UK - Nurse Lucy Letby Faces 22 Charges - 7 Murder/15 Attempted Murder of Babies #11

[Marantz4250b]

I'm not registered as an expert so please take this as my opinion

Stock insulin was usually in vials/ bottles around 10 mls .. they were multi use and had a rubber bung in the end which would self seal after a needle and syringe was used to remove the required amount..this would be a tiny amount..on a non diabetes specialist unit a vial would last months

Are you able to speculate as to why the number of vials ordered in one year was much higher than preceding or later years? It would appear that the prosecution are implying that it is of relevance to their case. Although I can't see how it is unless they were ordered by LL.

 

[Sweeper2000]

This is the kind of thing I would expect the jurors to ask. For instance “do we have a calculated amount to exactly how much insulin would have been administered“? A tiny amount is probably more excusable than a larger amount that would leave less room to speculate on. I would have expected more info from the prosecution on that. Also how a much larger dose would likely interact with the baby say for instance if it would cause much more damage thus creating the thought that it was much more likely an attempt to kill. Or even if there is the chance that if protocol wasn’t followed could any insulin still be in the equipment used? syringes, mixing equipment, long lines etc

the other thing I’ve noticed is that the insulin seems to be administered as a short term treatment for the babies so I don’t know if the insulin would be syringed and then disposed of immediately. No need to keep it if it’s not part of ongoing treatment. I can’t see any reason to keep it around in the fridge to curdle

 

[Sweeper2000]

Dan O'Donoghue
@MrDanDonoghue
·
35s

Court has adjourned, back at a later time of 1pm tomorrow.

I got there at 36 seconds tortoise. Lol

 

[Dotta]

Here’s a very curious happening In court today.

10 m

Judge has just called a five minute break, he remarks that prosecutor Nick Johnson KC has a rather 'flat monotone' voice....

Did one of the Jurors fall asleep???

 

[Sweeper2000]

Did one of the Jurors fall asleep???

not that we know of but it probably wouldn’t be a first Dotta maybe if tortoise goes we can find out if anyone has heads hitting the tables or iPads smashing on the floor.

 

[JosieJo]

Are you able to speculate as to why the number of vials ordered in one year was much higher than preceding or later years? It would appear that the prosecution are implying that it is of relevance to their case. Although I can't see how it is unless they were ordered by LL.

It seems to indicate that more was used on the unit that year ...I would guess that no more than 2 vials are ever in the fridge at one time ..their "stock level" ..May be 2....so vials were used quicker or disappeared

Options may be ???

More babies requiring insulin that year but I'd speculate the amount that year wouldn't equate to this alone

Someone could take a whole vial to keep on their person or take home

One may be dropped and broken but from my memory the vials are really thick bottles so unlikely

Or lots of insulin was being used unnecessarily

JMO

 

[JosieJo]

This is the kind of thing I would expect the jurors to ask. For instance “do we have a calculated amount to exactly how much insulin would have been administered“? A tiny amount is probably more excusable than a larger amount that would leave less room to speculate on. I would have expected more info from the prosecution on that. Also how a much larger dose would likely interact with the baby say for instance if it would cause much more damage thus creating the thought that it was much more likely an attempt to kill. Or even if there is the chance that if protocol wasn’t followed could any insulin still be in the equipment used? syringes, mixing equipment, long lines etc

the other thing I’ve noticed is that the insulin seems to be administered as a short term treatment for the babies so I don’t know if the insulin would be syringed and then disposed of immediately. No need to keep it if it’s not part of ongoing treatment. I can’t see any reason to keep it around in the fridge to curdle

For the last insulin case the medical experts spoke last ..they were the ones who stated how much insulin was needed to cause the reaction.

Regarding cross contamination of tiny amounts on insulin. Syringes are never reused. Plus no insulin would be in a line of a baby never having had insulin previously

 

[marynnu]

Are you able to speculate as to why the number of vials ordered in one year was much higher than preceding or later years? It would appear that the prosecution are implying that it is of relevance to their case. Although I can't see how it is unless they were ordered by LL.

They wouldn't have to be ordered by the perpetrator. Anyone would order them if stocks were a bit low, which may or may not be because someone has been helping themselves to it.

 

[magikarpmagikarp]

That wou
That would be unusual in my opinion. Any trained nurse can order stock medications. But yes, there will be a paper trail.
EDIT doctors don't order stock drugs.

As ever, JMO.

I'll concur with this. IMO, nurses are usually the ones to call pharmacy for replacement vials for unit stock, because we are the ones who get them and administer them, so we are the ones who find that they've run out and need to be replaced.

Really interesting post about the 2 ml vial. I would not have guessed it would be such a minute amount of liquid. That’s like a drop. I’m wondering what would happen if someone put a larger amount than that if only 1 ml is needed. I would have thought 5 ml would show more extreme consequences and not be treatable really but that’s a guess from someone without a clue really. If it is such a small vial how was there any spare for a poisoning ? I always thought it would be a jar with plenty to spare but that doesn’t fit with it being a controlled substance.

im wondering if that creates scope for potential cross contamination. If it’s such a small amount it might be conceivable that a nurse wouldn’t even notice its presence in a syringe or something else. Despite all preventive measures.

Neonatal doses are so small that some medications are drawn out of the vial in hundredths of an mL and diluted to 1mL to make administration easier. Many of our meds come in 2 mL vials and I've literally had to waste (dispose with a witness) 1.98 mL of fentanyl because we consider the vials single use only. I can't speak specifically to insulin because pharmacy does our insulin dilutions, but the idea of accidentally contaminating stock fluid (clears) for a basic infusion with insulin is as absurd to me as contaminating it with fentanyl or anything else. Medication errors happen - every nurse has their share - but in my opinion, to contaminate a bag of stock fluid that has nothing added prescribed, you'd have to be intentionally doing it. "Cross contamination" would not be a route for error. The only possible way I could imagine insulin being erroneously added to stock fluid would be if someone was preparing fluid with another drug and accidentally got the insulin vial instead of the correct drug. Happy to be corrected if UK nurses have a different experience due to different protocols.

 

[GoodDayToYouSir]

How will they link this to collapses that only occurred on LL's shifts?

I think that the defence is arguing for a lot of the cases that sub optimal care was the cause of the collapse, not some criminal interference by a third-party. So by highlighting examples from the report which show sub optimal care at COCH which aren’t related to these cases, the defence can build a stronger argument that suboptimal care is the cause.

In particular, if the defence can show that sub optimal care was behind the other excess deaths during the period for which LL is not charged, or that sub optimal care was behind other non-fatal collapses for which LL is not charged, then the defence would appear to be in a stronger position.

 

[Gottlieb]

Do you have examples please.

I don't think I've seen people here judging and interpreting what LL did or didn't do, outside the bounds of reporting what the experts allege she did or didn't do.

JMO

That with the alarms f.i. I remember reading on previous threads how people are commenting on the silent alarms - I silent my alarms 15 times a day because they are not relevant. Alarms not sounding are not the equivalent of murderous intentions.

Or her wanting to go back into the room with the most complicated cases - I have done the same several times too. Nursing is a mix of theoretical and practical skills. Practical skills can only get better through - guess what - practice. Even today if I have a bad experience like an unsiccessful reanimation or a rapidly deteriorating patient, my reaction is that I want to take the next such case because I want to manage such situations better, and the only way to get better at nursing is to do it. I am bad at administration duty so I asked for an extra administration shift. Because I want to get better at it. Not because some sick reason.
But I read in previous threads how people interpret her asking to go back into the same room as a sure sign of her guilt ("reliving her sin for pleasure" or so) or her looking for opportunity to kill more babies.
For me, it is a completely normal reaction to a high stress situation. I did and still often do the same. And I am not murdering anyone

Keeping handover notes at her home was also interpreted as sinister. I do keep handover notes, because I forget about them and bring them home in my pocket. If police would search my home there would be several handover notes with names of patients I have no recollections of anymore. It is suboptimal but we are humans that get very tired at the end of a long, exhaustinh shift. Such things happen.

So these are things I completely understand as a nurse but are mentioned here as red flags and signs of her being guilty.

We all do this - silencing alarms, wanting to practice situations that were less than ideal, or taking home handover notes. These are not red flags, these are just normal things every nurse does. That's what people who are not in health care do not understand and misinterpret.

But as I have told, I did not read all the threads and do not follow closely.

I would be deeply hurt though if my desire to practice a skill to be better at it would be misinterpreted as a desire to kill or relive some terrible scenario.

ETA: this is a personal opinion and not a medical opinion (my previous post was also no medical opinion but my own) but please delete if against tos

 

[marynnu]

I'll concur with this. IMO, nurses are usually the ones to call pharmacy for replacement vials for unit stock, because we are the ones who get them and administer them, so we are the ones who find that they've run out and need to be replaced.



Neonatal doses are so small that some medications are drawn out of the vial in hundredths of an mL and diluted to 1mL to make administration easier. Many of our meds come in 2 mL vials and I've literally had to waste (dispose with a witness) 1.98 mL of fentanyl because we consider the vials single use only. I can't speak specifically to insulin because pharmacy does our insulin dilutions, but the idea of accidentally contaminating stock fluid (clears) for a basic infusion with insulin is as absurd to me as contaminating it with fentanyl or anything else. Medication errors happen - every nurse has their share - but in my opinion, to contaminate a bag of stock fluid that has nothing added prescribed, you'd have to be intentionally doing it. "Cross contamination" would not be a route for error. The only possible way I could imagine insulin being erroneously added to stock fluid would be if someone was preparing fluid with another drug and accidentally got the insulin vial instead of the correct drug. Happy to be corrected if UK nurses have a different experience due to different protocols.

I think that the defence is arguing for a lot of the cases that sub optimal care was the cause of the collapse, not some criminal interference by a third-party. So by highlighting examples from the report which show sub optimal care at COCH which aren’t related to these cases, the defence can build a stronger argument that suboptimal care is the cause.

In particular, if the defence can show that sub optimal care was behind the other excess deaths during the period for which LL is not charged, or that sub optimal care was behind other non-fatal collapses for which LL is not charged, then the defence would appear to be in a stronger position.

JMO

You're right, too many things would have to go ridiculously wrong for this to be accidental. 2 nurses always check everything against a prescription, which didn't exist. And the rate is adjusted according to the blood sugars so even if an infusion were present by some bizarre set of events (impossible!), it would be stopped because of that.
All insulin infusions here are mixed on the unit as every one is unique to each baby according to birthweight.

 

[Tortoise]

I think that the defence is arguing for a lot of the cases that sub optimal care was the cause of the collapse, not some criminal interference by a third-party. So by highlighting examples from the report which show sub optimal care at COCH which aren’t related to these cases, the defence can build a stronger argument that suboptimal care is the cause.

In particular, if the defence can show that sub optimal care was behind the other excess deaths during the period for which LL is not charged, or that sub optimal care was behind other non-fatal collapses for which LL is not charged, then the defence would appear to be in a stronger position.

Which report has examples of other cases? Dr Evans reports?

The defence hasn't mentioned, in its opening speech, any other cases she isn't charged with.

JMO

 

[magikarpmagikarp]

I had a quick look back at Professor Hindmarsh's evidence for baby F, to see if any amounts were stated :


"Professor Hindmarsh says a rate of about 0.56ml/hr of insulin would have been required to lower Child F's blood sugar levels on the TPN bag."

"Overall, the infusion [rate] has essentially stayed the same.
"I can't be absolutely sure...but it's safe to assume that the glucose infusion rate did not change, which would imply that the amount of insulin around would be similar throughout the 17-hour period - allowing for the breaks when the infusion was discontinued."

By my reckoning that is 0.56ml x 17 = 9.52mls.

Professor Hindmarsh is shown a 10ml bottle of insulin, which normally comes with an orange, self-sealing cap.
To extract the liquid from the bottle, to administer 'therapeutically', a medical professional would have to use a syringe, the court hears. Mr Johnson says by 'therapeutically', Professor Hindmarsh means 'legitimately'. Professor Hindmarsh agrees, and says the dose would have to be measured out carefully.

Recap: Lucy Letby trial, Friday, November 25

It sounds to me like virtually a whole 10ml bottle was used on baby F, unless that's not how you calculate it.

Now, I am not totally sure, but it sounds to me like the undiluted insulin (humalog? 100 u/1mL), given at a rate of 0.56 mL/hour (or roughly 50 units per hour), would give this change in blood sugar. Presumably the insulin was added into a bag of fluid. I don't know the standard size of fluid bags on NHS unit, but on ours, the bags are 500 mL. But the rate of TPN doesn't need to change. Take the whole 10 mL vial of humalog, which I believe is 100 units of insulin per mL. So 1000 units of insulin per 10 mL. Now you add this to the 500 mL bag of TPN. Now your TPN has a concentration of 1000 units insulin / 510 mL of TPN. To deliver 50 units per hour, you'd have to run the TPN at around 25 mL/hr. If you added two vials, the TPN would have to run at 13 mL/hr. Add 4 vials and the rate of infusion could be even slower. Etc. I don't remember how big this baby was but depending on size and where they were on feeds, any of these numbers is plausible to me.

JMO.

EDIT - hold on, this doesn't pass my common sense test. 50 units of insulin sounds like an awful lot for an infant. Let me rethink. Leaving post up for transparency.

 

[Dotta]

That with the alarms f.i. I remember reading on previous threads how people are commenting on the silent alarms - I silent my alarms 15 times a day because they are not relevant. Alarms not sounding are not the equivalent of murderous intentions.

Or her wanting to go back into the room with the most complicated cases - I have done the same several times too. Nursing is a mix of theoretical and practical skills. Practical skills can only get better through - guess what - practice. Even today if I have a bad experience like an unsiccessful reanimation or a rapidly deteriorating patient, my reaction is that I want to take the next such case because I want to manage such situations better, and the only way to get better at nursing is to do it. I am bad at administration duty so I asked for an extra administration shift. Because I want to get better at it. Not because some sick reason.
But I read in previous threads how people interpret her asking to go back into the same room as a sure sign of her guilt ("reliving her sin for pleasure" or so) or her looking for opportunity to kill more babies.
For me, it is a completely normal reaction to a high stress situation. I did and still often do the same. And I am not murdering anyone

Keeping handover notes at her home was also interpreted as sinister. I do keep handover notes, because I forget about them and bring them home in my pocket. If police would search my home there would be several handover notes with names of patients I have no recollections of anymore. It is suboptimal but we are humans that get very tired at the end of a long, exhaustinh shift. Such things happen.

So these are things I completely understand as a nurse but are mentioned here as red flags and signs of her being guilty.

We all do this - silencing alarms, wanting to practice situations that were less than ideal, or taking home handover notes. These are not red flags, these are just normal things every nurse does. That's what people who are not in health care do not understand and misinterpret.

But as I have told, I did not read all the threads and do not follow closely.

I would be deeply hurt though if my desire to practice a skill to be better at it would be misinterpreted as a desire to kill or relive some terrible scenario.

ETA: this is a personal opinion and not a medical opinion (my previous post was also no medical opinion but my own) but please delete if against tos

So what is the use of alarms if they are silenced by staff as "not relevant"?

As for handover notes with patients' sensitive info - shouldn't they be brought back to place of work as soon as possible?
I wouldn't be happy if the details of my treatment and my name were lying in somebody's home

As for returning immediately to perform some previously done unsuccessful procedures on patients - maybe it is better to "cool off" and observe them when others perform them well?

JMO

 

[magikarpmagikarp]

Ok, it's confusing to me to talk only in milliliters instead of units per mL. I guess I just need more clarity on what they believe the concentration was to understand the actual numbers. Regardless, IF insulin has been added to the bag, the rate of infusion doesn't need to alter. The dose differs depending on how much was added to the bag. But my other post is an excellent example of how errors of scale happen in medication administration!!

 

[Tortoise]

That with the alarms f.i. I remember reading on previous threads how people are commenting on the silent alarms - I silent my alarms 15 times a day because they are not relevant. Alarms not sounding are not the equivalent of murderous intentions.

Or her wanting to go back into the room with the most complicated cases - I have done the same several times too. Nursing is a mix of theoretical and practical skills. Practical skills can only get better through - guess what - practice. Even today if I have a bad experience like an unsiccessful reanimation or a rapidly deteriorating patient, my reaction is that I want to take the next such case because I want to manage such situations better, and the only way to get better at nursing is to do it. I am bad at administration duty so I asked for an extra administration shift. Because I want to get better at it. Not because some sick reason.
But I read in previous threads how people interpret her asking to go back into the same room as a sure sign of her guilt ("reliving her sin for pleasure" or so) or her looking for opportunity to kill more babies.
For me, it is a completely normal reaction to a high stress situation. I did and still often do the same. And I am not murdering anyone

Keeping handover notes at her home was also interpreted as sinister. I do keep handover notes, because I forget about them and bring them home in my pocket. If police would search my home there would be several handover notes with names of patients I have no recollections of anymore. It is suboptimal but we are humans that get very tired at the end of a long, exhaustinh shift. Such things happen.

So these are things I completely understand as a nurse but are mentioned here as red flags and signs of her being guilty.

We all do this - silencing alarms, wanting to practice situations that were less than ideal, or taking home handover notes. These are not red flags, these are just normal things every nurse does. That's what people who are not in health care do not understand and misinterpret.

But as I have told, I did not read all the threads and do not follow closely.

I would be deeply hurt though if my desire to practice a skill to be better at it would be misinterpreted as a desire to kill or relive some terrible scenario.

ETA: this is a personal opinion and not a medical opinion (my previous post was also no medical opinion but my own) but please delete if against tos

No one has expressed opinions on guilt or innocence. If you see any you should report the posts.

What you may have seen is a post saying if she is guilty she might have done something for X reason, which is different. The prosecution is alleging in some instances she paused alarms when babies were found collapsed without an alarm sounding. They have also pointed out what hospital notes were found in a search of her home, and she was asked by police if she had kept them as souvenirs. She sent texts asking to go back in ICU after a death, and when she did go back in there another death occurred. These are the facts of the trial, and so they are viewed in the context of the allegations against her, as circumstantial evidence.

 

[Sweeper2000]

do we know if there was a stock level of insulin kept in the fridge? or Was it something used and then disposed of and then ordered as per need? it seems with what is a limited supply the opportunity for it to be misused would be much reduced. Say we know child e was given a dose of it the day before child f so would that vial have been disposed of ?

 

[magikarpmagikarp]

So what is the use of alarms if they are silenced by staff as "not relevant"?

As for handover notes with patients' sensitive info - shouldn't they be brought back to place of work as soon as possible?
I wouldn't be happy if the details of my treatment and my name were lying in somebody's home

As for returning immediately to perform some previously done unsuccessful procedures on patients - maybe it is better to "cool off" and observe them when others perform them well?

JMO

Well I have to agree with Gottleib here. Alarms are a tool. Alarms are loud to get my attention so that I can come and assess the situation, but they are actually irritating to the baby, and to small babies can even disturb them so much that it causes negative physiological changes. I silence alarms so I can do my job. When I come to check on the baby, I always silence the alarm and then I assess, which might look like "doing nothing" because I am reading the ventilator wave forms, observing for color, respiratory movement (chest rise) and so on so that I can make the correct interventions. Jumping in and doing without thinking just leads to doing the wrong thing. I am eager to hear the testimony on baby K (K, the one who was on paralytic but somehow self extubated?). When I first read of that episode, as a nurse I didn't immediately think LL was criminal or incompetent. But, having followed all the testimony so far, mostly the technical stuff rather than the social behavior, I understand why there have been concerns and a trial.

JMO.

 

[ColourPurple]

Hmmm, I'm not sure I'd agree there. If you poison a bag with something but someone else gives it to the patient then you kind of did administer it, you just did it by a rather circuitous route. At best you "caused" it to be administered.

I can certainly see how a guilty person might use that rationale to absolve themself of blame, though.

Yup, the bit in bold is what I'm saying . Technically it wouldn't be lying if they had not physically adminstered it.


Similar to how saying "I did nothing wrong" is not the same as saying "I didnt do anything". It can just mean that the person doesn't believe that anything they may have done, was wrong.