UK - Nurse Lucy Letby Faces 22 Charges - 7 Murder/15 Attempted Murder of Babies #9

[Tortoise]

You see, this is precisely the sort of statement which seems very wide open and "catch-all", if you will.

I mean an "inflicted injury" or "injection of air"! These are two wildly different diagnoses and modes of injury. Why would an expert who was apparently looking at these cases blind (ie; with no prior information of what the police suspect) arrive at those two significantly different conclusions? Conclusions which neatly fit the prosecutions theory.

The two conclusions seem to be so far apart as to be very unlikely to be independently arrived at. I'm sure there are dozens, if not hundreds, of other possible causes for the desaturations yet these two were settled upon.

Only mh opinion, obviously.

This is opening speeches, we haven't heard the experts' evidence for N yet.

The last time this happened it turned out to be a case of sub-standard reporting:

"The expert witness suggests that a piece of equipment made of rigid plastic may have been used to cause the injury to baby E."

A more comprehensive report stated:

"Dr Evans said: “there were a number of bits of equipment on a neo-natal unit that are relatively rigid.

“Plastic tubes used for suction, for instance, so it could have been interference with that.”

He said another medical instrument known as an introducer – a thin wire surrounded by plastic which can be used to intubate a baby – would be “more than sufficient to cause trauma if used inappropriately”.

Dr Evans said: “I cannot be 100 per cent certain what caused the trauma to the gastrointestinal system but it had to be some kind of relatively stiff (equipment) which was sufficient to cause this extraordinary bleeding.”

Rigid wire could have caused baby´s `extraordinary bleeding´, court...

We've been told in the opening speech baby N was stable at 1am when his nurse left for a break. 5 minutes later he came close to death because his oxygen levels fell so low. This mirrors many other cases where the nurse left the room and the baby collapsed while LL was close by. The medical experts are best placed to determine what could have caused a sudden unexpected collapse, going from normal breathing to a severe drop in oxygen. But, we haven't heard their evidence yet.

"Conclusions which neatly fit the prosecutions theory" is a loaded sentence. What reasons do you have for doubting that the prosecution is based on many medical expert opinions?

 

[Sweeper2000]

This is opening speeches, we haven't heard the experts' evidence for N yet.

The last time this happened it turned out to be a case of sub-standard reporting:

"The expert witness suggests that a piece of equipment made of rigid plastic may have been used to cause the injury to baby E."

A more comprehensive report stated:

"Dr Evans said: “there were a number of bits of equipment on a neo-natal unit that are relatively rigid.

“Plastic tubes used for suction, for instance, so it could have been interference with that.”

He said another medical instrument known as an introducer – a thin wire surrounded by plastic which can be used to intubate a baby – would be “more than sufficient to cause trauma if used inappropriately”.

Dr Evans said: “I cannot be 100 per cent certain what caused the trauma to the gastrointestinal system but it had to be some kind of relatively stiff (equipment) which was sufficient to cause this extraordinary bleeding.”

Rigid wire could have caused baby´s `extraordinary bleeding´, court...

We've been told in the opening speech baby N was stable at 1am when his nurse left for a break. 5 minutes later he came close to death because his oxygen levels fell so low. This mirrors many other cases where the nurse left the room and the baby collapsed while LL was close by. The medical experts are best placed to determine what could have caused a sudden unexpected collapse, going from normal breathing to a severe drop in oxygen. But, we haven't heard their evidence yet.

"Conclusions which neatly fit the prosecutions theory" is a loaded sentence. What reasons do you have for doubting that the prosecution is based on many medical expert opinions?

I thought it was. With most experts opinions before dr evans conclusions in 2017 giving natural causes as reasons. although the lack of post mortems leave questions.

“Medical expert Dr Dewi Evans, who was approached by the National Crime Agency to review the case in 2017, told the trial it was "astonishing" for such a small baby to vomit as severely as Child G did”

Lucy Letby: No natural cause for baby's vomiting, doctor tells trial

A doctor tells Lucy Letby's trial he "can't think of a natural cause" for a baby's deterioration.

www.bbc.co.uk

 

[Tortoise]

I’m not sure anybody could be completely unbiased in approach to a diagnosis if the national CRIME agency approached them and said explain this doctor. It’s very different in context to a fellow doctor approaching and saying the same IMO.

Dr Evans said "He was asked to investigate 33 cases in total, with two insulin cases later.
"I was the easiest physician and the most difficult. I was a blank sheet of paper. I had no idea and relied entirely on the evidence I could see from the clinical notes and applying my clinical experience and forming an opinion to the cause."

Recap: Lucy Letby trial, Tuesday, October 25

We don't have 33 or 35 allegations in this trial. Dr Bohin independently came to the same conclusions. We've also had no conflicting medical opinions to date, on which to base argument against the expert opinions tendered in the trial. These slurs against the experts are incredible, IMO.

 

[JosieJo]

I’m not sure anybody could be completely unbiased in approach to a diagnosis if the national CRIME agency approached them and said explain this doctor. It’s very different in context to a fellow doctor approaching and saying the same IMO.

I agree that if approached by NCA then any person conducting a review would have that in mind ...but they also cannot present a case that will not stand up in court or can be ripped apart by the defence

 

[Sweeper2000]

Dr Evans said "He was asked to investigate 33 cases in total, with two insulin cases later.
"I was the easiest physician and the most difficult. I was a blank sheet of paper. I had no idea and relied entirely on the evidence I could see from the clinical notes and applying my clinical experience and forming an opinion to the cause."

Recap: Lucy Letby trial, Tuesday, October 25

We don't have 33 or 35 allegations in this trial. Dr Bohin independently came to the same conclusions. These slurs against the experts are incredible, IMO.

I suppose my point is more in regards to how “blank” it is possible for any mere mortal to be, maybe in general but also in the context of being asked to investigate anything by a organisation that’s purpose is to investigate potential crimes.

I don’t doubt that dr evans is a thoroughly experienced and professional doctor but I don’t expect perfection from anyone. It’s not really a slur just an expectation for him to be more human than not.

here are two factual and well researched cognitive phenomena that may or may not affect the way a person looks at information.


“Confirmation bias is the tendency to search for, interpret, favor, and recall information in a way that confirms or supports one's prior beliefs or values.[1] People display this bias when they select information that supports their views, ignoring contrary information, or when they interpret ambiguous evidence as supporting their existing attitudes. The effect is strongest for desired outcomes, for emotionally charged issues, and for deeply entrenched beliefs. Confirmation bias cannot be eliminated, but it can be managed, for example, by education and training in critical thinking skills.

Biased search for information, biased interpretation of this information, and biased memory recall, have been invoked to explain four specific effects:

1. attitude polarization (when a disagreement becomes more extreme even though the different parties are exposed to the same evidence)
2. belief perseverance (when beliefs persist after the evidence for them is shown to be false)
3. the irrational primacy effect (a greater reliance on information encountered early in a series)
4. illusory correlation (when people falsely perceive an association between two events or situations).”

Confirmation bias - Wikipedia

en.wikipedia.org

and


“Frequency illusion, also known as the Baader–Meinhof phenomenon or frequency bias, is a cognitive bias in which, after noticing something for the first time, there is a tendency to notice it more often, leading someone to believe that it has an increased frequency of occurrence.[1][2][3] It occurs when increased awareness of something creates the illusion that it is appearing more often.[4] Put plainly, the frequency illusion occurs when "a concept or thing you just found out about suddenly seems to pop up everywhere."[5]”

Frequency illusion - Wikipedia

en.wikipedia.org

now i would have greater faith in a diagnosis if there Is an awareness of these cognitive processes and can be proven that steps were taken to alleviate them or take them into account.

I believe that these things are factored in by the NCA but I am not sure what steps were taken by them to ensure the information was not presented in a directive way, intentionally or not.

I may be incorrect but if Baby A was presented as the first case to be reviewed by dr evans then that’s probably a starting point and why I mentioned the “frequency illusion” And “primacy effect”.

 

[ColourPurple]

We've been hearing phrases such as "the handover sheet" giving the impression that it's a single piece of paper. I got the impression, though, that all the nurses got a copy each. If that's the case then it cannot be that LL was taking it home to hide evidence or information. It would be pointless anyway as there surely would be an electronic copy.

I Used the phrase "the handover sheet"as that's how it was reported. "In Letby's home search, officers recovered the handover sheet from the morning of June 25 whic included Child Q's name. This was a document which should not have left the" hospital.

If it was just one of several copies I would have expected them to say "one of the handover sheets from the moring of the 25th or " her copy of the handover sheet".

Obviosuly the main point is that it shouldn't have left the hospital at all. Having never worked in a hospital myself can any UK nurses or doctors confirm whether the handover sheet is a single document that is supposed to be filed away at some point or something every nurse on the ward would get a copy of at the start of every shift change?

 

[ColourPurple]

You see, this is precisely the sort of statement which seems very wide open and "catch-all", if you will.

I mean an "inflicted injury" or "injection of air"! These are two wildly different diagnoses and modes of injury. Why would an expert who was apparently looking at these cases blind (ie; with no prior information of what the police suspect) arrive at those two significantly different conclusions? Conclusions which neatly fit the prosecutions theory.

The two conclusions seem to be so far apart as to be very unlikely to be independently arrived at. I'm sure there are dozens, if not hundreds, of other possible causes for the desaturations yet these two were settled upon.

Only mh opinion, obviously.

I’m not sure anybody could be completely unbiased in approach to a diagnosis if the national CRIME agency approached them and said explain this doctor. It’s very different in context to a fellow doctor approaching and saying the same IMO.

His (Dr Evans)job is exactly that... to be unbiased, and as I posted before he said he has been brought in by the NCA before on other cases and the cases were closed as he concluded the deaths were accidental.(ie there was no confirmation bias or assumption that anything the NCA asked him to investigate must automaticlaly be suspsicous). And even in this case out of 35 cases he investigated he didn't find them all suspicious and charges weren't brought for all the individual cases. He has no reason or incentive to find the cases suspicious if they're not.

A second medical expert (Dr Bohin)then peer reviewed the same cases, and came to the same conclusions (with some minor differences on some cases). There was also a third medical expert who agreed that there had been air embolus, though unfortunately they passed away before completing their review. What are the chances that having been unbiased and found nothing suspicous in some previous cases, that Dr Evans would suddenly become biased/influenced by confirmation bias when investigating this case... and then so would the second doctor... and then so would the third doctor?




"Dr Evans said he was tasked with investigating a "clinical condition", not a "crime", when he became aware of the Countess of Chester Hospital case, when tasked by the National Crime Agency.He said the scenarios added up to a "constellation of worries" on what went on between June 2015 and June 2016.He adds that in past cases, he has been brought in by police and the conclusion was accidental, so the case was closed with no further police involvement.

He is asked about his 'state of mind' in his approach to the cases."My state of mind was very clear - let's find a diagnosis. Nothing to do with crime. Let's identify any specific collapse, and see if I can explain it."There were occasions where I couldn't explain it, and occasions where I found something deeply suspicious."There were incidents I found disturbing."

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

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

 

[Tortoise]

I suppose my point is more in regards to how “blank” it is possible for any mere mortal to be, maybe in general but also in the context of being asked to investigate anything by a organisation that’s purpose is to investigate potential crimes.

I don’t doubt that dr evans is a thoroughly experienced and professional doctor but I don’t expect perfection from anyone. It’s not really a slur just an expectation for him to be more human than not.

here are two factual and well researched cognitive phenomena that may or may not affect the way a person looks at information.


“Confirmation bias is the tendency to search for, interpret, favor, and recall information in a way that confirms or supports one's prior beliefs or values.[1] People display this bias when they select information that supports their views, ignoring contrary information, or when they interpret ambiguous evidence as supporting their existing attitudes. The effect is strongest for desired outcomes, for emotionally charged issues, and for deeply entrenched beliefs. Confirmation bias cannot be eliminated, but it can be managed, for example, by education and training in critical thinking skills.

Biased search for information, biased interpretation of this information, and biased memory recall, have been invoked to explain four specific effects:

1. attitude polarization (when a disagreement becomes more extreme even though the different parties are exposed to the same evidence)
2. belief perseverance (when beliefs persist after the evidence for them is shown to be false)
3. the irrational primacy effect (a greater reliance on information encountered early in a series)
4. illusory correlation (when people falsely perceive an association between two events or situations).”

Confirmation bias - Wikipedia

en.wikipedia.org

and


“Frequency illusion, also known as the Baader–Meinhof phenomenon or frequency bias, is a cognitive bias in which, after noticing something for the first time, there is a tendency to notice it more often, leading someone to believe that it has an increased frequency of occurrence.[1][2][3] It occurs when increased awareness of something creates the illusion that it is appearing more often.[4] Put plainly, the frequency illusion occurs when "a concept or thing you just found out about suddenly seems to pop up everywhere."[5]”

Frequency illusion - Wikipedia

en.wikipedia.org

now i would have greater faith in a diagnosis if there Is an awareness of these cognitive processes and can be proven that steps were taken to alleviate them or take them into account.

I believe that these things are factored in by the NCA but I am not sure what steps were taken by them to ensure the information was not presented in a directive way, intentionally or not.

I may be incorrect but if Baby A was presented as the first case to be reviewed by dr evans then that’s probably a starting point and why I mentioned the “frequency illusion” And “primacy effect”.

When police were called in, the doctors did not know if a single crime had been committed. The police aren't medical experts. That is why they consulted the experts.

Secondly, doctors are trained to make diagnoses by looking at the patient's medical records. If the symptoms aren't there they can't just say 'I've got nothing to base this on, but I'm going to treat you for the illness I diagnosed for Mrs Brown last week'. Recognising a cause or a symptom is not the same as confirmation bias, it's how medical practitioners work. These experts knew if they mistakenly reported something as sinister as deliberate harm they had better be able to withstand a shredding in court, with loss of reputation and career.

This, IMO, is most definitely a slur against all the medical experts. What you are proposing is that these experienced and independent doctors would not be careful, mindful of the consequences, and utterly meticulous to ensure that they do not misinform the court when they say that there is evidence that a nurse deliberately killed and attempted to kill babies.

I do not think that confirmation bias or frequency illusion can explain the experts finding evidence of deliberate harm for which police identified that one single nurse was not only working every single relevant shift over the year but was recorded attending to the baby or had been in the room at the time it happened.

MOO

 

[Sweeper2000]

His (Dr Evans)job is exactly that... to be unbiased, and as I posted before he said he has been brought in by the NCA before on other cases and the cases were closed as he concluded the deaths were accidental.(ie there was no confirmation bias or assumption that anything the NCA asked him to investigate must automaticlaly be suspsicous). And even in this case out of 35 cases he investigated he didn't find them all suspicious and charges weren't brought for all the individual cases. He has no reason or incentive to find the cases suspicious if they're not.

A second medical expert (Dr Bohin)then peer reviewed the same cases, and came to the same conclusions (with some minor differences on some cases). There was also a third medical expert who agreed that there had been air embolus, though unfortunately they passed away before completing their review. What are the chances that having been unbiased and found nothing suspicous in some previous cases, that Dr Evans would suddenly become biased/influenced by confirmation bias when investigating this case... and then so would the second doctor... and then so would the third doctor?




"Dr Evans said he was tasked with investigating a "clinical condition", not a "crime", when he became aware of the Countess of Chester Hospital case, when tasked by the National Crime Agency.He said the scenarios added up to a "constellation of worries" on what went on between June 2015 and June 2016.He adds that in past cases, he has been brought in by police and the conclusion was accidental, so the case was closed with no further police involvement.

He is asked about his 'state of mind' in his approach to the cases."My state of mind was very clear - let's find a diagnosis. Nothing to do with crime. Let's identify any specific collapse, and see if I can explain it."There were occasions where I couldn't explain it, and occasions where I found something deeply suspicious."There were incidents I found disturbing."

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

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

im just wondering why the conclusions by medical experts before the NCA presented these to dr evans in 2017 were of natural causes aside from I believe one case.

i Also believe there were clear medical reasons for the conclusions of accidents in his prior cases. It’s not so clear apparently in these and so one might be left to speculate Which is where biases may come in.

it’s also I think good form to have presented these cases to DR evans in a randomised way rather than what seems to be chronologically and perhaps not by the NCA.

I would like to see the steps taken to ensure biases were not present.


an example of quite disparate sequences in the events were Baby E and Baby N. Two examples of what seems to be significant trauma but no desaturation for baby E close to the time of the alleged injury who seems to have a more significant injury but a desaturation for baby N. although I still think there may be a possible medical explanation For the disparity.

it’s certainly not a slur when some Of them originally said natural causes and then when presented to a different doctor by the police he arrives at a totally different conclusion. Why the disparity? Is it possible that the presence of the police is suggestive by itself?

i also wouldn’t suggest there has been a lack of investigatory method on the part of anyone or baseless assumption. That hasn’t been suggested by anyone including me. Only that any individual will have certain perspectives or limitations.

my thinking would be that if as I said earlier baby A was presented as the first case to DR Evans that “sets the scene“ and lens By which the cases would be looked at further down the line which may or may not constitute “primacy effect”.

“the irrational primacy effect (a greater reliance on information encountered early in a series)”

this fits with the situation if Dr Evans was presented with the cases chronologically And is part of confirmation bias.

https://en.wikipedia.org/wiki/Confirmation_biashttps://en.wikipedia.org/wiki/Confirmation_bias

 

[Tortoise]

im just wondering why the conclusions by medical experts before the NCA presented these to dr evans in 2017 were of natural causes aside from I believe one case.

it’s certainly not a slur when some Of them originally said natural causes and then when presented to a different doctor by the police he arrives at a totally different conclusion. Why the disparity? Is it possible that the presence of the police is suggestive by itself?

There have been two such cases, so far. Babies C and D. Both post-mortems stated infection.

Baby C

Dr Evans

"He says infection was a part of Child C's status. He adds it did not cause Child C's death."

"He says while Child C had an infection, he was recovering from it, as he had gone off CPAP support, on to Optiflow.
"Respiratory wise, he didn't stay the same, he was improving."

Dr Bohin

"This was not a baby who was ill, this was a baby who was improving."

Dr Bohin's conclusion was that he had pneumonia, but that did not cause the collapse or kill him.

She added babies such as Child C do not collapse suddenly and without warning. She said an infection would not be the cause as that would lead to a gradual deterioration in the baby, not a sudden collapse and no response to resuscitation.

Baby D

Dr Evans

None of the other issues, eg pneumonia were relevant.

Dr Bohin

Taking into account the sudden nature of the collapses and the very quick recovery...I was very clear it wasn't infection

Dr Bohin adds she believed Child D died with pneumonia, not because of pneumonia.

--

Baby A's cause of death was unascertained and baby E didn't have a post-mortem.


Perhaps there is a difference between a standard post-mortem examination of the body and the organs, and a full forensic evaluation, encompassing clinical history and accompanying notes and observations.

MOO

 

[Sweeper2000]

@Tortoise

i am wondering also if there is a variance in the expertise between the groups of experts who gave the causes of death prior to and after 2017. Do we know if there were any reasons given prior to the investigation for the collapses?

Dr Bohin i believe is top of the league along with many of the experts who have given testimony in court, many Of whom I believe would be approached for a peer review.

I really don’t mean to put anyone down or cast shade on anyone’s expertise.

 

[Sweeper2000]

I’m also wondering why in certain case/s the presence of air in the blood vessels and something else maybe the bowel wasn’t picked up on earlier. Did the pathologist initially not have the x rays?

a more detailed analysis could certainly explain the differences.

 

[Becci]

I've missed a fair bit because it kind of frazzled my brain.
How many postmortems got carried out & did the pathologist note air embolism as a cause of death for the babies mentioned to have had an air embolism?
If not many premature babies have a postmortem perhaps air embolism might be more common than people think.
Just my own opinion because really I'm clueless on the subject.

 

[Sweeper2000]

I've missed a fair bit because it kind of frazzled my brain.
How many postmortems got carried out & did the pathologist note air embolism as a cause of death for the babies mentioned to have had an air embolism?
If not many premature babies have a postmortem perhaps air embolism might be more common than people think.
Just my own opinion because really I'm clueless on the subject.

I think but I’m not sure that prior to 2017 only one death was thought to be an air embolism but I’m not sure. Air embolisms are said to be very rare but it is suggested they may be underreported.

“Although uncommon, it's possible to get an air or gas embolism during surgery, some medical procedures, and when ascending to a high altitude.”

Air or gas embolism

An air or gas embolism is a serious problem that can happen to scuba divers and during some medical procedures. Read about the causes, symptoms and treatments.

www.nhs.uk

 

[katydid23]

That study was done in a South African hospital and it doesn't mention anything about nurses completing notes ahead of time.

There is nothing in the nursing notes in this case that suggests they were made ahead of time, they are largely retrospective. They'd have had to predict the monitor readings and collapses.

I don't see how nurses could routinely fill out their log ahead of time. From my experience, the supervisors and doctors often check in and discuss those notes while working with a nurse concerning a patient, and how would it look if the nurse had alreAdy written down the rest of that day's activities? I'd think it would be reprimanded.

When I was at the hospital recently with my 92 yr old mom, the doctor would stand alongside our nurse, kind of looking over her shoulder as they looked at her notes about my Mom's activities and treatments that day. At that time he'd coordinate with her about future treatments and needs. I can't imagine him looking at the notes and seeing things written down that had not happened yet. I don't think it would go over well.

 

[Becci]

I’m also wondering why in certain case/s the presence of air in the blood vessels and something else maybe the bowel wasn’t picked up on earlier. Did the pathologist initially not have the x rays?

a more detailed analysis could certainly explain the differences.

Honestly i've only just read this haha well looks like i copied you but it was something that came in my mind & i went straight to type. Sorry about that

 

[katydid23]

We've been hearing phrases such as "the handover sheet" giving the impression that it's a single piece of paper. I got the impression, though, that all the nurses got a copy each. If that's the case then it cannot be that LL was taking it home to hide evidence or information. It would be pointless anyway as there surely would be an electronic copy.

I'm not sure that ALL the nurses would get a copy each. I doubt they all did.

I am not a nurse so hopefully someone will correct me if I am wrong---I just spent 2 weeks at a hospital each day while my mom was admitted there.

At each shift change, there was a handover sheet that was given to our new nurse by the previous nurse. And they would be standing right by me and verbally going over the info, with each other. And only the new nurse, WHO WAS DESIGNATED FOR MOM'S CARE, would be given the 'handover sheet.'

They did have a computer stand in the room that seemed to have ALL of the info as well, but the handover sheet was a separate piece of paper which kept track of the daily log notes, and what tests were done, treatments and medications, appointment times for additional things, etc.

And they did a very intentional face to face handover of the sheet whenever our new nurse came on and the old one left. I made it a point to listen in because I got a real cleAr understanding of what was done each day and what was planned for the next shift.

I did not get the impression that ALL the nurses had a copy of my mom's handover sheet. Only the designated one for her.
I say that because one day our designated nurse was really busy with a new patient with complications. So she came in to our room and introduced us to a newly designated nurse to take over mid shift. And that new nurse had no 'handover' sheet for Mom until she was given it right then and there by the previous nurse.


HOWEVER, any of the nurses or doctors could probably get most of that info from the computer because they also put that same data into her chart which was on the computer.

So as to LL allegedly taking the handover sheet home---I think it is possible that it was to try and hide info if it was something that was just handwritten and not yet typed into the computer.

 

[katydid23]

It’s the comparison between baby N and baby E I’m not really understanding though. Why a desat for baby N but apparently not for baby E even with what seems to be a more significant injury?

I couldn’t say if the location of the injury would cause A difference in timing of a desaturation. One might think an injury to the throat would perhaps cause a more immediate lowering of blood oxygen caused by the swelling and consequent restriction of air flow.


scheduled for the ninth of january.

Baby E:
The witness told jurors the twins were born 11 weeks premature by caesarean section but were both making good progress. She was “absolutely thrilled” with their recovery and had been told that they could be moved to a hospital closer to their home: “I was absolutely over the moon. My two boys were perfect.”


BabyN:
Baby N was born at 34 weeks, weighing 3lb 9oz. "His clinical condition was “excellent” but he had haemophilia, a blood disorder. Subsequent investigations found him to have a mild version of the disease, and children of his age do not bleed for no reason, particularly in the throat, the prosecution say. The prosecution say Lucy Letby used Child N's haemophilia as a "cover" to attack him."


So it could be that baby N, having the blood disorder, haemophilia, was more prone to desaturation than baby E, who had no blood disorder. Baby N could have issues with blood not clotting, unlike Baby E.

 

[JosieJo]

In my opinion... the answer to why the causes of death did not pick up some of the causes that the experts did is exactly the same answer as the question.." why did this go on for so long"?

Because a member of staff causing harm to their patients, especially tiny babies is unthinkable.

The cause of death decision is generally led by what the senior ward Dr thinks.

I feel its only by looking at absolutely everything related to the case ..as the the review team have that it became clearer.

 

[ColourPurple]

i Also believe there were clear medical reasons for the conclusions of accidents in his prior cases. It’s not so clear apparently in these and so one might be left to speculate Which is where biases may come in.

On what basis do you "believe" that? We have been given no information whatsoever about Dr Evan's previous cases so how did you come to that conclusion?