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

[Dotta]

Yes, I agree. One minor detail though: air of this quantity from the long line or UVC is a theoretical risk of both procedures but it is not a standard occurrence. It would be considered a "never" event (ie very serious), and it would be quite rare.

Thank you for your answers - they are much appreciated.

I hope you will stay with us here and help the laypersons to understand these medical matters

 

[Tortoise]

Yes, I agree. One minor detail though: air of this quantity from the long line or UVC is a theoretical risk of both procedures but it is not a standard occurrence. It would be considered a "never" event (ie very serious), and it would be quite rare.

Thank you. So very unlikely to re-occur the following night to Baby A's twin sister, and again to other babies in the same unit in a short time frame.

 

[magikarpmagikarp]

Thank you. So very unlikely to re-occur the following night to Baby A's twin sister, and again to other babies in the same unit in a short time frame.

Yes, extremely unlikely. Additionally, air is most likely to enter accidentally at placement and at removal. If enough air was introduced to cause a collapse, I've been taught that it would happen pretty close to the time of the air being introduced - minutes at most. But air embolism is very rare in general so I think it's hard to say anything with certainty.

 

[Legal]

Bit of a delayed reply but I got sidetracked and only remembered just now.

I agree with this.

I was looking at the charging details and I was puzzling over why there is this period of 2 1/2 months between Child J (November 27th 2015) and Child K (February 17th 2016). And I was struck by the details given by the prosecution* in regards to Child K:

[on February 17th 2016] "At 3.50am, Dr Jayaram was standing at the nurses’ station compiling his notes. Although he did not have a view into Nursery 1, Dr Jayaram was aware the deisngated nurse was not there, a fact backed up by door swipe data. Lucy Letby was the only nurse in room 1, alone with Child K.
"Feeling uncomfortable with this because he was beginning to notice the coincidence between the unexplained deaths and serious collapses and the presence of Lucy Letby, Dr Jayaram decided to check on where Lucy Letby was and where Child K was."

Recap: Prosecution opens trial of Lucy Letby accused of Countess of Chester Hospital baby murders
*Note this is not in evidence yet, it comes from the opening speech.

It seems unusual to me that the doctor would have been acutely aware and uncomfortable over two months later if nothing else was happening. IMO. It was at this point that LL was moved over to day shifts.

This post piqued my interest, so I read the RCPH Service review and put together a timeline of events. I apologise if this has already been done, but I couldn't find one. The information below comes from chapter 3 (background and context) of the report and shows that by 17th February 2016, concerns regarding the number of neonatal deaths were high. (http://allcatsrgrey.org.uk/wp/downl...final_-for_dissemination-_08_02_17_1_30pm.pdf)

2014 – Countess of Chester hospital is evidenced as performing well compared to similar sized hospitals in terms of neonatal morbidity and mortality.

June 2015 onwards – paediatric consultants begin to become concerned about a higher than normal number of neonatal deaths, several being unexpected and unexplained. Most of the deaths had post mortems, all had been reviewed and one had undergone a root cause review. Some also had obstetric secondary review examinations.

8 February 2016 – a half day high level thematic review of ten of the cases took place, followed by a review of the nursing observations, staffing and junior rotas for the 12 hours before each of the deaths. No definite causal correlation was determined.

July 2016 – further in-depth analysis of activity and acuity from June 2015 was undertaken but no explanations found for the increase in mortality. Further discussions with the consultants revealed they had noted several babies had collapsed unexpectedly and had been unresponsive to resuscitation. Some had a distinct mottled appearance which had no definite explanation.

7 July 2016 – hospital changed to Level 2 Special Care Unit due to concerns about increasing neonatal mortality and RCPCH requested to conduct a review.

 

[BackRange]

I dont know exact figures but I think air embolus especially hospital acquired are rare.
I worked in the NHS for 34 years and I honestly have never seen one

I worked in the NHS as a nurse for 30 years and only saw one, an adult following a serious RTA

 

[Legal]

I don't have a medical background so I just googled air embolus. I didn't realise this was the same condition that can affect divers if they ascend too quickly (the bends). I was reading about it on an NHS website and one of the symptoms is bloody froth from the mouth. Didn't one of the babies have blood in the mouth? Is this why they suggest air had been introduced into the baby's blood?

Air or gas embolism.

 

[Charlot123]

Bit of a delayed reply but I got sidetracked and only remembered just now.

I agree with this.

I was looking at the charging details and I was puzzling over why there is this period of 2 1/2 months between Child J (November 27th 2015) and Child K (February 17th 2016). And I was struck by the details given by the prosecution* in regards to Child K:

[on February 17th 2016] "At 3.50am, Dr Jayaram was standing at the nurses’ station compiling his notes. Although he did not have a view into Nursery 1, Dr Jayaram was aware the deisngated nurse was not there, a fact backed up by door swipe data. Lucy Letby was the only nurse in room 1, alone with Child K.
"Feeling uncomfortable with this because he was beginning to notice the coincidence between the unexplained deaths and serious collapses and the presence of Lucy Letby, Dr Jayaram decided to check on where Lucy Letby was and where Child K was."

Recap: Prosecution opens trial of Lucy Letby accused of Countess of Chester Hospital baby murders
*Note this is not in evidence yet, it comes from the opening speech.

It seems unusual to me that the doctor would have been acutely aware and uncomfortable over two months later if nothing else was happening. IMO. It was at this point that LL was moved over to day shifts.

This, actually, exists. I prefer neither to listen to Dr. Jayram, nor to form an opinion about him, but didn’t we all have moments in life, when we’d suddenly understand what was going on, and even see how it would end?

It is not something outstanding and I don’t believe in “some” transcendence; in fact, I think it is strong interest in the question multiplied by logic that is working subconsciously, weighing in probabilities. Or maybe our subconscious seeing patterns.

So I can imagine Dr. Jay walking in and LL, perhaps, feeling very nervous at that moment, and him sensing it, and having this strange feeling, premonition, if you will, that it is her. And in fact, it factors in for me, personally, but it is not objective.

So perhaps Dr. Jay, being a doctor, science-based, could not accuse because of his intuition, and needed some facts? Didn’t want to witch-hunt?

Like today, we can’t base the case on Dr. Jay’s feeling, because it is still subjective.

 

[Dotta]

I wonder if it is possible for Prosecution to prepare an IT presentation - a kind of visualisation of air embolism in a body.

With the correct data input, these blotches can be presented for the staff who saw them in real babies.

And they can confirm if the blotches were the same or not.

As there are not photos of real ones.

And also it would show how much air was needed for the blotches to appear.

Moo

 

[arrogantcat]

RSBM.

I think that's overly cynical, at least in the UK. We haven't heard any evidence of investigators trawling for opinions and only selecting those which confirm a preconceived theory.

Perhaps. I’m admittedly a cynic!

But what do you suppose happens if one side secures an expert who says sorry, but they cannot support what their case is proposing? Do they put them on the stand anyway and damage their own case? Has that ever happened?

Are we to assume it is always mere coincidence that each side happens to first approach experts who have
confirmed their respective cases?

Either that, or we accept they do indeed cherry pick their experts to favour those who support their assertions.

 

[Dotta]

Perhaps. I’m admittedly a cynic!

But what do you suppose happens if one side secures an expert who says sorry, but they cannot support what their case is proposing? Do they put them on the stand anyway and damage their own case? Has that ever happened?

Are we to assume it is always mere coincidence that each side happens to first approach experts who have
confirmed their respective cases?

Either that, or we accept they do indeed cherry pick their experts to favour those who support their assertions.

But, as I understand, experts appearing in Court must be objective.

They are, after all, the ultimate authority in their field.

Experts are highly educated and respected professionals.

Would they risk their reputation by favouring one of the sides?

I doubt it.

It would mean travesty of Justice.

Moo

 

[Legal]

Perhaps. I’m admittedly a cynic!

But what do you suppose happens if one side secures an expert who says sorry, but they cannot support what their case is proposing? Do they put them on the stand anyway and damage their own case? Has that ever happened?

Are we to assume it is always mere coincidence that each side happens to first approach experts who have
confirmed their respective cases?

Either that, or we accept they do indeed cherry pick their experts to favour those who support their assertions.

Good question! It seems they don't need to put experts who contradict their case on the stand but they do need to disclose their existence to the other side, even though it may harm their case. Lots of useful information about expert evidence at the link below.

Expert Evidence | The Crown Prosecution Service

www.cps.gov.uk

Disclosure​

Investigators are under a duty to consider all of the material gathered in the course of an investigation and decide whether it is relevant to that investigation, and, in relation to material that is not being used as evidence, the prosecutor must decide if it should be disclosed. Unused material should be disclosed to the Defence if it assists the defence case, or undermines the prosecution case. This might include any draft report prepared by an expert instructed by the prosecution.

 

[arrogantcat]

I joined just to comment on the blotching. I hope my post adheres to the rules. I have been a bedside nurse in a regional perinatal facility/NICU in the US for almost a decade. The multiple comments from multiple doctors and nurses about the unusual coloration definitely caught my attention.

Mottling, or skin with a lacy appearance, sometimes called cutis marmorata, is something we see in the NICU a fair amount. It's caused by poor skin perfusion, and can be a sign of something as simple as cold stress, or as sinister as hypotension secondary to sepsis, acidosis due to respiratory failure, and so on. With cold stress, it resolves with increasing the environmental temperature. With hypotension, it improves when circulation improves. When it's acidosis, it improves when the acidosis is corrected.

The doctors and nurses who saw the blotching on the babies at CC were definitely familiar with what we call "mottling" from poor skin perfusion. It would not have been noted as unusual. Cutis marmorata in neonates usually causes a uniformly lacy appearance, either all over the exposed limbs or all over the body. This sounded different. It sounded like they were describing whole patches of the body that were white, red, or blue. I don't recall reading that any staff suggested it signified air embolism, just that it was striking and unusual.

With that said, I use a vein transilluminator when I place peripheral IVs on infants, and after I place the PIV, I flush the vessel with saline. Watching the movement of the saline through the illuminated vessels is striking, as the blood moves out of the way, to be replaced by saline, to be replaced by blood. It travels in a branching fashion, following the branching of the vessels. It is not hard to imagine that if air bubbles were passing through circulation, the tissue there would be deprived of blood (causing whiteness); then it would become cyanotic (causing blueness). The redness could be the blood returning. So each area would have its own color, causing a patchy discoloration that shifts and then fades. I was able to find an article which describes exactly this coloration in induced air embolism (in the heart tissue of dogs rather than the skin tissue of people, but blood vessels are blood vessels and tissue is tissue), and they explain the redness as "reactive hypermia" or the rush of blood coming back to the previously ischemic area. ("THE SIGNIFICANCE OF AIR EMBOLISM DURING CARDIOPULMONARY BYPASS" by Spencer, Rossi, Yu and Koepke, from 1965) Later if I have time I will see if I can find additional information.

If I put myself in the shoes of the staff, and saw that kind of patchiness on a baby, I would have thought it striking and unusual as well. If it was my first time seeing it, and perhaps my first or second time caring for a baby who had died, I might think that it was due to the changes of the skin at death. I would not have recognized it as *possibly* signifying an air embolism at that time, though.

I also found it especially difficult to think of alternate explanations for the swollen and bloody airways of babies on CPAP, and the case of the baby whose abdomen was completely full of air to the point that the baby went into respiratory failure and died. Usually that sort of thing is caused by a bowel infection with a lot of tissue death but it sounds like there was no evidence of infection for this baby.

Welcome! An excellent first post. Many thanks for sharing your insight.

How possible is it (in your opinion) for an air embolism to be caused by negligence or poor practice? From what we’ve heard so far they are incredibly rare. Could the Defence offer this up as a plausible explanation, or is intentional introduction the only likely cause?

 

[arrogantcat]

Good question! It seems they don't need to put experts who contradict their case on the stand but they do need to disclose their existence to the other side, even though it may harm their case. Lots of useful information about expert evidence at the link below.

Expert Evidence | The Crown Prosecution Service

www.cps.gov.uk

Disclosure​

Investigators are under a duty to consider all of the material gathered in the course of an investigation and decide whether it is relevant to that investigation, and, in relation to material that is not being used as evidence, the prosecutor must decide if it should be disclosed. Unused material should be disclosed to the Defence if it assists the defence case, or undermines the prosecution case. This might include any draft report prepared by an expert instructed by the prosecution.

Fascinating! It sounds like this might only work in one direction, too - so if the Defence finds experts that support the Prosecution’s case, they are not under the same obligation to disclose that?

Off to read more at the link - many thanks for sharing!

 

[Charlot123]

I wonder if it is possible for Prosecution to prepare an IT presentation - a kind of visualisation of air embolism in a body.

With the correct data input, these blotches can be presented for the staff who saw them in real babies.

And they can confirm if the blotches were the same or not.

As there are not photos of real ones.

And also it would show how much air was needed for the blotches to appear.

Moo

I wonder, there are so many atlases of dermatology. Can the witnesses be shown pictures? To show how the skin changes looked?

 

[Tortoise]

Perhaps. I’m admittedly a cynic!

But what do you suppose happens if one side secures an expert who says sorry, but they cannot support what their case is proposing? Do they put them on the stand anyway and damage their own case? Has that ever happened?

Are we to assume it is always mere coincidence that each side happens to first approach experts who have
confirmed their respective cases?

Either that, or we accept they do indeed cherry pick their experts to favour those who support their assertions.

I don't think it works like that.

I think in a case such as this, where you have unexplained and unexpected deaths, the police would ask independent experts in the relevant sciences to review the medical records, and only if the reports came back as foul-play then they build their charges/case from there. It's evidence led. They don't have a case before they approach the experts, even though they might have questions/suspicions after interviewing witnesses.

 

[Legally Bland]

Perhaps. I’m admittedly a cynic!

But what do you suppose happens if one side secures an expert who says sorry, but they cannot support what their case is proposing? Do they put them on the stand anyway and damage their own case? Has that ever happened?

Are we to assume it is always mere coincidence that each side happens to first approach experts who have
confirmed their respective cases?

Either that, or we accept they do indeed cherry pick their experts to favour those who support their assertions.

I think you're mistaken that you believe that expert evidence is used to confirm an investigative theory, rather than inform an investigation.

If you don't have any evidence of the prosecution cherry picking expert witnesses to confirm their biases I think I'll just ignore your posts on this matter.

 

[Charlot123]

Perhaps. I’m admittedly a cynic!

But what do you suppose happens if one side secures an expert who says sorry, but they cannot support what their case is proposing? Do they put them on the stand anyway and damage their own case? Has that ever happened?

Are we to assume it is always mere coincidence that each side happens to first approach experts who have
confirmed their respective cases?

Either that, or we accept they do indeed cherry pick their experts to favour those who support their assertions.

Experts are probably paid for their time in court, aren't they? Otherwise, why would an esteemed specialist take weeks off practice/research? There are people in any country whose job includes testifying in courts. There are some who refuse doing it, either, unless summoned.

Now, on a different limb, there are specialists who are known to perform trials for different drug companies. When they give independent lectures on new treatment modalities, at big conferences or symposia, they are required to disclose the list of all companies they collaborate with, so that other participants could verify the independence of their expertise. As it is always a fine balance.

If I were to weigh in the opinion of independent court expert, I'd like to see if he/she had testified in court before, for what cases, and what was the court's decision. Also, whether they were always witnesses for the prosecution, or for the defense as well.

 

[magikarpmagikarp]

Welcome! An excellent first post. Many thanks for sharing your insight.

How possible is it (in your opinion) for an air embolism to be caused by negligence or poor practice? From what we’ve heard so far they are incredibly rare. Could the Defence offer this up as a plausible explanation, or is intentional introduction the only likely cause?

I believe that most documented cases of air embolism have been entirely unintentional. Venous air embolism is usually less likely to be fatal, however babies have a communication between their venous and arterial circulation, so are more susceptible to harm from venous air embolism. Air embolisms can occur accidentally during some surgeries (especially cardic surgery) or in the course of providing intensive care. AE has been caused by damage to the lungs from high ventilator pressures, so that air in the lungs enters circulation. This was more common years ago, before surfactant and modern ventilator strategies were developed. It can be a complication of going on ECMO (heart-lung bypass). Babies in these circumstances are incredibly sick. Air embolisms have been caused by medical error. There was a case where a paramedic respiked an IV bag and in this process introduced air to the bag. When the bag was used to give IV fluids by gravity, a very large amount of air was able to enter the patient's circulation and she had a cardiac arrest and died. (You may be able to read about this case on the FDA website.) Gravity infusion is not usually done in NICUs because the volumes are so small. It would be very unlikely for modern infusion pumps to deliver enough air through an IV to cause an air embolism unless two conditions were met: the line of fluid was unprimed, and the pump was defective.

This is an old article from 1989 about pulmonary AE (that is, air that has entered circulation from damaged lungs). It explains much of the physiology of AEs. They also describe blanching, migrating pallor, bright pink vessels.

https://adc.bmj.com/content/archdischild/64/4_Spec_No/507.full.pdf

This article describes a very sad case where a baby getting maintenance fluids collapsed and died due to air embolism that was most likely caused by medical error. They were unable to say if there was also an equipment malfunction.

https://terrellhogan-wordpress.s3.amazonaws.com/uploads/2013/01/Infant-Death-Due-to-Air-Embolism-from-Peripheral-Venous-Infusion.pdf

 

[Charlot123]

I believe that most documented cases of air embolism have been entirely unintentional. Venous air embolism is usually less likely to be fatal, however babies have a communication between their venous and arterial circulation, so are more susceptible to harm from venous air embolism. Air embolisms can occur accidentally during some surgeries (especially cardic surgery) or in the course of providing intensive care. AE has been caused by damage to the lungs from high ventilator pressures, so that air in the lungs enters circulation. This was more common years ago, before surfactant and modern ventilator strategies were developed. It can be a complication of going on ECMO (heart-lung bypass). Babies in these circumstances are incredibly sick. Air embolisms have been caused by medical error. There was a case where a paramedic respiked an IV bag and in this process introduced air to the bag. When the bag was used to give IV fluids by gravity, a very large amount of air was able to enter the patient's circulation and she had a cardiac arrest and died. (You may be able to read about this case on the FDA website.) Gravity infusion is not usually done in NICUs because the volumes are so small. It would be very unlikely for modern infusion pumps to deliver enough air through an IV to cause an air embolism unless two conditions were met: the line of fluid was unprimed, and the pump was defective.

This is an old article from 1989 about pulmonary AE (that is, air that has entered circulation from damaged lungs). It explains much of the physiology of AEs. They also describe blanching, migrating pallor, bright pink vessels.

https://adc.bmj.com/content/archdischild/64/4_Spec_No/507.full.pdf

This article describes a very sad case where a baby getting maintenance fluids collapsed and died due to air embolism that was most likely caused by medical error. They were unable to say if there was also an equipment malfunction.

https://terrellhogan-wordpress.s3.amazonaws.com/uploads/2013/01/Infant-Death-Due-to-Air-Embolism-from-Peripheral-Venous-Infusion.pdf

Thank you.

Very interesting.

So, one case of a medical error causing air embolism is, theoretically, possible, especially (this is why we need neonatologists on WS!) - in prematurity? In the context of PDA, perhaps? - but two in the same unit, one after another, are very much outside of the realm of statistical probability? Seems so. JMO.

(I had the question if maybe some equipment was not up to date, but then thought that to be certified as Level II, COCH NICU had to have up-to-date equipment. And the nurses have to be adequately trained).

 

[catgreen]

I wonder, there are so many atlases of dermatology. Can the witnesses be shown pictures? To show how the skin changes looked?

but an air embolism is not a primary dermatological problem so I think it is unlikely (perhaps impossible) that it was ever captured on a photo in the situation that it occurs, or indeed that it would then be published in an atlas of skin conditions