UK - Nurse Lucy Letby Faces 22 Charges - 7 Murder/15 Attempted Murder of Babies #12

[Tortoise]

11:12am

Ms Williams's family communication note includes 'photos taken and treasure box and Bliss bag given...encouraged parents to come to the unit to visit and mum and dad both touched her...mum to be discharged to [Arrowe Park Hospital] to be with baby.'

11:14am

Ms Williams's further nursing note explains Child K had '2 further episodes of apnoea and de-saturation with loss of colour. Has been re-intubated twice and now has a 2.5ETT...'
Ms Williams tells the court she would have remained the designated nurse throughout that night shift for Child K.


[MY NOTE - CROSS-EXAMINATION]

11:16am

Benjamin Myers KC, for Lucy Letby's defence, is now asking Joanne Williams questions.
He picks up on what Ms Williams had just said, that she did not have much experience in dealing with babies born at 25 weeks gestation. Ms Williams agrees that was the case at the time in 2016.
Mr Myers says there is the potential for deterioration in such babies, as they an be 'unpredictable'. Ms Williams agrees.

11:22am

Mr Myers asks about the process of administering a 'lung surfactant'. Ms Williams says it would be kept in storage. It would be prescribed, but could be signed for retrospectively. Doctors would work out how much to prescribe based on the baby's weight, and they would administer it.
A prescription form is shown to the court, showing a '120mg dose' 'administered 0300'.
Asked if 0300 is the time of the dose given, Ms Williams says: "Yes." She adds that would be an "estimated" time the dose was given. The scheduled time appears as '0544' is because it is a retrospectively written note, the court hears.

11:25am

Mr Myers asks about the '94' leak reading for 0330 for Child K. He asks if that is a high air leak. Ms Williams agrees.
Mr Myers says it would be a reading 'to keep in mind'. Ms Williams agrees.
Mr Myers: "The aim would not to be to have a leak of 94%?"
Ms Williams: "Yes."

11:26am

Mr Myers asks if ET tubes can be dislodged if a baby moves or not, Ms Williams agrees. She also agrees that requires careful observation, and it can change from minute to the next, but there are procedures, such as clamps, to keep the tube in place.
Mr Myers asks if Child K had been 'quite active'. Ms Williams: "At times, yes."

Recap: Lucy Letby trial, Tuesday, February 28

The trial of Lucy Letby, who denies murdering seven babies at the Countess of Chester Hospital neonatal unit and attempting to murder 10 more,…

www.chesterstandard.co.uk

 

[Tortoise]

Mr Myers asks about the '94' leak reading for 0330 for Child K. He asks if that is a high air leak. Ms Williams agrees.
Mr Myers says it would be a reading 'to keep in mind'. Ms Williams agrees.
Mr Myers: "The aim would not to be to have a leak of 94%?"
Ms Williams: "Yes."

I'm not sure if 94% is a leak, I think it might have been written in the wrong column or something - yesterday's evidence said there was a 94% oxygen saturation reading at that time.

Dr Smith's cross-examination -

"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."

[...]

Nurse Williams evidence -

"The oxygen saturation reading for Child K of 70% at 2.45am would be considered 'low', while the 94% reading at 3.30am was 'normal' and 'improved'.
The prosecution say that would be indicative the ventilator was working as it should be."

Recap: Lucy Letby trial, Monday, February 27

 

[Tortoise]

11:30am

Mr Myers asks about the morphine administered, which he says can sedate a baby and stop them being as active.
Ms Williams says Child K would have received morphine after being intubated, not at the time of intubation.
Mr Myers asks about when this morphine was administered.
Ms Williams says the morhpine could start via a bolus or an infusion, then the other being administered.

11:31am

A prescription for a morphine injection is shown to the court. Mr Myers asks if this is a bolus. Ms Williams agrees.
Ms Williams agrees she has co-signed for it, and agrees with the administration time of '0350' recorded as being the time the morphine was injected.

11:36am

The morphine infusion prescription and administration chart is shown to the court.
This is prescribed by a doctor, and has a handwritten start time of '0350'.
Ms Williams says 0350 could be the start time, or it could be later. Mr Myers says the prescription wouldn't have a start time after it had already been administered.
Mr Myers asks about the 0330 fluid chart. Mr Myers says although it is said morphine commenced at '0330', it is an hourly chart, and that means the morphine could have been commenced at any time between 3.30am and 4am. Ms Williams agrees.

Recap: Lucy Letby trial, Tuesday, February 28

The trial of Lucy Letby, who denies murdering seven babies at the Countess of Chester Hospital neonatal unit and attempting to murder 10 more,…

www.chesterstandard.co.uk

 

[Tortoise]

11:38am

Ms Williams says, for the '0350 100mg/kg morphine' note, that is not in her handwriting, but having someone else write in that note box is not uncommon when working as a team.

11:40am

Mr Myers asks if the morphine bolus and the morphine infusion began at the re-intubation process, after Child K had suffered a desaturation.
Ms Williams: "Yes."

Recap: Lucy Letby trial, Tuesday, February 28

The trial of Lucy Letby, who denies murdering seven babies at the Countess of Chester Hospital neonatal unit and attempting to murder 10 more,…

www.chesterstandard.co.uk

 

[Tortoise]

11:45am

Mr Myers asks about the alarm going off, and a conversation with Dr Ravi Jayaram.
Ms Williams says the conversation took place not in nursery room 1.
He asked her, Ms Williams had said in her police interview, what had happened, and she had replied she did not know as she was not in the room, having gone to see the parents.
Mr Myers asks to clarify about what Ms Williams had said moments earlier: 'I thought the ET Tube was secure, but I was not there'. Ms Williams agrees.

11:47am

Mr Myers asks about the nursing note made by Ms Williams 'large blood-stained secretions'.
Ms Williams says she does not recall where that came in the timeframe of events.
She adds it is difficult to write notes retrospectively and highlight the significant events. She says it is likely that would have been seen at the time of the re-intubation as she would have been present.

11:52am

The prosecution rise to ask Ms Williams further questions.
Ms Williams is asked about the lung surfactant administration note.
Prosecutor Philip Astbury asks about the timings of the note. The 0544 would be the time the surfactant was prescribed, retrospectively. It would not have been done concurrently as Child K would not have been added as a new baby identification on the hospital's system at that point.
The time at 5.48am, when the note was filed, would have been the point when it was considered what time the surfactant was given, the court hears. The note records it administered as '0300'.
She says she does not recall who administered the surfactant.

Recap: Lucy Letby trial, Tuesday, February 28

The trial of Lucy Letby, who denies murdering seven babies at the Countess of Chester Hospital neonatal unit and attempting to murder 10 more,…

www.chesterstandard.co.uk

 

[sapphireminds]

I'm not sure if 94% is a leak, I think it might have been written in the wrong column or something - yesterday's evidence said there was a 94% oxygen saturation reading at that time.

Dr Smith's cross-examination -

"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."

[...]

Nurse Williams evidence -

"The oxygen saturation reading for Child K of 70% at 2.45am would be considered 'low', while the 94% reading at 3.30am was 'normal' and 'improved'.
The prosecution say that would be indicative the ventilator was working as it should be."

Recap: Lucy Letby trial, Monday, February 27

94% leak does not have anything to do with the amount of oxygen being given, it is the amount of air leaking around the ETT. For children and adults, they use a "cuffed" ETT, which has a little balloon at the end to make sure the tube stays in the right place and to prevent leaking air.

But babies cannot have cuffed tubes, their airways are too delicate and it can quite literally destroy their airway, which would be lethal. So we only use uncuffed tube and the ventilator has sensors that tell us how much air is leaking out when it pushes air in. If you have a baby with a tight fitting tube and a lot of swelling, you might have no leak.

If the tube is too small for the airway so it doesn't fill it enough, you will show a high leak.

It can also show a large leak if you are just at the thoracic inlet, meaning just barely intubated. The breathing tubes are cut on a diagonal so you could have the very tip still past the vocal cords, but half the tube could be out of the correct place, "leaking" air.

One good thing about leaks is that they help provide a "pop off" if too much pressure is being given. It can make ventilation and oxygenation (the two parts of breathing) more challenging though. You might have to turn up the pressure to compensate for the leak.

 

[Tortoise]

94% leak does not have anything to do with the amount of oxygen being given, it is the amount of air leaking around the ETT. For children and adults, they use a "cuffed" ETT, which has a little balloon at the end to make sure the tube stays in the right place and to prevent leaking air.

But babies cannot have cuffed tubes, their airways are too delicate and it can quite literally destroy their airway, which would be lethal. So we only use uncuffed tube and the ventilator has sensors that tell us how much air is leaking out when it pushes air in. If you have a baby with a tight fitting tube and a lot of swelling, you might have no leak.

If the tube is too small for the airway so it doesn't fill it enough, you will show a high leak.

It can also show a large leak if you are just at the thoracic inlet, meaning just barely intubated. The breathing tubes are cut on a diagonal so you could have the very tip still past the vocal cords, but half the tube could be out of the correct place, "leaking" air.

One good thing about leaks is that they help provide a "pop off" if too much pressure is being given. It can make ventilation and oxygenation (the two parts of breathing) more challenging though. You might have to turn up the pressure to compensate for the leak.

so you're saying it's pure coincidence that there was 94% saturation and no reintubation, and 94% leak at the exact same minute.

 

[sapphireminds]

so you're saying it's pure coincidence that there was 94% saturation and 94% leak at the exact same minute.

I don't know - I just know if they documented a 94% leak, that's what it would mean. If they documented 94% spO2, that would be saturations.

 

[Tortoise]

11:58am

Ms Williams's nursing note is shown to the court. She is asked if the note, written retrospectively, is written chronologically. Ms Williams says that ideally, that would be the case.
Mr Astbury asks about the infusion chart, where hourly records are made. The 0330 note is referred to. Ms Williams is asked if records are kept as close to the times where possible. She agrees.
Ms Williams says she does not remember being present for the 0350 morphine bolus.

12:01pm

Mr Astbury asks about the conversation Ms Williams had with Dr Jayaram.
Ms Williams is asked if Dr Jayaram asked her: "How did the tube move?" Ms Williams agrees.
The judge asks about the purpose of the morphine bolus, whether given before or after the infusion. Ms Williams said it would be done '3-5 minutes' for a procedure such as re-intubation, for pain relief to the baby.

12:02pm

That completes Joanne Williams's evidence.

Recap: Lucy Letby trial, Tuesday, February 28

The trial of Lucy Letby, who denies murdering seven babies at the Countess of Chester Hospital neonatal unit and attempting to murder 10 more,…

www.chesterstandard.co.uk

 

[Tortoise]

12:14pm

The next witness to give evidence is Dr Ravi Jayaram.

12:17pm

Dr Jayaram confirms he would have been on call as a consultant on the night shift of February 16-17, 2016.
He says he would have been called at home, and would have been called to come in for the delivery of a 25-week gestational age baby such as Child K, as the hospital would be aware there could be complications.
He tells the court, until the early 2000s, there was less structure, but in more recent times, if possible, mothers are taken to tertiary centres [such as Arrowe Park] to give birth. If that is not possible, babies can be cared for in the short term at level 2 centres such as the Countess of Chester Hospital.

12:18pm

He says, on balance, the risk would have been too great to transfer Child K and the mother for the birth at a tertiary centre.
He adds he was present at Child K's birth.

Recap: Lucy Letby trial, Tuesday, February 28

The trial of Lucy Letby, who denies murdering seven babies at the Countess of Chester Hospital neonatal unit and attempting to murder 10 more,…

www.chesterstandard.co.uk

 

[DinerMite]

Should be quite a pivotal day today with Dr Jayaram's testimony. Could go either way I feel.

 

[LorriB]

so you're saying it's pure coincidence that there was 94% saturation and no reintubation, and 94% leak at the exact same minute.

It's confusing isn't it? The reporting seems to suggest there was a 94% saturation and a 94% leak.

 

[Tortoise]

12:26pm

Dr Jayaram says it is significant, when talking through the medical notes he had written retrospectively, the mother had a 'spontaneous rupture of membranes' 48 hours before birth, as that could lead to a risk of infection.
He said it was relevant there were 'no fevers' recorded.
The medical notes record Child K was 'initially dusky, floppy, no respiratory effort'. Dr Jayaram said that was significant and in this situation, a pathway is followed including 'inflation breaths', which stimulates the baby's first gasps.
He says it is like blowing a balloon up for the first time - the lungs are difficult to inflate for the first time as they are filled with fluid.
The inflation breaths are completed after two cycles, and Dr Jayaram says the chest is then seen to be moving up and down.
The heart rate is then above 100 beats per minute, recorded two and a half minutes after birth.
Gasps are recorded after three minutes. Dr Jayaram said Child K would have initially been 'a little stunned', but the gasps are what the medical staff are looking for.
Oxygen saturation levels of 'above 85%' at six minutes are 'satisfactory'.

12:28pm

The initial intubation process is discussed.
Dr Jayaram says it can be difficult and risky, and it is important the oxygen saturation levels are high before starting the procedure.
A doctor has 30 seconds to attempt the intubation procedure. The court hears the intubation was done on the third attempt, with a smaller, size 2, ET tube.
He says, "ideally", a 2.5 ET tube would be used, but in these circumstances a size 2 tube was sufficient.

Recap: Lucy Letby trial, Tuesday, February 28

The trial of Lucy Letby, who denies murdering seven babies at the Countess of Chester Hospital neonatal unit and attempting to murder 10 more,…

www.chesterstandard.co.uk

 

[Tortoise]

It's confusing isn't it? The reporting seems to suggest there was a 94% saturation and a 94% leak.

I think the fact that she wasn't reintubated at that time, if there was a 94% leak and only 6% oxygen was getting through, and another chart shows sats of 94%, shows it was a recording error. That's why the doctor said he didn't understand it. IMO

 

[Tortoise]

12:32pm

Child K was transferred to the neonatal unit, on a ventilator.
Dr Jayaram describes Child K required around 60% oxygen. He says he could hear air going in and out of the baby girl's lungs.
The initial blood gas readings are taken, and it is acceptable for a 'little bit of leeway' on carbon dioxide levels.
Child K was given surfactant at 2.45am, Dr Jayaram had recorded in the notes.
A blood culture test was taken to screen for infection, as a routine test, and the baby girl would be treated on the assumption she already had an infection and would be treated with antibiotics.

12:35pm

A morphine infusion is recorded on the medical notes.
Mr Astbury asks when that would be administered. Dr Jayaram says he does not recall when that would have been, but it would not be immediately after transfer to the neonatal unit nursery room 1.
Dr Jayaram said he could hear Child K's heartbeat, and air going in and out of both lungs.
He said, for a 25-week gestation baby, he was "happy" with Child K's progress.

12:38pm

Dr Jayaram said he was happy the ventilator was working, as observed by Child K's chest moving, and being in good colour.
He tells the court that at this point, he informed the transport team about the situation, and they had advised there was a bed at Arrowe Park Hospital, and they advised for a UVC line to be inserted prior to transport.

Recap: Lucy Letby trial, Tuesday, February 28

The trial of Lucy Letby, who denies murdering seven babies at the Countess of Chester Hospital neonatal unit and attempting to murder 10 more,…

www.chesterstandard.co.uk

 

[magikarpmagikarp]

I am curious about the leakage. On our ventilators, we don't get a percentage of leak unless they are on CPAP (and then it's in the neighborhood of 90%) but you can tell a leak on an intubated baby by watching tidal volume in and tidal volume out and seeing how big the difference is. A 2.0 tube is pretty tiny even for a 25 weeker, so a large leak is plausible to me, just from the size of the tube. Like sapphireminds mentioned, a leak can also mean displacement. A very large leak might lead to reduced chest movement. It's reasonable to me that they would replace the breathing tube with something larger if the tube was displaced or getting adequate air movement was a problem. a leak, 94% or otherwise, does not mean a reduced oxygen concentration - it means reduced pressure. JMO.

 

[Tortoise]

12:41pm

Dr Jayaram is now being asked about Child K's desaturation at 3.50am.
A plan of the neonatal unit layout is shown to the court.
Dr Jayaram said he was "happy" with how Child K was "very very settled", having had to make only minor adjustments to the ventilator settings.
An infusion chart for the morphine is shown to the court, with a start time of 3.50am. He confirms that 3.50am would be the time that would be administered.

Recap: Lucy Letby trial, Tuesday, February 28

The trial of Lucy Letby, who denies murdering seven babies at the Countess of Chester Hospital neonatal unit and attempting to murder 10 more,…

www.chesterstandard.co.uk

 

[Tortoise]

12:48pm

Dr Jayaram says he was aware Joanne Williams was going to the labour ward to update the parents on Child K.
He said he was sitting at a desk around the corner from the entrance to nursery room 1. He says he was writing in notes, or waiting for the transfer team to come back.
He said he had been told Lucy Letby would be 'babysitting' at the time.
He says, at this point, in February, he was aware of 'unexpected/unusual events' and that Lucy Letby had been present.
He said: "I felt extremely uncomfortable [with Lucy Letby being there alone in the room with Child K]
"You can call me hysterical, completely irrational, but because of this association...
"This thought kept coming into my head. After two, two and a half minutes...I went to prove to myself that I was being ridiculous and irrational and got up.
"I think it was 2.5, 3 minutes after Jo had gone to the labour ward.
"I had not been called to review Child K, I had not been called because alarms had gone off - I would have heard an alarm. I got up and walked through to see [Child K]."
Dr Jayaram entered.
"I saw Lucy Letby standing by the incubator. I saw her, and looked up at the monitor, and K's saturations were dropping, in the 80s and continued to drop. The ventilator was not giving out an alarm.
"I recall looking up and saying 'what's going on?' and Lucy said something along the lines of 'She's having a desaturation'."
Asked what Letby was doing, Dr Jayaram replied: "Nothing."
He says Letby didn't say anything to Dr Jayaram until he had walked over and he had asked her what was going on.

Recap: Lucy Letby trial, Tuesday, February 28

The trial of Lucy Letby, who denies murdering seven babies at the Countess of Chester Hospital neonatal unit and attempting to murder 10 more,…

www.chesterstandard.co.uk

 

[Tortoise]

12:51pm

Dr Jayaram said he was looking at Child K. He disconnected the ventilator from the ET Tube and he tried to give breaths via the ET Tube, but Child K's chest was not moving.
He said he switched into 'professional mode' to resolve the situation, and it 'didnt make sense why the tube was dislodged'
He said he removed the tube - which wasn't blocked - and put a face mask to ventilate Child K. As soon as that was done, Child K's chest went up and down, without too much difficulty.
He says he does not remember anything else Lucy Letby said. He says he was probably telling her to bring equipment.

Recap: Lucy Letby trial, Tuesday, February 28

The trial of Lucy Letby, who denies murdering seven babies at the Countess of Chester Hospital neonatal unit and attempting to murder 10 more,…

www.chesterstandard.co.uk

 

[Tortoise]

12:53pm

Dr Jayaram says the original tube was not blocked, and there would be no reason for that to have been blocked, for the time it had been on Child K.
Dr James Smith reintubated Child K, and the same ventilator settings were selected, indicating - Dr Jayaram tells the court - Child K had not been declining.

12:57pm

Dr Jayaram's notes are shown to the court, where he had described it as a 'sudden desaturation'.
The oxygen saturation levels fell to 40%.
The tube was removed, Child K was bagged via a face mask, and 'sats recovered quickly'.
A size 2.5 ET tube was placed. 'Ventilator settings as previously'.
The size of the tube "did not have an impact" on the previous ventilation, Dr Jayaram tells the court, as Child K was "ventilating effectively" and did not have an impact on the "sudden deterioration".

12:59pm

Dr Jayaram says he cannot recall how long Joanne Williams had been away before the sudden deterioration had taken place.
He tells the court the transport team and the parents were updated, but he does not believe they were updated about "this event".

Recap: Lucy Letby trial, Tuesday, February 28

The trial of Lucy Letby, who denies murdering seven babies at the Countess of Chester Hospital neonatal unit and attempting to murder 10 more,…

www.chesterstandard.co.uk