UK - Lucy Letby - Post-Conviction Statutory Inquiry

[DianaWW]

There’s quite a bit of information missing from that statement of just the two figures- they only did the audit whilst LL was on a placement there, so they have pulled the 1% from their guesstimates, rather than making a direct comparison using data collected from other trainee nurses- they have compared her figures to the whole unit and all other qualified staff. At that point LL was a student on a training placement- they make no comparison to the percentages with other student nurses at the same point in their training. If you have a look online there is massive issues with the dislodgement of breathing tubes and them being incorrectly inserted in neonatal wards- to the point that in 2021(many years after LL was training) a working party of 23 experts across Europe was created, their figures on it potentially occurring during student placements was up to 80% error rate.

https://www.bjanaesthesia.org/article/S0007-0912(23)00498-1/fulltext#au22

I’ve only skim read, but that study seems to be focused on intubation techniques and issues with the process. Whereas during the inquiry they were discussing tubes becoming dislodged which is completely different.

 

[iamshadow21]

I’ve only skim read, but that study seems to be focused on intubation techniques and issues with the process. Whereas during the inquiry they were discussing tubes becoming dislodged which is completely different.

Agreed. It's like comparing a student phlebotomist failing to find a vein with someone deliberately yanking out someone's IV.

MOO

 

[Becky53]

https://thirlwall.public-inquiry.uk/wp-content/uploads/thirlwall-documents/Written%20Opening%20Statement%20of%20Family%20Group%201.pdf

OPENING STATEMENT ON BEHALF OF THE FAMILIES OF CHILD A, B, I, L, M, N & Q (Family Group 1)

https://thirlwall.public-inquiry.uk/wp-content/uploads/thirlwall-documents/Written%20Opening%20Statement%20of%20Family%20Group%202%20and%203.pdf

WRITTEN OPENING ON BEHALF OF THE PARENTS OF:
CHILD C, CHILD D, CHILD E, CHILD F,
CHILD G,CHILD H,CHILD J,CHILD K,CHILD O,CHILD P,CHILD R (family group 2 and 3)

 

[Tortoise]

There’s quite a bit of information missing from that statement of just the two figures- they only did the audit whilst LL was on a placement there, so they have pulled the 1% from their guesstimates, rather than making a direct comparison using data collected from other trainee nurses- they have compared her figures to the whole unit and all other qualified staff. At that point LL was a student on a training placement- they make no comparison to the percentages with other student nurses at the same point in their training. If you have a look online there is massive issues with the dislodgement of breathing tubes and them being incorrectly inserted in neonatal wards- to the point that in 2021(many years after LL was training) a working party of 23 experts across Europe was created, their figures on it potentially occurring during student placements was up to 80% error rate.

https://www.bjanaesthesia.org/article/S0007-0912(23)00498-1/fulltext#au22

She wasn't a student nurse in 2012 and 2015. She did training placements at Liverpool Women's after she qualified as a registered nurse.

 

[Ruthbullock]

I’ve only skim read, but that study seems to be focused on intubation techniques and issues with the process. Whereas during the inquiry they were discussing tubes becoming dislodged which is completely different.

It does discuss it further on, but this is only unexplained ones

516 Reducing unplanned extubations on a tertiary neonatal unit: a quality improvement project

Objectives Unplanned extubation (UE) is a frequently occurring, harmful event, following which 5–13% of babies require cardiopulmonary resuscitation.1,2 There is associated airway trauma3 and risk of intracranial haemorrhage.4 On our level 3 NICU, we aimed to reduce the UE rate to below the...

adc.bmj.com

 

[Ruthbullock]

She wasn't a student nurse in 2012 and 2015. She did training placements at Liverpool Women's after she qualified as a registered nurse.

She qualified as a Band 5 nurse in September 2011 and went on to start working full-time at the hospital from January 2012 before qualifying to work with intensive care babies in the spring of 2015.

Who is baby serial killer Lucy Letby?

Her trial spanned 10 months, but what is known about the nurse who murdered seven newborn babies?

www.bbc.co.uk

 

[Anxala]

‘Ghoulish sideshow’: Lucy Letby victims’ barrister speaks on parents’ behalf

Opening statement of Richard Baker KC at inquiry talks of toxic notions promoted by conspiracy theorists

www.theguardian.com

“The position of the families in this inquiry is unique. They are anonymised by ciphers, as are their children. Some are concerned that this has the effect of dehumanising them in the eyes of the public and media, and has cultivated an environment where people feel able to express vile opinions through social media, an environment where the serial killer who murdered or attacked their children is, by contrast, humanised or even venerated.

“You’ve met the families, you will know that they’re real people, you will understand that they have a simple and reasonable aim to live normal lives as disconnected from a monster who harmed them as possible.

“They have no interest in becoming permanent attractions at a ghoulish sideshow. Their request is to be allowed to grieve in private or for their surviving children to never know of a role that they played in this story.

“More tragically still, they feel that revealing their identities would cause them to become the focus for ill will. What does society come to where the parents of murdered or injured children should live with this fear?

“Everybody who recklessly promotes conspiracy theories, or who parrots without questioning the same tired misconceptions about this case, should be ashamed of themselves.

Late but nevertheless welcome.

 

[Tortoise]

She qualified as a Band 5 nurse in September 2011 and went on to start working full-time at the hospital from January 2012 before qualifying to work with intensive care babies in the spring of 2015.

Who is baby serial killer Lucy Letby?

Her trial spanned 10 months, but what is known about the nurse who murdered seven newborn babies?

www.bbc.co.uk

Yes, which is why I was correcting your statement that she was a student nurse. Her placements at Liverpool Women's were at the end of 2012 and the beginning of 2015.

 

[Ruthbullock]

Yes, which is why I was correcting your statement that she was a student nurse. Her placements at Liverpool Women's were at the end of 2012 and the beginning of 2015.

General nursing training is one thing- she was not qualified until spring 2015 to work in NICU or SCBU- she was doing her training placements in 2012 and 2015 and was not at that point qualified to work in special care baby units. That is why during the enquiry they referred to those 2 placements as training placements as she was not fully trained and qualified at that point to work in those specific units.
It perhaps doesn’t matter in the grand scheme of things- but I find it infuriating for the families when the hospital now comes out with how perfect it was normally and then during an audit LL was flagged- but we still passed her placement. The truth is likely much murkier- they didn’t need to mention there normal 1% (which shines a light on the magnificence of how they function normally) as to an outsider it makes me question why they also did and said nothing- what they actually know as fact is there was a UE on 40% of LLs shifts- so was it normal enough that no one flagged it and made her redo the placement or fail her placement, or was the teaching hospital failing the parents as well by not teaching the nurses how to do procedures properly. I’m sure there will be much more to come out about that audit and what if any impact it had (because if nothing else surely the point of an audit is to reflect and improve)

 

[iamshadow21]

General nursing training is one thing- she was not qualified until spring 2015 to work in NICU or SCBU- she was doing her training placements in 2012 and 2015 and was not at that point qualified to work in special care baby units. That is why during the enquiry they referred to those 2 placements as training placements as she was not fully trained and qualified at that point to work in those specific units.
It perhaps doesn’t matter in the grand scheme of things- but I find it infuriating for the families when the hospital now comes out with how perfect it was normally and then during an audit LL was flagged- but we still passed her placement. The truth is likely much murkier- they didn’t need to mention there normal 1% (which shines a light on the magnificence of how they function normally) as to an outsider it makes me question why they also did and said nothing- what they actually know as fact is there was a UE on 40% of LLs shifts- so was it normal enough that no one flagged it and made her redo the placement or fail her placement, or was the teaching hospital failing the parents as well by not teaching the nurses how to do procedures properly. I’m sure there will be much more to come out about that audit and what if any impact it had (because if nothing else surely the point of an audit is to reflect and improve)

Why wouldn't they pass her placement if nobody made the connection? She would have been doing this covertly.

What I know about Letby is as much as she wanted to harm infants, she wanted to be thought of as exemplary in her skills as a nurse. She wouldn't have dislodged a tube if there was a chance someone could connect her to it.

I wonder how many of these dislodgements she 'discovered' in order to participate in the 'rescue'.

MOO

 

[Tortoise]

General nursing training is one thing- she was not qualified until spring 2015 to work in NICU or SCBU- she was doing her training placements in 2012 and 2015 and was not at that point qualified to work in special care baby units. That is why during the enquiry they referred to those 2 placements as training placements as she was not fully trained and qualified at that point to work in those specific units.
It perhaps doesn’t matter in the grand scheme of things- but I find it infuriating for the families when the hospital now comes out with how perfect it was normally and then during an audit LL was flagged- but we still passed her placement. The truth is likely much murkier- they didn’t need to mention there normal 1% (which shines a light on the magnificence of how they function normally) as to an outsider it makes me question why they also did and said nothing- what they actually know as fact is there was a UE on 40% of LLs shifts- so was it normal enough that no one flagged it and made her redo the placement or fail her placement, or was the teaching hospital failing the parents as well by not teaching the nurses how to do procedures properly. I’m sure there will be much more to come out about that audit and what if any impact it had (because if nothing else surely the point of an audit is to reflect and improve)

I'm not sure we have sufficient information to know it was directly related to doing procedures properly. It sounds to me as if these breathing tubes were dislodged, moved after their placement, which is exactly what she was found guilty of doing to baby K. Nurses of LL's level wouldn't be inserting breathing tubes, they were all inserted by doctors at the CoCH.

 

[iamshadow21]

I'm not sure we have sufficient information to know it was directly related to doing procedures properly. It sounds to me as if these breathing tubes were dislodged, moved after their placement, which is exactly what she was found guilty of doing to baby K. Nurses of LL's level wouldn't be inserting breathing tubes, they were all inserted by doctors at the CoCH.

And a baby sick enough to have a breathing tube would be sedated. It's not like a feeding tube. So they couldn't dislodge them themselves.

MOO

 

[DianaWW]

Exactly, so it shouldn’t matter how much experience a nurse has, because the nurses aren’t the ones intubating, they shouldn’t be touching the breathing tubes should they? The point is that breathing tubes rarely dislodge on their own after insertion, for no apparent reason, yet they did so on almost half of her shifts during the period she worked there.

 

[Ruthbullock]

And a baby sick enough to have a breathing tube would be sedated. It's not like a feeding tube. So they couldn't dislodge them themselves.

MOO

It just isn’t the case that they can’t and don’t dislodge because the babies are sedated-
In the neonatal ICU (NICU), unplanned extubation has been reported as the fourth most common adverse event, and rates have been reported to be as high as 80.8%.

https://www.anesthesiologynews.com/Review-Articles/Article/08-19/Unplanned-or-Accidental-Extubation-in-the-Perioperative-Environment/55658?sub=2053C2CEFF596F6EDC5E4E010A2A93E8075301EF1F775CBA3CEE8D40CCB78F&enl=true&dgid/1000#

 

[Tortoise]

It just isn’t the case that they can’t and don’t dislodge because the babies are sedated-
In the neonatal ICU (NICU), unplanned extubation has been reported as the fourth most common adverse event, and rates have been reported to be as high as 80.8%.

https://www.anesthesiologynews.com/Review-Articles/Article/08-19/Unplanned-or-Accidental-Extubation-in-the-Perioperative-Environment/55658?sub=2053C2CEFF596F6EDC5E4E010A2A93E8075301EF1F775CBA3CEE8D40CCB78F&enl=true&dgid/1000#

Yet the rates here were reported to be less than 1% on all other shifts apart from Letby's. (And it was termed dislodgement, not extubation.)

 

[Sweeper2000]

Presumably she wasn't the only nurse included of her level of expertise and experience as well.

I doubt that stat "1%" is being used without due consideration for its relevance to the enquiry and situation.

 

[Ruthbullock]

Exactly, so it shouldn’t matter how much experience a nurse has, because the nurses aren’t the ones intubating, they shouldn’t be touching the breathing tubes should they? The point is that breathing tubes rarely dislodge on their own after insertion, for no apparent reason, yet they did so on almost half of her shifts during the period she worked there.

This is from New Zealand but is the form they complete after an unexpected dislodgement- have a look at the tickboxes of activities that were happening during it (I’m fairly sure they haven’t just added irrelevant ones to make the form longer).

https://media.starship.org.nz/cr0165-unplanned-extubation-review/14028776_CR0165_03-22_PDF_New_WEB.pdf

 

[Tortoise]

This is from New Zealand but is the form they complete after an unexpected dislodgement- have a look at the tickboxes of activities that were happening during it (I’m fairly sure they haven’t just added irrelevant ones to make the form longer).

https://media.starship.org.nz/cr0165-unplanned-extubation-review/14028776_CR0165_03-22_PDF_New_WEB.pdf

This link is about extubation, which is removal of the tube. It's not the same thing as tubes moving too far in or being in the wrong place after they've been correctly sited.

 

[Parker Knoll]

I watched it earlier …. So interesting - well done !
It was like knitting fog interviewing her.

 

[Marantz4250b]

FORTY PERCENT INCREASE in tube dislodgement at Liverpool whilst she was on shift ?
She was practicing there.
This is unbelievable.

Just catching up and heard this earlier - that's staggering!

"Statistics", which essentially never came into play during her trials, have been manipulated by her fans to promote her innocence.

I'm keen to hear their response to these actual statistics!

And this looks really, really, really bad for every hospital she's ever worked in and the NHS in general! How the AF can something like this be allowed to just slide by?