UK - Nurse Lucy Letby Faces 22 Charges - 7 Murder/15 Attempted Murder of Babies #4

[MsBetsy]

I agree. I suspect, though, that the defence may have their own experts to say that it is just what Mr Myers has suggested.

The prosecution witness has used the very specific and emotive word - "ridiculous". Another, possibly equally as qualified doctor, saying that it isn't "ridiculous" may do great harm to that evidence. I mean, they only need to show that it's happened once and that word would be in itself, ridiculous, surely?

I think by ridiculous he meant it would make no sense that a baby could die from infection and there not be any evidence of infection at autopsy.

I'm not sure how they would be able to show that it's happened before? How would they know if a baby died from an infection when nothing was found to support it?

 

[Dcflag]

Just catching up with today. I actually think Myers has done a terrible job so far. The answers to all his questions just makes me feel all the more affirmed that the experts absolutely know what they’re talking about.

I would say, if they don’t produce at least one medical expert that argues against the air embolus theory, then that means they can’t find one. My guess would be that all medical experts have come to a similar conclusion, that there are alternative possibilities but that air embolus is the most fitting given the clinical evidence. Otherwise you’d think they’d have their own medical experts. Surely.

 

[Charlot123]

2:59pm

A blood gas record showing a 'high' number for lactate (2.6 - outside the range up to 2) is shown.
Dr Evans explains he wouldn't be "particularly" concerned at such a reading, in the "whole picture", as he says one or two readings would be outside the normal range.
He describes the reading as "marginal", with all the other readings "normal", and Child A was "handling well".
He said he would not interpret an oxygen reading from a capilliary sample from a 'heel prick'.
He says if he saw such readings, knowing if the baby was "in air", he would not be "rushing to stick needles in him" unless there was a change in condition in the baby.

3:07pm

A NICU observation chart is presented for Child A, including the respiratory rate.
Mr Myers says the readings are "not stable."
Dr Evans disagrees, saying the readings are "within range".
The 'increase' in the respiratory rate readings were down to the insertion of the long line and UVC, handling of the baby and a heel price procedure which caused the baby discomfort.
Dr Evans said he would expect the heart rate to go up with an increased respiratory rate, which would be a concern. But as the heart rate had remained stable, he said he would "not be concerned" and Child A "was not even requiring oxygen", with saturation levels at about 97-99 per cent, "was about as good as it gets".

Recap: Lucy Letby trial, Tuesday, October 25

THE trial of Lucy Letby, who denies murdering seven babies at the Countess of Chester Hospital neonatal unit and attempting to murder 10 more,…

www.chesterstandard.co.uk

Finally the lactate was discussed. In fact, raising lactate means tissue hypoxia. First question, was the doctor on call alerted about it?

The problem is that the previous lactate levels were normal. Where were they taken from? If it was capillary, too, then it is the change, and a change might be concerning. I understand that potentially two reading can be different, but - why order blood gases from a heel if they are uninterpretable?

 

[magikarpmagikarp]

Finally the lactate was discussed. In fact, raising lactate means tissue hypoxia. First question, was the doctor on call alerted about it?

The problem is that the previous lactate levels were normal. Where were they taken from? If it was capillary, too, then it is the change, and a change might be concerning. I understand that potentially two reading can be different, but - why order blood gases from a heel if they are uninterpretable?

Capillary blood gases are the preferred method of getting a gas in a baby without an umbilical arterial line, an umbilical venous line, or peripheral arterial line. Capillary samples are less painful to obtain than venous or arterial sticks, and if the heel is well warmed, the blood should be mostly arterialized. This will give useful clinical information regarding the pH and PCO2. If the baby was on CPAP, that's what they were trending.

With that said, sometimes the heel wasn't quite warmed enough, or the baby is <24 hours old and has normal newborn acrocyanosis, or their feet are cold, or the blood just isn't flowing well and there was a lot of squeezing. A heelstick lactate will not be super reliable and will always be considered in the context of the whole picture. A single *slightly* elevated lactate from a capillary sample certainly is not concerning for a baby who is well appearing and in minimal respiratory support and requiring no supplemental oxygen. If they wanted to know what the lactate really was, they could have done an arterial stick or placed a peripheral arterial line (since it sounds like the umbilical site was no good), but that is very painful and would have been unwarranted. A baby for whom a rising lactate represented a disease process would have other signs of illness, and require escalating respiratory support. The lactate would also be quite a bit higher. The most likely pathologies that could contribute to rising lactate for a newborn baby would be congenital heart defect, sepsis or tissue death (secondary to NEC). I believe there has been no credible evidence that any of those issues were present. (Edit - also of course prolonged hypoxia due to respiratory distress, but he was "in air" with good saturations so that makes no sense.)

Only the greenest resident (registrar) would order an arterial gas to follow up on that heelstick lactate, with the clinical picture of a stable infant convalescing on CPAP. If I got that order as (an experienced) nurse, I'd argue not to. If they insisted, definitely would go over their head to the fellow (consultant) and ask that we not cause pain to a baby for no good reason.

 

[Charlot123]

So, simplifying this case to the most basic level, is it a choice of 2 options for the jury:

1) Did the baby(ies) die of natural or unnatural causes?
2) If unnatural, was LL the perpetrator?

Of course, the added complication is that there are so many cases, of both M and AM. I assume she could be found guilty of some, and not all? Thoughts?

I think they need to feed all data about all kids treated in the unit from 2012 till 2018, all info they have, as well as the names of all unit staff working in the unit during these years, and look at the probability of the kids being killed by LL.

 

[Charlot123]

"The consultant said that around the time of Child A’s inquest a group of clinicians had begun to raise concerns to hospital bosses about the “association we had seen with an individual being present in those situations and, how do I say diplomatically, being told we really should not really be saying such things and not to make a fuss”.

Presumably there is no way of us knowing when Baby As inquest was

And now I, indeed, want to know when Dr. Jay became a TV doctor.

If before 2016 - why didn’t he use his clout to push the case and “make a fuss”? Or were there forces stronger than his clout?

Or, maybe, the case got pushed merely because of the fame he got? And were it not for his “TV doctor” status, kids would continue dying?

Now, the group of clinicians went to hospital bosses and raised concern. Surely it is not the only time they raised concern, there probably were many things they raised concern about in that unit? And regarding what else were they told “not to really say such things and make a fuss”?

The doctors were shut up by administrators, essentially. How many times did it happen? In what context?

How narrow-minded could be the administrators in order not to see the slowly spreading abyss under their feet?

 

[Sweeper2000]

It’s interesting to note that the doctor was originally tasked with investigating the deaths of 33 children on a ward that that normally only had “3 or 4 “deaths in a year. I don’t know if those numbers are supposed to cover Lucy’s entire time at the unit or just for the years 2015 to 2016. that’s such a massive jump if it is in one year.

 

[Sweeper2000]

It’s interesting to note that the doctor was originally tasked with investigating the deaths of 33 children on a ward that that normally only had “3 or 4 “deaths in a year. I don’t know if those numbers are supposed to cover Lucy’s entire time at the unit or just for the years 2015 to 2016. that’s such a massive jump if it is in one year. Even covering Lucy’s entire time this is ten babies per year but I think it’s safe to say there is no concern for the years preceding 2015. I would like to find out why it is suggested that homicidal tendencies would suddenly come out after years of good service. Looking at the case the medical issues are notable but not conclusive and Lucy’s character and previous work record are all good nothing amiss. Again I think if 17 babies cases are under question with 7 having died it might go against the air embolism theory. Why fatal for some but not others in the majority of cases? Why would a healthy non concerning baby like baby A have a fatal deterioration where other compromised babies survived? it’s also interesting to note that baby A twin survived but not baby A. also If in cases of air embolism resuscitation efforts are “difficult“ and so often leads to death why would the majority of cases recover successfully And without apparent resuscitation difficulty ? Especially concerning multiple cases of twins who are in similar states of health with one pulling through and another not?

We really haven’t seen a single thing to suggest any deviance of character that in these cases I believe would be present. There isn’t anything to sugggest Lucy was out of sorts when if she had planned to kill them was unsuccessfull.
is also apparent in other cases of “nurses killing patients“ that people do notice unusual behaviour. In this case the opposite of that is true.

 

[MissMarbles]

It’s interesting to note that the doctor was originally tasked with investigating the deaths of 33 children on a ward that that normally only had “3 or 4 “deaths in a year. I don’t know if those numbers are supposed to cover Lucy’s entire time at the unit or just for the years 2015 to 2016. that’s such a massive jump if it is in one year.

I'm assuming he would have been asked to investigate all deaths over the period of time (whatever it was) rather than just ones police were suspicious about? Though it still seems like a very high figure either way.

 

[squish]

It’s interesting to note that the doctor was originally tasked with investigating the deaths of 33 children on a ward that that normally only had “3 or 4 “deaths in a year. I don’t know if those numbers are supposed to cover Lucy’s entire time at the unit or just for the years 2015 to 2016. that’s such a massive jump if it is in one year. Even covering Lucy’s entire time this is ten babies per year but I think it’s safe to say there is no concern for the years preceding 2015. I would like to find out why it is suggested that homicidal tendencies would suddenly come out after years of good service. Looking at the case the medical issues are notable but not conclusive and Lucy’s character and previous work record are all good nothing amiss. Again I think if 17 babies cases are under question with 7 having died it might go against the air embolism theory. Why fatal for some but not others in the majority of cases? Why would a healthy non concerning baby like baby A have a fatal deterioration where other compromised babies survived? it’s also interesting to note that baby A twin survived but not baby A. also If in cases of air embolism resuscitation efforts are “difficult“ and so often leads to death why would the majority of cases recover successfully And without apparent resuscitation difficulty ? Especially concerning multiple cases of twins who are in similar states of health with one pulling through and another not?

We really haven’t seen a single thing to suggest any deviance of character that in these cases I believe would be present. There isn’t anything to sugggest Lucy was out of sorts when if she had planned to kill them was unsuccessfull.
is also apparent in other cases of “nurses killing patients“ that people do notice unusual behaviour. In this case the opposite of that is true.

Letby is only accused of injecting air into the bloodstreams of the first few babies. Apart from the two she is accused of poisoning with insulin, the rest of the babies she is accused of attacking by inserting massive amounts of air into their digestive systems, not their veins.

 

[gill1109]

I think they need to feed all data about all kids treated in the unit from 2012 till 2018, all info they have, as well as the names of all unit staff working in the unit during these years, and look at the probability of the kids being killed by LL.

You are asking for something which is impossible to do ("look at the probability..."). More precisely: it is possible but only under many assumptions, and you can't prove that those assumptions are correct. Please read the RSS report about the problems of doing statistics and probability calculations in cases like this. There is a full version and a summary. Maybe you should start with the summary. RSS publishes report on dealing with uncertainty in medical “murder” cases

 

[JosieJo]

It’s interesting to note that the doctor was originally tasked with investigating the deaths of 33 children on a ward that that normally only had “3 or 4 “deaths in a year. I don’t know if those numbers are supposed to cover Lucy’s entire time at the unit or just for the years 2015 to 2016. that’s such a massive jump if it is in one year. Even covering Lucy’s entire time this is ten babies per year but I think it’s safe to say there is no concern for the years preceding 2015. I would like to find out why it is suggested that homicidal tendencies would suddenly come out after years of good service. Looking at the case the medical issues are notable but not conclusive and Lucy’s character and previous work record are all good nothing amiss. Again I think if 17 babies cases are under question with 7 having died it might go against the air embolism theory. Why fatal for some but not others in the majority of cases? Why would a healthy non concerning baby like baby A have a fatal deterioration where other compromised babies survived? it’s also interesting to note that baby A twin survived but not baby A. also If in cases of air embolism resuscitation efforts are “difficult“ and so often leads to death why would the majority of cases recover successfully And without apparent resuscitation difficulty ? Especially concerning multiple cases of twins who are in similar states of health with one pulling through and another not?

We really haven’t seen a single thing to suggest any deviance of character that in these cases I believe would be present. There isn’t anything to sugggest Lucy was out of sorts when if she had planned to kill them was unsuccessfull.
is also apparent in other cases of “nurses killing patients“ that people do notice unusual behaviour. In this case the opposite of that is true.

Not all the cases are due to air embolus..some insulin ..some milk overload etc...which obviously haven't been discussed with evidence yet.

Regarding twin A and B ..the witnesses yesterday said its possible less air was injected in twin B

Just a theory..its possible that if twin A was murdered.. its not out of the realms of possibility that because there was initial concern it may be due to the mother's blood condition (eventually ruled out) ..that a small amount of air was injected in twin B to make it seem like there was a connection.

Obviously no one knows for sure why a killer "starts" ...also if LL is a killer we have no way of knowing for sure baby A was the first

 

[Tortoise]

I think there might have been a mistake in the reporting, regarding "33 deaths".

This is what Dan O'Donoghue tweeted:

"Dr Evans tells the court that he originally examined 33 baby deaths"


This is what Chester Standard reported:

"He was asked to investigate 33 cases in total, with two insulin cases later."

--

Looking back through pre-trial news reports, in June 2019 police were investigating 33 cases which included 16 non-fatal collapses.


8 Feb 2017 - (CoCH's own investigation) - "There were 13 unexplained deaths between January 2015 and July 2016." Staffing 'inadequate' at Chester baby death hospital

May 2017 - (Police investigation began - 21 cases; 15 deaths and 6 collapses) - "DI Hughes said: 'When the investigation was first launched it was focusing on the deaths of 15 babies that occurred between the period of June 2015 and June 2016." 'In addition the investigation was also conducting a review of six non-fatal collapses during the same period." Health worker is arrested on suspicion of the murder of eight babies

Jul 2018 - (LL's first arrest - investigating 32 cases; 17 deaths and 15 collapses) - 'We are now currently investigating the deaths of 17 babies and 15 non-fatal collapses between the period of March 2015 and July 2016.' (same link as above)

Jun 2019 - (LL's 2nd arrest - investigating 33 cases; 17 deaths and 16 collapses) - "The probe has since widened and police are currently investigating the deaths of 17 babies and 16 non-fatal collapses between March 2015 and July 2016." Nurse Lucy Letby is re-arrested by police over baby babies in Cheshire

 

[Tortoise]

Just a heads up, I won't be able to cover the updates today because I'll only be here on and off.

 

[Sweeper2000]

Not all the cases are due to air embolus..some insulin ..some milk overload etc...which obviously haven't been discussed with evidence yet.

Regarding twin A and B ..the witnesses yesterday said its possible less air was injected in twin B

Just a theory..its possible that if twin A was murdered.. its not out of the realms of possibility that because there was initial concern it may be due to the mother's blood condition (eventually ruled out) ..that a small amount of air was injected in twin B to make it seem like there was a connection.

Obviously no one knows for sure why a killer "starts" ...also if LL is a killer we have no way of knowing for sure baby A was the first

Do we know if the concerns about the mother’s blood were raised in the 24 hours following baby A death? I believe it was the day after that baby b had complications.

 

[Sweeper2000]

It’s not my belief that the “kill switch” in cases of serial killers is something that happens spontaneously more that it is preceded by escalating patterns of harm on other beings Eventually leading to murder. It’s a fix the same way an addict will get “a fix”. In psychopaths there is always a low emotionality and in cases of serial killers this Low emotion creates a want of feeling and they get what they want (emotion) through the feelings bought about by the murders. It’s why they take souvenirs so they can relive the moment and kind of feel those things again.

Münchausen syndrome by proxy which doesn’t fit the bill here is the creation of false illness to draw sympathy and or attention to the caregiver.

 

[Sweeper2000]

Interesting that baby b who was “compromised at birth” and needed a ventilator shouldn’t have a fatal collapse even with a smaller amount of air but the relatively healthy twin baby A should. Also apparently no difficulty in recovery And a full recovery to discharge after four weeks.

 

[Sweeper2000]

11:07am

Mr Myers says Dr Bohin said Child A was "extremely stable" prior to collapse.
She said there was "nothing which was cause for concern".
11:04am

Dr Bohin said she is unaware of any genetic condition which would cause a baby to collapse and die within 24 hours.
She said genetic screening would only be done if staff had a suspicion the baby had a genetic condition.
11:01am

Dr Bohin said she had previously seen one example of an air embolus, and it was in a neonatal case, but was "very long ago". She said she could not recall the specifics of the case, but the air bubbles seen in the imagery were "very striking".
She said she had formed her views after excluding other possibilities.
10:58am

Dr Bohin said the first time she had contact with other medical expert Dr Evans was earlier this year, to discuss one of the cases in the trial, via a telephone conversation, as there had been a difference of opinion.
10:56am

Mr Myers refers to GMC guidance in giving evidence as an expert witness, and asks if someone who retired from clinical practice is still in the same position to give evidence for events which happened in 2015.
Dr Bohin says comeone does not lose their knowledge after retiring from on-the-job clinical practice, but if they keep up to date with clinical practice, they are not at a disadvantage.
10:52am

Ben Myers KC, for Letby's defence, is now asking questions to Dr Bohin.
Mr Myers asks if it is important that medical experts have current day-to-day experience in a medical environment.
Dr Bohin: "Not necessarily no - what you can't do is dispel the exerience they have had over many years."
She adds it is not "crucial" they have on-the-job current day-to-day experience. After further questions, she said such experience would be "advantageous".
10:45am

Dr Bohin said she looked at Child B's case "on its own merit", as with any other, when coming to a conclusion.
10:45am

She refers to the skin colour changes seen on Child B, and how "florid and different it was from anything they had seen before".
"It just didn't fit with any other potential different causes".
10:44am

Dr Bohin said other factors, such as infection or cardiac arrhythmia, could be discounted, and the only conclusion left was "air embolus".
10:43am

The prosecution refer to an event where the nasal prongs were dislodged, prior to the collapse.
Dr Bohin said the prongs can be "misplaced", and the babies are "probably quite uncomfortable", and if left for a prolonged period of time, there would be a desaturation, with prior warning.
She added: "It was noted, the prongs were replaced, and everything went back to normal".
Dr Bohin replies to the question if the misplaced prongs had anything to do with the subsequent collapse: "No, none at all".
10:41am

Dr Bohin said the circumstances of Child B's collapse were not normal, but "very concerning".
She said: "Despite being on CPAP, she was otherwise normal."
If such babies deteriorate, there is normally "prior warning", but there was "nothing to suggest she was going to collapse in this way".
10:38am

Dr Bohin says Child B was "compromised" at birth, and required respiratory support, which was "not that unusual" for someone of her prematurity.
"She stabilised very quickly," Dr Bohin added, and was "in air" with "normal" blood gases, and "stable enough" to have skin to skin contact with her mother and for feeds to be started.
10:36am

Child B collapsed at 12.33am on June 10, 2015, at the neonatal unit. She later recovered and, four weeks later, was discharged from the Countess of Chester Hospital.
10:34am

She confirms she has examined medical records, case notes and photographs for Child B, and peer-reviewed Dr Dewi Evans's report for her non-fatal collapse in June 2015.
10:32am

Dr Sandie Bohin is now giving evidence in respect of Child B.

 

[Sweeper2000]

11:38am

Mr Myers refers to a paper published by the International Journal of Critical Illness and Injury Services on air embolisms, which reports air can enter via the UVC during negative pressure in the vessel systems.
Dr Bohin says she knows this sort of thing can happen, but in adults, and is not aware of any neonatal cases.
11:32am

Mr Myers refers to the skin discolouration.
Dr Bohin explains there is a difference between a rash, such as chickenpox, and changes to colour in the skin, where it can go blue, or pale, or mottled.
11:31am

Mr Myers: "Would you agree the whole situation is sub-optimal at that moment?"
Dr Bohin: "No."
Mr Myers asks if the lack of fluids means the whole situation is sub-optimal for Child A.
Dr Bohin: "No."
11:28am

Mr Myers refers to Child A's lack of fluids for four hours.
Dr Bohin says it was "not ok", and "would not be optimal care", but he had "no IV access" and the doctors had to prioritise other matters on duty, and adds "it wouldn't cause a sudden collapse like with [Child A]."
"The only deterioration he could possibly have would be to drop his blood sugar."
11:27am

Dr Bohin said a long line can move if left in "for two weeks or more".
She said the long line would not have moved in the space of a day, and the recommendation is not to x-ray every day.
11:22am

Mr Myers refers to the insertion of the UVC and long lines.
Dr Bohin said the long line was not in the "best" position, but was in a "fine" position that was "safe" and would not cause problems with the heart.
11:15am

Dr Bohin: "Handling in a baby with respiration support can make the respiration go up."
Mr Myers asks if the heart rate would also go up.
Dr Bohin: "It can do...but not necessarily."
11:13am

She said the respiratory rate, in conjunction with other factors, would have been something staff "would have been aware of".
Mr Myers: "Would you say this was an alert?"
Dr Bohin: "Yes, but there was nothing else that needed to be done. He wasn't having a lot of desaturations.
"The next step would have been to ventilate him...and he didn't require that."
11:11am

The NICU Observation Chart is shown to the court for Child A.
Mr Myers says the respiration rate is "not stable".
Dr Bohin says it's above the normal rate, but "is stable". She said the range is 60-80 breaths, which is outside the normal range, but with CPAP breathing support, and 'in air'.
She said during the afternoon there would have been interventions which would have caused the respiration rate to rise.
11:09am

The blood gas record for Child A is shown, and Dr Bohin says the lactate number of 2.6-2.7 is 'slightly elevated' (a normal reading at the Countess was '2'), but has to be taken in context with other parameters which were normal.
11:07am

Mr Myers says Dr Bohin said Child A was "extremely stable" prior to collapse.
She said there was "nothing which was cause for concern".

 

[Sweeper2000]

It would be interesting to see how easily an individual would be able to administer an air embolism without detection. Room 1 would be easy as it’s the only room that seems to be out of sight. I might have thought that other staff would notice if someone was doing something out of the ordinary and would have been mentioned by someone already. The only thing they notifed was Lucy being present not Lucy doing things she shouldn’t have been.