Child E Timeline - Part 3 (from 11.40pm 3rd August 2015 to end of night shift 4th August 2015 - links at end)
Nursing notes and Clinical notes - purple text
Key events - red text
11.40pm –
Baby E’s 1st collapse (of 3) - with purple-blue blotching over abdomen.
11.40pm - LL retrospective nursing notes: "
11.40pm became Bradycardiac, purple band of discolouration over abdomen, perfusion poor, CRT 3secs. "Emergency intubation successful and placed on ventilator." LL’s further notes at 4.51am: 'Required 100% oxygen, saturations 80%, SIMV 22/5 rate 60. Further saline bolus and morphine bolus given. 2nd peripheral line sited. Once [E] began to deteriorate, midwifery staff were contacted." (electronic evidence). Although LL was participating in the resuscitation, she co-signed for medication given to a baby in room 4. (opening speech)
11.40pm - Dr H’s clinical notes, written retrospectively: '
Sudden deterioration at 11.40pm, brady 80-90bpm, sats 60%, poor perfusion, colour change over abdomen purple discoloured patches'. The note adds, after an improvement in sats, 'purple discolouration in abdomen remained', and a plan of action noted for E. (electronic evidence)
11.40pm - Dr H testifies that
prior to 11.40pm, E was still to be 'under close observation' by LL. Dr H testifies he was in the room when the 'sudden deterioration' happened, and was there with LL and another nurse. Those nurses “would have been gathering the drugs to be administered”. Dr H testified: "This was a strange pattern over the tummy and abdomen, which didn't fit with the poor perfusion - the rest was still pink, but there were these strange purple patches." “Some of the patches were still pink, but others were purple-blue, and were unusual. Dr H likens the purple-blue colour to “what you would see after going for a swim in cold water and coming out, with 'purple-blue' colour on the lips.” “The rest of the skin was 'normal colour'. The abdomen had 'purple patches', which didn't fit with an anatomical part of the body, it is difficult to describe in any detail, without a photo.” Dr H testified he has seen this in Child A before and had not seen it on any other baby, outside of the babies in the case. “The patches were 'different sizes' and in the region of 1-2cm big - 'not dots'. The areas were 'on the abdomen - not above the chest or below the groin - in the middle section'. The patches 'did not fit with the perfusion' seen. If the abdomen was dusky or white, then the whole of the body would gradually take that colour too. In the case of an affected blood supply, the blood would be lost from the legs first and the body would pull the blood 'into the middle of the body'”. X-exam - A nursing colleague had referred to 'discoloured abdomen' in a retrospectively written note at 1.30am. Defence says Dr H had referred to the discolouration being 'strange' and 'unusual', and 'appearing and disappearing' - that does not appear in the medical note. Dr H says that observation had "stayed with him" and the clinical note he made at the time was not 'forensic'. Defence reads out part of Dr H's police statement, referring to the discolouration being on the abdomen. Dr H says he does not recall the part of the statement of the discolourations' 'path to the body', and said he would not agree with the wording of that. Dr H testified he has not been in discussions with anyone in relation to these observations. Defence says by October 2018 (the time of his police statement), there had been discussions in the hospital about the skin discolourations. Dr H testified there were discussions to say it was unusual, but refutes any of the details of the discolourations had been discussed. Defence says Dr H is 'putting details together' from various observations. Dr H: "No." Defence says
Child A's skin discolouration, as referred to by Dr H in court earlier in the trial, were not mentioned in the clinical note at the time, or the note to the coroner [for Child A]. Defence says 'red patches' found on Child A were not mentioned for Child E. Dr H testified the overall discolouration observations were 'similar enough'. Prosecution re-direct - Dr H's interview with police Sept 2018 is relayed to the court. Dr H is asked about the skin discolouration, and says it is 'similar [between Child A and Child E]' and is not a rash. The interview transcript says E's discolouration was 'around the abdomen and chest', with 'purple patches' that 'suddenly come on'. "It came so quickly - not affected by the monitors or anything". "It was just these purple and pale patches". He was asked in the police interview if that was symptomatic of other cases, and Dr H said it was not.
11.40pm - Dr Wood SHO working in the paediatric unit immediately attended upon a crash call for E. He doesn’t recall being in the neonatal unit that night before 11.40pm. He signed a prescription for morphine for E. The accompanying medical note by Dr W says:
Sats 60-70%, morphine bolus – sats improved to 80%. He says resuscitation had already begun upon his arrival. He recorded notes. He recorded staff present – a team of 6 – including himself, Dr H, another doctor, and three senior nurses including LL.
11.45am – E was intubated as an emergency and put on a ventilator. Morphine administered – purple discolouration remained – bleeding settled
Dr H’s testimony - Dr H's notes record '
intubated as an emergency at 11.45pm'. He says although there were risks associated with this, the 'safer option' for E was to do things as an emergency.
An ET tube was inserted, with 'good air and chest movement' recorded, and the tube was recorded to be in the correct place. E was also 'put on ventilator', with 100% oxygen. The saturation readings were '60-70%', and after a morphine bolus was administered, those improved to 80%. The 'purple discolouration of abdomen remained', it is noted. E's blood pressure had dropped but was still in the normal range.
The plan was to administer further medication, but there was a concern that administering a drug to make the heart beat faster would lead to 'worse bleeding'. Dr H says 'from his recollection' the blood had settled and there was no further substantial amount of blood recorded. The court hears the preparations are made for the intubation during that half hour (prior). Dr H disagrees with the defence that it was a "delay" and was using his time "appropriately". "You make more mistakes when you are not taking your time." Defence says the blood transfusion is mentioned for the first time at a later note, after 11.40pm. Dr H says it would not have been appropriate to give more saline boluses without administrating fresh blood. He disagrees a blood transfusion was not considered earlier. He says his documentation is not as thorough as it would be now, and agrees in hindsight, it should have been documented more clearly. Defence says the intubation should have happened earlier. Dr H says there are benefits to an elective intubation compared to an emergency intubation, as the latter could cause stress and complications to the baby. He said that 'now' this would still have been the course to take in that situation.
Consultant’s testimony – she disagrees they were too slow to intubate E.
12 midnight - Mother (and father) with midwife returned to the neonatal unit and sat in the corridor while E was being worked on by medics. Midwife left after 10 minutes and mum was eventually allowed in once E had been stabilised.
4 Aug 2015, Tuesday
12.15am – LL’s notes:
heart rate 'down from where it had been earlier', and a drop in temperature, recording he was on 100% oxygen. (electronic evidence)
12.25am - Consultant paediatrician arrived at the neonatal unit. (electronic evidence) When she got there
E’s blood oxygen level was 80% in 100% oxygen. “they’ve improved since ventilation but they’re still not as good as we would like them to be”. (consultant’s testimony)
12.27am –
Chest and abdomen x-rayed - An x-ray is taken at 12.27am, relating to the chest and abdomen. (electronic evidence)
Consultant’s testimony –
x-ray showed E’s heart size was normal and his lungs were clear. “there’s no indication from the x-ray why E’s saturation was low” she says.
Dr H’ testimony – Defence asks why a consultation with surgeons was required following x-rays; Dr H says advice would have been taken from them once the extra results would have been acquired from the x-rays. Defence says he could have been dealing with a 'very serious situation indeed'; Dr H: "Potentially." Dr H says things were "changing" but E was still "stable". Defence: "Are you suggesting that a baby who has lost a quarter of its blood is not an emergency situation?"; Dr H: "What I'm suggesting is there are things to do and there is time to do it." Defence says transfusion was not being considered at this point, and one of the 'obvious things' to consider - "It is something you had failed to consider, isn't it?"; Dr H says it was likely considered, but accepts it was not documented at the 11pm note. Defence suggests it was a "serious mistake" not to consider blood transfusion; Dr H: "I disagree." Defence: "I would suggest you were out of your depth at this point"; Dr H: "I disagree, that is wrong and disrespectful to my ability." Defence says blood transfusion is not considered; Dr H: "we do have a plan, and we do have a discussion with a consultant."
Shortly after 12.30am – LL’s notes:
Shortly after 12.30am Child E was placed on breathing support and given medication after resuscitation. (electronic evidence)
12.36am –
Baby E’s 2nd collapse (of 3).
LL’s note: '
Resus commenced as documented'. (electronic evidence)
The consultant noted:
CPR commenced, along with ventilations, and medications. (electronic evidence)
Consultant’s testimony – her notes say E’s:
blood oxygen had fallen to 50-60% in 100% oxygen and he had no detectable heart rate. CPR was started. She was the team leader for the resuscitation efforts – she wouldn’t get involved in the physical tasks because “you lose awareness of the overall situation”. She says they did discuss blood transfusion but it’s not in the notes made. She agrees she should have gone to the unit sooner but doesn’t think she would have made any different decisions (from the doctors who were there).
Dr H testimony - Dr H said he and a colleague were stood at the end of the incubator, discussing what medication and plans were being put in place for E, when E collapsed. Dr H recalls the
resuscitation efforts began. Defence refers to E's collapse 'in front of the medical staff'. He says by this point, "there had still been no transfusion"; Dr H said there was no further evidence of bleeding after the second bleed. Defence: "The reaction to the second haemorrhage was far too slow wasn't it?"; Dr H disagrees.
12.37am – SHO Dr Wood recorded
efforts to resuscitate E from 12.37am. 5 doses of adrenaline were administered.
12.50am -
A blood transfusion is started for E at 12.50am, and several adrenaline doses are administered. (electronic evidence)
Dr H’s testimony - Defence says a blood transfusion, for O-negative blood, is noted at 12.50am on the medical notes. Dr H says the O-negative blood [a type which can be suitable for all blood transfusions] would be used in this instance as seeking a specifically matched blood type at this stage would take too long in acquiring it from the donor fridge.
Consultant testimony - says she does not think a late blood transfusion led to E’s collapse and death.
1.01am - LL's nursing note, for 1.01am, reads: '
chest compressions no longer required'. (electronic evidence)
The SHO recorded:
chest compressions stop at 1.01am, with ventilations continuing.
Dr H’s testimony:
[E]'s heart rate recovered at 1.01am, and the parents had arrived by that time.
1.15am –
Baby E’s 3rd and final (fatal) collapse –
LL notes: '
further decline, resus recommenced'. (electronic evidence)
SHO Dr W recorded:
E’s heart rate fell again and CPR recommenced.
Dr H’s testimony - He tells the court the blood supply was 'very poor'. He says during CPR, blood was coming out of Child E's nose and mouth, suggesting the blood pressure was low. He says the sight was "not very nice, particularly". Dr H is asked about the bleeding seen on E. He says: "I have never seen it in a baby, to this extent." He says he had seen the level of blood in a teenager, but not, relatively, in a baby as small as E. Defence says, in 'distressing detail' relayed by Dr H earlier in court, it had been discussed about blood coming from E's mouth and nose during CPR. Dr H said blood would 'keep coming out' until the cause of it is found. Defence says the cause of death would be 'acute blood loss'; Dr H said that cannot be known without a post-mortem examination. He says the blood loss could be a factor, but it is not 'black and white'. He said it was 'not his place' to call for a post-mortem examination. Defence says the blood loss seen would normally be 'fatal'; Dr H said it could be 'linked'. Defence asks if the actions taken were 'far too slow'; Dr H: "No." "Would you have admitted it if it was?"; "Yes."
Time? - Dr H’s testimony –
A pathology report for [E] is shown, with 'PT and APTT' readings. Those are two tests for blood clotting measurements. They were 'high, but not enough to be shocked by'. The readings were 19.5 and 53.6, compared to the normal ranges of '12.5-15' and '26-35' respectively.
1.23am - CPR was discontinued at 1.23am –
LL notes: '
resus discontinued when [E] was given to parents. [E] was actively bleeding.' (electronic evidence)
SHO Dr W notes:
CPR stopped and E was cleaned.
1.24am – SHO Dr W notes:
ventilation efforts stopped and E was given to his parents.
Shortly before 1.30am – LL’s notes:
resus was needed again, but was sadly unsuccessful (electronic evidence)
1.40am –
The time of death was recorded as 1.40am on August 4. No post-mortem was conducted.
Consultant testimony-at the time she thought E’s cause of death was NEC. She thought this because E was an at-risk baby, taking into consideration her colleague’s observations of gastro-intestinal bleeding and abdominal discolouration. She discussed with the coroner and they agreed for that to be put as E’s cause of death. She now doubts NEC because his observations were stable right up to the point of collapse and with NEC deterioration is normally slower. There were also no signs of NEC on the x-ray. She apologised to the parents in court for not pushing for a post mortem. She tells the defence “his deterioration was well outside what we would expect.”
1.45am – Dr H wrote his 11.40pm note in retrospect.
LL’s note: '
both parents present during the resus. Fully updated by nursing and medical team throughout. Parents wished for [E] to be baptised, Chaplain attended and carried out baptism and supported parents. Mum and dad held [E]’s hand as he passed away.” “'[E] was bathed by myself and photographs taken as requested, both were present during this. Consent obtained for [hair] and hand/footprints. Both distraught.” (electronic evidence)
The official documented report for the incident is made by LL: '
unexpected death following gastrointestinal bleed. Full resus unsuccessful.' (electronic evidence)
The mother says the father asked a few questions and they were told by the (female) doctor a post-mortem wouldn't tell them much more than what they had already been told by the doctor, and it would delay the transfer back home. Mother said "We just wanted to take him home."
Mother says LL bathed [E] and dressed him in a white gown. LL gave the parents a memory box. Mother said that after [E] died "
Lucy Letby gave us a memory box, which totally surprised me. It had footprints, a lock of his hair, a candle, a teddy. I was so overcome by emotions that this had been provided for me as I had no other memories other than that".
4.51am -
LL made “fraudulent retrospective nursing notes, failing to mention that E’s throat was bleeding at 9pm, and falsely claiming the mother had visited at the start of the shift and later at 10pm, and that there had been a meeting between the mother and the registrar at 10pm." (opening speech)
8am – End of LL’s night shift
8.21am - LL noted at 8.21am '
Parents resident on unit overnight. Wish to be left alone.' (electronic evidence)
8.58am – LL’s texts
Colleague: "You ok? Just heard about [E]. Did you have him? Sending hugs xx"
LL: "News travels fast - who told you? Yeah I had them both, was horrible."
Colleague responded that she had been informed by someone at the handover 'told me just now'. 'Had he been getting poorly or was it sudden?' ‘Poor you. You’re having a tough time of it.”
LL: E had a 'massive gastrointestinal haemorrhage'.
Colleague: ‘Damn. He’d always struggled feeding. I just feel for his parents and you. You’ve had really tough times recently.’
LL: E was 'IUGR [Intrauterine growth restriction] and REDF [Reversal of umbilical artery end-diastolic flow]' and was 'high risk'. She went on to describe how she felt ‘just awful’ and reported that the parents were distraught, saying "I feel numb".
----------------------------------------------------------------------------------------------------------------------------------
Murder charge Child E – air (allegedly) injected into bloodstream and bleeding indicative of trauma.
Links:
Opening speech – Chester Standard
Recap: Prosecution opens trial of Lucy Letby accused of Countess of Chester Hospital baby murders
Opening speech – ITV
Who are the children alleged to have been murdered by Lucy Letby? | ITV News
Mother’s and father’s testimony –
Recap: Lucy Letby trial, Monday, November 14
Unnamed nurse’s testimony (day shift) –
Recap: Lucy Letby trial, Tuesday, November 15
Electronic evidence –
Recap: Lucy Letby trial, Monday, November 14
Dr Wood (SHO)’s testimony –
Recap: Lucy Letby trial, Tuesday, November 15
Dr Harkness’s testimony –
Recap: Lucy Letby trial, Thursday, November 17
Consultant’s testimony –
UK - Lucy Letby Trial - Media, Maps & Timeline *NO DISCUSSION*
Midwife’s witness statement -
Recap: Lucy Letby trial, Tuesday, November 15
Supplementary text details Daily Mail
Colleagues of Lucy Letby told her she was 'terrible run of bad luck'
