In this episode Caroline and Liz explain what the prosecution experts say happened to Baby F, a premature twin boy who Lucy Letby allegedly tried to poison with insulin.
In this episode Caroline and Liz explain what the prosecution experts say happened to Baby F, a premature twin boy who Lucy Letby allegedly tried to poison with insulin.
Transcript of agreed summary of LL's police interviews re. Baby F from podcast -
"LL told the police that she remembered the twins because baby E's death had affected her. She denied deliberately harming baby F or injecting him with insulin, or putting the drug into his feed. Lucy Letby did however ask police whether they had checked baby F's nutrient bag and how they knew the insulin was in it at the time."
The jury is coming into court - less one of their number.
10:41am
The judge, Mr Justice James Goss, tells the jury one of their number has not come to court today as they are ill, so no evidence will be heard today.
Should the juror be well enough to attend tomorrow, there will be evidence heard.
The judge says had there been a full day, Tuesday would likely not have been a day of evidence heard, for other reasons.
Back at Manchester Crown Court for the murder trial of nurse Lucy Letby today. We're expecting to hear more evidence in relation to the collapse of Child G. Ms Letby is accused of attempting to murder the girl three times at the Countess of Chester Hospital in 2015
Defence counsel Ben Myers KC cannot make today's sitting, therefore the court is hearing statements of agreed evidence from various former colleagues of Ms Letby being read by the prosecution
A former colleague of Ms Letby, who cannot be named for legal reasons, said in her statement that she and staff on the neonatal unit had been 'surprised' by how 'very poorly' Child G became in early September as she had previously been 'stable'
Jury are now being shown an instructional video of how a ventilator works
Further instructional videos showing how suction tubes/heart rate monitors work are being shown to the court
Court adjourned till tomorrow. Not many updates today as Ms Letby’s leading defence counsel could not be present. Back tomorrow
Unnamed Nurse, CoCH, Designated nurse for baby G - day shift 7th Sep 2015
On Tuesday, jurors at Manchester Crown Court were read a statement from a nurse who took over Child G’s care at the end of Letby’s night shift. [...]
She went on: “Lucy told me (Child G) had vomited while under the care of (another nurse) and then became unwell. [...]
“She told me she had taken over as designated nurse because (the other nurse) did not have her intensive care course qualification.”
In the early hours of September 8, Child G was moved to Arrowe Park, where she had been born weighing just more than 1lb.
Medics suspected sepsis as Child G required ventilation support with 100 per cent oxygen but gradually she improved and was breathing for herself a week later.
Her markers for infection also fell as doctors ruled she was clinically stable and no longer needed specialist care as she was returned to the Countess of Chester on September 16.
Letby is accused of overfeeding Child G with milk through a nasogastric tube (NGT) and/or injecting air into the tube.
The court heard Child G was conceived via IVF and her mother had a “rocky” pregnancy, including incidents where she bled and feared she might miscarry.
When the mother reached the 23-week stage of her pregnancy, she was admitted to Arrowe Park Hospital in Wirral, Merseyside.
[...]
During the first 13 weeks of her life at Arrowe Park, Child G received regular brain scans that did not show any problems, the jury was told.
Monday December 12th 2022 - Live updates from Chester Standard
Colour Code
Blue text - Lucy Letby's (Defendant's) texts and Facebook searches Green text - Countess of Chester Hospital medical staff
Black text - Police/Intelligence Analysts evidence Orange text - Medical expert witnesses Purple text - Agreed Facts and Parents evidence
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Day 36 of Prosecution Evidence
Baby G
Dr Stephen Breary Consultant, CoCH
9:10am
The trial of Lucy Letby, who denies murdering seven babies at the Countess of Chester Hospital neonatal unit and attempting to murder 10 more, continues today (Monday, December 12).
We will be bringing you updates throughout the day.
9:12am
This is the 10th week of the trial before the jury.
Last week, very little evidence was heard due to juror illness on Monday, Wednesday, Thursday and Friday.
As is the case with all trials, all members of the jury need to be present in court to hear all of the evidence.
10:29am
The judge, Mr Justice James Goss, has entered the courtroom.
The trial will resume shortly.
10:32am
Dr Stephen Brearey is being called to give evidence in the case of Child G.
10:36am
Dr Brearey confirms he has reviewed his clinical notes from the time of the care for Child G, from August-September 2015.
He said by the time of the ward round, Child G was improving, having been at the Countess of Chester Hospital for a week [having been transferred from Arrowe Park Hospital], with main concerns being respiratory support.
He recalls prescribing medication to help with Child G's bowels.
On September 2, on the second ward round, there was a "pattern of improvement" and "everything was moving in the right direction".
10:40am
Dr Brearey's clinical note for 11am at Sunday, September 6, 2015, is presented to the court. He was the consultant for that weekend and carried out a check of Child G as part of a routine ward round.
Child G was 97 days old at this point. she had been born at a gestational term of 23 weeks and six days.
She was receiving feeds, including expressed breast milk, via the naso-gastric tube and bottles.
"Clearly she was making progress with that...and her oxygen requirement was coming down."
The court hears Child G was 'quite stable' at this point.
10:46am
Child G was 'still a little under' her target weight by this stage, at 1.985kg, but this was "normal" for pre-term babies.
Child G was on Gaviscon medication to help with the stomach lining, and other medication to help lower oxygen support requirements.
Child G's gut was "clearly working normal", the chest was 'clear' and the abdomen 'soft'.
Child G was considered to be at high risk of a chronic lung condition, as would be the case with many pre-term babies, and the plan would have been for monthly check-ups and a vaccine to help treat this.
10:51am
Dr Brearey then confirms he was called in, as the on-call consultant, at about 3.30am on September 7.
Dr Alison Ventress had called him in, and was in the process of intubating Child G upon Dr Breary's arrival.
Dr Ventress noted Child G: "Had very large projectile vomit (reaching chair next to cot and canopy). Abdo[men] appeared discoloured purple and distended."
Dr Brearey said he had not witnessed this sort of projectile vomiting before, in a pre-term baby "who has been stable for so long", without a suitable diagnosis of a condition which could cause projectile vomiting.
Child G deteriorated and Dr Ventress intubated the baby girl.
Dr Brearey confirms he was called in from home.
10:54am
He said Child G initially appeared she had stabilised after intubation, with 'normal' gas reading.
He was then called to the pre-term delivery that Dr Ventress had been called away to, for a delivery at 4am.
He said he was satisfied Dr Ventress had the situation under control, and there were satisfactory readings, so was called over to the delivery.
The blood gas reading was, on Dr Ventress's note, 'good', 30 minutes after intubation.
The ventilation status was also 'satisfactory'.
10:59am
At 5.30am, Child G had a profound desaturation.
"Her heart rate dropped to 60[bpm] and her oxygen [saturation] to 40% - which is unusual" when Child G was on a ventilator.
Dr Ventress wondered if the problem was the ventilation equipment, so moved to manual breathing support via a Neopuff device.
Child G was then reattached to a ventilator, before the ventilator was changed.
A 'large leak' remained, which meant the issue was unlikely to be with the ventilator.
The 'large leak', Dr Brearey says, he cannot explain, for a pre-term baby.
He says Dr Ventress was getting chest movement from Child G on the Neopuff device.
"It's perplexing and I can't think of a natural cause why that would happen."
11:05am
Child G had another profound desaturation at 6.05am and the decision was made to reintubate her.
The heart rate increased but the oxygen saturation levels remained low, despite further breathing support, with 100% oxygen ventilation and increased respiratory pressure.
Those levels were "low" in the context of those support measures being applied, Dr Brearey says.
'Thick secretions ++ in mouth' were noted, with a blood clot at the end of the ETT.
The oxygen saturation levels fell to 17%, with the heart rate down to 70bpm, and 'poor chest movement'.
Dr Brearey tells the court a heart rate under 100bpm was cause for concern.
He was called in urgently, the clinical note adds.
The naso-gastric tube was aspirated and 100mls was aspirated from Child G.
"This seemed surprising" as Child G had been fed 45mls every three hours, and Child G "had already had a large vomit which covered the cot and the area around the cot".
"It seems abnormal and I can't explain where that [aspirate] would have come from."
11:11am
The plan was to paralyse Child G, via a medication bolus, to allow for better ventilation, and to repeat a blood gas reading, and continue with morphine for sedation.
Child G was 'nil by mouth' and IV fluids were to be given. Standard medicine to treat neonatal sepsis was also to be administered.
The parents were 'about to be updated'.
Dr Brearey said at the time they were not sure whether there was a problem with Child G's gut, given the large aspirate and large vomit, which was why the baby girl was 'nil by mouth'.
An x-ray taken showed lungs of 'chronic lung disease', which was "known previously" and would not explain what had happened that night.
The abdomen had 'generalised gaseous distention' - "but nothing which would indicate obstruction", and nothing which would indicate NEC, a gastro-intestinal disease.
11:17am
A note from Dr Brearey recorded, for the abdomen x-ray - 'gaseous abdomen, no perforation'.
Dr Brearey's note adds, at 5.30am, 'compensated metabolic acidosis'.
Dr Brearey says this is an 'error on my part', given the pH readings, from a 'long night'.
The note concludes Child G's case 'will need discussion with Arrowe Park Hospital/Liverpool Women's Hospital' if her condition continued as it was.
11:21am
Dr Brearey tells the court Child G had an MRI scan following these events which "looked worse than previous scans". It was "still uncertain" what the long-term prognosis would have been since then, but since then Child G had developed dystonia, quadraplegic cerebral palsy, "as a result of brain damage in early life", which causes the muscles in the body to be stiff and have limited function.
Child G required further feeding support mechanisms, so the food Child G has is less likely to aspirate [into other parts of the body] and be prone to chest infections.
Child G was greatly dependent on the care of her parents. Dr Brearey adds: "I have great respect for everything they [the parents] have done for the last six/seven years."
Cross-Examination
11:23am
Ben Myers KC, for Letby's defence, is now asking Dr Brearey questions.
Dr Brearey confirms he was the neonatal lead at the Countess of Chester Hospital for 2015-2016, and continued to hold that position until 2020.
He said he would spend more time dealing with neonatal issues. Some of it would involve administration and management, but also development.
Mr Myers says at the time of Child G's events, Dr Brearey believed infection was the most likely cause.
Dr Brearey says his initial impression was that it was infection.
11:35am
Mr Myers says one of the problems was with oxygenation, and the ventilator was changed, but that did not resolve the problem with oxygenation. Dr Breary agrees.
Mr Myers refers to the ETT being removed at 6.10am, which was 'the same tube' being used for both ventilators.
When the tube was removed, the blood clot was found, and that could have had an impact on oxygen saturation levels.
Dr Brearey said it would not block it completely. He adds the blood gas results prior to that would not show that to be the case.
"It might have a small degree of influence," but he said it would not have a huge impact, and in his experience he had not come across such an event, given that pressures are involved in the tube.
Mr Myers refers to the aspirates found - he asks if there is any reference to milk/fluid aspirates on the note. Dr Brearey confirms the type of aspirate is not shown.
Mr Myers asks if Dr Brearey knew what the contents of that 100mls was.
"The only other possibility if it is not stomach contents is if it's blood, and I certainly don't recall 100mls of blood."
He said it would not be air, it would be recorded as fluid.
He says the process of aspirating from the NGT, if it's just air, then that would be 'not significant and not recorded'.
Mr Myers refers to Dr Ventress's recollection to court, that the '100mls' aspirated could have been air, although she was not 100 per cent sure, and if it was fluid, she would have recorded that.
Dr Brearey said he wouldn't be 100 per cent, but if it was not air, that would be recorded.
Mr Myers says the 100mls aspiration is not documented on Dr Brearey's note.
Dr Brearey says in retrospect, he was concentrating on Child G's care, and it would have been easier, if knowing what was to come, to have recorded it on his notes.
Prosecution re-direct
The prosecution rise to clarify about the blood clot, saying if that blood clot had blocked the tube, would the equipment have detected that. Dr Brearey said the equipment would have given off an alarm.
Monday December 12th 2022 - Live updates from Chester Standard
Colour Code
Blue text - Lucy Letby's (Defendant's) texts and Facebook searches Green text - Countess of Chester Hospital medical staff
Black text - Police/Intelligence Analysts evidence Orange text - Medical expert witnesses Purple text - Agreed Facts and Parents evidence
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Day 36 of Prosecution Evidence
Baby G
Dr David Harkness, Registrar, CoCH, day shift 7 September 2015
11:41am
Dr David Harkness, who has previously given evidence during the trial, is being recalled to give evidence in the case of Child G.
11:43am
He "vaguely" recalls the care of Child G, mainly from refreshing his memory by looking at clinical notes taken at the time.
He tells the court Child G was "quite stable" with a small amount of oxygen support, and the most amount of support was via feeding, but she was not far off going on to bottle feeds each time.
The feeds were 'greater than normal' to help Child G gain weight, as she was, at 1.985kg, a little underweight, and it was so Child G could go home without requiring naso-gastric tube feeds.
Dr Harkness confirms 'things were going in the right direction, generally', for Child G.
11:47am
For September 7, 2015, Dr Harkness notes the observations at the time of the event.
He said he was on a day shift and was informed of the 'sudden desaturation' during the handover.
He said sepsis 'was the most common' thing to think about whenever a baby has a desaturation, so Child G would have been treated for that.
Chest x-rays were also a common test to carry out.
11:56am
The oxygen levels for Child G were "still dropping every now and then", with the heart dropping also, and she was "not doing particularly well with her breathing, despite being ventilated".
During the daytime observation, the mean blood pressure for Child G was "low", despite being on medication to increase that, which Dr Harkness says was "worrying".
Child G's heart rate was 200bpm, which was high, and the urine output was very low.
The blood test taken for sepsis "was not an exact science"; the readings were "not alarming" but "difficult to take in isolation", the court hears.
12:02pm
Among the 9am plan for Dr Harkness on his notes, was 'discuss with tertiary centre' - as Child G was "so unwell".
A follow-up note from 10am showed Child G's blood pressure had risen to a normal level, a low carbon dioxide level, and the blood gas reading showed a high pH number of 7.646 and a high lactate number.
The plan was to decrease the ventilation support and repeat the blood gas in 30 minutes.
Dr Harkness says Child G was "incredibly sick", had stabilised by 10am, but still "incredibly sick and we were worried about her at that time".
He says the situation had improved but Child G needed a lot of support and was "not out of the woods at that point".
He said the blood test was inconclusive, and could not recall why aspirations was on his list, and there was nothing on his record that could 'conclusively' say it was sepsis or some other diagnosis.
Cross-Examination
12:08pm
Mr Myers, for Letby's defence, asks Dr Harkness if he agrees that a sudden deterioration for Child G is 'not uncommon'.
Dr Harkness says it is "very rare" in a stable, term baby.
Mr Myers refers to Dr Harkness's statement to police in 2018, in which he said for September 7, 2015, at 9am: [Child G] had a deterioration - which is not uncommon'
Dr Harkness says in his years of subsequent experience, he has seen considerably fewer sudden collapses.
At the time of the statement in 2018, he had had seven years experience.
He says as a point of generalisation, it was "not uncommon", but in term babies, it was 'uncommon', now he has had further years of experience and context.
Mr Myers says in Dr Harkness's statement to police, the deterioration 'was no surprise to him' as it was relatively common, as there was a risk of infection in such babies.
Dr Harkness says with further years, he has seen it "less and less", and would no longer hold that view.
He says at the time, he felt it was relatively common, from his time in Chester.
Monday December 12th 2022 - Live updates from Chester Standard
Colour Code
Blue text - Lucy Letby's (Defendant's) texts and Facebook searches Green text - Countess of Chester Hospital medical staff
Black text - Police/Intelligence Analysts evidence Orange text - Medical expert witnesses Purple text - Agreed Facts and Parents evidence
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Day 36 of Prosecution Evidence
Baby G
Senior Nurse Christopher Booth, CoCH, night shift 6th/7th September 2015
12:25pm
The court is resuming after a short break.
Senior nurse Christopher Booth is now being called to give evidence. He was employed at the Countess of Chester Hospital in 2015, and would sometimes be employed as a shift leader in the neonatal unit.
He confirms he recalls Child G was an "extremely premature baby" who was approaching her 100th day milestone.
He said: "We knew her well, we knew her family well."
He says Child G was making good progress and establishing feeds, sometimes via a naso-gastric tube and sometimes by bottle.
Philip Astbury asks if there was anything Mr Booth can recall about the time approaching Child G's 100th day.
He says it is a big milestone for babies on the unit.
He tells the court: "We do make a big thing about it - it's an important event, we make banners for the family, one of the staff members brings in a cake for the family to celebrate."
12:30pm
Mr Booth is shown the shift layout for the September 6-7 night shift, in which he was looking after a baby in one of the neonatal unit rooms that night.
He recalls, from his memory and what he has read from his statement, a call being put out when Child G had a "sudden deterioration", and her "colour was poor", at 3-3.15am.
He said he was not aware of the projectile vomiting incident earlier that night, and that was ascertained later.
He said he was there to help in the resuscitation efforts, having been 'quite peripheral' in the incident.
12:32pm
"A verbal call to seek assistance" was made at 3-3.15am. Mr Booth entered the nursery and saw Child G was being given breaths via a Neopuff device and oxygen support.
He says Lucy Letby was there along with another nurse, and a senior house officer, and an urgent call for the consultant Alison Ventress was put out.
'Rescue breaths' were being given to Child G. Mr Booth says he cannot recall who was administering these. He recalls after 10 minutes, it was "prudent" to move Child G into nursery room 1, which had more suitable equipment and was "more suitable" to treat "sicker babies".
12:34pm
He tells the court he assisted in the transfer of Child G to room 1.
He recalls he was aware of more apnoea episodes for Child G that night, but as he was happy with who was looking after Child G, he 'took a step back' from personal invovlement.
He says Lucy Letby was among the dedicated nursing staff for Child G.
12:37pm
Mr Myers KC, for Letby's defence, says he has no questions to ask of Christopher Booth.
Monday December 12th 2022 - Live updates from Chester Standard
Colour Code
Blue text - Lucy Letby's (Defendant's) texts and Facebook searches Green text - Countess of Chester Hospital medical staff
Black text - Police/Intelligence Analysts evidence Orange text - Medical expert witnesses Purple text - Agreed Facts and Parents evidence
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Day 36 of Prosecution Evidence
Baby G
Dr Dewi Evans, Prosecution Medical Expert, re. 1st alleged attempted murder charge, 7th September 2015
12:43pm
Nicholas Johnson KC, for the prosecution, recalls medical expert Dr Dewi Evans to give evidence, for Child G.
Mr Johnson reminds the jury this part of the case is for the first attempted murder charge on Child G (of three; the other two allegedly taking place on September 21, 2015).
12:47pm
The court hears Dr Evans has written several reports in respect of this case, the most recent being in September 14, 2022.
Mr Johnson refers to a report Dr Evans made in May 2018.
Child G was born at Arrowe Park Hospital on May 31, 2015, and two weeks later was examined via a cranial ultrasound to identify if there was any bleeding on the brain.
Dr Evans says this is carried out routinely, and the absence of any bleeding on the brain was a very encouraging sign.
The court hears Child G had been born "exceptionally early".
Dr Evans said in his report that gestational age of 23 weeks and six days was "at the limits of viability".
12:50pm
Dr Evans explains the type of IV access that was given to very premature babies such as Child G.
A follow-up ultrasound on June 30 showed no bleeding on the brain for child G, and was "very satisfactory", Dr Evans explains.
Child G was transferred to the Countess of Chester Hospital in August 2015. At the time of her discharge, Dr Evans said she was "stable", with known chronic lung disease which required oxygen breathing support, and CPAP.
Dr Evans: "It was the standard management of babies when they have chronic lung disease."
12:52pm
For the first couple of weeks at the Countess, Child G required 28-31% oxygen.
A follow-up ultrasound showed "nothing concerning", and Child G had normal observations, requiring medicines which were common for premature babies, such as Gaviscon and supplemental sodium and iron.
"All was well and her oxygen saturation was 95% which was very satisfactory".
12:58pm
Dr Evans says Child G's observations were "very satisfactory" at the Countess of Chester Hospital in early September 2015.
Child G's condition was getting "even better" with oxygen breathing support being weaned off.
1:02pm
The observation for the shift of September 6-7 is shown to the court.
The respiration rate is 'normal', with readings normally marked, in the three-hourly observations up to 2am. He says he is not sure why the individual readings have a cross and circle marked for the hourly observations afterwards, but suspects that is because Child G was on ventilation support.
The oxygen saturation readings are "very stable" up to 2am, with the baby girl's readings "as stable" as they were in previous days.
A mixture of medications is recorded on the intensive care chart for 4am onwards.
2:12pm
Dr Evans agrees that Child G was in a satisfactory condition, prior to the events of September 7, 2015.
Dr Alison Ventress's notes from the early hours of September 7 are shown to the court, describing Child G's projectile vomit at 2.35am, purple and distended abdomen, and increased oxygen requirement. 'Red in face and purple all over'.
Dr Ventress noted Child G had 'gone apnoeic and dusky', and upon additional breathing support, the oxygen saturation levels went up and the baby girl was taken to nursery room 1.
2:18pm
A photo is shown to the court with black circles indicating where Child G's projectile vomit patches went. One patch is in the cot, another patch is on the floor, and another is on the seat of an adjacent chair.
Mr Johnson continues to talk through the sequence of events, which Dr Evans confirms he has noted throughout his report.
2:19pm
Dr Evans said in his report, for the 100mls aspirate taken from Child G, "It is not clear how much of the 100mls was milk, and how much was air".
2:25pm
Mr Johnson asks about what happens if a baby's stomach is full.
Dr Evans says if you give milk gravitationally, no more milk will go in, as the stomach is full.
He says the baby is unlikely to absorb the final few millilitres of milk if the stomach capacity is, for example, 45ml, and the milk portion is 55ml. While the stomach could expand a little, the likelihood is the milk would drip out.
Dr Evans describes there is a way of "forcing" more milk into the stomach via a syringe, which "you would never do" as it would forcibly distend the stomach.
2:30pm
Dr Evans says he was looking for signs of an infection in the records, as it is one of the most common findings on a neonatal unit, so one is "always alert" to that possibility.
From Child G's blood test at 3.59am on September 7, the findings were all considered "normal" and did not point to a sign of infection, the court hears.
A subsequent blood gas reading, 10-12 hours later which contains 'CRP: 28' is "not particularly high" but is a sign of infection.
The subsequent blood gas reading after that was indicative of infection, Dr Evans tells the court.
2:32pm
Dr Evans says Child G, at birth, was "on the margins of survival", but it was the "skill of staff" at Arrowe Park which ensured her stabilisation.
He says there were no signs Child G was unwell prior to her collapse on September 7. He says the only two considerations were the chronic lung condition, which was common and for which she was receiving treatment, and establishing feeds.
"Considering her start in life, this was an extremely satisfactory state".
2:34pm
Child G's weight of 1.985kg was a little low, but she was tolerating bottle feeds every other feed (with naso-gastric tube feeding on the other occasions).
Dr Evans says Child G would likely have still required supplemental oxygen support once she went home.
2:40pm
The photo showing where the projectile vomiting patches landed is shown to the court.
Dr Evans says there are three black circles. The one in the cot indicates the baby was sick, which "would be worthy of note, but not unusual".
The second one between the chair and cot, on the floor.
"For a baby of 2kg to vomit that far is quite remarkable".
Dr Evans says there is a condition which can cause projectile vomiting of that length, as had been mentioned earlier today by one of the doctors, but Child G showed no signs of having that condition.
Dr Evans adds: "Even more astonishing is the vomit that ends up on the chair. That is several feet away.
"I can't recall a baby vomiting on the floor. I can't recall a baby vomiting that distance. It was described quite correctly as extraordinary.
"On top of that it was noted the abdomen was distended."Dr Evans said you cannot measure the volume of the vomit that had fallen.
2:43pm
Lucy Letby's note for Child G - 'large projectile milky vomit at 2.15am. Continued to vomit++. 45mls milk obtained from NG tube with air++. Abdomen noted to be distended and discoloured.'
Dr Evans said the 45mls aspirated was in addition to the vomit. 45mls of milk was administered by the feed.
"There can only be one explanation - [Child G] had received far more milk down the NG Tube.
"She may have also received a bolus of air from the feeding tube."
Dr Evans says that would also cause the abdominal distention.
He says the plunger end of the syringe was put over the end of the tube for the milk, which would have caused distention, then would have caused the baby distress, then "she would have vomited because of the gross distention".
2:46pm
The condition which can cause projectile vomiting can be excluded, the court hears, as the vomiting would have continued until the baby would have been taken into theatre for surgery.
Dr Evans says the muscles only 'go one way', and the only time this does not work is if the baby is compromised by something.
"In this case the baby was compromised by receiving a large volume of milk to the stomach".
In that instance, the stomach muscles contracted and that led to the vomit. He says the mechanism is similar to that seen in adults.
He says if an adult drank a large volume of liquid too quickly, there is a chance they could vomit.
2:51pm
Dr Evans says Child G's condition thereafter was "incredibly unstable", with "significant amount of oxygen deprivation" and bradycardia.
"Getting [Child G] back to where she was before 2am was extremely challenging and difficult.
"They managed to do so...but during that time she suffered prolonged oxygen deprivation...leading to irreversible brain damage."
The doctor's note of 'blood at the back of the throat' is referred to.
He said the bleeding was found at the initial resuscitation/intubation, and the significance of that was the baby did not have a bleeding disorder, so "therefore the bleeding present from the beginning from more or less the time [Child G] crashed."
2:51pm
Dr Evans says this case has been seen before, "much worse", in Child E.
The bleeding in this case was less, but still significant as it was "unexpected".
2:53pm
Dr Evans stresses Child G's infection happened "after the collapse".
2:55pm
Dr Evans says Child G's infection was 'CRP related', as those particular blood gas readings went from 'less than 1' to 'over 200' in the hours following her collapse.
2:59pm
Dr Evans's report from 2021 is now being discussed. He was asked to consider whether an infection was the cause of the projectile vomiting.
"With respect no, I consider the infection happened afterwards.
"An infection would not cause a baby to vomit halfway across the nursery room."
He also asks: "Where would the extra fluid come from?"
He says Child G must have had "far more" than the allocated 45mls milk feed fed to her.
3:02pm
Dr Evans is asked about Lucy Letby's explanation that babies can swallow a lot of air when they vomit.
"Well, they don't." Dr Evans replies.
He says excess air was administered to Child G, in addition to the milk.
He adds a baby with an infection has never presented in this way.
He also says a baby on a naso-gastric feed would not vomit. The NGT system would be set up, Dr Evans says, so the undigested milk would be aspirated prior to another feed. If there is a lot of undigested milk, then caution would be taken before administering another feed.
The pH would be measured before each feed to ensure the tip of the NGT is in the stomach, and not another orifice.
3:03pm
On this occasion, a pH reading of four would indicate the presence of stomach acid, indicating the NGT was in the correct place, Dr Evans says.
3:05pm
Dr Evans is asked to read out his further report, in which he says administering excess milk and/or air cannot be done "accidentally".
The effect of the stomach being overfull, the diaphragm "cannot move up or down", meaning "the baby cannot receive air in its lungs", which leads to oxygen deprivation, loss of oxygen saturation, bradycardia, and collapse.
Monday December 12th 2022 - Live updates from Chester Standard
Colour Code
Blue text - Lucy Letby's (Defendant's) texts and Facebook searches Green text - Countess of Chester Hospital medical staff
Black text - Police/Intelligence Analysts evidence Orange text - Medical expert witnesses Purple text - Agreed Facts and Parents evidence
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Day 36 of Prosecution Evidence
Baby G
Dr Dewi Evans, Prosecution Medical Expert, re. 1st alleged attempted murder charge, 7th September 2015
Cross-Examination
3:08pm
Ben Myers KC, for Letby's defence, is now asking Dr Evans questions.
He says Child G was 'born on the margins of survival', and Dr Evans agrees that is the case, having said so in his May 2018 report.
Mr Myers says a lot of work was needed to get Child G stable. Dr Evans agrees.
He says that, relative to where she began, she was a lot better.
Mr Myers asks if she was still prone to infection. Dr Evans agrees.
3:12pm
Mr Myers refers to Dr Evans, in his report, referring to Child G being treated "inappropriately" at 2am on September 7, 2015.
Mr Myers says that is worked on the basis that Child G's tummy would have been empty or almost empty at the time, as the nurse responsible would have aspirated Child G's stomach of all milk.
Mr Myers says 'we now know' the stomach was not aspirated prior to 2am.
Dr Evans says that was not the case, as the nurse had aspirated to get a pH reading.
Mr Myers says the nurse had not aspirated the milk, as she would not have done so in a baby as young as Child G as a matter of procedure.
Dr Evans: "No, this is too simple." He says milk is a neutral pH, so if the reading is '4', then that sample was indicative of acid in the stomach.
3:13pm
Dr Evans says after the projectile vomiting, over three areas of a nursery, there was an aspiration of 45mls of milk.
"There has to have been a significant amount of additional milk plus air to explain what happened to the little baby at two o'clock in the morning."
3:16pm
Mr Myers refers to the report, saying a nurse empties the stomach contents through aspirates.
Dr Evans: "The pH was 4 [in the stomach], 4 is acid."
Mr Myers says Dr Evans is basing what he says upon having her stomach aspirated before the 2am feed.
Dr Evans says there would have been no milk in Child G's stomach prior to the 2am feed, as the stomach was checked for pH.
3:22pm
Dr Evans says he is "totally satisfied" with his opinion that Child G's stomach was empty prior to the 2am feed.
The amount of vomit plus aspirate was "massive" and only had one explanation - "she had a huge amount of milk plus air".
Mr Myers asks if Dr Evans is basing his opinion on Child G's stomach being emptied of milk just before the 2am feed. Dr Evans says he is.
He says the nurse said she would not normally aspirate all the milk from a stomach [as in completely remove all trace].
Mr Myers says, in the six reports, there is no mention of the plunger to the syringe as a method to force more milk in.
Dr Evans agrees it is not in his reports, but he is telling him now.
3:30pm
Mr Myers says 100ml of aspirate was withdrawn at 6.15am, but the quantities of liquid/air were not known. Mr Myers says Dr Alison Ventress said it was "probably air". Dr Evans agrees he heard that evidence.
The clinical note for Child G on September 7, by Dr Ventress, is shown to the court.
Mr Myers relays Dr Evans's note relating to excess fluid inhibiting diaphragm movement.
Mr Myers: "In fact we know that the later collapse and desaturations came after [Child G] vomited [on the morning of September 7]."
He says "that is distinct" as Child G had "settled" by that point.
Dr Evans: "That is not correct, actually - she was in a very unstable condition."
Dr Evans says there is 'hardly' an entry where Child G is stable for any significant period of time that morning.
He says from the time of the vomiting, Child G "never fully stabilised".
He says the medical staff would not have anticipated the oxygen deprivation being "very marked" and for a "more prolonged time than they would have realised", and that was no fault of the staff.
He says Child G's condition was "an improvement" but she was "unstable", and had been "compromised from the point of vomiting".
3:32pm
Dr Evans says it is difficult for medical staff to "provide a running commentary" when trying to save a little baby's life.
The removal of vomit and 45ml aspirate had "got rid of the pressure" and would have led her to be "relatively better" - "and I use the words advisedly".
He tells the court he is "very satisfied" with the explanation he has given.
3:35pm
Mr Myers says the bleeding seen is "not even close" to the case seen with Child E.
Dr Evans says it is in the same area.
Mr Myers says to link it to Child E is to support the prosecution.
Dr Evans says that is not the case, and if he did not have access to the other cases, he would have come to the same conclusion.
He adds that Child G was, chronologically, was the first case he examined.
Mr Myers says there is no evidence of trauma.
Dr Evans says he does not know the cause, but seeing such bleeding was "incredibly concerning" and "worrying".
3:36pm
Mr Myers asks if it was possible Child G had a small haemorrhage.
Dr Evans says there would have been no reason for it. "No is the answer to that".
He says the back of the throat is a small area, and the blood was noticed around there.
3:41pm
Mr Myers says babies may vomit for many reasons. Dr Evans agrees.
Mr Myers asks is 'forceful vomiting' can happen. Dr Evans says he is not familiar with the term in that context.
Mr Myers says Dr Evans does not agree with Dr Ventress's evidence on projectile vomiting. Dr Evans says he only disagreed with infection being the cause of the projectile vomiting.
Mr Myers asks if Child G projectile vomited with such force because she was unwell. Dr Evans disagrees, and asks where the extra fluid would have come from.
Mr Myers: "We don't know [the quantity of vomit as it was not measured]."
"No, but it's a lot of vomit."
"We don't know how much, do we?"
"It was...an awful lot of vomit."
3:42pm
Gastro-oesophageal reflux can cause projectile vomiting, Mr Myers asks.
Dr Evans says it can, but that was not mentioned as a diagnosis in the Arrowe Park Hospital discharge letter.
It would not have caused the type of vomiting seen, Dr Evans tells the court.
3:50pm
Mr Myers refers to the CRP readings for Child G, which had risen throughout September 7, and was "consistent with infection". Dr Evans agrees.
Mr Myers says that could have been consistent with infection developing before the vomiting.
"No, it cannot."
Dr Evans says the CRP reading is raised at the time the infection presents.
He says the majority of babies, a CRP reading is raised at the time of the infection being present.
In this case, there were no other markers of infection prior to the vomiting.
Mr Myers says there was a "large watery stool", to which Dr Evans says was not unusual.
Mr Myers says there is no finding of aspiration pneumonia when Child G was taken back to Arrowe Park. Dr Evans says she does not believe she had that, but believes she had an infection which "probably kicked in" during the attempts to resuscitate her.
Mr Myers says that does not rule out an infection being present prior to the vomiting.
Dr Evans: "There is no clinical evidence to back up that hypothesis."
He adds: "I don't deal with 'ifs', I deal with evidence."
He says the charts show everything as they should be up to the point of the vomiting and desaturations.
Prosecution re-direct
3:54pm
Mr Johnson asks Dr Evans about the 'adding of a suggestion of a plunger being used' in the evidence, in the context of milk feeds.
Dr Evans had referred to the forcible additional milk feed method, without the additional context of a plunger, in his May 2018 report. Dr Evans says the method can only be applied with the use of a plunger.
Mr Johnson asks about the pH aspirate the nurse would have obtained, if the previous milk feed had not been digested/aspirated.
Dr Evans said the aspirate would have looked like undigested milk and the pH reading would have been neutral - around 7.
3:57pm
The feeding chart for September 5 is shown to the court, which Dr Evans says shows no vomiting, and no evidence of gastro-oesophageal reflux.
He says gastro-oesophageal reflux does not happen out of nowhere.
Dr Evans adds Child G was having normal bowel movements as well.
3:58pm
Dr Evans says, for the feeding charts and observations prior to the vomiting, "this is as good as it gets", with "no red flags", and is "very satisfactory".
Monday December 12th 2022 - Live updates from Chester Standard
Colour Code
Blue text - Lucy Letby's (Defendant's) texts and Facebook searches Green text - Countess of Chester Hospital medical staff
Black text - Police/Intelligence Analysts evidence Orange text - Medical expert witnesses Purple text - Agreed Facts and Parents evidence
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Day 36 of Prosecution Evidence
Baby G
Dr Sandie Bohin, Prosecution Medical Expert, re. 1st alleged attempted murder charge, 7th September 2015
4:00pm
Medical expert Dr Sandie Bohin is now being recalled to give evidence.
4:05pm
Mr Johnson takes Dr Bohin through her reports, in which she said there was "no cause for concern" in Child G's condition at the Countess of Chester Hospital prior to September 7, 2015.
4:08pm
Dr Bohin confirms Child G was given a 45ml milk feed via the naso-gastric tube at 2am on September 7, 2015.
Mr Johnson refers to the subsequent sequence of events, and that Dr Bohin had recorded what had happened from the medical staff's notes and medical charts.
4:11pm
Dr Bohin said Child G was, prior to the collapse, "very stable", with decreasing oxygen support required, and she was "managing very well" on that.
"From a respiratory point of view, all was well".
Child G was tolerating three-hourly feeds, and she was "progressing very well" for a pre-term baby.
The observation chart prior to the 2am feed on September 7 was "completely normal".
4:15pm
The episode of 'projectile vomiting' was 'concerning' as Dr Bohin said she had not seen babies, particularly those weighing 2kg, doing that.
She found that "extraordinary".
Dr Bohin said the milk must have come from somewhere, and the vomit has to go over the side of a deep-sided cot, on to the floor and the nearby chair "a considerable force has to be generated inside the abdomen".
She says there must have been "much more than 45mls of milk inside the stomach."
Mr Johnson asks if there is an 'innocent explanation' which could have explained the projectile vomiting.
Dr Bohin says "no", as the stomach was empty, with a pH reading of 4. If there was milk in the stomach, it would have 'neutralised' the stomach and the pH reading would have been higher.
"I think the stomach was empty, and she was given excess milk and possibly air...which distended the stomach."
4:18pm
Dr Bohin is asked by police about Lucy Letby saying babies can 'take on a lot of air when vomiting'.
Dr Bohin was asked if that was correct or not.
Dr Bohin tells the court: "That's not correct. Babies do not take on air when they vomit."
Dr Evans says it is 'astonishing' that a baby, that weighs 2kg, could vomit that far. 'It's quite extraordinary, something very, very unusual is going on here', he said
Dr Evans told the court that there can only be one explanation for this 'Child G had received far more milk down the NG Tube'
He added: 'An infection would not cause a baby to vomit halfway across the nursery room. Where would the extra fluid come from?' He says Child G must have had 'far more' than the allocated 45mls milk fed to her
Like Dr Evans, Dr Bohin says a baby of 2kg projectile vomiting was 'extraordinary'. She said for the vomit to move that distance there must have been a 'considerable force generated in the abdomen'...she says there is no innocent explanation for this
The Trial of Lucy Letby, Episode 9: Baby G, Part 1: “Just a little tiny thing” given just a 5% chance of survival at birth. But ‘she was a fighter.’
In this episode Caroline and Liz examine what happened to Baby G, the most premature baby in this case, who Lucy Letby allegedly tried to kill three times in a fortnight.
Blue text - Lucy Letby's (Defendant's) texts and Facebook searches Green text - Countess of Chester Hospital medical staff
Black text - Police/Intelligence Analysts evidence Orange text - Medical expert witnesses Purple text - Agreed Facts and Parents evidence
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Day 37 of Prosecution Evidence
Baby G
Dr Sandie Bohin, Prosecution Medical Expert, re. 1st attempted murder charge, 7th September 2015
At Manchester Crown Court again today for the trial of nurse Lucy Letby. Jurors will continue to hear evidence about the collapse(s) of Child G - who the Crown say Ms Letby tried to murder on three occasions in 2015
Medical expert Dr Sandie Bohin is continuing to give evidence today. She tells the court that it was 'extraordinary' for a baby the size of Child G - she was 2kg - to vomit as far as she did.. Reminder of yesterday's evidence Lucy Letby: No natural cause for baby's vomiting, doctor tells trial
She said: 'She would have had to have exerted a huge amount of force to vomit over the side of the cot and onto the floor and chair…that's surprising given she was only 2kg'
Dr Bohin is taking the court back through Child G's medical notes and spelling out the infant's early feeding history and how that developed. The notes show that through summer 2015 she was gradually improving
Dr Bohin makes the point that medics were considering giving Child G immunisations around the time of her collapse. She said the baby 'must have been well and stable' as medics 'wouldn’t consider giving immunisations unless a baby is absolutely stable'
On the incident of 7 September, Dr Bohin tells the court that Child G 'must at some point have been given an excessive amount of milk to projectile vomit and have a residual 45ml in stomach'
Cross-Examination
Ben Myers KC, defending, is now questioning Dr Bohin. He is taking the court back over Child G's medical notes from June 2015. Dr Bohin agrees at this time the premature girl was as 'sick as you could possibly be'
Mr Myers is looking notes that she had a discoloured abdomen. Dr Bohin says that at this stage the girl would have weighed just 500g and there would be no subcutaneous fat - so could see blood vessels (hence discolouration normal)
We're continuing to view notes on Child G from the first few weeks after her birth. They show she was on steroids (as she was having trouble with ventilation). Bleeding noticed at one point was put down to a 'probable pulmonary haemorrhage'
Dr Bohin notes that Child G had a low platelet count, which could explain the bleeding. She says 'certainly in a baby this fragile' a pulmonary haemorrhage could be lethal - states if it was indeed such a haemorrhage it was 'very mild'
Mr Myers is taking the court through a note from the end of July 2105 which showed a 'significant' desaturation before Child G was due to travel from Arrowe Park to the Countess of Chester.
Dr Bohin agrees that the infant was not well at this stage, 'she was still very young, still very vulnerable and prone to all sorts of complications due to her prematurity'
Mr Myers is making the point that, as an expert witness, Dr Bohin is allowed to hear all the evidence as it is presented to the court. She rejects suggestion that her conclusions have 'come from a dialogue with Dr Evans' (the other medical expert in this case)
Stuart Eccles, Medical Engineer, CoCH - Ventilator
Court has just been read a statement from Countess of Chester medical engineer Stuart Eccles. This was on the ventilation equipment at the hospital. Yesterday we heard doctors believed there could have been a problem with a machine as Child G was struggling to breath
Service records show that there was no such issues reported on 7 September 2015. He said the machines on the unit were 'very reliable'
Blue text - Lucy Letby's (Defendant's) texts and Facebook searches Green text - Countess of Chester Hospital medical staff
Black text - Police/Intelligence Analysts evidence Orange text - Medical expert witnesses Purple text - Agreed Facts and Parents evidence
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Day 37 of Prosecution Evidence
Baby G
Kate Tyndall Police Intelligence Analyst,
re. 2nd attempted murder charge, 21st September 2015
Police intelligence analyst Kate Tyndall is now back in the witness box. She is taking the court through sequencing evidence.
After Child G fell ill, she was transferred to Arrowe Park Hospital where she recovered over a number of days. On 16 September she was transferred back to the Countess of Chester. On 21 September, the Crown say there was second incident involving Ms Letby
Nursing notes recorded by Ms Letby show that at around 10:20 on 21 September Child G had two projectile vomits and went apnoeic for a short period. She suffered brief self-resolving colour loss and her blood saturations fell to 30%
Court being shown text messages between Ms Letby and a former colleague on the evening of 21 September. Ms Letby said Child G 'looked rubbish when I took over this morning then she vomited at 9 and I got her screened...mum said she hasn’t been herself for a couple of days'
Blue text - Lucy Letby's (Defendant's) texts and Facebook searches Green text - Countess of Chester Hospital medical staff
Black text - Police/Intelligence Analysts evidence Orange text - Medical expert witnesses Purple text - Agreed Facts and Parents evidence
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Day 37 of Prosecution Evidence
Baby G
Unnamed Nurse, CoCH, day shift 21st September 2015
A former nursing colleague of Ms Letby, who cannot be named for legal reasons, is now in the witness box. She is recalling the events of 21 September
Court told that Child G was cannulated, behind a screen, and placed on a Masimo monitor - a portable device attached to the patient by a sensor that continually measures oxygen saturations and heart rate levels.
After the doctors had gone, but Child G was still screened, the nurse told the court that she heard Ms Letby shouting for help. She said she responded, Ms Letby was using neopuff on the infant - who 'did not look very well at all'
She noticed that the monitor screen was black and had been switched off.
The nurse said this was not normal procedure (for the monitor to be off)
The nurse however has told the court that she asked to review her original statement to police last month - as she said she had seen in the prosecution opening that there was a suggestion Ms Letby had turned the monitor off - she said 'I knew that not to be the case'
She tells the court that on 21 September two doctors came her to apologise, as they had left the screen in situ and not switched the monitor back on
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