UK - Nurse Lucy Letby Faces 22 Charges - 7 Murder/15 Attempted Murder of Babies #6

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  • #321
So she had two separate medical notes for Baby B and Baby Q?
One could be a mistake, but two is leaning towards suspicious.

I might be getting confused with too much information, and am not sure she had handover sheets for both babies. But agree it’s very suspicious if true.
 
  • #322
Wasn’t it baby E whose parents refused an autopsy, which was described as a terrible mistake?
Yes, you're right. Child P DID have the post mortem "A post-mortem examination had the coroner concluding Child P died from Sudden Unexpected Postnatal Collapse but he was unable to identify the underlying cause. He certified the cause of death as “prematurity".

So child P died and needed a post mortem. Q is an unrelated baby who collapsed the next day - and Q's handover note was found at her home. And she was questioned by doctors after Q's collapse.

No mention whether P's handover noted was found at her home as well.
 
  • #323
10:41am

An interpreter will be required in court today, for an unusual reason.
The next doctor witness will be giving evidence from Switzerland, via videolink. Under Swiss law, the doctor's evidence will be coming from a court in Switzerland, and a French-speaking Swiss judge will be present. What is said in Manchester, and the doctor's evidence, will be translated into French by the interpreter in the Swiss court for the benefit of the Swiss judge.

10:46am

Through discussions between the two courts, it is now understood everyone in the Swiss court can understand English.
The judge in Manchester, Mr Justice Goss, has said the proceedings will carry on in English, and translation will only be required if there are either technical difficulties or the odd word which will require interpreting into French.

10:49am

Members of the jury have now come into court, and matters have been explained to them about the international videolink arrangement.
The next witness to give evidence is Dr Sarah Rylance.


 
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  • #324
10:54am

Dr Rylance confirms she was employed at the Countess at Chester Hospital as a registrar in June 2015, and worked a long day shift on June 20 that day.
She confirms she has the clinical notes for Child D to hand.
A reminder that, due to reporting restrictions, none of the children in this case can be identified.

11:03am

Dr Rylance says she does not believe she was present at the birth of Child D.
The details are recorded retrospectively, that Child D was born at 4.01pm on June 20.
The note includes: 'Bleeped again as midwife not happy with her colour' - she is not able to say whether that was her being bleeped again.
Child D 'looked dusky' and had 'poor respiratory [efforts]', with initial oxygen saturations at 48%, poor respiratory effort at 7.30pm.
The note adds 'transferred into incubator'.
After being given breathing assistancevia Neopuff, Child D 'pinked up quickly and started regular resps'.

11:05am

The prosecution ask for what Child D would have been assessed as.
Dr Rylance: "She responded well to the ventilation support she has been given."
"In relation to the blood gases, it's difficult to assess how that reflects on her clinical condition."
The blood gases suggest Child D had difficulties with breathing and metabolism, but Dr Rylance said she would not use the blood gases alone to make a diagnosis, but take it into context with other readings and observations.

 
  • #325
11:07am

Child D was 'transferred on to CPAP', and an IV saline solution was administered.
Child D was also started on 'triple lights' as part of phototherapy to treat her jaundice symptoms. That was the "maximum treatment" level, Dr Rylance, tells the court.

11:09am

Dr Rylance's notes, also record, for Child D at 8pm, the baby girl was on CPAP, 40% oxygen, and '[saturations] 100%'.
Child D's heart sounds were "normal", with an "ok" pulse rate, and it was noted there were regular breathing efforts, "but fairly shallow" and the abdomen was not distended.
The plan was to continue CPAP and administer dextrose, and repeat a blood gas test at 8.45pm.

11:12am

Dr Rylance's notes at 8.20pm record the parents were updated on Child D's condition, with "likely sepsis" and she was receiving antibiotics "to treat infection".
The doctor tells the court Child D's condition was, at this point, "responding well to interventions" and "appeared to be stabilised on the CPAP and making respiratory efforts."
"Overall I was happy with the the progress she had made, but she needed to be closely monitored and assessed."

 
  • #326
11:18am

A further entry is made at June 21, 2pm, in the clinical notes.
The entry records the insertion of a UAC and UVC into Child D.
The UVC was removed as it was 'only able to advance to 5cm'. Dr Rylance says usually "you are expected to advance it much further.
"It can be difficult and fiddly to do this procedure in new-born babies."
The UAC was inserted to 20.5cm, but did not get a blood sample back. An x-ray review found it was advanced 'way too far', and the route was 'not typical of a UAC'.
The UAC "should follow a typical route", the court hears, and the line was pulled back to 9cm.
A blood gas reading was taken and the readings were 'much improved'.
A second x-ray showed the UAC position was 'better', but the route was 'still not typical'.

11:23am

The 'much improved' blood gas reading was, Dr Rylance believes, a comparison with the previous blood gas reading.
The UAC was 'actually a UVC' and adjusted to be used as a UVC.
The plan was to continue CPAP for Child D and repeat a blood gas reading, and 'try to sample UVC' for various readings.
A review is carried out at 7pm on June 21, with 'presumed sepsis' noted.
A CRP reading of 1 is recorded, having previously been 6.
Dr Rylance, commenting on those readings: "I wouldn't attach particular significance to it," as both readings were "low", and would need to be taken in context with the baby's clinical condition and observations.

11:25am

Child D had been on CPAP all day, but 'in air' and 'saturating well', with 'no desat[urations].'
The initial blood gases post-exhubation at 9am were 'not good', so Child D was put back on to CPAP at 10.30am.
Dr Rylance said Child D had made good progress, and her ventilation status was "very satisfactory" at the time she reviewed her.

 
  • #327
Ok, the sepsis mystery has been solved, somewhat, with Dr Rylance's testimony today.

"Dr Rylance's notes at 8.20pm record the parents were updated on Child D's condition, with "likely sepsis" and she was receiving antibiotics "to treat infection"".

However, this was at 8.20am and it's noted she was treated with antibiotics. So still unsure why LL thought this was sepsis, even at 1.30pm 3.45pm and 4pm. Will see what else comes out of Dr Rylance's testimony. Also makes me wonder if this is why LL picked the patient - knowing she had likely sepsis (because of what her colleague told her a week ago - a baby who died of "overwhelming" sepsis). MOO.

Incidentally Dr Rylance looks like a big deal - Lead for Chronic Respiratory Diseases in NCD Management Unit (WHO HQ).
 
  • #328
11:32am

Under the heading 'sepsis', the CRP reading was '1', and Child D had 'not had [lumbar puncture] yet.'
Such a test is done in clinically stable babies to test infection has not spread, the court hears, but Child D was 'not stable enough' for that to be carried out.
Other observations were noted by Dr Rylance that Child D was 'responsive on handling', with 'chest clear, regular resp effort, minimal recession', abdomen 'soft, not distended'.
The feet were 'quite purple', but Dr Rylance says that would be as a result of frequent tests carried out. The court has previously heard heel prick tests would be done to get results such as blood gas readings.
Dr Rylance added: "Overall my observations were that she was stable and handling well...and responding well to treatment she had received throughout the course of the day."
Under 'impressions', Dr Rylance noted: 'stable on CPAP, tried taking her off but resp effort became irregular and desaturated a few times so put back on'.
Dr Rylance said she would not have attached a lot of significance to this, as "it takes babies some time to settle. She was obviously unwell when she came to the neonatal unit the previous evening.
"She needed a bit more time from the CPAP...allow us to transition having been ventilated and moving to breathing.
"If they don't seem to tolerate it well, you can just put them back on [CPAP].
"She was heading in the right direction, she just needed a little support from the [CPAP] machine without added oxygen."

11:34am

The note added, as part of the plan, 'leave on CPAP, await CRP...leave UVC for now to allow sampling for gases, continue [antibiotics].'
Dr Rylance says she was "happy" with Child D's clinical condition, having had "a very satisfactory day" and was improving, in good colour, not needing oxygen support.
"She has shown good improvement from the condition when I first saw her on the neonatal unit the previous evening."

11:37am

Ben Myers KC, for Letby's defence, is now asking Dr Sarah Rylance questions.
He says there were two instances of her examining Child D.
He said that at the end of the June 20 examination, she was "happy with [Child D's] progress".
"Would you agree she was at risk of complications?"
Dr Rylance says Child D had responded well to treatment, but the blood gases were not in the normal range, and that would require close observation.

 
  • #329
11:41am

Mr Myers points to Child D having 'lost colour' and 'floppy' when in her father's arms moments after birth.
"Do you agree that is worrying at that stage?"
Dr Rylance agrees the Apgar scores of 8/10 and 9/10 aren't relevant for 12 minutes later.
Mr Myers asks if the progress of Child D is based on the reference point from the worrying signs just after birth.
Dr Rylance: "My opinion of her at the end of the shift, my reference point is from when I first had contact with her on the neonatal unit, from when she required ventilation support.
"I wasn't invovled at her birth...I can't comment on her condition at the time. My writing [on the clinical notes] is based on what I had been told.
"It's my summary, but not my observations, if that makes sense."

11:42am

Mr Myers: "You will have known...she started grunting in theatre...reviewed after 1.5 hours, 'grunting but otherwise observations ok'."
Mr Myers asks if grunting can refer to respiratory effort difficulties.
Dr Rylance: "Yes it can."

11:45am

Dr Rylance says she is unable to recollect whether she saw Child D prior to her neonatal unit admission, but does not believe she was involved in the review to bring her to the unit.
She said: "From the point she came to the unit, these were my direct observations."
Mr Myers asks if Dr Rylance reviewed Child D at about 7.30pm.
Mr Myers: "She presents as a baby who is seriously ill?"
Dr Rylance: "Yes...at that point she was an unwell baby."

 
  • #330
11:48am

Dr Rylance says she believes the first time she reviewed Child D was in the neonatal unit. Had she done so before, she would have noted that from a ward observation.
The venous gases taken at that time show 'marked acidosis', Mr Myers asks. Dr Rylance agrees.
Mr Myers: "You explained to us these were abnormal and indicate difficulty with the respiratory system and metabolic components?"
Dr Rylance: "Yes, that's correct."
Mr Myers says those readings are taking into account the clinical condition for Child D.
Dr Rylance: "Yes."
Mr Myers: "But at this stage, weighing up the clinical picture, it was not a good picture, was it?"
Dr Rylance: "No."

11:52am

Mr Myers said at one point, Dr Rylance had referred to the examination as being 'normal', but there was quite a lot of Child D being 'abnormal'.
Dr Rylance says Child D was "not a healthy baby at this point in time".
She says she is aware Child D was later put on to a ventilator.
Mr Myers says infection is a 'leading cause' in neonatal deaths and can 'develop very quickly'.
Dr Rylance: "It can."
"As a rule, antibiotics should be given to a neonatal baby...
"There are different guidelines on whether babies should receive antibiotics, with clinical risk factors.
"When you have concerns...then you want the antibiotics as soon as possible."
Mr Myers says Child D's mother had her waters break many hours before giving birth, and that Child D was, at birth, 'floppy' and at risk of collapse.
Dr Rylance agrees Child D should have received antibiotics at this stage.
She adds this is reliant on someone else's documentation, and it is difficult to say precisely how Child D was responding at that time.
She says it would have been a good idea to start antibiotics as quickly as could be done, and that was done upon her arrival at the neonatal unit.

 
  • #331
11:55am

Mr Myers: "The reality is, from the point of collapse at 12 minutes...given everything we know, [the plan] would have been give antibiotics rapidly?"
"Yes, I think so."
Mr Myers says Child D was not given antibiotics until nearly four hours after birth, at the neonatal unit.
Dr Rylance agrees that would be the case.
"There was a four-hour delay in the delivery of antibiotics after birth?"
"Yes."
"You may not be responsible, but that falls below the standard of care for a new-born baby, doesn't it?"
"Yes."
"The purpose of antibiotics is to treat and reduce the risk of infection?"
"Yes."

12:00pm

Mr Myers refers to the blood gas readings on the afternoon of June 21.
Dr Rylance says there would have been a blood gas chart and the readings were presumably an improvement on what was previously taken.
Dr Rylance tells the court the intention was to insert a UVC and a UAC, "if it's possible to do so."
The court hears the 'UAC' inserted acted as a suitable UVC instead.

12:08pm

Mr Myers refers to the 'presumed sepsis CRP 1'.
He says the CRP reading increases from CRP 1 to CRP 6 later that night.
He says from those readings, they cannot diagnose infection on their own.
Dr Rylance: "Yes."
Mr Myers refers to an attempt to take Child D off CPAP by Dr Rylance, as noted, and an accompanying nursing note referring to the oxygen levels desaturating to the 80s.
He says "that is not a healthy state to be in, is it?"
"It reflects she needed more respiratory support, but the fact she had moved on from ventilator support, and needed no oxygen support, suggested it was improving.
"By trying to take her off CPAP, we wouldn't have done that if she wasn't stable.
"She didn't tolerate it, so we put her back on."
The improving clinical condition, Dr Rylance says, was from Child D arriving at the neonatal unit to her obersation the following day.
Mr Myers says the 'satisfactory examination' of Child D was carried out while she was on CPAP.
Dr Rylance says a lumbar puncture is "quite an invasive" procedure and there is a risk of that being carried out if a baby is still on breathing support.
In Child D's case, it was "weighed up" and it was felt it was not needed to be done at that time.

12:09pm

Mr Myers said Dr Rylance had identified sepsis and acidosis "at various points" and during the time she was cared for, Child D required breathing support.
He says that when Child D was taken off CPAP, she began deteriorating.
Dr Rylance agrees.

12:13pm

The prosecution, led by Simon Driver, rises to clarify about the notes made for Child D following birth.
"As of your last review on 7pm on June 21, what was your assessment of her at that stage?"
"From what I documented, [Child D] was stable...with minimal respiratory support and no additional oxygen support.
"In handling, she was responsive and making good progress and making good response to treatments over the previous 24 hours.
"She was not a healthy baby at that time [due to still requiring CPAP], but...clinically she was stable and making a lot of progress."

 
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  • #332
12:30pm

The next witness, who cannot be named due to reporting restrictions, confirms she was a neonatal unit nurse at the Countess of Chester Hospital in June 2015.
She tells the court night shifts would be "generally quieter" in terms of staffing numbers, and there were no set rules on when they would take breaks, and would depend on workloads.
When they were on breaks, another member of staff would be directed to cover for the designated baby. That role could be done by the shift leader.

12:34pm

The nurse confirms she was the designated nurse for two babies in room 2 on the night shift of June 21.
She said she cannot remember having any cause to be involved with Child D on the early part of that night.
A medicine chart is presented to the court showing the nurse was a co-signer for doses of medication for Child D at 9.23pm.

12:38pm

The nurse says her memory of Child D's collapse at 1.30am is "vague", but remembers her being "stiff" and having a "rash" on her abdomen.
She says she does not remember whether she was in the room at the time of the collapse.
She says, from her statement, colleague Caroline Oakley (the designated nurse) was not present in the room at that time.
She recalls Child D's appearance - the baby girl was 'discoloured' and "stiff". The discolouration "was like a mottled appearance", it was "an odd rash, it was unusual".
She said mottling would be blue and grey, whereas this was "not that colour". She said it was a "reddy brown" colour, which was "unusual", and this was found on Child D's abdomen.

12:41pm

The nurse says she wants to say she had seen this discoloured appearance again, but could not say whether that was before or after June 2015.
Asked by the prosecution to clarify, she tells the court she had not seen that discolured skin appearance in the years prior to that.
The nurse remembers Child D recovered quickly and was examined by Dr Andrew Brunton.
She says, from her notes, the rash had 'resolved' by that point.

12:42pm

The nurse added a similar event happened for Child D where she desaturated. She does not remember the circumstances but believed it was similar where she was given treatment, reviewed, and recovered.
She said she didn't remember seeing Child D, but would have done so as part of her shift. She said she didn't remember anything about the child's appearance or recovery.

12:46pm

The nurse tells the court there was further desaturating for Child D, she would have been notified to the room - but does not recall how - and there was a call for a medical review.
Full CPR was being carried out on Child D by the time Dr Brunton arrived in the room, the nurse tells the court.

12:52pm

The nurse recalls the efforts made to resuscitate Child D, which were made in established guidelines, and ultimately efforts were not successful.
She recalls the parents were there at the time.
After Child D had died, she recalls having a conversation with Lucy Letby on the resuscitation drugs used.
A chart advising dose levels for the drugs would usually be kept by the child, but this A4 chart, a laminated piece of paper, was missing.
The nurse said that chart was missing, and the resuscitation drugs were administered by calculating the doses with Child D's weight, and using her years of experience.
The chart "eventually turned up", the court hears, as "it must have gone missing in the stress of everything".
Lucy Letby asked the nurse how she knew what dose levels to give, and the nurse explained how she had done so.



 
  • #333
12:57pm

Mr Myers, for Letby's defence, asks the nurse about workloads between June 2015-June 2016.
The nurse agrees there was a higher workload during that time, with an increased acuity overall in the patients arriving in the unit.
Mr Myers asks about the 14 babies being on the unit on the night of June 21.
He says "ideally", the shift leader (which the nurse was working that night) would not be looking after babies on the unit for that shift. The nurse agrees.
Mr Myers said Child D was being looked after by Caroline Oakley, who was in room 1 (the intensive unit room), and another baby in room 2 (a high-dependency unit room), and that goes against the guidelines.
The nurse says: "It's not what the guidelines say, however, the ITU guidelines are quite specific."
The nurse says some babies in intensive care require different levels of care.
Mr Myers says, ideally, Child D would have 1-2-1 care that night.
"Ideally, yes."

12:59pm

Mr Myers asks about Child D's collapses that night.
The nurse confirms resuscitation attempts were only required on the third collapse.
Mr Myers asks about the rash - which the nurse described as 'mottled, white circles, with a reddy-brown colour'.
He asks if that is what the nurse remembers from telling the police, or from discussing it with colleagues.
The nurse: "No, that is how I remember the rash."
Mr Myers asks if that is how she remembers the rash, as 'reddy-brown' was not in the police statement.
The nurse agrees.
She also says she cannot remember how long the rash lasted.

1:05pm


The court is now hearing from Dr Emily Thomas, who in June 2015 was working at the Countess of Chester Hospital.
She remembers the night shift being busy on the children's ward, and her colleague Dr Andrew Brunton being called out to assist Child D.
She recalls an unusual rash appearance at the 1.30am collapse, with purple colouring around the abdomen.
Dr Thomas said she was in the middle of a septic screening in room 2 or 3 at the time of the third collapse.
She said she believed Lucy Letby was the one who had called for help, and recalled her being upset, saying what she recalled was: "This is my second baby that this has happened to".

1:06pm

She did not recall seeing a rash on Child D during the resuscitation attempts.


 
  • #334
I’m not sure it would be easily hidden especially with so many instances alleged. Every feeding time is noted so if you stick a syringe in one of those lines when it’s not expected by the allotted nurse who would be aware of feeding times it’s pretty obviously blatant. All those notes by staff are meant for one reason so you know and can keep to the timetable of scheduled care, anything out of that schedule would presumably likely be noticed. The care is supposed to be like clockwork otherwise it’s Sub optimal, however I would go to a professional and see if they agree with my non experienced opinion.
I think JosieJo is an experienced nurse herself Sweeper. So I think her opinion on whether these actions are easy to hide or not is extremely valuable.
 
  • #335
1:14pm

The next witness, Elizabeth Marsh, was working a night shift on June 21.
She said on this shift, she was looking after babies on the post-natal ward and babies on the neonatal unit.
She said she saw Lucy Letby giving chest compressions to Child D at the time of her third collapse.
She said she was not directly involved in the resuscitation attempts, and was involved in the transcribing of the efforts, writing the notes on a paper towel.
She said there was a short debrief at the end of that, but nothing more formal at that time.

1:24pm

The court also heard, from Dr Thomas's statement, there was a communication mix-up when Dr Brunton was on the telephone to what he thought was an on-call consultant, but was actually one of the parents of Child A and B.
By this time, Child A had died and Child B was being treated in the neonatal unit following a non-fatal collapse.
Previously, the court heard the parents of Child A and B would be in very regular contact with the hospital throughout the nights for an update on Child B's condition.
Dr Brunton was "mortified" when he realised the communications error had been made.

 
  • #336
I can see why the defence claims sub optimal care and now they have agreement from dr Rylance that it falls below the standard of care for a newborn baby when they didn’t give antibiotics after the birth considering the birth.

Also writing on a paper towel? Missing drug paperwork? Speaking to other parents thinking they’re a consultant? sounds a mess.
 
  • #337
"The court also heard, from Dr Thomas's statement, there was a communication mix-up when Dr Brunton was on the telephone to what he thought was an on-call consultant, but was actually one of the parents of Child A and B.
By this time, Child A had died and Child B was being treated in the neonatal unit following a non-fatal collapse.
Previously, the court heard the parents of Child A and B would be in very regular contact with the hospital throughout the nights for an update on Child B's condition.
Dr Brunton was "mortified" when he realised the communications error had been ma
de"

This is horrific! But how does this even happen? Surely hospital phones are connected internally to different departments and doctors. And it's a case of dialling an extension? How could someone mistakenly dial an external number to a family??

Someone made the call or answered the call and brought it to Dr Brunton. Father says a phone was being held up for Dr Brunton as below. Wonder who made the call???

"Andrew had a phone held up to him, and he was discussing the situation with someone on the other end.
 
  • #338
"The court also heard, from Dr Thomas's statement, there was a communication mix-up when Dr Brunton was on the telephone to what he thought was an on-call consultant, but was actually one of the parents of Child A and B.
By this time, Child A had died and Child B was being treated in the neonatal unit following a non-fatal collapse.
Previously, the court heard the parents of Child A and B would be in very regular contact with the hospital throughout the nights for an update on Child B's condition.
Dr Brunton was "mortified" when he realised the communications error had been ma
de"

This is horrific! But how does this even happen? Surely hospital phones are connected internally to different departments and doctors. And it's a case of dialling an extension? How could someone mistakenly dial an external number to a family??

Someone made the call or answered the call and brought it to Dr Brunton. Father says a phone was being held up for Dr Brunton as below. Wonder who made the call???

"Andrew had a phone held up to him, and he was discussing the situation with someone on the other end.
On Thursday the mum said it was LL : “A nurse, who the mother believed to be Lucy Letby, was holding a phone to Dr Brunton's ear, she recalled.”
 
  • #339
"The court also heard, from Dr Thomas's statement, there was a communication mix-up when Dr Brunton was on the telephone to what he thought was an on-call consultant, but was actually one of the parents of Child A and B.
By this time, Child A had died and Child B was being treated in the neonatal unit following a non-fatal collapse.
Previously, the court heard the parents of Child A and B would be in very regular contact with the hospital throughout the nights for an update on Child B's condition.
Dr Brunton was "mortified" when he realised the communications error had been ma
de"

This is horrific! But how does this even happen? Surely hospital phones are connected internally to different departments and doctors. And it's a case of dialling an extension? How could someone mistakenly dial an external number to a family??

Someone made the call or answered the call and brought it to Dr Brunton. Father says a phone was being held up for Dr Brunton as ow. Wonder who made the call???

"Andrew had a phone held up to him, and he was discussing the situation with someone on the other end.
I would have thought it quite easy to make this mistake as there is an emergency going on. They need to ring either mobile numbers or presumably 2 landlines, both with likely similar area code. I assume the consultant on call is at home?
 
  • #340
On Thursday the mum said it was LL : “A nurse, who the mother believed to be Lucy Letby, was holding a phone to Dr Brunton's ear, she recalled.”
Good spot!

Because surely whoever held the phone up to the doctor's ear is the one who took/made the call and checked it was indeed the on-call consultant?

If it was indeed her, that is really really really suspicious. No way can anyone mistake an external number to parents for an extension to the on call consultant. Surely.
 
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