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

[Dotta]

LL probably only needs to be convicted of a single murder to receive a whole life tariff.

Wayne Couzens, the cop who murdered Sarah Everard, received a whole life tariff, because he abused his position of trust and power as a police officer to abduct her. He was seen on CCTV flashing his badge at her to convince her to get in his car. Normally, for committing one murder, it would not legally warrant a whole life sentence.

Lucy Letby is in a similar situation, because she is accused of abusing her position of power and trust as a nurse, in order to commit murder. Only one murder conviction will put her away for life.

Even a single attempted murder conviction would carry a much long sentence than usual, in her case.

Spot on!
As usual @squish

 

[arrogantcat]

<modsnip: Quoted post as removed>I believe some serious failings were found within the department following these deaths, too.
Following investigation there were 24 recommendations given, including to hire two more specialist consultants.

No doubt LL’s defence team will make full use of this evidence of wider failings.

Source

 

[Whitehall 1212]

LL probably only needs to be convicted of a single murder to receive a whole life tariff.

Wayne Couzens, the cop who murdered Sarah Everard, received a whole life tariff, because he abused his position of trust and power as a police officer to abduct her. He was seen on CCTV flashing his badge at her to convince her to get in his car. Normally, for committing one murder, it would not legally warrant a whole life sentence.

Lucy Letby is in a similar situation, because she is accused of abusing her position of power and trust as a nurse, in order to commit murder. Only one murder conviction will put her away for life.

Even a single attempted murder conviction would carry a much long sentence than usual, in her case.

LL is presumed innocent until found guilty. Any subsequent sentencing is a matter for the judge.

The evidence was overwhelming against WC and the circumstances resulting in his whole life tariff, in terms of a breach of trust, were deemed unique to Police Officers.



Sentencing of Wayne Couzens by Lord Justice Fulford at the Old Bailey (30th September 2021)

The judge asked Wayne Couzens to stand in the dock and said:

"You have eroded the confidence the public are entitled to have [in the police] and it is critical that every subject in this country can trust police when they encounter them."

"In my judgement the police are in a unique position which is essentially different from any other public service.

"In this country it is expected that the police act in the public interest. They are dependent on the public's consent. We trust that they will act lawfully and in the interests of society.

“The misuse of a police officer's role that has occurred in this case, is of equal seriousness as a murder carried out for the purpose equivalent for a political cause.

"It is this vital factor which in my view makes the seriousness of this case exceptionally high.

“It was an overwhelming case against the accused.”

Lord Justice Fulford sentenced Wayne Couzens to a whole-life order, meaning he will be in prison for the rest of his life without ever becoming eligible for parole.

 

[ToroCat]

I have a question.

Medcabs
Automated medication dispensing systems

Medcab Delivers Exceptional Care While Lowering Risk

The medcab is one of the best investments a hospital can make in giving nurses more time with patients while reducing their stress and the risk for errors.

www.taloncontrols.com

https://snscourseware.org/snscphs/files/1610066894.pdf

My question is not only LL’s culpability, but also, how the heck could a nurse draw unaccounted for insulin in the NICU part of the hospital?

What hospital system allows the nurse to draw insulin: 1) without a doctor’s prescription?
2) without any trace in the dispensing system?

It is insulin! And if I remember correctly, she was also accused of adding morphine? A controlled drug? How can a nurse gain access to a controlled drug without any trace? And if she can, that means, anyone can steal morphine from a hospital, and none the wiser?

Maybe Lucy was wrong, but I see a huge system error. If insulin is kept in the refrigerator and the key is passed around, unaccounted for, it is an error on behalf of the hospital. If by the end and beginning of the shift, there is no counting of the insulin vials, it is an error. No comments about LL, specifically, but human factor is a tricky thing. And what if someone decides to take insulin home to take care of the ailing relatives?

About postcards. Personal example. I once knew a lady who was buying amazing postcards made by a local crafter and reselling them at $6 per card. When I found the crafter, I found out that they cost $ 5 from her. So I bought a lot, for b-days and for the coming NY.

Then I started using them. If anyone compares my behavior when I “saved” on postcards with my regular pattern (“who cares about postcards”?), there is a major difference. I have no doubt it can be tied up to malice, if someone wants to. IRL, the explanation is different. There would be an additional peak before the NY, as “2022” is not reusable.

In short, the postcards are not a proof to me. No way. Likewise, some explanations for human behaviors would be unusual, but not necessarily, malicious.

No matter how the trial ends, Chestershire hospital HAS to invest into a better drug distribution system. It is cheaper than dealing with the trial now

Hi, first time poster here. I’m an NHS employee, working within the NHS for 13 years, so hopefully I can try and answer some of the questions you raised.

Insulin is usually stored on NHS hospital wards in a locked fridge (either code or key accessed). It should be accessible to all nurses on the ward. However, it cannot be administered by anyone (either nurse administration or patient self-administration) without a doctors prescription. The prescription is checked by the nurse prior to administration and signed for post administration on either a paper or electronic medical prescription record. Administering without an existing prescription would be a huge breach of medication dispensing/administration rules. I’ve never seen a nurse even consider doing this, it’s taken extremely seriously!

So the system described at the CoCh hospital is completely normal, and the same as every ward and hospital I’ve ever worked in. Insulin is usually relatively easily accessible on a ward (as opposed to a fully controlled drug such as morphine, which has far stricter storage and administration procedures) because so many patients need to use it at various times - on an adult ward, for example, some adults may have to take up to 6-7 injections a day, at specific times. I can’t comment on how many neonates would require insulin as treatment relative to adults, although I suspect it’s likely much less.

Insulin doses are usually quite small amounts in relative terms of the amount of insulin in a vial or pen. Standard insulin strength is U100 - 1unit=1ml. A mealtime dose of insulin for an adult is often 4-6 units (4-6ml), which is quite hard to detect when taken from a 100ml vial.

I guess what I’m trying to explain is: the dose needed for a neonate is likely to be very small, even an excessive, dangerous dose, and likely barely noticeable if taken from a 100ml insulin vial. So very hard to pick up on these amounts if being used off-prescription, even if stocks were audited daily.

I hope this is helpful!

 

[Charlot123]

Hi, first time poster here. I’m an NHS employee, working within the NHS for 13 years, so hopefully I can try and answer some of the questions you raised.

Insulin is usually stored on NHS hospital wards in a locked fridge (either code or key accessed). It should be accessible to all nurses on the ward. However, it cannot be administered by anyone (either nurse administration or patient self-administration) without a doctors prescription. The prescription is checked by the nurse prior to administration and signed for post administration on either a paper or electronic medical prescription record. Administering without an existing prescription would be a huge breach of medication dispensing/administration rules. I’ve never seen a nurse even consider doing this, it’s taken extremely seriously!

So the system described at the CoCh hospital is completely normal, and the same as every ward and hospital I’ve ever worked in. Insulin is usually relatively easily accessible on a ward (as opposed to a fully controlled drug such as morphine, which has far stricter storage and administration procedures) because so many patients need to use it at various times - on an adult ward, for example, some adults may have to take up to 6-7 injections a day, at specific times. I can’t comment on how many neonates would require insulin as treatment relative to adults, although I suspect it’s likely much less.

Insulin doses are usually quite small amounts in relative terms of the amount of insulin in a vial or pen. Standard insulin strength is U100 - 1unit=1ml. A mealtime dose of insulin for an adult is often 4-6 units (4-6ml), which is quite hard to detect when taken from a 100ml vial.

I guess what I’m trying to explain is: the dose needed for a neonate is likely to be very small, even an excessive, dangerous dose, and likely barely noticeable if taken from a 100ml insulin vial. So very hard to pick up on these amounts if being used off-prescription, even if stocks were audited daily.

I hope this is helpful!

Thank you! This is great. This is what we need, people knowing local practices…

 

[JTS101]

<modsnip: Quoted post was removed>This is pure speculation and for that I apologise, but with regard to the note, I couldn't help wondering if perhaps bullying was involved. This affects different people in different ways, but adversely affects behaviour, including feelings of guilt, not being good enough for the job, depression and and increased sense that they were at fault. Unfortunately I have seen this happen in my time and seeing the note - in part reminded me of this. Just my own speculative opinion. Bullying can take many forms such as micromanagement, not being able to question authority, inappropriate apportioning of blame etc Just my own thoughts.

 

[Kinderbelle]

The speed of gastric emptying would indeed have an impact on sugar absorption and this is one of many complicating factors in balancing medications. Intestinal gas is usually expelled rather quickly (unless there is a blockage further down) delayed gastric emptying is more likely due to reduced gastric motility - an automatic reaction of the stomach and intestines to propel food along.

You also have to consider that the above is generally considered against the standard for full male and female adults. Neonates, postnatals, paediatrics and even the blurry lines of young adults prior to adulthood (but post 18) have entirely different physiological functions - with neonates being the absolutely most delicate in that scale.
The difference between processing of sugars between a neonatal and a postnatal baby is already astronomical, never mind the difference between a neonate and a fully grown adult.

 

[Charlot123]

To be honest, I joined the thread late (sad enough that there are elderly murdered in some cases, even more difficult to read about neonate victims (( ). So some parts of threads 1 and 2 I missed.

Here is Wikipedia.

“In July 2016, the neonatal unit at the Countess of Chester Hospital stopped accepting premature infants born before 32 weeks, partially due to an unexplained high mortality rate in 2015 and 2016, instead diverting them to other hospitals in the North West of England, such as Alder Hey. A series of investigations was initiated to ascertain the reasons for the sharp rise in mortalities, with an independent review being carried out by the Royal College of Paediatrics and Child Health and the Royal College of Nursing. Despite this report finding some staffing levels "inadequate", the Foundation Trust were unable to identify the fundamental cause(s) of the high mortality rate, with the independent report similarly finding "no single cause or factor identified to explain the increase .. seen in [the] mortality numbers".

In May 2017, the Foundation Trust brought in Cheshire Police to assist with the ongoing review, stating this was to "seek assurances that enable us to rule out unnatural causes of death."

After the arrest of the main suspect, Lucy Letby, the investigation was subsequently widened to include Liverpool Women's Hospital, another location at which Letby had worked.“

The question would be, before the police was brought in, did any peer suspect LL? Or was it the other “agency”’s idea?

Now, since their neonate unit has, essentially, stopped accepting prematures younger than 32 weeks, it skewed all statistics. So, no way to compare “pre-Lucy” and “post-Lucy”.

Now…imagine there was some factor, environmental or such, that is not there anymore, Lucy or no Lucy. (Changed floors, got rid of mold, bought better equipment, who knows?). This would improve the statistics. Right?

Now let me get on a limb here. Legionella Pneumophillae. Imagine that the sometimes-deadly bacteria was not identified as the cause of the outbreak of pneumonia, partially fatal, in Bellevue-Stratford hotel in 1976. Of the 2000 American Legion convention participants, 130 people fell sick, 25 of them dying. It took scientists a year to link the three events, dirty water in air conditioners, (Legionella) pathogen and the fatalities. Imagine this…what if after a year and no answers, Philadelphia police were brought in to give their opinion? They are not biologists. What is their logical thought? Well, that maybe a person working in the hotel hates American Legion so much that he/she poisoned the convention participants?

And as I was refreshing my memory on Legionnaires disease, here is what I read: “Much thanks to Dr. Janet Stout, who in 1982 discovered the presence of Legionella in hospital water systems”.

So how many people could have died, or maybe died, of hospital-acquired pneumonia before it all got known?

What I want to say: maybe there is, or was, a factor similar to L. Pneumonia in Countess of Chester Hospital, that (the hospital) is probably not new? And it is not there because they renovated the NICU, or such? And we, mankind, have missed the opportunity to isolate one more culprit? And LL takes the blame; but even worse, we have not expanded our knowledge. Then what?

Countess of Chester Hospital alleged murders - Wikipedia

en.m.wikipedia.org

 

[arrogantcat]

This is what makes me question LL’s guilt, tbh. Between “hospitals are disorganized, and nurses have to pick extra shifts, which doesn’t help the quality of care” and “there is a nurse killing babies in the hospital”, statistically, the first one is more probable. And while I don’t have the heart to blame the hospitals, it doesn’t mean that there should be scapegoats for bad statistics, either. I am wondering why cameras in NICU and ICU are not feasible (this in the country that virtually has five cameras on four corners). Something is amiss there, seems that neither the proof is air-tight, nor is there solid evidence of LL being innocent. It will be a hard case. I always wonder if there were different explanations for LL’s behavior, including her notes. For example: LL wants to write a book, where the hero is a nurse working in the hospital. And one of her heroes is a killing nurse. So LL would be “playing” the scenario, so that the book looks more close to life. It would look odd in NICU, but not mean. (In this case, there should be pieces of book on the computer, dialogues, or such.)

There is a fairly common CBT/self coaching practice mostly known as a ‘thought download’ that encourages you to get out all the racing thoughts in your head and put them down on paper. Your worst thoughts, your defensive thoughts, your wildest fears and emotions, etc.
The idea being that it’s healthier to get them out, and you’re more able to look at them critically and not necessarily be under their spell as much once you get them ‘out of your head’.

I do this practice most days, both for myself and for clients, especially in times of emotional distress. I’ve done it in my phone notes, on the back of envelopes and receipts - whatever I have to hand. (It’s very helpful! 10/10 would recommend as long as you’re not on trial for murder)

I think most of us, especially women, can relate to having some “maybe it’s all my fault, i must be a terrible person” type thoughts when accused of doing something wrong - even when we know we’re not to blame. It’s part of the normal functioning of a human brain.

I hear these exact types of thoughts from my lovely, non-murderous female clients every day! An example of a genuinely concerning thought would be something like “they should all be thanking me for doing this” or similar distorted thinking - none of which I see on the note.

It’s a bit terrifying to think that the normal panic of the human mind could be used to ‘prove’ guilt or murder, and shown to the national press!

JMO of course - no idea what LL’s intentions were with the post it.

 

[JTS101]

Hi, first time poster here. I’m an NHS employee, working within the NHS for 13 years, so hopefully I can try and answer some of the questions you raised.

Insulin is usually stored on NHS hospital wards in a locked fridge (either code or key accessed). It should be accessible to all nurses on the ward. However, it cannot be administered by anyone (either nurse administration or patient self-administration) without a doctors prescription. The prescription is checked by the nurse prior to administration and signed for post administration on either a paper or electronic medical prescription record. Administering without an existing prescription would be a huge breach of medication dispensing/administration rules. I’ve never seen a nurse even consider doing this, it’s taken extremely seriously!

So the system described at the CoCh hospital is completely normal, and the same as every ward and hospital I’ve ever worked in. Insulin is usually relatively easily accessible on a ward (as opposed to a fully controlled drug such as morphine, which has far stricter storage and administration procedures) because so many patients need to use it at various times - on an adult ward, for example, some adults may have to take up to 6-7 injections a day, at specific times. I can’t comment on how many neonates would require insulin as treatment relative to adults, although I suspect it’s likely much less.

Insulin doses are usually quite small amounts in relative terms of the amount of insulin in a vial or pen. Standard insulin strength is U100 - 1unit=1ml. A mealtime dose of insulin for an adult is often 4-6 units (4-6ml), which is quite hard to detect when taken from a 100ml vial.

I guess what I’m trying to explain is: the dose needed for a neonate is likely to be very small, even an excessive, dangerous dose, and likely barely noticeable if taken from a 100ml insulin vial. So very hard to pick up on these amounts if being used off-prescription, even if stocks were audited daily.

I hope this is helpful!

Welcome to the forums ToroCat, it is so good to have a viewpoint from someone with direct experience. As far as I know, neonates wold require tiny amounts of insulin to correct hyperglycaemia and overdose is always a risk (i.e. the blood glucose can very suddenly fall to critical levels unexpectedly) and for a frequently used, ad needed, drug it can be hard to audit.

 

[arrogantcat]

Hi, first time poster here. I’m an NHS employee, working within the NHS for 13 years, so hopefully I can try and answer some of the questions you raised.

Insulin is usually stored on NHS hospital wards in a locked fridge (either code or key accessed). It should be accessible to all nurses on the ward. However, it cannot be administered by anyone (either nurse administration or patient self-administration) without a doctors prescription. The prescription is checked by the nurse prior to administration and signed for post administration on either a paper or electronic medical prescription record. Administering without an existing prescription would be a huge breach of medication dispensing/administration rules. I’ve never seen a nurse even consider doing this, it’s taken extremely seriously!

So the system described at the CoCh hospital is completely normal, and the same as every ward and hospital I’ve ever worked in. Insulin is usually relatively easily accessible on a ward (as opposed to a fully controlled drug such as morphine, which has far stricter storage and administration procedures) because so many patients need to use it at various times - on an adult ward, for example, some adults may have to take up to 6-7 injections a day, at specific times. I can’t comment on how many neonates would require insulin as treatment relative to adults, although I suspect it’s likely much less.

Insulin doses are usually quite small amounts in relative terms of the amount of insulin in a vial or pen. Standard insulin strength is U100 - 1unit=1ml. A mealtime dose of insulin for an adult is often 4-6 units (4-6ml), which is quite hard to detect when taken from a 100ml vial.

I guess what I’m trying to explain is: the dose needed for a neonate is likely to be very small, even an excessive, dangerous dose, and likely barely noticeable if taken from a 100ml insulin vial. So very hard to pick up on these amounts if being used off-prescription, even if stocks were audited daily.

I hope this is helpful!

Super helpful! Thank you for sharing your insights and knowledge, and welcome to the forum!

Have you any insight into what would be routinely checked in the blood work?

 

[Whitehall 1212]

Hi, first time poster here. I’m an NHS employee, working within the NHS for 13 years, so hopefully I can try and answer some of the questions you raised.

Insulin is usually stored on NHS hospital wards in a locked fridge (either code or key accessed). It should be accessible to all nurses on the ward. However, it cannot be administered by anyone (either nurse administration or patient self-administration) without a doctors prescription. The prescription is checked by the nurse prior to administration and signed for post administration on either a paper or electronic medical prescription record. Administering without an existing prescription would be a huge breach of medication dispensing/administration rules. I’ve never seen a nurse even consider doing this, it’s taken extremely seriously!

So the system described at the CoCh hospital is completely normal, and the same as every ward and hospital I’ve ever worked in. Insulin is usually relatively easily accessible on a ward (as opposed to a fully controlled drug such as morphine, which has far stricter storage and administration procedures) because so many patients need to use it at various times - on an adult ward, for example, some adults may have to take up to 6-7 injections a day, at specific times. I can’t comment on how many neonates would require insulin as treatment relative to adults, although I suspect it’s likely much less.

Insulin doses are usually quite small amounts in relative terms of the amount of insulin in a vial or pen. Standard insulin strength is U100 - 1unit=1ml. A mealtime dose of insulin for an adult is often 4-6 units (4-6ml), which is quite hard to detect when taken from a 100ml vial.

I guess what I’m trying to explain is: the dose needed for a neonate is likely to be very small, even an excessive, dangerous dose, and likely barely noticeable if taken from a 100ml insulin vial. So very hard to pick up on these amounts if being used off-prescription, even if stocks were audited daily.

I hope this is helpful!

Super informative. Thanks @ToroCat and welcome to the thread

 

[JTS101]

You also have to consider that the above is generally considered against the standard for full male and female adults. Neonates, postnatals, paediatrics and even the blurry lines of young adults prior to adulthood (but post 18) have entirely different physiological functions - with neonates being the absolutely most delicate in that scale.
The difference between processing of sugars between a neonatal and a postnatal baby is already astronomical, never mind the difference between a neonate and a fully grown adult.

very good points Kinderbelle. I was trying to raise the point that even in neonates, gastric motility can vary, so can sugar absorption (which again could be independent of GM). You are absolutely right is that the difference between neonates - paediatrics and adults are astronomic. One other point is that neonates have developing physiology in many respects whereas adult physiology should be fully developed. This may be important in how the body responds to its own signals. I do admit that this is not my area of expertise, so I fondly welcome any comments

 

[Kinderbelle]

very good points Kinderbelle. I was trying to raise the point that even in neonates, gastric motility can vary, so can sugar absorption (which again could be independent of GM). You are absolutely right is that the difference between neonates - paediatrics and adults are astronomic. One other point is that neonates have developing physiology in many respects whereas adult physiology should be fully developed. This may be important in how the body responds to its own signals. I do admit that this is not my area of expertise, so I fondly welcome any comments

Your point about neonates having a developing system is spot on. In fact, full term babies gastric systems are considered incredibly delicate to a number of factors for a number of years. It's the reason there are formula milks designed to nurture the specific ages of 0-6 months, 6-12 months, 12 months and 2 + years (which are generally called "Follow On" milks, and you are recommended to give an infant under 12 months absolute minimum cows milk of any form. Even then, Follow On and Cows milk are only for babies who are weaned.

They don't just make these things up as they go along. There are reasons the NHS and NICE have strict guidelines about everything from sleep to poop to milk for newborn babies. The guidelines and protocols for NICU and PICU babies are even stricter.

The following link takes you to the recommendations for Neonatal Critical Care in NHS England, which are the recommendations LL would have been beholden to.

https://www.england.nhs.uk/wp-content/uploads/2019/12/Implementing-the-Recommendations-of-the-Neonatal-Critical-Care-Transformation-Review-FINAL.pdf

Another note to those in the USA and world wide: NHS England guidelines, protocols and standards can differ from that of NHS Scotland, NHS Northern Ireland, and NHS Wales. As much as you guys think we are one big happy family, when it comes to the NHS we are absolutely not.

****Lucy Letby was employed under NHS England and she was beholden to the standards set out under NHS England****

ETA: Info about milk for babies.

 

[ToroCat]

Super helpful! Thank you for sharing your insights and knowledge, and welcome to the forum!

Have you any insight into what would be routinely checked in the blood work?

With neonates, no, unfortunately, I couldn't tell you! but the evidence for one of the neonates that showed a low c-peptide and high insulin level is interesting. It indicates that exogenous (outside) insulin has been administered somehow. That neonate was, if I remember correctly, not prescribed insulin and was also on TPN (apologies if I am wrong!).

FWIW, prescribed insulin is not deliberately added to TPN bags routinely in the U.K. for adults, but I’m not sure of routine practice for neonates. I’d be surprised if it was though, as it’s generally thought to be much less safe than separate insulin administration.

 

[MachinaCollecta]

Thank you for your insights MachinaCollecta, Hyperglyceamia and Hypoglycaemia (high and low blood sugar) is a very complex situation and can have many causes, not always related to insulin (e.g. mother having gestational diabetes, some medications, infections, other medical conditions). If there was, for example, insulin resistance in the neonate (I do not know how rare this is), then that would make titration of blood glucose with insulin more challenging. On a note of concern was the low c-peptide levels previously reported. Insulin is made by the body together with c-peptide in equal amounts so a low c-peptide with high insulin indicates that insulin was introduced from the outside (insulin starts to disappear from the circulation within minutes, but c-peptide remains much longer). Also, I do not know if the blood samples were taken pre- or post mortem. Post mortem readings would have very little value.

Thank you for the insight! This shows that the issue is more complex than you might think, looking at this as a layman.

 

[Charlot123]

I thought that maybe in premature infants, pancreas is not developed enough to produce proteases that cleave proinsulin, but Child F had extremely high insulin measurements; in itself, it might be even more damning as it would be hard to imagine his pancreas being that effective, unless he had insulinoma. (But then, C-peptide should be high, too). So, yes, exogenous, or it seems so.

 

[bbsaz]

This is key. I really think the jury might benefit from visiting a neonatal or SCBU ward to see some infants of a similar age to those in this case to contextualise this (if that were remotely possible). We’re talking about incredibly tiny, fragile infants. Babies whose skin is so delicate that the wrong type of bandage can tear it. Babies who can fit in the palm of your hand. Babies whose organs haven’t all finished developing yet.

It’s an incredibly delicate and complex area of healthcare. The margins for error are especially fine in this patient group.

I'm not sure I agree - this was a level 2 unit, not level 3. Surely babies that fragile and small would be in the Womens or Arrow Park (level 3)?

 

[Dcflag]

I have a question.

Medcabs
Automated medication dispensing systems

Medcab Delivers Exceptional Care While Lowering Risk

The medcab is one of the best investments a hospital can make in giving nurses more time with patients while reducing their stress and the risk for errors.

www.taloncontrols.com

https://snscourseware.org/snscphs/files/1610066894.pdf

My question is not only LL’s culpability, but also, how the heck could a nurse draw unaccounted for insulin in the NICU part of the hospital?

What hospital system allows the nurse to draw insulin: 1) without a doctor’s prescription?
2) without any trace in the dispensing system?

It is insulin! And if I remember correctly, she was also accused of adding morphine? A controlled drug? How can a nurse gain access to a controlled drug without any trace? And if she can, that means, anyone can steal morphine from a hospital, and none the wiser?

Maybe Lucy was wrong, but I see a huge system error. If insulin is kept in the refrigerator and the key is passed around, unaccounted for, it is an error on behalf of the hospital. If by the end and beginning of the shift, there is no counting of the insulin vials, it is an error. No comments about LL, specifically, but human factor is a tricky thing. And what if someone decides to take insulin home to take care of the ailing relatives?

About postcards. Personal example. I once knew a lady who was buying amazing postcards made by a local crafter and reselling them at $6 per card. When I found the crafter, I found out that they cost $ 5 from her. So I bought a lot, for b-days and for the coming NY.

Then I started using them. If anyone compares my behavior when I “saved” on postcards with my regular pattern (“who cares about postcards”?), there is a major difference. I have no doubt it can be tied up to malice, if someone wants to. IRL, the explanation is different. There would be an additional peak before the NY, as “2022” is not reusable.

In short, the postcards are not a proof to me. No way. Likewise, some explanations for human behaviors would be unusual, but not necessarily, malicious.

No matter how the trial ends, Chestershire hospital HAS to invest into a better drug distribution system. It is cheaper than dealing with the trial now.

Full disclosure. I work in a vets. Not a hospital of any kind treating any human.

Our insulin isn’t locked away. It’s in a fridge. As for counting vials, it just isn’t possible. Say your vials at 15ml and you’re needing 1ml. You’re going to be drawing from one vial for a while and it’s not going to be easily discerned if a small amount has been drawn.

Having said, I’ve no idea why insulin isn’t locked away. You’d think ideally there would be the need for two keys to access the controlled drugs, with only one key to one person.

 

[Dcflag]

To be honest, I joined the thread late (sad enough that there are elderly murdered in some cases, even more difficult to read about neonate victims (( ). So some parts of threads 1 and 2 I missed.

Here is Wikipedia.

“In July 2016, the neonatal unit at the Countess of Chester Hospital stopped accepting premature infants born before 32 weeks, partially due to an unexplained high mortality rate in 2015 and 2016, instead diverting them to other hospitals in the North West of England, such as Alder Hey. A series of investigations was initiated to ascertain the reasons for the sharp rise in mortalities, with an independent review being carried out by the Royal College of Paediatrics and Child Health and the Royal College of Nursing. Despite this report finding some staffing levels "inadequate", the Foundation Trust were unable to identify the fundamental cause(s) of the high mortality rate, with the independent report similarly finding "no single cause or factor identified to explain the increase .. seen in [the] mortality numbers".

In May 2017, the Foundation Trust brought in Cheshire Police to assist with the ongoing review, stating this was to "seek assurances that enable us to rule out unnatural causes of death."

After the arrest of the main suspect, Lucy Letby, the investigation was subsequently widened to include Liverpool Women's Hospital, another location at which Letby had worked.“

The question would be, before the police was brought in, did any peer suspect LL? Or was it the other “agency”’s idea?

Now, since their neonate unit has, essentially, stopped accepting prematures younger than 32 weeks, it skewed all statistics. So, no way to compare “pre-Lucy” and “post-Lucy”.

Now…imagine there was some factor, environmental or such, that is not there anymore, Lucy or no Lucy. (Changed floors, got rid of mold, bought better equipment, who knows?). This would improve the statistics. Right?

Now let me get on a limb here. Legionella Pneumophillae. Imagine that the sometimes-deadly bacteria was not identified as the cause of the outbreak of pneumonia, partially fatal, in Bellevue-Stratford hotel in 1976. Of the 2000 American Legion convention participants, 130 people fell sick, 25 of them dying. It took scientists a year to link the three events, dirty water in air conditioners, (Legionella) pathogen and the fatalities. Imagine this…what if after a year and no answers, Philadelphia police were brought in to give their opinion? They are not biologists. What is their logical thought? Well, that maybe a person working in the hotel hates American Legion so much that he/she poisoned the convention participants?

And as I was refreshing my memory on Legionnaires disease, here is what I read: “Much thanks to Dr. Janet Stout, who in 1982 discovered the presence of Legionella in hospital water systems”.

So how many people could have died, or maybe died, of hospital-acquired pneumonia before it all got known?

What I want to say: maybe there is, or was, a factor similar to L. Pneumonia in Countess of Chester Hospital, that (the hospital) is probably not new? And it is not there because they renovated the NICU, or such? And we, mankind, have missed the opportunity to isolate one more culprit? And LL takes the blame; but even worse, we have not expanded our knowledge. Then what?

Countess of Chester Hospital alleged murders - Wikipedia

en.m.wikipedia.org

LL was moved from the night shift to day shift, and then subsequently to admin duties. This was before the police were involved, and around the time the independent review was carried out. They looked at a great deal more babies than on the charge list.

As for the limb you’re out on, I’m not sure there’s any pathogen that’s going to cause air inside the neonates, or synthetic insulin. But aside from that, it’s interesting reading. Reminds me completely off topic of Brittany Murphy.