Lucy Letby – obstetric intro & summary

As far as I know, no obstetrician appeared as an expert witness at the trial. This may not surprise most people; the allegations were of murder and attempted murder in a neonatal unit. But it’s surprising to obstetricians, because almost all neonatal problems have their origin in pregnancy. Prematurity obviously, but much else as well.

It is therefore even more surprising that no independent obstetrician appears to have even looked at the mothers’ clinical notes.

The evidence that this may be so comes from Professor Neena Modi, a member of Shoo Lee’s expert panel. She says the panel had asked for, but not been given, the mothers’ notes. For the full interview (click here). For 16.33 where she makes this point (click here).

Professor Modi is not just any professor. When the offences took place, she was the President of the Royal College of Paediatrics and Child Health, arguably the most senior paediatrician the UK. She is a precise and careful witness.

Since the panel had all the notes available to Letby’s new legal team, and the new legal team had been given all the notes available to her old legal team, and the prosecution has a duty to pass all their evidence to the defence, it seems reasonable to infer that neither side had copies of the mother’s records. If they did not have them, they cannot have looked at them.

Of course much information will have been copied into the baby notes, and the route of birth, and whether the baby was a multiple, is obvious. Growth restriction and fetal distress can also be inferred from the baby’s weight and condition at birth. And the parents will remember a lot.

But the significance of some details may not have been appreciated at the time. A transcribing nurse or doctor can hardly have imagined that years later a court would have to decide if a baby had died from natural causes or been murdered. The details may matter.

To take just a simple example. Consider an imaginary preterm baby, say 29 weeks, born by Caesarean because the mother had raised blood pressure, who later collapsed and died.

The baby notes will likely record the gestation, the Caesarean and the blood pressure. But they might miss the exact BP level, how long had it been raised, any response to treatment, whether the mother also had pre-eclampsia, or other complications, and the extent to which the blood pressure was compromising the baby’s health?

The baby notes will likely record whether the mother was in preterm labour or not, and if not, why the obstetricians had decided to deliver then. But they will rarely record all the maternal, fetal and other factors that had led to the choice of that precise gestation.

The baby notes will probably also record the main steps taken to reduce the risks of prematurity, whether steroids and magnesium sulphate were given, and whether clamping of the umbilical cord was delayed. But they might miss the precise timings. They should record obvious surgical difficulties but might miss the details. They rarely record the seniority of the surgeon.

The baby notes usually record whether the mother was given a spinal or general anaesthetic but typically little more about the anaesthetic.

The Shoo Lee panel have also alleged that poor, and occasionally even negligent, care was a factor in some deaths, and that the neonatal unit staff were neither qualified nor experienced enough to deal with some of the sickest babies.

If this may apply to the neonatal unit at the the Countess of Chester Hospital, it may also apply to the maternity unit. Only by reading the mother’s notes can we be sure that the pregnancy was managed correctly. The baby notes will rarely contain sufficient information to judge that.

Of course even if different obstetric care might have altered the outcome, that doesn’t necessarily imply negligence. There’s a wide area for expert judgment, and it’s easy to criticise with the benefit of hindsight. But it might be relevant to whether death was by natural causes or murder.

Anyway here’s what the Shoo Lee panel found in the baby notes. Sources here and here. Merged into trial order with both numbers and letters here. Many babies had more than one issue.

• Three full sets of twins (six babies), two of a set of triplets, plus two other individual twins from separate sets (two babies). In total ten babies came from a multiple pregnancy. The twin complications included at least two cases of twin to twin transfusion syndrome (TTTS), one so severe that it had required laser ablation of the placental vessels connecting the twins’ circulations.
• All but one baby was preterm (<37 weeks). Three were extremely preterm (<28 weeks), six very preterm (29-32 weeks) and six moderately preterm (33-36+6 weeks). Six babies also suffered from intra-uterine growth restriction.
• Thirteen babies were born by Caesarean, two vaginally, and for two the route was not noted by the panel.
• There were also cases of chorioamnionitis, pre-labour membrane rupture, a maternal haemophilia carrier, obstetric cholestasis, birth in a toilet, footling breech birth, one mother with placenta praevia/accreta, one with diabetes, and one with hypertension & antiphospholipid syndrome.

Plenty for an obstetrician to think about.

But first I need to sort out the babies’ letter and number codes, and explain about the different levels of neonatal unit (click here).

Jim Thornton