Introduction
This page[/B] contains evidence heard for child J & K.
Lucy Letby Case page contains live reporting links and opening statements including opening statements for each child.
Refer to
Wiki Navigation to locate pages for other babies.
Child J & Child K
Child J
Prosecution opening statement (child j)
Background (child j)
Child J, a girl, was initially stable but it was discovered she had a necrotic and perforated bowel. The prosecution say he really did have NEC.
She was transferred to Alder Hey for surgery to fit her with a stoma bag.
Child J 'recovered well' and was taken to the Countess of Chester Hospital on November 10, 2015. She had a relatively rare type of intravenous line fitted, a 'Broviac line'.
On November 16, medical notes referred to her as being well.
Incidents (child j)
But on November 27, she suffered an unexplained collapse in the early hours. Letby was on duty.
Before she went to work for that shift, Lucy Letby exchanged text messages with one of her colleagues.
The prosecution say It seemed that she was not happy with working conditions and she referred to the difficulties of looking after the babies who just needed feeding support.
Child J was one of those.
The prosecution add that it appeared working in such nurseries was "not sufficiently stimulating for Lucy Letby".
Letby was in a different room to Child J, and was not the designated nurse, but 'got involved', by co-signing for medication at 12.02am.
Letby's colleague was a band 4 nurse and not sufficiently qualified to give intravenous medication.
After 4.40am, that nurse thought Child J became pale and mottled.
She left the room for a short time, and upon her return another nurse was assisting Child J with breathing.
The last thing Letby had recorded on notes was at 3am. There is data from the door system showing Letby coming in at 3.47am. The prosecution suggest Letby had been on a break during that time.
Just after 5am, Child J suffered another desaturation and she was moved to the hugh dependency unit in room 2.
The registrar was called and Child J was working hard to breathe, but had otherwise recovered well.
At 6.56am, Child J's alarm sounded and Letby was among those responding.
A doctor attended and took control. He noted oxygen levels were 'unrecordable' and circulation 'poor'. There were symptoms of a seizure.
At 7.20am, Letby co-signed a chart for a 10% glucose infusion.
At 7.24am, Child J collapsed again. The doctor assisted in resuscitating her. Child J recovered and the doctor could not explain what happened from the results of various tests taken.
He considered the events unexplained.
Medical experts (child j)
Medical expert Dr Dewi Evans described the collapse at 7.11am as unexpected without any straightforward explanation.
He said that it was “of concern and consistent with some form of obstruction of her airways, such as smothering”.
The symptoms of a seizure suggested oxygen deprived to the brain.
Child J has not suffered a seizure since.
Dr Evans added: "Whilst I have concerns...one cannot rule out the presence of infection, despite the normal inflammatory markers… at the time of the two collapse episodes…I note also the presence of the stoma which could be the source of the organism(s) that caused her systemic infections.”
Dr Evans, in a follow-up statement, maintained 'airway obstruction' was the most likely cause of Child J's collapse.
Dr Sandie Bohin concluded that the issue was not infection because there were no “soft signs” and the gradual deterioration which might be expected, but the collapse was "sudden" and had caused seizures.
Police interviews (child j)
In interview, Letby said she had little recollection of Child J, but remembered the Broviac line.
She confirmed contact with Child J, but denied doing anything to cause her harm.
Facebook (child j)
In 2020, she was asked why she had searched Facebook for Child J's parents. She replied: "I don't remember doing that."
The prosecution said: "It is remarkable that on many occasions, when children who had suffered unexpected spectacular and life-threatening collapses were removed from her [Lucy Letby's] orbit, they had exceptional recoveries."
Defence opening statement (child j)
For Child J, the defence say "there is not a great deal of explanation" for what caused the deterioration from the prosecution experts.
The defence say there is "an assumption of deliberate harm being used to blame her" when it was actually "inadequate care" at the hospital.
Agreed Facts (child j)
Sequence of events from records (child j)
Intelligence analyst Kate Tyndall has returned to talk the court through events for Child J, who was born at
3pm on October 31, 2015, weighing 3lb 12oz.
Child J was admitted to the neonatal unit 10 minutes later.
A picture was taken of the baby girl.
She remained at the Countess until
4am on November 1, being transferred to Alder Hey, before coming back to the Countess on
November 10, being admitted to the neonatal unit by Lucy Letby.
Text Messages (1) (child j)
10th November 2015
The same day, Letby messages a colleague saying "It's chaos here" and she had had a row with another colleague.
A selection of messages, recovered from Letby's phone, are shown to the court for the period from
November 10-26.
Letby sends a lengthy message to her colleague explaining why the unit was 'chaos' and why she had a disagreement with a colleague, adding staff were "peeing her off".
Her colleague replies: "Nothing like a bit of team spirit eh! x"
Letby apologises for her rant, saying: "Just really gets me down sometimes and some...want the easy life"
Letby asks a colleague on
November 16 about how often a procedure for the Broviac line for Child J needed to be carried out. She receives a reply that it is carried out weekly.
Letby says she had three missed calls on
November 25, having been to Las Iguanas and was at salsa, saying no-one at the unit knew how to administer immunoglobin, and they rang her. Her colleague sympathises, saying they should not be ringing staff not on duty, but should be contacting Liverpool Women's Hospital first.
26th November 2015
At 10.30am, a doctor's note says Child J was 'pink, well perfused, no respiratory distress' 'Abdomen- soft. Mum says mild distention soft abdomen. Stoma looks healthy'.
The note adds 'if [increased] distention to inform' as the plan, along with the feed for expressed breast milk and donor.
Text Messages (2) (child j)
Letby messages a colleague saying 'staffing really needs looking at', before messaging colleague Jennifer Jones-Key to say 'sounds like you had a mad day'.
Letby adds the situation is 'just not manageable'.
Letby adds: "It's a nightmare isn't it...especially with no management x"
Jennifer Jones-Key said the staff [on duty] were going to ring Letby or Yvonne Griffiths the previous night [regarding how to administer immunoglobin], but thought that would have been done so sooner.
Letby adds the staff there should not have been in that position.
She adds, for her
November 26-27 night shift: "Ah well. Hopefully be a bit calmer for me tonight lol x"
A colleague messages Letby at 5.16pm: "U well rested for work? x"
Letby replies: "Yep I've had a chilled day and slept well..."
She adds: "Ready to face anything" with a strongarm emoji, before discussing about being contacted the previous night, and querying why she had been contacted when staff on duty had other lines of enquiry, such as Liverpool Women's Hospital or the transfusion department.
Letby, as she sets off to work, messages her colleague: "Off to the mad house x" with a neutral face emoji.
Once inside, she messages the colleague to say she is in room 3 of the neonatal unit for the night shift.
A shift rota for that night is presented to the court.
There are two babies in room 1, two babies in room 2, two babies in room 3 (both designated nurse Letby), and two babies in room 4, one of them being Child J.
In addition, there are two babies in transitional care, and two babies whose location could not be confirmed from the records.
Nurse Ashleigh Hudson records, for Child J at the November 26 night-shift handover: 'Observations satisfactory as charted...Broviac remains in situ...[Child J] appears to be in no pain or discomfort.'
Letby received and sent messages between
7.36pm and
10.53pm, but not related to Child J.
27th November 2015
At 1.57am on November 27, swipe data shows Letby recorded as entering the neonatal unit, at 3.47am and at 4.29am.
At 4.40am, an apnoea/brady/fit chart records Child J having an episode of apnoea, heart rate down to 100, lasting for three minutes.
At 5.03am, a desaturation to '30s' is recorded, heart rate to 100, lasting two minutes. In each event, a Neopuff device is administered.
Nurse Nicola Dennison records Child J looking unwell at 4.40am. In an untimed note [written retrospectively at 7.37am], Child J is moved from nursery room 4 to room 2.
Text Messages (3) (child j)
Letby says, in a message to a colleague, she had not had a good shift, as Child J had '2 profound desats' and there were 'only 5 staff' on duty.
The colleague replies: 'We closed again then? x'
Mr Johnson explains to the court 'closed' by this definition means the unit would be closed to new arrivals, not closed entirely.
Letby confirms the unit is closed until they can get someone in.
6.56am: There is an event timed as 6.56am which marks Child J's desaturation.
7.11am: A retrospective note created by Mary Griffith, referencing Lucy Letby, is made at 7.11am.
The note says '[Child J's] monitor went off at 6.56 myself and L Letby attended. Found baby with pale hands and baby very ridged...'
7.15am: A note is made at 7.15am recording that the parents of Child J are informed of the collapse and to come to the hospital as soon as possible.
7.24pm: Child J had a further collapse. Dr John Gibbs records the event in his notes.
Resuscitation efforts are made and a range of medication is administered, while observations are recorded and an x-ray made.
8.55am: Letby is recorded as using her swipe card at the neonatal unit acess door at 8.55am.
Text Messages (4)
10.30am:Lucy Letby messages Jennifer Jones-Key just before 10.30am: "Wow it turned manic - left at 9.15 but others still there."
The reply: "Warned you..don't know what it is", adding that things seem to go "pear-shaped".
Jennifer Jones-Key messages Letby saying, of the staffing situation, 'more staff will just go off sick'.
A colleague of Letby messages her on the afternoon of November 27 to say: 'Oh and Tony Chambers n some woman turned up earlier! x'
Letby replies: 'Gosh it's mad. At least things are moving in right direction. Is it bit calmer now? Still only 5 tonight? Hope Tony got stuck in and helped!!'
Letby is on a night shift on
November 27-28. She recorded Child J's vital signs and her fluids.
Nurse Mary Griffith messages Letby to say she had left the hospital at 9.45am, getting back home at 10.30am, adding she hopes Letby has a better shift tonight.
Letby replies: "You must be tired. Thanks for staying....still busy as only 5 on. [Child J] quiet hasn't done anything else abnormal and xray etc ok..."
28th November 2015
2.15am: Notes from a doctor on November 28, 2.30am, for Child J record '...no respiratory distress...'
The plan was 'continue to slowly increase feeds...to achieve full feeds by 1800 today'.
5.06am: Letby records further observations for Child J at 5.06am on November 28, with 'shallow breathing observed at times' and, in a family communication note, Child J had been 'out for cuddles' with parents, who 'seemed happier' that Child J was recovering and feeds were gradually being increased.
Child J continued to be cared for at the Countess of Chester Hospital's neonatal unit until
3.30am on December 18, 2015, when she was transferred to Royal Manchester Children's Hospital.
Witness Statements Agreed (child j)
Witness Evidence (child j)
Family - Mother (child j)
The mother of Child J is called to give evidence.
She says she had a difficult
Pregnancy, and following a difficult operation in London, one of her planned twins was lost.
She said she gave birth to Child J, a baby girl, at 32 weeks and two days gestation on October 31, 2015.
Child J "appeared to be extremely well" and was shown to her after birth, and there appeared to be "no concern" before the baby girl was taken to the neonatal unit.
The mother said she visited Child J later at the unit, she was in an incubator. The baby girl was seen in the 10-minute time there to produce a bit of brown bile.
Child J was then taken to Alder Hey by ambulance. The mother said she was told there were concerns about Child J's bowel at the time.
The mother said it was discussed afterwards that Child J had 'NEC' [necrotising enterocolitis: a serious gastro-intestinal disorder where a portion of the bowel becomes inflamed] and had emergency surgery at Alder Hey.
The bowel was 'cut', 1cm was removed - "a little amount", and the decision was made to give Child J two stomas.
Child J returned to the Countess of Chester Hospital on November 10, and the mother recalls being there frequently., establishing a routine. Child J was "absolutely" progressing well, going from being treated in room 1 (most intensive treatment), to room 2, to room 3, to room 4, over the course of four weeks in November.
Child J's mother recalls there were issues with the baby girl's weight gain, which 'concerned her' and she relayed those concerns "frequently".
She said those concerns were treated "not very seriously - they weren't overly concerned".
There were "quite a lot of challenges" with the stoma management.
Child J's mother says, between November 10-27, there were no major concerns with the stoma management, but the bags were not lasting as long as expected, and breastfeeding was impractical, but attempts at breastfeeding were made as Child J was doing well.
She tells the court the approach of staff at the Countess was different to Alder Hey. While Alder Hey was 'inclusive', the communication did not feel the same at the Countess.
Events leading up to the morning of November 27 are discussed, when Child J collapsed.
Child J's mother said the family were "really excited" to get Child J home, as she was off the heart monitor, and the mother was at the hospital ready to provide daytime cares, having also been involved in the night-time process.
The court hears it was 'a dry run' for life at home.
Overnight on November 25-26, Child J's mother was at the hospital, attending for cares, including stoma bag management.
On November 26, Child J's mother went and stayed home, intending to return as usual at 8am on November 27. She said 8am would be after the handover, and staff preferred parents not to be on the ward at the time of the handover.
The mother recalled receiving a telephone call on the morning of November 27 telling her Child J had collapsed, and to attend hospital as soon as possible. She said that would have been about 7.10am.
The mother attended the hospital as quickly as she could with her husband. Child J was in room 2 in a 'hot cot', connected back up to a monitor and looked "very floppy...pale, yellowy in colour and not very responsive".
Child J's mother said she was "totally and utterly shocked because prior to this, she was extremely well, she was coming home...we were preparing for her to come home.
"Other than the weight gain, everything was fine."
Child J's father spoke to Dr John Gibbs and the mother recalled joining in the conversation, being "very stressed about what I was seeing and experiencing".
After the collapse, Child J's mother said nurses led the care, and the parents stayed overnight.
It was established there was not an infection - it was "unknown at that stage", the mother tells the court, and Child J recovered "quite quickly".
By the afternoon of November 28, Child J was "back up to full feeds", the mother tells the court.
In the following weeks after that, Child J had another collapse around December 16, 2015.
"That was when we really started to see issues with the stomas and the bags", the mother tells the court, with the bags not lasting anywhere near as long as before, and would stop working as they should.
After the second collapse, there were "concerns" when Child J was pressed in the abdomen, she would wince and feel pain, so Child J was transferred to Alder Hey to have the operation reversed and the stomas were closed, the bowel reattached.
On January 5, 2016, Child J returned home.
Cross Examination
Mr Myers, for Letby's defence, asks the mother about Child J's birth, and that 'things seemed to be all right'. The mother agrees.
The mother said she saw the brown bile from Child J's mouth and informed staff at the Countess. She agrees staff were "concerned".
Mr Myers says if there was a point when they were asked if Child J should be Christened. The mother agrees.
The court hears Child J had an 11-day stay at Alder Hey, during which she had a bowel operation. The details of the procedure and how to use the stoma bags are relayed in court, and the mother says she and her husband had it explained to them.
The mother said she would not say the stoma bags procedure was explained as well to them by Countess staff.
Mr Myers asks if the mother was told 'this could be a bit of a rollercoaster - that babies could go up and down' for Child J. The mother replies she is not sure when that was said to her, and could have been after Child J collapsed.
The mother says Alder Hey checked with the Countess of Chester Hospital to do the recycling of the stomas, and the Countess hospital had said yes, but did not seem to be as prepared.
The mother, having looked at a statement she gave to police, says that on reflection, the Countess staff were not as prepared for such procedures, and the 'time-consuming process' meant she offered to help with the stoma and the bags.
She adds that without the expertise of her husband, she would not have been able to position the stoma bags correctly, and without the prior experience, it would be considered a 'challenging' procedure.
The mother tells the court she felt if she raised concerns on the stoma care, they were not taken as seriously by Countess staff as the staff at Alder Hey.
The mother says there were concerns raised 'frequently' about the lack of weight gain for Child J, and they were raised with Countess staff.
Those concerns were "not met with any changes - not taken very seriously", the mother tells the court.
After the first collapse, Child J's mother says they were much more alert on medication as 'things were missed'.
The mother says there was "a general concern" for Child J for an increased risk of infection.
Mr Myers asks if there was a case when Child J was not tidied up.
The mother replies 'yes', as there was one case where she arrived to find Child J's bottom had waste visible, and was wrapped around with a towel. She raised the issue with a consultant, after asking staff "what would you do in my situation?".
The mother said she felt "pushback" on raising those concerns.
Dr John Gibbs (child j)
Giving evidence on Monday, February 13, consultant paediatrician Dr John Gibbs said two “profound” desaturations around 5am on November 27, 2015 were “alarmingly low”.
He told Manchester Crown Court that the youngster, Child J, was stable for weeks after she previously underwent bowel surgery a day after her birth.
Child J recovered quickly after she received breathing support, but more desaturations followed at 6.56 am, together with a marked fall in heart rate.
Dr Gibbs also noted all of Child J’s limbs were “stiffly extended with her hands clenched”.
He said the stiffness took 10 minutes to settle which was a “reasonably long seizure”.
More breathing support, via a facemask, led to an improvement – but a further similar episode took place at 7.24am, jurors were told.
Dr Gibbs, now retired, said: “Again, (Child J’s) oxygen and heart rate dropped and she needed support for her breathing just as in the first episode.
“This episode was much shorter. She did display the stiffness of all her limbs and clenches of her hands, and on the second episode her eyes deviated to the left. It stopped after three or four minutes.”
He said that Child J had not suffered a seizure either before or since.
Simon Driver, prosecuting, said: “You cannot be certain as to what was the cause?”
Dr Gibbs replied: “All the investigations did not reveal any causes for her seizures.”
Cross Examination
Ben Myers KC, defending, said: “It’s not possible to say for sure whether the seizures caused breathing difficulties or breathing difficulties caused the seizures?”
Dr Gibbs said: “That’s correct.”
Mr Myers went on: “To be clear, you favour breathing difficulties first because your assessment was the drop in oxygen (levels) came before seizure?
Dr Gibbs said: “Yes. Exactly why and how the oxygen dropped, I don’t know.”
Dr Stephen Breary (child j)
Fellow consultant Dr Stephen Brearey told the court: “She (Child J) normalised very quickly over the course of the day and all the investigations we had undertaken couldn’t identify why she had the desaturations or explain why she had a seizure.
“I do know hypoxia causes seizures so that would be possibly the most likely cause.
“There remains the question why was (Child J) hypoxic when two or three weeks beforehand she had been breathing normally in air and there was no suggestion of infection.
“In fact, we stopped antibiotics 36 hours after starting them because there was no evidence of infection in the blood tests and she remained well for weeks afterwards.”
Nurse Mary Griffith (child j)
Earlier, nurse Mary Griffith – who worked more than 40 years at the Countess of Chester before retiring in 2016 – agreed with Mr Myers that Letby was “knowledgeable”, “caring” and “thorough” in her job.
She also agreed there seemed to a “very high admission rate” to the neo-natal unit around 2015/2016.
Child J was discharged home in January 2016 and was described as progressing “very well” at her final outpatient clinic more than a year later.
Medical Expert Evidence (child j)
Dr Dewi Evans (child j)
Giving evidence on Tuesday, expert medical witness Dr Dewi Evans told prosecutor Nick Johnson KC: “The first pair of collapses were unexpected because she was nice and stable before that.
“The second pair of events were more serious and required more in the way of resuscitation, but again were unexpected and I noted the markers for inflammation were normal which tended to rule out infection.
“The second pair coincided with what the doctors describe as a seizure or a fit. This is indicative of something going wrong with the brain.
“My opinion was that (Child J’s) brain was deprived of oxygen for a sufficient level of time to cause hypoxia ie loss of oxygen to the brain causing fits.
“As far as I know this was the only occasion when she had seizures and the cause of this was the hypoxia, the lack of oxygen to the brain.”
Mr Johnson asked the retired consultant paediatrician: “So far as the hypoxic incidents that had caused these seizures were concerned, could you identify any natural process that might have caused that?”
Dr Evans replied: “No, I could not. There was no reason why she should suddenly become hypoxic.”
Mr Johnson went on: “If infection had been the cause of her rapid decline would she have recovered as quickly as she did?”
Dr Evans said: “I don’t think she would. Babies who develop an infection usually recover over a period of days.”
Dr Evans agreed with Ben Myers KC, defending, that he could not rule out infection “for sure”.
Dr Sandie Bohin (child j)
However fellow expert witness, consultant paediatrician Dr Sandie Bohin, said she had excluded infection.
She told the court: “(Child J) was a well baby. She was ready to go home. Babies who are ready to go home do not have major desaturations which lead to prolonged resuscitation.
“These were completely unexpected and she required the Neopuff (face mask) ventilation for a long time before she came round and was well again.
“I thought that seemed extremely unusual – the speed of the collapse, the longevity of the resuscitations and the fact that she seemed to recover quite quickly.
“That is not the way that infection normally plays out.”
Dr Bohin noted that Child J was clinically well and back to her normal self before she even received antibiotics.
She said: “I exclude infection. I don’t think that was the cause of her collapse.”
Dr Bohin told Mr Myers she had not been able to identify an “obvious cause” for her collapses.
Child J had previously undergone bowel surgery a day after her birth but medics have said she was stable in the weeks that followed.
On the morning of November 27 she was being cared for in nursery room 4 in readiness for returning home to her parents.
Child J was later moved to room 2 for closer monitoring ahead of the second pair of collapses.
She eventually was discharged in January 2016 and was described as progressing “very well” at her final outpatient clinic more than a year later.
Child K
Child K - attempted murder allegation
Prosecution Opening Statement (child k)
Background (child k)
Child K was born at the Countess of Chester Hospital in February 2016, very premature, and weighing only 692g.
There was not time to deliver at a hospital for this type of maternity delivery care. Dr Ravi Jayaram, paediatric consultant, was present at her birth as a result.
Incident (child k)
Lucy Letby booked Child K on to the neonatal unit. Child had required help with breathing, but was stable and in as good a condition as a baby of that prematurity could be.
Arrangements were made for Child K to transfer her to Arrowe Park Hospital.
At 3.50am, Dr Jayaram was standing at the nurses’ station compiling his notes. Although he did not have a view into Nursery 1, Dr Jayaram was aware the deisngated nurse was not there, a fact backed up by door swipe data. Lucy etby was the only nurse in room 1, alone with Child K.
"Feeling uncomfortable with this because he was beginning to notice the coincidence between the unexplained deaths and serious collapses and the presence of Lucy Letby, Dr Jayaram decided to check on where Lucy Letby was and where Child K was."
"As he walked in, he could see Letby standing over Child K's incubator. He could see Child K's oxygen levels were falling. However, the alarm was not sounding and Lucy Letby was making no effort to help.
"Dr Jayaram went straight to treat Child K and found her chest was not moving, he asked Letby if anything had happened to which she replied, “she’s just started deteriorating now”.
Dr Jayaram found Child K's breathing tube had been dislodged.
Child K was very premature, and had been sedated and inactive. The tube had been secured by tape and attached to Child K's headgear.
Mr Johnson: "It's well recognised if you handle a child you can dislodge the tube accidentally, but any experienced staff member would recognise that.
"Dr Jayaram was troubled as the levels were falling and Nurse Letby had been the only person in the room."
The prosecution added: "On these monitors, all readings are set to default values in the neonatal unit.
"Saturation levels falling to the 80s, is a serious issue and if the machine is working properly, it would have an alarm if the saturation levels fell to the 80s, as Dr Jayaram noticed.
"There is an alarm pause button on the screen of the monitor - if you want to treat the child, you don't want the alarm going away. It will pause for one minute.
"Bearing in mind the rate displayed on the monitor, Dr Jayaram estimates the tube would have been dislodged between 30-60 seconds, and that is on the assumption the alarm had been cancelled once."
The court hears Dr Jayaram did not make a contemporaneous note of his suspicions or the alarm failing to activate.
Child K remained unwell and later died.
Medical experts (child k)
Medical expert Dr Dewi Evans viewed Lucy Letby’s failure to summon help as soon as possible was unusual.
The prosecution allege that Lucy letby was trying to kill Child K when Dr Jayaram walked in.
Police interviews (child k)
In police interview, when Dr Jayaram's account was put to her, she said no concerns had been raised at the time.
She said the alarm had not sounded. She said Child K was sedated and had not been moving around.
She also did not recall either any significant fall in saturations or there being no alarm. She accepted that in the circumstances described by Dr Jayaram she would have expected the alarm to have sounded.
she denied dislodging the tube and said she would have summoned help had Dr Jayaram not arrived, saying she was "possibly waiting to see if she self-corrected, we don’t normally intervene straight away if they weren’t dangerously low".
After the interviews - that suggestion made by Lucy Letby was referred to a nursing expert. Her view was that it was very unlikely that a nurse would leave the bedside of an intubated neonate unless they were very confident that the ET tube was correctly located and secure, the baby was inactive and then they would be away only briefly.
The nurse dismissed the idea that a competent nurse would have delayed intervention if there had been a desaturation.
Facebook (child k)
Letby was found to have researched Child K's parents on Facebook in April 2018 - two years and two months after Child K had died. When asked about this, she said she did not recall doing so.
Defence Opening Statement (child k)
For Child K, the defence say the tube was dislodged, and the prosecution say that was Letby's doing. "Letby does not agree she did that, nor is she seen to have done that."
The prosecution say Child K had been sedated.
The defence say it is disputed, that Child K was able to move, and there would be evidence to follow on that.
The defence say there was "sub-optimal care" and Child K "should not have been at the Countess of Chester Hospital in the first place", but in a hospital providing tertiary care.
Agreed Facts (child k)
Sequence of events from records (child k)
Cheshire Police intelligency analyst Kate Tyndall is now talking the court through the sequence of events for Child K.
They begin with text messages recovered from Letby's phone.
Text Messages (1)
16th February 2016
Letby messages a colleague about the unit being a "hive of activity" on February 16 in preparation for a visit from "the big bods", and there is a discussion on the possible of delivery of Child K.
Letby mentions one colleague had suspected conjuctivits, but had still come into work, and adds "Hope I haven't caught anything".
Said colleague had also not "done anything but moan" that day, Letby says.
Letby messages the ill colleague saying she hopes that colleague is felling better soon. The colleague responds she was felling better after a day of bed rest, and thanks Letby for her message.
The night shift for February 16 is shown to the court. The paediatrician of the week is John Gibbs, the on-call consultant is Dr Ravi Jayaram.
Lucy Letby is on duty, looking over two babies in room 2 at the start of the night shift.
There are two babies in room 1, three babies in room 2, three in room 3 and three in room 4. A further baby is in the Transitional Care Unit.
17th February 2016
Child K is later transferred to room 1 after she is born (
2.
Child K is born with 'dusky, floppy, no resp effort' at birth, and a heart rate of 60bpm.
The 'Apgar score' is 4/10 at one minute, 9/10 after five minutes and 9/10 at 10 minutes after birth. Previously, the court has heard the Apgar score measures how well a baby is doing in the minutes after being born.
2.40am: Child K was admitted to the neonatal unit at 2.40am due to her "extreme prematurity", Mr Johnson tells the court, as well as the fact she was to be transferred to a tertiary centre at a later point.
3.15am: Dr Ravi Jayaram makes a note to the transport team at 3.15am.
3.30am: Observations are taken for Child K at 3.30am. A blood sample later showed no bacterial growth recorded.
3.35am: Further communication is made with the transport team at 3.35am.
3.47am: Swipe data is recorded showing Child K's designated nurse Joanne Williams leaving nursery room 1 at 3.47am to go to the labour ward.
It is just after that, the prosecution say, the event alleged in the case of Child K happened, and the baby girl collapsed.
3.50am: The event is recorded as happening by Dr Jayaram and Dr James Smith at 3.50am - "sudden deterioration" - sats dropping to 40%, Child K bagged via ET tube with Neopuff.
The 'sats recovered quickly' following treatment, and Child K was reintubated.
Designated nurse Joanne Williams also recorded the event. She is a co-signer for Child K to be administered morphine, with the other co-signer being Lucy Letby.
4.20am: Lucy Letby is the co-signer for further medication for Child K at 4.20am, the other co-signer being nurse Caroline Oakley.
Further observations and medication administrations are given through the early morning.
6.04am: A nursing note is made for Child K by Lucy Letby, who was not Child K's designated nurse, at 6.04am-6.10am.
6.07am: An x-ray records the ET tube is in the right place at 6.07am.
6.15am: Dr Jayaram notes an event at 6.15am: '@0615 began to have lower sats & IV down to 2.5...Tube pulled back to 6cm".
Retrospective notes by Dr Jayaram record: 'Tube noted to have slipped to 8cm @ lips - withdrawn and heart rate picked up immediately.'
7.30am: Nurse Melanie Taylor takes over designated care for Child K for the day shift at 7.30am.
Lucy Letby has signed for a 7ml saline bolus for Child K at 7.30am.
Further records show that, throughout the morning, ventilation requirements for Child K gradually increased.
8.50am: The transport team arrived at the hospital at 8.50am, for transferring Child K to Arrowe Park.
9.15am: Dr Jayaram discusses transport arrangements in notes which are recorded at 9.15am.
Text Messages (2)
10.04am: A message sent to Letby at 10.04am from a colleague says: 'Hope you had a good shift and are in the land of nod now!'
Further records are made of attempts to stabilise Child K so she can be transferred to Arrowe Park, through medication administrations.
At noon, Child K is moved into a transport incubator.
12.25pm: The formal handover from the neonatal unit to the transport team took place at 12.25pm-12.30pm.
Child K arrived at Arrowe Park by
1pm on February 17.
Medical records showed Child K was cared for at Arrowe Park Hospital from 1.15pm on February 17.
Text Messages (3)
5.48pm: Letby messages her colleague at 5.48pm: '25wkr delivered so fairly busy...'
The message was in reply to a colleague saying she had hoped the shift had gone well, and expecting she was asleep at that time ('in the land of nod').
Letby adds: 'Everything ok? Not like you not to text back'. The colleague apologises.
Letby then messages about staffing limitations at the hospital for the following shift.
On Saturday,
February 20, 2016, the decision is recorded to withdraw life support from Child K. The time of death is recorded as 5.28am.
The doctor records, as the cause, 'extreme prematurity' and 'severe respiratory distress syndrome'.
Facebook searches (child k)
Lucy Letby made a Facebook search on April 20, 2018, at 11.56pm, for the surname of the family of Child K.
Witness Statements Agreed (child k)
Family - Mother (child k)
The court is now hearing a statement from the mother of Child K, who described being thrilled at the news she was pregnant.
At the 12-week scan at the Countess of Chester Hospital, an issue was identified - Child K had a build-up of fluid at the back of her neck. At the 15-week scan, she was reassured everything was normal.
She had regular scans, and further check-ups showed the fluid was disappearing gradually.
At 18-20 weeks, it was discovered Child K had a pocket of fluid at her lungs, but follow-up checks saw this had gone.
Just before 25 weeks, the mum recalls waking up with 'a few niggles and pains'. She was still working at this time.
The midwife was called, and she advised to call the labour ward at the Countess of Chester Hospital - she was advised to attend.
She was informed by a midwife there she had gone into labour "we couldn't believe it".
The mother stayed at the hospital and received treatment.
Discussion took place over transferring the mother to a tertiary centre, but the nearest one, Arrowe Park, was full.
On February 16, the mother was given further steroids, and the possibility of a C-section birth was discussed.
There were "no indications of any concerns" of Child K, who was showing no signs of any distress. The decision was made to leave things as they were at that time.
That evening, the mother recalls waking up in pain, and the button was pressed to alert medical staff.
Child K, a baby girl, was born at 2.12am. Staff worked on Child K for 30-45 minutes. The mother later found she had been born weighing 692g - 1lb 8oz.
The consultant explained that the gestational age of 25 weeks meant there would be a medical team solely to look after Child K, who would be placed into an incubator. Once stable, she would be transferred to the special care on the neonatal unit.
A female nurse came in and told the parents Child K was "fine and stable", and if they wanted to see her.
The nurse offered to take photos of the three of them, on the father's phone.
The pictures are timestamped at 4.31am on February 17, maing Child K only a few hours old.
The mother was woken up later informing a bed had become available at Arrowe Park. At 9am, the transfer team arrived at the Countess of Chester Hospital. They explained what was going to happen. The process took "some time" as the team had difficulty stabilising her. It was then when the parents considered a name for Child K.
At noon, it was "now or never", for Child K to be transferred to Arrowe Park. The mother had not been discharged at this point, and the medical team "desperately" tried to make it possible so she could be allowed to go to Arrowe Park, which was done at 2pm.
The parents arrived at Arrowe Park at 2.30-2.45pm. Later, arrangements had been made for the parents to stay at the purpose-built accommodation.
The mother recalled "the strangest feeling which she could not describe" on the morning Child K died.
At the neonatal unit, parents had no restrictions on visiting times. They went in
As soon as she walked in, she could see the readings, including saturations, were low. She knew straight away things weren't great.
A doctor was in the room at the time. "I looked and said, she's not good is she?" The doctor "confirmed the worst," explaining Child K had been fighting all night.
The parents had a long conversation with the doctor, and the decision was made to switch off life support machines.
Child K passed away in her father's arms.
A cot was brought into the room to allow the parents time privately with Child K, who had died on February 20.
Dr Jonathan Ford
An agreed statement is now being read from Dr Jonathan Ford, a former registrar at the Countess of Chester Hospital.
He reviewed the mother of Child K before the baby girl was born, and discussed the issues of extreme prematurity.
He said the longer the pregnancy could be, and delaying of the birth, the better.
He reviewed the mother again at 9pm on February 16, and it was agreed for 'conservative management'.
She was called back on February 17 at 1.20am, when the mother was 'in pain, in active labour'.
It later became 'inevitable' the mother would give birth. He delivered the baby. The birth was "uneventful" and Child K was passed over to the paediatricians.
It was noted, at the 14-week scan, Child K had a cystic growth at the back of her neck.
A detailed scan at week 16 and week 20, that was resolving, and there were no problems with how Child K's heart looked.
Elizabeth Morgan
The court now hears an agreed statement from Elizabeth Morgan, who says in her experience, it is very unlikely a nurse would leave the nursery of a baby if the baby's ET tube was not settled in a position and the baby was settled.
For a baby of this gestational age, it would be standard practice for a nurse to take corrective action, carry out checks and call for help if a desaturation was noted.
It would 'not be normal practice' to wait and see if the baby self-corrects, for a baby of this gestational age.
Witness Evidence (child k)
Dr James Smith
The next witness to give evidence in court is Dr James Smith, who was employed at the Countess of Chester Hospital in February 2016 as a specialist registrar.
Dr Smith recalls he did have a memory of Child K. He recalls being notified there would be a delivery of a '25-weeker' baby.
He recalls being present at the birth, and the baby girl was born in 'expected condition'. The Apgar scores of 4, 9 and 9 are 'good'.
Asked about the 'dusky, floppy, no resp effort' note, Dr Smith says the gestation presentation can be variable, but a good/reasonable sign is a heart rate, 'no resp effort' is not unexpected and the baby would present as 'floppy' as there had yet to be any breathing support supplied by medical staff.
He tells the court full airway breathing resuscitation support would be required, but that would 'not be unexpected' for a baby as premature as Child K.
Dr Smith describes the procedures he would have taken to stabilise a baby such as Child K in this scenario.
He says Child K's heart rate improved to 100bpm within two and a half minutes, and she was making respiratory gasps. The decision is then made to intubate.
The intubation is "technically difficult", he tells the court, due to the baby's size, and can take multiple attempts. He says Child K was stabilised after each attempt, and he had no worries about doing the procedure himself, without needing to hand over the procedure to the consultant, Dr Ravi Jayaram.
He successfully intubated Child K on the third attempt with a size 2.0 tube.
He tells the court if he had seen any signs of trauma, such as bleeding, on Child K at the time of intubation, he would have passed the procedure on. To the best of his recollection, he did not see any signs of trauma.
He tells the court there is nothing in the notes of any sign of trauma at this point.
The general clinical picture was Child K's signs were 'good', the resuscitation 'had gone successfully' and the first blood gas record was 'good - reasonable for the first reading'.
He tells the court that for all babies of this prematurity, antibiotics would be administered.
Dr Smith tells the court he would have been, to an extent, guided by advice from Arrowe Park Hospital in the treatment of a baby of this prematurity at the Countess of Chester Hospital.
Dr Smith says he would not have played any part in the connection of Child K to the ventilator at the neonatal unit, following transfer, and would not have had any knowledge of how to do so, as that connection would be a task carried out by nurses.
Dr Smith says he remembers coming back into the neonatal unit early on February 17, probably for labelling blood bottles.
He does not recall where the nurses were, but recalls Dr Ravi Jayaram giving breaths to Child K via the Neopuff, and that was already under way.
He said the readings, while unable to recall what they were precisely, "were not improving", and further measures were to be carried out.
The explanation for a "sudden deterioration" was either the breathing tube being dislodged or blocked.
The "correct decision" was for the tube to be removed.
Breathing mask support was supplied to Child K without a tube. Child K's oxygen saturation levels improved and Child K was reintubated.
A morphine bolus was administered to help the reintubation process.
Dr Smith says he did not see any evidence of trauma, and if there was anything obvious to show that, he would have informed Dr Ravi Jayaram, but he "did not see anything".
The prosecution ask if the Countess team followed the advice from Arrowe Park to take x-rays of Child K to check for tube placement. Dr Smith confirms they did, and a chest x-ray was carried out.
The radiology report said, from the x-ray, the ET tube was 'in satisfactory position' following the reintubation, along with the NG tube, while a UVC line required further adjustment.
The radiology report also recorded possible lung infection, which Dr Smith was expected in babies of Child K's gestational age.
Dr Smith re-examined Child K at 6.15am, when it had been noted Child K had lower saturations, with a blood gas reading which was "not good" and "worse than the previous gas".
The tube was 'pulled back' to improve the oxygen saturation levels, but the readings had 'not improved'.
The decision was then taken to remove the tube from Child K. 'Bagging' breathing support was provided to stabilise oxygen saturation levels, and Child K was reintubated once again.
Child K had responded 'very quickly' to the 'bagging' support.
Dr Smith says, from the notes, there is nothing to say the tube removed from Child K was blocked, and his memory has nothing to add to that.
A repeat x-ray reported: 'Satisfactory position of the ET tube. NG tube in situ...this would benefit from advancement by 5-10mm. UVC in satisafactory position.'
A lung infection was still suspected for the left lung, which appeared increased in density - 'looking more white', and reduced in volume compared to the right lung.
Dr Smith later wrote a transfer letter to Arrowe Park Hospital, which summarised the care given to Child K at the Countess of Chester Hospital, including details of intubations, medication administrations and a blood result.
Cross Examination
Benjamin Myers KC, for Lucy Letby's defence, is now asking questions in respect of the events for Child K.
He says Child K was born in extreme prematurity, and asks if there would inevitably be problems for the baby girl's care, particularly in relation to the lungs. Dr Smith agrees.
Dr Smith remembers being in the room when Child K's resuscitation efforts were taking place, and they were going well.
He says neonates with this gestation need a lot of support and resuscitation.
He cites a study that babies of that gestation age, found a 75% survival rate. Mr Myers suggests that figure could be more like 40-50% from another study. Dr Smith says he has cited the most recently available study he looked at.
Mr Myers says a tertiary unit is the most suitable place for treating babies of Child K's gestational age.
Dr Smith says they are more experienced at a tertiary unit, but level 2 units (such as the Countess of Chester Hospital at this time) have the equipment and have staff capable of treating babies of this gestational age, for the short term.
He says the correct thing to do would be to contact the level 3 unit in advance to enquire if transfer to there was possible in advance of birth.
He says seeing Child K's bruising on her hands and feet at birth was not something he had seen frequently in births, and was more likely seen by staff at tertiary centres. He said he had asked for an expert opinion on the subject of the bruising.
Dr Smith says level 2 centres do not look after babies of this prematurity, long term.
He says if mothers of 23-week gestational arrived at the hospital via ambulance, and delivery was imminent, that delivery would take place at the nearest hospital, with a set procedure in place to arrange transport to a tertiary centre when viable.
Dr Smith recalls it would have been better if he had written his own independent notes, in addition to Dr Ravi Jayaram's complete notes. He added he did write up the transfer letter listing the events and care for Child K.
Mr Myers asks why would Dr Jayaram write up those notes in the first place. Dr Smith says he would also have been on the paediatric unit on that night shift. He says as long as a senior doctor has been involved in writing, then the notes would be 'completed'. He says that 'ideally', he would have written notes up himself, independently.
Mr Myers asks about the initial intubation process for Child K.
He asks if Dr Jayaram should be the one to do that process, as the more senior doctor.
Dr Smith says: "No, not if the baby is stable."
He says the decision to take over could be the 'wrong decision' as the doctor carrying out the procedure would be familiar with the placement of where everything is.
Mr Myers asks if it's standard practice guidance for babies to be intubated within 15 minutes of birth. Dr Smith says he is not familiar with that number, and asks Mr Myers where that guidance has come from.
Dr Smith says if that was the number that is standard practice, then he would go with that. He says there are two different numbers for how long it was after birth for intubation to have taken place - one of them is 12 minutes.
Dr Smith is asked about lung surfactant which a note records as being administered at 3am, and if that, at about 35 minutes after intubation, is 'too long'.
Dr Smith says if there is good oxygen saturation recorded at the time, and Child K is stable, that would not be an issue, but if guidance is to administer that surfactant five minutes after intubuation, then that would be considered too long.
Dr Jayaram's note is shown to the court, written retrospectively. Dr Smith points out the note of surfactant administration is recorded as being made at '0245'.
Mr Myers asks about the insertion of a central line, done 'several hours' after Child K was born. Dr Smith says the procedure requires assistance, is difficult, takes time, needs a sterile environment and a stable baby. It also requires x-rays afterwards.
The line is 1mm thick being put into an umbilical cord line that is 1-2mm thick. It is, in this instance, 'a non-emergency UVC'.
Mr Myers says this is a procedure which, 'ideally' should be done by a consultant neonatologist at a tertiary centre.
Dr Smith says ideally, the baby would be born at a tertiary centre, but in these circumstances, the most experienced staff available at a level 2 centre, who are capable of this type of procedure, would carry out the procedure.
Mr Myers asks if it was 'too long' a time period. Dr Smith said the baby would not have been compromised by a longer time period.
Mr Myers asks if it was 'sub optimal'. Dr Smith says it would depend on the circumstances and the condition of the baby, and in Child K's case, the 'correct thing to do' was to prioritise the airway and breathing support, and lines could be put in later.
Mr Myers asks if the insertion of the line at this time fell outside the 'golden hour' principle.
Dr Smith says there is no difference in the method of the administration of initial medicines - the UVC was one option, but there are others.
Dr Smith agrees with Mr Myers the initial administration of antibiotics fell outside the 'golden hour' principle timing. The antibiotics were administered at 4.40am, according to electronic prescription records, sometime after the first hour of Child K's birth which ended at 3.12am.
Dr Smith adds, from a blood
test, there was no marker of infection, but if was sub-optimal that the antibiotics and vitamin K (administered at 4.20am) were not administered in the first hour, and cannot recall why that was the case.
After a short break, Mr Myers is continuing to question Dr Smith.
He refers to the intubation attempts made for Child K. Dr Smith says he used a 2.5 tube at first, then a smaller 2.0 tube was used, successfully.
Mr Myers asks about an air leak which was reported. Dr Smith says he was aware, and made reference to it in his third statement to police.
The 3.30am reading of '94' for air leak, Dr Smith does not know what that means, as it does not correlate to any of the other readings. He says the blood gas record for Child K was good, and the oxygen saturation for Child K was good, and oxygen requirement had come down. He says he does not believe that would mean only 6% (100% minus 94) of oxygen was getting into Child K.
He said a large air leak would result in a change to a larger ET tube bein considered, but that process would require reintubation.
He said, knowing there was good oxygenation and good gas, that would reduce the need for reintubation.
He adds that a tertiary neonatologist with more experience of ventilators might give a different opinion, but they would need to be called to give evidence. Dr Smith adds he also does not know what the 'resistance' figure on the chart signifies either.
Mr Myers asks about the reintubation of the tube for Child K, which involved a larger tube. Dr Smith says the first ET tube was working fine, then it was not, and reintubation was required.
The morphine bolus was applied to have "a sedative effect" on Child K.
The desaturation at 6.15am is referred to.
Dr Smith says the ET tube was pulled back, but saturation levels continued to decrease, so the ET tube was removed and bagging commenced.
The saturation levels improved, and Dr Smith says that meant there "was a problem with the tube".
Mr Myers says pulling the tube back and seeing no change [prior to the tube's removal] meant there was no problem with the positioning of the tube.
Dr Smith says the cause of the tube's movement could have been it 'slipping' from the clamp, for this deterioration.
Dr Smith says he did not recall any injury/blood/trauma with Child K, and if he had done so, he would have referred it to Dr Ravi Jayaram and asked them to take over the intubation process.
Mr Myers asks if, hypothetically, he had seen blood before intubation, if he would have checked for the source of it.
Dr Smith says it would depend on the amount of blood seen that would lead to how concerned he would be. He said if he had seen blood-stained secretions, he would make a note of it.
Nurse Joanne Williams
The next witness to give evidence is Joanne Williams, who was employed as a neonatal nurse at the Countess of Chester Hospital. She has returned to give evidence in respect of Child K.
She confirms she was working a night shift that night. She remembers Child K being born, and being on that night shift.
She remembers being called through at the birth of Child K, and recalls her being born at 25 weeks gestation. She said the delivery happened at the Countess, and Child K would be transferred later to a tertiary centre.
Ms Williams remembers Child K being bruised on her feet, which was not unusual a sight, as she had seen that in the past.
Immediate resuscitation was provided and Child K was intubated.
An observation chart is shown to the court for 'Baby Girl', as Child K had yet to be named.
Child K was on a ventilator for 45 breaths a minute when she was on the neonatal unit room 1.
As designated nurse, Ms Williams confirms she would check to make sure the ventilator was secure for Child K.
The oxygen saturation reading for Child K of 70% at 2.45am would be considered 'low', while the 94% reading at 3.30am was 'normal' and 'improved'.
The prosecution say that would be indicative the ventilator was working as it should be.
Ms Williams is being talked through her nursing note from the morning of February 17, 2016, in which she described Child K being born in 'fair condition'.
She was 'intubated at approx 12 minutes of age with size 2 ETT'.
Ventilation commenced, and a 'high leak noted'. Ms Williams said that is noted via the ventilator, and if there are any concerns, they are highlighted to the medical team.
She says that can sometimes be down to the size of the ET tube.
Staff would be alerted to the leak via the ventilator giving off an alarm, the court hears.
Ms Williams says there were no concerns over the leak, as the overall clinical picture for Child K was stable.
Ms Williams says the alarms would go off if the baby's clinical picture declined, such as the heart rate dropping or oxygen desaturation. Initially it would be a 'soft alarm', which is amber and makes a noise, then a more urgent alarm in red and 'more of an alerting' sound.
There is a way to pause the alarms, Ms Williams says. That could be paused for several minutes, once it had been activated, in the event of doing a procedure.
Ms Williams says she cannot recall if the alarm could be disabled in advance. The court hears a newer version of the monitors have since been installed in the hospital, where that is possible.
Ms Williams says at the time of the 'high leak', the clinical picture for Child K would have been assessed, and a check the tube was in the right place at the mouth.
The prosecution is now asking about the time period when Ms Williams left the nursery room to inform the family on what had been happening.
She said she would not have done so if Child K was not satisfactorily stable.
She tells the court, other than being born very premature, there was nothing of concern.
She does not remember asking anyone in particular to look after Child K in her absence.
Ms Williams recalls Child K being 'quite active' as she left, which was normal to see in prematurely born babies.
The court hears Ms Williams left the unit at 3.47am.
The intensive care chart for Child K on February 17, 2016 is shown to the court.
A reading at 3.30am says, for morphine, 'commenced'. Ms Williams is asked if that means morphine commenced for that time. Ms Williams agrees.
A reading for 0350 '100mg/kg morphine' is recorded. The note is not in Ms Williams's handwriting, and the court hears that would have been a bolus of morphine.
There is a prescription note for 0350 for a morphine infusion dose. Ms Williams says this is also not in her handwriting, and it is written by a doctor.
Asked again about the '3.30am' reading, Ms Williams says that would not have begun at 3.30am precisely, but in the time period after. She cannot say whether that happened before she left the room at 3.47am.
She tells the court Child K would have been stable when she left.
When Ms Williams returned, she heard a red alarm, "it seemed like an emergency, something was going on".
She says she felt upset, and it "always frightening to go back into a situation like that".
She recalls Dr Jayaram asked her what had happened, likely near the nursing station after Child K had stabilised. Ms Williams said Dr Jayaram had asked 'how did the [ET tube] move'.
She recalls Child K was reintubated, with a bigger ET Tube.
Asked about her '?ETT dislodged, removed and re-intubated' nursing note, Ms Williams tells the court there was a query that the ET tube had been dislodged.
Ms Williams had also recorded on her nursing note, for the ET Tube, 'large amount blood-stained oral secretions'.
The nursing note also adds 'Initially active on handling but now more settled'.
Ms Williams tells the court a morphine bolus would be given, instead of a morphine infusion, when carrying out a procedure such as inserting a UVC line.
Ms Williams's family communication note includes 'photos taken and treasure box and Bliss bag given...encouraged parents to come to the unit to visit and mum and dad both touched her...mum to be discharged to [Arrowe Park Hospital] to be with baby.'
Ms Williams's further nursing note explains Child K had '2 further episodes of apnoea and de-saturation with loss of colour. Has been re-intubated twice and now has a 2.5ETT...'
Ms Williams tells the court she would have remained the designated nurse throughout that night shift for Child K.
Cross Examination
Benjamin Myers KC, for Lucy Letby's defence, is now asking Joanne Williams questions.
He picks up on what Ms Williams had just said, that she did not have much experience in dealing with babies born at 25 weeks gestation. Ms Williams agrees that was the case at the time in 2016.
Mr Myers says there is the potential for deterioration in such babies, as they an be 'unpredictable'. Ms Williams agrees.
Mr Myers asks about the process of administering a 'lung surfactant'. Ms Williams says it would be kept in storage. It would be prescribed, but could be signed for retrospectively. Doctors would work out how much to prescribe based on the baby's weight, and they would administer it.
A prescription form is shown to the court, showing a '120mg dose' 'administered 0300'.
Asked if 0300 is the time of the dose given, Ms Williams says: "Yes." She adds that would be an "estimated" time the dose was given. The scheduled time appears as '0544' is because it is a retrospectively written note, the court hears.
Mr Myers asks about the '94' leak reading for 0330 for Child K. He asks if that is a high air leak. Ms Williams agrees.
Mr Myers says it would be a reading 'to keep in mind'. Ms Williams agrees.
Mr Myers: "The aim would not to be to have a leak of 94%?"
Ms Williams: "Yes."
Mr Myers asks if ET tubes can be dislodged if a baby moves or not, Ms Williams agrees. She also agrees that requires careful observation, and it can change from minute to the next, but there are procedures, such as clamps, to keep the tube in place.
Mr Myers asks if Child K had been 'quite active'. Ms Williams: "At times, yes."
Mr Myers asks about the morphine administered, which he says can sedate a baby and stop them being as active.
Ms Williams says Child K would have received morphine after being intubated, not at the time of intubation.
Mr Myers asks about when this morphine was administered.
Ms Williams says the morhpine could start via a bolus or an infusion, then the other being administered.
A prescription for a morphine injection is shown to the court. Mr Myers asks if this is a bolus. Ms Williams agrees.
Ms Williams agrees she has co-signed for it, and agrees with the administration time of '0350' recorded as being the time the morphine was injected.
The morphine infusion prescription and administration chart is shown to the court.
This is prescribed by a doctor, and has a handwritten start time of '0350'.
Ms Williams says 0350 could be the start time, or it could be later. Mr Myers says the prescription wouldn't have a start time after it had already been administered.
Mr Myers asks about the 0330 fluid chart. Mr Myers says although it is said morphine commenced at '0330', it is an hourly chart, and that means the morphine could have been commenced at any time between 3.30am and 4am. Ms Williams agrees.
Ms Williams says, for the '0350 100mg/kg morphine' note, that is not in her handwriting, but having someone else write in that note box is not uncommon when working as a team.
Mr Myers asks if the morphine bolus and the morphine infusion began at the re-intubation process, after Child K had suffered a desaturation.
Ms Williams: "Yes."
Mr Myers asks about the alarm going off, and a conversation with Dr Ravi Jayaram.
Ms Williams says the conversation took place not in nursery room 1.
He asked her, Ms Williams had said in her police interview, what had happened, and she had replied she did not know as she was not in the room, having gone to see the parents.
Mr Myers asks to clarify about what Ms Williams had said moments earlier: 'I thought the ET Tube was secure, but I was not there'. Ms Williams agrees.
Mr Myers asks about the nursing note made by Ms Williams 'large blood-stained secretions'.
Ms Williams says she does not recall where that came in the timeframe of events.
She adds it is difficult to write notes retrospectively and highlight the significant events. She says it is likely that would have been seen at the time of the re-intubation as she would have been present.
Prosecution
The prosecution rise to ask Ms Williams further questions.
Ms Williams is asked about the lung surfactant administration note.
Prosecutor Philip Astbury asks about the timings of the note. The 0544 would be the time the surfactant was prescribed, retrospectively. It would not have been done concurrently as Child K would not have been added as a new baby identification on the hospital's system at that point.
The time at 5.48am, when the note was filed, would have been the point when it was considered what time the surfactant was given, the court hears. The note records it administered as '0300'.
She says she does not recall who administered the surfactant.
Ms Williams's nursing note is shown to the court. She is asked if the note, written retrospectively, is written chronologically. Ms Williams says that ideally, that would be the case.
Mr Astbury asks about the infusion chart, where hourly records are made. The 0330 note is referred to. Ms Williams is asked if records are kept as close to the times where possible. She agrees.
Ms Williams says she does not remember being present for the 0350 morphine bolus.
Mr Astbury asks about the conversation Ms Williams had with Dr Jayaram.
Ms Williams is asked if Dr Jayaram asked her: "How did the tube move?" Ms Williams agrees.
The judge asks about the purpose of the morphine bolus, whether given before or after the infusion. Ms Williams said it would be done '3-5 minutes' for a procedure such as re-intubation, for pain relief to the baby.
That completes Joanne Williams's evidence.
Dr Ravi Jayaram (child k)
Dr Jayaram confirms he would have been on call as a consultant on the night shift of February 16-17, 2016.
He says he would have been called at home, and would have been called to come in for the delivery of a 25-week gestational age baby such as Child K, as the hospital would be aware there could be complications.
He tells the court, until the early 2000s, there was less structure, but in more recent times, if possible, mothers are taken to tertiary centres [such as Arrowe Park] to give birth. If that is not possible, babies can be cared for in the short term at level 2 centres such as the Countess of Chester Hospital.
He says, on balance, the risk would have been too great to transfer Child K and the mother for the birth at a tertiary centre.
He adds he was present at Child K's birth.
Dr Jayaram says it is significant, when talking through the medical notes he had written retrospectively, the mother had a 'spontaneous rupture of membranes' 48 hours before birth, as that could lead to a risk of infection.
He said it was relevant there were 'no fevers' recorded.
The medical notes record Child K was 'initially dusky, floppy, no respiratory effort'. Dr Jayaram said that was significant and in this situation, a pathway is followed including 'inflation breaths', which stimulates the baby's first gasps.
He says it is like blowing a balloon up for the first time - the lungs are difficult to inflate for the first time as they are filled with fluid.
The inflation breaths are completed after two cycles, and Dr Jayaram says the chest is then seen to be moving up and down.
The heart rate is then above 100 beats per minute, recorded two and a half minutes after birth.
Gasps are recorded after three minutes. Dr Jayaram said Child K would have initially been 'a little stunned', but the gasps are what the medical staff are looking for.
Oxygen saturation levels of 'above 85%' at six minutes are 'satisfactory'.
The initial intubation process is discussed.
Dr Jayaram says it can be difficult and risky, and it is important the oxygen saturation levels are high before starting the procedure.
A doctor has 30 seconds to attempt the intubation procedure. The court hears the intubation was done on the third attempt, with a smaller, size 2, ET tube.
He says, "ideally", a 2.5 ET tube would be used, but in these circumstances a size 2 tube was sufficient.
Child K was transferred to the neonatal unit, on a ventilator.
Dr Jayaram describes Child K required around 60% oxygen. He says he could hear air going in and out of the baby girl's lungs.
The initial blood gas readings are taken, and it is acceptable for a 'little bit of leeway' on carbon dioxide levels.
Child K was given surfactant at 2.45am, Dr Jayaram had recorded in the notes.
A blood culture test was taken to screen for infection, as a routine test, and the baby girl would be treated on the assumption she already had an infection and would be treated with antibiotics.
A morphine infusion is recorded on the medical notes.
Mr Astbury asks when that would be administered. Dr Jayaram says he does not recall when that would have been, but it would not be immediately after transfer to the neonatal unit nursery room 1.
Dr Jayaram said he could hear Child K's heartbeat, and air going in and out of both lungs.
He said, for a 25-week gestation baby, he was "happy" with Child K's progress.
Dr Jayaram said he was happy the ventilator was working, as observed by Child K's chest moving, and being in good colour.
He tells the court that at this point, he informed the transport team about the situation, and they had advised there was a bed at Arrowe Park Hospital, and they advised for a UVC line to be inserted prior to transport.
Dr Jayaram is now being asked about Child K's desaturation at 3.50am.
A plan of the neonatal unit layout is shown to the court.
Dr Jayaram said he was "happy" with how Child K was "very very settled", having had to make only minor adjustments to the ventilator settings.
An infusion chart for the morphine is shown to the court, with a start time of 3.50am. He confirms that 3.50am would be the time that would be adminsitered.
Dr Jayaram says he was aware Joanne Williams was going to the labour ward to update the parents on Child K.
He said he was sitting at a desk, around the corner from the entrance to nursery room 1. He says he was writing in notes, or waiting for the transfer team to come back to him regarding arrangements.
He said he had been told Lucy Letby would be 'babysitting' at the time - a common term used by the hospital to describe a neonatal nurse temporarily looking after a baby in the absence of its designated nurse.
He says, at this point, in February 2016, he was aware of 'unexpected/unusual events' that had happened recently, and that Lucy Letby had been present.
He said: "I felt extremely uncomfortable [with Lucy Letby being there alone in the room with Child K]
"You can call me hysterical, completely irrational, but because of this association...
"This thought kept coming into my head. After two, two and a half minutes...I went to prove to myself that I was being ridiculous and irrational and got up.
"I think it was 2.5, 3 minutes after Jo had gone to the labour ward.
"I had not been called to review [Child K], I had not been called because alarms had gone off - I would have heard an alarm. I got up and walked through to see [Child K]."
Dr Jayaram entered nursery room 1 through the entrance doors closest to his desk. Child K was at the far side of the nursery room, with Lucy Letby present.
He said: "I saw Lucy Letby standing by the incubator. I saw her, and looked up at the monitor, and K's saturations were dropping, in the 80s and continued to drop. The ventilator was not giving out an alarm.
"I recall looking up and saying 'what's going on?' and Lucy said something along the lines of 'She's having a desaturation'."
Asked what Letby was doing, Dr Jayaram replied: "Nothing."
He says Letby didn't say anything to Dr Jayaram until he had walked over and he had asked her what was going on.
Dr Jayaram said he was looking at Child K. He disconnected the ventilator from the ET Tube and he tried to give breaths via the ET Tube, but Child K's chest was not moving.
He said he switched into 'professional mode' to resolve the situation, and it 'didnt make sense why the tube was dislodged'
He said he removed the tube - which wasn't blocked - and put a face mask to ventilate Child K. As soon as that was done, Child K's chest went up and down, without too much difficulty.
He says he does not remember anything else Lucy Letby said. He says he was probably telling her to bring equipment.
Dr Jayaram says the original tube was not blocked, and there would be no reason for that to have been blocked, for the time it had been on Child K.
Dr James Smith reintubated Child K, and the same ventilator settings were selected, indicating - Dr Jayaram tells the court - Child K had not been declining.
Dr Jayaram's notes are shown to the court, where he had described it as a 'sudden desaturation'.
The oxygen saturation levels fell to 40%.
The tube was removed, Child K was bagged via a face mask, and 'sats recovered quickly'.
A size 2.5 ET tube was placed. 'Ventilator settings as previously'.
The size of the tube "did not have an impact" on the previous ventilation, Dr Jayaram tells the court, as Child K was "ventilating effectively" and did not have an impact on the "sudden deterioration".
Dr Jayaram says he cannot recall how long Joanne Williams had been away before the sudden deterioration had taken place.
He tells the court the transport team and the parents were updated, but he does not believe they were updated about "this event".
The court is shown Dr Jayaram's notes, plus writing by someone else at 5.40am recording a vial of Curosurf given.
Notes by Dr Jayaram are written retrospectively at 7.50am. He recorded at 6.15am, Child K 'began to have lower sats'.
He says the blood gas record from that point suggested the cause of that 6.15am deterioration was an issue with ventilation. He tells the court low blood pressure is also recorded.
Saline is administered but the blood pressure remained low.
The ET tube was pulled back but saturations remained low, so the ET Tube was removed. Child K's oxygen saturation levels improved in response to bagging.
The blood pressure dropped again at 7.25am. The saturations and heart rate dropped.
Child K was taken off the ventilator and Neopuff was administered.
Cardiac compressions were started as it was 'not sure enough blood was being pumped around the body' - Child K had not gone into cardiac arrest, but the heart rate had gone under 100 beats per minute.
The ET Tube "wasn't working", as it had 'gone in further' than it should have gone, the court hears.
Child K was recorded as 'now stable'.
Dr Jayaram says he had observed a chest x-ray for Child K showing the ET Tube was in the right place.
The transport team was estimated to arrive at 8.30am, and they led on treatment from later in the morning, the court hears.
Dr Jayaram says using the smaller, size 2 ET Tube, is not a problem as long as the baby was being ventilated.
He says a leak is recorded, and in itself is not of any clinical significance even if it is high, as it is important to ventilate the baby.
Dr Jayaram says the size of the ET Tube has no impact on the likelihood of it being dislodged.
Dr Jayaram says he was "happy" with the original intubation and "happy" they were adequately ventilating Child K.
He tells the court they would do investigations (such as x-rays) if they thought there was something they would need to change in management.
He says at the time Joanne Williams left the nursery room, there were no concerns of any potential deterioration for Child K.
He tells the court: "You wouldn't not have expected" Child K's lungs to have deteriorated to the extent shown in the few minutes Joanne Williams was away from the nursery room.
He says his thought processes for going into the room, when Lucy Letby was present, were only to prove to himself that everything was ok.
(Not clear exactly when cross examination started)
Mr Myers says Dr Jayaram was worried about being irrational at the time.
Dr Jayaram said he was concerned and didn't want to see Child K in a different condition. They were not based on a clinical reason, or if Child K had any underlying conditions.
Mr Myers said he believed, from Dr Jayaram's interview with police, the suspicious behaviour had been deliberate.
Dr Jayaram: "That had crossed my mind, yes."
Mr Myers: "You 'got her', then?"
Dr Jayaram: "No."
Dr Jayaram said he wanted this investigated objectively in a proper way, and there was "absolutely no evidence that we could prove anything - as that is not our job, we are doctors."
Mr Myers said he had told the police if the tube had been dislodged on purpose. He asks if he had confronted Lucy Letby.
"No, absolutely not." Dr Jayaram said he was focused on the situation.
Mr Myers says it did not happen in the way Dr Jayaram describes.
Dr Jayaram: "I am interested in why you say that."
Mr Myers says it is not documented in medical notes.
Dr Jayaram says that would not be the sort noted in medical documentation.
Mr Myers says there is nothing to say the tube is dislodged.
Dr Jayaram says it is obvious from the medical notes.
He says, in isolation, the incidents were unusual, and more concerning in a pattern of behaviour.
He said: "We, as a group of consultants by this stage, had experience of an unusual event, and there was one particular nurse.
"All of these events were unusual. Yes, if we put in Datix [incident forms] we could have investigated sooner and been here [in court] sooner."
He said he, and his other consultants, wanted to know how this could be investigated, and tried their best to escalate concerns higher up the hospital.
Mr Myers says there is no record anywhere of the suspicious behaviour noted.
Dr Jayaram says he did not anticipate being sat in a courtroom, years down the line, speaking to Mr Myers.
"If you feel someone is deliberately harming [children], you would do so, wouldn't you?"
Dr Jayaram said concerns had been raised before February 2016, and were raised again following this incident.
Mr Myers says Lucy Letby continued to work at the unit for a further four months.
Dr Jayaram says the concerns were first raised in autumn 2015 with senior management, but were told that there was likely nothing going on.
He said the consultants went 'ok', and against their better judgment, carried on.
"We were stuck, as we had concerns.
"In retrospect, we wished we had bypassed them [senior management] and contacted the police."
"We by no means had played judge and jury, but the association was becoming clearer and clearer.
"This is an unprecedented situation for us - we play by a certain rulebook, and you don't start from a position of deliberate harm.
"It is very easy to see things that aren't there - in confirmation bias.
"But these episodes were becoming more and more and more frequent by associaiton."
Dr Jayaram said it should have been documented throughout more.
He says he discussed the incident, but did not formally document it.
Dr Jayaram said he was getting "a reasonable amount of pressure from senior management not to make a fuss".
Dr Jayaram says he does not understand why an alarm did not go off, and why a call for help had not gone out when Child K was desaturating.
He said, in relation to the suspicions, he "did not want to believe it".
He said it "took a long time for police to be involved".
Dr Jayaram says the tube is 'very unlikely' to have been dislodged by a 25-week gestational age infant, in that short timeframe.
He says that can happen when a baby is 'very vigorous' - heavier, stronger babies, or when a baby is being handled or receiving cares.
Mr Myers said it was still possible for the tube to be dislodged by Child K.
Dr Jayaram says 'anything is possible', but Child K was 'not a very active baby', and a baby of this weight, size and age meant that was unlikely.
Dr Jayaram said the receiving consultant would not have assumed the tube had been dislodged by anyone else.
Mr Myers says the alarm on the ventilator was not alarming, according to Dr Jayaram.
Dr Jayaram says he had not got up because the alarm was going off. He said if it was, he would have been prompted to go in, and that would have been his reason for going in the nursery room.
Mr Myers asks if a conversation took place with Ms Williams after the desaturation.
Dr Jayaram says he does not recall the conversation. He says: "Why would I ask her what happened in the room when she wasn't there?"
The court is shown swipe data for Joanne Williams, who left the neonatal unit at 3.47am.
Mr Myers says it is very precise in coinciding with
Dr Jayaram's recollection of waiting two-three minutes before the desaturation is timed at 3.50am, and asks if Dr Jayaram always has such a precise memory.
Dr Jayaram says "In this event, I did."
He adds: "I kept telling myself, don't be ridiculous [about my suspicions]. I looked at my watch - I didn't have a stopwatch."
Dr Jayaram says he has never seen the swipe data, nor had cause to look at any data.
Dr Jayaram says it would be appreciated if Mr Myers gave an indication of where he was going with his questioning.
Mr Myers says an earlier police interview had Dr Jayaram not giving a precise estimate how long Joanne Williams had been out, but is able to give a more precise estimate now, several years later.
Dr Jayaram says he has had more time to reflect on this incident.
Dr Jayaram: "The point is, this incident happened in the window when she [Joanne Williams] was out."
He tells the court the incident of this night is "emblazoned" in his mind.
Dr Jayaram adds he "refutes" the allegation the care the hospital team provided contributed to the outcome of Child K.
Mr Myers asks if the focus on this incident was to "distract" from the overall care provided by the medical team to Child K.
Dr Jayaram: "Well, that's an easy one to answer: Absolutely not."
"Are you seeking to bolster suspicion against Lucy Letby?"
"Absolutely not."
Mr Myers asks if there was an opportunity, within the 48 hours before Child K's mother gave birth, to transfer her to a tertiary centre. Dr Jayaram says he does not have that decision to make, and cannot answer that, but adds there were many factors to consider.
Dr Jayaram is asked about the intubation process.
Mr Myers says the process was carried out by a 'relatively junior registrar', Dr James Smith. Dr Jayaram said Dr Smith had been assessed as competent and experienced enough, and it was 'standard practice' to carry out these procedures.
"I could see he could do this, and safely."
He adds if Child K was struggling to be ventilated at the time, and the heart rate and saturations were not being maintained, then he would have taken over.
Mr Myers asks about the high air leak.
Dr Jayaram says the 94% leak is a measured value, and is significant is the baby is struggling to be ventilated; but if the baby is being ventilated, then it is just noted.
Mr Myers says lung surfactant should be administered within five minutes of intubation. Dr Jayaram: "Ideally, yes."
He says it is used to improve gas exchange.
If it is given slightly later than expected, it would "not make much difference in the long run", as it is important the baby is receiving ventilation at the time.
Mr Myers asks why only Dr Jayaram and not Dr James Smith made notes. Dr Jayaram says he does not know why that was the case.
Dr Jayaram's medical notes are shown to the court, and the medicines are highlighted. Mr Myers says it appears the antibiotics have been delivered at the right time.
A prescription chart is shown for one of the medicines, 'time given 0445'. Dr Jayaram agrees it appears it was administered at that time, and should have been administered sooner.
He says the late administration of the antibiotics is important, the vitamin K not so.
Mr Myers says he will next talk about the morphine infusion.
Dr Jayaram is asked about the morphine infusion recorded, which appears on the notes above a note added, timed at 3.50am.
Dr Jayaram says, having seen the prescription chart, the morphine infusion would not have happened before the desaturation.
Mr Myers said Dr Jayaram had told police Child K had been sedated with morphine. Dr Jayaram said that was what he had believed at the time.
Dr Jayaram says Child K was not on a morphine infusion prior to the desaturation. "However", she was not a vigorous baby.
He says, in retrospect, he will accept the morphine was not running prior to the desaturation.
He says he is "surprised" it was not running sooner.
He says he believed, "in good faith", the morphine was running at the time.
Mr Myers: "Have you tried to shift your evidence? That you can't blame it on morphine?"
Dr Jayaram: "Even accounting for the fact she was not on morphine, she was a 25-week gestational age", small, and weighing 600g and was stable - 'poorly, but stable'. He says that the dislodging happened in such a short space of time was "concerning".
He says Child K was able to move her arms and legs, but not enough to dislodge a tube.
He says his previous statement was based on a "genuine misunderstanding based on my notes".
He says he does not accept he made a "deliberate error".
Dr Jayaram says he is not aware of a nursing note recording 'blood-stained oral secretions'.
The nursing note by Joanne Williams which refers to this is shown to the court.
Dr Jayaram says that is in the back of Child K's mouth, not in the tube, and is not clinically relevant. It was "not a significant finding".
He says he would have noted if the tube had been blocked, and he would have noted it.
Dr Jayaram says the tube blockage would lead to a gradual deterioration, quite quick, but did not fit the pattern of Child K's deterioration.
Mr Myers suggests the care of Child K provided could have been improved.
Dr Jayaram said it could have been better.
Mr Myers suggests Dr Jayaram has added to his account over the years.
Dr Jayaram: "I would disagree with that - you would be questioning my brevity and honesty."
Prosecution
The prosecution rise to ask about a couple of matters.
Dr Jayaram is asked if he has ever seen the electronic sequence of events [being shown in court], or the swipe data collated.
Dr Jayaram replies he has never seen either, nor had cause to see them.
The judge asks about the morphine infusion prescription chart, and asks Dr Jayaram which sections are in Dr Jayaram's handwriting. The sections including the 0350 start time are in his writing.
The infusion would have been administered by the nurses, Dr Jayaram tells the court.
That completes Dr Ravi Jayaram's evidence for Child K.
Dr John Gibbs (child m)
Taken from Dan O’Donohue Twitter (23/02/2023)
We'll be hearing from Dr John Gibbs this morning, who has since retired but was previously a consultant paediatrician at the Countess of Chester Hospital
Dr Gibbs is taking the court over his notes for the collapse of Child M on 9 April 2016. The prosecution say Ms Letby injected air into the infant's bloodstream causing a near fatal collapse. She denies all charges
Dr Gibbs examined Child M on the morning of 10 April. He said he queried whether infection/sepsis was the cause of the boy's cardio/respiratory collapse the previous day - 'it transpired he didn’t have either of those, so there was no proper explanation', Dr Gibbs said
Dr Gibbs said subsequent X-rays and heart scans offered no explanation for the child's collapse
Dr Gibbs said Child M 'still wasn’t behaving normally' on April 10, he was 'quiet and breathing slow' but he said that was 'explicable for a child that had very nearly died the previous afternoon'. The baby did eventually stabilise and was later discharged
Medical Experts Evidence
Mr Johnson explained to the jury he was not calling medical experts Dr Dewi Evans and Dr Sandie Bohin.
He said the prosecution and defence had agreed there was nothing they could add to the evidence already heard about Child K.
Police Interviews Summary
On Wednesday, March 1, prosecutor Nick Johnson KC read to jurors a summary of Letby’s police interviews about the incident, in which she denied any wrongdoing.
Letby told detectives at Cheshire Police she only recalled Child K because she was a “tiny baby” and the Countess of Chester did not usually take babies of her gestation and weight.
She said she had no recollection of the tube slipping and agreed that designated nurse Joanne Williams would not have left Child K unless she was stable and her ET (endotracheal tube) was correctly positioned.
Mr Johnson said: “She stated she would have raised the alarm if Dr Jayaram had not walked in and if she had seen the saturations dropping or that the tube had slipped.
“Miss Letby thought it possible that she was waiting to see if (Child K) self-corrected. She explained that nurses don’t always intervene straightaway if levels were not ‘dangerously low’.”
Following further questions from police, she suggested that maybe the tube had not been secured properly, he said. She denied that had been done deliberately.
Child K was transferred later that day to Wirral’s Arrowe Park Hospital where she died three days later.
The Crown does not allege Letby caused her death.
