LL Part 7: The Demise of Child C

Was she or wasn't she? Why are there so many contradictions?

Following on from our previous post (here)

June 10th

Evidence relating to the birth of Child C shows that this baby was growth restricted or small for gestational age (SGA) as a result of the mother being gestationally hypertensive (high blood pressure during pregnancy). The primary clinical issue that midwives and obstetricians seek to monitor and avoid in such cases is preeclampsia, which can result in the negative outcomes of stillbirth and maternal death. On the 10^th June, 2015 the mother, who had been staying in the hospital and therefore had an increased risk for nosocomial infection and, if not moving around sufficiently, deep vein thrombosis (DVT), had a scan that found an increased risk of stillbirth. She was taken to theatre shortly after and an emergency caesarean section (CS) was performed to deliver the baby.

The paediatric registrar in theatre, Dr Ogden, described Child C as ‘smaller than expected for that gestation’ as he was premature and weighed only 800 grams - and while the mother testified that nursing staff told her they ‘weren’t particularly concerned’ for his immediate care, as in most instances this is often said simply to comfort the naturally anxious and worried parent and should not have been used in court as it cannot be relied upon as proof of the accuracy of the claim made in the statement.

On arrival at the neonatal unit Dr Ogden noted signs that Child C was struggling to breath. Such collapse at some point between one hour and even up to one day after birth is not unusual. Midwives often talk about the fact that a baby immediately at birth wants to live and does everything it can to survive. But after some minutes to hours, and as the hormones like adrenaline that are circulating around in the baby’s blood stream wear off, the baby can be seen to collapse. Any potential issue such as respiratory distress syndrome (RDS), infection, or a congenital abnormality might only be properly noticed only after the baby starts this post-birth change from strong and healthy to collapse. He was immediately intubated and put on a ventilator. Dr Ogden admitted on the stand that this breathing issue could, on the face of it, be a sign of infection. A UVC and 10% dextrose solution were also ordered for Child C and one of the doctors had a discussion with the staff at Liverpool Womens’ Hospital regarding whether, due to his low weight, they were of the view he should be transferred to Liverpool. It was concluded that, for the moment and unless further issues arose, he would remain at CoCH.

June 12th

Moving forward to the morning of June 11^th, 2015, Child C was extubated and placed on CPAP with 41% oxygen support. His UVC had been taken out due to being ‘tissued’ (no longer in the correct position or patent), and he was awaiting insertion of a ‘long line’. Observations show that his respiration rate was becoming elevated even with the breathing and oxygen support and, like Child A, his lactates were getting high. His urine output was high, and his CRP levels were gradually increasing. A request was made to screen him for sepsis and he was placed on antibiotics in the short term ‘as a precautionary measure’.  At this point the parents were able to hold him outside the incubator for short periods. Dr Beech managed to insert the ‘long line’ on the third attempt, which was found to be properly positioned on x-ray. The x-ray also revealed that Child C had large amounts of gas in his stomach and intestines - which Dr Beech testified might have been CPAP belly - a common and far simpler reason for air to be there than the prosecution claim that Lucy Letby injected it. Child C was awaiting a lumbar puncture. Her contemporaneous clinical notes describe Child C as ‘comfortable’ and she testified that there were ‘no significant concerns’ for Child C at that point.

Yet again, and as with Child A, we have a neonate with signs of, and being treated as if he may have, a systemic nosocomial infection. Incongruently however, each clinician was writing contemporaneous notes asserting that Child C was ‘happy’ and ‘comfortable’, and during testimony in court brushed all evidence of any negative signs and symptoms aside by saying for each one that there was ‘nothing to worry about’.

June 12th

Another unfortunate issue that arises for the prosecution at this point is that the Neonatal Unit deputy manager testified that her clinical notes for Child C for June 12^th, 2015 had actually been recorded against a completely different child’s medical record. She testified that this was an ‘admin error’ - however, based on my own technical knowledge of these systems (having actually deployed, supported and championed more than one) such mistakes are almost always down to user error. She will have opened the wrong patient record or taken over a session on a computer that already had another child’s information open. She claimed that the error was noticed quickly, but described notes retrospectively entered on the 14^th as being the correct addition of her missing notes to Child C’s record for the 12^th. This would mean that it took two days, and only after Child C had died, before these notes were found to be missing and entered into the computer against Child C. Her notes are contradictory in part. They start out by reporting that the ‘long line’ had been inserted, but they also describe Child C as ‘unsettled at times’ which contradicts the idea proposed by the doctors that he was happy and comfortable. These inconsistencies do not appear to have been identified or addressed by those present in the courtroom. She also reported that Child C had been ‘too unsettled’ for the doctors to perform the lumbar puncture that might have identified if he had an infection in his cerebrospinal fluid (CSF). She also reports on observing the black bilious aspirate from Child C’s nasogastric tube at 6:30pm, suggesting that this clinical issue had not ‘gone away’. Rather, it persisted all day and into the evening. Her notes are couched in language that would suggest she was present for the events she described. As one of the most senior neonatal nurses present on the ward her observations would carry significant evidentiary weight, and strongly suggest that the medical staff in court were collectively downplaying or glossing over the true nature of Child C’s clinical condition.

June 13th

At 11:00am on June 13^th, 2015 his designated nurse, Deputy Ward Manager Nurse Williams, commenced weaning Child C off of CPAP. At 1:00pm he was taken off CPAP and moved to Optiflow and was noted to be ‘calmer’. A nasogastric tube (NGT) for feeding was inserted, but when fluid came out it was black and staff apparently could not or did not explain to the mother what it was. Dr Ogden described it as ‘dark, black’ and ‘bilious’ in her clinical notes. Nursing notes showed that Child C’s weight had dropped 10.4% to 717 grams. While medical staff and the medical experts during the trial kept reiterating that Child C was ‘stable’ and ‘healthy’ and that his demise was ‘unexpected’, Dr Ogden under cross examination initially sought to say it was hard to say whether Child C had ‘increased issues’, but was eventually forced to admit that there either would or at least should have been concerns at this point and that he would have needed closer monitoring. Whether this closer monitoring occurred is a matter of speculation.  

The black fluid could have been blood that had been standing in the stomach for some time or, given that the baby will have experienced some degree of stress in-utero as the mother became unwell and needing the emergency CS, a substance called meconium. Meconium is the black first stool that babies pass usually not long after birth but sometimes during or even before they are delivered. However, in order to have been inhaled or swallowed, meconium would have been visible in the placental sac and all over Child C as he was delivered. We have not heard testimony during the trial regarding this element and therefore cannot definitively say whether there was meconium present at his birth. It is, however, very common. But, this leaves us with the most likely option which is as Dr Ogden suggested, that this fluid was bile. Bile, or gastric juices, often has a greenish-black colour and is a common early sign of infections in the upper gastrointestinal tract such as Necrotizing Enterocolitis (NEC). NEC is a serious and life threatening infection caused by common hospital pathogens that I described in this earlier article. Both Nurse Williams and Dr Ogden noted in the medical record and while giving testimony that NEC was ‘a possibility’ and that the continued bilious aspirates during the day and afternoon were ‘a sign of NEC’. They both agreed NEC increased the risk of infant mortality and Nurse Williams agreed that this was a serious concern. Dr Ogden agreed under cross examination that Child C was a ‘high risk’ baby but sought to have the jury believe that in spite of all these very clear and present health issues, he was somehow in ‘good condition’. Yet, and somewhat confusingly, Child C was not being treated for suspected NEC. He wasn’t even being treated for the earlier suspected sepsis infection any more.

Child C was considered by Nurse Williams to be ‘feisty’ and ‘unsettled’, as he managed to pull his nasogastric tube (NGT) out twice during the morning of June 13^th, 2015. The NGT had been on ‘free drainage’ in order to drain any air building up in the stomach and allow the nurse to check for aspirates (the black bile). She described his abdomen in her notes as having ‘a slight shine but not veiny or distended’. This is the reason she still questioned whether he had NEC or not, as NEC usually presents with a distended abdomen. Nurse Taylor also testified as to ongoing concerns regarding NEC. However, and incongruously, Nurse Taylor described Child C as a ‘stable baby’ even after being shown evidence that he may not have been so stable. She even sought to downplay any significance of the ongoing bile aspirates. Ranitidine was administered via the NGT to counteract the bile aspirates, and it was decided that if the aspirates ceased he could commence evening ‘trophy’ feeds (test feeds of 1ml of expressed breast milk). However, and as we have already seen, the bile aspirates continued into the late afternoon amd evening.

A new graduate or junior nurse, Nurse Ellis, who had only been a nurse at the hospital since January was made Child C’s designated carer under the observation of a more senior nurse for the night shift on June 13^th, 2015. While Nurse Taylor was meant to be the ‘more senior nurse’ and was responsible for two other babies in the same room, Lucy Letby was present on the ward and had two lower acuity children to care for - the most serious of which only requiring hourly observations. Nurse Ellis described Child C as ‘doing well’ but ‘feisty’ between 8:00pm and 11:00pm.

Not long after 11:00pm Nurse Ellis reports leaving the room and being ‘just around the corner’ as she heard the alarm. By the time she re-entered she says Lucy Letby was beside Child C’s incubator. Lucy reported that Child C had just had a decel (bradycardia, or a drop in heart rate) event and a desat (drop in oxygen saturation). Curiously, Nurse Ellis cannot remember what Lucy was ‘doing’ at the time. She does not, however, report that Lucy had opened or had her hands anywhere near the incubator. The decel and desat both resolved quite quickly, and it did not appear that anything needed to be done for Child C as he had ‘self corrected’.

Nurse Ellis then says she sat at the computer near to but with her back to Child C’s incubator. She recalls that Lucy was still ‘in the room’ but not much else. Child C then had a further decel and desat which ‘did not resolve’ and required resuscitation. She says that when she ‘turned around’ Lucy was standing at the incubator. However, of the three nurses to testify on this point Nurse Ellis appears to have been the only one who remembers Lucy as being ‘near the incubator’.

Nurse Taylor described that she had also been in the room and had performed the neopuff procedure, but struggled to get any chest movement. At some point Lucy had come and suggested use of the ventilation support device known as the Guedel to aid Child C. A Guedel is a clear rigid and curved air tube colour-coded by size that goes into the mouth and holds the tongue down and out of the way so that the airway is clear at least for the oral portion. The Guedel was again followed by the neopuff as another nurse, possibly the shift leader as we will see later, asked Nurse Ellis to put out a crash call. That nurse remained in the room as Nurse Ellis went to put out the crash call and when Nurse Ellis returned, that other nurse was preparing to administer medications ready for Nurse Ellis to continue the chest compressions. The on-call registrar was first to arrive and Nurse Taylor recalls that chest compressions and resuscitation attempts carried on for some time. While she believed Lucy was present, Nurse Ellis could not recall Lucy’s role or what she was ‘doing’. The remaining registrars arrived shortly thereafter. Nurse Ellis became upset, at which point Lucy asked if she wanted Lucy to ‘take over’. Nurse Ellis replied in the affirmative, and simply up and left the room ‘to compose herself’ - leaving Lucy, Nurse Taylor, the other nurse, and the doctors all working on Child C.

Nursing notes say that Child C was handed over to Nurse Taylor after the crash and subsequent resuscitation. Nurse Taylor, you will recall, was the nurse who looked after Child A during the day shift as he too gradually declined and eventually died just after she had helped Lucy Letby start the dextrose infusion.

Reliability of Nurse Ellis’ recollection of events both when she wrote her retrospective notes the morning after Child C’s death, and in court, was questionable. Nurse Ellis at one point testified that while Lucy Letby was present for the second decel and desat event, she was not present for the first. If true, this would be significant as it would mean the prosecution cannot actually link Lucy as the instigator of the decel and desat events for Child C. However, during cross examination she couldn’t actually recall whether there had even been one or two events, nor even which one Nurse Taylor had been present for. When it was shown to her that she had never actually mentioned the first event in her nursing notes, she responded with refreshed memory that she must have ‘forgotten to write it’ because ‘it was a traumatic shift’.

In conflict with her evidence during trial, Nurse Taylor’s police statements had said it was Nurse Ellis who called her over when Child C had crashed, and she made no mention of Lucy Letby even being in the room. Under cross examination, Nurse Taylor claimed the police statements sworn years before and temporally closer to events were wrong and that Lucy had actually been there before the crash occurred - and had been ‘cool and calm’ as events unfolded. In fact, she testified on October 28^th, 2022 based on refreshed memory, she claimed she didn’t think it was necessary to include information regarding Letby’s presence to police. Another contradiction comes with the evidence of the shift leader who described only seeing Nurses Taylor and Ellis at the incubator for Child C, and while she said that at some point Lucy Letby ‘was there’, she could not recall when Lucy entered the room.  

The resuscitation attempt was ceased within 25-30 minutes of Child C’s crash. The medical team elected to withdraw care for him but he continued to ‘gasp’ and have a slow heartbeat for several hours.

June 14th

Child C was eventually given an IV injection of morphine ‘for comfort’¹ before being pronounced at 5:58am on the morning of June 14^th, 2015.

June 15th

On June 15^th, 2015 the mother was contacted by the coroner’s office and advised that Child C had ‘died of natural causes’ - yet Lucy Letby now stands before the court accused of his murder.

It is also significant that when Lucy Letby tells one of her colleagues at around 10:00am the day after Child C’s death via WhatsApp message that Child C has died, the colleague’s immediate reaction is to ask whether the death was caused by infection.

Conclusion

As we saw with Child A, Child C raises a number of issues for an honest prosecution.

While, and as with Child A, the prosecution maintain that Lucy Letby murdered Child C, we are still yet to see evidence for a motive - the mens rea element discussed in Part 2. Similarly, we also still lack evidence, or even the implication for evidence, concerning the act (actus reas) they allege she must have done to bring about the baby’s death. It isn’t, and should never be, sufficient merely to say ‘we think she did this’ or ‘she could possibly have done that’ - such statements are nothing more than speculation. Circumstantial claims based on ‘we believe she did it because she was in the room when...’ are, as I discussed in Part 6, nothing more than mere coincidence while any other possible explanation may remain unexplored or ‘in play’. Note my use of the word ‘possible’. The ‘other explanation’ doesn’t have to be definite, nor even probable. It is sufficient that some other explanation exists that is merely possible absent convincing rebuttal for that possibility.  

Like we saw with Child A, the evidence regarding the ongoing care provided to and medical condition of Child C again is liberally sprinkled with contradiction. We see the same doctor who suspected an infection called sepsis in both Child A and B, seeing the same signs in Child C. However, and unlike Children A or B, for Child C we do actually see suggestion that at least one other doctor and at one senior nurse were also contemplating infection. Yet, and again as we saw for Child A, even as the totality of clinical evidence was demonstrating Child C’s gradual and unchecked demise, each doctor and several nurses testified with refreshed memory that Child C was ‘doing well’, ‘healthy’, ‘not a concern’, ‘nothing to worry about’ and a ‘stable baby’. The two entirely contradictory clinical pictures in juxtaposition demonstrate their avoidance of the truth of their own involvement in each child’s ultimate demise, while decrying Lucy Letby as a murderer for whatever involvement she might have had. 

But the contradictions don’t end there. At least three different versions of events exist between the police statements different nurses gave in 2017 and 2018, and the version of events they described under oath regarding the presence of Lucy Letby near the incubator at the point when Child C ‘crashed’ the final time. Nurse Taylor didn’t mention Lucy’s presence in her original police statement. At all. The shift leader mentions seeing only Nurses Taylor and Ellis at the incubator when the alarms went off. Yet, under oath Nurse Ellis is adamant that Lucy was there long before, never having actually left after the second decel and desat event. And that brings us to the issue of how many decel and desat events actually occured. Nurse Ellis’ clinical notes only mention one, the one she calls the ‘second’ and at which Lucy came or was there to help. Yet Nurse Ellis’ testimony says there was another event that occurred prior to the event recorded in her clinical notes. And she said under oath that Lucy was not present for that earlier event. That is a significant contradiction because it means Lucy was not present when Child C had his initial decel and desat event - the one that any reasonable person would say started the ultimate chain of events leading to his eventual death. And if Lucy wasn’t near Child C to have caused that first decel and desat event, how can the prosecution argue that she caused the decel and desats that led to his death?

We also have the contradictions regarding when each infant is transferred to the NICU. In most hospitals it is policy and protocol to transfer premature neonates, especially ones like these who are premature, underweight and show issues that require breathing assistance at birth, immediately to the NICU. Yet, as we saw with Child A, there is a lag of between 4-6 hours between his birth and eventual transfer to the NICU located almost next door within the same building. Similarly, from the limited published accounts of the evidence presented in court for Child C we see a lag of two or more hours between his birth and eventual transfer into the NICU. Where are these fragile and poorly neonates ending up during these periods and what role does that location play in what appears to be the single consistent element in all of their experiences at CoCH - the presence of what appears to be the gradual onset of a nosocomial infection? Also, why is it that we have seen so far that one doctor suspects this infection and orders an initial bolus of antibiotics, only for there to be no mention of the babies receiving the ongoing standard course of antibiotics that should follow once they are transferred to the NICU? A key factor in creating antibiotic-resistant infection is not taking the full course of antibiotics sufficient to ensure that the pathogen is and remains defeated. And a key risk factor along with being premature, underweight and having undergone multiple and repeat procedures in deaths caused by each of the pathogens I described in Part 2 (and in creating the serious infection known as NEC) is that the neonate has previously recieved a short but insufficient course of antibiotics.

We could also wonder why it is that Nurse Taylor was never, as they say in the police dramas ‘in the frame’. So far we have explored the life and death of two of the deceased neonates. In both cases Nurse Taylor was the nurse with primary responsibility for each child - in Child A’s case she was the day nurse who missed all the gradual signs of his demise, and she was the nurse who performed the aseptic technique to connect his dextrose infusion approximately 20 minutes before he ‘crashed’. In Child C’s case she was the supervising nurse overseeing the much junior Nurse Ellis as she had what appears to be her first, or at least a very early, experience caring for the highest dependancy infants.

Finally, an important contradiction to consider is this: Why is it that by all appearances the only contemporaneous patient notes for Child C that actually suggest he wasn’t comfortable, calm, stable or happy on June 12^th, 2015 were the ones that Deputy Ward Manager Nurse Griffiths accidentally entered against another child’s medical record?

The next post in this series can be found (here)

1. A version of the infamous Liverpool Care Pathway