LL Part 8: The Death of Child D

Had she been left or resumed on CPAP, she might still be alive today.

Following on from our previous post (here)

June 18, 2015

1. The mother of Child D reports spontaneous rupture of membranes (SROM), meaning her waters had broken, early on the morning of June 18, 2015. She attended hospital at around 11:30am and midwives confirmed her waters had broken. She was sent home to await normal commencement of labour.

June 19, 2015

2. On June 19, 2015, at around 7:00am the mother returned to the hospital and because the she expressed concerns over the fact that her waters had broken more than 24 hours hence, was asked several questions by the midwife she saw. The mother confirmed she had come to the hospital the day before and that after waiting some length of time had been checked over and, in spite of her own concerns, had been sent home.

3. The decision was made to induce Child D but due to staff being busy the mother had to wait until a bed in the induction suite became available. The mother was eventually placed on a ward where she stayed overnight.

June 20, 2015

4. The mother expressed feeling ‘very worried and scared’, ‘unwell’, ‘not in control’ and ‘forgotten by staff’. She described that it was only after she had been to the bathroom on the morning of June 20, 2015 and had a ‘bloody show’ that a doctor was called who decided that they should continue watching and waiting for natural birth and that he would review in 4 hours.  

5. When reviewed at 11:00am on June 20, 2015, it was found that there was little change and that there had been very little dilation of her cervix in preparation for delivery of the baby. She was scheduled for another 4 hour review at 3:00pm at which, in part due to the fact that she was more than 50 hours post-SROM and in part because there was still no suggestion of dilation of her cervix, it was decided she should undergo emergency caesarean section (EMCS) as it was ‘not a good idea to wait any longer’ because the baby ‘appeared distressed’.

6. Child D was born at 4:01pm by EMCS on June 20, 2015 and required immediate breathing support.

7. At birth, Child D was described by the mother as ‘limp and pale’, ‘struggling to breath’ and ‘making a groaning noise’. Child D’s O²sats at birth  were 48%. A male paediatrician attempted to reassure her by telling her that because Child D had been born by caesarean, breathing would not be ‘as clear’. The mother described this paediatrician as ‘too careless’. He did not appear to her as inspiring confidence in his abilities.

8. Child D was sent with the father to a postnatal room to await the mother. After the mother’s incision had been closed and she had recovered, she was taken to the ward where her husband and baby were located.

9. The mother was worried about the appearance of Child D and was told by the paediatrician that one of the midwives would ‘assess Child D in a couple of hours’. She did not want to wait that long and after the same doctor had spoken with the consultant, Child D was taken to the NICU. Clinical notes show Child D was ‘grunting’, a clear sign she had respiratory problems, and had a ‘dusky’ appearance. She was admitted to the NICU at 7:30pm.

10. At 8pm Dr Rylance noted that Child D was on CPAP at 40% oxygen with saturations at 100%. Heart sounds were ‘normal’ and her pulse rate was ‘ok’. She noted regular breathing efforts but described them as ‘fairly shallow’ and the baby’s abdomen was not distended. She recorded that the plan was to continue CPAP and administer dextrose solution, and to repeat the blood gasses at 8:45pm.

11. At 8:20pm Dry Rylance noted that the parents had been updated on Child D’s condition, that Child D ‘likely had sepsis’, and was receiving antibiotics ‘to treat infection’.

12. Dr Chowdhury later noted that: ‘on moving the baby to the labour ward she had become blue/dusky. Child D’s O²sats on arrival NICU were 47%. With bagging and oxygen her O²sats rose’. Child D was ordered: (i) antibiotics; (ii) CPAP with 40% oxygen; and (iii) ‘double phototherapy’ because she was jaundiced.

13. An x-ray was performed showing ‘shadowing consistent with transient tachypnoea of the newborn (TTN). TTN is a respiratory disorder caused by a delay in clearance of fetal lung fluid after birth and causes ineffective gas exchange in the lungs (the low O²sats), respiratory distress and tachypnoea (abnormally rapid breathing). After the x-ray result Child D’s CPAP was removed and she was intubated with an endotracheal tube (ETT) and connected to a ventilator.

June 21, 2015

14. The following day, June 21, 2015 at 9:00am Nurse Bissell notes that Child D was ‘extubated following satisfactory blood gas’. On being extubated Child D was ‘initially apnoeic and required stimulation via neopuff/CPAP, but the breathing became more regular after a couple of minutes’. Eventually CPAP too was discontinued.

15. The mother was spoken to by a female consultant who described that Child D ‘wasn’t great’. Incongruently, Dr Brunton between 9:00 - 9:30am also spoke to the mother and said he was ‘very happy’ with Child D’s test results and described the neonate as ‘well’.

16. Nurse Bissell later noted that Child D’s blood gas (lactate) at 10:14am with the results ‘showing signs of respiratory acidosis’. Child D’s pH was 7.194. Child D was put back on CPAP.

17. Blood gasses at 12:10pm ‘showed further deterioration with increased metabolic acidosis’. Child D’s pH was 7.173, her perfusion was noted to be ‘poor’ and a doctor approved a decision to administer further medication.  

18. At 2:00pm Dr Rylance recorded insertion of a UVC and UAC. She said the UVC was removed as it was ‘only able to advance to 5cm’ and usually it should advance much further. The UAC was advanced to 20.5cm but did not get a blood sample back. An x-ray showed that the UAC was in ‘way too far’ and that the route was ‘not typical of a UAC’.  She records pulling back the UAC to 9cm. A blood gas reading was taken and the readings were noted as ‘much improved’. A second x-ray showed the UAC position was ‘better’ but the route was ‘still not typical’. The UAC it appeared was ‘actually a UVC’ and was adjusted for use as a UVC.

19. A nursing note made at 5:33pm records that the father had visited with Child D ‘most of the day’ and that he was up to date with her care plan. It also stated that the mother had ‘visited this evening’.

20. Dr Rylance reviewed Child D at 7:00pm and noted ‘presumed sepsis’. The CRP was recorded as 1, having previously been 6. She noted that Child D’s feet ‘were purple’ but assumed that was because of the previous heel prick tests. She noted that her overall assessment was that Child D was stable and handling well. She noted that a lumbar puncture for infection had not been done yet, and in court incongruously said she did not consider Child D stable enough for the lumbar puncture test at that time.

21. Child D’s father came to the NICU to visit and describes that neither he nor the mother were informed of any issues, and that Child D was very quiet when he held her in his arms. He says that they (the parents) repeatedly asked how Child D was doing because she appeared ‘very poorly’, ‘wasn’t feeding’, ‘and had tubes in her mouth’, but staff kept responding that she was ‘doing well’.

22. The evening handover notes show that another nurse, Nurse Oakley, was designated carer for Child D in neonatal room 1 for the night shift. Lucy Letby, who arrived on the ward at 7:26pm, was designated carer on the night shift for two other children in room 1. At the point where Nurse Oakley took over caring for Child D she states the baby was on CPAP and was receiving antibiotics.

23. At 9:23pm Nurse Oakley and another nurse from Room 2 co-signed administration of medications to Child D.

24. At 11:52pm Nurse Oakley did Child D’s blood gasses, which she described as ‘satisfactory’. She described Child D’s circulation as not ‘100 per cent brilliant’ but testified that this was common with newborn babies. She records that Dr Brunton came to review Child D.

25. When testifying, Nurse Oakley says she remembers ‘being very happy with Child D’ at that point of the night shift. That Child D was ‘only requiring a little assistance’ with breathing, and she was ‘stable’.

June 22, 2015

26. At 1:05am the fluids chart records a task that Nurse Oakley signed for, yet under oath claims Nurse Letby ‘must have done’ because Nurse Oakley was ‘on her lunch break’ from 1:00am.

27. At 1:14am Nurse Oakley recorded having done Child D’s blood gasses, which she again described as ‘satisfactory’.

28. Child D’s heart rate, which Nurse Oakley described up until this point as ‘completely normal’ peaked at 1:15am. Nurse Oakley described that this could have been after handling and/or a nappy change.

29. At 1:25am Nurse Oakley and Lucy Letby sign the medication register to say they had started a saline ‘fluids’ infusion. In court and under oath, Nurse Oakley states: ‘I presume that I connected the fluid’ as the nurse looking after the baby would administer it.

30. Retrospective nursing note by Nurse Oakley timestamped for 1:30am says: ‘called to the nursery by another senior nurse and nurse Letby. Child D had desaturated to 70%, requires oral suction as was bubbly and had lost colour. Discolourations to skin observed, trunk/legs/arm/chin.’ In her testimony, Nurse Oakley describes that Child D’s oxygen was turned up on the CPAP machines and Child D responded quickly and normal parameters resumed within an hour. Her saturations returned to 100% and so she was weaned back onto CPAP with room air only. She also described that the rash had ‘resolved’ between 1:30am and after the doctor’s review.

31. A 1:30am fluids reading records that Child D had received ‘nil by mouth’ and under aspirates recorded that oral secretions were markedly increased (oral secretions ++).

32. Dr Newby was called in to review Child D. He ordered increased fluids and ‘a number of drugs and solutions’.

33. At 2:30am Nurse Oakley recorded Child D’s observations as ‘returned to normal’. She considered Child D was ‘stable’.

34. At 2:40am the medication chart called for another infusion of saline with 10% dextrose. Nurses Oakley and Letby both signed for this infusion. The medication administration update for this prescription is made on the computer at 2:44am.

35. At 3:00am, Child D ‘crashed’ for the second time. Nurse Oakley records in a retrospective nursing note that: ‘Child D crying and desaturated again to 70s, commenced 100% O2 via CPAP and picked up well but skin discoloured again but less than previously.’

36. At 3:20am another medication is recorded as administered, with both Nurses Oakley and Letby as signatories. In her nursing note of this event Nurse Oakley says the doctors believed Child D would need more fluid on board.

37. A fluid chart record at 3:30am says ‘restart expressed breast milk (1ml)’. A final observations record at the same time reports ‘observations satisfactory’ and that Child D was ‘handling well’.

38. At 3:45am Child D ‘crashes’ again. A retrospective nursing note records that the alarm went off and Child D was ‘desaturated and then became apnoeic. Called Letby. Stimulation given’. A code alarm was put out and doctors were called to the neonatal unit.

39. The neopuff was retrospectively recorded by Nurse Oakley as having been used at 3:52am. An SHO was called to assist Dr Brunton and ‘resuscitation efforts began’.

40. The next time the parents saw Dr Brunton was in the early hours of June 22, 2015. The parents were woken at around 4:00am by a nurse and told to ‘come quickly’ because Child D ‘was poorly’. They rushed downstairs to the NICU to find Dr Brunton holding Child D and trying ‘really hard’ to resuscitate her. In court, the mother described Dr Brunton as ‘quite agitated’ and the parents were asked to ‘let Child D go’.

41. Resuscitation efforts were ceased, care was withdrawn and Child D was pronounced at 4:25am.

42. At 4:46am Nurse Oakley wrote a retrospective handover note describing Child D’s condition as: ‘lower limbs dusky and feet bruised. Doctors aware. Feet cool to slightly warm. Observations satisfactory’.

The observation charts show that Nurse Oakley recorded and signed for the observation readings hourly during her shift. No other signatures were present on the chart. They showed that while still on CPAP, and up until the crashes, Child D had been taken off oxygen support and was apparently maintaining O²sats at 100%. Child D’s respiration rate was also at the extreme upper end of what is considered ‘normal’ for a neonate. The charts also showed that minimal amounts of acidic aspirates had been recorded from Child D’s stomach during the shift, and that while they were ‘mostly clear’ there were occasional darker ‘bits’.

Questions:

Do the midwife’s questions at Point 2 suggest that there were no notes visible in the mother’s hospital electronic health record (EHR) of her attendance with SROM at 11:00am the hospital the previous day?

Why is it that Lucy Letby was the designated carer not just for two babies in Room 1, but also for a baby up until 10:45pm on the night of June 21, 2015 whose location is ‘unconfirmed’ (i.e.: nobody recorded or recalls where this third baby was - neither which room or incubator he or she was in)?

Testimony from November 3, 2015 suggests that in spite of a standard protocol requiring intravenous antibiotics be administered to mothers with prolonged ROM due to the high risk of infection, the mother, by all appearances, was not given any antibiotics. Further, testimony in court revealed that there was also a four hour delay in giving Child D antibiotics that were required because it was both protocol and it became apparent that she had some respiratory issues which included fluid on her lungs and her symptoms were suggestive of infection. What role did these omissions have on the eventual outcome for Child D?

Conclusions:

The circumstances of Child D’s demise raises questions generally for hospital protocol, policy and management tolerance of staff either mis-documenting or falsifying what is critical legal documentation. It also raises questions for some of the paediatricians and nursing staff - most significantly, Nurse Oakley. Further, and as we saw with Child A and Child C, Child D’s story raises significant issues for an honest prosecution.

Various clinical records and Nurse Oakley’s testimony suggest that at the very least some accidental or deliberate mis-documenting of events that occurred either differently to how they are reported or at times other than when they were supposed to have happened, with the clinical notes being entered to show occurrence at the appropriate time. This is seen in the medication note recording administration of the saline infusion at 1:15am. Three possibilities exist. Either:

(1)   as Nurse Oakley originally testified and as the medication records show, Nurse Oakley administered the infusion witnessed and concurrently signed for by Lucy Letby; or

(2)   Nurse Oakley was on her break as she later corrected during her testimony, and Nurse Letby administered the infusion alone or with the assistance of someone else with both nurses either prior to or after Nurse Oakley’s break agreeing to countersign the administration records as if both were present; or

(3)   Nurse Oakley and Nurse Letby together administered the infusion but at another time either prior to or after it was due to have occurred, and agreeing to countersign the administration record to show it occurred at the required time.

The first option, which is the most likely of the three if all policies, protocols and legal requirements were being adhered to, would suggest that the medication administration records are correct and Nurse Oakley perjured herself when claiming to have concurrently been on a break and in another part of the unit from 1:00am until she was called back at 1:30am when Child D crashed. The second and least likely option means that both nurses are compromised through the falsification of an administration record that did not correctly reflect the truth of events. Occam’s razor would dictate that if Lucy Letby had done the administration - a two-person job - during Nurse Oakley’s break and with the assistance of someone else, surely that person would have signed as witness. The third option suggests that administering medication in a ‘near enough is good enough’ manner but documenting it as if it happened ‘when it should have happened’ is something that is either tolerated, allowed or perhaps even encouraged on the unit. This would be illegal and can significantly compromise the care given to any patient, let alone a fragile neonate. For example, what if Nurse Oakley had actually been on break and another nurse saw that medication administration had not been recorded yet and, thinking she was fulfilling the doctor’s orders, administered it not knowing that Nurses Oakley and Letby had done it prior to Nurse Oakley’s break but had left recording of administration until after Nurse Oakley returned to the unit? (while you can retrospectively record administration, the system does not allow you to prospectively record administration as having occurred ‘at a time in the future’). Unknowingly, Child D could have ended up receiving the medicine twice twice. While for a bolus infusion of saline this might not seem so serious, for many other medications it certainly could be.

Nurse Oakley under cross examination again sought to retract her earlier admission when giving evidence in chief that she had been the likely person who administered the medication, by claiming that she thought it might not be her handwriting on the medication chart. However, she had not previously made this claim when shown the chart earlier in the day. Surely, if this were the case she would have stated it when presented the same chart by the prosecutor. She also sought to claim her nursing notes at 1:05am were simply what she had been told by Lucy Letby or another nurse in the room, Nurse Kate Percival-Ward - even though she couched them as her own observations and signed them herself. She also contradicted her own testimony on other points - like when she claimed that the appearance of the rash had always stuck in her mind, yet couldn’t remember several key specifics about what it looked like or where it was on Child D’s body and was struggling even to describe it.

That the unnamed nurse from Room 2 added ‘refreshed memory’ details in her testimony in court that were never present in her police statements regarding the rash being ‘reddy-brown’ as Dr Brunton had previously, and as Nurse Oakley’s similarly refreshed memory, had described it starts to make it look like the description of the rash is something that has evolved up to the point that each person is giving testimony in court. If nothing else it certainly suggests some degree of collusion among the witnesses which could mean they met up and were ‘given’ or ‘agreed’ facts prior to court, or that they were not appropriately sequestered prior to giving evidence.

Another doctor, Dr Thomas, testified that she had been doing a sepsis screen on another baby in Room 2 when Child D ‘crashed’ and believed it had been Lucy Letby calling for help for Child D. And while not recalling seeing a rash during Dr Brunton’s resuscitation attempt, she described Child D as having something different - ‘purple colouring around the abdomen’. Another nurse, Nurse Marsh, also testified differently to everyone else. She claimed to have been the scribe during the resuscitation attempt and while no evidence of her written record was presented to support the claim, she claimed it had been Lucy Letby and not Dr Brunton giving chest compressions during the resuscitation.

Yet again, and as we have seen with the previous neonates, what we also have is the juxtaposition between the gradual demise of a very unwell neonate while her condition was being represented by many of the staff at CoCH as ‘stable’, ‘well’ and ‘not concerning’.

X-ray images from June 21, 2015 showed Child D had subtle signs of a lung infection. X-ray images post-mortem showed that the infection was present but had been improving, but that air was present in front of the spine. Such air emboli are something that can happen after vigorous CPR is administered to a neonate (here and here) and are also evidence of air leak syndrome that occurs in neonates like Child D who are diagnosed with TTN (here). However, Professor Arthurs testified that it was ‘unusual’ in babies who have died without an explanation. He said that the particular amount of air observed is consistent with babies who have died of: (i) sepsis (which we know Child D was being treated for); (ii) sudden unexpected death in infants (which appears to be an apt description for Child D’s death); or (iii) a road traffic collision. Even though he had just described two clear explanations that fit Child D, he incongruently went on to testify that the finding of air was actually ‘consistent with, but diagnostic of, deliberate air administration’. His final conclusion does not make sense given his own description of the circumstances that can cause such air emboli. The fact that Professor Arthurs admits to never having seen a case of air embolus like this in his entire career means he is not an expert in this particular presentation and therefore his ‘expert witness’ testimony on this element should have been excluded. In this particular instance Professor Arthur’s evidence might possibly be characterised as ipse dixit - an unproven or unsubstantiated statement which carries little weight and is worthless. As such, [Professor Arthurs’] bold statement of his opinion is not of any real assistance.

Dr Rylance on cross examination admitted that it was clear Child D had begun to deteriorate when she was taken off CPAP, which suggests that had Child D either been left on CPAP, or had staff reacted swiftly and appropriately to resume CPAP, Child D might still be alive. Nurse Oakley admitted under cross examination that there were very clear signs that Child D was unwell, even as she disputed whether Child D was really an ‘intensive care baby’ or not.

This brings me to a final point, being that under cross examination by defence counsel Nurse Oakley, the designated nurse responsible for Child D’s care on the night Child D died, was clearly evasive, sometimes coming close to the point of being argumentative (for example, her arguing with defence counsel regarding Child D’s classification as an ‘intensive care baby’ before admitting that Child D was so classified). While most of the nursing staff recalled periods during 2015 of insufficient staffing, Nurse Oakley sought to claim she could not remember - even though she admitted she was required to be on one-to-one care for an intensive care neonate like Child D yet the on the night Child D died she was also the designated nurse for another infant in a completely different room of the unit. She eventually and begrudgingly admitted that this meant that the care she provided under such circumstances ‘fell outside the guidelines’.

My verdict post and lingering questions can be found here