 pm-10.30 pm... I only came on at 9 pm.
He described, in the statement, the aspirate, which was largely mucusy.
He said he could not be sure if there was a fleck of blood around Baby E's face on examination.
He could not be sure of the flecks of blood on the baby's face. Was this the flecks of blood the mother saw, but the prosecution claimed only Letby saw? Harkness says here that he too, examined the flecks.
'Baby E looked relatively settled and there was nothing to suggest that was going to change'.
The statement adds: 'However, around half an hour to an hour later there was a large amount of fluid which came up the tube.
'From memory, it was 12-14ml of blood, which for a baby was a substantial amount'.
Baby E brought up further 'fresh blood' in quantities which he had 'not seen in sudden cases since'.
Or before.
Mr Myers asks about the initial stages from the first clinical note, at 10.10 pm.
Dr Harkness confirms he has been asked to review Baby E, following the bile-stained aspirate '30 minutes ago'.
Mr Myers said all of what had happened in the 10.10 pm note had happened by 10.10 pm.
Dr Harkness says this was a 40-minute period of several years ago. He said this was 9.30-10.10 pm.
He said it would 'match up' with the note.
In the police statement, Dr Harkness said he would have been 'bleeped' by Lucy Letby.
He says that would have been the most common approach to be alerted to the nursery room 1.
He said he had seen a dirty aspirate, which may have contained blood flecks and bile.
Mr Myers says the police statement said Baby E had 'nothing dramatic' around the baby's face and could not be sure if there were any blood flecks.
Baby E was 'not in distress' and 'appeared fine'.
Dr Harkness says he does not know if he saw Baby E's mother and does not have a clear recollection. He says it could be the case, looking at the notes provided.
Mr Myers asks if Dr Harkness had 'any particular concerns' from the first reading. Dr Harkness says there wasn't.
IOW. Letby did nothing other than her job.
He agrees the second note, with blood vomit, was 'more concerning' and suggested a gastrointestinal bleed.
Mr Myers asks if such a bleed was 'serious'.
"Potentially," Dr Harkness replies.
Eh.. The baby bled to death. The “potential” came to pass.
Mr Myers suggests that a GI bleed should have led to a blood transfusion.
Dr Harkness says if there were other observations which collated that, he would have done so, but at this point, he would not have done so, as the blood vomit could have had other causes.
I would love to know when and how bleeding is ever anything other than bleeding.
He said a blood transfusion 'may have come up in a conversation' with a fellow doctor (Dr Woods, the only other “fellow doctor” there).
Mr Myers asks why that wasn't documented.
Dr Harkness says he cannot answer that ( (for legal reasons?)
The clinical note for 11 pm is shown to the court, which the court hears refers to the 'large amount of fresh blood'. Dr Harkness was called into the unit.
The '13ml blood-stained fluid' is a 'significant quantity', Dr Harkness confirms.
Mr Myers said this follows other blood which came out earlier, and a typical baby would have had something 'in the region of 120ml' in him at that time.
Dr Harkness agrees.
Mr Myers said there had been 27mls of blood and aspirate taken from him in that time, which was 'up to a quarter' of Baby E's blood.
Dr Harkness agrees.
Mr Myers says the heart rate is 'normal', but the saturation rate is 'low'. He says the heart rate 'should be higher'.
Dr Harkness says: "Not necessary - there are multi factors to that. It's part of a separate conversation with expert witnesses."
In the terminal stage of shock in heart rate cannot rise. Unfortunately, medicine is really, really hard to practice:
Shock can be summarized descriptively as circulatory impairment leading to a state of impaired oxygen delivery to tissues. Normal cellular or tissue oxygenation depends on blood flow, oxygen saturation, transport capacity of the blood, and tissue oxygen demand. If this deficiency is for a short time period, cellular metabolism could be impaired but reversible; however, if prolonged, it may become irreversible. Currently, there is no single direct bedside measure of shock. Various technical and clinical surrogates or biomarkers are used to estimate tissue oxygenation and perfusion in neonates and are discussed elsewhere in more detail in this issue. The challenge is that in the early stages of newborn shock many subtle compensatory mechanisms occur that may mask the degree of circulatory impairment. It may be difficult to appreciate these subtle changes, such that by the time shock becomes clinically obvious, the infant is often in an uncompensated state. Relying solely on BP to determine whether or not an infant is in shock is problematic: when the BP is genuinely low, the patient may be in the uncompensated or even irreversible state, but a normal BP does not necessarily imply a normal flow state, and equally, a low BP can be present in the absence of shock. Each of these factors makes management such a complicated area.
He says it is not as simple as saying one reading should go up in line with others. He says blood pressure was normal, and there were other factors to consider.
Mr Myers says the pairing of heart rate and saturations is 'not normal'. Dr Harkness says it is abnormal in the sense that the heart rate is normal and the saturations rate is abnormal.
Mr Myers asks why a consultation with surgeons was required following x-rays.
Dr Harkness says advice would have been taken from them once the extra results would have been acquired from the x-rays.
While baby E bled to death.
Mr Myers says he could have been dealing with a 'very serious situation indeed'.
Dr Harkness: "Potentially."
Fatally, actually, Dr Harkness.
Dr Harkness says things were "changing", but Child E was still "stable".
TBWS.
Mr Myers: "Are you suggesting that a baby who has lost a quarter of its blood is not an emergency situation?"
Dr Harkness: "What I'm suggesting is there are things to do and there is time to do it."
Except Dr Harkness didn’t “do it”. Life or death are not medical abstractions, they are goals.
Mr Myers says transfusion was not being considered at this point and one of the 'obvious things' to consider.
"It is something you had failed to consider, isn't it?"
Dr Harkness says it was likely considered, but accepts it was not documented at the 11 pm note.
Mr Myers suggests it was a "serious mistake" not to consider blood transfusion.
Dr Harkness: "I disagree."
Mr Myers asks about the staffing levels that night and asks what would have happened if he had been called to the A&E department.
Dr Harkness said he would have contacted the on-call consultant at that time to come over in that instance.
And finally, we get around to the missing consultant!
Mr Myers: "I would suggest you were out of your depth at this point."
"I disagree."
He adds that is "wrong and disrespectful to my ability."
Who cares if the baby’s dead? On no account offend the doctor!
Mr Myers says blood transfusion is not considered.
"But we do have a plan, and we do have a discussion with a consultant."
TBWS.
Mr Myers says the intubation should have happened earlier.
Dr Harkness says there are benefits to an elective intubation compared to an emergency intubation, as the latter could cause stress and complications to the baby.
But bleeding to death wouldn’t? Anyway, who does “elective” intubation outside of an operating theatre?
He said that 'now' this would still have been the course to take in that situation.
The court hears the preparations are made for the intubation during a half hour.
Dr Harkness disagrees with Mr Myers that it was a "delay" and was using his time "appropriately".
"You make more mistakes when you are not taking your time."
Like letting the patient die kind of mistake?
Mr Myers says the blood transfusion is mentioned for the first time at a later note, after 11.40 pm.
Dr Harkness says it would not have been appropriate to give more saline boluses without administrating fresh blood.
Finally! Saline is not the same as blood!
He disagrees a blood transfusion was not considered earlier.
So they took it into consideration but ultimately decided against it.
He says his documentation is not as thorough as it would be now and agrees in hindsight, it should have been documented more clearly.
To show they had decided against it.
The 'skin discolouration' observation is noted, and that it later 'remained' on the abdomen.
The differential diagnosis at this stage is Disseminated Intravascular Coagulation (DIC), but Dr Harkness wouldn’t know because he “hasn’t seen skin discolouration like that before”
A nursing colleague had referred to a 'discoloured abdomen' in a retrospectively written note at 1.30 am.
Mr Myers said Dr Harkness had referred to the discolouration being 'strange' and 'unusual' and 'appearing and disappearing'.
That does not appear in the medical note, Mr Myers says.
Dr Harkness says that observation had "stayed with him", and the clinical note he made at the time was not 'forensic'.
Neither was his thinking.
Mr Myers reads out part of Dr Harkness's statement to the police, referring to the discolouration being on the abdomen.
Dr Harkness says he does not recall the part of the statement of the discolourations' 'path to the body' and said he would not agree with the wording of that. He says he has not been in discussions with anyone in relation to these observations.
Mr Myers said by October 2018 (by the time of his police statement), there had been discussions in the hospital about the skin discolourations.
Dr Harkness said there were discussions to say it was unusual, but refutes any of the details of the discolourations had been discussed.
How is it possible to define unusual without detail?
Mr Myers says Dr Harkness is 'putting details together' from various observations. Dr Harkness:
"No."
Mr Myers says Baby A's skin discolouration, as referred to by Dr Harkness in court earlier in the trial, were not mentioned in the clinical note at the time or the note to the coroner. Mr Myers says the 'red patches' found on Baby A were not mentioned for Baby E. Dr Harkness said the overall discolouration observations were 'similar enough'. Mr Myers refers to Baby E's collapse 'in front of the medical staff'.
Myers says by this point, "there had still been no transfusion."
Dr Harkness said there was no further evidence of bleeding after the second bleed.
Mr Myers: "The reaction to the second haemorrhage was far too slow, wasn't it?"
Dr Harkness: "I disagree."
TBWS.
Mr Myers says a blood transfusion for O-negative blood is noted at 12.50 am on the medical notes.
Dr Harkness says the O-negative blood [a type which can be suitable for all blood transfusions] would be used in this instance, as seeking a specifically matched blood type at this stage would take too long to acquire it from the donor fridge.
The note of 12.36 am - CPR commenced, is mentioned. The transfusion would have followed. Mr Myers says, in 'distressing detail' relayed by Dr Harkness earlier in court, it had been discussed blood coming from baby E's mouth and nose during CPR.
Dr Harkness said blood would 'keep coming out' until the cause of it is found.
Or until anticoagulation stopped it.
Mr Myers says the cause of death would be 'acute blood loss'.
Dr Harkness said that cannot be known without a post-mortem examination.
Yes, it can.
He says the blood loss could be a factor, but it is not 'black and white'.
Yes, it is
Hypovolemic Shock.
The key to successful resuscitation is early recognition and controlled volume expansion with the appropriate fluid. The estimated blood volume of a newborn is 80-85 mL/kg of body weight. Clinical signs of hypovolemic shock depend on the degree of intravascular volume depletion, which is estimated to be 25% in compensated shock, 25-40% in uncompensated shock, and more than 40% in irreversible shock.
If blood loss is confirmed, initial resuscitation with 20 mL/kg of volume expansion should replace a quarter of the blood volume. Blood transfusion is preferred, but in an emergency, colloids or crystalloids can be used. If circulatory insufficiency persists, this dose can be repeated.
Once the first 10 mL/kg of blood volume is replaced, a decision to provide any further volume expansion should prompt the clinician to ascertain the cause of the hypotension and to evaluate the circulatory status. Information regarding central venous pressure (CVP) values in stable, ventilated newborns is limited; therefore, interpretation of readings in ill neonates is challenging. Its role in the management of systemic hypotension is uncertain, but serial measurements through an appropriately placed umbilical venous or other central venous catheter may help to guide volume expansion in suspected hypovolemia. In the absence of CVP, titration against clinical parameters should be completed. Frequent and careful monitoring of the infant's vital signs with frequently repeated assessments and reexamination is mandatory. The use of crystalloid or colloid solutions is appropriate unless the source of hypovolemia is haemorrhage, in which case whole or reconstituted blood is more appropriate.
He said it was 'not his place' to call for a post-mortem examination.
Mr Myers says the blood loss seen would normally be 'fatal'.
Dr Harkness said it could be 'linked'.
Yes, linked to more blood loss.
Mr Myers asks if the actions taken were 'far too slow'.
Dr Harkness: "No."
Yes.
"Would you have admitted it if it was?"
"Yes."
Really?
Prosecution
The prosecution rises to ask about the timing of Dr Harkness 'meeting the mother of Baby E'. Dr Harkness said that would have been the case, based on a nursing note.
The prosecution asked if that was from looking at Letby's note.
Dr Harkness agrees.
The prosecution says Dr Harkness's clinical note does not refer to meeting the family.
Dr Harkness said it could be documented but would depend on the level of detail of the discussion.
Dr Harkness's interview with police from September 2018 is relayed to the court.
Dr Harkness is asked about the skin discolouration and says it is 'similar [between between baby A and Baby E' and is not a rash.
The interview transcript says Baby E's discolouration was 'around the abdomen and chest', with 'purple patches' that 'suddenly come on'.
"It came so quickly not affected by the monitors or anything."
"It was just this purple and pale patches."
He was asked in the police interview if that was symptomatic of other cases, and Dr Harkness said that was not.
Blah Blah. TBWS: It was Letby wot done it. (IWLWDI)
What a load of tosh (my emphasis).
Baby E died from hypovolaemic shock, likely secondary to sepsis with disseminated intravascular coagulopathy. There is no evidence of harm other than the failure to diagnose and treat in an appropriate manner. Some CoGH staff clearly discussed "The Letby rash" and, after the 2018 police interviews, and conspired to include it in evidence. This conclusion is inescapable.