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

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12:45pm

The trial is now resuming after a short lunch break.


12:50pm

Ben Myers KC, for Letby's defence, is now asking Professor Hindmarsh questions.
He said the fast-acting insulin would not be visible.
Professor Hindmarsh confirms that type of insulin would have a "distinctive smell" about it.
Mr Myers says the concentration of insulin administered could, over time, could lead to complications for the patient.
Prof Hindmarsh: "That is correct."


12:57pm

Mr Myers said it would be about 25 minutes before the insulin administered would have its effect.
Prof Hindmarsh said it would take about 25 minutes for it to have its biggest effect.
Mr Myers says other than the heart rate and vomiting, Child F did not appear to suffer any other physical symptoms than the low blood sugar levels.
He asks, given the high level of insulin seen, would there be "more powerful, physical consequences?"
Prof Hindmarsh says vomiting is not an unusual feature.
In the magnitude of features, he says, the effects would be on brain function rather than any other peripheral manifestations.
He said physical features of hypoglycaemia would "not be easy to pick up in a newborn, or a premature" baby.
"Neurologically, that's different."
The features would also be "extremely variable".
The first symptom "could, and would often be, collapse and seizure".
Mr Myers says it is an alleged 17-hour period of exposure of high levels of insulin, and if the effects would have been more apprarent.
Prof Hindmarsh says high levels of insulin have been recorded in babies with underlying conditions, and they present well up to the point of collapse.
 
1:03pm

The intensive care chart for Child F is presented to the court again.
The blood sugar reading of 2.9 is recorded for 5am.
"2.9 would present in the normal range wouldn't it?"
A normal range would be 3.5 or above, Professor Hindmarsh says.
A reading of 0.8 is at 1.54am, and 2.3 at 2.55am. Mr Myers says, while low, that is a "significant increase".
He shows an IV chart, in the intervening period at 2.05am, an administration of 10% dextrose for Child F.


1:05pm

Mr Myers says the infusion chart, shown to the court, has a 10% dextrose bolus at 4.20am.
Mr Myers adds between 4.02am and 5am, the blood glucose reading for Child F rises from 1.9 to 2.9.


1:12pm

Mr Myers refers to the level of contamination in the TPN bags.
He refers to the blood sample taken at 5.56pm on August 5, nearly 17 hours after the first TPN bag was put up for Child F.
He says that reading "only applies to the second [TPN] bag."
Professor Hindmarsh: "It did, yes."
Mr Myers: "That won't tell us what the insulin level was at 12.25am, would it?"
Prof Hindmarsh: "No, it won't. we haven't measured that."
Mr Johnson, for the prosecution, rises to clarify insulin levels.
He asks would it be reasonable to infer that if Child F has similar blood glucose levels throughout the day, he had had similar insulin levels inside him during that day.
Professor Hindmarsh says there is a caveat in that there had been efforts to raise Child F's blood sugar during the day through 10% dextrose boluses.
"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."
He adds that would be his conclusion.


1:14pm

Mr Myers has one more query, to which Professor Hindmarsh clarifies that a measurement of blood glucose is not a measurement of insulin or insulin C-Peptide, but there are 'clear relationships' between the two, and what they would be expected to be.


1:16pm

He adds the blood glucose level, via infusion, was consistent, and "it would be reasonable to assume" the insulin infusion would also be at the same rate was it was at 5.56pm as it would be as earlier in the day.
 
1:18pm

Dr David Harkness is being recalled to give evidence.
He has previously given evidence in the trial, and was employed at the Countess of Chester Hospital in summer 2015 as a paediatric registrar.
He is being asked about the night shift of August 4-5, and confirms he was accompanied by Dr Christopher Wood.
Notes showed he saw Child F on three occasions during that night shift.


1:23pm

He is asked about the 1.30am observations for Child F on August 5, of milky vomit and high heart rate.
He confirms the observations were made by himself.
He noted a 'soft continuous murmur' which is 'very common in babies'.
The plan was to rescreen, and use a second line for antibiotics.
There were "concerns" for Child F's heart rate, and that Child E, the twin baby boy, had passed away the previous night.


1:29pm

Dr Harkness's notes are shown to the court from 2.30am.
He noted Child F had 'large milky aspirate' and was 'quieter than usual'.
He said, from the heart rate observations being 'higher than normal', he was troubled by the possibility of infection, stress and pain, but those heart rates would go to 180bpm, not 200-210bpm, and come back down after a few seconds/minutes, not remain constantly high.
A septic screen and a number of blood tests were called for.
The blood sugar level of 0.8 [underlined on the note] was "very low".
Child F was "handling well" and pink and well perfused, indicating good circulation, Dr Harkness says, with heart sounds 'normal', but with a very quiet murmur.
 
1:32pm

The two problems were hypoglycaemia and tachycardia.
Dr Harkness's plan was for a dextrose bolus, a saline bolus, antibtiotics, an ECG, and to consider medicine to slow the heart rate down - but that medicine had its risks and would only be used in the event of supraventricular tachycardia.


1:36pm

Dr Harkness's note at 3.30am for Child F showed a heart rate of 204.
A discussion with the on-call consultant Dr John Gibbs, in which it was decided it was unlikely Child F had supraventricular tachycardia as the heart rate would be closer to 300bpm.
Dr Gibbs suggested repeating the fluid bolus, continue to monitor Child F, and only to consider the heart-slowing medicine if the heart rate rose to near 300.
A blood gas reading suggested Child F was dehydrated at this time.
The plan was to continue to monitor Child F's sugar levels.


1:41pm

A 10% dextrose infusion is administered for Child F at 3.50am, plus a 10% dextrose bolus at 4.20am.
Dr Harkness said the administrations had "an effect", but the blood sugar levels "kept drifting up and down".
Mr Myers, for Letby's defence, says there will be no questions asked for Dr Harkness at this time.
 
3:16am

A table, created by Professor Hindmarsh, records all of Child F's blood sugar readings from 11.32pm on August 4 to 9.17pm on August 5.
They are:
5.5 (August 4, 11.32pm)
0.8 (August 5, 1.54am)
2.3 (2.55am)
1.9 (4.02am)
2.9 (5am)
1.7 (8.09am)
1.3 (10am)
1.4 (11.46am)
2.4 (noon)
1.9 (2pm)
1.9 (4pm)
1.9 (6pm)
2.5 (7pm)
4.1 (9.17pm)

A reading of 'above 2.6' is considered 'normal'.

Professor Hindmarsh says the hypoglycaemia is "persistent" right through the day until the conclusion of the TPN bag at 6.55pm.


Added to that "For the 5am reading, the blood sugar reading signature has the initials 'LL'.

So, after the TPN bag was started, the only blood sugar reading that was in the normal range that night, was the one LL recorded!! Interesting!!
 
So LL was on the night shift on the date of Baby F's assault, and would have gone home about 8am. The bag was removed at 10am because the line tissued. This may have stored some insulin in the surrounding tissues. But his blood sugar started to improve. Then his TPN bag was replaced (when - early afternoon?), and his blood sugar started declining.

The blood sample was taken at 5:55pm, 17 hours after the blood sugar tanking, and at least several hours after the first bag was replaced. This blood test showed abnormally high levels of insulin.

Exogenous insulin lasts 4-6 hours in the body, so this blood test was revealing what came from the second bag.

Are they alleging that LL also poisoned the second bag? She wasn't working at that time. Was this baby's TPN bags made up ahead of time and stored in the fridge? Could she have had access to both of them, and did they have his name on them?

I know they previously suggested that the line would have had insulin stuck to it, but the professor said that the rate of insulin administration was consistent, and you would think the amount coming from bits left over stuck to the line wouldn't be the same as it being mixed in the bag.
 
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It's hard to know, isn't it, when we know so little about LL's 'private' life prior to her arrest. But just to address, speculatively, some of the above:

If she owned the house, she could have purchased it with (financial) assistance from her parents. From the vague bits we know, they seem very close and supportive and proud of her. And they might have seen her getting a foot on the property ladder as important. So not that out of out ordinary maybe, if the case?

I'm assuming (and please correct me if I'm wrong) you're using the outpourings on the post-it note, where she, because of the accusations, despaired of ever having a family of her own? According to a google, that was written while she was facing disciplinary proceedings at work. So after the fact. And there's no mention of a partner. If she had a partner at the time (one that she shared a mortgage with), surely she would have included mention of him/her in her 'not deserving' outpourings, along with her parents and other family members?

In essence, what I'm trying to say is that her despairing at that point over never having a normal life again doesn't seem to include having a specific partner at the time who's now eg. going to reject/abandon her because of the charges, more the damage the charges will affect and impact upon a theoretical future one. And that her property ownership or otherwise is a very moot point in the context of understanding anything useful or significant about her at the time.

I hope that makes some vague sense.

The links I refer to - Lucy Letby trial - 'I am evil, I did this': Read the 'confession note' written by nurse accused of murdering seven babies


And the post-it note - https://e3.365dm.com/22/10/1600x900/skynews-lucy-letby-confession_5929755.jpg?20221013165456

Just to add, grateful thanks to all who continue to provide the court updates/transcripts and the 'medical' people who take such care with the medical info/explanations they provide to include those of us not in the medical world. They're so helpful in trying to get to grips with the evidence at the heart of this case.
In reference to the house buying, I know about 20 years ago they had a program for nurses to be able to get help with buying a house in the UK. I am not sure if this is still the case or not.
 
So LL was on the night shift on the date of Baby F's assault, and would have gone home about 8am. The bag was removed at 10am because the line tissued. This may have stored some insulin in the surrounding tissues. But his blood sugar started to improve. Then his TPN bag was replaced (when - early afternoon?), and his blood sugar started declining.

The blood sample was taken at 5:55pm, 17 hours after the blood sugar tanking, and at least several hours after the first bag was replaced. This blood test showed abnormally high levels of insulin.

Exogenous insulin lasts 4-6 hours in the body, so this blood test was revealing what came from the second bag.

Are they alleging that LL also poisoned the second bag? She wasn't working at that time. Was this baby's TPN bags made up ahead of time and stored in the fridge? Could she have had access to both of them, and did they have his name on them?

I know they previously suggested that the line would have had insulin stuck to it, but the professor said that the rate of insulin administration was consistent, and you would think the amount coming from bits left over stuck to the line wouldn't be the same as it being mixed in the bag.
I think the evidence from yesterday shows that the stock bags were made ahead of time and stored in the fridge. They didn't have any baby's names on them and were not put in any order in the fridge. It seems pretty unlikely that she would poison a stock bag on the off chance it would be used for baby F. I think in my opinion the most likely explanation is that the first bag was never changed. I know the nurses have testified that it would have been procedure to change the bag after replacing the tissued line. But did they say they have an independent recollection of doing so?
 
I think the evidence from yesterday shows that the stock bags were made ahead of time and stored in the fridge. They didn't have any baby's names on them and were not put in any order in the fridge. It seems pretty unlikely that she would poison a stock bag on the off chance it would be used for baby F. I think in my opinion the most likely explanation is that the first bag was never changed. I know the nurses have testified that it would have been procedure to change the bag after replacing the tissued line. But did they say they have an independent recollection of doing so?


The wording from the Chester Standard is as follows:


2:44pm

The nurse says her normal practice would have been for putting a new bag of fluids on the long line.
3:07pm

Ben Myers KC, for Letby's defence, asks about the administration of the drugs, and how they are administered.
The nurse says the 10% dextrose would come in 500ml bags, and can be divided up on the unit for infusions, or come available via the pharmacy in 50ml pre-made doses.
The nurse says she does not have an independent recollection of the event.
She confirms if the long line is tissued, it cannot be used again.
Mr Myers says if the long line is changed, then everything else is changed to avoid infection, including the TPN bag. The nurse confirms that would be the case.
Mr Myers: "You wouldn't put up an old [TPN] bag, would you?"
The nurse: "I wouldn't, no. And we wouldn't have put it up as we would have documented that."

BBM. Her normal practice. A bit more specific than the normal practice but still not definitive. And I agree that the version of events that seems most consistent with the pattern of test results is that it was the same bag.
 
The wording from the Chester Standard is as follows:





BBM. Her normal practice. A bit more specific than the normal practice but still not definitive. And I agree that the version of events that seems most consistent with the pattern of test results is that it was the same bag.

I just can't be convinced it wasn't the same bag . I think they have covered all possibilities because they can't be sure.

Best practice is that everything is changed when the long line is changed..but as it was only stopped for an hour or so I wouldn't be surprised if it was left hanging at the cot side and reconnected to the new line.

I feel if a fresh bag was put up it would be documented. The bag number would be registered on the sheet and the fluid balance chart would show it also
 
I just can't be convinced it wasn't the same bag . I think they have covered all possibilities because they can't be sure.

Best practice is that everything is changed when the long line is changed..but as it was only stopped for an hour or so I wouldn't be surprised if it was left hanging at the cot side and reconnected to the new line.

I feel if a fresh bag was put up it would be documented. The bag number would be registered on the sheet and the fluid balance chart would show it also
That quote above was from a different nurse, the unnamed nurse. Probably two of them signed for it.

This was the testimony of the designated nurse -

"Miss Tomlins told the court she recalled a new TPN intravenous feed bag being set up for Baby E [F] after a longline tube needed to be replaced because it had 'tissued'.

This would have come from the padlocked fridge on the unit. Nurses had access to bespoke TPN bags for individual babies and stock bags for more general use or where there was no time to wait for a bespoke bag. [...]

Asked what type of feed bag would have been used on August 4 [5], Miss Tomlins replied: 'It would depend on whether there were any more bags made up for him.

'If we had run out I assume we would have just attached to one of our stock bags and ordered more for him. It took a few hours for them to come from the pharmacy'."

https://www.dailymail.co.uk/news/article-11462603/Lucy-Letby-Trial-Three-colleagues-nurse-say-did-NOT-administer-insulin-alleged-victim.html

I still think she's mistaken, there's no reference to her nursing notes in any of this. The chart clearly doesn't record a stock number for a new stock bag or they would have presented it, and Mr Myers wouldn't have needed to ask the other nurse "You wouldn't put up an old [TPN] bag, would you?"

I think this testimony from Prof Hindmarsh is the only information the jury needs -

Prof Hindmarsh agreed with prosecutor Nick Johnson that the blood glucose measurements relating to the second stock bag suggested that it too had been contaminated “more or less to the same degree”.

The witness agreed with Ben Myers KC, defending, that the blood sample reading of high insulin came from the second stock bag so could not show what level was in the first bag attached in the early hours of August 5.

But Prof Hindmarsh said that similar blood glucose readings around the same period from a single person would likely mean they had a similar amount of insulin in their system earlier.

Baby´s heart rate soared after receiving insulin, murder trial told

He said Child F’s initial rise in heart rate was “consistent with the release of adrenaline, your first line of defence against a low blood glucose”.


Two contaminated bags does not make sense and I think this will have to boil down to what makes most sense. IMO
 
In any case, the 'night poisoner' couldn't have known that the line was going to tissue that day, and need to be interrupted/replaced with a different bag.

Did she not think that the baby would be tested if he had died in such circumstances? Perhaps she did set up the other nurse to start the infusion and want her blamed for it.
 
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