The U.S Marine Corp has a name for it.

Jamie Egan

12 min read

clusterfuck (n.)

"bungled or confused undertaking," 1969, U.S. military slang, from cluster + fuck, probably in the "bungle" sense.

Dr James Smith

The next witness to give evidence in court is Dr James Smith, employed at the Countess of Chester Hospital as a specialist registrar in February 2016. Dr Smith recalls having a memory of Baby K and being notified there would be a delivery of a '25-weeker' baby.

This means that he likely found out about an hour before it happened.

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

No, they're not. An Apgar score of less than five at any time is not good.

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

Apgar scores are the sum of three objective observations assigned to five categories. The score is calculated as follows:

Breathing Effort: If the baby is not breathing, the respiratory score is 0. If respirations are slow and irregular, weak or gasping, the respiratory score is 1. If the infant is crying vigorously, the respiratory score is 2.

Baby K score 0

Heart Rate

Note that heart rate is evaluated with a stethoscope, and it is the most critical part of the score in determining the need for resuscitation. If there is no heartbeat, the heart rate score is 0. If the heart rate is less than 100 beats per minute, the heart rate score is 1. If the heart rate is more than 100 beats per minute, the heart rate score is 2.

Baby K score 1

Muscle Tone: If the infant's muscle tone is loose and floppy without activity, the score for muscle tone is 0. If the infant demonstrates some tone and flexion, the score for muscle tone is 1. The score is two if the infant is in active motion with a flexed muscle tone that resists extension.

Baby K score 0

Grimace Response or Reflex Irritability in Response to Stimulation: If the infant does not respond to stimulation, the reflex irritability response score is 0. If grimacing occurs in response to stimulation, the reflex irritability response score is 1. If the infant cries, coughs, or sneezes on stimulation, the reflex irritability response is 2.

Baby K score 0

Colour: If the infant is pale or blue, the score for colour is 0. If the infant is pink, but the extremities are blue, the score for colour is 1. If the infant is entirely pink, the score for colour is 2Baby K score 0

Baby K had an Apgar score of 1 at one minute, God knows what at five minutes, and it would be another CoGH miracle if it were nine at 10 minutes.

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

Which is why the baby should have been born anywhere other than the CoGH.

In this scenario, Dr Smith describes the procedures he would have taken to stabilise a baby, such as Baby K. He says Baby K's heart rate improved to 100 bpm within two and a half minutes, and she was making respiratory gasps.

The gasps were so influential that:

The decision to intubate is then made. He tells the court that the intubation is "technically difficult" due to the baby's size and can take multiple attempts.

He says Baby K was stabilised after each attempt, and he had no worries about doing the procedure himself without needing to hand it over to the consultant, Dr Ravi Jayaram. He intubated Baby K on the third attempt with a size 2.0 tube. He tells the court if he had seen any signs of trauma, such as bleeding, on Baby K at the time of intubation, he would have passed the procedure on. To the best of his recollection, he did not see any signs of trauma. He tells the court there is nothing in the notes of any sign of trauma at this point.

Seriously? How stupid do these people think we are? There is an opaque plastic tube in the baby's trachea; how can he know what's happening beneath it? The general clinical picture was that Baby K's signs were 'good', the resuscitation 'had gone successfully', and the first blood gas record was 'good—reasonable for the first reading'.

Baby K was like all the other babies in this series. He was intubated at birth on the third attempt. But excellent and stable. A "reasonable" but "good" blood gas. He tells the court that antibiotics would be administered for all babies of this prematurity. Dr Smith tells the court he would have been, to an extent, guided by advice from Arrowe Park Hospital in treating a baby of this prematurity at the Countess of Chester Hospital. Dr Smith says he would not have played any part in connecting Baby K to the ventilator at the neonatal unit following transfer and would not have had any knowledge of how to do so, as nurses would carry out that connection. Dr Smith says he remembers coming back into the neonatal unit early on February 17, probably for labelling blood bottles. He does not recall where the nurses were, but he recalls Dr. Ravi Jayaram giving Baby K breaths via the Neopuff, which was already underway.

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

What further measures?

The explanation for a "sudden deterioration" was either the breathing tube being dislodged or blocked. The "correct decision" was for the tube to be removed. Baby K received breathing mask support without a tube. As his oxygen saturation levels improved, he was reintubated. A morphine bolus was administered to help the reintubation process. Dr Smith says he did not see any evidence of trauma, and if there were anything obvious to show that, he would have informed Dr Ravi Jayaram, but he "did not see anything".

So Ravi, after administering a few puffs via a bag, handed the job of re-intubation back to the guy who can't connect a ventilator and who screwed up the first intubation. The prosecution asked if the Countess team followed the advice from Arrowe Park to take x-rays of Baby K to check for tube placement. Dr Smith confirmed they did, and a chest x-ray was carried out. The radiology report said that, from the X-ray, the ET tube and the NG tube were 'in satisfactory position' following the reintubation, while a UVC line required further adjustment. The radiology report also recorded a possible lung infection, which Dr Smith was expecting in Baby k's of Child K's gestational age.

The possible "lung infection is called pneumonia by old-fashioned doctors and is very often fatal.

Dr Smith re-examined Baby K at 6.15 am when it was noted that Baby K had lower saturations and a blood gas reading that was "not good" and "worse than the previous gas." The tube was 'pulled back' to improve the oxygen saturation levels, but the readings had 'not improved'.

So it was the tube, then it wasn't the tube. We put it in, took it out, and shaken it all about. If there was a central line, what was the NG tube for? Don't they know that NG tubes cause apnoea and desaturation?

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

Please put it in, take it out and shake it all about. Baby K had responded 'very quickly' to the 'bagging' support.

Why, then, do you still want to use a tube? Dr Smith says that from the notes, there is nothing to say the tube removed from Baby K was blocked, and his memory has nothing to add to that. A repeat X-ray reported: 'Satisfactory position of the ET tube. NG tube in situ...this would benefit from advancement by 5-10mm. UVC in satisfactory position.'

What X-ray is this? The tube is out now. A lung infection was still suspected for the left lung, which appeared increased in density - 'looking more white', and reduced in volume compared to the right lung. Baby K had pneumonia. If he didn't have it in the womb, he got it in the GoGH because he hasn't been anywhere else. Maybe she got it from all the f@@king about with tubes that never worked.

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

And so, after brutalising the baby, she goes to where it should have been at the start.

You can't make this shit up.

Cross-Examination

Benjamin Myers KC, in Lucy Letby's defence, is now asking questions about the events for Baby K. He says Baby K was born in extreme prematurity and asks if there would inevitably be problems with the baby girl's care, particularly about the lungs.

Dr Smith agrees. Dr Smith remembers being in the room when Baby K's resuscitation efforts were taking place, and they were going well. He says neonates with this gestation need a lot of support and resuscitation. He cites a study that found a 75% survival rate for babies of that gestation age.

Mr Myers suggests that the figure could be closer to 40-50% from another study. Dr Smith says he has cited the most recently available study. Mr Myers says a tertiary unit is the most suitable place for treating babies of Baby K's gestational age. Dr Smith says they are more experienced in tertiary units. Still, level 2 units (such as the Countess of Chester Hospital at this time) have the equipment and staff capable of treating babies of this gestational age for the short term.

So why, then, Dr. Smith, if the CoGH was so good, did you need to transfer the baby?

He says the correct thing to do is to contact the level 3 unit in advance to inquire if the transfer is possible before the birth.

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

Every doctor should be an expert on bruising; my granny was an expert. Dr Smith says level 2 centres do not look after babies of this prematurity long-term.

Or, in this case, short-term.

He says if mothers of 23-week gestational arrived at the hospital via ambulance, and delivery was imminent, that delivery would take place at the nearest hospital, with a set procedure in place to arrange transport to a tertiary centre when viable. Dr Smith recalls that it would have been better to write his independent notes in addition to Dr Ravi Jayaram's complete notes. He added that he wrote up the transfer letter listing the events and care for Baby K. Mr Myers asked why Dr Jayaram would write up those notes in the first place. Dr Smith says he would also have been on the paediatric unit on that night shift. He says the notes would be' completed' as long as a senior doctor has been involved in writing. He says that 'ideally', he would have written notes up himself, independently.

That is utter bollox. Javi, the jinx, wrote the notes to make it look like he'd done anything, but what did he do apart from a few bag puffs?

Mr Myers asks about the initial intubation process for Baby K. He asks if Dr Jayaram should be the one to do that process as the more senior doctor.

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

Which she wasn't.

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

Like the mouth, the pharynx, and the larynx? Mr Myers asks if it's standard practice guidance for babies to be intubated within 15 minutes of birth. Dr Smith says he is unfamiliar with that number and asks Mr Myers where that guidance came from. Dr Smith says he would go with that if that were the standard practice number. He says there are two different numbers for how long it was after birth for intubation to have taken place - one of them is 12 minutes. Dr Smith is asked about lung surfactant, which a note records as being administered at 3 am, and whether that, at about 35 minutes after intubation, is 'too long'.Dr Smith says if good oxygen saturation is recorded at the time and Baby K is stable, that would not be an issue. Still, if guidance is to administer that surfactant five minutes after intubation, that would be considered too long.

The truth is that the consensus recommendation for initial stabilisation of very preterm infants is continuous positive airway pressure (CPAP) rather than routine intubation and surfactant treatment immediately after delivery. This avoids intubation, which will not be necessary for many babies and can cause early lung injury and infection, as in the case of Baby K. Randomised controlled trials and meta-analysis support selecting a CPAP strategy over a prophylactic surfactant treatment.

Dr Jayaram's note is shown to the court and written retrospectively. Dr Smith points out that the note of surfactant administration is recorded as being made at '0245'.Mr Myers asks about inserting a central line, which is done several hours after Baby K was born.

Dr Smith says the procedure requires assistance, is difficult, takes time, requires a sterile environment, and requires a stable baby. It also requires X-rays afterwards.

Dr Smith again makes the case for never having a preterm baby in the CoGH.The 1mm thick line is being put into an umbilical cord line that is 1-2mm thick. In this instance, it is' a non-emergency UVC'.

They are the same thickness in the units that succeed nearly 90% of the time on the first attempt. Mr Myers says this procedure should 'ideally' be performed by a consultant neonatologist at a tertiary centre. Dr Smith says ideally, the baby would be born at a tertiary centre. Still, in these circumstances, the most experienced staff at a level 2 centre, capable of this type of procedure, would carry out the procedure.

Back to the old, well-worn CoGH, self-serving circle to hell. Mr Myers asked if it was 'too long' a period. Dr Smith said a more extended period would not have compromised the baby.

I read that about ten times to understand what Dr. Smith was saying. He's saying that if he hadn't bothered to go near the delivery suite and if Javi the Jinx had never met Baby K, the outcome would have been no different. And you know? I think he's right.

Mr Myers asks if it was 'sub optimal'. Dr Smith says it would depend on the circumstances and the condition of the baby, and in Baby K's case, the 'correct thing to do' was to prioritise the airway and breathing support, and lines could be put in later. Mr Myers asks if the line insertion fell outside the 'golden hour' principle. Dr Smith says there is no difference in the method of the administration of initial medicines - the UVC was one option, but there are others. Dr Smith agrees with Mr Myers the initial administration of antibiotics fell outside the 'golden hour' principle timing. The antibiotics were administered at 4.40 am, according to electronic prescription records, sometime after the first hour of Baby K's birth, which ended at 3.12 am.

Dr Smith adds from a blood test, there was no marker of infection, but it was sub-optimal that the antibiotics and vitamin K (administered at 4.20 am) were not administered in the first hour, and I cannot recall why that was the case. After a short break, Mr Myers is continuing to question Dr Smith. He refers to the intubation attempts made for Child K. Dr Smith says he used a 2.5 tube at first, then a smaller 2.0 tube successfully. Mr Myers asks about an air leak which was reported. Dr Smith says he was aware of this and referenced it in his third statement to the police. Dr Smith does not know what the 3.30 am reading of '94' for air leak means, as it does not correlate to any other readings.

He says Baby K's blood gas record was good, the oxygen Saturation was good, and the oxygen requirement had come down. He does not believe that would mean only 6% (100% minus 94) of oxygen was getting into Child K. He said a large air leak would result in a change to a larger ET tube being considered, but that process would require reintubation. He said knowing there was good oxygenation and gas would reduce the need for reintubation.

He adds that a tertiary neonatologist with more experience with ventilators might give a different opinion, but they would need to be called to provide evidence. Dr Smith also does not know what the 'resistance' figure on the chart signifies. Mr Myers asked about the reintubation of Baby K's tube, which involved a larger tube. Dr. Smith says the first ET tube was working fine, then it was not, and reintubation was required.

The morphine bolus was applied to have "a sedative effect" on Baby K. The desaturation at 6.15 am is referred to. Dr Smith says the ET tube was pulled back, but saturation levels continued to decrease, so it was removed, and bagging commenced. Dr Smith says the saturation levels improved, meaning there "was a problem with the tube."

Mr Myers says pulling the tube back and seeing no change [before the tube's removal] meant there was no problem with the positioning of the tube. Dr Smith says the cause of the tube's movement could have been it 'slipping' from the clamp, which caused this deterioration. Dr Smith says he did not recall any injury/blood/trauma with Baby K, and if he had done so, he would have referred it to Dr Ravi Jayaram and asked them to take over the intubation process. Mr Myers asks if, hypothetically, he had seen blood before intubation and if he would have checked for the source of it.

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

As I said, this mess will go back to court only with the proper defendants in the dock