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The court heard Letby, who was the designated nurse in a different section but was present when Baby C collapsed, caused the issue at about 23:15 BST by inserting air into his stomach via a nasogastric tube.

On 17 January a nasogastric tube was inserted in a procedure to administer medication, food and fluids.

Nicola Heath, head of governance at the hospital, said an investigation identified the medic involved had not been trained to confirm the correct placement of a nasogastric tube, was not aware training was available and had wrongly interpreted the X-ray images.

The inquest heard there were two further incidents involving nasogastric tubes at the hospital - in 2017, when the medic who interpreted the X-ray had not been trained, and in 2019, when the doctor interpreted the image in error.

After the 2017 incident, nasogastric tube placement training became mandatory for junior doctors, but the medic in Mr Butler's case, "slipped through the net" as he was classed as a "clinical fellow" rather than a junior doctor.