LL Part 5: The Demise of Child A

Inconsistencies everywhere in the prosecution witness' evidence

Following on from our previous post (here)

This article is going to discuss the life and death of Child A.

A timeline of key events will be provided at the end of the article so that you may get a sense of where and when the different elements that are discussed took place.

For the purposes of clarity, terms in BOLD relate to the Shift Cycle area of the timeline. Times in BOLD relate to the actual time on the timeline.

1. Child A was the second of a set of twins born premature by emergency cesaerian section (EMCS) to a mother diagnosed with gestational hypertension (and who it was suspected may have had or was soon to have preeclampsia).

2. Child A was born during the evening of the 7th of June, 2015. Child A had shown breathing issues from his first minutes. Dr Beech testified that while still in theatre she had given him rescue breaths with the neopuff device on several occassions in the minutes after his birth because he repeatedly stopped breathing. A chest x-ray had revealed that Child A had Newborn Respiratory Distress Syndrome. Child A was also given medication to treat for suspected sepsis - a blood infection - prior to his being transferred to the neonatal unit.

3. Child A’s neonatal unit story starts on his first night (Night 1), during which another neonatal nurse cared for him (and during which there is no suggestion that we have seen that Lucy Letby was even on shift or present at the unit).

4. Between 7:30am and 8:00am on the morning of the 8th of June, 2015 Nurse Taylor came on shift and was made Child A’s designated carer for what was his first full day of life (Day 1).

5. Nurse Taylor, his designated nurse during Day 1, gave evidence in chief that she had ‘no concerns’ regarding his heart rate, respiration rate or temperature at any time during her shift. Other prosecution witnesses also testified that there were ‘no concerns’ regarding Child A’s condition during Day 1, nor at the start of the evening shift. However, on cross examination of Nurse Taylor this was contradicted, in that she acknowledged that she had missed evidence that she herself recorded and that we say demonstrates Child A’s gradual decline during the course of her shift. This included:

   1. That Child A’s lactates were already elevated beyond what were considered normal clinical levels at CoCH by the time Nurse Taylor had taken over caring for him. Her evidence also showed that they rose further when re-tested later in the day. Elevated lactates are a sign of anaerobic metabolism and, therefore, poor tissue perfusion (low oxygen causing tissue hypoxia) in the neonate. Elevated lactates for more than 6 hours can cause damage to multiple organs and increase the likelihood of mortality and disability in neonates.

   2. That Child A’s respiration rate had been steadily increasing during her shift. This is another sign that Child A’s body was trying to correct for the tissue hypoxia. We contend it supports the claim that he was actually showing clear signs of a gradual decline over the course of the day (rather than the ‘sudden and unexpected crash’ doctors would later claim).

   3. That child A’s fluid balance was upside-down. It was recorded that he had received only 2mls of donated expressed breast milk (dEBM) during her shift, while he had passed 25mls of urine. This created a fluid deficit in an already unwell premature neonate who should have received a minimum 60ml/kg/day of 10% dextrose solution (here).

6. The first evidence adduced regarding the improperly sited umbilical veinous catheter (UVC) comes in a retrospective note written by Nurse Taylor at 7:05pm, but recorded at the 1:00pm time on the chart. This note records that the: (i) original UVC was improperly positioned; (ii) UVC had been re-sited and was still in the incorrect position; and (iii) Nurse Taylor (or possibly the doctor) was aware Child A had received no fluids for several hours.

7. There is contraditory evidence regarding when the ‘long line’ UVC was inserted. During Nurse Taylor’s time on the stand it was suggested that the long line had been in situ from around 4pm (but she couldn’t say for certain). However, Registrar Harkness’ retrospective notes written at 9:30pm, and therefore after Child A had died, stated that he had visited the baby at 5pm and seen the UVC was not patent, and suggest this was when the ‘long line’ was inserted. Other notes he wrote at 7pm suggest that it was done then on the ‘first attempt’ - but he retrospectively changed this part of his evidence in Court as well, stating that it was probably done at some time ‘between 6pm and 7pm’. Therefore, all that can be said is that we can have no real faith in the accuracy of when the ‘long line’ UVC was actually inserted - just that it happened at some time between 4pm and 7pm.

8. An x-ray review sticker was added to the notes at 7:09pm at which point Registrar Harkness recorded that the ‘long line’ was ‘less than perfect’ and needed to be ‘pulled back’. In Court, and based on what he sought to claim was a ‘quite fresh’ eight year old memory, he stated he now believes his eight year earlier self was wrong and that the UVC was actually in the correct position. He accepted that had it been in the heart it could have caused significant and critical health issues for Child A and, as such, wanted to make certain all present in Court understood that he now remembered it had been appropriately sited and that it was not in any way an issue for Child A. The difference between having the UVC in the correct position at the Ductus Venosus (DV) - Inferior Vena Cava (IVC) - Right Atria (RA) junction, or having it slip into the heart of a tiny <1000g neonate, can sometimes be as little as a few millimeters.

   

9. It can be said that Child A definitely did not receive intravenous (IV) fluids from 1pm until the 10% dextrose infusion was started by Nurses Taylor and Letby at 8:05pm (7 hours and 5 minutes). However, based on the fluid balance issue noted at 5(c) from evidence adduced in Court under cross examination from Nurse Taylor, it is probable he had received no IV fluids for most, if not all, of Nurse Taylor’s entire shift (12+ hours).

10. The first time Lucy Letby learned of Child A was when she came on shift on the evening of the 8th of June, 2015. Lucy arrived and between 7:30pm and 8:00pm was given handover for approximately 15 minutes. She was then made Child A’s designated carer for what would be his second night (Night 2) on the unit.

11. There has been no suggestion that Lucy was involved in or was blameworthy for any other death or ‘crash’ of a neonate that had previously occured on the unit. Child A is the earliest and therefore the first neonate that the prosecution allege Lucy harmed.

12. Nurse Taylor stated that at around 8pm they had performed the emergency equipment checks (a common process in hospital wards at the start of shift).

13. At 8:05pm Nurses Taylor and Letby co-signed that they together had checked and started the 10% Dextrose infusion. This was a sterile (aseptic) procedure that required one of them to be gowned and gloved while the other assisted. While Nurse Letby’s evidence and the clinical notes suggest it was Nurse Taylor who was gowned and gloved and performed connection of the IV solution to the UVC, Nurse Taylor said she could not recall whether it had been her or not.

14. At 8:18pm Nurse Taylor started a computerised clinical note on the ward computer that was within a few feet and had full visibility of Child A’s incubator.

15. At 7:56am on the morning of the 9th of June, 2015, Nurse Letby retrospectively entered her own clinical notes into the computer. She recorded that at 8:20pm she had noted Child A’s hands and feet were white, and that he appeared centrally pale with poor perfusion.

16. At 8:26pm the oxygen saturation alarm sounded. Nurse Taylor says she could see Nurse Letby beside the incubator watching Child A, and that her hands ‘were not in the incubator’. She said she watched and waited to see if Child A would recover on his own as most babies do during a spontaneous desaturation (desat). It seems logical to believe Nurse Letby was watching and waiting for the same reason.

17. Nurse Taylor described that when Child A did not spontaneously recover, she arose and walked to the incubator beside Nurse Letby and they commenced treating Child A. They called to Registrar Harkness, who had been attending another baby in the same small room. He, and a student doctor, Dr Wood, both came. While Dr Wood acted as the scribe, Registrar Harkness assisted the nurses who he said had already commenced giving Child A rescue breaths with the neopuff. Child A’s oxygen saturation had dropped to between 70-80%, his heart rate had slowed (bradycardia), and one minute later at 8:27pm Registrar Harkness called a ‘code’ (the emergency bell was rung to call other staff to assist in resuscitating Child A).

18. Chest compressions were commenced and the first bolus of fluids and an infusion of adrenaline (drawn up by Nurse Taylor) were administered.

19. At 8:28pm Child A’s heart rate was reported as 60-70 beats per minute (around half of what was normal for a young baby). Child A was also intubated at this point.

20. By 8:33pm no heartbeat could be detected. However, resuscitation was continued.

21. With assent from the mother, at 8:57pm resuscitation efforts were ceased and Child A was pronounced dead.

22. At 9:28pm Nurse Taylor wrote a retrospective note timed to before Nurse Letby came on shift but after Registrar Harkness had sited the ‘long line’. This retrospective note recorded that Child A’s ‘observations are stable’ and that he was ‘pink and perfused’. She also entered that the UVC was still in situ but in the wrong position, and was to be used if no other access was available.

23. Child A ‘coded’ less than one hour after Lucy had come on shift, and was pronounced 31 minutes later. According to the testimony and exhibits, the period from Lucy’s arrival on the unit to Child A’s death was a total of 87 minutes. However, we must remember that for the first approximately 15 minutes Lucy was in handover elsewhere in the unit - so the period from when Lucy was allocated Child A to his death is more correctly stated as being around 72 minutes.

Conclusions

Child A raises a number of issues for an honest prosecution.

First, the mens rea or mental component - the intent to murder that I discussed at the end of this article. A common element seen with nurses or doctors who have been serial killers is that there is a reason they select which patients’ lives they take. In this instance one would expect that the nurse had some knowledge of the patient, and had time to form the opinion that the patient was perhaps going to have an awful and potentially painful life that warranted her special kind of ‘intervention’. However, in the case of Child A, there was simply no time for such reasoning and justification to have taken place.

Second, Nurse Letby came on shift (around 7:30pm). Spent 10-15 minutes in handover (7:30pm-7:45pm). Was allocated Child A and went to receive direct handover with Nurse Taylor (7:45pm- 7:55pm). Checked the emergency supplies with Nurse Taylor (7:55-8:00pm). Prepared and hung the 10% dextrose infusion with Nurse Taylor (8:00pm-8:10pm). At this point she began collecting observations of Child A while Nurse Taylor went to sit at the computer approximately four feet away from the incubator, and while Registrar Harkness and Dr Wood were at the third incubator in the room, not more than 10 or 12 feet away. She was in full view of a nurse and two doctors at all times from 8:10pm until a few minutes later when the alarm sounded and Nurse Taylor joined her at the incubator. Even if we were to call this the most opportunistic start to a serial killer’s career, the ability for access and to perform the necessary acts (actus reas) to bring about Child A’s death simply doesn’t appear to have been made out on the evidence provided.

Third, the prosecution and prosecution witness’ claim that Child A was stable, had no ‘concerns’, inexplicably ‘crashed’, that this was unexpected, and finally that this proves Lucy Letby killed Child A. This sequence requires too many inferential ‘quantum leaps of logic’ in order to arrive at the abductive conclusion the prosecutor demands. It simply isn’t a credible tale to spin when their own evidence demonstrated Child A was probably dehydrated, demonstrably acidotic, and that the only thing that was temporally linked to his final demise was that the dextrose infusion had finally been started - but almost certainly several hours too late and possibly delivered using a UVC that was not in the correct position. Registrar Harkness’ contemporaneous notation that the UVC needed to be ‘pulled back’ suggests it may have been in or too close to the right atria of Child A’s heart.

Fourth, several key prosecution witnesses showed that they had either a tenuous relationship with their recollections of events or, perhaps with some degree of guilt and seeking to deflect any potential blame elsewhere, created selective ‘refreshed memories’ of key events when giving evidence. It is simply incredible (meaning not credible) for a well-educated doctor to claim to have a ‘quite fresh’ recollection of the minutia of events from eight years and maybe a thousand or more patients ago, only to go on to contradict in key areas the version of events he recorded in nearly contemporaneous clinical notes (and probably described to police in the years since). It is equally incredible for a nurse to claim, whilst looking at the observation charts she wrote at the time, that there were no concerns about the infant then or now even as various indicators showed the early but clear signs of Child A’s demise.

It is these last points that support suggestions made by other qualified people online that the Lucy Letby prosecution might look from the outside more alike a witchhunt.

Addendum:

Later evidence from Neonatal Practitioner Caroline Bennion shows that she too was also present in the neonatal unit room where Child A was located - as she was tending to Child B at the time Child A ‘crashed’ and had been there from 7:30pm through to when the emergency was called for Child A. Given that Child B’s incubator was beside Child A’s incubator, this not only means there was a fourth person in the small ward room with visibility for what Lucy Letby was or was not doing, but it also means that like Nurse Taylor, Ms Bennion was standing no more than 4-5 feet away and had a better than excellent view. This evidence must significantly reduce the likelihood that there was an opportunity for Lucy to have done anything to Child A in the only window of opportunity - between the time that she and Nurse Taylor finished hanging the dextrose infusion and around 8 minutes later when the neonate’s O2 saturation alarm went off.

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The next post in this series can be found here