Lucy Letby Baby K

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Baby K

Count 14: Attempted murder of Baby K on 17 February 2016. Alleged mechanism: ET Tube Dislodgement (NO VERDICT)

Dr Shoo Lee's International Panel Summary Conclusions

BABY 11 SUMMARY [Baby K]
Baby 11 was a 25 week, 692 gm female infant who was born by footling breech. At birth, she was dusky, floppy, and had low heart rate (60/minute) and no spontaneous respiration. She was resuscitated with bagging and intubated after 3 attempts with a size 2 endotracheal tube (ETT). Blood stained secretions were noted. She was mechanically ventilated and a large air leak of 94% was noted. Her blood gases showed respiratory and metabolic acidosis. One and half hours later, she desaturated. A consultant bagged her with Neopuff but there was no chest movement. The capnography test was negative for carbon dioxide. He reintubated Baby 11 with a size 2.5 ETT, re-established chest movement, and stabilised the infant. Chest x’ray was consistent with respiratory distress syndrome or pneumonia. There were 2 further episodes of desaturation requiring resuscitation. Baby 11 was transferred to Alder Hey Hospital.

CONVICTION
The consultant alleged that Baby 11’s first episode of clinical deterioration was caused by deliberate dislodgment of her endotracheal tube, since bagging failed to move the chest and carbon dioxide was not detected by capnography. He alleged that the incubator alarms were deliberately turned off to prevent prompt rescue response because he did not hear the alarms when he entered the room.

PANEL OPINION
Baby 11 required a size 2.5 ETT. Instead, she was traumatically intubated with a size 2 ETT, with a resulting 94% air leak. As a result, ventilation was ineffective because 94% of the air was leaking out and only 6% was entering the lung. Effective gas exchange could not occur and mechanical ventilation could not generate sufficient pressure to keep the small air spaces in the lung open. This led to gradual collapse of the small air spaces in the lung and deteriorating gas exchange. When the tipping point was reached, the infant decompensated, desaturated and collapsed. Bagging to reopen the collapsed small air spaces in the lung requires relatively high pressures. With a 94% air leak, bagging with the Neopuff, which has a safety feature to limit air pressures, did not generate sufficient pressure to move the chest. Capnography did not work because the device measures build-up of carbon dioxide in the endotracheal tube during expiration, but with 94% air leak, the carbon dioxide could not build-up sufficiently to trigger measurement. There is no evidence to support dislodgement of the endotracheal tube. The consultant stated that he did not hear the alarms, but a nurse (not LL) stated that “When I returned to the unit, I immediately became aware of the alarms sounding from Baby 11’s incubator.”

CONCLUSIONS
1. There is no evidence to support a dislodged endotracheal tube.
2. The clinical deterioration was caused by use of an undersized endotracheal tube.
3. The initial intubation was traumatic and poorly supervised.
4. The consultant did not understand the basics of resuscitation, air leak, mechanical ventilation, and how equipment that were commonly used in the unit work, e.g. Neopuff and capnograph.
5. There is evidence that the incubator alarms were not turned off.

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Prosecution Opening Statement

Background
Child K was born at the Countess of Chester Hospital in February 2016, very premature, and weighing only 692g.
There was not time to deliver at a hospital for this type of maternity delivery care. Dr Ravi Jayaram, paediatric consultant, was present at her birth as a result.

Incident
Lucy Letby booked Child K on to the neonatal unit. Child had required help with breathing, but was stable and in as good a condition as a baby of that prematurity could be.

Arrangements were made for Child K to transfer her to Arrowe Park Hospital.

At 3.50am, Dr Jayaram was standing at the nurses’ station compiling his notes. Although he did not have a view into Nursery 1, Dr Jayaram was aware the deisngated nurse was not there, a fact backed up by door swipe data. Lucy etby was the only nurse in room 1, alone with Child K.

"Feeling uncomfortable with this because he was beginning to notice the coincidence between the unexplained deaths and serious collapses and the presence of Lucy Letby, Dr Jayaram decided to check on where Lucy Letby was and where Child K was."

"As he walked in, he could see Letby standing over Child K's incubator. He could see Child K's oxygen levels were falling. However, the alarm was not sounding and Lucy Letby was making no effort to help.

"Dr Jayaram went straight to treat Child K and found her chest was not moving, he asked Letby if anything had happened to which she replied, “she’s just started deteriorating now”.
Dr Jayaram found Child K's breathing tube had been dislodged.

Child K was very premature, and had been sedated and inactive. The tube had been secured by tape and attached to Child K's headgear.

Mr Johnson: "It's well recognised if you handle a child you can dislodge the tube accidentally, but any experienced staff member would recognise that.

"Dr Jayaram was troubled as the levels were falling and Nurse Letby had been the only person in the room."
The prosecution added: "On these monitors, all readings are set to default values in the neonatal unit.

"Saturation levels falling to the 80s, is a serious issue and if the machine is working properly, it would have an alarm if the saturation levels fell to the 80s, as Dr Jayaram noticed.

"There is an alarm pause button on the screen of the monitor - if you want to treat the child, you don't want the alarm going away. It will pause for one minute.

"Bearing in mind the rate displayed on the monitor, Dr Jayaram estimates the tube would have been dislodged between 30-60 seconds, and that is on the assumption the alarm had been cancelled once."

The court hears Dr Jayaram did not make a contemporaneous note of his suspicions or the alarm failing to activate.

Child K remained unwell and later died.

Medical experts
Medical expert Dr Dewi Evans viewed Lucy Letby’s failure to summon help as soon as possible was unusual.
The prosecution allege that Lucy letby was trying to kill Child K when Dr Jayaram walked in.

Police interviews
In police interview, when Dr Jayaram's account was put to her, she said no concerns had been raised at the time.

She said the alarm had not sounded. She said Child K was sedated and had not been moving around.

She also did not recall either any significant fall in saturations or there being no alarm. She accepted that in the circumstances described by Dr Jayaram she would have expected the alarm to have sounded.

she denied dislodging the tube and said she would have summoned help had Dr Jayaram not arrived, saying she was "possibly waiting to see if she self-corrected, we don’t normally intervene straight away if they weren’t dangerously low".

After the interviews - that suggestion made by Lucy Letby was referred to a nursing expert. Her view was that it was very unlikely that a nurse would leave the bedside of an intubated neonate unless they were very confident that the ET tube was correctly located and secure, the baby was inactive and then they would be away only briefly.

The nurse dismissed the idea that a competent nurse would have delayed intervention if there had been a desaturation.

Facebook
Letby was found to have researched Child K's parents on Facebook in April 2018 - two years and two months after Child K had died. When asked about this, she said she did not recall doing so.

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Defence Opening Statement

For Child K, the defence say the tube was dislodged, and the prosecution say that was Letby's doing. "Letby does not agree she did that, nor is she seen to have done that."

The prosecution say Child K had been sedated.

The defence say it is disputed, that Child K was able to move, and there would be evidence to follow on that.

The defence say there was "sub-optimal care" and Child K "should not have been at the Countess of Chester Hospital in the first place", but in a hospital providing tertiary care.

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Defence Closing Speech

Mr Myers turns to the case of Child K. He outlines the events and allegation. He says the allegation "illustrates a good deal wrong with this case". He says Child K "should not have been at the Countess of Chester Hospital", but should have been treated at a tertiary unit. He says arrangements were being made post-birth. He says a review carried out at Arrowe Park Hospital said care at the Countess was "sub-optimal". He says the defence acknowledge there is a question whether transporting the mother before birth was possible. He says Child K should have received surfactant.

Mr Myers says Child K was a tiny baby needing complex care. He says Dr James Smith agreed in cross-evidence that an experienced neonatalogist at a tertiary unit would have had more experience than him in looking after babies such as Child K. A mortality review at Arrowe Park Hospital said Child K's death was "avoidable", Mr Myers says. He says surfactant, to allow babies to breathe properly, should have been administered "straight away" to Child K. He says Child K could not breathe without assistance and it was "inevitable" she would need intubation. He says the "air leak" recorded "cannot be ignored". He says staff at the Countess "did not seem concerned". He says the defence acknowledge the oxygen saturation was high. He says a tertiary unit consultant had said the pressure [VTE reading] was "too low" and the oxygen saturation reading was "not consistent" with the air leak and pressure readings.

Mr Myers says the count is Letby "deliberately did nothing to help" when confronted by Dr Ravi Jayaram, and that by implication, she had harmed Child K. He says Letby did not recall what had happened. He says the allegation "relies on the credibility and reliability" of Dr Jayaram. He says the allegation had "morphed" against Letby. He says tubes can dislodge. He says Dr Sandie Bohin agreed tubes can dislodge even if a baby is sedated. He adds nurse Joanne Williams said Child K was an "active baby".

Mr Myers says Dr Jayaram had said Child K was sedated, and that was "a prime basis for blaming" Letby. He says Child K was not sedated until after the tube was dislodged and she was reintubated.

Mr Myers says Letby's presence on the unit allows the prosecution to "say what you like". He says if it is alleged she was 'caught in the act' by Dr Jayaram, she would not have gone back to dislodge the tube twice more the same morning, as is alleged by the prosecution. He says if Dr Jayaram had seen things in the way he told them, he would not have taken his eyes off Letby for the rest of the shift. "He would have been watching her like a hawk". He says the allegation is "not worthy of belief". He asks why Dr Jayaram, if he had seen what he had said, did not contact the police or 'whistleblow', or file a Datix report. He said he did "nothing".

Mr Myers says nurse Joanne Williams recalled Dr Jayaram had asked her what had happened, and who was in the room when the alarms went off. He asks why Dr Jayaram would ask her that if he had been in the room at the time, seeing Letby in there. He refers to a note on the transport team: "Call received from Dr Jayaram baby dislodged the tube and had to be re-intubated".

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Agreed Facts

Recorded Events and Messages/Facebook

Cheshire Police intelligence analyst Kate Tyndall is now talking the court through the sequence of events for Child K.

16th February 2015
They begin with text messages recovered from Letby's phone. Letby messages a colleague about the unit being a "hive of activity" on February 16 in preparation for a visit from "the big bods", and there is a discussion on the possible of delivery of Child K. Letby mentions one colleague had suspected conjunctivitis, but had still come into work, and adds "Hope I haven't caught anything". Said colleague had also not "done anything but moan" that day, Letby says. Letby messages the ill colleague saying she hopes that colleague is feeling better soon. The colleague responds she was feeling better after a day of bed rest, and thanks Letby for her message.

The night shift for February 16 is shown to the court. The paediatrician of the week is John Gibbs, the on-call consultant is Dr Ravi Jayaram. Lucy Letby is on duty, looking over two babies in room 2 at the start of the night shift. There are two babies in room 1, three babies in room 2, three in room 3 and three in room 4. A further baby is in the Transitional Care Unit. Child K is later transferred to room 1 after she is born.

17th February 2015
Child K is born with 'dusky, floppy, no resp effort' at birth, and a heart rate of 60bpm. The 'Apgar score' is 4/10 at one minute, 9/10 after five minutes and 9/10 at 10 minutes after birth. Previously, the court has heard the Apgar score measures how well a baby is doing in the minutes after being born.

2.40am: Child K was admitted to the neonatal unit at 2.40am due to her "extreme prematurity", Mr Johnson tells the court, as well as the fact she was to be transferred to a tertiary centre at a later point.

3.15am: Dr Ravi Jayaram makes a note to the transport team at 3.15am.

3.30-3.35am: Observations are taken for Child K at 3.30am. A blood sample later showed no bacterial growth recorded. Further communication is made with the transport team at 3.35am.

3.47am: Swipe data is recorded showing Child K's designated nurse Joanne Williams leaving nursery room 1 at 3.47am to go to the labour ward. It is just after that, the prosecution say, the event alleged in the case of Child K happened, and the baby girl collapsed.

3.50am: The event is recorded as happening by Dr Jayaram and Dr James Smith at 3.50am - "sudden deterioration" - sats dropping to 40%, Child K bagged via ET tube with Neopuff. The 'sats recovered quickly' following treatment, and Child K was reintubated. Designated nurse Joanne Williams also recorded the event. She is a co-signer for Child K to be administered morphine, with the other co-signer being Lucy Letby.

4.20am: Lucy Letby is the co-signer for further medication for Child K at 4.20am, the other co-signer being nurse Caroline Oakley.

6.04-6.15am: Further observations and medication administrations are given through the early morning. A nursing note is made for Child K by Lucy Letby, who was not Child K's designated nurse, at 6.04am-6.10am. An x-ray records the ET tube is in the right place at 6.07am. Dr Jayaram notes an event at 6.15am: '@0615 began to have lower sats & IV down to 2.5...Tube pulled back to 6cm". Retrospective notes by Dr Jayaram record: 'Tube noted to have slipped to 8cm @ lips - withdrawn and heart rate picked up immediately.'

7.30am: Nurse Melanie Taylor takes over designated care for Child K for the day shift at 7.30am. Lucy Letby has signed for a 7ml saline bolus for Child K at 7.30am.

Further records show that, throughout the morning, ventilation requirements for Child K gradually increased.

8.50am: The transport team arrived at the hospital at 8.50am, for transferring Child K to Arrowe Park.

9.15am: Dr Jayaram discusses transport arrangements in notes which are recorded at 9.15am.

10.04am: A message sent to Letby at 10.04am from a colleague says: 'Hope you had a good shift and are in the land of nod now!'

Further records are made of attempts to stabilise Child K so she can be transferred to Arrowe Park, through medication administrations.

At noon, Child K is moved into a transport incubator.

12.25pm-12.30pm: The formal handover from the neonatal unit to the transport team took place at 12.25pm-12.30pm.

1pm: Child K arrived at Arrowe Park by 1pm on February 17. Medical records showed Child K was cared for at Arrowe Park Hospital from 1.15pm on February 17.

5.48pm: Letby messages her colleague at 5.48pm: '25wkr delivered so fairly busy...' The message was in reply to a colleague saying she had hoped the shift had gone well, and expecting she was asleep at that time ('in the land of nod'). Letby adds: 'Everything ok? Not like you not to text back'. The colleague apologises. Letby then messages about staffing limitations at the hospital for the following shift.

20th February 2016
5.28am: On Saturday, February 20, 2016, the decision is recorded to withdraw life support from Child K. The time of death is recorded as 5.28am. The doctor records, as the cause, 'extreme prematurity' and 'severe respiratory distress syndrome'.

20th April 2018
11.56pm Lucy Letby made a Facebook search on April 20, 2018, at 11.56pm, for the surname of the family of Child K.

The court has just had a short break. Claire Hocknell is now talking the court through the neonatal unit review schedule, which documents that Child K was admitted to neonatal unit nursery room 1 at 2.40am on February 17, 2016. The designated nurse for Child K was Joanne Williams, who was also a designated nurse for a baby in room 2. Lucy Letby was the designated nurse for two babies in room 2.

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Lucy Letby in the Witness Box

Direct Examination

Lucy Letby gave this evidence on 16th May 2023.

Mr Myers moves on to the case of Child K, a baby girl born on February 17, 2016, weighing 692g at 25 weeks gestation. Mr Myers says there are three parts to this event, 3.45-3.50am, when a desaturation and a dislodged tube were noted, 6.10-6.15am, and 7.30am.

Dr Ravi Jayaram's notes are shown to the court. He records: 'Initially dusky, floppy, no respiratory effort' for Child K at birth. 'Successfully intubated ~20mins at third attempt by Dr Smith, transferred to NNU' For 3.50am: 'At 0330hrs 0350hrs sudden deterioration O2 sats dropped to ~40%. Bagged via ET tube with Neopuff...poor chest movement... Tube removed and bagged via facemask - Sats recovered quickly...reintubated...'

Nurse Joanne Williams records in nursing notes: '...approx 4-5 minutes later began to desat to 80s. Dr Jayaram in attendance and on examination colour loss visible and no colour change on CO2 detector, ?ETT dislodged, removed and reintubated on second attempt...large amount blood-stained oral secretions.' A further note by Joanne Williams: 'Baby has had 2 further episodes of apnoea and desaturation with loss of colour. Has been reintubated twice...'

Dr Jayaram's note, written at 7.50am, records: '@0615 began to have lower sats...tube pulled back to 6cm, sats dropped further, therefore extubated...responded to bagging, reintubated. Settled for next 30mins 0725 - Mean BP dropped to 14...sudden drop in sats, hr dropped to 100...cardiac compressions commenced for 1min. Tube noted to have slipped to 8cm...withdrawn and heart rate picked up immediately.'

Child K was transferred to Alder Hey later that day, but remained unwell and died on February 20.

Mr Myers asks if it was normal for a 25-week baby to be at a level 2 unit. Letby says it was not normal; babies would usually be cared for at a tertiary centre. She says she does not know why Child K was at the Countess of Chester Hospital.

The trial is resuming after a short break.

The layout of the neonatal unit is shown to the courtroom for February 16-17. Lucy Letby is the designated nurse for two babies in room 2 at the start of the shift. Child K was brought into room 1 during the night shift after her birth.

Letby is asked if she has any independent recollection of Child K. "I remember it was unusual [seeing a 25-week gestation age baby], and seeing her at some point...but cannot recall any of the contact."

Letby said she would go into room 1 to collect medication, and it was a "frequently used" room. Two other babies were in room 1, with designated nurse Caroline Oakley.

Mr Myers says there is a point, alleged, when Dr Jayaram sees Letby by Child K, and Child K's tube is dislodged.
Mr Myers: "Did you interfere with [Child K's] tube?
Letby: "No."

Letby denies being at the cotside when Dr Jayaram entered room 1, and says she does not recall any conversation with Dr Jayaram that night. Mr Myers refers to a police interview with Letby from July 2018. Letby was asked if she remembered Child K's deterioration - "No" was the answer. Letby said she recalled Child K only as she was a 25-week baby, which was unusual on the unit. Letby was asked by police if she was present when Child K's ET tube dislodged. "I don't remember."

Letby says she signed for morphine to be administered to Child K. She tells the court she had no involvement with Child K beyond that point.

Letby says in police interview she was not by Child K's incubator at the time Dr Jayaram entered room 1. She told police if the desaturations dropped to 80s, she would expect the alarm to go off for Child K. She said to police: "I don't know why the alarm would not have sounded." Letby was asked by police if she had turned off or deactivated the sound on the monitor. "No."

Letby tells the court "it does happen" that a tube can move "with an active baby". She told police "tubes can slip if not properly attached".

Letby says if she was there, and had seen the observations drop and/or the tube slip she would have summoned help. She denies being there at that point, or having any involvement in the tube being dislodged, or 'just watching'. She denies Dr Jayaram's report was accurate.

The neonatal schedule for February 16-17 is shown to the court. Letby is involved in the care of her two designated babies up to 12.30am, plus a baby in room 1 at 12.51am, 'assisting with cares'. Letby cares for her designated babies up to 2am, and assists in the medication of a fourth baby at 2.04am and 2.14am.

The chart shows Letby's records with her designated babies up to 3.30am, when - at that time - observations are made and a feed given to one of the designated babies. Letby says 3.30am would be a "rough time" of when it happened. The feed, observations, and a nappy change, could take half an hour - the quickest '20 minutes', the longest "up to an hour". She says in this case, this could have taken "15-20 minutes".

Letby is asked if, by doing this, she had any reason to be in room 1 at that time. Letby says she would not have had a reason.

Letby is then recorded, on the neonatal schedule, as caring for Child K after the event has taken place. The first recorded activity is for morphine administration, with Joanne Williams signing for the medication and Letby being a co-signer. Letby says this was because Child K was being reintubated and required morphine.

She does not recall being called to the nursery room. She does not recall being involved in the subsequent events for Child K.

Letby is asked about a Facebook search for the surname of Child K, made on April 20, 2018, at 11.56pm. Letby says: "You still think of patients you've cared for." She says she does not recall why she looked up the name at that point.

Letby says that night "was a busy shift" but, asked whether she had done anything that night to merit questions about it years later, Letby says: "No."

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Cross-Examination

Lucy Letby gave this evidence on 2nd & 5th June 2023.

Mr Johnson moves on to the case of Child K, born on February 17, 2016. Letby said, in her defence statement, she did not recall the events of February 17, and did not recall saying to Dr Ravi Jayaram that Child K had just started deteriorating. She said she had done nothing to interfere with Child K's tube or the alarm. She added the Countess neonatal unit was not capable, given its staffing levels, of looking after a baby of Child K's gestational age. Letby tells the court she has no memory of such a conversation with Dr Jayaram. She says it is "difficult" to dispute Dr Jayaram's recollection of the event as she had no memory of it. She denies she has changed her version of events since starting to give evidence.

Letby is asked if she understands the reason why Child K was born at the Countess.
LL: "Yes." Mr Johnson tells the court it was deemed 'too risky' to transfer Child K and her mother to another hospital at that stage, and that was why Child K was born at the Countess.
LL: "I don't know why more effort was not made to find a bed for her [elsewhere]."
NJ: "You have persistently given the impression that the Countess has taken on babies it [is not able to look after and that is why they collapse]."
LL: "Yes."
NJ: "Is that the reason you said to the jury you didn't understand why [Child K] was born at the Countess?"
LL: "I don't understand why she was born at the Countess."
NJ: "Is it to bolster your defence?"
LL: "No."
LL: "I understand why she was born there but I don't necessarily agree [with the decision to have her born there]."

Letby says she does not recall the latter two desaturations for Child K, and does not accept Dr Jayaram's evidence in the first desaturation. Mr Johnson says he will deal with these in a different order than chronologically; he will cross-examine on the second desaturation first.

Letby says she does not know what happened to Child K, so does not cite staffing levels as a contributory factor in Child K's desaturations. She says she feels "potentially" the ET Tubes were not secured for Child K.

The second desaturation occurred at 6.10-6.15am on February 17, 2016. The court hears a note on Child K's birth and assessment was typed up by Letby on a computer from 6.04am-6.10am. The note would have been taken from paper charts taken by the cotside.
NJ: "You were at [Child K's] cotside a minute or two before she desaturated, didn't you?" Letby says she would have got the notes from the cotside "at some point" prior to her typing them up.

Nicholas Johnson KC, for the prosecution, is continuing to cross-examine Lucy Letby on Child K.

Mr Johnson asks Letby about an ET tube document, which she had entered at 06.10am on February 17, 2016. Child K desaturated at 6.15am. Letby says she has "no memory of being at [Child K's] cotside."

Letby agrees Child K had been on morphine and would have been "well sedated"
NJ: "And yet the tube slipped again at 6.15am - just after you had been with her?"
LL: "I can't say that I was physically with her, no." Letby says the notes she would have obtained for Child K were at the end of the bed, and she has no recollection of being physically with Child K at the cotside.

Mr Johnson asks about the 7.25am-7.30am desaturation. Letby says she has no memory of it. Letby says she cannot recall any intervention regarding Child K at this point. Mr Johnson says one of Letby's colleagues was called to the nursery.
NJ: "What were you doing in nursery room 1 at 7.30am?"
LL: "I can't answer that, I don't have any recollection of it." The neonatal review is shown for February 17, 2016. Letby's duties include tending to her designated baby in room 2 at 7am. Mr Johnson says there was no reason for Letby to be in room 1 at 7.30am. Letby says there can be many reasons. Mr Johnson says Letby was "sabotaging [Child K] yet again, weren't you?"
Letby: "No." Letby says she has no memory of it.

Letby says she "cannot say" if Child K moved her ET Tube more than once. "I don't have independent memory of the tube slipping." Letby is asked to look at her police interviews for Child K. Within there, Letby said she had believed Child K's tube had slipped at an earlier point. Letby denies dislodging Child K's tube. Asked if she disputes her colleague's recollection of Child K's desaturation, Letby says she cannot recall.

Mr Johnson moves to the 3.50am desaturation - the first of the three desaturations for Child K. Letby agrees Joanne Williams was Child K's designated nurse. She agrees Joanne Williams left Child K before the 3.50am desaturation. She accepts that nurse left at 3.47am. Letby says she cannot recall Dr Ravi Jayaram's whereabouts at this point.

A note from the transport team at 3.41am is shown to the court: 'Called Dr Jayaram back with the above plan and he was agreeable totally with all the above'. Letby accepts that if this note is accurate, Dr Jayaram would have been around the nursing station at this time. Letby accepts that Joanne Williams would have asked someone to 'babysit' Child K in her temporary absence from the nursery. Asked if she disputes it was her to babysit Child K: "I have no memory of that." Letby says she has no memory of Dr Ravi Jayaram's account of him walking into the unit and seeing her standing over Child K's cotside, or that Child K was desaturating, or that Child K's ET Tube was displaced.

Letby denies trying to kill Child K. Letby is shown a copy of her 2019 police interview, specifically police talking through Dr Ravi Jayaram's account of events from the night. That was the evidence he had given in the trial, that he had felt 'uncomfortable' with Letby being in the nursery room 1 and entered, and saw Letby. Letby, in police interview, said she "didn't remember" the event. Mr Johnson suggests Letby is lying. Letby denies this. Letby denied, in police interview, dislodging the tube. Mr Johnson says Letby had earlier said the event "didn't happen".
LL: "I don't believe it did happen, but I have no direct memory of it."

Letby says it was "standard practice" at the Countess of Chester Hospital's neonatal unit to wait "a few seconds" - "10, 20" to see if a baby self-corrected during a desaturation.
NJ: "30 seconds?"
LL: "I can't say."
NJ: "You are lying, aren't you?"
LL: "No."
NJ: "Because you were trying to kill [Child K]."
LL: "No."

The nursing notes for Joanne Williams recorded 'large amount blood-stained oral secretions' for Child K. Letby says she did not believe she gave Joanne Williams that information.
NJ: "Did you ever see [Child K's] parents?"
LL: "I can't recall."
NJ: "Did you ever meet them?"
LL: "I can't recall."
NJ: "Then why did you search for them [on Facebook] on April 20, 2018?"
LL: "Because I have thought of babies on the unit over the years, and I do look back at them."
NJ: "You have a very good memory for names?"
LL: "Yes."
NJ: "Her name didn't appear on the handover sheet, did it?"
LL: "I can't say." Mr Johnson says Child K had been born earlier that day, and handed over to the care of Melanie Taylor, and Child K was transferred out of the hospital.
NJ: "How can you remember that name [of Child K]?"
LL: "I can't."
NJ: "Can't or won't?"
LL: "I can't."
NJ: "What was the significance of April 20, 2018?"
LL: "I can't recall."
NJ: "Do you remember the answer you gave to your counsel on May 16?"
LL: "No." Mr Johnson says Letby said you look back on 'all the babies you care for'. Letby says it was taken out of context, and she played a part in Child K's care via the morphine infusion.

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Witness Statements Agreed

Family - Mother

The court is now hearing a statement from the mother of Child K, who described being thrilled at the news she was pregnant.

At the 12-week scan at the Countess of Chester Hospital, an issue was identified - Child K had a build-up of fluid at the back of her neck. At the 15-week scan, she was reassured everything was normal.

She had regular scans, and further check-ups showed the fluid was disappearing gradually.

At 18-20 weeks, it was discovered Child K had a pocket of fluid at her lungs, but follow-up checks saw this had gone.

Just before 25 weeks, the mum recalls waking up with 'a few niggles and pains'. She was still working at this time.

The midwife was called, and she advised to call the labour ward at the Countess of Chester Hospital - she was advised to attend.

She was informed by a midwife there she had gone into labour "we couldn't believe it".
The mother stayed at the hospital and received treatment.

Discussion took place over transferring the mother to a tertiary centre, but the nearest one, Arrowe Park, was full.

On February 16, the mother was given further steroids, and the possibility of a C-section birth was discussed.

There were "no indications of any concerns" of Child K, who was showing no signs of any distress. The decision was made to leave things as they were at that time.

That evening, the mother recalls waking up in pain, and the button was pressed to alert medical staff.

Child K, a baby girl, was born at 2.12am. Staff worked on Child K for 30-45 minutes. The mother later found she had been born weighing 692g - 1lb 8oz.

The consultant explained that the gestational age of 25 weeks meant there would be a medical team solely to look after Child K, who would be placed into an incubator. Once stable, she would be transferred to the special care on the neonatal unit.

A female nurse came in and told the parents Child K was "fine and stable", and if they wanted to see her.

The nurse offered to take photos of the three of them, on the father's phone.

The pictures are timestamped at 4.31am on February 17, maing Child K only a few hours old.

The mother was woken up later informing a bed had become available at Arrowe Park. At 9am, the transfer team arrived at the Countess of Chester Hospital. They explained what was going to happen. The process took "some time" as the team had difficulty stabilising her. It was then when the parents considered a name for Child K.

At noon, it was "now or never", for Child K to be transferred to Arrowe Park. The mother had not been discharged at this point, and the medical team "desperately" tried to make it possible so she could be allowed to go to Arrowe Park, which was done at 2pm.

The parents arrived at Arrowe Park at 2.30-2.45pm. Later, arrangements had been made for the parents to stay at the purpose-built accommodation.
The mother recalled "the strangest feeling which she could not describe" on the morning Child K died.

At the neonatal unit, parents had no restrictions on visiting times. They went in

As soon as she walked in, she could see the readings, including saturations, were low. She knew straight away things weren't great.

A doctor was in the room at the time. "I looked and said, she's not good is she?" The doctor "confirmed the worst," explaining Child K had been fighting all night.

The parents had a long conversation with the doctor, and the decision was made to switch off life support machines.

Child K passed away in her father's arms.
A cot was brought into the room to allow the parents time privately with Child K, who had died on February 20.

---

Dr Jonathan Ford

An agreed statement is now being read from Dr Jonathan Ford, a former registrar at the Countess of Chester Hospital.

He reviewed the mother of Child K before the baby girl was born, and discussed the issues of extreme prematurity.

He said the longer the pregnancy could be, and delaying of the birth, the better.

He reviewed the mother again at 9pm on February 16, and it was agreed for 'conservative management'.

She was called back on February 17 at 1.20am, when the mother was 'in pain, in active labour'.

It later became 'inevitable' the mother would give birth. He delivered the baby. The birth was "uneventful" and Child K was passed over to the paediatricians.

It was noted, at the 14-week scan, Child K had a cystic growth at the back of her neck.

A detailed scan at week 16 and week 20, that was resolving, and there were no problems with how Child K's heart looked.

---

Elizabeth Morgan

The court now hears an agreed statement from Elizabeth Morgan, who says in her experience, it is very unlikely a nurse would leave the nursery of a baby if the baby's ET tube was not settled in a position and the baby was settled.

For a baby of this gestational age, it would be standard practice for a nurse to take corrective action, carry out checks and call for help if a desaturation was noted.

It would 'not be normal practice' to wait and see if the baby self-corrects, for a baby of this gestational age.

---

Witness Evidence

Dr James Smith

See also: INQ0107825 – Witness Statement of Dr James Smith, dated 19/08/2024

The next witness to give evidence in court is Dr James Smith, who was employed at the Countess of Chester Hospital in February 2016 as a specialist registrar.

Dr Smith recalls he did have a memory of Child K. He recalls being notified there would be a delivery of a '25-weeker' baby.

He recalls being present at the birth, and the baby girl was born in 'expected condition'. The Apgar scores of 4, 9 and 9 are 'good'.

Asked about the 'dusky, floppy, no resp effort' note, Dr Smith says the gestation presentation can be variable, but a good/reasonable sign is a heart rate, 'no resp effort' is not unexpected and the baby would present as 'floppy' as there had yet to be any breathing support supplied by medical staff.

He tells the court full airway breathing resuscitation support would be required, but that would 'not be unexpected' for a baby as premature as Child K.

Dr Smith describes the procedures he would have taken to stabilise a baby such as Child K in this scenario.

He says Child K's heart rate improved to 100bpm within two and a half minutes, and she was making respiratory gasps. The decision is then made to intubate.

The intubation is "technically difficult", he tells the court, due to the baby's size, and can take multiple attempts. He says Child K was stabilised after each attempt, and he had no worries about doing the procedure himself, without needing to hand over the procedure to the consultant, Dr Ravi Jayaram.

He successfully intubated Child K on the third attempt with a size 2.0 tube.

He tells the court if he had seen any signs of trauma, such as bleeding, on Child K at the time of intubation, he would have passed the procedure on. To the best of his recollection, he did not see any signs of trauma.

He tells the court there is nothing in the notes of any sign of trauma at this point.

The general clinical picture was Child K's signs were 'good', the resuscitation 'had gone successfully' and the first blood gas record was 'good - reasonable for the first reading'.

He tells the court that for all babies of this prematurity, antibiotics would be administered.

Dr Smith tells the court he would have been, to an extent, guided by advice from Arrowe Park Hospital in the treatment of a baby of this prematurity at the Countess of Chester Hospital.

Dr Smith says he would not have played any part in the connection of Child K to the ventilator at the neonatal unit, following transfer, and would not have had any knowledge of how to do so, as that connection would be a task carried out by nurses.
Dr Smith says he remembers coming back into the neonatal unit early on February 17, probably for labelling blood bottles.

He does not recall where the nurses were, but recalls Dr Ravi Jayaram giving breaths to Child K via the Neopuff, and that was already under way.

He said the readings, while unable to recall what they were precisely, "were not improving", and further measures were to be carried out.

The explanation for a "sudden deterioration" was either the breathing tube being dislodged or blocked.

The "correct decision" was for the tube to be removed.

Breathing mask support was supplied to Child K without a tube. Child K's oxygen saturation levels improved and Child K was reintubated.

A morphine bolus was administered to help the reintubation process.

Dr Smith says he did not see any evidence of trauma, and if there was anything obvious to show that, he would have informed Dr Ravi Jayaram, but he "did not see anything".

The prosecution ask if the Countess team followed the advice from Arrowe Park to take x-rays of Child K to check for tube placement. Dr Smith confirms they did, and a chest x-ray was carried out.

The radiology report said, from the x-ray, the ET tube was 'in satisfactory position' following the reintubation, along with the NG tube, while a UVC line required further adjustment.

The radiology report also recorded possible lung infection, which Dr Smith was expected in babies of Child K's gestational age.

Dr Smith re-examined Child K at 6.15am, when it had been noted Child K had lower saturations, with a blood gas reading which was "not good" and "worse than the previous gas".

The tube was 'pulled back' to improve the oxygen saturation levels, but the readings had 'not improved'.

The decision was then taken to remove the tube from Child K. 'Bagging' breathing support was provided to stabilise oxygen saturation levels, and Child K was reintubated once again.

Child K had responded 'very quickly' to the 'bagging' support.

Dr Smith says, from the notes, there is nothing to say the tube removed from Child K was blocked, and his memory has nothing to add to that.

A repeat x-ray reported: 'Satisfactory position of the ET tube. NG tube in situ...this would benefit from advancement by 5-10mm. UVC in satisafactory position.'

A lung infection was still suspected for the left lung, which appeared increased in density - 'looking more white', and reduced in volume compared to the right lung.

Dr Smith later wrote a transfer letter to Arrowe Park Hospital, which summarised the care given to Child K at the Countess of Chester Hospital, including details of intubations, medication administrations and a blood result.

Cross Examination
Benjamin Myers KC, for Lucy Letby's defence, is now asking questions in respect of the events for Child K.

He says Child K was born in extreme prematurity, and asks if there would inevitably be problems for the baby girl's care, particularly in relation to the lungs. Dr Smith agrees.

Dr Smith remembers being in the room when Child K's resuscitation efforts were taking place, and they were going well.

He says neonates with this gestation need a lot of support and resuscitation.

He cites a study that babies of that gestation age, found a 75% survival rate. Mr Myers suggests that figure could be more like 40-50% from another study. Dr Smith says he has cited the most recently available study he looked at.

Mr Myers says a tertiary unit is the most suitable place for treating babies of Child K's gestational age.

Dr Smith says they are more experienced at a tertiary unit, but level 2 units (such as the Countess of Chester Hospital at this time) have the equipment and have staff capable of treating babies of this gestational age, for the short term.

He says the correct thing to do would be to contact the level 3 unit in advance to enquire if transfer to there was possible in advance of birth.

He says seeing Child K's bruising on her hands and feet at birth was not something he had seen frequently in births, and was more likely seen by staff at tertiary centres. He said he had asked for an expert opinion on the subject of the bruising.

Dr Smith says level 2 centres do not look after babies of this prematurity, long term.

He says if mothers of 23-week gestational arrived at the hospital via ambulance, and delivery was imminent, that delivery would take place at the nearest hospital, with a set procedure in place to arrange transport to a tertiary centre when viable.

Dr Smith recalls it would have been better if he had written his own independent notes, in addition to Dr Ravi Jayaram's complete notes. He added he did write up the transfer letter listing the events and care for Child K.

Mr Myers asks why would Dr Jayaram write up those notes in the first place. Dr Smith says he would also have been on the paediatric unit on that night shift. He says as long as a senior doctor has been involved in writing, then the notes would be 'completed'. He says that 'ideally', he would have written notes up himself, independently.

Mr Myers asks about the initial intubation process for Child K.

He asks if Dr Jayaram should be the one to do that process, as the more senior doctor.

Dr Smith says: "No, not if the baby is stable."

He says the decision to take over could be the 'wrong decision' as the doctor carrying out the procedure would be familiar with the placement of where everything is.

Mr Myers asks if it's standard practice guidance for babies to be intubated within 15 minutes of birth. Dr Smith says he is not familiar with that number, and asks Mr Myers where that guidance has come from.

Dr Smith says if that was the number that is standard practice, then he would go with that. He says there are two different numbers for how long it was after birth for intubation to have taken place - one of them is 12 minutes.

Dr Smith is asked about lung surfactant which a note records as being administered at 3am, and if that, at about 35 minutes after intubation, is 'too long'.

Dr Smith says if there is good oxygen saturation recorded at the time, and Child K is stable, that would not be an issue, but if guidance is to administer that surfactant five minutes after intubuation, then that would be considered too long.

Dr Jayaram's note is shown to the court, written retrospectively. Dr Smith points out the note of surfactant administration is recorded as being made at '0245'.

Mr Myers asks about the insertion of a central line, done 'several hours' after Child K was born. Dr Smith says the procedure requires assistance, is difficult, takes time, needs a sterile environment and a stable baby. It also requires x-rays afterwards.

The line is 1mm thick being put into an umbilical cord line that is 1-2mm thick. It is, in this instance, 'a non-emergency UVC'.

Mr Myers says this is a procedure which, 'ideally' should be done by a consultant neonatologist at a tertiary centre.

Dr Smith says ideally, the baby would be born at a tertiary centre, but in these circumstances, the most experienced staff available at a level 2 centre, who are capable of this type of procedure, would carry out the procedure.

Mr Myers asks if it was 'too long' a time period. Dr Smith said the baby would not have been compromised by a longer time period.

Mr Myers asks if it was 'sub optimal'. Dr Smith says it would depend on the circumstances and the condition of the baby, and in Child K's case, the 'correct thing to do' was to prioritise the airway and breathing support, and lines could be put in later.

Mr Myers asks if the insertion of the line at this time fell outside the 'golden hour' principle.

Dr Smith says there is no difference in the method of the administration of initial medicines - the UVC was one option, but there are others.

Dr Smith agrees with Mr Myers the initial administration of antibiotics fell outside the 'golden hour' principle timing. The antibiotics were administered at 4.40am, according to electronic prescription records, sometime after the first hour of Child K's birth which ended at 3.12am.

Dr Smith adds, from a blood test, there was no marker of infection, but if was sub-optimal that the antibiotics and vitamin K (administered at 4.20am) were not administered in the first hour, and cannot recall why that was the case.

After a short break, Mr Myers is continuing to question Dr Smith.

He refers to the intubation attempts made for Child K. Dr Smith says he used a 2.5 tube at first, then a smaller 2.0 tube was used, successfully.

Mr Myers asks about an air leak which was reported. Dr Smith says he was aware, and made reference to it in his third statement to police.

The 3.30am reading of '94' for air leak, Dr Smith does not know what that means, as it does not correlate to any of the other readings. He says the blood gas record for Child K was good, and the oxygen saturation for Child K was good, and oxygen requirement had come down. He says he does not believe that would mean only 6% (100% minus 94) of oxygen was getting into Child K.

He said a large air leak would result in a change to a larger ET tube bein considered, but that process would require reintubation.

He said, knowing there was good oxygenation and good gas, that would reduce the need for reintubation.

He adds that a tertiary neonatologist with more experience of ventilators might give a different opinion, but they would need to be called to give evidence. Dr Smith adds he also does not know what the 'resistance' figure on the chart signifies either.

Mr Myers asks about the reintubation of the tube for Child K, which involved a larger tube. Dr Smith says the first ET tube was working fine, then it was not, and reintubation was required.

The morphine bolus was applied to have "a sedative effect" on Child K.

The desaturation at 6.15am is referred to.

Dr Smith says the ET tube was pulled back, but saturation levels continued to decrease, so the ET tube was removed and bagging commenced.

The saturation levels improved, and Dr Smith says that meant there "was a problem with the tube".

Mr Myers says pulling the tube back and seeing no change [prior to the tube's removal] meant there was no problem with the positioning of the tube.

Dr Smith says the cause of the tube's movement could have been it 'slipping' from the clamp, for this deterioration.

Dr Smith says he did not recall any injury/blood/trauma with Child K, and if he had done so, he would have referred it to Dr Ravi Jayaram and asked them to take over the intubation process.

Mr Myers asks if, hypothetically, he had seen blood before intubation, if he would have checked for the source of it.

Dr Smith says it would depend on the amount of blood seen that would lead to how concerned he would be. He said if he had seen blood-stained secretions, he would make a note of it.

---

Nurse Joanne Williams

See also: INQ0107028 – Thirlwall Inquiry Witness Statement of Joanne Williams, dated 23/07/2024

The next witness to give evidence is Joanne Williams, who was employed as a neonatal nurse at the Countess of Chester Hospital. She has returned to give evidence in respect of Child K.

She confirms she was working a night shift that night. She remembers Child K being born, and being on that night shift.

She remembers being called through at the birth of Child K, and recalls her being born at 25 weeks gestation. She said the delivery happened at the Countess, and Child K would be transferred later to a tertiary centre.

Ms Williams remembers Child K being bruised on her feet, which was not unusual a sight, as she had seen that in the past.

Immediate resuscitation was provided and Child K was intubated.

An observation chart is shown to the court for 'Baby Girl', as Child K had yet to be named.

Child K was on a ventilator for 45 breaths a minute when she was on the neonatal unit room 1.

As designated nurse, Ms Williams confirms she would check to make sure the ventilator was secure for Child K.

The oxygen saturation reading for Child K of 70% at 2.45am would be considered 'low', while the 94% reading at 3.30am was 'normal' and 'improved'.

The prosecution say that would be indicative the ventilator was working as it should be.

Ms Williams is being talked through her nursing note from the morning of February 17, 2016, in which she described Child K being born in 'fair condition'.

She was 'intubated at approx 12 minutes of age with size 2 ETT'.

Ventilation commenced, and a 'high leak noted'. Ms Williams said that is noted via the ventilator, and if there are any concerns, they are highlighted to the medical team.

She says that can sometimes be down to the size of the ET tube.

Staff would be alerted to the leak via the ventilator giving off an alarm, the court hears.

Ms Williams says there were no concerns over the leak, as the overall clinical picture for Child K was stable.

Ms Williams says the alarms would go off if the baby's clinical picture declined, such as the heart rate dropping or oxygen desaturation. Initially it would be a 'soft alarm', which is amber and makes a noise, then a more urgent alarm in red and 'more of an alerting' sound.

There is a way to pause the alarms, Ms Williams says. That could be paused for several minutes, once it had been activated, in the event of doing a procedure.

Ms Williams says she cannot recall if the alarm could be disabled in advance. The court hears a newer version of the monitors have since been installed in the hospital, where that is possible.

Ms Williams says at the time of the 'high leak', the clinical picture for Child K would have been assessed, and a check the tube was in the right place at the mouth.

The prosecution is now asking about the time period when Ms Williams left the nursery room to inform the family on what had been happening.

She said she would not have done so if Child K was not satisfactorily stable.

She tells the court, other than being born very premature, there was nothing of concern.

She does not remember asking anyone in particular to look after Child K in her absence.

Ms Williams recalls Child K being 'quite active' as she left, which was normal to see in prematurely born babies.

The court hears Ms Williams left the unit at 3.47am.

The intensive care chart for Child K on February 17, 2016 is shown to the court.

A reading at 3.30am says, for morphine, 'commenced'. Ms Williams is asked if that means morphine commenced for that time. Ms Williams agrees.

A reading for 0350 '100mg/kg morphine' is recorded. The note is not in Ms Williams's handwriting, and the court hears that would have been a bolus of morphine.

There is a prescription note for 0350 for a morphine infusion dose. Ms Williams says this is also not in her handwriting, and it is written by a doctor.

Asked again about the '3.30am' reading, Ms Williams says that would not have begun at 3.30am precisely, but in the time period after. She cannot say whether that happened before she left the room at 3.47am.

She tells the court Child K would have been stable when she left.

When Ms Williams returned, she heard a red alarm, "it seemed like an emergency, something was going on".

She says she felt upset, and it "always frightening to go back into a situation like that".

She recalls Dr Jayaram asked her what had happened, likely near the nursing station after Child K had stabilised. Ms Williams said Dr Jayaram had asked 'how did the [ET tube] move'.

She recalls Child K was reintubated, with a bigger ET Tube.

Asked about her '?ETT dislodged, removed and re-intubated' nursing note, Ms Williams tells the court there was a query that the ET tube had been dislodged.

Ms Williams had also recorded on her nursing note, for the ET Tube, 'large amount blood-stained oral secretions'.

The nursing note also adds 'Initially active on handling but now more settled'.

Ms Williams tells the court a morphine bolus would be given, instead of a morphine infusion, when carrying out a procedure such as inserting a UVC line.

Ms Williams's family communication note includes 'photos taken and treasure box and Bliss bag given...encouraged parents to come to the unit to visit and mum and dad both touched her...mum to be discharged to [Arrowe Park Hospital] to be with baby.'

Ms Williams's further nursing note explains Child K had '2 further episodes of apnoea and de-saturation with loss of colour. Has been re-intubated twice and now has a 2.5ETT...'

Ms Williams tells the court she would have remained the designated nurse throughout that night shift for Child K.

Cross Examination
Benjamin Myers KC, for Lucy Letby's defence, is now asking Joanne Williams questions.

He picks up on what Ms Williams had just said, that she did not have much experience in dealing with babies born at 25 weeks gestation. Ms Williams agrees that was the case at the time in 2016.

Mr Myers says there is the potential for deterioration in such babies, as they an be 'unpredictable'. Ms Williams agrees.

Mr Myers asks about the process of administering a 'lung surfactant'. Ms Williams says it would be kept in storage. It would be prescribed, but could be signed for retrospectively. Doctors would work out how much to prescribe based on the baby's weight, and they would administer it.

A prescription form is shown to the court, showing a '120mg dose' 'administered 0300'.

Asked if 0300 is the time of the dose given, Ms Williams says: "Yes." She adds that would be an "estimated" time the dose was given. The scheduled time appears as '0544' is because it is a retrospectively written note, the court hears.

Mr Myers asks about the '94' leak reading for 0330 for Child K. He asks if that is a high air leak. Ms Williams agrees.

Mr Myers says it would be a reading 'to keep in mind'. Ms Williams agrees.

Mr Myers: "The aim would not to be to have a leak of 94%?"

Ms Williams: "Yes."

Mr Myers asks if ET tubes can be dislodged if a baby moves or not, Ms Williams agrees. She also agrees that requires careful observation, and it can change from minute to the next, but there are procedures, such as clamps, to keep the tube in place.

Mr Myers asks if Child K had been 'quite active'. Ms Williams: "At times, yes."

Mr Myers asks about the morphine administered, which he says can sedate a baby and stop them being as active.

Ms Williams says Child K would have received morphine after being intubated, not at the time of intubation.

Mr Myers asks about when this morphine was administered.

Ms Williams says the morhpine could start via a bolus or an infusion, then the other being administered.

A prescription for a morphine injection is shown to the court. Mr Myers asks if this is a bolus. Ms Williams agrees.

Ms Williams agrees she has co-signed for it, and agrees with the administration time of '0350' recorded as being the time the morphine was injected.

The morphine infusion prescription and administration chart is shown to the court.

This is prescribed by a doctor, and has a handwritten start time of '0350'.

Ms Williams says 0350 could be the start time, or it could be later. Mr Myers says the prescription wouldn't have a start time after it had already been administered.

Mr Myers asks about the 0330 fluid chart. Mr Myers says although it is said morphine commenced at '0330', it is an hourly chart, and that means the morphine could have been commenced at any time between 3.30am and 4am. Ms Williams agrees.

Ms Williams says, for the '0350 100mg/kg morphine' note, that is not in her handwriting, but having someone else write in that note box is not uncommon when working as a team.

Mr Myers asks if the morphine bolus and the morphine infusion began at the re-intubation process, after Child K had suffered a desaturation.

Ms Williams: "Yes."

Mr Myers asks about the alarm going off, and a conversation with Dr Ravi Jayaram.

Ms Williams says the conversation took place not in nursery room 1.

He asked her, Ms Williams had said in her police interview, what had happened, and she had replied she did not know as she was not in the room, having gone to see the parents.

Mr Myers asks to clarify about what Ms Williams had said moments earlier: 'I thought the ET Tube was secure, but I was not there'. Ms Williams agrees.

Mr Myers asks about the nursing note made by Ms Williams 'large blood-stained secretions'.

Ms Williams says she does not recall where that came in the timeframe of events.

She adds it is difficult to write notes retrospectively and highlight the significant events. She says it is likely that would have been seen at the time of the re-intubation as she would have been present.
Prosecution
The prosecution rise to ask Ms Williams further questions.

Ms Williams is asked about the lung surfactant administration note.

Prosecutor Philip Astbury asks about the timings of the note. The 0544 would be the time the surfactant was prescribed, retrospectively. It would not have been done concurrently as Child K would not have been added as a new baby identification on the hospital's system at that point.

The time at 5.48am, when the note was filed, would have been the point when it was considered what time the surfactant was given, the court hears. The note records it administered as '0300'.

She says she does not recall who administered the surfactant.

Ms Williams's nursing note is shown to the court. She is asked if the note, written retrospectively, is written chronologically. Ms Williams says that ideally, that would be the case.

Mr Astbury asks about the infusion chart, where hourly records are made. The 0330 note is referred to. Ms Williams is asked if records are kept as close to the times where possible. She agrees.

Ms Williams says she does not remember being present for the 0350 morphine bolus.

Mr Astbury asks about the conversation Ms Williams had with Dr Jayaram.

Ms Williams is asked if Dr Jayaram asked her: "How did the tube move?" Ms Williams agrees.

The judge asks about the purpose of the morphine bolus, whether given before or after the infusion. Ms Williams said it would be done '3-5 minutes' for a procedure such as re-intubation, for pain relief to the baby.

That completes Joanne Williams's evidence.

---

Dr Ravi Jayaram

See also:
INQ0001986 - Pages 4-6 of [Police] Witness Statement of Dr Ravi Jayaram, dated 10/01/2019
INQ0001982 – Page 11–12 of [Police] Witness statement of Ravi Jayaram, dated 18/09/2017 [?]
INQ0010268 - Page 41 of Transcript of Day 14 of the criminal trial of R v Letby, Dr Ravi Jayaram re Child A, dated 24/10/2022
INQ0107962- Page 121 of Thirlwall Inquiry Witness Statement of Dr Jayaram, dated 30/08/2024
Dr Ravi Jayaram's oral testimony at the Thirlwall Inquiry

Dr Jayaram confirms he would have been on call as a consultant on the night shift of February 16-17, 2016.

He says he would have been called at home, and would have been called to come in for the delivery of a 25-week gestational age baby such as Child K, as the hospital would be aware there could be complications.

He tells the court, until the early 2000s, there was less structure, but in more recent times, if possible, mothers are taken to tertiary centres [such as Arrowe Park] to give birth. If that is not possible, babies can be cared for in the short term at level 2 centres such as the Countess of Chester Hospital.

He says, on balance, the risk would have been too great to transfer Child K and the mother for the birth at a tertiary centre.

He adds he was present at Child K's birth.

Dr Jayaram says it is significant, when talking through the medical notes he had written retrospectively, the mother had a 'spontaneous rupture of membranes' 48 hours before birth, as that could lead to a risk of infection.

He said it was relevant there were 'no fevers' recorded.

The medical notes record Child K was 'initially dusky, floppy, no respiratory effort'. Dr Jayaram said that was significant and in this situation, a pathway is followed including 'inflation breaths', which stimulates the baby's first gasps.

He says it is like blowing a balloon up for the first time - the lungs are difficult to inflate for the first time as they are filled with fluid.

The inflation breaths are completed after two cycles, and Dr Jayaram says the chest is then seen to be moving up and down.

The heart rate is then above 100 beats per minute, recorded two and a half minutes after birth.

Gasps are recorded after three minutes. Dr Jayaram said Child K would have initially been 'a little stunned', but the gasps are what the medical staff are looking for.

Oxygen saturation levels of 'above 85%' at six minutes are 'satisfactory'.

The initial intubation process is discussed.

Dr Jayaram says it can be difficult and risky, and it is important the oxygen saturation levels are high before starting the procedure.

A doctor has 30 seconds to attempt the intubation procedure. The court hears the intubation was done on the third attempt, with a smaller, size 2, ET tube.

He says, "ideally", a 2.5 ET tube would be used, but in these circumstances a size 2 tube was sufficient.

Child K was transferred to the neonatal unit, on a ventilator.

Dr Jayaram describes Child K required around 60% oxygen. He says he could hear air going in and out of the baby girl's lungs.

The initial blood gas readings are taken, and it is acceptable for a 'little bit of leeway' on carbon dioxide levels.

Child K was given surfactant at 2.45am, Dr Jayaram had recorded in the notes.

A blood culture test was taken to screen for infection, as a routine test, and the baby girl would be treated on the assumption she already had an infection and would be treated with antibiotics.

A morphine infusion is recorded on the medical notes.

Mr Astbury asks when that would be administered. Dr Jayaram says he does not recall when that would have been, but it would not be immediately after transfer to the neonatal unit nursery room 1.

Dr Jayaram said he could hear Child K's heartbeat, and air going in and out of both lungs.

He said, for a 25-week gestation baby, he was "happy" with Child K's progress.

Dr Jayaram said he was happy the ventilator was working, as observed by Child K's chest moving, and being in good colour.

He tells the court that at this point, he informed the transport team about the situation, and they had advised there was a bed at Arrowe Park Hospital, and they advised for a UVC line to be inserted prior to transport.

Dr Jayaram is now being asked about Child K's desaturation at 3.50am.

A plan of the neonatal unit layout is shown to the court.

Dr Jayaram said he was "happy" with how Child K was "very very settled", having had to make only minor adjustments to the ventilator settings.

An infusion chart for the morphine is shown to the court, with a start time of 3.50am. He confirms that 3.50am would be the time that would be adminsitered.

Dr Jayaram says he was aware Joanne Williams was going to the labour ward to update the parents on Child K.

He said he was sitting at a desk, around the corner from the entrance to nursery room 1. He says he was writing in notes, or waiting for the transfer team to come back to him regarding arrangements.

He said he had been told Lucy Letby would be 'babysitting' at the time - a common term used by the hospital to describe a neonatal nurse temporarily looking after a baby in the absence of its designated nurse.

He says, at this point, in February 2016, he was aware of 'unexpected/unusual events' that had happened recently, and that Lucy Letby had been present.

He said: "I felt extremely uncomfortable [with Lucy Letby being there alone in the room with Child K]

"You can call me hysterical, completely irrational, but because of this association...

"This thought kept coming into my head. After two, two and a half minutes...I went to prove to myself that I was being ridiculous and irrational and got up.

"I think it was 2.5, 3 minutes after Jo had gone to the labour ward.

"I had not been called to review [Child K], I had not been called because alarms had gone off - I would have heard an alarm. I got up and walked through to see [Child K]."

Dr Jayaram entered nursery room 1 through the entrance doors closest to his desk. Child K was at the far side of the nursery room, with Lucy Letby present.

He said: "I saw Lucy Letby standing by the incubator. I saw her, and looked up at the monitor, and K's saturations were dropping, in the 80s and continued to drop. The ventilator was not giving out an alarm.

"I recall looking up and saying 'what's going on?' and Lucy said something along the lines of 'She's having a desaturation'."

Asked what Letby was doing, Dr Jayaram replied: "Nothing."

He says Letby didn't say anything to Dr Jayaram until he had walked over and he had asked her what was going on.

Dr Jayaram said he was looking at Child K. He disconnected the ventilator from the ET Tube and he tried to give breaths via the ET Tube, but Child K's chest was not moving.

He said he switched into 'professional mode' to resolve the situation, and it 'didnt make sense why the tube was dislodged'

He said he removed the tube - which wasn't blocked - and put a face mask to ventilate Child K. As soon as that was done, Child K's chest went up and down, without too much difficulty.

He says he does not remember anything else Lucy Letby said. He says he was probably telling her to bring equipment.

Dr Jayaram says the original tube was not blocked, and there would be no reason for that to have been blocked, for the time it had been on Child K.

Dr James Smith reintubated Child K, and the same ventilator settings were selected, indicating - Dr Jayaram tells the court - Child K had not been declining.

Dr Jayaram's notes are shown to the court, where he had described it as a 'sudden desaturation'.

The oxygen saturation levels fell to 40%.

The tube was removed, Child K was bagged via a face mask, and 'sats recovered quickly'.

A size 2.5 ET tube was placed. 'Ventilator settings as previously'.

The size of the tube "did not have an impact" on the previous ventilation, Dr Jayaram tells the court, as Child K was "ventilating effectively" and did not have an impact on the "sudden deterioration".

Dr Jayaram says he cannot recall how long Joanne Williams had been away before the sudden deterioration had taken place.

He tells the court the transport team and the parents were updated, but he does not believe they were updated about "this event".

The court is shown Dr Jayaram's notes, plus writing by someone else at 5.40am recording a vial of Curosurf given.

Notes by Dr Jayaram are written retrospectively at 7.50am. He recorded at 6.15am, Child K 'began to have lower sats'.

He says the blood gas record from that point suggested the cause of that 6.15am deterioration was an issue with ventilation. He tells the court low blood pressure is also recorded.

Saline is administered but the blood pressure remained low.

The ET tube was pulled back but saturations remained low, so the ET Tube was removed. Child K's oxygen saturation levels improved in response to bagging.

The blood pressure dropped again at 7.25am. The saturations and heart rate dropped.

Child K was taken off the ventilator and Neopuff was administered.

Cardiac compressions were started as it was 'not sure enough blood was being pumped around the body' - Child K had not gone into cardiac arrest, but the heart rate had gone under 100 beats per minute.

The ET Tube "wasn't working", as it had 'gone in further' than it should have gone, the court hears.
Child K was recorded as 'now stable'.

Dr Jayaram says he had observed a chest x-ray for Child K showing the ET Tube was in the right place.

The transport team was estimated to arrive at 8.30am, and they led on treatment from later in the morning, the court hears.

Dr Jayaram says using the smaller, size 2 ET Tube, is not a problem as long as the baby was being ventilated.

He says a leak is recorded, and in itself is not of any clinical significance even if it is high, as it is important to ventilate the baby.

Dr Jayaram says the size of the ET Tube has no impact on the likelihood of it being dislodged.

Dr Jayaram says he was "happy" with the original intubation and "happy" they were adequately ventilating Child K.

He tells the court they would do investigations (such as x-rays) if they thought there was something they would need to change in management.

He says at the time Joanne Williams left the nursery room, there were no concerns of any potential deterioration for Child K.

He tells the court: "You wouldn't not have expected" Child K's lungs to have deteriorated to the extent shown in the few minutes Joanne Williams was away from the nursery room.

He says his thought processes for going into the room, when Lucy Letby was present, were only to prove to himself that everything was ok.

(Not clear exactly when cross examination started)

Mr Myers says Dr Jayaram was worried about being irrational at the time.

Dr Jayaram said he was concerned and didn't want to see Child K in a different condition. They were not based on a clinical reason, or if Child K had any underlying conditions.

Mr Myers said he believed, from Dr Jayaram's interview with police, the suspicious behaviour had been deliberate.

Dr Jayaram: "That had crossed my mind, yes."

Mr Myers: "You 'got her', then?"

Dr Jayaram: "No."

Dr Jayaram said he wanted this investigated objectively in a proper way, and there was "absolutely no evidence that we could prove anything - as that is not our job, we are doctors."

Mr Myers said he had told the police if the tube had been dislodged on purpose. He asks if he had confronted Lucy Letby.

"No, absolutely not." Dr Jayaram said he was focused on the situation.

Mr Myers says it did not happen in the way Dr Jayaram describes.

Dr Jayaram: "I am interested in why you say that."

Mr Myers says it is not documented in medical notes.

Dr Jayaram says that would not be the sort noted in medical documentation.

Mr Myers says there is nothing to say the tube is dislodged.

Dr Jayaram says it is obvious from the medical notes.

He says, in isolation, the incidents were unusual, and more concerning in a pattern of behaviour.

He said: "We, as a group of consultants by this stage, had experience of an unusual event, and there was one particular nurse.

"All of these events were unusual. Yes, if we put in Datix [incident forms] we could have investigated sooner and been here [in court] sooner."

He said he, and his other consultants, wanted to know how this could be investigated, and tried their best to escalate concerns higher up the hospital.

Mr Myers says there is no record anywhere of the suspicious behaviour noted.

Dr Jayaram says he did not anticipate being sat in a courtroom, years down the line, speaking to Mr Myers.

"If you feel someone is deliberately harming [children], you would do so, wouldn't you?"

Dr Jayaram said concerns had been raised before February 2016, and were raised again following this incident.

Mr Myers says Lucy Letby continued to work at the unit for a further four months.

Dr Jayaram says the concerns were first raised in autumn 2015 with senior management, but were told that there was likely nothing going on.

He said the consultants went 'ok', and against their better judgment, carried on.

"We were stuck, as we had concerns.

"In retrospect, we wished we had bypassed them [senior management] and contacted the police."

"We by no means had played judge and jury, but the association was becoming clearer and clearer.

"This is an unprecedented situation for us - we play by a certain rulebook, and you don't start from a position of deliberate harm.

"It is very easy to see things that aren't there - in confirmation bias.

"But these episodes were becoming more and more and more frequent by associaiton."

Dr Jayaram said it should have been documented throughout more.

He says he discussed the incident, but did not formally document it.

Dr Jayaram said he was getting "a reasonable amount of pressure from senior management not to make a fuss".

Dr Jayaram says he does not understand why an alarm did not go off, and why a call for help had not gone out when Child K was desaturating.

He said, in relation to the suspicions, he "did not want to believe it".

He said it "took a long time for police to be involved".

Dr Jayaram says the tube is 'very unlikely' to have been dislodged by a 25-week gestational age infant, in that short timeframe.

He says that can happen when a baby is 'very vigorous' - heavier, stronger babies, or when a baby is being handled or receiving cares.

Mr Myers said it was still possible for the tube to be dislodged by Child K.

Dr Jayaram says 'anything is possible', but Child K was 'not a very active baby', and a baby of this weight, size and age meant that was unlikely.

Dr Jayaram said the receiving consultant would not have assumed the tube had been dislodged by anyone else.

Mr Myers says the alarm on the ventilator was not alarming, according to Dr Jayaram.

Dr Jayaram says he had not got up because the alarm was going off. He said if it was, he would have been prompted to go in, and that would have been his reason for going in the nursery room.

Mr Myers asks if a conversation took place with Ms Williams after the desaturation.

Dr Jayaram says he does not recall the conversation. He says: "Why would I ask her what happened in the room when she wasn't there?"

The court is shown swipe data for Joanne Williams, who left the neonatal unit at 3.47am.

Mr Myers says it is very precise in coinciding with
Dr Jayaram's recollection of waiting two-three minutes before the desaturation is timed at 3.50am, and asks if Dr Jayaram always has such a precise memory.

Dr Jayaram says "In this event, I did."

He adds: "I kept telling myself, don't be ridiculous [about my suspicions]. I looked at my watch - I didn't have a stopwatch."

Dr Jayaram says he has never seen the swipe data, nor had cause to look at any data.

Dr Jayaram says it would be appreciated if Mr Myers gave an indication of where he was going with his questioning.

Mr Myers says an earlier police interview had Dr Jayaram not giving a precise estimate how long Joanne Williams had been out, but is able to give a more precise estimate now, several years later.

Dr Jayaram says he has had more time to reflect on this incident.

Dr Jayaram: "The point is, this incident happened in the window when she [Joanne Williams] was out."
He tells the court the incident of this night is "emblazoned" in his mind.

Dr Jayaram adds he "refutes" the allegation the care the hospital team provided contributed to the outcome of Child K.

Mr Myers asks if the focus on this incident was to "distract" from the overall care provided by the medical team to Child K.

Dr Jayaram: "Well, that's an easy one to answer: Absolutely not."

"Are you seeking to bolster suspicion against Lucy Letby?"

"Absolutely not."

Mr Myers asks if there was an opportunity, within the 48 hours before Child K's mother gave birth, to transfer her to a tertiary centre. Dr Jayaram says he does not have that decision to make, and cannot answer that, but adds there were many factors to consider.

Dr Jayaram is asked about the intubation process.

Mr Myers says the process was carried out by a 'relatively junior registrar', Dr James Smith. Dr Jayaram said Dr Smith had been assessed as competent and experienced enough, and it was 'standard practice' to carry out these procedures.

"I could see he could do this, and safely."

He adds if Child K was struggling to be ventilated at the time, and the heart rate and saturations were not being maintained, then he would have taken over.

Mr Myers asks about the high air leak.

Dr Jayaram says the 94% leak is a measured value, and is significant is the baby is struggling to be ventilated; but if the baby is being ventilated, then it is just noted.

Mr Myers says lung surfactant should be administered within five minutes of intubation. Dr Jayaram: "Ideally, yes."

He says it is used to improve gas exchange.

If it is given slightly later than expected, it would "not make much difference in the long run", as it is important the baby is receiving ventilation at the time.

Mr Myers asks why only Dr Jayaram and not Dr James Smith made notes. Dr Jayaram says he does not know why that was the case.

Dr Jayaram's medical notes are shown to the court, and the medicines are highlighted. Mr Myers says it appears the antibiotics have been delivered at the right time.

A prescription chart is shown for one of the medicines, 'time given 0445'. Dr Jayaram agrees it appears it was administered at that time, and should have been administered sooner.

He says the late administration of the antibiotics is important, the vitamin K not so.

Mr Myers says he will next talk about the morphine infusion.

Dr Jayaram is asked about the morphine infusion recorded, which appears on the notes above a note added, timed at 3.50am.

Dr Jayaram says, having seen the prescription chart, the morphine infusion would not have happened before the desaturation.

Mr Myers said Dr Jayaram had told police Child K had been sedated with morphine. Dr Jayaram said that was what he had believed at the time.

Dr Jayaram says Child K was not on a morphine infusion prior to the desaturation. "However", she was not a vigorous baby.

He says, in retrospect, he will accept the morphine was not running prior to the desaturation.

He says he is "surprised" it was not running sooner.

He says he believed, "in good faith", the morphine was running at the time.

Mr Myers: "Have you tried to shift your evidence? That you can't blame it on morphine?"

Dr Jayaram: "Even accounting for the fact she was not on morphine, she was a 25-week gestational age", small, and weighing 600g and was stable - 'poorly, but stable'. He says that the dislodging happened in such a short space of time was "concerning".

He says Child K was able to move her arms and legs, but not enough to dislodge a tube.

He says his previous statement was based on a "genuine misunderstanding based on my notes".

He says he does not accept he made a "deliberate error".

Dr Jayaram says he is not aware of a nursing note recording 'blood-stained oral secretions'.

The nursing note by Joanne Williams which refers to this is shown to the court.

Dr Jayaram says that is in the back of Child K's mouth, not in the tube, and is not clinically relevant. It was "not a significant finding".

He says he would have noted if the tube had been blocked, and he would have noted it.

Dr Jayaram says the tube blockage would lead to a gradual deterioration, quite quick, but did not fit the pattern of Child K's deterioration.

Mr Myers suggests the care of Child K provided could have been improved.

Dr Jayaram said it could have been better.

Mr Myers suggests Dr Jayaram has added to his account over the years.

Dr Jayaram: "I would disagree with that - you would be questioning my brevity and honesty."

Prosecution
The prosecution rise to ask about a couple of matters.

Dr Jayaram is asked if he has ever seen the electronic sequence of events [being shown in court], or the swipe data collated.

Dr Jayaram replies he has never seen either, nor had cause to see them.

The judge asks about the morphine infusion prescription chart, and asks Dr Jayaram which sections are in Dr Jayaram's handwriting. The sections including the 0350 start time are in his writing.

The infusion would have been administered by the nurses, Dr Jayaram tells the court.

That completes Dr Ravi Jayaram's evidence for Child K.

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Medical Experts Evidence

Mr Johnson explained to the jury he was not calling medical experts Dr Dewi Evans and Dr Sandie Bohin.

He said the prosecution and defence had agreed there was nothing they could add to the evidence already heard about Child K.

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Police Interviews Summary

On Wednesday, March 1, prosecutor Nick Johnson KC read to jurors a summary of Letby’s police interviews about the incident, in which she denied any wrongdoing.

Letby told detectives at Cheshire Police she only recalled Child K because she was a “tiny baby” and the Countess of Chester did not usually take babies of her gestation and weight.

She said she had no recollection of the tube slipping and agreed that designated nurse Joanne Williams would not have left Child K unless she was stable and her ET (endotracheal tube) was correctly positioned.

Mr Johnson said: “She stated she would have raised the alarm if Dr Jayaram had not walked in and if she had seen the saturations dropping or that the tube had slipped.

“Miss Letby thought it possible that she was waiting to see if self-corrected. She explained that nurses don’t always intervene straightaway if levels were not ‘dangerously low’.”

Following further questions from police, she suggested that maybe the tube had not been secured properly, he said. She denied that had been done deliberately.

Child K was transferred later that day to Wirral’s Arrowe Park Hospital where she died three days later.

The Crown does not allege Letby caused her death.

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Thirlwall Evidence Documents