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

[ConcernedThirdParty]

Sorry to spam posts - I'm a little unsure if the experts are going to produce evidence of either this happening in other known cases of air embolism, or if they have no such record, what this pattern might be, what the mechanism that causes it is and why that is suggestive of air embolism - the prosecution haven't hinted that we're going to hear that specifically so far - it's probably in their written reports somewhere and up to the defence to find and raise in questioning. Without that, it only serves to show that certain cases might have a common cause.

From the descriptions so far, I'm imagining the white and purple (and also red and blue and black) blotchy/mottled skin pattern they're describing is "Livedo reticularis" - which sounds like a specific thing and it is in the sense that there is a specific mechanism, but the degree of the contrast between white and purple etc and the potential causes are many. Whatever it is, it's not going to be something unknown to medical science or else how can they allege it shows anything if we have no idea what it is or what it indicates?

 

[ConcernedThirdParty]

Except the defence hasn't raised or questioned most of these points you have made....they certainly haven't questioned him on any biases he may have because of it being a police investigation. In fact they haven't tried to discredit him in any way. Even after all their questioning and hypothesising he maintained his conclusion that it was administered air. His research started long before the police investigation in any case.

That's the only evidence the jury have so far. Credible expert testimony from 3 medical experts from different parts of the country, practice and reviewing different information - all of whom have said the air was administered. Professor Arthur in particular will come across very credibly as GOSH is the largest centre of research into children's health in Europe and also at the forefront of child health care in this country. His thinking and conclusions will be very powerful. I think the defence would struggle to find an expert as credible tbh.

The defence hasn't introduced reasonable doubt yet, because there's still no explanation for the blotches that also work for the air at the base of the spine. If I was on a jury, I would trust 3 medical experts over a defence lawyer....

Looking at one of the post-mortem X-rays, he highlighted to the court there was gas within the bowel, he said a normal feature, and also the heart.
Prosecutor Nick Johnson QC asked if there was anything unusual about the X-ray.
Dr Arthurs replied: "You can also see a line of gas just in front of the spine. That is an unusual finding."
He said such an image would not be seen in deaths by natural causes but had been documented in cases of road traffic accidents and sepsis infection.
"In my opinion this was an unusual appearance. In the absence of any other explanation this appearance is consistent with, but not diagnostic, of air having been administered," he said.

Mr Johnson asked: "Have you ever seen this much gas in a baby that has not been explained?" to which Dr Arthurs replied: "Only in one other case."

When Mr Johnson said: "One of the other children in this case?", the doctor replied: "That's right."

Dr Arthurs said he based his opinion on a published peer-reviewed study in 2015 which looked at how common it is that gas occurs in older children who have died, albeit with "very few babies" included in the study.
He went on to review the deaths of 500 infants at Great Ormond Street. Mr Myers says Prof Arthurs looked at 500 cases at Great Ormond Street Hospital, which after narrowing down the criteria, amounted to 38 babies aged under two months, and of those, eight had gases in the greater vessels"

That is slightly different to the wording on Chester Standard - so it does seem that the placement in front of the spine is unusual in "natural causes" - though that still seems oddly to be in contrast to infection and though not mentioned in this source SIDS/SUID, which I would consider natural...

And the study from 2015 included presumably fewer babies than the 38 he found at GOSH of which 8 had similar findings - the point the Defence made was that his threshold for "unusual" was about 25% of the time.

The defence has already alluded to confirmation bias in the opening. There's plenty of time to raise that issue, but probably questioning people directly if they think they're falling victim to confirmation bias isn't the way to do it - really you'd want to have some other medical experts offer a different explanation (which we won't hear from until after the prosecution has called all their witnesses), but the defence doesn't really have equality of arms here because they haven't been able to conduct a multi-million pound investigation over 6 years - they're mostly stuck with what the police investigation chose to look at. I expect these points to be mostly made in closing, unless they are able to bring on an expert in confirmation bias in expert testimony or something like that (there are definitely people whose research would qualify them as such an expert).

 

[merrypason]

That is slightly different to the wording on Chester Standard - so it does seem that the placement in front of the spine is unusual in "natural causes" - though that still seems oddly to be in contrast to infection and though not mentioned in this source SIDS/SUID, which I would consider natural...

And the study from 2015 included presumably fewer babies than the 38 he found at GOSH of which 8 had similar findings - the point the Defence made was that his threshold for "unusual" was about 25% of the time.

The defence has already alluded to confirmation bias in the opening. There's plenty of time to raise that issue, but probably questioning people directly if they think they're falling victim to confirmation bias isn't the way to do it - really you'd want to have some other medical experts offer a different explanation (which we won't hear from until after the prosecution has called all their witnesses), but the defence doesn't really have equality of arms here because they haven't been able to conduct a multi-million pound investigation over 6 years - they're mostly stuck with what the police investigation chose to look at. I expect these points to be mostly made in closing, unless they are able to bring on an expert in confirmation bias in expert testimony or something like that (there are definitely people whose research would qualify them as such an expert).

And when they do that, I'll listen to what they have to say. But as it stands, and going by what is available to the jury and the public, they haven't done anything to challenge the witnesses' or experts' credibly. So you may think there's confirmation bias, the defence may think there's confirmation bias - but as of now - what evidence do the jury have to think that? And what reason do they have for not trusting the experts in front of them?

 

[notsure]

And when they do that, I'll listen to what they have to say. But as it stands, and going by what is available to the jury and the public, they haven't done anything to challenge the witnesses' or experts' credibly. So you may think there's confirmation bias, the defence may think there's confirmation bias - but as of now - what evidence do the jury have to think that? And what reason do they have for not trusting the experts in front of them?

The experts have not so far made any definite statements, as far as I've seen. They made observations based on their retrospective perusals of the cases and based on previous studies in hospitals with older children. I thought the defence team did a good job in raising questions about possible causes of air embolism, e.g., use of catheters and several other possibilities. Which the experts agreed were possible.

 

[merrypason]

Their statements are as definitive as anyone can be in the medical profession. As an example, birth control has a few% chance of failing. On the witness stand, someone testifying to its effectiveness would have to agree there was a chance it could fail. It still doesn't stop majority of the medical profession recommending it as a strong choice for protection against pregnancy and the public accepting that risk.

So for a lot of people hearing the same expert medical opinion from three people, of different regions/specialisms/assessing different info (x-rays v just medical notes etc) is powerful. No one knows how the jury will take in the information, but I would expect some of them would see today's testimony as evidence Child A's death was intentional.

 

[merrypason]

This was the defence's opening statement regarding child A.

The defence do not accept, for Child A, an air embolus was the cause, but one of "sub-optimal care", as a result of either "lack of fluids" or "various lines put into him, with potential to interfere with his heart rate".
"You will hear in this case, that the air present after death does not indicate an air embolus."

Mr Myers said air present in the abdomen "can happen post-mortem

Interestingly, he did not address Professor Arthur's point about the large amount of air by the base of the spine being unusual. He also hasn't addressed the blotches which happened before the post mortem. Based on the reporting he conflated air in the abdomen as being the reason for a finding of air embolus and questioned the Prof accordingly. The Prof said air in the abdomen wasn't unusual, it was the base of the spine and the large volume of it. The defence didn't actually question the volume of air either.

 

[Tortoise]

I haven't seen mention of the base of the spine in any of the reports today.

I have found this quote which is more specific than the other reports which only say "a line of gas just in front of the spine" -

"But the doctor then pointed out a third accumulation of gas – in a line just in front of the spine, running from the stomach to just beyond the heart."

Lucy Letby trial: Emotional nurse felt final heartbeat of newborn twin 'murdered', court hears

 

[JosieJo]

I haven't seen mention of the base of the spine in any of the reports today.

I have found this quote which is more specific than the other reports which only say "a line of gas just in front of the spine" -

"But the doctor then pointed out a third accumulation of gas – in a line just in front of the spine, running from the stomach to just beyond the heart."

Lucy Letby trial: Emotional nurse felt final heartbeat of newborn twin 'murdered', court hears

 

[JosieJo]

That made me go cold ...I've not been able to get the umbilical catheter still being in situ out of my head ...that along with LL writing ..line in situ Dr said not to use it.

 

[JosieJo]

@Tortoise can you remember whether LL herself documented anything herself regarding the rash on Baby A ? I've been searching but can't find anything

 

[Tortoise]

@Tortoise can you remember whether LL herself documented anything herself regarding the rash on Baby A ? I've been searching but can't find anything

I haven't seen it reported that she did.

 

[JosieJo]

I haven't seen it reported that she did.

Thanks

 

[ConcernedThirdParty]

This was the defence's opening statement regarding child A.

The defence do not accept, for Child A, an air embolus was the cause, but one of "sub-optimal care", as a result of either "lack of fluids" or "various lines put into him, with potential to interfere with his heart rate".
"You will hear in this case, that the air present after death does not indicate an air embolus."

Mr Myers said air present in the abdomen "can happen post-mortem

Interestingly, he did not address Professor Arthur's point about the large amount of air by the base of the spine being unusual. He also hasn't addressed the blotches which happened before the post mortem. Based on the reporting he conflated air in the abdomen as being the reason for a finding of air embolus and questioned the Prof accordingly. The Prof said air in the abdomen wasn't unusual, it was the base of the spine and the large volume of it. The defence didn't actually question the volume of air either.

He questioned his definition of unusual - pointing out that there was air by the base of the spine in 8 of the 38 cases he reviewed (which were not apparently murder by air embolus) and at the same time highlighting that there were only 38 babies under 2 months in that study and the other study didn't really look at babies. The professor agreed that other causes are possible - including problems with lines etc.

I think we're also approaching this with different priors - a nurse deliberately causing an air embolus is exceedingly rare, seeing a common illness present in an unusual manner or having no definitive explanation for an illness or death is not actually that uncommon in medicine. It's so common in babies that there is a term for it that came up today - Sudden Unexpected Infant Death - explanations are sometimes found for these post-mortem, but not always.

But you're also hearing a lot more certainty than I think is there:
"In my opinion this was an unusual appearance. In the absence of any other explanation this appearance is consistent with, but not diagnostic, of air having been administered"

 

[Tortoise]

He questioned his definition of unusual - pointing out that there was air by the base of the spine in 8 of the 38 cases he reviewed (which were not apparently murder by air embolus) and at the same time highlighting that there were only 38 babies under 2 months in that study and the other study didn't really look at babies. The professor agreed that other causes are possible - including problems with lines etc.

I think we're also approaching this with different priors - a nurse deliberately causing an air embolus is exceedingly rare, seeing a common illness present in an unusual manner or having no definitive explanation for an illness or death is not actually that uncommon in medicine. It's so common in babies that there is a term for it that came up today - Sudden Unexpected Infant Death - explanations are sometimes found for these post-mortem, but not always.

But you're also hearing a lot more certainty than I think is there:
"In my opinion this was an unusual appearance. In the absence of any other explanation this appearance is consistent with, but not diagnostic, of air having been administered"

I think he qualified that statement about sudden unexpected death - (BBM below)

"Trapped air such as this, Prof Arthurs explains, could be found in cases such as road traffic accidents, or infection such as sepsis - overwhelming infection in the organs of the body, or "very occasionally" outside of hospital in 'sudden unexpected death in infants'."

 

[merrypason]

But you're also hearing a lot more certainty than I think is there:
"In my opinion this was an unusual appearance. In the absence of any other explanation this appearance is consistent with, but not diagnostic, of air having been administered"

Because that's as much certainty as you're going to get in a trial like this. In fact in any medical opinion, there is always a possibility it could be something else. That's why we are encouraged to get a second opinion for diagnoses. So for me, the fact there's a second and a third opinion (from very different doctors and researchers) is enough certainty. The expert's theory works because it also explains the blotches - which the defence have not explained yet. They may have another explanation but so far I haven't heard it. And I wouldn't want to speculate on what they might present.

Until a defence expert presents an equally compelling alternative theory also backed up by a second opinion, that would also explain the blotches and why they happened so frequently in such a short period of time - the evidence to a layperson feels compelling that air was administered to Child A deliberately.

 

[Tortoise]

Because that's as much certainty as you're going to get in a trial like this. In fact in any medical opinion, there is always a possibility it could be something else. That's why we are encouraged to get a second opinion for diagnoses. So for me, the fact there's a second and a third opinion (from very different doctors and researchers) is enough certainty. The expert's theory works because it also explains the blotches - which the defence have not explained yet. They may have another explanation but so far I haven't heard it. And I wouldn't want to speculate on what they might present.

Until a defence expert presents an equally compelling alternative theory also backed up by a second opinion, that would also explain the blotches and why they happened so frequently in such a short period of time - the evidence to a layperson feels compelling that air was administered to Child A deliberately.

Perhaps some folk are waiting to hear the evidence of the experts who we've so far only been told will say the skin blotching/discolouration that none of the staff had seen before was a sign of air injected in the preceding few minutes?

It seems the defence were very keen to try to discredit the doctor's evidence of what he had seen.

 

[Charlot123]

11:34am

The trial is now resuming, with the next witness, Prof Owen Arthurs, consultant paediatric radiologist at Great Ormond Street Hospital, giving evidence.

11:34am

The court hears he has reviewed "many of the children in this case", and will be asked questions about Child A and Child B.

11:43am

Prof Arthurs is asked about a post-mortem x-ray for Child A.
He comments "unusual findings" in gas and air found in the baby boy, including "a line of gas just in front of the spine".

11:44am

He said such a finding is not found in cases of 'natual causes' death in babies.

11:47am

Trapped air such as this, Prof Arthurs explains, could be found in cases such as road traffic accidents, or infection such as sepsis - overwhelming infection in the organs of the body, or "very occasionally" outside of hospital in 'sudden unexpected death in infants'.

Recap: Lucy Letby trial, Friday, October 21

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

www.chesterstandard.co.uk

Still, since we can always accuse LL, is there a chance of hospital-acquired infection in these preemies? They come in outbreaks, but given they became more rare, this can be missed. Staph infections constitute 70% of septic infections in preemies, the other 20% fall on very nasty gas-forming bacteria. In this article, I paid attention that the carriers may be healthy staff. Neonatal Hospital-Acquired Infection - Pediatrics - Merck Manuals Professional Edition

P.S. and then I Googled "mottled skin in neonates". Two things popped up: strep B and (surprise!): in preemies - when they are exposed to cold. It doesn't take much because thermoregulation is impaired in them. So, either Lucy not covering them well, or something else not being regulated on the unit could cause that rash, blotches that later disappeared. The rash immediately dissappears when the baby is warmed up. But Google for yourself, I was surprised at how distinctive it looks.

 

[Charlot123]

Also we know in some of the other cases too other nurses and doctors noticed a rash. It's very hard to doubt a rash if multiple different people on different occasions have spotted it. So by the end of the trial, you may have a large list of witnesses to this rash, not needing a photo as evidence. In fact I think for one of the other cases, it was noted in the medical notes at the time as well.

Obviously several people saw it, so, believable. Are they specialists in rashes, however? Rashes are so tricky.

I looked up rashes in neonates; common or uncommon, they usually would not disappear postmortem. The one that could disappear was, as I have mentioned prior, exposure to cold; another mottling change of the skin was due to Strep B infection.

LL as the source of any hospital-borne infection on the unit, sounds plausible. This could explain so much, why no deaths when she started working, and then a slew of deaths (when she acquired the pathogen), and indeed, somehow these deaths being linked to her, but no one really understanding what was going on, and such different symptoms in these babies. This has happened before. JMO. (Tracking the depositions and not doubting the doctors' opinion; it is a horrible accusations, hence, so many questions).

 

[notsure]

Years ago, a senior medical consultant, an expert in his field, diagnosed me with a rare condition because of a distinctive rash he noticed on my legs. Afterwards, I realised that this "rash" was actually a pattern of indentations caused by sitting with my handbag pressing the fabric of my skirt against my lap. This and other misdiagnoses over the years have led me to realise that experts are not infallible.

 

[arrogantcat]

Years ago, a senior medical consultant, an expert in his field, diagnosed me with a rare condition because of a distinctive rash he noticed on my legs. Afterwards, I realised that this "rash" was actually a pattern of indentations caused by sitting with my handbag pressing the fabric of my skirt against my lap. This and other misdiagnoses over the years have led me to realise that experts are not infallible.

Oh I relate so much.
The first consultant I saw diagnosed me with a chronic illness. On follow up, I saw a different, more senior doctor, who told me the thing I’d been diagnosed with didn’t really exist.

I believed him so sought answers elsewhere instead - all manner of tests and scans and peeing in giant containers for months. Only to eventually be re-diagnosed with the original condition! And this was all at the same hospital!

Medical opinions are just that. Opinions.
If you look hard enough you will always be able to find a plausible expert to attest to whatever you want.

The game in court is to find enough experts who will say what you need them to, and who look good enough on paper and on the stand to win the jury’s confidence.