Prosecution evidence, February 27th 2023, Day 62 - live updates Chester Standard LIVE: Lucy Letby trial, Monday, February 27
Child K
Dr James Smith - Specialist Registrar
12:39pm
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.
12:40pm
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.
12:49pm
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.
12:53pm
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'.
12:57pm
He tells the court that for all babies of this prematurity, antibiotics would be administered.
12:59pm
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.
2:06pm
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.
2:12pm
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.
2:13pm
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".
2:19pm
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.
2:23pm
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.
2:25pm
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.
2:27pm
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.
2:29pm
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
2:33pm
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.
2:36pm
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.
2:39pm
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.
2:45pm
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.
2:54pm
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.
2:59pm
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.
3:01pm
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'.
3:11pm
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.
3:34pm
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 being 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.
3:39pm
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.
3:42pm
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.
3:44pm
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.
3:47pm
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.
