This is the complete trial testimony given by Dr Dewi Evans in the cases of the babies listed below. The text has been formatted for the web verbatim from trial transcript pdf documents, and includes both examination-in-chief and cross-examination testimony.
Tuesday, 25 October 2022
MR JOHNSON: Thank you, Dr Evans. You're still on oath.
DE: Yes.
NJ: Now, I would like to go from generalities, which you were telling us about last time, to specifics if we can, and just so that you understand and the jury understands how we're going to deal with this, I'm going to ask you questions about [Baby A] first of all, then you will withdraw and Dr Bohin will give evidence about [Baby A].
DE: Okay.
NJ: Then I'll recall you to deal with [Baby B] and you will be asked questions in cross-examination by Mr Myers, and after you have finished we'll get on to [redacted].
DE: Okay, thank you.
NJ: (Overspeaking) same exercise.
MR JUSTICE GOSS: So you understand, there won't be any cross-examination of you between the two children.
DE: Yes.
MR JOHNSON: Thank you. Now, Dr Evans, is it right that you have written four separate statements relating to the case of [Baby A]?
DE: Yes.
NJ: The most -- the two most recent are simply covering technicalities which cover documents that you were given after the first two statements you made?
DE: Yes, they are.
NJ: You have also made an overarching statement which pulls together evidence relating to all the children?
DE: Yes.
NJ: And I'm not going to deal with that at this stage. I will deal with that at the end of the evidence --
DE: Yes.
NJ: -- and the prosecution case, when the jury have heard about all the other children. So what I would like to concentrate on are -- is the evidence that you have put into two reports. The first was written on 7 November 2017 and the second written on 31 May 2018.
DE: Yes.
NJ: Have you got copies of those reports to hand --
DE: Yes, I have.
NJ: -- if required? Thank you. Now, I would just like the jury to understand, first of all, what your purpose was in your initial report? What had you been asked to do by the police?
DE: Yes. I became involved with this case in July 2017 via the NCA, that's the National Crime Agency, and they provide links between people from my kind of background who prepare work -- prepare reports for the police authorities. So as a result of a discussion between myself and the NCA, I visited Cheshire Police, and my role -- and their concern was that there had been a number of deaths in the Countess of Chester Hospital which were unusual in that there were far more deaths than they would expect, and that the deaths were -- followed collapses of babies that were otherwise quite stable, and not only were the babies stable, but following the collapse, in many of the cases, resuscitation was not successful and the baby died.
Therefore, given what we discussed a couple of weeks ago regarding my hands-on neonatology background and experience, I thought, yes, I can help, advise, review the case notes, and form an opinion as to what could have led to the collapse of the [Babies A & B] and others, but let's stick with the [Babies A & B], and why was it that despite very prompt resuscitation in [Baby A]'s case, it was unsuccessful and he died, having, a short time previously, been very well. So therefore my role was to look at the clinical evidence.
NJ: Yes, okay. Initially at least, was this a sort of sifting process?
DE: This was a preliminary process. I obtained copies of the case notes later that year and I prepared a large number of reports during November 2017, and this was one of the first ones. [Baby A]'s case was the first I carried out where the baby had died and where the cause of, firstly, the collapse and, secondly, the death I found quite disturbing and quite unusual.
NJ: Yes, all right. Now, as the case -- and by "the case" I mean the wider case -- has progressed, have you received more information?
DE: Yes, I have. My -- this goes off all the time. But all of my reports said: this is a preliminary report and I will provide additional reports if I receive, you know, more information regarding this case or any of the others. Yes.
NJ: And I'm talking in general terms at the moment, and not child-specific terms.
DE: Yes.
NJ: But that additional information, has it from time to time been specific information relating to individual children --
DE: Yes.
NJ: -- first of all?
DE: Yes.
NJ: So, for example, as the wider case has progressed, you have been sent witness accounts and that sort of thing from time to time?
DE: Yes.
NJ: Has that accumulation of information that you have received also included relevant information that bears directly on other children but has a relevance to a specific child as well? So it's directly -- putting that more clearly, it's directly relevant to a third party child, but because of similarities or differences, it has a relevance to the child under consideration?
DE: Yes. As I went through the cases, a pattern became apparent. In other words, I was seeing the same thing in other cases. And in certain cases the additional items of information reinforced my original opinion regarding the cause of the collapse. In other cases the additional information, not in this case but in other cases, the additional information led to me changing my mind about the cause of the collapse or, you know, what had gone on. So therefore, you know, we're clinicians, we rely wholly on evidence, and so in this particular case with the twins the additional -- the extra information I received over the next couple of years reinforced my opinion as to what had led to the collapse of the twin babies, yes.
NJ: Okay. What I would like to do is now concentrate on your more recent report, okay. So that the report of 31 May 2018 which, for anybody's note, is to be found at I744. Now, as part of your --
MR JUSTICE GOSS: Sorry to interrupt, just so that the jury aren't -- you don't have I744? Exactly. That's what was worrying me. So I want to make it clear. What it is, it's a report, but the witness is going to speak to his report. So it's his evidence. As I have said to you, it's on the evidence that is placed before you. Where there is reference to documents, as I anticipate there may be reference to documents, you will be told which documents a reference is being made to. All right.
MR JOHNSON: Do your reports, generally speaking, follow a formula?
DE: Yes, they do. Because I had to deal with a number of cases and I had no idea as to, you know, the time of any event, I did my report in date of birth order, which are more or less the same order that we've gone through them over the last couple of weeks, but not quite. So, for instance, my report on [Baby B] preceded the one on [Baby A] because she was the first twin. And if you look at all of my witness statements, this is just to be useful, the first page contains a line called "my reference" and for [Baby A] it has [Baby A], and before that there's a digit, 05. So he was the fifth of the cases I dealt with. And for 14 of the 17 cases, my preliminary report or my screening report, if you like, was -- were completed in 2017. The two insulin cases, which, you know, we've heard about, they were prepared later and there was one other case as well that I prepared later. But 14 of the 17 cases we're dealing with here, my preliminary -- my preliminary report, screening report, was completed in November 2017.
NJ: Yes, thank you. So one of the first things that you are obliged to set out in your report is the documentation or material that you have received on which you reach your opinion?
DE: Yes.
NJ: Is that right?
DE: Yes.
NJ: And that is listed in your reports, and one of -- under paragraph 3. One of the matters that you refer to is the post-mortem images of [Baby A]. Now, they are the radiographs, one of which the jury saw last Friday when Dr Owen Arthurs gave evidence?
DE: Yes.
NJ: Do you remember that?
DE: Yes, yes, yes.
NJ: And I would just like, if we can, please -- and I am afraid I didn't give Mr Murphy advance warning of this don't know -- can we just put on to the screen that particular image, just to remind the jury what it is I'm talking about. Thank you. Now, I'm sure the jury will remember this, Dr Evans. I think you saw Dr Arthurs giving evidence; is that right?
DE: I did.
NJ: And you saw Dr Arthurs refer to what he referred to as gas bubbles in one of the major vessels which are in a line above where we can see the spine of [Baby A] in that image?
DE: Yes.
NJ: Now, first of all, is this a picture that you received as part of the documentation?
DE: It was. The quality was not as good as this --
NJ: Yes.
DE: -- but I did see it.
NJ: Yes. Did you, as a matter of fact, from the point of view of a paediatrician, notice the gas bubbles that Dr Arthurs has told us about?
DE: No, no, no, this is very specialised stuff, and even with this quality X-ray, I don't think I would have picked that up as something abnormal.
NJ: No, all right, thank you. Now, if we could remove that image, please. As part of the material you received, you also were given the composite medical records of [Baby A]; is that right?
DE: Yes.
NJ: And whether or not it's true in [Baby A]'s case, from time to time we will come across some of the children in this case where additional medical records have been retrieved by the police after your reports?
DE: Yes.
NJ: And they have been -- you have dealt with those in supplemental reports?
DE: I have dealt with them and I think the other point to be made is that the -- the copies that the police obtained originally were not in the ideal order. They were -- you know, the documents were not in date order, which made it a little bit difficult to interpret from time to time because they were not -- some -- quite a lot of them were out of sequence, which was a bit annoying.
So the police actually got them in all in really perfect order so the reports we are talking about, you know, the ones that start J something, they are in good chronological order. But I didn't have the benefit of the -- of that quality of clinical notes when I was looking at these cases.
NJ: Okay. Now, I just want to deal with the formal statements that you had in [Baby A]'s case by the time you came to write your report on 31 May --
DE: Yes.
NJ: -- last year. You were given --
DE: 2018.
NJ: Did I say last year?
MR JUSTICE GOSS: Yes, you did.
MR JOHNSON: 2018, yes, sorry, you're quite right. You were given a number of statements from medical staff that had been involved with [Baby A]'s care; is that right?
DE: Yes.
NJ: You were also given a detailed report of Dr Beech, who was a paediatric registrar present at [Baby A]'s resuscitation?
DE: Yes.
NJ: You were given the statement of Dr Brunton, who was a registrar who dealt with [Baby A] the night -- on the night of 7 June; is that right?
DE: Yes.
NJ: Dr Brunton's report also covered [Baby A]'s readings at 6.45 on 8 June and the handover from the night shift on which [Baby A] had been born to the day shift on the 8th?
DE: Yes.
NJ: You also say a statement from the consultant Dr Saladi?
DE: Yes.
NJ: The statement of Dr Sally Ogden --
DE: Yes.
NJ: -- who worked on the day shift of the 8th?
DE: Yes.
NJ: And you also noted [Baby A]'s blood gas values on the day shift --
DE: Yes.
NJ: -- as being normal?
DE: Yes.
NJ: The fact he was in air on the day shift, didn't require additional oxygen, and his respiratory rates, as recorded in those observation documents that we see every hour on the hour?
DE: Yes.
NJ: Yes. You had material from Dr Ogden and/or Dr MacCarrick relating to passing the first UVC?
DE: Yes.
NJ: Just to remind us what a UVC is, please?
DE: It's an umbilical vein catheter or cannula.
NJ: Yes. And yesterday Dr Jayaram, the consultant paediatrician, told us that the catheter passing into the hepatic, the liver, vein was a matter of pure chance. Can you just explain to the jury how these things work?
DE: Yes, I can. With newborn babies the umbilical vein, which is the vein that supplies blood before the baby is born, is a very easy access point for giving intravenous drugs or fluids. So therefore it's much easier to put a cannula into an umbilical vein than to try and find a vein in an arm or leg. Therefore it's practical to pass a cannula into the umbilical vein. Now, once it goes through the umbilical vein, you hope that it will go through into the vena cava.
NJ: What is the vena cava?
DE: The vena cava is the main vein that supplies blood that comes from the lower limbs, from the legs, up to the heart.
NJ: So it's taking blood back to the heart?
DE: Taking blood back to the heart. It's the big, big vein in the body.
NJ: Is that one of the great vessels that were being spoken of by Dr Arthurs?
DE: Yes.
NJ: What is the other great vessel?
DE: The other great vessel is the aorta, and the aorta is the great vessel, the big blood vessel, that takes blood from the heart to all parts of the body.
NJ: Yes.
DE: So the aorta distributes blood that is oxygenated, supplying to the body, and then once the body has taken up the oxygen, the blood is returned to the heart via the vena cava, via this big vessel.
NJ: And the aorta, is that an artery?
DE: Yes.
NJ: Easy to remember. And an artery is -- an artery takes blood from the heart, a vein returns blood to the heart?
DE: Yes. The aorta delivers blood from the left side of the heart to the body, and the veins return blood to the heart, to the right side of the body, and then on to the lungs --
NJ: Yes.
DE: -- where the blood is oxygenated in the lungs, and then from there to the left side of the body, and pumped around the heart.
NJ: Thank you.
DE: That's the basic plumbing.
NJ: Yes, thank you. So aorta, artery; vena cava, vein. An easy way for people like me to remember. So that concerns the -- so I think I slightly diverted you from the question I originally asked, which was: what is the problem once you get into the umbilical vein with either going into the great vessel, the vena cava, or alternatively into the hepatic vein?
DE: Yes. You hope it gets into the vena cava. You've no control over where it goes. So unfortunately sometimes it goes into the portal system, the liver system. It was described as going into the wrong place. I would prefer to describe it as going into the place that's not ideal. It still works, it still works, but it's not ideal, and therefore usually if it gets into the liver side -- let's put it that way -- if it gets into the liver side, usually the plan is to remove it and have another go to see if it gets into the vena cava. But although it's not ideal -- having a cannula going in there, it still works. You know, you can still give fluids through it if you have to.
NJ: What is the problem with it going into the liver? Why does that reduce the efficacy of whatever it is that you're putting in?
DE: Well, the blood flow to the vena cava is far better. So you've got a nice continuous blood flow. So you're not going to get any complications.
NJ: Is the reason it's -- what is the reason why you can't direct it into the vena cava rather than it ending up in the hepatic vein?
DE: I don't know it's just that sometimes they go the wrong way.
NJ: Is it the equivalent of putting something down a tube and just hoping that when it reaches a junction it goes the right way?
DE: Yes. Cardiologists these days, they do these catheters and they have got direct vision of where everything is going.
MR JUSTICE GOSS: Internal cameras, so they can see it?
DE: We haven't got that system.
MR JOHNSON: Okay. So that's what Dr Jayaram told us about putting in a UVC and removing it. Then the second UVC was reinserted at 16.30. I want to come to Dr Harkness and his evidence next, please. Can we go to the notes, please. Let's deal with it this way: you will remember Dr Harkness' evidence concerning putting in a long line?
DE: Yes, I have been here all the time next door --
NJ: Yes.
DE: -- so I have listened to all the evidence, yes.
NJ: And was what Dr Harkness did standard treatment in the circumstances as they were being presented to him?
DE: Yes, yes, routine stuff.
NJ: And so far as that is concerned, what is the point -- what was the point of putting in this long line?
DE: Right. The importance of a long line is that -- you can put a peripheral line into a vein or you can put a long line in.
NJ: What is the difference between --
DE: The difference is this: if you put a peripheral line in, blood vessels -- veins in small babies are very friable. So therefore, if you squirt some fluid through it, it will break. The word we use is tissue. Whereas if you put a long line in, the tip of the cannula ends up in a larger blood vessel and therefore, with a bit of luck, it will stay there for a few days. Of course, the fewer occasions you need to pass a cannula into a small baby, the better, because it's technically quite challenging anyway. It's quite difficult getting a long line in. It needs quite a bit of skill and experience, but once it's in, it's in, and that saves nurses, doctors and babies a lot of stress.
NJ: Yes. Now, at paragraph 36 of your report of 31 May you deal with potential problems of long lines.
DE: Yes.
NJ: A word to which we were introduced yesterday by Dr Jayaram was tamponade.
DE: Tamponade, yes.
NJ: And Dr Jayaram, I think, described it as being a perforation in the heart. Well, you tell us what a tamponade is.
DE: Yes. The heart is surrounded by the pericardium. The pericardium is simply a lining around the heart. And usually there is no gap between the lining of the heart and the outside part of the heart tissue itself. But if you can get -- if fluid or anything gets in between the outside of the heart and the inside of the pericardium, this lining, it will constrict and restrict the ability of the heart to contract properly, and it's literally a deadly serious condition. If there's enough fluid there, usually fluid -- could be blood, could be fluid -- then it restricts the heart contraction and, you know, will lead to a deterioration in the child's condition and death.
NJ: Is there a clinically recognised potential connection between the insertion of a long line and a tamponade?
DE: Yes, there is. It's usually something -- there was quite a bit of publicity about this some years ago because there was a number of cases of babies who died from cardiac tamponade as a result of this creeping of the end of the long line through to the heart, penetrating the heart, and then the fluid going into the space between the pericardium and the heart. I'm sad to say in Swansea we had a case of that nature where a baby died from cardiac tamponade. So this is years and years ago and I'm not aware of any cases recently because of more care -- because of the awareness of this creeping phenomenon, but usually this is something that occurs in a long line that's been in for quite some time. It's not something that you get in a long line that's been in an hour or two. So we're talking long lines in for several days.
NJ: I think Dr Harkness told us if there has been this sort of perforation injury caused by either the wire or the end of the long line itself, it shows up on a post-mortem autopsy?
DE: Well, it would show up on even -- more obvious would be the evidence of the tamponade. In other words you would be able to see fluid or blood or whatever, you know, within -- outside of the heart itself and within the pericardium. So therefore diagnosed -- diagnosing cardiac tamponade at post-mortem would be a pretty straightforward thing to do.
NJ: Okay. Have you seen any evidence in this case to support that as a suggestion for what happened, as a cause for what happened to [Baby A]?
DE: None at all, no.
NJ: Now, we all heard evidence that at about 9.20 pm [Baby A] was found to be apnoeic, not breathing?
DE: Yes.
NJ: I'm sorry. 8.20. I'm seeing one thing and saying another. My fault. All right. We heard about the treatment that was given to him?
DE: Yes.
NJ: It may help just to remind the jury. If we can, could we go, please, to Dr Harkness' notes which are at tile 183. The jury will see straight away why I said 9 and not 8. These were notes made -- if you look -- when we look at the notes, you will see they were made at 9.20. It's the previous page which is -- it is my fault. We can see that Dr Harkness was called to [Baby A] at 20.26. Bagging it started via the Neopuff. Good chest movement seen. He then took us through the steps that he took in an effort to resuscitate [Baby A]. Do you remember that evidence?
DE: Yes, I do.
NJ: Was the treatment that was given to [Baby A] appropriate in all the circumstances?
DE: This was very good standard resuscitation procedure. It's what you would expect in any neonatal unit in 2015.
NJ: Now, we heard yesterday from Dr Jayaram, the consultant, about the various possibilities that were running through his head when he came to assist Dr Harkness a few minutes later. Again, were the possibilities which he was considering appropriate to the circumstances?
DE: Yes, they were. He went through a sequence of possibilities. I don't think I need to go through them.
NJ: No.
DE: But that is what I would expect any experienced paediatrician to do: is it this, is it this? In other words, 1, 2, 3, 4. I think he mentioned the four Hs and the four Ts. Great. A nice way of remembering all these things. So that's exactly what we would all do.
NJ: Now, for the -- to help other people's notes, I'm going to deal with your observation section of your reports, Dr Evans, which is paragraph 32 onwards.
DE: I have come without my mouse today. Right, yes.
NJ: Now, did you review the medical records relating to [Baby A]'s progress from his birth on the 7th to his collapse after 8 pm on the 8th?
DE: I did.
NJ: And have you listened carefully to the evidence that's been given in this trial concerning that period of time?
DE: I have, yes.
NJ: What view have you reached as to [Baby A]'s state of health just before the time he collapsed?
DE: Right. By the -- just before he collapsed, [Baby A] was in a stable condition. In my report I described it as perfectly satisfactory. "Perfectly satisfactory" is one of my little sayings. Probably better to describe it as being stable or satisfactory, but it was as well -- he was as well as could be expected. All the markers of well-being were very satisfactory.
What I mean is he was in air. So he was not requiring additional oxygen. His oxygen saturation was up in the high 90s, which is great. His heart rate was within normal limits. He wasn't requiring anything in terms of, you know, breathing support and his respiratory rate was slightly above the norm -- normal range.
So that was the only marker that was outside the normal range, but again, from a clinical perspective, what one tends to do is look at the overall well-being of the baby and so those markers -- I mean really by that time he, [Baby A], had survived the most dangerous journey of his life, really. You know, he was, you know -- I think this is why people get involved with baby care really, because, you know, by this time he -- you know, he'd -- would he have needed care because he was too small to feed himself, etc, but he was -- he was doing really, really well and I think everybody on the unit would have been really, really pleased with the way he was.
NJ: Yes. Now, so far as the repeated effort to insert the UVC was concerned, in your opinion, did that have any effect on [Baby A]'s deterioration?
DE: No. It didn't cause his deterioration at all. It's an upsetting procedure, obviously. You have doctors poking around in your tum with cannulas. So -- but it would not have caused his deterioration, no.
NJ: Equally, did Dr Harkness' insertion of the long line have any effect on [Baby A]'s deterioration?
DE: None at all.
NJ: We've heard of a phenomenon called apnoea of prematurity.
DE: We have.
NJ: Could you just explain -- just remind us what that means in practical terms, please?
DE: Yes. Premature babies sometimes forget to breathe, which is simply a way of putting it. Premature baby breathing is not always regular in and out, in and out, in and out, as you would expect with a full-sized baby. So therefore, with apnoea of prematurity, the breathing might be -- become more and more shallow with each breath, and then they might, you know, stop altogether. And then they start again and that is a pattern that we associate with prematurity.
If they forget to start again, which happens, that is apnoea of prematurity. It is a condition that every nurse is aware of, every doctor is aware of, so we know all about it.
NJ: What remedial efforts need to be taken for a baby that is exhibiting apnoea of prematurity?
DE: Very easy. It depends on other parameters. If the baby just started -- stopped breathing, the nursing attendant would maybe move a leg.
NJ: Dr Jayaram said poke the baby. Is that --
DE: Yes. I think that's a bit of vernacular, but yes. Just get the baby, you know, to jig up a bit, and that usually works. That works most of the time. And it's not a concerning matter if they start breathing straight away because these babies are connected to continuous monitoring. In other words, you don't measure the respiration every hour. You can see the wave pattern, as I described the other week, on a monitor. So you can see if the baby is breathing satisfactorily.
NJ: Yes. Now, you have heard the evidence from the witnesses concerning what I'll paraphrase as a "flitting rash". I'll give no further description than that.
DE: Yes.
NJ: In the context of what happened to [Baby A], what in your view is the reason for his collapse and death?
DE: Right. At the time I prepared my report, of course, I was not aware of, you know, the rash. It was much -- I knew nothing about the rash.
NJ: It's not in the notes, is it?
DE: No, there's nothing in the notes. I have heard all of this over the last couple of days, but it wasn't in the notes. So -- but I heard very -- I heard the descriptions of this rash and, in my opinion, I think the rash can be -- [Baby A]'s collapse fits together and go with a -- is sufficient to make a diagnosis that his collapse was the result of an air embolus. In other words, air had somehow got into his circulation.
I'd formed this opinion without knowing about the rash. I'd formed this opinion without anybody suggesting to me that anyone had made any -- expressed any concerns about air embolism at all, you know, in this case or any of the others.
NJ: Yes. I'll deal with air embolus in a second. But so far as other potential causes of death, was there anything that was, so far as you were concerned, a credible explanation for what had happened?
DE: Cause of collapse rather than cause of death?
NJ: Yes, sorry.
DE: We're always on the lookout for sepsis, for infection in babies, because prem babies are at risk of infection. There was no evidence of infection.
Hypoxia, lack of oxygen. There was no evidence of that. His sats, in other words his oxygen saturations, could not have been better, high 90s. So there was no evidence of that.
He was breathing well. You know, that's fine. And there was a bit of hiatus with regard to the fluid. You know, there was a period of about 4 hours, I think, where he didn't have fluid. His fluid rate at the time was 4ml an hour. So he lost 16ml -- potentially 16ml of fluid, but that in a baby, who was otherwise well, would not cause a sudden onset unexpected collapse.
NJ: Now, Dr Jayaram yesterday said that if the baby is dehydrated, there are consequences so far as the respiratory rate is concerned or the heart rate?
DE: Heart rate.
NJ: Heart rate, I beg your pardon.
DE: All doctors are familiar with dealing with patients of all ages who come in in a "collapsed" state to A&E where they've lost blood, you know, trauma. And in those cases -- or severe gastroenteritis in children, still common.
And in those babies, if they are severely ill as a result of loss of fluid, loss of, you know, diarrhoea, vomiting, loss of blood, the heart rate goes up.
So the heart rate was not high. The heart rate was pretty steady in [Baby A]'s case right until the time he collapsed.
So therefore although the failure to give him 4ml of fluid per hour --
NJ: I think it's 4ml per kilo --
DE: No, for him it was per hour. Day 1 at 60ml per kilo per 24 hours. He was 1.6 kilo, so that's about 100ml per day. So 24 hours, it's 4ml per kilo. So that's the way we work it out.
So therefore although he was devoid of fluid for 4 hours, the fact that he was on constant monitoring and the monitoring was great, you know, within normal limits, that was not an issue in relation to his collapsing.
NJ: Okay. Now, air embolus. How does an air embolus kill somebody? What is the mechanics of it?
DE: The mechanics is pretty straightforward. It interferes with the blood supply to the heart and lungs, to the lungs, and so the mechanism is the same as a clot from a -- that goes into the lung, what we know as a pulmonary embolus. It blocks off blood supply and kills you.
NJ: Now, we heard evidence concerning this purple or pink appearance that was -- that was flitting.
DE: Yes.
NJ: I want to ask you about an academic paper to which Dr Jayaram was referred yesterday. All right?
I just would like to put that page up on the screen, please. It's the second page that he was shown. Thank you.
Can we expand that left-hand column, please.
Now, you will remember, I'm sure, Dr Evans, that it was being suggested to Dr Jayaram yesterday that he in effect had lifted the explanation that appears in this academic paper and imposed it into his description. In other words, where it says: "In one of our own cases we noted bright pink vessels against a generally cyanosed cutaneous background."
That was the part that was quoted to him yesterday.
DE: Yes.
NJ: I want to ask you about the next sentence, please. It reads on follows: "This we attributed to direct oxygenation of erythrocytes..."
What is that word?
DE: Erythrocytes, red blood cells.
NJ: "... adjacent to free air in the vascular system, while the tissues continued to be poorly perfused and oxygenated." Can you translate that into language that I can understand, please?
DE: Yes. It's straightforward, really.
NJ: Well, for you!
DE: Right. Yes. First of all, just briefly about this paper, that is paper by Lee and Tanswell. And it's probably the best known paper in relation to pulmonary vascular air embolism in the newborn. It's published in 1989. So despite being over 30 years ago, it's a very well-known paper -- and the other reason it's well-known for British paediatricians is it was published in the Archives of Disease in Childhood, which is a monthly academic journal that all paediatricians receive.
So therefore it's the most -- so the Archives are the most widely read journal from paediatricians. Anyway, just to -- so this is not some obscure journal, you know, that nobody ever reads.
Right. In terms of this description, if babies collapse they become hypoxic, and the usual change in colour is they go blue. Okay? So they become cyanosed.
If their blood pressure drops, they may go white. You know, because there's no circulation.
So therefore the colour changes you find in collapsed babies, collapsed children, is a combination of blue and white because they are white if there's no blood getting into the peripheries, into the skin, and they're blue if the blood that does get there is hypoxic, in other words lacking in oxygen.
So that's what we're used to seeing in babies who collapse because of infection or any other cause, whatever.
So therefore what we've got here is: "Bright pink vessels against a generally cyanosed cutaneous..." You know, relating to the skin. So the fact that it's bright pink, now, that is remarkable. It's very unusual. It shouldn't be pink. You know, or if it's pink, why has the baby collapsed? It doesn't make sense.
Their interpretation is absolutely correct. They attribute it to the direct oxygenation of red blood cells -- in other words, red blood cells have got oxygen in them -- and adjacent to free air in the vascular system. In other words, there's air in the circulation. You know, air or oxygen in the circulation.
NJ: So air is 21% oxygen?
DE: And air is 21% oxygen. So this is remarkable. You should never, ever, ever have air in your circulation because of -- because it's dangerous.
And if the tissues continue to be purely perfused and oxygenated -- so they are really saying this makes no sense because we've got pink colouration and yet we've got collapsed patients. This shouldn't happen.
And they attribute it, quite correctly, to the fact that the cause is air embolism: air has got into the circulation.
NJ: So it is the blood, essentially, unoxygenated, but the red blood cells oxygenate themselves from the air, in other words the 21% of the air, that's in the 61 bloodstream?
DE: Yes. Yes.
NJ: That's the answer?
DE: Yes.
NJ: Now, initially, Dr Evans, you offered a potential alternative cause of [Baby A]'s collapse and death. Can we just deal with that. First of all, what it was, and secondly, whether you still suggest that that is a possibility.
DE: No. Right. This was the -- the twins in the first cases I dealt with were presented in this way, and it's not a criticism. None of us knew what had happened. In other words, we were -- you know, we just had no idea why these babies had collapsed.
So one of -- so what crossed my mind was obstruction in breathing, smothering.
The other possibility which I mentioned, part of the differential diagnosis that we -- you know, that doctors do is that he'd received an injection of some noxious substance. But I just mentioned that, I have dismissed that.
NJ: You're not suggesting that, on the evidence as you now know it to be, that that's a creditable alternative?
DE: No. If somebody asked me, give me five or six reasons why this baby could have collapsed, it would be one of the reasons. But no.
NJ: I'm sorry, you finish your answer.
DE: No, I finished.
NJ: Can I just deal with a term that you have used because it's likely we're going to hear it again during the evidence, so I'm asking you to define a differential diagnosis.
DE: Yes.
NJ: What is a differential diagnosis to a medic?
DE: Yes. If you have a patient, any patient, who presents with an illness, there may well be three or four reasons to explain this illness.
Babies are physiologically fairly simple individuals. So in a baby who has collapsed, the differential diagnosis would include hypoxia, lack of oxygen, sepsis, infection, airway obstruction, again causing hypoxia.
So we would go through a list. We've discussed tamponade. That's another.
So therefore there's a whole list of potential conditions that could compromise the stability of your baby. And that list of conditions is what we call a differential diagnosis.
NJ: All right. So is it another way in effect of putting what Dr Jayaram was articulating in the witness box yesterday, he was going through possibilities?
DE: Yes.
NJ: This is the method by which your profession, in effect, works in real time?
DE: Yes. It's thinking out loud.
NJ: Yes. Finally on [Baby A], please, Dr Evans, the means by which air could have been inserted into a baby's circulation. From what you know of the way in which [Baby A] was being treated, what are the possibilities?
DE: Well, there are only two, really -- sorry, there's only one, really. The air would have gone through an intravenous line. And that can only occur in two ways: accidentally or on purpose. And that's it. Yes, so those are the only two explanations.
Some time ago I obtained a copy of all the intravenous bits and pieces of equipment used at the Chester hospital, which we're all familiar with. We are all familiar with these lines from visiting people in hospital, an intravenous bag line. I won't go through the whole bit.
But doctors, nurses, we're so obsessive about ensuring that air does not get into the system, you know, we're absolutely obsessive about it, and always have been, and it's much better now than -- So having rigged up the system that was used in Chester, and it's in a room in this court, in this building, so we could demonstrate it if necessary. I rigged it all up.
There's no way air could have got into [Baby A] by accident. You know, the fail-safe systems, the monitoring, the alarm set-ups, which have been present for, you know, a couple of decades, I suppose, ensures that this is not something that can occur accidentally.
MR JOHNSON: Thank you. Well, I'm going to recall you a bit later to deal with [Baby B]'s case if I may, and Mr Myers is putting over his questioning until we've dealt with [Baby B]. So those are all the questions I have at this stage.
DE: So now Dr Bohin is coming in?
MR JOHNSON: Yes, please.
MR JUSTICE GOSS: I'm just going to see -- do you want to have a short break before we carry on or do you want to carry on for another 40 minutes?
(Pause)
MR JUSTICE GOSS: Right, good, we'll carry on.
MR JOHNSON: Thank you for now, Dr Evans.
MR JUSTICE GOSS: So thank you, Dr Evans. That's it for the time being, but you will be coming back later, some time this afternoon. Thank you very much indeed. But take your documents with you.
MR MYERS: Dr Evans, at the point we're at now, you have been provided with all the exhibits relating to the medical evidence of the children in this trial, haven't you?
DE: Yes.
BM: And so far as we know, you've had access to all the witness statements dealing with the medical aspects of the case?
DE: As far as I know, yes.
BM: As far as you know. And as the trial has been proceeding in front of the jury, you have been able to watch it, albeit from another courtroom on the link?
DE: Yes.
BM: So you've been able to follow what has been happening?
DE: Yes.
BM: Your involvement in this investigation began in 2017, did it?
DE: It did.
BM: And it's continued over the years since then, hasn't it?
DE: Yes.
BM: At the moment you're giving evidence about [Babies A & B]?
DE: Yes.
BM: And also some of the general issues relating to air embolus?
DE: Yes.
BM: You've prepared and provided a very large number of reports, inevitably, over the years, haven't you?
DE: Yes.
BM: And what you say about air embolus generally features across dozens of them, doesn't it?
DE: Well, a number of them, yes.
BM: Yes, a number of them then, however you like to put it.
MR JUSTICE GOSS: Well, dozens is 24-plus.
MR MYERS: It could well be dozens, actually, given the children you have looked at. The reports have covered particular children where it has been an issue in your view, haven't they?
DE: Yes.
BM: And they have also covered reports which have dealt with specific aspects of air embolus, haven't they?
DE: Yes.
MR JUSTICE GOSS: I was just checking that you mean literally, not a figure of speech.
MR MYERS: No, literally dozens, my Lord, but I'm grateful for checking that. It wasn't a figure of speech. With that in mind, could you tell us, what do you say are the features that support a diagnosis of air embolus?
DE: Sorry, can you say that again? What --
BM: What are the features --
DE: Oh, right.
BM: -- the characteristics to support a diagnosis of air embolus?
DE: Right. The first is that it occurs in a patient of any age where there is access to the circulation via an external line; in other words, an intravenous cannula. So there has to be some kind of access there, firstly.
The second point and the most important point is that an air embolus will lead to a sudden and unexpected collapse. A patient otherwise stable, irrespective of age, otherwise stable, suddenly collapses -- and by collapse I mean stopping breathing, change of colour, cyanosis and bradycardia -- in other words reduced heart rate -- and death. And this occurs all of a sudden.
There are additional features, and as with all of clinical medicine, you don't get all of these features in all of the cases. And as we've heard this week and last, the two major associated features are those of unusual skin discolouration, and I won't elaborate on that because I think we've explained that, and also the presence of air in the great vessels or air in various parts of the body. It could be the heart, could be the vein, could be the aorta. So those are the compounding features that lead to a diagnosis of air embolus.
The other point, which is also important from a clinical point of view, is that this collapse occurs not only out of the blue, but there is no other explanation that fits with the diagnosis of collapse.
The final point is that -- and this applies obviously to patients in hospital -- is that resuscitation is unsuccessful. Because of the way doctors are trained, you know, resuscitating patients is part of our bread and butter, so the procedures that we use to resuscitate babies, children, adults, are well known, well drilled into us. But when the resuscitation does not work, leading to the death of your patient, then that adds to one's confirmation of the diagnosis of air embolism.
BM: Thank you. Just in terms of your position with it, can I ask, when did you last see a case of air embolus in clinical practice?
DE: In my 30 years as a consultant paediatrician in Swansea, we had no cases of air embolus in the neonatal unit, and we had no cases of air embolus with which I was involved in the neonatal unit or anywhere else.
In relation to -- which is something I'm pretty proud of, by the way.
In relation to Swansea generally, one of the great tragedies that occurred to us in Swansea is a baby who suffered an air embolus as a complication of what should have been a routine surgical procedure. This was a baby of a few weeks old who was having an operation for a condition called pyloric stenosis. Part of the surgical procedure is making a nick in the lower aspect of the stomach without actually causing a perforation. What the surgeon does is ask the anaesthetist to inject air into the stomach to ensure there is no leak. It's routine.
For one reason or another, instead of injecting air both the stomach, he attached the syringe to the intravenous line, injected air into the circulation, the poor baby collapsed there and then, and resuscitation was unsuccessful, and the baby died. As you can imagine, this was absolutely awful. It was haunting. It led to a trial, a criminal trial, etc. And I think it's something that, despite not having anything to do with this particular baby, it's something that you never, ever forget.
BM: Understandably.
DE: So that's the closest I've got to a baby with air embolus: it is that rare and unusual.
BM: In fact that's something you refer to in one of your general reports, isn't it?
DE: Yes.
BM: You refer to it in --
DE: It's awful.
BM: -- a report of 3 June 2019. For those who are keeping a note, if it's relevant, it's page 475 of the statement. And in that case the baby collapsed very quickly; is that correct?
DE: Again, I have not seen the report, but yes. Yes.
BM: And resuscitation was not successful and the baby died?
DE: Yes.
BM: As it happens, there's certainly nothing you put in your report on that occasion, Dr Evans, suggesting there was any kind of discolouration that you have identified that was linked to that?
DE: I have not seen the report. I have not been involved in any way with this case. All I know is it happened.
BM: You're unaware of any discolouration or indication?
DE: I have no idea.
BM: So in terms of your clinical experience, there's no what could be said to be hands-on experience of diagnosing object encountering air embolus, is there, or how it presents?
DE: Absolutely not, and I think that's something I'm very relieved and pleased about, actually.
BM: We understand that, but in terms of how you're describing what you see in this case, you're not comparing that against any clinical personal experience, are you?
DE: Good heavens, no.
BM: No. In reaching conclusions about air embolus in this case, would it be right to say that to some extent you've relied upon what could be called a diagnosis of exclusion?
DE: Yes.
BM: And a diagnosis of exclusion is where a clinician looks at what he or she considers to be the available alternatives?
DE: Yes.
BM: And having discounted those that appear to be available, is then left with one or two options, maybe just one, and so in that way they reach a diagnosis in that route?
DE: Yes.
BM: And that's a diagnosis of exclusion?
DE: In this particular case there is more to it than a diagnosis of exclusion because we know about the discolouration. I'm happy to discuss that with you, and we know about Dr Arthur's reports about air in the great vessels.
So therefore in this -- when I formed my initial diagnosis, because I had reached the conclusion -- I reached a diagnosis of air embolus without knowing about the discolouration -- and we're talking about [Baby A] --
BM: In fact I'm talking generally at the moment. I will be coming to [Baby A].
DE: So in general it's a diagnosis of exclusion, but if you then discover additional items of information, discolouration is one, air on X-ray is another, and as Dr Owen Arthurs said, you don't need abnormal X-rays to confirm the diagnosis. So that just simply firms up your diagnosis.
BM: All right. So you're able to proceed -- no hands-on experience. I'm not -- I'm just pointing that out. You're not comparing it with anything, but you're able to proceed by way of a diagnosis of exclusion and you can look for supporting features where they exist.
You've also sought to rely upon research into this area where it's available, haven't you?
DE: Right. It is quite important to say that, yes. Part of clinical practice is a term we heard last week, evidence-based medicine.
BM: Yes, I asked Dr Owen Arthurs about with it, or Professor Owen Arthurs.
DE: Evidence-based medicine basically has four tiers: one's own experience is one; higher up is what you read in textbooks; and higher up still is what you read in medical peer-reviewed journals.
The problem with air embolus is that you have to rely firstly on -- well, very often on isolated case reports, one case here, one case there.
You have to rely on the fact that medical teams are honest enough to disclose that a child under their care died of air embolus because one tends not to spread news about the mistakes we make.
And most important of all, I think, in this -- with regard to air embolus, as we've -- as I said this morning, the main paper we refer -- the paper we refer to most commonly is the one by Lee and Tanswell, 1989. There are very little new publications regarding air embolus in babies. That is not a criticism, that's a compliment.
You can't produce research papers or publish papers on conditions that don't occur. And we have become obsessive, meticulous, throughout our careers in relation to avoiding getting air into the circulation of sick babies and sick children.
So -- so therefore -- so it's not a matter of having to apologise for quoting research papers that are 30 years old or more, nor is it a weakness, I believe, in quoting papers that involve one -- you know, just one case, for instance.
One of the papers I published was from Pakistan, I think, where they don't do post-mortems. So therefore the assistance that we get in the situation of this nature from research papers is inevitably relatively limited.
BM: What I just wanted to establish was that research papers play a part in what you do and they do, don't they?
DE: It does.
BM: Before I move on, I just want to ask you about one thing you said.
You said:
"We don't spread news about the mistakes we make."
Who is the "we" when you said: "We don't spread news about the mistakes we make."
DE: I think it's a royal we. It's a royal we.
BM: Well, "we" is who?
DE: It's a royal medical we. You know, it's human nature, I think, to share information with your nearest and dearest as far as your medical colleagues are concerned. You refer to the coroner, as has happened in many cases here. So you deal with it in that way and you have to run it past the -- you know, the health board, the health trust. But it's not something that you publish in the press -- public press and media.
BM: All right. So is it fair to say that people might be a little slow to acknowledge where they've made mistakes?
DE: Yes, absolutely.
BM: Now, when you consider a case that comes before you and there's been a serious deterioration or a death, I was going to suggest to you there's a number of options or conclusions you can draw. These are just initial points. We will get to the detail of everything in a little bit, Dr Evans.
Where there is a serious deterioration or a death, that may be due to an identified medical condition; that's one option, isn't it?
DE: That's correct, yes.
BM: I'm suggesting these are all things you must keep in mind when you're in a position that you're in?
DE: Yes.
BM: They may be due to a medical condition that is currently known but hasn't actually been identified in the proceedings, in the investigations associated with them?
DE: Well, if it's not been identified it can't be known.
BM: You know, Dr Evans, there is space sometimes for uncertainty in medical diagnosis, isn't there?
DE: Yes. That's a different point altogether.
BM: Well, is it the case that there may be a situation that is due to a medical condition that is known but not identified?
DE: Such as?
BM: Well, for example, a genetic condition. Tell us about the genetic testing in this case or metabolic testing?
DE: Genetic conditions causing air embolus, okay.
BM: No, you asked me. I'm answering your question: has there been genetic metabolic testing in this case?
DE: As far as I know, no.
BM: No, right.
DE: But I am unaware of any genetic -- for what it's worth, I am unaware of any genetic condition that would lead to (overspeaking) --
BM: So it's important to keep in mind a medical condition that is currently known but may be currently unidentified?
DE: It happens, yes.
BM: Sometimes you have to keep in mind it may be due to a medical condition that is currently unknown, sometimes?
DE: Well, these are hypotheticals, aren't they?
BM: Yes, they are there. There may be a problem in care given that has played a part in what takes place?
DE: In --
BM: In the care that has been given or treatment.
DE: Yes, yes, that's a possibility.
BM: That might be difficult to identify if people are slow to spread news about it, mightn't it?
DE: No, it would be difficult to identify if someone -- if a patient presents with -- in a way they have never seen before.
BM: It may be due to deliberate inflicted harm, of course?
DE: Absolutely.
BM: Sometimes the right outcome is to consider that ultimately it cannot be ascertained from the available evidence. It is unascertained.
DE: That is a term I'm familiar with, yes.
BM: Well, you have been appearing as an expert witness before the courts for many years, haven't you, Dr Evans?
DE: I have.
BM: And you are familiar that pathologists, for example, will find the cause of death unascertained?
DE: That is true.
BM: Indeed, you surely will have had reports where you have found the explanation is unascertained?
DE: That is correct.
BM: So that's always a possibility, isn't it?
DE: Yes, it is.
BM: I'm just looking at the range of where you can get to when you look at a situation; do you understand?
DE: Yes.
BM: Would you agree it's important not to focus disproportionately upon a conclusion of deliberate harm if there's no direct evidence of it?
DE: Would it -- can you say that again.
BM: I'll rephrase it: it's important not to hurry to a conclusion of deliberate harm if there's no direct evidence; would you agree?
DE: You never hurry to a diagnosis that has such serious consequences.
BM: And would you agree that the fact there is an allegation of deliberate harm should not be the starting point when you approach a clinical pathological situation to form an opinion?
DE: Absolutely.
BM: When you were asked to review the cases, and asked for your involvement in this investigation, you told us the NCA were the agency that contacted you; that's the National Crime Agency?
DE: Yes.
BM: Did they provide you with the theory that deliberate harm had been done?
DE: No. By the time that I had -- the NCA got me involved in this case, I had prepared nearly 50 reports for police authorities on other issues on top of all my other stuff with the Family Court, etc. So therefore I was someone who was known to them as someone who dealt with -- you know, with suspicious events.
Clearly the fact that the police were involved, you know, I would be have a bit naive not to appreciate that somebody was concerned about what was going on. And, you know, so they didn't tell me anything about what with happened. All I was told was -- and I think this was in the papers actually -- all I was told was there's a hospital in Chester where lots of babies have died and this is a hospital where three or four babies die per year, you know, which is -- you know, about the average for a baby unit of that size -- but somehow or other, over a very short period of time, they'd had loads of -- they'd had far more deaths, which is a worry. Several of the deaths were unexplained, which is even more of a worry. Several of the deaths occurred in babies who were otherwise -- who were previously stable, which adds to the worry. And several of the babies who had collapsed, resuscitation was unsuccessful, which is even more of a worry. So therefore we had a constellation of worries here and so the medical team got the police in.
So that's the -- that is how it is. And by the way, before -- and so when I went to see them, I said, look, just give me the clinical notes of all the babies within this window, this 12-month period. Give me the notes of all the babies who have died, all the babies who have collapsed, not died, notes of any baby, you know, where something has happened that you're -- where you can't explain it.
So it had nothing to do with investigating a crime. It was investigating a clinical condition. It's quite important actually. It's different.
All of my reports are based on investigating a clinical condition. My reports are clinical conditions. I'm not there investigating crimes; the police do that. I'm there, because of my medical expertise, to see if I can assist in forming an opinion regarding what's gone on. And I have done a number of reports where things were suspicious -- for police authorities elsewhere where it was obvious to me that some child had sustained some kind of unusual accident, but it was an accident, and therefore the police were able to close the file and, you know, that was that. So that happens as well. So it isn't that if I'm involved, you know, we're going to end up with somebody being charged with a serious offence.
So in this particular case that's where we started from. The disadvantage that the Cheshire Police had, and I had, at the beginning was that, you know, these babies had just collapsed and we had no idea why.
What I told them, and I think this is quite important from a diagnostic point of view, I said, look, if a baby collapsed -- collapses, something has happened. It might be the end result of an infection. It might be the end result of, you know, a brain haemorrhage. It might be the end result of a collapsed lung. You know, there are all sorts of reasons why babies collapse.
But if I can get all the reports, I will work out a timeline for you. That's the way I did all of these reports. That's the way I do all the reports I do.
I'll work out a timeline for you. Right, this baby was well up until a particular time and then suddenly he crashes.
Now, on the whole babies don't do that. You know, they don't suddenly crash. And on the occasion that they do, they deteriorate quickly, as we have heard already, you can resuscitate them quite easily.
So therefore what I said was, look, I'll go through all these notes for you and I'll identify every point where a baby has deteriorated, okay. That's the first thing I did.
The second thing I did, I said, right, let's see why these babies collapsed. Now, we will deal with this in another cases in this trial. There were a number of deteriorations where it was obvious why a baby had deteriorated: there was evidence of infection, evidence of a blocked tube, a collapsed lung maybe, pneumothorax. So --
BM: Sorry to interrupt, Dr Evans, may I just interrupt to ask, are you saying this is everything you've been told when this began (overspeaking) --
DE: No, this is what I did. This is what I did.
BM: If you just pause, I don't mean to be rude, but the question I asked was your state of mind, asking about what you thought when you were first approached by the NCA.
DE: No, my state of mind was very clear, which I think is why I'm still in demand as an independent medical witness. My state of mind was very clear: let's find out the diagnosis, let's find out what on earth is going on. Nothing to do with, you know, crimes or anything of that nature. Let's find out what's going on, let's identify any specific collapse. You know, let's see if I can explain all of this.
And there were occasions when I could explain it and there were -- and there were occasions where there was something that I found deeply suspicious, and, you know, we will -- if we are speaking generally, Mr Myers, there were cases that were -- there were incidents that I found disturbing. I don't want to talk about that today because that's for other cases.
So therefore when I investigate a case, when doctors investigate a case, you are only talking about one case. So I -- so in my initial scrutiny, you know -- you know, that is obviously was -- didn't cover everything, in my initial scrutiny I looked at 28 cases. Twenty-eight. And then they were followed by another five. So there were 33 in all, 33 in all, and then the two insulin ones came later.
So therefore I looked at loads of cases. In certain cases the reason why the little baby had died was very obvious. I recall there was one case where the baby was born severely asphyxiated, severe brain damage from birth, unsurvivable.
There was another baby -- there were other babies who had significant congenital malformations, incompatible with life.
BM: I don't want to take you away from the topic (overspeaking), Dr Evans?
DE: Yes, but that's the way clinicians approach things. Okay?
So it's quite important, I think, for members of the jury to appreciate that I was not investigating a suspect who was an individual who was suspected of inflicting harm on a baby. I was not doing that at all because, for the obvious reason, I was unaware of any suspect. The name Lucy Letby meant nothing to me. I didn't know any of these people. Air embolus had never crossed the radar of anybody in Chester, as far as I knew. The other events that we've spoken about, none of that was remotely run past me.
I had a -- I was on the easiest position and the most difficult. Easiest in that I had a blank sheet, "What on earth is going on here, Dr Evans? That's for you." Helping the police with their enquiries, if you like, Mr Myers.
I had no idea -- we had no idea and therefore I relied entirely on the evidence -- the evidence I could see from my -- from the clinical notes and applying my clinical experience to form an opinion as to the cause. So that is -- you know, that's how I did it.
BM: Can I just ask you to answer this, I don't mean to be rude, but as directly as you can, Dr Evans: is there any possibility that you might have allowed the suspicion of harm, when you were asked to look at these, to have led you to look for possible mechanisms in some cases?
DE: No, no. I wasn't looking for harm, I was looking for a cause.
BM: For example, when you were told the babies were stable and just collapsed, was that your starting point?
DE: No.
BM: Did you have telephone conversations with the officers of the NCA?
DE: No.
BM: None?
DE: As far as these babies are concerned, it was having a chat with my -- my contact at the NCA, da da da, let's go to Chester. So I spoke to her and said we don't know what is going on. Basically nobody knew what was going on as far as I could tell.
So I said, look, I can't tell what is going on, what I suggest is this -- this is before I, if you like, accepted the instruction to do anything for Cheshire Police.
What happened was they got in touch with -- the NCA and I got in touch, and Cheshire Police rung me, I think, and I said, look, let's -- I'll come up and see you. So I -- so -- I'll come up and see you.
So I drove up from Carmarthen, where I live, on a sunny day in July, and said look, I'll come and see you, I'll come and talk to you, I don't know whether I'm of any use to you, all I want you to do, bring me a case, bring one case file, just to give me a sort of idea of what's going on here.
BM: During the course of any discussion before you wrote the reports on [Baby A] or [Baby B], was the expression "air embolus" used at any point?
DE: No, no.
BM: Not at all?
DE: The first person who thought about air embolus in this particular case, as far as I know, was me.
BM: Well, we know that we have heard already from Dr Jayaram that the doctors at the hospital had already -- it seemed one or more had turned their mind to that at some point during that period. We know that, don't we?
DE: Do we?
BM: You listened to the evidence yesterday?
DE: Yes, but that was afterwards.
BM: No, during the period after [Baby D]. I asked Dr Jayaram about it.
DE: I can't remember that.
BM: Well, if you can't remember, that's how the paper was raised with him. Do you remember that yesterday, going to the paper? Do you remember going to the research paper with Dr Jayaram?
DE: I remember that.
BM: Yes. And my questions to him about going to look at this after the death of [Baby D] in June 2015 and how he and his colleagues were talking about this, pulmonary vascular embolism?
DE: But I knew nothing about any this.
BM: So when you had your chat with your contact at the NCA, did they not say at any point, "The doctors there think maybe it involves air embolisms?" Did they not give you that much of a steer?
DE: Not -- they didn't give me any steer at all. And I need to compliment the NCA, they never give you a steer. They just tell you, look, you deal with the police. They are very good, straight people.
BM: You do recall me asking Dr Jayaram yesterday, just so you're not at any disadvantage about the paper he went to look at?
DE: I can't remember the date. Yes, I heard that. Yes, I think there was far too much emotion in that, by the way. But, you know, I was only listening next door.
But I think what Dr Jayaram said was all of this followed -- I mean, I can't remember whether he said it was in 2017 or 2018 or whatever. I didn't -- I read about -- this morning Mr Johnson mentioned my second report where I quoted Dr Jayaram's -- Dr Jayaram's observations regarding the flitting abnormalities and things. If I could help --
BM: Could I put it this way, Dr Evans, In have asked you whether there was any conversation when you were approached by the NCA about air embolism and you say no?
DE: I can't remember any.
BM: About air embolus, you say no?
DE: It's -- I can't remember any.
BM: Right.
DE: Okay. I have been involved in this case -- this is the sixth year, so if I've overlooked something or other, that's -- you know. But I can't remember anything. But I think to help, Mr Myers here, I've got this, okay. Just a minute. Wrong one. Wrong twin.
BM: I would like to move on to [Baby A], but by all means if there's something else you would like to say about this. My questions have been very simple: did your contact at the NCA make any reference to air embolus when talking to you? Your answer, Dr Evans, is no, isn't it?
DE: No, not at all.
BM: Shall we move on to [Baby A]?
DE: That is what I was hoping we would do. If I could perhaps, before we go on, we will discuss in some detail -- no, you carry on. We'll come to this, I'm sure.
BM: We know that you've produced a number of reports with regard to [Baby A], haven't you, Dr Evans?
DE: Yes.
BM: I just want to be clear about some of the conclusions which you've presented in them before we look at his case.
DE: Mm-hm.
BM: In the report of 31 May 2018, which is the one we've been looking at principally this morning --
DE: Let me open that up, please.
BM: Yes.
(Pause)
DE: Right, yes, I've got that.
BM: Your conclusion in that is that: "The collapse was the result of inappropriate therapy within a minute or two before the deterioration."
DE: Something like that, yes.
BM: Well, it's not something like that. It's paragraph 38, Dr Evans: "In my opinion [Baby A]'s demise was the result of his receiving inappropriate therapy prior to his collapse, probably within a minute or two prior to his deterioration."
DE: Yes, his collapse. And the next sentence goes:
"His collapse is consistent with his receiving an air embolus."
Yes.
BM: Yes. You say that's consistent with an air embolus, and that is the rapidity of his collapse; is that correct?
DE: Yes.
BM: Very fast-acting indeed?
DE: Yes.
BM: Your view was that it was probably a bolus of air down the IV line?
DE: Yes.
BM: That is in paragraph 39.
DE: Yes.
BM: Now, you've explained how this is all based upon babies who were stable before collapse has happened.
DE: Yes.
BM: Just reminding ourselves where [Baby A] is concerned, we know he was very pre-term, 31 weeks and 2 days, wasn't 112 he?
DE: Yes.
BM: And 1.6 kilos?
DE: Yes.
BM: So low birth weight. And I think you acknowledge there are inherently problems that pre-term babies face that can make them quite fragile.
DE: Yes. I have heard that term. I don't think I have ever described a baby as being fragile. I think they are at increased risk, they are dependent. Fragile is too emotive, for me, as a term. It's not one I have ever used, I don't think, in relation to babies.
BM: They are prone to complications, aren't they?
DE: That's why we have neonatal units, yes.
BM: That's right, they're prone to complication, aren't they?
DE: Yes. Yes.
BM: Now, to look at what you say about [Baby A] and his starting point in this case, it's a sad fact that he lived for barely 24 hours; that's right, isn't it?
DE: Yes.
BM: And so when we are considering the problems that he encountered, do you agree we need to keep in mind, sadly, how short the timescale is that we're working with?
DE: Yes, yes.
BM: And in a timescale like that, there isn't a great length of time for serious problems to make themselves obvious, is there?
DE: The fact that he was as stable as he was prior to his collapse meant that he had survived the most perilous part of his life. And I'll go -- and in other words -- yes. So by the time that he was -- just prior to his collapse --
BM: I wonder if I could just ask you -- you've explained that. I wonder if I could respond to what you say about him being stable because that's what I would like to ask you about, Dr Evans, and I would ask you to help the jury with.
DE: Yes.
BM: You -- when you were dealing with the question of how stable [Baby A] was to start with, began by saying: "I have said his condition was perfectly satisfactory. It's better to say he was stable."
DE: Yes.
BM: Just so the jury can unravel what that means, in your reports you began by saying [Baby A] was in a perfectly satisfactory condition, didn't you?
DE: Mm-hm.
BM: You accept now, do you, that that's probably pitching it a little bit too high, isn't it?
DE: No, I think -- well, I'd rather call -- I don't want to get engaged in semantics here, but if you want to stick with perfectly satisfactory, I would say he was perfectly satisfactory for -- for his position at the time. In other words for a baby of his prematurity, aged 24 hours, his condition was satisfactory. If you want to make me look -- perfectly satisfactory, that's fine, but he was -- he was really good.
BM: You agree when he was born he needed rescue breaths before he was taken --
DE: He did.
BM: His rate of breathing was poor immediately after birth and he needed inflation breaths, didn't he?
DE: Yes.
BM: He was all right after about 4 minutes?
DE: Yes.
BM: By 9 pm -- I can go to the notes if you need them, but by 9 pm on the 7th there were pauses in his breathing when he wasn't being stimulated; yes?
DE: Yes.
BM: That's a potential problem, isn't it?
DE: Irregular breathing patterns are very common in premature babies. It's something that we -- one deals with on a regular basis, and it's not a cause for concern in a baby unit because they are on full monitoring.
BM: He was on, in fact, CPAP, wasn't he, to prevent the airways from collapsing?
DE: At the beginning he was, yes.
BM: If we look at the clinical notes, please, they're at slide 84 and it's page 1062. It's slide 84 in the [Baby A] profile.
DE: 1062?
BM: 1062?
DE: I've got it.
BM: My monitor doesn't appear to be working.
DE: Yes.
BM: It will appear in a moment, the ones in front of you.
(Pause)
It's coming on.
(Pause)
Thank you. If we just look at the top of that, please, Dr Evans, just to give us an idea of where we are on the morning of 8 June 2015, perhaps we can enlarge under where it says "Problems", Mr Murphy.
DE: All right, pre-term --
BM: Can we just let everybody see it, Dr Evans. If we just look at the top, this is the note from the clinical records saying "Problems". "Pre-term", which is in itself a problem, potentially, isn't it?
DE: Of course it is.
BM: "RDS", that's respiratory distress syndrome. That's a problem potentially?
DE: Yes.
BM: "Establishing feeds." That's a problem. "Suspected sepsis" at this point?
DE: Yes.
BM: And it's got maternal antiphospholipid syndrome and we are going to hear more about that and that's not something I'm focusing on in these questions. I'm not suggesting that's the issue here.
But certainly at this point there are legitimate concerns as to his progress, aren't there?
DE: No, there are. These are -- I'd rather call them issues rather than problems, but let's not get into semantics.
This is what any competent junior doctor would list as the issues facing [Baby A] at the time he arrived in the neonatal unit. In other words, we've to deal with the fact that he's pre-term, we have got to deal with the fact that he might have breathing difficulties, we have to establish his feeds because his sucking/swallowing reflex isn't mature. He's at risk of suspected sepsis, and then there is this unusual condition of maternal antiphospholipid syndrome.
By the way, I don't want to get involved with the antiphospholipid syndrome because I know there is a haematologist who knows far more about this, and this is not -- this is outside of my expertise.
BM: We're not raising any issue with that as it happens in any event, as I just said.
DE: So therefore this is -- for any baby of 31 weeks, the doctor would write these things down.
BM: Now, if we just look at slide 32, it's a little bit before this, the clinical notes at slide 32, page 1061.
DE: 1061, yes.
BM: We will just wait for it to come up on the screens, Dr Evans.
DE: Yes. I'm relying on my own.
BM: That's all right.
(Pause)
If we scroll down, we can see an X-ray review?
DE: Yes.
BM: If we look at that, just before 1 in the morning on 8 June, Dr Brunton, and it says "RDS-type picture"?
DE: Yes.
BM: So this isn't just something that's being written in the notes as a formula or something any competent clinician would say, we have got here from an X-ray something which is certainly consistent with respiratory distress syndrome, haven't we, on the X-ray?
DE: I have seen the X-ray. I have seen the report. There's nothing -- it's not too bad, actually.
BM: It's the sort of thing which might lead to some difficulty with breathing though, isn't it, RDS?
DE: This is why we put babies on CPAP.
BM: But in terms of where you're saying he's stable and whatever, just look at the various factors --
DE: No, no, this is at 0 --
BM: This is at 00.45 in the morning of 8 June.
DE: Yes. So this is -- he was born at 8.30 pm. Yes, 4 hours old. He's 4 hours old. This is the X-ray at 4 hours. My comment regarding stable relates to him at 23 hours of age.
BM: We know -- we've got blood gas readings up to as far as they go, and they are at tile or slide 29, page 1125, so let's have a look at that, please.
DE: 1125.
BM: Slide 29 for those of us on the iPads.
DE: Yes.
BM: Just enlarge the top half so that we can see that, Mr Murphy.
If we look down there, this is moving forwards now. We've had the X-ray. Just after midnight on the 8th. If we look at 6.37, look across to lactate. That's on the high side, isn't it?
DE: 2.6. Pretty marginal. Again -- again, from a clinical point of view, it's very important not to -- it's very important to look at the whole picture. Therefore, if you have a whole load of blood tests, you know, one or two might be slightly outside, you know, accepted, you know, the norm. 2.6. So it's over 2.
BM: Yes, and at -- what is that, 2.30, it's risen a bit more to 2.7, hasn't it?
DE: It's the same.
BM: Does it not -- would it not bother you if you were looking after a baby to see the lactate increasing above the recommended range?
DE: Not particularly. Well, it's not -- let's look at the whole -- let's look at the whole results, okay, for 14.13, I think they are. You've got a pH of 7.37, spot on normal. You've got PCO2 of 5.15. Spot on normal. It's a capillary gas, so you can't interpret the oxygen level. It's 4.66 but you can't interpret that.
BM: (Overspeaking) is a little low, isn't it?
DE: No, no, you cannot interpret that. Okay? You cannot interpret --
BM: Why is that one not interpreted? It's low, isn't it?
DE: No, it's not. It's a capillary sample, you can't interpret it. All right? Listen.
Then you've got a bicarbonate of 22.3, which is normal, and a base deficit of 2/2.5, which, is you know, less than 5, which is fine.
So therefore you've got this blood picture and you have a glucose, by the way, of 5.5 which is again normal.
Therefore you've got one, two, three -- one, two, three, four -- you've got five normal tests and one that is on the margins of being slightly up a bit.
BM: Just so the jury follow --
DE: Just a minute. And then on -- in addition, and I'm sure we'll come to this, in addition to that, even more usefully, I think, we've got this constant monitoring, heart rate, oxygen saturation, and they are also normal, and, as Dr Bohin said earlier, he's handling well.
BM: We are going to go there, don't worry, Dr Evans.
DE: We'll go there.
BM: Can I just check with oxygen: the standard range is 7.5 to 10 for blood gas, isn't it?
DE: For an arterial sample you would like it to be more than 7.
BM: More than 7?
DE: More than 7, 8, 9.
BM: Ten?
DE: Eleven, 12.
BM: Right. You say you don't really count this because it is from a heel prick?
DE: Yes.
BM: In any view, the oxygen is dropping from what it was at 6.37, isn't it?
DE: As I have said, I am not going to interpret an oxygen value from a capillary sample.
BM: Okay.
DE: Let me say that for all babies, for all times, I'm not going to do it.
BM: We don't have any readings, do we, as we get to the period we are most interested in, in terms of, sadly, the deterioration at about 8 o'clock?
DE: We do actually.
BM: Do we have any on this chart?
DE: No.
BM: You tell us where the readings are.
DE: On the neonatal --
BM: Are you talking about the respirations and heart rate and things like that?
DE: Yes.
BM: I'm going to that. I'm talking about blood gas readings, Dr Evans.
DE: Sticking a needle into a baby's heel hurts, so you can't do it every few minutes or so, so therefore -- it's done quite frequently in this particular case, which is fine, that's not a criticism.
If I saw these gases at 14.00 hours, 2 pm, and my baby at this time was in air, I would not be rushing to stick needles into that baby any time soon unless there was a change in his condition. That is what we call good clinical practice.
BM: How long can you leave --
DE: You don't stick needles in babies unless you have to, or unless there's a very good reason for it.
BM: How long would you leave it for?
DE: Until or unless something happens that makes you concerned that there's something the matter with the baby.
BM: Let's take a look at 1123, please, which is the observations chart.
DE: 1123.
BM: Provided on that --
DE: That's the one I was talking about.
BM: We will come to that in a moment.
That is slide 28 I've got down, but they appear in more places than one. So slide 28, if we could put that on, please.
We can see -- let's just increase the size on the -- in the yellow sections, please, Mr Murphy. We're familiar roughly with what we're dealing with here now.
Yes, you made reference to what Dr Bohin said before lunchtime. She said it was stable and not escalating having. That's her words, not escalating --
DE: Correct.
BM: -- the respirations on the chart, what we see.
DE: Let's go through them from the top down. That's the easiest way to --
MR JUSTICE GOSS: I think it would be better if you're actually asked a question and you answer the question, rather than just speaking to the document.
MR MYERS: I would be grateful for that.
Let me direct the question, Dr Evans, to assist with what we're looking at.
We're talking about stability. Right? And you made reference to Dr Bohin. I made note of what she said, which was, "Extremely stable, not escalating".
Now, if you look at the respirations, first of all, please, those are not extremely stable, are they?
DE: I disagree. Because the -- his respiratory rate is in the yellow bit, it's higher than the accepted normal range, it's 70-plus rather than 60, 50 or 60. But if you have any feature that is outside the normal range, you need to find out what the probable cause for this is. And you need -- as in every case, you need to interpret one individual criteria, marker, in relation to everything else.
So what we've got here, if you look at -- yes. So if you look at the respirations there, right, from the beginning. So in the first third they are all in the yellow, if you put it that way, and somebody has written down there "unsettled", I think. And then it falls to about 60, and then from -- I don't know, let's see -- 11, noon, say, from noon, it toodles along at about 70.
BM: Well, it's escalating in the afternoon, isn't it?
DE: It's higher than it was. But there's a perfectly good explanation for that.
BM: It's all stable -- it's all in the yellow patch, isn't it?
DE: Yes.
BM: Why is it yellow, that bit?
DE: There's a perfectly good reason for that.
BM: Well, what is it?
DE: Well, the doctors have been fiddling around with him, putting umbilical catheters in.
BM: Why is that section yellow? I wasn't clear, why is it yellow?
MR JUSTICE GOSS: I think he was giving you a perfectly good explanation.
MR MYERS: I apologise.
MR JUSTICE GOSS: He was giving you the explanation for it. I think. I'm not the witness.
DE: If you go through the medical notes, medical charts at this time, you will find that the doctors are doing what they can to, you know, make sure this baby stayed stable. So they have been putting umbilical catheters in. It's ended up in the wrong place. Nobody's fault. It happens.
Then around 6 o'clock, from what Dr Harkness said, they put an IV line in, a long line in. Sticking a needle in anybody's vein hurts, it's uncomfortable, you're handling the baby. Therefore all of this will make anybody, not just a little baby, you know, a bit unsettled, so therefore his respiratory rate goes up.
So what's important in clinical practice is that if you've got a feature that's outside the normal range, that you find an explanation for it. And there is an explanation for it.
This baby was being handled, quite correctly, by the way, but it meant that he was being fiddled around with because of the difficulties with cannulas and the difficulties and then getting the IV line in.
BM: Let me --
DE: So there we are. So that's -- so therefore -- so that in itself is an explanation, but even more important, all the other markers are normal or stable.
BM: Now, do you agree, first of all, the respirations are at least elevated for almost the whole of that period, Dr Evans?
DE: Yes, they are.
BM: Do you agree that they move down, they move up?
DE: Yes, they are.
BM: So the first thing is you agree, as we look at it, that is not steady. It's not at one level, is it?
DE: It's variable.
BM: Do you agree, as we look at it in the afternoon, it is escalating? Yes or no? Tell us if you don't. We can see it. What do you say?
DE: It's gone up -- it's moving between 75 and 80.
BM: There isn't a lot of chart left, is there?
DE: It's not escalating.
BM: Do you agree that when it goes on to the yellow, that's done because it draws attention to something that might be a problem?
DE: In isolation, I don't think you can make a diagnosis from an isolation. I don't know what we're getting at. But you've got an isolated increased respiratory rate in a baby who is pre-term -- who is pre-term and everything else is nice and normal.
BM: Do you agree that his respiration goes up? You might expect ordinarily heart rate to go up together with it.
DE: Yes.
BM: His heart rate doesn't go up, does it?
DE: No.
BM: That's odd, isn't it?
DE: No.
BM: You have just said you would expect it to go up and now you are saying it is not odd?
DE: I would expect the heart rate to go up if -- let's rephrase that.
If his heart rate had gone up as well, then I would be concerned about the baby. I would be concerned that he was then not stable. But in fact his heart rate is about as normal as it can be.
So therefore heart rate is a very, very good -- very, very good marker of well-being in a little babe. Therefore we have got this increased respiratory in isolation. Am I worried about it? No. Why am I not worried about it? Because he was in a neonatal unit with experienced nurses and doctors to look after him, and on top of that -- on top of that, he's not even requiring additional oxygen.
And that, for a prem baby, coming up to 24 hours of age, the fact he's able to breathe without additional oxygen and his saturations look -- at 97, 98, 99%, that's abouts a good as it gets. Okay?
So therefore his respiratory rate is above the normal range, but this little fellow is in air with normal saturations and a normal heart rate and a normal temperature. So great.
BM: Do you say it was good that he hadn't had -- I don't mean good for him, but was it clinically acceptable that he hadn't had fluids for at least 4 hours and maybe longer by the time --
DE: It's not good. It's not good.
BM: Is it acceptable?
DE: Well, it happens. This happens in neonatal units. This is the way of the world. And I think I discussed this this morning. Nobody would want a baby to go without fluids for 4 hours. Did it make a difference in his case? As I discussed this morning, no. Why do I say that? Easy: if he was experiencing fluid loss, fluid loss, then, as we know from patients who are admitted with fluid loss, the heart rate goes up. His heart rate didn't go up.
So it's unfortunate, but it is not something that -- it wouldn't be -- my word. We are all going to get COVID in a minute! Where are we? I'm getting distracted here.
BM: Let me help you. What I would like you to help us with is this, Dr Evans: is there a possibility that it is there's a problem for him not to received the fluids he was meant to have received for a period of -- and the blood sugar for a period of 4 hours? Is that a potential problem? That's what we need to know.
DE: His blood sugar-- the most recent blood sugar they took was 5.5, which is great, which is fine. That's fine.
BM: That was about 6 hours before the collapse, wasn't it?
DE: Yes.
BM: Yes.
DE: A blood sugar -- sorry.
BM: Just to assist you, Dr Evans --
DE: Excuse me. I'm being distracted by loads of people coughing. Just a minute.
So he lost 4 hours worth of fluid, which I think is -- he was on 4.15ml an hour.
So he missed out on a theoretical 16ml of -- of fluid -- now -- of 10% dextrose. And 16ml of 10% dextrose contains 1.6 grams of glucose and 1.6 grams of glucose contains 6 calories. So a baby who has lost out on 6 calories of calories is not going to drop a glucose value from 5.5 to a level where he crashes.
This baby did not have a little twitch or anything like that. He -- you know, he crashed to the extent he died.
BM: Going without --
DE: You know, so -- sorry. Let me finish this bit. So therefore it's unfortunate that he did not receive IV fluids for 4 hours. He did receive some oral fluid, by the way, 1 or 2ml, which is better than nothing.
BM: That's no substitute for failing to get the IV fluids, is it?
DE: No, no, no, no, no, it's unfortunate, but in this particular case it did not make a clinical difference, and that's the important point I need to -- that's the important point I need to express -- to impress.
BM: Going without fluid for the 4 hours is capable of causing dehydration; do you agree or disagree?
DE: Of course it does.
BM: And also going without the glucose that he was meant to receive for 4 hours is capable of leading to or triggering hypoglycaemia, isn't it?
DE: Yes.
BM: In a child which we no know now tachypnoeic, which is breathing too fast?
DE: Yes.
BM: But you don't see any of that as being a potential problem? Is that your evidence?
DE: It's not so much that it -- I don't see it as a potential problem. From the records I have seen, it did not become -- it was not a potential problem.
BM: We don't know that, do we, Dr Evans?
DE: Yes, we do actually. Yes, we do. This baby was in air, his saturations were 99%, his heart rate was nice and steady at 130/140, and his temperature was fine.
So we have got loads of markers here of a stable baby and I heard Dr Harkness say he was absolutely devastated by the baby collapsing because -- and Dr Jayaram the same -- this was a baby who was stable prior to his collapse.
Their words, not mine. Their words, not mine. But I'm just looking at these records and, yes, the heart -- the respiratory rate is tachypnoeic, yes.
BM: I'm going to avoid repeating question I ask to say where we disagree. That would be clear from the questions I'm asking and I'm going to move on so that we can get through the evidence.
Do you accept there is a potential risk of arrhythmia from the position of the long line? In other words, is there a potential risk that it could have been sited too close to the heart and created some sort of problem?
DE: Not in this case, no.
BM: Do you see that there's any obvious link in the relationship in time between long line insertion and then fluid running through the long line and then collapse?
DE: No. I'm not sure that question what you mean. There's no -- I mean, long lines are routinely used. They don't -- fluids running through a long line does not cause a baby to collapse.
BM: Do you recognise or do you accept, sorry, there's any risk involved in leaving a long line in place without fluid running through it for up to 2 hours?
DE: No, there would be fluid in it.
BM: Running through it, I asked.
DE: Not running through it. Right. If -- if there was -- right.
BM: Can I ask the question and then you can by all means expand upon it if you need to, Dr Evans. But what I asked was: is there any risk caused by leaving a long line in place without fluid running through it?
DE: There's a risk of the long line clotting.
BM: Tamponade. You have explained that's where fluid gets into the gap between the heart tissue and the external sac of the heart, the pericardium?
DE: Correct.
BM: When you made the report that you have been looking at and you were dealing with the question of tamponade -- and you deal with this at paragraph 36 of that report, page 752 -- what you say, Dr Evans, is that:
"Cardiac tamponade is a complication of long lines. It typically occurs in a baby where the line has been in place for sometime, probably 24 hours or more. This would not occur within minutes of insertion of a long line."
Just to be quite clear, did you think it had only been in place for minutes when you said that?
DE: Well, I'm not quite sure, but it wouldn't -- it didn't look within a couple of hours anyway.
BM: It could occur -- you say it couldn't occur within a couple of hours? Couldn't?
DE: No. Let's forget about tamponade. If there was tamponade there, it would be present on post-mortem.
BM: I just wanted to see why you say minutes at that present (sic).
Infection. Infection. Do you accept there are potential --
MR JUSTICE GOSS: I just want to get a note there.
(Pause)
Thank you, carry on.
MR MYERS: Sorry, my Lord.
MR JUSTICE GOSS: No, it's fine.
MR MYERS: Do you accept that there are potential signs of infection or developing infection from what we can see in the observations and the blood gas and the picture presented by [Baby A]?
DE: No.
BM: You don't regard high respiration as a possible indicator of it?
DE: Well, again, two things: it's an isolated sign, and secondly, there was no evidence of infection on post-mortem.
BM: It's entirely possible, in a fast-developing infection in a small child, for it to develop and leave little by way of pathological signs? It is, isn't it?
DE: This is -- this is simply wrong. Okay? This is simply wrong. What you're suggesting is that a baby would have an infection that was so spectacularly rapid that the baby would die, you know, despite having normal heart rate and all these other normal things, and where a pathologist found no evidence of infection on post-mortem. I mean, that's ridiculous.
BM: Okay. Can I just ask you to confirm this. In terms of blood sugar -- can I ask you to confirm this: at times of blood sugar -- in terms of blood sugar at the time of the collapse, are you able to assist us with what the reading was at that point?
DE: No. Perhaps you can remind me, but I --
BM: Well, we've seen there's a chart which has the blood sugar readings until we get to 2.15 that afternoon.
DE: Yes.
BM: After that point [Baby A] received no fluid and no more blood sugar, did he?
DE: We've been through that.
BM: Yes. I'm sorry to delay you, Dr Evans, but I wonder if you can help me with this. After that time he received no fluid and no blood sugar, did he?
DE: He received no fluid for 4 hours.
BM: And no blood sugar?
DE: No, he didn't have a blood sugar (overspeaking) --
BM: And we don't know what his blood sugar reading is at the time of his collapse is, do we --
DE: No.
BM: -- because no one has got it?
So can you discount in those circumstances a deterioration linked to hypoglycaemia?
DE: Yes, I can.
BM: Just so we can be clear, why do you say that?
DE: Because hypoglycaemia is pretty common in small babies, and it -- you know, they can be a bit jittery, they may have little fits. They don't just stop breathing on you -- well, because they don't.
But if they did, you know, they would respond pretty promptly to resuscitation. You know, so it's -- it's -- yes. So, you know, babies -- yes. So -- so there we are.
So hypoglycaemia is not -- is not a factor in causing this little baby's death.
BM: Just so it's quite clear where we are, although you've dealt with this, the suggestion I make to you, Dr Evans, is from the available signs there it, he was not stable and he was not in a good condition at the time that he collapsed. You disagree with that?
DE: I do. I heard the practising doctor say yesterday -- earlier they all used the word stable. Dr Jayaram did, Dr Harkness did. I'm not sure about the others. But yes, they said he was stable.
Looking at his markers here, apart from the tachypnoea, we have markers of a stable baby who, but for having an air embolus, would have survived.
BM: That is what he the practising doctors have said. Do you accept everything they say?
DE: Well, that's their opinion --
BM: Did you apply an independent mind to what they say?
DE: I have been pretty independently minded all my life.
BM: I just wonder, you said about people not spreading news about the mistakes we make. Are you looking at this as critically at the people who have given care as you are at other elements?
DE: Yes, I have actually. I've -- yes -- oh, yes.
BM: Right.
DE: I mean, oh, yes, I'm pretty independently minded.
BM: Can I ask one other thing about signs or indications we have with [Baby A], just before I move on, and if it's something you can or you can't deal with, please say, Dr Evans.
A finding in the post-mortem which you're familiar with, Dr Shukla. I don't mean you have it immediately to your fingertips. Do you want to remind yourself from the statement? It's a finding of congestion and haemorrhage at the time of the post-mortem.
DE: Say that again? Have you got his --
BM: It's page 724 in the statements.
DE: Is this one of the J numbers?
BM: It's an I number.
DE: I don't think I've got that. I have seen the report but I haven't (inaudible) last night. Tell me what you want me to answer and I'll see -- I mean, on the whole, if it's a pathology report, I'm more than happy to defer to the pathologist, okay.
BM: I don't expect to raise something on the hoof with you like that, Dr Evans. I don't mean that to be rude to you. If it's not something which you're turning your mind to, we can deal with it in due course if we need to. I'll deal with it that way, rather than ask you to form opinions as we go along.
DE: If it's a pathology report, I would defer to a pathologist, and I know there is a pathologist in this trial.
BM: There is.
I would like to turn to some issues relating to air embolism.
I have asked you to assist us with what you regard as the features of air embolism generally. Could you help us -- and the jury in particular -- with exactly what features you base your diagnosis of air embolism on in the case of [Baby A]?
DE: He was a stable baby whose only marker that was a little bit outside the normal range was his increased respiratory rate. Everything else was great. It couldn't be better: in air, high sats, etc. We've gone through this.
He suddenly crashes. What on earth is going on here? We've since heard about the discolouration. But before I knew about that, I thought if you -- if this baby has collapsed as promptly as that, and even more significantly, more significantly resuscitation was unsuccessful, that is an air embolus. That is an air embolus, in my opinion, and that was my opinion before I knew about the X-rays and the discolouration.
The fact -- we've heard about the discolouration since. That's what the medic said. I'm not in a position to challenge them, I wasn't there. That's what they have said. They have said it all week, and we have also heard Dr Arthur's scholarly opinion last Friday, which --
BM: So --
DE: Sorry -- which, in my opinion, reinforces my own clinical acumen regarding the cause of death in this baby.
BM: All right. So the fact you say he was stable, I have asked you about that. Sudden crash, resuscitation unsuccessful. In fact, whatever point it is you turned your mind to it, you regarded discolouration as significant in his case, don't you?
DE: Well, the discolouration, if we -- right (overspeaking).
BM: Do you regard it as significant, Dr Evans?
DE: Sorry?
BM: Do you regard it as significant in his case?
DE: Well, if -- if -- it's not my -- it's not my role as a witness to get engaged in what people call factual disputes. Those are matters for the court.
If members of the jury and others accept what Dr Jayaram and others say about the pattern of discolouration, you know, the pattern of discolouration and flitting movements and the redness and the pinkness as well as everything else. If -- if that evidence is accepted, that is what you get in air embolus.
BM: And you base that upon what you've read, the description in the report by Lee and Tanswell, don't you?
DE: Yes.
BM: Right. So if I can summarise what you say there -- I don't mean to do any disservice to it, but you are saying if what Dr Jayaram is right and if it matches what you see in that report, then that could be supportive of air embolus?
DE: It adds to the clinical diagnosis, yes.
BM: And the other matter you have referred to is air in the abdominal vessels?
DE: Yes.
BM: In terms of -- I just want to ask you some questions actually about collapse and speed of collapse, Dr Evans, just going through the factors you have identified.
My Lord, I won't finish this afternoon, and I don't know whether your Lordship would wish us to have a break at any point. If I just press on, I'm quite content to do so.
MR JUSTICE GOSS: Not unless anyone wants a break. No, press on, please.
MR MYERS: Collapse in neonates can be very rapid, can't it, Dr Evans?
DE: It can be.
BM: Your view is that administration of an air embolus could cause collapse within a minute or two?
DE: Quickly, yes.
BM: Quickly.
Do you agree that speed of collapse does not prove the fact of an air embolism, could it, because collapse could be fast for any number of reasons?
DE: A collapse of this speed in a baby in a neonatal unit with full monitoring, nursing care, is pretty unusual these days really. Pretty unusual in the last -- yes, it's -- there are usually warning signs. You know, babies just don't go from normal heart rate and sats of 99 to stopping breathing. It's --
BM: And you don't regard the respirations or anything to do with the blood gas as a warning sign?
DE: I know you keep going on about respiration. I respect that because it's all you've got to go on that's outside the normal range. That's fine. I have no problem with it. I have explained to everybody its significance. In other words you're aware of it, you know, it's there, but given all the other factors which were not there, ie they are normal, you know, and this baby is in a neonatal unit. He is in -- let's be blunt about this: he is in the safest place on the planet. A neonatal unit in the UK is as good as it gets. You know, we are -- neonatal practice in my lifetime has -- in the UK has -- it's fantastic. It's come on in leaps and bound. It's as good as any -- I'm not being partisan or anything like that. It is really good, I think anyway.
So he's in the safest place on the planet.
BM: I'm not going to repeat what we say are the relevant factors. The jury has heard that. I'm going to move on to the next topic on this issue.
Actually, before I do I want a clear answer to this, if you could help us: there are many conditions that can cause a rapid collapse in neonates, aren't there?
DE: Air embolus, suffocation.
BM: Are you speaking with an open mind, Dr Evans, to this jury?
DE: I'll give you a list: blocked tubes --
BM: We heard the first two that came to mind.
DE: These other cases -- I could give you -- Dr Jayaram gave you a list of the four Ts and the whatever yesterday.
Yes, there are a number of causes, but what we do as clinicians, we exclude those causes. We exclude those causes. And what's important is, when you are dealing with a baby or a patient who has deteriorated, you make sure that you exclude those causes that -- where prompt intervention makes a difference and you exclude those causes where prompt intervention -- where prompt treatment makes a difference.
So therefore in other cases in this -- in this series we will hear about blocked tubes. I won't go there now, but none of this is relevant to this particular baby because he did not have a tube in his lungs.
So therefore a pneumothorax, all those sorts of things, there's lots of them, but none of them are relevant to our particular case. That's it.
We have gone on and on and on and we're back where we started: we have ruled these out, or the clinicians have ruled these out. I have been able to scrutinise the clinical notes. So yes, I have ruled them out. Yes.
BM: Discolouration -- (overspeaking) -- we're going to hear about discolouration, not just in this case, but in a number of them, aren't we, Dr Evans?
DE: Yes, we are.
BM: It's something that was referred to the jury at the outset of the case. You heard the prosecution opening, didn't you?
DE: Yes, I did.
BM: Mottling of skin or discolouration of skin is, for a variety of reasons, common in neonates, isn't it?
DE: It is.
BM: And it can be non-specific, can't it?
DE: It is non-specific.
BM: It can be a sign of illness?
DE: Yes.
BM: It can be due to underlying conditions in the circulation?
DE: Yes.
BM: It can be linked to infection, can't it?
DE: Yes.
BM: It can be linked to blood pressure issues, can't it?
DE: Yes.
BM: They may be secondary to other things that are happening in the baby?
DE: Yes.
BM: Do you agree that you cannot confirm an air embolus from changes in skin colour?
DE: Correct. In isolation, no.
BM: And would you agree it would be flawed to treat discolouration as diagnostic of air embolism?
DE: Discolouration of skin is a generic term. It's a catch-all term. It simply means that the colour of the baby's skin is different to what you would expect it to be.
So therefore when you're talking about discolouration, it could be mottled, as you say. It could be blue. It could be white. It could be red. It could have spots. You could have -- you know, purple. So therefore discolouration is a generic term. It's a general term simply noting that there is something present on the skin that the doctor has noticed. So therefore you can't look at discolouration and say, oh, it is due to a specific condition. You can't go down there, so let's not go down there because it doesn't get us anywhere.
BM: Right. Now, insofar as the description that we heard about from that paper is concerned, I would just --
DE: Pardon?
BM: Insofar as the description from the paper that we have heard about is concerned, I would just like to look a little bit more about that. So I'm going to ask Mr Murphy to put page J2496 up on the screen, please, and that's the page from this paper.
DE: I've got my own copy of this paper, so I'll rely on that.
(Pause)
BM: If we could just enlarge perhaps the top half of the paper so we can see -- and the table as well, please.
DE: So we are on page 508, yes?
BM: Yes, of that paper, yes. Page 508 from the journal.
Just so the jury have a little context, because this features in reports you have written and others, this is a study -- confirm this for us, if you can, Dr Evans -- a study in 1989. That's when it was written?
DE: Mm-hm.
BM: Drawing together descriptions from other events that had happened. The authors had drawn together a number of events to analyse?
DE: No, they've drawn together a number of others cases.
BM: A number of case studies. It's a case study, isn't it?
DE: No, it is more than a case study, actually. If you look at cases from everywhere else, it's meta-analysis.
BM: They are looking at what has happened overall.
Now, help us with this: it's based on an analysis of -- I think it's 50 cases, isn't it?
DE: Fifty cases.
BM: Fifty cases?
DE: Three of them were theirs, I think. I can't remember.
BM: They looked to see -- and just so we can put this in context -- it says: "What phenomena, what items, are associated with infants who had definitely had pulmonary vascular air embolism?"
If we look at that table, we can enlarge the table to start with, we can see that, as a percentage of those 50, what sorts of features were associated with vascular air embolisms. So I wonder if we can enlarge the table at the top left.
DE: Yes, I've got this.
BM: There we go.
We are not going to go through all of these. I'm going straight to the item that we are interested in here, and that is that looking across the 50 cases, we have been hearing about discolouration and air embolus, in those 50 cases it's only in fact 11% of them -- can you see it says "cutaneous signs"? You know that means skin signs.
DE: Yes.
BM: In 11% do cutaneous signs feature.
DE: Yes.
BM: So that's approximately five or so out of the 50 that would have skin colour?
DE: Five of the babies.
BM: Yes, five of them.
First of all, there isn't a necessary link between air embolism and skin discolouration, is there?
DE: Well, you can have air embolism without skin changes.
BM: And in fact the vast majorities of those fall into that category, don't they?
DE: Yes. But I reached my diagnosis of air embolism without knowing about the skin -- skin signs. So, you know...
BM: You have talked about it quite a lot in your reports afterwards, haven't you, Dr Evans?
DE: Well, I did a -- there were so many cases here where I suspected an air embolus was a significant contributory factor, that instead of -- that I prepared a report, which I think is dated in 2019, where I reviewed as many items of literature as I could find. It's not that I reviewed them all in 2019, you know. Some of them -- I knew about some of them. So I collected them I put them all together in an 11-page report.
BM: Right.
DE: And as with virtually every clinical presentation, you do not get every feature in every case.
BM: Now --
DE: So -- so, you know, so you get 11%, that's fine. And I -- that's fine. I'm aware of that.
BM: So, given the part played by discolouration in the way this is dealt with, let's just look on from this. 11% of the cases it features. We then come to the description that we have heard. So can we scroll down to the section below that we have looked at before, please, in particular the highlighted section.
The section that deals with what's called cutaneous signs in that table is a section that's been outlined largely in terms of description. The section that's outlined there, isn't it, is a the description of them?
DE: Mm-hm.
BM: And of the five or so cases where there was any discolouration, it says that: "Blanching and migrating areas of cutaneous pallor were noted in several cases and..."
And then, the feature we've been looking at here: "In one of our own cases we noted bright pink vessels against a generally cyanosed cutaneous background."
Correct, Dr Evans?
DE: Yes, yes.
BM: So first of all, the links, such as it is to discolouration and air embolus is based principally upon this study, isn't it? It's based upon five out of about 50 cases in this study; yes?
DE: Yes.
BM: Of those five cases, only one of them involves bright pink vessels against a generally cyanosed cutaneous background --
DE: That was in their case, that's right.
BM: You say if we are to make any use of that at all, the next step is to assess the accuracy of descriptions of discolouration against that, isn't it?
DE: It is.
BM: Thank you. I have dealt with that. Thank you, Mr Murphy. In your reports you have taken the view that failure to respond to resuscitation, a resuscitation that was prompt and consistent, is supportive of air embolus?
DE: It is.
BM: Indeed I think you have said earlier when I was asking you about the features of air embolus that it's one of the matters that you regard as having a diagnostic value?
DE: Yes.
BM: And the -- your own experience, of course, sadly, in the case you have told us about, resuscitation didn't work?
DE: In this case, no.
BM: In Swansea, in your own personal experience?
DE: The operative thing, no, that was awful. No.
BM: Now, just to be clear, what you say about resuscitation is diagnostic to some extent. Failure of resuscitation is not in itself diagnostic of air embolus, is it, because there are many things which might lead to a failure of resuscitation? Let me make that easier if that's complicated, Dr Evans. The mere fact that resuscitation, not that there's anything mere about it, but the fact that resuscitation hasn't worked does not enable any clinician to say that must be the consequence of an air embolus?
DE: There was no evidence of any other clinical condition in this baby and we can spend all day and all week talking about what Dr Jayaram saw or didn't see and his colleagues. And we can spend all week discussing the presence of air in the great vessels. But you put the air in the great vessels and the discolouration and the unexpected collapse and the failure of resuscitation, and put all those four factors together and you have a diagnosis of air embolus.
BM: Well --
DE: Okay.
MR JUSTICE GOSS: That's not the question. The question is this, and I'll phrase it as I understand the question to be because it was perhaps the use of one word that made it slightly more difficult, and it was put "in itself", but I'll pose the question in a different way.
Failure of resuscitation is not of itself -- in other words looked at in isolation, of itself -- is not diagnostic of air embolus. That's the question. So you are just looking at one particular feature of this case, and saying that of itself is not diagnostic of air embolus?
DE: That's correct.
MR JUSTICE GOSS: Exactly. That's what I thought.
MR MYERS: I apologise if it wasn't clear, my Lord.
MR JUSTICE GOSS: No, I know -- yes. But you understand that it's --
MR MYERS: I'm grateful for the clarification. I'm grateful, my Lord.
MR JUSTICE GOSS: In other words, if you look at each of these features, what is being suggested is, looked at individually, of itself, none of them by itself is diagnostic of air embolus. I think that's the point you are making?
MR MYERS: It is. We are getting there. Thank you, my Lord.
MR JUSTICE GOSS: You say you don't just look at one, you look at all of them?
DE: That's what we do.
MR MYERS: And we say, even looking all of them, it doesn't inevitably follow. There's a dispute about that --
MR JUSTICE GOSS: Exactly. But we are taking it in stages, breaking it down.
MR MYERS: Thank you, but I am not going to go cover the ground we have covered. I am grateful, my Lord, thank you.
Let me deal with the final matter you described then, which is air in vessels.
We have heard this from Dr Arthurs.
You accept there are a number of reasons why there may be air in abdominal vessels?
DE: I do. This is a matter for Dr Arthurs, by the way, but yes, I do.
BM: In which case I don't need to repeat them now because we have been over them with Dr Arthurs.
I want to pause there before we move to the end of this section of what I'm asking you is to deal with where air embolus can occur. We have been looking at what lies behind the factors you have identified and looking at [Baby A]'s position.
I just want to ask you some questions about where air embolus does arise, coming out of what you said in your evidence to us this morning.
Without doubt, so far as we know, the most common cause of air embolus is actually in the course of medical treatment, isn't it?
DE: Yes, you have to have an IV line in.
BM: Yes. And it is the most common cause, isn't it, for a documented air embolus?
DE: There is no such thing as a common cause of air embolus. It's a very -- in babies it's a very, very rare and unusual condition, so let's not try and pretend that we're talking about something that's common here.
BM: I'm not trying to pretend anything.
The most frequent cause when it's encountered, Dr Evans, is what arises from treatment, isn't it?
DE: Yes.
BM: What's called an iatrogenic cause, isn't it?
DE: Yes.
BM: And of that, the use of venous catheters or long lines creates a risk, doesn't it?
DE: Yes.
BM: And just so that we can follow why that is, if the end of a catheter or a long line is open to the atmosphere whilst a baby, or indeed anyone, is breathing, that can create a negative pressure that means air can be drawn into it. That's correct, isn't it?
DE: No.
BM: Pardon?
DE: (Witness shakes head). I have heard of this and I have had problems of trying to work out what is meant by any of this. So let me try and answer this.
If you put a needle in an arm, in a vein, blood comes out. It is not that air comes in, blood comes out. We have all had blood tests: stick a needle in, blood comes out.
Anybody who has had a catheter inserted, a cannula inserted, until you make the connection, blood comes out. Air doesn't go in.
A very simple reason for that: the pressure in the vein is higher -- slightly higher than the pressure outside. The pressure inside is higher than the outside.
And not that you see it in babies because the veins are so small, but, you know, blood will come -- track back up -- up the cannula. It doesn't go the other way. It doesn't go the other way. I mean, come on.
BM: If respiration is taking place and a baby or an adult breathes in, as that takes place, that is capable of drawing air into a line, isn't it? You disagree?
DE: Yes.
BM: All right. So we can understand, can you tell us how it is then that a long line or a UVC can create a risk?
DE: I think there are rare conditions where you've got patients on goodness knows what -- you know, complicated treatments which would get in the way of intrathoracic pressure. I wouldn't within to go any further on that. It's not something that would happen in a neonatal unit with baby who is breathing on his own. Breathing spontaneously. In other words, this is not a baby who is on -- you know, sophisticated respiratory support.
So -- so let's dismiss that as a hypothesis. I can't -- I will not accept. That's the first thing.
BM: You disagree about that, Dr Evans, then?
DE: That's -- you know. You're welcome to get somebody else to explain it to you. But I can't. I -- you know, life is simple.
Let's keep it simple. If you've got a cannula in a vein and you disconnect it, to put a new -- whatever the reason, the blood will ooze out. Air doesn't go back in, blood comes out. Simple.
BM: Do you agree that you might have been influenced by the allegation itself rather than the facts in the conclusions that you're drawing?
DE: No, I was not influenced by the allegations because when I dealt with these cases there were no allegations. It's as simple as that.
BM: Do you think it might --
DE: Just a minute. Just a minute.
In 14 of the 17 cases that are, you know, part of this trial, I had completed my preliminary reports -- I accept they are preliminary reports -- and that our case is not -- not these, but there are other cases where I have changed my mind, etc, added, you know, and so on. Let's not go there. We can discuss that in the next few weeks.
But in 14 of the 17 cases I had reached my conclusions by the -- formed an opinion where I think I could -- by the end of November 2017. And again, and I think the members of the jury needs to know this, I was not aware of any nursing name or medical name that -- who was suspected of being involved in any way, and I know exactly when I heard about the name Lucy Letby for the first time. The BBC published it in early July 2018.
And I have been very straight in every report I have published -- I have written since July 2018. I have stated: I'm making this report recognising it's part of Operation Hummingbird and a suspect has been named by the press, that sort of thing.
So all -- all the cases -- sorry, on 14 of the 17 cases I had formed the opinion that you are hearing now well, well before any suspects were named, and I'm not claiming to be clever in any way, and the first person to come up with the idea, with the diagnosis, I should say, not the idea, with the diagnosis of air embolus in this -- in these twins was me.
We've heard Dr Bohin this morning agreed with me. You heard Dr Bohin saying that another consultant neonatologist who sadly became seriously unwell and has died, his -- his reports -- he did a peer review of my reports. He agreed with me. He agreed with me.
And since then I have had to, you know, look quite hard to get published papers to -- that are relevant here because it is such a rare condition.
BM: Can I just be clear then. Just answer this directly if you're able to, Dr Evans.
Do you accept there is a possibility that in this case the allegation itself that you were asked to look at has influenced you to look for possible mechanisms of harm because of the allegations rather than just the facts?
DE: No, no.
BM: You disagree with that?
DE: No, it's not -- no, no. I'm looking --
BM: That is all I want to know.
DE: Hold on. I'll answer that for you. What I need to do is look at mechanism, nothing to do with harm. We have already discussed that it could occur accidentally. I'm not satisfied that this could occur accidentally given what I have seen about the way, you know, we connect all these bits of tubing together.
So if it doesn't -- if it doesn't occur accidentally, then it occurs as -- with intent. And I think I have used the word "intent" once or twice in my report.
BM: Just looking at that report in 2017, the first one that you wrote, just at the end of it, paragraph 38, you suggest that one thing that might have happened here is that the person has received a noxious substance such as potassium chloride. There's no basis for that whatsoever, is there? But you suggested it.
DE: Back to the principle of differential diagnosis, I have been asked by the police what on earth has happened with this baby? So therefore I -- I gave them these ideas. But I have already said that I have dismissed all of -- I have dismissed that, and so that's it.
BM: What do you mean giving ideas? Do you mean testing things out just to see if it works? (Overspeaking) by giving ideas, Dr Evans?
DE: No, no, differential diagnosis is part of clinical practice.
BM: What do you mean "giving ideas" though?
DE: Differential diagnosis is a better way of expressing myself.
BM: There is no basis to suggest potassium chloride had been used, was there?
DE: None at all, as far as I know. That is why we have spent the last few hours talking about air embolus, which is what I think did occur --
BM: You suggested both things in that first report. You suggested air embolus and you also had a run at potassium chloride, didn't you?
DE: Of course I did, because you have to look -- you have to explore all potential causes.
Now, it's -- Mr Myers has spent a lot of time, could it have been other conditions, and I have said, no, and I have explained why. Fine. We are off to potassium chloride. I don't think potassium chloride was a factor here.
BM: I'm not suggesting it is. I am pointing out that it was something that you were ready to go with until it wasn't viable?
DE: I wasn't ready to go with it. I was presenting the police with a differential diagnosis. This was a screening report. All the reports I have prepared in 2017 were screening reports. I have been able to add to a number of them. I have changed my mind on a couple of them. And so on.
So, as far as these twins are concerned, air embolus is what caused [Baby A]'s death and [Baby B]'s collapse.
BM: I'm going to turn to [Baby B], if I may, Dr Evans.
Of the two of the twins, [Baby B] was the more poorly from birth, wasn't she?
DE: She was.
BM: And from birth she had serious problems with breathing, didn't she?
DE: I wouldn't call them serious -- just a minute, I want to open up my file, please.
I have only got a small laptop.
(Pause)
Are you referring to my -- which statement?
BM: At this point I'm just asking: from the evidence we have all been looking at this week, from what we've seen --
DE: I've got two reports here, 6 November 2017 and 31 May 2018. Which one do you want? Are you referring to --
BM: Shall we put up page 1266 from the clinical notes. That's what I'm looking at when I say about problems with breathing early on.
DE: Yes, she needed quite a bit of resuscitation.
BM: She did, didn't she? No chest wall movement initially, was there?
DE: Oh, she required good resuscitation. Very impressed with what treatment she had. Yes, she did.
BM: Just a minute, Mr Murphy.
DE: 1266. I'd rather look at my own file.
BM: You may not need to go through it because I have asked you about having difficulties with breathing and you have agreed, but just looking at what we can see on page 1266, which is at the back of slide 1, ladies and gentlemen, if anyone is following it on the iPads, for [Baby B], of course, to move across.
(Pause)
DE: I think I mentioned earlier that I reviewed [Baby B]'s notes before I reviewed [Baby A]'s reports. That's simply because she was the first twin. Okay? That's the only reason for that. So anyway, yes. Here we are.
BM: All right. We can see, right at the beginning, looking down at the bottom of this page, we have got: "Five inflation breaths need, no chest movement."
Can you see the bottom part of the page? Just highlight that.
DE: "Airway repositioned", that bit?
BM: "Blue and floppy, poor tone"?
DE: Yes.
BM: "Inflation breaths, no chest movement, no response in heart rate."
DE: Yes.
BM: She was given support and they did get her breathing, but can we move forwards, please, to 1271. I'm not sure that that is on the iPads, ladies and gentlemen. It might not be.
MR JUSTICE GOSS: No, it's not.
MR MYERS: Well, it's the clinical notes. We will see what they are in a minute. They deal with the chest X-ray at 10 o'clock on 7 June. Here we are.
Again we've got with [Baby B] an RDS type picture. Can you see that on the X-ray picture, Dr Evans, at 10 o'clock on 7 June?
DE: Yes, I have seen that.
BM: Just to remind everyone, we have seen an RDS type pictures where [Baby A] was concerned as well, hadn't we.
DE: Yes.
BM: And RDS, respiratory distress syndrome, happens because in a premature baby the lungs have not yet developed to the extent they can live easily in the outside environment?
DE: Right. This is now -- yes. This is the X-ray done at -- 8.30 she was born?
MR JUSTICE GOSS: Three and a half hours after birth.
DE: Yes. So this is -- so this is the X-ray done at 90 minutes of age.
MR MYERS: I was just asking: RDS, that comes out of being premature, doesn't it?
DE: Yes, it does.
BM: And the lungs don't have the sufficient flexibility inside them to work as they should do?
DE: That's correct.
BM: And that's why we give them surfactant?
DE: That's correct.
BM: A baby with breathing issues, like [Baby B], is prone to desaturate; do you agree?
DE: Yes.
BM: And in fact she does have desaturations on her history even after the event we're dealing with, doesn't she?
DE: Yes, she does.
BM: So putting things in context, this is the position when she was born. We know the event we're focusing on is in the early hours of 10 June.
DE: Yes.
BM: To something which is new for us to look at, but you make reference of it, Dr Evans, is 19 June, just thinking in terms of time, this thread of time, so some weeks after the deterioration we're looking at --
DE: Are you talking about my report now?
BM: If you give me one moment I'll take you to it.
(Pause)
Whilst we are going there, could we put on the screen, please, J1408. Thank you.
Just looking at paragraph 20. Thank you, Mr Johnson. Paragraph 20 of your report dated 31 May.
DE: 1408. So the nursing record? Okay.
BM: And if we just enlarge these. I need to get my eye in. It's a little difficult to read that.
Okay?
So as it happens, 19 June, 12.46:
"Written from care given at 12 o'clock. Handover taken. Equipment and alarm limits checked and satisfactory. [Baby B] nursed on Optiflow 3-litres in air. Masimo and apnoea monitors in situ. Observations satisfactory."
DE: Hang on, 19 June?
BM: Yes, paragraph 20 of your report, Dr Evans, dated 31 May 2017.
DE: She was born on 7 June.
BM: No, I said -- let me be clear.
We looked at the situation when she was born?
DE: Yes.
BM: I'm just turning to the situation not long before she was discharged from hospital.
DE: Oh, right, fine.
BM: So a week or two after the event we are looking at. I'm sorry if this wasn't clear.
DE: So this is 19 June?
BM: As it happens, we can see, looking at this, it describes a couple of fleeting bradycardias or desaturations. I'm not putting them on the same scale as what we're dealing with on the 9th and 10th, but there are recorded some issues with respiration at that point; that's correct, isn't it?
DE: Well, that's what it says.
BM: And if we move to the following day, page 1413.
DE: 1413, yes.
BM: Could we just enlarge, it please.
DE: 20 June?
BM: So this is now 20 June at 3.55.
DE: Yes.
BM: "[Baby B] settled. Around 21.30, 22.00 and 22.30 the apnoea alarm went on and desaturated to around 70 to 80% on each occasion and heart rate dropped."
So a little bit more marked, but three desaturations on that occasion; yes?
DE: Mm-hm.
BM: And this isn't extraordinary with a neonate, is it, can desaturate like this?
DE: Yes.
BM: And then a note for several days after her discharge from hospital, could we put up J1335. It will be in the notes which you have had, Dr Evans, although I don't know if this features in any of the reports you did.
DE: 1335?
BM: Yes, 1335. And if we just look at what this is, it's a paediatric assessment -- if we open up the top of the form, please, Mr Murphy --
DE: 1335.
BM: -- relating to 14 July. It looks like it's early in the morning, for [Baby B]. Emergency department at the Countess of Chester. Can we just move down, please, under "paediatric assessment". We might need to go to the next page.
If we can just go over the page.
Just pause here to see what leads up to what we're going to look at. Can we just enlarge the paediatric assessment, please, Mr Murphy?
So this is at -- that day, early hours of the morning, 02.50. Dr Caroline Prior. Just go down over the page, please, to 1336. Just the top part maybe and then we will come down to the description.
Just details relating to [Baby B].
DE: Mm-hm.
BM: Weight at this point 3 pounds and 11 ounces.
And then we just go down, please, to the bottom part: "Present complaint and systems. One month and 7 days. Discharged from the NNU 3 days ago on..."
Is that Nutriprem 2?
DE: Nutriprem is a premature baby milk.
BM: "Gave lactose and then fed this evening."
And this must be the report, isn't it?
"Vomited during the feed. Looked mucousy."
And then something and then: "Seemed to struggle in her breathing for a few seconds afterwards. Often mottled. No new colour change. Well otherwise today."
DE: Yes.
BM: Then it goes on. So she had been brought in because of some breathing problems and because she exhibited some sort of mottling there?
DE: Yes.
BM: No one is suggesting that mottling is associated with an air embolus or anything like that, but it's an example of mottling; yes?
DE: Yes, yes.
BM: Okay.
Just so we can see there's more formal records as we follow on. I don't want any mystery to it. Let's go over the page, please, if we could.
I'm not going to go through all of these, but we have in effect further checklists: "Examination. By the time of the examination, pink, well perfused, mottled as [something; I'm not sure what that says] for her."
"Mottled as normal for her."
MR JUSTICE GOSS: N for normal, I think.
MR MYERS: "Settled and alert, witnessed feedings, one posset but tolerated well."
Thank you.
Just stepping back from that. We have finished with that document, thank you, Mr Murphy.
Just turning now to what you say about [Baby B], Dr Evans, in her case there's some breathing issues associated with her health; would you agree, some respiratory issues?
DE: Well, all I have -- well, you've shown me this.
BM: And before then, when she'd been born, going into the unit.
DE: Nothing compared to the -- what we should call the index event. Nothing -- nothing comparable. Nothing at all comparable.
BM: No, that's right. The index event, as you put it, is far more marked. I'm not going to dispute that with you.
DE: Far more marked. You know, she needed resuscitating.
BM: She did. She did.
DE: It doesn't get any more serious than that.
BM: Well, let's look at that then. Let's look through what you say about --
DE: Where are we?
BM: -- what happened in her case. I'm looking at your report, Dr Evans, one moment, paragraph 26.
DE: Just a minute. 26. The one post-mortem?
BM: For [Baby B].
DE: Just a minute.
BM: 6 November.
DE: Just a minute. I've got the wrong one here.
BM: Let me just summarise to you, to assist, Dr Evans. Your opinion where [Baby B] is concerned is that this could be a collapse due to air embolus?
DE: Yes, that's my opinion.
BM: That's that. You also, looking at your first report, the 6 November 2017, paragraph 26 --
DE: Sorry, hang on. Right. Let's go through this one step at a time. Which report are you on about now?
BM: It's actually looking at the report you made on 6 November 2017.
DE: Thank you.
BM: Paragraph 26.
DE: Hang on.
BM: I'm looking at the suggestions.
DE: I have closed it. So 6 November? Right. Just a minute. I had closed it down by mistake.
BM: Well, I remind you. It's simple. You suggest smothering.
DE: Yes.
BM: So I'm just going through the suggestions you make. We have got air embolus?
DE: Yes.
BM: We've got smothering?
DE: Yes.
BM: You also, as we move forward, suggest in the next report, the 31 May 2018, that maybe somebody had removed the prongs on purpose, don't you?
DE: Yes, I have.
BM: Right. So you have gone with three possibilities now there. We've got somebody who has possibly introduced an air embolus and/or smothered her and/or removed the prongs on purpose?
DE: That's my differential diagnosis.
BM: Yes. Can I ask again, is any of that you being influenced by the allegation to look for something that really fits with that rather than just the facts?
DE: Right.
BM: That's what I'm asking.
DE: [Baby B] -- the first of the cases I dealt with was [Baby G]. We will come to her later.
So [Baby B] was the second of the 17 cases. She was the second case I reviewed. And -- I'm not going to go on any more about air embolus except -- just a minute -- except -- I'll just make sure -- except my -- the last line of my first report, the one of 6 November 2017, and I quote me, paragraph 28: "I am also of the view that she could have received a bolus of air intravenously. This would have caused the very sudden deterioration in her heart rate and the colour change described graphically."
So I was -- in my opinion I was on the ball from the beginning with her in relation to my concerns about air embolus.
This would have caused a very sudden deterioration in her heart rate and the colour change described graphically and that had nothing to do with Dr Arthurs' report because her X-rays were normal. It was nothing to do with [Baby A] because I did her report before I did [Baby A]'s, and in my opinion it's been reinforced particularly by what Dr Lambie said yesterday when she was talking about, you know, these colour changes moving every 10 seconds. I didn't know anything about that.
So therefore that adds -- that adds to my -- to what I think is my -- I hope this doesn't sound arrogant -- adds to any clinical acumen.
BM: Do you still say there was a removal of the prongs around about midnight?
DE: I don't know about that. It is something we should bear in mind.
BM: What is your basis for it?
DE: Well, I'll tell you. There are a couple of photographs I've seen of [Baby B]. They are not very -- they're snaps, you know. But the photographs have been shown, you know, in -- to see if we could help with the colour change and they are not good enough.
But what they do show -- I've not seen this originally. What they do show is the way that the staff at Chester fix the prongs in CPAP -- cases of CPAP. There's more than one way of fixing these prongs, and the way they do it is really very good. You know, it's very good. They have got a special bonnet and the baby is on her back and, you know, the prongs are obviously over her face and mouth. And I saw this -- I saw this photograph, you know, earlier in the week when we were discussing it. I thought, mm, unusual this.
You see, the trouble is, if you ask me, can babies -- could they be displaced accidentally, the answer is yes. But I -- all I can do is to say I have concerns and wonder whether they were -- whether these prongs were removed deliberately, okay. I'm not taking it any further than that, and it crossed my mind.
BM: Just to confirm, you heard the evidence of [Nurse A] yesterday who described the arrangement you're talking about and said it wasn't unusual for them to dislodge?
DE: Yes, I would accept that. I would accept that. That's why I haven't gone to town on it.
BM: Do you still stand by the suggestion this could be smothering?
DE: No, because if it was smothering, once you unsmother somebody and resuscitate them, they pick up very, very quickly.
BM: Now, when it comes to air embolus, one of the features you make reference to in your report of 31 May 2018 is discolouration of the abdomen, isn't it?
DE: In --
BM: Paragraph 26 of your report of 31 May 2018.
DE: Let me get my -- let me get my -- that report out. 31 May 2018.
My paragraph 26?
BM: Yes.
DE: Yes.
BM: Now, we've seen -- I don't want to go back over the paper, but we have seen the description in that paper about the bright pink vessels on the cutaneous background around the body.
If we just go to remind ourselves of the description given in the case of [Baby B], which is at S233 in our iPads, we looked at it this morning. That's slide 233 or page 1282 if anyone is going to the J numbers.
Slide 233. Thank you. Go into that.
(Pause)
We can go and see the descriptions. We've got -- there we can see the one which is seen by Rachel Lambie, the purple blotching over the body. Purple blotching.
DE: That's not Dr Lambie. That's [Dr B].
BM: No, [Dr B] writing down what Dr Lambie had told her. That's what that is, Dr Evans.
DE: Yes.
BM: That's Dr Lambie's account to [Dr B]. Purple blotching on the body.
Then if we go down a little further we can see what [Dr B] said, which was purple blotching on the right mid abdomen and the right hand; yes?
DE: Yes.
BM: Okay. So there you have the description given.
That doesn't -- that doesn't match what we have read in that paper on air embolus, have we, the characteristic bright pink vessels against a cyanose background, does it?
DE: She's writing down what -- she discussed this this morning.
BM: Yes. I'm just getting your opinion on this so we can see how strong it is when you're linking it to the discolouration we have read about on this article.
DE: No, no, I was talking about what Dr Lambie said in evidence yesterday, and her evidence -- she was very good, anyway, I thought. You know, she did it very well. And what she described, wow, you know, that was very convincing for me. And she was there. I wasn't. We weren't there. She was there, you know. And she went through the resuscitation, you know, really impressively. So I was really impressed with Dr Lambie.
BM: Is that your assessment of her as a witness, Dr Evans?
DE: Yes.
MR JUSTICE GOSS: Sorry, I'm not quite sure -- was that -- are you saying you were very impressed by her as a witness or as a clinician?
DE: No, as a clinician.
MR JUSTICE GOSS: That's what I thought. In other words, she did a very good job at the time.
DE: Yes.
MR MYERS: Well, we certainly don't dispute that with Dr Lambie.
We have had the description. I'm not going to keep reading it out. But if we're trying to see whether or not discolouration, which you identify, matches the one case that's picked out in the article by Lee and Tanswell, it's not the same, is it?
DE: We're going round --
BM: Do you agree it's not the same, Dr Evans? That's all I'm asking.
DE: No. What [Dr B] has written down there is not the same as the Lee and Tanswell description. It's not the same.
BM: Okay. There are no diagnostic tests we have to show that [Baby B] has any kind of air embolus, is there, or are there?
DE: No, there aren't. It's a clinical diagnosis.
BM: You've put quite some weight on the inability to resuscitate as being indicative of air embolus, haven't you?
DE: Yes, I have.
BM: And that's a key aspect of your opinion in the case of [Baby A], isn't it?
DE: It is. If you look at the Lee and Tanswell report, the mortality rate with air embolus is very, very high.
BM: That's right. There's only about four cases out of 50 where it didn't result in a mortality?
DE: Four out of 53 or something.
BM: You've relied upon that in the case of [Baby A] to make your diagnosis, haven't you?
DE: No, I --
BM: The inability to resuscitate?
DE: Yes, I have.
BM: Yes?
DE: You know, we've gone through this.
BM: And your research, as you say, has indicated that invariably collapse from air embolus is fatal?
DE: Sorry?
BM: Your research has indicated that invariably collapse from air embolus is fatal?
DE: Let's avoid the word "invariably".
BM: Well, I'm looking across it. We can go to that on another occasion. I won't enlarge right now.
[Baby B] responded well to medical support, didn't she?
DE: Yes, she did actually.
BM: And she made a swift and a good recovery?
DE: Yes.
BM: That is inconsistent with what you have identified as a key diagnostic feature with [Baby A], isn't it?
DE: No, it is not.
BM: And it contradicts your air embolus theory, doesn't it, Dr Evans?
DE: No, no, it does not.
BM: Okay.
DE: We've heard -- you know, we cannot do studies where we inject air into babies. We probably would not get ethical approval these days for injecting airs into rabbits, pigs or dogs. I don't know about that, by the way. So we -- anyway, we cannot do studies where we inject air into babies and find out what happens.
The little that there is in the literature says that the bigger the volume of air, the worse the -- the greater the danger. The faster the volume of air is given, the greater the danger. And therefore if [Baby B] had a smaller amount of air injected into her circulation, and if part of this air was, you know, within -- you know, it didn't all go in at the same time, then it helped save her life, plus the fantastic care she got off Dr Lambie and others.
So therefore let's not use the word "invariable". It's not a word that clinicians are very comfortable with.
BM: In fact, to be fair, when I asked you about the features of air embolus in your list of secondary features you didn't say "invariable". You said resuscitation is unsuccessful.
DE: That's why they die.
BM: Yes. But the fact that resuscitation was successful in the case of [Baby B] and there was a very quick recovery is utterly inconsistent with an air embolus, isn't it?
DE: That is incorrect. There are a couple of other cases where there are striking features consistent with air embolism where astonishingly the baby survived. We will discuss them in the next few weeks. Amazed they did survive, but that's a reflection -- I think that's indication of the quality of resuscitation in this unit, by the way.
But yes. So you can't say one minute -- you know, anyway, so that is it.
BM: Can't say one minute -- what were you going to say, Dr Evans?
DE: Simply -- [Baby B] had symptoms and features consistent with an air embolism. Because she was on a unit where the staff knew how to resuscitate babies, she had the best chance and therefore recovered, which is great. But her original collapse in the first place is entirely consistent with air embolism, and I reached that conclusion despite the fact that [Baby B] and [Baby A] were the first two babies I dealt with where the concept of air embolism and -- was an issue, was relevant.
BM: There's not actually any diagnostic feature where [Baby B] is concerned that can show this is an air embolism, is there?
DE: She collapsed unexpectedly. Resuscitation took far more than you would expect. She had these astonishing skin descriptions. As we heard from Dr Lambie yesterday, that adds to the clinical diagnosis she has an air embolus, and I'm more than happy to hear anyone who says different from a medical perspective. No disrespect to Mr Myers. You know, he's defending a lady. But if anybody wants to turn up with another alternative diagnosis, that's fine. But that is my opinion and I'm comfortable with it.
BM: I wanted to suggest the highest you could get to with this, if you were to go with that, is that it's unascertained. There's no sufficient basis for embolus, Dr Evans.
DE: I disagree with you.
MR MYERS: Perhaps time to stop, my Lord. We have finished with those questions for Dr Evans.
MR JUSTICE GOSS: Thank you very much. I owe you an apology. I interrupted at one point and said that one of the documents you were looking at, which was the medical note of [Baby B] on 19 June, were not on the pad. They are. They are in the additional documents. I was looking on the sequence of events list and there are two lists. I don't know whether you have been looking at these and going to documents through this way. If you did, and you went into additional documents.
So just for the benefit of the jury if they've been making notes of the numbers as you have been giving them, J1408 and the J1413 and the other documents to which you referred are all on the pad. So they're there.
So I'm sorry I was precipitous in my response in saying it wasn't there because I was only looking in the SOE, not the additional one.
MR MYERS: That's very kind, my Lord. No apology required. There are a lot of documents. I'm grateful to Mr Murphy for getting them on to the system. It's a lot to keep track of.
MR JUSTICE GOSS: Right. Now, do you want to --
MR JOHNSON: I'm happy to deal with it now and then Dr Evans has finished. I'll only be about five minutes.
MR JUSTICE GOSS: Let's just do that then. Sorry. I just wanted to apologise to Mr Myers.
MR JOHNSON: The notes of [Dr B] that are on the screen at the moment, Dr Evans, if you just look, it was suggested that what [Dr B] had noticed was inconsistent with the article. But the only part that was read to you was "on my arrival purple blotching" or "blotchiness", whatever that says, halfway down.
DE: Yes.
NJ: But in the next line it says "right mid abdomen and right hand pink and active". Do you see that? [Dr B] interpreted her own handwriting for us this morning. That "pink and active" wasn't read to you. Do you see that?
DE: Yes, yes.
NJ: Is that consistent or inconsistent with the Lee and Tanswell?
DE: It's a good point actually.
MR JUSTICE GOSS: Well, the point is that's the point. It's not for the witness to comment on it, realistically. It is there.
DE: Thank you, my Lord.
MR JOHNSON: All right. Thank you.
Arrhythmia was dealt with in passing. You dismissed it as -- so we're back to [Baby A].
DE: All right, yes, yes.
NJ: Arrhythmia from the long line was floated as a possibility?
DE: Yes.
NJ: Why do you dismiss that as a possibility?
DE: I dismiss that because there was no arrhythmia. I mean, the baby was on monitoring. You don't just get a beep beep beep, you know, giving a recording of 140 or whatever per minute. You get these QRS complexes going on regularly. So, you know, there was a normal heartbeat.
Well, an arrhythmia is an irregular heartbeat. So you can't have an arrhythmia if you've got a baby with normal heart rhythm. So there was no arrhythmia.
NJ: Thank you. Finally, can we go back to page 1413, which, as your Lordship has just told us, was in the additional material.
Again, part was pointed out to you and part was not, I think, and I just want to deal with the part that was not.
(Pause)
DE: 1413?
NJ: So -- yes, sorry. It was the desaturations that were being pointed out to you.
Can you see: "[Baby B] has been settled through shift. Nursed in cot. Around 9.30 pm, 10 and 10.30 apnoea alarm went off and desaturated to around 70 to 80% each occasion."
You said that was different.
But if we look in the next line, how was [Baby B] -- how did [Baby B] recover? What treatment did she need from those desaturations?
DE: As far as I can tell she recovered with -- she recovered on her own really. If you go to line 4 -- line 3, if you go:
"Heart rate dropped to 75-80, no stimulation needed. Recovered herself very quickly. Back up to 100%."
I assume that's 100% saturation.
NJ: Yes.
DE: Yes: "Very quickly back up to 100% with saturations and heart rate back up to 130-150."
NJ: Yes.
DE: So it's a bit frightening, but she self-corrected and these little babies do these things. But these -- you know, totally different to our index event, as I call it.
MR JOHNSON: Thank you very much, Dr Evans. Does your Lordship have any questions?
MR JUSTICE GOSS: No, I don't. Thank you very much.
Well, that completes your evidence at this stage. But as you've indicated, you will be back. Right, thank you very much. Remember, please, not to talk to anyone about this case or anything to do with it. Thank you very much.
DE: Thank you, my Lord.
Tuesday, 1 November 2022
MR JOHNSON: Would you just confirm your name for the record, please?
DE: It's Dr Dewi Evans.
NJ: Thank you, Dr Evans. Were you asked, as with the previous cases of which you have told this jury, to consider the circumstances surrounding the collapse and death of [Baby C]?
DE: I was, yes.
NJ: Thank you. And so far as your written reports are concerned, I'd just like to list them, please, for the sake of the record. Was your initial screening report dated 7 November 2017?
DE: That is correct.
NJ: Did you then write a full report, dated 31 May 2018?
DE: That is correct.
NJ: A supplemental report dealing with issues concerning [Baby C]'s platelet count and pneumonia on 26 March 2019?
DE: Yes.
NJ: A second supplemental report, dated 18 October 2020, dealing with CPAP and its connection with the distension of a neonate's belly?
DE: Yes, 8 October.
NJ: 8 October, sorry, I beg your pardon.
DE: Yes.
NJ: 19 October 2021, dealing with the stomach bubble, as it's been referred to, and the interrelationship with CPAP?
DE: Yes.
NJ: A report, which is undated, concerning or at least in the version we've got, just dealing with the medical records?
DE: Yes.
NJ: Yet another report, of 29 October 2021, dealing with the platelet count again?
DE: Yes. The previous one was 21 October.
NJ: The version we have isn't dated. Then finally, was there a report dated 11 September 2022 --
DE: Yes.
NJ: -- concerning the admission forms which had been omitted from the material that you had previously been sent --
DE: Yes.
NJ: -- by the police.
DE: Yes.
NJ: Thank you very much.
Now, I'd just like to deal with the material that you have received then. Looking at your initial screening reports at paragraph 3, were you sent records from Alder Hey --
DE: I was.
NJ: -- concerning [Baby C], which included images taken after his death and records relating to the autopsy?
DE: I did.
NJ: Were you also sent records from the Countess of Chester, which included the radiographs or X-rays?
DE: Yes.
NJ: Thank you. I think so far as what I'll call your substantive report of 31 May 2018 -- you reproduced again at paragraph 3 that list of documents?
DE: I have, yes.
NJ: Thank you. We've heard a lot of evidence over the last few days concerning [Baby C]'s progress from his birth on 10 June to his death on that final night shift. In general terms, first of all, having reviewed the records and now having had the benefit of hearing the evidence of the treating physicians and nursing staff, what conclusions have you drawn as to [Baby C]'s general state of health?
DE: Well, he was a vulnerable baby because he was preterm, 30 weeks' gestation, and on top of that he had IUGR, in other words his growth was retarded, so he was 800 grams at birth, whereas the average weight for a 30-weeker is about 1,400 grams. So therefore he had two significant risk factors in relation to his status at the time of his birth. This would mean admission to a neonatal unit and that he would need careful management, both with regard to nursing care, medical care and the monitoring that goes with all of that, over a period of many weeks. And during that time there would be -- he was at risk for a number of complications that we associated with prematurity.
NJ: Yes. Can you give us in a list the relevant risks, so not every conceivable risk, Dr Evans, but so far as his presentation was concerned?
DE: Right. The commonest risk is to do with breathing, with his respiratory system, and lots of premature babies require support with breathing. So therefore there was a breathing problem.
The second big risk related to feeding because the gastrointestinal tract is not necessarily geared to accept milk. Therefore there are feeding difficulties, which is why babies require intravenous nutrition.
The third concern related to infection and the infection could be respiratory, in other words a lung infection, or it could be an infection somewhere else.
The fourth complication would be -- sorry, and then in relation to the feeding difficulties, given his growth retardation he was particularly at risk from this condition we've heard a lot about called NEC, necrotising enterocolitis.
The fourth concern would be metabolic and, in particular, concerns that his glucose values would stay within normal and also he was at risk of jaundice, in other words his bilirubin value was likely to cause concerns.
So those were the main concerns as he would have arrived on the neonatal unit.
NJ: All right. I'd like to deal with those four headings of concern one by one, if we may, and look at [Baby C]'s progress from birth to collapse.
So dealing first with the issue of breathing, we've heard all the records and the witnesses' accounts of [Baby C]'s presentation so far as breathing was concerned over the period of his whole life.
DE: Yes.
NJ: And without repeating the detail of the evidence we have heard, Dr Evans, could you tell us your interpretation of the factual evidence that we have heard?
DE: Yes. His breathing situation stabilised over a number of days and, by that, I mean two main things. Firstly, the amount of respiratory support that he required continued to decrease, so we've heard about he was on CPAP, and then in the last 12 hours of his life he did not require CPAP, he required a system called Optiflow, which is basically nasal prongs to facilitate giving oxygen to babies.
So therefore that was a very, very encouraging sign that he was able to cope, breathing more or less on his own, and the other good sign was that the percentage of oxygen that he required continued to decrease. So air is 21% oxygen and soon after birth he was needing 40% oxygen, which is, you know, very common. And by the time or just before his collapse, his oxygen requirement was 25%, which is very low.
So therefore, those two markers were indicative of good markers of progress.
NJ: Additionally to the support that [Baby C] was receiving, both in the form of the mechanics by which assistance was delivered and in the sense of the amount of oxygen or supplemental oxygen he was receiving, the jury has been told that he had two periods, of about 2 hours each, of skin-to-skin contact with his parents during which time, other than being wafted from time to time with oxygen, he was receiving no breathing support at all. What's the relevance of that, please?
DE: That's even a better sign. In other words he was coping without any oxygen at all. You wouldn't dream of doing that with a baby whose respiratory condition was unstable or concerning.
MR MYERS: [sic] Yes, thank you. I'm going to move on to the feeding issue now, my Lord. It may be that that's a convenient point.
MR JUSTICE GOSS: That's a good point to break.
Dr Evans, ready to recommence at 2.05, please.
DE: Yes, my Lord.
MR JUSTICE GOSS: Thank you very much.
2.05 then, please, members of the jury.
(In the absence of the jury)
MR JUSTICE GOSS: The note I received was just an administrative matter, it didn't relate to the evidence at all, it was just an administrative matter so far as one juror was concerned.
(1.00 pm)
(The short adjournment)
(2.05 pm)
MR JUSTICE GOSS: Jury in, please.
(In the presence of the jury)
MR JOHNSON: Dr Evans, you gave us, just before the short adjournment, four headings of realistic risks so far as [Baby C]'s presentation was concerned. You have dealt with the issue of breathing. The second heading you gave us was feeding.
DE: Yes.
NJ: Could you give us, please, an explanation as to what the risks were so far as that was concerned?
DE: Yes. First of all, all babies who are 10 weeks premature require nasogastric feeding. Their sucking reflex and their swallowing reflex is insufficiently developed, therefore they need what we call enteral feeding, milk from the -- through the nasogastric tube into the stomach.
If they cannot tolerate that or there's a risk to giving oral feeds too early, then it is clinical practice to give what we call TPN, total parenteral feeding, basically giving all the nutrition intravenously. Given that [Baby C] was at risk of NEC, necrotising enterocolitis, the clinical team chose to feed him intravenously, which was the right thing to do.
So you then need to monitor the baby very carefully to make sure that he does not develop any gastrointestinal problems, particularly NEC, and one thing that is done routinely is that a nurse will aspirate the nasogastric tube to ensure that there's nothing in the stomach. And by nothing, I mean usually bile. If there's bile in the stomach then it could indicate that there is some -- that there is necrotising enterocolitis beginning to form or that there might be some kind of obstruction, you know, in the bowel.
But it's not just a matter of nasogastric aspirations, you're also keeping a careful eye on the baby, particularly its abdomen. Therefore we've heard about abdomens being examined and being soft, which is normal, or distended, which means they're full of something, usually air. And also you look at the overall well-being of the baby because obviously if there is a serious abdominal condition, then that's going to impact on the whole baby and, as we've heard previously, the heart rate will increase, the oxygen requirement would increase, the baby may have irregular breathing.
These are all the features you look for in a premature baby who may be sickening for some kind of problem.
NJ: All right. I just want to break that down into three headings, if I may. I'll deal with the aspirates first, then the abdomen, then the presentation.
Just dealing with the aspirates, the jury has heard evidence given and repeated in questioning to Dr Gibbs about several nursing notes.
DE: Yes.
NJ: Both in the typed notes and on the manuscript -- I'll call them feeding charts, although we know [Baby C] wasn't being fed until the very end. What do you have to say about those notes, first of all, in terms of what they actually show?
DE: Right. So far as the clinical notes taken by the doctors, they were very aware of the need to keep a careful eye on his abdomen and there are a number of entries saying "abdomen soft" or "abdomen soft but slightly distended". And given that he was on CPAP until the last 12 hours of his life, those are matters that you keep an eye on but it would not be a cause for concern. So that's the abdomen -- sorry, that's the clinical examination.
NJ: Yes.
DE: Aspirates?
NJ: It's the aspirates I was interested in.
DE: Sorry.
NJ: It's all right. Let's just deal with it. It's the colour black, first of all. Can we start with this from this position? What colour is bile first of all?
DE: Bile is green. It's dark green.
NJ: Okay. We have repeated descriptions of black bile or black fluid, however it's described in the notes. What conclusions do you draw from those descriptions, first of all?
DE: There's one entry of aspirating 2ml of black fluid from the nurses. Not black bile, it's black fluid. I don't know what it was, but usually black fluid from the stomach is indicative of what we call altered blood, in other words digested blood from the stomach. So the important thing is that it was only found on one occasion, it was only 2ml and it was black.
NJ: Yes.
DE: So that in itself you monitor it and you keep a careful eye on the baby's overall condition. It's not grounds for getting concerned that there's something horrible going on just because of one 2ml aspirate.
NJ: But we have several other records, one of what was suggested to Dr Gibbs to be a vomit --
DE: Yes.
NJ: -- and Dr Gibbs suggested was equally, or if not more likely, to be a posset, and also some notes of half a millilitre of black bile or something similar being aspirated. What do you say about those?
DE: There was a one-off vomit. So again, Dr Gibbs said it could be a posset, in other words little babies do bring up substances from the stomach. But if it's a one-off, if there's something serious going on, it's going to happen more than once. Therefore it's a one-off.
Aspirates?
NJ: Yes. And the half a millilitre of aspirates, what do you say about those?
DE: There were four records in the last 12 hours prior to his collapse of aspirating 0.5ml each of dark bile. Now, 0.5ml is a tiny amount. So the total amount of bile aspirated over 12 hours was 2ml.
I don't know if it's worth showing it, 2ml -- this is a 2.5ml syringe (indicating), so that's it. So the good news is it's only 0.5ml. The other good news is that the amount of bile aspirated is not increasing.
NJ: What's the significance of the absence of an increase?
DE: The absence of an increase tends to mean that the baby's not getting worse. It's not getting worse. So therefore it's unlikely that he has an intestinal obstruction, because if you've got an intestinal obstruction, and it's normal for a baby to produce some bile, then the amount of bile will increase in volume. Therefore there was no increase in bile.
The other point with an intestinal obstruction, of course, is that you'll get abdominal distension and you are particularly likely to get abdominal distension if you have a combination of intestinal obstruction and your baby is on CPAP anyway.
Therefore, the fact that nothing was getting worse was reassuring and it meant that [Baby C]'s general status was under control, it was under control.
NJ: Yes. I think three separate nurses have described [Baby C] as being feisty. That's the word they have used, each of them. Is that consistent with a child with an abdominal obstruction?
DE: No, no.
NJ: Why not?
DE: Well, no. I know exactly what they mean by feisty, he was a well -- you know, he was developmentally a 30-weeker, remember. He wasn't -- he should have been 1.4kg, but developmentally he was 30 weeks and he was a well 30-weeker from a neurological point of view, from a brain development point of view. Therefore, in other words, he was reacting to his environment in a very good way.
If you've got a serious abdominal problem, you're not going to do any of that. Therefore he would have been a good baby. And we also know he had an ultrasound scan of his head, which was normal, great. So therefore he was a feisty baby, he was doing very satisfactorily.
NJ: The next heading you gave us was one of infection.
DE: Yes.
NJ: Could you talk us through that, please?
DE: Yes. First of all, the chest X-ray showed abnormalities on X-ray consistent with a lung infection, so therefore, that was a source of infection. That's the first thing.
The second point was that a blood test called CRP, C-reactive protein, which is a marker of infection, had increased from 1 to 22 or 23.
Now, the important thing about that is that it had increased because the normal value is less than 10, so it was up to 23, not particularly high, to be frank, you know. You can get values way above this in babies with infection, but nevertheless his CRP was 22. The clinical team were aware of this, which is why he was on antibiotics. They were keeping an eye on him. He had evidence on X-ray of a chest infection.
The other marker, which is a non-specific marker of infection, I suppose, is that his platelet count fell. There was a value of 90 recorded and a value of 40 recorded.
Values of 90 or 40 on their own don't tell you very much, but if you've got a CRP that's increased and you have an X-ray that's not normal, the low platelet count was probably a non-specific marker of his infection.
NJ: Thank you. In terms of some sort of -- no, I'll move on to, I think, the fourth heading you gave us, which was the metabolism or met --
DE: Yes, his glucose levels. Apart from one low value, all his glucose values were satisfactory, they were within the normal range, which is great.
The other point that needs to be made is that he had a number of blood gas values during his last 24 hours and, again, they were within acceptable values.
We heard earlier about a blood test called lactate or lactic acid. That was normal. That suggests that his tissues, his body, was receiving satisfactory oxygenation.
There were other markers showing that he was getting satisfactory oxygenation anyway, so therefore metabolic-wise he was a very stable little baby.
NJ: You mentioned earlier, when you were giving us the four headings that we're presently deal with, the issue of jaundice and bilirubin.
DE: Yes, that's another metabolic issue. All premature babies become jaundiced. Babies are born with a high haemoglobin. The red cells don't live so long. So as they die, they'll release -- well, a substance that makes them look jaundiced, becomes jaundiced.
The good news with [Baby C] was that his jaundice values were very, very satisfactory. He did not become severely jaundiced. If you are severely jaundiced you need phototherapy. His condition was so good, they stopped his phototherapy quickly.
The other useful point about his bilirubin being not particularly high is that an infection that is not that controlled can damage your red blood cells, so an increased jaundice is another marker of infection. He didn't have it, so the important thing is, yes, he had infection, yes, we know where it was, and yes, it was under control because of the treatment he was receiving.
NJ: Yes. So lest it's not clear from the evidence you've given us so far, Dr Evans, where was his infection?
DE: In his lung.
NJ: And what was the infection, what label would you put on it?
DE: I would just call it pneumonia. Blood cultures were carried out, but as far as I know, no organisms were grown. This is very common in babies because, as I think we've heard from one of the doctors, because we are so concerned about infection in premature babies, one tends to do blood cultures and other blood tests, but you do not wait to get the result before starting antibiotics.
NJ: Yes. Does it come to the fact that you assume -- as you do the test, you assume you're going to get a bad result?
DE: Yes.
NJ: So you start to -- you hope for the best but prepare for the worst so to speak?
DE: That's absolutely correct, yes.
NJ: So you treat for what you fear may be the result of the test but you don't wait for the result before treating?
DE: That is correct.
NJ: All right. In your opinion, taking into account all the evidence you have read and heard, did breathing issues have any direct cause -- were they the cause for [Baby C]'s collapse?
DE: No. The breathing issues cannot explain his collapse.
NJ: Feeding issues, and by that I'm including a blockage of the gut or NEC or anything like that, did that cause [Baby C]'s collapse?
DE: No, that cannot explain his collapse either.
NJ: The infection that you've told us he had, namely pneumonia, did that cause his collapse?
DE: No. No, his infection was under control. Not completely resolved, but it would not cause a collapse and certainly not a collapse, as it were, out of the blue.
NJ: So if a baby with that sort of infection is on a pathway to collapse, what would one expect to see?
DE: Yes. We are familiar with treating pneumonia and if the treatment is not working, babies get worse. There are a number of markers that give you warning your treatment isn't working.
First of all, you may get an increase in heart rate.
NJ: Did we see that?
DE: Which did not occur. I've seen his monitoring charts and his heart rate is nice and steady, within the normal range, all the way until the collapse. So his heart rate didn't change at all in the hours prior to his death.
NJ: Yes.
DE: Respiratory rate, the same. It stayed within the norm. Even more useful, in my experience, is oxygen saturation, sats. They remained absolutely where they should be, high 90s, throughout.
So therefore, his oxygen saturations did not drop.
NJ: I'm sorry to interrupt you, but in terms of his oxygen saturations, in the context of an infection to the lungs, namely pneumonia, does the oxygen saturation have a bearing on your view about the part that pneumonia might have played?
DE: Oh, absolutely, because if the pneumonia is getting worse, then your saturations will fall and/or -- the two go together -- if the oxygen level does fall, then the clinical team would increase his oxygen requirement.
So therefore, he was on 25%, hardly any additional oxygen at all, but if his pneumonia was getting worse or had been getting worse during the previous few hours, then what you'd find is the oxygen requirement would have gone up, in other words the staff would have increased the oxygen requirement to keep the saturations at a satisfactory level.
None of this was necessary, so this is why clinically, his respiratory status was very, very stable, under control.
NJ: Yes. And finally, the metabolic issues, namely the glucose and the jaundice. Did they have any bearing on [Baby C]'s collapse?
DE: None at all. Several glucose values were done in the -- well, throughout his life. Apart from one, the values in the last day, all within normal values. Bilirubin had flattened out, great. And again, what we call blood gas values, there were a number of them and they weren't showing any trends, you know, worrying trends. They all fluctuate a bit from one test to the other, but the capillary values -- sorry, the capillary blood gases were all again as you would expect in a baby like [Baby C].
NJ: Yes. And so what in your opinion, Dr Evans, was the cause of [Baby C]'s catastrophic collapse and death?
DE: Right. During my preliminary report I didn't come to any conclusion at all. I just thought that this was difficult to explain for the reasons we've gone through. So we've had to go through possibilities.
In passing, one of the cases we're talking about is a little baby called [Baby G]. I'm not going to mention anything about her now obviously, but one problem that can cause a baby to suddenly stop breathing is if the abdomen is filled with air or filled with oxygen, filled with gas under pressure. A baby can tolerate a certain amount of gas in its abdomen, you know, that's not a problem, because we see that with CPAP.
But if you get a significant injection of air into the stomach, it will cause what we call splinting of the diaphragm. Now, the diaphragm is a muscle that sits between the abdomen and the lungs and the diaphragm has to move up and down for people to be able to breathe properly. If you get a load of pressure in your abdomen, that diaphragm can't move and you then get the so-called splintage and you will soon suffocate, you won't be able to breathe and you can collapse pretty quickly.
So therefore, his collapse is consistent with a volume of air injected into his stomach, it splints the diaphragm, stops breathing, he's less than 800 grams, so that's what happens.
NJ: Okay. I just want to -- because this is, as you've already alluded to, at least in passing, this is or may become a recurring theme in this case. All right? So I'd just like you to give the jury a bit more of an explanation.
Is the position this, that the lungs are in the upper part of the chest?
DE: Yes.
NJ: One on either side.
DE: Mm.
NJ: Beneath the lungs is a muscle called the diaphragm?
DE: Yes.
NJ: You said the diaphragm moves down as you breathe in?
DE: Yes.
NJ: So is the effect of it moving down to cause negative pressure in the upper chest?
DE: Yes, to suck oxygen, air, into your lungs, yes.
NJ: All right. But the diaphragm can move down normally, but if, underneath the diaphragm, the stomach is pumped full of air, what effect does that have on the movement of the diaphragm?
DE: It stops the diaphragm moving effectively.
NJ: And the effect of that is what?
DE: If the diaphragm is unable to move effectively, then your lungs cannot get air into them, cannot get fresh air or fresh oxygen. Without fresh oxygen you become hypoxic, in other words you lack oxygen, and obviously you cannot survive without oxygen, thus a collapse.
NJ: Yes. Now, in the context of [Baby C]'s death, have you seen an expert report written by a pathologist called Dr Andreas Marnerides?
DE: I have.
NJ: Have you also had an opportunity of discussing this case with Dr Marnerides at all or have you simply been limited to reading his report?
DE: I think I discussed it -- yes, I have discussed it with him.
NJ: In coming to your view, have you taken into account the findings of Dr Marnerides?
DE: I have.
MR JOHNSON: I won't ask you any more about that. If anybody else wants to ask you, they can.
Can I just have a moment, please, my Lord?
(Pause)
Those are all the questions I have at this stage, thank you.
MR MYERS: Dr Evans, you've explained today that your conclusion is that the cause of death in [Baby C]'s case arose from the splinting of his diaphragm.
DE: That is -- the mechanics of that, yes, is correct.
BM: You've had the relevant clinical material and the statements relating to [Baby C] for over 5 years or thereabouts, 4.5 years, haven't you?
DE: Yes.
BM: You've considered other cases featuring in this trial where you have provided reports giving the opinion that splinting of the diaphragm is a cause of death, like [Baby G], haven't you?
DE: Yes.
BM: Before today, just now, you've never suggested that splinting of the diaphragm on 13 June is the cause of death for [Baby C], have you?
DE: That's correct.
BM: This is the first time we're hearing it right now, isn't it?
DE: Yes.
BM: You are alert to the possibility of splinting of a diaphragm from the other cases you've looked at, aren't you?
DE: Yes.
BM: Your opinion, I'm going to suggest, and as far as you can go on the material available to you alone, would not take us to splinting of the diaphragm on 13 June, would it?
DE: Well, I don't jump to conclusions, so therefore, as we discussed earlier, this death was unexpected and could not be explained as a result of one or more of the usual illnesses that premature babies get. Doctors work as a team. We rely on opinion from other sources. And if you look at the combination of what I thought his clinical situation was, plus what I've read from Dr Marnerides' report and others, and on top of that the gaseous distension in the stomach, putting it all together that is an acceptable cause of collapse in my opinion.
BM: If you really thought that splinting of the diaphragm in the case of [Baby C] was a cause of collapse, you would have said that before today, Dr Evans.
DE: Not necessarily. I think when I came to this court first of all, I said that having prepared these reports initially over 5 years ago, in virtually all of the cases I've benefited from additional information since then, you know, from other experienced medical people, and if you receive additional information from other people in other disciplines, which allows you as a clinician to change or modify your opinion, that is what doctors do.
I was functioning very much as a clinician in any case of this nature.
BM: I suggest, Dr Evans, you have been driven by something which leads you to support the allegation rather than something based on the facts beneath it. That's what's going on here, isn't it?
DE: No. The fact is this baby collapsed having been stable up until more or less the minute of his collapse and therefore one has to explain that.
BM: I just want to deal with what you have said in -- is it eight reports that you've prepared in the case of [Baby C] plus one joint report? That's correct, isn't it?
DE: I think so, yes.
BM: Yes. And again, just to make it quite clear, in not one of them before today have you suggested that splinting of the diaphragm on 13 June was a cause of death?
DE: That is correct.
BM: The first report that we heard about, which is on 7 November 2017 -- in that report, Dr Evans, you said that, your paragraph 33: "One may never know the cause of [Baby C]'s collapse, he was at great risk of unexpected collapse."
That's paragraph 33 of that first report.
DE: All of this is correct.
BM: So you agree he, in fact, was at great risk of unexpected collapse?
DE: He was at risk of one or more of the complications you get in preterm babies we discussed earlier.
BM: Your words are --
DE: Sorry, sorry, sorry, but although he was at risk of them, he was in a neonatal unit, designated to look after him, with continuous monitoring of essential criteria such as oxygen, et cetera. So therefore, the risk was there. This is why neonatal units exist: they are to look after babies at risk of death, collapse or serious injury. Therefore the risk was there and if he had not collapsed on the 13th, he could well have -- you know, the risks were there until he was much bigger.
So the risk is there, the risk is there constantly, but those -- but although the risk was there, I was satisfied, what on earth is going on here -- I think we heard Dr Gibbs say he couldn't explain why this baby collapsed either. That's a pretty straightforward statement, actually. One may never identify the cause of [Baby C]'s collapse.
BM: Are you saying --
DE: I'm not the only doctor giving evidence on this particular baby and therefore they will give evidence in due course. So that's as far as I could get based on the information I had in 2017.
BM: Let's be clear: what you say there, based upon the records that you had access to and those statements at that point, was one may never identify the cause of his collapse?
DE: Yes.
BM: You were ready to acknowledge that then?
DE: Yes.
BM: And you were ready to acknowledge he was at great risk of unexpected collapse; do you agree?
DE: Yes, yes, yes.
BM: You also formed the view that you cannot exclude the role of infection in his collapse; paragraph 34.
DE: Yes. I think -- yes, I am quite happy to elaborate on that.
BM: Let me just ask before you do. That's on the basis of the sort of material in the medical notes that we've been looking at now, isn't it?
DE: Yes.
BM: And faced with that, back in 2017, you were able to say that we cannot exclude the role of infection, weren't you?
DE: Infection was a factor in [Baby C]'s short life. We know that. We know he had pneumonia. So it was a factor. It is possible to suggest that if he did not have pneumonia, he may not have suffered the collapse -- no, I want to rephrase that.
His pneumonia was under control. His pneumonia was under control. That's the important thing. He was on antibiotics, he was requiring hardly any additional oxygen, and his saturations were spot on. So therefore, his pneumonia was under control.
But it's my role -- I was investigating this unexpected collapse, it was my role not to -- to give an impartial view looking at all the issues, looking at all these issues. In other words, I don't prepare partisan reports, so therefore if you've got a CRP of 22, I've got to bear it in mind. If you've got an X-ray that shows pneumonia, I have to bear it in mind. Are a CRP of 22 and a pneumonia on X-ray in a baby requiring 25% oxygen sufficient explanation to cause his collapse? In my opinion, no.
BM: Your opinion -- sorry, Dr Evans, please continue if there's more.
DE: No, I've finished.
BM: Your opinion, do you agree, in that report was that you cannot exclude the role of infection?
DE: Infection was a part of [Baby C]'s general status during his life.
BM: You didn't say in that report infection was part of his general status. Dealing with your opinion as to death, you said you cannot exclude the role of infection in his collapse. It's there, Dr Evans.
DE: Infection was a factor in his life. Did it contribute...? It didn't cause his death. That's what I believe, didn't kill him.
BM: Saying you cannot exclude the role of infection in his collapse acknowledges that it may have played a part, doesn't it?
DE: It may have -- it was a contributory factor. We've heard about the four main contributory factors earlier today.
BM: Well, now you've come to give evidence to the jury, on the same occasion that you introduce splinting of the diaphragm, you have today discounted infection in any way, haven't you?
DE: No, I have not discounted infection. I have explained to everybody that the report of Dr Marnerides, who's the pathologist, highlights the issue of abdominal distension causing the diaphragm -- causing splinting of the diaphragm.
Now --
BM: Can I just ask you something about that?
DE: Please do.
BM: You are not just here to repeat what's in the report of Dr Marnerides, are you?
DE: I am here -- right. What we do as clinicians is this: we base our opinion on an accumulation of information. Okay? Nothing to do with being in a court or anything. We rely on three items of information: the history, the examination and the investigations. So we put all of that together.
In a patient who sadly dies, we then turn to pathologists to see if they can enlighten us on information that we are not too certain about. There's no point in getting a pathology opinion -- if I knew everything I would not need a pathology opinion.
So therefore, you need all of those things. The greater the bits of information you have, then the more likely you are in reaching a diagnosis. So in this particular baby, I'm not going to repeat what I said earlier, we know the history, he was a preterm baby, we know what the examination findings showed, we know what the investigations showed. The markers of infection are pretty marginal, a CRP of 22, in an otherwise -- a baby who wasn't -- just had an infection -- it's important, Mr Myers, to know -- he was recovering from an infection. If I didn't say that too clearly in my report, well, there we are.
But his supportive therapy wasn't getting worse, it was getting less, because for the last 12 hours of his life he was off his CPAP, right? He was off his CPAP. All he had was Optiflow, which is basically nasal prongs to deliver -- so you know exactly what percentage of oxygen the baby's getting.
So therefore, respiratory-wise, he wasn't even staying the same, he was improving.
BM: Can I ask you this, Dr Evans: are you trying to use what you anticipate will be the evidence of Dr Marnerides, the pathologist, to find a way of producing an allegation as to the harm that was done on the 13th --
DE: No, no --
BM: -- which you haven't made before today?
DE: Sorry, this baby was put in harm's way.
BM: That's something, so far as the 13th is concerned, that until you gave your evidence now, you have not identified to this point on the 13th, have you?
DE: What I did initially was --
BM: Can I ask that first, please? Can you answer that question (overspeaking).
DE: Ask it again.
BM: You have not in these reports, up until your evidence now, identified any specific way in which he was put in harm's way on 13 June, have you?
DE: Not in this first report, no.
BM: And you are coming up with things here now, as we go along, to try to support an allegation of harm on 13 June, aren't you?
DE: No, I'm coming up with clinically proven mechanisms that explain why babies collapse.
BM: Well, let's move then to your next report, the second one -- one specific reference was made to it -- of 31 May 2018, 6 months after the first one.
DE: Yes.
BM: In that report you say at paragraph 36, having had time to reflect from the first report: "One may never identify the cause of [Baby C]'s collapse."
DE: That is correct.
BM: "He was at great risk of unexpected collapse."
DE: Yes.
BM: That was your considered opinion, wasn't it?
DE: Yes, it was.
BM: And that's the position, isn't it, one may never identify the cause of [Baby C]'s collapse and he's at great risk of unexpected collapse?
DE: Right. He was at great risk, okay? He was at great risk. There's quite a big difference between being at risk of unexpected collapse and actually finding a cause for it. Again, as I have said, as a clinician, you play as a team, and part of your team in a child who sadly dies is the pathology.
BM: Is your team the other prosecution experts, Dr Evans?
DE: No, no.
BM: Who's your team, so we can be clear?
DE: The medical team. I have not seen any report that comes up with an explanation regarding [Baby C]'s collapse other than what I have said today and what Dr Marnerides has said in his report and what other people will say.
I have read reports that are -- I don't mean this disrespectfully -- I've read reports that come up with this idea and that idea and the other idea and all that sort of stuff, which is very interesting to me because I'm a clinician, I want to know what could have caused all this, but I have not seen a single report -- and I am happy to be corrected on this one -- I have not seen a single medical report that says I am wrong, [Baby C] died because of something else. I have not seen a single report that gets off the fence and tells me that. I am happy to be corrected, Mr Myers, but I have not.
Therefore this would always be -- this case, right? This case would always be a challenging case for any clinician and it's a challenging case because we know of his various pathological problems, so it is quite difficult to separate the pathological problems, infection, feeding, et cetera, that we heard about earlier, it's quite difficult to separate those from an event where he was placed in harm's way as a result of some kind of deliberate act.
Now, I don't think I could do that alone. But putting all the evidence together, then that is where we are.
BM: I'm looking at what you say here, Dr Evans. You don't mention in this report, the second one we came to, anything about splinting of the diaphragm on the 13th, do you?
DE: No, no, you've said that several times and we have all heard it.
BM: There are several reports, aren't there?
DE: Yes.
BM: In none of which do you mention splinting of the diaphragm on the 13th, do you?
DE: No, you have mentioned that and I have said, no, there isn't.
BM: You also in this report, paragraph 37, repeat that you cannot exclude the role of infection in his collapse, don't you? Paragraph 37.
DE: It is a factor in his general status, yes.
BM: And that's the truth of the matter, isn't it? You cannot exclude infection from his collapse?
DE: What you cannot do, you cannot exclude infection as a factor in his general status. What I can do, looking at all of this -- remember I prepared a load of reports looking at all of this -- is this. He's got an infection but it's under control. And we all -- you know, I've listened to the evidence from the other people. We've all heard the evidence from the local teams --
BM: It's your evidence we're looking at now, Dr Evans.
DE: Yes, I'm aware of that and that's my evidence.
BM: Let's move forward to about a year or so later, 26 March 2019, the next report. Paragraph 13.
DE: I don't have paragraphs on my copy. Hang on.
BM: It's page 6 of 7.
DE: I beg your pardon, I do.
BM: Two things here, page 6 of 7. Having reviewed all of this, about a year later, you say -- and it's in the centre of that paragraph: "It's therefore probable that infection was a significant factor in [Baby C]'s collapse during the late hours of 13 June 2015."
DE: Yes, yes, I've seen that, yes.
BM: And you recognised then that infection may be a significant factor in his collapse, didn't you?
DE: That was my opinion at the time and, as I have said, if, as a clinician, I receive additional information that allows me to change my opinion or modify my opinion, that is what we do as clinicians.
BM: But nothing has changed with regard to evidence of infection, Dr Evans, since then. You may have heard other things from Dr Marnerides, but nothing's changed on the evidence of infection, has it?
DE: No, he had an infection, he had pneumonia, it was -- on the monitoring that was present on the little baby, his monitoring was fine.
BM: The same evidence of infection is before the jury now as was before the jury at the time you came to that conclusion, isn't it?
DE: If this -- we are not relying -- well, we're not relying on my evidence alone. With this particular baby, I couldn't take it any further than what we've discussed this morning and confirmed just now.
BM: But you see, in March 2019, the possibility of someone forcing air down the NGT was in your mind, wasn't it?
DE: It was actually.
BM: But not on 13 June; yes?
DE: I don't know what you mean.
BM: Let me help. If we go to paragraph 14, please, Dr Evans. The jury --
DE: Oh yes, yes.
BM: The jury will recall we've seen the abdominal X-ray for 12 June at 12.38.
DE: Yes.
BM: Right.
DE: Yes.
BM: And as to that, what you do say, we've had a paragraph where you say: "It's therefore probable the infection was a significant factor in [Baby C]'s collapse during the late hours on 13 June."
In the next paragraph, you go on to say this: "I am suspicious of the gaseous distension reported on the abdominal X-ray on 12 June and wonder whether this represents inappropriate management whereby his attendant inserted excess air into his stomach via his nasogastric tube, doing so in the knowledge that it would cause the infant discomfort and distress."
DE: That was a possibility that crossed my mind at the time.
BM: At the time, just at the time?
DE: No, no, when I wrote this statement.
BM: When you say at the time, is it a possibility that came in and went out with this report or did it stay with you for longer?
DE: I don't know what you mean by that, actually.
BM: Is it a possibility that existed only when you did this report or have you stuck with the theory that there was air forced down the NGT on 12 June?
DE: Right. Whether --
BM: Can you answer that question first (overspeaking) help the jury with an answer, please, doctor.
DE: With regard to the 12th. That was one option. The other option was the CPAP. Because he was on CPAP at the time, which he wasn't when he collapsed. But he was on CPAP at the time. So that was one option. The other option was inadvertent air and we can't discuss it now, we'll discuss it later in this trial in relation to other cases. Therefore --
So therefore, by this time, I was aware of the fact that several babies had collapsed, some had died, in Chester, and, yes, so all of this was adding to my anxieties about what was causing all of this, yes.
BM: And your view, back in March 2019, was that there could have been deliberate harm done on 12 June via the NGT; yes?
DE: Can't rule it out.
BM: Pardon?
DE: There were two scenarios --
MR JUSTICE GOSS: "Can't rule it out", he said.
MR MYERS: I apologise, my Lord?
DE: You can't rule it out, two scenarios. That's one of them. The second one is he had CPAP -- he was on CPAP at the time.
MR MYERS: If we come forwards, there was, we know, a report prepared after a joint meeting of experts in August of this year, wasn't there?
DE: Yes.
BM: And Dr Marnerides was present at least for part of that meeting, wasn't he?
DE: Yes.
BM: The date of the report, there are various dates on it with the signatures, but we are looking at a period at or about the end of August. You signed it, Dr Evans, on 24 August 2022.
DE: Yes.
MR MYERS: Page M1257, my Lord.
MR JUSTICE GOSS: Thank you.
MR MYERS: That's where it starts. At page M1260, page 4 of the report, you were dealing with opinions on [Baby C]. This is a report that you signed off on, really, a month or two before this trial commenced, wasn't it?
DE: Yes.
BM: In that report, you say: "The massive gastric dilation seen on the X-ray of 12 June was most likely due to deliberate exogenous administration of air via the NGT."
That's what you say, isn't it?
DE: That was our conclusion at the time. I think this was a joint report, I think.
BM: Yes, but that's a conclusion between you and Dr Bohin, isn't it?
DE: Yes.
BM: By the time you did that you had all the material you required on the care of [Baby C], didn't you?
DE: Yes, I think so.
BM: Yes. And armed with that material, your view was that the 12 June was probably due to deliberate exogenous administration of air; is that correct?
DE: That was a possibility, yes.
BM: Most likely due to that, you say.
In that report, a matter of months or a month or two before this trial commenced, you make no suggestion that the diaphragm had been splintered by excessive air on 13 June, do you?
DE: Right. That follows, actually -- perhaps it wasn't -- it wasn't said specifically.
BM: Can we establish that first of all?
DE: Yes, that is correct.
BM: You didn't?
DE: That is correct.
BM: There are about 13 different points under [Baby C] --
DE: Sorry, I haven't got a copy.
BM: Let me ask this: if you had wanted to say it was splinting of the diaphragm, nothing stopped you from saying that, did it?
DE: If it wasn't said, it wasn't said.
BM: No, it wasn't said because it wasn't something that you had entertained as a possibility at that point, was it?
DE: Right. That is incorrect. What we have discussed here is -- let's stick with the 12th, okay? There was a distinct possibility that [Baby C] had excess air injected into his stomach on the 12th. That's what we said.
At the same time we realised that however much air was in his stomach, he was still stable from a respiratory point of view. So therefore, you would only -- so excess air injected into the stomach -- it's a complicated description, this. Injected air -- air -- sorry, start again.
Air injected into the stomach will cause the stomach dilation, but it'll compromise the baby only if the air -- if there's sufficient air and there's sufficient pressure to splint the diaphragm. Right?
Now, on the 12th, [Baby C] was in CPAP, which is a pretty non-invasive method of respiratory support, so therefore however the air -- however the air went in, it would have been insufficient to splint the diaphragm on the 12th. Okay? Because if it had splinted the diaphragm on the 12th he'd have died or collapsed on the 12th. He didn't. So therefore, however much air went into his stomach and intestines on 12 June, so we're talking 36 hours prior to his collapse, that -- and I have no idea how much air went in. However much went in was insufficient to destabilise [Baby C] from a respiratory point of view.
So therefore there was no -- so therefore there was nothing to suggest that the extra air would have splinted the diaphragm at that time. Okay? That was the last X-ray, by the way, that was taken -- that's not a criticism by the way -- the one on the 12th. That was the last X-ray. So the only X-ray -- sorry, so the only X-ray evidence we have is from the 12th, we don't have any from the 13th.
Therefore, I hope that distinguishes what I think is a mechanism, a scenario, that occurred on the 12th, compared to the scenario that occurred that led to his collapse.
BM: Dr Evans, we're looking --
DE: There are different -- the two are different, both in relation to volume of air that got into his stomach and intestines and the other -- in other words, it did not compromise him. And the second thing, which we're aware of, is that he had CPAP -- he was on CPAP as well. So those are -- the two events are quite different in the way that they affected [Baby C].
BM: Looking at your opinions, before we get to what lies behind this, your opinions and the way you have formed them, and I'd just like you to be absolutely clear, that as of a month or two before this trial, whatever may or may not happen as a result of it, your view was that 12 June was intentional harm, wasn't it?
DE: That was a possibility, yes, it was.
BM: Yes, that was your view. At the same time you had nothing to say about splinting of the diaphragm on the 13th, did you?
DE: On the 13th, I think he collapsed --
BM: No, in that report, your view, Dr Evans, I'm sorry if the question wasn't clear, at that time you had nothing to say in August of this year as to splinting of the diaphragm on the 13th, had you?
DE: No.
BM: No. What you have done in your evidence today is introduce something new with the purpose of supporting the allegation rather than explaining the facts, isn't it?
DE: No, no, that is incorrect. I'm here to support the jury and everyone in this court, trying to explain what was it that led to a baby who was very small and premature suddenly collapsing and where resuscitation was unsuccessful.
In doing that, I am totally upfront in saying that I am not relying on my opinion alone, I'm relying on other people's opinion -- sorry, other medical people's opinion as well. That is what doctors do. We do it all of the time. That is what we do. Okay? So I'm here to assist the members of the jury in sorting out what is a pretty complicated case.
BM: I'm suggesting to you, Dr Evans, that you are reaching for things that support the allegation rather than reflecting the facts.
DE: Well, I disagree with you. I have just explained the facts --
BM: Right.
DE: -- to you and that's it.
BM: Before I proceed with this, I'd like to ask you about one thing that occurred when you last gave evidence with that point in mind. It's something I couldn't deal with at the time because of the way that the evidence ran.
I wonder if we could just put up -- and I am sorry we have to go to the [Baby B] documents. Just for the purpose of this, could you put up, please, Mr Murphy, slide 233 from the [Baby B] pictures? I'm raising this question about your approach to the evidence, Dr Evans.
Page 1282 under [Baby B]. You need to come out and go back in again and then it is slide 233.
Just to reassure you and everyone else, Dr Evans, and the jury in particular, we'll get back to [Baby C] shortly.
Could we go behind that slide, please? When you last gave evidence, we spent a little time looking at the colours relating to [Baby B] and what you wanted to say about that. If we go over the page to the point where [Dr B], whose notes these are, [Dr B] -- I apologise, Mr Murphy, you might need to go back to page 1282. There we are, the centre of that page.
We'd been talking about the colours, the jury may recall, I know it seems a while ago, but we were talking about the specific rash from Lee and Tanswell, about the bright pink movements on it, the markings of that rash and there was this exchange at the conclusion of the evidence. It was after I have had finished asking you questions.
This was brought to your attention by the prosecution. The reference at the centre of the page, can you see: "Upon my arrival purple blotchiness, right mid-abdomen."
Do you see that?
DE: Yes.
BM: The prosecution said:
"Question: The notes of [Dr B] that are on the screen at the moment, Dr Evans, if you look, it was suggested that what [Dr B] had noticed was inconsistent with the article."
I was suggesting it was inconsistent with Lee and Tanswell.
"The only part that was read to you was: 'On my arrival purple blotching or blotchiness.' Whatever that says halfway down."
You said yes. And then you were asked this: "Question: In the next line it says: 'Right mid-abdomen and right-hand pink and active.'"
Do you see that?
DE: Yes.
BM: And it was said: "Question: [Dr B] interpreted her own handwriting for us this morning. That 'pink and active' wasn't read to you. Do you see that?"
You said yes. And you were asked this: "Question: Is that consistent or inconsistent with Lee and Tanswell?"
And your reply was: "Answer: It's a good point, actually."
Now, it is obvious, Dr Evans, I am going to suggest to you, that where with we see "[full stop] pink and active", this is not a description of a rash, it's is not a description of a pink and active rash or skin colour, but a description of the baby, isn't it?
DE: No, isn't, actually. This was something that was put to me at the last minute on Friday afternoon. I'll read it out. It was put to me without having discussed it with anybody. It says: "Right mid-abdomen and right-hand pink and active."
It did not say -- I can hardly see the dot after "right-hand". That's the first point. But I think more important: "Right mid-abdomen and right hand [full stop]."
It did not say "baby pink and active".
BM: You've been listening --
DE: Just a minute. Let me finish all of this.
So therefore -- so you could very easily interpret that -- we've since heard that [Dr B] meant right mid-abdomen -- hang on: "Upon my arrival, purple blotchiness right mid-abdomen and right hand."
Now, full stop. Okay? That's the significant marker which was consistent with Lee and Tanswell's paper, et cetera. Then there's a full stop. Right?
"Pink..." Lower case pink, by the way, it's not a capital P, good handwriting. It's a lower case pink. Then there's a squiggle which I assume means "and", it's not an ampersand: "Pink and active."
So that is what I saw. I did not read: "Baby pink and active."
The sentence -- normally sentences start with capital letters. It starts with a lower case "pink". If you are suggesting it is a new sentence -- and therefore making a meal out of this is something I find a little bit worrying.
BM: I'm asking you these questions for you to help the jury, Dr Evans (overspeaking) I am not asking you whether you are worried about it.
DE: Well, it's up to the jury, the jury can read that the full stop is not very clear, they can read that the pink starts with a lower case "pink" and there's no "baby" written before. It's not a new paragraph even. If that paragraph flows, let's read the whole sentence --
BM: We can read it.
DE: Just a minute: "On my arrival, purple blotchiness right mid-abdomen and right-hand pink and active."
That is what I would expect most people, laypeople, jury people, doctors, to read. If you were to -- if [Dr B] has said she meant "baby pink and active" then I would suggest you should have a word with her about making comments that are not completely clear. This is not my way of writing things down.
BM: You listened closely to the evidence of the witnesses dealing with this, didn't you?
DE: We've discussed [Baby B] and, by the way, with [Baby B] I came to my conclusions regarding air embolus --
BM: Can we get to the question I am asking you about. Please help the jury with this --
DE: I've helped the jury. You raised the issue of three (inaudible: coughing), none of which starts with an upper case, as a sentence starts, and you're making an issue of something called "pink and active" which follows an entry saying: "Purple blotchiness right mid-abdomen and right hand."
BM: [Dr B] that morning, before you gave evidence, said "pink and active" referred to the baby, didn't she?
DE: I can't remember that but it's not in the notes.
BM: You have told us about your 30 or 40 years of experience as a paediatrician, how you have seen medicine evolve. You know very well "pink and active" has nothing to do with a rash when you look at that?
DE: If you look at the whole sentence and that sentence is confusing, okay? At the very best it's confusing. You do not start sentences with lower case. If you're implying -- if you're relating -- the other thing you don't do is this: her earlier -- her previous sentence relates to the right mid-abdomen or right hand. So how on earth am I supposed to work out that the next sentence, which begins with a small p, relates to be baby being pink and active. If she'd said "baby pink and active", fine, good, we know exactly where we are. This is just making a meal out of something. I have no idea why, but there you go.
BM: The jury will decide whether this is a meal out of nothing.
Now please assist me: "pink and active" plainly has nothing to do with a rash, has it?
DE: "Right mid-abdomen and right hand pink and active."
The whole thing doesn't follow. If she'd said "baby pink and active" that makes sense.
BM: You're not independent in this at all, are you, Dr Evans?
DE: I beg your pardon?
BM: You're not independent as a witness. You keep saying you're an independent expert. You're not independent, are you?
DE: I am completely independent. I've been giving evidence in court for a long, long time. I know about impartiality, I know about the rules, and I know I'm here to assist the members of the jury in forming an opinion. I am not here for the prosecution, I'm not here for the defence; I am here for the court.
Mr Myers has been very kind in spelling out all the courses I attend in relation to my work for the courts, and that is something that is spelt out time and time again: if you are a medical witness, you are there for the court. In the family courts you are there for the --
MR JUSTICE GOSS: I think we've heard this before. Thank you.
Can I just interpose at this stage? Because it's been going round and round this: "Upon my arrival, purple blotchiness, right mid-abdomen and right hand."
Now, if that is a complete phrase or sentence, does that make sense?
DE: As a complete sentence that makes sense, my Lord.
MR JUSTICE GOSS: What does it tell you?
DE: That there's purple blotchiness of the right mid-abdomen and right hand.
MR JUSTICE GOSS: Right. Adding "pink and active", does it make sense?
DE: No, it doesn't, actually. I'm sorry, it doesn't. Saying baby pink and active, that makes sense.
MR JUSTICE GOSS: Yes. So if it is meant to be a full stop and then a capital letter, "pink and active", and refers to the baby, the baby is pink and active?
DE: Yes.
MR JUSTICE GOSS: So there's the purple blotchiness in the right mid-abdomen and the right hand but the baby is pink and active and that makes sense?
DE: If it says "baby pink and active" that makes sense.
MR JUSTICE GOSS: All right. There we are.
DE: A phrase saying "pink and active" --
MR MYERS: I'll move on.
MR JUSTICE GOSS: Yes.
MR MYERS: We've dealt with infection and what you have said about it, certainly up to today, Dr Evans. I want to move on to feeding.
Black bile aspirates are a cause of concern if they're produced by a neonate, aren't they?
DE: The nursing entry note is to black fluid, not to black bile. If we go to -- I think it's 1960.
BM: I'm asking you first of all: black bile aspirates are a cause of concern, aren't they?
DE: No, a bile aspirate is a cause to record. How much concern it is depends, relates to the context of what we're dealing with. As again, I keep saying this, as a clinician you look at all the features, you do not look at a single feature, you look at everything.
Presence of bile, yes, you need to take it seriously. You need to note it, yes.
BM: Right. So the presence of bile you take seriously. If the bile is black, that is more concerning than if it's green, isn't it?
DE: Not particularly. I think if it's black, as Dr Gibbs said, I think you've got to consider that it was altered blood, actually.
BM: If there's any vomiting associated with it, that's an additional concern, isn't it?
DE: If there's vomiting, you need to record it, yes.
BM: And if there's been bile, and I'm going to suggest dark or black bile, and vomiting, that is, as I've described to other witnesses, a red flag, isn't it?
DE: No, it's a marker, it's a record of what nursing and clinical staff, medical staff, look at. You need to look at everything in context. Okay? You need to look at everything in context. You can't go round choosing something that suits you, suits your case. You look at the whole patient, you look at the whole amount of information available to you.
BM: If you were looking after a little baby like [Baby C] with the issues that he had associated with him, would it not cause you concern if he produced black bile aspirates and vomiting?
DE: Right. I've looked at lots of little [Baby C]s and what you'd do is you'd record them, you record what's going on here.
Therefore, first of all, you look at the baby overall, okay? You look at the baby overall -- I'm not going to go through all of this --
MR JUSTICE GOSS: I was going to say, I think we've gone through this several times.
MR MYERS: I agree, my Lord. I'm just trying to ask the questions and they're not taking so long, the questions.
Signs of a blockage, Dr Evans.
DE: Sorry, signs?
BM: Of a blockage, abdominal blockage, include bile and vomiting, don't they?
DE: Yes.
BM: They include abdominal distension?
DE: They do.
BM: They may include bowels not opening?
DE: Yes, they do.
BM: All of which, as it happens, are present in this case?
DE: Yes, they do. Yes, they are.
BM: You'd expect in a baby, within 24 hours of birth, for air to be along the length of the gut, wouldn't you?
DE: Not necessarily in a little prem of this size, no. Not really, no.
BM: If air has managed to fill the gut, to distend it to the extent we have seen on that X-ray on 12 June, you would expect that to be moving through the gut, wouldn't you?
DE: I would expect it to move through, but it depends on this process, what we call peristalsis. Which is -- peristalsis is the wave that goes through intestines to push air and fluid and everything else through.
So I am not too sure about this, actually. I'm not too sure. You're talking about a prem baby, tiny baby, he's not had any food. Mm... I wouldn't be... It's not something I want to be dogmatic about.
BM: Large quantities of air do not get absorbed back into the gut wall?
DE: You'd get some air absorption, I don't know how much.
BM: But if we see the sort of distension we have seen in that photograph of 12 June, the sort of quantities we see there are not normally absorbed by a gut wall, are they?
DE: That's a lot of b.
BM: And it wouldn't be absorbed by a gut wall, would it?
DE: I wouldn't have thought so. Most of it comes up through the tube, actually, up the nasogastric tube.
BM: I'm grateful to Mr Maher who has explained that Dr Evans is too far from the microphone, so if you lean forward they will be able to pick it up better.
DE: Thank you.
BM: So the jury understand, when you have made reference in reports previously to air having been introduced deliberately down the NGT, that is based upon that X-ray that we've seen on 12 June, isn't it?
DE: No. It's not actually. It's on the fact that the baby collapsed unexpectedly on 13 June. All right? I've explained about the 12th June and that this -- and that whatever happened on 12 June did not splint the diaphragm because, if it had, the baby would have collapsed. What happened on 13th is totally different. But if I may fast forward here --
BM: Could I just repeat the question? I just asked you that you have regarded the air that we see on that X-ray on 12 June as what is indicative of air having been deliberately forced down the NGT that day. And you have, haven't you?
DE: That was an opinion I've expressed, yes.
BM: Yes, that's right, you expressed it in your report --
DE: Yes.
BM: -- I'm not going to read it out -- on 26 March 2019, didn't you?
DE: Mm.
BM: Yes?
DE: Yes, yes, yes, yes.
BM: And you expressed it in the joint report in August of this year?
DE: Yes.
BM: What evidence do you have of distension to the bowel or the abdomen post-mortem that indicates this was due to air down the NGT as a cause of death? What's the evidence you rely upon?
DE: I'm going to leave the interpretation of the autopsy to Dr Marnerides.
BM: What is the evidence you -- I am not asking you to repeat Dr Marnerides' opinion. What's the evidence you rely upon when you tell the jury that the diaphragm was splinted on the 13th? What's the evidence?
DE: Baby collapsed, died.
BM: A baby may collapse for any number of reasons. What's the evidence that supports your assertion made today that it's because of air going down the NGT?
DE: The baby collapsed and died.
BM: Do you rely upon one image of that?
DE: This baby collapsed and died.
BM: What evidence is there that you can point to that you rely upon, sorry, that indicates air had been forced down the NGT, Dr Evans?
DE: Right. To answer this more clearly, I need to introduce a concept that I've mentioned last week, which is to do with differential diagnosis. Okay? A differential diagnosis is something that all doctors rely on. If you think that there is no specific -- sorry, if you think that whatever's happened is not due to one phenomenon, it may be due to another phenomenon. Now, it's not in my report, so I have not mentioned it, but if pressed, I'm obliged to mention it.
This baby collapsed and died. This baby collapsed and died and I have -- on top of my list, and this is the result of what we've discussed. Is there a differential diagnosis? Well, the answer to that is yes. This baby could also have collapsed as a result of air being injected into his circulation intravenously.
BM: I beg your pardon, can you repeat that?
DE: You asked me, I'm going to answer. All right? Let me finish, please.
So therefore, there are three scenarios clinically. One is more likely than the other two for reasons we've discussed. I know this sounds awful, but what happened is this baby collapsed and died who had an infection that was under control. We've spoken about injecting air into the stomach, causing such high pressure it's interfered with his breathing.
The second scenario is that in the -- that air was injected intravenously -- intravenously -- causing an air embolus, which we discussed at some length last week.
BM: Have you ever come across a suggestion --
DE: Just a minute, you've asked me the question, I have the right to answer it.
The third scenario, the third scenario, which sounds even worse, is that this baby may have died as a result of a combination of air injected into his stomach and air injected intravenously, which sounds awful. But we've just finished the [Babies A & B] twins last week.
So therefore, from my perspective, from my perspective, if I was answering this question from an academic point of view rather than a clinical point of view, I would not be able to rule out any of those three scenarios. Right? Okay? It's as simple as that.
What I can rule out is that a baby who's in 25% oxygen, who has a lung infection, isn't suddenly going to drop dead, if I could phrase it in that way with apologies to his family.
BM: Let me ask now -- or deal with what you have just said. First of all, my question was: what evidence do you identify showing any expansion of the stomach that could create splinting of the diaphragm for 13 June? Do you have one piece of evidence that shows that?
DE: Air will dissipate rapidly, according to the pathologist, from the stomach following death. And the report I have read I think says that -- so...
So therefore, the -- therefore you can't look at the X-ray post-mortem to tell you one way or the other, but this is a matter that I would prefer to defer to radiologists, particularly radiologists who are experienced in dealing with post-mortem X-rays and to defer to pathologists who are, after all, the people who, you know, carry out post-mortems.
BM: So there's not one particular item, not one image or piece of evidence you can identify which shows air in the gut as a result of being forced in on 13 June?
DE: Well, I think that from what Dr Arthurs said, and we've mentioned [Baby B] just now so let's go back to [Baby B] --
BM: I am just asking about you, Dr Evans (overspeaking) answer that question.
DE: Just a minute, just a minute. This is for radiologists anyway and they said the absence or presence of air does not confirm or exclude anything of this nature. In other words, this baby collapsed and died and none of the -- as Dr Gibbs said, none of the normal or the natural pathological processes that can lead to the deterioration of a baby's condition explains why he collapsed. Therefore I think a baby collapsing and where resuscitation was unsuccessful -- you know, that's consistent with my interpretation of what happened. And of course, it's not that difficult to conceal, right?
BM: Turning to air embolus, one of the things that I've suggested to you, Dr Evans, is that you are coming up with things as we go along to support an allegation against the defendant rather than basing it upon the facts. You have heard me put that to you, haven't you?
DE: Right, you have said that to me several times.
BM: (Overspeaking).
DE: That is incorrect actually.
BM: Right.
DE: Let me say something more. We're back with [Baby C] now, are we? Right.
BM: No, I'd like you to answer the question.
DE: Well, I will answer the question. When I reviewed these papers originally, this was in November 2017, there was no suspect named, known to me --
BM: I'm going to --
DE: Just a minute, I need to explain how I have formed my opinion because I do object to being accused of making things up. You know, it's part of -- I don't like that. Right, so --
BM: Last time you were here, you went into quite a lot of detail about your involvement in the investigation. I have asked you whether you are coming up with things to support the allegation as we go along. You say you haven't done.
DE: No, no, I am coming up -- my opinion is based on the clinical information I have received from the clinical notes and, where necessary, backed up by information from medical people from other disciplines, like pathology, like radiology, who know more about this sort of stuff than I do.
So therefore -- it's a team, I'm putting forward all this information as a result of my own opinion some of the time, my own opinion allied to the opinion of other people or other cases.
Again, we've heard about Dr Marnerides' pathology report. It's his report, you know, that's fine. As far as I know, I have not seen a pathology report from Mr Myers saying something different. That's not my call. That's not my call. Okay?
BM: You --
DE: The only pathology, the only independent pathology opinion I have seen in relation to [Baby C] is from Dr Marnerides. If there is a pathologist out there who wants to say different, that is nothing to do with me, that is up to Mr Myers and his team.
BM: Now, air embolus.
Just to remind the jury, we've had eight reports from you before today. Until you mentioned air embolus a couple of minutes ago, has that featured in any reports of [Baby C]?
DE: None at all, no, I have said that.
BM: Now, air embolus is something you've been interested in during your time with this case, isn't it?
DE: This trial, you mean, or other cases?
BM: During your assessment of this investigation it has been something you have looked at in other cases, hasn't it, other babies?
DE: Yes, yes, yes, yes.
BM: In that first report, right the way through to the most recent joint report, never once do you make a reference to air embolus, do you?
DE: No, that is correct.
BM: No. You've told us what you look for with an air embolus, Dr Evans. In this case you were provided with all the relevant clinical and pathological material before today, weren't you?
DE: Yes, yes.
BM: And you've been able to make those reports based upon that, haven't you?
DE: No, no, I have said -- yes, absolutely in relation to this particular case I think everyone's heard my evidence-in-chief with Mr Johnson. That is what, in my opinion, led to this baby's collapse. If pressed, which is fine, I accept all of this, to come up with alternative explanations, then I feel I am obliged to assist the court by saying what are other explanations.
From a mechanism point of view, air embolus is one of them. I have certainly not put it down in my report, but if pressed to ask for other opinions, sorry, other causes, you see, if pressed to ask for other causes, then, yes, this is something that I think needs to be shared with the jury.
BM: You just came out with that as we went along to try and support the allegation, didn't you, Dr Evans?
DE: You keep saying that and that is not correct.
BM: And again you are not independent.
DE: Again you're just being insulting, so there we are.
MR MYERS: Thank you, my Lord.
MR JUSTICE GOSS: Mr Johnson?
MR JOHNSON: No, thank you. Does my Lord have any questions?
MR JUSTICE GOSS: I don't, thank you very much.
That completes your evidence this afternoon. But you will be coming back later in the trial. Thank you.
MR JOHNSON: We're moving on to Dr Bohin's evidence next, my Lord. There is one issue that -- I have discussed it with my learned friend at lunchtime, but I just wanted to expand on that now.
MR JUSTICE GOSS: We'll let Dr Evans leave the witness box. Thank you very much. Don't discuss this case or anything to do with any aspect of it with anyone, please.
DE: Yes, I understand, my Lord.
Wednesday, 9 November 2022
MR JOHNSON: I recall Dr Dewi Evans, please. Dr Evans, would you identify yourself for the sake of the recording, please?
DE: Dr Dewi Evans.
NJ: Thank you. Dr Evans, you have provided a number -- four, I believe, separate reports in the case of [Baby D]; is that correct?
DE: I have.
NJ: Thank you. If we could just list them for the record, please. Is the first is dated 7 November 2017?
DE: Yes.
NJ: Was that what you have referred previously to as your screening report?
DE: Correct.
NJ: Was your second report dated 31 May 2018?
DE: Yes.
NJ: Was your third report, dealing with some issues that were raised with you, 15 October 2021?
DE: Correct.
NJ: Your final report, what was the date of that, please?
DE: 21 October 2021.
NJ: Thank you. Does that simply deal with pagination in the medical records?
DE: Yes. Sorry, there were a couple of other minor reports, confirming various things --
NJ: Yes.
DE: -- little admin things, yes.
NJ: Thank you. As before, Dr Evans, I'll concentrate on your report of 31 May 2018.
Have you been present, albeit over the link in the court next door, throughout the evidence concerning the life and the death of [Baby D]?
DE: Yes, I have, apart from late Friday afternoon last week.
NJ: I'd like to deal with the material that you were sent first of all, if I may, please. That is set out in your report at paragraph 3, I believe. Did you receive the medical records from the Countess of Chester Hospital primarily?
DE: Yes, I did.
NJ: Did you also receive material from Alder Hey Children's Hospital in Liverpool?
DE: Yes, I did.
NJ: And did that material from Alder Hey primarily relate to the post-mortem examination of [Baby D]?
DE: Yes.
NJ: Did you also receive some medical photographs and some X-rays from the Countess of Chester?
DE: X-rays, yes.
NJ: I think one of the issues you raised in your report is that as at that date, in other words over 4 years ago now, you hadn't seen the gynaecological records relating to [Mother of Baby D].
DE: No.
NJ: But have you now seen those?
DE: Yes.
NJ: Thank you very much. Just to put this into the sequence then, I hope there'll be no problem with me just briefly setting out the chronology, taking it up at paragraph 6 of your report.
Do you list in chronological sequence various events during [Baby D]'s life?
DE: Yes, I do.
NJ: Starting with her birth at 4.01 on Saturday, 20 June?
DE: That is correct, yes.
NJ: You record her gestational age at 37 plus 1?
DE: Yes.
NJ: Her birth weight at 3,130 grams?
DE: Yes.
NJ: You have now seen the Apgar scores, which were referred to in evidence; is that right?
DE: Correct, yes.
NJ: Do you record, at your paragraph 8, [Baby D]'s original -- or initial, I should say -- oxygen saturation level at a low 48%?
DE: Yes.
NJ: I think that was at 19.30 hours on 20 June.
DE: Yes.
NJ: That's tile 8. I'm not asking us to look at it now, but if anyone wants to note it down.
You record [Baby D]'s blood gases at tile 12?
DE: Yes.
NJ: The fact that she, [Baby D], was treated with intravenous penicillin and gentamicin?
DE: Correct.
NJ: That information recorded at tiles 13, 14, 20, 21 and 22 of the sequence?
DE: Yes.
NJ: Together with a bolus of 0.9% sodium chloride?
DE: Yes.
NJ: And do you record also her saturations, blood gas results, which we have seen at tile 23, at about the time she was started on CPAP, ie 8 pm that evening?
DE: Yes, 100%, yes.
NJ: Did you then turn your mind to Dr Brunton's examination of [Baby D] at 21.45 hours on 20 June?
DE: I did.
NJ: And that information is at tile 34.
Did you note at your paragraph 11 that, although [Baby D] was showing signs of improvement, the medical staff decided to intubate her?
DE: Yes.
NJ: And did you record the fact that at 23.00 hours, I think it's tile 51 or tile 34 or tile 35, [Baby D] was given Curosurf?
DE: Yes.
NJ: Did you move on, on 21 June, to record at 1.50 the results of the blood gases which are recorded at tile 69?
DE: Yes.
NJ: Which is also J2218. And did you conclude that [Baby D] was stable on pressures -- on ventilatory pressures of over 5 --
DE: Yes.
NJ: -- in 30% oxygen, with a respiratory rate of 40?
DE: That's correct, yes.
NJ: The next event in the chronology, as you recorded it, was the fact that [Baby D] had the ET tube removed at 9 am on 21 June?
DE: Correct.
NJ: And then your paragraph 13. Did you record that at 2 pm on 21 June, the two lines were inserted through her umbilicus?
DE: Yes.
NJ: One was removed, the other remained in place and was withdrawn; is that right?
DE: Correct.
NJ: We know from the evidence of Dr Brunton, I think, that the line that he thought was an arterial catheter was in fact a venous catheter?
DE: Yes.
NJ: I think that's Dr Rylance, I beg your pardon. I think that's tile 133.
Did you record at your paragraph 14 that, in an entry timed at 19.00 hours on 21 June, [Baby D] had been: "... in air all day, saturating well, no desaturations"?
DE: Yes.
NJ: That, I think, is at least partially referred to in Dr Rylance's notes?
DE: Yes.
NJ: Did you next record the fact that immediately post extubation, so this is going back to the morning, [Baby D]'s blood gases had been "not good"?
DE: Correct.
NJ: And it was that fact that had led to her being put on to CPAP?
DE: Yes.
NJ: Did you record next the blood gas results at 18.44?
DE: Yes.
NJ: Then your paragraph 15, the fact that [Baby D] had passed urine for the first time?
DE: Yes.
NJ: So moving on to the night shift and your paragraph 16, this is in Dr Brunton's notes at tile 174, did you record the fact that Dr Brunton had recorded that at .10 hours Dr Brunton had recorded various readings for sodium, which was high, bicarbonate --
DE: Yes, sodium was low.
NJ: I beg your pardon.
DE: And "potassium H", that's hydrolised, not high, by the way. A minor point.
NJ: Not at all. Was it noted at that stage that [Baby D] had saturations of 100%?
DE: Yes.
NJ: That there was no increased work of breathing or signs of respiratory distress syndrome?
DE: Correct.
NJ: So that's the lead-up to the events that happened at about 1.30 in the early hours of the morning of 22 June; is that right?
DE: Yes.
NJ: Is that a fair summary of the facts as you set them out in your report?
DE: Yes.
NJ: Thank you. Did you turn your attention next to Dr Brunton's notes made at 01.40 hours?
DE: Yes.
NJ: Which is the jury's tile 214. I'm looking at your paragraph 17 now, please, Dr Evans. So far as you were concerned, and so far as the notes of Dr Brunton were concerned, and taking into account the evidence he has given, what did you feel were the relevant features of [Baby D]'s desaturation at that time?
DE: Well, I think the first point to say is that it would have been very, very surprising because up until then she was very, very stable. She was responding to the treatment that she had received from the age of about hours, when she was admitted to the neonatal unit. And just before this, she was having oxygen saturations of 100%, you can't do better than that, she was not requiring additional oxygen, her only support was CPAP, which simply gives the air at a slightly higher pressure to keep the lungs open. And clinically, there was no increased work of breathing. In other words, there was no evidence that she was suffering any respiratory problem. In other words, she was a very stable baby.
So for a baby who was over 3 kilos, that's nearly pounds, suddenly changing so rapidly is something that is incredibly unusual for anyone used to dealing with babies on a neonatal unit.
NJ: Thank you. You record the fact that the nursing notes record: "Extremely mottled +++ and tracking lesions, dark brown/black, across the trunk."
Did you find that to be of significance in this context?
DE: It's very significant and it's also again extraordinarily unusual. This is not something that happens out of the blue in one's experience of dealing with babies, particularly this comment regarding tracking lesions, suggesting they move around, and also the discolouration being described as dark brown/black across her trunk. In other words, across her chest and abdomen. And again, she was needing 60% oxygen, so she'd gone from not requiring any oxygen at all -- 21% oxygen, air -- to 60%. So that is pretty unusual.
NJ: All right. You noted next the information that's at tile 218, which is Dr Newby's note made at 2 am and the fact, as she has told them to us this morning, about these areas of discolouration on [Baby D]'s abdomen and also the information that's recorded at tile 224, referring to the cefotaxime.
DE: That's another antibiotic, cefotaxime.
NJ: The next entry to which you refer in your report, which is at paragraph 18, is blood gas readings taken from [Baby D], which are also set out in the tiles 219 and 222.
DE: Yes.
NJ: The fact that [Baby D] was clinically much improved, that the areas of discolouration had completely disappeared.
DE: Yes.
NJ: The next entry, so I'm going to your paragraph 20 now, please, Dr Evans, refers to a further note made by Dr Brunton, which the jury can find, if they want it, at tile 236, timed at 3.15 on the morning of 22 June, where noted: "Called urgently to paediatric ward as [Baby D] had further episode of being very upset and crying and desaturated to 80% in 100% oxygen."
DE: Yes.
NJ: "Skin discolouration again became more prominent but not as obvious as previously."
And then the fact that [Baby D] appeared distressed on CPAP with two plus marks and continuing: "Clinically appears very well. She is in air. There is no increased work of breathing. Abdominal palpation. Notes skin discolouration (slight) over the right side of the abdomen."
And the plan at that stage was to take [Baby D] off CPAP and to give her a fluid bolus and check the gas, her blood gases again, in a further 1 hour.
DE: Yes.
NJ: We come then to the fatal event, which was noted up by Dr Brunton at tile 253 at 04.35 hours.
DE: Yes.
NJ: This was a record of what Dr Brunton had seen when he'd been called to the neonatal unit at 03.55; is that right?
DE: Yes.
NJ: The relevant notes, if anyone wants to make a note, is J2226. You set out in your report the timings and events that are there set out in Dr Brunton's notes; is that correct?
DE: That's correct, yes.
NJ: I'm not going to run through those because we've been through them more than once already and we all have a written record of them in the sequence of events.
Now I want to move on, please, Dr Evans, to your paragraph 23. If we could just put up tile 220, please. If we go to the document behind, thank you very much.
If we can just see it all in one go if possible. Thank you very much.
At your paragraph 23, Dr Evans, did you review the information that is contained in this particular document that we can see on the screen?
DE: I did.
NJ: And did you start, in effect, with a verbal description of what can be seen from 19.00 hours on 21 June?
DE: Yes. I can't read it from here, but that's 19.00 at the beginning, yes.
NJ: All right. Well, by reference to your report, please, and we can go to the chart and point these things out one by one if we need to, do we start with [Baby D]'s heart rate at the top of --
DE: Yes.
NJ: -- the chart?
DE: Yes.
NJ: And how did you -- how would you describe what we can see on that heart record, please?
DE: Right. That is a normal heart rate record. The values vary all within the normal limits. There is one spike, ie increase in heart rate, just before the end of the mark, which then falls.
So therefore a normal heart rate, apart from that one increased spike, which is around -- between 1 and 2 am.
So therefore that's a normal heart rate apart from that one blip.
NJ: What about the respiratory rate, the respirations?
DE: Same again. All the respiratory markers are within the normal range, they're all 40 to 60, and you get an increase to 60 around the same time as the increased heart rate. So you've got two values of 60 and then you have the drop.
So therefore normal respiratory pattern up until about 1 in the morning.
NJ: And the temperature, any significance to any of those readings?
DE: Normal temperature readings.
NJ: Thank you. Further down the chart, if we could just scroll down, please.
DE: I think I'll open up my own because I can see it a bit better.
NJ: Can we see [Baby D]'s blood pressure recorded there under BP?
DE: (Pause). Right, I'll check my own because I can't read that on there.
There's a blood pressure value of -- two blood pressure values. The first is 69/45 with a mean pressure of 53.
NJ: Yes.
DE: And the next one is 66/34, with a mean pressure of 45.
NJ: Yes.
DE: And the last one is 68/39, with a mean blood pressure of 48. All those values are perfectly acceptable for a baby of [Baby D]'s size and age. So normal in other words.
NJ: Yes.
DE: And the other bits down the bottom, slightly above the value of BP, you can see O2 on the far left. There's a value O2. If you look at the values towards the right, there are three values of 21. There's 21, 21 and . That means 21% oxygen, of air, and underneath the line O2 you can see SaO2, that's what that reads, not very clear, it's oxygen saturation. There are three values: one is 100, one is 94, and the last one is 99. So that relates to oxygen saturation and values of 94, and 100. Perfectly normal, indicating good respiratory results.
NJ: Yes. All right.
DE: So a very stable baby, in other words.
NJ: So [Baby D] in air?
DE: Yes.
NJ: No supplemental or additional oxygen and recording blood saturations which, as you have told us, are perfectly acceptable?
DE: Yes.
NJ: Thank you. Did you move on to consider the findings at the post-mortem?
DE: I did.
NJ: Do you defer to the pathologist, Dr Marnerides, so far as the post-mortem is concerned?
DE: I do.
NJ: Did you consider the issue of the failure to give [Mother of Baby D] any antibiotics in the light of her premature membrane rupture?
DE: I did. I did -- I'm not sure. Yes. Yes, I did. Yes. I -- yes.
NJ: And I think to be fair, you also took into account the witness statement of [Mother of Baby D], which was supplied to you by the police, setting out the chronology of her treatment?
DE: Yes.
NJ: That is your paragraphs 30 and 31.
DE: Yes, I did.
NJ: You recorded, I think at your paragraph 31, that [Baby D] had been born 60 hours after her mother's membranes had ruptured.
DE: Yes.
NJ: Did you flag up under your observations a need to clarify the hospital's policy regarding giving antibiotics to mothers in [Mother of Baby D]'s position following the early rupture of membranes?
DE: Yes, I did.
NJ: Thank you.
Did you consider -- I'm going to your paragraph 33 now, please, Dr Evans. Did you consider the Apgar scores at 5 and 10 minutes that had been recorded for [Baby D]?
DE: Yes, I did. They were 8 and 9, which is -- both of which are satisfactory, yes.
NJ: Did you also then -- I'm going to your paragraph 34 -- did you also then look to seek to explain why it was that [Baby D] had been in a poor condition following her birth?
DE: Yes, I did. I thought that her condition was consistent with early onset pneumonia.
NJ: And what features of [Baby D]'s condition caused you to reach that conclusion?
DE: Well, she was -- the Apgar scores were satisfactory, so that's not too bad. But she was grunting and cyanosed soon after she was born and her respiratory rate was increased, so all of these are markers of some kind of respiratory problem.
NJ: Yes.
DE: And the commonest respiratory problem in any baby of weeks' gestation is infection, pneumonia. To add to that, her bilirubin was 92, which is raised, and although babies commonly get jaundice, if the bilirubin is abnormally high initially in the first 24 hours, it's not normal and in cases of infection the red blood cells haemolyse, they burst, and that causes the jaundice. So a raised bilirubin is a non-specific marker of infection in a situation of this nature. And on top of that, we've got grunting, which is again a well-recognised clinical indicator of something abnormal and worrying respiratory-wise. And of course she was cyanosed, you know, her colour was blue, was not normal.
NJ: Yes.
DE: So all of this, very straightforward, all of these added up to early onset pneumonia.
NJ: Thank you. Did you take the view that once she had been admitted to the neonatal unit, [Baby D]'s management had been acceptable or not?
DE: Yes. Once she got there -- she was about 4 hours of age when she got there and I thought her management was entirely consistent with what I'd expect of a modern neonatal unit.
NJ: Thank you.
DE: She received antibiotics and she received respiratory support and intravenous fluids.
NJ: Was the decision to remove the ET tube from [Baby D] at about 9 o'clock on the morning of the 21st a reasonable one in all the circumstances?
DE: It was, because she was getting better. She was making what I consider a very satisfactory improvement -- and in fact a far more rapid improvement than I would expect given the condition she was in when she arrived at the unit. But all the respiratory markers, monitoring, that were carried out were great and therefore she was taken off endotracheal intubation, yes.
NJ: Thank you. Having removed the ET tube and the blood gas results that were then reported, was it a reasonable decision to put [Baby D] on to CPAP to support her breathing?
DE: Yes, it was. Although she was satisfactory when full ventilation was removed, her condition did not settle completely and therefore standard management -- she still needs a little bit of support, CPAP is that form of support, so she was put on CPAP and she stabilised very, very promptly on what is, by any standards, very minimal respiratory support. So that was great.
And over the day, as we've heard, her condition stabilised and, you know, she remained very well.
NJ: Yes. Looking at things in the round and taking into account the evidence that appears in the records, and indeed that you have heard, what view did you come to so far as [Baby D]'s condition immediately prior to her collapse?
DE: Can I just put one bit there to get the chronology right --
NJ: Please.
DE: -- if that's okay?
NJ: Yes.
DE: She was stable on CPAP and the medical staff, in the evening prior to her collapse, took her off CPAP. This didn't work, so they put her back on CPAP. That is perfectly standard management, especially in a baby who by this time was not needing additional oxygen. She was a big baby, over 3 kg. Some babies don't like CPAP very much, you know, it's quite intrusive, can be -- having something over your face. So they tried her off CPAP. Her oxygen saturations dropped so they put her back on CPAP and her condition reverted to normal more or less straightaway and stayed perfectly normal in air, oxygen saturations normal, until the early hours of the following morning.
NJ: So what conclusion did you come to so far as her condition in the time immediately before her collapse some time after 01.00 hours on the 22nd?
DE: Just prior to that, if I'd seen her I would be very, very confident that she'd be very well the following morning and we would be looking to either maintaining her on CPAP, because she's still only, you know, a couple of days of age, or trying her off CPAP again to see if she can now breathe without CPAP.
So her condition could not have been better and her condition clinically was entirely consistent with a baby recovering from early onset pneumonia -- not recovered from pneumonia, recovering from pneumonia. Nobody, I think, recovers from pneumonia in such a short time. So this -- you know, she was really doing exceptionally well and clinically very satisfactory.
NJ: How would you describe [Baby D]'s response to the treatment that she had received?
DE: When now?
NJ: In the time immediately before her collapse.
DE: Oh, extremely satisfactory. You know, her improvement was far quicker than I would have expected, to be frank. It was remarkable that her oxygen values -- oxygen saturations, you know, 100% or 99% without the need for any supplemental oxygen at all. Now, that is an indicator of a baby whose lungs are functioning satisfactorily.
NJ: Thank you.
DE: So very good.
NJ: So you having told us that there is clear evidence that her lungs were operating satisfactorily --
DE: Yes.
NJ: -- can we look at the three collapses at about 01.30, .00 and 03.45 hours on the morning of 22 June, please.
DE: Yes.
NJ: We have heard evidence as to the nature of [Baby D]'s response following the first collapse. Is that typical in these circumstances?
DE: It isn't, actually. It's very unusual because her deterioration was very rapid. Her oxygen fell, her heart rate fell. It was very rapid, which usually is an indicator of some kind of serious pathology, you know, but if it is an indicator of serious pathology, then resuscitation will work, but this is followed by the need for far more in the way of clinical support. In other words, she would need additional oxygen, she would not have recovered so promptly.
But within a very short period of time, she was back, not requiring oxygen, and well. So this is an incredibly unusual response for a baby who's 37 weeks' gestation.
NJ: So what you're saying is the speed of her response and the nature of her response is inconsistent with the gravity of the collapse being part of the pneumonia that no doubt she had?
DE: It's inconsistent with the pneumonia or any other one of the -- inconsistent with what we call septicaemia or sepsis, in other words a generalised infection. If she had a generalised infection, sepsis, she would not have made this very prompt recovery within a very short period of time.
NJ: Yes. Looking at your paragraph 39, Dr Evans, did you remark on the abdominal discolouration which had been reported by the treating medical staff?
DE: Yes. The word I used was "intrigued". This was something that I found very unusual again. It was intriguing, both with regard to its appearance, and I think we've heard from the local people, local staff looking after her, their descriptions of all of this, noting tracking, bruises.
The other thing, which is even more remarkable, is that it disappeared. It disappeared within minutes according to my report.
So these abnormalities, they could not be bruises.
NJ: I think some of the treating doctors have referred to this, but why can't they be bruises?
DE: Bruising is due to damage to blood vessels under the skin, whether you get kicked in the shins playing football or whatever. If you get damage to tissues underneath the skin, the blood vessels are traumatised, they break. Blood leaks out of the tissues and then comes close to the surface, where the bruise appears. If that happens, as is the experience of all of us, I suspect, the bruising will last several days. So bruising will not disappear within a matter of an hour or two or less. So therefore this could not be bruises.
The other thing it could not be is what I think Dr Newby this morning described as purpura. Purpura, again, are blood spots. Same principle: tiny blood spots under the skin, which you get in any number of conditions. I think one of the people mentioned meningococcal septicaemia.
If you get purpura, if you get these little blood spots under the skin, they just don't disappear, they'll be there for days, and if they are due to some serious underlying condition, they don't just not disappear, but you get an increase in the number of purpuric spots. So you get a spreading of purpura and this is associated with continued deterioration in your baby, in your patient.
Therefore the fact of all of this discolouration disappeared in a short time, not bruises, not purpura.
NJ: Okay. In coming to your final conclusion, which we will come to in a moment, did you note the report of the post-mortem X-ray that had been taken of [Baby D]'s body?
DE: Yes, I did. Yes, I did.
NJ: Did you ask for some assistance from a pathologist in terms of interpreting air which was found within [Baby D]'s body following her death?
DE: Yes, I did.
NJ: All right. We can leave that for them.
Can we turn to your opinion, finally, please, Dr Evans, so your paragraph 43. Dealing with the issue of pneumonia, first of all, so far as you could tell, was this a pneumonia that affected both lungs or one lung?
DE: Well, the post-mortem says right-sided pneumonia, so just the right lung.
NJ: Yes. In your experience, what conclusion did you draw as to when [Baby D] had developed pneumonia?
DE: I think she had developed it before her birth and that would be the result of the prolonged ruptured membranes. So this was an antepartum pneumonia.
NJ: Antepartum, is that Latin for before birth?
DE: Yes, before birth.
NJ: Lawyers aren't allowed to use Latin anymore. I don't think doctors are prevented.
So far as that was concerned, if [Baby D]'s pneumonia had been sufficient to cause her death, what would you have expected the pattern of her decline towards death to have been? How would that have presented?
DE: Sure. If a baby's born with a severe pneumonia, usually affecting both sides, but not necessarily, where treatment fails to save her, what you find is that increasing amount of clinical input does not lead to an improvement. I'll explain all of this.
NJ: Yes.
DE: When she first presented, she was an unwell baby and required ventilatory support. She was on ventilation, she wasn't on just this CPAP. If her pneumonia had progressed, the clinical team would never have managed to get her off ventilatory support and they probably would have found that as the hours went by, she would have required more and more oxygen, in other words a greater concentration of oxygen probably. She'd have required ventilation with increased pressures, in other words it would have taken greater pressure to keep the lungs open. They would have had difficulties keeping her oxygen saturations at a satisfactory level.
This is what you get in babies who have a severe or a fulminant pneumonia. In [Baby D]'s case, none of this happened. She got better. And as I've said earlier, she improved far, far more rapidly than I would have expected. I would have expected her to improve over 2 or 3 days, say, but she in fact improved over hours -- or less than that, less than that, because she was placed on ventilatory support around 8 pm, I think, 9 pm.
NJ: Intubated 9 pm, extubated 9 am.
DE: And extubated 9 am. So over that night her improvement was such that she did not need what I would call full ventilatory support anymore, which is great. On top of that, her oxygen requirements had fallen, you know, didn't need any, and so all of the prognostic factors, all of the predictions for [Baby D] at this time were she was recovering from pneumonia -- not recovered, not fully recovered, but recovering from pneumonia and it would be therefore a matter of, and I use these words advisedly, a little bit of trial and error as to when the medical team would get her away from CPAP to get her breathing on her own.
NJ: Yes.
DE: So by 9 am -- at 10 am she was put back on CPAP and was stable on CPAP. So by any account, she was recovering satisfactorily from her pneumonia and essentially she was out of danger.
NJ: Do you exclude pneumonia as being the cause of [Baby D]'s death?
DE: No, no, the pneumonia did not -- was not responsible in any way for [Baby D]'s death. Pneumonia is probably the condition that clinicians like myself have dealt with more commonly than any other condition, you know, any other condition, really. And in a situation like this, you know, pneumonia with the correct treatment is curable. You just treat it, antibiotics, oxygen, breathing support if necessary, so standard pneumonia treatment. That's what we do. That's why she was in the neonatal unit.
NJ: Did you reach a conclusion as to what had caused or what was consistent with being the cause of [Baby D]'s death?
DE: Yes, I did. As we know, as with when I've given evidence before, initially all I had to go on were the clinical records and I formed the view this is an extraordinarily unusual collapse, unexpected collapse. This is something that is consistent with her having sustained intravenous air. In other words, she'd received an injection of air, of gas, through a vein into her circulation, causing what we call an air embolus.
As I've discussed earlier, air embolus is incredibly rare, but this is what -- this, I concluded, was the only explanation that -- the only cause that could explain [Baby D]'s collapse and death.
MR JOHNSON: Thank you. Those are all the questions I have for you. Thank you, Dr Evans. Would you wait there for some further questions?
MR MYERS: Dr Evans, you haven't been asked, so I'll ask you, what are the features that make air embolism the only explanation?
DE: Right, well, let me go through them. The first is that her collapse -- this was a collapse of a baby who was stable and who had an intravenous line in place and where the collapse was unexpected and the changes were rapid and very, very striking. In other words -- the drop in oxygen saturation being the main one. So that was my first stage in reaching this diagnosis of air embolus.
The second stage was the presence of this discolouration, which is unique in two ways. The first is that it was a pattern of discolouration that experienced neonatal nurses had never seen before and experienced medical people, one of whom is now a neonatologist in Glasgow, had never seen before and had never seen since. So we've got this extraordinarily unusual pattern of discolouration.
The second aspect of the discolouration was that it came and it went. It came and it went. Again, this is something that you do not find as a result of sepsis or other disorders. So that was my second step.
My third stage in reaching this diagnosis was that resuscitation was unsuccessful. This is the fourth of our 17 cases and I think we'll find in future cases that babies did deteriorate as a result of the usual complications that one gets in babies, infection mainly, and resuscitation carried out by experienced medical staff works. You don't need -- they just get better. So therefore the third step in getting to my diagnosis was the fact that she failed to respond to pretty -- well, pretty thorough efforts at resuscitation.
My fourth stage, which again I defer to the radiology and pathology opinion on, is the presentation of air in the great vessels. The local report said air in the aorta -- so the great vessels could be the aorta or the vena cava. So again we've got air in a great vessel, which is an incredibly unusual phenomenon, as our radiology colleagues will tell us. So that was stage 4.
The fifth stage is that none of the other issues that affected [Baby D] were relevant. You can't explain this on the presence of a pneumonia affecting one lung.
Her sodium was a little bit on the low side, you know, that wouldn't explain her collapse or discolouration or anything else.
So therefore, putting -- so we have four stages followed by the fifth and I think have excluded everything else.
So in my opinion, in [Baby D]'s case, we had a full house of clinical characteristics entirely consistent with her having sustained an air embolus, ie air injected into her circulation.
BM: Right, thank you. We'll come back to that shortly.
I want to go through next what we have in terms of her condition, leading up to the events in the morning of 22 June, Dr Evans --
MR JUSTICE GOSS: I think we might just have our mid-afternoon break at the moment.
MR MYERS: Yes, of course.
MR JUSTICE GOSS: I'm sorry to interrupt you, Mr Myers. I was going to have to interrupt you at some stage. I think this is a good time to have it. We'll just have our 10-minute break now. Thank you very much.
(2.53 pm)
(A short break)
(3.03 pm)
MR JUSTICE GOSS: Mr Myers.
MR MYERS: My Lord.
Dr Evans, you agree, don't you, that as we first encounter [Baby D] after her birth, her condition is entirely consistent with early onset pneumonia?
DE: I do.
BM: That's based in part because she was grunting and cyanosed, isn't it?
DE: Yes.
BM: Her respiratory rate was increased?
DE: Yes.
BM: Her bilirubin was 92. And in fact, it's not just that, is it? Her presentation in the hours that followed indicated the presence of a significant infection, didn't it?
DE: Yes.
BM: You'd said that it's quite common to encounter pneumonia and the presentation was straightforward. But she was actually quite poorly, certainly from about 12 minutes onwards, wasn't she, when we see her collapse?
DE: She was an unwell baby, yes.
BM: Yes. She was in a state of very poor health before she went to the neonatal unit, wasn't she?
DE: Yes.
BM: We know that her mother, [Mother of Baby D], hadn't been given antibiotics, contrary in fact to the guidelines of the hospital. You have seen that now, that's right, isn't it?
DE: Yes, that is correct, I heard the evidence, yes.
BM: And also in [Baby D]'s case antibiotics weren't given until hours after birth.
DE: That is correct.
BM: And that is a delay that falls below the acceptable standard in her circumstances, doesn't it?
DE: It does.
BM: Now, your evidence is that by the time of the events that commence about 30 hours after birth, maybe a little bit later than that, she was in a state you would say of near complete recovery; is that correct?
DE: She was recovering, she had not recovered, which is the natural history of pneumonia.
BM: Yes. In your report that you wrote, and the one that you were taken to, the second of the reports, it's dated May 2018, paragraph 44, you say that there was a window of near complete recovery. There's a difference, isn't there, between recovering and recovery; would you agree?
DE: "Near complete recovery", quite happy to use that, or use the word recovering. I think this is semantics. Perfectly happy to run with either observation.
BM: I'm going to suggest to you, the fact is [Baby D] was not anywhere near to a complete recovery, was she?
DE: She was recovering.
BM: Right. If she's recovering, that means she still has the potential to become quite unwell, doesn't it?
DE: She's in a neonatal unit, the best place for her on the planet. If she was becoming unwell as a result of infection, she would have had -- she was on full monitoring, she had nurses all round her, she had doctors round the corner, as it were, and we -- and we recognise, doctors and nurses on neonatal units, we recognise clinical characteristics that would indicate she is not as well as she was or she's getting worse. She showed none of those just prior to 1.30 in the morning.
BM: What I asked was if she is recovering, as opposed to being in a state of recovery. If she's recovering that means she still has the potential to deteriorate and become quite unwell, doesn't she?
DE: The potential is there, which is why she was on the neonatal unit, yes.
BM: Now, it is a fact, isn't it, that however we describe the assistance she got, she was never able to breathe for any period of time beyond an hour or so without assistance from some sort of breathing support?
DE: She was breathing on her own. CPAP does not assist you, does not fill your lungs up and down or in and out, as it were. It is a measure simply to assist keeping the breathing tubes open between breaths.
So therefore she was actually breathing of her own accord, but she needed this CPAP method as well. That is it.
BM: A child in good health will not need to be ventilated, do you agree?
DE: She was recovering from pneumonia.
BM: Let's go through what the treatment was. A child who is in good health will not need ventilation, will she?
DE: A child in good health would not need to be on a neonatal unit.
BM: So you agree with me then? She's not in good health?
DE: She was not in good health when she arrived on the neonatal unit. She was recovering in a remarkably short time afterwards.
BM: You just said a child in good health would not need to be on a neonatal unit and [Baby D] was on a neonatal unit, wasn't she?
DE: She had pneumonia.
BM: Because she's not in good health.
DE: She has pneumonia.
BM: That means she's not in good health, doesn't it? You're a doctor, that why I'm asking you. You're an expert.
DE: She had an infective illness that is within the remit of any neonatal unit to treat, so yes.
BM: You told the jury that, as we go through that day, all the respiratory markers were great. That's the language you put it in. Is that your evidence?
DE: They were satisfactory.
BM: Your words were: "All the respiratory markers were great."
DE: Okay, fine.
BM: You heard the evidence of Elizabeth Newby this morning, didn't you, Dr Evans?
DE: Yes.
BM: You know that once [Baby D] was taken off the ventilator, her blood gas readings began to deteriorate before she was put on to CPAP, didn't they?
DE: Yes, and my comment regarding her respiratory markers was related to her being put on CPAP.
BM: Right. Let's look at the whole picture. Her blood gas deteriorated when she came off the ventilator, didn't it?
DE: It did.
BM: Dr Newby was concerned that she seemed quiet and she didn't like her tone, it was stiff. She considered she may be suffering from sepsis in all the circumstances. You heard that, didn't you?
DE: I did.
BM: Then we found that, because the blood gas readings deteriorated round about 10.14, because of that, [Baby D] was then put on to CPAP.
DE: That's fine.
BM: Yes. So that indicates, doesn't it, that CPAP is necessary to give her some sort of support that she is at a disadvantage for if she doesn't have it, surely?
DE: That's why it's used.
BM: Right. So it is necessary to support or assist her breathing, whichever words you prefer?
DE: Yes. Let's call it assist.
BM: All right. It's necessary to assist her breathing, isn't it?
DE: Yes.
BM: We heard that still later, at about 12.10, the blood gas readings were still unsatisfactory at that point and Dr Newby considered some form of acidosis was responsible for that.
DE: Can you point me to that reading, please?
BM: We can put it up if you like.
DE: Yes.
BM: We'll put up, please, Mr Murphy, in one moment -- it's slide 112. Pop behind there. We'll enlarge, if we could, the central part of the chart which shows the readings for 10.14 and 12.10.
DE: Just a minute, I want to look at my own record because it's clearer for me. Give me the time again.
BM: 10.14 and 12.10.
DE: Right. Let's have a look. Right. 10.14. 10.14, this is just -- it notes, "To start CPAP". So this was just before she started CPAP.
BM: Yes.
DE: Therefore the CO2 is raised at 9, 9.02, and a bit later it's 9.97, so those values prove that it was appropriate to put her on CPAP.
BM: What I was asking you, Dr Evans, is by the time we get to 12.10, and we can see it here, in accordance with the evidence of Dr Newby and what we see on this table, the blood gas levels were still unsatisfactory even though she was on CPAP. You see that?
DE: Yes, well, she was put on CPAP and then 2 hours later the CO2 is down to 5.18, which is spot on. This is what we do, okay? If we have a child with pneumonia who cannot cope without CPAP, you put them on CPAP. Standard, routine clinical practice.
BM: Just looking at your assertion that all the respiratory markers were great, which is what you said to the jury that's what we're looking at --
DE: No, no. Nitpicking, I'm afraid. The issue is the respiratory rate during this time was satisfactory or great or whatever you wish to call it. So if you want to look at selected bits of information I am more than happy to comment on selected bits of information. But I think that what I would add to this, I've listened to every doctor who has given evidence, local doctor who's given evidence, and every one of them has said that when you're assessing a baby, you are looking at all the markers. In other words, the well-being, heart rate, respiratory rate, blood tests. You are looking at all the criteria available to you. What you can't do, what you cannot do is what is happening today, is looking at one or two things which are out of sync in this situation, as we're hearing, where a little baby came off ventilation, could not cope without CPAP, so she was put on CPAP. Standard medical care. Okay?
BM: We --
DE: Standard medical care.
BM: We know she had pneumonia, don't we?
DE: We do.
BM: That's part of the clinical picture, isn't it?
DE: Sorry?
BM: That's part of the clinical picture, isn't it?
DE: What now?
BM: That she had pneumonia?
DE: Yes, we know. I know.
BM: We know her condition the day before. I have just covered that and that's part of the picture to bear in mind, isn't it?
DE: Yes.
BM: We know that throughout the course of this morning, the morning we're looking at, if she didn't get respiratory support she deteriorated into acidosis. We know that don't we?
DE: Tell me about the acidosis. Which --
BM: We know that she deteriorated, don't we?
DE: Which figure are you pointing out?
BM: Don't you want to answer that question? We have had the evidence, Dr Evans, and we know she deteriorated, don't we?
DE: She did not stabilise when taken off ventilation so she required CPAP. That's fine.
BM: The whole picture is of a little girl who has respiratory problems, isn't it?
DE: Yes.
BM: Right. We know that, as we go on into the afternoon, her lactate levels were found to be higher round about pm?
DE: Um... Well, we discussed lactate. 1 pm, hang on, just a minute. Well... Just a minute, 1 pm... We've got a pattern here. Let me read them out. There's a 2.3. One of the medical people said that their lactate values were under 2.5, so we've got a 3.4 and a 4.5. These are values that are raised. This is what you get. This is what happened because she was -- one of them was prior to starting on CPAP. And by 2 pm, it's down to 1.8. So you know, again, we're looking at trends. So if one is looking at things in isolation, this is in -- this indicates that people don't understand how medicine works. I mean, I'm not trying to be rude to Mr Myers, but this is what happens.
We've got lactate a little bit high, CO2 is a little bit high, let's put her on CPAP. Two hours later, her CO2 is 5.18 and her lactate is 1.8. Great. And she's back in air. She's even -- which is great.
That's what clinical practice is about. It's not about picking on one or two markers that don't assist in the overall context of how one assesses a baby --
BM: I'm not going to --
DE: -- or any patient for that matter.
BM: I'm not going to repeat the questions or the points that I make. I've made the point already that the full picture is of a little girl who's unwell with pneumonia. You agreed with that, Dr Evans. I am not going to go back through that.
DE: She's unwell and she's --
BM: Let me move on (overspeaking) picture.
DE: -- recovering from pneumonia with the aid of CPAP. Great.
BM: In fact, when she was taken off CPAP, as we get into the evening, she deteriorated, didn't she?
DE: She did.
BM: That goes to show that she has a problem with respiration, doesn't it?
DE: No, it goes to show she needs treatment with CPAP.
BM: If someone needs treatment with CPAP because they desaturate without it, that is a problem with respiration, isn't it, Dr Evans?
DE: It's a problem that requires treatment with CPAP. And if you are looking at a baby of 37 weeks' gestation, who is over 3 kg and on CPAP, is in air with saturations in the high 90s, it's worth trying them off CPAP. It's worth -- listen now, listen. It's worth trying them off CPAP and if the oxygen saturation drops, you put them back on CPAP. I suspect that is something that happens most days of the week in every neonatal unit in the country.
BM: (Overspeaking).
DE: So she's really, really stable.
BM: You don't want to accept the possibility of problems with respiration because that would be something that may undermine your alternative proposal that this is air embolus; that's what this is about, isn't it, Dr Evans?
DE: No. I told you why I think she's got an air embolus. She died of an air embolus.
BM: When she was taken off CPAP we've seen she desaturated to somewhere in the 80s.
DE: Yes.
BM: Would you have just left her off CPAP in that situation?
DE: No, I'd have put her back --
BM: Why not?
DE: I would have put her back on CPAP.
BM: Why? Why?
DE: Because she needs it.
BM: Right. Why does she need it?
DE: Because babies who are recovering from pneumonia, from time to time, will need CPAP. It's a standard clinical treatment. It's what you do. You respond to how the patient responds to your treatment. Okay? It is standard clinical medicine that I think most people would find very straightforward to understand -- appreciate.
BM: It's not a great respiratory marker if she desaturates to 80 when taken off CPAP, is it?
DE: She was taken off CPAP --
MR JUSTICE GOSS: Answer the question yes or no. Just ask the question again.
MR MYERS: It is not a great respiratory marker that she desaturates to 80 when taken off CPAP, is it?
DE: Well, it simply means she needs CPAP, that's all.
BM: That's your answer, is it, Dr Evans?
DE: Yes, simple as that.
BM: You've told the jury how [Baby D] was very stable as we go through the evening until her collapse.
DE: Mm.
BM: And you said no evidence of a respiratory problem. That's your evidence?
DE: In air, oxygen saturations normal, heart rate normal, respiratory rate normal. Those are the four criteria, clinical criteria, that I would look to, and all of them were, prior to her collapse, within the normal range.
BM: In fact, you said: "Prior to her collapse, she could not have been better."
DE: She was stable.
BM: You said she was doing exceptionally well.
DE: She was doing exceptionally well.
BM: And do you agree -- is that your evidence, she could not have been better?
DE: She was recovering from pneumonia. For a baby of hours, I think, of age, given those clinical markers, she was doing remarkably well.
BM: Can we just move -- you said actually to the jury she could not have been better. Is your evidence seriously on her condition that she could not have been better?
DE: Given that she had pneumonia and she was recovering from pneumonia, what I said was that is -- she was recovering even better than I expected, actually. I think I said a few minutes ago that I would have expected her to recover over a period of a couple of days, but the fact that she had made this recovery, you know, made this recovery within 24 hours of admission to the neonatal unit --
BM: Can we scroll down the page? We've seen, and we've looked at it with other practitioners, that there is -- the readings at 23.52 and 01.14 both show increasing acidosis in terms of the pH for a start. Do you agree?
DE: 7.26, bit low. Nothing much to worry about.
BM: So those other practitioners, so we can be quite clear about this, the doctors and nurses who have come here and agree that shows an acidic pH, are they right or are they wrong in your professional expert opinion?
DE: It is a mild acidosis but, as every medic says, you look at the overall picture. If you scroll across that page she's on CPAP of 5 centimetres in air, therefore she has satisfactory oxygenation. It's a venous sample, which is not as good as an arterial sample, we heard that this morning. And so a pH of 7.26, you know, is slightly low, but nothing to worry about in isolation.
BM: When you produced the report that you were taken through in part a little while ago, you go through the various blood gas readings. You didn't refer, as it happens, to either of these two readings when you said that she was doing well. You may not recall it, but I can tell you, it didn't feature in your report.
DE: Okay, if I didn't, I didn't.
BM: When you went through your evidence to the jury a short while ago you went through various blood gas readings on the way to this point but you didn't mention these two readings that occur before the first event, did you?
DE: That's the whole point of my being here, to cover anything that's not been included in the report and that's not been included in evidence-in-chief. So if you want to raise these issues, I will answer them.
BM: You identified readings that showed an improvement during the afternoon, didn't you?
DE: Yes.
BM: You have made no reference in questioning so far or in your report to the readings that we see at 23.52 and .14, have you?
DE: And your point is?
BM: It would be helpful if you just answer the question. You haven't made any reference to them, have you?
DE: I haven't been asked about them.
BM: You haven't volunteered that, have you?
DE: I haven't been asked about them.
BM: They're not in your report?
DE: I haven't been asked. If you want me to ask about them I will answer them respectfully.
BM: Is it deliberate not to include readings that show a deterioration in the period before the first event?
DE: First of all, these readings in isolation, you cannot look at readings in isolation, as one keeps saying. If you want to ask me about those readings, I will answer them.
BM: All right. Can -- those two readings, do they demonstrate she could not have been better?
DE: She's in air, on 5 centimetres of CPAP, her pH is over .25, her CO2 on a venous sample is 6 point something, .5 I think, that's not too bad, I would settle for that. In a venous sample that's okay. And her base deficit is 5.6, I'm not going to get worried about that.
BM: 8.9 is bad, isn't it?
DE: And then it is 8.9, she is still in air, she's still on CPAP. And looking at... Looking at one little reading that is out of sync with everything else, this is not how clinical practice works.
BM: Maybe she was just not very well, Dr Evans.
DE: She was stable, she was recovering from pneumonia, she was in air with oxygen saturations of 100%. For a baby who had antepartum pneumonia, ie pneumonia before birth, to be at this stage of progress within this pretty short time, actually, that is something I would be completely satisfied with and, as I did volunteer earlier, I'd expect her to continue improving and she'd probably need to be on antibiotics for 7 to 10 days, maybe, depending on her progress. But you'd carry on with a course of antibiotics and then getting her off CPAP that evening didn't work, no problem with that, you put her back on CPAP. That's how it is, that's how it works. So the following day, if she'd not been the victim of an air embolus, that is my opinion, she would be nice and stable and the medics would have had another go at trying her off CPAP. That's where we are. This is the holistic approach that I take when assessing babies who have conditions like this.
BM: Do you agree that at paragraph 36 of the report that you were taken to, you say: "Immediately preceding her terminal collapse all the clinical markers were normal"?
DE: Clinical markers mean: heart rate, normal; respiratory rate, normal; oxygen saturation, normal; oxygen requirement, 21%, that's normal.
BM: Do you agree that what we're looking at for 23.52 and .14 are not normal? Are they normal or are they not normal?
DE: They are not concerning.
BM: Are they normal or not normal?
DE: 6.56, that's normal. Base deficit, 5.6, that's acceptable, within normal limits. 8.9, slightly raised. The other pH, 7.2 -- the other CO2 is under 6.56. I think that says 6.43, that's okay. Yeah, CPAP. In air again. Yeah. Stable.
BM: Do you agree she was unable -- we have been over this actually, but she was breathing with CPAP, wasn't she?
DE: She was.
BM: She deteriorated without CPAP, didn't she?
DE: Twelve hours earlier she did -- no, not 12 --
BM: No, not 12. 7.15 pm.
DE: Let's work that out. Anyway, several hours earlier.
BM: Her sodium levels were low?
DE: Slightly low.
BM: Platelets --
DE: Not a concern.
BM: Not a concern to you.
DE: No, no, not a clinical concern. A sodium of 126, which went up to 129, does not explain what happened to her and that which led to her death.
BM: And what you're doing, doctor, is deliberately seeking to exclude factors which go to show she may actually have been unwell. That's what you're doing, isn't it?
DE: She was stable. None of the issues that we've talked about, things like a base excess of 8.9 or whatever, none of this explains what happened to [Baby D] during the early hours of Sunday morning, 22 June. None of this is relevant, either in isolation or combined.
What does explain it is air embolus, and I've given everyone the five stages -- you don't need all five stages, but I've given you the five stages that [Baby D] experienced, entirely consistent with air embolus. The first four --
BM: You've (overspeaking). I would just like you to answer the questions, Dr Evans, we don't need the list again. You've given it to us and I'm going to go through it with you. May I proceed with the questions so we can deal with the actual issues I'd like to ask you about? Is that all right?
There are three different events, aren't there, that take place going into the early hours of that morning?
DE: Yes.
BM: 1.30, 3 am, 3.45?
DE: Yes.
BM: Those are the timings we have from the nursing notes.
We'll return to discolouration shortly, but in terms of breathing, on those occasions they were nothing more than, we don't underestimate them, desaturations, were they?
We'll return to discolouration shortly, but in terms of breathing, on those occasions they were nothing more than, we don't underestimate them, desaturations, were they?
DE: No, those desaturations were significant.
BM: To around the 70s?
DE: Yes.
BM: We have had desaturations when taken off CPAP to just a little bit above that earlier in the day, hadn't we?
DE: There's an explanation for that. Okay? There's an explanation for that. The explanation was she was tried off CPAP, put back on, tick, clinical management, that's the way it's done.
BM: It's not uncommon to have desaturations like [Baby D] had at 1.30 and 3 in the morning, is it?
DE: It's pretty uncommon for her condition to be such that it required crash calling and the efforts that were made to get her round on the first and second occasions.
BM: Efforts to get her round? What efforts on the second occasion? Tell us about them, please.
DE: Okay. Let me go through it in that case. Just a minute. I'll check on the... I'll check this through the clinical...
(Pause)
BM: There are no resuscitative efforts on the second occasion, are there, Dr Evans?
DE: Just a minute.
(Pause)
BM: We can go to the notes.
DE: No, no, I've got the notes on my -- I've got my own copy here, so I'd rather go through that, okay?
BM: To assist the jury, so we can have a look --
DE: I'm on J2222. The next one is 2223.
BM: Can we start with slide 218, please, Mr Murphy?
DE: Here we are. I'll give you the number now, just a minute. J2225. Okay?
BM: We've got on the screen now the actual notes, Dr Evans, so perhaps we could look at those because they're the original material we are dealing with.
DE: "Called urgently to paeds ward as [Baby D] had further episode of being very upset and crying and desaturated to 80% in 100% oxygen."
Right. Now, it's not that she desaturates to 80%, which is significant. But she desaturates to 80% whilst being in 100% oxygen. You can't -- that's pretty serious, right? That's pretty serious. Then it follows: "Skin discolouration again became more prominent but not as [reads sotto voce] previously. Appears distressed on CPAP."
Then the next line:
"Now in air. No increased work of breathing."
So therefore, this was a very, very concerning issue, okay? It's a very, very concerning issue. Any baby who was in air and is now saturating to 80% only, and requiring 100% oxygen to do it, and then soon after that, wow, she's back in air. So therefore there was a significant event round about that time. Okay?
BM: You were talking about the efforts, in effect, to resuscitate her. I was asking you to help us with where we see them on the first two events. So let's focus on the question because you talked about the importance of resuscitation and its failure as part of identifying air embolus.
DE: It is.
BM: You told the jury about the efforts brought to stabilise her on these first two occasions. We have the notes at .40 for Dr Brunton. We're looking through them. We can see them, it starts from: "Called urgently to review baby. Nurses noted that became extremely mottled. Also noted to have tracking lesions (dark brown/black) across trunk."
Nothing so far about resuscitation, is there? Is there, Dr Evans?
DE: This was a serious collapse, okay?
BM: I'm asking you to help us with the question of resuscitation because you've referred to that, so let's carry on. Can you see anything there about resuscitating her as a result of this desaturation?
DE: No.
BM: Right. Let's carry on:
"60% in oxygen."
That's on examination.
She's on CPAP. There's slight subcostal recession. We've got HS -- is that heart sounds?
DE: Where are we now?
BM: What's that, please?
DE: Right. "HS 1 and 2", heart sounds 1 and 2, "normal". "Plus 0" means normal.
BM: No resuscitation taking place whatsoever, is there?
DE: Well, she recovered.
BM: She did. So when you were suggesting there were efforts taken to bring her round from this, there are no efforts taken to bring her back that are resuscitative, are there?
DE: She recovered of her own accord.
BM: So one of the key factors that you identify for air embolus, when I asked you at the start of this, was the failure to resuscitate, resuscitation is unsuccessful.
DE: Yes, she died.
BM: At this incident, Dr Evans, she did not die, did she?
DE: She died a couple of hours later.
BM: We're looking at three events here.
DE: Yes.
BM: At this first one, 01.40, there is desaturation and she makes a full recovery. You agree?
DE: Yes.
BM: We have heard a lot of witnesses telling us about it who were there. Yes?
DE: A lot of witnesses?
BM: Telling us about it who dealt with it. And they described the recovery she made?
DE: Yes, I know.
BM: You've heard that?
DE: Yes, I know.
BM: You've also heard that there was no resuscitation required at all.
DE: No, no, she required resuscitation. She required resuscitation at her third and final and terminal collapse.
BM: Yes. We're dealing --
DE: So that is -- listen -- that is what I was talking about, okay? There were two previous very concerning deteriorations from which she recovered.
BM: Yes.
DE: And then -- and then -- well, then on the third occasion, she crashed and resuscitation was unsuccessful. And to repeat what I said earlier, this is quite remarkable in a baby given the situation she was just before that.
BM: I began this section by reminding us there were three separate incidents, I gave the times, you agreed with that.
DE: Three separate incidents.
BM: I suggested to you that the first two were followed by good recoveries. You made reference to the efforts taken to bring her back. We're dealing with that and there are no resuscitative efforts on event number 1, are there?
DE: No.
BM: And that, first of all, means that it's not right for to you suggest there were efforts to bring her back then. There weren't, were there?
DE: I didn't say that. What I said was that one of the features characteristics of air embolus is the failure of resuscitation. And you know, we've already -- so... and resuscitation failed --
BM: And there's no failure of resuscitation --
DE: -- on her third -- let's look at the whole picture --
BM: Well --
DE: -- on her third deterioration.
BM: We are looking at it, Dr Evans, and there is no failure of resuscitation on that first event, is there?
DE: I think we just said that.
BM: Right. Second event, 2 am, the one where you specifically refer to the efforts -- sorry --
DE: No, no.
BM: -- 3 am, the one where you refer to the efforts to bring her back.
DE: Let's -- no, no, let's not put words in my mouth. I'm quite capable of speaking for myself.
BM: Okay.
DE: The second effort: "Called urgently to paeds ward as [Baby D] had further episodes of being very upset and crying and desaturated to 80% in 100% oxygen."
From which she -- and then she recovered. But this was --
BM: Well --
DE: Just a minute. This is a serious event, all right? It's a serious event. Then on the third event, she died.
BM: I'm grateful for Mr Maher for assisting me with the record we have of the evidence as it unfolds. Because I would quite like to be clear about the way this questioning went, Dr Evans. People may recall it, they may not, but we have the note. I said to you: "Question: It's not uncommon to have desaturations like [Baby D] had at 1.30 and 3 in the morning, is it?"
And you said: "Answer: It's pretty uncommon for her condition to be such that it required crash calling and the efforts that were made to get her round on the first and second occasion."
That was your evidence.
DE: That was my opinion. She had two crash calls. That's serious, okay?
BM: You know and have spent time with these papers and have written four or five reports on this child, haven't you?
DE: I have.
BM: There is no evidence and she did not require efforts to bring her round on the first and second occasions, is there?
DE: She recovered of her own volition on the first and second occasions.
BM: So when you said to the jury minutes ago, in answer to my question that it wasn't uncommon to have desaturations like these two, when you said it required crash calling and the efforts that were made to get her round on the first and second occasions, there were no efforts, were there?
DE: That is incorrect. That is incorrect. You are completely confusing everybody, I think, because -- because on the second occasion, let's read it again: "Called urgently to paeds ward as [Baby D] had further episodes of being upset and crying and desaturated to % in 100% oxygen."
In other words, the nursing staff, or the medical staff, the nursing staff had put her in 100% oxygen. That is one of the stages of resuscitation, Mr Myers. You need to know this.
BM: And there is no crash call on the second occasion, is there?
DE: For goodness sake -- hang on: "Called urgently to paeds ward..."
You can interpret it any way you like: "Called urgently to paeds ward at 3 o'clock in the morning."
For goodness sake, that is -- it's good care, it's good care, but that's what happened. So again, making, you know, just playing at semantics doesn't get us anywhere, I am afraid. She was put in 100% oxygen. That is what you do to start the steps at resuscitation. If she doesn't need bagging and Neopuffs and all of that, great. She was put in 100% oxygen to get her round and they did. Great.
BM: And there is no requirement to resuscitate on the second occasion, was there?
DE: That was the second. That was the second occasion and she was put in 100% oxygen. That is one part of resuscitation, okay?
BM: And she recovered perfectly well, in fact, didn't she?
DE: Because of the resuscitation efforts that were carried out.
BM: Your evidence has been that one of the marking features of an air embolus is the failure of resuscitation.
DE: Correct.
BM: And for the second time, and the second desaturation we have, there is not a failure of whatever support was given, is there?
DE: It depends on how much air went in, first of all, and it depends on the rate at which the air went in.
BM: So you're changing --
DE: No, I'm not changing. Just listen now, just listen, okay? Therefore, the greater the volume of air that goes in, the greater the danger of death. The greater the speed at which the volume of air goes in, the greater the risk of death. And therefore -- and whilst air embolus is fatal in most cases, it's not fatal in all cases. What determines fatality probably -- probably -- because we know -- because we make so much -- we make such efforts to avoid air embolus, that it is very difficult to get -- I'm pleased to say it's very difficult to get research papers on it.
So therefore, on the second occasion, here we are, she's really unwell, you know, she's crying, desaturations to 80% in 100% oxygen, but the resuscitation was successful without bagging. In other words, if we go back to our first cases, this is what happened with [Baby B]. [Baby B] didn't die, she recovered.
[Baby D] recovered on the second occasion thanks to the % oxygen and -- and -- um... She... the volume of air was insufficient to kill her.
BM: You said --
DE: That's the gist of it on the second occasion.
BM: What you said in your report, the one which you rely upon and the prosecution took you to, at paragraph 42 was this:
"In my opinion, [Baby D]'s demise may be the result of tampering with her care during the early hours of June. I believe one needs to seriously consider that [Baby D] may have been given some intravenous air causing an air embolus. A small volume would cause a precipitous deterioration in a baby's condition and lead to efforts at resuscitation failing."
DE: That's correct.
BM: You also said it may explain the abdominal discolouration.
DE: Yes.
BM: In fact, on the two occasions that we're looking at so far, efforts at resuscitation did not fail, did they?
DE: It depends on the volume of air.
BM: You say: "A small volume would cause a precipitous deterioration."
That's what you said in your report.
DE: Yes. We can argue about how small is small because we don't know. We can't put a -- we cannot put a volume on and say any baby who receives so many millilitres per kilo will lead to death in all cases. I mean, that information is simply not available because air can only get into a circulation for two reasons. Either: some sort of horrible accident or as a result of a deliberate act.
Now, I am unaware of any -- you know, because of all the equipment and the care nurses and doctors take to avoid air getting in accidentally, people who give air intentionally are unlikely to write it up in the notes, are they? So you know...
BM: In fact both of the desaturations that we have looked at, the one at 1.30 and the one at 3 o'clock, could be regarded in fact as warning signs that [Baby D] was not well, couldn't they?
DE: No, that is clinically unacceptable. She -- I can't think of any, you know, of the conditions that make babies unwell leading to a presentation of this nature other than -- it just doesn't happen.
BM: And you vary what you say about air embolus because I would suggest to you --
DE: I do not vary what I say about air embolus. I have explained to you exactly what I've said about air embolus, recognising how limited our information is because of the care we take to avoid the condition occurring.
BM: You vary what you say, I'm suggesting, because you're influenced by the allegation rather than the actual underlying facts, Dr Evans.
DE: My information is based on evidence, the evidence that I presented in my papers and then -- and perhaps I could go back to my... I think I said to everybody at the beginning that when I did my reports, I did about reports in November 2017, you know, so they were screening reports, so sorry if I've left one or two things out.
But if I go back to my... Where are we here? If I go back to my original paper, I need to read this because I think I was -- just a minute.
(Pause)
Right. In my initial report I say, I quote: "In my opinion, [Baby D]'s demise may be the result of tampering with [Baby D]'s care during the early hours of June. I believe one needs to seriously consider that [Baby D] may have been given some intravenous air, causing an air embolus."
Right?
"A small volume would cause a precipitous deterioration in a baby's condition and lead to efforts at resuscitation failing. It may explain the abdominal discolouration."
Now, that report was dated 7 November 2017, so years to this. I was reliant at that time on the clinical notes only. I had no information regarding the pathology opinion, which we'll hear in future. I had no information regarding Owen Arthurs' opinion about aortic vein -- aortic gas. I had no information about Lucy Letby. None of this was known to me. No one had said, oi, there are babies dying of air embolus in Chester. I knew none of this.
I was investigating a baby with a blank sheet of paper, which I think is the term I used, from de novo, from the beginning.
That is the conclusion I formed 5 years ago to this week and, since then, I have heard from the local medical people, I have heard from the local nursing people, and we've heard from the other witnesses and they'll give their evidence so I'm not going to quote them.
So in this particular case I am entirely satisfied with my opinion regarding the cause of [Baby D]'s demise. Okay?
BM: And you have said at the outset of your evidence today, when I asked the features of air embolus in this case, you made reference to resuscitation being unsuccessful.
DE: I did.
BM: Yes. And when we look at what happened, to make it quite clear, there are two occasions when [Baby D] deteriorated and there was not death, there was not unsuccessful resuscitation.
DE: It depends on the volume of air given and it depends on the rate at which that volume of air is given. A baby like [Baby D] would be on various lines. If the air -- some of the air was not (inaudible) into her circulation immediately, in other words it was at the end of a line, you need to consider that she was on about 5ml -- I can't remember, but anyway, so many millilitres an hour, so a fraction of a millilitre per minute. And if that air, some of that air, was in the catheter, in the catheter, you know, injected into the catheter 10r but hadn't got into the circulation, that air would then infuse into her circulation over longer than -- would not be instant is what I mean, would not be instantaneous. Therefore that would explain the discolouration. It would explain her desaturations and it would also explain why giving 100% oxygen -- you can't give more than 100% oxygen by the way -- led to her recovery, if only for a short time.
Then next time, as I keep saying, the air that she suffered infused into her circulation was sufficient to kill her. That is it. Okay? That is my medical opinion, Mr Myers. Right?
BM: It was a very bad idea for her to be taken off CPAP, wasn't it, when she had just desaturated twice in the hours beforehand; do you agree?
DE: All right, we're back to that now, right. What time is this?
BM: I'm not meaning to delay you, Dr Evans, I'm not trying to be rude, so please be courteous to me with the questions I ask.
DE: What time was the CPAP?
BM: It was a bad idea that she was taken off it after the second desaturation, wasn't it?
MR JUSTICE GOSS: I think "a bad idea" is a bit imprecise. It was clinically inappropriate; is that what you mean?
MR MYERS: I prefer that, yes, thank you, my Lord.
It was clinically inappropriate to take her off CPAP after the second desaturation, wasn't it, Dr Evans?
DE: I don't know is the answer to that. I don't know is the answer to that because, you know, the medics thought that she was not tolerating CPAP very well and big babies quite often do not tolerate CPAP very well. So they took her off CPAP. They'd taken her off CPAP the night before, put her back on, she was fine, so therefore if her final -- so therefore CPAP had nothing to do with her final deterioration because if her breathing had become a bit irregular then resuscitation would have worked. Okay? That's what I'm trying to say. Sorry, you were confusing me with this -- you know, the final event with the getting her off CPAP the night before. Sorry about that.
BM: Before I ask you --
DE: No, no, right. Sorry. I'd just caught up with what you're trying to say. Because I thought you were back on the night before. Apologies for that. Right, let's start again.
She took her off CPAP. Was it a bad idea? I don't know. Did it make a difference? The answer is no, because if her deterioration was simply due to lack of CPAP then putting her back on CPAP or -- she'd have responded very easily to resuscitation. She didn't. She didn't, okay? She didn't. And anyway, lack of CPAP does not explain air in the aorta on post-mortem.
BM: I'll turn to the third event in a moment and deal with that. Before I do, do you agree that it is entirely possible that she could have died from infection?
DE: No.
BM: Could have done?
DE: No, no, no, no, no.
BM: That is consistent with the various adverse clinical signs we see during her life and continuing respiratory problems?
DE: Correct. She could have died from infection aged hours, but she didn't, and she responded superbly over the next 24 hours or so.
BM: You --
DE: She responded very satisfactorily over the next -- you know, during 21 June.
BM: To make it plain, on behalf of the defendant, I don't accept that, but I'm not going to go through the points that we have dealt with on that already?
DE: She responded to treatment for pneumonia. What more do you want?
BM: When the pathology was done at the post-mortem -- and you have seen the report of Dr McPartland, haven't you?
DE: I have.
BM: That examination disclosed acute pneumonia, not in just the right lung, Dr Evans, it disclosed acute pneumonia in the lungs.
DE: I am going to leave the pathology to Dr Marnerides.
BM: Yes. Well --
DE: I am deferring the interpretation of the pathology to Dr Marnerides. That is what clinicians do with regard to autopsy findings, so I am not commenting on that at all.
BM: Well, you can confirm the presence of acute pneumonia in the lungs, can't you, from the pathological findings, from the post-mortem?
DE: Well, if you -- where else do you get acute pneumonia except in the lungs?
BM: Well, you said "the lung" earlier. I'm just being quite accurate. It says "the lungs".
DE: I have explained I am deferring to Dr Marnerides' opinion on the autopsy; okay?
BM: And you have -- you were ready to point out where it was when you were asked questions a little earlier by the prosecution, weren't you?
DE: I was simply covering it. Let's leave the pathology to Dr Marnerides.
BM: I'm only doing what the prosecution did and asking you to confirm some aspects of what you were asked.
DE: There was one quote I said where I quoted the fact that there was pneumonia in the right lung. That is it. I am not commenting on the autopsy findings in the lung. That is a matter for the pathologist.
BM: Are you able to confirm there was acute pneumonia in the lungs?
DE: Leave it to the pathologists, please.
BM: And that it was indicative of acute lung injury?
DE: Can we leave the autopsy findings to the pathologists, please?
BM: So [Baby D] was born with pneumonia, wasn't she?
DE: She was.
BM: She was very ill with pneumonia, wasn't she?
DE: She was unwell with pneumonia, yes.
BM: She continued to exhibit respiratory difficulties at points throughout the remainder of her sadly short life?
DE: She did.
BM: And sadly, she died with pneumonia, didn't she?
DE: She had pneumonia when she died, yes, that's what the pathology said.
BM: And that is quite capable of being a cause of death in her case, isn't it?
DE: Not in her case, no. Not in her case, no.
BM: Now with the third --
DE: I have dealt with lots of cases of pneumonia, no.
BM: With the third event, you have emphasised, one of the first things you identified to the jury, first of all, that her collapse is unexpected. In fact, the third event followed two other collapses that had taken place, didn't it?
DE: From which she made a very quick -- astonishing recovery.
BM: You have told us about the steps that had to be taken to get her to that state of recovery, haven't you?
DE: She required 100% oxygen on the second time and then she was -- I and quote, she was then... "Clinically appears well and now in air, no increased work of breathing."
So therefore that is not what you find in a baby who's collapsed because of pneumonia. That's not what you find in babies who have collapsed because of pneumonia or sepsis where, you know, soon after the urgent call, they're in air, no increased work of breathing.
BM: Did you hear Dr Newby explain that after the second deterioration, her view was that [Baby D] was in fact on the verge of being put on to a ventilator? There was a low threshold to intervene if there were deteriorations from a respiratory point of view?
DE: Yes, I heard that.
BM: That's not an indication of a baby with whom the treating consultant regards is in some excellent condition, is it?
DE: But she wasn't put on ventilation, was she?
BM: She had been told --
DE: She wasn't put on ventilation. That's the whole point. If her condition was unstable, Dr Newby would have put her on ventilation. She was not put on ventilation, ie she'd made this astonishing recovery. Okay? That is it. Let's not try and confuse the issue.
BM: She had been there and she had found that her condition was such, didn't she, that if there was any further deterioration she would need to be put on a ventilator; do you agree?
DE: A different point altogether and I agree with that.
BM: Yes, she did.
DE: Different point altogether.
BM: Then we come to her being taken off CPAP, don't we?
DE: Yes.
BM: Which is in fact travelling in completely the opposite direction from that, isn't it?
DE: How do you mean?
BM: That withdrew support that she'd received up to that point, didn't it?
DE: The fact that she was taken off CPAP would indicate to me that the clinicians were satisfied that her condition was stable, that's the first point, because you're not going to reduce the amount of respiratory assistance if you take somebody off CPAP. So that's the first point.
The second point was that, apart from these skin discolourations which was recorded on this chart, she was in air, no increased work of breathing, let's try her off CPAP. That's okay. Gas in 1 hour, yes, okay. That is what we do, that is what happens.
BM: Do you agree that up to that point there had been nothing to indicate that she would do better off CPAP in the sense of the clinical markers and her respiratory condition?
DE: I don't know that. I don't know that. I've already explained that trying her off CPAP the previous evening was not -- you know, was a perfectly okay thing to do. It didn't work so they put her back on CPAP. So that's fine. She's now upset. I don't think she was -- I think it's due to CPAP, let's try her off CPAP. Not a problem because she, (1), is in a neonatal unit, safest place on the planet. She's on full monitoring. So if she doesn't cope without CPAP, they might find a drop in -- her breathing might increase or her heart rate might increase or her oxygen requirement might go up a bit or her oxygen saturation might drop to the low 90s. You know, I am just saying these are the sort of things that any experienced nurse would look for. So therefore let's try her.
What would not happen -- what would not happen -- let me be absolutely clear about this: what would not happen in a baby of 37 weeks, who is recovering from pneumonia, you take her off CPAP, she wouldn't suddenly crash and where resuscitation, including adrenaline, et cetera, was unsuccessful. That does not -- that is not a clinical process that anybody dealing with babies of this nature see. Whereas if she received a bolus of air intravenously, then we're back to my diagnosis of air embolus, which is what happened in this case. Okay?
BM: And your evidence on that is that if she receives a bolus of air intravenously, one of the features that gets top billing in your list, Dr Evans, is the presence of discolouration. You have been very clear about that.
DE: It's not top billing at all. I've explained to you the five steps, one of which is this discolouration.
BM: It was second, you said. First is the unexpected collapse. The second is discolouration.
DE: That's the sequence of events, not the order of priority -- of significance.
BM: As it happens there's no evidence or suggestion of any discolouration at all with the third collapse that we're looking at, is there?
DE: She collapsed, you know.
BM: And that is inconsistent with your theory of air embolus, isn't it?
DE: No, it is not. Okay? It is not. Babies collapse, they're doing their best to resuscitate her and they are sadly unsuccessful.
BM: There's no discolouration on that final occasion, was there?
DE: As far as I know nothing was recorded anyway.
BM: And that is inconsistent with the way you've described the presentation of an air embolus, isn't it?
DE: No, it is not, because what I said earlier was, I described the five criteria and I said you don't need all five to confirm a diagnosis of air embolus. So in [Baby D]'s case we had the collapse, failure of resuscitation -- sorry, and air in the aorta. That's for the radiologists to comment on. And the absence of, you know, anything else really. So yes. So yes, I'll stick with that, I'll stick with that.
BM: Your evidence on that in conclusion was: "A small volume caused a precipitous deterioration [this is in the report] in the baby's condition and lead to efforts at resuscitation failing and it may explain abdominal discolouration."
DE: Mm.
BM: Yes. On the two occasions when we have some abdominal discolouration, resuscitation doesn't fail, does it? Does it?
DE: Well, you said earlier she didn't need resuscitation, so you're now admitting that she did have resuscitation, so which one is it, please?
BM: On the two occasions when she had discolouration --
DE: Which one is it? Sorry, I am not picking on you, I just need clarification. You made an effort to tell me that she did not require resuscitation on the second event and I said to her (sic), yes, she did, she required 100% oxygen, and now you are trying to tell me she did require resuscitation, so which question are you asking me, please?
BM: Well, you understand the point, Dr Evans.
DE: No, I do not, actually.
BM: Resuscitative measures that failed do not feature in events 1 and 2, do they? They do not feature.
DE: Depends on the -- it depends on the volume of air given intravenously and the rate at which it was given.
BM: You agree --
DE: And I think we'll discuss that in a later case as well, so yes.
BM: I just want to confirm, taking that sentence to conclude this, you agree that resuscitative efforts did not fail on events 1 and 2, did they?
DE: She only required resuscitation with oxygen and it was successful.
BM: And although you talk about the embolus may explain the abdominal discolouration, there is in fact no abdominal discolouration on event number 3, is there?
DE: There is nothing recorded.
BM: You suggest they all missed it?
DE: I have no idea, I wasn't there. But if I've got a baby under my care, who's got no chest wall movement, heart rate under 60, you know, I'm not going to start looking at whether she's got a discolouration of her abdomen. I'm going to go full pelt to try and save a baby's life, for goodness sake.
BM: Have you seen any evidence of discolouration on the third event?
DE: I have just explained to you that I have not seen anything. I have no idea what the significance of that is, but -- yes, but this is not what -- yes, anyway.
MR MYERS: Thank you.
MR JOHNSON: Does your Lordship have any questions?
Questions from THE JUDGE
MR JUSTICE GOSS: Just this. We've had a lot of questioning about what actually was observed in relation to the three incidents and I just want to go back to slide , J2241, which are the notes written in retrospect by Caroline Oakley. On the right-hand side: "01.30. Called to nursery by SN Percival-Ward and SN Letby. [Baby D] had desaturated to 70s. Required oral suction as was bubbly and lost colour."
And she said in evidence about the "bubbly", she couldn't say whether that had come from the nose or the mouth, but "bubbly" and required oral suction. Can I just ask Dr Evans whether that has any significance at all in relation to that first incident?
DE: Right. I've seen this, my Lord. This is the 01.30 one, yes?
MR JUSTICE GOSS: Yes.
DE: "Discolouration to skin observed", so that was on incident 1.
MR JUSTICE GOSS: Yes.
DE: That's the first crash call, if I could call it a crash call.
MR JUSTICE GOSS: Yes, and then it goes on to say after the oral suction: "Discolouration to skin observed. Trunk/legs/arms/chin. Dr Brunton called to review. Saturations 100% and O2 [oxygen] weaned to air."
DE: Yes.
MR JUSTICE GOSS: Which indicates that she was given 100% oxygen.
DE: Well, she was given oxygen, my Lord, yes, and then once she got better, you've chopped down, you've reduced the oxygen, so she was weaned to air. In other words, she required resuscitation, she did not require --
MR JUSTICE GOSS: Well, in the form -- not physical resuscitation?
DE: No, no, no.
MR JUSTICE GOSS: But instead of just breathing -- having the assistance of CPAP in air, she was given 100% oxygen.
DE: She was given oxygen, which is step number 1 in any resuscitation process, yes.
MR JUSTICE GOSS: Can you just help on the bubbly aspect?
DE: I don't know.
MR JUSTICE GOSS: You don't know anything about that?
DE: I can't explain that. I can't explain that, sorry.
MR JUSTICE GOSS: Right. Then further down: "03.00. [Baby D] crying and desaturated again to 70s. Commenced on 100% O2 via CPAP and picked up well. Skin discoloured again but less than previously."
DE: Yes.
MR JUSTICE GOSS: So again, 100% air.
DE: 100% oxygen. Discolouration. She recovered without the need for Neopuff or...
MR JUSTICE GOSS: Right, thank you.
DE: And then she settled, handling well.
MR JUSTICE GOSS: That's it, I have nothing else I want to ask. I just wanted to be clear about exactly what was done in relation to those two incidents.
DE: So resuscitation was required on all three occasions.
MR JUSTICE GOSS: All right. Thank you. I don't have any other questions, thank you.
MR JOHNSON: Thank you, my Lord.
MR JUSTICE GOSS: Thank you, Dr Evans.
That completes your evidence at this stage. Thank you very much. That completes today's hearing. We'll break off there.
Monday, 12 December 2022
MR JOHNSON: Thank you, Dr Evans. Would you just, for the sake of the record, give us your full name, please?
DE: Dr Dewi Evans.
NJ: Thank you. Dr Evans, so far as the case of [Baby G] is concerned, the jury knows that there are actually three counts concerning [Baby G]'s case, counts 7 to 9 inclusive. All we're dealing with at the moment is count 7.
DE: Yes.
NJ: All right?
DE: Yes.
NJ: So the events of and leading up to 7 September.
DE: Yes.
NJ: Just as a reminder for the rest of us, there were events also on 21 September, about which you have written reports?
DE: Later I did, yes.
NJ: But for now if we just concern ourselves with the events of the 7th, please. If I can just summarise...
(Pause)
If I can summarise the position then, please. You have written several reports, haven't you, in [Baby G]'s case?
DE: I have, yes.
NJ: The first was dated 6 November 2017?
DE: That is correct.
NJ: Was that your original sift report?
DE: Yes, it was.
NJ: Did you then write a more detailed report on 31 May 2018?
DE: I did.
NJ: Followed by a report on 24 March 2019?
DE: I did.
NJ: And that report on 24 March 2019 concerned primarily the events of 21 September 2015?
DE: Correct.
NJ: You followed up with some additional reports of 17 October 2021?
DE: Yes.
NJ: 21 October 2021?
DE: Yes.
NJ: 22 April 2022?
DE: Correct.
NJ: And then finally, 14 September 2022?
DE: Yes.
NJ: Thank you. I'd like to start, if we may, please, with your report of 31 May 2018, which for your Lordship's note is at I2008.
It's a little time since we went through the sequence of events relating to [Baby G], so I'd just like to deal with a few dates with you first of all, please, Dr Evans. As you point out in your report, [Baby G] was born on 31 May 2015.
DE: Yes.
NJ: That was, of course, at Arrowe Park Hospital.
DE: Yes.
NJ: On 14 June 2015, so 2 weeks after she was born, she was examined via a cranial ultrasound; is that right?
DE: Correct.
NJ: Was that to identify whether or not she had any bleeding on her brain?
DE: Yes. Brain bleeds are very common in premature babies, so cranial ultrasounds are carried out routinely. The absence of bleeding is always a very encouraging sign.
NJ: Yes. Just to remind ourselves, of course, [Baby G] had been born exceptionally early, hadn't she?
DE: Yes.
NJ: 23 weeks and 6 days' gestation?
DE: Yes.
NJ: And she had weighed at birth 535 grams?
DE: Yes.
NJ: I think in one of your reports you described that as being at the edge of viability or words to that effect or the limits of viability?
DE: I did, I did.
NJ: On 29 June 2015, [Baby G] had what's called a Broviac line fitted; is that right?
DE: Yes.
NJ: And I think this sort of intravenous access is something that we'll hear about more in one of the other cases; is that right?
DE: Yes.
NJ: But in effect, is it IV access that's achieved by the surgeons?
DE: Yes. A Broviac line is inserted into a large blood vessel and it requires a surgical procedure and it's used in premature babies because getting IV lines is difficult and is painful, therefore you get a Broviac line in, into a main blood vessel, it can stay there for quite some time. It's how you would give intravenous nutrition -- we've heard about TPN -- and also intravenous antibiotics, if required, or any other requirement that needs intravenous access.
NJ: Was there a further ultrasound examination -- I'm looking at paragraph 8 at your report now -- a cranial ultrasound examination of [Baby G]'s brain on 30 June?
DE: Correct. That showed -- that was essentially normal. The important thing was no IVH. IVH is intraventricular haemorrhage. Therefore there was no evidence of bleeding into the brain. So a very satisfactory finding.
NJ: Did [Baby G] then remain at Arrowe Park, the tertiary hospital, until she was discharged on or about 13 August 2015?
DE: Yes, that's correct.
NJ: On your examination of the medical notes, did you find notes running up to and including 13.00 hours on 13 August?
DE: I did. I didn't summarise them all in detail, but yes, I saw that, and it covered her progress there, yes. And she was stable.
NJ: Yes. At discharge from Arrowe Park, was [Baby G] receiving ventilatory support via CPAP?
DE: Yes. She was requiring 30% oxygen. She was known to have what we call chronic lung disease.
NJ: Yes.
DE: Therefore she was still needing oxygen -- not a great volume, 30%, not a great concentration -- and she also required CPAP, which is this mechanism whereby babies receive their oxygen via slightly raised pressure. So it's a standard management of babies, premature babies, when they require -- when they have chronic lung disease. So having said all of that, she was stable.
NJ: So looking at your paragraph 13 of the statement of 31 May, Dr Evans, do we see there in effect you setting out in writing what you've just told us?
DE: Yes. I mean, her first couple of weeks at Chester, she was requiring 28% to 31% oxygen, therefore the same as she was when she arrived from Arrowe Park. Another brain ultrasound had shown -- reported what was described as mild bilateral ventriculomegaly, which is not uncommon and not generally deemed a concerning finding, more on the left than the right. Otherwise she had a normal heart rate, she had a normal breathing rate, she had a normal temperature. Her tone was described as being normal. She required support, medication-wise, so she was given Gaviscon, which is very, very commonly used in small babies, and she was also given a combination of diuretics, which again -- furosemide and spironolactone, and these are again drugs that are given in little babies. She had supplemental sodium. We heard earlier today that her sodium was a little on the low side, so she was having sodium chloride and Sytron, which is an iron supplement. So she was receiving iron.
So all was well and her oxygen saturation was 95%, which is very satisfactory.
NJ: Yes. You have just repeated a term that we heard for the first time this morning from Dr Harkness, which is mild bilateral ventriculomegaly, but you didn't give us any further explanation as to what that meant. Could you just remind us what it means, please?
DE: Yes. The brain has two hemispheres, left and right. And in the middle there are two potential -- well, holes, really, ventricles. Premature babies, if you get a -- are at risk of getting a haemorrhage, a bleed, into these ventricles which are set in the middle of the brain. The ventricles have a normal range which you can measure on ultrasound. [Baby G]'s ventricles were slightly larger than average. But as an isolated finding, this is not uncommon and it's something that you simply record.
NJ: Thank you. It may help us, Dr Evans, to go to the more recent jury bundle, which is this jury bundle number 2.
MR JUSTICE GOSS: Yes. You put it on the floor, I think.
MR JOHNSON: I think it's at the bottom, as always. It's the one with 24 dividers in or thereabouts.
DE: Yes.
NJ: This will help us to navigate your evidence as to [Baby G]'s condition, hopefully. Just to remind us, because it's been a while since we looked at this material, the first page, it's divider 7 of course because we're dealing with count 7.
The first page has the page number in the bottom right-hand corner in red, J6959.
DE: Yes.
NJ: Is this the observation chart running from 23.00 hours on 23 September (sic) through to 17.00 hours on 5 September?
DE: On 2 September.
MR JUSTICE GOSS: The 2nd.
MR JOHNSON: What did you say?
MR JUSTICE GOSS: The 23rd. You were eliding, I think, the 2nd and the 3rd, creating the 23rd. We knew what you meant because we are all looking at it in the top left-hand corner. We could see it starts at 23.00 on the 2nd.
MR JOHNSON: Sorry. It's having a day off. It's thrown me out. Right.
Dr Evans, do we see there that [Baby G] was being -- it's not always the case, but generally speaking, having her observations taken about every 3 hours?
DE: Something like that, yes.
NJ: Yes, there are exceptions to that, but generally speaking over that period of time, observations every 3 hours. So over that period of time, what would you observe as being her general state from the observations at least?
DE: Right. Very satisfactory. If we look at the first page, which goes from the 2nd to the 5th, you have a normal pattern of heart rate. You have a normal pattern for respiratory rate, 50 to 60. Her temperature's normal. Then towards the bottom on the extreme left hand, you've got SaO2, that's oxygen saturation, which we've mentioned, and her oxygen saturations measured -- there's 99, 98, 97, 100, et cetera. So all very satisfactory. And she's in oxygen, 30%, and then I think we heard earlier today that she was put on low-flow oxygen because her condition was getting even better.
NJ: Yes.
DE: So 0.06 and 0.07, that relates to the amount of oxygen she was getting. So that page, very satisfactory.
NJ: Okay. Could you just stop you there so we all follow what you're saying? So we have the SaO2, which is saturations inn oxygen; is that right?
DE: Yes.
NJ: Below that, O2, which is the chemical symbol for oxygen?
DE: Yes.
NJ: We see 30% reproduced on -- ignoring the one that's crossed out, there are four of those; is that right?
DE: Correct, yes.
NJ: And we then go to the entry at 11 am, 11.00 hours, on 3 September, and that goes to 0.08. Is that a reflection of the moment at which -- the means by which [Baby G] was being given oxygen changed?
DE: Correct.
NJ: So an improvement at that point in the sense of the intrusiveness of the system by which oxygen was being administered to [Baby G] was less?
DE: Correct.
NJ: All right. So a reflection of the fact she was doing better. We then have, what, cares; is that right?
DE: Yes.
NJ: Do you know what the next word is? Is it "position"?
DE: "Position" and "probe". I'm not sure what probe applies to.
NJ: All right. Moving on then, on the 6th into the 7th, and indeed -- well, we start on the 6th at 20.00 hours with a continuation of observations every 3 hours.
DE: Yes.
NJ: Is that right?
DE: Yes.
NJ: And that changes between 2 and 4 o'clock in the morning when it goes down to 2 hours and then from 4 to 5, it goes down to hourly observations?
DE: Yes.
NJ: Just to remind us, in the respirations line or section/block, we see that the rate of respirations is recorded in two different ways. One is with dots that look a bit like tadpoles --
DE: Yes.
NJ: -- which moves at 4 am to crosses in circles.
DE: Yes.
NJ: What do those two alternative ways of recording respirations denote?
DE: Right. Well, the first half, the bit on the left, is a continuation of the respirations from the previous few days. So her resps vary between 40 and 50/55. The crosses simply is -- I'm not quite sure what the crosses relate to. In the context of the fact we know she'd collapsed, so presumably these crosses indicate that she was receiving ventilatory support.
NJ: Yes.
DE: That is what I would assume is the difference in the way that her respiration has been recorded.
NJ: Yes. Well, I think you're right. I think those records of the cross in the circles coincide with the time at which she was put on to a ventilator.
DE: Yes.
NJ: Up to 2 in the morning -- we'll come to the rest of it in due course -- how would you describe -- I should say on the morning of 7 September, how would you describe [Baby G]'s observations?
DE: Again, very much the same as the day before. If we look to SaO2 again, we've got a number of recordings of oxygen concentration -- sorry, oxygen saturation, I mean.
NJ: Yes.
DE: The first one is 96 and then there's a 98, 98, 97, et cetera, 93, 92, 97. So again, very stable. Very, very slight variations, absolutely fine. Her oxygen requirement -- she is still on this low-flow measurement, which is why you've got 0.06 or 0.07 rather than an oxygen concentration itself. So therefore up until around 2 in the morning, her condition remains as satisfactory as it was for the previous few days.
NJ: Thank you. Before we have our midday break, if I just deal with the other documents here just to remind us where things are if people want to search them out as you continue with your evidence.
Turning beyond the observation charts, please, to the intensive care chart, which has the number 6962 in the bottom right-hand corner, does that record various substances being given to [Baby G] on 7 September --
DE: Yes, it does.
NJ: -- starting at 4 o'clock in the morning?
DE: Yes, it does.
NJ: We see 10% glucose, morphine, midaz -- is that short for midazolam?
DE: Midazolam. Yes, that's right.
NJ: Dopamine and then bolus and then what the bolus is is recorded, or sometimes recorded, alongside those figures, together with output of various things.
DE: Yes.
NJ: Then a page further on, 6971. Is this the blood gas chart?
DE: It is.
NJ: Which continues over to 6972?
DE: It does.
NJ: And then the final two pages in this section, are they the feeding chart?
DE: They are.
NJ: Being 5 September at 7012?
DE: Yes.
NJ: And the bottom half of that page, 6 September?
DE: Correct.
NJ: And finally at 7013, 7 September and the feed at 2 o'clock in the morning --
DE: Yes.
NJ: -- administered by [Nurse E]?
DE: Yes.
MR JOHNSON: My Lord, that may be a good moment.
MR JUSTICE GOSS: It is, certainly. Thank you very much.
We'll break off there and resume at 2.05, please, members of the jury.
(1.04 pm)
(The short adjournment)
(2.05 pm)
MR JUSTICE GOSS: Mr Johnson.
MR JOHNSON: Dr Evans, we had just reminded ourselves of the contents of the jury bundle in terms of the documents. We heard this morning from some of the treating medics that, in their view, [Baby G] was in an entirely satisfactory condition as at the beginning of the night shift of the 6th into 7 September. Would you agree with that assessment, first of all?
DE: I would, yes.
NJ: Thank you. If we could go to tile 80, please. If we scroll down, please.
This is Dr Ventress' note, if you recall --
DE: Yes.
NJ: -- concerning her being called to review [Baby G] at 02.35 and saying that she'd had:
"... a very large projectile vomit, reaching the chair next to the cot and the canopy. Abdomen appeared discoloured, purple and distended. She was distressed and uncomfortable, red in the face and purple all over, and then an increased oxygen requirement followed by full feed, 45ml aspirated, large watery stool passed, after which abdomen slightly better. [Baby G] relaxed and [something]..."
DE: "Appeared."
NJ: "... back to usual self."
Could we look at J26510, Mr Murphy, which was Ailsa Simpson's exhibit.
(Pause)
It was put on the screen during Ailsa Simpson's evidence.
(Pause)
MR JUSTICE GOSS: It's a photograph, isn't it?
MR JOHNSON: It is, my Lord, yes.
MR JUSTICE GOSS: I've found it in my note.
MR JOHNSON: Sometimes the old ways are the best.
MR JUSTICE GOSS: A handwritten note.
MR JOHNSON: If it's going to be a problem we'll come back to that, Dr Evans.
So going back to your report then, I'm looking at paragraph 15 in which -- so we're still in the report of 31 May 2018.
DE: Yes.
NJ: You identified those notes of Dr Ventress. You moved on to deal with the second page of what we can see on the screen in front of us now, which is, if Mr Murphy could scroll down, please, to note the fact that Dr Ventress had been called out of theatre because [Baby G] had gone apnoeic and dusky, that Dr Brearey was called in --
DE: Yes.
NJ: -- as he reminded us this morning. That, on arrival, Dr Ventress had noted the fact that [Baby G]'s saturation was 50% in 100% oxygen. That she became pink and well perfused with the mask on and CPAP. That Dr Ventress had tried to obtain intravenous access.
Right, thank you. We've now found AS4. So if we could just go back to that, please.
(Pause)
Just to remind ourselves of the evidence of Nurse Simpson, who marked with those black circles the locations of the vomit. And you indeed were shown these a few months ago, weren't you, or shown this a few months ago?
DE: Yes. Recently, anyway.
NJ: Relatively recently. Thank you. So if we could go back to the sequence, please, Mr Murphy. We may return to that photograph in due course.
Your paragraph 17 now, please, Dr Evans. You noted the fact, just at the bottom of the previous page, that [Baby G] was intubated at some stage between 2.35 and 4.40 in the morning. And you have reminded us, when we looked at the second page behind divider 8, page 6960, that the cross in the circle in the respirations column or part of the form indicates the fact that [Baby G] had been intubated. We can see that the first one of those is at 4 o'clock in the morning.
DE: Yes.
NJ: You also noted, and I think it's just at the bottom of what we're looking at on the screen at the moment, if we can scroll down, please, keep going down -- it may be on the next page -- the fact that some bloodstained fluid came up the trachea --
DE: Yes.
NJ: -- which we will return to in due course.
MR JUSTICE GOSS: That's on our screen now.
MR JOHNSON: Yes, thank you.
MR JUSTICE GOSS: Second line down.
MR JOHNSON: Thank you.
So: "Intubated, size 3 ETT, 8 centimetres at lips, bloodstained fluid noted coming up from trachea/between cords."
If we can go to tile 107, please, Mr Murphy.
Did you note next in your report what you describe as the note of the profound desaturation of [Baby G] at 05.30?
DE: Yes.
NJ: The fact that [Baby G]'s heart rate reduced to 60 and her saturations to 40%. That's about a third of the way up the page as we're looking up the page there, about half a dozen lines up.
DE: Yes.
NJ: There's an inverted arrow. Heart rate down to 70, sats 40%, perfusion reduced, refill time 3 seconds.
That [Baby G] had desaturated when put back on the ventilator, which Dr Brearey told us about this morning; is that right?
DE: Yes.
NJ: Then tile 117, please. Do you refer next to a further profound desaturation at 06.05 in the morning? It's further down. Do you see it there?
DE: Yes.
NJ: [Baby G]'s heart rate dropped to 80%, was re-intubated, whereupon her heart rate increased to 120, her oxygen saturations remained at 50, despite increasing pressure from the ventilator.
DE: Yes.
NJ: And this is where "thick secretions ++ in mouth" plus "blood clot at end of ETT" were noted by the treating physicians?
DE: Yes.
NJ: Thank you. Further down the page, do we see the re-intubation at 06.15 hours?
DE: Yes.
NJ: That the nasogastric tube was aspirated at that stage and 100ml of either fluid or air, or a mixture of both, depending on the evidence, was aspirated from the nasogastric tube?
DE: Yes.
NJ: I think in your report you made the following note: "It's not clear how much of the 100ml was milk, how much was air."
DE: Correct.
NJ: That was your note on reviewing the medical records?
DE: Yes.
NJ: Thank you. Did you then recount the fact that [Baby G] was given a paralysing agent, pancuronium?
DE: Yes.
NJ: Her blood gases, which we know are recorded on the paper documents that we have behind divider 7?
DE: Yes, got that here.
NJ: Thank you. And the fact that [Baby G] was transferred to Arrowe Park Hospital at about 3 am on 8 September?
DE: Yes.
NJ: Next in your report did you review the observation charts which we've looked at up to and including the time of [Baby G]'s collapse?
DE: I have.
NJ: So these are documents that we have referred to behind divider 7 at page 6960.
Did you also refer to the neonatal feeding charts --
DE: I did.
NJ: -- from the early hours of 3 September up to the time of [Baby G]'s first collapse --
DE: Yes.
NJ: -- at about 2 am?
DE: Yes.
NJ: Sorry, some time after 2 am I should say, on 7 September.
DE: Yes.
NJ: Those are or at least some of those documents are the last two documents behind divider 7 in the jury bundle.
DE: Yes.
NJ: Did you record the fact that [Baby G] was being alternately fed, by and large, with the nasogastric tube and a bottle?
DE: Correct.
NJ: So for examples of that, starting at page 7012, which is behind divider 8, which is the 5th and 6 September, do we see those facts recorded under the "route" column?
DE: Yes, we do. It's alternate nasogastric feeds alternating with bottle feeds, yes.
NJ: And from time to time do we see that [Baby G] was fed via both routes at about the same time? So as an example on 5 September at 11 am and at 18.00 hours and indeed at 23.00 hours do we see partially fed by bottle --
DE: Yes.
NJ: -- and partially fed by nasogastric tube during the same feed?
DE: Yes.
NJ: Just so that we understand, and lest we've forgotten some of the evidence we received several working days ago now, how quickly does it take for expressed breast milk to get from the tube where it's poured by the nurse into the stomach of the child under the force of gravity?
DE: Well, it's a gravitational feed and this is a question better answered by a nurse --
NJ: Right.
DE: -- because nurses are the ones who feed babies and I think we heard one of the nursing staff saying it could take anything from 5 to 20 minutes and that's fine, I would go along with that. It doesn't take a few seconds, it takes several minutes and it might take longer than -- some feeds than others.
NJ: Yes. But using your long experience of such things, does a baby -- what happens if a baby's stomach is full?
DE: Once the stomach is full, it's full. Therefore if you give milk gravitationally, that's the end of it, you won't get any more milk trickling down from the syringe into the stomach because the stomach is full. Therefore, if the stomach can only accommodate 45ml and you give, say, 55ml, then you're unlikely that the -- the baby is unlikely to absorb the final few millilitres of feed.
Clearly, stomachs are distensible, in other words they do expand to accommodate the volume of fluid they're receiving, but as a general principle if the stomach is full, then it's full and no more milk will run down the tube into the stomach.
NJ: Under the force of gravity?
DE: Under the force of gravity, correct.
NJ: As a matter of -- would there be a way of getting additional milk into the stomach if you couldn't get it in under the force of gravity?
DE: Well, the milk is given via syringe, where the plunger of the syringe is withdrawn, so it's the open end of the syringe that is connected to the nasogastric tube, which gets into the baby's stomach. But if you put the top end, in other words the plunger end, of the syringe into the syringe and press it down then you will force more milk or fluid through into the stomach.
NJ: All right.
DE: You never do that because obviously you would overdistend the stomach. So therefore this is why it is so important that babies who are on nasogastric feeds are only fed by gravitational means. In other words, letting the milk drip through slowly.
NJ: Yes. Thank you.
Did you refer next in your report to what we see on the final page behind our divider 7, namely [Nurse E]'s note at 02.00 hours on the morning of 7 September? I'm looking at your paragraph 21 now, Dr Evans.
DE: Yes, thank you. Yes.
NJ: Did you refer to the fact that, in the nursing record, there was a note of the fact that there had been a large -- what was recorded as a "large projectile milky vomit" at 02.15?
DE: Yes.
NJ: Followed by the words "continued to vomit ++"?
DE: Yes.
NJ: Followed by: "45ml milk obtained from NG tube with air ++"?
DE: Yes.
NJ: And that: "Abdomen was noted to be discoloured and distended. Colour improved few minutes after aspirating tube. Remained distended but soft"?
DE: Yes. There's a misprint there. It's got "discoloured and discoloured".
NJ: Yes.
DE: It should be "discoloured and distended".
NJ: Yes. Did you refer at your paragraph 23 to the blood gas results?
DE: I did.
NJ: And for the jury's information, they are at pages 6971 to 6972.
So far as those results were concerned, if we can start with the results at 03.59 on the morning of the 7th. I'm not sure they actually appear in the table that we have, do they? I think you have made a note of them. But if anybody wants to write them on to the blood gas results, I think -- were you looking for signs of an infection?
DE: Yes, yes, I was, because as we have heard infection is probably the commonest risk factor for any baby on a neonatal unit. So therefore one is always on the alert for evidence of infection.
NJ: Yes.
DE: So I can go through those three...
NJ: Yes, well, I think we heard from Dr Brearey this morning something of at least some of these readings, didn't we --
DE: Yes.
NJ: -- in his evidence? At 3.59 in the morning the CRP reading was less than 1?
DE: Correct.
NJ: The WBC, what's that?
DE: That's the whole blood count-- sorry, that's the white blood count, but it's the total white blood count. There are different types of white cells, so the main two are neutrophils and lymphocytes, so therefore the total white count is 10.1, which is fine. The neutrophil count -- the neutrophils are the white cells that increase first during or as a result of infection. So the neutrophil count of 1.4 is perfectly normal and tends to rule out infection.
NJ: Right. So just taking a step back and summarising the position from the blood test at 03.59, so in other words a couple of hours or two and a half hours, even -- sorry, no, an hour and a half after the vomit, the projectile vomit, did those blood test results show any evidence of infection?
DE: No.
NJ: By 14.18, later that day, so about 10 hours later or so, was there any change to those results?
DE: Yes, there was. The CRP is now 28, so that is an increase and that could be interpreted as a marker of infection. It's not particularly high, but the important thing is it's gone up and it's 28. The total white cells, 11.2, so no difference between 11.2 and 10.1. But you also have an increase in the neutrophil count to 6.5.
NJ: Yes.
DE: And again, the key thing there is that the neutrophil count has increased. A value of 6.5 is not particularly concerning, but in conjunction with a CRP of 28 it would suggest that the neutrophil count has increased and therefore it's an indicator of infection. So this is -- yes, so this is 10/12 hours later.
NJ: Yes. By 22.53, had the CRP count or value risen to 106?
DE: That is correct. So therefore this is a very significant increase, consistent with infection.
NJ: Yes. Now I want to move on, if we can, please, to the observations section of your report, please, Dr Evans. That's paragraph 30.
DE: Yes.
NJ: You refer there to [Baby G]'s remarkably small size.
DE: Yes.
NJ: You describe her as -- we discussed before the adjournment that she was "at the margins of survival" --
DE: Correct.
NJ: -- when she was born.
DE: Yes.
NJ: And you thought it was a reflection of the skill of the staff at Arrowe Park Hospital that she survived.
DE: Yes.
NJ: Did you look at the care that [Baby G] received at the Countess of Chester between being admitted there in August, 14 August, and collapsing some time after 2 am on 7 September?
DE: I did.
NJ: Could you find any evidence in the medical notes that during her time at Chester, [Baby G] had been unwell up to the point of her collapse?
DE: No. Her condition was stable. She was requiring oxygen because she had chronic lung disease and, if we recall the discharge summary from Arrowe Park, there were only two issues there. One that she has chronic lung disease and the second active issue was establishing feeds.
NJ: Yes.
DE: So those were the only -- so therefore given her start in life, this was an extremely satisfactory state.
NJ: So given her breathing issues, just going back to our paper documents behind divider 7, what do those documents at -- the first two documents at 6959 and 6960 tell us so far as those breathing issues were concerned prior to her collapse?
DE: They are all extremely -- they're indicative of a baby who's got chronic lung disease, who is stable and would be expected to continue to remain stable until she would be well enough to go home, probably after she would have been fully established on bottle feeding.
NJ: Yes. And so far as establishing her on bottle feeding is concerned, we have a snapshot of that in the final two documents behind divider 7 in the sense of we have the full day on the 5th, we have the full day on the 6th, and we have the single feed prior to collapse. But what do those documents tell us so far as the establishment of that regime was concerned?
DE: Again, all of these are very satisfactory findings. She's 2 kilos by now, so that's a fair weight, slightly less than you'd expect for her gestational age, but satisfactory, and she is coping with bottle feeds every other feed.
NJ: Yes.
DE: So you know, that is satisfactory. And what you would normally find is that over the -- you know, over the next week or two, she would be given more feeds by bottle and fewer feeds by nasogastric tube until she was well enough to go home, and she would probably have gone home still requiring oxygen supplements.
NJ: If the jury wouldn't mind keeping open page 7013, and if Mr Murphy would put back up on the screen exhibit AS4, please, which is a photograph.
At paragraph 32 of your report of 31 May, Dr Evans, you refer specifically to the entry made in the -- by Dr Ventress.
DE: Yes.
NJ: And you drew certain -- so you quoted it and we've just looked at it. But you expressed a concern in your paragraph 33. Could you tell the jury what your concern is and, in particular, by reference to what [Nurse E] has written there on page 7013?
DE: Well -- 7013, right. We'll start with what [Nurse E] said because she says at 02.00 hours [Baby G] had EBM, expressed breast milk, with fortifier, which is extra calories, less Gaviscon, which is given commonly to little babies, and was given 45ml of feed via nasogastric tube.
The column re-vomit aspirate says pH 4. PH 4 means acidic, therefore there's acid in the stomach, that's what she says.
Then I think I'll read my paragraph 33.
NJ: Please.
DE: Paragraph 33 relates to the fact that she'd had this projectile vomit and I quote --
NJ: And we can see in pictorial form on the screen where the vomit landed, can't we?
DE: Yes. Let's mention that.
NJ: And how would a baby be lying in that contraption?
DE: Presumably, the baby would be lying with its feet towards this end of the photograph and its head at the top end.
NJ: That was the evidence, certainly.
DE: Okay. There are three black circles. The one in the cot obviously indicates that the baby was sick and had vomited in the cot. Babies do vomit and therefore the fact that the baby vomited in a cot would be worthy of note but not unusual.
The second circle is the one between the chair and the cot on the floor. For a baby of 2 kilos to vomit that far is quite remarkable because on the whole, when babies vomit, they tend to vomit over their babygros, you know, and over whoever's holding them if they are held by someone. But that is as far as it goes unless they have a condition called pyloric stenosis, that Dr Brearey mentioned this morning.
NJ: Yes.
DE: And he said projectile vomiting is something he's only seen with pyloric stenosis and the same applies to me as well. Pyloric stenosis is a condition that turns up and a baby will vomit quite far away.
But even more astonishing is the vomit that ended up on the chair. Now, that is several feet away. I can't recall a baby vomiting as far as the floor, but certainly I can't recall a baby vomiting that distance and it was described correctly as projectile vomiting and that is quite extraordinary.
So therefore there is something very, very unusual going on here for [Baby G] to show up in this way with this vomiting and, on top of that, of course, they have noticed that her abdomen was distended. Well, you know, small babies don't have muscles in the abdomen, therefore if you put a lot of fluid or a lot of air into the stomach, the abdomen will swell.
NJ: Yes.
DE: And as well as vomiting -- and you can't measure accurately the volume of vomit because it'll be all over the floor and all over the chair -- on top of that the nurse staff aspirated -- in other words they got the syringe and extracted 45ml of feed from the nasogastric tube. This was in addition to the milk she had vomited.
NJ: Right. Let's just -- sorry to stop you, but if Mr Murphy could help us by reminding us of what Lucy Letby wrote down at tile 79, please. If we can go to the original note behind the tile, please.
So: "[Baby G] had large projectile milky vomit at 2.15, continued to vomit ++. 45ml milk obtained from NG tube with air ++. Abdomen noted to be distended and discoloured. Colour improved few minutes after aspirating tube, remained distended but soft. Reg Ventress asked to review. To go nil by mouth with IV fluids."
So just going back to your report then, please, Dr Evans, with my apologies for stopping you and referring the jury back to Lucy Letby's note, could you continue your explanation?
DE: Well, if I continue on my paragraph 33, really.
NJ: Yes.
DE: So the entry from (inaudible) makes it clear the member of staff aspirated 45ml of feed from the NG tube in addition to the milk she had vomited. There can be only one explanation: [Baby G] had received more, far more, than 45ml of feed down the NG tube before she vomited at 02.15 hours. She may also have received a bolus of air from the feeding syringe used for feeding. This caused the abdominal distension, the distress, the change of abdomen colour and the vomiting.
So therefore, just to add to that, just one thing, really. So [Baby G] must have received far, far more milk down the tube. She probably had more air as well. And given that it had caused the abdominal distension, et cetera, I don't think this got down by gravity, so the mechanical explanation is that the plunger end of the syringe must have been put over the syringe and the milk forced down, squirted down the tube, if you like, using a syringe, and this caused the baby -- would have caused the abdominal distension to start off with, then it would have caused the baby distress and, of course, she would have vomited because of the gross overdistension of her stomach.
NJ: So given that you've told us that in the absence of pyloric stenosis -- well, let's deal with pyloric stenosis first before I ask you this question. Why do you exclude that as a possibility for what happened?
DE: Well, pyloric stenosis is something that occurs with babies 6 to 8 weeks of age or thereabouts and it doesn't occur and disappear, it requires a surgical procedure to treat the overgrown muscle at the bottom of the stomach.
NJ: Okay.
DE: Therefore if she had pyloric stenosis the vomiting would have continued until somebody took her to theatre and operated on her.
NJ: Can we exclude that as a possibility?
DE: We can exclude pyloric stenosis completely.
NJ: You have told us that baby of this size and age would be incapable of producing the amount of force required to vomit out of the cot on to the floor and beyond on to a chair.
DE: Mm.
NJ: So what's the physical explanation for how this baby undoubtedly did manage to do that?
DE: Well, she -- well, right. The whole of the gastrointestinal system has a series of muscles, from the mouth all the way through. A particular kind of muscle is called smooth muscle. Muscles only go one way, therefore milk will go from the mouth down through the oesophagus, through the stomach, through the intestine and then out the other end. So it's one-way traffic.
The only time this does not work is if the baby's compromised by something. Okay? So in this situation the baby was compromised by receiving a large volume of fluid into the stomach, and in that situation, the stomach muscles would contract and the contraction of the stomach muscles would lead to the baby vomiting. This is not unique to babies. If anybody drank too much fluid too quickly, you'd end up with a similar pattern of vomiting.
So therefore the mechanism of it is straightforward.
NJ: Is it like putting a large amount of air or fluid, or a combination, into a balloon to stretch the balloon and then letting your fingers off the end in effect? Is that the sort of idea?
DE: No, I'd make it simpler than that.
NJ: Go on.
DE: I'd make it simpler than that. You can't be flippant in this. But if an adult drank a large volume of liquid too quickly they would probably vomit --
NJ: Right.
DE: -- because there is a rate at which liquid can go from stomach to intestines through to the intestine, therefore any indulgence of drink leads to vomiting.
NJ: Okay.
DE: The stomach muscles contract and it all comes out.
NJ: All right.
DE: So this is what happened to this little baby.
NJ: Thank you. Moving on to your paragraph 35, Dr Evans. Did you look at the X-rays of [Baby G] and, in particular, one that was timed just before 5 am at --
DE: I did. Now, I emphasise I'm not a radiologist, so we do have a radiology opinion, but obviously I'm familiar with looking at X-rays of the abdomens and chests of little babies, so this is about the limit of my radiology competence as it were. And the X-rays shows chronic lung disease and a great deal of air in the abdomen, yes.
NJ: We'll leave that for the radiologists in due course.
Thereafter, so far as this report was concerned, were there -- did you come to any conclusions about what happened to [Baby G] following this unusual vomit at anything between 2.15 and 2.30?
DE: Yes, I did. Her condition over the next few hours was incredibly unstable. I'll explain it in more detail, but this is a time when she's experienced a significant amount of oxygen deprivation. There are recorded values of oxygen saturations 40% and 50% and also bradycardia, heart rate down, and also lowish blood pressure.
So therefore, getting [Baby G] back to where she was before 2 am turned out to be extremely challenging and extremely difficult. They did get her round because obviously she survived, but she suffered sufficient oxygen deprivation to cause significant irreversible brain damage.
NJ: Yes.
DE: And her resuscitation was quite difficult. I've heard Dr Ventress' testimony and Dr Brearey. So it was quite difficult for all, and I just mention one or two things.
The first thing that Dr Ventress mentioned was when she tried to intubate the baby, in other words you put a laryngoscope into the back of the throat to get a tube in, an endotracheal tube, she noticed blood. She noticed blood not just at the back of the throat but the other side, in other words on the lung side of the vocal cords.
NJ: Yes.
DE: So in other words, there was bleeding. Now, this doesn't mean -- this doesn't... The fact there was blood beyond the vocal cords, in other words towards the lungs, doesn't mean that the bleeding came from beyond the cords, it could be that the bleeding came from the upper -- from the back of the throat and, you know, and then trickled down through the cords. You can't say one way or the other.
But certainly there was bleeding there and the important thing about the bleeding is that this was found at the initial resuscitation. So in other words although they had tremendous difficulties with ventilation, the bleeding was not noted an hour later or with a second intubation or with a third intubation. And the significance of that is this: that the bleeding was there from the first time that the baby was -- from the first occasion that resuscitation with intubation was attempted.
And we know that [Baby G] did not have a bleeding disorder, in other words she was not at increased risk of haemorrhage or bleeding. So therefore, the bleeding was present from the beginning. And I think Dr Harkness said the same thing: there was blood at the back of the throat, so there was bleeding at the back of the throat from more or less the time that [Baby G] crashed/collapsed.
NJ: Is this the same sort of bleeding we've seen so far in any other case so far as you can tell or is it different?
DE: Right. Well, we've seen this before, but much worse in little [Baby E]. That's case number 5, the first of the twins. But the bleeding that we found there was much worse, he lost a third of his blood. So the bleeding here was not major. But the fact that it was present is not something that one would normally expect and it cannot be explained on the basis of vomiting only.
NJ: No. The possibility of pulmonary haemorrhage, so bleeding from the lungs, do you regard that as being a realistic source of the blood in this particular case?
DE: No, I do not. Pulmonary haemorrhage is a killer and if the haemorrhage was in the lungs itself, she's unlikely to have survived, quite frankly. But she certainly wouldn't have picked up -- although she took several hours to pick up, I don't think she'd have picked up in such a short period of time. So I don't think pulmonary haemorrhage was a factor in this collapse at all.
NJ: So far as the issue of infection is concerned, from your interpretation of what happened did you regard infection as being a credible explanation for [Baby G]'s vomiting and collapse some time after 2 am?
DE: No, not at all. [Baby G]'s infection, in my opinion, occurred after the collapse. I think it is worth explaining this in some detail because it applies -- it's applied to previous babies and it will apply to babies we're going to be discussing later.
The key thing is that when babies start to sicken for an infection, nursing and medical staff in baby units are alert to subtle changes. So the oxygen requirement may go up, the oxygen saturation may go down. The breathing may become a little bit irregular. They generally don't -- they're not quite as well as they should be. There's none of that. There's none of that. There is this complete stability.
You might get pooling of blood -- sorry, pooling of milk in the stomach. That did not occur. We know that she was on 45ml every 3 hours and all of it was going through either by bottle or by NG tube.
Therefore there were no markers of infection clinically at all. And then 2 hours, nearly 2 hours after her collapse, the blood tests we've discussed showed a CRP of less than 1 and a neutrophil count of 1.4. Normal.
Now, we know that CRP is not always increased at the presentation of infection, but it is in -- it is more likely than not to be increased. But the other thing that's important in [Baby G]'s case is that her infection, if I could put it that way, was very CRP relevant. In other words, her CRPs really shot up. So 12 hours later, it was 28, which is not particularly high. 20 hours or so later, it was 106, and I think there was a value of over 200 later on after she'd been transferred.
So therefore, none of her clinical features indicate infection. None of the blood tests indicate infection. So in my opinion, the infection occurred after the resuscitation, most likely, and this is not a criticism by the way, most likely in association with all the efforts they made to get her going, you know, to save her life, really. So there we are.
NJ: Thank you. Moving on, if we may, and I'm moving on, Dr Evans, to a later report of yours, please, of 17 October 2021 and I'm looking specifically at your paragraph 7, which is, I think, your page 5, if your print is as mine appears on the screen.
DE: My response to the 10 questions?
NJ: Correct, yes. I think you were asked to consider Dr Ventress' suggestion that [Baby G]'s initial collapse, when she projectile vomited and 45ml of milk was aspirated from her stomach, you were asked to consider whether that was consistent with being the product of an infection.
DE: With respect to Dr Ventress, no, I don't agree with that. I think the infection occurred afterwards.
NJ: Yes. Is that for the reasons that you have already explained?
DE: Yes, yes, yes. And of course, infection would not cause a baby to vomit halfway across the nursery. And where would the extra fluid come from? Because even after vomiting, they aspirated 45ml of milk from the stomach, so therefore she had only been fed 45ml. So if you are fed 45ml, some of the milk will have already gone through the stomach into the duodenum, you're not going to aspirate every millilitre anyway because, you know, you can't aspirate 100%, but they still aspirated 45ml. They also aspirated air.
Where on earth did the air come from? Plus all the vomit on the chair and on the floor and everywhere else. So therefore, she must have had far, far more volume of milk than 45ml.
NJ: All right. Now, one of the things you were asked to deal with on the issue of air was something that Lucy Letby told the police when she was interviewed.
DE: Ah, right.
NJ: I'm now looking at your paragraph 7 at page 7 of your report, it's the same report, 17 October. So the suggestion made by Lucy Letby in her interview was that an explanation for there being a lot of air in [Baby G] was that when babies vomit they swallow a lot of air.
DE: Well, they don't. They don't. I mean, you'll vomit -- air will come out with liquid. It won't go back in.
NJ: Therefore if a baby doesn't swallow large quantities of air, what conclusion did you draw as to how the air got there that was aspirated with the milk?
DE: Right. As far as the initial one is concerned, I think as well as having quite a lot of additional milk pushed down into the nasogastric tube, I think she had excess air as well down that tube, and that contributed to the abdominal distension. So she had air down the tube and excess milk down the tube.
NJ: Yes.
DE: Yes.
NJ: And so far as Dr Brearey's evidence -- we have had differing versions of the 100ml aspiration from Dr Ventress and Dr Brearey as to whether or not it was air or whether it was fluid, possibly milk. But would infection account for either as far as you are concerned?
DE: No, no. I have never seen a baby with an infection present in this way. You know, it's just not the way they present.
NJ: All right. I think at a later stage -- and I'm looking now, Dr Evans, at your report of 22 April 2022, 22/4/22 -- you were asked about whether or not it was normal for babies who are fed via NGTs to vomit at all.
DE: Well, they don't.
NJ: It's your paragraph 4.
DE: Yes, they don't. Because what -- you see, it has been explained before, but I'm not sure it's been explained clearly enough. When you have a baby on nasogastric feeds, the nurse will put a syringe before the feed -- before the feed the nurse will put a syringe on to the top of the nasogastric tube and aspirate, in other words suck back from the syringe to see if there's any residual milk there.
They do it for two reasons: first of all, to see if there's residual milk because if the milk -- if there's a fair bit of milk from a previous feed that has not gone through, then you need to be careful about giving more milk. The second reason they aspirate the tube is to measure the acidity of the stomach content, and the reason they do that is to ensure that the end of the nasogastric tube is actually in the stomach. Okay?
The stomach has acid. Nasogastric tubes can come out and can go down the wrong way, go into the lung, so the last thing you want to do is to give milk into the wrong orifice, into the lung. Therefore, the reason that they measure pH before each feed is to ensure that the tip of the nasogastric tube is actually in the stomach.
If the baby is on bottle feed then you don't need to do that because obviously the baby will swallow normally and the milk will go down the right hole, into the stomach. But with nasogastric feeding you must ensure as a nurse that the nasogastric tube tip is in the stomach and this is why you measure its pH and a pH of 4, acid, tube in the correct place.
NJ: Thank you. Can I turn finally, please, to your report of 22 April 2022 and to really the conclusion of that report, please. I'm looking at paragraph 12.
DE: I'll just read it. This is my last paragraph:
"Inserting an excessive volume of fluid/milk via nasogastric tube with or without associated air cannot occur accidentally. A professional member of staff, nursing or medical, who gives a small baby an excessive volume of milk places that infant in harm's way. It places the infant at risk of vomiting and the complication of aspiration pneumonia. Excessive volume of fluid in the stomach also interferes with diaphragm movement, splinting the diaphragm..."
Meaning the diaphragm can't move up and down: "... leading to the risk of respiratory distress, respiratory failure and cardiorespiratory collapse."
So that was my final...
NJ: So the diaphragm is the very strong muscle under the lungs; is that right?
DE: Correct, yes.
NJ: And as the diaphragm moves, it reduces pressure in the lungs, which draws in air?
DE: Correct.
NJ: Is that right?
DE: Correct.
NJ: The effect of the stomach being overfull of air and/or fluid has what effect on that movement of the diaphragm?
DE: If the stomach is full of fluid, the diaphragm cannot move down. The diaphragm needs to move down to suck air in. If the diaphragm cannot move down because the stomach is full of air, then the baby cannot receive air and oxygen into its lungs, and it'll lead very rapidly to oxygen deprivation, oxygen reduction, in other words oxygen saturations falling, followed by bradycardia, in other words heart rate falling, followed by collapse.
So that's the mechanism of a sequence of this nature. I think we'll hear about that at a later time with another baby. But as far as [Baby G] is concerned, this is what compromised her.
MR JOHNSON: Thank you, Dr Evans. Would you wait there, please, for some further questions?
MR MYERS: Dr Evans, the way that you described [Baby G], her condition at the time of her birth, was that she was born on the margins of survival.
DE: Yes.
BM: That's the expression you used.
DE: Yes.
BM: She was extremely preterm, wasn't she?
DE: "Margins of viability" was the term I used, actually. She was very preterm, yes.
BM: Right. I'm actually looking at your second report, the main one we've looked at, Dr Evans, 31 May 2018. Page 11 of 16. It's 31 May 2018 report.
DE: "Margins of survival", yes.
BM: Yes, the expression you used was "margins of survival", wasn't it?
DE: Yes. I used viability somewhere else I think, but anyway.
BM: Right.
DE: Same thing.
BM: She was extremely preterm, wasn't she?
DE: Correct.
BM: And she was a very low birth weight?
DE: Yes.
BM: And in the initial period at Arrowe Park a lot of work had to be done just to get her through that period, didn't it?
DE: Absolutely.
BM: By the time that she came to the Countess of Chester Hospital, she was stable on CPAP, wasn't she?
DE: Correct.
BM: And so it could be said that, relative to where she began, she was doing very much better, wasn't she?
DE: Yes, indeed.
BM: Do you agree she was still a little baby that would be prone to infection?
DE: Yes.
BM: With regard to the events of 7 September, which is what we're looking at now, when you came to consider this -- can you confirm how you put this, please -- if we look at your paragraph 41 at page 14 of 16, you give your opinion. I just want to look at this and then look through where we are with the evidence now.
You say: "In my opinion, [Baby G] was treated inappropriately at or around 02.00 on 7 September. The aspiration of 100ml of milk and air plus the projectile vomiting is entirety consistent with some action where [Baby G] was given an excessive volume of milk via her NGT. [Baby G] probably received a volume of additional air via the NGT as well."
Then you go on to say: "In [your] opinion, an individual experienced in working with small babies would have known that such an action would have placed the infant in harm's way."
And that was the principal mechanism you identified, wasn't it?
DE: Yes.
BM: When you did that, and when you considered your reports, and looked at what lay behind the projectile vomit and what follows, you worked on the basis that [Baby G]'s tummy would have been empty or almost empty at the time of the 2 am feed, didn't you?
DE: Correct.
BM: You worked on that basis because what you understood to be the case was that the nurse responsible for [Baby G] would have aspirated her stomach of all milk, if there was any, before a feed took place?
DE: Correct.
BM: We have heard the evidence of [Nurse E] and we now know that [Baby G]'s tummy was not aspirated before the feed at 2 am, don't we?
DE: No, we don't, actually. You cannot measure pH unless you aspirate the stomach. The way you aspirate -- the way you measure pH is you put the syringe in the -- a syringe on top of the nasogastric tube, see if you can get some acid out or some fluid out and measure the pH. Therefore we know for certain that she aspirated the stomach because otherwise she could not have written down pH 4. Okay?
BM: We have all heard [Nurse E]'s evidence.
DE: I heard it as well.
BM: Yes, and what she said was that she took sufficient to be able to measure the pH --
DE: Yes.
BM: -- which didn't require very much.
DE: No.
BM: But she said that in a baby of [Baby G]'s age she would not have aspirated the stomach contents to see what was there. She simply would not have done.
DE: Okay.
BM: You heard that, didn't you?
DE: Yes.
BM: And she agreed that she could not -- therefore it couldn't be said how much milk was or wasn't in [Baby G]'s stomach by the time of the 2 o'clock feed. That's the effect of her evidence, isn't it?
DE: Well, no, no. This is far too simple. You see, milk is not acidic. Milk is neutral. Therefore if you aspirate anything and you end up with a pH of 4, then you won't have any milk there because milk will tend to neutralise the acid in the stomach. So if you've got a pH of 4, which is pretty acidic, then you can't have had any milk there. Okay? That's basic chemistry, by the way.
BM: Dr Evans, we have heard [Nurse E] say that the volume -- the pH doesn't bear upon how much milk was in the stomach, she was clear about that, you heard her evidence on that, didn't you?
DE: Well, my evidence is this: if the pH is 4, it's acidic and it's indicative of acid in the stomach. If there was a significant amount of milk mixed up with the acid, mixed up with the stomach content, then the pH would not be 4. That is my evidence and that's what I'm sticking to.
BM: Now, the reason I suggest that you are disputing this is that your theory as to harm is based upon the stomach's contents having been aspirated before the feed. That's what your theory is based upon, isn't it?
DE: No, it is not, actually. No, it is not. It is based on extraordinary presentation. You have 45ml aspirated from the stomach after the vomit. And the vomit has spread itself over the canopy, over the floor and over the chair. And when the -- so even after the vomiting, even after the vomiting -- goodness knows how much vomit you need to spread yourself over three areas of a nursery -- on top of that there was an aspiration of 45ml, so even if -- 45ml plus air. Therefore there has to have been a significant amount of additional milk plus air to explain what happened to the little baby at 2 o'clock in the morning. That's it.
BM: One moment, please. When I said that you have relied upon the nurse aspirating it, let's just be clear about how you base your evidence in your reports. Can you look at page 5, please, of the report dated 17 October 2021?
What you say, paragraph 7 (a), when dealing with the aspirates -- and I am talking about what you say about the nurses: "A nurse will aspirate the nasogastric tube of a baby prior to giving the next feed. This ensures the stomach is empty."
That's what you say, isn't it?
DE: Yes.
BM: And that is something you're basing your findings upon, that [Baby G]'s stomach must have been empty at the time of the 2 o'clock feed, isn't it?
DE: Her pH was 4. 4 is acid. If there was milk in the stomach, the pH would not be 4.
BM: Let's go through all the evidence of what the nurses say. You say the nurse will have aspirated the NG tube, don't you?
DE: I'm here to give my own evidence, okay?
BM: And in your next report, 22 April 2022, if you look at page 2 of that, please, Dr Evans --
DE: Sorry, where?
BM: Page 2 of 6, your report of 22 April 2022. Page 4904 of our statements, my Lord. It's page 2 of your report.
DE: Right.
BM: You said this, paragraph 4: "It is unusual for babies who receive their feeds via NG tube to vomit. The attendant nurse aspirates the NG tube prior to giving the next feed to ensure that the stomach is empty."
DE: Correct.
BM: You base what you say about [Baby G] projectile vomiting in part upon her having had her stomach emptied by aspiration before the 2 o'clock feed, don't you, from what you said there?
DE: The stomach was empty apart from one millilitre maybe, enough to measure pH. There would have been no milk in her stomach when [Nurse E] gave her her 2 am feed. That is my evidence, that is my opinion.
BM: That's what you're saying. But so there can be no confusion, did you hear [Nurse E] give her evidence?
DE: I did.
BM: And did you hear her say that you wouldn't aspirate the stomach contents at every feed because that would mess with the digestion? You might do it once or twice in a shift potentially. Did you hear her say that?
DE: I did.
BM: And did you hear her asked:
"Question: If there's no particular issue with [Baby G] up to the 2 o'clock feed you'd have no reason, for instance, or anyone else, to start taking out all the contents of her stomach to check how she was doing, would you?
To which she said: "Answer: No, you wouldn't do that with a baby like this."
DE: No, she was -- sorry, we've been through this. Over the past several days she'd had 45ml of milk, either by NG tube or by bottle, and she'd coped well. And I also heard [Nurse E] say that after the feed she went for her break and she would not have gone for a break if she was worried about a little baby. So that's what I heard and therefore I am totally satisfied with my professional opinion regarding the content of this stomach at 2 o'clock in the morning.
BM: So do you base your opinion upon the stomach having been aspirated before that feed?
DE: No, I base my opinion on the fact that she vomited, projectile vomited something, most of us have never heard of before, in the situation of this nature, and the amount of vomit plus the amount of aspirate was massive and can only be explained -- I put in my report that there's only one explanation. There aren't very many medical conditions for which there is only one explanation. This is one of them. Therefore she had a huge amount of milk plus air just before this vomiting occurred.
BM: Can I be clear by asking this question and ask you to answer the question, Dr Evans, and I'll move on: do you base what you say on the understanding, at least in part, that the stomach contents must have been aspirated by the time the 2 o'clock feed took place?
DE: I base my opinion on the fact that the stomach was empty.
BM: You base it on the stomach being empty?
DE: Yes.
MR JUSTICE GOSS: The last way in which you put that question added "at least in part". Previously you had not had "at least in part". You were saying it was based on the stomach having been aspirated.
MR MYERS: Yes.
MR JUSTICE GOSS: You're now putting it -- it's suggested that at least in part, do you base your opinion on the stomach having been aspirated before that feed at 2 o'clock?
DE: A question for me?
MR JUSTICE GOSS: For you, yes.
DE: Sorry.
MR JUSTICE GOSS: Sorry, Dr Evans, yes. You see, the question was put in a slightly different format then.
DE: Oh no, my opinion is, I think, fairly straightforward. The stomach was empty of milk at the -- just before the 2 o'clock feed. And whether it was empty of milk because [Nurse E] did not aspirate -- you see, what [Nurse E] said was: "I wouldn't normally aspirate all the milk."
That's fine. That's completely different to saying, "I did not aspirate the stomach fully at 2 am". She didn't say that because I heard what she said. She said that's what she would normally do. Now, that's what nurses do.
So therefore this was a stable baby, tolerating 45ml of milk every 3 hours, make sure the pH is acidic, that's fine. And therefore she -- therefore the stomach was empty because it was empty but I base my opinion on the fact, you know, that the projectile vomiting, my Lord, was a result of her having this massive additional amount of milk just before the vomit, plus air as well, probably, or almost certainly.
MR MYERS: I'm not going to rehearse [Nurse E]'s evidence again, my Lord, we have heard that, we can go back to that to see precisely what she said.
MR JUSTICE GOSS: I wasn't asking about that. I had understood, because previously it had been put, as I understood it, and maybe I misunderstood it, to Dr Evans that he was basing his opinion purely on the fact that [Nurse E] had aspirated before the feed. And then you said "at least in part". I just wanted to be clear what Dr Evans' answer to that question was.
MR MYERS: I'm grateful to Mr Maher for showing me this.
I had put to Dr Evans: "You base what you say about [Baby G] projectile vomiting in part upon her having had her stomach emptied by aspiration before the 2 o'clock feed?"
MR JUSTICE GOSS: Yes. That was much earlier on. But then the question just immediately before, I think, you modified it slightly.
MR MYERS: I'm trying to give Dr Evans the opportunity of either way, if it plays any part, and we say he's saying it doesn't.
We have the evidence of [Nurse E] and I'm not going to repeat all of that. We can return to that in due course. We hear what you say about it, Dr Evans.
What you have done is you have given a description of force feeding by using the plunger of the syringe to press into the body of the syringe, haven't you?
DE: Yes, I have.
BM: You said you press the plunger and you force it down the tube.
DE: Yes.
BM: That bit of description is something you've added to what you say today, isn't it?
DE: It's not in my original report.
BM: Well, we've got six reports. It's not in any of them, is it?
DE: Okay. You've heard it now.
BM: Just wondering, have you added that, Dr Evans, because you're thinking, well, maybe if there was more milk in there and it hadn't been aspirated, I'll have to change it and suggest a mechanism to force it in? Is that what you have done?
DE: No, I haven't.
BM: In terms of aspiration, when nurses aspirate, they may draw out liquid, mightn't they?
DE: Correct.
BM: They may draw out air; do you agree with that?
DE: One or two millilitres maybe.
BM: Do you agree that a large quantity of air can be withdrawn?
DE: You're more likely to get a large quantity of air... It depends how much air you've put in in the first place, really.
BM: We know that 100ml of aspirate was withdrawn round about 6.15, don't we?
DE: We do -- sorry?
BM: 100ml of aspirate, something, was withdrawn round about 6.15, wasn't it?
DE: Correct.
BM: You have seen the notes don't clarify what was, do they?
DE: That's true.
BM: You have seen what Dr Brearey had to say this morning?
DE: I did.
BM: Did you hear what Dr Ventress said about that?
DE: I did.
BM: And her view was it was probably air.
DE: Yes, I did.
BM: When you dealt with your conclusions with the prosecution, and just the final part that you were dealing with, Dr Evans, you were asked about paragraph 12 in your report of 22 April 2022. So let me just ask you about that, please. Page 3 of 6. I'm going to ask Mr Murphy, if he would, please, to put up tile 80. The first page of tile 80. It has two pages, we can start at the first page.
If we scroll down, please. Thank you very much. Leave that there for the moment.
You had described in your paragraph 12 the following and I'm going to remind us what you say and then ask some questions about it.
You said: "Inserting an excessive volume of fluid/milk via a nasogastric tube with or without associated air cannot occur accidentally. A professional member of staff, nursing or medical, who gives a small baby an excessive volume of milk places that infant in harm's way."
You give [Baby G]'s weight on the date: "It places the infant at risk of vomiting and the complication of aspiration pneumonia. An excessive volume of fluid in the stomach also interferes with diaphragm movement, splinting the diaphragm, leading to the risk of respiratory distress, respiratory failure and cardiorespiratory collapse."
Yes?
DE: Yes.
BM: That's what you said. And I take it what you are doing there is linking excessive volume of fluid down the NGT to ultimately respiratory distress, respiratory failure and cardiorespiratory collapse; is that what you're doing?
DE: Yes, that's correct.
BM: In fact, we know that the later collapse and desaturations come after [Baby G] had vomited, didn't they?
DE: I didn't look at the later collapse during this. I'm happy to discuss that when we discuss it later, but I'd rather stick with this for the time being.
BM: It's my fault for not being clear. We know that as the morning proceeded, from 04.40 on this note, which pre-dates that, as we go through that morning there are a succession of incidents, aren't there?
DE: Yes.
BM: Desaturations, aren't there?
DE: Yes.
BM: We know that they commence some time after [Baby G] had vomited, don't they?
DE: Yes.
BM: And if we just scroll down this page just to have a look down, if you would, Mr Murphy -- can you just go back up, it's the bottom part of the page -- we have what Dr Ventress reported, rather recorded, that had been reported to her, that: "There had been a very large projectile vomit reaching the chair" --
DE: Yes.
BM: -- "next to the cot and canopy. The abdomen appeared discoloured, purple and distended. [Baby G] was distressed and uncomfortable, red in the face and purple all over. Oxygen to the IL via nasal cannula. Desaturated to 80s but [Baby G] (sic) okay."
It says: "Full feed (45ml) aspirated. Large watery stool passed after which abdo slightly better and [Baby G] relaxed" --
DE: Yes.
BM: -- "and appeared back to usual self."
DE: Yes.
BM: So that is the position when Alison Ventress attended round about 2.30?
DE: Yes.
BM: If we go over the page, we can see there was a plan to cannulate with IV fluids, unfortunately delayed due to the delivery of another preterm baby.
DE: Yes.
BM: Do you recall Dr Ventress explaining that [Baby G] seemed stable enough for her to leave her at that point --
DE: Yes, I do.
BM: -- with that plan? The problems that then follow commence roughly about an hour after that, don't they, because it's about 3.30 that she was called back?
DE: Something like that, yes.
BM: So whatever it is that lies behind desaturations later on, that is distant and distinct from the projectile vomit, isn't it?
DE: No, it's not.
BM: Because [Baby G] had settled by that point, she did not have a splinted diaphragm, nor was she in respiratory failure after Alison Ventress had left her, was she?
DE: That's not correct, actually. She was in a very unstable condition. If you go through all of the entries from around 2 am until about 6.30/7 in the morning, there's hardly an entry there that notes that she is stable for a significant amount of time. There are a number of entries -- if you look at what I've got on the screen here, "Dr Brearey called in" -- this is five lines down: "On arrival sats 50%..."
Oxygen saturation at 50% is life-threatening, you won't survive on 50%: "... despite being in 100% oxygen."
And she's having IPPV from a nurse.
So from the time of the vomit, the projectile vomit, [Baby G] never fully stabilised. Okay? That's quite important to know that. What the medical and nursing staff would not have realised, and this is not a criticism, is that all of this had compromised her far more than they anticipated, leading -- in other words, the oxygen deprivation was very marked and probably occurred for a longer period of time than they realised, which is why she's got the brain damage, et cetera, now.
So therefore she was never stable from the time of the projectile vomiting and the abdominal distension. There was an improvement, okay? There were improvements. If you aspirate a baby's stomach, get 45 ml out, you're taking the pressure off. If she passes a stool, which happens, more pressure is reduced from the abdomen. Therefore there was an improvement, but she never, ever stabilised during the whole of this time.
BM: She was not in respiratory failure after the vomit, was she?
DE: Well, she was. I mean if she wasn't in respiratory failure they wouldn't have intubated her.
BM: That came -- you understand the point I'm asking you. That came over an hour later, wasn't it?
DE: Well, first -- right. Perhaps you could scroll more.
She was compromised from the time of the vomiting, all right? Having worked on neonatal units for a long, long time, when things happen they occur as quickly as this, then it's -- you can't run a running commentary of what you're doing when you're trying to save a little baby's life.
So therefore she was unwell from the time of the vomiting. Oxygen... Let's have a look here. Here we go. Anyway, she was unstable from the beginning, she was never right and that's why she needed all the activity she had.
BM: And if the feed at 2 o'clock had caused her diaphragm to be splinted in the way you've described to us before on a number of occasions, there would not have been a period of maybe 45 minutes that followed when she was settled and able to be left by Dr Ventress, would there?
DE: No, I disagree, because by vomiting -- if she vomits, she gets rid of all the fluid, someone aspirates 45ml of fluid on top of that, and therefore that creates a stability of some -- you know, for a temporary period of time. In other words, the vomiting -- by vomiting she got rid of the pressure and therefore reduced the splinting of the diaphragm that was taking place. Okay?
Therefore that's what happened and that's why she was, and I use the words advisedly, relatively better after she had vomited because the splinting, which I have described, which I'm very happy with -- very satisfied with my explanation regarding the diagnosis. Once she vomits, that offers some relief to the diaphragm, allowing the diaphragm to move a little bit better than it did before. Okay? That is the mechanism. That's how it works.
BM: When we look at the issue of bleeding -- and we're on the right page here so we can just scroll down a little bit, please -- we can see: "Intubated size 3 ETT, 8 centimetres at lips, bloodstained fluid noted coming up from trachea/between cords."
You have said, with some qualification, that we've seen something like this with [Baby E], haven't you?
DE: We did.
BM: This isn't even close to what we saw with [Baby E], is it?
DE: It's the same area, it's the upper airway, okay? It's not the upper airway, I beg your pardon, it's the back of the throat. But in terms of seriousness, no, I agree, but we do see it in a later case as well (overspeaking) come to next year.
BM: [Baby E] had a diagnosed gastrointestinal haemorrhage, didn't he?
DE: Yes.
BM: This is not a gastrointestinal haemorrhage, is it?
DE: No. I think this is an upper airway -- I think this is a back of the throat haemorrhage.
BM: And you suggesting a link to [Baby E], Dr Evans, is you doing something simply to support this prosecution allegation rather than properly reflect the facts that we have, isn't it?
DE: No, no, I'm not, I'm looking at this case in isolation, as I have done with all the other six cases we've discussed here. If it wasn't for the other six cases, my opinion regarding this case would have been exactly the same. And in fact, because I had nothing to go on when I did the initial review, I went according to the dates of birth. So this is the one I did first. I reached this conclusion without having known about [Baby E] or any of the other cases. So this was my first case because from date of birth wise, [Baby G] was the oldest of the babies. So yes, so that is factually incorrect what you're suggesting.
BM: In the case of [Baby E], there was profuse active bleeding taking place, wasn't there?
DE: I know.
BM: Pardon?
DE: I know.
BM: Yes. In this instance, there is no active bleed identified or taking place, is there?
DE: They couldn't identify it. It depends on the degree of whatever it is that occurred.
BM: There's no evidence of trauma identified anywhere with the oropharynx or the trachea, even with them looking into it, is there?
DE: I don't know what caused the bleeding, but bleeding in the back of the throat in a baby who's stable is incredibly unusual and very, very concerning. It's very, very concerning. [Baby G] did not have a bleeding disorder and yet when they tried to -- the first time they intubated her there was blood at the back of the throat, enough blood to go through the cords into the trachea. Now, that's a worry, okay? That's a worry.
BM: Bloodstained fluid, it says, doesn't it?
DE: Well, I think Dr Ventress said she could visualise blood beyond the cords.
BM: And there can be natural, as in non-trauma based, reasons for bloodstained fluids, can't there, like this?
DE: No.
BM: You disagree?
DE: In this particular case I disagree with you.
BM: And a baby in [Baby G]'s condition may have had a small haemorrhage that could cause some sort of bloodstained fluid like this, couldn't she?
DE: Why? No reason for it.
BM: But it can happen, can't it?
DE: No, she's 100 days old, she's been stable for a long, long time. No is the answer to that.
BM: And you referred to, "Pulmonary haemorrhage would be a killer", I think is the expression you used.
DE: That's the word I used. She did not have a pulmonary haemorrhage.
BM: Small babies, as it happens, can have pulmonary haemorrhages of different degrees, can't they?
DE: She did not have a pulmonary haemorrhage. That's my opinion.
BM: But you don't identify anywhere, and no one does, any source of haemorrhage, do you, or they?
DE: Well, the back of the throat is not a very large area. And the blood was noticed there and it is noticed beyond the cords, so it was there or thereabouts.
BM: We know that later -- and we can go, please, to tile 107, page 2, and scroll down, please, Mr Murphy. Thank you.
Just above the X-ray review, a few lines above, we can see it says: "Bloodstained fluid in oropharynx."
DE: Yes, back of the throat.
BM: This is after the re-intubation. You can see that at 06.15?
DE: Yes.
BM: And a small amount of blood after re-intubation, bloodstained fluid, however we describe it, that could be due to intubation or re-intubation on this occasion, couldn't it?
DE: Oh yes. If the bloodstained fluid had occurred for the first time at this time, then I wouldn't be able to say whether it was due to resuscitation or not, but that is not the case. Blood was noticed at the first resuscitation, at the first effort at intubation by Dr Ventress --
BM: Yes.
DE: -- and was noticed again for the second time. So this was -- the important thing to say here is this was not the first time that blood had been noticed in the back of the throat. That's the important thing.
BM: This could be due to intubation, this one?
DE: This could be.
BM: And for the first one there's no identified site of any trauma or any identified cause, is there?
DE: No one found anything.
BM: Projectile vomiting I'd like to ask you about next, Dr Evans. Babies may vomit for many reasons, mightn't they?
DE: Yes.
BM: With more or less force?
DE: Yes.
BM: Forceful vomiting in a neonate can happen, can't it?
DE: I don't use the word -- I'm not familiar with the term forceful vomiting. I'm not sure what it means. I'm not being awkward, it doesn't... It has no medical relevance. Sorry about that.
BM: A child that is unwell and it's having an effect upon their stomach, a baby like this might projectile vomit; do you agree?
DE: No.
BM: There's a division of opinion between you and Dr Ventress on that, isn't there, Dr Evans?
DE: I don't think so.
BM: You say, with respect to her evidence, you don't agree with her evidence on this.
DE: I don't think Dr Ventress said that babies will have projectile vomiting as a common side effect/complication of an illness. I don't think she said that.
BM: Well --
DE: Sorry, what I disagree with Dr Ventress is she said infection caused the vomiting. I disagree.
BM: Yes.
DE: The infection occurred after the collapse.
BM: But you heard me put to her by reference to her statement where she'd said that projectile vomiting could be caused from infection?
DE: If she said that, fine, but I don't agree with her. I'm not being condescending, but she was a registrar at the time, and we've heard -- I'm not going to criticise junior doctors for their opinion, okay? I'm not going to do that, I think it's unfair.
BM: Well, it is possible for [Baby G] to have vomited very hard, projectile vomiting, because she was unwell; do you agree or agree with that?
DE: No, not that degree of vomiting, no.
BM: Pardon?
DE: Sorry, and if she had vomited because she was unwell, where would the 45ml still in the stomach have come from?
BM: We can't actually say -- let's say that there was more than 45ml in the stomach at the time of the vomit, that for whatever reason more milk had gone in there than should have been there for that one feed. We can't say how much extra there actually was, can we?
DE: We can say there was a fair bit. There was quite a lot I would say.
BM: We don't know, do we?
DE: Yes, we do.
BM: There's no measurement of how much vomit there was, is there?
DE: No, but it's a lot of vomit. It's a lot of vomit, you know.
BM: We don't know because we don't have an image of it, do we?
DE: No, but it's a lot of vomit.
BM: You don't know how much there was, Dr Evans.
DE: There was quite a lot. 45ml is not much more than this glass. You've got a vomit on the chair, you've got vomit on the canopy, and you've got 45ml or more still left in the stomach. That's an awful lot of vomit.
BM: And if, for whatever reason, [Baby G] had not digested the milk that had been given to her at an earlier feed and milk had been fed over that, that could mean there was more than 45ml in her stomach, couldn't it?
DE: That is pure hypothesis. There was no milk in her stomach because the pH was 4 and milk is neutral, therefore the pH would not have been 4.
BM: I'm not going to go back and debate the evidence of [Nurse E] with you, Dr Evans. We've heard it.
DE: Anyway, I disagree with that point.
BM: Gastro-oesophageal reflux can cause projectile vomit, can't it?
DE: Yes, it can.
BM: And it's possible that [Baby G] had or developed gastro-oesophageal reflux, isn't it?
DE: The discharge letter from Arrowe Park from mid-August did not mention gastro-oesophageal reflux. What it says was, in terms of active issues, chronic lung disease and establishing feeds. She was on Gaviscon, which is used commonly, but there was -- she's got reflux afterwards. She may well have had some reflux but the reflux would have been minor, would not have caused her any problems, and certainty would not have caused the sort of vomiting we've been discussing all day.
BM: Is gastro-oesophageal reflux something that can develop in a baby over time? So they're not born with it but it develops over time?
DE: It depends on the cause actually. It depends on the cause. So... No. I mean, it doesn't occur in... It doesn't occur in 3 hours between one feed and the next, I'll tell you that.
BM: But it occurs over time in a baby, doesn't it? And when we move beyond 7 September, as we're going to do, we see that [Baby G] was a baby who had a marked predisposition to vomit, didn't she?
DE: Once we go beyond 7 September -- and I'd still rather talk about this later -- she is so awfully compromised by the brain oxygen deprivation that she's a completely different baby, sadly.
So therefore whatever applies before the 7th, you cannot apply that after the 7th. We know this from the MRI, from the scans, et cetera, that she had. Anyway. So this was the event that compromised her overall health.
BM: That's what you're saying, isn't it?
DE: No, no, there's plenty of evidence of that.
BM: And that's an opinion you're constructing in support of the prosecution, isn't it?
DE: No, it is not. We will hear, I suspect, of -- I've seen the results of... Dr Stivaros, I think, the neuroradiologist. He's mentioned how the scans before all of this were okay and the scans -- the MRI of the brain after this were not okay. So it's nothing to do with supporting the prosecution: I am giving evidence as I see it and the evidence, in my opinion, is very clear.
BM: Where infection is concerned, the CRP in [Baby G] was at 28 by about 2.18 on the 7th, wasn't it? We know that as a fact.
DE: At what time?
BM: By 2.18 on the 7th, her CRP reading had gone up to 28.
DE: 2.18 in the afternoon?
BM: Yes.
DE: Yes. Yes, 12 hours later.
BM: Yes. And by 22.53, so a little before five to 11 in the evening, it was up to 106?
DE: Yes.
BM: That's consistent with infection, isn't it?
DE: Yes.
BM: We know that by the time she was at Arrowe Park on the 9th, it was at 218.
DE: That's right, yes. I remember that.
BM: That could be consistent with infection developing before the vomit or after the vomit, couldn't it?
DE: No.
BM: Well, it could be, couldn't it?
DE: No, you're wrong.
BM: It takes between 24 and 48 hours for CRP to peak, doesn't it?
DE: It varies, actually. What you cannot do is you can't do a case-controlled study on the rate of growth or rate of development of CRP. In most cases, CRP is raised at the time the infection presents, not in all cases but in some cases. So what you've got is -- and I don't know whom you're quoting, but the paper I read is that the CRP is always abnormal by 24 hours plus.
BM: Dr Ventress agreed it's 24 to 48 hours to peak.
DE: I haven't got a transcript, I'm not sure what -- if that's what she agreed with, but anyway, as I said, I'm not here to criticise junior doctors in training.
BM: She's giving her evidence now. Is she a consultant now, Dr Evans?
DE: Yes, well, fine, but she wasn't at the time.
BM: Yes, but giving her evidence now, she is, and she agrees with that, doesn't she?
DE: If she wants to agree with that, we'll have to have a respectful disagreement.
In the majority of babies who have an infection, the CRP is raised at the time --
BM: Right.
DE: -- of infection, okay? Not all of them, not every one of them. And as we've discussed there was nothing else -- there were no other markers of infection in [Baby G]. In other words she wasn't off her feeds, her temperature hadn't gone up, she wasn't desaturating, her oxygen requirement was with low flow. In other words, all the markers were of her getting better. You do not suddenly do this. Anyway.
So therefore there were no markers of infection prior to her projectile vomiting.
BM: She passed a large watery stool, that was abnormal for her, didn't she, at -- shortly after the vomit?
DE: That's not abnormal actually. There's something called a gastrocolic reflex -- not reflux, reflex. We know this from anybody's who's looked after babies: you give them a feed and the next thing they fill their nappy. So she's had a load of milk into her stomach, so the gastrocolic reflex kicks in, and she passes a stool. That's okay.
BM: While she was at Arrowe Park Hospital, correct me if I'm wrong about this, there's no finding of or treatment for aspiration pneumonia, is there?
DE: When now?
BM: At Arrowe Park after she's admitted there having been taken there from the Countess of Chester.
DE: I don't think she had aspiration pneumonia, actually.
BM: And the mechanism that we've had described at one point was she might have aspirated something and created an infection, that's not right, is it?
DE: I don't know. I know she had an infection. Okay? We know that she had an infection. Nobody grew any bugs as far as I know. For the nth time, she responded to the treatment that she had. She was a very resilient little baby, actually. So she had an infection. Yes, she had an infection and it probably kicked in, you know, during the time that they were trying to save her life.
BM: You cannot -- to be clear about this, you say it probably kicked in then, you cannot discount the possibility it was present and kicked in at some time before the vomit? You can't discount that, can you?
DE: (Overspeaking) no clinical evidence whatsoever to back up that hypothesis, none whatsoever.
BM: I'm not going to repeat what I've put to you about the CRP, but I'm just asking, it's something that cannot be discounted, is it?
DE: It's not what caused her collapse.
BM: If there is an infection she's suffering from, will that interfere with her ability to digest her milk?
DE: Oh, yes, yes (inaudible).
BM: And if she had an infection and if she received more milk than she should have received, is that more likely to precipitate a vomit?
DE: Well, you've got lots of ifs, haven't you?
BM: Yes.
DE: I stick with evidence. I don't stick with ifs. So there's no evidence that she -- there's no evidence that she had infection. In fact all of the evidence is that she did not have an infection and I've got all -- you know, you only have to look at this observation chart here. All of it is absolutely as it should be, right up until she gets this projectile vomiting, no infection. Okay?
MR MYERS: Those are the questions I want to ask, Dr Evans. I won't debate the evidence. That will come later.
MR JOHNSON: Just two things, please, Dr Evans. I'm just trying to find a reference before I ask you.
It was suggested to you in cross-examination that you were adding the suggestion that the plunger on the syringe had been used and that this was really an addition to your evidence.
DE: Mm.
NJ: Okay? That was being suggested in the context of milk.
DE: Mm.
NJ: Can I just go to your report of 31 May, please, at paragraph 33. It's been suggested that you were adding the concept of forcing stuff in to help the prosecution case because you saw there was a problem. Okay?
DE: Yes.
NJ: In paragraph 33 of your report of 31 May --
MR JUSTICE GOSS: 2018.
MR JOHNSON: Yes, my Lord, thank you.
Three lines from the end of that paragraph, what do you say?
DE: "[Baby G] had received far more than 45ml."
That one?
NJ: Yes. Read that and the next sentence, please?
DE: "(inaudible) NGT tube before she vomited she may have also received a bolus of air from the feeding syringe used for feeding."
NJ: How can you get a bolus of air into a child without using the plunger?
DE: You can't.
NJ: Air won't go down under its own --
DE: No, air goes up. Yes. So if the air had gone down, it needed a plunger for it to be pushed down. So yes.
NJ: Well, I'm only mentioning this because it was suggested that this isn't something that features in your report, all right?
DE: Yes, fine.
NJ: You were asked about gastro-oesophageal reflux.
DE: Yes.
NJ: At one stage, your response was it doesn't develop between two three-hourly feeds.
DE: Correct.
NJ: Because the suggestion is, apparently, that [Baby G] had some, if not all, of her previous feed from 11 o'clock in her stomach when she was given the feed at 2 o'clock.
DE: Mm.
NJ: So let's deal with a couple of issues. If [Baby G]'s stomach had been full before she was fed at 2 o'clock, and [Nurse E] had aspirated something to check for a pH, what would [Nurse E] have got back?
DE: She'd have got back some milk.
NJ: Would it have been digested or undigested?
DE: It would have still have looked like milk.
NJ: And would the pH of that be 4?
DE: It might be slightly acidic. A pH of 7 is neutral. Therefore a pH of 6 is slightly acidic, pH 5 is more acidic, pH 4 even more acidic. So you wouldn't have that pattern of acidity if -- because the milk would have partly neutralised the acid. And anyway, if she'd aspirated some milk, you know, it would look like milk.
NJ: Gastro-oesophageal reflux, how does that start to develop in a child of 100 days?
DE: It doesn't start overnight. If she had reflux -- you know, she was on half bottle feeds, if she gastro-oesophageal reflux, a nurse would have noticed a bit of milk coming up between feeds, perhaps, a bit of milk coming up between feeds, that sort of thing.
NJ: Let's just look at the feeding chart, if we may, which we have behind divider 7, I think.
MR JUSTICE GOSS: It's the second to last document in that section, J7012.
MR JOHNSON: There we have two days' worth of feeding at three-hourly intervals as you have told us.
We have a "vomit/asp" column for 2 days. Reading down from the top, we have -- well, what does it say, something acid?
"Positive acid. Positive acid. Positive acid."
DE: Yes.
NJ: Then pH 4 for the final NG tube. Is that indicative of -- is that feeding chart indicative of a child with gastro-oesophageal reflux?
DE: No, not really. Anyway, you can't diagnose reflux on pH values. The other point by the way --
NJ: What about the lack of vomiting?
DE: She's not vomiting.
NJ: What does that tell us about whether --
DE: If she's not vomiting she hasn't got reflux, so how are you going to diagnose it? The other point -- sorry, go on.
NJ: Sorry, does it go from nothing for 2 days to projectile vomiting in 3 hours?
DE: It just doesn't. That does not happen, okay? That does not happen. Nothing -- this projectile vomit has nothing to do with gastro-oesophageal reflux, okay?
MR JOHNSON: Thank you.
Does your Lordship have any questions?
Questions from THE JUDGE
MR JUSTICE GOSS: The other thing that you were wanting to say. The other thing. You kept saying, "The other thing", and then Mr Johnson would cut you off.
DE: Oh yes. Just for completion, really. If the milk goes in and is digested, you have a bowel action, and it comes out the other end. She had a number of bowel actions over these last 2 days, which is what you'd expect. So it goes in one end, is digested, the waste stuff comes out as a bowel action, and she had bowel actions. The last one was at 23.00 hours, so just 3 hours -- so all of that is indicative of normal gastrointestinal function. That's all.
MR JOHNSON: Thank you. I'm sorry I cut you off.
MR JUSTICE GOSS: Is it possible or not, I don't know, just to see this pattern of feeds and the comments in relation to the feeds, like demand fed, fed well, this sort of thing, as to whether there was any sort of difficulty, apparent difficulty, of [Baby G] in digesting these 45ml feeds?
DE: No, this is about as normal as you get in a baby needing NG feeds. If I just looked at this in isolation, I'd say, this is great, this is as good as it gets, to be fair. There are no red flags here, there are no concerning issues here. This is very satisfactory.
MR JUSTICE GOSS: Right.
DE: It's as good as that.
MR JOHNSON: Thank you.
MR JUSTICE GOSS: Thank you, Dr Evans. That completes your evidence on this aspect.
Wednesday, 18 January 2023
MR JOHNSON: Welcome back, Dr Evans. For the record would you identify yourself, please?
DE: Dr Dewi Evans.
NJ: Thank you, doctor. You have already told the jury that you have written several reports relating to [Baby G]; is that right?
DE: Yes.
NJ: And so far as the incidents of 21 September 2015 are concerned, you address those first in your report of 24 March 2019 --
DE: Yes, that is correct. That is something I had overlooked in my first report.
NJ: Yes. Well, I'll come to that in a second, but can we just go back to your -- just to set the scene, as it were, and to remind the jury of [Baby G]'s progress. Can we look at your report of 31 May, please, 2018?
DE: Yes.
NJ: So far as that report was concerned, that followed your initial sift report, didn't it?
DE: Yes, it did.
NJ: Which was compiled, like so many others, in the latter part of 2017?
DE: Correct.
NJ: If you wouldn't mind, please, could you go to page 3 of 16 of your report of 31 May 2018. There you deal with [Baby G]'s clinical progress; is that right?
DE: Yes.
NJ: Your paragraph 6 makes it clear that she was born on 31 May 2015.
DE: Yes.
NJ: She was of very, very low weight at birth, 535 grams.
DE: Correct.
NJ: And she had been born at Arrowe Park Hospital, which of course we know is a tertiary centre.
DE: Yes.
NJ: There then followed a prolonged course of treatment at Arrowe Park.
DE: Yes.
NJ: Which included a transfer to Alder Hey Children's Hospital in Liverpool, where what's called a Broviac line was inserted to administer medication and feed; is that correct?
DE: That's correct, yes.
NJ: And [Baby G] was transferred from Arrowe Park to the Countess of Chester Hospital on 13 August 2015.
DE: Yes.
NJ: You reviewed her treatment from 14 August through to 7 September -- and 7 September, of course, was the occasion on which [Baby G] produced a projectile vomit, which got as far as the chair next to her cot --
DE: Correct, yes.
NJ: -- and also the floor. And 45ml of feed was removed from her stomach after the vomiting.
DE: Correct.
NJ: And you've already given us evidence about your views so far as that is concerned.
DE: That is correct.
NJ: I'd like to turn, if we may, then, to your report of 24 March 2019. So this was the third of your reports; is that right?
DE: Yes.
NJ: At your paragraph 5 onwards, did you conduct a further review of the clinical data relating to [Baby G]'s stay at Chester?
DE: I did.
NJ: Thank you. Did you note what you describe as a significant event on 21 September 2015 which in your previous two reports you had not addressed?
DE: Correct.
NJ: Just to give the jury some sort of idea of what you were dealing with, at paragraph 3 of that report, so just going back to page 2, you refer to the volume of material that you had received concerning [Baby G]'s treatment.
DE: Yes.
NJ: How many pages of material were there relating to this single child?
DE: Just over 4,000.
NJ: Yes. All right. So there you were in March of 2019 conducting a further review. I'm looking at your paragraph 6 now, Dr Evans. What did you note?
DE: Well, having looked at it again, I found another event, as we already mentioned, on 21 September, and this is -- this occurred during the morning, around 10 o'clock in the morning, on 21 September, when she had what were described as two further projectile vomits. These were witnessed by nursing staff.
Now, a projectile vomit is where the baby vomits far beyond its body size, so therefore these were very significant vomits and, even more worryingly and more significantly, her oxygen saturation dropped and it dropped to 30%.
Now, normal saturation is over 90%, so an oxygen saturation of 30 is very, very low and is life-threatening. In other words, you've got to get the oxygen level back to normal as soon as possible.
NJ: Yes.
DE: So that is what happened on the morning.
NJ: Thank you. Because it's a month since we heard this evidence, if Mr Murphy would help us, please, can we go to tile 50 first of all.
This is the note written by Lucy Letby relating to an event that she recorded as having occurred at 10.15. If we can just remind ourselves of what she wrote, please.
The note says at 10.15: "[Times] 2 large projectile milky vomits. Brief self-resolving apnoea and desaturation to 35% with colour loss."
DE: Top right there. Top left, sorry.
NJ: Top left, yes. So if we just go above that slightly, Mr Murphy, to take in the line above where it says: "NG tube feed. EBM [expressed breast milk] given..."
Presumably that should say "at 9 o'clock" as [Baby G] was feeding (inaudible: coughing).
Then where the arrow is: "10.15 x2 large projectile milky vomits. Brief self-resolving apnoea. Desaturation to 35% with colour loss. NG tube aspirated: 30ml undigested milk discarded. Abdomen distended, soft. Doctors asked to review. Temperatures remain low. Tachycardic over 180 beats per minute. Mum states that [Baby G] doesn't appear as well as she did yesterday."
If we could just move on to put this into overall context to the next tile, please, Mr Murphy, and to the record of Dr Fielding.
We'll work off the analyst's typed transcription of the handwritten notes. We can see it says:
"[Baby G] had episode at about 10.20 where she had 2x projectile vomits witnessed by nursing staff, after which she was apnoeic for about 6 to 10 seconds. Went blue. Saturations decreased to 30%. Last feed 9 am. Nurse called for help. On going back to [Baby G], colour..."
Is that "normal"?
"... breathing plus crying."
So is that the material that you were referring to?
DE: Yes, yes, yes.
NJ: Thank you. So that's your paragraph 6, Dr Evans. Did you also in your report refer to other material from that particular date and events which had been recorded?
DE: Yes. The important bit is that the examination of [Baby G] showed that the abdomen was distended, in other words the abdomen was larger than it should be, and that her bowel sounds were active. Now, bowel sounds active means that the intestinal system was working perfectly well, but the abdomen was distended, which would occur if the abdomen was either full of milk or full of air or full of a combination of milk and air. So that's the pattern that occurred here and that occurred despite her having vomited, because by vomiting, of course, you'd expect any abdominal distension to reduce because some of the substance in the stomach had been vomited up.
NJ: Yes.
DE: So in other words, this was a very significant concerning issue, particularly in relation to -- particularly in association with the oxygen saturation dropping to 30% and that she went blue and she also stopped breathing for a few seconds.
NJ: Yes.
DE: So a concerning event.
NJ: Yes. So what did you -- going to your opinion section, your paragraph 18 onwards, what conclusions did you draw from your review of all those circumstances?
DE: Right. Well, I thought that, generally speaking, she'd had a potentially life-threatening episode of vomiting and oxygen desaturation. That was my overall impression and that there was one explanation for this, which is that [Baby G] had been given far more milk during her nasogastric tube feed an hour earlier. The plan was to give her 40ml of milk and she had been tolerating that amount of milk by bottle the previous day, 40ml or 45ml, so therefore if you -- if she had been given 40ml of milk then it would not explain how she had two large vomits, two large projectile vomits, and on top of that there were still 30ml of milk left in her stomach.
So therefore my conclusion was that she had not received 40ml of milk, she had received a lot more than that, and it was the excessive amount of milk that she had received had caused this episode at 10 o'clock on 21 September.
NJ: Did you limit your opinion to the substance being inserted into [Baby G] being restricted to milk?
DE: Well, it could have been milk or it could have been milk and air. And there's no way of saying how much milk and how much air. Of course, you do not vomit air, you can only vomit a liquid, and therefore there was -- clearly a large amount of milk, over and above 40ml, had been given to the little babe, which is what caused her vomiting in the first place.
MR JOHNSON: Yes. Thank you, Dr Evans. Would you wait there, please, for some further questions?
MR MYERS: Dr Evans, just with regard to when this appears in the reports that you produced, we know you provided an initial report on [Baby G] on 16 November, didn't you --
DE: That's correct.
BM: -- of 2017?
DE: 6 November, actually.
BM: Sorry, 6 November 2017. And then you provided a second report on 31 May 2018.
DE: That is correct.
BM: And as you've just explained to us, this incident on the 21st was identified by you in your third report on 24 March 2019?
DE: Correct.
BM: The nursing notes are items that were provided to you from when you first began to consider the case, weren't they?
DE: That's correct.
BM: Your view when you wrote the report, your second report, on 31 May 2018 -- bear with me one moment, please...
(Pause)
I'm looking at paragraph 27. Just to assist the jury whilst you turn that up, these first two reports both focused on the incident on 7 September, the first incident?
DE: Yes, that's correct.
BM: And in the second report, having looked at the material, you said this at the end of paragraph 27:
"I scrutinised these entries [this is the rest of the clinical entries]. They record reasonable progress. I have not found any evidence of any acute life-threatening event."
That's what you said, wasn't it?
DE: That's correct.
BM: Now you did say that at a time when you had been able to read these nursing notes, didn't you?
DE: Not really. What I did initially -- if we recall, I prepared about 30 reports which were done towards the end of 2017 and I concentrated -- 30 reports is a lot of reports and they were sift reports, as we've heard. And this case had 4,000 pages plus. That's about eight of these folders (indicating). And quite frankly, the event of 21 September, I overlooked it, didn't see it. And I didn't see it because I concentrated my review on the medical notes more than the nursing notes. So I overlooked it, simple as that.
BM: When you did make reference to this event in your third report, the one dated 24 March 2019, you also identified the 30 September as a date that required further consideration, didn't you?
DE: I did.
BM: What you said at paragraph 20 was:
"There is a need to review the nursing and medical staffing present at the intensive care unit during the hours leading up to the events of 30 September 2015."
DE: I did.
BM: Just so the jury can see what it is that had caught your attention then, I'm going to ask Mr Murphy, if he would, please, to put J7425 on the screens. Ladies and gentlemen, this isn't in the sequence of events, it's something additional, but it relates to this period. If we go to the right-hand side of page 7425 -- we're there, aren't we? -- this is the section. When you did the report in which you identified 21 September, you also identified this, didn't you, Dr Evans?
DE: Yes, yes, yes.
BM: And what had caught your attention was this: we can see it's 30 September, at 17.04, an entry by MT, who we know is Melanie Taylor and what we have is as we go down: "Bottle fed [halfway down the report]. SVIA at start shift."
Is that self-ventilating in air?
DE: Correct.
BM: "Having a few desats. Informed doctors before handover due to..."
Is that immunisations, "imms"?
DE: I think so, yes.
BM: "1x profound saturation apnoea requiring position changed and oxygen this morning. Bottle fed very well this morning. Observations within satisfactory limits, no increased work of breathing. ROP this afternoon."
I'm not sure what ROP means. Can you help us?
DE: I think it's retinopathy of prematurity examination maybe. Maybe. I'm not sure actually.
BM: It moves on: "Dr Butcher does not need follow-up ROP screen. Has updated mum. Very sleepy after ROP. Increased desats so put onto nasal prong oxygen."
So that was something additional that you thought required further consideration; is that correct?
DE: I did.
BM: Right. We can take that down, please, Mr Murphy.
With regard to the incident on 21 September, Dr Evans, particular points about that, it's described as projectile vomiting in the notes, isn't it?
DE: It is.
BM: And it's that in particular that you have identified as a cause for concern, isn't it?
DE: Yes.
BM: We don't have on this occasion any indication of the extent or distance of the vomit, do we? You didn't have that to work with like you did on the 7th?
DE: No.
BM: The event itself on the 21st, the one we're talking about today, does appear to have been a relatively brief and self-resolving event, doesn't it?
DE: I wouldn't call it self-resolving. They had to address the issue, her stomach was aspirated, the doctors were called. She was quite unwell during this period of time. So it wasn't one of these self-limiting desaturations, it was much worse than that. And of course, the key thing was that she actually vomited two large vomits.
BM: It was brief, wasn't it, relatively brief?
DE: No, it wasn't. You see, the only thing that was brief was that she stopped breathing for 6 to 10 seconds. Now, 6 to 10 seconds might not sound a lot but this was a baby by this time who was over 2 kilos and had been feeding by bottle the day before. So this was quite a serious event. I don't think it was as serious an event as the one we discussed before Christmas, but it was a significant event.
BM: Dr Fielding, whose notes we've just been to, and whose evidence we heard on 14 December 2022, was the doctor who came and attended to [Baby G] on this occasion, wasn't he?
DE: Yes.
BM: Just so we can keep the evidence in mind because it's a while ago, he was asked that this had been a brief episode and there had been a relatively swift recovery, his answer to that was yes, Dr Evans --
DE: Yes, I heard that. As I've said, I don't think this was as serious an event as the earlier one, yes.
BM: The air. You've mentioned air in the bowel or in the X-rays; is that correct?
DE: Yes, yes, yes.
BM: It's a feature, isn't it, of [Baby G] throughout her stay in whichever hospital she was in that there were multiple occasions when there was air in her intestines or bowels over the months of treatment?
DE: That is correct.
BM: Dr Fielding also described -- we can put up tile 51, please, Mr Murphy. Can we go into the tile, please?
MR JUSTICE GOSS: Do you want to go to the document behind it?
MR MYERS: Please. Could we go to the notes, please, Mr Murphy? My fault.
MR JUSTICE GOSS: I've tried to do it on the iPad and it says it can't find the PDF. Are you the same?
MR MYERS: I can assist. We have seen this before, so I can simply read what it is that I wanted to refer to.
Dr Fielding recorded that [Baby G] passed a loose green stool about 10 minutes after the vomit.
DE: Yes.
BM: Do you agree, Dr Evans, that it is possible that a loose stool -- thank you, here we have it.
It might in fact be over the page, please, if we can go over the page after all of that.
MR JUSTICE GOSS: Towards the bottom of that page, there's a reference to the episode.
MR MYERS: Yes. The reference I wish to make, I'm not sure it follows this or not, it's something he referred to. Is there a page that follows this, Mr Murphy? If we go down to the lower half of that page, we can see it says: "Bowels open. Loose stool. Green colour."
DE: Mm.
BM: Do you accept there are circumstances where that may indicate some poor health or some indication of becoming unwell?
DE: Difficult to say just with one. Right. There are a few things this tells me. First of all, it tells me there's no intestinal obstruction. In other words, the vomiting is not due to some blockage because everything is going through and some of it is coming out the other end, so we can be sure of that.
One loose stool... loose stool. Babies have loose stools, you know.
BM: If we move, please, to tile 58 then, just following on. Just the pathology sample. We can go into this. Thank you.
Just look at the CRP, which is in the centre of the page. We understand a little bit about CRP, as we all do, Dr Evans, you may know a great deal more, but that is C-reactive protein, which can be a marker of infection potentially?
DE: Yes.
BM: It is raised slightly at this point, isn't it?
DE: Yes, it's over 10, so it's 18, so it's marginally raised, yes.
BM: All right. Thank you for those, Mr Murphy. Thank you, Dr Evans.
With regard to the vomiting, do you agree that once [Baby G] returned to the Countess of Chester from Arrowe Park there was a more marked history of vomiting from that point onwards?
DE: Well, there's a huge change to [Baby G]'s overall health following the event of 7 September. And this relates to the abnormalities found on MRI I think carried out on 15 September from memory. The brain scans carried out at Arrowe Park did not show any significant abnormalities and I think we had the report from the neuroradiologist, so her brain scans prior to 7 September were satisfactory.
Her MRI of the 15th showed very significant abnormalities. And therefore from 7 September onwards, [Baby G] was a completely different baby from a developmental point of view.
It's the events of 7 September that changed her significantly from a neurological point of view, in other words from the brain development point of view, and so, yes -- and I think -- well, we now know that [Baby G] receives feeding by tube. So in other words, vomiting has been a significant part of her life from mid-September.
BM: Yes, that's right. In your third report, paragraphs 13 and 14, you list some of the occasions from the notes in which vomiting features in the records that are kept of her at the Countess of Chester, don't you?
DE: Yes.
BM: We may see a little of this later. There are numerous events after her return to the Countess of Chester on 16 September when she is recorded as vomiting, aren't there?
DE: That's correct, yes.
BM: And therefore, whilst there is the vomiting on the 21st that you identify, conceivably that could be part of a pattern of vomiting which has continued thereafter as a result of earlier events?
DE: No, I disagree with that.
BM: Okay.
DE: The reason I disagree with that is to do with basic arithmetic. In other words, I'm sure that she had more milk than she should have on the 21st. The reason for that is basic arithmetic. If she had had 40ml in there was no way that she would have vomited -- had two projectile vomits, sorry, two large vomits, and there was still 30ml still left in the stomach.
So in other words, that does not add up. The only explanation for that is that she must have had more than 40ml in the first place before she had this crash, short-lasting crash compared to 7 September, before she deteriorated at 10.15 in the morning on the 21st. So that's the difference between that incident and all the other episodes of vomiting which we've discussed.
BM: We don't know, do we, how much milk actually came up in the vomits, do we? We don't know.
DE: We don't.
BM: What we have is a description that says "two large projectile milky vomits".
DE: That's pretty descriptive.
BM: It may be but there's no way we can get from that to say how much milk there was in the stomach at the time of the vomit, is there?
DE: How much is a vomit? It would be more than 10ml. In other words -- I mean, 10ml is a tiny amount, tiny a volume, so, you know, no experienced nurse would describe two vomits of 5ml each, because that's what would have to occur -- I mean, 5ml is a teaspoon. I don't do a lot of cooking, but it's a small amount.
So therefore it has to be that she had more than 40ml at around 9 o'clock or just before this episode. And of course, that would explain her distended abdomen as well. By vomiting she corrected the abdominal -- to some extent the abdominal distension. And by -- vomiting plus aspirating the milk from the stomach, that is what led to her recovery.
But the 21st September event is different to all of the other episodes. We just mentioned the 30 September one there, for instance, where she desaturated but there's no history of vomiting, for instance.
So 21 September is quite different to the other episodes in my report and in the notes.
MR MYERS: So the position is quite clear, my Lord, we don't accept that there is any way of measuring the vomit that was produced, but I've asked the question. I'm not going to repeat the question.
MR JUSTICE GOSS: It's clear what your question is and it's clear what the doctor's answer is. I'm sure the jury understand the point. It's a description but it's not a quantified description.
MR JOHNSON: Yes. Does your Lordship have any questions?
Questions from THE JUDGE
MR JUSTICE GOSS: Only this: there has been reference to quite a lot of other entries about vomiting. Are there any other entries to projectile vomiting?
DE: Not that I know, my Lord. I don't think so, no.
MR JUSTICE GOSS: I don't know, I'm just asking that, whether it's going to be dealt with or not.
MR MYERS: Yes, it will be dealt with with the next witness, my Lord.
MR JUSTICE GOSS: Thank you. Thank you very much.
MR JOHNSON: Your Lordship may remember that Dr Bohin actually did a vomiting review, if I can use that shorthand.
MR JUSTICE GOSS: Yes. Well, thank you, Dr Evans, that's it for now. Thank you very much.
Thursday, 9 February 2023
MR JOHNSON: Welcome back, Dr Evans. Could you confirm your identity for the sake of the recording, please?
DE: Dr Dewi Evans.
NJ: Thank you. Dr Evans, in the complicated case of [Baby I], have you written several reports?
DE: I have, yes.
NJ: Was your first sift on 18 November 2017?
DE: The 8th.
NJ: The 8th, I beg your pardon.
DE: 8 November 2017, yes.
NJ: Your more substantive review on 31 March 2018?
DE: May.
NJ: May, sorry, yes.
DE: 31 May 2018.
NJ: My eyesight. Your next report, I'll see if I get this one right, 25 March 2019?
DE: Correct.
NJ: And then I think at least three further reports dealing with various issues, one in October 2021?
DE: One on 24 June 2021, one on 19 October 2021, 21 October 2021 --
NJ: Right.
DE: -- and the 29 October 2021 and one recently (inaudible) September. So there have been quite a few.
NJ: I'd like to use, as the basis of your evidence, the substantive report of 31 May 2018, but weaving in the corrections that you have since introduced.
DE: Yes.
NJ: As in all the other cases of which you have spoken, did you receive a large bundle of medical evidence or medical records relating to the treatment of [Baby I] at several different hospitals?
DE: I did. They totalled nearly 2,000 pages, yes.
NJ: Did those records, as in other cases, include X-rays?
DE: They did.
NJ: Did you record [Baby I]'s movements between where she was born at the Liverpool Women's Hospital to Chester, back to Liverpool, back to Chester, then to Arrowe Park and back to Chester, where, sadly, she died on 23 October 2015?
DE: I did, yes.
NJ: Thank you. I'd like to deal with the events the jury have heard about primarily. It may be that you're asked about other issues, but I'm going to confine my questions to the events that the jury have been through in the sequences for. All right? Starting with the first event, which was 30 September 2015, it's set out in your report at paragraph 34, I think.
DE: Yes, 34.
NJ: Did you review [Baby I]'s situation and behaviour and presentation on that day?
DE: I did, I did, and the initial entry, my paragraph 34, was noting that she was a little pale, but handled well. The abdominal examination had noted that her abdomen was full, but soft, and she had a reducible umbilical hernia, which is a common finding in premature babies. In other words, her examination was the same as before and the day before she was self-ventilating in air. In other words she was not requiring additional oxygen and she was not requiring any kind of ventilatory support. So she was breathing on her own.
Then later, on 30 September, she became extremely unwell, had a large vomit, became apnoeic, ie she stopped breathing, and her oxygen saturation dropped to the 30s. Oxygen saturation should be in the mid to high 90s in babies, so a drop to the 30s is extremely disturbing and is literally life-threatening and so she required bagging, in other words she needed resuscitation measures.
NJ: Yes. What time was that, please?
DE: That was -- right, that was mid-afternoon, 13.36 hours, that's when she needed resuscitation. Then later, by 16.30 hours, so later that afternoon, she was pink, in other words normal colour, her heart rate was 130, normal again, her oxygen saturation was now 99%, and she was in air, in other words perfectly normal, and her respiration rate was 28, which is within the normal range. There's a note that the chest was clear, which is clinical shorthand for normal, and the only concern was that her abdomen was distended, that was the word they used, but there were bowel sounds in all areas. In other words, her intestines were working because the bowel sounds could be heard. So therefore, this was a very surprising and sudden onset collapse out of a baby who was previously in a very stable condition.
Another entry noted that she had a respiratory arrest, ie apnoea, stopped breathing, and she was also distressed on handling. So she was an upset little baby.
NJ: Yes. Is this at 10 pm on the 30th?
DE: Yes, 10 pm on the 30th. When they did the blood gas at that time, her blood gas values were satisfactory. If you have breathing difficulties, your carbon dioxide value increases. Her carbon dioxide value was 5.8, which is acceptable. If you have some other problem, your pH value or your bicarbonate value or your lactate value becomes abnormal, they were all within normal limits. So therefore, she made a good recovery following her resuscitation.
NJ: So far as subsequent events were concerned, what in effect happened after that?
DE: Moving on, there was an entry at, again, 22.35 hours, so late at night, again noting that she had become apnoeic, stopped breathing, and bradycardic, her heart rate had fallen, there was chest movement with the Neopuff.
But the other important factor was that the entry that noted:
"Aspirated NGT air ++" (sic).
What that means is that she had a nasogastric tube in, NGT, and air, a lot of air, had been apparently aspirated. Normally, you would only get a little bit of air when you -- what nurses do, sorry, let's... You place a syringe on top of the nasogastric tube and you suck up on the syringe and you'd normally get 1/2/3ml of air maybe.
So therefore, for a nurse to enter "air +++" (sic), it doesn't actually measure the volume of air that was aspirated, but three pluses is usually the greatest number of pluses a nurse will use when aspirating air.
She also aspirated 2ml of milk, which is quite acceptable. That's just a couple of millilitres of milk. That's not a concern. And of course she had vomited. So obviously, all of the milk had disappeared from her stomach as a result of the vomiting.
So therefore by that time there were chest movements, in other words she was breathing normally again, and her sats -- sats meaning oxygen saturation -- and her heart rate had normalised.
As I noted a couple of minutes ago, she was breathing in air with saturations of 99%. Therefore she'd had this extraordinary sudden onset collapse, she'd vomited, loads of air had been aspirated from the NG tube and she had rather promptly recovered.
Then a chest X-ray was actually reported as showing splinting of the diaphragm due to bowel distension and moderately severe bowel distension involving the small and large intestine.
I'm not a radiologist, but I've seen these X-rays or X-ray, we've heard the radiology opinion from Professor Owen Arthurs, but the X-ray shows very striking evidence of lots of air in the abdomen and, as we have noted in an earlier case, if there's a lot of air in the abdomen, ie in the stomach, and in the intestine, that interferes with a baby's diaphragmatic movement, and the diaphragm needs to move up and down for a baby to be able to breathe properly.
NJ: All right. Just dealing with the vomiting, lest it's not entirely clear, was that at 16.30 on the afternoon of 30 September? Your paragraph 35.
DE: Yes. She had a huge vomit at 16.30, yes. I've described it as a large vomit.
NJ: Yes. And thereafter, she had been nil by mouth; is that right?
DE: Yes.
NJ: Okay. If the jury want to remind themselves, my Lord, it's in divider 12 of the number 2 jury bundle and it's in the first section of documents there, page 14780. I don't know where your copy has gone, Dr Evans. Somebody's removed the documents from the witness box for some reason. You'll find about half a dozen documents or so, starting with the observation charts, moving on to the blood gas record, and then the feeding charts. It's document J14780. We see noted there 16.30: "Large vomit plus apnoea."
DE: Yes.
NJ: Then what may be an arrow, I don't know. And then "NBM", nil by mouth.
DE: Yes.
NJ: So that's what we have called event number 1.
Event number 2, 13 October. You, and indeed the jury, may recall this as being an event that happened in nursery number 2 --
DE: Yes.
NJ: -- shortly after Ashleigh Hudson had been helping a colleague in nursery number 1.
DE: Yes.
NJ: We heard evidence that Ashleigh Hudson had returned to the nursery, the lights had been off, and Lucy Letby, said Ashleigh Hudson, was standing in the doorway and made reference to [Baby I]'s appearance.
DE: Yes.
NJ: Right. So taking up that event, and in your report, please, Dr Evans, it's your paragraph 45; is that right?
DE: Yes, yes.
NJ: What did you in particular note about that event?
DE: Well, this was a far more serious event than event number 1. What I noted was that an entry during the early hours, timed at 03.36 hours, said [Baby I] had been found "blue, apnoeic in cot", in other words her colour had drained, she was cyanosed, she was a blue colour, which is what happens if you stop breathing, and she was apnoeic, in other words she was not breathing.
So this led to her needing resuscitation, so she required CPR, in other words chest compressions, and needed intubation, in other words an endotracheal tube was passed into her trachea, into the lungs, and she also required adrenaline on three occasions. She required saline, in other words an intravenous bolus of fluids, salt fluid. She also required sodium bicarbonate, which one gives if the baby becomes acidotic, and she also required dextrose.
All of this was given between 03.31 hours and 03.45 hours, so she had very, very intensive resuscitation over a very short period of time. And the entry notes that by 03.45 hours, there were signs of life and I was present when the local medical and nursing team described this last week.
So her heart rate increased to 100, cardiac compression was stopped, ventilation was continued, and she was transferred to ITU, in other words to a nursery 1, and in terms of treatment, infection is always a consideration when a baby collapses, so she was given some new antibiotics. She was given metronidazole, which is the antibiotic one uses if one suspects necrotising enterocolitis. She was also given ciprofloxacin, which is a broad spectrum antibiotic, which is very effective for what we call Gram-negative organisms. So she had that, so she responded very well --
NJ: Yes.
DE: -- but following what I would consider extraordinary efforts to get her going.
NJ: Yes. Moving on to incident number 3, Dr Evans, which occurred getting towards the end of the night shift of the 13th into 14 October 2015. You deal with this in one of your subsequent reports.
DE: I dealt with it initially in paragraph 51, then I dealt with it in more detail in a subsequent report, but for some reason I left this out of my summary.
NJ: All right. Well, let's deal with your more detailed analysis of what happened, please, Dr Evans.
DE: Yes.
NJ: It's at page 2 of 4 of your report of 25 March 2019. What event was it that you noted, first of all, so far as events in the early part of 14 October were concerned?
DE: Right. Again, very similar event to the one the previous day. So again, desaturations of oxygen at 07.00 hours on 14 October, and despite being on high pressure ventilation and in 100% oxygen. So again, her heart rate at 07.45 hours in the morning -- this is the morning of the 14th, this is my paragraph 51.
NJ: Can we start with events just before 6 am on the 14th, please, which is I think is your previous paragraph.
DE: Yes. Sorry, this is my paragraph 50. So this is just before 6 am on 14 October. [Baby I] had deteriorated. Her heart rate was 180, which is slightly higher than it should be. Her abdomen is distended and mottled. So her abdomen is larger than it should be. It's mottled, in other words the colour of the abdomen is normal, which could be due to poor perfusion of blood into the abdominal area. And the entry also notes that she was tender on palpation. In other words, when you placed your hand on the abdomen, she responded -- she would have responded and you could have -- an experienced doctor would have picked up that her abdomen was tender, and she actually received a morphine infusion.
So that was the early marker during the early hours of 14 October that she was unwell. Then later she had a significant deterioration at 7 am, not improving with bagging, and she was on high pressure ventilation. As I noted, the pressures were 34/5 and pressures of over 25/5 are usually considered to be pretty high in a premature baby. Again, she was in 100% oxygen. So she was really an unwell baby.
Continuing the sequence, by 07.45, her heart rate was below 60 and she received a saline bolus again and adrenaline and bicarbonate, and the consultant arrived at just before 8 am and they considered her condition -- they considered transferring her to Alder Hey Hospital because of concerns regarding her abdomen. But she stabilised and by 6 pm, in other words 12 hours later or 10 hours later, she was now back in 26% oxygen, in other words hardly requiring any oxygen at all, and she was still on ventilation but the pressures now were low, 16/5 -- that's a very low pressure -- the respiratory rate was 35, which is again pretty normal.
Dobutamine, which is a sort of adrenaline-type drug, had been stopped, the morphine was reduced, and the entry by 9.30 pm had shown that she was in a stable condition.
That's the information I got from the medical notes.
NJ: Yes. So that's incident 3, your summary, in effect --
DE: Yes.
NJ: -- of the evidence that we've heard?
DE: Yes.
NJ: Moving on to [Baby I]'s final collapse on night shift of the 22nd into 23 October, you deal initially with this in your report of 31 March 2018.
DE: Yes.
NJ: So far as your pagination is concerned, it may be your page 28 (inaudible) 32 at the bottom of the page. I don't know if you have the same print as I have.
DE: What's the paragraph number?
NJ: There aren't any paragraph numbers in the version I've got, I'm afraid.
DE: Right.
NJ: But you run through things chronologically, so it's the last three pages or so of your report.
DE: Yes. The paragraph starting: "[Baby I]'s final collapse occurred around midnight..."?
NJ: Just before that because I'd like to deal with the lead-up to that. Do you summarise the events of the 22nd into 23 October?
DE: Yes. This is in my paragraph 67 where I note: "The entry timed at 03.04 hours on 22 October noted that her oxygen saturation is 96% and above."
In other words, normal: "There is no increased work of breathing."
In other words, you know, she's breathing satisfactorily: "There's a long line in place [that's an intravenous line to give fluids] and she's receiving her nutrition intravenously."
Again, the other bit of good news is that the aspirates -- and I mean the aspirates from the nasogastric tube -- are minimal, in other words normal, and the abdomen is soft and non-distended. So therefore [Baby I] was now a stable baby.
NJ: All right. If we can look at that in the paper version behind divider 12. It may help the jury just to remind themselves of this. It's in the fourth set of paper documents, so it has the blue 4 in the top right-hand corner. It's at the back of divider 12 there, Dr Evans.
We're looking at J15034 through to 15035, which gives us [Baby I]'s observations if you've got those.
In handwriting, towards the bottom of the page, do we have the saturation levels --
DE: Yes.
NJ: -- of [Baby I] from --
DE: Yes. This is the chart I'm talking about.
NJ: Thank you. And that covers, as we can see, the 20th, 21st and indeed part of 22 October?
DE: Yes.
NJ: The last --
DE: It does.
NJ: -- five columns are the 22nd, I think?
DE: Yes, it goes up to -- yes, it does.
NJ: Just reading across, do we see SaO2, which is the saturation levels of [Baby I]?
DE: Yes.
NJ: Do we see that they are consistently high for the 20th, 21st and 22 October?
DE: Yes, they're all in the high 90s, mid to high 90s, which is absolutely normal.
NJ: Do we see that throughout that period of time [Baby I] was in air?
DE: She was in air, in other words she was not requiring additional oxygen.
NJ: And turning over on to the final page of that document, which is the 22nd, so it runs to the beginning of the final shift, we see there that that deals with 11 am through to 11 pm?
DE: Yes.
NJ: 11 pm hasn't been filled in for reasons that Ashleigh Hudson told us about.
DE: Yes.
NJ: But do we see that also [Baby I]'s saturation levels are there recorded in handwriting?
DE: Yes.
NJ: 100, 95, 97 and 96%?
DE: So high 90s, normal.
NJ: And always in air?
DE: And again in air, yes.
NJ: 21 being the fractional percentage of oxygen in air?
DE: Correct.
NJ: Yes.
MR JUSTICE GOSS: Could I just interrupt you there? Is that the last sheet in that section?
MR JOHNSON: It should be. Is it not in your Lordship's?
MR JUSTICE GOSS: I put it behind the... I had it behind the...
MR JOHNSON: It's not the final sheet.
MR JUSTICE GOSS: The reason is that Dr Evans -- it wasn't -- when we turned over from the previous sheet, he didn't have it as the next sheet. Could you put it behind? I'm just asking to rejig the witness box bundle. Take it out and if you could put it behind the previous observation chart so it forms the sequence, essentially. Do you see my point?
DE: Yes.
MR JOHNSON: So the pagination runs correctly.
MR JUSTICE GOSS: Thank you very much.
MR JOHNSON: All right. So you noted [Baby I]'s saturations, first of all. Did you move on to also note the fact that she, at just before midnight, was rooting?
DE: Yes.
NJ: Which we've heard about, both last week and indeed this morning from, I think, Dr Gibbs.
DE: Yes. Rooting is a very pleasant, normal reflex of newborn babies. What it means is that if you place a finger, your finger, against their lip, the side of their lip --
MR JUSTICE GOSS: We've heard it described.
DE: All right. It's a sign of well-being.
MR JOHNSON: Yes.
MR JUSTICE GOSS: Thank you.
MR JOHNSON: We then heard of the collapse of [Baby I]; is that right?
DE: Correct, yes.
NJ: And you have set out in general terms the circumstances surrounding that collapse in your various reports; is that right?
DE: I have, yes.
MR JOHNSON: All right. I'm going to move on to your opinions. My Lord, that may be the best point for a break.
MR JUSTICE GOSS: Yes. We'll have our 10-minute break now, please, members of the jury. Dr Evans, thank you very much.
(11.58 am)
(A short break)
(12.08 pm)
MR JOHNSON: Dr Evans, I want to deal with these incidents one by one if we can, please. Starting with Wednesday, 30 September.
DE: Yes.
NJ: If I can just ask Mr Murphy to help us by putting the first sequence of events on to the screens, please. If we go to tile 73 first, please. These are the notes of [Dr A] and no doubt you and the jury remember [Dr A]'s witness statement and indeed the notes -- the witness statement being read and the notes being referred to.
If we can just remind ourselves, this is an event that is recorded as having happened at 16.30 that afternoon. There are [Dr A]'s handwritten notes concerning the vomit that you've already told us about; is that right?
DE: Yes.
NJ: Then there was a subsequent desaturation at about 19.00 hours, so at just before the handover from Lucy Letby to Nurse Bernadette Butterworth.
DE: Yes.
NJ: [Dr A]'s notes, so far as that are concerned, are at tile 97. If we can go to tile 97, please, Mr Murphy, because there was a point that I need to pick up from that.
It's the same note in effect. That, at the top of the page, is a note from what happened at 16.30.
If we scroll down the page, please, we come to a note made by [Dr A] arising out of the chest X-ray, about which we heard evidence. Do you remember that?
DE: Yes.
NJ: In the third line of [Dr A]'s note we can see: "No air in biliary tree. No falciform ligament."
You may recall his Lordship invited us to help the jury with what that actually meant when it was read out. Can you just help us with that in the context of this particular X-ray and what had happened to [Baby I]?
DE: Yes. Simply there was no air in the biliary tree, in other words there was no air -- the absence of air in the biliary tree is a normal finding.
NJ: What is the biliary tree?
DE: The biliary tree is the bit underneath the liver where the gall bladder -- and the gall bladder drains from the liver into the intestine.
NJ: So is it part of the digestive process?
DE: It's part of the digestive process, yes. So it's the tube that connects the pancreas, the gall bladder, yes, and where the -- yes, that's what it is.
NJ: Falciform ligament?
DE: I'm not sure -- it's simply saying that there's no air there, that's all.
NJ: So is this in the context of investigating whether there's some digestive abnormality to which the vomiting might be attributable?
DE: Yes, in this particular case they were concerned about necrotising enterocolitis on a number of occasions. If you have a baby with suspected necrotising enterocolitis, one of the serious things, serious findings, is that you get perforation of the intestine. If you get perforation of the intestine, you get leakage of air into the abdomen and that air may be found on the abdominal X-ray. Therefore the absence of this air means there is no air. Therefore you cannot explain any of this on the basis of any kind of intestinal catastrophe.
NJ: Okay. So dealing with [Baby I]'s collapses and her vomiting at 16.30 on 30 September, just to put this into context, can we go back to the paper documents, please, behind divider 12 at the beginning. It should be the second page in, which is 14715.
DE: Yes.
NJ: Do we see there, Dr Evans, that hourly observations of [Baby I] had begun at 3 pm, 15.00 hours?
DE: Correct.
NJ: Do we see that [Baby I] had no respiratory support?
DE: Correct.
NJ: Her sats were 96 and 95, 93, 100% in oxygen, between 15.00 and 20.00 hours.
DE: In air, actually.
NJ: Sorry, yes, in air.
DE: In air, yes. Normal oxygen saturations, not requiring oxygen, extra oxygen.
NJ: Yes. So what conclusions did you draw so far as the episodes of desaturation and the episode of vomiting was concerned at 16.30 and 19.00 hours on that first occasion, 30 September?
DE: The conclusion I drew was that something had happened out of the blue. If she had been sickening for an infection or one of the complications that one gets with premature babies, I would have expected over the previous hour or two or three or more, for instance, for her to need a little bit of oxygen support. I would have expected her heart rate to change, to increase. There might have been drops in her oxygen saturation. There was none of this. So she was entirely stable right until she suddenly collapsed.
My conclusion was that she had collapsed as a result of some kind of event and, looking at the X-rays and looking at the clinical pattern, my opinion was that [Baby I] had been subjected to an infusion of air, in other words air had been injected into her stomach. If you have a large infusion of air into the stomach that interferes with the ability of the diaphragm to move up and down, therefore that interferes with your breathing.
Anything that interferes with your breathing will quickly reduce your oxygen to your tissues, reducing your oxygen saturation, and then reducing your heart rate. In [Baby I]'s case she had a large -- what was described as a large vomit.
NJ: Yes.
DE: The large vomit was therapeutic because by vomiting, she was reducing the pressure in her abdomen and therefore making it easier for her to breathe. And on top of that, as we described a few minutes ago, she had a nasogastric tube in and someone aspirated "air +++", three pluses.
So therefore that would have reduced the abdominal pressure even more, and this is what led to her recovery.
NJ: Yes, all right. Just dealing with the issue of splinting of the diaphragm, if we go to the X-ray, please, at tile 78, what does that show us?
DE: Right. Now, I'm not a radiologist, but that is the diaphragm, that area there (indicating). Below the diaphragm you've got loads and loads of air in the whole of the intestine. There's lots and lots of air everywhere. I think that's the stomach (indicating) -- I'm not too sure if it's the stomach or a large bowel, actually.
NJ: I think Dr Arthurs told us that that was part of the bowel.
DE: Yes, I think so. Anyway, we've got a large amount of air, and Dr Arthurs knows much more about this than me, in the whole of the abdomen. If you have air in the abdomen, you know, that's the whole of the abdomen all round there (indicating), that diaphragm would normally move up and down. But if there's a lot of air there, in the abdomen, it cannot move up and down effectively, and that will lead to the oxygen desaturation, which would have led to the collapse.
The other point I make here is that these are the lungs -- and it's not the best quality X-ray, that's not a criticism, but there's no sign of lung collapse and there's no sign of pneumothorax.
NJ: So in your opinion, just to be absolutely clear, so far as [Baby I]'s desaturations on 30 September was concerned, your view was the cause of that was?
DE: Splinting of the diaphragm caused by an injection of air into the stomach, increasing pressure within the abdomen, interfering with diaphragm movement and therefore causing her collapse.
NJ: Yes, all right. Can we move on to 13 October, please, Dr Evans. Just to remind us all, this is the occasion when [Baby I] was found collapsed in nursery 2 --
DE: Yes.
NJ: -- in the early hours of the morning.
DE: Yes.
NJ: This was at about 03.20 on the morning of the 13th.
DE: Yes.
NJ: The apnoea alarm hadn't sounded, as we heard from Ashleigh Hudson.
DE: Correct.
NJ: But her saturations and heart rate had both dropped and she required some resuscitation, including adrenaline?
DE: She needed an awful lot of resuscitation, actually, and her condition -- this is event 2. Her condition on this occasion was much worse than on event 1. Her heart rate had dropped, had recorded values of 50, which is very low for a baby, it should be 120 or more. Her oxygen saturation was very low, had dropped to 53, that's extremely low and placing her life at risk. And I also noted that at one stage they were unable to detect a heart rate.
So therefore, if they were unable to detect the heart rate it suggests that her heart was not pumping normally.
So the resuscitation they introduced was incredibly vigorous, adrenaline on three occasions and, as earlier, bicarbonate, dextrose and saline boluses. They then did an abdominal X-ray and this was -- I'm sure we can see it, it shows lots of air in the stomach and in the intestines.
NJ: Just to remind us of the degree of breathing support or not that [Baby I] was getting in the immediate time before this collapse, if we go in the paper documents, please, to the second divider in section 12. The documents with the blue 2 in the right-hand corner.
If we find the observation chart that's numbered J14719, we can see that as from 7 am on 11 October, [Baby I] had been having her temperature checked only. There'd been no checks of her heart or of her respirations. Is that right, first of all?
DE: That's what the statement says, yes.
NJ: Okay.
DE: That's what the chart says, sorry.
NJ: It does. We then see, reading across, that although somebody hasn't written in 12 October, it should be written in between 21.30 and 09.30?
DE: Yes.
NJ: Which are the fifth and sixth columns from the right respectively. And it would follow that 13 October, in other words the time immediately before this collapse, begins in the very final column on that page?
DE: Yes.
NJ: So at 01.30, we can see that [Baby I] was on no respiratory support. She was in air; is that right?
DE: Sorry, where?
NJ: We're looking at the very final column on page 14719.
DE: Right, okay. Yes, she's in air, yes.
NJ: Then immediately after the collapse is the first column on the next page, 14720. We see that she'd been intubated, her respiration level being marked with a cross in circles; is that right?
DE: Correct, yes.
NJ: That she was on 15-minute observations, which then went to half an hour and then in due course went to an hour?
DE: Yes, that's correct.
NJ: So looking at the collapse, the fact that she was on no support at the time and looking at the nature of the collapse, what conclusions did you reach as to the cause for [Baby I]'s collapse at 03.20 that morning?
DE: I came to a similar conclusion to event 1 because, again, the collapse was unexpected, she was stable before all of this, but it was much more serious on this occasion, it required even more robust resuscitation, but there had been some kind of incident where her breathing and heart rate had been compromised. I think there's an X-ray somewhere.
NJ: There is.
DE: That shows again lots of gas in the abdomen.
NJ: Yes. Sorry, it was on my screen, I've just lost it. It's about 4.30 that morning, the X-ray. I'll just find it. If Mr Murphy could go to [Baby I] 2, please. Tile number 80. It's an X-ray at 04.25 hours.
So just by reference, perhaps using the mouse that you have there, Dr Evans, can you, in short form, talk us through what you're talking about?
DE: My mouse has stopped working.
(Pause)
Right. So this X-ray shows the chest and about half of the abdomen, so again we've got --
NJ: I think we know the lungs --
DE: The lungs are there (indicating), they're okay. And here (indicating) you've got loads and loads of air in the intestines. Lots and lots more air than you'd anticipate, than you'd expect normally. That's all one can say, really.
NJ: Yes. You've already told us that your opinion was it was in effect that air that had caused this desaturation; is that right?
DE: Something had occurred to interfere with her breathing, so again we're back to splinting the diaphragm. So that is -- given what had happened on event 1, we're seeing a similar pattern of sudden onset deterioration, from which she recovered following robust resuscitation, yes.
NJ: It may be that you'll be asked in more detail to look at the surrounding circumstances, but so far as you were concerned, was there any suggestion in the surrounding circumstances preceding or indeed immediately succeeding this incident that would give cause to believe that there were some benign cause for what happened to [Baby I] at that time on the 13th?
DE: Well, up until, you know, the time she suddenly deteriorated, she appeared to be well. She was in the nursery, the lights were down, as we heard. It was early morning. A nurse had -- she was on monitoring. A nurse had moved away to prepare milk, I think. So this was a nice, well prem baby, simply being looked after in a neonatal unit until she would have been well enough or big enough to go home. So there weren't any warning signs as far as one could tell that would have alerted any nurse or doctor to the possibility that [Baby I] would suddenly have collapsed during the early hours of the morning.
NJ: Thank you. Now, moving on to the third event, which was between 5 am and 7.45 am or so the following day, 14 October. I'm now turning, Dr Evans, to your subsequent report of 25 March 2019.
If Mr Murphy could help us, please, and we go to the third sequence of events for [Baby I]. Tile 70 first of all, please. This is the marker for the first event on the 14th. The second event is at 07.45 and the marker or the record of that is in Dr Neame's notes at tile 115. What conclusions did you draw about this collapse, please, Dr Evans?
DE: Similarly to events 1 and 2, that again she had stabilised following event 2, but then on this occasion her abdomen had become very distended, areas of discolouration. The examination noted: "Abdomen firm and distended."
So again, that her condition had deteriorated as a result of some kind of event that had interfered with her breathing and I really came to a similar conclusion to the one I did for events 1 and 2.
In the report I said -- it states: "The events of the early hours of 14 October are also suspicious and suggestive of inappropriate care, most likely due to the perpetrator injecting a large volume of air into the stomach via a nasogastric tube."
So that was my opinion at that time.
NJ: Just taking that opinion and looking at alternatives, so far as infections or anything like that were concerned, could you see in the records any suggestion of a sort of benign explanation which could account for what happened to [Baby I] when she collapsed?
DE: There was no evidence of it. Secondly, her response to resuscitation is not what one would expect if she had an infection.
Infections tend -- as a result of infection, babies tend to recover over a number of days, not over a matter of minutes or an hour or so or less. So there was no sign of any other complication. There was no collapsed lung, there was no pneumothorax, there was no infection. Again, I think we had X-rays that showed this astonishing large amount of -- volume of air.
NJ: Yes. If anyone wants to refer to it, and if Mr Murphy could quickly put it on to the screen, please, it's tile 129.
Let's start with tile 85, which is after the earlier of the two collapses. This is an X-ray taken at 06.05, following the collapse at about 5 am.
DE: Again, here we are, this is lungs as before, no collapse. That's the diaphragm there (indicating). The whole of this is the abdomen (indicating) and it is absolutely full of air. And this degree of air would be likely to cause interference with breathing. If you look here, I think this here is a nasogastric tube (indicating), so she did have a nasogastric tube in her stomach at the time. So again, I formed a view similar to the view I'd formed regarding events 1 and 2.
NJ: The X-ray taken later that morning was taken at just after 8 o'clock. It's tile 129, please, Mr Murphy. I think the report suggests that it's a similar picture to the one that had been seen earlier in the day.
DE: Yes.
NJ: Is that a fair summary?
DE: I think that's a fair comment, actually, yes, lots of air.
NJ: The jury already have that evidence in the sequence of events in the form of Dr Wright's report. And of course Professor Arthurs has already given us his view.
So moving on, if we may, please, to [Baby I]'s final collapse and her untimely death.
DE: Yes.
NJ: And going back to your original -- your fuller report, please. Dr Evans, can you talk us through, please, what in your view was the cause for [Baby I]'s final collapse and death?
DE: Yes. I thought on this occasion that she was subjected to an infusion of air again. But on this occasion, I think it was more likely that the air was injected into the blood circulation. Going back over the previous few days, she'd been stable, she'd stabilised, she was recorded as breathing spontaneously in air, her oxygen saturations were 96% or higher. In other words, a very stable, well baby. We've talked about rooting, so that's fine.
But suddenly, she collapses, as we heard from Dr Gibbs' evidence this morning.
NJ: Yes, okay. As we have with the others, if we may, let's go to the paper documents to remind ourselves of the picture. So this is divider 4. Right at the beginning of divider 4 is the observations chart, which is page 15034.
DE: We're still in section 12, are we?
NJ: We're in section 12, the fourth divider. The first page is the one we were looking at before. I think we've looked at it at some stage anyway. It's the 20th, the 21st and 22 October --
DE: Yes.
NJ: -- and it runs through on the following page, 15035, to 23.00 hours on 22 October.
DE: Yes.
NJ: And of course, 23.00 hours was left blank for the reasons given to us in evidence by Ashleigh Hudson.
DE: Yes.
NJ: But just concentrating on the general picture, we've got heart rate, respiration rate, temperature, saturations in air, and the position of a probe.
DE: Yes.
NJ: They're all features that are recorded in this data on two separate pages?
DE: Yes.
NJ: What is the general picture so far as whether or not [Baby I] was a well child or whether there was something to suggest there was something wrong?
DE: [Baby I] from these results was a very stable baby. Her heart rate was around 140, which is normal for a baby of this age. Her respirations were 40 to 50, which is normal for a baby this age.
Oxygen saturations, she was on continuous monitoring, but we've got four values here, 100, 95, 97, 96, can't get better than that, so despite being known to have chronic lung disease she was not needing additional oxygen, so that's very satisfactory. And she was in air, in other words 21% oxygen. So this was a stable baby from this account.
By this time, of course, she was several weeks old, she was about 1.8 kilograms from memory, so she was now a good size.
NJ: We heard from Ashleigh Hudson about [Baby I]'s relentless cry at about the time of the first collapse at about midnight. And then that being repeated on the second occasion.
DE: Yes. I think the relentless crying from Ashleigh Hudson's opinion was on the first part of the --
NJ: Both collapses, yes.
DE: So Ashleigh Hudson's evidence was very moving because nurses and doctors know what one would call a normal cry sounds like because babies will cry if they're hungry, they'll cry if you take blood tests from them because it hurts. But it was clear that this was a very abnormal, different kind of cry, and I would have interpreted that cry as the cry of a baby who was in pain and a cry of a baby who was severely distressed. In other words, this baby was in severe pain from the description we heard from the local team last week and this morning. That is an extremely disturbing phenomenon. We heard it in previous cases about this abnormal cry. So there was no obvious explanation why she was crying relentlessly and it was very loud. That's what we heard.
NJ: Yes.
DE: Because there wasn't -- it wasn't as if somebody was shoving needles into her or, you know, causing her harm at all. So this was an extremely disturbing phenomenon.
NJ: And thus you concluded, so far as the causes of her collapse and ultimately her death were concerned, that was the result of what?
DE: I think she was a victim of having air injected into her blood circulation. This also probably explains her crying, her distress, and the failure of the medical team the second time round to save her life.
MR JOHNSON: Thank you, Dr Evans. Would you wait there, please?
MR MYERS: Dr Evans, do you agree that [Baby I] was in general a very poorly baby regardless of the particular events that we're looking at?
DE: No, I don't, actually.
BM: Do you agree that she had recurrent episodes of abdominal distension regardless of the events that we're looking at?
DE: She did.
BM: Do you agree that she had recurrent desaturations regardless of the events we're looking at?
DE: Yes, she did.
BM: Do you agree that she required oxygen in various ways, not all the time, but through periods of her time on the neonatal unit?
DE: Yes.
BM: Do you agree there were periods when she had infection or suspected infection and received treatment for that?
DE: Yes, she did.
BM: Do you agree that there were periods when she had suspected NEC and received treatment for that?
DE: Yes.
BM: Do you agree that she failed to put weight on as would have been expected?
DE: Her weight gain was -- could have been a bit better, but there are explanations for that, as for the reasons that we've been discussing this morning, yes.
BM: Do you agree that the failure to put on weight could be a consequence of the cumulative problems with her ill health over time?
DE: Yes.
BM: We've been looking at four events. There's an additional matter I'd like to ask you about, Dr Evans, about 23 August 2015.
DE: Yes. I'm familiar with that event, yes.
BM: There are abdominal -- there's abdominal distension identified in the case of [Baby I] on that day, isn't there?
DE: There is, yes.
BM: And there'd been radiographs of that, haven't there?
DE: Yes.
BM: I'm turning to just ask you this. In your first two reports, so the report on 8 November 2017 and the report on 31 May 2017, in both of those you set out that you formed the view she'd received a large bolus of air via the NGT, the nasogastric tube, didn't you?
DE: That was my opinion at the time, yes.
BM: In other words, something was done to her that should not have been done to her?
DE: Something like that, yes.
BM: Moving to event 1, 30 September 2015, you've given evidence to us just now that in your opinion this arises because of splinting of the diaphragm by an injection of air into the stomach.
DE: That was my opinion and that was the report of the local radiologist as well in relation to the X-ray taken at the time.
BM: In relation to splinting of diaphragm. The local radiologist didn't say anything about injecting air into the stomach?
DE: No, splinting of the diaphragm, I said.
BM: When you made your first report, your opinion was that this was due to air injected in the stomach via a syringe down the NGT, wasn't it?
DE: Something like that, yes.
BM: And you repeated that in your second report, didn't you?
DE: I did.
BM: How much air would it take to cause that to happen?
DE: A lot, but what I can't say, and nobody can say, is how much because what you cannot do, you cannot carry out some kind of research where you inject increasing amounts of air into a baby's stomach until they either vomit or stop breathing. I mean, that would be grossly unethical and therefore you cannot carry out a research study to do that.
What we do know is that normally, babies will have a small amount of air in the stomach because they swallow air, and that doesn't cause them any problems. We also know that babies who are on CPAP will get air into the stomach, and that normally doesn't cause them problems.
Therefore, for a baby to vomit, that's the first point, means that she would have had an awful lot of air injected into the stomach. Professor Arthurs suggests more than 20ml in his evidence, but he cannot give a figure. You would need to give an awful lot of air and milk for a baby to vomit because you don't vomit air, you only vomit liquid. And of course, the nurse who applied the syringe to the nasogastric tube got out "air +++."
My experience from these cases -- I don't know of any baby that's had more than three pluses of air ascribed to them. So therefore, she must have had an awful lot of air injected into the stomach to cause both the vomiting and the collapse.
BM: Do you know how long it would take for the air to be injected as you're suggesting, let's say at the time of the event at 4.30 in the afternoon?
DE: No.
BM: How can quickly would there be vomiting and desaturation if the abdomen has been splinted?
DE: I can't say. You can't say.
BM: Help us.
DE: You can't say. I suspect it'd be quite quick, but again, because this is something that's incredibly rare, this is incredibly unusual, the cases that we're hearing about in this trial are incredibly unusual in their presentations. It's not possible to give an exact volume of air and it's not possible to give an exact time in terms of minutes following the injection of air that the baby would vomit. But I suspect that the greater the volume of air injected, then the earlier -- sorry, the quicker the baby would vomit, but I wouldn't want to put a time on it.
BM: Is there any data or research that you have as to how this mechanism would work?
DE: No, the only times I've seen events like this is in this -- are in these series of cases.
BM: So this is something you have come up with for this series of cases, is it?
DE: What you do in clinical medicine is you look at all options and once you've excluded every other option, then maybe you're left with -- maybe you're left with just one explanation. And in my opinion, this is the explanation in this particular case.
BM: To be clear, you cannot tell us how much air would be involved?
DE: No (overspeaking).
BM: You cannot tell us how long it would take for that air to be put in?
DE: No, just quite a bit.
BM: And you cannot tell us how quickly there would be a reaction to that air having been put in?
DE: It would have occurred quickly, but given the rarity of this and the fact that one -- well, first of all, one cannot do research to check this out because it would be unethical, partly because of the rarity of the phenomenon, and thirdly, people who inject air inappropriately into babies' stomachs tend not to record the volume of air they've injected into it.
BM: But there is in fact no clear basis to show air has been injected into this stomach at all, is there?
DE: Oh yes, there is, because we've got these abdominal X-rays with loads of air in them and that air got in there somehow and the only way that air can get into the gastrointestinal is into the oesophagus, into the stomach. Therefore that's pretty compelling evidence that air has gone in and the fact that on this occasion and in previous cases when the NG tube was aspirated lots of air came out. Therefore we know the air's gone in because it's come out. It couldn't have come out if it hadn't gone in in the first place.
BM: Did you accept what Professor Arthurs says with regards to the radiograph on 30 September, that there are features of NEC in association with that?
DE: He showed one marker of NEC on one of the X-rays and he showed a little circle at the bottom, the bottom left looking at the X-ray, so the bottom right quadrant of the X-ray. I think that's the only finding he noted where he said maybe that could be due to NEC.
BM: When we come to the episode round about 7.30 pm in the evening, you've identified from the notes of Bernadette Butterworth the entry "aspiration +++", haven't you?
DE: Yes.
BM: And you heard the evidence from Nurse Butterworth that that took place after the Neopuff had been used on [Baby I]; you recall that?
DE: Oh yes. If she'd had resuscitation, then of course that's an explanation for the air, but of course the air was in there beforehand, which is why she had collapsed in the first place.
BM: No, you don't know that, Dr Evans.
DE: She had abdominal distension which was noted at the time of her collapse.
BM: You have been listening to the evidence in the course of the case, haven't you?
DE: Yes.
BM: You heard Nurse Butterworth say she saw the stomach extend as the Neopuff was being used on it?
DE: Yes, I did, actually.
BM: Which can be a cause of stomach distension, can't it?
DE: It would have added to the distension she had before.
BM: And what we have on 30 September is actually consistent with [Baby I]'s ongoing condition, isn't it?
DE: No, it's not. No, it's not. I'll just mention necrotising enterocolitis. First of all, I think the medical and clinical team in Chester were very sharp in querying NEC in prem babies. That's good practice because early intervention can stop the NEC getting worse.
In this particular baby, there's little -- we've got one bit of one X-ray where there may be evidence of NEC. But sadly, we've got more evidence to show that she had did not have NEC, which is that there was no evidence of NEC on post-mortem. Therefore, necrotising enterocolitis was not a significant factor in [Baby I]'s illnesses and I make no criticism of the clinical staff for considering NEC in their diagnosis. That's good practice. But given that the poor baby died and there was no evidence of necrotising enterocolitis on the pathology report, then we've got pretty compelling retrospective evidence showing that necrotising enterocolitis was not a significant feature in one or more of [Baby I]'s deteriorations.
BM: I make it plain, Dr Evans, I'm suggesting to you that when you look at that event, you are taking different bits of evidence and putting it together with a prosecution bias to support this allegation.
DE: Well, I keep getting told of my prosecution evidence, which is obviously untrue, because when I was investigating this case and all of the other cases, nobody was being prosecuted, nobody was being arrested, nobody had a finger pointed at them. All I had to go on were the clinical notes and I was -- I never visited the hospital, I never spoke to any of the medical staff, I never mentioned -- I never -- no one in Cheshire Police said anything to me about any particular nurse.
I looked at the events, as I said, some months ago, with a blank sheet of paper and I wasn't looking to point the finger at anyone, I was looking to find out what on earth was causing this collapse and the other collapses that we saw, that we've seen. So therefore, there is no prosecution bias at all in my evidence here and I think to add something to that, which I have not mentioned before, I'm familiar with giving evidence to lawyers acting for the defence in criminal cases, more of them actually than for the police, so I don't think that lawyers acting for the defence will turn to doctors who are prosecution-minded, if I could put it that way. So therefore this persistent fiction that I am a prosecution person is a pure fantasy, it is incorrect, and it's incorrect in this case and it's incorrect in all of the other cases.
I was the first to identify the issues in this case and in other cases and I did so in 2017 and I relied and -- sorry, I depended entirely on the clinical notes. Since then, I've heard lots of additional information and as far as I can tell, as a consultant paediatrician, from the information we've had from Dr Gibbs today, the clinical team last week, all of them reinforce the conclusions that I came to over 5 years ago. Okay?
MR MYERS: My Lord, I'm going to turn to event 2, but I just notice that it's 12.58 and I wonder whether this would be an appropriate point to stop.
MR JUSTICE GOSS: Certainly. There's no point in starting on event 2. Thank you very much.
We'll break off then, members of the jury. Could you be ready, please, to come back into court at 2 o'clock? Thank you very much.
(1.00 pm)
(The short adjournment)
(2.00 pm)
MR JUSTICE GOSS: Yes, Mr Myers.
MR MYERS: Dr Evans, I am going to ask you some questions now about what's described as event 2, which is the early hours of the morning of 13 October 2015. In your evidence you said that something had occurred that had splinted [Baby I]'s diaphragm and, given the events, probably a similar pattern to event 1.
DE: Yes.
BM: Just to keep track, in your first report on 8 November 2017, and in your second report on 31 May 2018, you made it clear that your concerns were that a large bolus of air had been introduced via the nasogastric tube, didn't you?
DE: Yes.
BM: That's what you were saying at that point. In fact, do you agree there is no evidence that an NGT was in situ before that collapse? Do you agree with that?
DE: I need to check that.
BM: If we look in the paper charts that we've got behind divider 12 at the events. Page 14789. So it's after the observation charts for event 2. Can you see, Dr Evans?
DE: Yes.
BM: The feeding is all by bottle, isn't it, at this point?
DE: Yes, it is.
BM: If we go over the page again, feeding for the one entry that we have is by bottle, isn't it?
DE: Yes, yes.
BM: Therefore, if that's right, there would be no nasogastric tube for air to be put down, wouldn't it?
DE: I would need to check that to get it right. It's quite common for nurses to leave nasogastric tubes even when babies are getting used to bottle feeds, so I'd need to check that, okay?
BM: It's not a surprise point for you, this, is it because it's something which you considered when you came to write your report on 19 October 2021, isn't it?
DE: Wait a minute... What did I say then?
BM: I'm looking at page 7 of that report. My Lord, it's the statements page 4498.
DE: Which paragraph is this?
BM: It's the top paragraph on page 7. So we've had the report in 2017 saying air down the NGT. We've had the report in 2018 on 13 October saying large bolus of air down the NGT. Then what you say in your fourth report, which is 19 October 2021, is this:
"In relation to the specific question and assuming that she did not have an NG tube in place at the time of her collapse, the explanation for her being found cyanosed and not breathing is that this was the result of airway obstruction: [Baby I] was smothered. If she'd stopped breathing as a result of some natural event one would have expected alarms to go off quickly following her respiratory arrest. She would have been discovered before her heart stopped and her response to resuscitation was satisfactory. From then onwards [Baby I] had an NG tube in place."
All right? So first of all, do you see what I'm referring to?
DE: Yes, I do.
BM: Secondly, it had been drawn to your attention in the course of the writing of the reports that there may not have been an NGT in place; that's right, isn't it?
DE: That's why I said some event had taken place, so if an NG tube was in place, we're talking air. The other option I came up with was smothering. The other option I came up with was that she was smothered, in other words there was an airway obstruction of some description which had caused this collapse.
BM: So once you discover there was not an NGT in place, you simply switch to an allegation of smothering, don't you?
DE: It's another explanation, it's another explanation for why a baby who is stable would suddenly collapse and require such extraordinary degree of resuscitation. So yes.
BM: It's another example, Dr Evans, of you looking around to work out some sort of explanation that can support the allegation, isn't it?
DE: No, it is my looking to see what -- looking for an explanation as to what caused this baby to collapse on 13 October when there was no evidence of infection or collapsed lung or any of those other things we've discussed over the last few weeks that could explain it. Therefore that is what led to my exploring these options.
Whatever it is, one cannot explain her collapse of 13 October as a result of some -- one of the common causes that causes babies to collapse.
BM: And gaseous distension of the bowel on the X-ray after 4 o'clock that morning isn't going to be caused by smothering, is it?
DE: No.
BM: So that doesn't even fit with that piece of evidence, does it, smothering?
DE: What I believe and what I consider is that she was put in harm's way as a result of some event on the 13th. If she has an NG tube in place, that's the best -- that's the most likely explanation. If you ask me could she have suffered a smothering event, that is an option I considered in my later report.
BM: If we move forwards in time, we've got the joint report that we've referred to that you signed in August of last year, didn't you?
DE: Yes, I did.
BM: And of course, as part of that you considered the case of [Baby I].
DE: Yes.
BM: I'm looking at the statements -- sorry, it's on the DCS at M1265, my Lord. But Dr Evans, you deal with 13 October in your joint report at paragraph 9 of that joint report, page 9. Have you got that?
DE: I do.
BM: Now, we've had the first two reports of air down the NGT. We've had the fourth report with smothering. Now when we get to August 2022 we have this at point 9, page 9: "The collapse on 13 October was secondary to excessive amounts of air introduced into the gastrointestinal tract via the NGT and to air embolus."
DE: Yes.
BM: So in August this year, you were having a run with air embolus on this, weren't you?
DE: Three possible options, all of which represent inflicted injury, inflicted cause, none of which can be explained on the basis of a natural history of what happens to premature babies. So, yes, those -- all three options were matters that I think one should consider. The air embolus thing -- we'll go on to item 4, I'm sure, where the evidence for air embolus is more striking. But yes, we've got three possibilities. Which one it is, all of them represent inflicted injury of some description.
BM: Did the reports -- in the four reports where you dealt with causation before the joint report, no reference to air embolus at all, was there?
DE: That's correct.
BM: And air embolus comes up 5 years later, doesn't it?
DE: Yes, it does.
BM: And that's because you are chopping and changing as you go along to try to find a mechanism to support the allegation, aren't you?
DE: No, I am not. I am not. What I think we need reminding of is that I -- when I prepared my reports in 2017 and 2018, I was relying wholly on the clinical notes. I was unable to speak to any of the nursing staff, I was unable to speak to any of the medical staff, I did not have the benefit of discussing things with fellow paediatricians, I did not have the benefit of discussing with Dr Owen Arthurs or anyone else.
So therefore my opinion is based on less evidence than at the time than what we have now. And of course, I did not have the benefit of listening to the Chester nurses and Chester medics when I was preparing this report. Therefore, to suggest that my report 5 years ago could give you all of the answers, you know, 10 out of 10, is unrealistic.
I'm used to giving evidence where one accumulates additional evidence, as one goes along, and so that's what's happened in this particular case. We've got four events we've discussed here and all of this is extremely challenging, obviously, and some of the evidence I have heard I only heard last week, you know, the effect of the crying, for instance, it was relentless, loud and so on.
Now, I knew -- you know, the medical notes note she was crying but not that... So therefore my reports are more likely to be picked up by showing bits missing than any other report because my report was relying on less information than anyone else. I'm not going to apologise for that. That's the way it is. Mr Johnson has described my reports as sift reports, in other words: let's look at what's going on here. But what I have said all the time is that event 2 and events 3 and 4 was the result of inflicted harm. Okay? And so I've raised the issue of smothering, I've raised the issue of air embolus. The evidence in favour of air embolus is more compelling in relation to event 4, which is what led to her death. But that is why clinicians don't apologise for forming an opinion and then amending their opinion as new information comes into being.
BM: Crying doesn't feature on the 13th, doesn't it?
DE: No, I know it doesn't.
BM: There is nothing in the clinical notes you have to support a diagnosis of air embolus, is there? Because if there was, you would have made it earlier, wouldn't you?
DE: Well, nobody raised the issue of air embolus from -- sorry, none of the local team raised the issue of air embolus and having -- so I was more comfortable in forming a view that it was... that her collapse was the result of air in the stomach rather than air in the bloodstream given what -- partly because of what had happened on 30 September. So yes.
BM: By your fourth report in October 2021, you had statements available because, for example, you make reference to crying, don't you?
DE: Well, that's why we've raised the issue in 2022 about air embolus, so yes.
BM: And in 2021, the fourth report, you still don't mention air embolus, even though you had all possible material then, do you?
DE: I didn't have -- I hadn't heard the evidence that we've heard in this trial in 2021. We've only heard that last week.
BM: Well, it can't be because of the evidence in the trial because you mention air embolus in your joint statement in 2022. You haven't even mentioned it today when dealing with 13 October, have you?
DE: No.
BM: So mentioning it in the joint statement in 2022 has nothing to do with the trial, does it?
DE: I don't follow what you're getting at.
BM: You just told the jury that you have heard evidence in the trial and that helped you form your opinion.
DE: It adds to all the other evidence I've heard over the last 5 years. So everything -- we're clinicians, we accumulate information from all sources of -- from all sorts of sources. The greater the amount of information we get, the more accurate the diagnosis.
BM: You mention air embolus in 2022, don't you?
DE: I did.
BM: Yes, and you have dropped it on this event in your evidence today, haven't you?
DE: No, I haven't dropped it at all. I've kept it for evidence -- for event 4 because I am -- because the evidence in favour of air embolus in event 4 is more compelling, so I've kept it for event 4. After all, it's what happened in event 4 that led to the death of the little baby.
BM: And today you haven't made any reference to it in event 2, although you did in your joint statement, didn't you?
DE: Yes, that's correct.
BM: Let's look at event 3, please. I think we've got to grips to the fact that there's two parts allegedly, round about 05.00 and 07.30.
DE: Yes. Event 3, I included it in my report of 31 May 2018, but I left it out of the summary in that report, which is what led to my needing to do another report on 25 March. That's because I simply overlooked it in the summary. I didn't overlook it in preparing my report.
BM: Let's break that down. Event 3, Dr Evans, when you dealt with this case, [Baby I]'s case, in your first report in 2017, you had available to you the necessary clinical notes, didn't you?
DE: I did.
BM: And you made no reference to any event in what we call event 3, did you?
DE: I did, actually.
BM: No, not as a suspicious event.
DE: Just a minute, bear with me, bear with me.
(Pause)
I have, actually, paragraph 45 of my report of November 2017 says: "The next entry's at 05.55 hours on 14 October. Just before 6, [Baby I] had deteriorated. Heart rate is 180. Abdomen is distended and mottled and is tender with guarding on palpation."
So I did mention that in my original report and I also added for good measure that I'd seen the X-rays at 06.05 hours and 08.03 hours on 14 October and note at paragraph 46 in my original report: "Both note significant dilatation and air in the intestine, and a chest X-ray timed at 11.18 on 15 October shows little change to the chest X-ray carried out 2 days later."
So yes, I had picked up the event 3 in my original report --
BM: Right.
DE: -- but apologies for not including it in the summary.
BM: Now I'd like you to answer the questions I'm going to ask as accurately and concisely as possible to assist us all. I have just put it to you that you didn't mention event 3 as a suspicious event in your first report; yes? That's what I asked you. Do you recall that?
DE: Yes.
BM: You've told the jury that you have referred to event 3 in the first report.
DE: It is in the first report.
BM: Right.
DE: It is in my first report, yes.
BM: You go through what happened on 14 October in your general chronology in the first report, don't you, at paragraph 45?
DE: I do, yes.
BM: Yes. When we come to your opinion, let's turn to paragraph 22, where you identify suspicious events. Let's go to paragraph 22.
DE: Yes.
BM: Are you there? Page 22, sorry, of 23.
DE: Which paragraph is this? Because my copies are different to...
BM: Starting at paragraph 69 in your first report.
DE: Yes.
BM: Right. At this point you set out what you consider to be suspicious events, don't you?
DE: Yes, I do.
BM: Right. You set out that in your opinion, paragraph 69: "[Baby I] received inappropriate care on 23 August."
DE: I did.
BM: You say she received inappropriate care on 30 September?
DE: I did.
BM: And, you say, 13 October?
DE: I did.
BM: You say the 22nd into 23 October?
DE: I did.
BM: You don't mention 14 October as a suspicious event anywhere there, do you?
DE: No, I left it out.
BM: And you've just deliberately tried to confuse the issue in answer to my question by taking us back into the body of your report where you talk about the chronology, haven't you?
DE: No, I have not, actually. I should remind everyone that I prepared over 30 reports in a very short period of time for Cheshire Police at a time when nobody was pointing fingers at anybody and where there were no suspects. On this particular occasion I overlooked 14 October. It's as simple as that.
When I was asked what about 14 October, because it's very clear that there was a suspicious event on 14 October, I am sorry that I left it out, so when I was reminded of that I put it in, in my report of 25 March 2019. So yes, I overlooked it, and I'm sorry about that, but it was an oversight and not because I did not consider it suspicious.
BM: If you considered it suspicious you'd have put it in, wouldn't you?
DE: No, if I had had a bit more time, instead of preparing 30 reports in a month, over 30 reports in a month, if I'd been preparing this report and only this report, I suspect I'd have put it in actually.
BM: If we move forwards then to when you've had about another year of time, 31 May 2018, rather 6 months, we have your opinion on the second report at page 30, don't we?
DE: We do and I left it out again.
BM: And you mention 23 August, 30 September, 13 October and the 22nd and 23 October; yes?
DE: I did, I left 14 October out.
BM: That's because actually you understood at that point that what happened on 14 October is sadly a natural consequence of whatever happened on the 13th. That's what happened?
DE: The two events were fairly close together. They were within 24 hours. I just wonder in my mindset whether I -- you know, whether I put 13 and 14 together instead of separating them, but I'm not going to apologise for that. If I get asked to clarify the events of 14 October, which is what happened, then I will clarify it. That's what I have done. That's fine.
BM: In fact, Dr Evans, what happened on the 14th and in fact on 15 October, sadly, is a consequence of [Baby I]'s deterioration on the 13th, the one event then, and could be seen in that way, couldn't it?
DE: I'm not sure. No, I disagree with you there. She recovered on the 13th and then crashed again on the 14th. Babies don't do that -- if for instance the 13th event was due to infection or one of the common causes then I would not have expected her to recover so quickly. I'd have expected her to show signs of being unwell before that anyway. I would not have expected her to recover so quickly. And I would not have expected her to crash so precipitously on the 14th.
So I'm here giving evidence. In my opinion, the event of 14 October is a suspicious event.
BM: On the 14th, having stabilised on the 14th, she then crashed, sadly, even more dramatically going into the 15th, didn't she?
DE: She did.
BM: And that is, sadly, the course of [Baby I]'s condition isn't it?
DE: No, it isn't. No, it is not. You see, that is where you're wrong.
BM: You agree on the 14th into the 15th we started with Dr Neame with her on the ventilator at 21.30 being stable and with good blood gas, didn't we?
DE: Yes.
BM: And then it's going into the early hours of the following morning, on the 15th, that [Baby I] deteriorates dramatically, doesn't she?
DE: She deteriorates, yes.
BM: She deteriorates enough to have to be transferred out of the hospital, doesn't she?
DE: Yes, she does.
BM: And taken to the tertiary unit, doesn't she?
DE: She was.
BM: That event on the 15th followed from her medical condition, didn't it?
DE: It did.
BM: And working back in the same way, so did the 14th follow from the events of the 13th, didn't it?
DE: No, no, no. When she arrived at Arrowe Park on the 15th -- let's have a look. There was an explanation for the fact she deteriorated: she had a blocked ET tube. Therefore it was not a suspicious event. They unplugged -- they removed the tube in Arrowe Park and she picked up and she returned to Chester at 10.30 on the 17th. So she was in Arrowe Park actually for quite a short time.
In this case and in all other cases, what I have done and what we've all done, we've looked at all events where the little girl has deteriorated and we've looked for a cause. Now, a blocked tube is a cause of a deterioration, so it's not suspicious. And once it was treated, yes, she recovered. But these events that were introduced by the prosecution today were suspicious and out of the ordinary. And where the explanation relates to excessive air in the abdomen and in the end excessive air -- well, air, not excessive air in the circulation.
So therefore, separating -- I think I've said in my first report that this is the most complicated case to date. I've mentioned that. So I'm not going to try and duck that one. This is a -- we've got four events, four suspicious events here, so these -- you know, this is a very, very complicated case. And if I could quote something -- just a minute. I'm not going to apologise for taking my time over this. If I could find it. Never mind. Anyway, I've said somewhere that this is the most complicated case. This is a highly complicated case. Paragraph 74, yes. So there we are.
BM: Event 4 I'm turning to next, Dr Evans.
DE: Yes.
BM: By the way, do you accept that on the 13th into 14 October, event 3, 14 October, abdominal distension, first of all, was consistent with [Baby I]'s ongoing condition, wasn't it? She had a tendency to abdominal distension?
DE: No, she had a tendency to abdominal distension, but her abdominal distension, which was recorded on a number of occasions, did not lead to her deteriorating, despite her abdomen being bigger than, you know, than the average, she was a stable baby. Okay? Now, premature babies don't have a lot of muscles in their abdomen and therefore if you're not used to -- the abdomen of a little prem baby quite often looks quite big. But if the abdomen looks quite big but they are stable from a breathing point of view, it's not a cause for concern and if they're stable from a feeding point of view, in other words there's milk going in one end and poo going out the other, again that is no cause for concern.
So that is what we're looking for rather than the shape of the abdomen itself.
BM: And so far as the 14th is concerned, [Baby I] was on a ventilator and she also received assistance from the Neopuff. Neopuff in particular is quite capable of causing distension, isn't it?
DE: It will add to any distension that is there, yes.
BM: You can't distinguish between what it adds or what could have been there by any other means, can you?
DE: If there's some abdominal distension at the beginning and then you give them Neopuff and it gets more, gets worse, then I think it's reasonable to suggest that it's the Neopuff that is adding to the distension.
BM: And if that happens, it becomes very difficult, if not impossible, to work out what is due to the Neopuff and how much was there in the first place?
DE: That is correct.
BM: Event 4. We move to the evening, very late night of the 22nd into 23 October. In your evidence you explained to the jury that you regard this, the cause of this, as in effect an air embolus intravenously, don't you?
DE: I do.
BM: And you've said that's because of crying and distress and the failure of the medical team to save life.
DE: Yes. There are other things which I've mentioned, but which I have not mentioned in detail in my reports, which is to do with mottling. I'll explain why I have not explained that.
There are lots of discolouration changes recorded by the doctors, but I think the significance of them has become apparent as I was listening to their evidence.
If the examination notes comment on mottling of the skin, then you cannot use that indicator as a marker of air embolus because mottling simply means discolouration, poor circulation of the abdomen. Dr Gibbs this morning was going on about mottling of the abdomen but not of the face, her face was pink, and then she was pink all over within 5 minutes. That type of discolouration cannot be explained on the basis of -- it's more difficult to explain that discolouration on the basis of poor perfusion.
So therefore, the main reason why I've reached the conclusion of air embolus is that the little baby died -- sorry, the little baby collapsed and the resuscitation was unsuccessful.
In terms of crying, the description of Ashleigh Hudson was very, very striking, you know, relentless crying, loud crying. Nurses are familiar with nurses' (sic) crying. So she was in pain, okay? She was in pain, she was in distress. That is Ashleigh Hudson's description --
BM: Dr Evans, I'm going to come to crying shortly. I wonder if I could just deal with the features you've given us just to move this on a little bit, please.
DE: Okay.
BM: Mottling. Talking about mottling and skin colour, that is you're adding to this now, isn't it?
DE: No, no, no, no. Mottling was something that was described by the medics. It's a non-specific feature in an unwell baby and there is more than one cause for it. And, as in every case I've prepared a report for, if I cannot rule out another cause, I don't include it as a factor in inflicted injury.
BM: You're including mottling --
DE: Sorry, I only -- I limit my opinion regarding inflicted injury to events where there is no indicator at all of a natural cause. Okay? So I think that's important. In other words, the threshold, the bar I set myself for coming down on the side of this collapse or this death being due to inflicted injury means that I've ruled out the usual causes.
So therefore, with mottling I have not included it because there's more than one cause for mottling.
BM: Right, so mottling does not go to demonstrate air embolus, does it?
DE: Not on its own, no.
BM: And Dr Gibbs is quite clear the mottling was on the trunk and the peripheries, do you remember that --
DE: Yes.
BM: -- not just the trunk? And he also generally described the colour being consistent with poor perfusion.
DE: Yes.
BM: Right. So colour doesn't really make this air embolus, does it?
DE: Oh, mottling doesn't, no.
BM: No. And the factors -- to get back to your evidence earlier, the factors which you say raise air embolus are the crying, the distress and the failure of the medical team to save life?
DE: The fact that she crashed in the first place, I think, is the more significant factor actually, yes.
BM: And as for the very sad events that form the later part of what happened that morning, they took place after [Baby I] had just had one crash, didn't they? There's two parts to this, isn't there?
DE: Yes, there's the one around midnight and then the one about an hour and a half later, yes.
BM: And the one actually about 1 hour and 10 minutes later followed a crash, didn't it?
DE: Yes.
BM: And in fact, Dr Gibbs has given evidence that in that situation, there probably does lead to a weakening of her ability, cardiac ability to withstand what was happening.
DE: Right. She was well enough following her first crash to be noted to be fighting the ventilator, which is a good sign, and well enough for Dr Gibbs to take the tube out and she was well enough to carry on breathing on her own, right, after crash number 1, the one around midnight. She had made that level of recovery.
So if she was unwell enough or, for what it's worth, well enough for Dr Gibbs to go home -- now, I've been in this situation loads of times at midnight where you resuscitate a baby and, if you're not too happy, you definitely do not go home. So therefore, she was stable following the first crash and whatever the effect of the first crash would be insufficient for her to crash once more an hour later unless something else had happened.
The second crash was not spontaneous, in my opinion, and the second crash was not a side effect of the first crash if I can put it that way. Okay?
BM: And she, it seems, made a striking and very good recovery after the first crash, didn't she?
DE: She did, yes.
BM: Which is utterly inconsistent with a suggestion there's a failure of the medical team to save life?
DE: No, they saved her on that occasion. I mean, there have been several cases in this trial consistent with air embolus, where they had actually saved a life. [Baby B] being the first one. So I cannot compliment the team enough for the efforts they made to save a number of these babies. They really threw everything at them.
BM: You just chop and change your theory on air embolus to suit the facts, don't you, to fit in with the facts?
DE: No, no, no, clinical medicine -- that's the way of clinical medicine: you apply the same principles to each condition and hopefully your treatment works. If your treatment does not work then you lose your patient. That sadly is the case. That applies to all conditions. People get heart attacks, most survive, some don't, you know. It's the way it is, sadly.
BM: So --
DE: It's not chopping and changing, okay?
BM: If we look at the first event that night, where you are saying it's air embolus because you rely upon crying, distress and the failure of the medical team to save life. That appears to be an air embolus in which it wasn't necessary for the medical team to save life.
DE: Sorry, I don't follow that. Say it again?
BM: It wasn't fatal, was it?
DE: The first one, no, it wasn't, actually.
BM: Right. So if your criteria for what is an air embolus -- and I apologise if this is not clear, I'll set it out clearly -- is crying and the failure of the medical team to save life, that cannot apply to the first part of what happened that night, can it?
DE: It does because air embolus is fatal, but it is not fatal in 100% of cases. It was not fatal in the case of [Baby B] [Surname of Babies L & M] and it was not fatal -- sorry, not [Baby B] [Surname of Babies L & M] , [Baby B]. And it was not fatal in one of the cases we're going to be discussing later. They nearly gave up on that particular case. We'll discuss that in a couple of weeks.
So it's not always fatal. And in the research I did, appreciating that there is not a great deal of research about air embolus in babies, I have picked up one or two cases where the evidence for air embolus was clear but where the babies survived. So you do get survival with air embolus but it is unusual, sadly.
In [Baby I]'s case she survived the event of midnight thanks to the resuscitation she had. But sadly, she didn't survive her second event. And in my opinion, the second event was the result of a second injection of air into her circulation. It was not a complication of the first crash of 23 October.
BM: Dealing with the first event therefore, the only matter that leaves then on which you base this as an incidence of air embolus is crying or distress?
DE: Right. Let's talk about the crying then, shall we?
BM: Perhaps you could answer the question to assist us all, Dr Evans. The only matter that you rely upon for air embolus is crying or distress. That's what we're down to, isn't it?
DE: No, it is not. It is not. It is a sudden onset of deterioration that is life-threatening in a baby who was otherwise -- who had been stable, okay, who had been stable. We've gone through this in these notes here: right up to just before she crashed she had a normal heart rate, a normal respiratory rate, saturations ranging from 96 to 100% in air. Right? That was the -- that was her condition right up to late on the 22nd. That is this chart here (indicating). That is this chart here.
So she was an extremely well little baby, you know, she was stable and in satisfactory condition.
BM: I want to make it plain, we don't accept she was an extremely well little baby, but I'm not going to rehearse that (overspeaking) I was asking --
DE: She was a well, stable baby where you'd be telling the parents, look, she's doing very nicely, she needs to put a bit of weight on, but you need to go and paint the nursery. Okay?
So therefore she was stable and there was no indication that she would suddenly deteriorate for none of the reasons, as I keep saying, that one associates with the complications you get in premature babies.
BM: As to crying and distress, a baby may cry or become very upset for any number of reasons; do you agree?
DE: Of course.
BM: And it can be very subjective the impression that someone forms and what they describe after a baby has been crying. It's a matter of their description, isn't it?
DE: Oh... I... I trust nurses to know the difference between the cry they are used to hearing and a cry that they've never heard before or is very unusual. I respect the -- I think the evidence of Ashleigh Hudson was incredibly clear, objective, clinical. She was very composed in discussing something that was very, very challenging.
It was clear, when I heard her, that this cry was quite different to what any neonatal nurse would normally be used to hearing.
BM: We're not taking issue with Ashleigh Hudson as to how she described what she heard about that cry. I make that clear. It's what you interpret from it that I'm exploring, Dr Evans.
DE: No, no, there's a difference, you see. There's a difference as well, which is not only was she crying, but her heart rate had dropped, her oxygen saturations was in her boots --
BM: You don't know what caused that. You've no idea what caused that, Dr Evans.
DE: I've just told you: she had suffered -- this is entirely consistent with an air embolus.
BM: It's utter guesswork.
DE: It's simply not guesswork. I'm quite happy to elaborate on the issue of the crying and what it likely to have caused the crying. It is not guesswork at all, it's consistent with what has happened in previous cases here and it's certainly consistent with what led -- and it certainly is an explanation for what caused this baby to deteriorate and where resuscitation was not successful and she died. She died from the complications of an air embolus. That is my opinion.
BM: Do you agree that you're coming up with things just to try to find ways of supporting the allegation that's being made? Do you agree?
DE: You keep saying that, on the basis presumably that if you repeat a fiction often enough, it ends up as a fact.
MR JUSTICE GOSS: There's no need to comment on it. You have been asked that question a number of times. There we are. I'm not being critical of either of you. It's not a helpful dialogue.
MR MYERS: Let me go to what I'd like to ask next, my Lord. If we go to page 9, point 11.
DE: Which report is this?
BM: The joint report, please.
DE: Right, okay.
BM: There's a reason why I asked the question, my Lord. I understand your Lordship's words, but I just want to go to this with the question I've just asked in mind.
This is the report you made in August last year. You say this about 22 October:
"The collapse on 22 October was secondary to excessive amounts of air introduced into the gastrointestinal tract via the NGT and to air embolus secondary to blood in the vessel."
DE: Yes.
BM: So back in August you were having a go at the air down the NGT theory, weren't you?
DE: Yes.
BM: That's because you will go for whatever mechanism you think you can work with, Dr Evans, to support this particular allegation.
DE: [Baby I] was a victim of inflicted injury; okay?
BM: So you --
DE: [Baby I] was the victim of inflicted injury. The evidence in favour of air down the stomach on 30 September, event 1, is compelling. The evidence in favour of air into the calculation on 22/23 October is compelling. In terms of the contribution of air down the stomach on the last event or air embolus on event 2 or 3, that is more debatable. But in terms of event 4, she died as the result of an air embolus -- of air injected into her circulation. If she had air injected into her stomach as well, that is something I cannot rule out.
BM: You understand, don't you, it's not for you to invent an explanation just because you may believe there was some form of blame? You understand that, don't you?
DE: I have never invented a diagnosis in the whole of my career.
BM: And you agree that in the first four reports we have, up to 2021, you never make reference to air down the nasogastric tube with regard to the event of 22 October, do you?
DE: In my original reports, my opinion was that her terminal event was the result of air into her circulation and that is what, in my opinion, led to her death.
BM: And you maintained that over four reports, didn't you?
DE: Yes.
BM: Then last year, 2022, you added air embolus; yes?
DE: Hang on. I had air embolus all the time.
BM: Sorry, you added air down the NGT, didn't you?
DE: We did, actually, we did, yes.
BM: Then giving evidence to the jury today, you've dropped that, haven't you?
DE: I think air into the circulation is the more significant phenomenon in relation to event 4, which was her terminal event.
BM: I want to ask you something else bearing in mind the criticisms I've put in the questions I have asked you.
My Lord, we have some material I would like to hand to the jury with the assistance of the clerk. Some agreed facts.
MR JUSTICE GOSS: Yes, certainly.
(Handed)
MR MYERS: There's a copy for your Lordship. It's some additional material to the bundle handed to your Lordship if reference needs to be made to it.
The first pages, ladies and gentlemen, could you put these behind divider 3 in bundle 1? Go to jury bundle 1. If you go to divider 3, you'll see the agreed facts. We haven't looked at these for some time. If you go to the back of those agreed facts, ladies and gentlemen, you should come to fact number 14 that dealt with videos. I just want to check we're all there.
If you open the files up, these agreed facts follow on. This is agreed fact 15, you'll see. So if you slot this in behind the page with 14, we can carry on. You've got a copy of those that you can see, Dr Evans.
I will just read through these and then there are some questions, Dr Evans. I should say, just so there's no confusion, ladies and gentlemen, we have put the agreed facts in. What we are going to look at in these facts relates to a different case, it's not this case, it relates to something in the family courts, but it'll become clear when we look at it.
I'll read them into the record. You follow it, please, Dr Evans:
"On 5 December 2022, Lord Justice Jackson gave a decision in writing on an application for permission to appeal in the Civil Division of the Court of Appeal.
"16. This application for permission to appeal related to a care order made in June 2021. The care order had been made in the Family Court. This care order is made in respect of two children who are unconnected with the children in the trial of Lucy Letby. The care order was unrelated to the care of Lucy Letby.
"The application for permission to appeal the care order was accompanied by a report from Dr Dewi Evans, dated 14 April 2022. This report supported the position of the applicants, who were the parents of the children for whom the care order had been made. Lord Justice Jackson refused the application for permission to appeal against the care order. Included in his reasons for this refusal were the following matters, which he set down in writing:
"'1. This application challenges the findings of fact that led to the making of a care order in June 2021 in respect of L and S following the discovery in February 2020 that newborn S had sustained nine fractures caused on at least two separate occasions.
"'2. The applicants now argue that this court should hear an appeal and direct a retrial on the basis that the judge's findings were wrong, relying on a report from Dr Dewi Evans, a consultant paediatrician with no previous involvement in the proceedings, accompanied by certain research papers, as showing that the injuries may have occurred accidentally due to S's exceptionally low vitamin D levels.
"'It is of great concern that the parents and the wider family might have been encouraged by this opinion to believe that the judge's findings might be revisited. The report is, I regret to say, worthless and offers no support whatever for this application for permission to appeal or indeed for any other application to re-open the findings.'"
At 19:
"Lord Justice Jackson concluded his reasons as follows:
"'Finally, and of greatest concern, Dr Evans makes no effort to provide a balanced opinion. He either knows what his professional colleagues have concluded and disregards it or he has not taken steps to inform himself of their views. Either approach amounts to a breach of proper professional conduct. No attempt has been made to engage with the full range of medical information or the powerful contradictory indicators. Instead, the report has the hallmarks of an exercise in working out an explanation that exculpates the applicants. It ends with tendentious and partisan expressions of opinion that are outside Dr Evans' professional competence and have no place in a reputable expert report. For all these reasons no court would have accepted a report of this quality even if it had been produced at the time of the trial.'"
I'm going to ask you some questions about what we have there, Dr Evans.
DE: Yes, certainly.
BM: Lord Justice Jackson is a Lord Justice of Appeal; you're aware of that, aren't you?
DE: I am now, yes.
BM: That makes him one of the most senior judges in the country; you're aware of that?
DE: I assume that.
BM: Pardon?
DE: I assume he was. I didn't know. I don't know the gentleman. I didn't know of the gentleman.
BM: Included amongst his comments and reasons -- and I'm looking in particular at 18(iii) to remind us all of a couple of points. First of all he says that the report is worthless. Do you agree he was right about that?
DE: I don't agree with that. I'm not going to comment on his judgment. His judgment is his judgment, which I respect. In terms of my medical report, has the jury received a copy of my report?
BM: We have copies of the report here. You have that.
DE: Right. As far as my report is concerned, I am more than happy to stand up for it. In other words, to stick with it.
A bit of background to my report: it's a report I did pro bono, in the public interest. Basically, what it means is you do a report when there's no fee involved. You do a report for free. I have done a number of pro bono reports and there are occasions when families are unable to get Legal Aid --
BM: Dr Evans, I'm going to stop you there.
DE: I'm sorry, you've raised this issue.
BM: I asked you --
DE: My Lord, I'm sorry, I need to explain all of this because I think the jury will not understand the background to this report.
BM: I asked a simple question, my Lord, as to whether Dr Evans -- Lord Justice Jackson was right to describe the report as worthless. That's what I asked. The questions I'd like to ask are focused. If there's further explanation, of course Dr Evans can give it and I'm going to turn to what he says about the nature of the report. But it really would assist if I can proceed by asking questions rather than getting involved in an explanation that, frankly, we haven't asked for at this point but we will come to it.
MR JUSTICE GOSS: No. You have asked him whether it is worthless. Dr Evans has said it's not worthless and he says that he was -- he provided -- he was just explaining the circumstances in which he was asked to provide a report, there was no fee involved, he was doing it, as is said, pro bono publico, for the public good, and that is background.
You were going to ask a series of questions about the report. He will have the opportunity to answer those questions and then he can also be asked further questions in re-examination in relation to it.
Do you understand?
DE: Yes, my Lord. I'm not going to give a speech, I'm simply going to give a very brief summary of the background, which I think is important for the jury.
MR MYERS: Perhaps I can proceed with this, my Lord, and we will deal with the background as I go along, but I would be grateful if I could continue with the question I'm asking.
MR JUSTICE GOSS: You ask the question, Mr Myers, and we will see where we go from there.
MR MYERS: Thank you, my Lord.
Can we turn to agreed fact 19, please, Dr Evans?
I want to deal with these. The first line makes reference: "Dr Evans makes no effort to provide a balanced opinion."
Can you see that?
DE: Yes.
BM: Do you agree with that?
DE: No.
BM: Has Lord Justice Jackson got that wrong in your opinion?
DE: Right --
BM: Has he got in wrong in your opinion?
DE: Lord Jackson's judgment is Lord Jackson's judgment. I don't agree with it because if I agreed with it, I would be -- I wouldn't have written the report in the way that I've done. What I think we need to know is this: I sent this report to the solicitors. I had no idea it had been sent to the court. My report -- I stand by my report. My report does not contain the usual statement of truth, which accommodates all the reports that I've sent in relation to the Family Court. I had no idea about this judgment until I heard about it 2 weeks ago. And even more concerning from my point of view, this is a unique example, a unique case for me and I'm not very happy about it because having sent the report to the solicitor, nobody got in touch with me. And normally what happens is when you send a report to the solicitor, they get back in touch with you -- I mean, this was in South Wales, I sent an email, I'll call round in Swansea, all that sort of stuff, the solicitor happened to come from my home town. I said, "I'll come and talk to you, we'll discuss this, we'll go through everything. If you think there are bits in it that you're not comfortable with, we need to review it or amend it or whatever". I knew none of that.
What concerns me particularly is that I have prepared dozens and dozens and dozens of reports for the Family Court. To my knowledge, my Lord, there's only one report where the judgment went against me in 30 years of doing this work, and that judgment was reversed on appeal. Okay? That's the only -- this is the only judgment that's gone against me in a Family Court that I know of in over 30 years.
Obviously, it saddens me because I've got a -- I wouldn't say it's a 100% record, but I'm in huge demand for my opinion in the Family Court because of my track record over 30 years or more as a witness in my own practice and as an independent witness.
So this is a one-off for me, right? It's a one-off for me. I had no opportunity, right? I had no opportunity to discuss it with anybody because nobody got in touch with me. I had no opportunity to review it. There were two mitigating factors with this particular family. One was the vitamin D value, which was very, very low, and if your vitamin D value is low, your bones are weaker. That's the first point.
The second point is this family were not on the radar of Social Services. They were a stable family and they were in a no man's land because they didn't have their kids with them, they didn't have much access to them. If you look at it carefully, I did not challenge the fact that these were suspicious injuries. I looked at them very, very carefully and said, look, this family needs a second chance. That was my main report in preparing this report -- that was my main emphasis for preparing this report.
I've done a number of pro bono cases, in other words cases where I don't charge a fee, over the years, and several of them have led to a successful outcome where people have given families a second thought. I was unable to do it in this case because there was a breakdown in communication between me and the solicitor. Okay?
The second thing, and this was the mistake I made, when I did my report I should have put a caveat in saying "for your eyes only and not for disclosure other than to the family without my agreement". I didn't put that in. That was a mistake on my part. I'll know better next time.
So therefore, this judgment is based on an experience I have never, ever had in 35 years of working as a medical witness and in 50 years as a doctor working with paediatrics. So it's a complete one-off. It's a complete one-off. It's an interesting diversion from what we've been discussing over the past 3 months. It's got nothing to do with this trial we're talking about at all and as I say I am unhappy with it and -- and, you know, that's the way of the world.
I thought these parents needed a second chance. I was quite prepared to go the extra mile when I did this report in whenever it was, April last year, and that remains my opinion. So therefore that is my clinical opinion as a consultant paediatrician. I was not working as a medical expert and, as anybody who's seen my report can say, this was a letter to solicitors, it was not a letter addressed to the court. Righto?
So that's the way it is. I'm not going to comment on the judgment, I respect judgments, and just to repeat myself, this is the first judgment that's gone against me in over 30 years, apart from the one that was reversed. Quite pleased with that. The judgment that was reversed is in the public domain, anybody's welcome to see the original judgment and the reversed one. And the Appeal Court was very critical of the first judge, actually, in that particular case, and you're welcome to see that. It's on my laptop and I'm quite happy to provide it for you.
Every other case I have done -- and there are dozens and dozens and dozens of them -- where I have acted for the benefit of the court --
MR JUSTICE GOSS: You've said this.
DE: I'm sorry. This is obviously something I find quite upsetting. Every other judgment has come in favour of the opinion that I have expressed. This is the isolated one.
MR MYERS: Continuing with my questions, Dr Hall (sic), still on agreed fact 19, you can see four lines up, it refers to: "The report has the hallmarks of an exercise in working out an explanation which exculpates the applicant."
Just so we understand, are you saying Lord Justice Jackson is wrong in saying that's what the report is doing?
DE: I think we're talking at cross-purposes, actually. My report was based on my clinical background and my clinical experience.
BM: Next, it says: "It ends with tendentious and partisan expressions of opinion."
I had to look "tendentious" up. It means: "Having or showing an intentional tendency or bias; presenting a biased view."
It ends with: "... tendentious and partisan expressions of opinion that are outside Dr Evans' professional competence and have no place in a reputable expert report."
First of all, is Lord Justice Jackson wrong when he says it ends with tendentious and partisan expressions of opinion?
DE: Well, I don't agree with that, and again I base my opinion and my reputation -- if you prepare reports for the court, Family Court or Crown Court, that are partisan, you tend not to last very long as an expert witness because you will get caught out.
I have been giving reports for over 30 years, therefore someone must believe that my reports are impartial and they're there for the benefit of the court.
If I'd had more opportunity to discuss this report with the people concerned, it wouldn't have worked out -- it would have worked out better. So I'm not happy with a report -- with the way things have turned out and I feel sorry for the family and I feel sorry for everybody else.
BM: You say that the document, it's a letter to the solicitors, that's what you said, but Lord Justice Jackson calls it a report throughout. Can I be clear, that's because it is a report, isn't it?
DE: Hang on. It says, "Dear Mr Solicitor", and, "Re this little baby", so it's a letter to a solicitor because that's what it says on the tin.
BM: It runs to one, two, three, four, five, six, seven, eight pages, doesn't it?
DE: Eight page, nine references. I take what I do seriously and I don't take short cuts. I took a fair bit of time over this because part of the problem I had was that the baby was admitted to the hospital where I used to work, so I knew everybody involved with this case, which has added to the conflict, but there we are.
BM: And you provided this as, in effect, an expert report to support an application to bring an appeal, didn't you?
DE: Well, what I wanted -- obviously, you know, I'm not a lawyer, I'm a doctor. What I wanted was for this family to have increased contact with their parents and -- for these parents to have increased contact with their kids. That is my philosophical position as a children's specialist and, you know, father and grandfather and all that sort of stuff. So that's what I wanted.
What I was hoping, actually, was that my report could have led to the local authority, my previous old authority, saying, hmm, perhaps we should increase contact between the children and their parents, you know, as a future plan. Whatever happened 2 years ago, whenever it was, look, these parents are -- children need to be with their parents and therefore I think, and I still think, that there was an opportunity for increased access, supervised access. These kids, by the way, are in the care of the grandparents, just to let the members of the jury know. I thought the parents needed more access. The older child is missing her mum --
BM: Dr Evans, I'm asking you --
DE: Just a minute. Let me finish, right? Let me finish because you're making a meal of -- making a big issue out of something of this, so I need to defend myself as to how I did it, talking -- I'm living in the real world.
So that is what I was angling for and this is what I still angle for, actually, that there should be greater access for the family. The fact that it went to the Appeal Court, I had no idea about any of that. I'd no idea about this judgment until I heard about it a week last Monday.
BM: Are you suggesting to the jury that you did not believe this was going to be used to try to support an appeal? Are you saying that?
DE: No, what I'm saying is that I -- no, no, what I'm saying is that was a letter to the solicitor. I was hoping that he would discuss it with a barrister. I was hoping that the barrister and solicitor between them would get in touch with me saying, these are the pros and cons, no, you can't do this, yes, you can do this. I'm not a lawyer, but I know the procedure obviously. This is what I thought would happen. Therefore this came as a bolt out of blue and I thought, oh dear, it hasn't worked this time, but I am satisfied that there are several pro bono cases I have done that have led to a good outcome. So there.
BM: Let's look at some of the language you use in this report and the suggestion I'm making that this is a report.
Paragraph 1:
"Mr and Mrs [the names are out] are the parents of... They have asked me to review injuries."
Do you see that?
DE: Yes.
BM: When you do that, you know that is with a view to re-opening this before the Court of Appeal if you can, don't you?
DE: No, it wasn't --
BM: You said no, let me press on.
DE: No, no, it wasn't. It was -- my view was: oh, let's see if the local authority, whom I know in South Wales, let's see if we can do something to improve contact, increase the contact, between the parent and their kids. That was my goal. The idea that it would go to the Court of Appeal did not cross my mind.
BM: You're trying to bluff your way through appalling criticism from a senior judge, aren't you, Dr Evans?
DE: No, I'm not. I appreciate this is a diversion, yet another one of Mr Myers' diversions, but there we go, but I am more than happy to defend myself and I regard in this particular case -- for those of us in the medical field, the issue of vitamin D values and their significance, if any, in the cause of fractures remains a debatable point. Okay? I led the metabolic side of paediatrics when I was in Swansea.
So vitamin D values of 12, you're talking an incredibly low value. The consensus view from 2012 is that it's not -- they do not get more fractures. Sorry, they... It's whether a lesser force can cause a fracture is a point for debate. All right? So that's a point of debate. And these parents, when they discovered the fractures (inaudible: coughing) --
BM: Could you just wait, Dr Evans, for the lady to please recover?
(Pause)
MR JUSTICE GOSS: Do you want a break now? Because we're due a break. How much longer are you due to be?
MR MYERS: I'll probably be a matter of minutes, my Lord, but how long we're going to be I really don't know, but I will be minutes with my questions. I'll be quick.
MR JUSTICE GOSS: Shall we have the break now? It might be better and then you can compose yourself. Thank you very much.
(In the absence of the jury)
MR JUSTICE GOSS: We'll resume in 10 minutes, Dr Evans. Thank you.
(3.10 pm)
(A short break)
(3.18 pm)
(In the presence of the jury)
MR MYERS: Dr Evans, can we go to paragraph 6 of the document, please?
DE: Which document?
BM: Second page, paragraph 6. We're looking at the -- it's the one that says "Report of Dr Evans" at the top of it, the one we've been looking at. Can you see page 2, paragraph 6?
MR JUSTICE GOSS: You're there.
DE: Are we still with this...?
MR JUSTICE GOSS: Yes, page 2, paragraph 6. Your report of 14 April.
DE: I don't have a paragraph 6. I've got 15...
MR MYERS: You're looking at the agreed facts there, Dr Evans. We're going to the report. You were given a copy of the report behind those agreed facts and we're looking at it. If you keep going forwards. There we are.
DE: You're talking about my own report?
MR JUSTICE GOSS: Yes. Paragraph 6.
MR MYERS: Top of the page, "Report of Dr DR Evans".
DE: Yes.
BM: That's what it says?
DE: Yes.
BM: Paragraph 6 says: "In preparing this report, I declare a number of interests."
Then it sets out your professional qualifications and concludes by saying: "... and also in relation to the numerous reports I have prepared as expert witness for courts England, Wales, Scotland and Northern Ireland."
It says "report" at the top of the page, it says "In preparing this report" at paragraph 6. This is a report, it is not a letter.
DE: Well, we're talking semantics, okay? We're talking semantics. I can only repeat what I said before the break, where my interest as a consultant paediatrician is the welfare of the child, or the children, and if I could quote two sentences in paragraph 4 in relation to this particular case, which I stand by, and I quote:
"Currently, there appears to be some kind of life sentence in relation to both the placement of the two children and also the level of contact between them and their parents. This is completely unreasonable and has the potential to cause far greater long-term harm to the children than anything that occurred during the child's infancy."
I go on: "I am not familiar with any kind of published work that endorses the current arrangement as one that is in the interests of the child and his sister."
So that was my position then. It is my position now. And that's it. Whether you call this a report or a letter or whatever is pure semantics.
BM: You tried to tell the jury it was a letter, didn't you, to the solicitor?
DE: It is a letter.
BM: If we go to page 3, same document, top of page 3, again it says "Report of Dr DR Evans", doesn't it?
DE: It's how I do all of my letters to solicitors, Mr Myers, okay?
BM: The bottom of that page sets out on that page and over on to the next page your professional background, doesn't it?
DE: Yes, it does.
BM: That's because this is being presented as an expert report, it's not a letter.
DE: Does it matter?
BM: Dr Evans, you knew that this would be relied upon to bring an appeal or to try to challenge a decision before the Court of Appeal. You knew that, didn't you?
DE: I did not know that, actually, because nobody ever got in touch with me having sent this letter to these solicitors.
BM: Look at paragraph --
DE: Nobody. I could not get -- they wouldn't get in touch with me, so there you go, you know.
BM: Can we go to paragraph 47, please? The final paragraph. We've gone through the various pages.
It says:
"I would be pleased to support Mr and Mrs [name redacted]'s application to seek a new hearing where the court can benefit from access to crucial additional information contained in this report."
DE: Yes.
BM: "I believe that there are compelling grounds for supporting their request for increased contact with their children with the aim of allowing both to return to their parents full time."
You know, and you knew very well, this was to be used as a report to get a new hearing because that's what it says in that paragraph, doesn't it?
DE: That would have been three or four steps down the line. All right? That would have been three or four steps down the line. I was hoping we would have sorted things out before that was necessary. That was not to be, so there we are, and I think that if you -- and I am very sorry that the solicitors never got in touch with me. There you are.
BM: You're aware, amongst your duties as an expert, there is a duty to notify the court in a case if there is anything against you that is capable of being considered as undermining your reliability, credibility or impartiality? You're aware of that duty, aren't you --
DE: Yes.
BM: -- on an expert? And that includes a duty to disclose any adverse judicial comment, doesn't it?
DE: Yes.
BM: You were made acquainted with this report 2 weeks into January at the start of this term, weren't you?
DE: Yes.
BM: And you were asked: "Would you have informed the parties in this case of what Lord Justice Jackson said"; yes?
DE: Where is this?
BM: In fact, do you have the document attached that says, "Plan of meeting: Dr Evans". It should be attached to the back of the bundle you've got.
DE: Yes, I know that, it's...
BM: Can you look down to the second page, point 11? Can you see point 11?
DE: Yes.
BM: You were asked this question -- and this is now by the parties in this case, an inquiry into this. In fact, you were asked by the prosecution and this was provided to you: "Have you been informed of the judge's finding?"
And you said -- this is 16 January: "I saw a very brief report from the Local Authority saying they didn't agree with me. I didn't respond to or from the local authority disagreeing with my opinion. I don't think there was anything I could do about that and didn't follow it up. Upon reading email from judge, Dr Evans states he knew nothing about it, has never seen it or been aware of this document [as read]."
And you said this: "If Jackson LJ thinks my report is worthless, that's his opinion. I can't argue that. I wasn't aware the solicitor had sent it, the email or the report, to the court. If I had received it I am not sure I would have told you about it because I didn't think it was an adverse judgment."
Yes?
DE: You saw this judgment before I did. Right? Everybody in this court saw this judgment before I did. So I think I can claim to be a bit miffed about that. I saw the judgment for the first time a week last Monday or 2 weeks last Monday when we restarted after Christmas. So I knew nothing about it before then and I can't... I can't comment on things I know nothing about. I'm not particularly happy with the solicitors for the way they've dealt with it, but that's nothing to do -- that's outside of my control.
BM: Let's be clear about the point I am raising, Dr Evans, the question I'm asking. I asked about the duty of: "... an expert to notify the court and the parties of anything that may undermine reliability, credibility or impartiality."
That's what I asked you, wasn't it?
DE: Yes.
BM: And you're aware that includes a duty to let us know if there's any adverse judicial comment, isn't there?
DE: Yes.
BM: Yes. And what you're saying, in answer to the question, was if you knew about that ruling you're not sure you would have told us about it because: "I don't think it's an adverse judgment."
That's the point I'm making.
DE: I don't think this is getting us anywhere. This is a very brief -- this was a very quick report that was -- where I was presented with this judgment on the Monday morning and I think this was done very quickly, didn't have time to think much about it, you know. So if I'd had a bit for time to think about it, I would have -- perhaps I would have written it a bit more constructively. But I think it's very unfair on anyone to criticise me for the report I have prepared given that they had the judgment before I did. And if that's the way the system works, I don't think it's a very good one.
BM: This report, so we all know, was brought to our, the defence's, attention, but obviously not by you but by a different route --
DE: Sorry? I didn't hear that.
BM: This report was brought to the defence's attention but not by you.
DE: I don't know who brought it to your attention.
BM: If we hadn't known about it and if no one had known about it but you did, would you have kept it to yourself?
DE: I didn't know about it.
BM: If you knew about it?
DE: I did not know about it. If I had known about it, I would have informed the court obviously. That's what you do. But I didn't know anything about it. As I said, I didn't even know the judgment -- I didn't see the judgment, I didn't know my report had gone (inaudible).
BM: Now --
DE: I knew nothing about it and it's a one-off and there we are, but I'm not going to apologise for going the extra mile in support of parents. So there we are.
BM: The criticism at point 19 of the agreed facts, I want to look at that: "Dr Evans makes no effort to provide a balanced opinion."
Remember that one? Do you want to go back to the agreed facts, Dr Evans.
DE: Well, I think it is a balanced opinion, actually, because I've never -- because if you read my first letter -- sorry, my first paragraph: "Mr and Mrs... are the parents of... They've asked me to review injuries sustained by their baby when he was 8 weeks of age."
I haven't ducked the issue that this baby had received injuries. Okay? You know, I'm no softy. I know my way around inflicted injury and I do object to being accused of being partisan because, as I've said earlier, if your reports are partisan, you don't survive very long in court. I've been giving evidence in Family Courts in England, Wales, Scotland, England (sic), everywhere, for the last 30 years, and my reports are impartial and, as a result of my reports, some people have -- some babies who were removed from their parents have returned and none of them, as far as I know, have suffered other injuries.
BM: I haven't asked a question that question --
DE: This is cherry-picking of the worst kind, which is fine. I can understand all of this.
BM: Right, can I ask the question --
DE: I know what this is about. Okay? Fine.
BM: Do you mind if I ask a question?
DE: Carry on.
BM: Paragraph 19, taking you to where it was. Look down, please. The reference to "working out an explanation". You see that criticism?
"The report has the hallmarks of an exercise in working out an explanation..."
DE: Well, I --
BM: No. First of all, do you see that?
DE: Yes, of course I do, yes.
BM: That is precisely what you were doing in this case at various points, isn't it?
DE: It is not. It is not. As far as -- which case are you talking about now, this trial?
BM: Let's stay with [Baby I]. That's why we have you jumping between NGTs, air emboli and smothering, isn't it?
DE: I do not jump around. What I do as a clinician, as all clinicians do, you form an opinion regarding the cause of a particular event and if there's more than one potential cause, then I will mention more than one cause.
In the [Baby I] case, whether it's air down the stomach on event 1, air into the circulation on event 4, and then a debate as to whether there was air in both the stomach and circulation in the other events, what is relevant to me is that I have excluded all the usual causes and that all of these events are consistent with inflicted injury. I have been consistent with that throughout. I've been consistent with that throughout.
As you can see in my report of November 2017 and I have not heard anything -- sorry, and everything that I have heard from the local doctors, the local nurses and other experts' opinions adds to the opinion that I formed 5 years ago. That is the reality of the [Baby I] case and that is the reality of all the evidence I have given in this trial to date.
BM: Well, Dr Evans, Lord Justice Jackson's decision, as set out in that paragraph, in that agreed fact, accurately describes aspects of your approach to this case generally, doesn't it?
DE: I disagree. That is just making things up and, as usual, being rather insulting. Not for the first time.
MR JOHNSON: Does your Lordship have any questions?
MR JUSTICE GOSS: No, I don't, thank you.
That completes your evidence at this stage then, Dr Evans. But of course, you'll be coming back --
DE: Yes, thank you, my Lord.
MR JUSTICE GOSS: -- to give further evidence in relation to other cases. Please don't talk to anyone about anything to do with this case. Thank you.
(The witness withdrew)
Tuesday, 7 March 2023
MR JOHNSON: Welcome back, Dr Evans. For the record would you identify yourself, please?
DE: Dr Dewi Evans.
NJ: Thank you. I hope I'm correct in saying that you have completed five separate reports or statements on the case of [Baby N].
DE: I have.
NJ: Thank you. They are dated, for the record, 3 June 2018?
DE: Correct.
NJ: 17 January 2019?
DE: Correct.
NJ: 24 June 2021?
DE: Correct.
NJ: Then there is a pair on 21 October 2021?
DE: Yes.
NJ: As before, your initial statement was a sift?
DE: Yes.
NJ: The second statement was more considered?
DE: Yes.
NJ: And then subsequently, you've dealt with administrative issues such as pagination, but you've also given us some further detail on issues that have been raised with you after your considered report?
DE: That is correct, yes.
NJ: Thank you. Just to put this case into the overall context, this was, I think, the 29th case that you were asked to look at?
DE: Yes.
NJ: Thank you. I would like to take, if we may, as a template for your evidence the report of January 2019. There did you set out the circumstances surrounding [Baby N]’s birth --
DE: I did.
NJ: -- which we have heard in evidence?
So far as the material that you were given, did that consist of the medical records from the Countess of Chester, which included some radiology material?
DE: Yes.
NJ: An index and also some medical records from Alder Hey Hospital --
DE: Correct.
NJ: -- in Liverpool?
DE: Yes.
NJ: Taking up, if we may, your report at paragraph 4 -- I'm looking at your overview to start with -- did you note the breathing issues, the grunting issues, that had occurred shortly after [Baby N] was born?
DE: Yes, I did. These lasted for a few hours, soon after his birth, but settled quickly.
NJ: Did you also note the results of the blood tests, the coagulation results in particular?
DE: I did and noted that the factor VIII value was recorded at 3%.
NJ: Yes. Did you, as a matter of fact, towards the end of your report, invite the police to consult somebody with the sort of specialist knowledge that Professor Kinsey has?
DE: Yes.
NJ: Did you go on to consider the circumstances surrounding [Baby N]’s collapse at shortly after 01.00 hours in the early hours of 3 June?
DE: I did.
NJ: And in particular, did you refer to the note made at the time by the doctor concerned, saying that [Baby N] had desaturated down to 40%?
DE: Yes.
NJ: He was unsettled, there was an increased work of breathing?
DE: Yes.
NJ: He looked mottled?
DE: Yes.
NJ: And dusky?
DE: And screaming.
NJ: And screaming, of course, yes.
DE: Yes.
NJ: You referred also, I think, to the nursing note entry made by Nurse Booth, which recounted the fact that [Baby N] had continued to cry, as it was put in the nursing note, for 30 minutes?
DE: Yes.
NJ: Thereafter, did you review the medical records covering the time following that and the events in the early hours of the morning of 15 June?
DE: Yes, I did. What I found was that having recovered from this event on 3 June, his progress was pretty uneventful really. He was making satisfactory progress as you would expect of a baby who was premature but otherwise well.
NJ: Did you refer at your paragraph 13 to the events at 01.45 on the morning of 15 June?
DE: I did.
NJ: For anybody's note, they're at tile 80 and are [Dr A]'s notes.
DE: Yes, I did. I heard [Dr A]'s testimony yesterday and the note that he was -- had noticed mottling, which is a discolouration of the skin, and this -- but otherwise his heart rate and his heart sounds were normal, he had good air entry in his lungs and his abdomen was normal and there were normal bowel sounds. They also did -- [Dr A] carried out blood gases, capillary gases. They were all satisfactory. The lactate value was 3.2, which is minimally raised, but in isolation is not of clinical significance.
NJ: Yes. And that in effect is what he told us yesterday?
DE: Yes.
NJ: Did you move on to consider [Dr A]'s notes which were at tile 84 in the second [Baby N] sequence and some desaturations which had been noted on the monitor?
DE: Yes. Again -- we're talking about 05.15 hours?
NJ: Yes.
DE: Again, some more blood tests. So first of all, the capillary refill time was 3 seconds, and you'd want it to be 2 seconds or less really, so it's slightly increased and could be indicative of baby becoming unwell for some reason. His white cell count was 7.4, which is normal, in other words there was no indication of infection from the white cell count value. Platelet count 309, which is normal again. CRP value was less than 1, which again is a marker of infection, and a value of less than 1 is normal.
But [Dr A] was sufficiently concerned, I think because the capillary refill time was slightly prolonged, to stop oral feeds and give a bolus intravenous infusion of 10% sodium chloride, which is standard practice, and he also added an antibiotic.
NJ: Again, we heard, I think, from [Dr A] about that yesterday.
DE: Yes.
NJ: Did you move on then to consider the notes that had been made by [Dr A] at 08.00 hours that same morning?
DE: I did. These notes indicated a far more significant deterioration in [Baby N]’s condition because his oxygen saturation had dropped to 48%. Now, that is low and life-threatening. His heart rate was 80. That is very low and very, very concerning. And those values were sufficient for him to require what he called bagging or being bagged up. He also had a mottled appearance of the skin once more and also reduced tone -- in other words, he was more floppy.
So these are very concerning matters and were sufficient for him to be transferred to the intensive care nursery.
NJ: Yes. You recorded additionally, I believe, the fact that [Baby N] had been given medication in preparation for an elective intubation?
DE: Yes. He received morphine, which is a drug given for pain relief and for -- yes, pain relief. He also was given suxamethonium, which is a muscle relaxant, which one gives as a pre-med in anaesthetics to relax the muscles if you're preparing intubation. And he had atropine as well. So anyway, there were three efforts made. They were, sadly, unsuccessful.
NJ: Yes. The jury has heard evidence yesterday concerning blood being seen at this stage of the process and no doubt the jury will come to their own conclusions in due course. But you have noted that fact, haven't you?
DE: Yes, and it's clear from the evidence I've heard yesterday and from the notes I'd seen before that the blood was noticed in the oropharynx, in other words at the back of the throat, and the blood was present prior to the efforts at intubation.
NJ: That, as you will understand, Dr Evans, I think is disputed on behalf of the defence.
DE: Okay, right. That was my understanding anyway.
NJ: Yes. That's one of the issues that the jury will in due course be invited to determine.
Did you go on to consider [Dr A]'s notes of [Baby N]’s vital signs together with those noted by Dr Ukoh at 10 am that morning?
DE: Yes. The 10 am notes noted a respiratory rate of 28, which is normal, a heart rate 149, normal, and oxygen saturation 100%, which again is clearly satisfactory. His blood pressure was 88/51, which is absolutely fine. And on this occasion his capillary refill time was less than 2 seconds, which is normal. In other words, showing normal perfusion of the skin. And again there was an additional note about there was no evidence of what they describe as abnormal posturing, in other words his tone was not abnormal. So these were normal findings.
NJ: Did you go on to note a later desaturation at or about 14.50 hours that afternoon?
DE: Yes, I did. Yes, I did. Again -- which part is this?
NJ: We're at paragraph 19 of your report.
DE: Yes. He desaturated once more at 2.50 in the afternoon and the entry notes blood in the oesophagus and in the nasogastric tube and he required some resuscitation, he required bagging and, again, needed or was given two fluid boluses of sodium chloride, which is standard treatment in a situation of this nature.
NJ: We then heard evidence which you have summarised concerning a continuing series of events, which culminated ultimately at about 19.40 that same day when preparations were being made by the Alder Hey team to intubate [Baby N].
DE: Yes. Very striking that a number of people were unable to intubate [Baby N] during this afternoon, which is why they called the Alder Hey folk, yes.
NJ: And we heard that [Baby N] required, after his collapse at that stage, CPR?
DE: Yes.
NJ: And received multiple doses of adrenaline?
DE: Yes.
NJ: And sodium bicarbonate?
DE: Yes. Six doses of adrenaline in all and sodium bicarbonate, yes.
NJ: As part of your review did you look at the observation charts, in other words the yellow and white charts which the jury have hard copies of?
DE: I did.
NJ: Did you also review the nursing entries, both from June and 15 June?
DE: I did. Yes, I did.
NJ: So just going to page 20 of 27, please, Dr Evans. It's your observations section, paragraph 58. What overall view, in a nutshell, did you take of [Baby N]’s progress from his birth until his collapse shortly after 01.00 hours on 3 June?
DE: My overall observation was that it was known that his mother was a carrier for haemophilia, but that he was well following his emergency caesarean section, not requiring much in the way of resuscitation.
So therefore, that would have been satisfactory for a baby who's 34 weeks of age, gestational age.
NJ: Did you regard his deterioration at 01.00 hours on June as being an everyday type of occurrence for a child in his position?
DE: No. In my sift report I overlooked it, let's be frank about that, but it was rather unusual in that he seemed to be fine at about 9 hours of age, and what was striking was this very sudden and very significant drop in oxygen saturation to 40%, so very low. He responded with 100% oxygen. We heard from the doctor who said she was crash called to something else, to another patient, sorry, and when she came back he was asleep, in air, with normal saturations. Therefore this very sudden onset of something with a very quick improvement, which is something very unusual.
NJ: Yes. Now, this apparent desaturation was associated with what Dr Loughnane described as screaming.
DE: Yes.
NJ: Did you think that was significant, the use of that particular word?
DE: Well, it's very unusual for babies to cry other than when you're doing blood tests or causing some sort of discomfort, usually by putting intravenous lines in or taking blood tests from a heel prick. So they will cry. But once you stop the procedure, they usually stop crying fairly quickly. They don't carry on crying.
As for screaming, this is an incredibly unusual description in my experience of a baby, 6 weeks premature, screaming. That's very unusual. And again continuing to cry for half an hour. So that was something that, having looked back on these notes, struck me as very unusual.
NJ: Did the length of time, the 30 minutes -- is that -- it may be implicit from what you've already said, but is that unusual?
DE: Yes, the length of time is very unusual -- well, the fact of screaming, that the term screaming was used, is very, very unusual for a doctor to describe a baby in a baby unit, and the fact that it was the nurse, actually, who recorded the crying continuing for 30 minutes. So that is an exceptionally unusual finding in a neonatal unit and it's not what you would get because a baby is hungry, for instance.
NJ: So did you come to a conclusion as to what, in your view, had caused [Baby N] to react in that unusual way?
DE: By this time, of course, this is case 29, and I was aware of, you know, all the other cases we'd done because these files arrived with me later than the others, the first 28. It struck me that this baby might -- that something had been done to this baby to cause this episode of screaming.
And so I went back over my notes, I went back over the overarching view I made in relation to injection of air into the circulation from other scientific papers, and there were a couple of them, a couple of papers, who described babies who had accidentally received an intravenous injection of air into the bloodstream and screamed, collapsed and died.
Now, all of that -- none of this was known to me before I became involved with this investigation, and of course it repeated what we've heard in previous cases with [Baby I], [Baby I], case 8, possibly [Baby E], where one heard, I think with [Baby E], this horrendous cry, as his mother described it. [Baby I], again, a significant cry.
We know that babies who get intravenous air for whatever reason, there is an increased risk, hardly (inaudible) because they're small, of course, so you don't need as much air to cause problems. And secondly, they still have this hole in the heart, this foramen ovale, so any air can get from the right side of the heart into the left side of the heart. If it gets into the left side of the heart, it could get into a heart blood vessel, coronary artery. So technically, it could cause a heart attack, you know, which is incredibly painful. I can't prove any of this by the way.
NJ: Let's stick to, if we may, rather than getting involved more arcane areas, whether you thought that this particular event was a naturally occurring event, in other words whether it was one of the vagaries in behaviour of an infant on a neonatal unit or whether there was some other cause for it.
DE: This was unusual. This was unusual. This baby, very quickly following his birth, had recovered. So he was well at 9 hours of age. In other words, there was no grunting, one did not have any of the features you get with breathing difficulties. So there was none of this and then suddenly, out of the blue, he collapsed very, very precipitously and this is what is remarkable.
Equally remarkable is the fact that he recovered so quickly. So for instance, if he had deteriorated because he was sickening for an infection, we're talking June now, I would not have expected him to be back asleep, breathing in air, you know, soon afterwards. So therefore all of this, as we've heard several times, is incredibly unusual and not the sort of thing one has seen, despite one having spent most of one's career looking after babies in baby units.
NJ: So far as the issues of 15 June are concerned, the events of the early hours -- and by the early hours I'm talking about from midnight through to before 07.00 hours, okay?
DE: Right, yes.
NJ: In that period of time, did you draw any conclusions from the evidence as it was presented to you on paper and as you have heard it during this trial?
DE: As I've heard it during this trial, and clearly it's much easier to form an opinion having heard everyone else's evidence, I would say that during the early hours his condition is what could be explained -- could be explained -- on the basis he was sickening for an infection. In other words, he was not quite as well, skin mottling, you know, that kind of thing, but not -- in other words, if I'd been there I would have done what [Dr A] had done and considered, "Hmm, he is sickening for an infection". We know the results subsequently did not prove an infection, but that is what I would have done. I would have done what [Dr A] did.
NJ: You say the results didn't prove an infection thereafter, but looking at those results in the succeeding days, was there any evidence of an infection?
DE: No, none at all.
NJ: But thereafter, there are several collapses from 7.15 onwards. What view did you take of those events?
DE: I'm not sure what -- it's quite difficult what to make of those. The key event for me was the fact that there was a deterioration around 8 am, which was more significant. In other words, his oxygen values dropped, his heart rate dropped significantly, and the most significant finding for me was that the doctors decided to intubate him, correctly, but when they put a laryngoscope in to visualise the vocal cords, the back of the throat contained lots of blood --
NJ: Yes.
DE: -- which meant that they were unable to intubate him, so they carried on with BiPAP.
NJ: So far as that is concerned, we've heard the factual evidence, we know where the issues lie between the prosecution and the defence. Would it be fair to say that your expert opinion can't really assist the jury in deciding whether the blood was there before the intubation or it was the intubation that caused the blood? It's a matter for them to look at the evidence and make their own minds up?
DE: Yes. If a doctor who had passed a laryngoscope said there was blood there, well, there was blood there. I can't help in that situation.
NJ: Okay. But what view -- on the assumption that the blood was there before the laryngoscope went in, what conclusion did you draw?
DE: Right. My conclusion was that there was bleeding. I obviously can't claim haematology expertise. I know the baby had haemophilia. I've read Professor Kinsey's report and heard her evidence this morning that babies whose haemophilia is moderate will not spontaneously bleed. It was my opinion that the bleeding was the result of trauma to his upper airways.
NJ: Yes. The issue for the jury is how the trauma is caused?
DE: Yes.
NJ: Is it the laryngoscope or is it something else?
DE: Yes.
MR JOHNSON: All right. I note the time, my Lord, but I'm almost finished.
MR JUSTICE GOSS: I think then finish if you're talking about a few minutes.
MR JOHNSON: Yes, thank you.
Did you in your report defer -- it's your paragraph 76 -- to a paediatric haematologist?
DE: Yes, absolutely.
NJ: Which in effect is what Professor Kinsey is?
DE: Yes.
NJ: So far as later events were concerned that day, beginning at about 15.00 hours and culminating in the dramatic collapse at about 19.45 or thereabouts, did you come to any views so far as what had caused that was concerned?
DE: Really, I mean, [Baby N] had a very torrid time of it during this time and, of course, I knew by then that not only was there blood in the back of his throat and therefore that could have compromised him at any time during the future, but I think the original -- the 8 am inspection noted that the epiglottis was swollen, which is what caused the problem, which would make intubation more difficult, and therefore it is difficult to say whether his subsequent deteriorations were the result of the problems he suffered from around 8 o'clock in the morning.
MR JOHNSON: Yes. Thank you very much. My Lord, that may be a convenient moment.
MR JUSTICE GOSS: Yes, certainly.
2.05 then, please, members of the jury. Thank you very much.
(1.04 pm)
(The short adjournment)
(2.05 pm)
MR MYERS: Have you got your papers ready, Dr Evans?
DE: Yes.
BM: I'm going to start with the events of 3 June --
DE: Yes.
BM: -- from round about 1.10 in the morning. You dealt with this in three of the reports that you've prepared for us, haven't you, in particular 3 June 2018?
DE: Yes.
BM: 17 January 2019?
DE: Yes.
BM: And 21 October 2021?
DE: Yes.
BM: The first time you deal with 3 June is in that first report. In that report I ask you to look at paragraph 58. I know it's described as a sift report, that's the way it's been put, but let's look at paragraph 58. Tell me when you're there.
DE: Yes.
BM: Dealing with [Baby N]’s position, having reviewed the notes, the papers you had, your opinion was: "There is nothing to suspect any significant problem until the early hours of 15 June."
That's what you said then, isn't it?
DE: That is correct.
BM: That's on the report of 3 June 2018.
DE: Yes.
BM: By the time that you wrote this report, you've told us this was report number 29.
DE: Yes.
BM: So you were familiar with the issues in the case, weren't you?
DE: Yes.
BM: If we put up the notes, please, from Dr Loughnane at tile 161, Mr Murphy. This is sequence 1 for [Baby N], tile 161.
We see the notes there. We'll look at them again in a little bit, Dr Evans. You will have looked at these notes in the course of preparing this report, won't you, into [Baby N]?
DE: I would have.
BM: If we scroll down please to the key section, Mr Murphy. Are we able to go overleaf to the 01.10 report? A little bit further down, so we've got the entirety there.
You had the opportunity to read that as well, didn't you?
DE: I did.
BM: When you wrote that report in June 2018, nothing there caused you concern, did it?
DE: Overlooked it.
BM: I'm going to suggest you are -- you have told us in your evidence that you have decades of experience as a paediatrician, don't you?
DE: Yes.
BM: And if you considered this to be significant, you would have said so in your first report, I suggest, Dr Evans.
DE: Let me go through, it's only five or six lines, and I think it will explain why I did not take much notice of it.
01.10. Before this, the baby was stable. I think we will accept that. Asked to see, desaturated. Fine, okay, that's a concern:
"Unsettled and increased work of breathing. Got upset. Looked mottled, dusky. Saturations reduced to 40% and then [arrow] 100% oxygen."
Okay? Therefore that is a concerning event: "On my arrival. 40% oxygen."
I'm not sure whether that means the baby is now on 40% oxygen or having an oxygen saturation of 40%. I would interpret that as being in 40% oxygen. That is the way I would interpret it.
"Screaming" -- at the time, let's be frank, I had not associated screaming -- it was screaming, okay? So baby's -- he was screaming. There was sternal recession.
Key entry here: "Poor trace on sats probe."
In other words, we're not quite sure whether it's accurate or not. He is pink, okay? Good: "Attempt to settle."
That is the whole of the entry. That is not a criticism by the way because the next entry is: "Crashed bleeped away (inaudible: coughing)."
If we go up the next two lines, please: "On return, SVIA [spontaneous ventilation in air], sats 100%. Asleep. Work of breathing improved."
In other words, he is back to normal. So therefore, in the grand scheme, looking at 1,200-odd pages, that did not strike me as something that I -- at the time was significant, especially as a few pages later, ie the events of 15 June, were far more striking.
So that is my response to the way I looked at those few lines.
BM: You say 1,200 pages. Most of those pages are scans that don't play a part in what we're looking at here, aren't they? There are hundreds and hundreds of pages of scans; yes? This is in the first few pages of the clinical notes -- it is in the first few pages, isn't it, Dr Evans?
DE: I have made my response and that is my answer.
BM: And can you assist me, it's almost the first entry you come to of any substance in the clinical notes, isn't it?
DE: I've told you what my answer is.
BM: And it's easy to read?
DE: I have told you what my answer is.
BM: I suggest you said you didn't consider it to be significant because it wasn't actually. That's the reason. Do you agree or -- well, you disagree with that, don't you?
DE: Right. In my evidence in other cases, I have described in many cases, most of the cases, what I have called standalone cases. What I mean by that is this: that from looking at the clinical notes, only looking at the clinical notes, there were features there that, in my opinion, were concerning and also consistent with one or more of the babies being the victims of inflicted injury, okay, inflicted injury as a standalone case.
I'm not going to go through all of them, we can do that at another time.
Now, this event of 3 June is not, in my opinion a standalone case. In other words, if I'd been presented with this sheet on its own, without knowing about the others, I'd have said: well, this is concerning, interesting, you know, suddenly deteriorating and then suddenly improving, how do I explain that in isolation? This is very difficult to explain.
BM: You'd already prepared 29 reports by this time, hadn't you?
DE: I'd prepared 28 reports, I think.
BM: Yes. Let's move to the second report, which is dated January 2019.
DE: Yes.
BM: If we go to your views of this event, it's at paragraph 63. By this point now, you have identified this and you say:
"It's my view that [Baby N]’s deterioration, his distress is consistent with him being the victim of some kind of inflicted injury which caused severe pain and distress and destabilised him."
"Inflicted injury." There is nothing actually from what we see in these notes to support the suggestion that there is an inflicted injury here, is there?
DE: That was my opinion then and that is my opinion now. And I'll explain to you the way that my opinion evolved --
BM: I'd be grateful if you'd answer the question. If further explanation is necessary, you can be asked, but I'd be grateful if you could simply assist with explaining what I'm asking and dealing with those questions.
DE: If you ask me the question, I'll answer it if I can.
BM: Is there evidence of physical -- physical evidence of inflicted injury in what we see on this occasion?
DE: From my report of 2019, the answer is yes, and I'll tell you what they are. There was a sudden deterioration at 40%, the screaming and the crying that lasted minutes. I explained to you that in 2018, I was not aware or familiar with the association between screaming and the injection of air into the blood system, didn't know about it at the time. But you will also know that in 2019, I collected a whole load of scientific papers, put them all together in what was described as an overarching report in relation to air embolus and quoted a load of papers. We've already said it's difficult to get scientific papers on this condition because it's so rare, so unusual, and I think that was January 2019, I'm not quite sure, I don't have a copy with me.
In those papers -- in those papers, there are papers who quote babies being given air, accidentally, into the circulation, screaming and dying. So therefore, we've got those two, those papers. In addition to that, which reinforces the opinion I made in 2019, since the beginning of this trial, we have heard of other cases -- [Baby I], case number 8, being the most striking example of a baby screaming as part of her deterioration.
Now, that was not evident from the clinical notes that I saw in 2017, so I didn't know that at the time and I didn't know about the other babies and the extreme crying or screaming. So all that information is information that I discovered since the beginning of this trial. So therefore, the information from the beginning of this trial has reinforced the opinion I expressed in -- whenever it was -- January 2019. But I did not know about the association with screaming, I don't think, during what Mr Johnson calls the sift report.
BM: In that report, the second one that I'm asking about, you make absolutely no reference to an air embolus, do you, at any point? Do you?
DE: I'll check it. I think I made that in my second -- my third report, I think.
BM: This is the second report. We've got the first report of 8 June 2018 when you identified nothing, you simply say 15 June is the time that is significant. We've got your report of 17 January 2019. You don't mention an air embolus, do you, Dr Evans?
DE: I do not.
BM: No. You use the expression "inflicted injury", don't you?
DE: I use that as a generic expression which I've used in other cases.
BM: You agree there's absolutely no evidence of any physical injury from what we see on the 2nd or 3 June, is there?
DE: I disagree with that. I should also add as clinicians, we accumulate evidence. In other words the more information we get, the more likely we are to reach a diagnosis.
So therefore, in my first report I overlooked this, and I think I've explained why: in my second report I am now suspicious and by my third report I am more prepared to commit myself to the diagnosis of what happened here.
BM: What you are doing, Dr Evans, is coming up with different theories to try to fit an allegation to give support to it. That's what you're doing, isn't it?
DE: No, no, I'm functioning as a clinician. This, you will find, is what clinicians do. We start with quite often minimal information and then, as the information accumulates, then it's more -- it's more possible to reach a diagnosis. This is what clinical practice is all about, irrespective of whether somebody is the victim of an inflicted injury.
BM: You don't mention air embolus until we come to your third report on 21 October 2021?
DE: That is correct.
BM: That is 3 years after we've been going with this particular child; that's correct, isn't it?
DE: Yes.
BM: In fact, the material you've pointed out to the jury is the same material you had been looking at up to that point, isn't it?
DE: No -- sorry, the presentation of [Baby N] on 3 June was different to the other cases where we've discussed --
BM: No, I'm talking about the material relating to [Baby N] that you base air embolus on, in that report in October 2021 is material you had had since 2018. It's the same material.
DE: It's the same material --
BM: Yes.
DE: -- but the way you interpret the material depends on the additional information you get.
BM: And this is you, by the time we get to October 2021, moving away from "inflicted injury" and now having a shot at air embolus, isn't it? That's what we have.
DE: I think in the circumstances I think this is very likely what happened to the little baby actually, yes.
BM: We know that Dr Loughnane arrived on that unit at 01.07. We know the report of the collapse was at about o'clock.
DE: Yes.
BM: You heard her evidence?
DE: Yes, I did.
BM: We can see it says here "pink" and her evidence was by the time she got there he was looking pink, so he'd recovered, that's what she said?
DE: Yes.
BM: So this had gone on for 7 minutes?
DE: Yes.
BM: So this must be the swiftest air embolus in the history of air emboluses, Dr Evans. Seven minutes, air embolus?
DE: It could well be.
BM: A world record?
DE: It could well be.
BM: Rapidly dissolving nitrogen?
DE: It depends on the volume, it depends on the rate of infusion. Those are the two characteristics that determines what happens to the baby. And the baby received 100% oxygen, so that's what happened.
BM: You have put this in because you want to find something to support the allegation and this is the best you can come up with, isn't it?
DE: It's not like that at all. What I have said in my reports, in this particular report, is that I'm aware, and I've said earlier today -- is that it's case 29, that this is not a standalone event. But you cannot overlook the events that have happened that we've discussed in this trial over the past few months. I have not said that in any report before this but I think it's worth noting that this is what I've said in this particular case. In other words, I am looking at all of the options and I think that's quite important.
BM: We've heard what's been said about the features of air embolus so far in this trial. So looking at this, first of all, there is no characteristic discolouration, is there?
DE: Not as far as I know.
BM: There is in fact absolutely no significant collapse at all, is there?
DE: Saturation dropping to 40% is a significant collapse, sorry.
BM: There was no collapse requiring resuscitation?
DE: Required 100% oxygen. Any baby who requires 100% oxygen who was previously in air has something significantly the matter with them.
BM: We've seen plenty of cases in this case not linked to the allegations where there are desaturations and oxygen provided to babies; that's standard, isn't it?
DE: No. If you have -- what prem babies do sometimes is they desaturate, their oxygen drops, they may drop from, I don't know, the low 90s to high 80s say, and it resolves spontaneously. We've had many of the nursing staff say that, short-lasting, you know. But a drop to 40% in a baby who was previously in air is very, very striking and very significant, even if -- if they recover in 7 minutes, but the doctor concerned was crash called away, you can't blame her for that, so therefore that may -- so that may limit the information that she was looking at.
BM: Her evidence was very clear. Are you seeking to put a perspective on what she said to the jury?
DE: No, I heard her evidence. You heard mine and that's my opinion.
BM: You weren't there, were you, Dr Evans?
DE: No, no, I heard her evidence.
BM: Her evidence was: "By the time I arrived he was looking pink".
So he's recovered, and then she went on to say: "I'd expect his sats to be high 80s or 90s."
That's when she attended. Do you recall that?
DE: I can't recall every word, but I was next door, but it was 40, you know, it was 40 when she was called and an oxygen saturation of 40 is concerning and potentially dangerous.
BM: This was --
DE: It is dangerous, not potentially dangerous.
BM: The entry for screaming you have told us all is incredibly unusual, "exceptionally unusual" is the language you've used, isn't it, today in your evidence?
DE: Yes. I don't think I've ever heard babies screaming in baby units. They cry. They certainly don't cry for minutes.
BM: It can't be that unusual, Dr Evans, because you didn't make reference to this when you first read it and it's -- did you?
DE: It's one word, screaming.
BM: Do you agree that descriptions of how a baby cries or how it screams are subjective, aren't they?
DE: Depends on their experience, really.
BM: We've seen the report of the baby getting upset is the way this was -- if we just scroll up, please, scroll up and look at the top of the screen. The report given to Dr Loughnane was "unsettled and got upset". Do you see that?
DE: Yes.
BM: We've seen the clinical notes of Nurse Booth who was present -- who wasn't present, but reported it as crying. This word, screaming, is used by one person, this doctor here, isn't it?
DE: Well, you know, there's screaming, you've got looked mottled, dusky, you said there was no sign of abdominal discolouration or skin discolouration. That's not strictly true. Looked mottled, right? That is skin discolouration. It is not specific for any condition but you can't say it wasn't there. I've already said that I was not aware of the association between screaming and air embolus in 2018, so there you go. So we've got, you know, he's dropped his sats to 40%.
BM: The question I asked you, Dr Evans, was if they were a characteristic description of air embolus and you've agreed.
DE: It is not characteristic of air embolus, but you cannot say that there was no -- you cannot say that there was no change in its skin colour.
BM: I didn't say that.
DE: No, no, I'm sure we'll agree on this one. He looked mottled, therefore there was skin discolouration. Is it characteristic of air embolus? No, it is not.
BM: So your reference to it is an attempt by you to try to work a piece of evidence in to support your evidence, is that correct, seizing on the word "mottled"?
DE: No, I am replying [sic] standard clinical practice, which is what I've done throughout my career and what I've done throughout this trial.
BM: If it doesn't denote an air embolus, and we agreed there's no characteristic discolouration of an air embolus, why did you stop as you were going through to make a point of identifying "mottled" then?
DE: Because it's written there. It's on -- it says there, "Looked mottled".
BM: In any event --
DE: Sorry, there's a difference between "looked mottled, dusky". Okay? There's a difference between "looked mottled, dusky" in a baby whose oxygen drops to 40% and then is back in air within a few minutes and was pink when the doctor saw her (sic). There's a difference between that and "looked mottled" in a baby whose blood pressure was a bit low or who's sickening for an infection or requiring 40% oxygen because of breathing difficulties, for example.
This baby's "looked mottled" is in association with those other features. It is not characteristic of air embolus, but it's -- you cannot say that there were no skin discolouration changes in this baby. There were. And the other thing that's interesting in this particular case is, and if we accept what Dr Loughnane said, is that when she got there he was pink. Therefore whatever the skin discolouration was, was short-lasting, and this is something we've heard the local doctors mention in association with other clinical cases in this trial.
BM: You can't tell the cause of the screaming from the fact it records "screaming" or "got upset", can you?
DE: Sorry, I was -- I missed that because of the coughing, sorry.
BM: You can't tell the cause of what lies behind the screaming from the fact the word "screaming" is put there, can you?
DE: You accumulate evidence, that's what clinicians do, and you form an opinion.
The other point in this particular case, I've already said about --
BM: Is your answer no to that, Dr Evans?
DE: Just a minute, just a minute. I've already said at least twice that this is not a standalone case like the other cases I've given evidence in. The events of June is not a standalone event, I've already said that. But looking at the thing, on the whole, I think we have concerns here and we have to explain this event somehow and the more likely explanation is as I've described.
BM: A baby of 35 weeks can cry or scream persistently and loudly, first of all, can't they? Is that correct?
DE: Well, you know.
BM: And [Baby N] in fact was 10 hours old and not receiving feeds at this time?
DE: Well, you know. He's not -- if he's... Yes.
BM: And a neonate of that age can cry or scream loudly because they're hungry, can't they, as it happens?
DE: Oh come on, for half an hour?
BM: They can cry or scream loudly?
DE: Come on. for half an hour?
BM: They are not going to cry for half an hour collapsing with an air embolism, are they, Dr Evans? That's a fact.
DE: If they're hungry, they're not going to drop their saturations to 40%, they're not going to require 100% oxygen, and if you suggested that any neonatal nurse would let a baby cry for half an hour because they're hungry, I think you would upset an awful lot of neonatal nurses, so let's forget all that. Let's forget about hunger being the explanation for this, shall we?
BM: The point being you simply can't diagnose air embolus from screaming, can you?
DE: Of course you cannot.
BM: Right. When you were talking about screaming, you said this before lunchtime. You were talking about the connection between screaming and air embolus and you were talking about the way air moves through the heart. You said:
"Answer: If it gets into the left side of the heart, it could get into a heart blood vessel, coronary artery. So technically, it could cause a heart attack, you know, which is incredibly painful. I can't prove any of this by the way."
Are you seriously suggesting this is a heart attack that's taking place? Is that why you said that?
DE: I don't think you can rule that out, actually.
BM: So you --
DE: I don't think you can rule that out.
BM: It's a self-correcting heart attack?
DE: Heart attacks -- I don't want anyone to have a heart attack, but most people survive heart attacks, okay?
So you've got the option -- you've got -- if it goes to the left -- sorry, if a bubble of air gets to the left side of the heart, it can go anywhere. If it goes to the abdomen, you see the skin discolouration. If it gets to a coronary artery it will cause ischaemia to a coronary blood vessel -- there are three coronary blood vessels, by the way. If it gets to the brain, it can cause a neurological problem, lack of oxygen to the brain.
So where the bubble goes can vary, but the key thing is the volume of the bubble and the rate at which it goes there. So therefore, as I have mentioned more than once in other cases, what doctors do, we list what we call a differential diagnosis. Okay? We list all possible options. So therefore, what I didn't mention this morning was I listed a number of possible options. Looking at this again, I think that my opinion, as I expressed in the second of my three reports is correct.
BM: There's not even a recorded change in heart rate, is there?
DE: Not recorded there.
BM: Or blood pressure?
DE: Not recorded there.
BM: It's an unusual heart attack to have no change in heart rate, for instance, isn't it?
DE: Not recorded there. I have -- I don't recall ever seeing from my neonatal practice a heart attack in a baby, but that's because one tends to avoid injecting air into their circulation.
BM: You see, what you were doing this morning with the jury was suggesting that because a heart attack can be painful and because [Baby N] is recorded by one person here as screaming, this may be a heart attack. That's what you were trying to say, wasn't it?
DE: What I said this morning is if air had gone into the coronary artery, which is -- it'd cause a heart attack, let's use the scientific term, it would cause lack of oxygen or ischaemia to the heart muscle. Let's avoid the lay term. That would cause severe distress and pain.
If it goes anywhere else then the features change. It goes to the brain, brain problems. If it goes to the abdomen, you get skin discolouration. If the bubble goes into the feet, then your toes will go white. In other words, it depends on where it goes.
BM: So your evidence, so we can understand this, is that this may be signs of a heart attack brought on by an air embolus?
DE: I think that we have to seriously consider that this baby was the victim of an air embolus on 3 June. Whether the bubble went into the heart or the brain or anywhere else is difficult to say.
BM: You've referred to research, a paper or something, you read involving screaming and air embolus, haven't you?
DE: I have.
BM: That's in your third report at page 4598 in our pages and there are two publications you refer to, aren't there?
DE: Yes.
BM: One of them is called Broadhurst. We've got here the situation with [Baby N]. My Lord, it's at page 4598 of the statements, if the reference is to be made, and it's page 2 of the statement dated 21 October 2021.
DE: Just a minute, here we are.
BM: It's easier if I read your summary --
DE: This is "Death by Error" by Anne (sic) Broadhurst; yes?
BM: "Death by Error" by Daphne Broadhurst describes several cases, and this is one of the two cases you are referring to:
"She notes a baby of 8 months who was receiving intravenous fluids. The family reported the presence of air bubbles in the line after the nurse squeezed IV bag. The baby screamed, turned blue, arrested and died. The cause of death was said to be cerebral air embolus."
DE: Yes.
BM: Clinically, and factually, that has absolutely nothing in common with what we're looking at here with [Baby N], does it?
DE: I disagree. This baby was 8 months to start off with, so far bigger. A baby of less than 2 kilograms would require far less in the amount of air.
And then in this particular case, there were lots of bubbles there, so again we're back to how much air and the rate at which it was given.
BM: The other paper that you referred to, I'm going to the detail of what you have put, just following on on the same page of your statement, is Seoul's publication, isn't it?
DE: Yes, it is.
BM: It describes an infant death due to air embolism from a peripheral venous infusion?
DE: Yes.
BM: "The case relates to a 11-week-old baby who returned to hospital 5 days following a hernia repair."
It says the mother was concerned about the colour of the site there and the question of infection.
DE: Yes.
BM: "An intravenous catheter was inserted into an infusion pump in the back of the right hand. The infusion pump was connected to the intravenous line. The nurse flushed the intravenous line with normal saline and the report says immediately thereafter the nurse started the infusion pump and returned to the head of the crib to record the time. Meanwhile the baby's cries had turned into screams. He then coughed or gasped loudly. His back arched, his arms stiffened, he lost consciousness. Resuscitation was not successful and after 5 minutes of effort he was declared dead. The chest X-ray carried on during the resuscitation was described as being of poor quality. No air was seen in the vascular structures o or the heart. A post-mortem X-ray taken 12 hours after death was reported to show air in the pulmonary and systemic circulation as well as air in the portal venous system beneath the diaphragm."
That, factually and clinically, has nothing in common with the situation with [Baby N] in this case, does it, Dr Evans?
DE: That is incorrect. What I've said is that I've quoted papers that associate screaming with injection of air. I haven't taken it any further than that. That is what I've said in my report and that's what I'm saying now. As well as that, again, repeating myself, this is something we've heard in other cases in this trial.
BM: You have gathered bits of what you can to try to put together some kind of allegation based upon air embolus to fit the allegation, not the facts. That's what's happened, isn't it?
DE: No, those are the facts, that is the clinical evidence, and by the way, I've not heard of any other explanation that fits as clearly as the interpretation I have given in relation to this particular event.
BM: 15 June, Dr Evans.
DE: (Speak sotto voce).
BM: Let's have a look now at... 15 June, Dr Evans. I'm going to the report that your evidence was principally drawn from, you gave it from this morning, the report of January 2019.
DE: Yes.
BM: You've explained to us today, you reviewed the deterioration of [Baby N] during the night or rather the very early morning of 15 June, haven't you?
DE: I have.
BM: And there was a brief summary of [Dr A]'s clinical notes throughout the course of that night, wasn't there?
DE: Yes.
BM: Then we came to the desaturation at about 7.15 in the morning; yes?
DE: Yes.
BM: And then the question of the intubation and the blood that is seen around that time?
DE: Yes.
BM: Right. When you were dealing with this, you said this about it. Let me start with your opinion. I would like to go to paragraph 71. You said: "It's probable that [Baby N] sustained trauma to his oropharynx some time prior to the doctors being asked to see him at 1.45 on 15 June."
DE: Mm.
BM: "Inserting any kind of implement, such as a nasogastric tube, into a baby's mouth and thrusting it into the back of the throat would be sufficient to traumatise the soft tissues of the oropharynx, causing bleeding and subsequent generalised deterioration."
DE: Yes.
BM: And so, first of all, there you're saying that he sustained trauma to the oropharynx some time prior to the doctor seeing him, so some time before 1.45 in the morning. That's what you said, isn't it?
DE: I've got that time wrong.
BM: And then we go to paragraph --
DE: Sorry, I got that time wrong.
BM: Then we go to paragraph 78. It's not just -- let's go to paragraph 78: "I suspect that if [Baby N]’s initial bleeding problems were due to spontaneous bleeding from his oropharynx, his condition would have deteriorated significantly during the next few hours."
Well, we're not talking about spontaneous bleeding. But you conclude that paragraph with this: "It is my opinion that [Baby N]’s oropharyngeal bleeding was the result of some form of trauma to the back of his throat during the early hours (pre 01.45) of June 2016."
That's what you say, isn't it?
DE: Got that time wrong, sorry about that.
BM: Well, you -- you said that now twice in that report, haven't you, 1.45?
DE: Yes, but it's wrong.
BM: But we've got the clinical entry for 1.45 by [Dr A] when he first sees the baby, don't we?
DE: There was no blood. The blood was noticed for the first time at 08.00 hours, and therefore by putting 01.45 -- by talking about oropharyngeal bleeding I should have said "from around 08.00 hours". Got my time wrong, sorry about that.
BM: On paragraph 83 in the same report, you advise the need to look at nursing and medical care present during the night shift of the 14th and 15 June.
DE: Yes.
BM: So you're quite clear at the time of that, on your assessment, that you're looking at something that starts or has its start in the very early hours of 15 June, weren't you?
DE: What I confused was the fact that he wasn't as well as he had been at 01.45 hours and the fact that the bleeding was part of his problem, although the bleeding did not -- was not found until 8 am. Okay? So I've got that wrong. I got it wrong. My responsibility is to correct any errors I have made.
So the baby was unwell from around 01.00 hours, but the bleeding in the back of the throat was noticed at around 08.00 hours. That's the key thing. If my report has confused the two things, my apologies.
BM: Is it not that at that case you were drawing a direct line in a deterioration that began at 01.45 and, as you saw it, culminated in bleeding being seen at 8 o'clock in the morning? Is that not what you were doing?
DE: He was seen at 1, 3 and 5 am, I think, and nobody commented on any bleeding. The bleeding was noticed at 8 am, and that's where I got it wrong.
BM: And you link that to the desaturation that he experienced at 7.15, don't you?
DE: Yes.
BM: Yes, you put bleeding together with desaturations being elements of the same event, don't you?
DE: Well, you can't... I... You cannot say that. What we appear to be certain about from the evidence we've heard from the local people is there was bleeding evident when the laryngoscope was passed into the mouth at 8 am --
BM: Just to pause there, I'm not going to debate -- there's an issue, and you know exactly what Mr Johnson was referring to earlier today, there's an issue as to when that blood was seen.
DE: That's fine. That's a matter for others, I accept that.
BM: Your evidence on this is -- you said, there's a collapse from 17.15 (sic) onwards, that was how you described it this morning when you gave evidence. He collapses from 7.15 (sic) onwards in the morning. Is that right?
DE: No, his deterioration was from -- well, it must have been from just before they decided to intubate him. The doctors decided to intubate [Baby N] at 8 am, so therefore his condition had deteriorated sufficiently by that time for him to require intubation.
BM: Yes.
DE: So his deterioration was pre-8 am. There was no suggestion that he required intubation during any of the earlier assessments by [Dr A].
BM: And we have the desaturation recorded at about 7.15 that morning, don't we?
DE: I'm sure it is. I can't remember what it was.
BM: If we put up tile 141, please, Mr Murphy. Tile 141. And if we go behind that to remind ourselves of the timing. Scroll down, please. Thank you.
It's down, if we go to the bottom left, 07.15: "Baby crying and dropped saturations."
Do you see that?
DE: Yes.
BM: I'd like us to be able to understand your evidence, and I don't say that to be rude, Dr Evans, but to understand it, you are linking that 7.15 desaturation to the blood that is identified in the course of intubation, aren't you, or are you saying they're two completely different events?
DE: No, I think connecting the two is not unreasonable from a clinical point of view.
BM: Even though no blood is seen at 7.15?
DE: As far as I know there was no blood seen, but there was blood at 8 am. We only know for sure, if we accept the evidence of the local people, there was blood at 8 am. And you know, by 8 am he was very unwell. His sats had dropped to 48%, I couldn't remember that then. His saturations had dropped to 48%, very low -- this is paragraph 16 of my report -- and his heart rate had dropped to 80 and he was bagged and given Neopuff and so on.
So therefore he was very unwell by 8 am. But at that time he was sufficiently unwell to require intubation.
BM: So contrary -- we've been over this: you don't say now at least that it began at 1.45 in the morning; you're clear about that?
DE: Got the time wrong, apologies.
BM: You identify the desaturation at 7.15?
DE: I have.
BM: And the desaturation which, following this through, leads to the requirement for an intubation?
DE: Yes.
BM: And you draw the link between that desaturation and blood at the time of intubation?
DE: Sorry, say that again.
BM: You draw the link between that desaturation and blood at the time of intubation?
DE: Well, something caused the desaturation. Would blood in the back of the mouth cause desaturation? Yes.
BM: Right.
DE: You can't go further than that.
BM: You accept no injury at any point is identified to the oropharynx by any of the numerous practitioners who saw [Baby N] that day?
DE: I'm not sure you can say that. All I've read is that there was swelling of the epiglottis and, in my opinion, the swelling to the epiglottis reflects trauma. The epiglottis is a very soft piece of tissue that overlies the airway and it doesn't take a lot to traumatise it.
BM: Do you agree no source of blood, as in a fresh-flowing source of blood, is identified in the oropharynx or in that area by any practitioner?
DE: Well, if the area's covered in blood, you're not going to find any tear or abrasion underneath.
BM: It's not covered in blood throughout the whole period the practitioners are looking at it, is it? We have heard from them.
DE: It's the area -- there was so much blood there they couldn't intubate, let's put it that way.
BM: At this time it is said that the intubation had to stop because of blood?
DE: That's what they said.
BM: At other times the only reference has been to swelling?
DE: Yes.
BM: At no time has anybody identified any injury in or around that mouth, despite repeatedly looking at it through a laryngoscope, have they?
DE: That is incorrect, because what you've got there is a swollen epiglottis and, in my opinion, that swollen epiglottis -- that epiglottis was swollen as a result of trauma.
BM: You are seeking, again, to support the allegation, aren't you, by reference to a theory that can do that but not by the basic facts?
DE: No, I am putting clinical facts together in a way that makes clinical sense.
BM: I suggest you're putting things together to try to construct an allegation, Dr Evans, on this case here.
DE: No: clinical consistency --
BM: When you spoke about your involvement in this case at the start of this trial, you talked about being contacted by the National Crime Agency; do you remember that?
DE: Yes.
BM: Is that how you recall this, they contacted you?
DE: We got in touch, yes.
BM: And they wanted you to deal with this?
DE: Well, the way it works -- by this time I think I'd been in touch with the NCA about 40 times or so where -- what happens is a police authority gets in touch with the NCA, we have to look for an opinion from somebody of my professional background, we've got a baby here with abusive head trauma or suspicious injuries or whatever, you know, and a police authority in the West Midlands or West Mercia or wherever, Humberside, I've been involved with loads of them, want a medical opinion. I reply to the NCA saying, tell the police authority to get in touch with me. That's the way it works.
And in this particular case, it was Cheshire Police. I'd not had any dealings with Cheshire Police. I think Cheshire Police got involved in May 2017. They got involved with me, I think in June or July 2017. And someone from Cheshire Police rang me up and I said, "I'm not sure what's going on here, I'll come up and talk to and you we'll take it from there". So that's how it started.
I went up to --
BM: It's how it started that I want to ask you about so let's stick with that, Dr Evans, and I would be grateful if we can look at an email at D24, please, Mr Murphy. It's just one email I want to ask you about. We can all see this. We can see at the top: "Dewi Evans, 21 May 2017. To: the National Injuries Database re Op. Suspicious Unexplained Death."
Do you see that?
DE: Yes.
BM: You'd been working with this body on a different investigation at this point, not this one, and the National Injuries Database provides support and advice for the serious crime investigation roles of the National Crime Agency, don't they?
DE: Sorry, say that again.
BM: The National Injuries Database, who you're emailing, provide support and advice for serious criminal investigations involving forensics to the NCA, the National Crime Agency?
DE: They're called FMAT, the Forensic Medical Advice Team, now. But anyway, same lot.
BM: So you're talking to your contact:
"Dear Nick.
I've received a lots of documents from [and we have redacted other details] the police op [whatever], but not the autopsy result. I'll liaise with DS [redacted] directly. Should sort quickly once I get all the files.
Incidentally, I've read about the high death rate for babies in Chester and that the police are investigating. Do they have a paediatric/neonatal contact? I was involved in neonatal medicine for 30 years, including leading the intensive care set-up in Swansea. I have also prepared numerous neonatal cases where clinical negligence was alleged. If the Chester Police have no one in mind, I'd be interested to help. Sounds like my kind of case.
I understand that the Royal College has been involved, but from my experience the police are far better at investigating this sort of problem."
First of all, I'd be grateful if you can answer the specific questions I ask, Dr Evans. This is you contacting the NCA, isn't it? Yes? You contacting them?
DE: Well, it isn't, it's about another case. I can't remember what that other the case was. So I got in touch with them. This is the way the NCA works. As I said, I'd done dozens of cases for the police authorities via the NCA by 2017.
BM: This is you putting yourself forwards, in effect touting for this job, isn't it?
DE: I dislike emotive terms like that (overspeaking) --
BM: All right. Putting your forwards for this job.
DE: I was offering my professional opinion if that was in their interest. Okay?
BM: "Sounds like my kind of case."
Yes? That's you advancing yourself as someone who can do for them what they require, isn't it?
DE: And it looks as if I have.
BM: It's you ready to give them what they want, isn't it?
DE: No, no. I have dealt with several police cases where I went through the report and I said, look, this case does not cross the threshold of inflicted injury or suspicious injury or whatever. My case -- my opinions are impartial and independent.
The other thing that -- might be worth telling you, Mr Myers, at this stage is this: in the past 5 years I don't only give evidence via the NCA or to the police authorities, I also give evidence to law firms representing defendants. In fact, in the last 5 years I have given more -- prepared more reports for lawyers acting for defendants than for the prosecution or the police.
Now, lawyers acting for defendants are not known for looking for evidence from doctors who rubber stamp prosecution expert evidence. As a result of the numerous cases where I've acted for the defence -- I think my record is somebody being found not guilty in half an hour because the prosecution case was awful, that was my opinion anyway. All of this is in the public domain by the way.
Therefore I act for the defence if I'm asked for. Most of my work is, as it is for most paediatricians, for the Family Court. And in the Family Court, it's complicated, but you act as what we call a joint expert witness. And I think the members of the jury need to know this: you act for the local authority, the people acting for mother, father, child.
And we had this discussion a few weeks ago: as far as I know, in the Family Court, I've had no judgments against me apart from one that was reversed on appeal, apart from the altercation Mr Myers raised recently (overspeaking). I need to explain this, I need to explain all of this because I think the members of the jury need to know that I give an opinion if asked and if it's within my expertise. Now, with neonatology being part of my clinical practice for a long, long time, this very much was within my clinical remit or, to use a lay term, "Sounds like my kind of case", okay? I can't even remember who Nick was actually but there we go.
So therefore that's how people correspond. It's not, dear sir, yours truly and all that sort of stuff. That's how emails work, okay?
BM: Thank you.
DE: Therefore that's how I got involved with this case: NCA and me first, Cheshire Police followed.
BM: And when you make reference to the family matter, you just talked about the Family Courts, that was the matter that's been raised with you before during this case, the ruling from Lord Justice Jackson, isn't it?
DE: Yes, that is true.
BM: This is a record dated 21 May 2017 -- take it down, Mr Murphy, please. We'll go back to it if we need to.
I'm going to suggest to you, Dr Evans, that at some point before you started writing reports, you were told by the police of suspicions about suspicious rashes and air embolus (overspeaking) you were told that or it was indicated to you, I'm going to suggest, before you wrote any report.
DE: No, that is completely untrue. Okay? It is totally untrue. The first time I heard a local doctor mention the word air embolus was a couple of weeks ago. I'm not sure whether it was Dr Gibbs or Dr Jayaram, Dr Jayaram I think, when he talked about the cold chill going down his spine. I knew nothing about air embolus. The first person I know of to raise the issue of air embolus in this particular series of cases was me. And I did that in case number 1. Okay?
In the first case I thought, oh my God, what's going on here? This is -- you know it was very much an "oh my God" scenario.
I'm not going to go at length about case number 1. For [Baby A], if we remember, I formed the view that it was his collapse and the inability of the staff to resuscitate him was the result of his receiving air embolus. I did not know at the time about the skin discolourations; I heard about that later. I did not know at the time about Owen Arthurs' finding of air embolus on post-mortem X-ray (overspeaking) --
BM: That's your characterisation -- if we can just pause for one moment, Dr Evans --
DE: Just a minute. I want to finish this.
BM: My Lord --
DE: I want to finish this because if you're going on wild goose chases, I want to --
MR JUSTICE GOSS: You can finish the answer and then you ask the question.
DE: Therefore I didn't know any of that. But that's what led me --
MR JUSTICE GOSS: You have said all this before. We've heard all this before.
DE: I had nothing at all -- I knew nothing at all, sorry, about air embolus from the police. I was not told anything about any suspect or named anybody and I knew absolutely nothing and, as I said at the beginning of this trial, it's quite important to repeat this, at the beginning of this trial my role --
MR JUSTICE GOSS: You have said this, Dr Evans. I know. You've said it at least once, more than once.
DE: Yes, I know.
MR JUSTICE GOSS: All right? Ask your question, Mr Myers.
MR MYERS: So far as Owen Arthurs is concerned, that is matter that is to be determined in the case.
DE: So what now?
BM: So far as Owen Arthurs is concerned, what his X-ray shows or doesn't show is a matter that the jury are going to determine in this case. You understand that, don't you?
DE: I do understand that, yes.
BM: What I want to ask is this: one of the cases that you referred us to and that you rely upon when saying that on the 2nd or 3 June [Baby N] had an air embolus over that period is a case that concluded with a post-mortem X-ray taken 12 hours after death, reported to show air in the pulmonary and systemic circulation as well as air in the portal venous system beneath the diaphragm. That was indicative of air embolus in that case of Sowell, wasn't it?
DE: That seemed to me -- yes, that's correct.
BM: That is direct evidence of air in the pulmonary and systemic circulation, so in the lungs and in the cardiovascular system?
DE: Yes.
BM: And in fact we do not have that in this case, do we? We don't have that, do we?
DE: Right. Professor Arthurs' opinion is his opinion, but when I heard his evidence, he said you do not need to find air in the circulation in -- in the post-mortem circulation of babies to confirm air embolus. That is what he said. That's his opinion, he's the radiologist, I am not.
BM: You relied upon that case to support what you are saying here and, do you agree, we do not find air in the pulmonary or systemic circulation in any of the cases we're dealing with in this trial, do we?
DE: This Sowell case was a massive air embolus where a baby died and he was several weeks old, so the comparison is not exact. The comparison is not exact.
BM: You're the one making the comparison, aren't you, Dr Evans?
DE: No, no, the comparison -- I quoted these papers because of the association between air embolus in these two cases and screaming. The baby screamed. I didn't know about that until I did my online searches for air embolus. Didn't know that.
MR MYERS: Those are my questions, my Lord.
MR JOHNSON: Does your Lordship have any questions?
MR JUSTICE GOSS: I don't. Thank you very much, Dr Evans. That completes your evidence at this stage.