Compiled by Sofie Terleska, original version is here: LucyLetbyTrials subreddit
(Delay in proceedings)
(In the absence of the jury)
Mr Justice Goss: Mr Johnson, Mr Myers, may I confirm I’ve received your respective documents. Subject to one or two queries, I don't know what you are specifically inviting should happen, Mr Johnson.
NJ: I was inviting my learned friend initially to make corrections but I know his position is that there is nothing that requires correction. It's a document that points out issues we have raised.
Mr Justice Goss: Can I say that there were points during the course of the speech that I was going to remind the jury of the actual evidence upon so I am not going to pursue any suggestion of pointing to something and identifying it. I shall simply in my narrative, which as you will learn shortly, is going to be a recitation of the evidence with very little, if any -- well, there will be a little bit of comment here and there but substantially no comment and no reference to it.
There is just one matter upon which I do need your assistance. That's to do with Dr Evans and the radiograph with air in the brain. There's one, isn't there? You say there are two, Mr Myers says there’s one.
NJ: It was the heart, I think, not the brain.
Mr Justice Goss: Sorry, in the heart. There is reference to air -- yes, all right.
BM: Professor Arthurs, yes. There were two references which the prosecution identified: one during cross-examination relating to Baby E, one during cross-examination relating to Baby O. It's item 3 in the prosecution's list and also item 3 in ours.
It's apparent when one goes back to the evidence that item 1 with Baby E actually came out of questioning about that image from the Lee and Tanswell document.
Mr Justice Goss: So it was in relation to the image, not to an actual radiograph?
BM: The image, yes.
Mr Justice Goss: I just want to confirm with Mr Johnson that you accept that.
NJ: I must say, I hadn't picked up that detail if that's right.
Mr Justice Goss: I've seen what you have said, Mr Myers, and that's what I understood the situation to be.
NJ: If that's right then that's right.
Mr Justice Goss: That's that. Then the other point in relation to this, as I understand it, is that Dr Evans, when he referred to the great vessels, when he was talking about air in the great vessels --
BM: Dr Arthurs, my Lord.
Mr Justice Goss: Dr Arthurs, sorry -- was referring to air in the great vessels, he was not specifically identifying the heart as such, but he made this comment in relation to one of the radiographs that there was air to be seen in the heart and that was it, but then he didn't actually address that in any further detail.
NJ: Well, one of the points my learned friend makes is that the prosecution haven't actually relied on air in the heart and we never did because --
Mr Justice Goss: Exactly.
NJ: -- it's a non-specific finding. The issue arose because, we say, it was being turned into a point.
Mr Justice Goss: All right. There we are.
Then there's one other thing -- and I just didn’t have the wherewithal over the weekend, because I was quite busily engaged, to confirm one thing.
Sorry, there is another matter, Mr Myers. Whether Dr Evans and Dr Bohin are neonatologists. You expressly did not contradict their assertion that they were neonatologists. Their qualifications, which I shall recite, are that they have been neonatologists.
BM: We accept Dr Bohin, by training at least and experience on the face of it, is a neonatologist. Our cross-examination of Dr Evans, and in fact I'd be grateful if this is a matter to deal with, to give your Lordship the correct references, but it was plainly directed towards the fact that he didn't have -- we questioned that he had the relevant experience and that he was a paediatrician by training. His evidence was that he had spent a lot of time working in neonatal units, but we were drawing that distinction most definitely. It would help probably if I could find your Lordship that reference.
In the course of submissions to the jury we said he was not a neonatologist. We didn't actually say that about Dr Bohin and the passage identified by the prosecution was a reference to them not being in the same league as Dr Babarao and we dealt with that in this response under item 1.
Mr Justice Goss: Right.
BM: It's important because the prosecution's document had taken a passage from my submissions and it said that -- I'd like to just explain this to my Lord. One moment, please.
(Pause)
Yes, it's right under item 1 where they say there are several things that were said and they put the quote from my speech:
"Dr Evans is not [and it has square brackets] a neonatologist, no matter how he boasts of his credentials, nor is any other prosecution in this case."
We understand that by putting it in square brackets the prosecution were shortening what was said, but what was said he is not a neonatologist -- and we put this is at our page 6 in our response:
"Dewi Evans..."
We didn't say "not a neonatologist", we said: "Dewi Evans is not in that league, no matter how he boasts of his credentials, nor is any prosecution witness in this case."
Mr Justice Goss: I don't want to get involved in the semantics --
BM: No, I know --
Mr Justice Goss: All I wanted to do is to tell the jury what the actual situation is, not what they may or may not be described as.
My proposed summary, and I would be grateful if counsel could listen to this, would say that: "He is a consultant paediatrician who was in full-time NHS clinical consultant paediatric practice in Swansea from..."
And then I need help on from when it was. I’ve noted 1980. There's another reference to 1986 somewhere and I'm just wondering if someone could look at the report to confirm exactly what the correct date is, but we can pass on that:
"... to 2009 and was responsible for setting up, supervising and leading a neonatal intensive care service in Swansea from his appointment, developing intensive care services from scratch. His experience was very much hands-on. His operational and managerial roles including serves as clinical director of paediatrics and neonatology in Swansea between 1992 and 1997, and 2004 to 2008. Neonatology is the care of babies up to around 4 weeks of age."
I hope that accurately represents what his experience and qualifications are.
NJ: Yes. It's 14 October, which is Day 8, and it’s page 7 of the transcript. I can read what he said.
Mr Justice Goss: If you would, please.
NJ: "I qualified from the Welsh National School Of Medicine in 1971. I carried out my first paediatric post 18 months later. So my paediatric junior training took place in Swansea initially, then in Cardiff and in Liverpool. Each phase of my training involved specific training working in a neonatal unit."
Then he says:
"I was appointed consultant paediatrician in Swansea in 1980. The most significant part of my brief, I think, was the development of newborn services for babies, particularly developing intensive care services for babies, which we did from scratch, really."
Then I asked:
"How would you define your role in the development of those neonatal intensive care services in South Wales?"
He said:
"Swansea was one of the bigger units in South Wales so we covered the area extending throughout the whole of South-west Wales over time. Initially it was very much a matter of getting on with it, trying to get good equipment, getting the nursing and" --
Mr Justice Goss: I don't need that.
NJ: And then:
"So therefore we developed all those services during the 1980s and the 1990s in Swansea..."
Mr Justice Goss: I think I've summarised it accurately and fairly. It was just the date of 1980 I wanted --
NJ: Yes.
Mr Justice Goss: -- which I had written down and then somewhere else I saw 1986, but there we are.
So your complaint, Mr Myers, or your criticism of him, is that he essentially trained as a paediatrician, specialised in neonatology, but doesn't have -- that is the extent of his experience as I've summarised it?
BM: It is. My Lord, just so it's plain, the way we dealt with it, and I found the reference, when we cross-examined Dr Evans on 14 October last year -- and this is for your Lordship's reference at page 70, line 12, on Day 8, 14 October, through to page 71, line 18 -- we established with him that he's not a consultant neonatologist, it was put to him:
"You're not a consultant neonatologist, are you?"
He said:
"Answer: I'm a consultant paediatrician, that's correct.
"Question: You are a consultant paediatrician and you have significant experience in neonatology of over 30 years.
"Answer: Yes."
We went through that with him. It was put to him:
"Question: The bulk of your experience in neonatology is via the unit you set up in Swansea?
"Answer: Correct.
"Question: And that was during the 1980s into the 1990s?
"Answer: [And he added] And the 2000s."
So it was over that period, from the 1990s to the 2000s:
"Question: So in that sense [we went on to say] you weren't someone who was working exclusively in neonatology?
"Answer: That is correct."
So that was the type of issue.
Mr Justice Goss: I understand. I'll refer to that, thank you very much. I don't think there are any other matters that I need to continue with unless there’s anything you want to say, Mr Myers.
BM: We don't enlarge upon the written material your Lordship has had. We understand the process your Lordship is engaged within and our concerns were there. I won't reiterate all of that now. Your Lordship has that and we can proceed as your Lordship sees fit.
Mr Justice Goss: I'm not going to engage in a process of correcting. All I'm going to do is tell the jury what the evidence is and say, "This provides the context of the submissions that you have heard", in other words, I'm contextualising the submissions.
BM: Yes, we understand that. With that in mind, your Lordship knows we don't accept the description of correcting, although I won't descend to the arguments which were given to your Lordship, but we have put the corresponding evidence and issues alongside those and we may do that yet if we have the opportunity with the other matters that were raised, though we take it that your Lordship does not take these as a guide to what is said in summing-up.
Mr Justice Goss: What I will do is simply, when we have breaks, of which there will be quite a few over the course of the next few days, I will invite counsel, if they wish to correct anything that I have said which is erroneous, I'd be very grateful for you to correct me. But what I will not engage in is seeking to advance arguments, you wouldn't expect that in any event, but simply any corrections, and I hope there will not be many, but there is a huge amount of material, and of course this is a summing-up, this is not a recitation of all the evidence, and I can't -- I'm not going to descend to arguments and counter-arguments, I will simply set out the general positions of the prosecution and the defence and then remind the jury of the evidence, giving them references, but not -- and I’ll tell you this now so that no one is in any way surprised, I'm not going to invite them specifically to look at documents as I'm going through my summing-up because they have the documents. I shall make references and invite them to note references if they so wish but I am not going to start, because if I started where would I stop and we would be here for weeks.
BM: Yes.
Mr Justice Goss: So that is, as you will hear in a moment when we start, the format of the summing-up. As I say, I would, please, welcome corrections --
BM: My Lord, we understand.
Mr Justice Goss: -- which can either be done in the presence or the absence of the jury. It might be better if they're done in the absence of the jury, I think.
BM:We agree.
Mr Justice Goss: All right.
Would anyone object to the usher distributing -- is it easier for you to distribute when the jury are in place?
(Pause)
(In the presence of the jury)
Mr Justice Goss: I see that each of you collected a copy of my second set of legal directions, "Legal Directions 2", to which I shall come in due course and I shall refer you to those directions as and when they are appropriate, all right? But don't for the moment trouble to look at those directions.
In 2015 and 2016, there was a significant rise in the number of babies who suffered serious and unexpected collapses in the neonatal unit in the Countess of Chester Hospital. The prosecution case is that these collapses were not natural events but were caused by the defendant, Lucy Letby, using various means to harm babies, intending that they should die. Some died, others were resuscitated or, in the cases of alleged poisoning by insulin, the source was removed.
A number of the babies were subjected to what the prosecution allege were repeated attempts to kill them. After a year, it became clear that, of all the nursing staff and doctors, the defendant and her alone was at work on the unit at relevant times and was sometimes present when unexpected collapses occurred.
Following the deaths of Baby O and Baby P and the collapse of Baby Q on successive days on the 23rd to 25 June 2016, the defendant was confined to clerical work and stopped from patient nursing duties.
As I have told you already in my written Legal Directions 1, you have to consider a total of 22 alleged offences and return verdicts on each of them, applying those legal directions. There are other directions of law relating to the evidence that I must give you and they are in writing and headed "Legal Directions 2", to which I have already referred.
I shall refer to those directions at the appropriate relevant times during the course of this summing-up, which obviously is going to take some time, as I said to you before counsels' speeches, but it will not be exhaustive. I repeat and emphasise that it is your view of what is significant and relevant to the decisions you have to make and your resolution of the conflicts in the evidence you have to make that is important.
I begin by reminding you of the background and context of the events giving rise to the offences alleged on the indictment. The Countess of Chester Hospital is, and was in 2015 to 2016, a busy general hospital with a maternity unit within which was the neonatal unit, in which premature and sick babies were cared for at that time and to which I shall refer as "the unit"; that's the neonatal unit.
Given that we are concerned with the hospital structure and layout of the unit in 2015 to 2016 and events at that time and the prevailing situation and practices, I shall use the past tense in my summary. Even though it's still a functioning hospital, I shall refer to it in the past tense.
In the Cheshire and Mersey Neonatal Network, which adopted the prevailing standard NHS structure in England and Wales, a three-tier system of hospitals was operated, the tertiary system, with which you are now familiar and it is set out in section 1 of the agreed facts, which are in your second jury bundle. You needn't refer to it now, if you need to remind yourselves about the system, that's where it is.
The Countess of Chester was a designated level 2 unit and routinely provided care for babies of 27 weeks’ gestation and babies that required intensive care for up to 48 hours.
You have a plan in your first jury bundle, section 4 of the ground layout of the neonatal unit and some adjacent areas. It's a guide and not a scaled and wholly accurate depiction of the unit. You also have photographs and walk-through recordings, one being close to the time of the events and a more recent one recorded on 3 October 2021, when equipment had been removed and the unit had been vacated.
One room, marked on the plan as room 1, was the ICU room and was often referred to as "nursery 1". There were four incubators and two computers in there as well as other equipment. Nurse Melanie Taylor remembered it as shown in the walk-through recording.
Room 2 was the high dependency unit, the HDU, often referred to as nursery 2, and rooms 3 and 4, nurseries 3 and 4, were special care babies' rooms.
The details in relation to the rooms and the means of entry and reliability of swipe data are set out in section 3 of the agreed facts. Also in that section are the details relating to the medical staff.
The very last evidence you heard in the case was from Lorenzo Mansutti, an estate plumber for the hospital since 1986. The Women and Children's Building, of which the unit forms part, was built in the 1960s. There have been issues with the drainage system in that building, assorted and various blockages, maybe once a week, he said. There was one occasion in 2015 to 2016 when he believed a hand basin in nursery 1 in the unit backed up with foul water.
He was also taken through plumbing incident reports, including one on 26 January 2016, when at 02.30 hours the floor of nursery 4 was flooded because a mixer tap was switched on and a sink was blocked by waste products having been put down it. That was not on a date oraround the time of any incident in the indictment.
There were nine other incidents in the Women and Children's Building, not all of which were in the unit.
The doctors and nurses all worked on a shift system. The doctors comprised the conventional grades of hospital doctor, consultants at the top, with specialist doctors in training below, identified by a T number, registrars being next and senior house officers in the lowest grade. The number of years registrars and senior house officers had undergone specialty training reflected their level of experience. The doctors would cover the children's ward and the neonatal unit, so would not necessarily remain within the unit for the full duration of a shift.
There were seven consultants at that time. Dr Gibbs explained that every specialty in the NHS wanted and wants more staff. An increase had been planned for many years and was necessary because of the need to comply with the European Working Hours Directive, which was applicable at that time. This was a nationwide problem in paediatrics. Dr Gibbs said it would have been better if more consultants were available, but he refuted the suggestion that there was any compromise of the appropriate level of care given at that time.
There was a consultant of the week, who covered both the paediatric ward and the neonatal unit. That style of cover was common for a district general hospital and one that they had followed for many years prior to 2015.
He said they weren't complacent about whether they were offering appropriate care for babies on the unit. They carefully monitored activity on the unit and each year they would look at the outcome measures, a crude but important one being the number of babies who died on in the unit.
And every year, up to 2015, the number of deaths on the unit were within the expected number for a unit of their type in the region, which was less than the national average. Yet with those same consultants, in 2015 to 2016, the number of deaths increased significantly, with a marked difference in both the number of deaths and in the unusual and unexpected nature of the deaths.
The defence contend that this was a consequence of the increased number of neonatal babies at that time and the higher acuity of those babies. As I shall remind you, as the number of such cases increased, the clinicians started to think the unthinkable, as it was described, that these were not naturally occurring, sudden collapses but the consequences of deliberate harmful acts.
Generally, there would be paediatric consultants on duty between 09.00 and 17.00 hours each day and one on call at night, who was within 10 minutes of the hospital. I shall use the 24-hour clock at all times toavoid confusion with AM and PM and I won't say “hours" each time, I will just give you the numbers.
Registrars and senior house officers were always either in the paediatric wards or in the unit and the registrars, who would have up to 11 years' post-qualification experience, generally provided the senior medical cover overnight.
In her evidence the defendant was asked about her relationships with other members of staff. She confirmed that, apart from Dr B, who was very involved in the attempt to resuscitate Baby P, count 21, and with whom she didn't have the best working relationship, she had no problem or issue with any of the doctors and had a normal working relationship with them at the time of the events in this case.
She loved Dr A as a friend, but was not in love with him.
Later, she characterised Dr Stephen Brearey, a consultant and neonatal lead at the hospital, as "a bastard" after the investigations had begun. He, she said, was one of four consultants, the others being Dr Jayaram, Dr B and Dr Gibbs, who have conspired together falsely to apportion blame on her and, she believed, to cover up the failings at the hospital.
Nurses who worked at that time in the unit generally fell into one of four bands in the hierarchy below the ward manager; agreed fact 12 in section 3. Band 6 nurses were at the top. Below them were band 5 nurses who were split into those who had done special training in caring for ICU babies and those who had not. Below them were band 4 nurses, also known as nursery nurses.
The nurses worked in shifts. It was the general rule that a nurse who started on a shift in the unit remained there for the whole shift. The day shift generally started at 07.30 with the preceding night shift ending half an hour later at 08.00, during which time a handover would take place.
Melanie Taylor, a band 6 nurse, often referred to as Mel, was the first member of the hospital staff to give evidence. That was on 19 October last year. She was the first of many witnesses who gave evidence screened from others in the courtroom. She explained the handover process. I remind you of the oral direction relating to a witness being screened, which I gave you at the time and which you now have in writing. It is legal direction 1 in the second set of legal directions, and I have to read through them, although you have a copy of them, so I'll read through each of these directions as and when they are relevant.
A witness giving evidence from behind a screen is permitted by law and is now commonplace, the purpose being to assist the witness to give their best evidence. It has no relevance to the quality of their evidence as a witness and you should attach no significance whatsoever to a witness giving evidence in such a way.
You judge the witness in exactly the same way as you judge any other witness. You certainly do not hold it against the defendant or her case that a witness has given their evidence in this way.
And I'm sure you wouldn't do that and you probably can't even remember which witnesses were screened and which weren't, certainly all of them. You’ll remember some, not all of them. So attach no significance to the fact that there were screens for some witnesses.
Other witnesses, some other witnesses, gave evidence over a video link, sometimes from other parts of this country or from overseas, Switzerland and Australia, you will remember. This was purely for the convenience of those concerned and was an obvious cost and climate-saving measure. Of course, you do not attach any significance to any of them giving evidence in this way. You judge them as witnesses in the same way as you judge any other witness in the case.
You've heard from a number of nurses that all the nurses coming on duty would have a huddle in a separate room, which the shift leader of the previous shift would pass on general information in relation to all babies. The nurses would then go to their own designated baby or babies for a one-to-one with the designated nurse coming off shift, who would give them an in-depth handover and provide handover sheets for the babies.
In accordance with the British Association of Perinatal Medicine, BAPM, standards, there would generally be one nurse to one baby receiving intensive care, one nurse to two high dependency babies, and four special care babies to one nurse.
At the cot side of each baby there would be a clipboard with that baby's charts, such as observations and fluid charts. Those charts were completed at the time and the times were recorded on them. Caroline Bennion said observations take about 10 to 15 minutes if straightforward and could take up to 25 minutes if care or repositioning had to take place.
The time recorded for the readings and observations were taken around the time of the observations and not precise to the minute. The general nursing notes were written up on a computer retrospectively. In her evidence, the defendant confirmed that these were the procedures and you have now become very familiar with all the various hospital documents.
When making nursing notes, you did have an accurate electronic time of the time of starting to make that note and the completion of that note.
Staffing levels. A number of neonatal practitioners, Nurse A, Caroline Bennion, Nurse B and Caroline Oakley and Kathryn Percival-Ward, now Percival-Calderbank, and Belinda Williamson, then Simcock, were asked about staffing. [Nurse A] said there were periods when they were short-staffed and they didn't always reach the BAPM guidelines, to which I shall refer, as they have been during the trial.
Ideally, there should be two band 6 nurses on any shift. Sometimes there were potentially more babies in the unit than there were meant to be. When a shift was a bit short of staff, a nurse might be asked to staff a shift or do an extra shift and there would be flexibility with the rota. Nurse A also said they always had a lot of senior staff who supported the junior staff, but 2015 to 2016 was a busy period with more babies requiring a higher level of care, higher acuity, and there were times when the BAPM gold standard could not be achieved.
Melanie Taylor remembered there were a lot of busy shifts around that time. Nurse B also said the unit was very busy in 2015 to 2016, admissions seemed to increase and they had far more intensive care babies. It wasn't always possible to follow BAPM guidelines on staff ratios, but staff were giving up breaks to provide care.
Caroline Oakley didn't remember the unit being unduly short-staffed, there were always a lot of babies and it was always quite busy.
Kathryn Percival-Ward, now Percival-Calderbank, said there were a lot of babies that became sick at that time and they were particularly busy.
Belinda Williamson said at times it was difficult to get hold of a doctor when needed, particularly at night if the paediatric ward was busy, but in relation to nurses she said it was rare for there not to be two band 6 nurses working on any shift as the BAPM guidelines provided.
In his evidence, Dr Stephen Brearey accepted that staffing levels were lower than BAPM standards during this period when the College reviewed their care in September 2016. It was also noted in that report that this was similar to other units and, at the time when these events happened, their staffing levels were better than all the other local neonatal units in Cheshire and Merseyside at that time. Those units didn't have the same mortality problems as the Countess of Chester.
A good deal of questioning by Mr Myers, and his submissions to you, was directed towards staffing levels and the level of care provided by both medical staff and neonatal practitioners and, in some cases, their level of experience in dealing with some of the more vulnerable neonates. There is evidence of occasionswhen, contrary to the standard, a nurse on a shift was the designated nurse for more than one intensive care baby. There is also evidence of occasions when nursing staff complained about particular shifts and when care was sub-optimal; in other words, not as good as it should have been.
The potential relevance of this evidence in this trial is whether any specific or identified failing of or by any of the clinical or nursing practitioners, whether by way of inexperience or competence or numbers on duty at any time or by error, was or may have been relevant to the deterioration of any baby or to an event that you are considering.
In particular, whether a failure of care or mistake may have been causative of the sudden deterioration in the condition of any of the babies in this case or adversely affected their chances of recovery and, if so, which. For example, there was an admitted failure to give Baby D antibiotics after birth and a delay in giving surfactant, about which I shall remind you.
In the great majority of cases of the babies in this case, the defendant herself accepted that staffing levels or negligence in their care or treatment of them played no or no causative part in their collapse and/or death. I shall review all the cases for you, identifying in each of their cases the history of the baby, their condition and the circumstances in which they variously required emergency resuscitative treatment, what was done and what was not, and the expert evidence in relation to the way that the clinicians and nursing staff treated the babies and what the defendant said about any potential nursing or clinical mistakes.
It will be for you to determine the relevance of these matters to the deteriorations, collapses and deaths. In his address Mr Myers said there was plenty of sub-optimal care, that the doctors at the hospital have resisted criticism, and he repeatedly suggested that they were blaming the defendant for failings in what had happened and had gone out of their way to damage her and use it as an opportunity to cover bad treatment and poor outcomes.
He submitted that the evidence in relation to alleged types of harm inflicted was inconsistent with an intention to kill, suggesting:
"Why use different ways when an early alleged harmful act has been successful? Why change what worked?"
These, and other propositions he advanced, are not evidence in the case, rather they are inferences or conclusions he invites you to draw which proceed from and are based on the defendant's position that she did nothing to harm any baby.
As I have already directed you in my written directions 1, it is your determinations of who is, and who is not, telling you the truth, and reliable, and the conclusions you draw from all the evidence that you make your decisions.
I shall endeavour fairly to refer to relevant evidence, some of which will involve you having to contextualise counsels' submissions, so you must concentrate on the detail and, if you wish, refer to documents, charts and notes. I am not going to put a single document up on the screen for you to look at during the course of this summing-up because you have them all on your iPads and can look at any you consider are or may be relevant when you are deliberating on your verdicts.
In the case of two of the babies, there is evidence of unprescribed insulin having been administered when it was wholly inappropriate; they are, of course, Baby F, count 6, 5 August 2015, and Baby L, count 15, 9 April 2016, each of whom was a twin.
In their cases, the prosecution invite you to conclude that there can be no doubt that someone intentionally added insulin to the nutritional food and the dextrose that was being given to Baby F and Baby L respectively, and the chance of there being more than one person acting in that way can be entirely discounted. Medical negligence or accidental want of care could not, they submit, on any view have played any part in those cases.
The defence, consistent with the defendant's case that she was not responsible for adding insulin to infusions for either baby, put the prosecution to proof in relation to the fact that manufactured insulin was deliberately introduced to both those babies and that it was the defendant who was responsible for that and, if you are sure that it was, that she intended to kill.
They invite you to question the evidence of the taking of the samples, their handling and testing and, given the potential consequences of insulin poisoning, the lack of harm caused. I shall, therefore, remind you of the evidence relating to the blood sampling, testing, the results and the associated processes and other linked evidence when I come to those counts.
The prosecution say that this evidence is of major significance, being incontrovertible evidence, if you accept it, that someone was deliberately and knowingly doing something that was completely contrary to normal practice and very dangerous and which must, they allege, have been done with the intention of endangering the lives of those children.
They say that this assists and informs you in relation to the cases of other children who suffered sudden and unexpected collapses for which there was, at the time, no apparent medical explanation or where, for example, infection was suspected as a possible cause, but then later excluded by the test results when they came through.
The prosecution submit it is key evidence in relation to the issue of whether these collapses were natural occurrences or rather the consequence of deliberate, malicious and wrongful acts, characterised by Mr Johnson as sabotage, by someone intent on fatally harming the children.
By reference to my legal directions relating to circumstantial evidence and coincidence, at the conclusion of his address Mr Johnson gave you the lists of features in relation to the various collapses of the children that the prosecution say amount to circumstances that, taken with the clinical evidence and expert medical evidence, as well as the features of messages, the retention of medical documents and the notes that the defendant made and kept, leads you to the conclusion that these children were deliberately targeted and one person was responsible for their sudden collapse and, in some cases, their deaths.
The defendant's case is that she was a dedicated, caring and conscientious nurse who never did anything to harm any child. Babies do collapse for no apparent reason and there are, it is submitted, potential medical reasons for at least some of the collapses. If there was such a person intent on harming children, it was not her.
Lucy Letby was born on 4 January 1990 in Herefordshire and was brought up in Hereford by her parents. She is now 33 and was 25 to 26 years old at the material time between June 2015 and June 2016. She went to a local sixth form college, she always wanted to work with children, and picked A level subjects to enable her to study for a degree in nursing.
She studied for her three-year nursing degree at Chester University, working at the Countess of Chester Hospital twice during her training in 2010 and 2011. In 2012, she started as a band 5 nurse at the Countess of Chester, working predominantly in nurseries 3 and 4. [ Nurse A, a band 6 neonatal practitioner who qualified in 1992, was the defendant's mentor when she was in training. They became good friends. The defendant said she always strove to go on every course she could. She, in turn, was a mentor to student nurses from 2012, responsible for teaching them, carrying out paperwork on the competencies that they need to achieve.
In March/April 2015, having completed a six-month course that involved a university module, assessments, assignments and a placement at Liverpool Women’s Hospital, a level 3 hospital, the defendant qualified in the specialty enabling her to care for the sickest babies on the unit or those requiring the most intensive care.
In 2015, she and Bernadette, often referred to as Bernie, Butterworth, were the only band 5 nurses on the unit with that specialty. All band 6 nurses had that qualification as well. So in other words, the band 6 nurses and two of the band 5 nurses with that special training, of whom she was one.
I turn next to the next legal direction I must give you, which relates to character. Legal direction 2. As you know, the defendant has never been in trouble with the police and has no criminal convictions, reprimands or cautions recorded against her; that is set out in agreed facts section 10, fact 59.
Not having previous convictions of any kind does not, of course, provide any person on trial with a defence, but it is something which you should take into account in her favour in two ways. First, it may make it less likely that she would deliberately harm any babies being cared for at the hospital. Second, it is also something that you should consider in her favour when deciding her credibility, in other words, whether she was being truthful in her evidence to you about these events. It is entirely for you to decide what weight, if any, you attach to the defendant's previous character in the light of all the circumstances and the facts as you find them to be.
The defendant said that over a 12-month period she cared for probably hundreds of babies and never did anything that was meant to hurt any of them. She only ever did her best to care for them. Hurting a baby was completely against everything that being a nurse is. She was there to help and to care, not to harm, she said. She always prided herself in being very competent.
Christopher Booth, Chris Booth, confirmed she was very conscientious, hard-working and willing to help. Nurse A described her as highly professional and dedicated to the work she was doing. They would talk a little about babies on the ward and it was quite usual for them to message each other. Nurse A also said that sometimes she remained friends with the parents of babies she had nursed on Facebook and confirmed that sometimes a nurse went to the funeral of a baby who had died if that was what the parents wanted.
Another nurse, Jennifer Jones-Key, said she was a good friend of the defendant at the time. She said the defendant was a capable and hard-working nurse who gave a high level of care. Eirian Powell, the ward manager, described her as an exceptionally good nurse.
In her evidence the defendant said that during the period 2015 to 2016, she was predominantly allocated to intensive care babies because there were a lot of them on the unit and because of the available skill mix of the nurses. She was newly trained and could bring her skills from the tertiary centre for other people to learn from. She had a kind of passion for that area of work, she said. She enjoyed all aspects of her work, but she particularly enjoyed the intensive care side and staff knew she enjoyed that area.
She said she never used her phone when in any of the nurseries. It's apparent from the evidence of messaging that she would message friends and colleagues, both when at work on the unit and at home.
Her health over this period was generally good. She had no time off work. She did have a condition called optic neuritis, which is inflammation of the optic nerve, and it caused pain and discomfort and blurred vision at one point in 2015 and she was under the ophthalmology team at the Countess of Chester and also the Walton Centre in Liverpool, but it resolved itself.
She was very flexible, living on site in accommodation at Ash House from when she first started in January 2015 until 15 March 2014, when she moved into a flat in town until 1 June 2015, before moving back to Ash House, as recorded in her diary, and living there until 6 April 2016, when she recorded moving out from there to the house she had bought at 41 Westbourne Road.
So at the time of the events we are concerned with, she lived first at Ash House, then moved to her home in Westbourne Road just before Baby L and Baby M were born. She was often asked to do more than the prescribed 13 shifts per month. She was particularly friendly with Nurse E, Minna Lappalainen, Dr A, Nurse A and Jennifer Jones-Key. Some of those people supported her after she was moved to non clinical duties and that was very important. She said they were the only form of support she really had.
She was devastated when she was taken off clinical duties in July 2016 and being told that there was going to be testing of competencies. She had always prided herself in being very competent. It really affected her, being taken away from her support system and given a non-clinical role. She registered a grievance on 7 September 2016 about her redeployment. It was at that time that she became aware that she was being held responsible for deaths on the unit, receiving a letter from the Royal College of Nursing. She said it was sickening, devastating, and she changed as a person. Her mental health deteriorated and she felt isolated. She was only allowed contact with Nurse E, Minna Lappalainen and Dr A; the latter was a close friend.
She was first arrested on 3 July 2018 at her home at 06.00, as set out in agreed fact 25. She was then interviewed over 3 days before being released on bail and went to live with her parents in Hereford.
Her house and that of her parents were searched and various documents, including shift handover sheets and resuscitation notes, diaries and sheets of closely written notes were found and seized, to which I shall refer in due course.
She was rearrested on 10 June 2019, further interviewed, and further searches were conducted and again she was released on bail.
Finally, she was arrested a third time on 10 November 2020, interviewed and charged, and has remained in custody since then.
The arrests, she said, traumatised her. She accepted that a large proportion of the prosecution papers were served on her in early 2021, though not all, and that by February 2022 she knew the important features of the allegations. A defence statement was confirmed by her on 11 February 2022. Some of its contents appear to be different to what she said in evidence to you, and I now refer you to the next legal direction, legal direction 3, "Defence statement".
Just as the prosecution must disclose all of the evidence upon which they intend to rely, the defence must also serve a formal defence statement which informs the court of those parts of the prosecution case with which the defendant disagrees and the facts upon which the defendant is to rely in their defence. This is to enable the issues to be identified and for each side to prepare for the trial so that neither is taken by surprise. In this case the defence statement was served in February 2022. You have been provided with a copy of the relevant parts of it.
The prosecution asked the defendant about things she said in that statement compared to what she was telling you in evidence. If you find there is a material difference in what she said in her defence statement and what she said in evidence to you, just as with any witness, you are entitled to ask yourselves why.
The defence say that there was a vast amount of material to be considered and digested and there have been significant delays between when the events occurred and her receipt of all the prosecution material, which made her task more difficult.
It is for you to assess the reasons put forward by the defendant. If you find any inconsistencies to be without significance or you accept that any account was or may be true then you should ignore the differences. It's only if you are sure that there is a significant material change of account and the reason for it is that she is not telling the truth to you about the matter that you may take that change as providing some support for the prosecution case, but you must not convict the defendant wholly or mainly on the basis of such changes. It's always for the prosecution to make you sure of guilt.
Before I turn to the evidence relating to the events, I need to give you two further legal directions which relate to delay and expert evidence. These are directions 4 and 5. Sorry, you put them down, take up the document again.
Legal direction 4. I did say when we parted company last week that I was going to check that you have all the documents. We'll come back to that in a moment. You do have all the documents, I'm confident of that, including my first legal directions, and as and when I refer to documents, which will be very rare, you can refer to them.
Legal direction 4, "Delay". There have inevitably been delays between the events giving rise to the allegations and the defendant -- the taking of witness statements, her being questioned about them by the police and then giving evidence some 7 or 8 years after the events. All witnesses, including the defendant, have been dependent on, in part, contemporaneous records and notes and what they recalled when making statements closer to the events.
Some have clear recollections of certain events by reason, they say, of their unusual and memorable nature. For all, the passage of time is likely to have affected memories about exactly what happened and the ability to recall all detail of events, even with the benefit of contemporaneous records, so make appropriate allowances for that and take account of the delay and, in particular, any disadvantage caused to the defendant in relation to being able to recall with precision what took place and remembering details which may have assisted her.
You know from agreed fact 57, for example, there was no swipe data for entry to the unit available for the period between 17 July and 22 October 2015. I just point out that that's something that is missing: there’s simply no evidence because there's no swipe data. So if it's relevant, you take it into account.
So that's the direction in relation to delay. Then expert witnesses. This is a long direction, as you will see, and I'll go through it with you and you can refer to this if you so wish when you are deliberating in due course.
Expert witnesses. Expert evidence, given by someone with specialist knowledge, is given in order to help you with matters which are likely to be outside your knowledge and experience. You have heard evidence from experts in the following disciplines, namely in paediatrics and neonatology, Dr Dewi Evans and Dr Sandie Bohin. In paediatric haematology, Professor Sally Kinsey. In paediatric radiology, Professor Owen Arthurs. In paediatric neonatology (sic), Professor Stavros Stivaros. In paediatric endocrinology, Professor Peter Hindmarsh. In forensic pathology, Dr Andreas Marnerides.
You would expect to hear evidence in a case such as this from people with an expertise in these particular areas. They provide you with evidence about medical matters that is within their own area of knowledge and expertise. Each owes a duty to the court, as an expert witness, of independence and their role is to be a witness and not an advocate. Each has an expertise gained from their accumulated knowledge and research in a particular specialised area of medicine.
Although you know that experts were instructed on behalf of the defence, and there were meetings between experts, the only witnesses from whom you have heard were called by the prosecution. The defence have addressed you on what they submit is the limited expertise of the prosecution witnesses as well as theextent and reliability of the body of medical and scientific material relied on by some of them, in particular Dr Evans and Dr Bohin, and their approach to their role as an expert witness, including their independence and duty to act as a witness and not an investigator. I shall remind you of the limitations and criticisms relied on by the defence when I come to their evidence.
You are entitled to, and no doubt will, consider the respective opinions of each expert when coming to your own conclusions about the case. However, as with any witness, it is for you to decide whether you accept some or all of the evidence of any expert witness. It's your view as to the significance and reliability of this evidence that is important.
In this case the factors that you should take into account in determining the reliability of the expert opinion include the extent and quality of the data and material upon which the expert opinion is based, the validity of the application of the evidence by the expert to the known medical criteria.
In relation to part of the evidence from Professor Arthurs relating to the cases from the records of Great Ormond Street Children's Hospital, he reviewed the extent to which any opinion based on that material has been reviewed by others with relevant expertise, the extent to which the expert's opinion is based on opinion forming outside the expert's own field of expertise, the completeness of the information available to the expert, and whether the expert took account of all relevant information in arriving at his or her conclusion.
You should be astute to any potential flaws in an expert's opinion which detract from its reliability. For example, the extent to which it is based on a hypothesis which has not been subjected to sufficient scrutiny, including experimental or other testing, or on an unjustified assumption or relies on an inference or conclusion which has not been properly reached.
The expert evidence is part of the case and you should have regard to all the evidence, including but not confined to the expert evidence. Put another way, you do not consider expert evidence in isolation. Each expert was giving opinions purely from the viewpoint of their own specialised knowledge. Each was obliged to confine their opinions to conclusions they could draw from their own specialism.
You do not consider the opinions of the individual expert witnesses in isolation. Rather, you consider them in the context of all the other evidence in the case, including other medical evidence, both expert and clinical, and any relevant circumstantial evidence in order to determine the cumulative weight of all the evidence.
The expert evidence is given, of course, by reference to the evidence of the clinicians, the doctors and nurses and nurse practitioners of various levels of qualification and experience, and all the clinical and other data about which I shall remind you when I summarise their evidence in relation to individual children.
The medical practitioners were making clinical judgements and acting on them in real time as the various events occurred. They, the clinicians, do not give expert opinion evidence as to the cause or causes of the events, though they can, and did, give evidence excluding possible causes as a result of observations, that's observations at the time, and the results of tests, scans and radiographs on the basis of their knowledge and experience.
I hope you understand that. As I say, you can go through it again. In a sense it's obvious, but it's important that is how you have regard to the expert evidence when you come to make decisions in this case.
I shall deal, as I've said, with each baby in turn. A great deal of what I say shall be by way of summary because it is not controversial. It will be dense and factual, not out of insensitivity to the human situations of those involved, the very understandable emotional reaction to what happened and the personal trauma and loss, but because you are making decisions on the facts, be they agreed or you find established by the evidence, and the conclusions you draw from admitted or proven facts. It refers back to those original written directions I gave you about not trying this case on emotion but on evidence.
I shall refer to tiles in the sequence of events and to J documents so that if you think a particular document may be important, you may note it. But remember, my review will necessarily be selective and is not exhaustive. It is your view, I repeat, of what is important and what is not and the conclusions you draw from all the evidence that matters.
I am very conscious of the fact that you have already listened to 9 days of speeches. Those speeches were necessarily selective of and focused on parts of the evidence that each party submitted was relevant to your decision-making. I shall provide a narrative of events, endeavouring to put matters in sequence and in context so that you have the evidence and you will have notes and you'll be able to refer to documents in relation to these events as they were proceeding in time.
I begin by reminding you of the evidence relating to Baby A and Baby B, the subject of counts 1 and 2, being respectively alleged offences of murder and attempted murder.
Count 1, Baby A. The twins Baby A and Baby B were born by emergency caesarean section on the evening of 7 June 2015 to [Mother of Babies A & B] and her fiancé [Father of Babies A & B].
Because [Mother of Babies A & B] had been diagnosed in February 2011 with antiphospholipid syndrome, to which I shall refer by the acronym APS, which is a rare autoimmune disease that afflicts about 0.05% of the population, it was a high-risk pregnancy and she was under the care of both the University College London Hospital and the Countess of Chester Hospital.
The pregnancy was fine until the 28-week point when [Mother of Babies A & B] was admitted to the Countess of Chester Hospital and monitored. On the afternoon of Saturday, 7 June, due to increasing blood pressure, she underwent an emergency caesarean section procedure under general anaesthetic.
Baby B was born first at 20.30 hours and weighed 3 pounds 11 ounces, 1.66 kilograms. I'll always give you the different measurements as some work in metric and some work in the old weights. She needed medical assistance to start breathing. [Baby A] was born a minute later and weighed 3 pounds 12 ounces, so just over 1.66 kilograms.
The babies were at 31 weeks and 2 days' gestation when delivered. There were no complications of delivery and blood loss was minimal. It was a straightforward delivery.
Just over 24 hours after he was born, at 20.58 hours on 8 June, Baby A was pronounced dead. The cause of death, following a post-mortem examination carried out by a pathologist at Alder Hey Children's Hospital, was unascertained.
Professor Sally Kinsey, an expert in paediatric haematology, confirmed that the twins' mother's condition of APS did not pass to either [Baby A] or [Baby B], so can be discounted as a relevant consideration in either of their cases.
The prosecution case is that [Baby A] did not die from any natural disease or cause but had air administered exogenously, in other words injected, into his venous system through a line by which he was being given intravenous fluids. This must have been a deliberate act, and one which all nursing staff, including the defendant, knew was dangerous, and that the intention was to kill him.
The defence case is that although it is accepted that the defendant took over as Baby A’s designated nurse and was at his cot side when his Philips monitor sounded because he had collapsed and stopped breathing, she did nothing to harm him and never introduced air intravenously into him, and has raised the possibility of the delay of the insertion of a long line, meaning that he was without fluids for some hours, as compromising him.
I summarise the evidence as to the events surrounding Baby A's short life. A good deal of it was read to you as being agreed, so I will not burden you with all the sources. When born, he was assessed to be of good tone, not floppy, and blue/pink in colour, which was normal, but no heartbeat could be heard. A Neopuff mask was applied and he was fully breathing by himself regularly with a small amount of pressure by 10 minutes after birth.
He was in good condition, on continuous positive airway pressure ventilation, CPAP, which is the acronym I shall adopt rather than reciting the full name of it, which is breathing assistance that is regularly given to premature infants, and he had a cannula inserted, providing intravenous access to his blood system.
Senior Neonatal Practitioner Caroline Bennion, who now has nearly 30 years' experience in neonatal care, was at the delivery of the twins. She provided care for Baby B, but also carried out some observations for Baby A at 04.00 hours that first night in room 1, the nursery for intensive care babies, with whose location you are familiar, as marked on your plan.
Baby B was in incubator 1, to the right as one enters the room, and Baby A was in the adjacent incubator, number 2, on the back wall. Baby A, she said, was clinically stable when reviewed at 23.50 that night. He had been commenced on antibiotics and intravenous fluids. Blood cultures taken later came back negative. His heart size was normal. X-rays of his lungs showed a slight haziness of both lung fields in keeping with mild respiratory distress syndrome of prematurity, but nothing of note.
Now, that's something about which we heard a lot during the course of this, mild respiratory distress syndrome of prematurity, and I'll refer to it in relation to the babies to whom it is relevant.
The nasogastric tube was inserted by 3 centimetres by nursing staff on the direction of Dr Brunton. Dr Theresa MacCarrick, a senior house officer doing paediatric training at that time, came on duty at 08.30 hours on 8 June, the day after the birth. The plan was to keep Baby A on CPAP, but to start to feed him through a central line to provide ongoing parenteral nutrition.
Under supervision by the registrar, Dr Sally Ogden, Dr MacCarrick inserted an umbilical venous catheter, a UVC, into the umbilical vein, which leads to a much larger vein, the inferior vena cava, which brings blood back to the heart, thereby enabling Baby A to receive nutrition, fluids and medication directly into his blood system.
There was no problem with the catheter and it was used by nursing staff. However, the X-ray taken that afternoon revealed the catheter had deviated from its intended course and was sited in the hepatic circulation, as can happen, because there is no ability to control the path of the catheter when it has been inserted. Do you remember? Very early on in the case you heard this evidence: it was put in and quite often it would deviate and not go into the vein.
Two subsequent attempts to re-site it both resulted in the catheter again sitting in the hepatic circulation and so the catheter was not used after the first one had been removed at around 16.00 hours.
As I shall remind you in a moment, a long line was later inserted at 19.00 by Dr David Harkness, another registrar who was then in the fourth year of his neonatal training, an ST4.
Melanie Taylor had come on duty at about 7.30 that morning, 8 June, taking over as designated nurse from Ashleigh Hudson, and was the designated nurse for both Baby A and Baby B on that day shift. Baby A was stable and satisfactory. His respiratory rate was elevated at times but this was not unusual for a baby on CPAP. She had no concerns about him. She confirmed that Baby A had no fluids intravenously after 16.00 hours because that's when the UVC was removed, but had some expressed milk at 18.00.
Mel Taylor's shift ended at 20.00. She handed over to the defendant, who had swiped in at 19.22. She, Mel Taylor, had no direct recollection of that handover but will have handed over from the records between 19.30 and 20.00 and said there were no concerns, save to get some fluids into him.
By reference to tiles 172 and 174 she confirmed that a 10% dextrose 500ml bag had been prescribed and was to be given via the long line that had been inserted by Dr Harkness at 19.05. That's tile 154, the insertion of the long line.
All three babies in that nursery, Baby A, Baby B and the other baby, had a requirement for long lines to be inserted, so three lines had to be inserted, one into each of the babies.
Dr Harkness had come on duty at 17.00, Baby B was the first to have a long line inserted, followed by Baby A. Dr Harkness succeeded on the first attempt to insert the line through the vein to the front of the elbow, the antecubital fossa. You heard from another registrar, Dr Gail Beech, in relation to another baby, Baby C, the child the subject of count 3, that a registrar can have two or three attempts to insert a long line before a consultant needs to be called.
At the time Dr Harkness was unsure, until an X-ray was taken, as to whether the positioning of the line was exactly where it needed to be. He thought it was imperfect but good enough to use. Dr Dewi Evans said that the long line was not a cause of any problem and there was no evidence of any tamponade, which is a puncture of the lining surrounding the heart that causes fluid to get between the lining and the heart and will restrict the ability of the heart to contract properly. If there was or had been such damage, he said, it would show up on a post-mortem examination. There was no damage.
Dr Sandie Bohin, in her report, said that the line was not in the best position. In her evidence she explained it was not in the optimal position but it was in a safe position and not a dangerous position, it was perfectly safe to use.
As required, there were two signatures for the dextrose, Melanie Taylor's and the defendant's, and the infusion through the long line commenced at 20.05. Mel Taylor thought it was after the dextrose infusion had been started, when she was sitting at the computer in room 1, that Baby A started to deteriorate. There are recorded times of her entering events on the computer for Baby B at 20.14 and 20.18 behind tiles 177 and 178 respectively, which is evidence of the time she was at the computer.
Baby A's heart rate dropped and his saturations dropped. The defendant was standing by the cot. The alarms sounded. When Baby A didn't recover, Mel Taylor went over, thinking he was going to recover, and at some point she said the defendant was giving him Neopuffs. Mel Taylor said she performed a support role, drawing up emergency drugs, but was not directly involved. She said it was a bit of a blur. She had a very vague recollection of what happened. Her notes made retrospectively are behind tiles 169 and 170, made at 21.28 hours.
In her evidence, the defendant told you she was not expecting to work on 8 June, but received a request at 09.21 that morning from Yvonne Griffiths to work that night; tile 69. Being flexible and with no commitments, she was happy to help. She was the designated nurse for Baby A; tile 162. She remembered going to nursery 1 to get the handover from Mel Taylor. Dr Harkness was in there doing a procedure.
There was a lot going on. Mel Taylor was preparing fluids for Baby A and explained that he had been without them for some hours and, being the sterile nurse, started to run fluids through the line. The defendant was told by Mel Taylor and Dr Harkness that the long line, the cannula which was coming out of his left arm, was suitable for use. She was responsible for hanging the bag and setting the pump and confirmed, co-signing the prescription sheet behind tile 174 timed at 20.05. She then had the handover from Mel Taylor, who went to the computer, and she, the defendant, went to Baby A's cot to do equipment checks.
She said she noted he was jittery, which is involuntary jerking movement of the limbs, and an abnormal finding. His Philips monitor sounded. She noticed his colour had changed and he was apnoeic. The most important thing she noted was his hands and feet were white. He wasn't breathing. She started to Neopuff him. Her nursing note, written in retrospect and behind tile 228, referred to "centrally pale and poor perfusion".
She explained his limbs were white and centrally he was pale but not as white as his limbs. Mel Taylor and Dr Harkness came over and Dr Harkness told them to stop the fluids, which she did. An emergency crash call went out. Dr Jayaram and Nurse A came very quickly.
Nurse A was the 20.00 hour shift leader that night and the designated nurse for two other babies in the unit. She was out of the unit, in the staff toilets, when Baby A suddenly deteriorated. Her swipe card recorded her entry through the unit doors at 20.20; tile 180. Dr Rachel Lambie came into the maternity ward at 20.22.
Nurse A said she could see on the monitor that Baby A was apnoeic. She gave him chest compressions. She had never seen a baby look that way. He had a discolouration she had never seen before: "Very white with sort of purply blotches and very cyanotic [blue] as well."
When cross-examined, it was drawn to her attention that in her witness statement, made in May 2018, she said: "He was centrally very pale and unusually his limbs were what I can only describe as white."
She accepted this differed from her evidence. In a further statement, made 2 months later in July 2018, she added that Baby A looked like Baby B, which was: "Very pale, blotchy discolouration, pretty much like all over, very like her brother."
She thought there was maybe a lot of discussion at the time about what the rashes were because it was so unusual. She told you that no one had ever suggested what she should say about the events with Baby A and Baby B. If anyone had, she said in all probability she would have told the police.
The defence draw these inconsistencies in her account to your attention and I need to give you a legal direction about witnesses generally giving accounts of events at different times that are or may be inconsistent with each other, and this is legal direction 6, which is the last of the evidential legal directions, "Inconsistent statements". This applies to, as I have just said, any witness where you find there is a difference between what is said in evidence and what has been said on a previous occasion.
What a witness says in the witness box and in any witness statement he or she made about events is all evidence in the case for your consideration. Where there are or appear to be differences in accounts, it is for you to decide how different they are and whether or not the differences, or any of them, are important. If you decide that any differences are not important then you should ignore them. If you think that any differences are important you should consider the reason given for the difference or inconsistency. If you are sure that the explanation is valid, you may accept what the witness said in their evidence in the witness box. If you reject the explanation or you are not sure they are telling the truth, you should treat both what the witness said in their statement and what they said in the witness box with caution.
If, having done so, you are sure that what the witness said in their evidence is accurate and reliable, then you may rely on and take it into account. If you are not sure whether any version is accurate then you should not take any into account because you wouldn't be sure of any account.
You do not have a copy of the witness's statement when they were questioned on it, just as you do not have the statement of any witness.
So this is really no more than a commonsense approach, but it is a legal direction that you must apply and must consider and treat, where there are inconsistencies, evidence with caution and assess where the truth lies.
Baby A was intubated at 20.28 by Dr Harkness so that he could be put on a ventilator. Good air entry was achieved, his heart rate dropped to 60 to 70, that's beats per minute, and compressions were started. He was given saline and boluses of adrenaline on several occasions.
Dr Jayaram, the on-call consultant, had arrived at 20.23. It was agreed that the UVC should be pulled back slightly. It was fit to be used in the short term but it had, of course -- that is what Dr Jayaram said — already been removed. There continued to be good chest movement and air entry but no heartbeat could then be heard. Chest compressions continued for 10 to 15 minutes, before a collective decision was made to stop the efforts at resuscitation. Baby A's life was pronounced ended at 20.58.
Dr Harkness said Baby A's death was incredibly unexpected. He was a well baby who had no reason to suddenly deteriorate. He described very unusual patchiness of his skin, which he had never seen before. The patches were a kind of purple/blue colour, there were red patches and white patches. They were all over the body and were there from shortly after the event when the heart stopped beating. The only other time he has seen this was later, in the case of one of the [Babies E & F] twins, to which I shall come in due course.
Criticism was made of his not referring to these features at the time in the notes that he made and the defence challenge his evidence, saying that you cannot find it reliable, it not having been put into the notes at that time.
I'm going to continue for a little bit, not that long, but certainly about another 5 to 10 minutes, and then we'll have the mid-morning break. I'll come to a convenient point in the narrative to break off.
Dr Rachel Lambie, now a consultant community paediatrician in Crewe, was a senior registrar at the hospital in her sixth year of specialist training in 2015 and was the paediatric registrar on call on 8 June. Her card swiped in to the unit at 20.28. Active resuscitation of Baby A was taking place, which went on for 30 to 40 minutes and she helped, but there's nothing more she could add.
The consultant, Dr Ravi Jayaram, who had been in post at the Countess of Chester since 2004, and had become the administrative head of paediatrics in 2009, was on call when Baby A collapsed. Baby A had stopped breathing when he arrived. His heart rate was 90 to 100 beats per minute and electrical activity was normal. Baby A was pale and had unusual patches of discolouration, which Dr Jayaram had also never seen before. He was quite floppy as well, he was very pale to blue, but there were very unusual pink patches, mainly on the torso, which would flit around. Babies, he said, very rarely have a heart problem. It was very unusual that, despite appropriate and timely treatment and blood going round his body, Baby A was deteriorating. And even when he was intubated his heart rate began to drop when it should have been going up.
In his notes at the time Dr Jayaram said:
"Legs noted to look very white and pale before cardiac arrest."
His explanation for not referring to the unusual pink patches was that he had not considered it clinically significant or clinically relevant. He made no reference to the patches in his statement to the coroner made on 24 July 2015. He explained that his statement had to be factual and based on what was written in the notes and he was not aware at the time of the clinical relevance of them. It was, he said, a matter of regret that he had not mentioned them.
His concluding remarks were that he could not explain how this death had happened. In his witness statement to the police, made on 18 September, he referred to:
"Unusual discolouration, flitting patches of pink area, the blotches were fairly ill-defined and on a background of blue/grey."
He became aware people were talking about a rash on Baby B and he looked up many things and did a literature research. He accepted that colleagues, as a group, had been talking about the deaths. He was referred to a paper in a medical journal by Lee and Tanswell; this is document J24946 -- there's been quite a lot of reference to the Lee and Tanswell document and that’s the reference, J24946 -- which mentions:
"Blanching and migrating areas of cutaneous pallor."
And:
"In one of our own cases we noted bright pink vessels against a generally cyanosed cutaneous background."
Dr Jayaram said he had not been influenced by that paper in his subsequent descriptions in his witness statement in 2017 and in his evidence to you.
I'm going to break off there because I'm going to come to what the defendant said about this at this stage.
I just want to correct something I said about the UVC having being removed. It hadn't of course been removed, it was left in place but not to be used. So sorry, Dr Jayaram's note was right, it was still in place. So that's what was used during the attempt at resuscitation.
We'll have a ten-minute break now. As you’ll appreciate, it is quite dense, but I'm hoping it's providing a helpful narrative for you to work from.
Thank you very much.
(In the absence of the jury) MR JUSTICE GOSS: Anything thus far now that I've corrected that one obvious error that I made? Thank you very much. We'll start again at about midday.
(11.48 am)
(A short break)
(12.03 pm)
Mr Justice Goss: Thank you, Mr Myers, I will correct that.
BM: It's clear to everybody.
Mr Justice Goss: I'm very grateful. It was a slip of the tongue and I'll correct it.
Actually, just before the jury are brought back in, there's been a request from members of the media to have my written -- a copy of my written legal directions, the second version. I don't quite know... I don't have a problem with that, but they'll have to check their notes because I did add slightly to it and make odd comments along the way.
BM: There were a few additional comments, yes.
Mr Justice Goss: Yes, exactly, but the substance is not different and, subject to this correction, which in fact was on the original document.
BM: Yes, it was.
Mr Justice Goss: I misread it.
MR MYERS: Easily done, my Lord.
Mr Justice Goss: It's not you, Mr Pilling, I know. All right, thank you.
(In the presence of the jury)
Mr Justice Goss: As you probably noticed when I was giving you the expert direction, going through that expert direction with you, I misread what Professor Stavros Stivaros' specialty is: it's paediatric neuroradiology. I'm having to correct that for the transcript. You will have seen that and you have the written document.
Returning then to Baby A, the defendant was first interviewed by the police about Baby A's case on 4 July 2018. You have the agreed transcriptions of the relevant parts of that interview at the beginning of your lever arch files, interview bundle 1 from [document redacted] onwards. I'm not going to go through this now or refer you to the details of it. There follow in that bundle the transcripts of the interviews relating to the babies in indictment order.
In addition to reminding you of the defendant's evidence about individual babies, I shall give you a very brief description of the summaries of the interviews, but as I've said before, you consider all the evidence and you decide what is important. If I'vereferred to something in a summary you consider unimportant, ignore that and attach significance to anything you think is important.
In a nutshell, she remembered Baby A and the handover from Mel Taylor and said he was a little bit jittery in his appearance and his limbs. Mel said the doctors had confirmed the long line ready to use and fluids were run. Within minutes, maybe 5 minutes, his colour changed and he became quite pale and mottled in his skin, almost white. She remained by his cot side and Mel Taylor remained in the room, writing her notes, she thought.
Dr Harkness was in the room dealing with Baby B and Caroline Bennion was also in the room. She could not remember if the alarm went off. In her evidence, as I have just reminded you, she said the Philips monitor had sounded. The mottling she saw was blotchy, red and purple, almost a rash-like appearance, like blotchy red marks on the skin, which she thought could be a sign of infection, low blood sugar, being cold or low blood gas, and they appeared on his hands and feet and the left side of his body where his line was, but he was centrally pale.
She thought it was still there when she called Dr Harkness and Caroline Bennion and they were advised, that's the nurses, to stop the fluids on the long line straightaway. She went to [Baby A] and found he was apnoeic and not breathing. She did not recall the resuscitation. She thought there might have been a problem with the long line or the fluid attached to it, which she believed Mel Taylor had attached. She thought it was her who gave [Baby A] to his parents.
She had seen two very preterm babies pass away at Liverpool Women's Hospital's when she was training there.
Baby A's death was not expected or anticipated. Her concern was that maybe the bag of fluid that he was being given was not what they thought it was and she believed Mel was the one who connected it, but they checked the bag together.
She found the process after death, of completing Baby A's handprints and footprints and taking photographs, quite a nice thing to do for the baby and she saw it as a way of giving parents memories. She didn't keep in touch with the family after Baby B left the unit. She said the handover notes were usually disposed of in the confidential waste. She didn’t recall what she did with Baby A's. She didn't remember anyone else giving Baby A care between the handover to her, which was the first time she met him, and his collapse.
She was asked further questions on 11 June 2019; [document redacted] onwards. From her memory it was Mel who connected the fluids to Baby A she confirmed she was standing by his incubator when he collapsed. She did not know how he would have received a bolus of air. It would be very hard to push air through a long line. She did not know a lot about air embolisms. She knew that when priming lines they were always taught to prime the line fully, to make sure that the lines didn't have any air in them because that would be dangerous to the patient and all nursing staff were very meticulous about checking the lines:
"You don't want air going into the bloodstream [she said], you don't know exactly how it would affect the baby."
In questioning on 10 November 2020, [document redacted] onwards, she denied having pushed air through Baby A’s peripheral line or his UVC and wasn't aware of any way air could be accidentally inserted through the UVC and couldn't explain how it got there. She was unaware of the physical effects of an air embolism and any changes to the appearance of the skin.
Her relationship with the parents of the babies in this case on the unit was only ever professional. She could not recall using social media to research the parents. She could not explain why she had searched for [Mother of Babies A & B] on Facebook on three separate occasions in June 2015 and once on 2 September 2015, not remembering having done so or why she had done so. She thought she may, in September, have been looking for a update on Baby B.
In her evidence the defendant repeated she could not remember the resuscitation clearly. She did remember his death being a huge unexpected shock. Because she was the designated nurse it was her role to assist parents after the death. Nurse A helped her with the hand and footprints and she started the memory box.
After he died, she felt they should retain the bag of fluids and infusion line for checking and testing. She labelled the bag and the attached line and put it in the sluice room. She did not know what happened to the bag after that.
She was stunned. Baby A's death was a complete shock to all of them. She contacted people to talk, they were her support team. The sort of messaging behind tile 248, when Nurse A said she “did amazing", and 249 would happen frequently.
She had witnessed two or three deaths before Baby A's. She said staffing levels contributed to Baby A's death, identifying the amount of time he was without fluids and the line insertion. These factors would, she said, have put him at increased risk of collapse, making him less able to fight off infection on any procedures. He was left with a UVC that was not being used and the line was not removed.
As I shall remind you shortly, the expert evidence is that these factors made no difference at all. She said that if there was an air embolus, Mel Taylor was responsible because she, the defendant, did not have access to his lines. She would never put air into a line. She was at his cot side when he collapsed checking the equipment and the incubator but could not touch the lines because his incubator was closed.
She disagreed with the descriptions of the discolouration of Dr Harkness and Nurse A. She said he had purple patches and white patches and a discolouration pattern she had seen before which she didn't consider abnormal. She considered the colour change came on very suddenly.
Well, the defendant searched for Facebook for [Mother of Babies A & B] at 09.58 on 9 June; that's tile 231. She said it was, she thought, curiosity: she wanted to see people involved in that awful event. She accepted having also searched the following day and on 25 June. It was a common pattern of behaviour for her, she said. Baby A and Baby B were on her mind quite a bit at that time.
I turn to the expert evidence, reminding you that you have my written direction in relation to such evidence. The expert evidence was all called by the prosecution. It was explored, tested and challenged under cross-examination and you should examine it with care in order to determine its reliability.
Some of the propositions put to the witnesses were accepted. Some were not. As I directed you in my first set of directions, the proposition in any question only becomes evidence if and only if the witness agrees with it.
Mr Myers, as well as being critical of the hospital, the clinicians and the experts, repeatedly expressed his opinions in his submissions to you on the merits of the expert evidence. That, of course, was his right but it has to be by way of submission to you. He cannot give evidence as to whether it is right or reliable, that is for you to determine.
As I have said, it's right you should consider the expert evidence with care and, in the way that I have directed you in writing, you're not bound to accept it, there is no burden on the defence to disprove it, but there is no evidence from any defence expert.
Dr Rajeev Shukla, a consultant paediatric pathologist, carried out a post-mortem examination of Baby A at the Royal Liverpool Children's Hospital at 12.30 hours on 10 June 2015 and made his written report on 14 September 2015. His findings included those set out in paragraph 20 in section 4 of the agreed facts. I shall not go through them, but will summarise them as they are explained by Dr Marnerides. If you want to have them open, by all means do: they're in section 4 of the agreed facts, paragraph 20 of the agreed facts, but I shall dovetail Dr Marnerides' evidence into the findings of Dr Shukla.
Before I turn to that evidence, though, I go first to other expert evidence in Baby A's case, reminding you of the evidence of Professor Owen Arthurs. Professor Owen Arthurs is a paediatric radiologist. A paediatric radiologist is a specialist in the interpretation of radiological images in children. He is a consultant paediatric radiologist and professor of radiology at Great Ormond Street Children's Hospital, a fellow of the Royal College of Radiologists, a fellow of the Royal College of Paediatrics and Child Health, and the holder of a doctorate in imaging. He was asked to consider the cases of a number of the children in this case. He considered the case of each child on its own merits and his findings on the images in that child's case related to that child only and were based solely on the imaging and were confined to his own expertise in the discipline of paediatric radiology.
He was provided with four radiographs or X-rays of Baby A, taken at different times when he was alive. They are behind tiles 31, 128, 142 and 156 in the sequence of events. They were all slightly different, but there was nothing particularly remarkable about them in terms of his heart and lungs.
He did, however, note that the umbilical catheter was in slightly the wrong place. Images taken on 10 June, after Baby A's death, showed that in addition to the normal expected gas you would see in a baby post-mortem, there was also a line of gas just in front of the spine in one of the large vessels of the body, which he pointed to and could be seen running along the length of the spine.
That, he said, was an unusual finding. It was so unusual that Professor Arthurs reviewed several of his cases that they had had at Great Ormond Street to try and identify in what circumstances it might occur. In several hundred photographs of babies who had died of natural causes, gas was not seen in that location. If there had been a severe fracture -- not a simple fracture, somewhere in the body, such as a fracture through the skull base in a road traffic accident — which might also break blood vessels then gas could be introduced and then circulated round the body. That explanation could obviously be excluded in this case.
The other circumstances in which it might be seen is overwhelming infection in most of the organs of the body, sepsis, but in such a case there would be clear identifiers from the pathology at the autopsy as to whether the baby had overwhelming infection. Baby A did not have any such identifiers.
Occasionally, and very occasionally, babies die from SUDI, sudden unexplained death in infancy. It is a recognised phenomenon that occurs in babies of the age of about 3 to 9 months. This, of course, was not such a case; Baby A was only 1 day old.
Occasionally, medical staff have seen it when a baby has undergone extensive resuscitation, the hypothesis being that there is some natural gas in the body after death and it is possible that the resuscitation could circulate it around if the resuscitation was successful in moving blood with gas in it.
Gas can also be introduced through cannulas, long lines and umbilical catheters. It was possible that it was introduced via the long line, which was in place until it was removed during resuscitation, or via the UVC. The appearance of the gas in the post-mortem image was consistent with that method of introduction and that would be an alternative explanation in the absence of any other.
Professor Arthurs has never seen this much gas in a child's body that has not been explained, save in one of the other children in this case, Baby D, the subject of count 4.
From a radiological point of view, the appearance of gas in Baby A's large vessels was, said Professor Arthurs, consistent with air having been administered to him but not diagnostic of it. In other words, the finding was consistent with air having been administered but it does not, as a radiological finding in itself and considered on its own, determine that it was the cause. You understand, therefore, the difference between consistency and diagnosis from a single finding.
In cross-examination, Professor Arthurs explained in more detail how he reached the conclusion that it's unusual to have this radiological finding. He had looked at a published paper, to which I shall refer in a moment, and then went through 500 cases from the Great Ormond Street Hospital where he looked at the children’s X-rays and found six cases where gas was identifiable in the large vessels, five of whom had had traumatic injuries and the sixth had died of sepsis. He then narrowed his search down to 100 who were under the age of 1 year when they died, of which 38 were under 2 months. Of those 38, he found eight cases where they had gas in the great vessels and who had died of trauma, road traffic accidents, sudden unexpected death in infancy, SUDI, congenital heart disease and disseminated malignancy. He found no unexplained cases of gas in that location after a detailed review.
He accepted this was an observational study and could not be a controlled study, in other words a study in which you would administer air to a baby and then observe the consequences and radiological findings. That, for obvious reasons, could not be a study which could be undertaken.
He also accepted the cases were not representative of babies who are 1, 2 or 3 days old but it was representative of the typical deaths that are encountered that are referred to Great Ormond Street Hospital, and whilst not being representative of every neonatal unit in the country, it was, he said, representative of perinatal autopsy in the types of babies who need a cause of death established.
When he gave evidence on the second occasion on 3 February this year, Professor Arthurs gave further evidence about the published paper to which he had referred in relation to how common it is to see post-mortem gas in some of the great vessels of the body, the aorta and the IVC. It was published in the Journal of Forensic Pathology and Imaging in 2015. He was one of the authors. It was not designed to answer that specific question and was not addressing the direct question of air embolus which was something that was very rare, that is air embolus.
That paper looked at post-mortem CT scans, which, the professor explained, was creating a three-dimensional image of each child using lots of different X-rays at the same time in a large range of children, several of whom were older children, and to see whether any of those were particularly relevant to the babies in this case.
As a result of my query as to how many of the babies were very young and premature, he'd gone back to the paper and said of the 48 cases presented, six were of relevant age, being less than 6 weeks old, and of those six he only found gas in two of them and in both of those cases there was an explanation. And I've already given you the various explanations that he had found when he looked at that.
One died with a twist in the small bowel, so a clear explanation of why there would be gas in the great vessels near the bowel, and the other baby who was premature had a very small locule of gas in the IVC, so not the sort of thing you would see on an X-ray, and had died of NEC, necrotising enterocolitis, and infection. There were no unexplained cases of post-mortem gas in the great vessels.
He was asked in cross-examination about the image from the Lee and Tanswell paper, J4946. He explained it showed a pulmonary vascular air embolism, which is a specific type of air embolism that comes from the lungs. It was of a child who had lung disease to the point where the lungs have burst or some of that air has entered into the blood supply around the lungs. They also have a big chest tube in, so they have two points of entry of air into their system. As a result of that, the air is then circulated and the child has a pulmonary air embolus, which could be an example of air entry that is iatrogenic, that is being in the course of medical procedures. It could have been either the chest tube or it could have been a complication of the ventilation given the lung disease that that child had.
When Professor Arthurs gave evidence a third time on 16 March this year, he gave further evidence about the air embolus and X-rays radiographs. Radiographic evidence of air embolus is rare, both seeing any radiographic evidence of air embolus is rare and in cases where air embolus is suspected, seeing anything on the radiograph is rare. If you cannot see it on an X-ray, that doesn't mean there wasn't an air embolus.
In his experience, most air embolus occurs as a result of the introduction of air during the manipulation of lines, so it is iatrogenic, being caused by the medical profession. In relation to the timing of an air embolus and the taking of radiographs, if a baby were to have an acute air embolus event, they would need to be resuscitated fully and the event of resuscitation might take so long as to prevent you getting a radiograph. So he explained one of the reasons you don't have imaging evidence of acute air embolus is because the imaging of the event isn't the important thing at the time. The priority of the medics is to save the life. If all the air had dissipated within half an hour, or something like that, then an X-ray taken an hour later won't show anything.
Also, there is no reliable guidance anywhere as to the exact quantities of air that are needed to induce air embolus or for how long it lasts in the circulation.
Dr Andreas Marnerides is a consultant perinatal and paediatric pathologist, based at St Thomas' Hospital in London. A pathologist has an expertise in interpreting specimens from the living, such as biopsies to help clinicians make a diagnosis and in performing post-mortem examinations. A perinatal and paediatric pathologist has the sub-specialty of dealing with the paediatric population; that is the time around a woman’s pregnancy and the early time after the baby is delivered, and children.
He carries out about 250 perinatal and paediatric post-mortem examinations a year, about half of which are forensic examinations, in other words being requested by the police and coroners. He obtained his medical degree from the University of Athens in 2002, then trained inforensic medicine there, before training in paediatric and perinatal pathology at the Karolinska Institute in Stockholm, before becoming a consultant at St Thomas’ Hospital, which is one of the main teaching hospitals in London, in January 2013. He's a fellow of the Royal College of Pathologists and holds the diploma of medical jurisprudence from the Royal Society of Apothecaries in London.
He told you about the process of post-mortem examinations, which typically start with a post-mortem radiology examination, followed by an external examination looking for dysmorphic features -- that is something that has not formed in the way they expect it to form, for example ears being lower than normal -- and noting of injuries and marks of medical intervention. And many will make a detailed or less detailed assessment of how the post-mortem phenomena, that is decomposition, has developed and may take samples and swabs.
The pathologist then proceeds to an internal examination, making an incision exposing the internal organs of the body, taking photographs and samples of the organs and outside it, where appropriate, as well as samples. He explained that in the case of each of the babies in which there was pathological evidence, he considered their case in isolation and did not use any findings in relation to one in the case of another. He also explained that he was provided with accumulating evidence, which added to the knowledge he gained from his initial information and that he accepted and acted on clinical information and opinion provided by clinicians, including, where relevant, evidence and opinions from radiologists, and relied and acted on their opinions unless, by reason of his pathology findings, he was not satisfied with their opinions.
In other words, if he was told by a clinician about something and he said, well, the pathology doesn't support that, doesn't confirm that, then he wouldn't rely on the clinician, otherwise he would rely on the clinician.
His expertise therefore is the pathology of conditions that have resulted in death. That's a carefully worded phrase in response to what Mr Myers submitted to you about how he's not concerned with the living, he's only concerned with the dead. His expertise is in the pathology of conditions that have resulted in death.
It may help you to turn to agreed fact 20 in section 4, page 7 in jury bundle 1. I said there would be an occasion when I refer you to documents. So if you would, please, in section 3, turn to the agreed facts.
It'll make it easier as I go through this evidence. Jury bundle 1, section 3, sorry -- I said section 4. Section 3, yes. Page 7. All got it?
Internally, the pulmonary arteries in Baby A's cardiovascular system were found by the pathologist Dr Shukla, who carried out the post-mortem, to be crossed. You can see that under the heading "Cardiovascular system":
"Pulmonary arteries are crossed with the left pulmonary artery originating to the right and above the origin of the right pulmonary artery."
Dr Marnerides said that was an isolated malfunction and had no clinical consequence:
"As to be expected, the foramen ovale was patent."
In other words, open. That closes in later life.
In relation to the respiratory system, the lungs, which Dr Marnerides said will have been about the size of a plum, contained more blood than what would be expected to be seen, but that was a very common, very non-specific finding.
Microscopically more capillaries were seen to be full of blood and there was blood between some of the balloons in the lung, called the alveoli, some of which had collapsed. The alveolar ducts appeared dilated and contained squames, indicating amniotic fluid aspiration. This, he said, was normal as babies ingest amniotic fluid in utero, when they are in the womb, and Baby A was only a day old.
There was no evidence of infection, bacterial or viral. There were no other abnormalities.
In relation to the histology, in two sections -- that is very thin slices taken from the samples of tissue from the lungs -- Dr Marnerides could see occasional, very occasional, relatively large spherical empty spaces or globules within the lumens, that is the inside of the ring of the vein. When the slide was stained with the appropriate substances they were empty structures which meant it was either fat or air. He excluded fat by testing and concluded that it was more likely than not that these spaces represented air. He saw a similar thing in a section from the brain. He could see that the lumen was surrounded by blood, which told him, not categorically, but it was most likely that this bubble of air went there while this baby was alive because there was a response to it; it's a haemorrhage, bleeding. But he emphasised these findings could not be taken as absolute proof of an air embolus.
He considered the question of whether the air present was the result of decomposition and said it was highly unlikely that it was not (sic) because for decomposition to result in air into the vessels you need to have evidence of decomposition, which is typically visible to the naked eye. So you see in decomposing bowels a greenish discolouration of the abdomen.
Most importantly, on histology, that is under the microscope, the structures look autolysed and you can say whether there has been significant decomposition or not. In this case there was not decomposition.
The other reason is that a haemorrhage around that vessel in the brain wouldn't be expected if that was due to decomposition, so although he could not categorically say it wasn't, he could confidently say it was highly unlikely to be a result of decomposition.
Splinting of the diaphragm and stimulation of the vagal nerve, or both, are the two known potential mechanisms known to result from the distension of the stomach and bowels. From a pathology point of view, Dr Marnerides could not say whether or not these had occurred. What the pathology could do was exclude reasons for the air to be there, such as decomposition.
When asked about air in the circulation system, Dr Marnerides said that because the foramen ovale is typically open in babies, and was in Baby A, his understanding was that the difference in pressure, left to right, between the two chambers in the heart makes it more likely that instead of air going up into the pulmonary arteries, it will travel into the left atrium of the heart and then into the left ventricle and then into the systematic circulation, the arteries. So that is how air in the venous system can get into the arteries, because of the foramen ovale being open and going into the heart, a different chamber in the heart.
In relation to tamponade, if there was evidence of tamponade at post-mortem, one would have seen haemorrhage or bleeding into the sac that surrounds the heart, which is called the pericardium. Dr Shukla did not see blood there and there was no such blood in the photographs, so there was no evidence of tamponade.
Baby A didn't have pathology features of pulmonary hypertension, but because he died so young, even if he did have pulmonary hypertension, Dr Marnerides would not expect him to have features of pulmonary hypertension because they would not have had enough time to develop. Whether he did have such features was a matter for clinicians.
Dr Marnerides said he had general knowledge that the insertion of a long line can induce arrhythmia. Dr Marnerides' understanding from the clinical review was that there was no evidence of any natural cause of death. From the pathology review, there was no evidence indicating a natural disease, so there was, overall, in his opinion, no evidence that a natural disease could explain Baby A's death. On the basis of the clinical information and the findings, with the caveats that he explained in relation to how these findings can be interpreted and which I've summarised, he took the view that Baby A's death would be explicable on the basis of air embolism which, on the information, would appear to have been by injection, the insertion of air into a vascular access line.
Dr Dewi Evans was the first outside expert to become involved in the case. He was asked by the National Crime Agency in 2011 (sic) to review the unusual number of deaths of stable babies who collapsed and in respect of whom resuscitation was unsuccessful at the Countess of Chester. He is a consultant paediatrician who was in full-time National Health Service clinical consultant paediatric in Swansea from 1980 to 2009 and was responsible for setting up, supervising and leading a neonatal intensive care service in Swansea from his appointment, developing intensive care services from scratch. His experience was very much hands-on, he said. His operational and managerial roles included serving as clinical director of paediatrics and neonatology in Swansea between 1992 and 1997 and 2004 and 2008. And he said those duties eventually covered the whole of South Wales.
Neonatology is the care of babies up to around 4 weeks. Neonates have specific anatomical and physiological features. He has not been in full-time clinical practice since 2009, but has often acted as an expert witness.
I'll tell you more about him as an expert witness. As well as making an overarching statement in respect of all the children, in the case of Baby A Dr Evans wrote a number of reports.
His role was to look at the clinical evidence. He was told that there were normally three or four deaths a year. He asked for notes on any baby who had died or collapsed where there was no explanation. On the whole, he said, babies don't suddenly collapse.
He looked at 35 cases, looking for the cause. He obtained copies of their case notes. In some of the cases he found there was an obvious cause: infection, a blocked tube or a collapsed lung. Baby A's was the fifth case he dealt with and he found the cause of collapse and death to be unusual. Having received ongoing information about individual children, a pattern became apparent. In some cases additional information caused him to change his mind. He relied on the information that he received.
Dr Evans' evidence has been and remains the subject of repeated criticism by the defence. In general terms they contend he is not a neonatologist, having qualified as a paediatrician, although his specialty, as I've just summarised, was in neonatology for almost 30 years. He has not been in practice since 2009. His expertise, they say, is not good. He has constructed theories designed to support the allegations on the indictment rather than to form and present an independent opinion on the basis of the facts. He's acted as an investigator and has given evidence in a manner that, it is said, was improperly subjective, dogmatic and biased.
They point to his putting himself forward to assist in the case at the outset and suggest that you can infer he was not telling the truth when he said he had not been told by the police that clinicians expected air embolus as a potential cause of some of the collapses.
In any prosecution there is a duty on the prosecution to disclose to the defence any material in the possession of the prosecution or of which they are aware which undermines the prosecution or assists the defence case. And that will be a note saying, "This is what he was told and when he was told that". No such note has been disclosed in this case.
You are entitled to draw inferences in the case, as I have already directed you in my first set of legal directions, but you must not speculate. The prosecution point to the context of his instructions. At the outset there were a large number of incidents that required review and sifting in order to identify those cases in which there was no identifiable medical cause or apparent reason for a baby's event or death.
They point to Dr Evans' long clinical experience in neonatology. That initial sift identified such incidents and Dr Evans expressed preliminary views as to possible mechanisms on the information then available to him, his sift reports.
As a result of the sifting process, he identified that in two cases, those of Baby F, count 6, and Baby L, count 15, a baby was deliberately and wholly inappropriately given unprescribed insulin, thus providing, say the prosecution, clear evidence of someone in the unit deliberately harming babies.
Further, his opinions were given without knowledge of the other material in the case relating to shift patterns and potentially incriminating material relating to the defendant. And there is evidence from other experts supporting some but not all of the conclusions he reached. In other words, he wasn't looking at all the evidence, he was just looking at the clinical evidence as to case where, on the notes, a death or an event appeared to be unexplained.
That's a bare summary of the respective arguments in relation to the evidence of Dr Evans and I shall remind you of more details and specific criticisms in the individual cases as and when I come to remind you of them. It is, I repeat -- and I know this is becoming tedious for you to hear, but it is very important — it is for you to assess the reliability of the evidence of any witness, be they a witness of fact or an expert giving opinion evidence, and the weight to attached to it in the light of all the evidence in the case. It’s important therefore, as with all witnesses, to assess their conclusions in the context of all the evidence relating to the child in question and the opinions of others who have a relevant expertise in that child’s case and, of course, the evidence in the case as a whole.
In the case of Baby A, Dr Evans noted that at about 08.20 hours Baby A was apnoeic; tile 183. Dr Harkness' note was, he said, a very good standard resuscitation procedure and Dr Jayaram did exactly what should be done.
Before he collapsed, Baby A was in a stable position and as well as could be expected. He was in air -- that's breathing in air -- not requiring oxygen. The repeated efforts to insert the UVC, though upsetting, would not have caused his deterioration, nor would the insertion of the long line. Babies sometimes do forget to breathe. If they do, they start again. It's apnoea of prematurity and you move a leg, jig it up a bit.
At the time of collapse, there was no evidence of infection or lack of oxygen. He was breathing well. His loss of potentially 16ml of fluid by reason of not having anything put down a line would not make a material difference or cause a sudden collapse. If a baby is seriously ill by reason of lack of fluid, the heart rate goes up. Heart rate is a very good marker of well-being. The elevated heart rate and variable respirations behind tile 28 on J1123 were when Baby A was being handled and all other markers were stable and he wasn't requiring additional oxygen.
An air embolus interferes with the blood supply to the heart and lungs, blocking off the blood supply. The usual combination of babies in collapse is being blue and white. A bright pink is very unusual and is attributable to having red cells in air in circulation.
Discolouration of itself is not diagnostic of air embolus. You cannot confirm an air embolus from discolouration alone.
He referred to and was asked about a paper, the paper by Lee and Tanswell, published in 1989, which addressed what phenomena, what items are associated with infants who definitely had pulmonary vascular air embolism. In five of the 50 case studies there was discolouration. Blanching and migrating areas of cutaneous pallor were noted in several cases. And in one of the author's own cases, as I've already reminded you, there was the bright pink vessels against a generally cyanosed cutaneous background.
Dr Evans denied that he had been influenced in reaching his conclusion of air embolus in this case on the basis of that report. There is no way air could have got in by accident. Dr Evans had no clinical experience in his 30 years of neonatal care in Swansea of air embolus, though there was a case of an anaesthetist injecting air into the stomach of a baby a few weeks old, having inadvertently attached the syringe to the intravenous line and then injected air into the circulation. Resuscitation was unsuccessful and the baby died.
In Baby A's case there was a combination of sudden and unexpected collapse, stopping breathing, a change of colour, cyanosis, bradycardia and death. The major features were the unusual skin discolouration, air in various parts of the body, and no other explanation. To some extent, he did rely on a diagnosis of exclusion of other possibilities. He was the first person who thought of air embolus. There had to be intravenous access and it was probably a bolus of air down the intravenous line, is what he said.
Dr Sandie Bohin is a member of the Royal College of Physicians and a fellow of the Royal College of Paediatrics and Child Health, having qualified as a doctor in the mid-1980s. She trained as a neonatologist, a doctor who looks after small babies, when she was a senior registrar working at the University of Leicester University Hospitals. She worked there from 1996 until the end of 2008 as a consultant neonatologist. That was a large tertiary neonatal unit that covered 10,000 deliveries of babies and had about 600 admissions a year at that time. It covered all aspects of neonatology.
In 2009 she moved to Guernsey in the Channel Islands and became a consultant paediatrician with neonates there. Latterly she also worked at the University of Bristol Regional Intensive Care Unit for between 2 to 4 weeks a year where she just does neonatal intensive care and high dependency and some transfers.
She has written and contributed to research papers with Professor David Field and latterly contributed to chapters in books on neonatal respiratory function and on neonatal transport.
The defence accuse Dr Bohin of lacking independence. They say she was instructed to peer-review Dr Evans and what she has done is, they say, to go as far as she has been able to go in enthusiastically supporting him and the prosecution. She knew what was coming because she generally heard all the cross-examination of Dr Evans. She repeatedly denied these assertions and said that her views were her own.
Any expert witness, including any defence expert witness, if called, hears all the evidence, including cross-examinations, and are under the same duty to the court of independence regardless of by whom they have been instructed. It's for you to judge the validity of the criticisms of her evidence.
She was asked by the National Crime Agency to look at the cases and case notes of the babies where there were concerns about collapses and deaths that people considered to be unusual and to try a find a cause for potentially why they had collapsed and also to comment on whether she agreed or disagreed with Dr Evans’ findings or made some additional findings herself.
She was provided with the medical reports, including imaging relating to the children under consideration, and the reports of many experts such as Professor Arthurs and the pathologist Dr Marnerides and, in the case of Baby A, a statement from Professor Kinsey, a haematologist based in Leeds, and part of a witness statement from the notes made by Dr Jayaram dated 18 September 2017 and the medical notes made by Dr Harkness and the post-mortem report written by Dr Shukla from Alder Hey.
Having been born 10 weeks early, it would be anticipated, said Dr Bohin, that Baby A would have some problems, but he didn't have them. He was a stable baby, not in oxygen, his heart rate and temperature were stable throughout. His respiratory rate, in terms of breaths per minute, was slightly at the upper end of normal but was stable at that rate, so this wasn't an escalating respiratory rate, it was stable. He was handling well when the nurses routinely cared for him, changed his nappy or cleaned him. He didn't suddenly deteriorate, he tolerated all those things really very well, so he was extremely stable.
Neither the UVC nor the long line contributed to his collapse and death. He wasn't being troubled by apnoea of prematurity and wasn't unstable in that way and none of the other causes of apnoea were pertinent to Baby A.
He was so well that the treating team decided to give him some feeds.
Collapsed babies do not have a pink blotchy rash that came and went. There are potentially lots of causes for rashes in babies, particularly babies who have collapsed in the way that Baby A did and, unfortunately, if you see lots of babies who have collapsed, you are aware that they are grey/blue, they may be white, but they don't have the type of rash that was described in Baby A's case: a pink blotchy rash that seemed to fluctuate and come and go.
So in her experience, things like infection, sepsis and hypoxia could not cause that type of rash. Dr Bohin came to the conclusion, looking at a differential diagnosis, excluding the other possible causes as she could, air embolus was the only plausible explanation.
Air can get into the venous system in one of two ways: either accidentally or deliberately. Her experience is that nursing staff and medical staff, who either put in the lines or who subsequently care for the lines and change fluids, are absolutely meticulous to prevent any air getting into those lines. So the lines and the little connecting ports are filled with saline so that even the tiniest air -- I'll start that again.
So the lines and the little connecting ports are all filled with saline, so even the tiniest air bubble can’t get into the line, is something that is just ingrained in nursing and medical staff. So she thought that air getting into accidentally was extremely unlikely.
In addition, the pumps that are used to administer bags of fluid have an alarm on them, so from the bag to the pump, the tubing then goes to the patient. Those pumps have alarms that detect air coming down the line, so if air inadvertently got into the line it would stop at that pump because it would pick that up. So the only way air could get into a baby would be further down the line after the pump.
Studies dealing with volume and speed of emboli are to be treated with caution, said Dr Bohin, because the studies are mainly either in adults or they're animal studies, they're not studies that have been done on babies. The information from adult and animal studies would seem to suggest that if you have a large, fast injection of air, you get a different set of clinical results than if you have a slow infusion of air.
The papers that she had relied on on this subject have suggested that 3 to 5ml per kilogram of body weight would or could be fatal to a baby; Baby A weighed 1.6 kilograms.
Under cross-examination, she said she had seen one case of air embolus in clinical practice in Leicester as a registrar. She didn't know of any genetic condition that could have caused Baby A to collapse and die within 24 hours of life. His raised respiration was an alert but nothing was done because nothing needed to be done.
She would not expect the heart rate and the respiration rate to track each other, which they weren't. The long line was in a safe but not optimal or best position. Not giving fluid for 4 hours was not okay and not optimal, but handling in a baby on respiratory support can make respirations go up. Although air embolus is reported as a known risk from venous catheters in adult literature, she has never known it to be a risk in neonatal practice because the bore of the tubing is so small, nor has there ever been an alert sent out to neonatal clinical teams that it is a risk.
I only have, in relation to Baby A, to remind you of the evidence of Professor Kinsey, but I'll do that after we break off and then I will move on to Baby B. Could you be ready, please, to continue at about 2.08? Some time shortly after 2 o'clock. An hour and 5 minutes. Thank you very much.
(In the absence of the jury)
Mr Justice Goss: Mr Myers, is there anything?
BM: Nothing from me, my Lord.
Mr Justice Goss: It was very helpful, if I may say so, that you sent an email in relation to the correction that was necessary, so I'm very happy, if I do make any errors, for them to be sent by email.
BM: We can do that, particularly when it's something formal like that.
Mr Justice Goss: Exactly. I was very grateful for that.
Nothing, Mr Johnson?
NJ: No, thank you.
Mr Justice Goss: Thank you very much.
(1.03 pm)
(2.05 pm)
(The short adjournment)
(In the presence of the jury)
Mr Justice Goss: I'm conscious this is very detailed, so we'll have a break at about 3 o'clock and then we'll do a final session. We won't go on late because your ability to concentrate will diminish as the afternoon progresses, obviously, but I'll keep an eye on you.
Professor Sally Kinsey, an expert in haematology, explained that an embolus is something that shouldn't be in the circulation. The most common form of embolus is from a blood clot. Another form is a fat embolus, where bone marrow from fractured bones gets into the circulation.
If air is injected into a vein it will go into the venous side, the blue side of the diagram that she showed you. In the case of a young body, particularly a preterm baby, where the foramen ovale, the flap to which I've referred several times, is still open some of these little bubbles can get into the arterial circulation, that is into the red side of the diagram, so that you can start to see bubbles in the blood being pumped out by the heart. I referred to that this morning.
The bubbles will go down the arterial system in the big vessels first, going right up to the smallest capillary, until the air bubble is lodged, not being able to go any further because the blood vessel in front of it is smaller; that blocks the arteriole. The space in front of that blockage is then bloodless because no blood is getting through, so it becomes pale.
The stagnant red cells behind the blockage will release their oxygen and then gradually will re-oxygenise others, so when the red cells lose their oxygen they go a bluish colour and then, because they’re near a bubble with oxygen in it, they will absorb that oxygen and then turn pink again. That will then disappear into the tissues and it will go blue again so a fluctuating colour distribution and pallor can be seen.
Professor Kinsey confirmed that in terms of Baby A's blood properties there was no explanation for spontaneous bleeding. That did not mean that he might not have had a gastrointestinal haemorrhage for some other reason unconnected with blood clotting or haematology and her assessment did not establish the cause of bleeding.
The conclusions that she did draw were from the descriptions of the doctors who attended Baby A and the features of the blotchiness on the skin, particularly the commentary about pallor and pinkness and blueness on the skin. She was quite brought up short by this and her concerns were cemented by the comments of those present at the time of Baby A's collapse, particularly what Dr Jayaram said in his witness statement made 2.5 years after the event, and not the description that he noted at the time. That description was consistent with air embolus.
She qualified this opinion by saying she is a haematologist and not an expert in air embolus. The expert you would want when an air embolus happened would be an anaesthetist, there with a needle, to remove the air from the right ventricle of the heart if you had time. She was taking a standard understanding of circulation and gas exchange and seeing how that might apply to what is alleged in this case.
Air embolus features in the skin are very rare, she has never seen it herself. She has seen what little there is about it in medical literature but it was a pretty stark description of what she took to be an air embolus.
The prosecution case is that the defendant caused that air embolus by injecting air intravenously and killed Baby A, intending to do so. The defendant says she did no such thing.
The following day Baby A's twin sister, Baby B, collapsed and I therefore turn to count 2, attempted murder.
I remind you that Baby B's birth weight on the evening of 7 June was 3 pounds 11 ounces, 1 ounce lighter than her twin brother. She was born blue and floppy with a low heart rate, which persisted and progressed, needing resuscitation, as set out behind tile 2 in the sequence of events. She was transferred to the unit, the neonatal unit, intubated and placed in an incubator and on a ventilator in nursery 1. She progressed well, was on CPAP and remained stable.
The allegation is that the defendant attempted to kill Baby B by injecting air into her venous system during the night shift of the 9th and 10 June.
Nurse A came on duty at 19.30 on 9 June, the evening after [Baby A] had died, and was Baby B's designated nurse. On handover there were no concerns.
Baby B had had a good day and continued to improve. Mum and dad had had cuddles. She was receiving CPAP and hourly observations.
Tile 150 in her sequence of events fronts Nurse A's retrospective note of the shift from 20.00 to 02.00 hours, so in other words the first six and a third hours of the shift:
"No bradys or desats. She was tolerating 3ml of donated expressed breast milk two-hourly. All observations were satisfactory. She was active and handling well."
The defendant was also on duty that night. Tiles 145 and 146 identify those on duty for that shift and their allocated babies. The defendant was the designated nurse for two babies in nursery 3, EB and HT. She said in evidence that she had no recollection of which babies she was responsible for.
Tile 210 fronts the note Nurse A wrote in retrospect at 07.28 on 10 June, setting out that at shortly before midnight Baby B desaturated to 75%. She was found to have pushed her CPAP prongs out of her nose and they had to be repositioned, something that is not uncommon. Sometimes, as the babies start to feel better, they push the prongs out themselves. It took a little while and a little bit of oxygen to recover. Her heart rate remained stable and she had a good respiratory rate throughout.
Once she had settled, her capillary blood gas was taken and was normal. She was stable. She had a long line with a drip infusion which included total parenteral nutrition, TPN. The product name was Babiven, a product with which you became very familiar during the course of this case. The pump infuses at a set rate and can detect any air bubbles coming down the line and stop the infusion if it detects one.
At 00.05 hours, 5 minutes past midnight on, 10 June, Nurse A and the defendant signed for lipid, a form of fat that is infused -- your reference is tile 213 -- which was something the defendant agreed she had done when first questioned by the police about Baby B on 4 July 2018.
There was a strict rule that two nurse practitioners must sign for any prescribed medication and check it against the prescription. The lipid is supplied in a syringe which is connected to the infusion line. If there are two lumens, that is two separate sides running down one line, they join the infusion line after the pump. Nurse A could not remember if it was a double lumen.
At 00.16, the defendant took blood gas readings for Baby B; J1668, behind tile 215.
At 00.30 hours, Nurse A had her gloves on and was standing up across the room by the half wall in room 1, nursery 1, drawing medication up and could not see Baby B. Her alarm started.
The defendant went over to Baby B and said, "She's apnoeic, she's not breathing", and asked Nurse A to go and get help. Sometimes, said Nurse A, babies do appear apnoeic and quite often they recover quickly. Baby B didn't. They had to use Neopuffs because she wasn't breathing for herself.
She suddenly looked very ill, very pale and had a blotchiness to her skin. She looked like her brother, Baby A, with pale, white blotchy discolouration generally all over.
In her nursing note behind tile 218 Nurse A wrote:
"00.30. Sudden desaturation to 50%, cyanosed in appearance, centrally shut down, limp, apnoeic, CMC [continuous mechanical ventilation] via Neopuff commenced and chest movement seen. Colour changed rapidly to purple blotchiness with white patches. Started to become bradycardic [slowing heart rate]. Emergency call for doctors put out. Continued with Neopuff via Guedel airway until Dr Lambie arrived."
In her evidence the defendant said although she didn't have a good recollection of the shift, Nurse A and her were in nursery 1. She accepted from the charts that she had been in nursery 1 and had involvement in the setting up of a new bag of Babiven and lipid for Baby B.
The observation chart for Baby B behind 237 has some incomplete recorded observations at 12.00 hours, with no initials at the foot of the column. The ones up to that time bore the initials [initials of Nurse A], Nurse A.
She confirmed in evidence that the 01.00 observations were recorded and initialled by her, the defendant. Contrary to Nurse A's evidence, she said that Nurse A alerted her to the fact that Baby B had deteriorated by calling her over. Baby B had become quite mottled and dark all over her body, a dark mottling colour. She said it was like general mottling they see on babies. It was not unusual but she said they were concerned about her. Baby A had been pale and white; Baby B was more purple. She did not see what Nurse A said she saw. She accepted that she had the opportunity to have access to the IV lines of both Baby A and Baby B just before they collapsed, but said she didn't access the lines.
The defendant was first interviewed by the police about Baby B on 4 July 2018; that's in your interview file, obviously, behind [document redacted], the next one along, page 1 onwards. She said she could not remember the shift with any clarity other than from the notes.
She did not remember her involvement with the care of Baby B. She confirmed having signed the nutrition prescription behind tile 213 with Nurse A, who was Baby B's designated nurse, and the record of infusion behind tile 241, and recording observations on the observation chart behind tile 237 at 01.00.
She did remember Baby B displaying some mottling that looked a bit similar to that seen on Baby A's appearance the day before. It was more extensive and covered more of her body. It was like a purply-red patchy rash-like appearance. She thought Nurse A may have alerted her to Baby B’s appearance. She observed this before any resuscitation began. She could not recall if Baby B was attached to a monitor but assumed she would have been. She did not recall any alarm sounding. She did not have any recollection of her interactions with Baby B or how she got to the point of collapse, nor did she recall having any concerns for her.
Baby B was in nursery 1 and she would have attended to her if her designated nurse was on a break or engaged with another baby. She confirmed that she would have handled Baby B to an extent to give her the medication and attach lines because it needs two people to connect to a long line or a UVC.
She recalled being with Baby B's parents in the nursery and how upset Baby B's parents were. They had waited a long time for Baby A and Baby B and they were much-wanted babies.
She had not kept in touch with them. She had kept in touch with one or two families from Liverpool Women’s when she did her placement there. She did not remember any collapse event on that particular shift.
When interviewed 11 months later, on 11 June, page 17 onwards, she said it was possible she took the gas readings shortly before Baby B's collapse. She did not do anything deliberately to harm Baby B.
The third interview was on 10 November 2020. She had no explanation for Baby B's collapse. She was asked, page 21, about messages between her and Nurse A in which she said:
"Odd that we lost three in different circumstances."
She said she didn't recall that message conversation or saying that she couldn't get -- sorry, she couldn’t recall -- I'll start that again.
She said she didn't recall the conversation or saying that she couldn't get her head around Baby A.
Dr Rachel Lambie, who is now a consultant paediatrician in Crewe, was then a senior registrar at the hospital. She received a crash bleep, which directed her to Baby B's beside. When she arrived, Baby B was on bag-and-mask ventilation, having had, she was told, a sudden and unexpected apnoea. The most memorable thing, said Dr Lambie, was Baby B's colour. She was a very dusky, pale grey colour and, as they were helping her, she was then developing widespread blotches, patches of a purply/red colour. They would flush up, last about a few seconds, 10 seconds, and then disappear and appear elsewhere. They were flitting around her body, all over.
After about 10 minutes, Baby B started moving for herself and recovered, but it took about an hour and a half for her colour to improve. So the patches weren't there for 30 minutes, but it took that time for her general greyness to disappear and her normal pink colour to return.
In her clinical notes, to be seen behind tile 243, written at 02.30, Dr Lambie described a:
"Widespread purple discolouration of the skin with white patches."
She inserted the breathing tube, the Guedel, to which I've referred. The vocal cords were normal. Urgent blood tests were taken to look for infection. When they came back there was no overwhelming infection.
The blood clotting figures were normal and cell numberswere normal.
Dr Lambie said this was a very unusual event that she had not seen before and hasn't seen since and recovery was rapid. She wondered whether there was a widespread sepsis or a problem with her blood clotting, coagulopathy, but the test results ruled that out. Professor Kinsey confirmed that the results did not support any coagulopathy. The gas results also came back as normal.
The defendant said that she had been asked by Dr Lambie to get a camera, which she went to get from the manager's office, and she said she got it very quickly. On her return, Baby B had stabilised and her colour had returned to normal. So that was an occasion where a clinician was asking for photographs to be taken of what was to be seen, but the event was concluding by that time the camera arrived according to the defendant.
Dr B was the consultant on call that night. She had been a consultant at the Countess of Chester since 2005. She was called out at 00.37 and arrived at about 00.50. Dr Lambie reported to her what had happened and [Baby B]'s appearance. When she arrived, there was purple blotching to the right-hand mid-abdomen and the right hand. Her notes are behind tile 233 for your reference purposes.
The heart rate had picked up to 143, which was a good sign. The acid level was sub-optimal and the carbon dioxide level was a bit high. The blood count was okay, there was no sign of infection, no bleeding problems, the X-ray showed the ET tube was okay, there were diluted loops of gas in the bowel, which are often seen and not significant. Dr B was puzzled by the cause of the discolouration.
If a baby has an infection, the skin changes do not resolve. If the baby has sepsis they are really sick. This rash was so florid, it came out of nowhere and resolved quickly. It was also very unusual that a baby who was quite stable suddenly stops breathing, responds to treatment, and then in a couple of hours is almost back to normal.
The following night, Nurse A was back on duty. Baby B had been extubated and taken off the ventilator and was back on CPAP and did well thereafter.
Professor Arthurs examined six photographs, which showed some changes in the lungs, which were of premature lung disease, which would be expected, and no other abnormalities. It is very rare to see air embolus as a cause of death or as a radiological diagnosis, as
I've already explained to you, and the absence of air embolus in a radiological image does not mean that it didn't happen.
Dr Dewi Evans noted that Baby B required more resuscitation at birth, but from then on she was stable, requiring little by way of support. All the markers of well-being were satisfactory and she was considered well enough to be taken out of the incubator and to be given to her mother for love and attention. She was prone to desaturations.
He, again, formed a differential diagnosis, which was that her collapse was either the result of smothering, in other words obstruction of her airways, or an air embolism. The discolouration of her abdomen was very striking and quick. If the cause was hypoxia, starvation of oxygen to the brain, or sepsis, it tends to stay, it doesn't just come and go. He considered it may have been the result of a small volume of air being injected into her long line. The pattern of collapse was very similar to Baby A's, so it was more likely that the cause was the same.
In Baby B's case, the fact that she survived suggests that either the volume of air was less or it got into her circulation more slowly, or a combination of the two. There was no sepsis and nothing else to explain this collapse, which was so sudden and unexpected. There was no evidence of any problem with her lungs or heart.
Dr Bohin concluded from the clinical notes that at birth Baby B was clearly compromised and needed some help to establish a normal breathing pattern. She required resuscitation at birth, which would not be particularly unusual for a baby born at just after 31 weeks' gestation, and she responded very well to appropriate resuscitation provided by the medical and nursing team and stabilised very quickly.
Initially, she was on BiPAP, which is a specific form of CPAP. It is CPAP with a little bit of extra support, but she did very well on that. She was then converted to CPAP but was in air and her blood gases were normal. She was very stable and able to have times off CPAP, for 2 hours on the first occasion, with no changes in the readings and almost 2.5 hours on the second, having skin-to-skin contact with her mother, and for feeds to be started. She went back on to CPAP after the second period off because of increased work of breathing, though this wasn't reflected in the observation chart because that simply records the number of breaths per minute. There was nothing in the observation chart that would suggest that she was compromised in any way.
The circumstances of her collapse was very concerning. Sudden collapse is not something you see, you usually get prior warning. There was no connection between the nasal prongs being dislodged earlier and the sudden desaturation. There were no other warning signs that would herald an imminent collapse. She discounted infection and cardiac arrhythmia and was left with the conclusion that this was an air embolus, partly on the basis of a diagnosis of exclusion, but also because of the florid skin changes and the differences from anything she had seen before. She looked, she said, at each case on its own merits.
Professor Sally Kinsey confirmed that all blood results in Baby B's case were normal for her age and at the time of testing. She reached the same conclusion that she advanced in the case of Baby A in relation to an air embolus. The account in terms of features was consistent with those discussed in the medical literature, including the paper by Lee and Tanswell.
She was referred to the descriptions of those present: Dr Lambie describing a widespread purple discolouration of skin with white patches and Dr B noting purple blotchiness of the right mid-abdomen and right hand and, towards the end, the purple discolouration had also resolved.
In her note the defendant described her as "cyanosed in appearance". It was pointed out to Professor Kinsey that there was no reference to pink or bright red patches.
The prosecution say that this wholly unexpected sudden and otherwise unexplained collapse was caused by air embolus as a result of air being injected into her by the defendant, who accepted she had access to the lines of both twins before their respective collapses.
The highly unusual features of discolouration observed by medical and nursing staff, including the defendant, which was similar to that seen on Baby A the previous day, in the context of the expert evidence and the absence of any other medical explanation can lead you, they submit, to the conclusion that she attempted to murder Baby B
The defence say it's not as straightforward as that and, for the reasons that were advanced to you by Mr Myers, they say that you cannot, on the evidence that is before you, exclude this having been a natural event.
I move on to count 3, Baby C. He died in the early hours of 14 June 2015, 6 days after Baby A died and 4 days after Baby B’s collapse. As I shall remind you, the experts found it difficult to identify the cause of death, but Dr Marnerides concluded it was the excessive injection or infusion of air into the nasogastric tube.
The defendant says she did nothing harmful to Baby C and the defence say you cannot safely exclude a natural cause, such as a gastrointestinal blockage. They say Baby C should have gone to a tertiary unit, been examined earlier than he was, and there was a failure to react to bile aspirates and vomiting, complacency and a lack of care.
Baby C was born at 15.31 hours on 10 June 2015 at a gestational age of 30 weeks and 1 day to [Parents of Baby C]. His growth in the womb was not as it should have been. There was IUGR, intrauterine growth restriction. [Mother of Baby C] was admitted to hospital on 5 June with raised blood pressure. A scan early on the morning of 10 June revealed that there was no blood flow through the cord, reverse end-diastolic flow, reverse EDF, ie the blood flow from the placenta to Baby C was at times going back on itself, so he needed to be, and was, delivered that day by caesarean section.
Baby C was taken to the Resuscitaire. Dr Sally Ogden, then a paediatric registrar level ST3, was present at the birth. Baby C weighed 800 grams, just over 2 pounds 2 ounces, which was a low weight for a baby of his gestation. It was accepted by the clinicians who were involved with his care that he was on the borderline for remaining at the Countess of Chester.
He was born in good condition, no resuscitation was needed. He was pink, well perfused and his circulation was good. His Apgar scores were pretty good: 7 at 1 minute, 9 at 5 and 10 minutes.
He was taken to nursery 1 in the neonatal unit. Dr Sally Ogden's notes made at 17.00 hours are within the documents behind tile 5, J1910. There were no risk factors and he was started on antibiotics; tile 10.
Because he displayed signs that he was working hard to breathe, which is often seen in preterm babies and is not in itself unusual, he was intubated and placed on a ventilator. Dr Ogden's plans for the next steps are set out in the notes at J1901 behind tile 8. Her shift ended at 17.00 hours. Dr Brunton made notes at 18.00 hours.
Dr Yoxall, a consultant at Liverpool Women’s Hospital, was spoken to, and he was happy for Baby C to stay at the Countess of Chester.
At 18.00 hours that day, Baby C was taken off the ventilator and commenced on CPAP, which, according to the nursing notes behind tile 11, he was tolerating well. A UVC was inserted, as recorded on the nursing notes behind tile 12, which had to be pulled back; tile 13.
Professor Owen Arthurs examined a radiograph taken at 18.19 hours. The tube was indeed slightly too far in and should be pulled back. There was gas in the stomach and small bowel and nothing abnormal to be seen.
A radiograph taken at 22.38 hours that night showed the tube had been withdrawn slightly and there was normal gas in the stomach and small bowel. The left lung was white, which was consistent with a clinical sign of a left-sided chest infection. The right lung was normal.
Bernadette Butterworth was Baby C's designated nurse for the night shifts of the 10th to the 11th and the 11th to 12 June. J913 behind tile 15 is the relevant document for the night of the 10th/11th. Although he was unsettled at times during the night, Baby C was the same at the end of the shift as he had been at the beginning.
Dr Ogden was on the day shift the following day, the 11th, and undertook a ward round at 11.00. Another of the documents behind tile 15, J914, is the relevant one to which you can refer for the details: readings were normal and very stable for a preterm baby, save for a high level of lactate at 4.3. His metabolics were just over the treatment line, so phototherapy treatment was to be started to address jaundice. He handled well and observations were normal. He was responding as expected.
A cranial ultrasound was carried out by Dr Gail Beech and shown to Dr Saladi, a consultant. No abnormalities were detected on that ultrasound.
Bernadette Butterworth was back on duty again for the night of the 11th/12th, as I've just reminded you. Baby C was unsettled at times and his UVC was out when she took bloods on the morning of the 12th, but not for long, because the bed was not that wet, and she had carried out hourly observations. The abdomen was distended, soft to firm, but not hard. He was quite unsettled at times and kicking. He was desaturating and requiring a bit more oxygen, but was pretty much the same over her two shifts. In other words, over the night before and this night.
Dr Gail Beech made entries on the clinical notes at 10.15 on 12 June. J1917 is the relevant document. There were no infections or sepsis. There were some things that needed watching: the CRP, capillary refill time (sic), had increased; the white blood cells were low; he was slightly jaundiced but phototherapy seemed to be working; lactate was on the high side but was coming down, which is a positive sign; and he was having skin-to-skin contact with his mother. Looking at all the data together, nothing stood out as worrying or concerning, but a few things did need to be watched. There was a plan to start cautious trophic feeds if certain conditions were met; J1918.
At 12.45, a long line was inserted, at the third attempt, into the left saphenous vein to a depth of 11 centimetres. An X-ray was taken at 12.38 on 12 June; it is J1996. It was centred on Baby C's abdomen and Professor Owen Arthurs told you the most striking thing was the dilatation of the stomach, which was full of gas and unusual.
Professor Arthurs' evidence was that the radiographs show left-sided chest infection but also marked dilatation of the stomach and the small bowel. There were several potential causes, he said, which would include CPAP belly, sepsis, NEC or exogenous air administration. Professor Arthurs said it was the small bowel that was inflated.
He agreed with Mr Myers that a twist in the gut can cause an accumulation of air. There was no marker of a blockage, no evidence on the imaging, nor any clinical sign of a blockage, and none was found on autopsy, which it would have been had there actually been any blockage, nor was there any evidence of NEC.
At 14.15 hours, Dr Catherine Collins examined Baby C; J1919 is the relevant document. His readings were unremarkable and he was on 40% oxygen. His anterior fontanelle was soft, which is good, and no abnormalities were detected. His abdomen was soft.
Yvonne Griffiths, the neonatal unit deputy manager and a band 6 senior nurse practitioner, was [Baby C]’s designated nurse on that day shift of 12 June, taking over from Bernadette Butterworth; J1950 is her note.
At 18.30, bile was noted on Baby C's blanket. The NG tube was aspirated and 2ml of black stained fluid was obtained. Had he been having enteral feeds at that time, they would have stopped them, but he wasn't. He didn't desaturate.
Melanie Taylor took over as Baby C’s designated nurse on the night of 12/13 June. His data, behind tile 24, looked stable. Two entries, she said, were slightly out of normal but not unusual or any cause for concern. The data behind tile 40, J2009 and 2010, included entries of 0.5ml of dark bile from the nasogastric tube at 21.00 hours and a vomit of dark bile at 24.00.
He was fairly stable on CPAP. Bile aspirates was a concern, she said, but is not unheard of in neonates and is not necessarily a major cause for concern.
J1945, behind tile 45. Melanie Taylor wrote at 00.03 the tummy was soft, not distended, which was a good sign. At 05.25:
"Platelets low. Doctors aware."
He was a stable baby. In relation to these entries Dr Gibbs said that the vomit of dark bile was a worry, but the aspirates were not increasing, the vomiting did not persist, he had a soft abdomen and his overall observations were satisfactory. Had there been an obstruction it would have been expected to be found at the post-mortem.
Dr Katherine Davis was the senior registrar on duty that night shift, the 12th to 13 June. Behind tile 20 on J1920, Baby C was noted at 21.20 to be nil by mouth due to bilious aspirates. A blood culture was taken. There was no growth at 36 hours, which was obviously after his death. CRP was slightly raised. The phototherapy for jaundice, which she said was very common in newborn babies, was stopped at 17.00 hours because he didn't need it. He handled well on examination and was active. His abdomen was soft, he had bowel sounds and was not discoloured. She said they were aware of the dark bile aspirate and vomit but there was no other suggestion of NEC. If he had NEC she would have expected Baby C to look very different and NEC was not the only explanation. He was possibly a baby with sluggish bowels. Black bile was not normal but not unknown in premature babies.
Dr Sally Ogden was on duty again on Saturday the 13th. Her clinical note is J1921 behind tile 77. There was reference to the very dark bilious aspirates. These she said were findings of a concern and may have indicated NEC or an obstruction in the gut or infection. She noted his bowels were not open and the abdominal X-ray showed a loopy bowel and was distended. CRP was elevated, which was a marker for infection. The blood cultures were negative. He could not have the planned lumbar puncture because his platelets were low. He was still pink, well perfused, his heart sounds were normal, his chest was clear, he had no increasing problems with breathing, no hernias, his abdomen was soft and not distended, which she said was a reassuring sign. Bowel sounds were heard. She auscultated -- that's listened -- to his abdomen and heard normal bowel sounds, which was a normal finding. If they had been abnormal she would have noted it. His weight had dropped to 717 grams.
The notes go on to refer to Baby C being reviewed by Dr Gibbs and the starting of intravenous ranitidine, a medication which targets stomach acids.
Dr John Gibbs was a consultant paediatrician working at the Countess of Chester from 1994 until his retirement towards the end of 2019. He saw Baby C several days over the first days of his life. Had he had any concerns he would, he said, have noted them. He saw him on the morning of 13 June. The notes, J1921 and 1922, are behind tile 77. They are the relevant ones.
Dr Gibbs had no particular concerns about Baby C that day. The gastric aspirates were not a particular concern at that time. They were not copious and the stomach naturally produces some acid and stomach secretions. There can be aspirates in a baby that has not been fed. Aspirates can irritate the stomach, as can the nasogastric tube. When babies are developing NEC, the abdomen hardens.
At 15.55, he carried out an ultrasound scan of Baby C's head and will have had to examine him. The scan was normal and he recorded nothing of concern.
Joanne Williams, a band 6 neonatal practitioner, took over nursing care of Baby C at 08.00 that morning, of Saturday, 13 June. Her notes are J1947, behind tile 69. Baby C was on CPAP -- nasal CPAP in 26% of oxygen. His capillary blood gas was very good. He was very unsettled in the morning, but that was not uncommon. He had skin-to-skin contact with his mother and calmed down straightaway. Optiflow, a less invasive form of assistance, but which can still lead to a build-up of air in the belly, was commenced at 13.00.
He was very settled that afternoon though there was a slight increase in his respiratory rate. His platelets had improved slightly but were still low. Clinically, he remained stable and was on free drainage from his NGT to stop the accumulation of air in his stomach and so they could see any aspirates. Tiles 83, 96, 102, 116 and 120 front the various charts, records, notes and reports relating to events that day to which you can refer for details. I'll repeat: 83, 96, 102, 116, 120.
At 18.00 hours his CBG, capillary blood gas, had improved, and there was a plan, if aspirates reduced, to commence enteral feeds that night. Baby C had done well during that day shift.
We come to the shift of the night of 13/14 June when Baby C suddenly collapsed and died. The messaging showed that the defendant offered to work that shift. In the messages she sent behind tile 18 she wrote:
"I need to throw myself back in."
By which she said she wanted to get back into the unit and back into looking after babies because that was what she was taught at Liverpool Women's: when you have difficult shifts or babies pass away, the way to sort of overcome that is to go straight back into the environment and carry on.
In a further message behind tile 20 she said:
"Think from a confidence point of view I need to take an ITU baby soon."
She wasn't allocated an ITU baby for that shift that night. Sophie Ellis took over as Baby C’s designated nurse the night shift of 13/14 June. She was a band 5 nurse and not intensive care trained, but was supported on the shift by a band 6 nurse, Mel Taylor, who was the designated nurse for another baby in nursery 1.
Mel Taylor said Sophie Ellis was a very competent nurse. Nurse B was the shift leader. The defendant was the designated nurse for babies JE and PE in nursery 3. In a message to Jennifer Jones-Key behind tile 152, the defendant said to her that she felt she needed to be in nursery 1. At the handover, the hope to start Baby C on feeds was discussed. Baby C's observations at 20.00 hours were satisfactory. His respiration rate was 58 to 73, elevated at times. He was pink and well perfused, active and alert.
Sophie Ellis' nursing note is behind tile 139 and again, later, behind tile 231. The registrar, Dr Katherine Davis, agreed to start trophic feeds. At 21.00 hours in the ICU chart at J2009, there is noted dark bile. Dr Davies said they were aware of this but there was no other suggestion that Baby C had NEC, which was a possible explanation, but if he had NEC he would have been expected to look very different. He was possibly a baby with sluggish bowels.
Dr Gibbs was also asked about this vomit and said he was not concerned by one vomit. If there had been a blockage he would have had repeated vomits.
At 22.34, the defendant sent a message, tile 161, saying she had done a couple of meds in 1, nursery 1. She also thought Sophie Ellis didn't have the skill and experience of premature babies; J2010.
The intensive care unit chart behind tile 169 records that at 23.00 Sophie Ellis gave Baby C 0.5ml of expressed breast milk. She had aspirated the tube first and there was some very small, light green bile. Until that time, he was doing well, a feisty little baby who was very active. Then tile 182, fronting J1950, he:
"Had two fleeting bradys (self-correcting, not needing any intervention) shortly before prolonged brady and apnoea requiring resus."
The time was 23.15. She explained she had left the room for a short time and was at the nurses' station when she heard Baby C's alarm. She heard an alarm, she didn't know which one, go off so she went back in and she saw the defendant standing by Baby C’s incubator and she said, "He's just had a brady and desaturation".
This was not something that Sophie Ellis put in the nursing notes, it was a detail she gave to the police when she made a statement in January 2018. She said she'd forgotten when she made the notes as she had had a traumatic event, obviously what followed.
She couldn't remember what the defendant was doing at the time. The brady and desat resolved quite quickly. Sophie Ellis said she didn't do anything to Baby C or see anything done to him. She went over to the computer in the room but the wall prevented her from seeing Baby C. The defendant was in the room, she didn't know if anyone else was. Baby C had a further brady and desat and an apnoea, which he didn't resolve, so they had to intervene. The defendant was stood at the incubator on the right-hand side.
Nurse B was alerted to the crisis in nursery 1 by a shout for help. She immediately went into the room and believed she saw Mel Taylor and Sophie Ellis were beside Baby C's incubator, but she could not say she was 100% sure. They had a Neopuff and tried to ventilate him. He wasn't breathing and his oxygen saturation levels were very low. He was very blotchy. She wasn't aware of the defendant being in the room.
Sophie Ellis said that when she re-entered the room Nurse B asked her to take over chest compressions. It was put to Sophie Ellis that the defendant was not present at the first fleeting bradycardias and desaturations or at the start of the second. Sophie Ellis said she didn't know. She didn’t know whether Mel Taylor was there or not. She didn’t remember Mel Taylor going to assist Baby C or helping Mel Taylor assist Baby C. She didn't agree that the defendant came in at some time after her and Mel Taylor were dealing with Baby C.
Mel Taylor said in evidence that when she first approached Baby C's incubator, the defendant was already there, but she thought Sophie was there at some point and may have called her over. In her witness statement to the police on 8 February 2018, she said that when Baby C collapsed she was pretty sure she was in nursery 1, feeding another baby and remembered being called over by Sophie, making no mention of the defendant at all.
In her evidence she said the defendant suggested using a Guedel airway. She said she had never used one before and thought the defendant inserted it and then they used it to apply Neopuffs. They started chest compressions before the doctors arrived.
In her evidence, the defendant confirmed that she was the designated nurse for JE and PE in nursery 3 and said she had very little independent memory of events. Page 3 of 9 of the neonatal review showed at 23.00 she was looking after JE and PE in nursery 3. She said she was first alerted to any problem when she was called to help, she believed by Sophie Ellis. She wasn't in nursery 1 and wasn't aware of doing anything for Baby C before she went for help.
She was asked about passages in her interview when, from page 11 onwards, she said she didn't remember specifically when she entered the room or why. She said she answered as she did because Sophie Ellis had placed her in the nursery. In fact, she told you, she had no recollection of being there with the alarm sounding and saying anything to Sophie.
She believed she asked Sophie Ellis to put out a crash call. Mel Taylor was looking after Baby C, he was apnoeic and needed respiratory support. She did have some recollection of Nurse B being there. Sophie Ellis put out the crash call. Sophie Ellis' evidence was that Nurse B asked her to put out a crash call, it was not the defendant who asked her.
The defendant said from that point, full resuscitation commenced and she did perform some chest compressions.
I'm then going to move on to the evidence of the clinicians as to what followed from that point onwards, so that's a good point to have a break. I'll continue the narrative in relation to Baby C after a ten-minute break. Thank you.
(3.03 pm)
(3.13 pm) (A short break)
(In the absence of the jury) Mr Justice Goss: Thank you both, you're absolutely right, I realised actually as I was reciting both: one was an ad lib in fact, the other was just a mistake, for the reason that you actually anticipated, so I shall first correct both those matters and then continue.
NJ: I recognised it because it was a mistake I have made myself amongst others.
Mr Justice Goss: I'm just going to ask -- well, I'm going to make a decision that we might finish just slightly before 4 o'clock because I don't want to start another baby this afternoon. I'd rather do each in turn. They will have had quite a lot today. Thank you.
(In the presence of the jury)
Mr Justice Goss: I shall break off maybe just slightly before 4 o'clock this afternoon, in fact, because I want to complete a baby and not start another one and go halfway through. It's better that you can sort of compartmentalise each case.
Before I continue with my narrative in relation to Baby C, I must correct two things, and I’m grateful to the barristers who are listening very carefully, as you are, to what I'm saying. As I was actually saying one part of the summing-up I realised that I thought I had transposed evidence that in fact relates to another baby.
May I take you back to Baby A. At the very end of my summary of the evidence I referred you to what Professor Kinsey had said about blood properties and saying about spontaneous bleeding and the like. That did not relate to [Baby A]'s case, that in fact related to Baby E’s, but she was giving evidence on the same day about those two babies and I just put that passage into the wrong baby. So just ignore that part.
Professor Kinsey had -- I'd reminded you of what she had said about Baby A earlier on, but the abnormal blood properties I shall repeat and remind you of in relation to -- or lack of them in relation to Baby E. So don’t attach any significance to that, please.
The other error I made was that I referred to CRP and I said capillary refill time. It's not, it's C-reactive protein. Some of you had picked that up. That was a slip of the tongue, all right? Apologies for that.
If and when I make more mistakes, they will be corrected as soon as they are brought to my attention. All right?
So back to Baby C and the clinicians.
Dr Katherine Davis arrived and took over the airway. When she asked for chest compressions to be stopped briefly, there was no heart rate or respirations. Dr Gibbs was called; that was at 23.28. The three attempts of Dr Davis to intubate were unsuccessful because the vocal cords were very swollen. There were clear oral secretions but no blood. The absence of any heart rate continued.
After that, Baby C's mum entered the room. Sophie Ellis said that she got upset at this point. It was the first time she had ever been involved in that situation and it was just completely overwhelming. It was very sudden and very unexpected. Lucy Letby was stood opposite her and said, "Do you want me to take over?" Sophie Ellis said yes, left the room, and didn’t re-enter the room after that, took a minute to sort herself out, and went to look after some of the babies in nursery 2.
Mel Taylor was then asked to take over as Baby C's designated nurse. When Dr Gibbs arrived at 23.35, Baby C was pale with purply-bluey mottling, which is common for a person in cardiac arrest because there is no circulation. There were no signs of life. He succeeded in intubating Baby C and gained good entry to his chest. Baby C was given a succession of seven boluses of adrenaline, three boluses of saline, two of sodium bicarbonate and one of calcium gluconate.
Whilst they were waiting for the priest to arrive to baptise Baby C, he showed some fairly minimal signs of life. He was baptised, taken off the ventilator and given palliative morphine and lived for 5 hours, dying at around 05.00.
Dr Davis said even the smallest, sickest babies would respond to the resuscitative treatment he was given for a short time. Dr Gibbs confirmed that. Even if he had suffered a collapsed lung, it wasn't compromising his resuscitation. He had no bleed on the brain.
Dr Gibbs couldn't think of any natural disease process that would allow a heart to restart later on when you hadn't been able to get that heart to restart with full intensive care and multiple doses of adrenaline. So whatever catastrophic event led to his death was reversing or had reversed after they stopped resuscitation. He didn't understand that to be from a natural disease process.
The evidence of [Parents of Baby C] was read to you as agreed evidence. [Mother of Baby C] was requested to go and see Baby C urgently and when she got to the unit she could see CPR being performed on him.
Two or three doctors were present and several nurses were present. She was told Baby C's heart rate had suddenly dropped and he had stopped breathing without any warning, it had been very sudden and unexpected. She contacted her husband and told him to come to the hospital urgently. She didn't really know what was happening and didn't take in the severity of it until she was asked by a neonatal nurse, somewhat unexpectedly, whether she wanted someone to call a priest. She felt quite shocked and she asked the nurse if she thought he was going to die, to which the nurse responded, "Yes, I think so". She had never met the nurse before and was surprised to receive this information from a nurse rather than a doctor.
The nurse did not tell [Mother of Baby C] her name. She was in her mid to late 20s with a fair complexion and brown hair tied back in a ponytail. [Father of Baby C] arrived on the unit whilst they were waiting for the priest. Baby C was still in his incubator and remained there until after he had been baptised. The resuscitation stopped but he continued to breathe. They were taken to the family room and Baby C was given to them, they took it in turns to cuddle him.
Their respective parents were also called to the hospital and joined them. They remained with Baby C in the family room cuddling him, waiting for him to die. Two neonatal nurses were with [Parents of Baby C] throughout this time. One was the nurse who had asked whether they wanted to call for a priest, the prosecution say that's the defendant, and the other whose first name was, she thought, Mel.
The nurses would check on them and took Baby C's hand and footprints for them to keep. At one point one of them, who [Father of Baby C] thought could have been the defendant, because he'd subsequently seen her picture and name in a newspaper, but he was not 100% sure, came in with a ventilated basket and said words similar to, "You've said your goodbyes now, do you want to put him in here", referring to the basket. That shook them. [Mother of Baby C] said, "He's not dead yet". The nurse then attempted to backtrack and diffuse the situation. They didn't want to leave him while he was still alive.
There were a series of text messages from the defendant from tile 294 onward in response to Nurse A's reference to something "being odd about that night and the three others that went so suddenly". I shall not repeat the detail to which you were referred, it's in the evidence.
When interviewed on 4 July 2018, the defendant remembered Baby C as a small baby who deteriorated not long after his first feed by one of the nurses in which she was not involved. Her only involvement was in the resuscitation. She could not recall handling him prior to that. She was not working in room 1 that night. She had a vague recollection of doing Baby C's hand and footprints while he was sat with mum and dad but did not specifically remember and could not be certain. She would have had some interaction with the parents. She found Baby C's death quite hard because he lived for several hours and she had not seen that before.
She accepted that she had made Facebook searches for both [Parents of Baby C] approximately 10 hours after the death, but could not remember doing them or why.
In relation to the series of WhatsApp messages between her and Jennifer Jones-Key on the evening of 13 June 2015, she agreed she wanted to go back into nursery 1 as it could be hard to go back into an ITU environment after having a sick baby so she preferred to go straight back in.
She said she had no recollection of making that comment relating to putting Baby C in the basket and questioned whether she was the nurse who said that. As far as she knew, she did not say that comment to the parents. She was very sad for them.
In her evidence she said she couldn't recall any specific contact with the parents, though did she recall them being at the resuscitation. She may have had contact after that, but could not recall it.
She said she made a Facebook search at 15.52 hours on 14 June for [Parents of Baby C] and said she did that because the family were very much on her mind. “When you go home from work", she said, "you don't forget about the babies that you've cared for and what’s happened." She carried on searching over the ensuing months because there were times when they would enter her mind. She said that what the parents had been through was unimaginable.
Nurse B said that the neonatal unit was extremely busy between 2015 and 2016. The admission rate seemed to increase and they had far more intensive care babies, the staff manager was fighting for more staff, and it wasn't always possible to follow BAPM guidelines in relation to nurse allocation. However, she refuted the suggestion that Baby C's level of care was compromised by staff shortages. Baby C was provided with one-to-one care that night and the level of care he was given was not influenced by staffing levels.
She thought JE was the most poorly baby on the ward on that night and she instructed the defendant to carry out hourly observations on JE. She was alerted to a crisis in nursery 1 by a shout for help. She went in and saw Mel Taylor and Sophie Ellis beside his incubator. They had a Neopuff device and tried to ventilate him. He looked very unwell. He was mottled and a crash call was put out. The defendant was in the room when that call went out.
After Baby C died, Nurse B asked Mel Taylor, as designated nurse for Baby C, to carry out the job of offering the memory box and she took over the baby that Mel had been caring for. She also asked the defendant to focus back in nursery 3 on baby JE because she was still heavily concerned about him. She asked her to do that more than once and to leave Baby C’s family with Mel. However, the defendant went into the family room a few times. It was not part of the defendant's responsibilities to go into that family room at this time, she said.
When interviewed on 4 July 2018, the defendant said she could not recall being told by Nurse B to stop helping Melanie Taylor in the aftermath of Baby C's death and to go and look after her own designated baby.
Dr George Kokai, a consultant paediatric pathologist, carried out a post-mortem examination of Baby C at the Royal Liverpool Children's Hospital at 10.00 hours on 16 June 2015 and made a written report on 25 September 2015. His findings are at paragraph 21 in section 4 of your agreed facts. In the abdominal cavity he noted that:
"The stomach and all loops of bowel and mesentery showed a normal rotation pattern, apart from the descending colon, which crossed the midline into the right lower abdominal cavity."
Which Dr Marnerides explained is not an abnormality, it is very often seen in babies and is seen in adults. The only complication it may cause is called volvulus, which is when the colon is allowed to twist around itself. Complications of volvulus could be that the baby starts to vomit or not produce any stool. They are in severe pain, they have a fever and it is something that you don't miss and is obvious. So in the absence of a volvulus, which there wasn't in Baby C’s case, this was not an abnormal finding. Although it descended in a different way, it wasn't an abnormality relevant to his demise.
On the histology examination, there was evidence of acute pneumonia. Dr Marnerides explained that one can die from pneumonia but one can also die with pneumonia, meaning pneumonia was present but was not the cause of death.
On the information he initially had, Dr Marnerides came to the conclusion that it was reasonably plausible that Baby C had died from pneumonia. After having received further clinical information, which indicated that the clinical assessment was that Baby C had pneumonia but clinically he was stable, he was responding to treatment and was giving no indication that collapse was imminent, and taking account of the meeting between all the expert witnesses, prosecution and defence, he reviewed his opinion.
The descriptions pathologists receive from neonatologists of babies dying from pneumonia is of a deterioration of a baby which is progressive and not responding to the treatment, which was not the presentation that he was informed of in the case of Baby C. The clinical assessment was he was stable, responding to treatment and suddenly collapsed, which was not consistent from the clinical point of view that the baby could have died from pneumonia.
He relied on and took account of the clinicians' observations of massive gastric dilatation -- ballooning, basically -- of the stomach, and considered the reports by the radiologists, both from the defence and the prosecution, who agreed that there was an infection and pneumonia but there was also massive gaseous dilatation of the stomach, and the bowel loops were dilated, so sorts of air in there. And having heard the discussions at the meeting and having considered the potential explanations about how such a dilatation could have been caused he revisited the cause of death. He also took into account the digital photographs taken at the post-mortem examination which showed a distended stomach and distended bowel loops in the left part and, to a little extent, crossing the midline. There was no evidence of NEC, which he excluded, as did the other experts.
Professor Arthurs was of the view that it was the small bowel that was dilated in the radiographs. Dr Marnerides explained that there was no evidence, either from the post-mortem of Dr Kokai or from the photographs or from the radiology, that there was a stenosis, which is the bowel being narrower than it should be, or atresia, which means a complete block of the lumen. He came to the conclusion that the most likely description was of a dilated stomach and bowel for which the only other possible explanations were post-mortem gas and CPAP belly.
He confidently excluded post-mortem decomposition as the source of the gas. The bowel looked normal at post-mortem. There were no microscopic findings to suggest that decomposition was of any significance and, most importantly, the sampled segments of the bowel that he looked at on histology looked normal.
Baby C had been off CPAP for over 12 hours. The blood gas record behind tile 121 tells you when Baby C was on various forms of assistance with his breathing. No air had been attained from aspirates shortly before his collapse.
In relation to CPAP belly, he expressed himself with caution as he was not the expert on how CPAP actually works in babies and he relied on the clinicians. From his experience as a pathologist dealing with neonates and discussing cases with neonatal care unit doctors and from reading the literature, he had never, in over 10 years, come across a description or a suggestion of CPAP belly accounting for the arrest of a baby, nor has he been asked by any of his colleagues at St Thomas’ Hospital could this be a possibility. So he thought that, though it was a theoretical possible alternative to air being put down the nasogastric tube, he had never come across such a description in any published material, never seen it and could not think of a reasonably plausible mechanism.
In Dr Marnerides' opinion, the explanation for Baby C's sudden collapse against the background of his pneumonia was the excessive injection or infusion of air into the nasogastric tube.
Dr Dewi Evans explained that, from birth, Baby C had two significant risk factors: he was a vulnerable baby and he had retarded growth, so required careful management, nursing and medical care and monitoring over many weeks.
Addressing the various concerns in turn, his breathing stabilised over a number of days, respiratory support decreased, he was more or less breathing on his own, the support having been decreased from CPAP to Optiflow, his oxygen requirement had decreased to 25%, and when he was having skin-to-skin contact he was breathing in air.
In relation to feeding, all babies born 10 weeks premature require a nasogastric tube in order to be fed milk. Aspirates and the abdomen should be checked. The aspirates were not increasing and he had had only one small vomit. There was no indication of an obstruction. The description of Baby C being feisty was not consistent with an intestinal problem.
So far as infection was concerned, he had a lung infection as seen on the X-rays. His CRP had increased and his platelets value had fallen. He was, however, being treated for his pneumonia.
In relation to his metabolism, all save one glucose value were within the normal range, his gas values were acceptable, and there were markers that he was getting satisfactory oxygenation. His jaundice values were very satisfactory and his infection was under control, so breathing and feeding issues could not explain his collapse.
The pneumonia infection did not cause his collapse. If the treatment for pneumonia is not working, a baby gets worse. The heart rate did not increase, the respiration rate stayed within the norm, his oxygen saturations remained where they should be. His collapse was difficult to explain. Initially, Dr Evans reached no conclusion. He agreed that Baby C was at great risk of an unexpected collapse and he could not exclude the role of infection in the cause of his collapse. But the infection was under control and he was suspicious of the gaseous appearance. He said:
"A baby can tolerate a certain amount of gas in its abdomen but if it gets to a significant amount of air in the stomach it can cause splinting of the diaphragm. Baby C's collapse was consistent with a volume of air being put into the stomach, splinting the diaphragm and stopping the diaphragm from moving and so preventing the lungs from filling."
This was a conclusion he had never mentioned before he gave his evidence. That was the first time he gave his conclusion, Mr Myers addressed you about it last week. It was not advanced in any of his eight reports in Baby C's case or in the joint report.
Dr Evans said that he'd seen the report of Dr Marnerides and discussed it with him and had taken it into account in reaching his conclusion but denied he was coming up with things now as he went along to try and support an allegation of harm on 13 June. His opinion was based on the suddenness of the collapse:
"His pneumonia was under control, he was on antibiotics, requiring hardly any additional oxygen and his saturations were spot on."
You may remember the points towards the end of cross-examination when Mr Myers and Dr Evans were interrupting and speaking over each other -- that occurred more than once when he gave evidence -- and Dr Evans was pressed on the features he relied on to reach his conclusions and he went on to explain differential diagnosis and said that, from an academic point of view, air embolus could not be excluded. He’d not mentioned that before but said it was his role to give an impartial view, looking at all the issues, not to prepare partisan reports. You'll recall Mr Myers’ criticisms of those very late references to these possibilities.
Dr Sandie Bohin readily acknowledged that Baby C was potentially at risk of complications and required assistance with breathing most of his life but said that in the early days he did well, he was a baby that was improving:
"Clearly, he had an infection [for the reasons that Dr Evans referred to] but he still continued to improve and was being treated with antibiotics. Babies with pneumonia will slowly deteriorate, often there are signs of a very slow decline. Pneumonia did cause him to collapse and did not kill him. Having an underlying illness will have made resuscitation more difficult and contributed to his not surviving resuscitation."
Dr Bohin looked at the records and noted there was no recording of air amounts being aspirated and there was a fleeting mention of air on free drainage. Bile amounts were small. It was known that, on 13 June, Baby C was aspirated, but it is not known if any additional air was aspirated.
Her conclusion in relation to the possible causes of why it was that Baby C had this bubble in his stomach on 12 June was that if the nasogastric tube was not on free drainage and was not aspirated, then it could well have been down to accumulation of gas by CPAP.
The blood gas record behind tile 121 sets out the various forms of breathing assistance he received. The alternative explanation was that there was a deliberate introduction of air down that tube. The medical staff at the time were clear that the abdomen was soft, that the baby was well, so they didn't appear to be concerned about the abdomen. Baby C didn't have the kind of conditions that could have caused problems with the gut and, in any case, they would not have caused the sudden and catastrophic collapse, which was unresponsive to resuscitation:
"Premature babies do get infections and do become unwell. It would be rare and very unusual for them to collapse in this way and they are usually responsive to resuscitation."
In her opinion, Baby C died with his pneumonia, which could have made him less responsive to resuscitation but not because of pneumonia.
In response to questioning about a potential obstruction of the bowel, Dr Bohin said that if he had had a bowel obstruction, Baby C would have been expected to have a distended abdomen and either no bowel sounds or abnormal high-pitched sounds known as tinkling. From Dr Ogden's note, "Abdo soft, not distended, bowels sounds heard", there was no obstruction.
The defence referred to there being no description of the bowel sounds. Dr Bohin's response was that if there were no sounds or they were abnormal she would have expected that to be recorded. There were, in her opinion, no clinical indicators of obstruction. She accepted, Dr Bohin, that she had not identified a cause of Baby C's collapse.
Just in relation to the question of dying with pneumonia and not of pneumonia is concerned, I remind you of my first legal directions relating to a cause, not necessarily the only cause, but a cause of the death. I'm not going to ask you to look back at that now, but you'll remember the specific passage -- I don’t have my copy to hand at the moment -- about the act or acts of the defendant would have -- you'd have to be sure were a cause, not necessarily the main cause or the only cause, but a cause of the death. So you understand that. So that's the importance.
If you do not exclude pneumonia entirely as a cause of death then that doesn't arise. You've got to essentially exclude pneumonia as the sole cause of death. I hope that's clear. You'll see it when you come back to it and address those questions that I set out for you in my first legal directions.
The next baby is Baby D, count 4 on the indictment. I cannot complete my summary of the evidence relating to her in the next 15 or 20 minutes; it is going to take longer than that, it will take about 40/45 minutes, I should think. So in those circumstances, as I indicated to you at the very outset, I'm conscious of the fact that you've spent consecutive days now listening to people and you've spent the best part of the court day listening to me, so we will turn to Baby D’s case when you're refreshed at 10.30 tomorrow morning. Thank you very much.
Please remember your responsibilities, as I'm sure you do, as jurors in this case: no communications with anyone and no research about anything to do with the case. Thank you very much.
(In the absence of the jury)
Mr Justice Goss: If there is anything, please just send me an email and I'll deal with it tomorrow morning. Thank you very much. Did someone want to come --
BM: Yes, we would, thank you for asking, my Lord.
Mr Justice Goss: A visit, please. Thank you.
(3.46 pm)
(The court adjourned until 10.30 am on Tuesday, 4 July 2023)
(10.30 am)
(In the absence of the jury)
Mr Justice Goss: Thank you, Mr Myers, for your note.
I will mention that first of all.
BM: It's just one matter, my Lord, thank you.
Mr Justice Goss: It did actually occur to me as I was speaking, but I will correct it immediately.
BM: We're grateful, thank you.
Mr Justice Goss: Not correct, I'll make it clear. It’s clarifying the situation.
(In the presence of the jury)
SUMMING-UP (continued)
Mr Justice Goss: Just one further matter in relation to the case concerning Baby C, which I had essentially finished yesterday. I did not make it clear, or certainly sufficiently clear, that in the case of Baby C, when I was reminding you of the evidence of Dr Marnerides and Professor Evans (sic) relating to the massive gaseous dilatation of the stomach and bowel loops that Dr Marnerides relied on, they related to X-rays and clinical notes on 12 June and not 13 June, which of course was the time or which was when he collapsed at shortly before midnight on 13 June. I’ve been asked to make that clear and I do make it clear, I should have made it clear to you yesterday.
I turn then to Baby D, count 4, an allegation of murder. [Mother of Baby D] gave birth by caesarean section to a baby girl, Baby D, at 16.01 on Saturday, 20 June 2015 in the Countess of Chester. Baby D was her first child. She died 36 hours later at 04.25 on 22 June. The prosecution allege air had been injected into her venous system.
Parents of Baby D had married the previous year. She was fairly well during her pregnancy and Baby D was born at 36 weeks and 1 or 5 days' gestation and weighed 3.13 kilograms, nearly 7 pounds; a normal birth weight.
Her waters had broken in the early hours of 18 June and she went to the hospital later that morning, but was sent home. Julie Robson was the midwife who saw and examined her and, following a discussion with Dr Finney, arrangements were made for an appointment for her thefollowing morning. Julie Robson cannot recall why the decision was not made to commence on oral antibiotics.
Mother of Baby D returned the following day, Saturday, 20 June, and birth was induced. [Mother of Baby D] was very worried, scared and felt unwell. After a time, to see if the birth could happen naturally, it was decided by Dr Joanne Davies, a consultant in obstetrics and gynaecology with a special interest in maternal medicine, that an emergency C-section delivery should be undertaken.
Dr Davies led the gynaecological and obstetric review after Baby D's death to ascertain what had happened up to the point of delivery. She confirmed that when the membranes go, there is an increased risk of infection and that risk gets greater after 24 hours and she accepted that because [Mother of Baby D] was 12 hours under 37 weeks' gestation, so in other words there’s a guideline, the guideline for her was to be given antibiotics and this had been missed and she said that infection in neonates is a leading cause of death.
However, there was no evidence pre-birth that [Mother of Baby D] had an infection, nor was there any pathological evidence of her or the placenta having any infection.
The prosecution case is that although Baby D died with pneumonia, her cause of death was air embolus. The defence say you cannot be sure of that, she may have died of infection.
Baby D was delivered by C-section under an epidural anaesthetic at 16.01. Midwife Anna McManus, whose agreed evidence was read to you and who was involved in the birth, said Baby D was born in good condition, had an Apgar score of 8 at 1 minute, having quite a pale colour, but after 5 minutes started to pick up and was scored 9. She went back to her parents and Anna McManus noticed Baby D was grey and seemed quite floppy.
[Mother of Baby D] described [Baby D] being quite limp and didn't have much movement and was grey in colour and seemed to struggle to breath, making a groaning noise and she was unable to breast feed her. Anna McManus took her to the Resuscitaire, where she conducted intermittent positive pressure ventilation for 2 minutes.
At around 5 pm, Baby D's grunting became louder and she was showing no interest in breastfeeding, so she contacted Dr Rylance and it was agreed that she should be transferred to the neonatal unit for an infection screen. She was taken to the unit at around 7 to 8 pm and was put on CPAP.
Dr Sandie Bohin said that the routine delay in clamping the umbilical cord indicated that Baby D must have been in reasonable condition at birth and told you about the common occurrence of babies' chins dropping to their chests and compromising their breathing when they are newborn, which may have accounted for her colour.
However, she said there were clinical signs in the operating theatre of her having an infection, namely her low temperature and grunting. She should have been screened, said Dr Bohin, at that stage.
Dr Sarah Rylance, who gave her evidence from Switzerland over a video link, confirmed Baby D was brought to the unit for screening. Her initial sats were 48%. She looked dusky, poor respiratory effort, as recorded on tile 14, J2214 and J2215. Dr Rylance agreed that she was an unwell baby. She was transferred to an incubator and given IPPV via Neopuff. She picked up quickly and started regular respirations. Her readings were abnormal and indicated acidosis and suggested difficulty with breathing, but an assessment had to be made in combination with the rest of her clinical examination.
Antibiotics were administered and she was transferred to CPAP at 20.00, given a bolus of saline of 31ml and started on a triple lights to bring her bilirubin level down to stop her becoming jaundiced.
Her heart sounds and capillary refill were normal, both femoral pulses were present, her pulse rate was okay, her chest was clear, her abdomen was soft and not distended. The plan was for Baby D to continue on CPAP, be given dextrose and to repeat gases.
Her parents were updated that it was likely sepsis because of the prolonged rupture of the membranes. Dr Rylance thought the most likely cause for difficulty with breathing and abnormal blood gas was infection. She wasn't well at that time.
However, she responded well and appeared to be stabilised on CPAP, so overall Dr Rylance was happy with progress but Baby D needed to be closely monitored and assessed.
Dr Andrew Brunton, now a neonatologist at the Royal Hospital in Glasgow, was an ST4 paediatric registrar at the Countess of Chester in 2015 and was on duty that night. He had a handover from Dr Rylance, read through the notes, and at 21.45 undertook an examination of Baby D. His notes, J2215, are behind tile 34. Although there was a slight clinical improvement in her readings, she was still on CPAP with 48% oxygen. Her respiration rate was sub-optimal and she had respiratory distress, though her oxygen saturation levels of 97% to 99% were acceptable. It was considered best to intubate and ventilate her to give her medicine in the hope that she could be taken off the ventilator relatively quickly.
The consultant on call, Dr Newby, confirmed that she was phoned by Dr Brunton and she agreed that, given that Baby D was requiring 48% oxygen and had a relatively high acidosis, this was appropriate. Following two unsuccessful attempts, which is not unusual, and having been given intubation drugs, she was successfully intubated.
A radiograph taken at 22.22 hours, which is behind tile 43, showed very little abnormal according to Professor Arthurs. He observed that there was gas in the stomach on the right side. Baby D was given surfactant, the brand name as you know is Curosurf, a protein that is involved in gas exchange in the lung and can be deficient in babies, at 23.00.
At 01.50, tile 69, all the blood gas results were an improvement and the clinical signs were good as she was being weaned off the ventilator. Dr Newby confirmed there was no sign of pneumothorax on review of the X-ray and that the Curosurf will have helped. Your reference is tile 107.
Dr Brunton extubated Baby D at 09.00. She seemed good, ventilating in air on her own and her sats were 100%. Dr Newby felt she was a bit quiet, as though her tone was a little bit increased, she was a bit tense and stiff to handle and her blood gas results 1 hour after extubation were not so good as they had been on CPAP. Moro, which apparently is a primitive reflex, was present and normal.
Dr Newby felt it likely there was an element of infection. Dr Bohin considered she clearly had an infection, pneumonia, but was getting better.
On that Sunday, 21 June, [Mother of Baby D] was told Baby D was up and down all night and needed to be on CPAP, but the female consultant seemed to think they hadeverything under control. She said she saw Baby D on the evening of Sunday the 21st at about 7 pm, 19.00, with her husband. In relation to the timing, she said she must have looked at her watch.
She was pushed into the room because she was in a wheelchair. There was only one nurse in the room. She drew a picture of where Baby D was, the left-hand incubator as you walk into the room. She said Lucy Letby, the defendant, was sort of hovering around Baby D, but not doing much. She had a clipboard or something as she was looking at the machine. [Mother of Baby D] asked her if everything was okay and the defendant replied, "Yes, she's fine". She just stuck around watching over them.
[Mother of Baby D] asked her to go away or just give them some privacy. She said that Baby D looked a good healthy colour, pink, tiny but she looked chubby, healthy, okay. [Mother of Baby D] said she did not know the nurse’s name at the time but she saw her again when Baby D died and described her and later saw pictures of her.
[Father of Baby D], whose evidence was read to you, did not mention this visit. That day was Father's Day and he had received a card which the staff had put together with a photograph of Baby D stuck inside with her on CPAP and intubated. Later in the day, he thought, he was given a welcome card and another photo of Baby D looking a lot healthier and showing signs of getting better and not on CPAP.
[Father of Baby D] made many visits to see [Baby D] and remembered two specially trained neonatal staff working in the ward, called [redacted] and Ailsa. He said they were both friendly and warm and what you would expect from nurses working in a baby unit. They comforted him and made sure everything was okay for him and made him feel welcome when he went to the ward.
At 9 to 9.30 that evening, Dr Brunton came round to her room and was happy with the results of the latest tests. The jaundice was clearing and he promised that they would be able to cuddle her the following day.
Dr Rylance made a note at 14.00 on that Sunday; it's tile 133. It was agreed that umbilical lines should be added. Although it was intended that Baby D should havea UAC and a UVC, the UVC only advanced a short distance and was removed. The UAC, in fact, went into the umbilical vein where it was or became a low-lying UVC. However, it could still be used to take blood samples for tests.
Although there were still signs of acidosis from blood gas readings at 10.14 and 12.10 hours, her gas readings were much improved. The plan was to continue with CPAP in air and repeat gases at 18.30.
A radiograph taken at 13.32 that day, which is behind tile 132, showed two features according to Professor Arthurs. The first was obvious: the umbilical venous catheter had been pushed up too far and needed withdrawing. The second was more subtle and it was at the bottom of Baby D's right lung: there was a little bit of opacification, some opaqueness. Dr Arthurs agreed it could represent a right-sided infection or pneumonia, but the magnitude of the infection was nothing like that in the case of Baby C.
Dr Rylance reviewed Baby D at 19.00, tile 158. Her CRP, a marker for sepsis, was 1, which was normal and did not indicate sepsis, the normal range being 1 to 10, but they would still treat her for infection. Dr Rylance and Dr Newby confirmed that infection is a leading cause of death in neonates, it can develop very quickly and antibiotics, which are intended to treat and prevent infection, should be given as soon as possible and a four-hour delay fell below the required standard for a baby in Baby D's condition.
She was saturating well on CPAP in air all day. There were big improvements at 18.44 on previous gases. From a respiratory perspective, she had made good progress.
Fluids. She had been given a bolus of saline earlier in the day to try and improve her perfusion. She'd just passed urine, her blood glucose was normal and her blood pressure was unremarkable. In relation to sepsis, a repeat CRP had just been taken. She was not stable enough at that time to have a lumbar puncture.
On examination, she was responsive on handling, she was stable, handling well and responding well to treatment with fluids, antibiotics and respiratory support. Her tone was reasonable, she was not particularly floppy. She was stable on CPAP but when they tried taking her off her respiratory rate became irregular and she desaturated a few times. The nursing notes record that she dropped to the mid-80s so they put her back on CPAP.
Dr Rylance did not attach a great deal of significance to this. She had been taken off a ventilator that morning and it takes babies time to settle. She just considered she needed a bit more time and a bit more respiratory support. She was not needing oxygen, just a bit of pressure to help with her breathing. The plan was essentially to continue as before. Dr Rylance was very happy with her clinical condition: she had had a very satisfactory day, generally improving in terms of needing less respiratory support, handling well, was a good colour and wasn’t needing any oxygen. She was then, she said, a stable baby making good progress.
Dr Brunton was the registrar on the night shift. He confirmed Baby D was now off the ventilator. He noted the blood gas results at 21.00, which are on J2222 and J2223 behind tile 174. The sodium level was low and the creatine level was high. Some treatment was potentially required, but she was not critically swollen and there was no evidence of a fluid-related issue. She was saturating 100% and was clinically improving. There were no signs of increased work of breathing or respiratory distress. Her chest was clear, her heart sounds were normal, her abdomen was soft, bowel sounds were normal, and there was no enlargement of organs, femoral pulses were present and normal. The plan was to commence enteral feeds of milk at 1ml every hour and increase as tolerated. There would be repeat blood and gas tests at midnight.
Caroline Oakley, a senior neonatal band 6 nurse with 20 years' experience at that time, was acting as shift leader that night on the 21st to 22 June. She was also Baby D's designated nurse and she was also the designated nurse for a child in nursery 2. She accepted that occasionally babies can deteriorate quite suddenly.
She arrived at the hospital in good time for her shift, swiping in at 19.23 on the 21st. Tile 168 in the sequence of events sets out the staff on duty that night and their allocations to the various babies on the unit, one of whom, EH, came into the unit late in the shift.
The defendant was the designated nurse for two babies in nursery 1.
Understandably, Caroline Oakley was dependent on notes made at or shortly after the time of readings and events during the shift, but she had some recollection of what happened. She said she will have had a full handover and will have been aware of the increased acidosis.
Tile 107, behind which is J2241, is her note of events from the start of the shift at 20.00. She observed that Baby D's lower limbs were a little bit dusky and her feet were bruised, which may have been from heel pricks and about which she was not worried. Her circulation was not 100% perfect. She was on nasal CPAP in air, so no added oxygen. Her gases were satisfactory, she didn't require phototherapy treatment for the jaundice and her CRP was fine.
Behind tile 169 is the observation chart J2291. Caroline Oakley described the readings from 19.30 to 00.30 as all completely normal, although Baby D's heart rate and respirations were up at 01.15, which she explained may have been a change. She remembered being very happy with her. She was stable.
Behind tile 170 is J2285, about which Caroline Oakley commented Baby D was breathing beautifully in air and saturating her blood with 100% oxygen. Her fluids were going in completely fine.
In relation to aspirations there was a minimal aspirate of 1ml that was acidic and discarded and a moderate amount of gas. At 00.30 there were 4ml of mucky, clear, acidic aspirate. She wasn't being fed and these aspirates did not worry Caroline Oakley. She attached minimal importance to them.
Behind tile 203 is J2250, the neonatal infusion chart. At 01.25, Baby D was given 31ml of saline. Both Caroline Oakley and the defendant signed for it. Because she was her designated nurse, Caroline Oakley assumes she infused it, but she said the handwriting of the time of 01.25 was not her handwriting.
The first event. Behind tile 207 is J2241, in which Caroline Oakley described an event at 01.30, when she was called to the nursery from the resus room, where she was on a break, by Kathryn Percival-Calderbank, then known as Percival-Ward, and the defendant.
Kathryn Percival-Calderbank was a senior neonatal practitioner of 22 years' experience, having qualified as a nurse in 1988 and worked in the neonatal unit at the hospital since 1993. On that night shift she was responsible for three babies in room 3 and one in room 4. She was aware Caroline Oakley had been on her break and went to look at Baby D, who was nice and stable and settled, and checked her monitoring, saturations and heart rate.
She was okay when she popped back in about 10 minutes later. While she was at the computer around the corridor, she was altered to the alarms having gone off, went into nursery 1, and found the monitoring was showing Baby D was desaturating and her heart rate was dropping. She thought she was assisted by someone and had a feeling it was the defendant and one of them went to get Caroline Oakley.
Baby D started to respond to Neopuffs. She noticed that she had a rash on her trunk and arms from her chest downwards. It wasn't like a normal rash, like when a baby becomes septic, it was mosaic, brown/red and not a spotty rash or petechiae, which are little spots like a rash, red and raised. It seemed to be vessels of blood meeting up with each other, oval-shaped. She had not seen it or anything like it before.
In her interview by the police before she made her witness statement, which is dated 9 January 2018, she stated:
"Her trunk and her legs went a mottle-y colour and was odd."
This was unusual discolouration, she said, and blotchings over her body. She discussed it with Dr Brunton when he arrived. [Baby D] responded to treatment and settled back into a normal pattern of breathing and, after a while, the discolouration seemed to disappear and dissipate.
Caroline Oakley wondered what was happening. She wrote on the fluid balance chart behind tile 231:
"Desaturated to 70s. Required oral suction as was bubbly and had lost colour."
Which was something she was told had happened at 01.05, so wrote "PP LL". Then she saw and wrote:
"Discolouration to skin observed trunk, legs, arms, chin."
She couldn't remember the exact rash but it was something she had not seen before. It was dark and unusual, it was like a deep red-brown, different to mottling and different to what she had seen before:
"Sometimes [she said] when they are poorly, babies can look white and have a mottled appearance."
She remembered thinking this was an unusual rash. She did remember that there had been talk about an unusual rash that had been seen recently.
The oxygen had been turned up on the CPAP machine before she arrived and [Baby D] had responded and her saturation levels went back up to 100% by the time Dr Brunton arrived. So, said Caroline Oakley, Baby D had had an episode but had responded very quickly and was back to normal. The gas tests were repeated and the results were all good.
Nurse C, who was a senior neonatal level 6 nurse with postgraduate qualifications and the shift leader that night, was the last nurse to give oral evidence on these events. She had a limited memory of them and was careful to say so when she was asked if she could remember specific matters. She remembered Baby D being stiff and having a rash on her trunk and abdomen in this first event. There was mottling, patches of circular white skin and a reddy-brown colour around. It was an odd, unusual rash. She had not seen that colour before.
Dr Brunton arrived at 01.40 to review Baby D. His notes are behind tile 214. From the information from the nurses, he recorded extreme mottling and Baby D had tracking lesions which were dark brown/black across her trunk, the oxygen level she was given had been increased from air to 60%. There was slight subcostal recession, which means the muscles between the ribs were coming in and out, which they had not been doing before. She was working to breathe. On examination, the lungs, heart and abdomen were all normal. There were areas of skin discolouration across her trunk that were light brown.
The plan was to take a blood gas, give a fluid bolus and contact the consultant on duty, Dr Newby.
The changes in the skin were a completely new situation he had never encountered before. Tile 215 is the pathology sample taken at 01.51. The lactate level, at 2.75, was slightly on the high side, which could be indicative that she was unwell or it could be indicative of nothing at all.
Dr Emily Thomas, a senior house officer, saw the rash and in her statement, which was read to you, said it almost had the appearance of a meningococcal-type rash. It was purple in colour and mainly over the abdomen and seemed to settle down and the rash appeared to fade after Dr Newby arrived.
Dr Newby's note is behind tile 218. By the time she arrived, Baby D was saturating well on CPAP in air. Peripherally, her feet had prolonged refill time. There were two "bruised" areas to her abdomen, like evolving purpura, which is a big bruise under the skin. They were like elongated areas, linear bruises. It was almost like a brown discolouration. They didn't know what to make of it. They added sodium chloride to the fluid and increased the dose of antibiotics to cover infection and added another one, cefotaxime.
Baby D was picking up and seemed more settled. She, Dr Newby, stayed for about an hour. The UVC, said Dr Brunton, was low-lying but there was nothing else to note. At 02.40 the blood clotting factors were slightly abnormal but there was no evidence of bleeding. Clinically, she had much improved and the areas of discolouration had completely disappeared. Dr Newby advised to leave the UVC and plan as previously.
Professor Arthurs examined the radiograph taken at 01.57, which is tile 216 in your sequence. He could see that the line had been withdrawn and was in the correct place. There was nothing unusual to be seen. The left lung base at the top of the diaphragm looked pretty clear. The three radiographs were consistent with a baby breathing in air and not needing any treatment for the infection that was present.
At 03.00, there was a second event, tile 234. At that time Caroline Oakley said Baby D was crying and desaturated again. She was commenced on 100% on oxygen via CPAP. Her skin was discoloured again, but less than on the previous occasion. Dr Brunton was called. He remembered Baby D being agitated and upset, which was unusual for her and he felt at the time it was something to do with the face mask. The skin discolouration again became more prominent, but was not as obvious as previously. She had improved by the time he arrived.
Clinically, she appeared very well. She was now in air and there was no increase in breathing difficulty.
The plan was to trial her off CPAP, give her extra fluids to increase the perfusion of her skin and take gas readings in 1 hour. Although he had encountered babies with a fluid deficiency before, he'd never encountered this skin discolouration before.
In relation to the discolouration, Dr Newby said bruising and purpura, bleeding under the skin, would not disappear in an hour and then reappear.
The neonatal infusion chart behind tile 237 records that at 03.20 a prescribed saline bolus was signed for by Caroline Oakley and the defendant, and at tile 239 the same chart records that at 03.30 they were to start donated expressed breast milk.
Caroline Oakley said that the medical staff were happy with Baby D and to restart with milk and continue with fluid through the cannula and they were happy with the UVC site. Caroline Oakley changed Baby D's nappy, she had a nice wet nappy, and had passed meconium. She said if she thought she was unstable she would not have changed her nappy because if babies are unstable they do not like to be handled.
Tile 240 fronts a record that Baby D was settled and handling well. Tile 241, the observations chart, records that at 02.30, her heart rate was fine, her respirations were high but were fine by 3.30.
The third event. At 03.45, Baby D's monitor was alarming. Tile 251 fronts the notes. Caroline Oakley found Baby D had desaturated and stopped breathing. She was apnoeic. She called the defendant for help. She stimulated Baby D to no effect and bagged her with Neopuffs at 03.52.
Dr Thomas heard shouts for help and stated that Baby D was being bagged as she was struggling to breathe and her oxygen levels had dropped. Dr Thomas asked one of the nurses to put out a crash call for Dr Brunton.
Tiles 253 and 254 record that Dr Brunton was bleeped at 03.57 and ran when he was crash called. Nurse C said she went into the room before Dr Harkness arrived and she did full resus with Caroline Oakley and the defendant. Dr Harkness said Caroline Oakley and Dr Thomas were around Baby D's bed space providing emergency treatment when he arrived. He joined in, taking over the airway. Her heart rate was less than 60, there were no chest movements, there were secretions +++ from her nose or mouth.
[Parents of Baby D] had been woken up and rushed downstairs to Baby D and saw Dr Brunton trying really hard to resuscitate her. A phone was held to Dr Brunton's ear to speak to Dr Newby, but the person to whom he spoke was not Dr Newby. Baby D was intubated and the chest wall then moved, showing air was being pumped into her lungs.
Dr Newby arrived during the resuscitation at 04.07. Full resuscitation was in process. Baby D had been intubated and was receiving full CPR. She was given repeated doses of adrenaline, fluids and sodium bicarbonate, all of which were necessary as Baby D was dying in front of them.
At 04.18, after 28 minutes of resuscitation, during which time there had been no response and no heartbeat, it was decided to stop. Her parents were told that they had to let Baby D go and at 04.25 Baby D was pronounced dead.
At 04.50, tile 280, Dr Newby had a discussion with Baby D's parents in relation to the unexpected and very sudden collapse and the need for a post-mortem. Dr Newby agreed that babies can sometimes suddenly collapse, but was surprised Baby D did because, although she was concerned when she'd been in at 1 o'clock that morning after the first episode, she did not appear to be a baby in extremis. She was saturating well, in air, on CPAP, she'd had had a normal gas after that episode, she was handling okay. Baby D's collapse was not what she was expecting to happen that night.
After the incident, Nurse C had a conversation with the defendant about volumes of the drugs for resuscitation that were administered because the laminated A4 sheet with the calculations on it, that you heard about, that’s there for resuscitation purposes, was not on the resuscitation trolley. The defendant asked Nurse C how she knew the amount of fluids to be given. Nurse C explained that she knew the doses because she had worked in the ICU for a long time and had learnt them and recommended that she, the defendant, did so as well.
Dr Jo McPartland, a consultant paediatric pathologist, conducted a post-mortem examination of Baby D at the Royal Liverpool Children's Hospital at 11.15 on 23 June. In her report, made on 3 August, corrected by a further report on 13 May 2019 -- those first two reports were in 2015 -- as set out in paragraph 22 in section 4 of the agreed facts, Dr McPartland identified her findings of fact:
"In relation to the lungs, there was patchy acute pneumonia, most prominent within one of the right lung samples, with some hyaline membranes present, indicating diffuse alveolar damage [the alveoli being the tiny air sacs in the lung which allow gas exchange]."
This indicated, said Dr Marnerides, that there had been a response to infection.
He, Dr Marnerides, agreed that pneumonia was likely to have been present at birth.
Professor Arthurs examined and referred you to a standard lateral radiograph, that is taken from the side, taken of Baby D after her death. What was striking, he said, was the black line from left to right, just in front of the spine, which was gas in the aorta or the inferior vena cava, the IVC, the great vessels that carry blood from or back to the heart or in both of them. So both of the great vessels.
This was an unusual appearance and not typical of what they see in children who have died without an explanation. That amount of gas is seen in babies who have died of sepsis or overwhelming infection or sudden unexpected death in infants, which would not in any event apply to a neonate, in trauma, road traffic accidents and the like. It was present in two other children in this case, one of whom was Baby A. There was more air in Baby D than in Baby A.
One of the explanations for this finding was that someone was injecting air into the child. In the absence of any evidence that suggested that Baby D died of overwhelming sepsis or any of the other explanations that have been put forward, Professor Arthurs concluded that the radiographs were consistent with but not diagnostic of external intravenous air administration. It was one of the explanations. The images identified the presence of the gas but cannot give an explanation for its presence, but the clinical history can.
You'll remember, I said at the very outset, his specialty is confined to the interpretation of the radiographs, you have to look at all of the evidence relating to the case in question.
Dr Marnerides said that the presence of air in a large intra-abdominal vessel was significant. Decomposition played no part in its presence and there was no evidence of decomposition and the interval between the death and the time of the post-mortem was not long enough for gaseous production to start and decomposition could be excluded.
To make the assessment of whether she had died from or with pneumonia was, he said, for the clinicians. Air bubbles could not be identified on histology, so from the pathology point of view it could not be proved that air embolus was the cause of death. If you see air bubbles in histology, that is something in keeping with it, that is in keeping with air embolus. If you don’t see them, you cannot say that it is not a case of air embolus. He concluded that the infection that was there, which appeared to have been a congenital infection, so explicable on the basis of the premature rupture of the membranes, would not sufficiently explain the death.
In his opinion, it did not explain the death because of the clinical assessment. There was no other natural disease that could explain the death, nor was there any other morphologically evident natural disease from the post-mortem examination. So in his view Baby D died with the pneumonia rather than dying from the pneumonia.
The post-mortem examination and his findings from the review could not positively confirm or refute the cause of death. On the findings of the post-mortem and the radiology and the findings and assessment by the clinicians and the absence of any other evidence of disease which could account for the prematurity of this death, Dr Marnerides concluded that the likely explanation for Baby D dying was air embolism by the injection of air into a vascular access line.
Dr Evans, having considered the medical notes, including the post-mortem report of Dr McPartland, the medical photographs and X-rays and having heard all the evidence from the neonatal clinicians and the nursing staff, except for the latter part of the evidence of Caroline Oakley, said that the first episode at 01.30 was very surprising and unusual. Baby D was responding to treatment, her only support was CPAP, and clinically there was no increased work of breathing; she was a stable baby.
Suddenly changing so rapidly was incredibly unusual for someone dealing with neonatal babies. He had seen the witness statement of [Mother of Baby D] and thought that her condition was consistent with early onset pneumonia. She was grunting and cyanosed, which indicated a respiratory problem, and raised bilirubin was a non-specific marker for infection.
She was initially an unwell baby and in very poor health. He was of the opinion that she had developed pneumonia before birth; so another clinician saying that she was born with pneumonia. However, by the next morning she was making a recovery and was, in Dr Evans’ opinion, recovering from the pneumonia, so it was reasonable to remove the ET tube.
She stabilised very promptly when back on CPAP and again it was reasonable to try her off CPAP given that she had had pneumonia, was recovering from it and her oxygen levels were 100% in air.
Her first collapse was very rapid. The speed and nature of her response was inconsistent with a pneumonia or sepsis by way of generalised infection. The abdominal discolouration was intriguing both as regards its appearance and it disappearing within 35 minutes. It could not have been bruising or purpura, which spread and don't disappear, and there is continuing deterioration of the baby.
It was the discolouration and pattern never seen previously by experienced neonatologists which came and went and none of the known discolourations or rashes that are seen in a neonate are anything like approaching what was described by the staff treating Baby D.
Although there were some individual fluctuations in her readings, all the markers and trends were of recovery at that time. Dr Evans considered that none of the other issues that affected Baby D were relevant and he couldn't think of any conditions that would lead to events that ended with an unsuccessful attempt to resuscitate at the third incident.
His opinion was that the events were consistent with intravenous air, an injection of air or gas into her system, causing an air embolus. This was the only cause that explains her collapse and death.
In relation to her recovery in the first two episodes, he explained that the greater the volume of air that goes in and the greater the speed at which the air goes in, the greater the risk of death, and the method of administration is unknown and you do not always get death with an air embolus. For obvious reasons clinical trials cannot be undertaken.
Air can get into the venous system either by accident or deliberate administration. He couldn't think of any other conditions that make babies unwell leading to a presentation of this nature. "Other than that", in other words air embolus, "it just doesn’t happen", he said.
Dr Bohin peer-reviewed Dr Evans' views and conclusions. I've already reminded you of her comments on Baby D's clinical notes up to the first event at about 01.30 on 22 June. The striking feature of all events, she said, was that they were sudden and unexpected and came out of the blue and the first two were associated with unusual mottling of the skin. She found them perplexing and had no clear cause.
In the second episode it was a concern that Baby D was distressed and crying. Full-term babies often fight CPAP because they find it uncomfortable, but Baby D had tolerated it well up to then. Although she considered antibiotics were administered late, she was treated appropriately in the unit and there was nothing to indicate death was imminent. She was clinically well, she was in air, had normal blood gases, she had no respiratory compromise at all and this was not a picture of a baby with a pneumonia severe enough to kill her.
Usually, babies will show a gradual decline and deterioration and an increase in the kind of care that they need, so their respiratory rate will continue to climb, they will not tolerate being on CPAP, and their blood gases will decline, so they will need to move from CPAP to more invasive ventilation. Their blood parameters will alter and become abnormal and they may need extra drugs to help with their blood pressure. There is an altogether slow clinical decline rather than a sudden collapse.
Taking into account the suddenness of the collapses and the very quick recovery of some of them she was clear it wasn't the infection that had caused the sudden collapse, it had to be something else that had to be unusual and odd.
The suddenness of the collapse and the clinical condition also showed that she had episodes of this unusual skin discolouration, which the medical team described and which does fit with previous cases of air embolus seen in adults and, to a lesser extent, in children but she acknowledged that there is very little literature on neonates. There was also the issue of air in the great vessels found on post-mortem radiographs.
Excluding other things, making a differential diagnosis, that is crossing-off things that don't fit with that clinical picture, and the scenario, she came to the conclusion that Baby D had air administered to her intravenously, either through the UVC or the peripheral cannula that she had in her hand.
Dr Bohin speculated that Baby D recovered so quickly from the first two episodes because, as they know from animal studies, with air emboluses it is the volume of gas and the speed at which it is delivered that is fatal or can prove fatal. So she thought if the volume of air administered in the first two cases was small that wouldn't have been enough to kill Baby D. What they do know is if a large volume of gas is administered into a vein, when it gets to the right side of the heart, if the volume is sufficient, it causes a gas lock within the heart and then causes sudden circulatory collapse. She thought that in the third collapse the volume of air was larger than it had been previously and caused the circulation to stop.
Under cross-examination, Dr Bohin denied that she had minimised the clinical factors in Baby D's case and denied having been influenced by the allegation rather than the medical facts that she was looking at.
Lisa Walker, a neonatal assistant, band 4, which meant she could only look after special care babies and not intensive care or high dependency babies, told you about an incident when she was in room 3 on a day shift when there were three babies and her and the defendant were feeding two of them. The defendant was feeding a baby on the right-hand side of the room by a nasogastric tube through a 10ml syringe that was screwed on to the very end of the tube. Milk is fed by gravity, but if Gaviscon or a fortifier is added to the milk, making it thicker, it can be pushed by the syringe. The alarm on the portable monitor that only records heart rate and saturation levels was going off. It was the desaturation alarm.
Lisa Walker went over to help. The defendant stopped the feed and gave the baby gentle stimulation and some facial oxygen. At first, the baby didn't respond. She saw Kate Bissell walking past the door, so she shouted for help, that is Lisa Walker shouted for help, because the baby was not picking up. Kate responded and a doctor who was working on thecomputer came in.
They gave the baby gentle stimulation and the baby recovered. The doctor and Kate left the room and the defendant then asked Lisa Walker quite firmly why she shouted for help. Lisa Walker was quite shocked because you can't have enough help in that situation but didn’t respond because she said, "You don't question colleagues, do you?" She said the defendant was quite cross. In her witness statement she had said:
"Lucy's demeanour when she said to me what she did wasn't really being annoyed, I don't think, I think it was saying she would have been fine and didn't need any help."
Between tiles 286 and 349 on the sequence, a very long section of tiles, there are details of a number of WhatsApp messages passing between the defendant and Nurse A following Baby D's death, and also with Caroline Oakley and Minna Lappalainen. The dates and terms of the messages are to be seen from the tiles and I shan't refer to them in detail. They contained references by the defendant to the full resuscitation, it being upsetting for everyone and the parents being distraught, the number of deaths and their circumstances in the short period involved, possible causes of Baby D’s death, and her thought that there was an element of fate involved. You've heard evidence as to the messages and the arguments in relation to them.
At 21.51 hours on 25 June, the defendant searched for [Mother of Baby D] and [Father of Baby D] on Facebook. Over 3 months later, on 3 October, she made two Facebook searches for [Father of Baby D]. When interviewed by the police on 4 July 2018, you know it's in the Baby D section in your records of interviews, the defendant said she did not then remember Baby D or her colleagues (sic) or anything about that particular shift.
When taken through the notes, she agreed she was involved in her care and assisting with medication where two people were required.
When interviewed a year later, on 11 June 2019, she did not remember calling Caroline Oakley back or being in nursery 1. She denied having administered any air into Baby D's body or doing anything deliberately harmful to her.
She was interviewed a third time on 10 November 2020. She said she couldn't remember doing Facebook searches in respect of both Baby D's parents 3 days after her death. She didn't know what she was looking for but she wouldn't have been looking for photos of the babies. That was a suggestion that was being put to her.
In relation to the messages she sent to Nurse A after Baby D's death, she said she could not recall why she said that Baby D looked like she was suffering from overwhelming sepsis or 20 minutes later saying to her:
"I think there is an element of fate involved, there is a reason for everything."
In relation to the message sent later that evening to Nurse A, saying that Liz Newby was suggesting it may have been meningitis, she said Yvonne Farmer had said that Dr Newby felt it may have been meningitis. She could not remember if Yvonne Farmer had said that to her.
In relation to the message chat, she had no recollection of the messages, the message conversation with Minna, who suggested to her in a message that she have counselling and her responding saying she couldn't.
In her evidence the defendant said she didn't really remember the shift on which Baby D collapsed and died. She was the designated nurse for two babies in nursery 1, MRE and JE -- you'll remember I've referred to JE in relation to other incidents with which we are concerned -- and will not have come on duty until 19.30, referring to the swipe card data behind tile 163, showing that she entered the unit at 17.26 (sic), so she could not have been on the unit by 7 pm, as [Mother of Baby D] had timed her contact with her.
She was taken to line 116 of the neonatal review at 1.25 showing an infusion of Baby D that commenced at that time undertaken by her and Caroline Oakley. She said that she didn't recall that taking place. She said she would have been caring for the babies that she was allocated and helping anybody else on the unit that needed any assistance with their medications.
There were also jobs to do at night, equipment checks and various things. She didn't remember being called into the nursery by anyone at 01.25. She didn’t remember Baby D desaturating at 03.00 or collapsing at 03.45.
I move on to Baby E. Count 5, another allegation of murder. Baby E and Baby F are the subject of counts 5 and 6.
On Wednesday, 29 July 2015 at about 18.00, [Mother of Babies of E & F] gave birth by caesarean section in the Countess of Chester at 29 weeks and 5 days' gestation to identical twins, Baby E and Baby F. She had been transferred there from the Liverpool Women's Hospital for capacity reasons. The hospital there couldn't take her. So this meant that she was over an hour's drive from the home of her and her husband, [Father of Babies of E & F]. The twins were their first babies.
It was a routine caesarean section according to the agreed evidence of the consultant obstetrical gynaecologist who delivered them, Dr Simon Wood, and both twins were born in good condition.
Baby E was born first. He weighed 1.327 kilograms, just under 3 pounds, and was not a growth-restricted baby. Baby E died less than 6 days later at 01.40 hours on Tuesday, 4 August. There had been bleeding into his upper gastrointestinal tract, which Dr Evans said was caused by a trauma, and the prosecution case is that Baby E too died of air embolus.
Dr C, the consultant paediatrician present when he died, confirmed in answer to general questions that Baby E was very premature, making him inherently unstable, was diagnosed with twin-to-twin transfusion syndrome, which can increase the overall risk of death after birth, but was something that they see routinely with identical twins and, according to Dr Bohin, was in its mildest form and was not requiring any treatment. Dr C also agreed that, like all babies they look after in the unit, he was capable of quite a dramatic change of condition.
[Mother of Babies of E & F] thought both boys were in good condition for their period of gestation. They were transferred to the unit shortly after birth and placed in nursery 1. The medical notes show that [Mother of Babies of E & F] went to the unit the following day and cuddled Baby E because he wasn't on CPAP. She was very keen to express milk for her boys and would take it down to the unit. You'll remember she was saying that was the one thing she felt she could do for them. She took down some milk on 31 July. The boys were progressing really well. Baby E was doing better than Baby F.
On that day, because his glucose level was raised, Baby E was given insulin intravenously for 3 hours; the prescription is behind tile 94. The following day, Saturday, 1 August, [Mother of Babies of E & F] gained the impression that the twins were managing fine and were fit enough to be transferred to a hospital nearer to their home by ambulances that had neonatal facilities.
Both continued to do well. Baby E was stable and put on a smaller dose of insulin from 19.30. He was breathing well. The next day, Saturday, 2 August, he was again stable, on 23% oxygen and had time out of his incubator.
On the unit observation chart behind tile 56, J2654, the readings over the 24-hour period from 18.00 on 2 August to 17.00 on 3 August were an extremely satisfactory pattern of well-being according to Dr Evans.
Nurse B was the designated nurse for both Baby E and Baby F on the day shift of 3 August. She took over from Melanie Taylor. Behind tile 61, J2586, is her note, made at 10.44 that morning, in which she confirmed that mum was on the unit from 09.00 and had long periods of skin-to-skin. She and Baby E could have as many cuddles as they wanted. She did a top-to-toe assessment of Baby E, who was self-ventilating in 25% oxygen air, he had no signs of respiratory distress, he was pink and well perfused and his capillary refill rate was 1 second. His respiratory and circulatory systems were normal and his long line and pump were normal. He was on a cautious feeding regime. He handled well, which meant that his tone was normal. Everything remained well. There was a minimal to 1ml of partially digested milk found on the NGT, which was normal. Intravenous caffeine was given as prescribed.
I'm just looking at when it would be a good time to have a break, and there's really no natural convenient break point because I'm into the narrative of events leading up to a significant event, so I think we’ll break off now, we'll have our ten-minute break and then you've got equal slots of 1 hour 10 minutes for each session this morning. All right? Thank you very much.
A ten-minute break then.
(11.39 am) (11.49 am)
(A short break)
(In the absence of the jury)
BM: My Lord, there was one matter that maybe just came at the beginning of the break, but one matter we had asked your Lordship to consider, but it can be dealt with at a later point, if possible, just arising out of the evidence of Baby D.
Mr Justice Goss: Yes, certainly, up to you. If it's easier to do it now or later --
BM: We're in your Lordship's hands. Whenever is convenient for the court is when it matters, as long as your Lordship is able to consider it. We sent a message just as the break came so it may well not have reached you. It came quite late and I expect that's why --
Mr Justice Goss: I'm sorry, I haven't seen that.
BM: I'd rather your Lordship see that before I ask your Lordship to entertain it.
Mr Justice Goss: Shall I just continue then?
BM: By all means do, I just identify it.
Mr Justice Goss: Thank you, Mr Myers. I was checking my emails and nothing... All right, thank you.
(In the presence of the jury)
Mr Justice Goss: Dr Emily Thomas, now a consultant paediatrician, then an ST1 doctor in general paediatric training at the Countess of Chester, confirmed the notes indicated that she was asked to review Baby E that morning. Behind tile 78, document J2553, it is noted that Dr Ventress did a ward round at 11.45.
Dr Thomas said she may have been on that round but, if she wasn't, she would have been fully aware of the notes. She could see that Baby E had opened his bowels. She examined Baby E at 14.10. Tile 86 fronts the note in her handwriting. Baby E had had skin-to-skin, his sats were now 95% in 25% oxygen, which was a small amount of oxygen. He had good tone and movements, he was handling appropriately, there were no signs that he was unwell or in discomfort or distress. This will have been confirmed, she said, by nursing staff. There was no increased work of breathing. His heart sounds were good and he had good femoral pulses. His CRT was normal. His abdomen was soft and not distended, normal. He had not further opened his bowels and bowel sounds were normal. There were no suspicious aspirates. He had a soft fontanelle, normal. Her condition(?) as well was that he was well and stable and she was happy to proceed and continue with the plan.
Nurse B wrote a further retrospective note at 17.24, a continuation of J2586. Baby E's heart rate and respiration were stable, but his BM, his blood sugar, was high at 18.4 and he was passing urine at a higher level than normal, though it was not a very high volume. His insulin infusion was restarted but at a lower rate than he had been given previously. He'd not been receiving insulin that morning.
Dr Thomas noted this in a note timed at 14.50. Tile 94 relates to the administration of insulin at 15.00. At tile 96 the fluid balance chart records it was recommenced at 15.30, being signed for by Nurse B. Tile 95 relates to the results of the blood test taken 24 hours after Baby E was started on antibiotics: the result was completely normal, so there was no indication of infection.
Intravenous antibiotics were being given as prescribed, the cultures were negative, which indicated the absence of bacteria. He was self-ventilating in air, his respiratory system seemed fine. Dr Thomas made a note at 19.30 that Baby E's CRP was less than 1. The amount of oxygen he was needing was now improving, his neutrophils having improved.
She said they tend to look for trends. In relation to his BM, his sugars were now settling. They would closely check fluids and increase fluids if necessary. There was no sign of bacterial infection. Dr Thomas’ clinical assessment at that time was that Baby E was definitely stable and, if anything, showing some signs of improvement.
Nurse B said Baby E was doing well on that shift apart from his high blood sugars. She did not consider the various recorded readings to be a worrying trend of inflammation.
Dr C, when asked in evidence about the readings that afternoon, said they were all within normal and did not cause any clinical concern. The blood glucose levels were higher than they would like and may indicate stress, but were what they commonly see in babies of his gestation and were not an unexpected part of their clinical course. The problem they cause is dehydration, which is why they treat them.
Although the blood glucose was outside normal limits, they would not expect that to lead to the clinical collapse like the one seen in Baby E several hours later.
In relation to the blood gas pH reading at 14.38 of 7.293, Dr C explained that preterm babies aren't normally managing their own pH, so clinicians accept readings of above 7.25, whereas the natural range in adults is 7.35 to 7.45. [Baby E]'s deterioration thereafter was well outside what they would expect, she said.
On that Monday, 3 August, [Father of Babies of E & F], who was commuting from home, left the hospital at about 5 pm, 17.00 hours. [Mother of Babies of E & F] was having skin-to-skin contact with Baby E, which finished at about 18.30, and changed his nappy and did his cares. She then went upstairs to the post-natal ward to express some milk and have something to eat. This was between 19.00 and 20.30.
The shift changeover that evening was, as usual, at 19.30. The relevant tile is 114. The registrar on duty was Dr Harkness. The senior house officer was Dr Christopher Wood. Dr C, the consultant paediatrician on call, was in hospital accommodation, a five to ten-minute walk to the unit. The shift leader was Caroline Oakley. The other nurses on duty were the defendant, Belinda Williamson and two nursery nurses Lisa Walker and Valerie Thomas.
Tile 115, which is also reproduced on paper as the first page in tab 5 of your large neonatal review file, shows the locations of the babies and allocations of nurses from the start of the shift. The alterations during the shift are depicted on page 11 at the end of that review.
The defendant was the designated nurse for both Baby E and Baby F in nursery 1. Belinda Williamson could not now recollect having any contact with Baby E. She was referred to the neonatal fluid balance chart behind tile 125 on which she accepted she had made a series of entries in relation to Baby E's fluid balance at 22.00 and with her signature at the bottom of the column.
Towards the bottom of the adjacent column for the 21.00 aspirate, there are the words "omitted, discarded 16ml mucky". The defendant said that the feed at that time was omitted because there had been 16ml of mucky aspirate. She said that senior house officer was informed by telephone and told them to omit the feed. She didn't in her nursing note name the doctor who was asked. She said they didn't always write the doctor’s name. There would only be one SHO on duty, so it could be checked.
In the 22.00 hours column, there are written the words "15ml of fresh blood". The defendant accepted she wrote this. She got fresh blood and Dr Harkness attended.
Belinda Williamson would guess that the other 22.00 entries written by her were as a result of someone asking her to do some of the observations for them, which was not unusual.
The defendant said she couldn't answer why Belinda Williamson was carrying out observations at 22.00. She denied she had got Belinda Williamson to put the entry on Baby E's chart for 22.00. The neonatal review chart in the A3 file, to which she was taken, identified that at 21.59, lines 58 and 59, Belinda Williamson was engaged with Caroline Oakley in administering medication to JE and feeding JE, who was in nursery 2, and for whom Lisa Walker was the designated nurse.
She was also referred to tile 131 and the document behind it and confirmed that she co-signed for the administration of medication for Baby E, timed at 22.27, and also co-signed for other medications behind tiles 132 and 133.
At 22.38, she was engaged in checking the prescription for Baby E for insulin, making sure that everything was right, making up the concentration and the syringe and connecting the syringe to the cannula or port for infusion.
Dr Christopher Wood, now a GP on the Wirral, was at the very end of a four-month placement at the hospital as part of his GP training and was working as the on-call senior house officer in the unit for that night shift. He had been present at the birth of [Babies E & F]. He was asked whether at some point on that evening, it was suggested around 9 or 10 in the evening, he recalled receiving or was informed about -- receiving a call or was informed about an aspirate, a bile-stained aspiration, not a bleed, on the unit. He said he didn’t recall. He didn't remember whether it definitely didn’t happen or he just couldn't recall being informed about it. He did say if he had received information from a nurse that required him to see a patient on the unit, on seeing the patient he would make his assessment and record this in the medical notes and, if needed, would seek further advice from his registrar.
Behind tile 128 is J2556, which is Dr Harkness' note made at 22.10, recording that he was asked by the defendant to see Baby E. He thought he had been bleeped. That would be the normal way. When he got there, the defendant was in room 1. He was told that there had been a large, very slightly bile-stained aspirate 30 minutes before he had been called. He accepted that that event could or would have been around 21.30.
When he got to the room, he was shown a sample of bloody aspirate, mainly stomach contents containing small amounts of flecks, tiny minuscule amounts of blood that was not fresh. His recollection is that while he was there:
"A sudden large vomit of fresh blood, a 14ml aspirate, occurred."
That was what he wrote in his note. He noted the background. There was reference to potential background markers for the heightened risk of NEC, namely reduced end-diastolic flow to the uterus and intra-uterine growth restriction -- (12.03 pm)
(No audio feed from court)
(12.05 pm)
Mr Justice Goss: There was nothing in the notes about a possible blood transfusion, but Dr Harkness said he will have considered it and Dr C believes they discussed that in at least one of the pre-collapse conversations.
Baby E had been due a feed at 21.00. [Mother of Babies of E & F] said she took some expressed milk down to the unit, arriving a touch before 21.00, 9 pm. She didn't recall seeing anyone else at that time. Her twins were, she thought, the only babies in nursery 1. Baby E was in the incubator to the right as you entered the room and Baby F was to his left against the back wall. They were indeed the only babies in the room.
The defendant was in there at the workstation, busy doing something, not near Baby E. [Mother of Babies of E & F] could hear him crying from the corridor. It was nothing like she had heard before, a sound that shouldn’t have come from a tiny baby. She couldn't describe it: it was horrendous, more of a scream than a cry. She immediately went to Baby E and saw he had blood coming out of his mouth. There was blood on his face and around his mouth. It was not on or going on to anything else.
In her witness statement, made on 27 July, she said it was:
"Like a dribble pattern. It didn't look like it was completely fresh. It was blood."
She was asked if it was possible that it was some sort of dark liquid with flecks of blood in it around his chin. She said it was not, it was blood.
In re-examination, she said:
"It wasn't dripping, it was smudged and didn't look completely dry and was darker, it wasn't bright red."
You have seen the drawing, J2324, with the marked areas round the mouth, with the blood mainly below the lower lip down towards the tip of the chin.
She was panicking, thinking there was something wrong. She used the containment technique of putting her hands on his head and tummy. She asked the defendant why he was bleeding and what was wrong. She said the feed tube from the back of the throat will have been rubbing and that will have caused the blood. This was something the defendant said she had no recollection of saying when she was interviewed by the police.
In her evidence, the defendant said she didn't recall Baby E screaming. He was unsettled at times but not screaming, nor did he have blood around his mouth when his mother, who she thought had brought expressed milk, came down at around 21.00.
When cross-examined about this, she said she thought [Mother of Babies of E & F] brought milk down at 21.00 but couldn't be sure. She did not tell her the bleeding was the insertion of the NG tube and she would not tell parents to go away. She agreed that, in her interview relating to Baby N, she did say that an NG tube can cause bleeding from trauma. She said she had not fallen out with [Mother of Babies of E & F] and the first time she, the defendant saw blood, would be at 22.00, in nursery 1, and she called Dr Harkness down.
[Mother of Babies of E & F] accepted what she says she was told by the defendant, but was concerned. The defendant told her to go back to the ward. She did as she was told because the defendant, Lucy Letby, was in authority and knew better than her and she trusted her completely. She returned to the post-natal ward and rang her husband because she knew there was something very wrong and she was frightened. The call data, J2431, shows that there was a call at 21.11 for 4 minutes 25 seconds. She told him about her concerns. [Father of Babies of E & F] said that his wife was upset and very worried about Baby E because she had seen bleeding from his mouth. It was definitely in that call, said [Father of Babies of E & F], that there was reference to bleeding and not in a later call.
[Mother of Babies of E & F] said she was upset and spoke to the midwife, Susan Brooks, who was administering medication to her. Susan Brooks wrote in her patient care notes:
"Care since 20.00 hours, [Mother of Babies of E & F] was post-natally well. I had given her some medication and she asked to let her know if there was any contact overnight from neonatal unit as one of the twins had deteriorated slightly."
Susan Brooks said that at 23.30, there was a call from the neonatal unit, asking [Mother of Babies of E & F] to go down in 30 minutes as Baby E had a bleed and required intubating and that he was very poorly. Susan Brooks noted that [Mother of Babies of E & F] was obviously very distressed and wanted to go straightaway. [Mother of Babies of E & F] said the midwife came and asked her to call her husband, which she did, and the midwife spoke to him on the phone.
That call, according to her phone data, was, she said, at 22.52.
She was taken down to the unit, the time being recorded by Susan Brooks at midnight, where she sat in the corridor, watching the team of people around Baby E's incubator working on him and was allowed to go in and see Baby E around 10 minutes later.
I pause in the narrative of events at this point to remind you of what the defendant said when first interviewed about Baby E on 4 July 2018 in the section BAG. She recalled caring for Baby E, he had been started on insulin earlier in the day on 3 August, but was otherwise doing well. He was starting to have enteral feeds, but after some feeds she got aspirate back from his NG tube and his abdomen was becoming distended. He was reviewed by doctors and medication commenced but his abdomen continued to distend and became discoloured. He then required respiratory support and began bleeding.
It was on the second time she fed him that she obtained a large aspirate back from his NG tube that contained bile and was usually a sign that he was not digesting feeds or potentially there was an infection.
She showed Belinda Simcock, now Williamson, and they decided to omit the feed. Prior to this large aspirate she had no concerns about Baby E.
It was about an hour after this that his stomach began to distend. When she got blood back in his NG tube she thought she had shown Belinda Simcock but was not sure Belinda was there when she obtained it. She could not remember if she found the blood before or after his deterioration. It was fresh blood and she believed it was from his abdomen. She looked at her notes and stated that if she had seen blood on Baby E prior to the large vomit of fresh blood then it would have been in the notes and charts. She confirmed that she would have told a doctor if at any time she had found blood on Baby E.
In the second interview, on 11 June 2019, she said she could not remember what Baby E was like when [Mother of Babies of E & F]attended the ward and whether he had blood on him at that time or telling [Mother of Babies of E & F] not to worry and go back upstairs. She also said she did not know why she would say that it was the feeding tube irritating his throat and that was not a normal reason for a baby to have blood in his mouth. She said she must have made an error in putting it was at approximately 10 o'clock that [Mother of Babies of E & F] attended, it must have been earlier. She could not specifically remember any bleed.
In her evidence she said that so far as the events from 22.00 were concerned, referring to tile 38, that 14ml of fresh blood at that time was very concerning. I've already reminded you that in her evidence she said that the first time she noted blood will have been at 22.00. She called the doctor and Dr Harkness came; tile 128.
There are, therefore, significant conflicts between the evidence of [Mother of Babies of E & F] and [Father of Babies of E & F] and the defendant and you've heard submissions as to the significance of those conflicts in relation to the circumstances, the nature and time of the bleeding and what is said to be the evidential link to the later case of Baby N, and you have also heard the defence arguments in relation to why you should find the evidence of [Mother of Babies of E & F] unreliable in relation to her timings.
The significance of this evidence and the resolution of those conflicts are, of course, matters for you.
Dr Harkness made a further clinical note at 23.00. He didn't think he had left the unit. There had been a further GI blood loss and desaturation to 70%. Baby E needed immediate medical assistance. There was 13ml of bloodstained aspirate from the NGT on free drainage, which was a mixture of blood and stomach aspirates. His blood pressure was stable and very good and his heart rate was very good, his saturations remained at 60% to 70% in 100% oxygen. He was making a good respiratory effort and so it was not as a result of a breathing problem that he was not maintaining his oxygen saturations: something was interfering with oxygen getting into his bloodstream. This was a significant desaturation and there had been a loss of some fluid and a loss of blood.
Dr C said something dramatic had happened. It was, she agreed, a very serious situation, an emergency. The plan of Dr Harkness was to replace the losses with fluids, maintain strict checks on fluid balances, electively intubate Baby E, administering a sedative and painkilling drugs, the plan being to get him stabilised on a ventilator, take chest and abdominal X-rays and discuss them with the surgeons at Alder Hey.
Dr C agreed to this plan and told you that she was happy with it and, in hindsight, she wishes she had got there sooner, but she didn't think she would have made any different decisions to the ones that had been made had she been present. Both of them were thinking Baby E may have NEC and were addressing that in the way they believed to be appropriate.
Baby E suffered a sudden deterioration at 23.40. The clinical note of Dr Harkness was written at 01.45. It's behind tile 149 and is J2557. He was just getting ready to intubate Baby E electively, the drugs having been prepared. The defendant was in the room, as was another nurse. Dr Harkness noted that Baby E had:
"Bradycardia of 80 to 90 beats per minute, saturations 60%, poor perfusion."
Which was a sluggish blood supply to the limbs. There was also colour change over the abdomen with purple discoloured patches, which in his evidence he described as:
"A strange pattern over the tummy which didn't fit with poor perfusion. The patches were in one area and then in another. It was unusual and not fitting with a baby that had shut down with poor perfusion. His head and upper legs and arms were pink, normal colour. It was hard to give a clear description."
He'd seen this in Baby A as I have already reminded you. That was the only other time he had seen it before and he said he has not seen it since. The patches were of different sizes, in the region of 1 to 2 centimetres, possibly bigger, and were just over the abdomen. He carried out an emergency intubation, inserting a 2.5-millimetre tube and establishing a good airway.
Dr C arrived, checked the radiograph and saw the ETT and NGT were in the right places, there was no evidence of gas in the bowel or of any intraperitoneal gas, which would have been indicators of NEC. She saw no discolouration of Baby E's abdomen. They were discussing Baby E's situation when he collapsed at 00.36.
Dr Wood attended the unit on the crash call. Resuscitation attempts had already begun when he arrived. Being the most junior doctor he acted as scribe noting events and times as they occurred and then writing them up in the notes. Behind tile 164 is J2560, which is the note of the personnel present and timings that he wrote up at 01.25 on the morning of the 4th.
In interviews the defendant was taken to her medical note, which are behind tile 206, and a reference to a purple band of discolouration over the abdomen, which she thought was a purplish area around his umbilical area which she didn't think she had seen before.
In her evidence she said that at 23.40 his stomach was distending and there was a very red band on the abdomen. She wondered if he was bleeding into his abdomen. The discolouration stayed throughout. He had declined. He was actively bleeding into the free drainage port at the end of the NG tube.
The defence challenged the clinical decisions of Dr C, including the failure to give an earlier blood transfusion. Dr C explained that Baby E's cross-matched blood wasn't ready by that time. They had emergency O negative blood that they could access on the labour ward if needed. She didn't feel his collapse was due to blood loss because there wasn't the deterioration in his observations over a period of time that would have fitted with that. She didn't believe that not having blood until his resuscitation led to his collapse and death. A blood transfusion is not without its risks and he wasn't showing clinical signs of significant blood loss at that point. So they did consider it but she didn't think, even with hindsight, that he should have had a blood transfusion at that point.
Baby E's oxygen saturations dropped and he had no detectable heart rate. The resuscitative measures are set out in the documents behind tile 197, J2258 and J2259. Baby E had good bilateral airways throughout and there were no problems with ventilation. He was given five doses of adrenaline and other medications listed and 20ml of blood. There was a detectable heart rate from 01.01, but Baby E was still not breathing.
The tests from the blood sample taken from him all indicated an extremely poor clinical condition that was not compatible with life, but could not tell them anything about the cause of the collapse. The heart rate started to drift down again and it was not felt that continuing to treat him was in Baby E's interest.
He was transferred to his parents where he died by 01.40.
I return to the defendant's evidence. She said that the discolouration she saw was not the same as what Dr Harkness described. She said it was like a solid block of purpleness over his abdomen. Baby A was different, he had pale and whiteness and more like a mottled look. Baby E was bleeding from his mouth and nose when chest compressions were performed. She assisted with the resuscitation. It was not something that she wanted to happen and she was there when he died. She found his death very traumatic. She completed a Datix form at 05.53 on 4 August, which is behind tile 218, reporting:
"An unexpected death following a GI bleed. Full resus unsuccessful."
She said that collectively, the medical team were late in giving the blood transfusion after the profuse bleed at 22.00, she denied having done anything to harm him.
After Baby E had passed away, [Mother of Babies of E & F] had contact with the defendant, who she said asked her if she would like to bath Baby E. She did not feel able to, she was broken. The defendant bathed Baby E in front of her in the unit and he was then put in a white gown and given back to them and went into the incubator, where he stayed. In her evidence the defendant said that the parents bathed Baby E.
Shelley Tomlins, now living in Australia, then a band 5 neonatal nurse, came on shift at 07.30 that morning, taking a handover from the defendant. She provided emotional support for [Parents of Babies of E & F] and was present when there were discussions with the consultant, Dr C, about a post-mortem.
At the time Dr C felt that Baby E had died of NEC. She discussed having a post-mortem with the parents. [Mother of Babies of E & F] said Dr C told themthat it wouldn't tell them very much and wouldn't be able to tell them any more than what she was telling them as to how he died. It would delay their transfer back home and they just wanted to take Baby E home.
Dr C discussed her conclusion that Baby E had NEC was the most likely explanation for the cause of gastrointestinal bleed at the time for a baby of his gestation and condition with the coroner and Dr C agreed with the coroner that they would put on the death certificate that as the cause of death. No post-mortem was carried out. Although she felt at the time NEC was the most likely explanation, Dr C completely agreed that with hindsight she should have requested a post-mortem. She was keen to avoid any further distress to Baby E's parents and she apologised to them that she didn't push for a post-mortem.
The defendant had an exchange of Facebook messages with Nurse A from tile 222 onwards, in which she said in a message behind 229 that Baby E had a massive GI bleed and she guessed he was a very high risk:
"It was just awful because he was bleeding from everywhere during resus."
In the third interview on 10 November 2020, she confirmed he was bleeding from his nasogastric tube, his mouth and, she thought, rectally. On 4 August there was an exchange of messages with Jennifer Jones-Key in which the latter referred to them being:
"On a terrible run at the moment."
And the defendant responding:
"He had massive haemorrhage. Could have happened to anyone."
And in a later message:
"This was abdominal. I've only seen pulmonary before."
You have all the messages and their contexts set out in the sequence of events.
When interviewed by the police on 10 November, the third time, 2020, she said she was aware it was an abdominal bleed because they were getting blood back from the NG tube and he passed blood rectally, indicating an abdominal issue.
She made searches for [Mother of Babies of E & F] on 6 August and 14 September, followed by further searches in October for both [Mother of Babies of E & F] and one for [Father of Babies of E & F], going up to 10 January 2016. They're all in the sequence of events.
In her evidence she confirmed having made the searches, again now saying that that was something she does quite often. Baby E and Baby F came into her mind. These searches did not apply to just babies on the indictment. Looking more than once was more than a normal pattern of behaviour for her.
In relation to agreed facts 39 and 40, which concern the photographs that were found on her phone, she said that she took the photograph of the thank-you card for the [Babies E & F] family at 03.40 on 20 November 2015 at the hospital because it was something she wanted to remember. She quite often took photos of cards, it was nothing unusual. She also took a photo of her shift pattern, which is J233225. You will remember it was put up on the screen.
Professor Arthurs considered the available X-rays in Baby E's case and confirmed that there was no evidence on the radiograph of an air embolus in his circulation, but said that there would have to be quite a lot of air for you to see it on the radiograph and that would have had to be done quite close in time, so the radiograph would have had to have been taken almost immediately were that to have happened. So he could not exclude the fact that it may have happened, it was just not demonstrated on the X-ray. So the fact that one can’t see air in the great vessels or other part of the circulation doesn't help either way in determining whether that was the cause of death.
There were no features of NEC on the X-ray. If the baby were to die of NEC within hours of the X-ray, you might expect to see some of those features. That's of NEC.
It was in Baby E's case, and not Baby A's as I erroneously stated yesterday, you remember I corrected it in the afternoon -- in which Professor Kinsey confirmed there was no explanation in his blood properties for spontaneous bleeding. That did not mean that he might not have had a gastrointestinal haemorrhage for some other reason unconnected with blood clotting or haematology, and her assessment did not establish the cause of the bleeding, but she was simply saying from a haematological point of view he didn’t have a blood clotting problem.
Dr Evans reviewed all the medical records in Baby E's case, including the material from Alder Hey, photographs, radiographs and extracts from witness statements. Taking all that information into account, together with the evidence that he heard, he concluded that Baby E's condition between his birth on 29 July and the time of the handover on the nursing shift at about 20.00 on the evening of 3 August was incredibly stable and his blood tests accorded with that. He was at increased risk of NEC because of the absent end-diastolic flow. His treatment was managed appropriately following his birth, he was not given oral feeds for the first few days, and he did not develop NEC.
If a baby has NEC to any significant degree they become gradually unwell. You might find a bit of abdominal distension, the usual markers of tenderness, heart rate might go up, the respiratory rate might go up, the baby's oxygen might drop, Baby E would not have coped with handling in any way. These initial markers are pretty non-specific but if you're used to dealing with premature babies, Dr Evans said, you would pick up these signs of early NEC.
Abdominal distension is a well-known symptom of NEC. In an aspirate taken from a baby with NEC you might expect an increased amount of aspirate, which on the whole is usually of bile and watery juices. Dr Evans didn't consider that NEC was a viable explanation for what happened to Baby E.
He said there were two major issues in Baby E’s case. The first was a significant haemorrhage from the upper gastrointestinal tract, somewhere between the mouth and the stomach. Something had caused this significant haemorrhage. Baby E had lost a lot of blood in a short period of time, sufficient to destabilise him generally.
The second was the discolouration, the very unusual pattern of patches, which, Dr Evans said, apart from in this case -- this case as a whole -- he had seen only in literature presentations as a marker of an air embolus. He thought [Baby E] was suffering from an air embolus. These two major problems were why resuscitation was not successful. His initial thought, as set out in his report of 31 May 2018, was that there had been some sort of trauma due to an NG tube. Having more recently seen the type of NG tube that was used at the hospital, he didn't think it could have caused any trauma.
He thought Baby E suffered trauma from some other form of injury and referred to a number of bits of equipment that are relatively rigid, plastic tubes used for suction or an introducer, which is a thin wire surrounded by plastic, which are used to intubate a baby, which would be more than sufficient to cause trauma if it was used inappropriately. Whatever it was, there was no potential innocent explanation for the degree of bleeding.
The other option was a bleeding ulcer. Dr Evans had never seen a bleeding ulcer causing this sort of presentation and Baby E was not a baby experiencing distress.
In relation to other possible issues about which he was questioned by the defence, Dr Evans said Baby E’s raised glucose was a result of him not producing his own insulin. The dilatation of his bowel was due to a lack of oxygen and would not be an issue 5 days after his birth. There was no evidence that he was acidic. His massive haemorrhage was not something that occurred as a natural phenomenon. In his opinion it was caused by trauma. There was no evidence, he said, of a natural cause.
Dr Bohin was asked to review the reports of Dr Evans, but formed her own opinion, she said, and refuted the suggestion that she was merely going along with the suggestions of Dr Evans. She studied the medical records and said there was nothing in the records of a tube being inserted after 29 July.
So far as insulin was concerned, the records showed that Baby E received insulin between 07.00 and 10.10 on 31 July. It was then stopped and he was restarted on a lower dose between 16.00 on the 1st and 07.00 on 2 August at less than half the previous dose, and then at the same dosage from 15.30 on 3 August until his death.
She examined the feeding chart. He was given half of 1ml of milk every 2 hours from the night of 31 July. The feeding charts setting out precisely what he was given and when are J2718 to J2720.
On 2 August, at about 09.30, Baby E developed a very mild oxygen requirement of 24%. Clearly, the clinical team were concerned that he might be developing an infection and, as per normal practice, he had what was regarded as a partial septic screen. Blood tests were taken and a blood culture to look to see if there were any bugs in the blood. He was started on antibiotics, cefotaxime, just in case he was showing early signs of an infection. His blood gases were normal and there was no increased work of breathing.
At 09.00 on 2 August, Baby E's feeds were increased to 1ml every 2 hours. His abdomen was described as "full but soft". At that stage his bowels had not opened. The feeds were increased at 15.17 and 19.00 on 3 August to 2ml of milk, the material being behind tile 92.
I have reminded you briefly of the circumstances of the omission of the 21.00 feed. At 22.00 hours, a large vomit of fresh blood was recorded in the nursing notes. The blood gas results at that stage were normal. The examination of Dr Harkness revealed a soft, non-tender, non-distended abdomen with normal bowel sounds. He was prescribed a bolus of sodium chloride, a dose of ranitidine and an injection of an antibiotic, metronidazole. The blood gas results showed signs of respiratory acidosis, the pH was lower than it had been, the CO2 was raised, the metabolic component, ie the base excess, was normal. The glucose was up a bit at 10.6, but not anything really to worry about, and the lactate was normal. The haemoglobin on the gas was 185, which was normal.
At 23.40 there was the sudden deterioration in the conditions which I remind you are behind tile 149: heart rate was low, a bradycardia between 80 and 90 beats per minute, and low saturations of 60%. His perfusion was poor, so he wasn't a pink baby, and his abdomen developed the features Dr Harkness described in terms of discolouration. The clotting screen results are at J2704.
The prothrombin time at 19.45 was marginally above the normal range and the activated partial thromboplastin time well within the normal range. It is not suggested there was a blood clotting problem.
Dr Bohin said the decision not to hold a post-mortem was a poor decision.
Between his birth on 29 July and the time of the handover on the nursing shift at about 8 pm, 20.00, on 3 August, Baby E was incredibly stable and his blood tests accorded with that. He was at risk of increased NEC, his treatment was managed appropriately following his birth. NEC has no single presenting feature but it can present with feeding intolerance temperature instability, abdominal distension, abdominal pain and, if it's more severe, bloody stools. It can present with a gastric perforation. Babies with NEC do not go from being well one minute to being very, very unwell within a matter of minutes or even a couple of hours. He had been tolerating his feeds and had passed meconium. She had dealt with NEC on a number of occasions and Baby E, in her opinion, did not have clinical features consistent with NEC.
The 16ml of aspirate before he was fed at 21.00, 9 pm, struck her as being really odd and out of keeping with what had gone before. You don't take the volume of aspirate in isolation, she said, you have to link it to the baby's clinical condition, which had been fine, and he'd shown no signs of any gastrointestinal disturbance.
He had tolerated those feeds up until that point and had no aspirate at all. She was at a loss to explain where this 16ml had come from, having had no aspirate before and having nothing in his tummy for 2 hours.
On the subject of bleeding being caused by an NG tube, the fact of trying to place that tube in the nose can sometimes cause minor trauma to the delicate lining of the nose and you sometimes get some very minor bleeding. She had never seen a baby haemorrhage or have blood around the mouth as a result of a nasogastric tube insertion.
It appeared that Baby E had a huge amount of haemorrhage at 22.00, vomiting fresh blood of unknown volume. That was an extremely unusual feature and to have an additional 14ml of blood in the syringe attached to the nasogastric tube, which in combination and together with the further 13ml recorded at 23.00, which she felt was very likely to be an estimate and could have represented over 25% of his blood volume.
Haemorrhage of this magnitude in neonates is vanishingly rare. Dr Bohin has never seen a baby having a gastric haemorrhage in this way. Babies do sometimes have gastric erosion and ulceration, but it does not result in haemorrhage of this fashion.
Taking all these factors into account and her experience, she thought Baby E died because of an air embolus. On that day he had the discolouration that was described by Dr Harkness. He suddenly collapsed where his previous clinical condition was not one where that was expected, and he did not respond to what was standard resuscitation. So on balance she thought he had an air embolus. The haemorrhage made him unstable, but she didn't think that was the cause of his death. Baby E didn't have NEC.
Well, I'll start reminding you of the evidence in relation to Baby F, but obviously I'll have to break off at some point for lunch.
Baby F, the subject of count 6, attempted murder, was born at 17.54 on 29 July, in good condition, cried at birth and weighed 1.43 kilograms, so was slightly heavier than Baby E.
Dr Sally Ogden was present at his birth. The birth details are behind tile 5 in his sequence. He was admitted to the neonatal unit 16 minutes after birth at 18.10 hours. He was intubated and had a very low blood glucose level of 1.9. He was extubated the following day, 30 July. His blood glucose rose to 15.1, which was very high, and at 03.40 on 31 July the administration of manufactured insulin, Actrapid, was started; that’s tile 10. He responded well to the insulin and his blood glucose an hour later at 04.40 had dropped to 8.7. The Actrapid was stopped at 06.20 hours.
The defendant, who had not been on duty that night after his birth, was on the night shift in the unit on three successive nights, on the 1st, 2nd and 3 August from 19.30 hours. She was the designated nurse for Baby F.
Tiles 13 to 21 front relevant events, including the feeding regimes. Tile 17 relates to the feeding regime for the night of the 1st and 2 August. Baby F was prescribed Babiven and lipid, administered intravenously up to 3 August.
Nurse B, who was on duty during the day of 3 August, confirmed that, apart from a transient respiratory issue after Baby F was taken off CPAP and put on Optiflow for a time, all was well. Feeds were increasing and he was tolerating milk.
From tile 22 you have the records detailing Baby F's care from 01.00 hours on 4 August.
As you well know, the prosecution allege that Baby F was given manufactured synthetic insulin via the bag of Babiven that was hung by the defendant or that was hung during the course of the night shift of the 4th and 5 August. They also allege that, by reference to the blood sugar readings on the 5th and 6 August, the next bag of Babiven that was hung at midday, 12.00 hours, on 5 August, which will have been taken from stock, had had a similar amount of insulin put in it so that Baby F continued to receive insulin until that bag was replaced.
Insulin, explained Dr C, is a hormone that is made by the body in the pancreas to help regulate blood sugar levels; that is endogenous insulin. It is also a manufactured medicine that can be given as a drug to diabetics who do not produce their own insulin; that is exogenous insulin, in other words coming from outside the body. Dr Gibbs further explained that when insulin is produced naturally in the body, the insulin molecules attach to the C-peptide molecule and they are broken apart and both are secreted from the pancreas into the blood.
The C-peptide stays in the blood much longer than insulin, so normally, the C-peptide level is much higher in the blood than the insulin level. Synthetic insulin made by a drug company doesn't have any C-peptide attached to it, so it's very abnormal to have a high insulin level when there's a low blood sugar. There are rare disorders that premature babies can suffer where they produce and secrete too much insulin themselves. Baby F was not such a baby.
As they are entitled to, the defence do not admit that the evidence establishes that Baby F or Baby L, the subject of count 15, were given manufactured insulin, and they put the prosecution to proof. In other words, you must be sure that the evidence of Professor Hindmarsh and all the related evidence of sampling and testing --
(12.50 pm)
(12.51 pm)
(No audio feed from court)
Mr Justice Goss: They also argue that if it is established that insulin was added to TPN bags by someone, there is a huge evidential gap proving that the defendant was that person. Her case is that she was not responsible.
In relation to Baby F, the defence point to the absence of direct evidence that she tampered with any TPN bag. She did not have exclusive access to bags. She was not on duty when a Maintenance bag was hung and was providing the infusion at the time that the incriminating sample was taken, the line and giving set having also been changed by that time.
And finally, if she was intent on murder, why didn't she attack Baby F on some other occasion that she was looking after him on nights before 3 August, I have reminded you she was on duty on previous nights, or when she was back on the unit on 8 August?
With all this in mind, I remind you of the evidence relating to the taking and testing of the blood sample, its integrity and reliability and other evidence surrounding this alleged offence.
On Tuesday, 4 August Shelley Tomlins, a band 5 staff nurse, was on duty during the day with Nurse B.
At 10.00, Shelley Tomlins completed the observation chart for Baby F; it's behind tile 64. He was 6 days old. The readings were acceptable for a neonate, indeed all the readings on that chart, which go up to 17.00 hours that day were.
Dr Gail Beech, a registrar at the time, was on duty that Tuesday and behind tile 67 is the note of the weekly review she conducted in preparation for the Wednesday ward round the following day. You can refer to that note if you wish.
They were establishing feeds and awaiting genetic results for T21, which is Down's syndrome, which, when received on 7 August, were negative. His hyperglycaemia, high glucose, for which he had been prescribed Actrapid in the early hours of 31 July, had resolved, he was on antibiotics and standard drugs. His sats were 92% to 97%, he had good gases, there were no concerns about his cardiovascular system, his heart sounds were normal, his weight loss of 9.6% was normal after birth. He was on small enteral feeds of expressed breast milk via a nasogastric tube straight into the stomach supplemented by TPN with no lipids via a long line. His head scan was normal.
On examination, he was active, pink, his chest was clear, there was no increased work of breathing, his femorals were good, his abdomen was soft, bowel sounds were heard and there were no hernias.
Nurse B's note of that day is behind tile 53. In summary, Baby F remained on Optiflow but had reduced oxygen, his heart rate was stable, his long line was working satisfactorily. Based on all notes and observations, Nurse B said that:
"Apart from a slight respiratory issue in the morning there were no other concerns that were outside normal prematurity."
Behind tile 145 is the neonatal parenteral nutrition sheet, J3143. For 4 August, Dr Beech prescribed and signed for Babiven but no lipid, dextrose or other infusion. That prescription was sent off to the pharmacy and the made-up bag will have been received on the unit about 17.00. That entry was signed for by the nurses Nurse A and the defendant and then struck through against a time of 00.25. It was said not to be required.
Below that entry is a further prescription for day 7 for Babiven, lipid and 15 milligrams per kilogram per day prescribed by Dr Chris Wood. This was because the small enteral feeds had been stopped and Baby F was back on lipid. The defendant in evidence identified that she signed for administration of those prescriptions and the timings. You have a paper copy of what is tile 147 as the first document in section 6 of your second jury bundle.
The new TPN bag was hung at 00.25 on 5 August. Yvonne Griffiths, the neonatal manager in the unit at the time, explained the prevailing situation in relation to TPN bags and the contents of the fridge in the treatment room, of which you saw photographs, although they were taken some 3.5 years after these events, and the tower of shelves to be seen adjacent to the fridge containing NG tubes, dressings, creams and the like was in an adjacent separate small room opposite nursery 1 and not in the position next to the fridge shown in the photographs that were taken all those years later.
The fridge, in which there was a list of the contents on the inside of the door, contained a supply of TPN stock bags of both Babiven and Start-up Babiven, as well as made-up prescribed Babiven and insulin in the form of Actrapid -- and two boxes could be seen in the photograph that you were shown on the top shelf.
That fridge was kept locked. There was one set of keys, which would start in the possession of the shift leader and then be in the possession of anyone wanting to take something from the fridge. That bunch of keys included keys to cabinets containing intravenous and oral antibiotics and medication which were always in nursery 1. There was no system for signing the keys in and out.
Any request to replenish stocks was done by a requisition book. That booklet represented the only source of audit of Babiven ordered into the unit. There was no way of knowing what was in the fridge when the orders were made. A check would be undertaken every night, but in particular on Monday mornings and Thursdays because the pharmacy would not supply medications over the weekend.
Baby F was the only baby in the unit on that night shift of the 4th and 5 August who was receiving TPN.
That's a convenient moment to break, members of the jury. It is actually exactly 1 o'clock. Could you be ready, please, to continue at 2.05? Thank you very much. Remember your obligations as jurors.
(1.00 pm) (2.03 pm)
(The short adjournment)
(In the absence of the jury)
Mr Justice Goss: Mr Myers, thank you. I've read your note and I have seen Mr Johnson's response as well. I’m happy to refer to this, but what I propose to do is to put it in its context, in other words revisit that whole section, because it really comes within the section that I gave about Professor Arthurs.
BM: Yes. The reason we raised it is because in chief he gave a list of possible causes and although he included resuscitation in his report, for whatever reason that wasn't something he said in chief, and therefore simply in cross-examination we adduced that from him, which he agreed. Of course, the matter raised by the prosecution is to do with the question of the strength of the association, which is a slightly different issue, although it's one on which we've already made our position plain to your Lordship. But insofar as there's a list of alternatives, it certainly was one of the ones that he included on it, and as your Lordship knows, that's important to the defence because it something which applies across the board here as does the alternative the prosecution favour.
Mr Justice Goss: If you look at page 13 of the document that Mr Johnson sent under item 5, that's the top of the transcript there, it's above the passage that's highlighted. I can read it out if it's easier.
BM: I have it now. Mr Justice Goss: This is air on radiographs. It perhaps begins at the bottom of the first page -- previous page, 12, I'll read it out, then you can all hear it:
"Answer: We've seen it in some children who have undergone extensive resuscitation. I am just referring to my report where we didn't see this very commonly on radiographs in those circumstances, but we are now performing CT scans, which are more detailed scans, of babies who have died, which allows us to see smaller locules of gas, smaller and smaller -- better imaging effectively.
"Question: So a CT scan is more discriminating?
"Answer: Yes."
And then:
"Answer: In that sense we have seen it occasionally [this is post-mortem gas] following resuscitation and the premise is that we hypothesised that there is some natural gas in the body after death and it is possible therefore the resuscitation could circulate it around if it was successful in moving blood around with gas in it."
BM: Yes. And indeed when we cross-examined him with Baby D, he then talked about redistribution of the gas in that way.
Mr Justice goss: Exactly, that's what he said. What I’m going to do is to try and dovetail all that together.
BM: We're grateful. We understand the requirement that it is in context but it's just -- and we understand also that your Lordship, having taken the list that was initially presented in examination-in-chief, it was exactly as your Lordship presented it but something that was missing from that at that stage, which was introduced in cross-examination, was the potential contribution of resuscitation (overspeaking) --
Mr Justice Goss: But I am just alerting you to the (inaudible: distorted) I am going to be -- I will explain what it is and what the evidence is and I shall probably read out, in fact, what Professor Arthurs says, I think that's the best way of dealing with it, the relevant passages from the transcripts.
BM: Thank you, my Lord.
Mr Justice Goss: Thank you very much.
Mr Johnson, is there anything you wish to say?
NJ: No, thank you, it's all in the document.
(In the presence of the jury)
Mr Justice Goss: A matter relating to what I said this morning when I was reminding you of the evidence of Professor Arthurs about the findings in relation to Baby D of the air in the great vessels. What I’m going to do is remind you of what I said then and then supplement it with what was said in cross-examination so that you have the whole context about possible causes, according to Professor Arthurs, from a radiological point of view of seeing air in the great vessels on radiographs.
What was striking, he said, was the black line from left to right just in front of the spine which was gas in the aorta or the IVC, the great vessels which carry blood from or back to the heart or in both of them.
This was unusual in appearance and not typical of what they see in children who have died without an explanation.
That amount of gas is seen in babies who have died of sepsis or overwhelming infection or SUDI, which would not in any event apply to neonates, in trauma, road traffic accidents, and the like. Then he went on to say that he also saw it in the cases of two other children, including Baby A.
Now, "and the like" was in a sense taken further during the course of cross-examination and he was asked about whether CPR could account for blood in the great vessels. He said that as far as radiographs are concerned, he was looking at X-ray images and then he explained about CT scanning, which was multiple (inaudible: distorted) so you get much more detail and says that they can see a lot more in CT scans and in effect it's more discriminating.
Then he said about air in babies to be seen on radiographs. He said:
"In that sense we have seen it occasionally following resuscitation and the premise is that -- we hypothesise that there is some natural gas in the body after death and it is possible, therefore, that the resuscitation could circulate it around if it were successful in moving blood around with gas in it."
That he said was the only other possible explanation.
In cross-examination, he said:
"Question: (Inaudible: distorted) able to explain that where there has been resuscitation, CPR, that can lead to gas emerging in the great vessels.
"Answer: Yes. We don't think that resuscitation causes gas, but we think that normal gas that's in the post-mortem state could be re-circulated if there’s vigorous cardiac resuscitation.
"Question: So it encourages the gas to come out of solution in the blood, in effect?
"Answer: I think it more redistributes the gas in effect."
I'm grateful for that being raised with me and I've added it to my summing-up to assist you.
I had just said we were at the stage with Baby F and I said he was the only baby on the unit that night of the 4th and 5th who was receiving TPN, total parenteral nutrition.
In addition to [Nurse A] and the defendant, Nurses Sophie Ellis and Belinda Williamson were on duty in the unit over that night. The shift leader was Belinda Williamson. Nurse A was Baby F's allocated nurse. He was in nursery 2. Nurse A's nursing notes are at J2991.
She was really happy with him between 20.00 and 01.00. The observations are at J3191, the blood gas record is at J3255, and the fluid balance chart is J3203.
Behind tile 144, J3143, is the fluid balance chart from after midnight, the time that the nurses tried to change all the fluids. There was no way of knowing who gets the bags out, she said, the keys would change hands and it wouldn't necessarily be the designated nurse who would get the bag out of the fridge. The checks would then be undertaken, checking that the labels matched the baby's name and that everything matched up.
Dr Beech's prescription of earlier that day -- well, in fact earlier the preceding day but on the previous shift -- was started at 00.25 and signed for by the defendant and Nurse A. There was no way of knowing 100% from the documents who did what. By that time lipid was not required because Baby F was on milk and did not have the need for it.
The evidence of Professor Hindmarsh was that there must have been synthetic insulin in that bag of Babiven TPN and it will assist you if you have to hand Professor Hindmarsh's blood glucose log for Baby F, which is in section 5 at your first jury bundle, as I go through the events.
We became very familiar with this document and I can see, as I saw at the time, a lot of you made notes on this very document and highlighted various points about it. I'm not going to go through it all now because it’s there, you're very familiar with it, but I noted, and you may well have noted, that it's probably worth adding in the box down (inaudible: distorted) begins 05/08/2015 at 01.54, below the first entry at 01.54, if you haven’t already done so, 02.05, dextrose started 10%. And then between 04.02, 04.20 and 05.00, 04.20 dextrose, 10%, 3ml. These were boluses to reflect the background of ongoing insulin actions. The significance is what Professor Hindmarsh referred to as the subsequent readings were affected by those boluses.
Between 01.00 and 04.40, the observations chart document at J3191 behind tile 214 records that there was a sudden rise of Baby F's heart rate and respirations at 01.00 with the heart rate up to 190 beats per minute and then up to over 200 beats per minute and respirations up to 70 per minute, each at levels in the yellow, unacceptable levels, and Belinda Williamson said that will have been brought to her attention.
Sophie Ellis, who was the designated nurse for baby EJ, administered antibiotics and other medication to Baby F in the early hours of 5 August as set out behind tile 168.
Dr Harkness, the registrar on duty that night, attended the unit at 01.30 with a senior house officer, Dr Chris Wood, who made a clinical note at the review. It was noted that there were multiple small milky vomits and 9ml of milk aspirate. Baby F was tachycardic at around 200 beats per minute, otherwise he was well.
Professor Hindmarsh said that vomits and a rise in the heart rate are associated with hypoglycaemia.
Around an hour later, Dr Harkness was asked to see Baby F again. He was still tachycardic. His heart rate was 200 to 210 beats per minute with narrow complexes in the beat and there were large milky aspirates. His blood glucose level was very low at 0.8, a reading which Dr Gibbs told you was worryingly low.
On examination and testing, nothing else was abnormal except his creatine level, which was slightly abnormal, and Dr Harkness wondered if he was dehydrated. He also queried whether it was sepsis. He spoke via phone to Dr Gibbs who advised him that the heart rate and rhythm was unlikely to be supraventricular tachycardia, SVT, because, as Dr Gibbs told you, if he had an inherent problem in the pacemaker of his heart, the rate is usually closer to 300 beats per minute, so it wasn't SVT.
Dr Gibbs approved the plan, which was the administration of a 2ml per kilogram dextrose bolus as well as a bolus of saline, salt water, to improve his general circulation, to start him on a second line of antibiotics, cefotaxime and teicoplanin, and address the possibility of an infection and undertake a twelve-lead ECG, which is a much more sophisticated way of picking up problems with the heart than the heart monitor.
(Pause)
The intravenous infusion prescription document is behind tile 167, J3146. [Nurse A] identified her signature at entries 3 to 8 between 02.00 and 04.20.
Belinda Williamson identified her signature for a bolus of saline at 02.55 and she thought it was her signature for boluses at 02.05, dextrose, 03.35, saline and 04.10, saline. She agreed she played a part in the administration of medication in the early hours of that morning.
In her nursing note at 06.56, Nurse A summarised the events up to that time. The note referred to the large milky vomit, the heart rate going up to 200 to 210 beats per minute, the respiration rate increasing to 65 to 80, and [Baby F] becoming quieter than normal. The glucose level at 0.8 was dangerously low.
Nurses Nurse A and Sophie Ellis and Belinda Williamson were clear that they had not administered any insulin to Baby F. Similarly, you heard from Nurses Cheryl Cuthbertson-Taylor and Valerie Thomas, both now retired, who were working that night shift, who said that they never in their time as nurses at the hospital added any substance, including insulin, to a TPN bag,indeed they never had any dealings with TPN bags because they were band 4 nurses.
Similarly, Kate Brammall, who worked on the day shift on 4 August, said that she never added anything to a TPN bag, it was something that was never done.
Kate Bissell, a senior neonatal nurse at the hospital who was carrying out audits on 4 August and had nothing to do with the delivery of a TPN to the unit that day, confirmed that she had never added anything to a TPN bag. So none (inaudible: distorted) said they had or had ever added insulin to a TPN bag.
Dr Gibbs conducted his consultant's ward round at 8.30 on the morning of 5 August. His clinical notes are behind tile 238. Baby F had a high heart rate and was showing a slight decrease in circulation. His blood sugar level, glucose level, had dropped to 1.7, which was unexpected, so another bolus of dextrose was given. His symptoms did not fit together said Dr Gibbs.
Shelley Tomlins was Baby F's designated nurse. At 0.40 that morning Baby F was tachycardic, his heart rate still being quite high, but his other observations were normal. The reference is to tiles 213 and 214.
Dr Sally Ogden saw Baby F at 10.00 hours. The clinical notes of her ward round with the consultant Dr Saladi are behind tile 238. His blood sugar had dropped from the previous reading but until this point he wouldn't have been receiving any dextrose because he wouldn't have had a line in. Do you remember there was an interruption (inaudible: distorted) line in?
There was a problem with the line in the right leg which had become tissued, meaning the infusion was going into the tissues rather than into the vein and was probably painful for Baby F, so they stopped the TPN via the long line and, according to Dr Saladi, moved the TPN to a peripheral line (inaudible: distorted) and gave glucose through that.
Then, at 10.30, a new long line was inserted into the left foot as referred to in tile 244 which, when reviewed on X-ray, was satisfactorily placed and she recorded that the new long line was to be used and the old line had been removed.
Shelley Tomlins was taken through the relevant charts, readings and notes relating to events during the course of that day, which are behind tiles 215 to 221. Boluses were given and readings taken, which invariably showed low blood sugar levels. Boluses were given at various times. You saw a video recording demonstrating the Alaris (inaudible: distorted) plus infuser pump, how it's set up with the bag containing the fluid running into a giving set and filter, then running down to the catheter, giving access to the vein. A bolus cannot be given through the pump. The alarm alerting staff to occlusion in the line or air in the line can be muted for 2 minutes. You also saw a video recording of the Alaris syringe driver.
Nurse C explained (inaudible: distorted) TPN going through the infuser pump. There would be ports enabling the 10% dextrose to go through either another Alaris pump or a syringe driver and then the lipids going through a further syringe driver or into the long line into the vein. Some of the long lines had two lumens.
In addition to the removal of the long line and the insertion of the new long line, Shelley Tomlins confirmed that she zeroed all the pumps at 12.00 hours, tile 259, J3204. They had been off for 1 hour during which time his blood sugar had risen to 2.4.
She hung a new bag at 12.00, tile 261. The neonatal parenteral nutrition -- the neonatal parenteral nutrition prescription. She was unsure as to whether the writing of the start and finish time was in her writing. She said the new bag, which replaced the bespoke bag that had been made for Baby F, will have been taken from the stock of bags in the fridge on the unit.
The stock bags did not have added vitamins, so they could be stored for much longer. She thought there would be about five bags stored in the fridge at any one time and there was no log or record. Everything that was left in the fridge was counted every night shift and, if anything had been used, more would be ordered.
The keys to the fridge were usually held by the nurse in charge. As I've already reminded you, any one of the nurses could go and ask for the bunch of keys and end up accidentally having them in their pocket for a while after, so it wasn't strictly enforced and there wasn't any log or record kept of who was entering the fridge or what was in it or who had the keys at any given time.
Premade syringes of morphine, intubation kits and small amounts of premade drugs for use with the intubation kits and (inaudible: distorted) insulin were kept in there. If the insulin wasn't kept in the fridge, it was in the nursery where medications like antibiotics were kept in cupboards, which were locked as well. The keys were on the same bunch of keys as the fridge key.
On tile 274 at 15.00, the word "restarted" is written indicating it looked like they'd stopped the dextrose and restarted it. The intensive care chart, J3204, shows that at 15.00 and 16.00 Baby F had received boluses of 10% dextrose. His blood sugar was still low at 1.9.
At tile 277, a blood sample at 15.01, had a blood sugar of 1.3. At 17.40, as recorded on J2963 behind tile 291, Dr Beech was asked to prescribe 15% dextrose over 24 hours at handover, to stop the TPN, check urinary (inaudible: distorted), cortisol and insulin. She assumes she was asked to do this by a consultant.
The nursing notes of Shelley Tomlins behind tile 215 just before she went off duty confirm:
"Persistent hypoglycaemia."
And:
"Therefore after discussion with Dr Jayaram, Baby F now changed from TPN, lipid and dextrose to just dextrose and NaCl [sodium chloride] added."
And:
"New fluids commenced around 7 o'clock this evening."
She then made a note that bloods had been taken via a venous sample and sent to the laboratory. It was at 19.00 that the infusion from the TPN bag was stopped.
Dr Beech, who was the first witness to comment on the results of the pathology, collected blood samples taken at 17.56 behind tiles 292 and 293. We heard more evidence about the results from Dr Gibbs, Dr Anna Milan, a consultant clinical biochemist working in the Clinical Biochemistry Unit at Liverpool Foundation NHS Hospital Trust, and from Professor Peter Hindmarsh, emeritus professor of endocrinology at University College London and also a consultant paediatric endocrinologist at University College London Hospitals.
An endocrinologist deals with the hormones in the body that regulate a number of areas, such as overall metabolism, glucose or sugar metabolism, fat metabolism, growth and development and air(?) response to stress.
The sample was frozen and will have been transported to the Liverpool Royal by courier or taxi. The analyser, which was manufactured by Roche, a global provider of such equipment, was checked and the results were held until technically validated. Then they were interpreted and phoned through to the Countess of Chester.
The records showed that the sample taken at 17.56 was booked into the system at the Liverpool Royal at 16.15 the following day. Applying the same(inaudible: distorted) unit of measurement, picomoles per litre, the level of C-peptide was undetectable, being less than 169, and the level of insulin was 4,657. The C-peptide figure should, in health, be anything between five and ten times the size of the insulin figure. This result prompted the chemist to message the Countess of Chester, reporting that the result was:
"Low C-peptide to insulin, query exogenous."
Which Dr Milan said was shorthand for saying: is this exogenous, it looks like it?
It was suggested it be sent to Guildford for further testing in relation to exogenous testing. This was not done, Baby F having recovered, and so the sample, which was preserved for 7 days, was thrown away.
Professor Hindmarsh, drawing together the data from the prescription and administration notes over the period of the ongoing hypoglycaemia which had taken place despite five bolus injections of 10% dextrose and the ongoing glucose delivery from the 10% dextrose infusion that was running concomitantly and the glucose that was also contained within the total parenteral nutrition, said that would give a glucose infusion rate of somewhere in the region of 12 milligrams per kilogram per minute, which is twice the normal requirement of a baby and to which had to be added the contribution from the five bolus injections also given. So in terms of the amount of glucose being administered, a minimum of twice the normal daily requirement, probably more than that, was being given to Baby F.
When the professor returned to give evidence on 24 February in relation to Baby L, he revisited the log he produced of blood glucose readings for 5 August.
He explained that the increased readings of 2.3 at 02.55 and 2.9 at 05.00 hours are consistent with the administration of the two respective 3ml boluses of 10% dextrose at 02.05 and 04.20 hours against a background of ongoing insulin action. He went through the calculations, which are not in issue and of which I need not remind you.
Following the discontinuation of the intravenous feeds, there were two further glucose measurements: one at 11.46 of 1.4, so not too much different from the 10.00 reading, then a further value at 12.00 of 2.4 millimoles per litre, which would imply that the blood glucose had started to increase spontaneously because at that stage there was no contribution from the intravenous route. In other words, Baby F was receiving double the normal requirement of sugar as a result of the combination of TPN and dextrose and yet, when taken off the double quantity of sugar, his blood sugar actually increased.
In relation to the slightly different measurements of 1.3 and 1.9 taken close together at 17.56 and 18.00 respectively, one was a plasma glucose measurement and the other a near-patient blood glucose measurement. There's a slight difference, said Professor Hindmarsh, between the two. If you compare a finger prick or heel prick blood glucose measurement with a plasma value, the blood glucose measurement should be increased by about 10% to 15%. This is also relevant when comparing the plasma laboratory value in Baby L's case with the record of all other blood values.
In relation to the dangers of very low insulin, Professor Hindmarsh explained that the brain is reliant on a constant supply of glucose for functioning. It doesn't store any glucose in reserve to any significant degree. It can store glucose as glycogen. That will only last 20 minutes. After that, there is no other energy available for functioning of the brain.
During hypoglycaemia, the body can generate ketones, the breakdown products from fat, and the brain can utilise the ketone bodies from that breakdown of fat as a substitute for the glucose that's missing. However, if the low glucose hypoglycaemia is caused by an excess of insulin, the insulin will reduce and the blood glucose and -- that source of energy will switch off ketamine (sic) causing a situation of hyperinsulinaemic hypoglycaemia. The brain is then very susceptible to incurring damage. That damage depends a little bit on the duration of the hypoglycaemia and also on the depth of the hypoglycaemia.
Initially, if you go down to a blood glucose of 2.6 or 3, then you'll have mild confusion, and if you are involved in any cognitive process, such as reading and writing, then there will be a deterioration in that. As you progress further down in terms of the blood glucose delivered to the brain, and that's not much, then it can lead to seizures, death of brain cells, coma, irreversible brain damage and, on occasions, death. Dr Evans confirmed this when he gave evidence.
Synthetic human insulin has been in use for the last 20/25 years or so, possibly more, and is regularly stocked in the hospital pharmacy. Actrapid is the commonest ward stock and is short-acting. Long-acting insulins are given subcutaneously and are not relevant in this case. It is not possible to give insulin via mouth, by the oral route, because it is a large molecule and can't(?) be broken down, so it could not be administered through a nasogastric tube.
In relation to the subcutaneous route, under the skin, there would have to be multiple subcutaneous injections, roughly every 4 to 6 hours over the 17 or so hours of hypoglycaemia that Baby F had. And to get that effect you'd probably have to do that almost at the same time as the total parenteral nutrition bag was set up, so there would be quite a few objections, and it’s also difficult to start to explain why there is such a quick return towards normal blood glucose, particularly when the TPN stopped at 18.55 and there was an almost instantaneous rise to 2.5 and, by 21.17, normoglycaemia had been achieved, whereas with subcutaneous injections there wouldn't have been such a rapid response.
This implied that an intravenous route was the most likely explanation. There were two ways of administering it intravenously: the first is bolus injections of insulin, where hypoglycaemia will occur 20 to 30 minutes after the bolus injection. If nothing is done, the blood glucose will then start to rise back up again and be normal some 60 to 90 minutes after the bolus injection. So to maintain hypoglycaemia over such a protracted period of time, multiple intravenous injections, roughly every 2 hours, would have had to have been administered.
The second way is through an infusion. This, thought Professor Hindmarsh, was the most likely way of achieving the blood glucose effects observed, a continuous infusion using the bags of fluid that were available. That fitted the time when the fluids were discontinued for re-siting the cannula at 10.00 on 5 August and would also be consistent with the events or measurements that took place after the TPN was stopped at 18.55.
(2.42 pm)
(No audio or video feed from court)
(2.44 pm)
Mr Justice Goss: Professor Hindmarsh calculated from the blood sugar results that the rate at which exogenous insulin was being administered to [Baby F] to maintain a steady state insulin concentration of 4,657 picomoles per litre, and adding some slight amounts to deal with adhesiveness of insulin to plastic, would need an insulin infusion rate of approximately 1.2 units per hour.
Using that calculation, he concluded that 0.6ml of insulin would need to be added to the TPN bag to deliver the rate of insulin he calculated Baby F was receiving. It's a clear fluid and would be invisible to the naked eye and you wouldn't notice any change in the shape or size of the bag. It's obviously a very small volume.
The same amount would have had to be added to the stock bag of TPN that replaced the bespoke bag after the long line was re-sited as the blood sugar concentrations were about the same.
Professor Hindmarsh concluded that Baby F's clinical presentation from just after midnight on 5 August to the early evening of the same day was explicable, and only explicable, by the fact that the fluid he was receiving had been contaminated with insulin.
Dr Evans concluded at an early stage of his review of Baby F's medical records in 2018 and early 2019 that Baby F had received exogenous insulin and that it had been given via the intravenous route used to facilitate nutrition, TPN in the 500ml bag or bags delivering the nutrition from just before 01.54 on 5 August until the infusion was stopped at 18.55. From 21.17 hours that day, the glucose readings were of normal values and remained so thereafter.
Dr Bohin agreed with Dr Evans' conclusions and added that there was evidence to indicate that the TPN bag had been changed during this period and therefore two bags must have been contaminated, the originally prescribed one and the one that was made up in its place, which followed the protocol that a new bag would be put up when a long line was changed.
When interviewed on 10 June 2019, the defendant remembered Baby F as the surviving twin of Baby E, whose death had affected her. She did not remember the incident other than looking at the notes provided. She agreed her signature was alongside a TPN bag entry at 00.25 on 5 August. She could not remember whether she administered the TPN bag or not. The other signatory was Nurse A.
The TPN bags were kept in the top of the locked fridge and the insulin was kept at the bottom. All nurses, including nursery nurses, had access to the fridge along with doctors. She confirmed there was one set of keys that would be passed between them. The relevant TPN bag would have been made up in the pharmacy, labelled "Twin 2 [Surname of Babies E & F]" in a secure bag and marked to this effect. This would have been checked before being set up.
In terms of connecting the bag to a baby, if you're starting fresh you have to get a new giving set into the bag, run the fluid through and then connect it to the baby or sometimes they would just do a fluid bag change, unscrewing the old one and putting the new bag on. They tried to do that with someone else all the time.
She was unsure whether TPN bags had a port for the addition of a medication, but in any event medication would not be added into a TPN bag. She didn't remember any involvement with connecting the bag to Baby F at 00.25. If a bag had to be disconnected it should not be reattached as it was no longer sterile. Once disconnected a bag should be disposed of in the sluice room.
The defendant agreed there was a significant drop in Baby F's blood sugar in the reading at 01.54 on the 5th. This was dangerously low. She had no idea what had happened to cause the dramatic decline that followed. She denied having deliberately harmed Baby F and denied giving him any insulin or placing any in his TPN bag.
She asked the police whether the TPN bag was checked and asked the officers how they knew after the event whether the insulin was there at the time the bag was checked.
In the interview on 10 November 2020, when asked about Facebook searches on [Mother of Babies of E & F] on nine separate dates between 6 August 2015 and 10 January 2016 and on [Father of Babies of E & F] once, she said she couldn't remember making them. She thought it may have been to see how Baby F was getting on because, as a member of staff, you would care about what happens to the babies and obviously they'd been through a really difficult time.
She said it was possible she was looking for photographs of Baby F. She could not recall if she'd successfully accessed an account on Facebook or found anything. She did not know why she had messaged Nurse A at 8.53 on 5 August 2015 telling her about Baby F's sugar reading of 1.8, which was a low reading, at 8 o'clock that morning when they had finished their shift but thought it might be to update her. She didn't know how she'd obtained the reading for 08.00 am but assumed it was by looking at the charts.
In her evidence she said she now accepted the readings and measurements. She did not remember hanging the TPN bags and thinks Nurse A must have. She agreed that it seemed Baby F had been given insulin and it was in the TPN bag. She did not know where it had been put into the bag but canvassed the possibility of it happening in the CIVAS unit where the bag was made up. She confirmed she did not know about C-peptide at that time and denied that she knew that the bags had not been kept.
She knew at the time that Baby F's blood sugar levels were low and accepted that adding insulin to the TPN was highly dangerous and life-threatening to a child of his age. She accepted that insulin was in the TPN bag hung at 00.25, or very shortly thereafter. She said she frequently searched for [Mother of Babies of E & F] because she was somebody who was often on her mind. Baby E's death did stand out to her and she often thought of them as a family. She got on well with [Mother of Babies of E & F] at the time and wanted to see how Baby F was doing because she got to know the family and he was the surviving twin of Baby E.
Obviously, I'll be coming back to insulin again when I come on to Baby L's case, but that's all I'm going to remind you of in relation to Baby F.
I turn then to Baby G.
Baby G is the subject of three counts on the indictment, 7, 8, 9, all allegations of attempted murder. I'll make a start, we'll have a break, and then I shall complete, I anticipate, my resumé of the evidence relating to her today. That will then be enough for today because there are three events that I have to remind you of.
Baby G was born at 23.57 on Sunday, 31 May 2015 in Arrowe Park Hospital, a tier 3 hospital. She was very premature, being only 23 weeks and 6 days' gestation and weighed 535 grams, just under 1 pound 1.3 ounces.
She was not breathing and was blue and floppy, was given ventilation breaths and was intubated. She was at the margins of survival when she was born. She stabilised, was taken to the hospital's neonatal unit and placed in an incubator, where she became pink and well perfused. She remained intubated and was in respiratory distress before things settled down.
Her chances of survival were very low, but she did survive, being cared for for 11 weeks in Arrowe Park Hospital. She had events during that time, one being on 4 June when she was very unstable and had problems with blood pressure, then episodes of bleeding, culminating on 29 June with a pulmonary haemorrhage, requiring a Broviac line until 30 July. By 12 July, she was in a special care or high dependency room, a lot better and quite stable.
On 13 August, at a gestational age of 34 weeks and 3 days, Baby G was transferred to the Countess of Chester in a stable condition and with no obvious problems. She had been on expressed breast milk feeds since 22 June and weighed 1.26 kilograms, so she was almost 2.5 times her birth weight.
The defendant remembered Baby G, who had a lot of ongoing issues when she arrived at the Countess of Chester. The prosecution case is that the defendant deliberately overfed her milk, once on 7 September and twice on 21 September 2015.
Baby G remained clinically stable over her first 3 weeks at the Countess of Chester. Dr Stephen Brearey, a consultant -- and as I reminded you yesterday, he was the neonatal lead at the hospital at that time -- first reviewed Baby G on a ward round on 22 August. The general trend for that time was one of improvement in terms of respiratory statement and establishing feeds, which continued.
Baby G's intensive care observation chart for the period of 2 September through to the start of the night shift of 5 September is J6959, and that's the first document in section 7 of your second jury bundle.
She was stable and well, having occasional desaturations after feeding, which were all self-correcting. On 6 September, when Dr Brearey was the consultant on duty, her oxygen requirement was continuing to come down and her feeds were well established. She was having milk by NGT and bottles, she was on fortifiers and Gaviscon.
She was in the cot in the far corner of the room, near the window in nursery 2 on 6 September. Her designated nurse for the day shift on that day, commencing at 08.00, was Victoria, known as Vicky, Blamire. She was a special care baby, the lowest of the levels under the BAPM standards in terms of neonatal care. Her observations relating to heart rate, respirations and temperature are on the next page in section 6 -- is it section 6 or section 7? I've given you two different section numbers there. It is section 7. Sorry about the first wrong reference.
It's on J6960, which is behind tile 56. Vicky Blamire described the readings as fine and she was a stable baby and one about whom she had no concerns. She was being fed by nasogastric tube and bottle at three-hourly intervals. Her feeding chart is behind tile 27. In summary, she received four feeds of 45ml each of expressed breast milk, with Gaviscon and a fortifier, which made the consistency thicker. Two ofthose feeds were by bottle and two by tube. Nothing untoward occurred.
Dr Brearey saw Baby G that morning and confirmed she was quite stable and improving. On examination she was pink and well, her chest was clear and her abdomen appeared soft. Preparations for her discharge home continued.
Vicky Blamire handed over to Nurse E, tile 47, who became Baby G's designated nurse for the night shift on the evening of the 6th and 7 September. Behind tile 47 are the handover details. Baby G was the only baby in nursery 2 during that shift. The defendant had a baby in nursery 1.
Count 7, an allegation of attempted murder, relates to events surrounding a projectile vomiting episode at around 02.30 on the morning of 7 September and after the noted time of 02.15.
Baby G, as I've reminded you, was in nursery 2. The prosecution case is that after Nurse E had given Baby G her feed at 02.00, the defendant deliberately injected milk and air by a syringe into her and noted the event at 02.15 to link it to a feed a short time earlier.
Before I remind you of the details of the evidence relating to that event, we'll have our ten-minute break and I'll continue then.
(3.01 pm)
(A short break)
(3.11 pm)
Mr Justice Goss: 7 September 2015 was Baby G's 100th day of life. The nurses were making a banner for her to celebrate. Ailsa Simpson was the shift leader that night and Dr Alison Ventress was the registrar on duty.
Nurse E completed the observation chart at three-hourly intervals at 20.00, 23.00 and 02.00.
The entries in the next three columns with her initials are at the bottom of J6960, which is the second page in section 7 of your second jury bundle. Baby G was still on nasal prongs and some oxygen. Nurse E commented that, at 20.00, the respiration rate was at the higher end of normal, but her heart rate and temperature were normal and remained so, the respiration rate having dropped by 02.00. That can all be seen on the chart to which I've just referred.
She looked stable. The feeding charts are behind tile 57, J7012 and J7013, and you have paper copies in the last two pages in section 7AA. The first two are at the bottom of J7012 and the last one is at the top of J7013.
Nurse E said she usually completed the chart after the feed. The feeds were as they had been over the previous shift, comprising 45ml of expressed breast milk with Gaviscon and a fortifier. The feeds were all measured out. Those at 20.00 and 02.00 were given by NGT because Baby G was asleep. The one in between, at 23.00, was by bottle. At that bottle feed she recorded under the PU and BO columns that Baby G had passed urine and a large normal bowel movement. She fed well. The defendant agreed her readings were good at this time.
Nurse E described the process for feeding via NGT. The syringe was attached to the end of the tube, a bit of the stomach contents, about half a millilitre or less, were withdrawn or aspirated, put on to one of the pH indicator papers to check that the tube was in the right area of the body or not, an acid reaction of 5.5 or below confirming that the aspirate had come from the stomach, any surplus milk aspirate was put back into the baby's tummy. The syringe would be taken off and the plunger removed. The syringe was then reattached to the tube and the milk feed was poured into the tube using the end of the plunger to make the milk go down, tilting the syringe to one side and letting the milk go down by gravity. The syringe was then topped up as the milk went down until it had all gone.
It was then detached from the tube and the end was put back on to the tube. She would take the observations while the milk was warming, feed time and the observations were recorded at around that time frame before the feed was given. Usually babies' breathing rates go up after a feed.
The pH acidity tests of both feeds were recorded as 4, which confirmed they were acidic and had come from the stomach.
After the feed Nurse E went on her one-hour break. She said this was likely to have been around 02.05 to 10 on the morning of the 7th. If Baby G had looked unwell or she had had any concerns, she would not have taken her break.
When she came back from her break 1 hour later the lights were on in nursery 1. She went to nursery 2 to check on Baby G but she wasn't there, so she went back to nursery 1 and was told by staff that Baby G had been unwell while she had been on her break. That, she said, was unexpected. Baby G had been in her cot, was fed and settled when she left her, and there hadn't been anything on her observations so far that shift that had caused her any more concern than usual for a baby that was a low-flow oxygen.
Ailsa Simpson, the shift leader that night and the designated nurse for AC in nursery 1, described it as a relatively calm shift. Baby G was in good condition, feeding well, weighed just under 2 kilograms, and was progressing as the nursing staff hoped. The neonatal review on page 3 of 7, line 26, says she was feeding or fed AC at 01.15.
She said that would take no longer than half an hour, but she could not be definite about the time it did take. She co-signed for the fortifier and Gaviscon and medications for Baby G, as can be seen from the documents behind tiles 64 to 66 at 23.00 and again at 01.46 and 01.47.
She last updated the computer with Nurse E at 01.47. She said she then embarked on getting the milk from the fridge for baby AC's next feed in nursery 1 at 02.20, which is the timing given to the feeds set out in line 41 of the neonatal review. All her timings were approximate. She was referred to the record of another baby on the unit at that time, DB, the document is J29020, which has medication being administered to that baby, DB, by Nurse Christopher Booth and she was a co-signer at 02.13. She wasn't sure where the computer was that this signing was documented on. She would have had to have been with Chris Booth at that time.
After about 5 to 10 minutes after she had finished feeding AC in nursery 1, she was sitting at the nurses’ station, almost opposite the door to nursery 1 and about 10 to 12 feet away from Baby G's cot, when she heard a significant projectile vomit. The defendant was sitting with her at the station. When she was interviewed prior to making a witness statement on 1 September 2018, she said that as they were going over to Baby G's cot, a time she estimated as about 30 seconds after the vomiting, Baby G's alarm went off, indicating a significant drop in oxygen levels and heart rate.
There was a large amount of milk she had been fed and it had come back up. She could see vomit in it and on the bed sheets and the side of the cot, on the floor next to the cot, and on the arm of the chair beyond that. She directed a police officer to mark the areas on a photograph, which depicted a different chair, but in the same position as the one that was there at the time. You have seen that photograph, I'm sure you'll remember it, for which your reference is J26510. They sat Baby G up and, realising her heart rate and saturation levels had dropped, gave respiratory support in the form of Neopuffs.
In her witness statement made on 1 September 2018 Ailsa Simpson said:
"Lucy and myself were sat at the nurses' station from about 01.15. As far as I can recall neither Lucy or I moved from that station during that time."
In an earlier statement made on 9 February 2018, she said:
"Prior to Baby G's observation and monitor alarm activating, I cannot remember where the other staff were. Once the observation monitor alarm activated at the nurses' station, I immediately jumped up and ran into Baby G's nursery along with Lucy."
She confirmed that that statement was prepared from an audio-recorded interview the police conducted on the same day in which, when asked where Lucy was, she replied:
"Either she was probably sat outside with me at the nurses' station or possibly in with whoever she was looking after that night."
On that shift the defendant, as I've said, was the designated nurse for baby IH in nursery 1. In her evidence she said that her recollection was that she had no contact with Baby G on that shift before the vomiting episode. She remembered Baby G as a baby who had a lot of ongoing issues, but agreed, from the feeding charts and observations on the 6th and 7 September, Baby G’s readings were good up to the 02.00 feed.
She was sat at the nurses' station with Ailsa Simpson and had been there a few minutes when they heard an alarm and a loud retching sound. They both went in and found Baby G vomiting from her mouth and nose and struggling to breathe. No one else was in there.
She could not recall any contact with Baby G on this shift before this. She referred to the neonatal unit review on which she was documented as taking observations and feeding baby IH in nursery 1 at 02.00, something she said that would take a few minutes.
She said that they immediately started to give Baby G Neopuffs, her abdomen was firm and red, she thought she used the Neopuff and Ailsa went for help. She did not attribute the event to staff levels or Baby G's treatment up to that point. She identified a possible nursing problem of Nurse E overfeeding Baby G, but didn’t believe that she did. She agreed it was an extraordinary vomit that she had not seen from a neonate.
When interviewed by the police about this event on 5 July 2018, which is in the [document redacted] section of the interview file, the defendant said it was a shock to have three deaths in June, one in August and one in September. She said:
"You just have to find a way to deal with it and carry on to provide the job and care that you give."
She didn't feel that there was anything that needed to be looked into. It was just a shock for everyone. She recalled Nurse E being Baby G's designated nurse on 7 September and Nurse E was on her break when this happened. She agreed that the notes suggested she took over care at 02.00 but she could not recall why. There were no clinical concerns at the start of the shift.
She had found Baby G vomiting. It was projectile vomiting of a large volume of milky-coloured vomit. She said that sometimes babies did vomit, but not very often was it a projectile vomit. She questioned whether the baby had just been fed, but confirmed that she was not involved in Baby G's feeding. She thought maybe she’d gone to help Baby G because she heard her vomiting.
When asked about the significance of the air obtained from the nasogastric tube, which she recorded as ++, she replied that:
"Sometimes when babies vomit, they can take on air as well if they're gasping with the vomiting."
The volume of air from the NG tube was a larger volume than the general amount that would usually be obtained, but she was not sure of the cause of the air in Baby G's abdomen. She said that air could accumulate if there was a bowel problem or infection.
She thought that the vomit went into the cot and down Baby G's clothing. She heard her vomiting and may have seen her vomiting.
When interviewed again on 11 June 2019 about the collapse on 7 September, she said she didn't believe Nurse E would have left Baby G had there been any concerns. In relation to the vomit she agreed there were two possibilities: Baby G must have received more than the 45ml of milk or she had not digested the milk from her previous feed. She thought she could have projectile vomited on 40ml of milk. She denied overfeeding Baby G or administering air via her feeding tube. She had no explanation for how the large volume of air could have got into the stomach.
In evidence she said it was an oversight that she did not mention when interviewed that the vomit went on the floor and on the chair. She said it was an extraordinary vomit that she had not seen in the case of a neonate.
Nurse Christopher Booth answered the call for help, arrived in the nursery when other staff were already there and Baby G was being given oxygen and breaths via Neopuffs and helped with the resuscitation.
Dr Alison Ventress was the registrar on duty that night. She confirmed that there were no concerns raised by the clinicians handing over at the start of the shift. For your reference, tiles 80, 84, 107, 117 to 119 and 136 are the relevant medical tiles. She was reliant on the notes made at the time. Her note behind tile 80 recorded that she was called urgently at 02.35. The agreed evidence of Lisa Walker was that Dr Ventress arrived within minutes of the call.
It was put to the defendant that this means that the event occurred very shortly before she was alerted and some time after Nurse E had been feeding her at 02.00 and gone on her break.
On her arrival, it was reported to her that Baby G had:
"... had very large projectile vomit, reaching chair next to cot and canopy, abdo appeared discoloured, purple and distended."
The note continued:
"Baby G distressed and uncomfortable. Red in face and purple all over."
She could not recall whether this was something she was told or saw for herself. Her oxygen had been increased, her desat levels had dropped to the 80s but her heart rate stayed normal. Then:
"Full feed (45ml) aspirated."
She was not sure if she had asked the nurse to do that or whether the nurse had done that before she arrived. The note went on:
"Large watery stool passed, after which abdo slightly better and Baby G relaxed and appeared back to her usual self."
Again, she was unsure as to whether this was something she was told.
The next line onwards was her input when she was there. It was:
"Planned to cannulate, start IV fluids and take some bloods."
However, she was called urgently into theatre. By this time Baby G was better and she was happy enough to leave her and was not worried.
Less than half an hour later, she was called out of theatre because Baby G had gone apnoeic and dusky. This was shortly before 03.30. She stopped breathing, her sats had dropped to 50%. When Dr Ventress arrived, Baby G was receiving IPPV. Her heart rate was okay, it took around 5 minutes for her sats to pick up. She was thenmoved to nursery 1 on CPAP.
Dr Ventress tried unsuccessfully to insert a cannula or drip on two occasions. Baby G then had a further profound apnoea, her heart rate went down to 70 and her oxygen saturations went down to 40, her perfusion worsened, her cap refill time was 3 seconds -- it should have been 2 or less. IPPV using a mask was started again and there was a gradual improvement.
Dr Ventress decided to incubate her in order to put her on a ventilator rather than persisting with CPAP via a mask as that forces air into the tummy as well. A size 3 ETT was inserted. While she was doing that Dr Ventress noted bloodstained fluid was coming up from the trachea or between the vocal cords, which she said was likely to be fresh blood, a small amount. It was unusual to have blood coming up from beneath the vocal cords, she said, because that is not an area that they would touch with the laryngoscope. Good bilateral air entry was achieved and the capnograph was positive and her sats improved.
In her first police interview the defendant was asked about the record of a profound desaturation and marked colour loss with an apnoea at around 03.15. She could not recall how long it had taken for Baby G to desaturate or who was present when the profound desaturation took place or where she was at that time.
Dr Brearey arrived at about 03.30. In relation to projectile vomiting, he said he'd seen it in babies with other diagnoses but not in a preterm baby like Baby G who had been stable for so long without the diagnosis of pyloric stenosis, which Baby G didn't have. She responded well to the treatment and her readings returned back to normal, although some air was leaking back up the windpipe. Dr Brearey was called to theatre, but he was content with her progress.
At 05.30, whilst still on the ventilator, there was another profound desat. IPPV was started and the team wondered if there was a problem with the ventilator. Dr Brearey, who was still in theatre, said it was very unusual for babies to desaturate when on a ventilator. It was perplexing that he couldn't think of a natural cause why that would happen. The flow sensor was changed, but that made no difference, so they changed the whole ventilator.
There was a further profound desaturation at 06.05, by which time Dr Brearey was in the unit. Her sats remained low and she was being given 100% oxygen.
The decision was made to re-intubate. The ETT was removed at 06.10 and:
"Thick secretions ++ in the mouth and a blood clot at the end of the ETT."
Were noted. So, said Dr Ventress, there was some blood coming up from the windpipe or lungs that caused the clot and that could have been interfering with the flow of air.
Despite a jaw thrust to bring the chin forward and using a Guedel to lift the tongue off the back of the throat, the sats and heart rate had fallen. The nasogastric tube was aspirated as the abdomen appeared very large and around 100ml was aspirated, which, said Dr Ventress, was a lot. And she couldn't say 100% from that entry that it was air because she hadn't documented what it was, but she thought that she would have documented if it was not air.
Dr Brearey said he assumed it was milk or fluids and, if it was, he couldn't explain where it had come from, although he couldn't be 100% sure he took it to be milk or stomach contents because you don't aspirate air with a syringe -- from a syringe.
Baby G was re-intubated with a slightly larger tube at 06.15. Dr Ventress noted when looking in the mouth that there was bloodstained fluid in the oropharynx, which is just below the throat. She suctioned below the vocal cords, but nil was obtained. A traumatic intubation can sometimes cause trauma, but she did not see any trauma.
X-rays taken at 04.48 and 06.36 confirmed chronic lung disease of prematurity that all babies born at 23 weeks would have. There was a lot of air in the bowels but no evidence of perforation.
The defendant recalled Baby G carried on having desaturations, she didn't know why and recalled her being re-intubated. She said she carried on providing support for Baby G for the rest of the shift. Her case is that she did nothing wrong and did not falsify any times in the notes. She identified a potential nursing problem with Nurse E having overfed Baby G, but didn't believe that she had.
She accepted that air or milk could have been pushed from the feeding syringe into Baby G's stomach, which was something she accepted in the 2019 police interview, but denied that she had injected any milk or air in this or any other way.
Behind tile 147 are J2366 and J2367, which are Dr Harkness' notes from 09.00 hours. The overnight query as to the cause of the sudden deterioration was sepsis or aspiration, that is inhaled vomit. Baby G was continuing to require and receive a relatively high amount of respiratory support and having desaturations and bradycardia, she was still quite unwell with low blood pressure and her heart rate was very fast. She had good perfusion but low urine output. She was paralysed and sedated. Low neutrophils can be a sign of infection, but they slowed the breathing down.
Contact was made with Arrowe Park Hospital. Things had improved by 10.00, but she needed a lot of support and was not out of the woods. The blood tests were inconclusive of sepsis. There was nothing concrete in relation to determining the cause of the collapse. There were no recorded malfunctions in relation to any of the four ventilators being used in the hospital on 7 September.
Baby G was readmitted to Arrowe Park Hospital the following morning, 8 September, at 04.30, with presumed sepsis leading to multi-organ dysfunction, requiring intensive support. She was very unwell on arrival, had severe hypertension and an MRI scan suggested a significant hypoxic or ischaemic insult abnormality in both cerebral hemispheres and possibly established infarcts. A radiograph taken at 05.00 did not, said Professor Arthurs, show evidence of NEC.
She required a blood transfusion for anaemia and vitamin K for blood coagulation. She was changed to single antibiotic therapy and she completed a seven-day course of meropenem. She gradually improved to not needing any support on her discharge to the Countess of Chester 8 days later on 16 September. She was self-ventilating in air and continuing to establish enteral feeding. The presumption of sepsis was based on her clinical picture and markedly elevated CRP as her cultures for infection were all negative.
The WhatsApp messaging passing between the defendant and Jennifer Jones-Key and Nurse A is set out in the sequence of events. In some of those messages, for example tiles 210 and 238, and a long sequence over 29 minutes from tile 246 onwards, there are direct references to Baby G's condition and being a high risk baby. The messaging continued to the point of Baby G’s transfer to Arrowe Park Hospital at 02.30 hours on 8 September.
Dr Evans reviewed all the medical notes and the marked photograph of the extent of the vomit. He noted Baby G's condition was stable and satisfactory up to shortly after the 02.00 feed:
"When a baby's stomach is full [he said] no more feed can be given under the force of gravity, so it's important only to feed by gravitational pressure. You could, but should not, force milk down the syringe into the stomach having inserted the plunger."
He confirmed that infection is, for babies on the NNU, the highest risk factor. He had only seen projectile vomiting in cases of pyloric stenosis, which Baby G did not have. It is something that occurs with babies 6 to 8 weeks of age or thereabouts and it doesn’t occur and disappear, it requires surgery.
He couldn't recall a baby vomiting as far as Baby G did in this case. He noted the subsequent extraction of 45ml of feed. It was his opinion that Baby G was compromised by receiving a large volume of fluid or fluid and air into the stomach. In that situation the stomach muscles would contract and the contraction of the stomach muscles would lead to the baby vomiting. This was not, he said, unique to babies. He proceeded on the premise that the stomach was empty prior to the 02.00 feed.
In relation to Nurse E saying that she had withdrawn only a small amount of aspirate to test that the end of the tube had been in the right place by giving a pH reading of less than 5.5, he accepted that he'd based his opinion, at least in part, on the stomach contents having been aspirated. The pH reading of 4, which was acidic, was indicative of acid in the stomach. If there was a significance amount of milk mixed up with the stomach contents the acid would look like milk and wouldn't have an acidity of 4.
He also said babies fed by NG tube do not vomit. The aspiration of the stomach after the vomiting and the passing of a stool will have taken pressure off the abdomen and there was some improvement of her condition, but she was compromised from the time of vomiting and suffered significant oxygen deprivation to cause significant irreversible brain damage.
He referred to Dr Ventress noticing blood on the lung side of the vocal cords, indicating Baby G was bleeding prior to the first resuscitation attempt. She did not have a bleeding disorder. He discounted pulmonary haemorrhage, that is haemorrhage in the lung itself, describing it as a killer, and she would have been unlikely to have survived such an event if it had occurred. There was no natural reason for any bleed before the projectile vomiting.
In relation to the role of any infection, by 14.18 hours, some 10 or so hours after the vomit, Baby G's CRP had risen to 28 and the neutrophil count had risen, which was a marker for infection. Twenty hours or so later it had risen further and peaked after she had been transferred to Arrowe Park. The infection occurred after the collapse and was not a cause of the vomit. He had never seen a baby with an infection present in the way that Baby G did. In his opinion she must have had more than 45ml of milk and had excess milk and air down the tube.
When challenged as to reaching his conclusion because of other cases of unexpected incidents, he said that this was the first case he looked at and reached his conclusion without knowing about any of the other cases.
Dr Bohin said she had never seen a baby weighing 2 kilograms vomiting, it was something quite extraordinary, and concluded it must have been a huge vomit of milk, considerably more than 45ml. In answer to the questions that you asked, namely what is the maximum amount of fluid the stomach of a baby of Baby G’s size could hold, how much would cause the diaphragm to be compromised, Dr Bohin said there isn't a right answer to the first question, the maximum amount such a baby could hold, and there was nothing much in the literature. A stomach of a baby that has not been fed is very small. Over time, in term babies, as they increase feed day on day, the stomach, which is muscular, stretches to be able to accommodate that. There is no research that she could find that provided an answer.
From her own experience and being at post-mortems, the neonatal stomach in a two-kilogram baby is very small, about the size of a plum, but it can actually extend a lot and in a baby who has been fed over many weeks and months, as Baby G had been, the stomach would actually have enlarged. So it's impossible to be precise as to the volume of a stomach in a baby who had been fed for many months.
Similarly, it was impossible to answer the second question, how much would cause the diaphragm to be compromised, because for some babies with normal lungs a distended tummy might press up on to their lungs only a small amount and wouldn't actually affect them very much. But Baby G's lungs were not normal because she had chronic lung disease and so most probably there wouldn't need to be much distension before her lungs were compromised, but in terms of the volume in the stomach she couldn't give an answer to that.
Dr Bohin read the nursing and medical observations charts for the whole of Baby G's feeding history, which you have. Prior to the 15 June on the second, fourth, sixth, seventh and fourteenth days of June there were episodes of desaturation. Some were markers of her being gravely ill, others were related to her chin being on her chest or handling.
On 14 June, when she was 14 days old, an ET tube was inserted. Enteral feeds, milk feeds, were cautiously commenced at half a millilitre every 4 hours via an NGT on 15 June. They were tolerated and gradually increased. There was no vomiting and the nursing staff recorded the nasogastric tube aspirates as minimal, which she took to be less than a millilitre.
Because the breast milk was tolerated, some fortifier was added from 26 June. There was a hiatus in feeding breast milk because Baby G had to have a Broviac line inserted by the surgeons at Alder Hey under general anaesthetic on 26 June.
On 29 June she probably had a pulmonary embolism. There was fresh blood on suction. Dr Bohin said that in a baby of this age and gestation, a pulmonary haemorrhage was not inevitably -- would not inevitably be a killer, but normally would be.
The feeds on 30 June were hourly feeds at 3ml every hour which were increased to 4ml every hour. When that happened Baby G had a single large nasogastric aspirate.
The feeds were continued and thereafter were well tolerated to the extent that breast milk fortifier was reintroduced. Between 30 June and 3 July she continued to be fed by hourly nasogastric feeds.
On 3 July the feeds were increased in an attempt to get her to gain weight. That increase was well tolerated and there was no vomiting or increased nasogastric aspirates.
She developed frequent desaturations. There had been one on 1 July which was diagnosed as being due to poor lungs. The desaturations were self-correcting, not requiring any help or intervention from nursing staff.
On 3 July there was the first mention of gastro-oesophageal reflux and she developed very thick secretions from her breathing tube from which they subsequently grew a bug.
They elevated the cot and started a course of erythromycin, an antibiotic. They also started her on Gaviscon for Babies, which in powdered form is added to the milk and forms a sort of raft over the top of the stomach contents and it makes it more difficult for you to vomit them.
Baby G was extubated on to BiPAP, a form of CPAP, on 7 July. She continued to tolerate feeds by which time they were 5ml every hour.
On 31 July Baby G had three desaturations which were not self-correcting and required a brief increase in her oxygen concentration. There was a re-intubation because the tube had slipped and had a blood clot. Thereafter, she recovered and continued to have very fleeting self-correcting desaturations after feeds, which was very normal in neonates of her size, said Dr Bohin.
On that day, 31 July, she also had a single large nasogastric aspirate of 10ml prior to the feed at 5 o'clock and that feed was subsequently omitted but thereafter she was fed without any problem and she was well enough to be given her immunisations the next day, but she was not transferred to the Countess of Chester as had been planned.
On 3 August Baby G had an increase in her desaturations accompanied by bradycardias. The medical team were cautious and did an infection screen and started her on antibiotics. Feeds were continued and she continued to tolerate feeds. There was no vomiting and aspirates were minimal.
On 12 August Baby G was doing well, so that the feeds were increased to double amounts two-hourly rather than hourly, a change that was well tolerated, which meant that she could tolerate that sort of doubling of volume in her stomach and that her stomach could accommodate that and, as I've already reminded you, it was then that she was transferred from Arrowe Park Hospital to the Countess of Chester on 13 August.
I've gone through those in some detail just to remind you so you don't have to look through all the records and it gives you a sort of overview summary of what her pattern of progress was while she was in Arrowe Park until she went to the Countess of Chester.
Dr Bohin concluded, on all this evidence, that it was clear that, as noted on J7012, certainly by 6 September, Baby G was tolerating the alternate nasogastric three-hourly tube and bottle feeds she was having. There was no vomiting. There was no mention of aspirates and where the nasogastric tube had been tested for acidity prior to a feed on 5 September, the nurses either marked positive for acid without actually writing down a pH figure or, at 20.00 on the 6th, the nurse recorded a pH of 4, which is acid. All those feeds were well tolerated.
The pH value of 4 recorded by Nurse E at 02.00 was not consistent with there being a large amount of undigested milk in the stomach; a pH of 4 was very acidic. If there was undigested milk in the stomach that would buffer or neutralise the pH and you would expect the pH to be higher than that. A neutral pH is 7. Anything less than that is slightly acidic.
She had reviewed the subsequent feeding charts from Arrowe Park and the Countess of Chester and where there were minimal aspirates or where there were milky aspirates the pH was usually around 5.5 or 5, but never as low as 4.
In relation to Nurse E's entry at 02.00 on the 7th, she concluded that the stomach was empty at the time that feed was given because the pH from the aspirate was 4 and she wouldn't have expected the pH to be that low if there was a large volume of undigested milk in the stomach. It was pointed out to her that in her report of 28 March 2019 she stated:
"The NGT was recorded as being checked prior to this feed. At this check no large residual volume of milk was found in the stomach, ie it was empty. 45ml of feed was given."
It was put to her that she based her opinion at that time on the stomach having been aspirated and she was now modifying her opinion to accommodate the evidence of Nurse E and, implicitly, having heard the evidence of Dr Evans. She refuted any suggestion of having discussed the matter with Dr Evans or having changed her reasoning. She said that she based that opinion on the pH level and having read all the feeding notes and not as a result of Dr Evans saying that.
As a consequence of her having vomited in a projectile way as described, and then 45ml of feed having been recovered or aspirated from her stomach, Dr Bohin concluded that [Baby G] must have had an additional excessive volume of milk in her stomach at some point after her 02.00 feed in order for her to be able to projectile vomit a large amount of milk and have a 45ml residual amount within her stomach.
There was nothing in the records to reasonably suggest that prior to this incident she was a child that was prone to vomiting. Forceful vomiting is not common in a neonate. Gastro-oesophageal reflux can develop but cannot explain what happened in Baby G's case. Infection does not present with projectile vomiting. At the stage at which she had vomited, any infection played no part.
She accepted that the general rule is that there is a 24 to 48-hour period in which C-reactive protein peaks in an infection and it declines quickly after reaching a peak.
The highest reading was 218 from a test at 07.23 on the 9th, which was about 53 hours after Baby G's vomiting episode, which suggested the onset of the infection was after the event. She also said that the 100ml of air or liquid, or a combination of the two, that was aspirated at 06.15 could be accounted for by infection.
Finally, I move on to counts 8 and 9. Baby G was discharged from Arrowe Park at 15.00 on 16 September and returned to the Countess of Chester. Counts 8 and 9 relate to events during the day shift at about 10.20, that's count 8, and 15.30, count 9, on Monday, 21 September.
Valerie Thomas was Baby G's designated nurse for the preceding night shift of the 20th to the 21st. The relevant documents from the handover are from tile 30 onwards. At the end of her shift in her nursing notes, behind tile 44, written at 07.19 hours, she wrote:
"Written in retrospect for care from 20.00 to present. Observations satisfactory. Temp 36.4 to 36.7. Well wrapped up. 3x8 feeds continued EBM. On 165ml per kilo. Using own bottles. Completed bottles but had one NGT feed at 03.00 to rest. Settled late after 21.15 feed. Fed by dad. Has passed urine and bowels open. Medication given as prescribed by NNU staff. Routine bloods taken this morning at 06.00 and sent to lab. For imms today."
In her statement, read to you as agreed evidence, she considered the observations were satisfactory. The temperature was a little low but she was well wrapped up.
Tile 45 in your second sequence of events in Baby G’s case sets out the personnel on duty for the ensuing day shift on 21 September. The paediatrician of the week was Dr Gibbs. Dr Newby was on call. The registrar on duty was Dr Harkness.
The shift leader was Caroline Bennion. The defendant was Baby G's designated nurse for the shift as well as being the nurse for babies BH and CM; those three children were all in nursery 4.
Other nurses on duty were Nurse B, Shelley Tomlins and Caroline Oakley. There was an event, the first event of that day, which is not the subject of any charge that was noted by the defendant in her nursing notes that are referred to and set out behind both tiles 48 and 50. That's the same sheet in, fact of the notes, so you can either see it on 48 or 50. She described this event in these terms:
"Written for care given from 08.00. Emergency equipment checked. Fluids calculated. Baby G nursed in a cot. Baby G appears pale. Temperature 36.4. Hat in situ and well wrapped. NG tube feed EBM given. At 10.15, two large projectile milky vomits. Brief self-resolving apnoea and desaturation to 35% with colour loss. NG tube aspirated. 30ml undigested milk discarded. Abdomen distended, soft. Doctors asked to review. Temperature remains low. Tachycardic. Greater than 180 beats per minute since vomit. Mum states that Baby G does not appear as well as she did yesterday. U&E, FBC and CRP taken and sent. Blood gas as documented. Blood sugar 9.9mmol. To go nil by mouth. Commence IV fluids and antibiotics. Care handed over to S/N Nurse B approximately 11.30."
In a message to Nurse A behind tile 111 the defendant said that:
"She looked rubbish when [she] took over."
The defendant told you that she remembered the incident and having concerns about Baby G's temperature and ongoing low temperature. Baby G was about to receive her immunisations.
At 09.00 her temperature was normal, tile 46. She said she had given that feed. It was recorded behind tile 47 and was 40ml of EBM by NG tube. The vomit was after this feed. She would have tested the pH before the feed but not aspirated the contents. She was being treated as a term baby.
She couldn't recall how she was after the feed. She was alerted to the vomit by the monitor. She believed she was in nursery 4. Baby G stabilised and she asked for a doctor, if a doctor could review her.
Tile 54 refers to the observations chart of which you have a paper copy. The first doctor to attend was Peter Fleming, then a senior house officer at the hospital. His note is behind tile 51. It recited Baby G's medical history by way of problems, followed by a set of results for bloods timed at 01.17 that morning. He then referred to the report of the event that required his presence and he noted it as follows:
"Two times projectile vomits witnessed by nursing staff, after which she was apnoeic for around 6 to 10 seconds, went blue, sats down to 30%."
By the time he arrived, she was breathing and crying and seemed to be recovering. Her colour was normal but slightly pale. She was well hydrated. Her tummy was distended, but her liver and spleen felt normal, so they weren't responsible for the distension, and the tummy was soft and non-tender.
He discussed the case with the registrar, Dr Rachel Chang, and concluded that the best plan going forward was to aspirate the NG tube and leave it on free drainage, delay the next feed, observe the stomach over the next hour, take heel prick bloods, a full blood count, U&E, which relates to kidney function, and CRP, which can be an indicator of infection. The immunisations planned for that day would be held off and there would be a review in 1 hour.
Care of Baby G was handed over to Nurse B at 11.30 because Baby G was going to be transferred to nursery 1 where she, Nurse B, had another baby.
I move then to the circumstances of the second event that day, which gives rise to count 9.
Nurse B's nursing note is behind tile 72. She said Baby G was pale and quiet when she took over, which was not her normal self, and her heart rate was high. She didn't recall her to be a vomity baby, Baby G's observation chart for 20/21 September is behind tile 61 and you have a paper copy as the first document in section 9 of your second bundle.
Her heart rate had settled by the time she completed her first entry timed at 12.45. The feeding chart is behind tile 69 and records that at 09.50, an entry initialled by the defendant, she was fed 40ml of EBM by NG tube and then:
"30ml x2 milk projectile vomit. Blood sugar reading of 9.2. Bowels open +++, loose watery and green. Reviewed by doctors."
Nurse B thereafter recorded nil by mouth. Her nursing notes are behind tile 72 to which you can refer.
Dr Rachel Chang reviewed Baby G at 11.50. She noted she was pale, tachycardic, with a heart rate up to 190 beats per minute, had one feed delayed and had no further vomiting. She documented that:
"According to nursing staff and parents, [she] was not herself."
On examination, Baby G was self-ventilating in air, had good oxygen levels and her heart rate had settled to 160 to 170. Her tummy was soft and distended so she recommended partial screening for sepsis.
Dr Gibbs recommended a broad spectrum antibiotic, cefotaxime. Baby G needed to be cannulated, however because of her prematurity it was difficult to achieve and required seven attempts. A temporary cannula was initially fitted in order to get samples so they could check for bugs in her bloodstream and was also used to administer antibiotics and also 10% dextrose intravenously into Baby G, but it was unusable for fluids until Dr Gibbs finally succeeded in cannulating her at about 7.20. By which time she had been without fluids for about 6 hours.
This day was the first day that Dr Gibbs had direct involvement with Baby G. He was aware of her medical history. He went to the unit after completing his paediatric round and saw Dr Chang's note. He said that projectile vomits in a premature baby who had been feeding satisfactorily since returning from Arrowe Park was unusual, although he accepted that gastro-oesophageal reflux, which was potentially part of her condition, may lead to vomiting and possible forceful vomiting but not to projectile vomiting.
He also said that a drop in her oxygen level to 30% was a severe desaturation. The reassuring features were that she remained in air, spontaneously ventilating, her oxygen levels were good and her capillary refill time was good, her heart rate was a little high, but it settled. The plan was not to feed into her tummy but set up intravenous access.
Nurse B remembered Registrar Harkness and Dr Gibbs coming to the room to attempt the cannulation after Dr Chang had been unable to do so. She believed Baby G was on a procedure trolley and remembered her being screened from others in the room and the sticky part of the monitor being switched from limb to limb so they could see veins in different parts of Baby G's body, her hands, wrists, feet, ankles. She didn't remember how many times it was moved.
When the doctor finished on the trolley the procedure was they would then let a nurse, and preferably the designated nurse, know that they had completed what had gone on, the screens would be removed and the baby placed back in their cot.
She next saw Baby G when the defendant called for help. This was the event at 15.27, count 9. Nurse B was not in that room when she heard the call and went to the doorway and saw the defendant providing breathing support for Baby G who was in the cot using a Neopuff. The defendant said Baby G wasn’t breathing and Nurse B could tell that she wasn't. She didn't look well at all. She was a poor colour. She didn't remember if the monitor was attached but it was switched off -- the screen was off and she was unsure whether the probe was attached.
She shouted for Caroline Bennion who came quickly to help the defendant. Baby G responded very quickly to the treatment, was put on to Optiflow, was then moved to nursery 1 and kept on full monitoring and under very close supervision.
Baby G's mum was informed of Baby G having stopped breathing and came from the family room. She was placed in an incubator without clothes. Her tummy was normal, her poos were abnormal.
The defendant said that screens had been put round Baby G because she was having a procedure, cannulation. There was no one with her in nursery 4 at that time. That was the only nursery in which she had any responsibilities, being, I remind you, the designated nurse for Baby G and two others. At 15.00 she initialled an entry for RH in nursery 2, J2912, something that would have taken a couple of minutes.
It was common practice for staff periodically to look behind a screen. She happened to look and noticed that Baby G was on her own behind a screen on the procedure trolley where she should not have been left without anyone there. She did not recall being told at any time by the doctors that they had finished with Baby G and that she needed to be put in the cot. Baby G, she said, was blue and not breathing. The monitor was not on her. She immediately picked her up and put her in her cot, Neopuffed her, and called for help. Nurse B came and spoke to her.
She said she was keen to put a Datix report in about Baby G having been left unattended without a monitor on. She didn't take the matter any further because she took an assurance from her that she, Nurse B, would deal with it.
When first interviewed about the episodes on 21 September she vaguely remembered the shift and thought Baby G was in nursery 4 and she was her designated nurse. The notes were gone through and she said from reading her notes it would appear that there wasn't an issue with the 9 o'clock feed. She didn’t remember the two large projectile milky vomits at 10.15.
In interviews on 10 November 2020 she was asked in more detail about events on 21 September. She remembered going behind a screen and finding Baby G on the procedure trolley unattended. She had not switched the Masimo monitor off and could think of no reason why it would have been, it was bad practice, and she confirmed that you would never routinely leave a baby alone on a procedure trolley behind a screen. She confirmed that someone had made a mistake in turning off the monitor and leaving Baby G on a trolley unattended behind a screen.
She could not remember having made the numerous Facebook searches for Baby G's mum, [Mother of Baby G], on 21 September, 5 November 2015, and 23 January 2016, 16 February 2016 and 1 September 2016. She had no comment to make about them.
She did not recall sending the message to Nurse A at 21.20 on 21 September, saying:
"Looked rubbish when I took over this morning then she vomited at 9 and I got her screened."
Or why she sent that message.
Nurse B said she hadn't been told that the cannulation was complete and said that both Dr Gibbs and Dr Harkness apologised to her after that second event. Dr Gibbs accepted that the monitor should not be switched off and, if the sensor had to be moved to effect the cannulation, it should have been applied to another limb. He had little recollection of the event and admitted that he had no recollection of whether the sensor had to be removed or what he did after the cannulation or of any conversation with Nurse B. He accepted it was possible that Baby G was left unattended and without the monitor switched on after the cannulation:
"If she [that's Nurse B] said that it happened, then it must have."
And he apologised for having done so, but he didn't remember it.
He said he would not have left a baby unattended and would have told the nurse present that they were leaving. Dr Gibbs also said that a prolonged cannulation event could distress Baby G and cause her breathing difficulties and that it was not surprising that there was a further apnoeic episode with desaturation, but added that such an episode may not have been caused by the cannulation.
Dr Harkness did not recall the monitor being detached. It was important to keep it on and attached. He said he definitely wouldn't have turned it off. He thought he probably told one of the nurses that they had finished. He remembered leaving the room to document the event.
In his witness statement he said he did not remember speaking to a nurse after the cannulation. In evidence he accepted that it was possible that Baby G was left on the table and the screens were still there when he left the room. He went straight to the paediatric ward to complete the handover. He couldn't remember himself and Dr Gibbs apologising to Nurse B for leaving Baby G unattended behind a screen and for failing to switch the monitor back on.
Nurse B said she spoke to the shift leader, Caroline Bennion, and the ward manager, Eirian Powell, about this second event but she was unaware as to whether any formal complaint via the Datix system was made; she didn't make one.
Caroline Bennion recalled Baby G needed to be cannulated and that she and the defendant were with Dr Chang when Dr Chang fitted the temporary cannula.
Eirian Powell, who was on a phased return to work that day, had no recollection of anything clinically untoward being brought to her attention. She explained that if an untoward clinical event occurred she would have anticipated learning of that event either by it being reported in Datix or to her orally and she would then have investigated it.
An X-ray of Baby G's abdomen had been taken at 12.21. Dr Wright's report on that X-ray is tile 60. There was:
"Marked gaseous distension of bowel throughout the abdomen excluding the rectum, which contains a little gas. Transition point at the rectosigmoid junction and Hirschsprung's disease should be clinically considered. The differential diagnosis includes sepsis. No free peritoneal air or intramural gas identified. Please fax the report to clinical team."
In relation to sepsis, tile 59 refers to venous blood having been taken in respect of which no bacteria had grown 5 days later. This, said Dr Gibbs, did not rule out infection but lowered the possibility that she did have an infection. Baby G did not have Hirschsprung's disease; that was the agreed evidence of Professor Simon Kenny which was read to you.
Later that evening, in a message exchange with Nurse A, the defendant, in the message behind tile 211, sent at 21.20, said that Baby G:
"Looked rubbish when I took over this morning then she vomited and I got her screened."
The prosecution say that this was incorrect as far as Baby G's condition was concerned and the wrong time of the vomits. The defendant said the latter, the timing of the vomits, was a mistake and she was pale as recorded on her note, but accepted she was otherwise in good continue at the start of the shift. She denied that she was trying to create the impression that this was a child who was sickening for an infection and that it happened nearer handover than it really did.
There were no issues in the following night shift; that was the agreed evidence of Dr Alison Ventress. Baby G was stable and improving.
Dr Evans and Dr Bohin both gave evidence as to the episode of projectile vomiting at 10 o'clock, 10.00. Dr Evans made no reference in his first two reports of 6 November 2017 and 31 May following his initial sift of the cases to this first event that is now the subject of count 8.
In the second report he said he scrutinised the rest of the clinical entries and did not find any evidence of any acute life-threatening event. He explained that he had over 4,000 pages of materials relating to Baby G alone and concentrated his review of the medical notes rather than the nursing notes and accepted that he simply initially missed this event.
When he reviewed the evidence again, as set out in his report of 24 March 2019, in addition to the note of the defendant behind tile 50 in which she recorded two large projectile vomits, a brief self-resolving apnoea and desaturation, to which I've referred, he noted the record made by Dr Fielding transcribed on tile 51, which I've already reminded you of.
Dr Evans also referred to Baby G's abdomen being distended, so larger than it should be, and that her bowel sounds were active, meaning 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, despite her having vomited. You would expect any abdominal distension to reduce, he said, because some of the substances in the stomach had been vomited up. This was a very significant concerning issue, particularly in association with the oxygen saturation dropping to 30%, going blue and stopping breathing for a few seconds. He concluded that she had probably had a life-threatening episode of vomiting and oxygen desaturation for which there was one explanation, which was that Baby G had been given far more milk during her nasogastric tube feed an hour earlier.
The plan was to give her 14ml of milk and she had been tolerating that amount of milk by bottle the previous day, 40ml or 45ml, so if she had been given 40ml of milk then it would not explain how she had two large projectile vomits and there was still 30ml left in the stomach.
He concluded she had not received 40ml of milk, she had received a lot more than that, and it was an excessive amount of milk or milk and air. He accepted that the events on 21 September were not as serious as the one on 7 September, which was responsible for a huge change in Baby G's overall health.
The abnormalities found on an MRI carried out on 15 September from memory, she(?) said, at Arrowe Park showed very significant abnormalities, whereas previous scans had been satisfactory. From 7 September onwards Baby G was a completely different baby from a neurological and developmental point of view and vomiting was a significant part of her life.
Dr Bohin noted from the records that Baby G was feeding well, tolerating her feeds and the day before she had been fed by bottle, apart from one feed when she was asleep.
On the 21st she was given a feed at 09.00 via nasogastric tube because she was apparently asleep and shortly after that had two large projectile vomits which caused her to stop breathing temporarily and desaturate. She said that the feeds didn't add up, as I've already referred to, and she concluded that the feed at 9 o'clock via the nasogastric tube prior to the projectile vomit was in excess of 40ml.
The events of the 7th and 21 September were strikingly similar, but the consequences were different. Dr Bohin accepted that after 3 October vomiting by Baby G became much more of a feature. The records showed that from the 3rd to 8 October Baby G was recorded as having one or two vomits each day which varied from small to large and some were after cares. Domperidone was added to the anti-reflux regime on 17 October 2015 because of the vomiting.
She was taken to a number of records of such vomits and there were vomits, two large vomits, on 8 October, J7452, after which she was put back from four-hourly to three-hourly feeds. A few self-correcting desats and two large digested milk vomits were noted on 9 October. On 15 October, a quite large projectile vomit. On 17 October, a large vomit following a night-time feed. And on 23 October, a large vomit following a feed.
When asked about Baby G's father saying that he had seen Baby G projectile vomit on occasions after 9 September, Dr Bohin commented that what parents commonly describe as projectile vomiting is what she would say is forceful vomiting, but not projectile, as projectile vomits go a huge distance.
Professor Arthurs said that from the radiological point of view, putting aside her lung changes and some chronic lung diseases associated with her prematurity, she essentially had several episodes of bowel distension that seemed to resolve. Each of these, he said, should be interpreted in the context of how unwell she was at the time.
The opinions of the treating clinicians and nursing staff needed to be taken into account when drawing conclusions. There were obviously several episodes where Baby G was acutely unwell. From the radiographs, there wasn't anything specific to suggest any abnormalities. The radiology did not assist in relation to the opinions of Dr Evans and Dr Bohin by way of attributing events to deliberate overfeeding.
If the baby had been overfed with milk, they wouldn't necessarily see that on an X-ray, said Professor Arthurs. The X-rays all show a lot of gas in the abdomen, so overfeeding with milk, a combination of milk and/or air could cause these findings. Excessive milk on its own would not show on the images; air could, and air and milk could. There was nothing on the X-rays that that would really provide a diagnosis as to why that had happened.
I'm sorry we've gone on a bit longer than I'd anticipated, but I just wanted to finish Baby G so that we can move on to the next baby at 10.30 tomorrow morning. Would you please remember and adhere to your responsibilities as jurors and be ready to resume at 10.30 tomorrow morning. Thank you.
(In the absence of the jury)
Mr Justice Goss: I don't think you --
BM: No.
Mr Justice Goss: -- are going to have a visit?
BM: No, not this afternoon.
Mr Justice Goss: No visit this afternoon, thank you. I may have misunderstood that. I think your solicitor --
BM: Yes, but not a visit from us.
Mr Justice Goss: Not a legal visit.
BM: No, thank you.
Wednesday, 5 July 2023
(Delay in proceedings)
(In the presence of the jury)
SUMMING-UP (continued)
Mr Justice Goss: I'm sorry about the 15-minute delay in your being brought into court. There was an administrative matter with which I had to deal, so I apologise.
I move on then to counts 10 and 11 on the indictment, which concern Baby G(sic). They are both allegations of attempted murder on consecutive nights, the 24 and 25th, and the 25th and 26 September 2015, so some 3 and 4 days, respectively, after the Baby G events on the 21st, which is where we ended yesterday.
The baby concerned, Baby H, was born at 18.22 on 22 September 2015 at the Countess of Chester and so was only a few days old at the time. Her mother, [Mother of Baby H], and her husband, [Father of Baby H], had been wanting a baby and she had a healthy pregnancy, the only complication being that she is type 1 diabetic. Baby H was born in good condition at 18.22 on Tuesday, 22 September at 34 weeks and 5 days' gestation by emergency C-section, as her mother's blood sugar level kept dropping and it was a struggle to control it.
It was an uneventful birth. Baby H weighed 2.33 kilograms, so 5 pounds 2 ounces. Her Apgar score was 7 at birth and 10 at 5 minutes. By reason of being born before 39 weeks' gestation, she was more likely to have respiratory distress syndrome, RDS, and more likely to struggle to maintain her body temperature. This and the maternal diabetes meant she was at high risk of developing hypoglycaemia in the neonatal period and it was for these reasons that she was admitted to the neonatal unit.
Between the morning of 24 September and about 04.00 hours on Sunday, 27 September, Baby H was very unstable, suffering a number of pneumothoraces of the left lung, a leak in the lung allowing air to escape into the area around the lung known as the pleural cavity, as well as episodes of profound desaturations and bradycardia.
The pneumothoraces were addressed by the insertion of chest drains and, in the case of the tension pneumothoraces, by a needle thoracentesis, which involved releasing the air by inserting a needle into the pleural space. I'm sure all this is coming back to you as I recite it.
A number of aspects of her care and treatment were sub-optimal. Dr Evans and Dr Bohin agree that surfactant should have been administered to Baby H earlier given that she had respiratory distress syndrome by reason of her prematurity. This would have aided gaseous exchange to improve oxygenation, surfactant being a lung product in which neonates who are born early will be deficient. Also, there was an unacceptable delay in intubation for the purpose of ventilation between the development of the pneumothorax by 06.00 on 24 September and the intubation at 08.10 hours; in other words, 2 hours and 10 minutes later.
Further, the needle used in the first thoracentesis on 24 September was not removed after the tension caused by the air had been removed and the chest drain had been inserted as it may have punctured lung tissue if the lung expanded.
Finally, it was not recognised at the time that air had re-accumulated by 20.50 on 24 September and Baby H appeared to be breathing against the ventilator. There was a delay and the second drain, inserted by Dr Saladi, may have been interfering with other structures in the chest.
However, in the opinion of both Dr Evans and Dr Bohin, although the pneumothoraces were probably a complication of Baby H's condition and some or all of the shortcomings in relation to aspects of the treatment may have added to the later pneumothoraces, none, they said, was causative of the sudden collapses at 03.22 on the 26th, which is the subject of count 10, and at 00.55 on the 27th, which is the subject of count 11, for which neither of them could find any cause.
After the collapses, Baby H was transferred to Arrowe Park Hospital on 27 September, leaving the Countess of Chester prior to 05.30 hours. The transporting consultant neonatologist, Dr Srinivasaro Babarao, wrote that from the ventilation perspective, Baby H was stable. The oxygen requirement was less than 30%, which was not worrying at all. The chest X-ray revealed no pneumothorax. Blood pressures were fine and good for her gestation. The capillary refill time and heart rate were normal. Blood sugars were stable and there was no bradycardia. The base deficit was normal. There was a good urine output. The CRP was high and the temperature was slightly low for a baby. Her blood count was normal.
After an uneventful transfer, they arrived at Arrowe Park at 05.55, where, over the course of the next 2 days, her management was quickly de-intensified, the chest drains were removed, ventilation was weaned and she was extubated by 29 September and feeds were started. She remained well and had no further cardiac arrest. An echocardiogram showed a structurally normal heart with mildly raised pulmonary pressure, which was normal for a baby of her age. She returned to the Countess of Chester on 30 September.
The prosecution case is that recognising, as they do, that Baby H had a challenging condition and acknowledging the sub-optimal care, looking at the overall picture, the coincidence of the defendant being on duty in the ward and having involvement with Baby H during those shifts on those nights when children suddenly collapsed unexpectedly and for no identifiable reason, then once removed from the ward to Arrowe Park she progressed without significant incident until further unexpected collapses in the context of other evidence and relating to her interest in the family and other events, about which you have heard, you can be led to the sure conclusion that, however she did it, the defendant was responsible for the sudden and life-threatening collapses by deliberately harming Baby H on two occasions.
The handover sheet for Baby H was found in the Morrisons shopping bag under the defendant's bed in her home after her arrest, as were handover sheets for Baby G and Baby I. She didn't remember having taken them home and didn't know why she had 231 handover sheets there. >The defendant accepts staffing levels had nothing to do with Baby H's collapses but said that she did nothing to harm her. She denied having dislodged the chest drains but questioned whether they were securely put in.
She was a premature baby with RDS who received sub-optimal care in the early stages of life and during the course of her treatment and that added to the risks of desaturations and bradycardia and there was a cumulative effect that led to her collapse and requirement for resuscitation. The defence say her care was sub-optimal and you cannot be sure that there is no innocent natural explanation for these episodes.
Well, that's the background. Baby H had been fine --
I'm sorry...
(Pause)
I've realised that I've duplicated some of my notes in relation to this and I did refer, of course, to desaturations. There were the incidents between the 23rd and 25 September, to which I have referred. I will give you a little more detail about them because it is appropriate. So I'm going to go back and revisit some of those events briefly because it relates to what the defendant's case is in relation to these charges.
On the night of 23/24 September, she was on non-invasive ventilation, her heart rate was fine, she was on BiPAP, her breathing was with a gasping pattern and her oxygen level requirement was 60% and that was she was ventilated.
At 10.05 on the morning of the 24th, she had an acute desaturation on the ventilator and was not responding to the Neopuff. This was a consequence of the pneumothorax and nothing else. There was a left-sided pneumothorax and at that time her oxygen requirement increased and she was starting to struggle, which suggested that the pneumothorax was bigger than first thought. A needle thoracentesis was performed, inserting a butterfly to provide the immediate release of air, and there was an instant improvement in her condition.
The first of three chest drains was then inserted. She was clinically much better after that. She remained on the ventilator. Her heart rate remained stable throughout all the procedures and she was pink and well perfused. She was given Curosurf through her endotracheal tube, but as I've already reminded you, she was not given it earlier, and the needle was left in place.
At 01.25 on the 25th there was a profound desaturation, no breath could be detected on the ventilator and the chest drain was no longer fluttering. 70ml of air was aspirated, but the X-ray confirmed that there was a tension pneumothorax. That was an emergency life-threatening situation. In a tension pneumothorax the heart and midline move over to the opposite side and that could be seen on the X-ray behind tile 48.
There was a further desaturation at 01.45, the consultant was called, Dr Jayaram arrived, and despite a further needle thoracentesis, Baby H continued to have poor chest movement and poor entry and she suddenly dropped her saturations.
The ET tube was removed and appeared to be blocked with a mucus plug, she was bagged and re-intubated. The decision was taken to insert a second chest drain lower down than the first, going in around the seventh or eighth intercostal space. This was of a different kind: the first had been a pigtail drain, as you will recall, and none was available, so it was a different type of drain, and that was confirmed by an X-ray, which is behind tile 75, to be in a good position. The tip of the drain would move with respiration anteriorly and, as you saw from the sequence of X-rays that were taken, the drain would move around in the pleural space. But it remained there in the pleural space and that reflected that the pneumothorax had decreased and resolved.
Under cross-examination Dr Jayaram did not consider a chest drain could come into contact with the heart or vagal nerve and he'd never known that happen. It could come into contact with the pericardium, the sac surrounding the heart, but that was very unlikely and would not compromise the function of the heart. He didn't believe it was actually causing abnormal stimulation of the heart muscle or the vagal nerve.
On the afternoon of the 25th at 16.21, Baby H had a further desaturation; tile 160. Nurse D put out a crash call and Neopuffed her on 30% oxygen. She then started to breathe spontaneously and had good saturations by the time the doctors arrived. It was thought that the ET tube was blocked or dislodged and it was replaced by the registrar.
Dr Gibbs reviewed the X-ray taken after replacement of the ET tube. There was still a left-sided pneumothorax but it was small and not a tension pneumothorax.
The drain Dr Jayaram had inserted had moved outwards. Dr Gibbs fixed it more securely to the chest wall. He was not aware of any internal structures (sic) by movement of the drain: it was still functioning, waswell inside the chest and was moving outwards, away from the heart.
So that's a summary of the proceedings up to the night of the 25th/26th: two chest drains in place by that time, pigtail drain and another one, and the episodes that there had been associated with difficulties in relation to ventilation.
On the night of the 25th/26th, the defendant was Baby H's designated nurse. On the previous morning, the 24th, at 09.15, she'd sent a message to Nurse E, which is behind tile 27, saying:
"It's completely unsafe."
A reference, she told you, to staffing levels in the unit, and she was referring to a different time.
At 14.07 hours that day, she sent a message to Sophie Ellis, behind tile 33, this is on the 25th, saying:
"It was pretty bad so far, how busy the unit was and the number of babies."
In her evidence she said she'd come across chest drains at Liverpool Women's Hospital, where the drains were always stitched into the skin, but hadn't seen one at the Countess of Chester and none of them there, including the doctors, that's the staff there, were overly familiar with them. She also said that the third drain had to be obtained from the children's ward.
Baby H was the only baby in nursery 1 that night. Nurse A was the shift supervisor. She looked after Baby H -- she said looking after Baby H was quite a task for the defendant, but she was qualified and was very competent and she trusted she would ask her if she had any problems.
Dr Bohin noted that at 20.50 hours Baby H was struggling and appeared to be breathing against the ventilator. A blood sample was taken at 22.02 and at 23.05, a blood transfusion that had been prescribed at 15.00 hours was commenced. This eight-hour delay was longer than normal.
Nurse A did not know why, but she signed for the two bags of blood that were needed. The transfusion time was 4 hours. Baby H's father, [Father of Baby H], was in the room with [Baby H] with his mother-in-law until just before midnight. According to the defendant's notes and what she said to Dr Ventress, Baby H had further episodes of desaturations prior to 23.50.
Dr Ventress said the taking of the blood sample could have been a trigger event of one and she improved with bagging and suctioning of the ET tube after the second; tile 210. An X-ray revealed there was air in the central part of the chest. The second chest drain, said Dr Ventress, had almost fallen out and so reduced its function. By 01.00 hours, of what was now 26 September, tile 216, her oxygen requirements had gradually increased to 70% and she required an increased amount of ventilation and pressure.
Dr Ventress called Dr Gibbs, who said that, very unusually, despite having two chest drains, Baby H had developed another tension pneumothorax. It had not been possible to drain it. Dr Gibbs looked at the X-ray behind tile 200, taken at 22.56, his note is at tile 228. The two chest drains were blocked with yellow serous fluid, so he inserted a third chest drain, an 8.5-centimetre pigtail drain, on the left side. Both Dr Gibbs and Dr Jayaram said that chest drains can become blocked. Dr Gibbs also agreed that there is a potential risk of a chest drain touching the heart, but in Baby H's case she had bradycardia after the chest drain had been removed.
There was then a marked improvement. This is after the third chest drain had been inserted. The lungs moved better and the oxygen requirement reduced to 30%. The X-ray behind tile 229 showed the lung had fully expanded by 02.30. There was no pneumothorax. In retrospect, it is apparent that air had re-accumulated but this was not recognised at the time.
In evidence the defendant accepted staffing levels had no direct relevance to the events of that night but said there was potential incompetence with regard to the location of the chest drains and how they were secured. Her nursing note, behind tile 208 and also tile 261, for that night was written between 04.14 and 04.28. Nurse A was there to assist her with any drugs and maintain the chest drain, being, said the defendant, supernumerary so far as nursing duties were concerned. She called on her from time to time and she co-signed for medications. Her note, reference to which I've just given you, recorded that:
"At 23.30 bradycardia and desaturation requiring Neopuff in 100% oxygen to recover. 10ml aspirated from chest drain by Registrar Ventress. Following poor blood gas and 100% oxygen requirement, Consultant Gibbs attended the unit and inserted a third chest drain. All three drains swinging and serous fluid present. Dressing in situ. X-rays taken as documented."
The note of Dr Ventress was that she was called at 23.50 and that Baby H had bradycardia and desaturation and had to be Neopuffed. The defendant also recorded on the intensive care chart, J12701, behind tile 199, of which you have a paper copy in section 10 of your second jury bundle, an entry at 22.10:
"Desat 52% during heel prick. SHO present. Serous fluid ++ x2 drains."
There was no reference to this event in her nursing note and the SHO was not identified. The defendant said she commonly did not name the doctor. The SHO on duty, Jessica Scott, made no note of such an event. The prosecution allege that the defendant was falsifying records. Dr Ventress also noted that the defendant had told her that there had been:
"Several episodes of desaturation in the past 2 hours."
The defendant said in evidence she couldn't confirm she had told Dr Ventress anything. The prosecution allege she was falsely representing Baby H had been having problems for a couple of hours, which aren't matched by the charts and the notes. There was also an error in the notes in relation to the blood transfusion, which was completed at 03.05, being a four-hour transfusion commenced at 23.05 and so finishing at 03.05, as recorded in the transfusion prescription behind tile 239, and not at 02.00, as recorded in her notes. The defendant said these differences were just mistakes and she was not deliberately fabricating them.
And when asked about Dr Ventress advancing the second chest drain back 4 centimetres, as it was almost out, as noted behind tile 210, she denied sabotaging the drains and being responsible for the profound desaturation at 01.35, referring to the drains not being stitched in place as she had seen was the practice at Liverpool Women's Hospital.
At 03.20, Dr Gibbs left. He was called back from home at around 03.30, tile 262, by Dr Ventress, Baby H having had a further desaturation that required her to be Neopuffed at 03.24, tiles 245 and 246, and she was given a bolus of adrenaline. This is the event giving rise to count 11.
Dr Ventress noted the heart rate reading was 92 on the monitor and her sats were reading 70%, but as soon as the chest compressions were stopped the heart rate decreased again. At 03.35, behind tile 248, a further dose of adrenaline was given.
Dr Gibbs arrived at 03.36; tile 251. She was given further adrenaline and at 03.45, tile 253, she was given atropine, which is medication to prevent bradycardia and is a later part of the cardiac arrest algorithm protocol.
At 03.46, tile 255, the chest compressions were stopped as the heart rate had improved to 120 and then to 160 and stayed high and her colour started improving. Dr Ventress had no further direct dealing with Baby H and had no direct recollection of anyone who was present at the resuscitation.
She was referred to messaging, which for your reference are tiles 511, 517 and 518, sent early the following morning, 27 September, in which the defendant was saying to her:
"Baby H had resus again but not as long-lasting as it was for us. She went to Arrowe."
To which Dr Ventress responded:
"Oh crap. Do they know why she did it this time? I'm glad she's been transferred. How are you? Really rough set of nights for you."
The defendant answered:
"No, did exactly what she did for us: desat and didn't pick up and dropped heart rate. Looked fine again after though, but made decision to transfer, which I think was sensible."
Dr Gibbs referred to the note behind tile 262. The cold light did not suggest there was a tension pneumothorax. He carried out a limited cardioecho and there was obvious fluid around the heart. There was a tiny rim of "[query] air" against the left side of the heart but there was no evidence of a tension pneumothorax. He confirmed the administration of a third dose of adrenaline and thought a dose of atropine would help to speed up the heart. A spontaneous heart rate of 160 was achieved, he said, 22 minutes after the commencement of the resuscitation. He tried to work out why Baby H arrested.
This was a cardiac arrest with no obvious pneumothorax and certainly with no tension pneumothorax. Her electrolytes were normal, so not likely to be the cause of the cardiac arrest. There was no evidence of a tamponade, that is fluid around the heart squashing or compressing the heart, which can cause a cardiac arrest. Her blood sugars had all been normal, so hypoglycaemia could be ruled out as a cause. There was no evidence of toxins or a thromboembolism, a blood clot affecting her heart, which is very rare in a premature baby anyway. Her temperatures were normal, so extreme cold, which can cause cardiac arrest, is not relevant.
Applying a differential diagnosis, hypoxia, lack of oxygen leading to profound bradycardia and hypotension low, blood pressure, was the likely cause. That didn't tell them why she got the hypoxia leading to these problems.
During the morning shift of the 26th, Dr Soni spoke to Dr Rath a consultant neonatologist at Arrowe Park Hospital about a possible transfer to Arrowe Park, but Dr Rath had advised against it as Baby H was unstable and had chest drains, so she remained at the Countess of Chester for the night of the 26th/27th.
It was during this shift that the event charged as count 11 occurred, when she had a profound desaturation at 00.55. Baby H was in nursery 1. The defendant had two babies in nursery 2, NC and EM, and said that she didn't have much to do with Baby H on the shift.
Shelley Tomlins, who gave evidence from Australia, was Baby H's designated nurse. She relied on her nursing notes behind tile 392.
Early in the shift, at 20.15, Baby H tolerated the removal of one of the chest drains reasonably well and the documents show she was given a bolus of morphine sulphate at that time. Fifteen minutes later, at 20.30 hours, she had a profound desat and brady. Her ET tube was blocked. The doctors were crash called. Dr Matthew Neame, now a consultant at Alder Hey, then a registrar, was bleeped at 20.49, tile 399.
On his arrival, Baby H was being Neopuffed and his recollection was that the defendant was providing the breathing support. He got the impression that she was the nurse in charge of her. He had no recollection of Shelley Tomlins being there, but accepted it was possible. He recalled seeing the old ETT blocked with thick yellow/brown secretions. He re-intubated Baby H with a 3.5 ETT. Shelley Tomlins didn't know if that was the old ETT or the new one; she thought probably the new one.
Initially, there was good entry, but then it ceased to be effective after around 2 minutes, so the tube was removed. There were yellow secretions noted in the tube after removal. Shelley Tomlins noted:
"Copious secretions obtained via ETT and orally bloodstained."
The X-ray revealed no recurrence of a pneumothorax.
In her evidence the defendant said she was not aware of these events having occurred. When cross-examined she was referred to her message to Nurse A at 21.51 behind tile 406 in which she said:
"I've been helping Shelley, so least still involved but haven't got the responsibility."
She agreed she was helping.
At 00.55, Baby H had a profound desaturation to 40%, despite equal bilateral air entry and positive capnography. ET tube suction yielded nil secretions.
At 01.07 she remained in the stable condition until 01.30 hours that night when the events behind tile 412 were recorded.
Dr Neame was called to attend as Baby H had had a desaturation, bradycardia and was not responding to bagging or suction. Again, the defendant was present and he thought he spoke to her, but he could not remember who else. There was another or others there and he said it was possible that Shelley Tomlins was there and gave him the history, but he could not remember. He was more concerned on this occasion because it wasn't completely clear why she had deteriorated. Transillumination, reference tile 442, showed no further pneumothorax. They could detect air going into Baby H's lungs and were concerned because of the previous finding of sticky secretions in her airways.
He remembered being told that Baby H had remained alert with no abnormal movements noted during the resuscitation event. Her oxygen levels were around 60%, her heart rate was around 60, but there was movement of her chest and some air was noted as going into her lungs. She was alert and her eyes were open.
Dr Saladi was called in from home. Dr Neame wanted extra help because there was no clear explanation for this event and that it happened a relatively short space of time after the last, after which she'd seemed perfectly stable.
Dr Neame removed the breathing tube and increased the breathing pressure, using the Neopuff. Baby H's condition still didn't improve at that point. A cold light test was negative so there was no evidence of a re-accumulation of the air around the lungs using that test.
Baby H was re-intubated again with a 3.5 millimetre ET tube and it was confirmed that air was going into both of her lungs. Her oxygen level and heart rate remained low. Chest compressions were started at 01.07 and adrenaline was requested. A second cold light test was negative. The first dose of adrenaline was given at 01.08. Attempted aspiration of the chest drain at 01.12 yielded around 5ml of air, so there was no re-accumulation of air outside the lungs.
At 00.13 (sic), her heart rate recovered to a more normal level for a baby who's unwell and her oxygen level rose to 100%. They stopped chest compressions. Dr Saladi arrived 2 minutes later. He relied on his clinical notes which are behind tile 458. He undertook an ultrasound of the head as well to see why Baby H had suddenly desaturated and become unwell. The scan was normal, he ruled out re-accumulation of the pneumothorax and went through the checklist of potential causes of desaturation in a neonate. Her heart rate, respiratory rate, saturations and capillary refill were all within acceptable limits. There was some respiratory acidosis with a build-up of acid but that, he said, might just be a reflection of the baby receiving resuscitation and it was something they needed to monitor. He discussed the case with Dr Rath, a consultant at Arrowe Park Hospital, as there was no explanation for these profound desaturations and bradycardias needing external compression and they set a plan, including taking another X-ray, further tests, complete a cranial ultrasound and discuss the case with the Arrowe Park Hospital.
A blood sample for tests was collected at 02.54, tile 463. The only result that stood out was CRP, the infection marker, which was more raised than previously, and the white cell count was slightly elevated. Baby H was taken to Arrowe Park later in that shift. Behind tile 498 is Dr Neame's signed handover completion at 05.20 for the transport team that came to collect Baby H.
The defendant was interviewed on three occasions about the incidents. In her first police interview on 5 July 2018, she recalled caring for Baby H because she had chest drains in and being Baby H's designated nurse on 26 September, but did not recall where she was when the profound desaturation took place and had no recollection of being present. She presumes she was alerted to Baby H's monitors alarming and did not recall seeing a lot of yellow milky serous fluid coming out of Baby H's chest drains and Baby H being a pale blue colour. She thought that could be indicative of some sort of airway problem stopping her getting enough oxygen. She could not recall who made the crash call. From the notes she believed she commenced Neopuff with oxygen and called for help.
In the interview on 11 June her attention was drawn to the saline bolus administered to Baby H at 02.50 hours on 26 September, tile 235. She confirmed her signature but wouldn't say confidently that the countersignature was Nurse A's. She could not say that she herself had administered the bolus and was unable to explain why Baby H had collapsed. She denied intentionally harming Baby H and described her as a sick baby at the time.
She said in the third interview on 10 November 2020 she had done nothing to harm Baby H. She agreed she'd searched for Baby H's mother, [Mother of Baby H], on Facebook at 01.18 on 5 October 2015, but could not remember doing so.
In her evidence the defendant said she had no awareness of any of these events and did not recall being involved in them. She was not alleging the cardiac arrest was contributed to by nursing staff levels but she did allege medical mistakes. She denied it was a shift on which she wanted to be in nursery 1.
She referred to the neonatal review for this event, page 5, and referred to her and Shelley Tomlins giving medication to Baby H, namely benzylpenicillin and a flush of sodium chloride, reference tiles 405, 414 and 415, at 22.12, and then starting a morphine infusion with her at 22.38. Her next involvement was administering medications between 03.41 and 03.44.
She was referred to her use of Facebook at 00.45 at tiles 433 and 434, but denied she was bored and says she may have been on her break or may have been covering for Shelley Tomlins. She agreed Baby H was on hourly observations, tile 435, but none were recorded at 01.00. The bleeps for the SHO and consultant were at 01.04 and 01.06. She could not say if she was there when Dr Neame arrived.
She denied having interfered with Baby H's tubes on any of the occasions during that shift.
Baby H was the twelfth case that Dr Evans considered. He reviewed her history. She showed early signs of respiratory distress syndrome. It was very unusual for a baby to require three chest drains. He thought the original pneumothorax was a consequence of RDS. Managing a pneumothorax is difficult. However, the collapses at around 03.20 on the 26th and shortly before 01.00 on the 27th were not a consequence of a pneumothorax because that had been treated. There was no blocked tube. Infection was an option but she was on antibiotics and the pattern of the collapses was not consistent with infection. Her deterioration would have been far more gradual and there would have been other indications of infection.
When cross-examined he recognised that pneumothorax was probably a complication of Baby H's condition and that she had a very challenging condition and that he was not ignoring her series of problems involving the delays and problems with the chest drains, but said that they were dealt with. He pointed to the overall picture: she was on ventilatory support, receiving intravenous feeding and was sedated on morphine. She improved significantly and quickly as a result of treatment and when taken to Arrowe Park they found her to be stable. Her urinary output and blood pressure were fine and they ruled out infection.
Dr Bohin noted the presence of RDS, which she said was the underlying cause of the pneumothoraces and had the surfactant been given earlier, it would have reduced but not removed the likelihood of developing a pneumothorax. A pneumothorax had developed by 06.00 on the 24th and there was an unacceptable delay between then and intubation at 08.10.
The butterfly needle used to perform the thoracentesis should not have been left in place. It was there when the X-ray was taken at 08.58. It may have punctured lung tissue. She confirmed it was very uncommon to have three chest drains, however the drain served its purpose until the evening of the 24th when, in retrospect, air had re-accumulated, but this was not recognised at the time and in due course a third thoracentesis -- third chest drain was required and a thoracentesis and, once in place, the second chest drain stabilised the situation.
By 02.15 on the 26th, the drains appear to have been blocked and Dr Gibbs inserted the third drain, which was successful and the oxygen requirement immediately reduced.
The event at 03.24 was different: there was equal air entry, the chest wall was moving, the drains were patent and fluid was coming out of the drains. The lung was not collapsed and the end of the ETT was not blocked. This was a very different collapse that required over 20 minutes of resuscitation for which there was no obvious clinical or mechanical cause.
The collapse at 00.55 the following morning, with bradycardia and desaturation, was not improved by re-intubation. It mirrored the previous collapse, had no obvious cause, and didn't respond to measures. The second drain didn't move on the 26th and wasn't touching the heart on the 27th either, so bradycardia could not have been caused by touching the heart or the vagal nerve and would not have been the cause of the bradycardia.
Dr Bohin confirmed that, unlike the earlier collapses before those two nights, where there was a pneumothorax or a blocked tube, she could not identify any cause for these significant collapses, the subject of counts 10 and 11, that required resuscitation.
Professor Arthurs confirmed that the 15 radiographs from the 22nd to 27 September showed a recurring pneumothorax. The bowel gas pattern was normal throughout. In relation to chest drains, he explained that there was no ideal position. The drain needs to be somewhere in the pleural space and have the desired effect of draining the pneumothorax. There was movement of the second chest drain. On the issue of the possibility that one of the drains in some way touched the heart or the vagal nerve and precipitated a decline in the child, he said chest drains aren't known necessarily to cause bradycardia and desaturations. They are not a common cause on a neonatal unit, otherwise they would be seeing it in almost every baby who had a chest drain in. As radiologists, they don't comment on the position of chest drains because they're largely not relevant to the care.
An X-ray is a two-dimensional image of a three-dimensional structure. The heart is at the front of the chest, so although on some of the images the drain looks as though it's touching the heart, it may actually be several centimetres away from the heart because it's going round the chest wall at the back, for example, but he did accept that the drain may have touched the heart, he simply could not say from the radiological point of view.
Radiologists don't try and examine where chest drain positions are in detail, largely because they tend not to cause any problems. And so long as the drains are resolving the complication their precise position isn't really that relevant to a radiologist.
So that's the evidence in relation to those two incidents on the two consecutive nights.
I move on to Baby I, count 12, an allegation of murder. [Mother of Baby I] gave birth to Baby at 21.02 on 7 August 2015 at Liverpool Women's Hospital. Baby I was born prematurely at 27 weeks' gestation and weighed 970 grams, 2 pounds 2 ounces, in very good condition with an Apgar score of 9 out of 10 at 1 minute and 5 minutes. She had a daughter at that time who was then 1.5 years old. Her partner is [Father of Baby I]. During the pregnancy, Baby I was noted to have IUGR, intrauterine growth restriction, and [Mother of Baby I] had a prolonged pre-labour rupture of the membrane and was on antibiotics for almost a week, her waters having broken at 22 weeks' gestation.
Baby I had an umbilical arterial catheter and a long line through which she was fed with TPN, total parenteral nutrition. The catheter was removed on 12 August, 5 days after she was born, as it was no longer needed. She was on a ventilator for 10 hours and then on CPAP. She was on a course of 5 days' antibiotics from 13 August as there were markers for infection, although she was stable from a respiratory point of view and had time off CPAP.
On 18 August she was ready to go to the Countess of Chester, where she was expected to continue to improve with no ongoing concerns. So initially, in the Liverpool Women's Hospital from the 7th to 18 August.
Baby I passed away in the Countess of Chester at 02.30 on 23 October 2015. The prosecution case is that on four occasions, namely 30 September, 13 October, 14 October and 23 October, all at times when the defendant was working in the unit, Baby I suffered sudden and unexplained episodes when she desaturated and required resuscitation. Each event was, say the prosecution, a consequence of her being deliberately harmed by the defendant and the final event, in the middle of the night of 22/23 October, caused her death and they say the defendant is responsible for her murder.
The defendant's case is that she did nothing to harm Baby I on any occasion. Whatever the cause or causes of her sudden deteriorations, she was not responsible.
Baby I had a history of recurrent episodes of abdominal distension and desaturations on other occasions, had required oxygen in various ways at various times, and there were periods when she had infection or suspected infection, for which she received treatment and had suspected NEC.
It is argued that you cannot be sure that the defendant deliberately did something or things to her that caused her death and that she did not die of natural causes. The prosecution say that all potential natural causes, including NEC or other bowel disorders, can be excluded and the evidence of the features of the events, their sudden onset and, save in the final event, rapid recovery can and should lead you to the sure conclusion that Baby I was deliberately fatally harmed and the defendant was responsible.
I’ve given you that general background and comments and I now go on to remind you of the chronology and the detail of the events in Baby I’s life. On 23 August, which was 5 days after Baby I had been admitted to the Countess of Chester and her 16th day of life, it was noted at 09.37 that morning that there was a small amount of fresh blood in Baby I's stool, which was mucousy; the relevant nursing note is J13807.
Her designated nurse on that shift, Nurse C, asked for a clinical review, which was carried out by Dr B, who was on the ward, at 11.15. Her note is J13758.
Nurse C noted that Baby I was settled and handled well, she was on CPAP but having, periodically, 2 to 3 hours off it, being put back on when she had clustered desaturations, which was not unusual and was an indication that she needed to be back on CPAP.
She didn't have any increasing oxygen requirements and was warm and well perfused throughout. She had good capillary blood gas, which measures the pH and the amount of carbon dioxide in the blood and indicates how well the CPAP is working. She was tolerating two-hourly feeds of expressed breast milk via her NGT and her abdomen was distended, which was reported as normal for her.
Her abdomen was soft and veins were apparent all over her trunk. Nurse C's next note is timed at 17.19. Dr B ordered an abdominal X-ray, tests revealed no evidence of an infection, the plan was to observe her. She had a further stool that was yellow and slightly orange in colour at 16.30 and that was free from obvious blood and mucus. She was passing urine well and was warm and well perfused and was stable. Nurse C had no immediate concerns.
Dr Sally Ogden, whose clinical note is J13760, was asked to review Baby I's abdomen. Repositioning of the NG tube after an X-ray which was taken at 22.03 on 23 August and which showed that the tube was too far in, that happens quite frequently, appeared to resolve the issue of the discontinued abdomen. It wasn't that the tube was in the wrong place, it was just that it wasn't deflating the air properly, so it will have been in the stomach. There was nothing about this episode other than routine neonatal management of a quite frequent occurrence. The defendant wasn't working on that day.
Consultant Dr Elizabeth Newby had contact with Baby I on 26 August when conducting the grand round that day. She noted Baby I handled well. She also conducted a routine review on 30 August and noted she was fairly stable.
Six days later, on 5 September, Nurse C was on duty for the night shift and was the designated nurse for Baby I for part of the night. Others on duty for that shift included the defendant.
Nurse C took over Baby I from Val Thomas at 20.30 hours because she was obviously deteriorating. Baby I was very quiet and desaturating frequently, especially at handover, on handling. She had a series of significant desaturations during that shift and had to be put on to Optiflow, Neopuffed and then intubated and was given a blood transfusion.
Her low temperature, desaturations and paleness pointed towards infection and NEC. Dr Bohin, when asked in cross-examination about this episode over the 5th and 6 September, said it was very different from the later episodes. She had clinical signs of an infection, she had a high white cell count, a high neutrophil count, which is compatible with and indicative of a bacterial infection, and had a high platelet count of 96, which you see where there is a lot of inflammation. She slowly deteriorated because of that infection. She had a septic screen early on and was started on antibiotics but continued to slowly decline and ended up on the ventilator. It was not a sudden and unexpected collapse.
Later that day, 6 September, Baby I was returned to the Liverpool Women's Hospital on a diagnosis of suspected NEC. After her admission at 18.50 hours, and whilst Nurse Nicola Simmons was involved in setting up a new intravenous line at that hospital, she had a profound bradycardia upon repositioning. This was not uncommon but indicated something was wrong. Her airway was found to have large creamy secretions in her ET tube, which may have blocked her airway, possibly as a result of being moved. Nurse Simmons gave Baby I suction, she recovered from the episode. Her drugs, antibiotics, and dextrose were changed.
Later on in the day Baby I had settled. She had good tidal volumes, her blood gases, heart rate and capillary refill time were normal. Her case was discussed with the surgical team and it was decided she did not need a surgical review.
Sorry, not the surgical team -- was consulted with -- the case was discussed with the surgical consultant at Alder Hey and it was decided that she did not need a surgical review.
It was thought she had sepsis rather than NEC. Her antibiotics were changed and stopped 5 days later. She continued to self-ventilate in air and tolerate her feeds, which were increased. She did have self-correcting desaturations on 13 September, but did not have NEC and was well enough to return to the Countess of Chester on 13 September in the expectation that she would continue to improve and there were no ongoing concerns.
Her history and condition on return to the Countess of Chester, as noted by Dr Harkness, is at tile 9. She was on small two-hourly feeds. There were no concerns. She was alert, pink and handled well.
I now turn to the evidence relating to the four events which the prosecution say are directly relevant to Baby I's death on 23 October. The first concerns an episode on Wednesday, 30 September. >Following her return from Liverpool Women's Hospital on 13 September up to 29 September, nothing remarkable had occurred. [Mother of Baby I], in the statement read to you, referred to an event she said was at around 3 pm on a day in mid-September after Baby I's return to the Countess of Chester, when a nurse called Lucy phoned her and said she had noted that Baby I's belly was extended and she would get a doctor to check her.
[Mother of Baby I] went to the hospital and thought Baby I's stomach did look veiny and swollen. A female doctor came and checked Baby I over and said that it seemed soft to touch. As the doctor didn't show any concern, she left shortly after 3 pm. That's [Mother of Baby I] left shortly after 3 pm. Baby I was taking her feeds without incident. On Tuesday, 29 September Dr Lucy Beebe, or Hunt as was then called having since remarried, who was training to be a GP and had worked in four neonatal units, reviewed Baby I for the grand round that was to take place the following day. Tile 46 is the relevant tile.
She had no respiratory distress, her chest was clear, she handled well, there were no issues with her breathing and nothing of concern in relation to blood clots. She was anaemic, which is very common, and could account for her looking pale. She was gaining weight at the expected rate. They were very happy with her at that point.
As recorded behind tile 24 in the note by Shelley Tomlins, the day shift up to 16.10 was unremarkable. Another nurse, Lisa Walker, carried out a skin patch test on her at 13.00, which she would not have done if Baby I had not been well. Baby I was given bottle feeds by her father over the night of the 29th and the 30th. Jennifer Jones-Key was Baby I's designated nurse for the night shift of the 29th to the 30th. Tiles 31 to 42 are the tiles relating to that shift. Nothing remarkable occurred.
Tile 43 and onwards set out the day shift from handover at 07.30 to 08.00 on 30 September. Baby I was in nursery 3. The defendant was the designated nurse for all three babies in that room. Her nursing note for the period 08.30 to 13.36 is behind tile 45.
In evidence, she said she had some memory of the shift and didn't do anything to cause the ensuing events to happen.
There was a grand round by the consultant, Dr Newby, it being a Wednesday. Tile 48 refers to Baby I being given a 35ml bottle feed by her mother at 10.00 hours.
At the grand round Dr Harkness' agreed evidence was that at 11.40 hours on 30 September, Baby I's temperature had come down slightly to 36.2. Other than being pale, which fitted with anaemia, her abdomen was slightly larger than typical for a baby. However, it was the same as the previous day and there was nothing to worry about as she had opened her bowels. The plan was to watch and see how she got on.
Dr Newby said that they were at a stage of establishing feeds and weight gain and Baby I was stable. I pause there in the narrative to remind you of Dr Newby's evidence about the weight of preterm babies because this was a topic that was relevant in relation to Baby I.
The target for weight gain is 15 grams per kilogram per day. There are standard centiles which chart the weight of babies from birth, taking account of their prematurity. The 50th centile is the weight at which 50% of babies at that age are expected to be. Baby I was always well below that. Between 25 August and 20 October, her weight gain about 0.6 of a kilogram and meant that she went down to below the 0.4 % centile. When asked about this, Dr Newby agreed that failure to put on weight may indicate an underlying health problem and Baby I’s weight was low and dropped down the centiles. But she said she had had numerous episodes throughout her life where they had been unable to feed her because of abdominal distension or initially when she was first born and when she was ventilated, so they often find that premature babies may grow along the lower centiles because it's a different situation to a term baby that just comes out -- that's out at birth -- and feeds.
As you know from the evidence, in the last weeks of her life there were a number of episodes which resulted in her enteral feeds being interrupted and, at times, even requiring intravenous feeds via a long line.
Dr Bohin, on the subject of Baby I's weight, said that premature babies will often cross centile lines before they settle on a line and grow along that centile line, so it was no surprise that she dropped from the 50th centile, but thereafter she didn't grow appropriately, but that was because she'd been ill. Her low weight did not predispose her to the four episodes of collapse from which she suffered.
Dr Newby was also asked about adrenaline. Sherefuted the suggestion that more and more doses of adrenaline can become counterproductive. She explained that the longer resuscitation continues, the chances of success diminish and there is no particular amount of adrenaline that is counterproductive. I’m inserting that because it comes later on in relation to the resuscitation, but that was her evidence and the evidence in relation to doses of adrenaline being counterproductive.
I'm going to take the break at that point. I know that because we started a bit late it's not quite as long as we normally have, but that's a good convenient point at which to break for our 10 minutes. Then we'll continue at 12.05. Thank you very much.
(11.57 am)
(A short break)
(12.07 pm)
Mr Justice Goss: I'm sorry about yesterday and the late sitting. Can I just reassure you that today and tomorrow we will finish by 4 o'clock, so you needn't worry about that. Next week will be a subject that I will come to later on because next week you will be deliberating on your verdicts and I'll decide what the sitting times should be, but they won't be before 10.30 because it's inconvenient for anyone to be here before 10.30, but whether it's going to be 4.00, 4.15 or... I will say now it won't be beyond 4.15, but I might say 4.15 because there will have to be smoke breaks and things like that. All right? Back to Baby I and tile 58. The next feed at 13.00 hours was recorded by the defendant as a 35ml feed by NGT, Baby I being recorded as asleep in the feeding chart entry and she initialled that time. The paper copy of that is in section 12 of your jury bundle. The defendant said it would take about 15 minutes.
Behind tile 61 is the nursing note made at 13.36, in which she wrote:
"3x8 feeds EBM, 2 bottles to 1 NG tube. Abdomen appears full and slightly distended. Soft to touch. Baby I straining ++. Bowels have been opened. Mum feels it is more distended to yesterday and that Baby I is quiet. Appears generally pale, not on monitor, but nil increased work of breathing. Handling well and waking for feeds. Doctor to review. To continue with current plan." She agreed that the reason she gave for calling Dr Beebe was the low temperature. In evidence she said the reference to waking for feeds was to the 10.00 feed because, of course, two were by tube. According to the defendant's note, written as an addendum at 19.31 that day, behind tile 65, Baby I was reviewed by doctors at 15.00 as she was mottled and monitoring was recommenced. There is no doctor's note. The defendant thought it was Dr A who carried out the review, which is what she had said in police interviews.
At 16.00, the defendant recorded that she gave Baby I another 35ml bottle feed by the NGT as she was asleep; tiles 68 and 69. She denied that she force fed and caused the vomit half an hour later. She did not know whether she had been there when Baby I vomited.
[Mother of Baby I] had left the unit and [Father of Baby I] was at work, so neither of the parents were there.
Tile 71 is the report of a large vomit and apnoea in the feeding chart and the defendant’s account written in the nursing notes. She wrote:
”At 16.30 Baby I had a large vomit from mouth and nose ++. Suction given. Became apnoeic with bradycardia and desaturation (30). Help summoned and IPPV given for approx 3 minutes in 100% oxygen to recover. Doctors were crash called. Transferred to nursery 1 and placed in an incubator for closer observation."
When interviewed, she could not recall how she became aware of Baby I's large vomit, as noted behind tile 72, or who put the call out. She confirmed Baby I was then moved to nursery 1 and she remained her designated nurse.
In evidence, she said staffing levels did not cause or contribute to the event and incompetence was not an issue. She didn't recall any concerns on handover at the start of the shift and the medical notes from the grand round painted a positive picture. Baby I was due her immunisations the following Monday.
She went over to Baby I when she vomited. She referred to the messages behind tiles 164 to 171 that evening in which she said it was nice to hear positive comments about her and she thought Nurse A was sticking up for her. A lot of staff, she said, were very drained physically and emotionally.
Dr A’s note is behind tile 30. Baby I had been bagged on a resuscitator and oral and nasal suction had taken place. Although her saturations had dropped to the very low level of 30% and her heart rate had dropped as well, when he arrived she was pink and her heart rate was 130, her saturations were 99% in air and normal. She was breathing well, there was no effort for breathing and she wasn't working hard. Her chest signs were clear. Her abdomen was a little bit distended and she had active bowel signs all over. Her fontanelle was normal, as was her tone and movements.
The plan is in his note: blood tests, a full blood count and a CRP, as markers of infection, and a blood culture for presumed infection. Chest and abdominal X-rays were ordered. Feeding was then to be by intravenous fluids and intravenous antibiotics were started. The venous gas results were raised but that was not surprising as they had come at a time of collapse and it was not possible to say whether the levels preceded or were because of the collapse.
Bernadette Butterworth, who came on duty for the night shift on the 30th with Nurse A and Kate Brammall, recalled Baby I's heart rate dropping and her desaturating and having to use the Neopuff. As they did so, she noticed Baby I's stomach, which she thought was slightly distended anyway, getting larger, and she asked the defendant to aspirate the NG tube, which she did. They got quite a bit of air out and a little bit of milk, she thought 2ml. Nurse Butterworth recorded it as "+++ of air", so there must have been a fair bit.
Baby I settled down after she had been aspirated, her chest movements came back, as did her saturations.
In the final interview on 10 November 2020, the defendant said she did not know why there was so much air that came out of Baby I's stomach when it was aspirated on 30 September. In her evidence she said that she had not pumped Baby I full of air.
The doctors then arrived. Dr A’s entry at 20.00 related to the X-rays. The chest X-ray showed perihilar shadowing, that's where all of the airways or the blood vessels that join the lungs into the main breathing apparatus and the main blood vessels have some increased markings, which could be consistent with infection but he couldn't say any more.
The abdominal film showed there were dilated loops of bowel in the lower quadrant but there was no air in the biliary tree and no obvious falciform ligament. There wasn't air tracking back up the bowel, which is evidence of NEC. He wrote a diagnosis of presumed NEC with a very, very low score.
Dr Harkness saw Baby I at 22.00 that evening by way of a routine review because of the events in the day. She was breathing well for herself, the blood tests did not show any indication of obvious signs of infection. She was still receiving antibiotics and she still looked pale. Baby I did not like being touched or being handled to change her nappy, which again suggested an infection.
Her abdomen was still distended and you could see visible loops, which means they were full of air. He could hear her bowels, which was a good sign. As with severe NEC, this can stop your bowels from moving. A repeat of the blood gas showed the lactate had gone down to 1.1, which was good, and there was nothing concerning.
Christopher Butterworth (sic) recorded that:
"Over the course of the shift [Baby I] handled much better without desats and bradys."
Ashleigh Hudson took over the care of Baby I at thestart of her long day shift at 07.30 on 1 October. Tile 196 is the relevant tile. Her observations were satisfactory, her temperature was stable, she appeared pale but pink and well perfused, she appeared to be well.
Dr A saw and reviewed Baby I at 09.00 on 1 October. He noted her previous care and presumed NEC, the plan for nil by mouth, a further CRP, and 3 days of antibiotics. He observed she was alert, active, pink, well perfused with a heart rate of 150 and oxygen saturations of 97% in air. The abdomen was soft and markedly less distended.
At the end of her shift Ashleigh Hudson noted Baby I had remained stable, her abdomen was soft and less distended, there had been some heart rate fluctuation around 18.00, but within the satisfactory range. Nothing stood out.
Baby I continued to receive care at the Countess of Chester. The defendant was off duty on 1 October, then worked three long days on the 2nd, 3rd and 4th and was off on the 5th.
Dr Newby saw Baby I on the 4th; J14369 is the note. She was self-ventilating in air, being fed a combination of supplements and expressed breast milk three-hourly and there was a note that she was nil by mouth for 24 hours last week, referring back to earlier events.
She was recently screened for sepsis and NEC and was negative at 36 hours. On examination she found Baby I's abdomen to be very soft, her bowels had opened resulting in a soft yellow stool, she appeared stable and there were no concerns, so they were just going to continue with the current plan.
In the early hours of 5 October, over a period of 3 minutes, the defendant searched on Facebook for [Mother of Baby I], [Father of Babies E & F], and [Mother of Baby H]; tiles 2, 3 and 4 in the section for event 2. She worked late on the 6th, had a training day on the 7th and was off work on the 8th, 9th, and 10 October.
By 12 October Baby I's feeds were up to 54 or 55ml every 4 hours. The neonatal feeding chart is at tile 8 and her weight was up to 1.83 kilograms.
Dr Harkness saw her at 11.15. He had no concerns. There were no nursing concerns recorded for 12 October; tiles 10 and 22. Baby I was feeding well and handling well and pink with a capillary refill less than 2, heart sounds were fine, tummy was soft, she had bowel sounds, her CRP had gone from 71 to 21 and now down to 8, so that was really good. There was nothing, said Dr Harkness, to suggest anything was going to happen.
She was pale that evening, but her tummy was soft to touch; tile 27. At the shift handover at 19.30 to 20.00, the defendant had a single child who was in nursery 1. Ashleigh Hudson became Baby I's designated nurse.
Baby I was in nursery 2 and Ashleigh Hudson was also the designated nurse for two other babies in that room, Baby G and JF. The note made by her on takeover, behind tile 32, this is Ashleigh Hudson's note, records that the equipment, alarm limits and feeds were checked, Baby I's temperature was 36.5, she was demanding and tolerating four-hourly feeds and feeding well. She was alert when awake, pale pink in colour, but well perfused. She took a further 55ml of milk at 21.30 and passed urine and her bowels opened ++; tile 38. Tiles 44 and 45 record that her temperature and the position of the probe were checked and at 01.30 on the 13th she took a bottle feed; tiles 44 and 45.
So I move to the second event. This occurred at around 03.20 that night, which was of course now Sunday, 13 October. Ashleigh Hudson wrote her note at 05.04. That's to be found behind tile 48: >"When in the nursery, Neonatal Nurse Lucy Letby noticed that Baby I looked quite pale. When turning the light on for closer examination, we found Baby I to be very pale in colour and not moving. Apnoea alarm in situ had not sounded. Breathing was shallow and respiration rate appeared low. Philips monitoring commenced and Senior Neonatal Nurse Laura Eagles and Paeds SHO Katarzyna Clegg shouted to assist. 30% Neopuff O2 commenced whilst Philips monitor establishing a trace. Philips monitor saturations 53%. Heart rate in 50s confirmed via stethoscope."
That's the note. The defendant wrote her note later at 07.59. It is behind tile 47. She will have been able to read the earlier note of Ashleigh Hudson. She wrote:
Baby I noted to be pale in cot by myself at 03.20. SN Hudson present. Apnoea alarm in situ and had not sounded. On examination Baby I centrally pale. Minimal shallow breaths followed by gasping observed. Ventilation breaths given via Neopuff and further help summoned."
Dr Neame recorded he had been bleeped at 03.33; tile 49. Chest compressions were commenced at 03.35. There was no heart rate; tile 50. The resuscitation measures are set out on tile 42, and at tile 54 the defendant's retrospective note sets out the resuscitation measures. [Baby I] was given three boluses of adrenaline and Dr Newby was called.
A minimum of 22 minutes after the collapse, at 03.45, there were signs of life. Care for Baby I was taken over by the defendant at that time; tile 71. Emergency blood was ordered and she was given a blood transfusion at 04.20; tile 78. An X-ray at 04.25 showed marked gaseous distension of abdominal bowel loops; tile 80. Venous blood collected at 04.25 had no bacterial growth after 5 days' intubation; tile 81.
Care of Baby I was handed over to the day shift at 07.45. The nursing note compiled by the defendant at 07.59 is at tile 120. Belinda Simcock then became Baby I's designated nurse for the ensuing day shift. Ashleigh Hudson confirmed that she gave Baby I the feed at 01.30, although she didn't sign it off on the chart. She was in good clinical condition, behaving appropriately for her age and seemed behaviourally very stable. Her temperature had been very stable and the fact that she was waking and cueing for feeds herself was really encouraging at the time. There had been discussion about discharge planning, although she wasn't quite ready. Their perception was that she was very stable at the time.
In the half hour preceding the emergency she assisted a colleague, Laura Eagles, with a procedure in nursery 1. She thought she was away from nursery 2 for about 15 minutes. Then she went back. She would not have left Baby I if she had been unsettled. There were two colleagues in the area and she asked one to keep an eye on her. Caroline Oakley has no recollection of being asked to keep an eye on Baby I while Ashleigh went and did something else.
After she had finished assisting with the procedure, Ashleigh Hudson went to the milk room to fetch milk. She then went to nursery 2. Nobody was there. She was preparing milk on the worktop to the left of Baby I with her back to her. The defendant was standing in the doorway. They were talking and the defendant then, from where she was standing, said, "Baby I looks pale", or, "Don't you think Baby I looks pale?" She was about 5 or 6 feet away from her, pointing to the distance from the witness box to where the clerk of the court sits.
The light in the room was switched off but the corridor light provided some illumination. She refuted the suggestion that the room light was dimmed and not off. There was a canopy over the upper half of the cot that obscured any light from the baby's face. The canopy covered about the upper half of Baby I. There were blankets in place over her. Ashleigh Hudson couldn't see the top half of Baby I because she was obscured by the canopy and the lighting. She switched the main light on and was closer to her than the defendant. She could then see her face was pale. The defendant, she said, would not have had a better view than her. She went to Baby I, pushed back the canopy and blankets, and realised she was in poor condition.
She selected one of the photographs taken in August 2020 that best showed the lighting at the time. She knew that the lighting had changed and was brighter by this time and that Lucy Letby had been arrested, but this did not influence her in her choice of photograph.
The photograph is document J25368.
Baby I was in a quite critical condition she said. She was incredibly pale, almost white. They removed her clothes at the start of resuscitation. She hadn't responded. She was very still, not moving her limbs and there was no normal respiratory pattern, only gasping a handful of times a minute. She was floppy. Her apnoea alarm attached to her abdomen had not sounded.
If there was no movement, it will not sound (sic). Ashleigh Hudson said it was very surprising that Baby I had deteriorated so rapidly. The defendant had come to the cot side and they tried to resuscitate her,using a Neopuff and chest compressions. Dr Neame came into the room, then Nurses Laura Eagles and Caroline Oakley, so Ashleigh Hudson took a step back and contacted Baby I's parents. The defendant doesn't allege that staffing levels or medical or nursing incompetence contributed to the event. >When first interviewed she remembered the event. She and Nurse Hudson went into the nursery and put the light on in the nursery for something. She looked over at Baby I and noticed her face was pale in colour. They went over and removed the covers and undid her babygro to check her colour centrally. She was shallow breathing and gasping. She could not recall having treated Baby I up to that point.
She started to give her Neopuff ventilation and a call for help was made. She denied injecting air into her stomach and indicated she had aspirated air from the stomach. She could not remember at what point they put the lights on, whether it was before or after they saw Baby I. She thought they were at the doorway when she spotted how pale Baby I was and that they had just put on the lights. She could not remember why they had gone in and turned them on. The nursery was never that dark that you would not be able to see the baby.
In the second interview on 11 June 2019, she remembered telling Ashleigh that Baby I looked a little bit pale at the doorway, saying:
"Maybe I spotted something that Ashleigh wasn't able to spot. The rooms are never that dark that you would not be able to see the baby at all. There's always a level of light for that reason."
From the position that she was, she said she thought she could notice that Baby I was pale and wasn't well.
When they switched the lights on she did look dead. Baby I would have been wearing a babygro and possibly a cardigan. There was always a degree of light that would be on the cot.
In her evidence she was asked how she could spot Baby I's colouring and Ashleigh couldn't. She responded she had more experience "so she knew what she was looking for", which she corrected to "looking at".
When interviewed again, on 10 November 2020, sh agreed she had described Baby I as "not good" in texts to Nurse A after the shift and had asked to care for Baby I again the next night as it was quite common to keep the same baby for continuity of care.
In her evidence she said she could not recall having any involvement with Baby I before the event occurred.
She agreed Baby I was doing well and couldn't remember which one of them, her or Caroline Oakley, had been asked to look after nursery 2. She didn't believe she was as she would have remembered.
She did recall herself and Ashleigh Hudson going into nursery 2 together, but didn't recall where she had been. Ashleigh Hudson was doing something on the worktop and she was stood in the doorway of the room and could see Baby I's face and her hands. She could not recall specifically what lights were on. The nursery was never in complete darkness as they need to be able to see monitors and the babies themselves. They put more lighting on and pulled back her clothing. Baby I was gasping and shallow breathing, so the alarms did not go off. They called for help.
She was asked about what she had said in interview about putting on the lights and not being sure at what point they did so. She did remember telling Ashleigh Hudson that Baby I looked a little pale at the doorway. She explained that her memory was that the lights were on a dimmer switch and they turned those lights up when they entered at the time they saw Baby I.
The room was not as dark, she said, as shown in photograph J25368 and the cot was nearer the work bench. She could see Baby I's face and hands.
Dr Matthew Neame was bleeped at 03.23. His note of attending is behind tile 49. On arrival, the nurses were providing breathing support by Neopuff ventilation in 100% oxygen and she was being given chest compressions. Baby I was pale and floppy. He took over managing her airway and improved the management of her airway, after which the chest wall was moving with the ventilation breaths. He also increased the pressure on the breathing support to help with the resuscitation and successfully intubated her to secure the airway.
Cardiac compressions continued. A cold light test for pneumothorax was negative.
Dr Newby was contacted and arrived at 03.36. As shewalking down the corridor, the defendant was leaving the room. When she arrived, resuscitation led by Dr Neame was ongoing. Baby I was intubated and CPR was ongoing. She noted that there had been no concerns during the day in relation to Baby I tolerating her feeds.
The notes behind tile 60 record the drugs Baby I was given and their timings. She was given three doses of adrenaline at 03.31, 03.36 and 03.45 as well as saline and dextrose. It took 12 minutes of resuscitation before signs of life were detected at 03.45. It was, said Dr Newby, definitely a serious state of affairs.
At 05.20, Baby I was being managed on a ventilator with the settings as set out on the note: on oxygen at 43% with 150ml per kilogram per day of fluids and no longer being fed, a blood transfusion was provided, she was mottled with normal heart sounds and had been started on all three antibiotics that are named in Dr Neame's note. He described her as "stable for a baby on ventilation".
An X-ray revealed that the breathing tube was too far in and had to be withdrawn by 1 centimetre and the NGT was not far enough in. The defendant agreed to re-pass it.
At 05.26, it's noted that the nasogastric tube had been re-passed with acidic gastric aspirates by the defendant, which indicated it was in the appropriate position. The X-ray also showed patchy bilateral air space, shadowing and bowel loops distended but there was no evidence of air having leaked out of the bowel.
Dr Harkness reviewed Baby I at 16.00 that day, so that afternoon. Her blood gases and her ventilation were all acceptable, her blood pressure had been dropping throughout the day. She had been put on dopamine, which had improved it. Bowel sounds were there. They'd sent X-rays over to Alder Hey, to the team there, to review and had asked for their thoughts.
He had also inserted a long line at that time into her right thigh. They were waiting to hear back from the surgeons to find out what they thought, but otherwise he would describe her as sick but stable and still on the ventilator.
With regard to her earlier collapse they were thinking along the lines of NEC as her abdomen had got larger and firmer. There was nothing definitive in relation to NEC but it was grumbling on.
I turn then to the events of the next night shift. This is in the third sequence of events -- I'm sorry, I should have said the references I was giving you to the second sequence of events. This is now the third sequence of events.
The defendant was also the designated nurse for Baby I on the following night shift of 13/14 October, taking over her care at 19.45. There were three babies in nursery 1. The other two were being cared for by Joanne Williams. Of course, Baby I had already been transferred into nursery 1 the previous night shift.
At 20.30, the defendant sent an SMS to Ashleigh Hudson saying she had got Baby I; tile 13. She was on inotropes and gone up with ventilation, but stable when handled and referred to her abdomen and some changes on X-ray, but Alder Hey were happy for them to keep her -- that's the Countess of Chester to keep her for now.
The shift leader was Caroline Oakley. From 21.28 there was an exchange of WhatsApp messages between the defendant and Nurse A, tiles 25 on sequence 3 onwards, to which you can refer for the details. At tile 31 the defendant told Nurse A that she'd got Baby I:
"Not great, on inotropes, 70% O2. Thinks it's abdoAHCH don't want her at the mo.”
Tile 40 fronts the defendant's note made at 21.49 in relation to the shift up to that point. That's up to 21.49. Nothing untoward is recorded. There was reference to:
"Abdo full but soft and some bruising, [query] from chest compressions [that had taken place the night before]."
Dr Neame carried out a night review at 22.05; his record is behind tile 46. The results of a blood test at 17.00 were good, her respiratory situation was stable and fluids were positive. Baby I was settled and pink, had good chest wall movement and equal air entry. Her breathing was a bit squeaky, which you sometimes hear in ventilated babies, her heart sounded normal, her abdomen was distended but soft, with some tenderness, and her bowel sounds were normal.
She was receiving a moderate amount of respiratory support but was stable. Behind tile 60 is her nursing note made retrospectively at the end of the shift.
At tile 74, the defendant wrote a nursing note at 5 am:
"Abdomen noted to be more distended and firmer in appearance with area of discolouration spreading on right side. Veins more prominent. Oxygen requirement began to increase. Colour becoming pale."
There are no medical records relating to observations at that time.
At 05.00 on 14 October, Dr Neame was asked, he thought by the defendant, to see Baby I due to an increased oxygen requirement and reduced blood oxygen levels on the saturation monitor. Tile 79 fronts the relevant note. On his arrival, Baby I was receiving Neopuffing with pressures of 20/5, her oxygen concentration on the Neopuff machine was 100%, but her blood oxygen saturation level was only 77%, which was low. There was some evidence of chest wall movement.
Her heart rate was a little high. Her abdomen was distended and mottled, the mottling of the abdomen was unusual, and she grimaced on palpating the abdomen, which he concluded was tender.
Dr Neame increased the pressure and noted that there was some improvement, so restarted the ventilator with some increased pressures and an increased concentration for oxygen. His impression was that the increasing abdominal distension may have caused Baby I's lungs to become squashed, making it harder for her to breathe and maintain normal oxygen levels. She was more unwell, her oxygen levels were low and she needed increased breathing support. The other aspect that stood out for Dr Neame was a change in the appearance of her abdomen with a change in the skin and increased tenderness.
At 06.20, having received the X-rays and blood gas test results, he spoke to the on-call consultant, Dr Jayaram. His note is behind tile 90 and was written at 08.10. The findings from the abdominal X-ray, which included the small appearance of the lungs and the dilated appearance of the bowel loops, were in keeping with his earlier assessment.
Dr Jayaram was told of the massive abdominal distension. The tube was in and the chest wall was moving and gas was going in and out of the lungs, but in spite of this and being in 100% oxygen, they couldn't get good saturations. Following the discussion, it was decided to continue with the ventilation settings that Baby I was receiving. The cold light test for pneumothorax was negative. He contacted the surgical team at Alder Hey, who said they would look at Baby I's X-rays and contact them, that's the Countess of Chester, with a plan in the morning. A pneumothorax was included.
Shelley Tomlins was one of the nurses who came on duty at 07.30 that morning of the 14th, taking over from the defendant as Baby I's designated nurse. Her first notes were written at 09.22. At handover, from 07.30 to 8.00, she thought she went straight in to get a bedside handover from the defendant because Baby I wasn't well and there was going to be a lot to talk about.
The defendant was probably already at the bedside when she walked into nursery 1. She couldn't remember how long they got into the handover before Baby I had a cardiac arrest when they were looking at her. Her notes recorded this was minutes after arriving on the unit. Yvonne Farmer was in the room. Jo Williams did the chest compressions. Dr Neame led the resuscitation. She was then stable on a ventilator. Shelley Tomlins recalling that she passed urine anda small bowel movement and that her abdomen was very large, pale and veiny, with an umbilical hernia evident, with an area of slightly greyish discolouration.
Dr Neame thought her bowel had blown up so massively that it was compressing her lungs.
Dr Jayaram arrived at 07.59. His detailed notes are behind tile 122. By the time he arrived, Baby I was stable.
From an X-ray at 08.03, tile 129, there was nothing to suggest a pneumothorax. The ETT was in a good position, there was ongoing quite significant abdominal distension. He suspected the lungs were compressed and weren't moving a huge amount of air in and out. His notes recorded that at 08.25 Baby I had another acute deterioration of her saturations, so they took her off the ventilator, hand ventilated her with Neopuff, and her saturations picked up to 89%. It was clear, he said, that in spite of the higher rate of morphine and the dose she had had of suxamethonium, a very short-acting muscle relaxant, which seemed to make a difference, she was still breathing against the ventilator, so they decided to start her on vecuronium, another muscle relaxant that works longer term.
In her evidence the defendant didn't have any recollection of the shift and Baby I's deterioration other than what was in her notes. She said staffing levels had no relevance to the event and she was not saying there was any medical incompetence or mistakes made. She agreed that in her nursing note, behind tile 60, the signs were initially good and didn't now recall the discolouration.
In relation to Dr Wright's report on the X-ray, which is behind tile 85, that the gaseous distension of the bowel had increased, she said that she had not inflated Baby I with air and sabotaged her at around 7 o'clock.
At 11.00, Dr Harkness noted Baby I's blood pressures were poor, her lactate was high, she had a good urine output, and her blood cell count was high, which was a sign of infection, inflammation and stress. In discussions with Alder Hey, it was thought she may have a stricture, a narrowing of the gut.
By 16.00, her ventilation had much improved and the pressures on the ventilator had come down, as had her CRP. At that stage they still had no answer as to whether it was NEC or possibly a stricture.
On 15 August (sic), it was decided that Baby I should be transferred to Arrowe Park. She arrived at 15.30, was ventilated with a breathing tube -- this was the evidence of Dr Babarao -- she was on intravenous fluids and routine sedation. She was pink, warm and well perfused. Her abdomen was soft.
She remained stable until 00.13 on the 16th, when she had a sudden episode of bradycardia and desaturation. Her breathing tube was found to be blocked with dark-coloured blood, probably from her previous collapse. She responded very quickly and the heart rate and saturations came up. She was then spontaneously breathing and she received PEEP to support her breathing. She was saturating well and had a good weight and respiratory pattern, so they decided not to re-intubate her, but to try a lower level of respiratory support, which was high flow.
They visually checked the oral cavity and the vocal cords where the breathing tube went in to check for any evidence of trauma. There was no fresh bleeding or any significant injury so they commenced with high flow in about 35% oxygen.
The following morning she was reviewed. She was stable and had very good blood gases and no issues with her breathing, no respiratory difficulty. Her blood pressures were fine, urine output was good and her abdomen was soft and not distended. There were no markers for infection and the blood cultures that were taken in Chester were also negative. The triple antibiotics were continued. She had low phosphate; all other blood tests were reasonable.
The following morning, 16 October, another review was completed and notes were made to reduce the phosphate infusion as her levels were coming up and she was moved to the high dependency unit as she was stable on high flow and her gases were good. She had been very stable since transfer.
A contrast study to see if there was any narrowing in the bowel at any point or any obstruction was to be arranged at one of the two tertiary hospitals. There were no issues overnight and gases remained good, oxygen requirement was down and she remained stable. Baby I was transferred back to the Countess of Chester the following morning, 17 October.
I mistakenly said August a short time ago. It was on 15 October it was decided that she should be transferred to Arrowe Park. You probably noticed my error at that particular point.
We now move on to the fourth event on 23 October, the day that Baby I died, but I will break off now and we'll do that of a piece when we resume at 2 o'clock, please.
I just want to remind you, I know that this is very repetitious and must become very tedious for you to hear it every time we have breaks, but I just want to emphasise to you that the importance of adhering to your obligations as jurors, which includes no form of communication with anyone about anything to do with this case and any of the details of it or anything about it or any views that you may have about it or researching anything on the internet about anything to do with this case must be adhered to. I'm sure you are adhering to them, and you'll be sick and tired of me saying this, but you'll appreciate as we get closer and closer to the end of the trial, maintaining what I called, you'll recall, the integrity of the jury system, you deciding this case on the evidence that you hear and the assessment you make of it, is so vitally important.
Thank you very much and thank you for hearing that yet again.
(12.56 pm)
(The short adjournment)
(2.00 pm)
Mr Justice Goss: On to event 4 and the fourth sequence of events. Baby I was pronounced dead at 02.30 on 23 October 2015, 6 days after her return from Arrowe Park Hospital.
As she had been the night before, Ashleigh Hudson was Baby I's designated nurse for the shift of the 22nd to 23 October. Baby I was not an intensive care baby, but was in nursery 1 in an incubator as a precautionary measure.
Behind tile 9 is Ashleigh Hudson's notes of her cares from around 20.00 on 21 October, written at 03.04 on 22 October. So this is the first of the two night shifts:
"Self-ventilating in air. Observations satisfactory as charted. Baby I was unsettled and rooting at start of shift. Settled with dummy and containment holding."
Ashleigh Hudson told you Baby I was stable. The ensuing tiles record her vital signs and the neonatal fluid balance chart. There were no entries at 23.00 because Baby I's long line had been removed, and with the defendant's help, due to constant occlusions, blockages. She was alert and well, pink and well perfused; tiles 91 and 92. TPN was administered peripherally from then on, lipids being suspended until the long line could be sited.
Prior to that, the defendant had been engaged in messaging various colleagues about matters, including babies, and at tile 68 referred to: "Baby I still waiting [that is to go to Alder Hey] but had had an abdo scan that was fine."
You have a paper copy of the intensive care chart for that night shift in your second jury bundle in section 12.
Her heart rate was stable and within the acceptable range. Her respirations were also good, save for one raised reading at 22.00. She was self-ventilating in air and her sats were between 96 and above.
There was no increased work of breathing. Her VIP score was optimal. Her abdomen was soft and not distended. She looked very well, being pink, well perfused and stable. She was on free drainage through the NG tube. In evidence the defendant agreed that she was settled and stable.
Ashleigh Hudson handed over to Caroline Oakley for following day shift; tile 17. Baby I had a long line in, fluids going through, and she was still nil by mouth, waiting to go to Alder Hey for a barium enema.
She was unsettled at times, obviously very hungry, but was usually settled with a dummy. They were getting minimal clear aspirates from her NG tube, her abdomen was fine, soft and not distended. She had also passed urine and her bowels were opened. Her cares were attended to by mum. Her readings and observations during the remainder of that day were unremarkable, as set out in the ensuing tiles.
For the ensuing night shift of 22/23rd, as I have said, Ashleigh Hudson was her designated nurse again and for baby AB in nursery 1. The defendant was the designated nurse for two other babies, one in nursery 2 and one in nursery 3. Melanie Taylor and Christopher Booth were also on duty.
Behind tile 48 is Ashleigh Hudson's nursing note for the handover at 19.45 on 22 October. The defendant, in her defence statement, said she did not recall a lot of the detail of the night Baby I died. She said in evidence she thought staffing levels may potentially have been relevant. Also, Dr Chang being called away to another case and Dr Gibbs not being there might be relevant.
At just prior to midnight, Ashleigh Hudson remembered that Baby I was unsettled, crying, so she attended to her in the incubator and tried to settle her by the usual measures of containment holding and a dummy with sucrose as a comfort measure. It didn't seem to work. She was very unsettled, it was quite a relentless cry, so she tried to reposition her on to her tummy, which sometimes would settle her, but did not on this occasion. It was very loud crying, relentless, almost constant. There was no stopping and starting, no fluctuation, something that she had not heard from her before.
Within seconds of putting her on her tummy, she became very quiet and started having pauses in breathing. Ashleigh Hudson turned her back over and shouted for help around the same time. The defendant came in to give her assistance. They got her into position for giving her ventilation breaths. Baby I did not respond to ventilation breaths of oxygen and they crash bleeped the paediatric doctors. That call went out at midnight, 00.00.
Ashleigh Hudson's note of the event behind tile 99, made at 03.39, recorded that Baby I was very unsettled, became very quiet, apnoeic, dusky in appearance, which was indicative of poor perfusion. Her abdomen was soft and non-distended prior to resus, no change from handover.
In her evidence, the defendant said she did not hear Baby I cry in a way she had never heard before. She was quiet when she went into the nursery and apnoeic.
When Dr Rachel Chang, who was the first clinician to attend, arrived, Baby I was having two-person ventilation. She had desaturated to 40%, her heart rate was 60, falling to 30. She was told she'd been crash called because Baby I had had a significant deterioration at the time of crying. She took over the ventilation and started chest compressions. Dr Gibbs was called.
Baby I was in cardiac arrest and was intubated by Dr Chang. Good ventilation was achieved. The defendant and Ashleigh Hudson were the two nurses involved she said. They continued with chest compressions. Baby I showed signs of improvement over 5 minutes. Her heart rate picked up. When Dr Gibbs arrived, Baby I was being ventilated with a Neopuff through an ET tube, she was active, which meant she was moving, she had a pink-coloured face but was pale and mottled, blue in her trunk and peripheries, an indication of reduced circulation. She was receiving a bolus of saline to improve her circulation. Her colour steadily improved over the next 5 minutes and then she became pink all over. There was moderate abdominal distension.
Dr Gibbs, in discussion with Dr Chang, decided to extubate Baby I and let her ventilate herself. She was fighting ventilation, which was a good sign. They did not have any concerns that she would not be able to self-ventilate. Dr Gibbs could not understand what natural disease would have caused her deterioration and yet she had recovered so rapidly. Either he had to sedate her heavily, paralyse her and carry on ventilating her or take out the endotracheal tube and see how she managed.
Babies collapse because something has affected them, usually it's some sort of disease process. Sometimes premature babies can deteriorate quite quickly, usually they would hope to have some warning that they were deteriorating, that's why they monitor and perform observations on babies. >In Baby I's case she had been fine up to just before midnight, her breathing had been fine, her tummy had been soft and not distended, so she had rapidly deteriorated shortly before midnight. Although some diseases and some disorders can come on quickly, common disorders, being infection, haemorrhage or NEC or severe lung disease, once the baby has deteriorated to the extent of needing ventilating, it is not going to go away suddenly. So he would have expected Baby I to be floppy, unresponsive, not resisting being ventilated.
That was why Dr Gibbs couldn't understand what natural disease had affected her that she had recovered so quickly.
At that time, although she was hungry, hunger does not cause someone to suddenly be in severe pain or appear to be in pain and then rapidly deteriorate, so it appeared to be something else rather than just being hungry. Once you've got distressed and breathed out heavily, your lungs can collapse down a bit because they are getting smaller. And because Baby I had chronic lung disease of prematurity it would be more difficult for her to re-inflate the lungs so at that time that is what he had supposed had happened and he wasn't sure what had happened to cause that collapse.
A radiograph, which is behind tile 116, showed a large stomach bubble and the tube was in a satisfactory position. There were no indications of any need to do a septic screen. When Dr Gibbs left, Baby I seemed stable. She was in air and was content, sucking a dummy.
When she was cross-examined about the records leading up to midnight, the defendant was asked about J34535, the record for baby HS for whom she was the designated nurse and was to be transported back to Royal Stoke University Hospital. Dr Chang examined HS and noted her to be safe for transfer at 22.00.
In her nursing note, J34537, written between 22.50 and 22.52, the defendant wrote:
"To commence 10% glucose for transfer, awaiting arrival of transport team."
The IV fluid chart, J34542, for HS showed the start time for the infusion altered from 23.00 to 24.00. Although there was an entry in the fluid balance chart, there was no entry at midnight in the the allegation that she was J34546, for 23.00, there was no entry at midnight in the pressure VIP line.
In response to falsifying paperwork to cover her activities, the defendant said the entry of 23.00 was an error, which she then corrected to 24.00.
Just over an hour after that first event, at 01.06 there was a further event from which Baby I never recovered. The relevant tile is 130. Between the events, Ashleigh Hudson said [Baby I] was behaving entirely normally for her and as she had been before the first event. She was not in nursery 1 with Baby I all the time between the events and was alerted to Baby I being unsettled. She did not recall whether it was the monitor alarming or hearing her cry when she was either at the nursing desk or at the computer, which was directly opposite the nursing desk in nursery 1.
When she re-entered the nursery, the defendant was already with Baby I, trying to comfort her, trying to settle her. At that point in time, her observations were normal, she wasn't desaturating, she wasn't bradycardic, she wasn't apnoeic, she was crying. The defendant was at the incubator with her hands in the incubator with a dummy, trying to settle Baby I, who was crying in the same sort of way as in the event an hour earlier, loud and relentless.
Ashleigh Hudson's concerns were that she was going to have another episode and collapse. Within about 60 seconds of being in the room, Ashleigh Hudson said something along the lines of, "She's going to do it again, it's the same cry". The defendant responded, "She just needs to settle, she just needs to settle".
Ashleigh Hudson thought she was trying to reassure her. Baby I's relentless cry persisted. They couldn't settle her and, as before, she then became quiet, began to have slow pauses in breathing, her heart rate started to drift down, she became bradycardic and her saturations started to drift. They initiated oxygen delivery again, ventilation breaths, and shouted for help.
Christopher Booth attended. Rather than bleep, Ashleigh Hudson then went to the delivery room to get clinical help. Dr Chang attended; tile 132. When she arrived, the defendant and Melanie Taylor were in nursery 1. Baby I was pale, her sats were low, her heart rate was dropping. She was being ventilated on Neopuff. The succeeding events are documented from tile 134 onwards.
Compressions were commenced at 01.16. Dr Chang intubated Baby I and achieved good air entry, but she did not improve. Adrenaline and bicarbonate of soda were administered, the details are recorded in the notes.
Further doses were given. Dr Gibbs arrived at 01.23, his notes are behind tile 193. Baby I was receiving chest compressions as well as being ventilated with a Neopuff. She was mottled and purple and white all over, indicating poor perfusion.
The ventilation was changed over to a bag to achieve higher pressure, but her sats and heart rate remained low with an abnormal slow rhythm. Over the succeeding minutes, she was given boluses of adrenaline as well as boluses of bicarbonate, atropine and calcium gluconate.
Her heart rate increased temporarily at around 01.20. Chest compressions were stopped temporarily at 01.45 after 29 minutes of resuscitation and she was given saline to improve her circulation.
At 01.50, her heart rate dropped to 70, her saturations dropped and cardiac compressions were restarted and she was given further boluses of adrenaline to a total number of eight and atropine. All attempts at resuscitation failed and the decision was made to stop. Baby I was extubated, given to her parents and Dr Gibbs confirmed that she passed away at 02.30.
Melanie Taylor said they were all devastated, even more so because they knew the family and Baby I so well, and they'd been through so much. It was pure shock. This was the second baby whose death she was directly involved with on the unit. Before that, she had been there a few years and wasn't involved in any death. She was never concerned about any of the care or treatment that the babies had on the unit.
The defendant helped Ashleigh Hudson after Baby I's death because this was Ashleigh Hudson's first death.
When Mother of Baby I and her husband were bathing Baby I, the defendant came back in, was smiling and kept going on about how she was present at Baby I's first bath and how much Baby I had loved it. She told you, the defendant, that she said this because she was trying, in that awful situation, to have a little bit of whatever can be normal and referring to a positive memory. Baby I had really enjoyed her first bath. It wasn't meant with any malice. They still talk to babies, they still treat them as if they're alive. It was just trying to reflect on a happier memory.
At 09.40 that morning, Dr Gibbs informed the coroner's officer because he didn't know or couldn't understand why Baby I had died. On 9 November there was a debrief that was attended by the hospital chaplain who had started to attend the debrief meetings because of the sudden increase in deaths in 2015, despite nothing else changing. Clinical practices hadn't changed and staffing levels hadn't changed from previous years. The defendant and Ashleigh Hudson also attended. The note is document J14297. There was a short general review of the history and the comment that:
"Removing ETT after first collapse might not have helped."
Dr Gibbs said this referred to a possibility it might have been better to leave it in because it was unclear why [Baby I] had collapsed, so depending on why she had collapsed, keeping the ETT in might have helped. But he couldn't understand any natural disease process that had affected Baby I that had caused her to collapse and recover so quickly that required the endotracheal tube to remain in. She was behaving as though she did not need an ETT by fighting ventilation and being very active and remained stable for 40 to 45 minutes post-extubation after her first collapse.
He also noted and accepted that it was possible that her poor response to the second resuscitation might have been due to the heart being compromised by previous cardiorespiratory collapses.
There was a good deal of messaging between the nursing staff and some messaging between Dr Ventress and the defendant. It begins from tile 228 in the fourth sequence of events. Amongst the messages were ones passing between Nurse A and the defendant at around 272, which included references to the defendant feeling that she had to prove herself.
Two weeks later, on 5 November, a day that she was off work, between 20.30 and 23.44, the defendant searched on Facebook for [Mother of Babies E & F], [Mother of Baby G] and [Mother of Baby I]; tiles 293 to 295. The next tile, 296, is the text of a photograph recovered from the defendant's phone of a card to [Mother of Baby I], [Father of Baby I] and family, the [Baby I] family, from the defendant, which she took on the unit before giving the card to a colleague to give to them on the day of [Baby I]'s funeral, which was Tuesday, 10 November. You have a copy of the photographs from the phone.
Almost 6 months later, on 29 May 2016, a day the defendant was off work, she searched for [Mother of Baby I] a third time on Facebook at 23.00.
When interviewed by the police the defendant did not remember the shift of 13/14 October, but agreed from the notes that she was Baby I's designated nurse. She agreed she had noted some bruising/discolouration evident on the sternum and the right side of the chest from chest compressions and she thought it was spreading from the centre of her abdomen across to the right side. She didn't remember if she was present when Baby I collapsed.
She remembered drawing up the drugs for the resuscitation. She couldn't remember if she was the person to find Baby I collapsed, maybe she had gone to her because she was crying. Generally, she had a recollection of Baby I coming and going to other hospitals and there was a general feeling on the unit that she was being transferred to the Countess of Chester too quickly and before she was ready and the transfer process was quite stressful for her.
She had sent a sympathy card to the Baby I family, tile 296, and photographed it. She had not sent cards to other parents. This was the only one she had ever sent. It was upsetting losing Baby I. She said she often took images of cards she sent. She didn't know why she had searched for [Mother of Baby I] on Facebook on 5 October and didn't have any recollection of doing so and didn't recall the searches on social media for [Mother of Baby I] on 5 October 2015 at 01.16, 5 November 2015 at 23.44 and on 29 May 2016. She asked to care for Baby I on the following shift she was on for continuity of care and because she wanted to care for her.
In evidence to you, the defendant said she didn't have any independent recollection of any of the details of event 4 and didn't recall whether she was there after the second collapse. She did recall settling her after crying, but didn't know if this was after the first or second event. Her memory started from Baby I being resuscitated. She did not remember Baby I being unsettled and appearing to be rooting and hungry. She thought Ashleigh called her to help when Baby I appeared to be unsettled. She couldn't remember her condition.
She referred to the neonatal review which showed she had no involvement with Baby I up to the event and she didn't recall where she was between the two events during the shift. She was there when Baby I died. This was Ashleigh Hudson's first experience of death, so she helped her.
In relation to the funeral on 10 November she was working nights at that time and was advised she could send a card, which she did. This is the sympathy card, J13163 and 13164, of which she took images that were on her phone, agreed facts 41 and 42. She said she photographed the majority of cards she sent and referred to D29, a photograph of a card congratulating a close friend and her family on the birth of a daughter.
In cross-examination it was pointed out to her that in paragraph 120 of her defence statement she had said:
"I called for Ashleigh who came in."
And after saying she had no recollection now, that meant she came into the room. She did recall trying to settle Baby I, who she thought was rooting and hungry.
She did not recall Ashleigh saying, "She [was] going to do it again, it [was] the same cry". She denied she had pumped air into Baby I's stomach.
Professor Arthurs reviewed all the in-life radiographic material from 19 August. Up until then, the material was unremarkable. There were non-specific findings of bowel gas dilatation of the stomach on the radiographs of 23 August but no features of NEC.
By 5/6 September, Baby I was developing lung changes of chronic lung disease of prematurity and she had some residual distended bowel loops but no features of NEC.
On the 30 September image in the Baby I 1 sequence at tile 78, he could see lung disease of prematurity but her abdomen was very distended because her diaphragm was quite high up. The distended abdomen would have been obvious clinically. There could be a small amount of air within the bowel wall rather than simply in the tube, he said. Again, there were no features of NEC.
An image of 13 October, tile 80 on the third sequence of events, taken at 04.25, just after the second incident, showed the large bowel was quite distended. Professor Arthurs thought it was large bowel distension and not stomach distension.
On the radiograph behind tile 129, taken at 08.03, there was an almost identical appearance but the stomach had been decompressed.
By 24 hours later, tile 305, at 03.17 all of the bowel had now decompressed, so it had all gone down.
There was no more dilatation, the diaphragm had come down, so clinically she wouldn't have had such an extended abdomen. That episode had resolved within 24 hours or so.
On her return to the Countess of Chester, the bowel on 18 October was normal, there was mild dilation of the right sided loops on the 20th. On the 23rd, shortly before her death, tile 116 on the fourth sequence of events, the lungs were back to normal for her prematurity. There was a nasogastric tube in place and massive dilatation of the stomach all the way across the midline. The image cannot give any clue as to the cause but it was quite unusual, said Professor Arthurs, to see babies with this degree of dilatation of the stomach.
It causes splinting of the diaphragm, compressing up against the diaphragm and preventing the baby from bringing the diaphragm down in order to breathe, so you could get respiratory complications as a result of that.
The post-mortem imaging showed Baby I also had a large amount of dilatation in the bowel, but she had that ante-mortem, in other words before she died, so that there was dilatation in the bowel both before and to be seen post-mortem.
He explained that there are not very many conditions that cause intermittent dilatation of all the bowel and occasionally of the stomach as well. That is not a feature of NEC and there were not very many other features of NEC in her case. It would be apparent from the autopsy whether the bowel had been recently or previously affected by NEC and we know from Dr Marnerides that it was not.
So one of the explanations for this would be giving air down the NG tube. Had Baby I had several episodes of sepsis, where she was generally unwell with an infection, it is possible that the bowel stops working and gets dilated from those, typically not the stomach, and again that's because most babies like this have an NGT in the stomach and they are either regularly being aspirated or they are on free drainage, which allows the gas to freely emit from the body. So it's quite unusual, given that context, to see this degree of stomach dilatation in particular.
For babies who are on CPAP sometimes the gases can go down into the stomach and distend the stomach, but she was mainly intubated and ventilated by conventional means and he did not think, that's Professor Arthurs, that CPAP was a cause for several of these findings. He did not know how much air it takes to generate the sort of appearance to be seen on these images as those experiments can't be carried out for obvious reasons, but he would guess that it would be more than 20ml or 50ml of air because nurses can draw those amounts from a stomach. So if those possibilities are excluded it follows that one is left with the inference that someone has deliberately injected air.
Dr George Kokai, a consultant paediatric pathologist, conducted a post-mortem examination of Baby I at the Liverpool Children's Hospital at 14.30 on 26 October and made a written report almost 2 years later on 25 September 2017, agreed fact 23 in section 24. Dr Marnerides was dependent on the findings reported by Dr Kokai as the histology slides had been destroyed.
Baby I did not have NEC. Although she had chronic lung disease there was no inflammation, so no evidence of an infection going on in the background of that chronic lung disease that may be an explanation for why she had died. Nor was there any recent bleeding. So she nothing occurring acutely shortly before she died.
There were changes around the ventricles in the brain, indicating that there had been a hypoxic ischaemic event, a reduction of oxygen supply, to the brain anywhere between 1 to 2 weeks earlier and not shortly before her death.
He could not see any traumatic injuries, any facial dysmorphic features or abnormalities externally. The organs showed normal structure. The segments of bowel that he could see in the photographs were very dilated, apparently because of the presence of air. Other than that, he could not see any abnormality. The one unusual finding was a markedly dilated bowel, apparently with air in it.
Dr Marnerides was very sceptical that Baby I died of natural causes. The hypoxic ischaemic brain injury that Dr Kokai described could not be attributed to her birth.
Had that brain injury occurred around the time of her delivery, the CT scans around the time of her first collapse would have picked much more advanced changes rather than the small haemorrhage that they did pick out. So the starting point of that hypoxic brain injury cannot be tracked back to the point of delivery, it must have been sustained at some stage after her birth. The hypoxic injury itself cannot explain the final collapse.
The collapses on 30 September and 13 October were more likely due to the infusion of air into her stomach and bowel. There was no evidence at the post-mortem that revealed morphological evidence of some sort of natural disease which would account for excessive air being identified in Baby I's gastrointestinal tract.
He explained that although they cannot morphologically prove it, the two proposed mechanisms in the literature, which are entirely reasonable and make sense on the physiology and pathophysiology of the human body, to be observed in the living, excessive air in the stomach causes a collapse in one of two ways: either by a splinting of the diaphragm, an over-distension causing a splinting because of the air pushing it up so the lungs cannot work, or, because of where the stomach is located and how the nerves go down, you can have stimulation of the vagus nerve because of the pressure against it, resulting in cardiac arrest.
In the absence of sufficient clinical or post-mortem findings to explain the fatal deterioration, and given the presence of air detected radiologically, in the absence of findings of post-mortem decomposition or an underlying disease like NEC or obstruction or volvulus, in his opinion the excessive air in her stomach and bowels was caused by the excessive injection or infusion of air down the NGT into the gastrointestinal tract.
When cross-examined, Dr Marnerides agreed that Dr Evans' review of Baby I's medical notes failed to demonstrate a natural disease process to which that first clinical deterioration back on 23 August could be attributed.
The defence suggest that this event, as recorded in the nursing note back on 23 August, was a similar event to later ones and, as the defendant was not on duty at that time on 23 August, she could not have administered air down the NGT on that occasion.
Both Dr Evans and Dr Bohin gave their opinions in relation to each of the four events. In relation to the first event on 30 September, Dr Evans noted Baby I was entirely stable, right until she suddenly collapsed. He concluded she collapsed as a result of some kind of event. And looking at the X-rays and the clinical pattern, in his opinion she'd been subjected to an infusion of air, in other words, air being put into her stomach. A large infusion of air into the stomach interferes with the ability of the diaphragm to move up and down and that interferes with the breathing.
Anything interfering with breathing will quickly reduce oxygen to the tissues, reduce oxygen saturation and then heart rate.
Baby I had a large vomit, which reduced the pressure in her abdomen and therefore made it easier for her to breathe. On top of that, she had a gastric tube from which air +++ was aspirated, which will have reduced the abdominal pressure even more, and this led to her recovery on that occasion.
The X-ray at tile 78 showed a large amount of air in the large bowel. Though not a radiologist, he saw loads of air in the whole of the intestine, the bowel preventing the abdomen from moving up and down effectively, and that would have led to oxygen desaturation which also would have led to the collapse.
He also noted there was no sign of lung collapse or pneumothorax.
Put shortly, in his opinion, her saturations were caused by splinting of the diaphragm caused by an injection of air into the stomach.
Under cross-examination, Dr Evans agreed that Baby Ihad had recurrent episodes of abdominal distension and recurrent desaturations, regardless of the four events under consideration, had required oxygen in various ways at various times, and there were periods when she had infection or suspected infection and received treatment for that, and periods when she had suspected NEC and received treatment for that.
He accepted her weight gain could have been better and could have been a consequence, the cumulative failure to gain weight, of the cumulative problems with her ill health over time.
He agreed that in his reports of 8 November 2017 and 31 May 2018, in relation to -- maybe 2019 -- to the abdominal distension on 23 August, about which I have reminded you, he had formed the view that Baby I had received a large bolus of air via the NGT. He said he did not know how much would have been injected to splint the diaphragm but it would have to be quite a bit, nor did he know how long it would take or how long it would be there before there was vomiting and desaturation.
There was no data on this and, of course, no one could carry out clinical trials.
He said the X-rays were compelling evidence of the injection of air and added that air had been aspirated as well. He refuted suggestions that he looked at the event of 30 September, took bits of evidence, and then put them together with a prosecution bias in order to support his allegation, repeating that no one was being prosecuted or had been arrested when he reviewed the clinical notes, which were what he relied on in identifying untoward events.
Dr Bohin confirmed she had read all the clinical and nursing records and reviewed the salient events and features she identified in her report. In relation to that first event on 30 September, she noted that prior to the collapse Baby I was well and giving no causes for concern. She had no respiratory symptoms, was self-ventilating in air, she was gaining weight and her collapse was sudden and unexpected. She didn't have any of the usual things that would cause a baby to collapse suddenly. She wasn't suffering from an infection because that doesn't present in this way. Nor did she think that she had a malrotation or an obstruction in her bowel that caused her abdominal distension or an intraventricular haemorrhage because they tend not to come and go.
Baby I had abdominal distension and the X-ray showed huge gaseous distension, so much so that the lungs were squashed, which could easily be seen on the X-ray. She too thought that abdominal distension had splinted the diaphragm, squashed her lungs, which were not normal, being the lungs of a premature baby who had mild chronic lung disease, so it would not take much to tip the balance to squash those lungs and that in turn facilitated her collapse.
She considered but discounted NEC. A distended abdomen is not the only feature of NEC and Baby I had no other features of NEC either clinically or on X-rays.
In her opinion the collapse of Baby I was caused by the administration of air via the NGT into the bowel.
In relation to the second event, Dr Evans noted that at 03.36 on 13 October Baby I had been found blue and not breathing and required very intensive resuscitation over a very short period of time in the form of chest compressions, intubation and adrenaline on three occasions and an intravenous bolus of salt, fluids, sodium bicarbonate and dextrose. This, he said, was a more serious episode than the first. He came to a similar conclusion to the cause he did for the first event because again the collapse was unexpected and she had been stable. At tile 80, the X-ray showed lots more air than you'd expect in the intestine which interfered with her breathing, splinting the diaphragm from which she recovered following robust resuscitation.
She had appeared well, there were no warning signs, as far as he could tell, that would have alerted any nurse or doctor to the possibility that Baby I would suddenly have collapsed that morning. When cross-examined attention was drawn to the absence of evidence that there was an NGT in place at the time of the collapse and this was something -- and that this was something of which he was mindful, having written in his report on 19 October 2021 that if Baby I did not have an NGT in place the other explanation for her collapse was an airway obstruction in the form of being smothered. It was suggested to him that this was another example of his looking around for an explanation to support an allegation of wrongdoing.
It was also pointed out to him that in a joint report dated 13 August 2022, he raised air embolus as a possible explanation, which he had not mentioned before. Dr Evans explained that now he had more evidence and the opinions of others.
Dr Bohin's opinion was that the appearance of the X-ray associated with the collapse and discolouration of the abdomen could be accounted for by the exogenous administration of air via the NGT into the bowel and also an air embolus, in other words air being deliberately administered into an intravenous line.
There was no evidence of NEC or of an obstruction and she couldn't find any pathological reason for the abdomen to have the appearances that were seen on the X-ray.
She was not able to say from looking at the notes whether there was or was not an NGT in place at that time. Staff were not particularly good at recording when they inserted removed or changed NGTs. Despite their paperwork having boxes for them to fill in it was often incomplete.
Baby I was bottle feeding and had been for several days so there was no clinical need for her to have an NGT. However, it is normal practice to leave an NGT in place for some days after a baby gets back to full bottle feeds just because it's an unpleasant procedure to undertake and just in case they require tube feeds again, so the nursing staff tend to leave them in for several days. She didn't know what the policy was in Chester. There is no other evidence that a tube was removed but there was no evidence that a tube was in place either.
It only takes seconds to put one in place or to remove one. She accepted that in her report she'd written:
"I do not think that Baby I had an NGT in situ prior to this event. She had been bottle feeding and therefore wouldn't have needed one. I could find no reference to an NGT being in situ in the nursing notes."
So, as I've said, she accepted that there was no evidence as to whether there was or wasn't at that time. She considered air in the vein was a possibility because the staff give a description of a bruise-like discolouration over the right side of the sternum. In her opinion CPR chest compressions don't cause that sort of bruise. Over the years she's attended many, many resuscitations of newborn babies both on a neonatal unit and in a regional cardiac unit, where CPR is much more common, but has not seen children or babies with significant bruising over their chest. So she couldn't account for this discolouration from a pathological process, so deduced it was down to an air embolus associated with the ensuing collapse.
When cross-examined it was put to Dr Bohin that, having seen Dr Evans' reports, she was backing him up whenever she felt able to do so. In particular, it was suggested to her that, at the very least, she would never have come up with an air embolus in the way that she was in other cases had she not been exposed to Dr Evans' theories.
She refuted that, emphasising that she was independent and reached her own conclusions, in some cases disagreeing with those of Dr Evans. She was asked how an air embolus presented. She responded:
"It can present in a variety of ways in neonates. It occurs very rarely."
She has seen it twice in her career: in one, a baby who was receiving ECMO therapy, which is a specific sort of therapy on a cardiac unit where babies are put on a kind of bypass machine as a temporary measure until their lungs or lungs and heart can recover from their underlying illness and an air embolus got into the circuit. That's a known risk and she could see bubbles and the child immediately had a cardiac arrest.
For the symptoms she could only go on what was reported in the literature and that presents either as a full unexpected collapse and the person dies or it can present with a collapse where, after resuscitation, the person recovers. Most of the studies have been done in older children and adults. There may be a drop in blood pressure or a drop in heart rate, there may be skin changes. The clinical presentation is, she said, wide and varied.
The mechanism she was proposing was that air is injected into a vein, it goes into the right side of the heart and then goes across the small hole between the top two chambers of the heart, the foramen ovale, about which I reminded you yesterday, which is present in newborn babies and sometimes remains present for life; in others it closes. If that happens then blood can go across that little hole and, if you inject air, air can also go across that little hole and is then pumped through the left side of the heart around the circulation and can lodge in the skin and other organs.
Dr Bohin agreed that there is nothing specific about discolouration that makes it characteristic of an air embolus. Discolouration is not specifically characteristic or indicative of a particular condition but it is consistent with air embolus.
In relation to the third event towards the end of the following night, Dr Evans said there was an early marker at just before 06.00 on 14 October that Baby I was unwell when her heart rate was slightly higher than it should be and her abdomen was distended, mottled and tender on palpation. There was then a significant deterioration at 07.00, very similar to the one the previous night but more prolonged.
Transfer to Alder Hey Children's Hospital was considered but she stabilised during the day.
He again came to the conclusion that the most likely cause was the injection of a large volume of air into the stomach via an NGT. There was nothing in the records to suggest any benign explanation which could account for what happened. Her response to resuscitation is not what one would expect if she had an infection. There was no sign of any other complication, there was no collapsed lung, there was no pneumothorax.
Under cross-examination, it was pointed out to him that he never formally identified this as an event in which Baby I received inappropriate care. Dr Evans responded that he had made reference to a significant dilatation of (inaudible: distorted) first report and it was an oversight on his report not to identify it and was not because he did not consider it was a suspicious event. It was. He had been required to prepare over 30 reports in a short space of time.
It was put to him that the events subsequent to 13 October were a continuation of that event. His response was that they were separate events. The deterioration which led to Baby I's admission to Arrowe Park was a result of a blocked ET tube, a separate and explicable cause for her condition.
Dr Bohin, based on the appearances of the X-ray, the discolouration of the abdomen and Baby I's collapse, said Baby I's collapse can again be accounted for by the exogenous administration of air into the bowel and air embolus, ie air being put into a vein, her reasons being that, as well as the bruising on the right side of the chest, the abdomen had become distended and hard, the staff had noted spreading areas of discolouration over the abdomen, and then resuscitation was required within the hour. The X-ray after that showed that there was widespread gaseous distension and she could find no clinical pathological reason for that appearance.
Finally, in the fourth event, Dr Evans noted that at 03.04 on 22 October, her oxygen saturation was normal at 96% and above, there was no increased work of breathing and she was receiving her nutrition intravenously through a line. The aspirates from the NGT were minimal and her abdomen was soft and non-distended. She was a stable baby.
Her recorded observations at J15034 through to J15035 behind -- there's a copy in writing in your -- sorry, there's a photocopy in your jury bundle of the note -- recorded oxygen saturations levels that were consistently high for the 20th, 21st and 22 October.
She was breathing in air, not requiring any respiratory support.
He also noted that at just before midnight, she had been rooting, which was a good sign. He thought that on this occasion she was subjected to an infusion of air again, but on this occasion he thought it was more likely that the air was injected into the blood circulation. Going back over the previous few days she had been stable, she had stabilised. She was recorded as breathing spontaneously, her oxygen saturations were higher, 96% or higher, in other words she was a stable, well baby.
He thought the relentless crying, in the way Ashleigh Hudson had described, at the time of the first collapse and then repeated on the second occasion during that night was the cry of a baby who was in pain and was severely distressed. There was no obvious explanation why she was crying relentlessly and it was very loud, being the victim of having air injected into her blood circulation probably explains her crying, her distress, and the failure of the medical team the second time round to save her life.
When cross-examined, he agreed that the joint report of the experts of August 2022 -- in that report he said 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 (sic) and that this was something he had not mentioned before in relation to this event and he denied he was going for whatever mechanism he thought would support the allegation. He explained that Baby I died as a result of an air embolus. If she had air injected into her stomach as well that was something he could not rule out.
It was then that he was asked about the material in section 4 of the agreed facts, beginning with agreed fact 15 relating to the judgment on paper of Lord Justice Jackson with which you are familiar and Mr Myers referred you to it. You have the context of that written decision which arose out of a case in which Dr Evans was asked for his views on a case in the Family Court in which a very young baby suffered fractures and was taken from his or her parents and provided to the solicitors. He provided to the solicitors representing a report without charging for it, hoping it might assist them in gaining increased contact with their child and not knowing, he said, that without reference to him it would be submitted to support an appeal. It was, said Dr Evans, in very different circumstances from the evidence relating to babies in this case.
The Appeal Court judge who considered and dismissed the application to appeal on paper, that is without hearing any oral evidence, expressed strong views about the quality and contents of the report as detailed in the agreed facts.
The defence submit that the inconsistency of Dr Evans in his opinion as to the causes of some of the desaturations in this case undermines his reliability and the judge's criticism is relevant to the issue of the approach and impartiality of Dr Evans as an expert witness of the medical evidence in this case and it supports, they say, their contention that he has behaved in the same way in this case.
As with all evidence, it's for you to decide the significance of the comments of Lord Justice Jackson in that case, about which you know no more than the agreed facts, to any of the babies in this case having regard to the evidence you have in this case, both to the facts and circumstances of the events, the evidence of others, including experts, and your assessment of all of that material.
Dr Bohin was of the opinion that the cause of death in Baby I's case was air embolus, air being injected into an intravenous line. She based this on the features of a sudden and unexpected catastrophic collapse and the compelling evidence of her being unsettled and agitated and crying in a way that the nurses felt was unusual.
It was very different crying and she was inconsolable. Dr Bohin thought she must have been in severe pain to be this upset and agitated. This, and the distension of the abdomen and the sudden collapse, led her to think that this was an air embolus. She had considered whether there was anything there to support the suggestion that this collapse and death was the result of an innocent process but could think of nothing that would cause the mottling of the trunk.
The description of Dr Gibbs of Baby I having a pink face but mottled trunk and limbs associated with her becoming very, very unsettled was, to Dr Bohin, a baby in pain and it may well have been that she was hypoxic at that point, in other words there was low oxygen in her blood because that causes you to become agitated.
The inconsolable crying was a baby in pain and that may have been due to the fact that the heart had become starved of oxygen in the process of an air embolus.
When air goes into the heart, it can cause a lock in the heart, which can be a painful process and effectively causes the collapse, which is what she thought happened here.
That completes my review of the evidence in relation to Baby I. We next move on to Baby J, count 13. But we'll do that after the break.
(3.03 pm)
(A short break)
(3.13 pm)
Mr Justice Goss: Count 13, Baby J, an allegation of attempted murder on 27 November 2015.
Baby J was born to [Mother of Baby J] and [Father of Baby J] at 15.00 hours on 31 October 2015 at 32 weeks' gestation after her mother's waters had broken. It was a difficult pregnancy and they lost a twin during the pregnancy at 17 weeks.
Baby J appeared to be extremely well but after a short time produced some brown bile and was taken to Alder Hey Hospital in the early hours of 1 November.
She had a perforated bowel and underwent emergency surgery. The surgeons removed a part of the bowel and created two stomas, from one of which partly digested food was taken and then it was recycled into the other, thus enabling it to progress through the bowel to excretion.
Baby J was returned to the Countess of Chester on 10 November. The defendant was the nurse who admitted her. She was fed on her mother's expressed breast milk and some donor milk. She had no respiratory problems or complications. She moved to having all feeds by bottle over 2.5 weeks. She progressed well, eventually moving into nursery 4.
It was a challenge managing the stomas and a fistula developed in the recycling stoma, but it could be managed and it was planned that the bowel would be reconnected. She had issues with gaining weight, but the hospital staff were not overly concerned.
Nicola Dennison, a nursery nurse with approaching 30 years' experience by that time, and who was Baby J's designated nurse when the events in the early hours of 27 November occurred, told you that babies with stomas don't tend to grow terribly well.
[Mother of Baby J] said that between the 10th and 27 November, there were no major problems with the stoma bags. The plan was for her to stay a couple of nights and to get involved in the night-time process before going home with Baby J. She stayed for the nights of the 25th to the 26th and for the day of the 26th doing cares, feeding her, changing her nappies and stoma bags.
She went home the night of the 26th to the 27th. Between tiles 16 and 64 you have a number of series of messages passing between the defendant and other nurses working in the hospital at that time in relation to babies, issues and the differences between them, which speak for themselves. In particular, between tiles 45 and 58, to which she referred, the defendant was messaging with Nurse E about the fact that nursery nurses should not be doing stoma bags, how busy the unit was, and it being:
"... shocking that they were willing to take responsibility for things they have no training in or responsibility for."
In the one behind tile 61 she said what a nightmare it was all getting and they would have to send babies out, which was a reference to the number of babies and the high acuity she said.
At the end of the night shift of 25/26 November, no obvious problems were noted, tile 68, Nurse Nicola Dennison noting that at the end of that shift Baby J was stable, no desaturations and no obvious problems from the stoma fistula, nor was there anything untoward at 10.30 on the 26th; tile 72. There were more messages passing between the defendant and Nurse E and some between the defendant and Jennifer Jones-Key during the 26th relating to the manageability of work and the management; tile 80 onwards.
It was during the shift of that night, Thursday the 26th into Friday the 27th, that the events the subject of count 13 occurred. In summary, [Baby J] had two sets of sudden and unexpected desaturations towards the end of that shift which required resuscitations, and in the later one there were features of a seizure or fitting.
Baby J had no previous or subsequent history of fitting. There was, according to Dr Bohin, no cause for the events. Dr Evans felt infection could not be ruled out. The prosecution say that although no specific form of harmful act can be identified in her case, the defendant did something or things to Baby J that caused these collapses intending, as they allege in other cases, to kill her.
The defence argue that infection cannot be ruled out as the cause and, together with her denial of wrongdoing and the absence of any identifiable cause, you cannot be sure that she, the defendant, did anything to harm Baby J.
The details of the shift handover are behind tile 140. The defendant was the designated nurse for two babies in nursery 2. Nicola Dennison was Baby J's designated nurse in nursery 4. She described Baby J as a lively, alert and engaging baby who had medical concerns but at that point was a well baby, ready for going home.
Mary Griffith was also on duty that night and was the designated nurse for another baby in nursery 2, FB.
Nicola Dennison had difficulty remembering the details and timings of incidents. Her note behind tile 160 on the apnoea/brady/fit chart recorded two entries there, one at 04.40 and one at 05.03, and you'll readily remember that you have a paper copy of that document, the apnoea/brady/fit chart.
She did remember one of them was when she thought she was giving Baby J a feed. She had to break it off and she got the doctors to review her, and she attended an incident when Baby J had lost colour and was desaturating and she needed to be repositioned and then Neopuffed. She thought she may have got muddled up with the incidents when she made up her retrospective nursing notes. Mary Griffith remembered an event at about 5 or 6 o'clock in the morning of the 27th when she was in nursery 2. She heard an alarm go off in nursery 4. She went to nursery 4 and saw Nicky, Nicola Dennison, had the Neopuff on Baby J because she'd gone apnoeic and desaturated. As she walked in, the doctors were a few seconds behind her and took over and she left because there were enough members of staff to deal with it.
Dr Verghese was the SHO on duty that night, which he remembered was a busy night because twins who had been born at home were admitted to the unit that night, EC and FC, and they were put into room 2 between 06.10 and 06.30.
Dr Verghese's note is behind tile 165. He recalled attending only once. His note is timed at 05.15. The swipe data records show him entering at 05.03; that's tile 164.
The entry prior to the O/E abbreviation with which you are familiar, on examination, that the doctors would put down, was that he was told what had happened, in other words what came before OE was what he was told, not what he had seen.
Baby J had had two profound desats, the first to the 30s, which may not be a true reading as below 70 there may be factors affecting its reliability and the siting of the probe, and the reference to "being handled during stoma cares". The second was a desaturation to the 50s which was profound. The nurses had to intervene and give some respiratory support. The baby was pale and mottled afterwards and was working hard with her breathing. He considered that, given the abnormal colour and working hard with her breathing, at least one was significant.
On examination she was alert, stable from a cardiovascular status, and her increased rate of breathing was the only concern. The plan included the taking of blood cultures to test for infection.
Dr Verghese was looking for a medical cause and the greatest risk is infection and he discussed the case with the registrar, Dr Austin, who confirmed that antibiotics was a suitable course of action. Dr Austin also called the on-call consultant, Dr Gibbs, and called him in. Baby J was moved to nursery 2, where the defendant had two babies.
In her evidence, the defendant said she wasn't asserting that staffing levels or competence were relevant or there were any medical mistakes, but she did said it was widely talked about that band 4 nursing staff were doing stomas and she sometimes felt that nursery nurses were undertaking roles they weren't trained for and referred to the terms of the text messages at tiles 55 and 56.
She said it was a very busy shift. She accepted Baby J had progressed well and was going to be going home soon and had no respiratory problems prior to 27 November. She said she had no idea these events were happening. She said that nurses go in and out of the unit frequently if needed and referred to tile 159, which showed her coming in through the unit doors at 04.29. She said there was no way of knowing how long she had been out of the unit. There was messaging traffic as how busy it was that night. Texting by the defendant stopped at 06.49, tile 193.
Dr Gibbs did not have any previous involvement with Baby J. He entered the unit at 06.34. It is reasonable to infer that it was in relation to the twins EC and FC who had just been admitted. His notes relating to Baby J are behind tile 196. He acquainted himself with Dr Verghese's note of the earlier desaturations.
Baby J then dropped her oxygenation level again but this time she also dropped her heart rate. On the earlier occasions, she had dropped her oxygen levels alarmingly but not dropped her heart rate much.
This time she dropped her oxygen levels and her heart rate was needing support from the nurses. He wasn't with Baby J when she first dropped her oxygen saturation level but came in and assisted Nurses Griffith and Letby, who were with her.
Both a drop in heart rate and a drop in oxygen saturation levels are of concern and can cause serious problems to a baby if not addressed, but both occurring together is more concerning than just one occurring by itself. There is uncertainty about which one comes first: a drop in oxygen level can lead to a drop in heart rate level, but conversely a drop in heart rate level can cause the oxygen level to drop.
Dr Gibbs' note is behind tile 197. Baby J had two further episodes of sudden desats "to unrecordable levels". The first one was at 06.56 and the second about 28 minutes later at 07.24, plus bradycardia. Both episodes were associated with clenching of hands, stiff limbs, the upper greater than the lower, and on the second occasion her eyes deviated to the left.
She was displaying two seizures. Her eyes deviating to one side was a sign of a seizure, particularly in neonatal babies. In the first episode the stiffness took 10 minutes to settle and she needed Neopuff ventilation for about 20 minutes. Her perfusion was poor and she was given 14ml of saline after 14 minutes.
In the second episode, which started about 8 or so minutes after the Neopuffing had ended, all the features of the seizure settled after 5 minutes and she required similar ventilation for about 5 minutes. Dr Gibbs was looking for reasons why Baby J had displayed these two seizures. They were not explained by a low blood pressure, because it wasn't low, nor were they explained by abnormal electrolyte levels because they weren't abnormal. The potassium being a little low does not cause seizures.
In relation to the medical causes of deterioration, the greatest risk is infection or sepsis, so they tested and treated for infection by antibiotics, but there was no bacterial growth after 5 days on the specimen taken before the last two seizures. An ultrasound scan of her head did not reveal any cause for her seizures. She'd never presented with seizures before this morning and has had no convulsive seizure or stiffening seizure again to his knowledge; Dr Gibbs followed Baby J up in clinic after she had left the neonatal unit until she was 19 months old.
In relation to the cause of the seizures he would favour a drop in oxygen leading to the seizure. Exactly why and how the oxygen dropped he didn't know. It was not consistent with Baby J's course up to that stage that she should suddenly drop her oxygen level, but he accepted he could not be definitive.
Professor Arthurs reviewed all the X-rays of Baby J. The relevant image was taken at 08.54, about an hour and 20 minutes after the second event, the last event. It was unremarkable and the bowel gas was unremarkable, so for all intents and purposes within normal limits. It could not assist in providing any explanation for this event.
When interviewed by the police on 4 July 2018, the defendant recalled [Baby J] as she arrived with a Broviac line and a stoma. They didn't have babies with Broviac lines or stomas in the unit very often. She did not remember a series of collapses in the early hours of 27 November. She was not Baby J's designated nurse but according to the notes she did administer medication shortly after midnight, tile 149, and it was her signature on the infusion prescription chart at 07.20, tile 204. She thought she only treated her after her collapse that resulted in her being moved nurseries.
When interviewed a year later, on 12 June 2019, her involvement with administering medication was because Baby J's designated nurse, Nicola Dennison, was a nursery nurse and not authorised to administer certain medications. She thought Nicola called her for help when Baby J collapsed. She denied having done something to make her unwell.
In a third interview on 10 November 2020, she accepted she had searched for both of Baby J's parents once on Facebook on 17 December, but could not remember having done so.
In relation to messages to colleagues about Baby J, she could not remember who told her Baby J had been fitting and thinking, "Maybe sepsis".
The defendant told you in her evidence that she was aware of this second pair of events. At 06.56, Mary Griffith and her heard the alarm in nursery 4, went in and found Baby J fitting. No one was with Baby J. They began to use the Neopuff system and shouted for Dr Gibbs to come and review her. Baby J was then moved to nursery 2. Before this she had nothing to do with Baby J.
She thought she was in nursery 3 when she was asked to help with the second episode at 07.40, she didn't recall doing the infusions with Mary Griffith.
She accepted that from the terms of her Facebook message to Nurse E at 06.28, tile 177, she knew that Baby J had been moved to nursery 2 by that time and had had profound desats, a reference to the events at 04.40 and 05.03, and that the twins were admitted to nursery 1 at 06.10 and 06.30. She also agreed that she was messaging at 06.43 in relation to the twins, tile 168, and her messaging stopped at 06.49, and there were no recorded actions by her in the neonatal review between 06.23 and 06.56. She denied that she had been in nursery 2 between those times, 06.23 and 06.56, sabotaging.
Baby J remained at the unit until about 08.00. Nurse Ailsa Simpson took over as designated nurse for Baby J for the day shift on 27 November. Baby J remained stable throughout the shift and nothing abnormal was detected.
Dr Stephen Brearey reviewed Baby J at 1.20 pm, 13.20, that afternoon having read the notes of his colleague Dr Gibbs about the profound desaturation events towards the end of the night shift and noted that there were no significant blood glucose or electrolyte abnormalities to explain the seizures and that the blood tests and X-rays that were taken showed no evidence of an infective cause at that stage for the sudden deterioration. Dr Brearey's note is behind tile 258.
The ultrasound scan was entirely normal and there was nothing of concern in relation to the blood test results. Although the blood transfusion requirement was not quite met, they decided to give a transfusion.
Abdominal X-rays did not raise any abdominal concerns or cause for what had taken place. Dr Wright's report is behind tile 262.
Alder Hey were consulted and did not recommended any action. Dr Brearey had no concerns. It was, in retrospect, he said, quite a remarkable recovery from what happened overnight, really. She normalised very quickly over the course of the day and all the investigations couldn't identify why she had had the desaturations that she did have and didn't explain why she had a seizure.
Hypoxia can cause seizures if the brain becomes hypoxic, starved of oxygen, so that would possibly be the most likely cause for the seizures. But then it still remains a question why was [Baby J] hypoxic when for 2 or 3 weeks beforehand she'd been breathing normally in air and there was no evidence of infection in the blood tests and none of the investigations they did suggested any significant infection anywhere. In fact, they stopped antibiotics 36 hours after starting them because there was no evidence of any infection in the blood cultures or the subsequent blood tests the following day. The defendant was Baby J's designated nurse the following night of 27/28th and there were no issues with her that night. The defendant said she never wanted things to be going wrong. Dr Brearey saw Baby J again on the 29th and there was nothing of any concern.
Dr Evans confirmed that all the markers of inflammation for infection were indicative of no infection. There was no increase in temperature or air and her oxygenation saturations were all good and all the results of the blood taken by Dr Gibbs at 07.00 hours were satisfactory.
The first collapses were unexpected, as were the second ones, which were more serious, required more resuscitation and coincided with a fit or seizure. This was indicative of something going wrong with the brain.
In his opinion, like that of Dr Brearey, Baby J's brain was deprived of oxygen for a sufficient length of time to cause brain hypoxia, in other words loss of oxygen to the brain, causing the fit.
She's not had any subsequent seizures so there's no evidence of her having an inherent predisposition to epilepsy. Epilepsy occurs in children, but if her seizures were due to an epileptic focus then she would have had seizures in the future. Dr Evans could not identify any natural process that might have caused that hypoxia.
It was also the opinion of Drs Gibbs and Brearey that infection wasn't the cause of her seizure. Had infection been the cause of her rapid decline he didn't think she would have recovered as quickly as she did.
Babies who develop an infection usually recover over a period of days and not this promptly. She was at risk of infection and Klebsiella oxytoca was grown from the central venous line site from the skin around the site and is capable of causing infection in vulnerable infants and Dr Evans accepted that the presence of an infection could not be ruled out for sure.
Dr Bohin explained that these events were completely unexpected and Baby J required the Neopuff ventilation for a long time before she came round and was well again and that seemed extremely unusual, the speed of the collapse, the longevity of the resuscitation, and the fact that she seemed to recover well quite quickly afterwards. Infection, in her opinion, was not responsible for that isn't the way that infection plays out, so having looked at other things that may have caused this, she didn't come to any major conclusion other than there were serious and unexpected deteriorations.
Because she had the stomas and a Broviac line, Baby J was at risk of infection, but her observations in the days prior to and on the day of this event -- her recorded temperature, her heart rate and respiratory rate -- were all stable and she was tolerating her feeds. Babies who are kind of brewing an infection tend to exhibit subtle abnormalities in some or all of those things, particularly intolerance of feeds, which shows you that all isn't well and you need keep a special watch on them. She didn't exhibit any of these things until she had her desaturation, which can be a feature of infection. But then, having resuscitated her, she seemed to be better and back to normal, which is not a feature of an infection because by the time she was clinically well, and described by the medical team to be back to her normal self, she hadn't even received her antibiotics by that point, so Dr Bohin excluded infection. She didn't think that was the cause of the collapse.
When asked under cross-examination about the presence of infection despite the absence of normal inflammatory markers, she said that the first inflammatory marker showed a CRP of less than 1 and her subsequent inflammatory markers were also low. So although nothing is ever 100% in medicine, it madeinfection very, very unlikely to have been a cause for her collapse.
[Redacted]
That's a good moment to break off because I'm coming on to the event in that case. So 10.30 tomorrow morning, please.
I'm just going to say to you a little more about where we're going to go. I'm not going to complete my summing-up tomorrow and we're not sitting on Friday, so even if I did complete it at around this time in the afternoon, you wouldn't be starting your deliberations tomorrow. So there is no question, you will not be starting deliberations in this case tomorrow, you will be doing that some time on Monday when I've finished my summing-up to you, which I anticipate will be around midday, something like that. So it'll be earlier rather than later on Monday.
The usher will communicate to you about the necessary arrangements so far as sustenance is concerned during the period that you are in retirement next week and I will be able to give a clearer picture at the end of tomorrow when you will begin your deliberations in this case because I will have got that much further in the summing-up. All right?
So that's the timetable. Remember your responsibilities as jurors, as you have done for the last 9 months, and 10.30 tomorrow morning, please.
We will, as I said to you, finish by 4 o'clock tomorrow. Thank you.
(In the absence of the jury)
Mr Myers: We would be grateful to have an opportunity to speak, my Lord.
Mr Justice Goss: Certainly. Thank you very much.
(3.59 pm)
(The court adjourned until 10.30 am on Thursday, 6 July 2023)
(In the presence of the jury)
SUMMING-UP (continued)
[Redacted]
Mr Justice Goss: I move on, therefore, to counts 16 and 17,[Babies L & M]. At 10.13 on Friday, 8 April 2016, [Mother of Babies L & M], the wife of [Father of Babies L & M], gave birth by caesarean section to twins, Baby L, referred to in the notes as twin 1, and Baby M, twin 2. They were 33 weeks and 2 days' gestation.
It had been a routine pregnancy until March. [Mother of Babies L & M] was then admitted to hospital for 2 weeks before the semi-selective caesarean section. Twin 1, Baby L, did not appear to be growing at the correct rate.
The birth went well. Both babies were born in good condition and did not require breathing support in theatre, both weighed about 3 pounds. The defendant, who was working a day shift that day and the next, was present at their birth, as was Dr Bhowmik, then a registrar.
The twins were admitted to nursery 1 in the unit and the defendant was Baby L’s designated nurse for the rest of that day shift. This, as you know, is a second case in which the prosecution allege a baby, wholly and inappropriately and without medical approval, was given unprescribed manufactured insulin. It is alleged that the defendant attempted to kill Baby L by putting insulin into bags of dextrose solution, the first of which was set up 2 hours after he was born. As is common for premature babies, his blood sugar level was low.
The plasma from a blood sample taken later in the afternoon provided readings that are only explicable on the basis that Baby L had been given exogenous insulin. The infusion from that first bag of 10% dextrose continued until the following day, Saturday, 9 April. Another bag may have been put up at midday, 12.00 hours, and a new one, with a stronger concentration of dextrose, 12.5%, was put up at 16.30 on 9 April.
A further bag with a concentration of 15% dextrose was put up at 02.30 or 03.00 on 10 April and yet another was put up at 01.45 on 11 April. I'm going to go back to the chart in relation to this in a moment.
Professor Hindmarsh was of the opinion that the hypoglycaemic event continued from 9 April to about 15.00 hours on 11 April, with the insulin being infused intravenously by way of having been added to the infusion system in several bags that had been made up, which could all have been done at once. That's adding to the infusions.
On a conservative view, the addition of in the region of 10 units of insulin to a bag would be sufficient to produce the hypoglycaemic effect and also to generate the plasma insulin concentration that was measured in the sample on 9 April. The vials of insulin contain 100 units per millilitre, so 10 units is a tenth of a millilitre, 1% of the volume of a bottle, which would not be noticeable just on a routine stock check and, if added to infusion bags, the addition of one-tenth of a millilitre would not be noticed in a 500ml bag, nor would there be any change in the colour of the bag nor would you see any cloudiness in the bag itself.
Professor Hindmarsh was of the opinion that, depending on how many bags were hung, two or three bags had insulin added to them. If the plastic giving set isn't changed then insulin, being a protein, will stick very nicely to plastic so the giving set as well could potentially have insulin stuck on to the walls of the tubing, from which it could fall off over a period of time as well. He agreed that although sticky insulin could account for some of the insulin being infused from the walls of a previous giving set over time it would require additional insulin to maintain the levels up to 11 April. That's a number of bags.
In Baby M’s case, it is alleged that the defendant injected air into his abdomen on the second day of life, Saturday, 9 April. There is an obvious overlap in the evidence relating to the respective events in their cases, but, as with other cases involving twins, there are separate sequences of events and the evidence has been separated as much as possible. I remind you first of the evidence relating to Baby L, count 14.
The defendant worked four long day shifts, starting on Wednesday, 6 April to Saturday, 9 April. She told you at that time she had moved into her house and drew attention to messages between her and Sophie Ellis and Nurse E on the evening of 8 April at tiles 57 to 63 relating to work and her taking Saturday the 9th as an extra day. The unit was still fairly busy, she said, but not quite as busy as previously.
Dr Bhowmik inserted a peripheral intravenous line into Baby L’s left hand at 11.15 on 8 April, an hour after he was born; his clinical note, made at 12.00 hours, midday, is behind tile 12. On admission to the unit, Baby L was generally well, being active and alert. His breathing rate was a little bit elevated at 65, but not a concern as it is common for babies born by caesarean section. His weight was low and his blood sugar at 1.9 was a bit low, but this was common for premature babies.
He was started on intravenous fluids with glucose. Behind tile 13 is the defendant's nursing note, written as his designated nurse at 17.42. In relation to the low blood sugar, she wrote:
"Initial blood sugar shortly after birth 1.9 micromoles. Advised by Reg Bhowmik to commence a 10% glucose at 3ml per kg per hour and give 60ml per kg per day of donor-expressed breast milk. Myself and shift leader A [that's Amy] Davies have discussed this with Reg Bhowmik as does not follow the hypoglycaemic pathway."
The reference to the hypoglycaemic pathway was to the policy at the Countess of Chester to feed babies with milk before infusing them with dextrose. The decision was for Dr Bhowmik. Amy Davies had no concerns about this. Dr Bhowmik prescribed the dextrose. The infusion therapy prescription sheet is J17948 behind tile 10 and it's the first paper document in section 15 of your second bundle. Dr Bhowmik wrote out the prescription and the rate of infusion. The first two entries were struck through by him and the third, at a rate of 4.4ml per hour, was the set rate, which was checked by the defendant and Amy Davies, who were responsible for administering it, each of them initialling the sheet.
In her evidence the defendant confirmed that dextrose bags of concentrations of 10% and 50% were kept in the cupboard in nursery 1 and said insulin was kept in the equipment room. 10% bags were very commonly used and were non-patient specific. She couldn't recall if any were kept under lock and key.
>The first infusion started at midday, 12.00 hours, on that Friday, 8 April. It was a 500ml bag of 10% dextrose. The bags would normally be changed every 24 hours unless the concentration of dextrose changed, in which case a new bag would be used. The dextrose solution was then pumped through the giving set and a filter into the cannula that had been inserted by Dr Bhowmik into Baby L’s left hand.
Later that afternoon, at 14.35, the defendant and Amy Davies administered antibiotic medication to Baby L; tile 30. Amy Davies carried out the regular observations, noting and initialling the results on the observation chart between 10.00 and 18.00; J17987, the sixth page document in section 15.
Amy Davies denied having administered insulin to Baby L and was unaware of anyone else doing so. Insulin, she said, would usually only be given to a baby who has two consecutive blood sugars over 12 and is hyperglycaemic. Although it is not a controlled drug, the insulin would have to be prescribed by a doctor.
In section 6 of your first jury bundle you have a three-page table of blood sugar readings and the times, concentrations, rates and volumes of dextrose administered to Baby L from the records from 10.58 on 8 April, 45 minutes after he was born, until 23.00 on 11 April, some two and a half days later. It might be helpful for you to have that to hand because it is a good reference document. There you are, that one.
The first bundle, section 6.
I'm going to make some specific reference to some of the entries, but I shall also refer to other things and you can then refer yourselves to that table as I go along as I'm reciting the history of events.
Professor Hindmarsh was asked to look at this case by Dr Evans. This was the 60th case that Dr Evans had been asked to look at and when in the notes he found the result of the plasma test with a very high value of insulin and a low value of C-peptide at 264, when, as you know, the readings should have been the other way around, he suggested, that's Dr Evans suggested to the police, that they should approach a specialist in endocrinology to review his findings.
Professor Hindmarsh told you that newborns and neonates have higher glucose requirements than children and adults and it is generally accepted that any reading of a blood sugar level of under 2.6, or according to some 2.4, millimoles per litre is a cause for concern.
So it was in keeping with the low reading of 1.9 at 10.58 that an infusion of dextrose had been commenced; the first entry on the chart. Behind tile 5 -- don't go to it, I'm giving you the reference -- you've got a paper copy, which is page 8 in section 15 of your other bundle -- are the blood gas results, which record the figure of 1.9, to which I have just referred as the first entry. You can now follow the readings on that chart.
At 12.14 to 12.15 it had risen to 2.5 and then at 16.00 it was 5.8, then fell back to 3.3 at 18.10. All those entries were signed for by the defendant on the document behind tile 5.
Tracey Jones, a senior lecturer in nursing and then working as an agency nurse at the Countess of Chester, covered Baby L as his designated nurse for the night shift of the 8th/9th. Her note of that shift is behind tile 78. There were no concerns. Baby L’s pre-feed blood glucose readings were all above 2 millimoles, as you've seen from the chart, all the readings up to the first thick black line on that first page. Therefore they were to discontinue monitoring as requested by the registrar. The registrar said there's no problem with the readings so you can discontinue having to take them.
The records against the initials of Tracey Jones were that his glucose level was 2 at 20.00 hours and 2.4 at 21.00 hours. No readings of blood sugar levels were recorded after 21.00 because, as I've said, they were told to discontinue.
However, there are what appear to be recorded blood sugar levels on the fluid balance chart J18031, just above the feeds row of, 2.3 at 21.00 hours, 2.2 at 22.00 and 3.6 at 24.00.
The observation chart behind tile 54 -- you have a paper copy at page 6 -- has Tracey Jones' initialled entries at the bottom of the page following on from those of the defendant's up to 06.00 on 9 April. No fluid bags were changed during the course of Tracey Jones' shift.
Mary Griffith took over from Tracey Jones and was the designated nurse for both [Babies L & M] on the day shift of Saturday, 9 April. The defendant was also on that shift, so coming on to the unit at 07.30 for handover and was the nurse responsible for GT and TSB, who were also in nursery 1.
The clinical and nursing personnel on duty that shift are in your neonatal review and behind tile 88. Belinda Williamson, then Simcock, and Ashleigh Hudson and a nursery nurse, Angela McShane, were the other nursing staff. Mary Griffith said Baby L was stable in nursery 1. Behind tile 98 is the nursing note written at the end of the shift.
Towards the back of section 15 in your second bundle you have a paper copy of the fluid balance chart from 01.00 to 24.00 hours on that Saturday, 9 April. That is the document behind tile 97. The next document is the continuation chart for the following day, Sunday, 10 April.
Going back to the table that you have, you will see that the blood sugar readings, which were recommenced at 10.00 hours and which are recorded there, are reproduced below the -- in the bottom quarter of that page. You can see the entry at 10.00 hours.
Professor Hindmarsh's evidence was that Baby L’s blood sugar levels on 8 April were low in some cases, but basically acceptable. But by the first reading at 10.00 on 9 April, Baby L was hypoglycaemic, so against the 10.00 entry, that is when he is hypoglycaemic, and that insulin must have been added some time after midnight and by 09.30 that morning at the latest.
He explained it is fairly easy to get insulin into a dextrose infusion by drawing it up in a needle and syringe and inserting it through the portal at the bottom of the bag in the same way that the concentration of dextrose in a bag of 10% concentration is increased by adding some from a 50% concentration bag. You saw the video recording of that process being undertaken.
For reasons that I reminded you of in Baby F’s case, and having regard to the readings, Professor Hindmarsh said that at least three bags must have contained insulin. If the insulin had been infused by individual intravenous boluses to result in the blood sugar readings that were obtained, it would have required between 10 and 12 boluses at least. The bags could all have had insulin added to them at the same time, he said. A very small quantity of insulin was required. As I have said to you, it is 1% of a 10ml bottle of insulin added to a -- one-tenth of a millilitre added to a 500ml bag. Once in the dextrose bag, it would not be known that it was there from either smell or from appearance.
The agreed evidence of Karen Morris read to you was that in 2015 and 2016 Actrapid was the only insulin used in the unit at the Countess of Chester. It's a fast-acting insulin and came in a 10ml vial, which contained 100ml a unit. This is also relevant evidence relating back to the case of Baby F. You will remember I said I would come on to the other evidence relating to insulin when I came to Baby L’s case.
At that time a member of the pharmacy team would attend the unit once a week on a Friday and assess what amounts of stock drugs, which included insulin, were required. They would then replenish the unit's stocks later that day. Alternatively, unit staff could complete a stock requisition book, requesting extra if they needed it. They no longer have any of those paper records. The reports show that in 2014 a total of three vials of Actrapid were issued: one in January, one in April and one in November.
In 2015, a total of six vials were issued: one in May, one in August, and two in both October and November.
In 2016, two vials were issued: one in April and one in July.
Mary Griffith said it was quite a shock when the blood sugar level dropped after the increase in volume of dextrose at 10.00 hours, the reading taken at 12.00 hours being 1.6 pre-feed. So at that time the volume of dextrose was increased to 3ml per kilogram.
The defendant in evidence said she couldn't assist with was why there was a low reading at that time. She had nothing to do with insulin and the bags.
Mary Griffith was not prepared to say that the bag was changed at 12 midday. The volume was increased and she agreed that when it was put to her that the bags — she agreed when it was put to her that bags were normally changed every 24 hours.
The defendant said a new bag was commenced at that time by them. The defendant said she had nothing to do with the bags before then and couldn't explain the reading at 12.00 hours.
Mary Griffith said she also took a blood sample by way of a heel prick. This was some time after 12.00. She could not remember the exact time but she wrote in her notes that after the rate was increased to 3ml per kilogram:
>"Blood sugar 1 hour later, 1.6. Blood taken for lab but due to emergency, not podded at once."
Podding was placing the sample in a plastic pod for putting into the air-driven system or chute, sending it straight to the lab. She said she gave the sample to someone for podding and that the emergency was the collapse of Baby M, which was at about 16.00. She was making up a 12.5% dextrose bag for Baby L when Baby M’s alarm went off and he collapsed. The defendant went over to him.
You'll recall the playing of the video, to which I have already referred, about the process that is undertaken when a 12.5% bag is made up, adding dextrose from a 50% bag.
The blood sample was labelled as having been taken at 15.35 hours. The evidence therefore is that it was taken some time after the recorded blood sugar of 1.6 at 12.00 and the labelling at 15.35.
Mary Griffith went to help with the resuscitation of Baby M and the doctors arrived soon after and she handed over responsibility for Baby L to Belinda Williamson.
The only time that Baby L’s dextrose bag was changed, said Mary Griffith, was when the new bag with 12.5% dextrose was put up, which was after the blood sample had been taken.
The blood sample labelled as having been taken at 15.35 on 9 April for testing of insulin and C-peptide levels was received at the Royal Liverpool Hospital at 15.47 on 11 April. Had there been any mislabelling, Dr Anna Milan told you the sample would have been rejected and no analysis would have been undertaken.
She confirmed all the quality control testing processes that are carried out in relation to the equipment before and after samples are analysed and the standard operating procedures and performance checks were carried out by the Royal Liverpool in relation to Baby L’s sample.
Reference was also made to external quality assessment routinely carried out by the United Kingdom Laboratory Accreditation Service, which, explained the scheme director of that service, Dr Gwen Wark, a highly qualified clinical biochemist, sends out a variety of samples to laboratories for testing, which they have already tested, every 6 weeks without them, that's the hospital laboratories, knowing that the service is the source of the request. The accreditation service then compares their results. The laboratories have two targets to achieve.
Dr Wark produced four reports: two covering the period relating to the testing of Baby F’s sample and two covering the period of Baby L’s sample. All results fell within the required targets. Dr Wark said that, based on the records in their laboratory in Surrey, in terms of accuracy and efficiency, the laboratory at the Royal Liverpool was performing very well in relation to the required criteria of testing.
In short, there is no evidence to doubt the reliability of the test results, you may think.
Baby L’s sample provided readings of 264 picomoles per litre for C-peptide and 1,099 picomoles per litre for insulin. The results are set out in J26995 and J26996, of which you have paper copies in the back of section 15. They were sent to the Countess of Chester who were alerted to a problem. As Dr Milan explained and Dr Gibbs and Professor Hindmarsh, those results were the wrong way round. I remind you again that normally your C-peptide should be five to ten times higher than the insulin if it's insulin and C-peptide that you have made yourself.
Dr Gibbs said that as his insulin level was 1,099, Baby L’s C-peptide level should have been somewhere between 5,000 and 10,000; in fact it was 264. So there was far more insulin than C-peptide, which is a reverse of the normal situation. This meant that most of the insulin in Baby L’s blood was manufactured synthetic insulin, which does not have C-peptide associated with it, and it had been given to him and was therefore exogenous insulin. Baby L had not had prescribed synthetic insulin and it would have been totally inappropriate to do so. To give it to someone was dangerous.
Both the insulin and C-peptide results were rung through by a colleague of Dr Milan, Dr Sarah Davies, to the consultant medic in the biochemistry laboratory at the Countess of Chester with the comment:
"Difficult to interpret without the concurrent glucose but if the patient was hypoglycaemic at the time it's a very inappropriate set of results."
Baby L was indeed hypoglycaemic. Dr Milan was not aware of anything that gave her any concern as to the accuracy of the results. She was asked in cross-examination about the possible effect on the stability of the sample if it was not stored properly and a possible failure to spin the sample to remove the cells or chill or freeze it as quickly as should be the norm. She explained that in the case of insulin, the consequence is the reading is more likely to go down, so if the sample had not been treated appropriately, the true insulin level could have been even higher than the recorded result. C-peptide is very stable, having a much longer half-life.
Professor Hindmarsh confirmed this was the case. A delay of 6 hours would -- so the reading itself was a minimum rather than a maximum.
Dr John Gibbs, referring to results of the analysis and the results on J18025 and J18026 behind tile 190, also confirmed that a low growth hormone, which can cause low blood sugar level, was not the cause in Baby L’s case and this was confirmed by Professor Hindmarsh. The cause for the hypoglycaemia was the exogenous administration of insulin.
In her first police interview, the defendant explained Baby L’s low blood sugar levels were not a huge surprise. Additional glucose and/or feeding would usually resolve the issue. She confirmed her signatures on the charts and agreed that she had had significant involvement in his care. She said a neonate would only be given insulin in the event of high blood sugar levels. She said very prolonged low blood sugar levels can cause brain damage and even death. It wasn't a common thing to have a baby on insulin, but there were babies on insulin. She had completed a competency framework and they had the hypoglycaemia pathway policy on the unit.
Although insulin was kept in a locked fridge on the unit in the equipment room, the keys were simply passed between registered nurses and nursery nurses. There was no record of who had the keys or a requirement to keep a log of what was removed unless they were controlled drugs.
Any addition to an infusion bag was very rare. It would be added using a syringe via the port in the bag itself and would have to be prescribed by a doctor.
She confirmed her signatures on the infusion therapy chart behind tile 115. She denied having deliberately administered insulin to Baby L and did not believe that a mistake could have been made by administering the wrong medication with two people signing for the drug.
When it was suggested that the insulin was a deliberate act of sabotage, she replied, "That wasn't done by me". She didn't know how insulin could be given accidentally and said that if used inappropriately, it would cause hypoglycaemia. She thought an explanation for insulin in Baby L’s circulation was that it had been in one of the bags or the fluids he was already receiving and she denied responsibility for that.
Based on this evidence, the prosecution say there is incontrovertible evidence that, like Baby F, Baby L was given manufactured insulin and that must have been done at some time prior to the blood sample being taken at 15.35 on Saturday, 9 April and the readings indicate it must have been before the 10.00 hours reading of 1.9 that day.
Their case is that insulin was added to the bag of dextrose that had been hung at midday on 8 April, the first bag, early in the shift of the 9th, and resulted in the analysis of the blood sample that was taken at 15.35 on 9 April and accounted for the blood sugar levels remaining persistently low from 10.00 hours, despite the dextrose infusions. This, they say, was done by the defendant when she was on shift.
The issue, therefore, is who was responsible and what they did by causing exogenous insulin to be administered to a newly born baby who was hypoglycaemic.
The other nurses on duty in the unit over the relevant period, Tracey Jones, Mary Griffith, Belinda Williamson, Nurse B, Bernadette Butterworth, Valerie Thomas, Minna Lappalainen, Clare Bevan, Ashleigh Hudson and Lisa Walker all say they did not administer any insulin to Baby L and were unaware of any being administered.
Despite the increased administration of dextrose on the afternoon of 9 April, and I'm looking at the first page of the chart, at a concentration of 12.5%, Baby L’s blood sugar levels remained low. Dr A was on duty on the night of the 9th to 10 April. His notes at midnight behind tile 226 record that during his night review Baby L’s blood glucose levels were falling and he assumed he was called because falling levels can cause seizures, organ damage and brain injury.
Baby L was requiring more glucose than he would expect. Accordingly, Dr A wanted to boost the blood sugar levels. He adopted a holding position prior to inserting a long line at 01.30 hours. We're now on to the next page and you can see the readings as they went along.
Then he changed the fluids. He discontinued the 12.5% dextrose infusion and commenced a new infusion of 15% dextrose. The fluid balance chart, of which you have a paper copy, J18033, following on from J18032, records the discontinuing of the 12.5% bag at 03.00 on the 10th and the 15% dextrose then being infused via a long line and thereafter the blood sugar figure rises to 2.9 at 11.00 and then remains between 2.7 and 2.9 until 11.00 on that day when it is 2.8.
Professor Hindmarsh says that there must have been insulin in the 12.5% bag hung at 16.30 by Belinda Williamson and Ashleigh Hudson and in the next bag of 15% dextrose hung the following day at 02.30 or 03.00 on 10 April. It was after the second 15% dextrose bag was hung at 1.45 on 11 April, later that day, that blood sugar levels improved.
The conclusion to be drawn, say the prosecution, is that from the time of the commencement of the second 15% dextrose bag he was no longer being infused with insulin.
At least one, and possibly two if there was a change of bags at midday on the 9th, of the 10% bags had insulin infused into them and one 15% bag was infused with insulin.
In her evidence, the defendant accepted that the results of the blood tests prove that somebody, for no legitimate reason, put insulin into Baby L’s dextrose if everything had been done properly in terms of testing and that the readings on 8 April showed there was a naturally resolving hypoglycaemia that was resolved by the administration of dextrose on the 8th and it had resolved by midnight on the 8th but then, after a gap in the taking of readings, there was an exceptionally low reading and a series of low readings from 10.00 hours on the 9th.
She also agreed that the only nursing staff in common between the shift on which [Baby F] received insulin and the shift on which Baby L was to receive insulin were herself and Belinda Williamson.
She accepted the activities of Mary Griffith, Baby L’s designated nurse, set out on page 3 of Baby L and Baby M’s neonatal review between 9 am and 9.30, from entry 21, that she was with other children, so out of the nursery where Baby L and the two babies for whom the defendant was the designated nurse in that nursery, but denied that she took this as an opportunity to poison Baby M.
That completes my review of Baby . I will deal next with Baby M, but we'll break now and have the ten-minute break and then continue with Baby M after the break.
(11.42 am)
(A short break)
(11.52 am)
(In the absence of the jury)
Mr Justice Goss: Thank you, Mr Myers, Mr Johnson. In fact, I haven't looked at the transcript, but did I say:
"In retrospect he wished they had bypassed management and gone to the police and put in a Datix form"?
BM: Yes, that followed.
Mr Justice Goss: It's equivocal. That's the point.
BM: It’s on the transcript as it is --
Mr Justice Goss: I shall make it clear. I'm really grateful.
BM: It was just a slip.
Mr Justice Goss: It's not a slip, it's infelicitous phrasing. It's wishing for two things, but it becomes slightly equivocal. I'll make it very plain, don't worry.
(In the presence of the jury)
Mr Justice Goss: I said something that was unclear when I was reminding you of the evidence of Dr Jayaram and it's been brought to my attention.
[Redacted]
So Baby M. Baby M was born in good condition, crying, blue, good tone, was slow to pink up and had occasional shallow breathing. He was given five ventilation breaths at 3.5 minutes, then his sats improved, he pinked up. At 10 minutes his saturations were 93%. All this is to be found behind tile 2.
Although he was not an intensive care baby, he was placed in an incubator next to Baby L in nursery 1 in the top right-hand corner of the room as one enters. He too had a peripheral line inserted.
From tile 22 onwards, between 11.13 and 12.09 that morning, there was messaging between the defendant and Nurse A and Nurse E to which you can refer for the details if you so wish.
On the following morning, 9 April, the defendant did that extra shift -- that was the Saturday, you'll remember she volunteered to do the Saturday shift. Baby M was given antibiotics that night; tile 74.
Tile 83 sets out the staff allocation for the day shift on that Saturday, 9 April. Mary Griffith was Baby M’s designated nurse. He was being fed expressed breast milk via an NGT at two-hourly intervals. Dr Ukoh saw Baby M on his morning ward round at 10.25. On examination, this is behind tile 88, he looked well and settled. He was mildly jaundiced, his abdomen was soft and normal.
Tile 91, he had a small posset with wind at 11.00. Tile 96, timed at 12.15, Mary Griffith noted his stomach was a little distended and his work of breathing was increased.
At 12.30, tiles 97 and 98, Baby M’s vital signs were recorded together with the data in the fluid balance chart by Nurse B because Mary Griffith had been sent on a break.
At 14.30 hours, J18866, Mary Griffith noted that Baby M was to be nil by mouth because she had aspirated 1.5ml of bile before a planned feed. This stopping of enteral feeds will have been the decision of a doctor. Nurse B confirmed this and said Baby M was well at 14.15.
At 15.30, an intravenous infusion of 5.3ml of 10% dextrose was set up; tile 127. J18371, the first paper document in section 16, at the entry towards the middle of that sheet, records the defendant and Mary Griffith as the nurses setting up the infusion. At 15.40, the same two nurses were administering a 10% dextrose bolus to Baby M’s twin brother, Baby L.
At tile 135, at 15.45, benzylpenicillin was administered to Baby M. The update in respect of that being made by both Mary Griffith and the defendant; tile 136.
Tile 137, a prescription was signed by the defendant and Mary Griffith at 15.45 for sodium chloride for Baby M with that being updated on the computer at that time; tile 138.
As I reminded you when I was dealing with the evidence concerning Baby L, Mary Griffith said that about 16.00 hours she was preparing the 12.5% dextrose infusion for Baby L when Baby M’s alarm went off.
The parents had left the nursery about 10 minutes earlier. The lights were flashing. The defendant went over to see and she said, "Yes, it's an event, it needs to be sorted".
Mary Griffith stuck her head round the door and asked for the resuscitation call to be put out.
Ashleigh Hudson said the defendant asked her to crash bleep Dr Jayaram and she told the switchboard to put out a crash call.
Nurse B said she was by the side of the defendant who administered resus breaths via a Neopuff or an Ambu bag. Although the Neopuff produced chest movements, Baby M wasn't breathing for himself and didn't improve. Compressions were commenced and emergency drugs were administered. The medical staff arrived pretty promptly.
Nurse B said her role was to draw up and check the resuscitation drugs. Notes were drugs given and when. She remained at the bedside but didn’t have a direct vision of Baby M. She was shown a piece of paper towel, exhibit PMB8, on which a number of entries which corresponded to the entries in the clinical notes behind tile 171 and were of the times and the medication administered. You have a paper copy in section 16 of your second bundle.
She recognised her writing of entries relating to doses of adrenaline given. That paper, that piece of paper, was subsequently recovered from a Morrisons bag beneath a bed in a bedroom at the defendant's home on Wednesday, 4 July 2018, as was a blood gas record timed at 16.22 for Baby M. Mary Griffith said she had never taken any notes or readings home.
Nurse B also confirmed that the rolling blood gas record reading had the information from 16.22 recorded on it. She confirmed that once the information has been placed on the rolling blood gas record, her practice was to put the original document in the confidential waste bin or the clinical waste bin, the contents of which both get incinerated. This led to the allegation put to the defendant that she must have taken that piece of paper out of the waste bin.
Belinda Williamson took over making the fluids up for Baby L and took no part in Baby M’s resuscitation. Dr Ukoh was one of the attending clinicians. Senior house officer Dr Barrett arrived shortly after Dr Ukoh. She described Baby M as "pale and floppy and looked very, very unwell.”
Dr Ukoh’s retrospectively written note of the events is behind tile 149. He was in the unit when the unusual sudden and profound apnoeic episode and cardiorespiratory arrest occurred. He described Baby M as "Pale +++". Cardiac massage was started. Dr Jayaram arrived at this point. His notes written at 17.40 are behind tile 210.
By the time he arrived, three doses of adrenaline had already been given and Dr Ukoh had already intubated Baby M at 16.10, at which point Dr Barrett took over the task of giving chest compressions. Baby M was not breathing for himself, his cardiac output was not sufficient to pump blood round the body to supply the organs of his body. The entries relating to the resuscitation, which required six doses of adrenaline and other resuscitative drugs and saline, were contemporaneously recorded and he relied on the note of those details when he compiled his note.
The resuscitation took under 30 minutes and included taking over Baby M’s breathing following intubation and his connection to a ventilator. The readings at 16.22 were taken during the resuscitation. There was a significant metabolic acidosis of cardiorespiratory arrest and they reached a point where they were going to have to think about withdrawing support and he might not survive.
Then Baby M suddenly recovered. His heart rate came up and he started breathing and they could stop CPR. Dr Jayaram said that he saw pink blotches or patches that would appear and disappear on Baby M’s skin and then other ones would appear and disappear. He noted them on his abdomen because that was the most obvious bit of his body that you could see because the rest of his body had people covering his chest, doing CPR. He noticed that when he got there during the start of the resuscitation.
Once circulation was restored and his heart rate came above 100, they vanished. It was very similar to what he had seen with Baby A, whose collapse was very similar.
He made no note of having seen it and first mentioned it in his witness statement. He said his priority at the time was dealing with the actual situation, explaining things to parents, working out his post-resuscitation care and he was thinking through things that could be going on. Infection, sepsis, hypovolaemia and pneumothorax were all issues that he addressed in the plan as set out in his notes.
He and colleagues started to say this was something different. The whole consultant body sat down two and a half months later on 29 June 2016. Someone mentioned air embolus and Dr Jayaram was prompted to do a literature search, where he found the paper to which reference has been made. The following morning, he emailed the link to colleagues because that paper described the skin discolouration that he and colleagues had seen. He had never seen anything like it before Baby A and has never seen it since Baby M.
When cross-examined, Dr Jayaram said he told the police about seeing the discolouration when interviewed and remembered it because it was unusual but he had not appreciated the clinical significance of it at the time and that was why he didn't record it in the notes at the time. He disputed that failure to note it was incompetent and rejected the assertion that he did not note it because it never happened. He was dealing with the clinical situation. In retrospect, the relevance is very clear: at the time there were other things going on, other events going on. These situations are stressful and busy. He denied it was a detail that had not happened and subsequently had been added by him for some reason. He denied that that was the case. He agreed that shortly after the death of Baby D in June 2015, Dr Brearey, the neonatal lead, conducted an informal review of circumstances into the deaths that had occurred and he noticed that Lucy Letby was the nurse looking after these babies. He confirmed that he still worked with Dr Brearey and saw Dr Gibbs intermittently and saw members of staff, but said they did not discuss the case. They did discuss the impact it might be having on them and they supported each other because it was extremely difficult at this time to focus on what they needed to be doing and he said that he avoided media reports.
When interviewed on 5 July 2018, the defendant remembered Baby M and the day that he collapsed in some detail. He was the fifth baby in nursery 1, which usually only held four babies. Consequently, he was attached to a portable Masimo monitor and was in the corner of the nursery, which is not a usual place, and Mary Griffith was his designated nurse.
She recalled the monitor going off when she was checking drugs with Mary Griffith. She started an airway for Baby M while Mary went for help. She agreed that she had co-signed for medications at 3.30 and 4.45 pm but was not sure if she administered them. She was the first at his cot side when his alarm activated.
She denied doing anything to harm Baby M. She took over as his designated nurse at the resuscitation as Mary Griffith was not ITU trained. She did not know why he desaturated. She recalled it was a busy day.
In a second interview on 12 June 2019, the following year, she confirmed she was drawing up medications when Baby M’s alarm sounded. In relation to the paper towel with the drug administration notes on it, PMB8, found at her home, she thought she must have taken it home inadvertently. She could think of no reason why she kept it but felt it was an error on her part, not emptying her pockets before leaving work and then inadvertently taking the note home.
She said it may have been put to the side and forgotten about and denied that it was to remind her of an attack on Baby M. She was shown her diary, NAC10, and agreed that she had recorded "LD", a reference to a long day, and "twins" -- so the entry is "LD and twins" -- on 8/4/16 because she said she attended their delivery.
She'd also entered LD extra twin days -- sorry, I'll start that again, I apologise.
She also entered "LD, extra, twin resus" on 9 April 2016, 9/4/16, documenting this, she said, as she had done an extra shift and had documented what happened that day. The resus was a significant event.
In the third interview on 10 November 2020, she was asked about the messages she sent at that time to Mary Griffith and Nurse E and the reference to the unit being in a dire way with staff. She said staffing concerns were readily discussed amongst nursing staff and shift leaders.
In her evidence, the defendant said that the delivery of twins stood out in her mind because it was the first delivery she had been to where she was the allocated nurse for a baby by herself. They were very stretched that day in providing for all of the needs of the babies on the unit to make sure they were all cared for and Baby M wasn't in a correct space in the nursery.
Potentially, if Baby M had been in a proper space and they hadn't been as stretched with staff, maybe things would have been acted on quicker. He wasn't on a correct monitor and was just in a corner space, which wasn't ideal.
She had a direct memory of this event and remembered Nurse B and Dr Jayaram at the resuscitation, but said there was no discolouration, anything like that described by Dr Jayaram, and no discolouration was brought to her attention.
The lighting will have been on full, but it was harder for her to assess because she was not used to caring for Asian babies, so the colour change, if any, was difficult for her to see. She did not notice any colour change. Tile 152 was her note.
At 15.30, tile 127, she agreed she started a dextrose bag for Baby M with Mary Griffith, and it must have been after that, after 15.45, that the process of making up the 12.5% dextrose started. She denied that it was while Mary Griffith was getting sterile that she sabotaged Baby M.
When reminded of the evidence of Mother of Babies L & M that it was about 10 minutes after she left the boys that a nurse called Yvonne came running up and said she had to go back and took her down in a wheelchair, she could not remember whether Baby M’s parents were there.
In relation to the resuscitation notes in the Morrisons bag, she said it was common practice for such notes to be written on pieces of paper and paper towels and they went home with her in her uniform and she could not recall specifically what she did with them.
Tile 171, the blood gas readings, replicated those from the readings from the machine printout which was found under her bed in her home. She said she will have put the blood gas machine printout in her pocket to write the readings up. It was an error on her part that it didn't go in the bin. She denied she had taken it out of the confidential waste bin, she had never done that, it will have gone home with the handover sheet. The notes were not something that she specifically kept or had any use for. She put it under her bed because she collected paper.
She continued to care for the twins quite frequently. She was the designated nurse for Baby L on the 16th, 17th, 24th and 25 April, over which time there were no adverse incidents.
Baby M was discharged from hospital on 3 May. She didn't want to harm the twins, she said.
I remind you briefly of Baby M’s recovery after he had been resuscitated.
Dr A came on duty that night and familiarised himself with the events of the afternoon. At 02.55 on 10 April, he carried out a night review of Baby M. His note is behind tile 300. Baby M was settled and had been all evening. He had no abnormal movements, his heart rate, respiratory rate and blood oxygen concentration in air were all normal. These acceptable observations were leading them towards taking him off the ventilator.
Morphine had been stopped at midnight so that he would have more respiratory effort of his own to allow him to be taken off the ventilator. He was extubated at 03.20 and put on BiPAP. At 06.00 he was moved down a step of respiratory support from BiPAP to CPAP. At 08.00 he was settled on CPAP. There was no respiratory distress and the plan was to review his progress on the ward round.
Samantha O'Brien, then a nurse in the unit, took over from the defendant as Baby M’s designated nurse for that night shift. She recalled the defendant describing it as a long resuscitation and told her that they had been just about to stop their efforts when they got a heart rate. She didn't recall being told why Baby M had collapsed. To her knowledge, it was never found out. She also confirmed that Baby M improved quickly during the night.
Laura Eagles said Baby M was in reasonably good health. There were no significant events in relation to Baby M on the 10th given the fact that he'd come off the ventilator quite quickly after suffering his collapse. Baby M recovered well from his collapse.
Dr Gibbs first met Baby M at 09.35 on 10 April and examined him. His clinical note is behind tile 348. There was no explanation for his cardiorespiratory arrest. He had been suffering recurrent brief bradycardias. He was on CPAP and breathing normally. There was an increase in carbon dioxide levels and he was a little bit acidotic. His breathing was a bit slow. A full blood count yielded normal results. His abdomen was soft and not tender.
At 10.15, Dr Gibbs was asked by Laura Eagles to look at Baby M because his breathing had slowed down and stopped briefly and he had desaturated to 60%. He responded to being Neopuffed. Dr Gibbs said he made a steady recovery but on that morning, the 10th, he still wasn't behaving normally, in that he was quiet and his breathing was slow, which was explicable for a child who had very nearly died the previous afternoon, so it could have been a consequence of that that he wasn't behaving normal and had some breathing difficulties. It could also be partly the consequence of all the medication he had received to be mechanically ventilated for 10 hours or so after the cardiorespiratory arrest.
His recovery continued and he was discharged on 3 May, by which time he was feeding well.
Other possible causes of his collapse, namely NEC, an infection or any heart defect, were excluded, and the agreed evidence of Dr Shauq, a consultant cardiologist at Alder Hey, was that X-rays confirmed that a potential issue noticed by Dr Brearey of a Eustachian valve was in fact perfectly normal. So it wasn't an issue.
The agreed neurological evidence of Dr Stivaros, the lead consultant neuroradiologist at Royal Manchester Children's Hospital, was that Baby M’s MRI scan of his brain on 27 May 2016 at the Countess of Chester showed abnormal appearances of Baby M’s brain, which was most likely caused by the cardiorespiratory collapse he suffered on 9 April.
His reading of the clinical history did not identify any other point in time when such neurological injuries are likely or even hypothetically likely to have arisen. The imaging could not determine the underlying cause of the collapse as to which he deferred to clinical opinion.
The damage to Baby M’s brain is, sadly, not recoverable, and over time he may well deviate from his peers in regards to attainment and cognitive or motor function.
Professor Arthurs received six separate radiographs, the most relevant being the first dated 9 April at 17.00, tile 192. The other was dated 9 April, the same day, at 19.12, 2 hours and 12 minutes later, tile 238. The radiographs were taken to check the line position. The lungs were clear and the bowel gas pattern was normal and the same comments applied to the second radiograph. So there were no radiographic features of these images which could either support or refute the suggestion of an intravascular air embolus. Simply, they neither support or refute an air embolus, so there is no radiographic evidence to help you.
Dr Evans, on all the evidence, concluded that Baby M was a preterm baby, born in good condition and, prior to his collapse, there were no concerns regarding his clinical stability. The only concern was that his feeds, his oral feeds, were discontinued at 15.00 hours because of a bilious aspirate. There was no change in heart rate or respiratory rate, so the collapse was completely unexpected and quite precipitous, so Dr Evans did not think his collapse was in any way the result of the fact that there were a couple of millilitres of aspirate from the feed, especially as oral feeds had been stopped anyway so his stomach was empty.
He was surprised that Baby M did recover following a very, very robust resuscitation. This begged the question whether Baby M received some noxious substance prior to his arrest or whether he received a bolus of air intravenously via his long line.
His collapse could not be explained on the basis of pneumonia or any other infection. He was able to breathe within 4 hours of his collapse. If the collapse was due to pneumonia or other lung problem, such as aspiration or infection anywhere else, he would not have expected him to make such a prompt respiratory recovery. He was breathing well before the collapse and he was breathing well within a reasonable time after the collapse. He did have a few problems the following morning that were not as serious and not unexpected given his experience of nearly dying.
His other concern about him was that his collapse had caused some neurological damage, some brain damage, which is why the staff noticed stiffened posture in the limbs. His fingers and toes curled and his feet and hands inwardly rotated, which are the features to be expected in babies who have experienced lack of oxygen to the brain.
His opinion at the time was that his collapse was a consequence of some substance or air getting into his circulatory system; in other words, he received air intravenously. He explained air in a syringe injected into the bit of tubing between the bung and the end of the cannula going into the baby's vein, what he called the dead space, would then be pushed down by the fluid that was being pumped at whatever rate the pump was set to administer the fluid and enter the blood circulation some time later and cause a collapse at a later time.
So taking everything into account, including the descriptions from Dr Jayaram about what he saw and from the nurses about the circumstances immediately surrounding the collapse, in his opinion Baby M’s collapse was an air embolus, air having been administered to him some time before 16.02.
He excluded infection of any type as a reasonable counter-explanation, there being no evidence of infection and the blood tests that look for infection before and after his collapse all being normal. The difficulties in the 24 hours or so following his collapse were the result of oxygen deprivation to his brain and the complications arising from his hypoxic event, a lack of oxygen to the brain.
It was put to Dr Evans in cross-examination that air in the circulation will not dissipate within 30 minutes. He accepted that there was no empirical or research basis for the way air dissipates in blood after an air embolus has caused a cardiac arrest because you cannot carry out such research evidence and he explained it on the basis of physiology. The air gets into the baby's circulation, into the right side of the heart and into the lung. Cardiac massage will dissipate the bubbles of air in the lung, which will be absorbed there because it is a small volume of air.
He referred to the difference between the effects of air embolus in a baby and an older child or adult because of the baby's foramen ovale and air getting from the right side of the heart into the left side of the heart, then wherever it goes after that depends on a number of factors, but it will dissipate.
If it gets into the blood vessels supplying the abdomen, you'll get discolouration. If it gets into the blood vessels supplying the brain, you could find air in the cerebral blood vessels and you could also get neurological abnormalities. He agreed that in cases of air embolus, most do not survive. Whether you survive or not depends to some extent on how much air goes in and also the rate at which the air goes in, so therefore where you have catastrophic air embolus in cases that have been written up in the papers, the bolus of air is so large that the baby collapses and recovery is impossible.
Very little air is required to cause a collapse. He also agreed that the volume of the dead space between the bung and the end of the cannula would be a volume of about 0.32 of a millilitre.
Dr Sandie Bohin also concluded that Baby M was a premature infant who was stable and well immediately prior to his collapse. There was some early jaundice for which he was receiving phototherapy treatment, but there was nothing to suspect any medical problem was imminent.
The team had started intravenous antibiotics as a precaution because of the early jaundice, but actually there were no biochemical markers of infection, either then or later. She had to find some way to explain that a baby who was previously well had suddenly collapsed, had a very prolonged cardiorespiratory arrest from which he almost did not recover, and then, within a short space of time, appeared relatively stable again. She could think of no other things that could cause that other than an air embolus. The changes in skin discolouration by Dr Jayaram were compatible with an air embolus.
She explained there were three possible ways in which Baby M could have had air administered. Firstly, it could have been through the yellow self-sealing rubber bung that was the kind of T-piece used at the time with a needle and syringe. The second was if a three-way tap was in situ through one of the bungs or with a syringe through the spare portal. If no three-way tap was in place, which she thought was unusual because Baby M was on antibiotics, then it would be used for administering antibiotics. Air could have been injected using a syringe directly into the T-piece once the IV fluids had been disconnected.
So at the time of administering antibiotics, if there wasn't a T-piece, you would have to undo the IV fluids and then give the antibiotics by attaching a syringe at that end so that antibiotics, other fluids or air could be administered in that way.
The actual volume of air that causes a baby to collapse and die is unknown but if a large volume of air was injected by whichever means, that would immediately cause some sort of air lock in the heart and the baby would have a cardiac arrest and die and would not be able to recover. If the amount of air injected was of a smaller volume and was not injected as in big a push but was in the dead space and then all of this was filled with air, which is a small volume, but the fluids were then reconnected, then that would take some minutes to get to the baby because Baby M was only on a very slow infusion rate of 5.5 or 5.3ml an hour of fluids, which is 0.8ml per minute. So if air was in these pieces of equipment it would take some minutes to actually get into the patient and to the heart to cause the collapse.
But because the volume was not sufficient to cause the air lock and cardiac arrest, it didn't cause a sudden death. It did cause an arrest from which he was resuscitated.
Under cross-examination, Dr Bohin too accepted that most babies die from air embolus but said it was not inevitable. She denied that she had simply looked for some explanation and reached for air embolus. She had looked for a differential diagnosis of possible causes and then either confirmed or excluded them. She couldn't think of a medical cause that was unascertained. She accepted there has to be consideration of the possibility of a medical cause that has not been identified, but looking at the entire history, as she did, nothing else came out of the history or his clinical presentation which would lead her to think that there was an underlying cause which, up until the point of his collapse, had not been discovered, not then, not since. Precipitous cardiac arrest in well babies is incredibly unusual.
She settled on air embolus principally because of the unexpected nature of rapid collapse and then recovery in a baby that was previously well and the findings of Dr Jayaram with the skin changes.
In relation to infusion through the T-piece, she explained that when a bolus of antibiotic or adrenaline is given, it will be flushed through with a few millilitres of saline, which will infuse the medication more quickly into the bloodstream.
That completes my review of that count, the attempted murder of Baby M.
Baby N, counts 17, 18 and 19, three further allegations of attempted murder, the dates being on 3 June and two events on 15 June.
Baby N was born at 13.42 on 2 June 2016 by planned caesarean section at 33 weeks' gestation. He weighed 3 pounds 11 ounces, 1.67 kilograms. His mother, [Mother of Baby N], is haemophiliac. In due course, blood tests confirmed Baby N was haemophiliac as well, but as I shall remind you, that had no relevance to the events relating to the counts in this case. His Apgar scores were recorded as 9 at 1 and 5 minutes respectively. He was admitted to the unit at 14.00 hours.
The prosecution case is that, when in the unit, Baby N suffered three unexpected and unusual collapses -- one in the early hours of 3 June, the day after he was born, which is the subject of count 17, and two episodes 12 days later on 15 June, counts 18 and 19 -- that are all attributable, allege the prosecution, by inflicted trauma by the defendant who was working on the unit at the time and were acts carried out with the intention of killing Baby N. In other words, they say, attempting to murder him.
The defence case is that the defendant committed no harmful act, there are inconsistencies in the various accounts, and there are explanations for the physical findings other than the conclusions reached by the expert witnesses on behalf of the prosecution and so you cannot be sure that the defendant attempted to murder Baby N.
Before I remind you of the profound desaturation at shortly after 01.00 on 3 June, count 17, I summarise Baby N’s history in the unit up to that point. The relevant observations on his administration to the unit at 14.00 on 2 June are behind tile 9. Caroline Oakley was his designated nurse on the day shift. Her nursing note is behind tile 10. His colour was pink and his readings were normal. Dr Bhowmik, the registrar, confirmed the initial observations were satisfactory. Behind tile 15 are the clinical notes of Dr Ukoh written at 14.50 that afternoon, setting out the antenatal and birth history and Baby N’s transfer to the unit and his observations on examination at that time, 14.50.
He had some intermittent grunting, increased work of breathing, cool peripheries and some transmitted upper airway sounds, which are not unusual in babies born by caesarean section due to excess fluid on the lungs. The practice is to observe for 4 hours to see if these symptoms settle down before considering a sepsis screening. At 15.10, tile 19, it was recorded on the apnoea bradycardia fit chart that:
"Crying, dropped sats. 60% oxygen via Neopuff."
Ultimately, that desaturation went down to 67 and lasted for a minute, as recorded by Caroline Oakley.
At tile 20 are some nursing notes made by Caroline Oakley at 15.30, which record:
"Transferred to hot cot at 28.5 degrees. Dressed and nursed supine. Allowed to rest. Sounds very mucousy. Grunting intermittently. Saturations 93% to 100% in air. Temperature 36.4 when checked at 15.00. Hot cot increased to 39 [the maximum temperature]. Dropped saturations to 67% when upset. Temperature beginning to recover. Orogastric tube passed and donor-expressed breast milk, 9ml two-hourly, commenced. Reviewed by Dr Ukoh. Awaiting blood results before giving vitamin K."
That's the note.
Caroline Oakley said she had no recollection of events apart from what was written in her notes. There is nothing to suggest that the OGT, the orogastric tube, had been changed or physically once she originally inserted it. There is no indication to suggest that there were any difficulties with placement of the tube.
Count 17. The staff on duty and their allocation that evening, 2/3 June, are to be found behind tiles 52 and 53. Melanie Taylor was the shift leader. Baby N was in room 1 and his designated nurse was Christopher Booth. The defendant and Sophie Ellis were also on duty. The defendant was the designated nurse for two babies in nursery 4.
From tile 68 onwards the defendant engaged in Facebook messaging with Nurse E, telling her they had a baby with haemophilia and that it was a complex condition. In her evidence, the defendant said that everyone was quite panicked about having a baby with haemophilia. She was asked about feeding her baby AF in nursery 4 at 20.30, reference J30921, which is AF's feeding chart, using two hands when she was at that time messaging Nurse E constantly from 20.00 hours, those messages being tiles 90 to 130, an exchange that referred to her being asked for advice for Mel Taylor and her use of the acronym FFS and a message from Dr A, which involved a suggestion relating to "go commando", which she said she didn't know what that meant, and laughing emojis. She said the feed must have happened at a different time and refuted the suggestion that she had used one hand to push the feed through using a plunger on the end of the syringe.
Dr Jennifer Loughnane, then a registrar, now a consultant paediatrician, carried out a night review at 22.55. Tile 161 covers her notes on which she was reliant when giving evidence, having no direct recollection of events. Baby N was self-ventilating in air, had a respiration rate of 60, his sats were good and he was not needing any respiratory support. There was no grunting and zero distress. He had a normal heart rate of 140 beats per minute and his CRP was less than 1.
The notes also made reference to the test for haemophilia and delaying the administration of the vitamin K injection. He was pink and well perfused. Consideration was to be given to starting enteral feeds.
Christopher Booth, Baby N’s designated nurse, went for his break at about 01.00. He had no concerns at all for Baby N and handed the care over to another nurse, but he did not remember who this was.
Melanie Taylor, Sophie Ellis and Nursery Nurse Valerie Thomas did not have any recollection of the collapse of Baby N, nor did they know who was caring for him whilst Christopher Booth was on his break. The defendant was the only other nurse on duty that shift.
Tile 173 documents Dr Loughnane entering the unit from the labour ward shortly before seeing Baby N at 01.10. She was asked to see him and was told, she couldn't remember by whom, that he had got upset, he looked mottled and dusky and his sats had dropped to 40%, so they put him on 100% oxygen.
On her arrival, she noted he was in 40% oxygen and was screaming. He had sternal recession, a mark of increased work of breathing. The trace wasn't picking up very well on the sats probe, but he looked pink, so it sounded like he was recovering. A desaturation to 40% was quite a significant desaturation. A lot of babies will have the odd desat, she said, usually into the 80s and stuff. She couldn't recall how the 40% of oxygen was being delivered. It was probably in the incubator.
Because screaming is not a word she wrote often in notes, she usually wrote unsettled or crying, she suspected he was particularly upset, but she now had no direct recollection. They tried to settle him. Then Dr Loughnane was crash bleeped to the maternity ward at 01.20. She said she wouldn't have left if his oxygen saturation was 40%.
On her return at some time prior to 02.00, [Baby N] was self-ventilating in air, his sats were back to 100% and he was asleep. His work of breathing had improved. He was settled again and looked to be back to how he was previously.
Behind tile 179 are a set of capillary blood readings at 02.04. Compared to the earlier 17.15 readings, on the whole the gas was better. The only concern would be that the lactate had gone up, but that may be a consequence of it being a capillary sample, which can sometimes be higher because they are squeezing when they take the sample.
When Christopher Booth returned from his break, he was surprised to learn that Baby N had become very unsettled, had been crying and fractious and suffered a profound desaturation. By the time he returned and when he returned, Baby N had calmed down and his oxygen levels had recovered and he remained stable for the rest of the shift.
His nursing note behind tile 1272 was in these terms:
"One episode whilst I was on my break whereby Baby N was crying ++ and not settling. He became dusky in colour, desaturating to 40s, responded to facial oxygen within 1 to 2 minutes. Crying subsided within approximately 30 minutes and colour returned to normal. Pink. Dr Loughnane aware of this episode. No further episodes observed."
His update at tile 191, timed at 06.13, recorded that there had been no further episodes, oxygen saturations had been consistently mid-90s to 100% since, he was self-ventilating in air, his respiratory rate had been approximately 50 to 70, minimal recession evident, only in view of earlier episode he remained nil by mouth on a 10% dextrose infusion via a peripheral cannula.
The prosecution case is that the defendant sabotaged Baby N in some way that caused this collapse. The defendant said to you that she had no memory of this event and did not know there had been an incident with Baby N. She agreed he'd been in good shape at the start of the shift and didn't believe it was a collapse that required resuscitation. She referred to tile 175, which timed her entering the unit at 01.15. She denied she used the absence of Christopher Booth from the nursery on his break to sabotage Baby N.
Dr Bhowmik saw Baby N on the ward round at 11 am that morning, 3 June. Her note is behind tile 231. In summary, Baby N had been screened for sepsis the previous day due to persistence of the intermittent grunting and was now on antibiotics with a differential diagnosis of either TTN or possible sepsis. He had also been nil by mouth and was on intravenous fluids in view of his respiratory distress to prevent choking or aspiration.
On the ward round he was breathing without any support in room air and had oxygen saturations of 100%. His blood gas in the morning was satisfactory.
On examination, he had mild sternal recession, a common sign of increased work of breathing in newborn babies, especially those born prematurely, and a respiratory rate of 60 per minute with no nasal flaring or grunting. The rest of his examination was unremarkable: he was pink, well perfused with normal heart sounds and femoral pulses, normal abdominal exam, normal anterior fontanelle and no bruising. He was put on enteral feeds. He was receiving phototherapy now for the jaundice.
Christopher Booth was also Baby N’s designated nurse for the following night of 3/4 June. Behind tile 276, his note timed at 03.01 on 4 June recorded no significant desaturations, bradycardias or apnoeic episodes overnight. The two-hourly enteral feeds had been increased to 8ml donor-expressed breast milk and had been well tolerated. His IV fluids were reduced accordingly.>Nothing untoward ensued then until Wednesday, 15 June, when there were two events that give rise to counts 18 and 19.
The defendant said at that time she owned a house, had hobbies and had an active life. She referred to messaging on the 13th about going away on holiday with Nurse E and another which started on 16 June for a week. She worked shifts on the 8th to the 10th, the 11th and the 13th to 15 June.
Baby N’s designated nurse over the shift of 13/14th was Abigail Jeffels. Her nursing note is behind tile 8 in the second sequence of events for Baby N. He was stable and feeding on demand from a bottle. His weekly bloods had been sent off for analysis.
At the nursing shift handover to the day shift on 14 June, in other words at the end of the night shift, the defendant became Baby N’s designated nurse. Jennifer Jones-Key took over as his designated nurse the following night shift of the 14th to the 15th. There were no concerns as to his condition at that point.
Jennifer Jones-Key made notes towards the end of the shift on the 15th between 05.51 and 06.02. They record that he was taking his bottles well in his incubator, but was very unsettled in the early part of the night, which was up to midnight. He took 60ml of feed at 21.00. She noted:
"Just after the 01.00 feed he looked very pale, mottled and slightly veiny. His abdomen looked slightly bigger."
Belinda Simcock advised he be put on a saturation monitor. He was reviewed by Dr A. Behind tile 80 is Dr A’s note. Baby N was settled. There was mottling to the torso and limbs, which could be signs of sepsis. Otherwise, his observations were normal.
Capillary blood gas tests were undertaken and his lactate and blood sugar levels were slightly elevated. Dr A directed observations be kept over the next 2 hours.
Tile 84 -- I should say, this is in the second sequence of events, there are three sequences of events for the allegations as far as Baby N is concerned. Tile 84 recorded that when he saw him at 03.45 Baby N had had five desaturations while on the monitor, his mottling had resolved, and all his observations were normal. There was a slight rise in his base excess, further blood tests were ordered.
There was a third review at 05.15. There was a prolonged capillary refill time of 3 seconds, which was a non-specific sign that suggested the blood flow to the skin was being directed elsewhere. His oral feeds were stopped and he was put on an infusion of intravenous glucose and given antibiotics. He was also given a saline bolus to improve circulation. The defence say that these were signs of his condition deteriorating.
Nurse Kathryn Percival-Calderbank had been the shift leader for that night of the 14th/15th. She said Baby N had been fairly settled after the last review. The observations up to 07.00 were normal; J19314 behind tile 133.
At around 07.15 on the 15th Baby N had another desaturation, the event now the subject of count 18. The prosecution allege that just before handover, at 8 o'clock, the defendant did something to destabilise Baby N.
There is messaging to which you can refer between the defendant and other nurses during the shift. Jennifer Jones-Key was at the computer at the desk opposite the nurseries. The defendant had arrived earlier and had gone into the room where Baby N was because, she said, as she had had him the previous day, in order to see how he was and had been allocated him again for that day shift.
Jennifer Jones-Key became aware that assistance was needed in that room. Baby N had had a profound desaturation to 48%, which was sufficient to affect his heart rate, which dropped to 80. Her nursing notes of this event are behind tile 141.
Tile 143 fronts Dr A’s note, which was written at 08.00. He said he was asked to see Baby N. He swiped into the unit at 07.16, tile 142. Baby N’s saturations had been 100% at 01.00, 05.00 and 07.00, being in 25% in oxygen at 05.00 and 07.00. He was being bagged using a Neopuff circuit. His mottled appearance had reduced. Dr A decided to move him to nursery 1 and continued to monitor his saturations.
The nursing shift was changing. In nursery 1 he attempted to intubate Baby N using a laryngoscope. He saw blood in the oropharynx at the back of the throat that prevented him from seeing the entry to his airway. He believed he visualised it on his first attempt to intubate but was not sure. The back of Baby N’s throat looked unusual. There was a degree of swelling. He couldn't discern where the blood was coming from. Not having had to perform this procedure on Baby N before, he wasn't sure whether this was long-standing or new.
He made three unsuccessful attempts to intubate him, not being able to visualise the tracheal inlet, and suction did not clear the view enough to allow him to intubate and he didn't want to cause any mechanical trauma. He didn't believe that he applied cricoid pressure and couldn't see a bleeding source. He remembered the defendant was helping with the attempted intubation. Dr A then commenced Baby N on BiPAP and a further bolus of sodium chloride to help boost the circulating volume of his blood was prescribed. A chest X-ray he requested confirmed that there was no pulmonary haemorrhage. He remained in contact with his colleagues and the defendant about Baby N.
Moving on in time, tile 461 relates to 22.22 hours that night of 15 June when he sent an update to the defendant about Baby N’s condition and then another at 01.03 on 17 June 2016 when he sent a further medical update, which is behind tile 498. It referred to Baby N’s good progress in the intensive care unit at Alder Hey, which is where he was sent after a further event on the afternoon of the 15th, who were unsure, that's they at Alder Hey were unsure, how he became unwell. His blood cultures were good, which indicated the microbiology did not suggest infection, and they were optimistic that Baby N would be okay.
All right. I'll break off at that point and we'll resume again at 2 o'clock, please.
(1.00 pm)
(The short adjournment)
(2.00 pm)
Mr Justice Goss: In her first police interview on 10 June 2019, the defendant remembered Baby N had an airway issue that was very unusual and they had to get a team from Alder Hey to come over. She couldn't remember any issue before that. He was a really difficult baby to intubate. She was his designated nurse in nursery 1.
She was asked about the intensive care charts behind tiles 172 and 238 in sequence 2 and the references to blood. She said that if the NG tube had been inserted forcefully, it can cause a bit of trauma going down that can result in a small amount of blood, about 1ml. She did remember Baby N bleeding when they were having difficulties with the airway, but agreed that the notes indicated that he did have blood before intubation, but she wasn't sure why.
In the second interview, which was 2 days later, both of these were in June 2019, she said she often arrived on the unit before 7.30 to be ready to start a shift at that time. On 15 June 2016 she said she went into nursery 3 to talk to Jen, which was something she regularly did.
In her evidence the defendant confirmed that she looked after Baby N on 14 June during the day, handing over to Jennifer Jones-Key. She didn't recall any concerns. She referred to tile 31 in which she noted that once phototherapy was completed he was ready for home. She also referred to the note of Jennifer Jones-Key relating to Baby N being very pale and having a slightly veiny and mottled abdomen at just after 01.00, that's on the 15th, and the subsequent entries. His condition, she said, deteriorated during that shift.
When cross-examined she agreed that, as far as the charts were concerned, there was nothing suggestive of a problem, his observations were normal.
She swiped in through different doors to the unit at 7.10 and 7.12 prior to the morning shift on the 15th. That's tiles 136 and 137.
She recalled going to nursery 3 to talk to Jennifer Jones-Key, who was a close friend, who was in the room with another baby, not Baby N. She was stood at the doorway. It happened within minutes: Baby N’s monitor went off, she went over to him from the doorway where she was, he was in the cot space on the right-hand side, he was bluish and not breathing properly. She Neopuffed him, Jennifer came over, Dr A was on the unit straightaway, Kate Percival-Ward was around. Baby N recovered, then the same thing happened again: there was a similar episode and he became very mottled.
The decision was made by Dr A to transfer him to nursery 2. She did not remember the reinsertion or re-passing of the NG tube. In nursery 1 he was not recovering, so Dr A decided he needed to be intubated. She started to get the equipment ready and her and Bernadette Butterworth started getting the drugs ready and they were administered at 8.06.
She recalled blood being seen and said her nursing note behind tile 233 read to her that blood was observed once intubation had been attempted. She referred to entries on the care chart behind tile 173 in relation to some blood and on her own nursing note behind tile 233 and other charts.
In her note in the family communications section of J19233 behind tile 233, which she started at 14.12, she wrote the parents were contacted, both phones were switched off and a message was left.
In cross-examination she was referred to her nursing note behind tile 151, written at 13.53, which made no reference to the event at 07.15. She agreed she had written out the events of her arrival in nursery 3 because, she said, she had taken over care from 07.30.
She was asked about her note written at 13.53, which recorded:
"Fresh blood noted in mouth and yielded by suction ++."
And agreed that the suction would have been done by the doctors during intubation. The first time she definitely remembered seeing blood was prior to the I-Gel insertion, which was at 15.00, which was after the event that's the subject of the next count, count 19.
[Father of Baby N]’s, Baby N’s father, evidence was read, that he was at work and received a phone call from Baby N's nurse, Lucy. Lucy said that, "Baby N had been a bit unwell in the night but is okay now". The defendant said she did not make such a call. This was the occasion to which I referred in my set of legal directions of evidence being read as agreed, where you don't have to resolve the issue. But here, in relation to this, it was not something that should have been agreed evidence, so she was saying something different, and so you have to decide who is telling the truth and who is reliable about this particular piece of evidence if you think it assists you in reaching your verdict on count 18.
In the third police interview on 10 November 2020, she had said she could not recall telephoning Baby N’s father on 14 June or telling him that Baby N was okay, it was a coincidence that Baby N became unwell that morning the moment when his parents left him to get food between 11 and 12.
A further episode of desaturation occurred at around 14.50 hours, after Baby N’s parents had left the unit that afternoon, which is charged as count 19, to which I now turn.
Dr Huw Mayberry was crash bleeped to attend. His clinical note is behind tile 245. He was told there had been a sudden deterioration after 3ml of blood had been aspirated from Baby N’s NG tube. His sats had dropped to 44%. On his arrival, he opened the airway and proceeded to bag Baby N to ventilate him. He was aware that Dr A had tried unsuccessfully to intubate him. He bleeped Dr Saladi and then attempted to intubate him.
He could see the vocal cords, but was unable to get a clear view because there was a substantial swelling in the airway. It was unlike anything he had encountered previously. He didn't recall seeing any blood. Dr Saladi's note said:
"Desaturated this afternoon at 2.50 pm with blood in the oropharynx and blood in the nasogastric tube. Improved with bagging, elective intubation planned, following pre-medication. Unsuccessful attempt with two registrars and two consultants."
Dr Brearey also then attempted to intubate Baby N without success. Advice was sought from the North-west Transport Service and the ENT team at Alder Hey for managing the difficult airway. In due course Baby N was successfully intubated by Dr Frank Potter at his first attempt at 19.53, assisted by Dr Benjamin Lakin, having deteriorated significantly shortly before they arrived early that evening. Once placed on a ventilator and given medication he started to improve and was stabilised sufficiently to be transferred to Alder Hey intensive care unit that night, leaving the Countess of Chester at 23.20.
He had remained on the adrenaline infusion following the episode of effective cardiac arrest at Chester, which was fairly quickly decreased. He needed ventilation, but not in very much oxygen and not very high pressures over the course of that night and, he thought, the following day.
After 2 days in the intensive care unit he went to the high dependency unit and he continued to have episodes of apnoea but they were less frequent and altogether less troublesome. Further investigation was carried out when he was readmitted to Alder Hey later and no abnormalities were found.
The defendant's addendum nursing note written at 18.30, behind tile 233, records:
"Infant has had periods of apnoea during the morning requiring stimulation and increasing oxygen/PEEP. Improving by afternoon. Observations stable. Remains cool, so incubator temperature increased. Approximately 14.50, infant became apnoeic with saturation to 44%, heart rate 90BPM. Fresh blood noted from mouth and 3ml blood aspirated from NG tube. Neopuff commenced and doctors crash called. Events documented in medical notes. Unable to obtain secure airway."
In her evidence the defendant said that after the aspiration of 3ml of blood at approximately 14.50 she had some memory but not a great deal. The atmosphere was becoming increasingly chaotic, there was a sense of panic around the unit. About 10 or 15 people came.
Once the ETT could not be inserted, it was decided the team from Alder Hey would come. She said there was no factor VIII left so some was brought from Alder Hey. She referred to her note behind tile 233 that at 19.40, which was before the intubation, Baby N was stiff and his back was arching. She said he was the focus of attention of the whole unit at that time, they were all very worried about him. She was stressed and anxious because she had never experienced that before and if they couldn't get an airway, he would have to undergo surgery.
Baby N was reviewed regularly on nine occasions by Dr Saladi over the period up to 19 November. Apart from treatment for his haemophilia there were no major issues regarding his physical or cognitive development.
I remind you of the relevant evidence of Professor Kinsey, an expert in paediatric haematology, who you'll recall gave evidence in the cases of Baby A and Baby B.
Haemophilia is due to a reduction in a blood coagulation factor called factor VIII. The coagulation system is there to prevent us from bleeding catastrophically following injury. It's quite a rare bleeding disorder and falls into three ranges, severe moderate and mild. Baby N fell into the moderate range, which made him more likely to bleed and more sensitive to trauma than a non-haemophiliac and to have a need to be given factor VIII to help manage an injury causing bleeding on a "when it's required" basis rather than on a regular basis.
Being in the moderate range and in hospital and being closely watched meant there was no requirement for him to continue to be given factor VIII. No intracranial bleeding was identified on cranial ultrasound and MRI scans. Professor Kinsey did not identify any issue relating to Baby N’s blood that, on the evidence, had any impact on his collapse on 3 June, nor did she see anything in the time between the 3rd and 15 June which was caused by a potential issue with Baby N’s blood.
In relation to the events at about 07.15 of 15 June and the succeeding 3 hours or so, she said that a spontaneous bleed could not be explained by Baby N’s haemophilia because a baby of that range would not be in a position to damage themselves in the throat and with his level of haemophilia he would just not have a spontaneous bleed.
Any instrumentation potentially could cause bleeding. A pulmonary haemorrhage, which is a very serious condition in which the lungs bleed and fill up with blood and the baby becomes very compromised, was not a viable explanation for what the treating medics saw in Baby N. He had been well and suddenly became unwell and recovered very promptly.
The defence don't suggest this was a careful spontaneous bleeding or a pulmonary embolism. The issues in this case are when and how the bleeding that was seen by the witnesses was caused.
In relation to Baby N there were no radiographic images that could illuminate the issues relating to the first events in the early hours of the morning of 3 June. The images on 15 June, tiles 176 and 421, do not assist either. So radiographically, there is nothing to assist.
Baby N was the 29th case that Dr Evans was asked to look at. He noted his history, the events of the 3rd and 15th, and his recovery. The event of 3 June was a very sudden desaturation with a very quick improvement. Screaming was an incredibly unusual description and continuing to cry for half an hour was very unusual. It struck him that something had been done to the baby to cause him to scream. He frankly accepted that this was something he overlooked when he prepared his initial sift report. It struck him that something must have been done to him. He was not suggesting he had an air embolus: this was a sudden collapse and an equally remarkable quick recovery.
In relation to 15 June, although Baby N had signs of sickening for infection, the results in succeeding days did not disclose any evidence of infection. Dr Evans' opinion was that, on the assumption that the blood was there before the laryngoscope went in, the bleeding was a consequence of trauma. He thought the most likely cause was inflicted trauma to the mouth or pharynx.
Dr Bohin described the event of 3 June as a life-threatening desaturation. It was very, very unusual for a baby to cry for 30 minutes. She had never experienced a neonate crying for this long and never heard a neonate scream. He must have been in pain.
There was nothing to account for a prolonged episode of distress. It could only be secondary to inflicted painful stimulus. She could go no further than that.
In relation to the events of 15 June, Baby N was bleeding. It was not a pulmonary haemorrhage or bleeding from the stomach. She couldn't identify any natural cause and thought there was some inflicted trauma to the oropharynx area that caused some bleeding.
In relation to 15 June, although he had signs of sickening for infection, the results in succeeding days did not disclose any evidence of infection.
I turn then to [Babies O & P], also known as [Surname of Babies O, P & R], counts 20 and 21. On Tuesday, 21 June 2016, [Mother of Babies O, P & R] gave birth to identical triplet boys. She and her partner, [Father of Babies O, P & R], knew when she was 12 weeks pregnant that she had conceived identical triplets. She had routine steroid injections at 23 weeks, she went into labour at 33 weeks and 2 days' gestation, and the boys were born by C-section.
Baby P was the first born and Baby O was the second born at 14.24. I shall refer to each of the boys by their first names. Baby O died 2 days after he was born and Baby P died the following day.
Baby O was born in good condition and his Apgar scores were good. He weighed 4 pounds 7 ounces, described by Dr D, the doctor assigned to him at birth, as "quite a good weight". He cried immediately. He was admitted to the unit at 14.45. Behind tiles 5 to 9 are the records of Baby O’s condition.
From 17.03 on that day to 13.00 the following day, there was nothing remarkable in his condition. At that time the defendant was on holiday in Ibiza. She was abroad from the 16th to 22 June.
Facebook messages were exchanged between the defendant and Dr A. There were also messages passing between the defendant and Jennifer Jones-Key. In the messaging the defendant said she did not mind being busy and enquired about the triplets. She also said she felt most at home with ITU, intensive care, and the girls knew she was happy to be in nursery 1.
I remind you that in your first bundle in section 7, you have the cross-references of the Baby O and Baby P sequence of events tiles, in other words where they are duplicated you can see where they are in those.
Samantha O'Brien was Baby O’s designated nurse on the day shift of 21 June, the day the triplets were born. Behind tiles 48 and 49 is her note made at 18.29 at the end of the shift. As I've said, nothing remarkable.
Amy Davies, a neonatal practitioner, was the designated nurse for both Baby P and Baby O on the night shift of the 21st to 22 June. She was not advised of any concerns at handover. Both were on CPAP. She had no concerns about them during the shift, nor did Caroline Oakley, who was shift leader that night, and said they were "fine and stable".
Baby O was moved from nursery 1 to nursery 2 on the day shift of 22 June. Caroline Oakley was also shift leader the following night, of the 22nd to 23rd, and Sophie Ellis was Baby O and Baby P’s designated nurse. Both were in nursery 2, both the boys.
Baby O had had a good day shift, going down from CPAP to Optiflow and starting on some enteral feeds, stopped his antibiotics and his blood results were okay; tile 89.
Tile 55 is the observation chart. His observations and saturations were very good and he was very stable.
Behind tile 85 are Sophie Ellis' nursing notes for the shift. He was receiving TPN through a cannula and enteral feeds via an NGT. He was tolerating them well. She was just obtaining partly digested milk aspirates, which was under half of the feed volume four-hourly, which was reassuring. Sophie Ellis said she would have noted if it was a concerning aspirate. The relevant fluid chart is behind tile 53.
Vicky Blamire gave Baby O his feed at 07.00. On the note behind tile 105 Sophie Ellis recorded:
"Abdo looks full, slightly loopy, appeared uncomfortable after feed. Registrar Mayberry reviewed. Abdo soft. Does not appear in any discomfort on examination. Has had bowels open. To continue to feed but monitor."
Dr Mayberry confirmed that he examined Baby O, remembering him as a triplet, and said he was a child who was well in themselves. His abdomen was mildly distended but when palpated, as recorded in the nursing note, was entirely soft. He had no concerns.
Sophie Ellis said Baby O had had a very stable night. He had got up to full feeds, had a positive blood gas and his antibiotics were stopped. All positive things. His full abdomen at just after 7.30 was noticed and reviewed and there was no imminent concern from that so they continued as they were.
In relation to the suggestion he was being overfed, she was referred to the feeding chart behind tile 167and the entries that followed in the ensuing day shift’s feeds and the reference to trace aspirates, which mean a very small amount of aspirates, at the 8.30, 10.30, and 12.30 feeds, which showed he was tolerating his milk feeds well.
Dr Mayberry was asked about and discounted free blood in the peritoneum and said there was nothing to indicate that Baby O was in discomfort from any injury at that point in time. Sophie Ellis' note was consistent with Baby O not being unwell.
The defendant accepted that Baby O was fine during the shift of 22 June and the ensuing night shift into 23 June. Melanie Taylor was the day shift leader on that day shift on 23 June. The defendant was the designated nurse for Baby O and Baby P, who were in nursery 2 with their brother, Baby R. She was also the designated nurse for another baby in nursery 2 and was the only nurse in nursery 2. She had said in police interviews that she remembered Baby O and Baby P and had been their designated nurse in nursery 2.
In her evidence she said they were high dependency babies and the nurse ratio was meant to be 1 to 2. She also pointed out that in nursery 1 there were two nurses for four babies when the intensive care ratio was meant to be 1 to 1.
However, in cross-examination she confirmed she wasn't suggesting that staffing levels or medical or nursing staff caused or contributed to Baby O’s collapse and that he was not a high dependency baby.
It was her first day back after her holiday. She had a student with her on that day, Rebecca, referred to as Becky, Morgan, who was on the first day of her placement at the hospital. The defendant was her allocated mentor and said she had to take her on an induction process, explain procedures and show her round the unit and that she would be in close proximity to her most of the time but it was not fully direct supervision.
She was at a point, that's Becky Morgan, that she could conduct NG tube feeds. Becky Morgan confirmed it was her handwriting in the columns which bore her initials, RM, on the various charts and in other columns, those charts being the feeding and observation charts behind tiles 94 and 99.
Melanie Taylor confirmed there were no concerns at the beginning of the shift. She didn't recall any particular issues at that time.
Dr Katarzyna Cooke, who trained in Poland as the equivalent of a registrar and was then working at the Countess of Chester as an SHO, conducted a ward round at 09.30 on 23 June. Her note made at the time is behind tile 121.
There were no nursing concerns and Baby O’s observations were normal. Everything was reassuring -- this is at 09.30: the abdomen appeared full but not distended, was soft, non-tender, there were active bowel sounds and no masses. Everything was as it should be. She had no clinical concerns and he was making good progress.
In her evidence the defendant accepted Dr Cooke's evidence that an abdominal issue could be excluded and that there was not any haematoma on the liver at this time, so the injury to the liver must have been inflicted some time after that during the shift.
The result of the blood culture taken on 21 June came back negative after 5 days, indicating there was no infection. Melanie Taylor said there was nothing of concern in the readings on the fluid balance chart behind tile 115. She recalled going into nursery 2 about an hour or two before Baby O’s collapse and feeling that Baby O didn't look as good as he had done. She said to the defendant, "I don't think he looks as well", and asked if they should move him to nursery 1, thinking if he was going to deteriorate, there was more equipment on hand and emergency trolleys in there.
The defendant replied, "No", she felt he was okay and wanted to keep him in nursery 2 and to keep the triplets together. She was quite insistent. Mel Taylor felt put out because she felt the defendant was undermining her decision.
The defendant said she didn't recall any specific details about talking about Baby O going into nursery 1. Nursery 1 was very full and she didn't remember being dismissive to Mel about where Baby O needed to be. Mel was within her rights, she said, to override her and take the baby from her.
Tile 168 records that Dr A’s first review was at 13.15. He believed he was in nursery 3 when he was asked by the defendant to see Baby O as there were concerns his abdomen was distended and he had vomited. That vomiting, which was not a posset or reflux, was unusual. The feeding chart, the neonatal balance chart -- the paper copy is the last document in section 20 of volume 2 -- recorded feeds at 10.00 and 12.00 that are initialled by the defendant.
Dr A’s clinical note behind tile 168 recorded that Baby O’s heart rate was elevated, his respiratory rate was slightly elevated and his abdomen was distended. The blood gas readings revealed his blood was more acidic than Dr A was expecting, as was his base excess. His lactate was also elevated. He didn't know what had precipitated this. He re-cannulated him at a fresh site and commenced Baby O on intravenous fluids and prescribed antibiotics, having a concern of an early infection. There was in due course no evidence of an infection. He also directed an X-ray.
The defendant's nursing note is behind tile 169:
"Reviewed by Reg Dr A at 13.15. Baby O had vomited undigested milk. Tachycardic and abdomen distended. Nasogastric tube placed on free drainage. Septic screen carried out. Blood gas poor as charted. 10ml per kilogram saline bolus given as prescribed along with antibiotics. Placed nil by mouth and abdominal X-ray performed. Observations returned to normal."
There is an entry on the blood gas record, J23667, behind tile 170, at 13.20, that Baby O was on CPAP. He was not. The defendant accepted that putting a child on CPAP was a medical decision. She said she couldn't say why she wrote this, saying it should be he was on CPAP via Neopuff. The prosecution say this was a deliberate false record.
Dr Bohin could find no record of Baby O being put on to CPAP, which could, CPAP, cause some distension to the abdomen, but not to the degree that was to be observed.
In interviews, the defendant said she was present when Baby O began vomiting after his feed and was moved to nursery 1 and she continued to care for him. She remembered his abdomen becoming quite distended and him being intubated and having a drain put in his abdomen. She would have been present throughout the feed at 10.30 and 12.30, which would only have taken a few minutes. She did not recall who was present when he vomited. Melanie Taylor said she didn't know where she was, but the defendant was in nursery 2 when Baby O collapsed at around 14.40. She couldn't recall whether it was a call or an alarm that alerted her to it, but when she went into nursery 2, the defendant was already there and Dr A, who was in nursery 3, arrived after her.
The defendant, in her first police interview on 5 July, said that she discovered a collapse at 14.40 after hearing Baby O’s monitor sounding. She could not recall anyone else being present in the room at the time. Baby O was mottled all over, with a red abdomen. The mottling was sort of blotchy, purply-red rash, which was a deterioration and could be infection mottling.
The defendant's evidence was that she heard a monitor alarming and, when she went in, she found it was Baby O’s. She called for Dr A who was in the nursery next door. Baby O looked unwell and needed Neopuffing. He was more mottled, his abdomen was a bit redder. She said that mottling can be a sign of infection or cold; they see it quite often in babies.
The decision was then made to move Baby O to nursery 1. Melanie Taylor remembered pushing the incubator with Dr A. Dr A’s note of this event is behind tile 199.
There had been a desaturation and bradycardia, Baby O’s heart rate had dropped to 80 to 90 and his sats to 50 to 60. He was mottled, his skin looked unusual, which may have been caused by his low heart rate and oxygenation. He was bagged up and transferred to nursery 1 with a Neopuff requirement in 100% oxygen. The details are in the note behind tile 199.
Baby O was intubated at the first attempt between 15.03 and 15.08 and connected to a ventilator on normal settings for a preterm baby on 30% oxygen, antibiotics and boluses of sodium chloride had already been given and he was given a further bolus. Dr A planned to leave him for half an hour before taking further blood gas tests. He went to speak to the parents.
Behind tile 201 is the corresponding note made by the defendant:
"Approximately 14.40 Baby O had a profound desaturation to the 30s, followed by a bradycardia, mottled ++ and abdomen red and distended. Transferred to nursery 1 and Neopuff ventilation commenced. Poor perfusion."
She told you she did nothing to Baby O to introduce air and drew attention to the neonatal review at or around lines 97 and said that the entry relating to the administration of cefotaxime and a saline flush was after and not before Dr A had been called, as per his note, and that he was then given a further bolus after transfer to nursery 1.
Dr Brearey was present when Dr A intubated Baby O and noticed a small rash, 1 to 2 centimetres in size, on the right side of the chest wall, which was purpuric in appearance, which is very, very rare in neonates and is commonly a sign of sepsis. It was unusual that he also had good perfusion. He then appeared to be stabilising.
He did not have sepsis. The blood sample taken at 13.39 came back 5 days later with no bacterial growth.
The defendant said the description of the rash that Dr Brearey said he saw was not what she saw.
Professor Arthurs referred to the radiograph that is behind tile 197. It is untimed but it is accepted that it was taken at around 14.40, the time of the profound desaturation. The image revealed a lot of gas in the stomach and the small and large bowel, which he said could be caused by NEC or an infection, neither of which was applicable in Baby O’s case, or by the administration of gas down the NG tube.
At 15.51, Baby O went into neonatal arrest. The defendant's nursing note recorded:
"Doctors crash called at 15.51 due to desaturation to 30s with bradycardia. Chest movement and air entry observed. Minimal improvement. Re-intubated. CPR commenced 16.19 and medications/fluids given as documented."
Dr A was crash bleeped back to the ICU. He was bagged through his ET tube with minimal success.
Dr B, the consultant on call, was present. His ET tube was removed and he was re-intubated at the first attempt. Good air entry was achieved and Baby O was recommenced on the ventilator on the same settings; the details are in the note behind tile 218.
At 16.15 Baby O had another episode of bradycardia and desaturation, tile 228 and the continuation sheet behind tile 228 are the relevant documents. His heart rate was 60 and his oxygen saturation was 50%. He was hand ventilated on a Neopuff circuit, cardiac massage was started at 16.19. He was given sodium bicarbonate, sodium chloride and adrenaline as noted on the resuscitation sheet.
Dr Brearey was called back at 16.30 during the resuscitation. Tiles 206 and 286 front his relevant notes. Baby O was baptised. Despite ventilation via a Neopuff and chest compressions, which were inflating his lungs, and the medication administered, there was no effective heartbeat. An intraosseous sample was taken from the right shin, which showed he still had a metabolic acidosis. His haemoglobin was low at 86 but not low enough to cause his collapses. His abdomen was still distended.
The rash had disappeared, so it was definitely not a purpuric rash, which was perplexing to Dr Brearey. He had never seen it before and he's not seen it since.
A radiograph taken at 14.46 behind tile 466 was examined by Professor Arthurs. In his opinion the NGT and ETT were appropriately sited. That was a view he expressed in his report and to which he adheres.
Because, unusually, they were getting no response to the resuscitation after at least 30 minutes, by agreement care was withdrawn, resuscitation was stopped and Baby O died.
It was, said Dr Brearey, deeply distressing for all involved. Baby O had been born in good condition like his siblings and was following a healthy path. His deterioration came out of the blue, two desaturations and bradycardia on a ventilator was exceptional. His rash was unusual. They excluded all natural causes.
Dr A said it was exceptionally unusual. Dr Brearey later held a debrief at which he said the defendant did not seem upset. When interviewed, the defendant said she thought she was in the nursery with Baby O at the time of his final collapse at 15.51 and that Dr A had left to update Baby O’s parents. She was shocked and upset by Baby O’s death. She just remembered his abdomen kept swelling up and they ended up doing a drain and intraosseous access, which were not nice things to see.
His death was unexpected, the day was particularly busy, the doctors were back and forth, being pulled in various directions. There was an element of delay each time a registrar had to be called.
In her evidence, she said she remembered Baby O’s death but not the precise moment that he desaturated and needed a crash call. She remembered parts of the resuscitation and them struggling to get an intravenous access, so an intraosseous needle was used, which is quite brutal thing to see, and they had to go and get the equipment from the children's ward.
She remembered Dr Brearey inserting a drain into the abdomen in view of it being so red and swollen; she had not seen that before. She did not remember the rash disappearing.
After Baby O died she said everyone was completely flat, there was a complete change of atmosphere. For her it was devastating. She said:
"You want to be able to save every baby in your care. It was not what is supposed to happen, you're not supposed to watch a baby die."
She explained that the messaging with Dr A in the post-indictment sequence from tile 111 on 30 June related to Dr Jess Burke and the suggestions that she had done something wrong. In the sequence of events for Baby O, that's from tile 329, there were messages with Dr A in which, at 331, the defendant referred to her not having completed all the documentation and the notes being in her pocket. She said they were to come back the next day for completion of the documentation for drugs.
[Father of Babies O, P & R], Baby O’s father, said Baby O’s stomach was definitely swelling at one point:
"It was like ET's stomach, like a big pot belly, which went down and then there was another point where you could see all his veins. They were bright, bright blue, all of them, and they were going different colours and his actual body looked like he had really, really bad prickly heat and that got worse and then it went down again. It was literally like you could see something oozing through his veins."
You'll recall him pointing to his body on the video recording when he was describing that.
Dr B and Lucy were pretty much the main ones dealing with Baby O. There were loads of people rushing in and out, passing things. Dr B did not have an explanation, she couldn't give a reason why he had passed away and was quite upset and very apologetic.
The defendant, in her evidence-in-chief, said she didn't see anything like that described by [Father of Babies O, P & R]. In cross-examination she thought she had done some chest compressions. She did not know how Baby O got his liver injury, she was not responsible.
When he was cross-examined, Dr Brearey was asked about the entry on the note behind tile 268:
"IV cannula inserted at McBurney's point to try to decompress abdomen. Small amount of blood."
And said he was nowhere near the liver and deniedhe had caused the bleeding that was found at the post-mortem. He said he was aware of confirmation bias and disagreed with the suggestion that he was biased against the defendant.
When the fact that the defendant had been present at three events was brought to his attention by Eirian Powell in June 2016, his comment in the meeting at that time was:
"No, it can't be Lucy, not nice Lucy."
The senior nursing staff at the hospital could not believe that it was true that anyone was harming babies and none of the senior staff wanted to believe it either. No one was red-flagging the deaths, but the senior clinicians, he accepted, were becoming increasingly concerned about the number and nature of the unexplained collapses. He asked an external neonatologist to review them.
It was his opinion, backed up from the BadgerNet data that they all use in the country for neonatal care, that there wasn't a significant increase in acuity or, as in a chicken or egg situation, you could argue that the cases themselves created an increase in acuity in the unit due to the more intensive care they were providing because of the sudden collapses, which he thought was much more likely.
Whilst emphasising that in every case of collapse they identified they identified areas where care could be improved upon, he said there was not a single case in which shortage of staff or sub-optimal care had an impact on any of the outcomes.
When he was challenged about not contacting the police, he said the reason was because they wanted to escalate this appropriately within the structure of the hospital rather than directly going to the police themselves without the support of the medical director and the executives in the trust. It was suggested that the reference in his witness statement made in 2017 to the defendant rejecting his suggestion that she take the weekend off after Baby P’s death was further evidence of confirmation bias. His response was that it was not, she did reject his suggestion, in other words would not take the time off after Baby P’s death, which was the next day.
The Countess of Chester neonatal unit was redesignated from a level 2 to a level 1 on 7 July 2016 by their own decision for reasons of looking after staff and their welfare because everyone was very stressed and upset by all these events. They reduced the number of cot spaces from 16 to 12 and increased the gestational limit from 27 to 32 weeks. They still maintained the high dependency cot spaces in the unit, making them somewhere between level 1 and level 2 as a unit, but he agreed they were not taking the same volume of babies at the same acuity after that.
Melanie Taylor helped to prepare and draw up drugs at the resuscitation. She was asked about exhibit KDH2A, on one sheet of which were notes of the resuscitation of Baby O. None of the handwriting on any of those documents was hers. Once the details had been transferred on to the medical notes and records by being scanned or formally written up, the rough note should be put in the confidential waste.
Behind tile 498 is a Datix report submitted by the defendant in relation to Baby O’s death on 30 June to1 July in which the issues she raised was: "Infant had a sudden acute collapse requiring resuscitation. Peripheral access lost. Intraosseous access required. Resources not available on unit."
Dr Brearey explained that peripheral access was not lost and asked for the report to be corrected on 25 July. The reference to resources was probably to a EZ-IO device not being in the unit at that time, which was common, he said, in most neonatal units in the country, so the previous way, of using a screw needle manually, was used.
Dr George Kokai, consultant paediatric pathologist, conducted a post-mortem examination of Baby O at Royal Liverpool Children's Hospital at 14.00 hours on 28 June 2016. He made a written report on 25 September 2017.
Dr Marnerides, as with every other case, confirmed that he did not take into account the evidence relating to other children when drawing conclusions about Baby O and Baby P’s respective cases. He took you through a presentation of the injuries to Baby O’s liver. The two red dots on the anatomical mannequin show where Dr Kokai in his report mentioned the presence of two subcapsular haematomas, which are bruises underneath the thin membrane, the capsule, of the liver.
The post-mortem photographs showed the nature and size of the haematomas. Dr Kokai also described an area of blood clot and the remnants could be seen in another photograph. Dr Marnerides said a pathologist would think this was a rather large haematoma also involving a large part of the substance of the liver. There was also much more haemorrhage into this liver when you actually looked at the undersurface and on one photograph, taken by Dr Kokai, at the margin of the bruises, there were superficial lacerations which, Dr Marnerides said, was most likely due to an impact injury. It could not tell him whether it was accidental or non-accidental impact.
Dr Kokai recorded that there was 25ml of free blood in the abdomen and there was a haematoma which measured 2.5 by 1 centimetres, which would equate to a 20ml blood clot. The distribution of the bruising and the pattern and appearance of the bruising indicated an impact-type of injury and he was fairly confident that it was caused by an impact injury. In the neonatal care unit setting where people are trained how to give CPR, one may see bruising to the liver, but it would be very small areas of bruising and they will be distributed on the surface of the liver, typically on the anterior edge of the superior surface of the liver. They would be small and there wouldn't be extensive haemorrhage into the liver. The liver is not an anatomical area where CPR is applied. There is no way of measuring the force required, but it would be of the magnitude of jumping on a trampoline and falling.
>He, Dr Marnerides, has only seen this extensive haemorrhage in livers in two children, not babies, who had been in accidents with bicycles: the wheel against the abdomen can cause this. He has seen it in babies who have not been in a neonatal care unit, who have suffered a non-accidental type of injury, typically with other injuries to the abdomen and injuries to the brain. In other words, cases of inflicted non-accidental injury.
He didn't think CPR could produce this extensive injury to the liver. In his experience and his understanding of the literature, this injury cannot be explained by CPR. He has never heard it being accepted that this sort of injury could result from CPR. Further, from the radiology review and the clinical experience review, the information and the assessment was that there was also profound gastric and intestinal distension following excessive injection or infusion of air via an NGT and further evidence from the radiology and clinical review that there was also embolism of air into the vessels.
So, Dr Marnerides concluded that the cause of death would best be described by combining the injury to the liver and the embolism of air in the vessels as the cause. There was no evidence from the post-mortem findings that could either confirm or undermine the likelihood of there having been an injection of air into the vasculature. You would not necessarily expect to see any sign on the skin itself overlying the site of the impact. It is very common that you see nothing from the outside, especially in babies who have the most devastating injury internally and yet nothing at all is visible externally. For the chest drain to have caused the damage to the liver there would have had to have been repeated episodes of touching and bruising the liver and not perforating it. He did not consider that to be plausible.
Dr Marnerides was of the view that the cause of death would best be given as inflicted traumatic injury to the liver, profound gastric and intestinal distension following acute excessive injection of air via the nasogastric tube and air embolus due to the administration of air into a venous line. In other words, an impact injury to the liver, air into the NGT and air into the circulation.
Professor Arthurs, whose evidence relating to the large amount of gas in Baby O’s radiograph taken at 14.40 hours on the afternoon he died I have reminded you of, also referred to radiographs from the post-mortem examination which were taken through the baby from right to left and showed gas in the heart, one of the great vessels, something that could not be seen on a radiograph taken from -- an image taken from the front, which the in-life images were. That, he said, was an unusual finding. You see post-mortem gas like this in babies who have sepsis and things like NEC, conditions Baby O did not have. It's also seen in conditions after traumatic events and in the case of older children who have undergone resuscitation, so this gas could be explained in Baby O’s case, either by trauma, if that was felt to be significant, or by resuscitation, if that was felt to be significant, to move some of the air in the body around. An alternative cause was an air embolus.
Dr Evans, in his report of 2 June 2018, felt that from the information he had at that time, there was some trauma to the liver, which had led to the collapse. He favoured this possibility because there was no reason why this baby could have collapsed and resuscitation was unsuccessful. Chest resuscitation carried out appropriately by experienced doctors doesn't get near the liver, therefore any cardiopulmonary resuscitation or pressing on the chest to get the heart going would not traumatise the liver and not be responsible for liver bleeding. He thought that the air in the abdomen seen on the X-rays was excessive and could indicate air having been infused into his stomach via the NGT, which had tracked into the intestines, causing abdominal distension.
After this report, he was given further information by the police, causing him to write a further report dated 25 March 2019. He was told about Dr Mayberry not finding any concerning pathology at about 07.30 on 23 June and Dr Cooke had no concerns on her examination 2 hours or so later, as well as Dr Brearey's report that the rash disappeared a short time after he had noticed it, meaning it could not have been purpuric.
So Dr Evans, on revisiting the vital signs for Baby O on 23 June, to be seen on J23658, of which you have a paper copy in section 20, he noted the trends of rising heart and respiratory rates, which were markers that something was going on but didn't tell them the cause.
The precipitous collapse thereafter and the apparent rash which then disappeared was consistent with Baby O having received an injection of air into his blood circulation. He remained of the view that he may have sustained some sort of trauma. His conclusion was that his sudden collapse was likely to be the result of air embolus and the bleeding within the liver and into the peritoneal cavity, the abdomen, would have contributed to the collapse.
His opinion was that Baby O’s terminal collapse was consistent with him being the victim of an air embolus and he couldn't find any evidence where this could have occurred accidentally.
When cross-examined, he said that good perfusion at the same time is something that you do encounter in the course of an air embolus where the air will go -- where the evidence will go will vary. If the air went to a particular part of the abdomen or the chest wall, then you will find the abnormalities there. But if the air does not go to other parts of the body then those other parts of the body will be normally perfused.
He thought it was very unlikely that some injury to the liver was caused by vigorous chest compressions. He'd never seen it and never read about it.
Dr Bohin reviewed the chronology of Baby O’s progress until 13.30 hours on 23 June and noted the details of the various events, the acidosis and high lactate readings, and the resuscitations. She also had regard to the findings of the post-mortem and the opinions of Dr Marnerides and Professor Arthurs. Baby O was very well, was fully fed and receiving minimal support and was not giving the clinical team any cause for concern until he vomited at 13.30 on the 23rd.
Although there was a trend to an increase in heart rate and respiratory rate, this was not thought to be significant by the clinical team treating him at the time and they decided that they would watch and wait to see what happened.
The subsequent X-ray, taken at around 16.00, showed a huge amount of gas within the abdomen for which she could find no easily explicable natural reason; he'd not been bagged at that time. She concluded that the cause for the degree of abdominal distension and vomit was excessive air being put down the NGT into Baby O’s stomach. Alternative natural cause possibilities, namely bilious vomiting, NEC and a mid-gut volvulus, were all excluded.
She further noted the account of Dr Brearey in relation to the right side of the chest, the description of [Father of Babies O, P & R] and the opinion of Professor Arthurs, and concluded that Baby O had signs that were compatible with an air embolus: the discolouration of the chest, the ongoing discolouration of his abdomen, his failure to respond to routine resuscitation, and the air seen at post-mortem. She could not conceive of any innocent cause for an air embolus in the context of the treatment that Baby O had received.
She accepted in cross-examination that there are a small series of people that claim that there's damage to the liver after resuscitation, but she has never seen it in her many resuscitations of neonates over 35 years of practice, including working in a major cardiac unit.
She was challenged about having known about Dr Evans' conclusions and her not having performed an independent assessment. She refuted the suggestion that she did her best to support an allegation of Dr Evans as far as she was able to. You, as I have said before, will have to consider whether Dr Bohin was or was not striving to provide an independent opinion or whether her conclusions were a product of striving to support a case against the defendant.
On all accounts, Baby O’s was an unexpected death. The defendant in her evidence said she didn't know how he died and she didn't recall any causes for concern and confirmed it was not her case that staffing levels or medical incompetence contributed to his death. The prosecution say you can exclude natural causes and find that this was another case where there is evidence of deliberate, unlawful harm having been done to him and that the person responsible was the defendant.
She denies any wrongdoing and it is argued on her behalf that this was a natural deterioration and the findings relating to air could have been a result of acts of resuscitation.
The following day, Baby O’s older brother, Baby P, died, and I shall turn to his case after the break.
(3.06 pm)
(A short break)
(3.16 pm)
Mr Justice Goss: Baby P weighed 4 pounds 9 ounces at birth at 14.23 on Thursday, 21 June 2016. He was born in very good health. He cried spontaneously and was active.
After 6 minutes of life, he was in normal air. His condition on examination are behind tiles 7 and 8 in his sequence of events.
Dr A described him as being in very good health for a baby of his gestation. Initially, Baby P went into nursery 1 with his brothers, but the next day, like Baby O, he was moved into nursery 2. A collective decision was made to put all the triplets on antibiotics and CPAP as a precautionary measure because of the risk of infection and respiratory distress syndrome.
His venous gas results were acceptable for a newly born baby. By reference to Dr B’s notes made at 11.45 on 22 June, J23840, overnight and into the following morning there was no change. He was stable, on CPAP but now in air. His fluids were still being run through his peripheral cannula at the same rate. Nothing had happened that was a concern.
At 10.00 the following day, Saturday the 23rd, the notes of Dr Cooke, behind tile 64, recorded that there were no nursing concerns and his observations were normal. It was a systematic review. She did not miss anything and everything was correctly documented. His antibiotics were stopped, Baby P was self-ventilating in air, his feeding had progressed normally, he was being fed expressed breast milk by an NG tube. Everything, including a cranial ultrasound scan, was completely normal.
At 18.00, Dr Cooke reviewed Baby P with Dr Gibbs because of Baby O’s unexpected death at 17.47 and the concern that there was an infective process going on.
The relevant note is behind tile 134. Dr Gibbs noted that Baby P had a normal breathing pattern and his abdomen was full, mildly distended but with tenderness, and had active bowel sounds. He appeared to have redness at the base of his umbilicus, which may have been due to scratching caused by his nappy or cord clamp. It was not an uncommon finding.
Dr Gibbs also made the decision to do a full blood count, along with bilirubin, and to start him on second-line routine antibiotics and to have an abdominal X-ray, all as precautionary measures, especially in view of Baby O’s collapse and death. He said that Baby P appeared very well. It was also the plan that Baby P should continue on NG tube feeds, but if there were any concerns, they should be stopped and he should be fed intravenously.
The blood culture collected at 18.35 came back on 29 June after his death with no growth of any bacteria, so there was no infection, and the white cell counts were not high, so no suggestion of infection; that's tiles 145 and 181.
Sophie Ellis was the designated nurse for both Baby P and Baby R on the night shift of the 23rd to the 24th. She had been a duty the previous night and had learned that Baby O had died in the late afternoon of the 23rd.
Her nursing note is behind tile 169 with an entry made at 01.31 and 01.48 on the 24th. His observations had, up until that point, at least been within the expected parameters. She noted that he had had one desaturation into the 80s and one episode of bradycardia into the high 90s, which had self-corrected, with no intervention required.
She said that sometimes preterm babies do have desaturations and bradycardias that can be due to immaturity or other factors. She kept a close eye on him because of Baby O. She also noted he did at times have a low-lying heart rate between the high 90s and 110, which she brought to the attention of the senior house officer, Dr Henton. This was not deemed to be a set of data of concern. Sometimes if the babies are in a deep sleep they can have a low-lying heart rate.
In relation to feeds, she referred to the fluid balance chart, which is behind tile 171, of which you have a copy in section 21 of your second jury bundle, documents J23981 and 23982. Baby P was on two-hourly 15ml feeds via the NGT. On the feeds of 22 June, from 02.00 up to 20.00, there were small or trace amounts of aspirates, as recorded by the defendant or her student nurse Rebecca Morgan. At the 20.00 feed Sophie Ellis aspirated 14ml of milk aspirate with a pH of 3, so acidic, which she returned to Baby P and then fed him a further 15ml.
She placed him on his tummy because sometimes it helps with feed tolerance and she noted:
"To monitor aspirates and inform the nurse in charge"; tile 169.
That was Kate Percival-Calderbank, then Percival-Ward, or Kate Ward as she's referred to in the notes, a senior and experienced nurse practitioner.
There was a further feed of 15ml at 22.00 and then at the midnight feed she aspirated 20ml of milk, which again was acidic, which she discarded. She also noted that the abdomen was full but soft. The registrar, Dr Mayberry, was informed, and was going to see Baby P but was called to a resuscitation in A&E, so he thought the safest thing to do was to put him on to intravenous fluids. The aspirate was a significant amount but there was evidence that the gut was moving. Feeds were then stopped and Baby P was started on 10% dextrose infusions.
At 04.00, 25ml of air was aspirated by Kate Percival-Calderbank and noted by Sophie Ellis, and at 07.00, 5ml of air and 2ml of milk, which was acidic, was aspirated. If any of the aspirates had been bilious Sophie Ellis said she would have noted it. Baby P’s NG tube was then placed on free drainage so that any fluids or air in the stomach could be drained off.
In the last section of the note, towards the end of the shift, Sophie Ellis noted that Baby P’s abdomen had been soft and non-distended and Kate Percival-Calderbank noted that Baby P seemed comfortable and settled and seemed like a well baby.
Kate Percival-Calderbank recounted an occasion when she had allocated the defendant to an outside nursery rather than an intensive care one and she said that she was unhappy being put in the outside nurseries, saying that she felt it was boring and she didn't want to feed babies, she wanted to be in the intensive care nursery. They also found that when she was in one of the outer nurseries, if there was anything going on within nursery 1, she would definitely end up back in there, and they were worried about her mental health because it can be upsetting, emotional and sometimes exhausting as well and sometimes it's good to come out of that environment. She went into the outside nurseries but was not happy with the decision.
The defendant's evidence was that she never found other work boring and didn't recall having this conversation with Kate Percival-Ward/Calderbank.
Sophie Ellis handed over the care of Baby P to the defendant at the end of the night shift on the morning of Friday, 24 March. The others on that day shift are set out behind tile 258. Rebecca Morgan was also with her that day. The mood was a bit more sombre and sad.
She noted the observations at 09.00, 11.00 and 13.00 on the chart behind tile 132. In the defendant's nursing note behind tile 263, her first entry written in retrospect at 21.18, she wrote:
"Observations within normal range. Baby P nil by mouth. IV fluids, 10% dextrose, 50ml per kg, running via peripheral line. Line occluding, high pressures. NG tube on free drainage. Trace amount on tube. Abdomen full, loops visible. Soft to touch."
When asked about the similarity to a description about the abdomen she wrote in Baby O’s notes behind tile 105 in his sequence, she said it was not a fabrication and this note was a truthful observation.
In her first interview and in evidence she said she was asked to be designated nurse to give continuity of care for his parents and she thought that was the right thing to do.
Christopher Booth became the designated nurse for Baby R, who was the only other baby in nursery 2 with Baby P. The babies, he said, had been quite stable overnight. He recalled Baby P’s feeds had been stopped because his abdomen had been distended and aspirated. He was shown two sheets which were from PBM4, J23795, which he identified as the handover sheets that he received.
Such notes, he said, should be thrown away in the confidential waste. On occasions he has taken them home in the pocket of his uniform but he's then taken them back on his next shift and destroyed them.
Baby R was stable, fully monitored in the far end of the nursery. Dr Ukoh conducted his registrar ward round that morning at 09.35; his note is behind tile 289. On examination, Baby P was mildly pale, but had no recession, so was having no difficulty in breathing. On listening to the heart, there was a very soft murmur in a specific part of the chest, which was not untoward for a baby only 3 days old. He had a moderately distended abdomen and some bloatedness. The abdomen was soft.
Although it wasn't normal to find a moderately distended abdomen that was bloated, because it was soft it was a bit less worrying. The skin was slightly mottled, which might be poor perfusion or cold or mild acidosis. He ordered full blood tests, planned for trialling a long line for TPN, and keeping him nil by mouth for now. His overall impression was that he was a child that they needed to keep an eye on, being premature and had that distension, in particular, in relation to NEC and infection, but he wasn't particularly unwell.
About 20 minutes later, he thought, he was examining Baby R when he was called back to Baby P, whose oxygen levels, which had been 100%, had dropped to 60% and his heart rate, which had been normal, had dropped to 80 beats per minute. Student Nurse Becky Morgan said she was at Baby R’s incubator when Baby P had an apnoea, bradycardia and desaturation with all the alarms going off. The doctor was writing his notes and no one else was in the room. The defendant was not in the room talking to her.
She helped the doctor take the lid off Baby P’s incubator. A lot of people appeared very quickly. She remembered Dr Jessica Burke and Dr A who both came in after the defendant.
Christopher Booth said he and Lucy Letby were there in the room when Baby P collapsed and in her evidence the defendant also said that she was. Dr A recalled being bleeped and asked to come. Christopher Booth remembered that during the day Baby P]’s stomach was distended. Becky Morgan did the scribing for a short time at the beginning, but became upset and left the room. Dr B, the consultant on duty, was on a call to the coroner in relation to the unexpected events relating to Baby O’s death when she was asked to see Baby P again. Tile 625 fronts her notes of the events of the day.
Dr Ukoh proceeded to give some face mask ventilations with the Neopuff to support the breathing. When he arrived, Dr A came over, took over the airway and intubated Baby P. When he got there, Baby P’s heart rate and oxygen saturations were still at the level noted by Dr Ukoh. He was being bagged in air by a Neopuff circuit. At this time Baby P’s oxygen saturations were improved by using a Guedel airway. The intravenous line was lost and attempts by Dr B and Dr Ukoh to re-site it were unsuccessful, so intraosseous access was gained in both of the legs.
Dr B spoke to Dr Rackham, a paediatric consultant at Arrowe Park with a special interest in neonates, and then to the neonatal transport team, Contact North-west, who advised further vascular access be obtained, which Dr B succeeded in doing.
The blood gas results taken at 09.51 was a poor gas. It was a metabolic acidosis with some components of a respiratory acidosis. That suggested that over the previous 15 to 30 minutes Baby P had been working hard in part with his respiration. He intubated Baby P with a 3 millimetre tube at the first attempt and started him on continuous mandatory ventilation, he said, on normal settings for a baby of his age and size, 75% oxygen.
Adrenaline was given at 9.55, 10.02, 10.08, 10.15 and 11.10 because of the poor heart rate and poor perfusion. A subsequent gas at 10.06 had a lower bicarbonate value than the previous one and at 10.15 he was given some bicarbonate for the metabolic acidosis.
He had been given morphine to sedate him at 11.10 and then was given pancuronium at 11.32 to paralyse him, which Dr Bohin said was entirely correct. At 10.46 there had been an improvement; the relevant document is J23961 and you have a paper copy. His pH had improved, his carbon dioxide level was reduced because of the ventilation and it was no longer a respiratory acidosis, but the bicarbonate readings were now lower.
At 11.30, Baby P had a second episode of desaturation and bradycardia. CPR was recommenced. He was given adrenaline and pancuronium, a relaxant and paralysing drug, and spontaneous circulation was restored at 11.36, with the ventilator recommenced on the same settings.
Dr B did not understand what was going on. The blood gas at 12.08, tile 178, pleased Dr B. She recalled a conversation with the defendant in nursery 1 at that time, when, on telling her that the transport to Liverpool Women's Hospital would be arriving soon, the defendant said something along the lines of, "He's not leaving here alive, is he?" Dr B was shocked and said, "Don't say that". She thought they were winning at that point and found it a unusual comment and caused her real anxiety about what was going to happen to Baby R. In her evidence, the defendant said that potentially she could have said this, she had no recollection. She said that Dr B was becoming increasingly stressed as the events occurred, she was the same. There wasn't any clear plan from the doctors. It was beyond their level of care, she said.
At 12.28 Baby P had a further desaturation and bradycardia; tile 420 is the relevant tile. CPR was commenced and he was bagged via Neopuff again. He was given boluses of adrenaline. The capnograph indicated a problem with the ET tube, which Dr A said could have been coated by secretions or may have been blocked by mucus. Dr B, who recalled being in the kitchen with Dr A making a drink, and the defendant was with Baby P, ran back to the nursery. Baby P was desaturating and it looked like he had dislodged his tube.
Dr B accepted there was no reference in the notes to a tube being dislodged. She found it highly unusual that a child who'd been paralysed had dislodged a tube.
In her evidence the defendant, who said she had no recollection of the event and relied on her nursing note, which was behind tile 292, said that from her recollection there was no reference to a tube dislodging. It was removed and replaced by a 3.5 millimetre tube at 12.32.
There is no evidence of anyone checking whether or not it was blocked after it had been removed. All episodes of desaturation and bradycardia were accompanied by a profound colour change and poor central and peripheral perfusion, which suggested that his heartbeat and his cardiac output were insufficient to maintain normal colour, either within the central circulation and more extreme at the peripheral, both fingers and toes.
A radiograph had been taken at 11.57; the image is behind tile 401. It was not viewed by the clinical team until 12.30, after the collapse a few minutes earlier. It showed a moderately sized right pneumothorax, a partial collapse of the right lung, which was decompressed by a thoracentesis, putting a small cannula into that space, which was a temporary measure to relieve the air and allow the lung to re-inflate. It was not a tension pneumothorax, nor was it life-threatening. The bowel gas was within normal limits with no evidence of obstruction or perforation and no gas to suggest NEC. The ET tube could safely be advanced by a further 10 to 12 millimetres.
A radiograph behind tile 434, taken at around 12.30, confirmed that the ET and NG tubes were satisfactorily positioned, a right-sided chest drain was in situ, and Dr Wright noted there was a shallow residual right pneumothorax at that point.
At 12.51 further bicarbonate was administered followed by another bolus of saline at 12.55. Because of concerns about blood pressure and cardiac output, an infusion of dobutamine, which improves heart contractility, was started at 13.10. At 13.25 another bicarbonate dose was given after advice had been given to Dr B by Dr Rackham. [Dr A]’s memory of Baby P]between 12.50 and 13.25 was that it was very, very busy, both in looking at Baby P and seeing how he was progressing and he would have been setting up, ready to put a chest drain in as a definitive treatment for his pneumothorax.
At 13.30, Dr Brearey carried out an ECG to see whether there was a possible cardiac cause for Baby P’s deterioration. There wasn't. He had a normal heart with good contractility. There was no evidence of any congenital heart disease that might cause a sudden collapse or pulmonary hypertension or of fluid around the lining of the heart.
At 14.30, metronidazole and hydrocortisone were both given, the latter because of concerns about cardiac output and blood pressure and the metronidazole was further treatment for any presumed infection as this was potentially still an episode caused by sepsis.
A dose of 240 milligrams of Curosurf was given down the ET tube directly into the lungs. Up until to point the work of breathing and the effect that the inefficient breathing was having on the blood gases, making him acidotic, was a major component of his problems. There was no apparent or clearly identifiable cause as to what was going on.
At 15.00 a pigtail drain was inserted in the chest. Dr Rackham arrived at that time, bringing another baby to the Countess of Chester and to collect Baby P.
In her evidence, the defendant said she recalled the pneumothorax and said there was a general decline. About halfway through section 21 in your second volume is document 23955, the neonatal unit resuscitation record up to 12.55, on which times of chest compressions and the administration of various medications are recorded. Amongst the drugs given was adrenaline. By reference to the adrenaline prescription note J23917, which is behind tile 385, and you have a paper copy in section 21, and the infusion prescription and infusion chart, which is behind tile 286, and again you have a paper copy, the next document in that section, you have a record of timings and doses of adrenaline given.
It was apparent that there was a miscalculation in the infusion prescriptions as a result of which the rate of infusion was twice the intended prescribed amount following the collapses at 11.30 and 12.28. Dr Rackham agreed that an excess of adrenaline can lead to a greater rise in blood pressure than expected and can cause blood vessels to constrict and lead to lactic acidosis, but said that during his time with Baby P, from 15.00 or 15.15 onwards, and during his resuscitation, he saw no evidence of an increased heart rate nor was he getting any information that Baby P had side effects of too much adrenaline, which would be fast heart rate, excessively high blood pressure or an abnormal heart rhythm.
At 15.14 Baby P went into a cardiac arrest, CPR was administered. The details are behind tile 545. In the final X-ray, taken at 15.36.53, behind tile 574, a pigtail drain was in situ and Dr Wright reported:
"Tubes again satisfactorily positioned. Right chest drain in situ and the pneumothorax has fully resolved."
Dr Rackham confirmed that there was no breathing effort from Baby P, his perfusion was poor, his heart rate fell gradually over the 1 to 2 minutes after the initial collapse, and his heart rate dropped below 60 beats a minute. Compressions were started and resuscitation was carried out by the team from the Countess of Chester with him and the nurse with him.
Between 15.15 and 15.54 Baby P was given seven doses of adrenaline, three doses of sodium bicarbonate and one dose of phenobarbitone, a drug to treat fits or seizures as they had no explanation for why Baby P’s condition had changed and on the small chance this was actually being caused by a seizure or a fit. It had no effect.
He was also given a fluid bolus and a dose of atropine to try to speed up the heart. He was continually monitored and being reassessed by the team throughout the ventilation and air entry remained good.
There was no problem with the airway. Intermittently there was an audible heartbeat and an irregular heart trace.
The point was reached, following discussions with Baby P’s parents, where resuscitation was stopped at about 16.00 hours. Baby P was passed to his parents and died.
[Mother of Babies O, P & R] said Baby P’s stomach looked very similar to Baby O with his discolouration and his prominent veins, but his stomach wasn't swollen like Baby O’s. [Father of Babies O, P & R] said that when they got down to the room it was like pandemonium. It was worse than the day before. There seemed to be more people on hand.
Dr B couldn't give them a reason for why Baby P had passed away. She was quite upset and apologetic, saying there was nothing more they could do, they tried everything and they didn't any answers for them, but they were going to get to the bottom of it. "It was the same again", he said, "It all started the same and it was all very similar to how Baby O went", apart from he couldn't remember Baby P going all different colours in the veins and his stomach swelling. What he could remember was seeing Baby P struggle for his life.
Dr Cooke, though not referred to in the note, recalled assisting with CPR on Baby P following his collapse. The deaths of both triplets was the first time she had seen a neonatal death in her career and left a lasting imprint on her memory. It was unexpected, especially as she did not recall any concerns raised by nursing staff, nor the night team of doctors on call.
Dr Rackham said no cause for Baby P’s collapse was identified and they did not have a reason to explain the collapse. And he felt that they had carried out the resuscitation well and in accordance with all the appropriate guidelines.
He explained that because of the two unexplained deaths and not knowing what had happened, they felt it was most sensible to observe Baby R in an intensive care unit. Dr Rackham examined Baby R, who was on high-flow humidified oxygen, was stable, pink, well perfused active and alert with normal tone, his chest was clear, his saturations were at 100%, his abdomen soft and not distended, and his bowel sounds were normal. He was stable for transfer to Liverpool Women's Hospital.
Dr B thought that was the only way that Baby R was going to live. It was put to Dr B this was something she was coming up with to dramatise the situation for your benefit. She denied that she was trying to dramatise anything, it was tragic enough as it was.
She was aware at that time that the data being presented that their mortality rate had been higher and they were an outlier, but she heard nothing of any physical harm being done by a particular member of staff and knew nothing of the concerns of Dr Brearey and Dr Jayaram. She'd heard gossip and comments about the defendant but nothing concrete implicating her in deaths or raised mortality rates. She had no reason to believe that she was responsible, she said, before Baby O and Baby P’s deaths.
The defendant, when interviewed, said she felt panicked when Baby P deteriorated. She remembered it being very chaotic. It was devastating for all of them when Baby P died, it was an unexpected death.
In evidence she said she gave a lot of medication that day. Notes were made on pieces of paper or paper towels and then written up in the relevant charts. She didn't remember any discolouration. There was an increasing sense of anxiety on the unit and a great relief when the transport team arrived.
In her third interview, on 11 November 2020, she said she liked being in intensive care and having babies all the way through. She liked the variety. She recalled sending the message to Sophie behind tile 645 about Baby P’s downward spiral, similar to Baby O’s, and the message to Nurse E, tile 333, in Baby Q’s sequence about being worried in case there was a bug in the unit. She said this was something that was discussed on the unit. She denied having done anything to harm Baby P.
Dr Gibbs said that the death of two of the [Babies O, P & R] triplets was the tipping point for his realising that something was very abnormal and wrong. Before that point, the defendant's involvement by being present on the unit or most often caring for the baby concerned in some of the unusual or unexpected collapses had been noted by him Dr Brearey and Dr Jayaram. They worked as a team and he knew that Dr Brearey, as lead clinician for neonatology, had raised concerns with the management.
After the deaths of [Babies O & P], safety measures were introduced, one of which was the consultants insisting that the defendant be removed from the neonatal unit. They had to resist repeated attempts by senior managers for her to come back to the unit.
Dr George Kokai carried out a post-mortem examination of Baby P an hour after he commenced the examination of Baby O and made a written report on Baby P the same day as he made the report on Baby O, 25 September 2017. As reported on by Dr Kokai and depicted in the images he took at the post-mortem, there were injuries to Baby P’s liver. Having gone through the histology and the findings of Dr Kokai, Dr Marnerides said he had no morphological evidence, that is no naked eye visible evidence, and no microscopically visible evidence to indicate a natural disease that would account for Baby P’s death.
Dr Kokai reported that there were three small subcapsular haematomas, so bruises, on the front edge of the right lobe of the liver and a very small haematoma on the underside. The three haematomas on the front edge of the right lobe could be a rare manifestation of prematurity.
The very small haematomas on the undersurface cannot be explained by anything from the medical side of things. The alternative would be a form of injury to the liver. There weren't features of a severe impact to this liver because there wasn't a huge bruise or haemorrhage into the liver or the superficial lacerations related to the bruise, so he could not say there had been huge impacts to this liver. It could be some sort of impact, for example, due to cardiopulmonary resuscitation, so he didn't feel, viewed on its own facts and in complete isolation, he could have a confident answer on what the explanations for these were. It could be a combined effect of haematomas of prematurity and cardiopulmonary resuscitation and he didn't have enough to say it was an impact, an inflicted injury.
From the pathology point of view there was evidence from the examination of the lungs of features that would be consistent with a pneumothorax complication, but he felt confident that he could attribute that to the contemporaneous medical intervention. Otherwise, there was no morphological evidence indicating an acutely occurring natural disease process that would explain why Baby P collapsed. He had no explanation and could not see how a natural disease could have resulted in that.
His understanding of the clinical assessment was that there was no clinical evidence of a natural disease accounting for this being consistent with a natural cause of death. Having had the benefit of the discussion with the experts, both from the prosecution and from the defence, and of considering other proposals in terms of potential explanations, Dr Marnerides came to the conclusion that there was gastric and intestinal distension following excessive injection or infusion of air via the nasogastric tube, either splinting the diaphragm or stimulating the vagal nerve.
Professor Arthurs reviewed the radiographs in Baby P’s case. The best image of the bowel dilation was the second of the three he reviewed, taken on 23 June at 20.09, behind tile 173. The first was taken on his birth date, which was a chest X-ray and which was normal. The second taken on the evening of 23 June showed a nasogastric tube going into the stomach which was moderately dilated with loops of small bowel and large bowel going all the way down. This was gas throughout the gut, very similar to the appearance of Baby O. This degree of gas was quite unusual in a baby like this. It didn't show obstruction, it didn't show NEC, and there was a nasogastric tube in situ. He did not suffer from infection, NEC or obstruction to the bowel that you can be born with, so one was left with other causes, such as administering air via an NGT.
Professor Arthurs was not asked to comment on the three X-rays taken on 24 June at the various stages of Baby P’s collapse.
Dr Evans said Baby P’s lung function prior to the events of 24 June were "as good as it gets", but he was concerned about the air in the intestine over the night of the 23rd/24th. He commented that despite the aspirations of air at 04.00 and 07.00 and the addendum note at the end of the night shift made at 06.39 by Sophie Ellis, behind tile 249, that the abdo had been soft and non-distended, the defendant's nursing note at 08.00 behind tile 263 recorded:
"Abdomen full, loops visible, soft to touch."
He was at a loss to explain how Baby P had collapsed. He was of the opinion that he was resuscitated appropriately and the pneumothorax, which was a leak and not a tension pneumothorax, was caused and most likely increased by the bagging.
In relation to his final collapse, when he was preparing his main report, the only thing he could think of was that he'd suffered complications from the pneumothorax. The ECG of Dr Brearey excluded the possibility of pulmonary hypertension, so looking back he wondered whether the excess gas may not have been natural and he had been given air down the NGT, which could have contributed to his not absorbing his milk during the night but not compromised his breathing, and thought that he had more air on the morning of 24th.
There was no credible natural cause for his collapses: no sepsis, no significant haemorrhage, no NEC, no brain problem.
He referred to and was cross-examined on the guide issued by the Resuscitation Council UK entitled Newborn Life Support, which, on page 63 under the heading "Where should I press?", states:
"Compress the sternum over its lower third. If you press too high on the sternum, the heart is not compressed. If you press to low, you risk damaging the liver. Place your thumbs or fingers on the sternum, just below an imaginary line joining the nipples."
He said an experienced or competent clinician or nurse would not cause any damage to the liver and he had never known damage to be caused in a resuscitation.
He was again challenged by the defence that he was simply coming up with theories and the fact that in his reports he linked the potential infusion of air before the night shift to the collapse the following morning at 09.40 without reference to nursing notes at 06.39 and 08.00 showed this.
He was also referred to the normal gas readings at 20.27 on the 23rd, behind tile 178, but repeated that the air could have compromised his ability to digest milk and not his breathing. He repeated that the compromising of his breathing recurred with the splinting of his diaphragm the following day as a result of an additional volume of air, prior to which he was stabilising by 07.00 the next morning, and said that, since his reports, he had now a far better understanding of the sequence of events. He was not trying to shunt things forward to implicate the defendant or anyone. He had raised concerns about the night shift and the start of the day shift.
Dr Bohin, having gone through the events and confirmed that the infusion rate of adrenaline was twice the intended dose, said that the apparent overdose of adrenaline didn't have any adverse effect. The infusion was started after Baby P had had at least two of his collapses and already had a metabolic acidosis by then.
After the adrenaline was started, albeit at double the dose that was intended by the prescriber, his blood pressure didn't go up, save for one reading at 13.00 of 81, which was high, after which it dropped down. His heart rate didn't go up briskly, or at all, and he already had a lactic acidosis, so it was impossible for her to estimate what contribution this dose of adrenaline made to the lactic acidosis, but it certainly didn't affect his blood pressure or his heart rate adversely.
In relation to the acidosis she explained that the blood gases were taken after Baby P had had cardiac arrests, which inevitably will have increased the lactate on their own, regardless of whether there was adrenaline infusing. That why it's impossible to establish the contribution that an adrenaline infusion was making to the blood lactate.
She was concerned about the additional abdominal X-ray taken at 20.09 on the 23rd as a precautionary measure on the instruction of Dr Gibbs and the amount of gas within that X-ray, which Professor Arthurs described as "moderately full of gas". But there was gas that goes from the stomach and there's abdominal distension right the way through the bowel to the rectum.
Subsequently, over the course of the night, Baby P started to become intolerant of feeds and the abdominal distension reduced but the defendant recorded his abdomen as "distended and loopy" before he had a collapse, followed by subsequent collapses, the cause of which were difficult to explain.
The X-ray should have been done sooner, after the first collapse, and there was an issue about whether attention should have been paid to that pneumothorax sooner. It was possible that it was caused by the bagging or high ventilator pressures and could have contributed to the collapse at 12.28. She thought that the abdominal distension observed by the defendant splinted his diaphragm and adversely affected Baby P’s breathing and caused his collapse and that the air in his abdomen the night before was abnormal.
She could find no reason for that amount of air to be in his abdomen and felt that the air had been introduced via the NG tube and was not naturally occurring air. Her conclusion was that the air had been injected into his NG tube at some point or points, which led to splinting of his diaphragm, which subsequently caused his collapse. She could not explain why he went on to have further collapses and could not think of any naturally occurring phenomenon that would have led to those further collapses. Neither the ventilatory strategy nor the adrenaline administration caused the collapse.
Baby R was removed, as I've told you, from the Countess of Chester the day after Baby P died.
Baby Q, the subject of the final count on the indictment, count 22, suffered a sudden and unexpected collapse, but we will break off there, it's 4 o'clock. It's been a long day. On Monday we will start at 10.30 because we're not sitting tomorrow. You should, the usher will tell you, bring your refreshments with you because you will be beginning your deliberations before the lunch break, probably after about an hour. More from me on Monday morning. All right? But the usher will explain to you and I will give you a series of more directions -- not in writing, I'm not giving you any more paper -- some more directions about the procedures during retirement.
Thank you very much indeed. 10.30, Monday morning. Remember your responsibilities as jurors.
(In the absence of the jury)
Housekeeping
BM: We would like a visit.
Mr Justice Goss: Yes, please.
NJ: You may recall, my Lord, on Friday, just after Mr Myers finished, I raised the issue of the exhibits and what the jury have access to in retirement. I'm happy to say that we've now reached agreement between us as to what there is. What I will do, before the jury retire, please, though, is formally exhibit everything that's in the digital file, make that declaration, if I may, by agreement --
Mr Justice Goss: Yes.
NJ: — so that just in case something is in the -- everyone has checked the digital file, but just in case there's something in there that wasn't formally exhibited in the trial, it doesn't have the catastrophic consequence that otherwise it would have.
Mr Justice Goss: All right. I'm very grateful for that then. I will also confirm before I send the jury out — probably what I'll do is complete my summing-up, have a short break for the jury, and then give them the directions in relation to what's going to happen after the ushers have been sworn to act as bailiffs. So we’ll try and get everything organised.
NJ: The only other thing that I did mention a long time ago was that we have digital photographs. They’re not of a particularly high standard, but digital photographs of all the witnesses when they actually came to give evidence and they were generally taken downstairs. They are available. I'm not suggesting that it should be suggested to the jury, it's not evidence, if they require it in retirement, it's just --
Mr Justice Goss: Well, Mr Myers can think about it. He can say whether he thinks that's --
BM: Well, I understand from what Mr Johnson says that it's really there just to assist the jury if they require to be reminded what a witness looked like or who they were. It's not something to be given to the jury as an aid to begin with and we wouldn't seek that.
Mr Justice Goss: Are you content for me to make the offer if they did require to look at a photograph to remind themselves or what?
BM: Certainly I don't invite your Lordship to do that. It's something the prosecution did, but most of these witnesses have appeared on multiple occasions and one imagines they've left some impression. If there is a problem with recalling a witness and the jury convey that to us then we have this facility if it assists. But we would rather they not embark upon or in any way interpret it as an invitation to embark upon looking at photographs.
Mr Justice Goss: Well, it shouldn’t be mentioned then, should it?
BM: No, I would be grateful if your Lordship didn’t.
NJ: The only reason I asked for it was because a jury in another case that lasted a long time that I was involved in, a lot of medical evidence, asked for photographs.
Mr Justice Goss: That’s fine. They’re there. If they do, but I’m not going to excite them into the idea of doing it.
NJ: No.
Mr Justice Goss: All right, thank you very much.
(4.06 pm)
(The court adjourned until 10.30 am on Monday, 10 July 2023)
10.30 am
(In the absence of the jury)
Housekeeping
Mr Justice Goss: Mr Johnson?
NJ: My Lord, just before the jury comes in, if I may, we have handed to your Lordship this morning hard copies of the documents for the jury, and if I could go through the formality at some convenient point of formally exhibiting all these documents, just in case there’s something we omitted to exhibit during the course of the evidence. That will override any problem that might later occur if I’ve failed to do that.
Mr Justice Goss: Thank you. Mr Myers?
BM: Nothing to add to that, my Lord.
Mr Justice Goss: Thank you very much. I suggest we do that straightaway. They are to be distributed to the jury?
NJ: They are.
Mr Justice Goss: The other thing that will be distributed to the jury is sheets of labels which, I will explain to them in due course, are to go on their various documents, which will then be bundled up and taken to the jury room in a confidential bag, unique to each juror. That’s the sort of housekeeping issue with which I’ll deal at the end of my summing-up.
So you know what I’m proposing to do by way of timetable, I anticipate that I will have completed, to all intents and purposes, my summing-up before or around midday. I’m then going to ask the jury to put the labels on their documents in court, then to go for a short break, 20 minutes or thereabouts, as long as it takes for all the documents to be taken to their deliberating room, and also if counsel want to raise anything that I have said this morning that requires any correction or anything like that so that we can deal with that, and then say a few more words and send them out — swear the bailiffs and send them out to begintheir deliberations.
(In the presence of the jury)
Mr Justice Goss: Good morning, members of the jury. Each of you has been given, as I can see, a sheet of labels bearing your own name. When I complete my summing-up, which will be at around midday, I should imagine, I shall give you instructions as to what to do with those labels. So just leave them to one side for the moment, please, and I will resume my summing-up in a moment.
Before I do that, Mr Johnson is just going to distribute a set of final documents to you, which there’s no need for you to look at, they are in a sense a formality, and he will explain to what they relate. It’s by way of completion of the evidence.
NJ: Yes, my Lord. This is simply formalising what we have in fact achieved during the course of the evidence. They are hard copies of lists of material in addition to what’s on the sequence of events charts. So when the jury on their iPads go to the additional documents, they should find the documents that are listed in these lists.
Mr Justice Goss: I am holding it up to show you.
NJ: It’s just if you can’t find something, they’re divided child by child, and if they’re not on the list then you haven’t got them, I’m afraid.
If I can go through the formality, my Lord: by agreement between the parties, on a belt and braces approach, exhibiting all these documents in these lists, that’s a legal formality that’s required, so I do that now. If I could ask Mr Stansfield to at some convenient stage give the jury a copy of one of each of these documents.
Mr Justice Goss: Yes. The first is a schedule of the video evidence, so that’s a reference document for you as well. It’s entirely up to you where you put these. I’m going to make a suggestion about my legal directions and I’ll do that now when you’ve received these.
NJ: There shouldn’t be any surprises in what you’ve just been given. It’s just an easy ready reckoner list to cut down any time you may need to spend trying to find things, really. That’s the only point.
(Pause)
Mr Justice Goss: I don’t know where you’ve put them my written legal directions 1 and 2. It’s entirely up to you, but you might find it most convenient to put them with the indictment in the first jury bundle because they obviously relate, particularly legal directions 1, to how you approach the counts on the indictment.
If you do that then you each know where they are. So both sets of legal directions: the first relating to how you approach your decisions on the counts on the indictment and the second, the evidential directions.
(Pause)
SUMMING-UP (continued)
Mr Justice Goss: The final count on the indictment, count 22: Baby Q, attempted murder, June 2016.
Baby Q was the 17th and last baby in this case and was born by emergency caesarean section at the Countess of Chester on 22 2016 at 04.09.
His mother, [Mother of Baby Q], had the misfortune of having a heterotopic pregnancy, a second baby being outside the womb and it having to be removed by surgery.
After 5 weeks in the hospital, Baby Q was delivered at 31 weeks and 3 days’ gestation. He weighted 2076 kilograms, 4 pounds 8 ounces. His tone was poor at birth, his Apgar scores were 4 at 1 minute, 7 at minutes, and 9 at 10 minutes.
Susan Dillon, the midwife present at the birth, noted that he was in good condition for his gestational age. He was taken to the unit at 04.23. There were no signs of infection.
Three days later, on Saturday, 25 June, Baby Q vomited fluid, desaturated and had bradycardia in an event at 09.10.
The prosecution case that this was a consequence of liquid, and very possibly air, being injected down his NG tube causing splinting of his diaphragm and compromising his breathing, and although it cannot be discounted that he may have been developing mild NEC, that would not account for the sudden vomiting, desaturation and bradycardia from which he recovered.
The defence say that the possibility of developing NEC and the attribution of his collapse to an event unrelated to an act or acts of deliberate harm cannot be excluded.
Christopher Booth was Baby Q’s designated nurse for the long day shift of 23 June from 07.30 to 20.00, the day after he was born. Baby Q was on nasal CPAP, was coping well, self-ventilating in air, and he could confidently leave him off CPAP for a longer time. He obtained a lightly bile-stained aspirate at 09.00, as can be seen on the intensive care chart at page 3B in section 2 of your second jury bundle and so he, Christopher Booth, omitted enteral feeds. It was an unremarkable shift, he said, where Baby Q made good progress.
Tanya Downes, now a lecturer at Chester University, then a bank nurse working at the Countess of Chester, was the designated nurse for Baby Q for the night shift of the 23rd to the 24th. She remembered the shift as it was the night of the EU referendum.
Baby Q was self-ventilating in air. He’d passed meconium. As can be noted on the intensive care chart copied as sheet 3B in section 22 of your second jury bundle, she aspirated 2ml of bile or bloodstained aspirate at 21.30, which she described in evidence as a coffee ground aspirate and for which she sought a paediatrician’s review. She also noted that the stomach was not bloated and there were bowel sounds in all four quadrants.
At 23.30 she noted a new NG tube was inserted. She explained this involved removal of the old one and replacement. She was not asked about that but Dr Bohin said, as a matter of routine, any nurse would have checked for aspirates after insertion to make sure it was in the right place.
As noted on the fluid balance chart behind tile 61 — the paper copy is on page 10 in section 22 she aspirated 1.5ml of bile at 04.00. She had no concerns during the shift.
After Baby Q had been discharged from the hospital a month later, on 25 July 2016, she recalled him having to be readmitted to the out-of-hours clinic with gut problems. There had been a history of siblings, she said, having milk allergy problems.
Nurse D was Baby Q’s designated nurse for the day shift of 23 June. She noted that Baby Q appeared to have a cluster of a few bradycardias in the morning, but that seemed to be due to a loose ECG lead as once it was replaced there were no further episodes of bradycardia. His observations were stable.
Samantha O’Brien took over as Baby Q’s designated nurse for the night shift of the 24th to the 25th. Behind tile 70 is her nursing note made at 05.25 on the morning of the 25th. He was stable, self-ventilating in air, and didn’t have any increased work of breathing or respiratory distress.
There is a paper copy of the observations chart at page 2 in section 22. It’s J24307. Nothing untoward is recorded in relation to his cardiorespiratory observations.
Baby Q continued on trophic feeds of 0.5ml every [illegible] hours, which he was tolerating. The fluid balance sheets are J24330 and 001, behind tiles 61 and 62, with paper copies at pages 10 and 11 and in section 22.
There were intermittent moderate acidic aspirates, meaning the milk was partially digested at some feeds, which were returned, including a 3ml aspirate at 03.00 on the 25th. He was given nystatin, a standard precautionary medication against thrush given to babies of less than 32 weeks’ gestation; J24189.
The blood gas results behind tile 79 recorded at [illegible]:58 on 25 June were checked by the registrar on duty, Dr D, for review, because the pH had dropped a little bit compared to the previous blood gas, which was done the previous morning.
Samantha O’Brien noted in the nursing notes behind tile 86, towards the end of her shift, after Dr D’s review, that the current management of care was to continue. Her general impression of Baby Q’s state of health during the shift based on her documentation was that he was stable throughout the shift. She had not documented anything that would alarm her.
Dr D confirmed that the blood gas sample was a little more acidic but was within acceptable limits.
The defendant took over as Baby Q’s designated nurse for the day shift of 25 June. Baby P had died the previous day and Baby R had been moved from the Countess of Chester.
The defendant was informed that Baby Q had had large aspirates overnight, so she would not call him as being in good condition. Mary Griffith also had a baby in nursery 2, YM. Minna Lappalainen was the shift leader.
The defendant recorded Baby Q’s vital signs for [illegible].00 on the observation chart, which is behind tile 88.
Tiles 97 and 98 are the vital signs and fluid balance charts, duplicates of what appear behind tiles 61 and 62. The paper copies are pages 10 and 11 in section 22. There are gaps in the entries at 09.00
At about 09.10, Baby Q’s alarms sounded and he desaturated. Mary Griffith explained that before this happened, only her and the defendant had been working in nursery 2. She had been doing cares for YM prior to feeding him, with her back to the defendant when the defendant, who had been dealing with Baby Q, asked her if she, Mary Griffith, was staying in the nursery because she had to go into nursery 1 to see another baby. She was at that time also the designated nurse for baby BM in nursery 1, who was on hourly observations and there are entries on charts apparently initialled by the defendant for BM, J31674 and — I think that may be [illegible] and 674, but certainly 674, including one at 08.30.
It was normal practice to ask the remaining nurse in the room to keep an eye on another baby.
Shortly after the defendant had left the nursery and Mary Griffith was tube-feeding YM, Baby Q’s alarms went off. She looked over and saw his saturations had dropped. She could not abandon her baby mid-feed immediately and called for Minna Lappalainen, made her baby safe, and then went to Baby Q and sucked him out because he had vomited. She said Minna Lappalainen then started Neopuffing Baby Q.
Mary Griffiths plan of locations is J24077 and she said she was at point A, Baby Q at point B and Minna Lappalainen’s desk was at point C.
Minna Lappalainen remembered being called by Mary Griffith, who said there was an alarm going and Baby Q had been sick. She went to Baby Q immediately and could see he had been sick and there was mucus coming out of his mouth. She turned him on his side, made sure his airway was clear, and gave him oxygen.
Behind tile 101, J24314, the apnoea/brady/fit chart, was completed by Nurse Lappalainen. The paper copy is page 10 of section 22.
She recorded a brady of 98 and desaturation to 68 that lasted for 3 minutes intermittently. She wrote on that chart:
”Baby found to be very mucousy. Clear mucus from nasopharynx, oropharynx removed. Clear fluid ++. O2 via Neopuff given post-suctioning. Dr A was emergency called to attend. NGT used to aspirate stomach by Nurse L Letby.”
In evidence Minna Lappalainen confirmed that there was some — some fluid wa coming out of the nose and the fluid was clear. There was no milk or particles.
The defendant’s nursing note, which is behind tile 102, recorded that at 09.10 Baby Q had:
”Vomited clear fluid nasally from mouth, desaturation and bradycardia, mottled ++. Neopuff and suction applied. Dr A attended. Air ++ aspirated from NG tube.”
Nurse Lappalainen said she was not overly concerned.
In her first interview on 5 July 2018, the defendant remembered being Baby Q’s designated nurse. When she came on duty she recalled he had a low temperature and was tachycardic. He was handling well and well enough to be left in the care of another nurse. She returned to nursery 2 after 9.10 to see Baby Q being attended to as he had vomited, was mottled and desaturated. She thought that Nurse Lappalainen was giving him Neopuff and that Nurse Griffith and a doctor may have been there too. She didn’t think she had seen the vomit but she was told that he had vomited clear fluids.
Regarding the aspiration of air ++, she could not remember if that was something she or somebody else did. When asked about the air in Baby Q’s stomach, she suggested that babies sometimes gulp air when they vomit and she thought that an alternative for how air could get into a baby could be due to some sort of blockage in the bowel.
In the second interview on 12 June 2019, she recalled asking Mary Griffith to watch Baby Q in nursery 2 while she attended to another baby for whom she was caring in nursery 1. She accepted that Baby Q collapsed within minutes of her leaving nursery 2 and that he was stable when she left. She wouldn’t have left him had that not been the case. She denied deliberately leaving the room to blame the collapse on other staff and explained that the baby in nursery 1 was due cares. She denied administering air via Baby Q’s NGT or otherwise acting in any way to cause the collapse.
In the final interview on 11 November 2020, she denied giving Baby Q anything that would have caused him to be sick and she said that babies could deteriorate at any time.
In her evidence to you the defendant said she noticed Baby Q was on the cold side, so she decided she would prefer for a doctor to see him before she fed him at 09.00. She was concerned about his temperature and needing his incubator temperature to be increased and his blood gas had not been as good.
She arranged with both Mary Griffith and Minna Lappalainen that she was going into nursery 1, where she went shortly after 09.00 and where, at 09.04, she assisted Minna Lappalainen with medication for baby JA. She was in there for a few minutes.
She was asked about entries on Baby Q’s fluid chart, J24307, which is behind tile 97 at 09,00 when there should have been a two-hourly feed. Although fluids are recorded, the O2 and saturations are not recorded and the column has not been initialled. She couldn’t explain why she hadn’t filled them in. It had been a mistake, she said.
When interviewed, she said her memory had been that she was going back to BM in nursery 1 to do cares. It was pointed out to her that BM did not need cares. She couldn’t say for definite now what she was doing, but BM was an intensive care baby, so she wouldn’t have left her for too long a period without checking on her. She denied that she had just sabotaged Baby Q and was looking for a reason to get out of nursery 2 when Mary Griffith appeared back in the unit.
She could hear something going on outside nursery 1 and could see Minna and Mary Griffith in there with Baby Q. She was informed by Minna that he had vomited and it was very mucousy. He was still receiving a bit of pressure from Neopuffs. She didn’t help with steps to help Baby Q. She had no part in giving him oxygen via Neopuff after he had been suctioned.
In relation to her nursing note she had no recollections of aspiration via NGT and was told air++ was aspirated from the NG tube. She said this wasn’t a significant event and was something that they would deal with routinely. It needed intervention but it was certainly not on a scale of needing collapse and resuscitative measures. It wasn’t serious.
Dr A was called to the unit at 09.17 because of the vomit and then desaturation and minor bradycardia. In his note, which is behind tile 103, he wrote that as a result of the bagging, Baby Q’s oxygen saturations returned to 100%, but he continued to require PEEP to hold his lungs open at the end of positive-end expiratory pressure — I’m sorry, he required PEEP and because of that was moved to nursery 1 and then started on CPAP. As a precaution he was started on antibiotics.
Referring to his blood gas record, J24326, page 8, paper copy, section 22, his gas at 06.58 was a very acceptable gas.
The reading at 09.56, after the event, which Dr A thought was a venous and not a capillary gas, as recorded, was markedly different. The pH was lower, the carbon dioxide was higher, so this was a respiratory acidosis, he said. The base excess had increased to minus 6 fromminus 2.8 and the lactate had increased from 1.2 to 4.
Baby Q was given sodium chloride at 10.10. That reduced his heart rate. He continued on CPAP with 25% oxygen. He was presumed at that time to have sepsis. The biochemical results that came back showed that Baby Q was a little dry and that may well have been partly responsible for his increased heart rate in the range of 190 to 200, but it did not give any explanation for the vomit.
The blood gas readings at 11.12 will have been done within the unit and showed that his pH had normalised, his carbon dioxide had come down to an acceptable level, his bicarbonate had changed slightly, his base excess halved, and he was down to 21% in oxygen.His glucose was very slightly increased but his lactate had come down slightly and it was pretty much the same as it was at 06.58 that morning.
The chest X-ray and report that was taken, timestamped at 11.52, that is behind tile 135, showed mild interstitial shadowing with a trace of fluid in the horizontal fissure. There was no focal collapse or consolidation, no suggestion of a large amount of foreign matter in the lungs, nor does it suggest that he had a chest infection or one was evolving, so nothing showing any responsibility for his collapse.
Dr Gibbs in evidence confirmed that Baby Q’s sudden deterioration at 9.10 was not in keeping with a little baby who was getting tired with their lungs slowly closing down because they are stiff.
The plan was to increase fluids. At 19.10, Dr A noted the gases taken at 18.22, which do not appear on the blood gas record and will have been taken from the paper slip produced by machine, were acceptable, but he was retaining carbon dioxide and was starting to turn towards a more respiratory acidosis. He was looking tired whilst being on CPAP, so, having consulted with Dr Gibbs, it was decided to intubate him rather than wait. Baby Q was successfully intubated and placed on the ventilator. There was no sign of any infection taken at 20.25; that is behind tile 217.
Dr D, the registrar on duty that night, on the 25th/26th, examined Baby Q at 00.30. Her notes are behind tile 275. His gas was acceptable, he had no markers for sepsis, was very unsettled at times, but had no activities suspicious of seizures and his pulse was high, 194 beats per minute.
At 06.50 she was asked to see him because of his poor gas. The record is behind tile 109, paper copy at page 9 in section 22. The fifth entry includes a high PCO2 reading, which she considered was a respiratory acidosis, which she resolved by adjusting the ventilator settings.
Nurse Amy Davies remembered that he was a bit restless and unsettled at the beginning of the shift, the night shift that is, and she got a doctor to review him, but said he was stable throughout the remainder of that shift and gave no cause for concern.
Dr A returned to duty on the day shift of 26 June. Baby Q had dark green bile aspirates at [illegible]:00, no normal bowel sounds and small loops of bowel were palpable, which was unusual. An X-ray taken at [illegible].04 that morning, J24299, showed to the radiologist a single loop of mildly distended bowel on the left side of the abdomen. Dr A felt it was on the right side and arrangements were made for Baby Q to be transferred to Alder Hey and Baby Q left the unit at the Countess of Chester at 18.20 that day.
Dr Benjamin Lakin, a consultant in paediatric critical care, including paediatic intensive care, at Alder Hey Children’s Hospital stated in agreed evidence that, by reference to medical records, Baby Q was admitted to the paediatric intensive care unit for assessment because of concerns about his distended abdomen and deteriorating condition and the possibility of it being NEC.
The discharge letter from the Countess of Chester described the issue being a profuse vomit with desaturation. When assessed by Dr Holek, Baby Q was stable and did not require high levels of support on the ventilator or drugs such as inotropes to support his circulation and his abdomen was very slightly swollen.
These were all signs of a baby who was quite stable. Dr Lakin reviewed Baby Q on the evening of 26 June at [illegible].24 and found him to be stable. He was assessed by surgical colleagues at 21.40, who felt she was stable but with some subtle signs suggestive of NEC. He was next reviewed at 14.24 on the 27th, after he had successfully been taken off the ventilator. He remained stable, his abdomen had returned to normal and his abdominal x-ray had also normalised. The decision was made to transfer him back to the Countess of Chester, to complete a course of antibiotics, and restart feeds at the end of the treatment period. He remained stable and his bloods were acceptable.
Dr Stivaros, a specialist paediatric neuroradiologist, said that the images taen at that time could be explained by Baby Q having suffered a significant hypoxic ischaemic event at the time.
In terms of Baby Q’s subsequent health, his mother said he was in and out of the hospital many times, at least three times a year as an inpatient, with various infections, as he had a weakened immune system. He had some disabilities and, in August 2018, the paediatrician, Dr Howyada Isaac, in a witness statement dated April 2020, said his development was mildly delayed in August 2018.
He was, according to consultant paediatrician Katherine Davis, diagnosed with a mild right-sided weakness and developmental delay. He remains under her care and she would expect Baby Q to have a normal lifespan but it will be necessary to continue to monitor his development as he grows and to provide appropriate support as needed.
Professor Arthurs examined a number of radiographs of Baby Q’s chest and/or abdomen. Two relevant ones were taken at the Countess of Chester on 26 June, the day after the collapse and before his transfer to Alder Hey. One was stamped as having been taken at [illegible].05, which Dr A thought had been taken 12 hours later at 17.05, and that’s the time I put in the narrative when I was relating to you the narrative about that. The other was taken at 11.58.
In the first, that’s the one date stamped as being at 05.05, there was a single loop of dilated bowel on the right side, which was slightly abnormal and another area on the left side, which could be pneumatosis, which is gas within the bowel, which had gone up into the bowel wall. Both were the sort of mild features that radiologically could be early signs of NEC but they were not diagnostic of it and had to be correlated with his behaviour and clinical signs.
If the first image was taken at 05.05 and not 17.05 then the image at 11.58 showed an improvement. If the first image in time was the one taken at 11.58, which is a known time and an undisputed time and the other one was taken at 17.05 and not 05.05 then radiologically there was a deterioration. However, when Baby Q was X-rayed again at Alder Hey at 20.22 that evening, things were settling and, of course, clinically he was settled and improved.
Whether Baby Q had NEC and, more specifically, whether NEC was relevant to the event at around 09.10 on the morning of the 25th was considered by both Dr Evans and Dr Bohin.
Baby Q’s was the 27th case that Dr Evans reviewed in 2017. He said that although there were markers relating to his gastrointestinal system that Baby Q was unwell, namely a bit of bile coming up and he wasn’t really tolerating his feeds, from 09.10 something totally different happened which could not be explained on the basis that he was sickening for some kind of gastrointestinal problem. He vomited clear fluids after being on virtually no oral feeds and the last entry of aspiration by the night staff showed nothing coming up in the tube. In addition to the vomiting, he also suffered a very significant deterioration, his heart rate falling below 100 and his oxygen saturation dropping to 68.
It was not clear how to put it all together. He vomited, he was resuscitated very promptly, his oxygenation returned to normal. The suspicion regarding NEC was perfectly reasonable, as was keeping him off oral feeds and putting him on antibiotics used in cases of NEC and putting him on CPAP, as was later ventilating him and then, in due course, transferring him to Alder Hey.
Dr Evans deduced that Baby Q could not have vomited clear fluid or vomited anything at all unless quite a significant amount of some clear fluid had been placed down his NGT earlier before 09.10, with or without some air as well, to make him vomit and he would not have deteriorated in dropping his oxygen saturation and his heart rate unless his diaphragm had been interfered with. In other words, he was unable to breathe properly because his tummy was full of liquid and that is what led to the oxygen desaturation and to the reduction in heart rate. Once he had vomited, which was nature’s way of unsplinting his diaphragm and making it easier for the resuscitation to be successful, he recovered.
In relation to the air ++ or +++, the earlier Neopuffing could be one of the explanations, although there was very little Neopuffing taking place, or as well as having some clear fluid put down his NG tube, he could have had some air inflated into the stomach as well. Air and liquid, as a matter of the combined volume, would add to the stomach distension and increase the risk of splinting the diaphragm. He said when babies vomit they do not swallow air.
In cross-examination he accepted that in his first report of 2017 he stated he believed that Baby Q was given a lot of air via his NG tube into his stomach and made no reference to fluid at all. In his second report, in 2018, he stated Baby Q’s deterioration during the early hours of the 25th was due to inappropriate care and believed he was given a lot of air via his NGT into his stomach. The aspiration of a lot of air ++ at 09.10 was noteworthy, that may have destabilised him.
It was put to Dr Evans that he had added fluid now to keep the allegation going rather than to simply reflect the facts. Dr Evans refuted that. He had stated in his report of 21 October 2021 that if Baby Q had vomited clear fluid he must have been given clear fluid orally,either inthe form of water or a clear solution, such as saline from an intravenous bag. In addition, he received a lot of air as well. It is most likely this was administered via the NG tube.He also said that the evidence he heard from people who were looking after him had been a great help in forming an opinion regarding the accuracy of what happened at 09.10 on that day.
Having seen an X-ray report from Professor Arthurs that there was an abnormality, which radiologically may be reflecting NEC, he thought that NEC could not be ruled out but its presence or otherwise did not explain the destabilisation and drop in his saturations or why he was vomiting clear fluids.
The fact that he settled so promptly at Alder Hey suggested that NEC was not a feature that caused his deterioration at 09.10 that morning. If he was sickening from NEC from late Friday/early Saturday morning he wouldn’t have settled as quickly. Once back at Chester on 28 June, they were able to introduce oral feeds and he did not have any further significant gastrointestinal problems until he was sent home on [illegible] July.
The other option is that his bowel problems post 09.10 could be the result of ileus, which is the intestines stopping working. Dr A said that on the morning of the 26th, the day after this incident, he was not hearing any bowel sounds. He was on ventilation and morpine, which can cause constipation and can interfere with bowel activity.
Dr Bohin commented on the clinical and nursing notes, including the defendant’s description of the 09.10 incident, the start of trophic feeds the previous day and the aspirates, observing that the aspirates were not excessive or uncommon for babies having feed intolerance, which she thought Baby Q probably had, and thought at this time his abdomen was soft.
She noted the two-hourly fluid entries — J24431, behind tile 62, which is page 11 in section 22 — which the defendant had appeared to initial the 08.00 entries. No feeds were recorded for 09.00 when they were due.
On the accounts of the witnesses, Dr Bohin did not know where the +++ of clear fluid came from. Baby Q not having received any feeds since 07.00 (?) and then only a tiny amount of milk. In relation to air, Nurse Lappalainen’s Neopuffing was intermittent for [illegible] minutes, which was, in Dr Bohin’s opinion, unlikely to have caused air ++.
She also noted the observation chart at J24307, which is page 22, showed an escalation of the heart rate and a commensurate rise in respiratory effort prior to [illegible] o’clock, which was an acute event occurring over minutes and within the previous hour and was not something that happened over previous hours before that or days. She therefore concluded that Baby Q had been given air down his NG tube, which had caused him to become distressed and caused the increase in heart rate and respiratory rate and distended his abdomen so much that effectively the diaphragm squashed the lungs, which caused him then to decompensate and become mottled and desaturate and required resuscitation. The collapse was not consistent with anything that could reasonably be explained by some naturally occurring illness or condition.
In cross-examination, she agreed that if there was mucus +++ and if it had to be removed by suction or by pulling it out, it could actually interfere with breathing. However, she said that Baby Q was on a ventilator and babies on ventilators often create mucus and he’d never had a problem with mucus up until that point, so she didn’t know why he would suddenly then produce mucus +++ that caused him to become mottled and desaturate in the way that he did.
She entirely refuted the suggestion that in the process of vomiting, or maybe immediately afterwards, a baby may suck in a lot of air and that could introduce more air into the baby, saying that was breathing and they wouldn’t ingest any more air than through natural respiration. After a vomit, she said, you carry on breathing normally and she didn’t think you would ingest more air by breathing normally.
In relation to the ingestion of air via the Neopuffing, she said that this was after the collapse and intermittent for 3 minutes and wouldn’t account for the air ++.
She accepted there were aspirates and a problem — that aspirates can be an early indicator of NEC, but it was also consistent with other things such as ileus. She also said that temperature instability is not diagnostic of NEC, it can be artefactual or environmental. You can get it with infection but it does not give you the diagnosis of NEC.
In her opinion, Baby Q got better too quickly for it to be mild NEC. Children that have mild NEC are treated with gut rest, so you don’t feed them, usually for around 10 days, and they are given three antibiotics empirically. You rest the gut for 10 days before slowly reintroducing foods. Baby Q had conservative treatment, but also recovered, got off the ventilator, didn’t have any more bilious aspirates, didn’t have any bloody aspirates, didn’t have any bloody stools. His gut was completely fine within 24 hours. That, for her, was not a baby that had mild NEC.
She thought he had an ileus because he’d been destabilised. He was on a very large dose of morphine, which could account for what was seen once he was ventilated.
The Alder Hey surgeons sent him back to Chester because he didn’t have NEC. Baby Q wa returned on [illegible] June, as I’ve already told you. The defendant was his designated nurse the following day, the 29th, and on the 30th.
Messages passed between the defendant and Dr A and other nurses, particularly from tile 239 onwards when she was enquiring of Dr A about what Dr Gibbs was asking in relation to Baby Q being left unattended.
There is a sequence of messages in the post-indictment messaging sequence, including ones in which Dr A reassured her that the review found they, that’s him and the defendant, both did everything well and had done a perfect job in response to her expressions of self-doubt in her abilities.
There was a reference to infection risk and the risk of air embolus and her reaction to being taken off nursing duties.
After the defendant was taken off nursing duties, she registered a grievance with the trust on [illegible] September. She said she didn’t know what to do. She was precluded from contact with all but a few work colleagues and the events were having a massive impact on all her life. It was emotionally difficult and she felt very lonely.
When asked about a note on an annual leave request form, page 48 of the images, which was found in a desk at Mostyn Lodge where she had been working up to her arrest, she coulldn’t remember when she wrote it. It was not all at the same time. It was what she did, she said, she writes down lots of things.
The names on that note were people who were important to her at the time. She was fighting for her career and wanted someone to help her. She couldn’t cope with it. She only ever did her best.
I’ve already referred you to the agreed facts of her arrest in July 2018, June 2019 and November 2020.
Searches of both her home in Chester and the home of her parents in Hereford were carried out in the early hours of July 28 (sic) and then further — there were further searches on the 10th to 11 June 2019 as detailed in section 6 of the agreed facts in your first jury bundle.
The details of the interviews conducted after her respective requests are set out in section 7 of the agreed facts.
In section 8 you have the index of the images within the search presentation, the presentation itself being in the additional documents section of the post-indictment sequence of events, the last sequence of events on your iPads. I’m not going to take you to it, you can remind yourselves of any images that you wish to in your retiring room.
There were various papers, all now collectively in the exhibit reference bag NAC2. You have images of the writing on them to which reference has been made. In particular, the “not good enough” note and phrases, “I killed them on purpose because I’m not good enough”, “I am a horrible evil person.”
The defence invite you to find that these were the writings of a hard-working, committed person, written for herself, who wanted to excel at the job that she was clearly very good at and was distraught at what was happening, being wrongly targeted and blamed, they submit, for a system that failed and the faults of others and for which she bore no responsibility.
The prosecution agree that they are the writings of a troubled person but they say they refer to certain babies and people and were being written by someone who was troubled by the terrible things that they had done and were being investigated and that she was in part confessing to what she had done.
There is also a 2016 diary with entries in April on the 8th and 9th relating to LD, long day, and “twins” and “resus” and on the 23rd and 24 June to LD and references to “J and E”, and on the 25th to M; the images are exhibit 12.
In an Ibiza bag underneath the bed in bedroom 2 were handover sheets for the period 23rd to 28 June 2016, some with handwriting on the back, which appear to refer to resuscitations, PMB4.
In a Morrisons bag there was documentation relating to “Twin 2 [L & M]”, that’s Baby M, and 31 nursing handover sheets that related to a total of 17 babies, 13 of which were for babies who are named in the indictment.
The four (sic) babies for whom there were no handover sheets were Baby A, Baby C, Baby D, the subject of counts 1, 3 and 4, who all died in June 2015.
The total number of handover sheets seized from both addresses was 257, of which 21 involved babies in the case, four in the Ibiza bag and 17 in the Morrisons bag.
The various documents seized in the searches were the subject of questions in the interviews, termed as overarching interviews. The last section is in your second jury bundle, the interview bundle.
The first and second interviews were on the 3rd and 4th July 2018. They were after she had been arrested for the first time. In relation to the note, NAC10, the sheet of paper filling both sides, which you’ll remember having seen, she said she wrote these things in July 2016 because everything got on top of her after she had been removed from the unit and she was going to have to redo her competencies and her practice might not be good enough. It made her feel guilty and really isolated and she was blaming herself.
She went to a GP and was given antidepressants. She wrote about killing herself because her practice hadn’t been good enough, but she never made any mistakes. She thought the police would be involved and she would lose her job, which she loved. She was panicking. She felt she was being victimised by the consultants, Ravi Jayaram and Stephen Brearey. She thought the nurses were a good nursing team. She thought she wrote these things down as a way of getting it on paper and it helped her process it a bit more.
Despite what she had written, she had not killed them on purpose. She felt if her practice had not been right then she had killed them and that was why she wasn’t good enough. She was very career focused. She wrote, “The world is better off without me”, because she had disappointed people. She wrote, “I am evil, I did this”, because that was how it had all made her feel at the time.
That year had been difficult because they were seeing more babies with complex needs, chest drains, stomas, and quite a few extremely premature babies with congenital abnormalities, a lot of twins and then triplets. She thought staffing levels were quite poor at times, with an inadequate skill mix sometimes.
She was doing a lot of additional shifts and overtime and didn’t think a lot of support was being offered. She said she didn’t have any paperwork or medical records relating to any of the allegations for which she had been arrested at home, but might have inadvertently taen some handover sheets home.
She was interviewed again 11 months later on [illegible] June 2019. She said handover sheets should ideally be placed in the confidential waste bin. The handover sheets that were found at her home had inadvertently been taken home in a pocket. She didn’t keep them for any specific reason. They were kept in a folder in a spare room because she didn’t know how to dispose of them.
Sorry, there may be a technological problem. I’ll just have to pause there.
(Pause)
I’m sorry, there will now be a short break in my summing-up because it’s going to need investigating, but I have very nearly finished. So would you please just go into your room and you’ll be brought back in when you’re ready.
(11.28 am)
(A short break)
(11.34 am)
Mr Justice Goss: The issue is resolved. What I’ll do is I’ll just go back a few senttences and resume from the interviews that took place on 10 June 2019, a year after the first set of interviews.
She said handover sheets should ideally be put in the confidential waste bin. The handover sheets found at her home had been inadvertently taken home in a pocket. She didn’tkeep them for any specific reason. They were kept in a folder in the spare room because she didn’t know how to dispose of them. She hardly ever looked at them. She hadn’t got a shredder.
In her evidence she did confirm that she had a shredder which she had bought between 5 April 2016 and her first arrest in 2018, which was shortly before she was first interviewed. She only shredded bank statements, she said. The handover sheets and notes were insignificant and she had forgotten she had a shredder when she was interviewed. It was an insignificant item.
When asked about Baby M’s blood gas records, exhibits 7 and 8 in the case, which was found in the Morrisons bag, she said it was one of many she took home. It was an error onher part that it wasn’t shredded. It was an error on her part that it wasn’t shredded. She accumulated paper which she accepted she moved around with her. The sheets had no meaning at all to her, they were just pieces of paper she had difficulty in throwing away.
In the 2019 interviews she referred to her support network of colleagues who I identified earlier in this summing-up last week: Dr A, Nurse E, Nurse A, and Minna Lappalainen.
She confirmed her status as a band 5 nurse, her experience, and having started onthe unit in January 2012, and the courses she had completed including being trained to give babies medication via a long line, Broviac line and umbilical venous catheter, UVC, for the safe administration of boluses.
She didn’t recall any specific training about insulin. She said she learned through experience. She had not had training about air embolisms and was not really aware of them and had heard of them more from an adult perspective. She could not think of special training in any dangers if things were done incorrectly apart from being mindful not to leave a line open.
In the final interview she was asked about her personal diaries. She made reference to the collapses of babies in the diaries because it was a way of thinking things through in her own time, expressing thoughts on paper. She thought she started documenting names after concerns had been raised in February 2016 that there had been a rise in the mortality rate. She was asked about the note in the diary KL4, in which she had written “Kill me”. She wrote that because sometimes she wished she was dead. She had lost everything, wasn’t workingon the unit, and hated working in the office.
In her evidence she said that on 26 June 2016 she liked all the doctors at the hospital. She was worried that she was in trouble because she had made a mistake in relation to Baby ! and was very upset and worried but didn’t realise that there were serious concerns about her.
The contents of some of the emails were pointed out to her and she accepted that she was having “a meltdown ++”.
She referred to the note behind tile 107 in the post-indictment sequence of events, an SMS timed at 27 June 2016, with no named recipient. The note reads, “Death x2”. She said there were things she needed to document for babies that she had been caring for when she next went back to work, that she hadn’t documented so far.
In messages to Nurse E she referred to the risk of air embolus and thankfully her submitting a Datix report. That report related to baby JA and was made on 1 July 2016. She wrote:
”Upon administering IV medication via UVC, the port on one of the lumens was noted to not have a bung on the end and was therefore open. Registrar informed. Lumen not accessed. Bung added and line labelled `not to be used’.”
She denied that she was covering for herself for any suggestion of accidental air embolus and said it was simply what she found and felt it needed to be documented. She also referred to tiles 234 and 239 and denied she was getting her defence in with her friends.
She was asked about the conspiracy by the four consultants who she believed had apportioned blame on to her to cover failings at the hospital and confirmed that she was not relying on individual failings because that was above her pay grade. Rather, she was asserting that the nursing staff acuity wasn’t quite right and she didn’t think that some of the babies had adequate care over a period of time and there was nothing she wished to add.
She was asked why on 25 June 2015, over 2 minutes from 21.50, she searched for [Mother of Babies A & B], then Mother D and Father D. She said the connection was that they were babies that had died or had been seriously unwell. She said that she searched for Mother I, then Father EF and then Mother H over 3 minutes from 01.16 on 5 October 2015 for the same reason and they were on her mind.
She didn’t say that to the police when she was interviewed because she couldn’t recall why she had looked at some of them. She denied that she was checking up on her victims. Baby I was still a patient at the hospital on 25 June, but they were on her mind.
In relation to her searches on Thursday, [illegible] November 2015 for [Mother of Babies E & F], Mother G at 23.41 and Mother I at 23.44, she denied having read Mother G’s name from one of the seven handover sheets with that name on it and said they were all on her mind at the time. All the parents of the babies for whom she had searched were on her mind. She often thought of [Mother of Babies E & F].
She was asked why, in the note purported to be written to the [OPR triplets], she wrote to all three of them. She said she couldn’t recall why she wrote to all three when Baby R was not dead.
I return to where I began and refer you to my legal directions 1, but I will not go through them again, and I’ve asked to you put them with the indictment for your assistance.
You have there set out in legal directions 1 what you must do and not do and what you have to reach conclusions upon, the importance of reaching decisions on all the evidence, and determining in relation to each alleged offence whether you are sure of the defendant’s guilt or not.
You also have my legal directions 2 in relation to the evidential matters, including the defendant’s character, inconsistencies between her evidence and her defence statement, inconsistencies in the evidence of any witness, the effect of delay and expert evidence.
You have to consider the evidence relating to the collapse of each child, their condition in the period leading up to the events, the nature of the collapse, its features and consequences as described by witnesses, as well as what the defendant has said and done, be it in messaging or in person, before, during and after any event, including her enthusiasm to be in nursery 1, the taking and retention of hospital documents, and Facebook searches, and what she has said at various times of the investigation about what she has done. Where there are conflicts in versions of events, words or actions that you consider significant, you have to decide whether resolution of those conflicts assists you in reaching conclusions in relation to the offence under consideration and, if they do, where that leads you.
If you are sure that two of the babies, Baby F and Baby L, had Actrapid, manufactured insulin, inserted into the infusion bags that were set up for them 8 months apart in August 2015 and April 2016 respectively, and you are sure that was done deliberately, you then have to consider whether that may have been a coincidence, two different people independently acting in that way or were they the acts of one person and, if so, who.
You have to be sure that the child whose case you are considering was a victim of an intentional harmful act or acts of the defendant and, if it was, what her intention was at the time. She, of course, denies she ever did anything wrong.
Although you have to decide on the evidence in each child’s case, there were certain common features, as listed by Mr Johnson. This is the part of my first legal direction relating to circumstantial evidence and coincidence.
The defendant was on duty on every occasion an event occurred. There were ten babies hwo collapsed that had good air entry into their lungs but their saturations were dropping. Mr Johnson gave you the lists and invited you to write them down.
Five of the babies, if you accept the evidence of [Mother of Babies E & F], had unusual bleeding, some in their throats, which was seen by medical staff.
Eight of the babies demonstrated discolouration, which was seen by doctors in more than one baby and unique in all their experience. The defendant said that in many of the cases she either did not see the discolouration or there was no discolouration to be seen.
Eight babies suffered unexpected life-threatening collapses and then recovered very quickly, which was very unusual and could not be explained in medical terms.
Another feature common to events concerning five babies is that they occurred within a few minutes of their designated nurse going on a break or leaving the room.
In Baby P’s third event the defendant who was his designated nurse was in the room, but the doctors were out of the room.
As I have just reminded you, when Baby Q collapsed, the defendant had just gone to another nursery.
Four of the premature babies were heard to be screaming or crying uncharacteristically at the time of their collapse.
In the cases of two babies another nurse was worried about them, but the defendant reassured them just before they fatally collapsed.
There were seven babies who collapsed shortly after their parents had left the nursery.
Four babies recovered quickly from collapses when they were taken to other hospitals.
There were three cases where it is alleged the defendant participated inappropriately in post-death bereavement procedures.
There was one baby, Baby O, who sustained an impact injury to his liver that, on the pathological evidence, was a consequence of the application of considerable force.
The prosecution say that this is not a series of unconnected events and, when put in the context of the expert and medical evidence, the administration of insulin and the finding of air in the great vessels in some babies and the post-mortem evidence of Dr Marnerides and all the other evidence, you can be sure that the defendant committed all the offences upon which you are trying her.
The defendant denies she committed any harmful act. She was, I repeat, hard-working, dedicated and caring. She never falsified records and there is evidence of which you were reminded of other nurses failing to complete some entries on charts. Anyone can make mistakes or fail.
Her keeping of confidential documents had no sinister purpose, nor did her searches on Facebook, which she ultimately said in evidence she only made because she was thinking of the families at those times. Her handwritten notes were something she did as a habit and were a product of despair.
The defence say you cannot be sure that in any case she murdered a baby who died or that she attempted to murder any baby who survived. Some of those babies were very premature and at high risk of sudden collapse. The evidence upon which the experts rely in relation to air embolus, they say, is based on theories and not well-established medical knowledge. There have been inconsistencies in accounts and, it is submitted, the experts have lacked independence and reliability.
Well, that is no more than the barest summary of the respective arguments, which, as you know, took 4 or [illegible] days in each — as far as each side was concerned to pu tthose arguments before you.
Shortly, it will be for you, on all the evidence that you have heard, to perform your task of reaching verdicts on the 22 alleged offences charged on each indictment.
So I come back to where I started this morning, the labels that you have. This is, I’m afraid, a rather tedious administrative job you’re going to have to do. Would you please put the labels on each of your files that you have, your notebook and any loose papers? They will then, for each of you individually, be placed in large confidential bags and, during a break that we’re going to have now of about 20 minutes, they will be taken to your room.
When you return to court, I will have a few more things to say, but very few. The ushers will then be sworn to act as your bailiffs and you will begin your deliberations. So please just stick labels on the documents.
You may wonder why you have to do this and other people can’t do it. It’s because these are your confidential documents. They will be destroyed at the conclusion of the case.
(Pause)
Put them on the schedules you’ve just been given this morning as well. It’s just for the avoidance of any doubt or difficulty. As I say, what will happen is you just leave them all piled up on your respective desks. Each of your documents will be put into an individual bag, individual to each of you, and will then be taken the jury room and placed there in the retiring room, where you can open the bag, the bag will be sealed.
(Pause)
I’m going to say a few more things about the tablets and what’s going to be available to you in your deliberating room. What I’m going to do now is — because once I do send you out to begin your deliberations there are strict procedures that have to be followed, I’m going to just, as I say, say but a few words, but they are important words, that I want you to have in mind when you do go out to start your deliberations.
We’re going to have a twenty-minute break to enable all these to be collected up, transferred and so on, and it’ll be a sufficient time for you to be taken from the room behind here and to have some refreshment before you come back in, in about 20 minutes, if you so wish, and obviously a comfort break if you want it. There are facilities as part of your retirement room for comfort breaks during the course of the day.
Have you all finished? That was very quick and efficient, if I may say so. I’m going to ask you now to leave the courtroom, it’ll be a twenty-minute break, have some refreshment if you want it, and then return. Everything will have been removed from your desks by then.
(In the absence of the jury)
Mr Justice Goss: It will be about 20 minutes. Would it be possible for the defendant to remain there or will you take her downstairs? You can stay up here, can’t you? All right. We’ll let you know when the court is ready to continue. Thank you very much indeed.
Are there any matters that anyone wishes to raise?
NJ: No, thank you.
BM: There’s one matter, but perhaps I can inform your Lordship in the way that we have done and we can raise it with your Lordship if appropriate, but at least it gives your Lordship to consider it. It’s a matter entirely for your Lordship.
Mr Justice Goss: Thank you, that’s very helpful. I entirely agree, that’s the best ay of dealing with it. I’ll address it when the moving of the jury’s documents has been completed.
BM: If your Lordship sees fit. It’s entirely a matter for your Lordship. I’m going to send the matter through first before your Lordship says anything upon it.
Mr Justice Goss: That’s very helpful. Thank you very much indeed.
(11.57 am)
(A short break)
(12.46 pm)
Mr Justice Goss: Thank you, Mr Myers. Yes, I am going to say something straightaway in relation to the matters you raised.
BM: We’re grateful. Thank you, my Lord.
Mr Justice Goss: It won’t be in the format you’ve done it, but it’ll be done in an appropriate way, addressing what you said.
BM: Thank you.
Mr Justice Goss: Can I raise just one other matter before the jury come in? I don’t know whether you’ve seen the jury room AV instructions or not.
BM: No.
NJ: No.
Mr Justice Goss: This is a document that are the written instructions prepared by Mr Murphy about how to connect the iPad to the screen and then other instructions asking the jury to plug their iPads into charging boxes for overnight charging. You’re welcome to look at it, but it is as neutral as that.
BM: We accept that, of course, my Lord.
Mr Justice Goss: Thank you very much.
BM: Just for your Lordship’s information, it was apparent, almost inevitably, there are two items that we will need to add to the exhibits. It doesn’t prevent matters from proceeding now. That’s in hand.One is photographs of a house, the other is related to social media material. They will be added to the bundles and it just requires two additions to the exhibit list the jury have, which they will receive fairly shortly. But it was apparent they were absnet and therefore it’s important to rectify that as soon as possible.
Mr Justice Goss: Of course. If you’re content for the jury to —
BM: Yes.
Mr Justice Goss: There is one other thing in relation to sitting days from now on.
(Pause)
BM: My Lord, Mr Johnson reminds me it may be helpful for me to let the jury know that they will be receiving these so they’re formally exhibited as part of the process that began this morning so they have it before they retire. I’ll simply say it in the most neutral fashion.
Mr Justice Goss: You do it the way that Mr Johnson did just so they are not taken by surprise when two more documents arrive.
BM: I’ll let them know, thank you, my Lord.
Mr Justice Goss: All right, an addition to the list.
BM: An addition to the list.
Mr Justice Goss: Jury in, please. Thank you.
(In the presence of the jury)
Mr Justice Goss: I’m sorry that was longer than anticipated. It was actually a bigger job doing everything than had been anticipated.
I’ve been asked to remind you, and do remind you, that in relation to the list to which the prosecution referred ad that I summarised shortly before we broke off, the defence submitted that they were not similar, the events, in that the features differed in relation to at least some of the descriptions and that they did not establish the patterns the prosecution said they did, and that you have to consider whether the factual basis for any event relating to any baby on any given list had been established in evidence to the necessary standard before you could rely on it as an event. All right? So I do that.
Mr Myers has got one — there is no criticism of anyone involved in relation to this as you’ll appreciate there is a vast amount of material in this case. There are going to be two items that will need to be added to an exhibit list. Mr Myers will just explain this. It’s not going to stop us from proceeding but he will just explain.
BM: Thank you, my Lord.
Yes, in addition to the list that you have, ladies and gentlemen, there will be two further exhibits to be added to it that we’ve had in evidence, but it’s important that I identify them so you have all of that before you retire. You’ll remember what they are.
The first one is photographs of Ms Letby’s house that were introduced when she gave evidence, so that will be added to the material that you have and on the list.
The second item is that schedule of social media material, you will remember, that came in towards the end of the evidence and she was asked questions about that by the prosecution and by the defence.
They will be added to the list, my Lord, and the jury will have those shortly.
Mr Justice Goss: In the list form, not the —
BM: They’ll have access to the exhibits and they’ll also have them on the lists too (overspeaking) —
Mr Justice Goss: You’ll have them on the list and they’ll be on the iPads —
BM: Yes.
Mr Justice Goss: — so you then have the reference to be able to locate them on the iPads if you want to, the pictures of the house for argument’s sake. I’m just saying that. All right.
When you do go to your deliberating room in a moment, Mr Murphy will be able to assist you at any time if any technology problems arise. But he’s already linked an iPad to a large screen in the room so that if you wish to put up a document on a large screen that you can all be looking at at the same time for group reference or discussion, that can be done. It’ll obviously be much easier saying, “Let’s all look at document behind tile so-and-so”, if it goes up on the screen and you can all see what it is, and that will make life easier, we hope, in relation to this.
There will be spare iPads in the room if you need any. If the iPad that you’re using malfunctions and you want a replacement, it’ll be there. All you do is log in with your own personal details and you’ll have another iPad that you can use.
If you do need any technical assistance then please tell the jury bailiff. There will always be a jury bailiff outside your room and he or she will then accompany Mr Murphy into the room, who will come in, deal with the technology issue that has arisen, and the usher will stay with you whilst Mr Murphy is there. You must not discuss anything about the case whilst they are in the room. Your deliberations are confidential to you and, as you know, there is a lifetime confidentiality in relation to your deliberations, no disclosure to anyone. I shall remind you of that at the very end of the case in any event.
If you have any questions that require you to be brought back into court, you do not need to bring your iPads with you. It’s only when all 12 of you and no one else is present that you should discuss anything about the case.
How you conduct your deliberations is entirely a matter for you. You should, of course, respect each other’s opinions and value any different viewpoints that you bring to the case. Everyone should have a chance to speak. You should listen to one another and no one should be or feel pressured.
You are under no pressure of time. At the end of the court day, which will be at 4 o’clock each day, you will be brought back into court and, after giving you a short further direction, you will be sent home and you will then resume your deliberations on the next working day at 10.30. So that will be the court days hereafter.
When you are not deliberating, your retiring room will be locked and no one will be able to enter it, so it will be exactly as you leave it when you resume the next day and no one will see anything that’s there, any notes that you make or anything that is written there.
Do not under any circumstance make your own enquiries about anything to do with the case or talk or communicate with anyone in any way — and that is even with each other now — except when you are all together in the room in which you are deliberating as a group of [illegible] and after you have been brought back into court and I have sent you out to deliberate on your verdicts again. Do you understand that?
So even when you’re waiting to come into court, assembling in the morning and youall happen to be together, don’t say anything about the case itself.
When you leave court at the end of a court day, end of discussion about the case completely, no reference to anything to do with the case.
All 12 of you must hear what is said by any one of you at any time about the evidence in the case and your decisions in relation to the case.
I remind you of your legal responsibilities as a juror that you received on the first day of trial and which I have repeated to you ad nauseam, I appreciate, during the course of the trial. But you will appreciate the significance of it and the seriousness of this case.
Smoke breaks. You will be able to have five-minute smoke breaks, one mid-morning and one mid-afternoon. One of the jury bailiffs will escort those wanting to smoke to an appropriate area, and if there’s anyone who doesn’t want to smoke and wants to go out and be with the smokers, they can if they so wish. Another bailiff will remain in the retiring room with those who do not wish to smoke or go out with the smokers. When separated, it follows from what I just said, be you a smoker or remaining in your room, you must not discuss anything about the case. When you do want a smoke break, just write it on a note, then knock on your door and give it to the jury bailiff and then the smoke break will take place. All right? One morning, one in the afternoon, of your choosing so far as the time is concerned.
It may be helpful, if you have not already done so, to select a foreman — that person can, of course, be a man or a woman — who can organise and lead your discussions, ensuring that they are focused on the evidence and the law and that everyone has a fair opportunity to express their opinions at any time.
The foreman will also inform the court when you have reached your verdicts and deliver them on your behalf when you are brought into court for that purpose. You can, if you so wish, agree to select a different man or woman to be your foreman at any time before the verdicts are delivered. It doesn’t have to be the same person for the whole period of your deliberations.What you do and the decisions you make in your deliberating room are entirely for you.
If you do need assistance then write your question or the assistance you require down ona piece of paper and ask the jury bailiff to give it to me. Do not talk to the bailiff about your question or anything to do with the case. That again follows from what I’ve said about not talking to anyone about the case.
If, after you have been deliberating for a considerable time, you are unable to reach unanimous verdicts, I shall call you back into court and give you further directions, but, as you know, from my directions of law, your verdicts should be unanimous verdicts on each count of the indictment.
You have my written directions and you should follow them. Although it is a matter for you, you might find it helpful to begin by reminding yourselves of my first set of written legal directions and applying the sequential questions as a template to guide your discussions on the evidence and your conclusions of fact. You may want to select someone to write down key points or conclusions that you reach. It’s entirely a matter for you how you want to conduct your discussions.
If anyone is not following the legal instructions or refuses to deliberate, I’m not suggesting anything like this will happen but if this were to happen, or relies on other information outside of the evidence so that juror is not acting in accordance with their jury oath or affirmation to try the case on the evidence, the court must be told straightaway. A note should be written, handed to the jury bailiff and brought in to me. That’s an exceptional eventuality, but that’s the procedure to follow should that highly unlikely event occur.
When you reach your verdicts on all counts on the indictment, your foreman should inform the jury bailiff and you will be called back into court. The clerk of the court will then ask your foreman to stand and he or she will then be asked on each count whether you have reached a verdict and then whether you find the defendant guilty or not guilty. That’s just the procedure that’s followed so that you know what will happen. It’s relatively straightforward in prcedural terms in this case because the charges are clear, what has to be proved, and there are no alternative verdicts or anything like that. All right?
Thank you very much. That completes my direction to you. I’m going to ask you now to retire and commence your deliberations. Obviously, it is the normal break time for refreshment. You have, I believe, brought some refreshment with you. That will be available there for you and then I will next see you, I anticipate, at [illegible] o’clock. All right? Thank you very much.
When the ushers have been sworn to act as your jury bailiffs, would you please go to your retiring room and commence your deliberations?
(Jury bailiffs sworn)
By way of assistance to all concerned, the pattern will be, assuming that the jury take more than today to reach verdicts in this case, on succeeding days and today the court will not sit between 1 and 2 o’clock. There will be no need for the defendant to be brought up for a 1 o’clock adjournment. The court will simply be sitting. You will be informed when the defendant is to be brought up on each occasion apart from the start of the court day. Thank you very much.
(Jury in retirement)
(1.04 pm)
(Adjournment)
(4.00 pm)
(In the presence of the jury)
Mr Justice Goss: As I said I would, I bring your deliberations for today to an end now and in a moment you’ll be able to leave this courtroom and building and go home and be ready, please, to continue at 10.30 tomorrow morning. In the meantime, as I directed you earlier to day, do not talk to anyone, including each other, about anything to do with this case until you have come back into court at 10.30 and been taken from here back to your retiring room and continue your deliberations as a jury of 12 people all together in your jury retiring room. All right? Thank you very much indeed.
I discharge the ushers from their oaths to keep you in a retiring room and you are free to leave this courtroom and I’ll see you at 10.30 tomorrow morning. Thank you very much.
(In the absence of the jury)
Mr Justice Goss: Mr Johnson, Mr Myers, I formally put on the record something that did happen this afternoon, which was that Mr Murphy’s assistance was required because there were two documents, I think it was, that were not behind the tiles that they should have been. They had been part of the presentation, but they were not available on the iPads that were available to the jury, something that I actually have encountered during the course of this trial, that for some reason they didn’t get uploaded. So I gave permission to Mr Murphy to upload those documents for the jury’s benefit and that has been done. I take it, Mr Murphy, that has been done or is being done?
Mr Murphy: It’s in progress, my Lord.
Mr Justice Goss: It’s in progress, all right. But they are documents that are in evidence.
BM: Of course.
Mr Justice Goss: There’s nothing untoward about it, but I didn’t want to waste time and let Mr Murphy get on with dealing with that.
BM: Thank you, my Lord.
Mr Justice Goss: Thank you very much. There’s nothing else?
BM: No. I know that Ms Santolini would be due to see the defendant if she could remain downstairs after the court rises.
Mr Justice Goss: Certainly. Does anyone else want to see her?
BM: That may happen, but certainly there will be a visit from someone.
Mr Justice Goss: These are different staff who haven’t been here. Ms Santolini, who is a nurse, will see the defendant at some time before she is taken from this building, please. She knows, I take it, that the court is rising now?
BM: Yes.
Mr Justice Goss: So she should make her way there as soon as possible.
BM: Thank you, my Lord.
Mr Justice Goss: Thank you very much.
(4.05 pm)
(The court adjourned until 10.30 am on Tuesday, 11 July 2023)