LL Part 22: The Trial for Baby K

The Prosecution Case

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.

Following on from our last post on the Lucy Letby Trial Here

Baby K’s mother had started to go into premature labour during February 15. The plan that afternoon had been to prevent or at the very least delay labour to provide sufficient time to transfer her to a hospital with a higher acuity Level 3 neonatal unit. Baby K was still at least three weeks earlier in gestation than the Countess of Chester Hospital (CoCH)’s then Level 2 unit should be caring for. However, between devising the plan and putting it into action Baby K’s mother progressed sufficiently that Dr Brigham, the obstetric consultant, believed the risk of delivering in the ambulance mid-journey was too great. She cancelled the transfer, recording that she believed the mother’s waters could break at any time. 

Baby K’s mother’s waters finally broke at 1:52am on the morning of February 17. Baby K’s mother had gone into premature labour but was only 6cm dilated, making vaginal delivery unlikely. Baby K was 24 weeks 6 days gestation when she was born, 35 hours after her mother had first gone into labour, at 2:12am on February 17. Baby k weighed a mere 692 grams.

Baby K’s APGAR scores were 4/10 at one minute, and 9/10 at both five and ten minutes after birth. While, and as the prosecutor stated in his opening statement, babies with scores of 7/10 and above are considered to be a baby in good condition - these would be at or near term babies. Even a premature baby will be delivered and while still under the influence of both the lasting effects of oxygen and nutrients still in their system from the mother and adrenaline and other hormones like oxytocin that help them endure the delivery process, attempt to breathe and even have high APGARS. However, it is not unusual for everything to then start to drop, and the baby to crash once all of these beneficial influences have worn off.

For this reason, the prosecutor’s statement during his opening address that the APGARs mean a baby is in good condition was not the whole story, and would no doubt have been misleading to the jury.

February 17

Letby was assisting Nurse Williams with the needs of another baby in the neonatal unit at the time Baby K was born in theatre. Baby K was delivered by caesarean section at 2:12am and due to being floppy, not breathing, and having a heart rate of 60 beats per minute required immediate resuscitation. Resuscitation was led by Dr Smith, who was described during the trial as both a locum and a trainee. From about three minutes after delivery doctors noted gasps from Baby K, which they said suggested Baby K was trying to breath on her own. They testified that from around four minutes Baby K was attempting to breathe spontaneously. Critically, the oxygen saturation levels of this extremely tiny 692gm premature neonate had only risen to 85% at the six minute mark, even with the full range of medical support that CoCH had to offer.

Almost certainly at the point where her reserves ran out, Baby K started to crash. Given her size and prematurity it was deemed necessary to intubate Baby K in order to provide complete breathing support. However, Dr Smith took three attempts to successfully intubate Baby K, twice with what he acknowledged may have been the wrong (too large) breathing tube. She was eventually intubated at 2:32am, twenty minutes after her delivery. Pulmonary surfactant was administered at 2:47am, well after the third breathing tube was finally in place. During the administration procedure Baby K’s already low (60%) oxygen saturation dropped to 50%. In his testimony Dr Jarayram sought to characterise this extremely low and worrying reading as ‘good’ for Baby K. Blood cultures were taken - which when returned from the lab five days later were found to be clear. However, while Dr Jarayram and the prosecution sought to present this as ‘fact’, and proof that Baby K never had an infection. It means nothing of the sort. In the same way that any test can return false negatives and positives, a negative blood culture does not, as Dr Jarayram implied during his testimony, absolutely rule out infection. I have written previously about the wealth of research showing that as much as 89% of patients with sepsis will have negative cultures and that many believe cultures lack the sensitivity required to detect all, or even a broad range, of infective bacteria. In fact, blood cultures rarely show anything and many clinical staff are actually shocked when they do happen to return a positive result. Culture-negative sepsis is common. That Baby K might have appeared free of infection at birth is not evidence that she did not acquire infection during her time in CoCH’s neonatal unit. A nosocomial infection would explain the later diagnosis of a severe lung disease by doctors when she was taken to Arrowe Park, and any infection will progress extremely rapidly in such a tiny and fragile neonate.

Baby K was transferred to the neonatal unit at 2:40am. Nurse Williams was assigned as her designated nurse. Baby K was the only patient she was responsible for during the remainder of the night shift. 

The first clinical event occurred not long after arrival, when Dr Smith was just outside the room and while Dr Jarayram was directly tending to Baby K. Baby K underwent a sudden desaturation and Dr Jarayram’s initial response was to disconnect the ventilator and provide manual breaths using the neopuff device. Dr Smith described in testimony that his observation on entering was that Dr Jarayram’s intervention was not effective - that what Dr Jarayram was doing wasn’t working. Dr Smith offered to reintubate Baby K. After a bolus of morphine to calm the baby which also unfortunately acts as a respiratory suppressant, and two more intubation attempts, Baby K was again put back on the ventilator. At this point Baby K had undergone five separate intubation procedures with three larger and two smaller breathing tubes. The two doctors decided to classify this event as a ‘displacement’ even though they could find no clinical explanation for the entire event. Curiously, there was no mention of the ‘displacement’ incident at all in Dr Jarayram’s retrospective 4:50am clinical notes.

A chest x-ray was taken at this time which the radiologist described as hazy with increased shadowing observed across Baby K’s chest. In recognising that this could be observed with chest infection, Dr Smith in testimony sought to assuage the jury that he believed it was not due to infection, but rather he wanted them to put it down to administration of the pulmonary surfactant - a lipoprotein used to decrease surface tension and effectively prevent the inner lining of the alveoli from sticking together and effectively closing down.

At 3:15am the transport team were called to collect Baby K and take her to Arrowe Park. Dr Babarao would be the consultant neonatologist riding with the transport team.

At 3:20am Nurse Oakley recorded that another baby in Room 1 pulled out their own breathing tube, necessitating use of the neopuff and eventually, at 3:40am, bipap. This evidence was discussed during the trial as evidence that it is normal and not unusual for these neonates to pull out their own breathing tubes. When this event actually occurred was then contradicted in that the prosecution recalled their analyst who acknowledged that the event had actually been recorded in the digital medical notes 24 hours earlier on the 16^th of February and incorrectly recorded by the prosecution on the schedule of events as occurring on the 17th. The prosecution’s neonatal schedule was updated to correct for the fact that this and other events from both the 16^th and 18^th had been incorrectly recorded by the prosecution, on the 17^th. The prosecution analyst testified to discovering that some pages had been placed out of order and sought to apportion blame for the error on the hospital’s production of documents in service of the investigation and Letby’s prosecution.

At 3:30am an intensive care note was written by Nurse Williams recording a ’94% leak reading’ from the ventilator. Nurse Williams also described Baby K as looking well. In her testimony she said that she would have alerted the doctors to the leak reading and also would have checked that the endotracheal (breathing) tube was correctly in place prior to leaving the unit to update the parents. During cross examination Dr Smith sought to deny the ’94% leak reading’ meant what the common sense reading of it might suggest - that 94% of the oxygenated ventilator air was leaking from the ventilation tube. Rather, he claimed this meant there was no leak and that the baby’s oxygen saturation was actually 94%. He supported his reading of this note by noting that the carbon dioxide clearance reading was 49, and stated that this meant the ventilator tube was doing what was intended. He conceded that the leak reading meant some air must not have been getting in, but said that if it meant only 6% of air was getting in then this ‘did not make any sense’. He deflected by resorting to the defence that he did not build the ventilator and therefore did not know what the builders meant by that reading.

Consider the ramifications of this: This means that the doctor who is supposedly trained on using this machine, who is configuring the settings for this individual baby, is telling the court he doesn’t understand what the ventilator means when it gives him a warning. He appears to be conflating oxygen saturation and a leak reading warning together and, as this incongruency is pointed out to him, is deflecting away from what is potentially his own lack of competence by telling us it is an issue for the manufacturer to explain. Was he or was he not trained on and certified to use this complex medical device? If not, why was he using it on this fragile and extremely premature baby? Why didn’t he get someone more experienced who was trained on the device to configure it and read its warnings, as would be normal hospital policy? This is further demonstration of the general lack of competence of the paediatric doctors who were ostensibly caring for these premature neonates at CoCH.

Dr Jarayram gave evidence that even though he was present and was the senior doctor caring for Baby K, he was ‘unaware at the time’ of the readings from the ventilator machine. He stated that he does not normally look at these readings unless there is a problem. In this case it is clear that there was a problem, but in his mind he had chosen to believe no problem existed. However, Dr Jarayram when cross examined acknowledged that it was a high leak, contradicting Dr Smith’s characterisation of the reading as having been somehow confused with Baby K’s oxygen saturation.

At about 3:30am Baby K appeared on Dr Jarayram’s clinical notes to have had her second desaturation event. Dr Jarayram reports that he arose from the nurses station and entered the room, and that on doing so his first reflex was to scan the monitors. He claims to have observed Baby K’s oxygen saturation ‘in the 80s’ and falling. He also reported that Nurse Letby was standing beside the incubator, but importantly, that her hands were not in the incubator. This would also imply the incubator hood and hand ports were closed because he surely would have told us if they were still open. He claims to have asked Letby what was happening, and that she responded that Baby K was desaturating. In direct testimony he stated he did not hear the oxygen saturation monitor’s alarm, which should have been audible at the time.

Dr Jarayram recorded that Baby K’s chest did not appear to be moving even though the incubator appeared to still be functioning. He observed that on listening to Baby K’s chest with a stethoscope there was very little air sounds - leading him to check the ventilator. He admits there wasn’t any evidence that the air tube had been tampered with, but that he disconnected the breathing tube and proceeded to give Baby K manual breathing support - to which Baby K responded positively. His prosecution-led testimony centred on creating the impression that at the time he was worried Letby had manoeuvred or dislodged the breathing tube, even though he admitted that significant movement would have been required to achieve this outcome. On Dr Jarayram’s order, Nurses Williams and Letby co-signed at 3:30am for, and administered, a morphine bolus to Baby K. Dr Smith then inserted a new breathing tube and the two doctors proceeded to insert the UVC and UAC.

The transport team record shows that Dr Jarayram was on the telephone to them at 3:41am. Nurse Williams had also left the neonatal unit at some time after 3:30am to visit with the parents, and returned at 3:47am.

At 3:50am a slow morphine infusion was started.

At 4:50am Dr Jarayram, who had observed the delivery, resuscitation and intubation in theatre, wrote retrospective medical notes timed several hours earlier. In them, he described Baby K as having ‘no fevers’. He also wrote that Baby K’s transfer to Arrowe Park’s Level 3 NICU would occur once the umbilical catheters had been placed and checked by x-ray.

At 5:55am The transport team recorded that Dr Jarayram advised them by telephone that Baby K had dislodged her breathing tube and it had been reinserted. At this stage Baby K still had not had an x-ray to check the siting of the UVC and breathing tube. Dr Jarayram responded under cross examination that this was their interpretation and that he had never said her breathing tube had been dislodged. He also stated that didn’t even know whether the person he spoke to was medically qualified.

A note was recorded against the 6:07am x-ray of Baby K describing that the left lung was observed as quite hazy. This, following on from the clinical notes for the 16th and 18th, was the second item of data entered into evidence that was later found to be inconsistent and corrected. Later evidence spoke of the x-ray machine being incorrectly calibrated, and described using evidence showing the radiologist hadn’t entered the ward using her security swipe card until 6:09am to identify that the x-ray was not taken until at least a few minutes later - at almost the exact time that the 6:15am desaturation event occurred.

At around 6:15am Baby K underwent her second sudden desaturation event. There was also a marked increase in carbon dioxide and a drop in blood pressure. Dr Jarayram noted that at this time he pulled the breathing tube out by half a centimetre. However, he found that this did not help and based on oxygen saturation readings, had potentially exacerbated events. A bolus of fluids was given to address Baby K’s now very low blood pressure.

At 7:25am Baby K had a third desaturation event coupled to a decrease in heart rate to around 100 beats per minute. Dr Jarayram noted that the breathing tube had again migrated, which he described as about 1.5cm further inserted into Baby K. He described that breathing tube was moved back and Baby K’s heart rate self-resolved.

The unnamed nurse came on shift and assumed the role as shift leader for the 7:30am shift change. She recalled arriving a few minutes early for the handover huddle and Letby calling for help at 7:25am. Nurse Taylor was also present as she had been designated as Baby K’s nurse for the day shift. The unnamed nurse’s recollection was that on entering the room Letby had her hands in the incubator applying the neopuff to Baby K. She claimed to also have noted that the breathing tube was inserted further than it should be, even though she had never seen this baby before. She recalls Dr Jarayram and several other nurses coming to help, and seemingly in contention with Dr Jarayram’s evidence, she described that the breathing tube was then removed. She observed that a new tube was inserted and Baby K was placed back on the ventilator. The unnamed nurse assisted Nurse Taylor to draw up medications and chart observations for Nurse Taylor. An unnamed doctor who also came on for the day shift recorded insertion of an arterial line into Baby K.

At 7:50am Dr Jarayram wrote a retrospective clinical note recording that he had aborted insertion of the UAC because it would not pass through the umbilical artery. He also described the 6:15am desaturation and noted that the left lung was hazy and that this either indicated infection or surfactant. In direct testimony, Dr Jarayram acknowledged that the desaturation was clinically explainable by the haziness of the left lung. Dr Jarayram also recorded the current situation for Baby K, including noting that: (i) her CRP was less than 1, which he admitted did not preclude possibility of infection, (ii) that her heart rate was stable at 130 beats per minute and (iii) her abdomen was still soft.

The transport team arrived at CoCH just prior to 9:00am and left the neonatal unit with Baby K at 12:40pm. Nurse Taylor recalls that Baby K’s respiration needs had continued to increase during the day shift, and that she had had to administer a series of medication doses ordered by the doctors in order to lower Baby K’s now high blood pressure before transport.

Baby K arrived at Arrowe Park at 1:15pm on February 17^th. The consultant neonatologist Dr Babarao reported that Baby K had a severe lung disease (remember that Dr Smith said shadows on the x-rays was pulmonary surfactant and not a chest infection and that Dr Jarayram said there was no infection - are we to believe the infection spontaneously appeared during the ambulance ride to Arrowe Park?). Another doctor on the transport team, Dr Kamalanathan, also described Baby K as extremely unwell, and said, in contradiction to the evidence of pretty much every single doctor at CoCH that this was not uncommon for such a very premature baby. Dr Babarao described Baby K as extremely ill, with a now low and uncontrolled blood pressure, uncontrolled blood sugars and kidney failure related to her prematurity. It is notable that none of these conditions had been identified or treated at CoCH. Further, when asked during the trial to review the 3:30am intensive care clinical note he points out a different value, the VTE value of 0.4, which he says is the volume of gas reading and was very low, supporting the contention that the 94% leak reading might actually mean air was escaping and not being correctly delivered to the lungs of Baby K. This testimony contradicts Dr Smith’s and again supports my own contention that there was a lack of competence in the care of premature neonates at CoCH.

Baby K was cared for at Arrowe Park for almost two days until care was withdrawn with the parents consent. She died at 5:28am on February 20^th. The cause of death was noted as severe respiratory distress and extreme prematurity. The mortality review at Arrowe Park concluded that Baby K’s extremely poor condition on arrival meant that her death was unavoidable, and notably that she had received sub-optimal care at CoCH. The sub-optimal care included multiple repeat procedures, delays in achieving patent central lines and administration of fluids and antibiotics, and the three contended extubations - one of which Dr Babarao was present for and witnessed first-hand as part of the transport team uplifting Baby K from CoCH. 

Discussion

Preterm labour can be unpredictable and often won’t look like labour with a term baby. It can even look like it is going to happen, sometimes for several days before it actually does. That Baby K’s mother spent almost two days on delivery suite without transfer may not actually be all that unusual or improper - even though it looks to many on the outside like clinical mismanagement. People online have aggressively demanded why at some point during the two days the mother wasn’t transferred. It is possible the mother may have been contracting every ten minutes for hours on end, and with very little respite. This presentation would make any midwife or obstetrician naturally cautious about sending the mother out on the road. In the meantime, the delivery suite bed for the mother or NICU place for the baby at Liverpool Women’s or Arrowe Park may also have become unavailable. It appears this is what occured and that at some poit there was even consideration of sending mother and baby even further north to Preston. Even if with the 20/20 perspective of hindsight we might want to disagree, the midwives and obstetrician I have spoken to tend to support Dr Brigham’s assertion that she feels she made the right decision not to transfer at the time. There are simply too many moving parts that can diverge, with the net effect being to critically impact any effort to make adherence to a pre-set clinical plan nigh on impossible.

That said, the prosecution reading the report by Dr Ian Dady seemed out of place and a little like guilding the lily. It was unnecessary to further expand upon the explanation of the presence of the mother and eventually Baby K at CoCH. This evidence came across as little more than an attempt at justification for the sake of ensuring those witnessing the trial did not come away harbouring any impression that not transporting the mother was a failing on the NHS as an overarching entity, a brand, or CoCH as an agent of that entity.

Babies born before 25 weeks have somewhere between 31.9-68.4% chance of survival - meaning roughly that between 4-7 neonates like Baby K will die and that Baby K is statistically more likely to die than live. Researchers write that the survivability rate for babies born at 24 weeks is about 40% - meaning 60% (or 6/10) are expected to die. Of those babies that survive, some will have severe and profound disabilities, some will have moderate or mild disabilities, and a smaller number will have no obvious effect - at least until they get to school and learning disabilities or other issues become apparent. 

Most NHS Trusts accept that a higher number of around half of all babies born within the 24th week of gestation will die. Most also accept that some will have profound disabilities but, and here’s the real kicker - they tend to downplay the effect of prematurity on those that do not have profound or initially obvious disabilities. Note the footnote in the dark blue diagram that buries the more significant cerebral palsy in with ostensibly mild learning disabilities and behavioural problems.

When you talk to very experienced nurses and midwives they will tell you that the 24th week of gestation is really the limit or border of survivability - and the earlier into that 24^th week the baby is delivered the more likely it is that they will not survive. That said, and even though the NHS would have us believe nearly half are totally unaffected, the truth is that almost no neonate born at this exceedingly early stage comes through completely unscathed. They need exceptional measures just to survive their first days. Beyond that their prematurity results in a very long several-month stay in the neonatal unit. Further, even if they do survive to go home they almost always require more care and attention than babies born much closer to or at term, and need anywhere from 4-10 times higher rates of healthcare visits (GP, specialist and nursing care) than their term-born peers.  

Much was made both during the trial and in both the mainstream and social media about whether it is normal for a nurse to wait and see if a desaturating baby, self corrects. From an evidentiary standpoint this became a moot point the moment Nurse Griffith admitted during cross examination that this was something nurses typically did. Nurse Griffith acknowledged that a nurse will wait, even while paying attention to other signs such as skin colour, to see if the baby self-resolves before intervening into the baby’s incubator. The neonatal unit is already extremely stressful for the premature baby - with stressors including bright lights and loud noises during procedures, and studies finding that neonates experience an average of anywhere from 16 to an excessive and traumatic 70 potentially painful procedures per day. We have already seen how procedures were performed on these neonates repeated times, sometimes by doctors who were not yet competent at their conduct. Nurses are aware that increased numbers of interventions are stressful to the baby and seek to keep their own impositions to a minimum - if the baby can self-correct then this is always preferable to opening and intruding within the incubator another time.

“Stable”

Another matter that was brought to the fore was the administration of prophylactic antibiotics to Baby K even though fever was absent when Dr Jarayram observed the neonate after birth. This comes in the torturous and incredible testimony of Dr Smith in which he describes a baby with a heart rate of 60 beats per minute, around 1/3^rd of normal and requiring resuscitation, as ‘encouraging’, and incredibly capstones his evidence with this most ignorant, self-congratulatory and unscientific observation:

[Baby] K would have been stable the whole time as Dr Jayaram was present throughout, and if there were concerns he would have stepped in.

Incredulously, is it the presence of Dr Jarayram that we have to thank for Baby K’s supposed stable condition? Dr Smith also testified that at the time he was rescuscitating and intubating Baby K he had, and I infer by extension the jury should have, no concerns for Baby K. He used the word stable more than half a dozen times whilst on the stand. His testimony was nothing less than ridiculous.

First, the mere fact that this baby was so far premature (24w6d) meant it was far from being able to met the clinical definition of the term ‘stable’. Second, that he had to go through what he described as ‘up to three cycles of resuscitation’ in order to get even some signs of respiratory life also means Baby K wasn’t stable. Third, ‘gasping’ is not ‘breathing’ - far from it. That he was intubating Baby K to provide complete breathing support by definition means this fragile human being, whether a premature neonate or a grown adult, was not stable. Fourth and finally, that antibiotics were considered necessary, even prophylactically, means that there was some consideration in the theatre that Baby K might actually not be stable. While we were told that a blood test showed ‘no signs of infection’, the situation for such a small neonate can change quite literally minute to minute. As a final aside, I do wonder why the supposedly illustrious ‘tv’ paediatric doctor stood aside and watched as a locum/trainee first performed multiple cycles of resuscitation and then failed on the first two attempts to intubate Baby K. If he is as skilled and experienced as he likes to portend, why was he ‘observing’ from across the room rather than using his medical skill to ensure the best care for this premature infant? While Dr Smith side-steps this issue by inferring that it meant Dr Jarayram had confidence in him, much of his testimony left me concerned. And with more questions and than answers…

Use of the term ‘stable’ throughout this and the first Letby trial has been both extra-clinical (meaning outside the clinical context) and deceptively misleading for both juries who we know will not be medically trained or understand the complex and often cryptic nuances of clinical terminology.

There are also further contradictions in Dr Jarayram’s testimony. During the first trial when discussing the administration of pulmonary surfactant to premature neonates, he had confirmed it was ideal to administer the surfactant within five minutes of intubation. During the current trial for Baby K, he initially disagreed with this when put to him by the defence barrister, responding only that it should occur within thirty minutes. When his previous testimony was put to him, he sought to emphasise the word ‘ideally’ and downplayed the five minutes. He went on to admit that the time taken to eventually administer surfactant to Baby K wasn’t ideal, and that it should have been given sooner. During cross examination Dr Jarayram makes several comments that would indicate that by this time he and Dr Breary had some degree of confirmation bias affecting their thinking regarding the deaths and incidents on the unit, and Lucy Letby. He admits that at this stage of their review, they could no longer think that the deaths were natural causes and that they were having ongoing uncomfortable thoughts about Letby’s continued presence.

And...

Dr Jarayram has consistently proven himself to be nothing short of economical with the truth. Was the alarm sounding, possibly sounding but he doesn’t remember, or not sounding at all? At the time and in the police interviews he wasn’t certain, yet during the trial some process of refreshed memory has rendered him absolutely certain it was not - yet Nurse Williams says when she entered the room on returning from visiting with the parents that she heard ‘alarms going off’. Dr Jarayram believes, or at the very least does not recall, blood on the breathing tube - yet here again Nurse Williams stated that she observed ‘a large amount of blood-stained oral secretions’. Further, he never once mentioned in his clinical notes regarding Baby K that the breathing tube had been dislodged. In spite of this he went on to say in an ITV interview that the whole event was permanently etched in his memory and that the only possibility was that Letby had dislodged the breathing tube. Still, he categorically testified during this trial that he did not see Letby touching the incubator or the tube being dislodged. In spite of this, the following incredulous and dishonest headline was promulgated in the mainstream media the next day (from the Daily Mail):

It has always been the mainstream media that were doing more to direct public opinion and bias potential jurors. Certainly more than any of us who have been questioning the integrity of the investigation and evidence presented during the trial.

The sad truth is that the outcomes of this and the first trial were being fomented by the media from as early as 2018 in the court of public opinion…

Certainly well before any verdict was rendered.

******

Erratum: This article originally mentioned caesarean birth which had been mentioned by one of the doctors, but corrected to uneventful birth, during his testimony. For whatever reason the words stuck in my head and I repeated them here. I recall at the time thinking that I should make something of the juxtaposition of the two things.

Part 23 of my series on the trials of Lucy Letby can be found Here