The unusual skin discolouration of a baby boy “didn’t fit with anything I had ever seen”, a doctor told the murder trial of nurse Lucy Letby.

Consultant paediatrician Dr Ravi Jayaram responded to an emergency alert after the premature newborn twin suddenly collapsed on the neo-natal unit at the Countess of Chester Hospital.

Child A is said by prosecutors to be the first victim of Letby, 32, who allegedly caused him to stop breathing by injecting air into his bloodstream on the evening of June 8 2015.

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Dr Jayaram told the jury of eight women and four men the situation he faced was “unusual” as the youngster’s observations were stable up to the point of collapse.

Giving evidence at Manchester Crown Court on Monday, he said: “(Child A) was pale. What I did not give any clinical significance to at the time was unusual patches of discolouration. I didn’t actually record it in the notes.

“Pink patches, mainly on the torso, which seemed to appear and disappear and flit around.

“I had never seen anything like it before but my focus at the time was on ABC, airway, breathing, circulation.”

He added: “I could not explain the sequence of events, why they had happened. I couldn’t explain why it had happened in the first place and couldn’t explain why the physiological responses to timely and appropriate interventions did not happen as they should have happened.”

Dr Jayaram agreed with Ben Myers KC, defending, that he did not reference unusual discoloration in his clinical notes recorded less than three hours after Child A died.

The doctor said: “As I stated at the time I didn’t appreciate the clinical significance of this whatsoever. Over time, having seen it on further occasions and in retrospect, absolutely.”

When suggested to him by Mr Myers that he had not actually seen such discolouration, Dr Jayaram said: “As a paediatrician of 30 years and a doctor of 32 years, if my character was such that I would make things up I would hope, friends, colleagues, doctors, nurses, parents, families, would have picked up on this before now.”

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Mr Myers also asked why the consultant had not mentioned any discolouration in a July 2015 statement to the coroner presiding over the inquest of Child A.

Dr Jayaram replied: “My concluding remarks when I gave evidence is that I couldn’t explain how this had happened, It was not my job to say ‘it may have been this’ because at that time I had no evidence.”

He told the court he was aware there was talk on the unit about a “moving” purple rash on the body of Child A’s twin sister, Child B, who the Crown allege Letby tried to kill with a similar air injection the following night.

Dr Jayaram said there were similar discussions following the death of Child D on June 22 2015, who is also said to have been murdered by the defendant using the same method.

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He said that some time after Child D’s death he “alighted” on a research paper entitled Pulmonary Vascular Air Embolism In The Newborn.

The medic said it described a series of accidental events of air embolism – where a blockage in the passage of blood occurs – and a similar pattern of discolouration.

In his first interview with police in July 2017 the doctor spoke of the “bright pinkness of patches against a bluey/grey background” on Child A, the court heard.

Mr Myers asked: “You didn’t make that description in your notes at the time?”

“No,” said the consultant.

The barrister said: “Or in your statement to the coroner?”

“No,” he repeated.

Mr Myers went on: “Has your description of what you said to the police and what you say now been influenced by what you saw in that paper?”

Dr Jayaram said: “I would say it has not… I remember reading this paper for the very first time and feeling really quite cold and worried. It is a matter of regret for me I didn’t mention it to the coroner at the time.”

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The consultant said that around the time of Child A’s inquest a group of clinicians had begun to raise concerns to hospital bosses about the “association we had seen with an individual being present in those situations and, how do I say diplomatically, being told we really should not really be saying such things and not to make a fuss”.

Dr Jayaram added: “It is a matter of regret that had I suggested this, and it could have been happening, I didn’t really have any hard evidence apart from the association we had seen. And it is a matter of regret and I wish I had been more courageous.”

Asked again by Mr Myers, whether his description of skin discolouration had been influenced by the research paper, the doctor said: No, absolutely, categorically not.”

Letby, originally from Hereford, denies the murders of seven babies and the attempted murders of 10 others. The trial continues on Tuesday.