Here are defense points and cross examinations for Child A:
Child A:
The defence do not accept, for
Child A, an air embolus was the cause, but one of "sub-optimal care", as a result of either "lack of fluids" or "various lines put into him, with potential to interfere with his heart rate".
You will hear in this case, that the air present after death does not indicate an air embolus."
Mr Myers said air present in the abdomen "can happen post-mortem".
CROSS EXAMINATION DAY /Day 4 of Evidence
Ben Myers KC, for the defence, is now questioning Miss Taylor.
Mr Myers: "Do you find that even with the notes, it can be difficult to recall what happened?"
Miss Taylor: "It is, but...in my witness statement, if I was not sure, I said I was not sure."
Mr Myers examines the staffing levels at the Countess of Chester Hospital neonatal unit.
'For babies in intensive care, it should be one nurse to one baby', he tells the court, and 'one nurse to two babies' for high-dependency babies, and 'one nurse to four babies' in the special care nursery room, he tells the court.
Rotas would be relayed to staff "a month in advance", Miss Taylor says.
"If they [the neonatal unit] were busy", then some nurses would be asked to come in "at short notice".
Miss Taylor explains the shift leader gives the hand-over to the new nurses coming in for the following shift in a 'huddle', lasting '10-15 minutes'. The shift leader would be a 'band 6 nurse'. The shift leader is "usually pre-allocated", but could change.
There would be a 'handover sheet' with babies' names and an outline of care provided the previous shift.
Mr Myers: "And that handover sheet would be kept by him or her throughout the shift?"
Miss Taylor: "Yes, that's correct."
Generally," that handover would last until about 8pm, the court hears.
Mr Myers explains that some duties "require two nurses", such as administering medication and checking it is correct.
Mr Myers points to a section of the intensive care unit chart for Child A, where a different nurse to the designated nurse has signed for the observations at 4am on June 8. The designated nurse has signed for other hours including 2am, 3am and 5am.
He asked Miss Taylor: "There is absolutely nothing unusual about that, is there?"
Miss Taylor responds: "No."
Mr Myers asks Miss Taylor about the layout of the Countess of Chester Hospital neonatal unit.
Mr Myers said Child A would have required "constant observation" despite being deemed "stable" in the neonatal unit. Miss Taylor agrees.
He added that pre-term babies would also be "prone to infection". Miss Taylor agrees.
Mr Myers: "They can be prone to collapses, can't they?"
Miss Taylor: "I don't know if I would agree with that, exactly."
Mr Myers said a baby fitted with a UVC would be 'intensive care'. Miss Taylor agrees. Child A had become an 'intensive care baby' during the day shift as he had required.
Mr Myers said Miss Taylor would have been looking after an intesive care baby (ITU), as well as another baby which required a lot of care - which falls outside the guidelines.
"In terms of ITU, they technically are intensive care, but not as intensive - some babies require a lot of hands-on, one-to-one care. Some technically become ITU, but in terms of care, they are more like HDU."
Mr Myers: "Were there, at the time, a lot of poorly babies?"
Miss Taylor said that particular shift was a busy one, she recalls. She accepts that an increased number of poorly babies coming into the unit would create an increased demand on nursing staff.
Mr Myers asks why a baby's temperature would not necessarily be recorded every hour on the chart.
Miss Taylor says the temperature records involve putting a thermometer under the baby's arm, which the "babies don't like", while a heart rate is done on the monitor, while
while the respiratory rate would be manually counted through observation.
Mr Myers asks if handling babies (for example, to take their temperature) could led to an increase in the baby's stress, which would lead to an increased risk of deterioration.
Miss Taylor: "...to a certain degree, yes."
She adds if a temperature is recorded for one hour in a stable reading, the baby's temperature would not necessarily be taken on the following hourly check.
Melanie Taylor's nursing note for June 8 is shown to the court, at 1pm.
It documents the insertion of the UVC for Child A.
Miss Taylor said she cannot remember the two attempts of insertion of the UVC, but sees it is made on her notes.
The note, written at 7.05pm, says: "UVC in wrong position, reinserted...again in wrong position. Cannula tissued. Doctors busy on ward 30. Aware no fluids running for a couple of hours. Long line inserted by Reg Harkness. awaiting X-ray. Remains settled on NCPAP. Enteral feeds of donor expressed breast milk started at 1ml/2hourly."
The intensive care chart is shown to the court, showing 'cannula tissued' at 4pm.
Miss Taylor explains she might have written 'cannula tissued' retrospectively, so it could be before or after 4pm when that was noted.
Mr Myers said Miss Taylor would have had to wait for a doctor to put a long line in.
Mr Myers: "You said it was very busy - and that caused a delay, didn't it?"
Miss Taylor: "Yes."
Mr Myers: "It's important to make sure the tip of the long line is in the right position, isn't it?"
Miss Taylor: "Yes."
"It's a sterilised procedure? It's very thin."
"Yes."
Miss Taylor says she's not too familiar with the long lines as she is not involved with the procedure.
The judge clarifies Mr Myers' question, asking if it is important to get fluid in once the long line is in place. Miss Taylor agrees.
Miss Taylor says she is not aware of anything that might have been running through the long line prior to the 8pm 10% dextrose administration.
Mr Myers adds "the conventional practice" is for fluids to be administered immediately in the long line after it is inserted.
"Yes. Ideally we would get an x-ray first."
Mr Myers says there was a delay because the doctor was delayed elsewhere.
Miss Taylor: "I think so."
Miss Taylor is asked about the retrospectively written note at 9.28pm on June 8, which begins.
"Observations stable, pink, well perfused. UVC still insitu, but in wrong position, to be used if no other access available.
"Long line inserted by reg Dr Harkness, secured, x-rayed. 10% dextrose run through and connected to long line."
An observation chart showing the respiration rate is 'elevating', Mr Myers says, throughout the day is shown to the court.
"Yes, a little," replies Miss Taylor.
A blood gas record chart shows the lactate levels had increased on the records of 12.13am, 6.37am and after 2pm, with levels at 1.6, 2.6 and 2.7. The latter two readings are, Mr Myers says, outside of the desired area. No other records are given.
Miss Taylor says she does not know what time the long line was inserted.
Mr Myers says there was a delay in getting the x-ray.
Miss Taylor: "From memory, I cannot remember the timings, but possibly."
Letby's notes, written retrospectively at 7.56am on June 9, are shown to the court. They begin: "Glucose commenced via long line...UVC remained in situ from day shift, instructed line not to be used by registrar.
"[Child A] noted to be jittery, was due to have blood gas and blood sugar taken.
"At 8.20pm [Child A] hands and feet noted to be white. Centrally pale and poor perfusion..."
Mr Myers: "He should have been getting fluids during this four-hour period, shouldn't he?
Miss Taylor: "Yes."
Miss Taylor says she cannot remember whether it was herself or Lucy Letby who administered the fluids.
Mr Myers said "two nurses" are involved in the process, and one has to be in sterile conditions.
Miss Taylor: "I honestly don't know whether it was me or Lucy [who was in sterile clothing]."
The defence say it was Miss Taylor who was the one in sterile clothing for the fluid administration, with Lucy Letby assisting. Miss Taylor says it could have been that, or the other way around.
Mr Myers: "When the deterioration commenced, you were at your computer making notes?"
"Yes."
A note by Miss Taylor is made at 8.18pm for Child B.
"It shows you were at the computer at 8.18pm?"
"Yes."
"Was Dr Harkness also in that room?"
"I don't remember."
"You could see where [Child A] incubator was, and the alarm sounded."
"Yes."
"When you went over to Child A, could you recall whether he was breathing or not?"
"I don't recall."
"Would it be fair to say that what followed makes it difficult to recall - that there is a lot of activity surrounding the cot?"
"When you realise that extra support is needed, yes."
Mr Myers: "Lucy Letby went to support the family at one point, do you recall that?"
Miss Taylor: "I don't remember that."
Miss Taylor says if Letby was the designated nurse, she would be involved with assisting the resuscitation attempts.
She adds that designated nurses would often be the one to provide support to the family afterwards.
Memory boxes, Miss Taylor says, are collated with permission of the family.
Mr Myers: "Do you recall about whether there was any discussion about whether the fluid bag should be kept?"
Miss Taylor: "I don't recall that, no."
Miss Taylor is presented with an interview transcript, dated February 7, 2018, one of a series of interviews she had involving babies in her care at the Countess of Chester Hospital.
The interview says Miss Taylor believed that sometimes, babies collapsed with no explanation.
Miss Taylor: "When I said that, that is what I believed to be true - whether that's my rational brain, trying to rationalise what happened."
Mr Myers reads from the statement: "It's a shock to us, because we have such a low rate."
Miss Taylor: "That is what I believed, that was my opinion at the time. I tried to rationalise what happened at the time. Whether that's true - I'm not medical - but that was my opinion at the time."
[My note: Redirect - Prosecution]
The prosecution say this interview concerned a different set of twins.
Miss Taylor: "I feel like I shouldn't have said that - I tried to rationalise that, because as a nurse, that is what I tried to do."
The prosecution shows the intensive care chart to the court again, focusing on the feeding records between 4pm-8pm.
The feeding of expressed breast milk at 4pm and 6pm were "trophy feeds". Miss Taylor explains small amounts of food are for the stomach to be lined so it could help get the stomach used to future feeds.
A 6pm 'output' of 25mls of urine is noted. Miss Taylor says that is weighed via the nappy - a "tried and trusted method", the prosecution say.
"Does that show fluids were passing through [Child A]?"
"That does."
"Does it follow that fluids that go out must have gone in?"
"It does that fluids that have gone in through the day, yes."
Blood gases records were noted by the defence as "being outside the optimum range".
The prosecution say with those records in mind, was Child A still 'stable'?
Miss Taylor: "Yes."
She explains the elevated respiratory rate was not uncommon, and other symptoms, such as the baby grunting, would be noted as part of a bigger picture. The elevated respiratory rate and blood gas level would not be, in isolation, uncommon, but still "relevant".
Miss Taylor says she does not remember Child A being "jittery", and had not documented it in her notes. She says if she had seen Child A being jittery, she would have noted it.
She adds it would be considered as part of a bigger picture. "It does not necessarily [mean] a concerning cause, but it is something to consider."
END OF PROSECUTION OPENING SPEECH Chester Standard: 11:37am Mr Johnson: "Following those events, the consultants suspected that the deaths and life-threatening collapses of these 17 children were not medically explicable and were the result of the actions of Lucy Letby. "No doubt they were...
www.websleuths.com
