Medics who flagged up worries about nurse Lucy Letby were unaware two babies had been poisoned with insulin, the murder trial heard.
A connection to Letby’s presence on the Countess of Chester Hospital’s neonatal unit amid unexpected collapses of babies was made from June 2015.
The “tipping point” for action to be taken by consultants did not take place though until after the deaths of two triplet boys in June 2016, which led to the removal of Letby from the unit.
But in August 2015 and April 2016, two separate blood test results revealed newborns had high levels of manufactured insulin in their system.
On neither occasion was it escalated to senior consultants that both children had been given insulin externally.
None of us regrettably realised two babies had been poisoned by insulin, so we didn’t have the full picture— Dr John Gibbs
On August 5, 2015 the blood sugar of Child F, a twin boy, dropped to dangerously low levels a day after his brother, Child E, collapsed and died.
A blood sample was sent to the Royal Liverpool Hospital for analysis which confirmed the insulin detected was not naturally produced.
The result was phoned through to the Countess of Chester’s biochemistry lab on August 13.
By that stage Child F’s blood sugar had stabilised and he had been moved to a different hospital closer to his parents’ home.
A doctor involved in the care of Child F said she was “at a loss” to explain the blood test findings.
The medic, who cannot be identified for legal reasons, told Manchester Crown Court: “This is something we found very confusing at the time because (Child F) had only been prescribed insulin five days previously (on July 31).
“I recall looking to see if anyone else had been given insulin to see if there was any possible accidental administration. No-one was prescribed in the neonatal unit with insulin at that time.”
On April 9 2016 another twin baby boy, Child L, had a hypoglycaemic episode in which his blood sugars plunged.
His brother, Child M, also suddenly collapsed on the same day before both boys later recovered.
A blood sample taken from Child L was again sent to the Royal Liverpool for tests.
That too showed a high level of insulin which had been given to the patient.
The result was phoned through to the Countess of Chester on April 14 and entered on the computer system.
But again its significance did not appear to be appreciated as Child L’s condition had improved and he was discharged weeks later.
Consultant Dr John Gibbs told the trial: “Nurse Letby seemed to be involved in all of the cases that involved me. Other consultants were involved with other babies.
“None of us regrettably realised two babies had been poisoned by insulin, so we didn’t have the full picture.”