LL Part 20: It was a miracle that Baby G Survived

But there was always a high chance of a short, debilitating life.

PLEASE NOTE: If you are involved in the Appeal of Conviction or retrial of Lucy Letby on the charges related to Baby K, please stop reading and close your browser.

Continuing from our previous article on the Lucy Letby Trial here.

This article describes the first of three incidents, blamed on Lucy Letby, that occured for Baby G at the Countess of Chester Hospital.

Arrowe Park - Birth to Week 10

Baby G was born 16 weeks premature (gestation: 23w6d) on May 31st 2015 at Arrow Park Hospital. Her mother had started bleeding during week 22. She had been taken to hospital for checks and eventually released home. During week 23 her waters had broken and she had been rushed to Arrowe Park. She gave birth in a patient toilet and upon ringing the emergency bell in that bathroom stall, found it to be non-functional. She was extremely premature and in poor condition and was immediately placed on ventilation. She weighed 535g. From July 17 she was taken off ventilator and placed on continuous CPAP. During her entire time on CPAP she had recurrent desaturations. On August 1, during her 8^th week of life at Arrowe Park, she was given several immunisation injections.

Further complicating matters, during her time at Arrowe Park Baby G had also been diagnosed with a metabolic bone disease - osteopenia. While a baby normally acquires around 80% of their mineral accumulation during the third trimester (the last 12 weeks gestation), Baby G had been born late in the second trimester and had therefore missed much of her opportunity to develop sufficient mineral density in her bones. Osteopenia is a metabolic bone disease of prematurity (MBDP) that causes bone demineralisation - which is when the neonate’s bones lose minerals faster than her body can replace them. For such small and extremely premature neonates it can be difficult to maintain sufficient and comparable (to what the neonate would receive in utero) intake of minerals necessary to arrest and reverse the condition. Also, common medications such as corticosteroids and diuretic therapy lead to bone reabsorption - a breaking down and release of even more of the bone minerals into the bloodstream and thus a worsening of the condition. Neonates with osteopenia are often called fragile infants, because it is not uncommon for doctors, nurses and parents to inadvertently break long bones and ribs during even extremely careful routine handling. There is also strong suggestion in recent literature that the hypophosphatemia that comes with osteopenia prolongs the need for ventilator support and that osteopenia delays transition to full enteral feeding.In England, around 7.6% of babies (approximately 48,000 annually) are born premature. Even worse, Baby G was one of the subset of 6% of premature babies (approximately 2,900 annually) born before 28 weeks. Sadly, more than half of all babies like Baby G who are born during week 23 do not survive. For those that do, there is a high probability that life expectancy will be significantly reduced and complicated by a range of debilitating medical conditions that mean parents can become full-time carers.

In 2009 the survival rate for neonates born at or after 24 weeks with osteopenia was 56%, meaning 44% died in the first weeks of life - and survival rates in this group have continued to rise as we understand the impact and needs of the condition more. However, for neonates born at 23 weeks or earlier, greater than 50% will die in this early period. When you consider that by being so premature Baby G already had a probability of survival of less than 50%, and you then factor in the impact of this additional diagnosis, we find that at best Baby G had around a 1.5-2/10 (15-20%) chance of surviving to discharge. That Baby G survived more than 4 weeks was already beating the odds. But we should remember that she would have been very fragile, very unwell, and her survival rate to discharge would have been not much improved. Even the most minor of infection or insult could have upset the delicate balance that was keeping her alive. More serious infections like sepsis and NEC are both risk factors for osteopenia, and common¹ in neonates already diagnosed with osteopenia - with NEC occurring in almost half of all osteopenia-afflicted neonates. NEC is often fatal and negatively impacts osteopenia by further increasing bone reabsorption.

She was cared for at Arrowe Park for ten weeks until the night of August 13, when she was transferred to the Countess of Chester Hospital (CoCH).

Countess of Chester Hospital - From Week 10

Within one shift of Baby G’s arrival at CoCH, on the morning of August 14, nursing notes written by Nurse Bennion showed that Baby G had come to CoCH on CPAP to support both inhalation and exhalation with 29-40% oxygen supplementation. However, during that first morning the doctors had decided to begin trialling Baby G off the CPAP for 1 hour, twice daily. They were also considering whether to do away with CPAP altogether and replace it with the less supportive Optiflow nasal high-flow (NHF) cannula.

At this point in time all nutrition and fluids were being supplied to Baby G via enteral feeds - through a nasogastric tube positioned to deposit the fluids directly into the stomach. Those first notes by Nurse Bennion’s also show that while most neonates with osteopenia would be provided various mineral and vitamin supplement infusions, Baby G was not currently being treated for her osteopenia.

Incident 1 - September 6-7

Moving forward, at 2:00am on September 6, Baby G’s feeding chart showed she had progressed to being fed with expressed breast milk (EBM). A breast milk fortifier², a powdered supplement containing additional calories, proteins and white-powder vitamins similar to baby formula, was being added to Baby G’s EBM. This is usually done to promote growth and bone development and to aid the neonate to put on weight. Baby G was also requiring regular doses of Gaviscon. Gaviscon would normally also be mixed into her EBM and because of its sterile nature, should not be stored prepared and therefore only be opened and prepared with the feed at the time of administration. Gaviscon is normally only given to babies with a strong relationship between administration of feeds and a gastric reflux issue. There are significant contraindications for the use of Gaviscon in children under 1 year³, and most hospital protocols strongly urge caution when administering to premature neonates. Lucy Letby had been on night shift and administered several medications to Baby G during the early hours of September 6, witnessed by another nurse.

At 7:30am on September 6, Nurse Blamire became the designated nurse for Baby G during the day shift. Nurse Blamire recorded hourly observations for Baby G and was co-signer for some of her medications.

Dr Brearey recorded observations in a clinical note at 11:00am.

It had been charted by this point that the now 14 week old Baby G weighed 1.985kg - but it should not be forgotten that this was still technically 2 weeks before what should have been her term due date.

Nurse Blamire’s nursing notes at 3:37pm record that all safety equipment was present and correct, and that Baby G continued to receive regular feeds. At 6:44pm Nurse Blamire recorded that Baby G had received another bottle and a bowel movement. Up to this point there have been no issues identified or raised that could reflect on the care provided by Letby on the previous shift. Baby G appears all through the day shift to be stable and to have no major concerns.

Handover of the seven neonates on the unit to the night shift consisting of five nurses took place at 7:30pm. The unnamed nurse became the designated nurse for Baby G in Room 2, and Lucy Letby was designated to a neonate next door in Room 1. Remember that one of the five nurses would have been the shift leader, who would not normally be allocated a specific baby but would manage the ward and float between and potentially cover the other four nurses as they took breaks during the night. This means the ratio was more correctly four nurses to seven neonates (4/7), with some requiring 1:1 care.

The unnamed nurse directly cared for Baby G during the shift and documented observations and other procedures. Baby G’s observation charts were described in court as having been documented every three hours, and as showing Baby G’s heart rate was always in the ‘normal range’ during the night shift. Lucy Letby co-signed as the witness for some instances where the unnamed nurse prepared and administered medications to Baby G. For other instances during the shift such as the medication recorded as being administered at 1:46am on the morning of September 7, Baby G’s 100^th day since birth, Nurse Simpson signed as having witnessed the unnamed nurse during preparation and administration.

The unnamed nurse charted observations at 2:00am. These recorded that aspirates with a pH of 4 were drawn and that Baby G had just received 45mls of milk (EBM plus fortifier plus Gaviscon) enterally via the nasogastric tube. She commented that Baby G appeared to be asleep during this time.

At 8:57am Lucy Letby recorded a retrospective note charted for 2:00am stating that care of Baby G was transferred to her following, meaning after, a large milky projectile vomit at 2:15am. Her note reported that Baby G had continued to vomit excessively and that 45mls of milk and a large volume of air was drawn out of Baby G via the nasogastric tube. She also reports that Baby G’s abdomen was distended (bloated) and discoloured, and that while the colour improved a few minutes after aspirating the stomach, the abdomen remained distended but was now soft. Registrar Ventress was on duty and was asked to review, but had been called to theatre. She advised that Baby G should be switched to IV fluids and enteral feeds should cease. The unnamed nurse recorded a retrospective note at 7:49am saying that she had transferred care of Baby G to Lucy Letby following a vomit and apnoeic episode after the 2:00am feed. Her note also records that Baby G’s father had been present on the unit for the first part of the night, that Baby G’s abdomen had been full but soft and that she had observed Baby G had a period of straining or uncomfortability whilst being held by her father. The parents, once notified, arrived back on the unit at approximately 3:45am and were therefore present for events that occurred after that time. Registrar Ventress at 4:40am recorded a retrospective note timed for 2:35am saying that she had been called to review Baby G at 2:35am, that Baby G had a very large projectile vomit that reached the canopy (hood) of the cot and chair next to the cot, was distressed and uncomfortable, and was red in the face and purple all over. Her note also prescribes resumption of Oxygen via the NHF nasal cannula at a rate of 1litre per minute.

Letby recorded a nursing note at 3:00am saying that Baby G’s bowels had opened and she had had a very large green watery stool. At 3:15am she added that Baby G had suffered a ‘profound desaturation’, with her oxygen saturation level dropping to 20% with marked colour loss, apnoea and bradycardia at 50 heart beats per minute (bpm). The neopuff with 100% oxygen was used and Baby G’s observations (breathing, heart rate and oxygen saturation) improved but she remained apnoeic.

Reg. Ventress was called out of theatre and told of developments with Baby G. It was she who had previously noted that Baby G should be nil by mouth and cannulated so that intravenous (IV) fluids could be administered. However, this had been delayed due to her being called to deliver another baby in the delivery suite.

Reg. Ventress eventually arrived and witnessed the ongoing intermittent apnoea issue, noting that Baby G’s oxygen saturation was only 50% in 100% oxygen, and that was in spite of Letby correctly applying the neopuff device as well. Reg. Ventress noted that Baby G’s heart rate was ‘ok’. Dr Brearey’s retrospective notes recorded for 3:30am report that he was called in at that time because Baby G had had a large vomit and loose watery stool followed by desaturations and bradycardia. He states that on his arrival to the neonatal unit Baby G was intubated by Reg. Ventress and that a small amount of blood was visible on intubation, that blood samples were taken and sent off, and that Baby G’s oxygen saturation was ‘good’ after she had been intubated. At 3:15am Baby G was moved to Room 1 of the neonatal unit - the room for intensive care babies. Her parents were advised of the incident by the unnamed nurse at 3:45am.

The blood samples for Baby G were recorded as having been taken at 3:59am, and Nurse Letby recorded observations, and fluid balance and intensive care charts at 4:00am. As she had been moved to intensive care, Baby G’s observations would now be recorded hourly instead of the previous three-hourly.

An x-ray of Baby G’s abdomen was taken at 4:49am. The report records ‘generally slightly distended bowel loops, but gas noted in rectum, no transition point, mural or free gas detected on balance’. Essentially, he is saying that Baby G’s abdomen was slightly swollen, that there was ‘gas’ (flatus?) in the rectum that had yet to pass through the anal sphincter, that there was no evidence of areas where the bowel changed from being dilated (swollen with air) to obstructed or normal (so-called ‘transition points’), and that on his assessment no gas had escaped into (mural gas) or beyond (free gas) the intestinal wall. As I have noted in previous articles, free gas is notoriously difficult to detect - especially where, as is common in the neonatal setting, a single top-down image of the patient is taken.

Nurses Letby and Simpson co-sign for medications prepared and administered to Baby G at 5:15am, and for a neonatal infusion prescription (fluids) at 5:30am. Reg. Ventress’ medical notes also timed at 5:30am record that Baby G had another profound desaturation event with her heart rate dropping to 60 bpm and oxygen saturation as low as 40%. Baby G was taken off of the ventilator and the neopuff, via the ventilator’s endotracheal tube (ETT), was again used to recover her observations. Reg. Ventress diagnosed that there was a ventilator problem and after initially replacing the flow sensor, elected to swap out the entire ventilator unit. Dr Brearey’s own notes for the same time record that Reg. Ventress also changed the ETT and that the replacement showed ‘less leak’. This means that within a two hour period Baby G had been intubated twice by Reg. Ventress. The final notes for this incident say that Baby G had been sedated, and that her ongoing management plan needed to be discussed with Arrowe Park or Liverpool Women’s Hospital.

Baby G continued to deteriorate, having another desaturation and bradycardia event at 6:05am. While with treatment her heart rate mostly recovered, her oxygen saturation stayed at 50%. At 6:10am Reg. Ventress removed the ETT (Baby G’s second extubation in only 35 minutes) and observed a large amount of thick secretions in Baby G’s mouth. She also noted a blood clot at the end of the ETT. Baby G was then given positive pressure ventilation via a facemask until 6:15am, when Reg Ventress again sedated and reintubated Baby G for the third time in under 3 hours. During this procedure, Reg. Ventress reported the appearance of blood-stained fluid in the oropharynx.

Reg. Ventress also reported aspirating approximately 100mls from Baby G’s stomach via the nasogastric (NG) tube and that Baby G’s abdomen appeared ‘very large’. This suggests there was continued distention of Baby G’s abdomen.

Dr Brearey’s notes stated Baby G’s capnograph at this time was ‘positive’ but on the evidence presented in court it was difficult to identify what that meant. Was the capnograph generally positive overall? Did it provide a positive indication for respiratory distress? Or shock? All we do know is that the two doctors planned to continue Baby G’s current medications including an infusion of the respiratory depressant, morphine. In stark contrast to the ‘positive’ tenor Dr Brearey’s notes, Nurse Letby’ nursing notes recorded that Baby G had been sedated and reintubated at 6:15am, had clear air entry with bilateral (both sides expanding equally) chest movement, had been started on a 10% glucose infusion and the morphine infusion. However, the net result was that Baby G appeared agitated and was described as ‘fighting the ventilator’. More medication was administered and Baby G appeared to settle and synchronise with the ventilator. The medications were co-signed again by Nurses Letby and Simpson.  

A second x-ray was taken and reported at 6:36am, with the significant change being that the appearance of the lungs was improved, which the radiographer put down to improved inspiration.

Just after the day shift took over on September 7, Dr Harkness visited the neonatal unit and at 9:00am made notes regarding his observations of Baby G being ‘paralysed and sedated’ but ‘well perfused’. He noted that the plan was still to discuss Baby G’s situation with Arrowe Park or Liverpool Women’s Hospital, meaning this had not yet been done. Letby, who whilst now being off-shift and preparing to leave to go home and sleep was diligently still writing up her patient notes at 9:15am. She wrote that the parents had been fully updated by herself, Reg. Ventress and Dr Breary, and that they were anxious but understood the need for ventilation. At 10:00am Dr Harkness updated his note to say that Baby G’s colour had ‘improved’. An umbilical venous catheter (UVC) known as a ‘long line’ was inserted at 3:00pm but it was apparently not until around 3:30pm when Dr Jayaram spoke with a consultant neonatologist at Arrowe Park. Dr Jayaram’s note at that time simply states: ‘spoke with consultant neonatologist at Arrowe. Agrees with current management plan.’ He too noted the distended abdomen, along with ‘cool hands and feet’. He also noted that Baby G’s blood gases had raised metabolic acidosis.

A further medical note recorded at 4:30pm says that Baby G needed another long line, and that she remained unwell.

During the early part of the day shift Baby G had two more desaturation and apnoeic events and her ventilation was increased. During the day her blood pressure deteriorated and her IV cannula site became white. Her infusions were moved to another cannula, which was why the doctors had been trying to get a patent long line inserted. At 9:45pm that night and after consultation with a consultant neonatologist from Arrowe Park, the decision was made to transport Baby G back to Arrowe Park’s NICU. The ambulance was booked for 10:43pm yet at 11:00pm Baby G was still on the unit and had observations recorded by her designated nurse, Nurse Simcock. At 11:35pm she recorded another set of observations, administered morphine and a dose of antibiotics. This is the first time we hear about Baby G receiving antibiotics. Her note concludes that they were still awaiting the transport team.

The unnamed nurse who was designated nurse for Baby G during the day had texted Lucy Letby at 6:06pm saying that during the day shift they had finally decided Baby G had sepsis. In a text message sent to Lucy Letby later in the evening she said that they had put Baby G on ‘triple antibiotics’, which tends to confirm the implication that the dose mentioned above may have been one of the first or first few Baby G had received.

The transport team arrived at midnight. An unnamed consultant paediatrician recorded notes at 1:00am on September 8 saying that Baby G was still very sick. At 1:05am as they were preparing to take her, the Transport teams notes recorded that Baby G’s abdomen was very distended, full and veiny. The formal handover to the transport team was recorded at 2:35am and Baby G left CoCH at 3:00am.

Baby G stayed at Arrowe Park from September 8 to September 16, when she was unfortunately to return to CoCH.

Discussion

As we have discussed in earlier articles, every additional procedure a neonate must endure increases the risk for infection and impacts their survivability. Baby G had been considered generally stable until she was transferred to CoCH. It can be seen that as soon as she arrived at CoCH the doctors there decided that, rather than seeing her stable over a day or two first, they would immediately change up her treatment and management plan. The negative effects of this decision can be eventually be seen in that after a period her health seriously deteriorated such that early in the morning of September 7th her designated nurse had to call in a nurse from another part of the unit who was more qualified to deal with intensive care babies, which is how Lucy even came to be involved with Baby G. Baby G was already seriously unwell, and from this point on was more under the care of the doctors, specifically Reg Ventress and Dr Brearey, for what was both the next few hours of her life, and the remaining hours of Letby’s shift. Even though Letby went off shift and handed over to another nurse, Baby G’s health continued to deteriorate and she continued to show overt signs and symptoms of serious infection, although it would not be until hours before she was returned to Arrowe Park before her treatment for sepsis was commenced. As we saw, in the space of around 13 hours Baby G had three intubations, two extubations, an IV inserted, has been heavily sedated and has had two insertions of the UVC long line. The IV would also go on to be resited, but that would happen later in the evening.

Of all of the babies to have ended up in the CoCH neonatal unit, and that were described during the Letby trial - Baby G was the most premature, most fragile and most likely to have died no matter what anyone did.

It seems inconceivable that when Baby G had a medical condition (osteopenia/MBDP) that is associated with a prolonged requirement for breathing support and had been receiving continual breathing support for the entire period before arriving at CoCH, the doctors at CoCH chose within her first day, even within her first hours on CoCH’s neonatal unit, to discontinue continuous breathing support. It would seem more prudent in hindsight to have allow Baby G to settle into the unit and monitor her for any signs of stress from the transport process and change in environment.

Further, and given that the implication was always that Letby had done something to the breathing tubes and throats of several babies, including Baby G, to cause them harm, it should be noted here as well that the first instance of blood in Baby G’s throat was: (i) when she had just been intubated by Reg. Ventress; and (ii) while Reg. Ventress and Dr Brearey were still in charge of and caring for Baby G. Yet the prosecutor, Mr Johnson, made the point of stopping testimony on December 1, 2022 at around 11:24am to posit the question, “This is another case where a baby is bleeding at the mouth?” This question, articulated rhetorically and more as a statement of fact, cannot have been intended any other way except to lead (or bias) the jury to believe that somehow Lucy Letby had caused the bleeding even though intubation of such a tiny neonate commonly results in minor oral or throat scratches and bleeding, and in this case the most likely cause was the multiple intubations and extubations being performed at that time by Reg. Ventress.

One consideration that seemed largely absent from any of the clinical testimony and medical notes was that of the fact that the oesophageal bleeding ‘beyond the vocal chords’ was only appeared to get worse with the repeated intubation and extubation of Baby G. There is also a complete lack of consideration for the fact that prolonged (more than 10 days) intubation of neonates can lead to a range of medical complications, from oro-dental to respiratory distress, ventilator-acquired pneumonia and even injuries to the oropharynx, temporomandibular joint and tongue. Finding blood or blood-tinged fluids on the ETT tube is also common, and can potentially indicate complications from pulmonary haemorrhage to neonatal pneumonia. Neonates at the highest risk of neonatal pneumonia are those who are born earlier than 28 weeks gestation and those with a range of other complications and comorbidities (hypoxia, acidosis, hypovolaemia, congestive heart failure, coagulation abnormalities etc.). Baby G was born at 23 weeks gestation and was frequently hypoxic.

However, and as with all of the previous neonates we have considered, the evidence after this first incident strongly supports the possibility, consistent with the others, of bacterial infection causing sepsis or NEC. The reflux, projectile vomiting, distended abdomen, discolouration and bloody or dark green bowel movements (remember the watery green diarrhea) are all potential signs of NEC (here and here).

Green watery bowel movements can also be indicative of a blockage or narrowing of the bowels.

It is disturbing that the first time we heard of Baby G receiving antibiotics was as they were preparing to transfer Baby G back to Arrowe Park. Given all the signs and symptoms suggestive of sepsis or NEC, we can only hope that Baby G had actually started to receive antibiotics much earlier than this.

We can sympathise with the parents if, as they testified, that all the way along the doctors told them only that the effect of her prematurity and all her comorbidities meant that Baby G would be ‘a little clumsy’. The parents should have been prepared from the beginning with the expectation that if she survived, Baby G was very probably going to require significant care and would not have a normal life or life expectancy. As I described in the opening paragraphs of this article, around half or more of all neonates born before 24 weeks die. Of those that do survive, more than half will have a shortened life expectancy affected by debilitating medical conditions.

Sadly, when she finally went home 56 days after the events described above, Baby G was a blind or near blind quadriplegic with cerebral palsy being fed enterally through a tube. Baby G required full-time nursing care in the home. We should all have compassion for the parents irrespective of the outcome of the Letby trial and any future appeals and retrials. They, like all parents, would have been hoping for a perfect baby. And while they may still consider their baby to be perfect, it is and was never their fault that their child requires such complex care and is unlikely to ever grow up and be independent.

We will continue investigating the events surrounding Baby G after she was returned to CoCH in the next article.

The next post in our series on the Letby Trial can be found here.

E&OE

1. In this study (published April 2021) nearly half (46.2%) of all premature neonates with osteopenia went on to develop sepsis, and more than one-third (38.5%) of all premature neonates with osteopenia developed NEC. Given that sepsis is often the precursor of NEC, this suggests that 83% of all babies with osteopenia that develop sepsis will escalate to NEC. Another more recent study (published February 2023) found almost identical incidence rates.

2. These are usually described as a commercial human milk fortifier (HMF).

3. Gaviscon Infant is not recommended by the manufacturer for use in babies under 1 year, and especially premature babies.

***Note that the image of a premature neonate in a hospital cot is not Baby G, but a random open source public access image sourced via Google.