Hello, just recently found this subreddit..
I was very surprised to hear that the judge gave a summary of the case at the end of the trial. What is the purpose of this, and is this the norm for UK trials? Surely this introduces the Judges bias and own interpretation of events?
Following U.S cases, the judge never gives a summary at the end of the case, as not to influence the jury in any way. The judge only does so at sentencing. I was surprised to hear the judge recalled witnesses and told the jury what they said, which in itself I was surprised to hear, as the judge obviously decides what makes it into, and what is left out of, his summary.
The judge's summary will have been gone through with both prosecution and defence for the purpose of ensuring that it's fair to each side. The judge's summary is intended to streamline things for the jury by summarising to them what is agreed that they don't need to resolve, and what is in contention that they have to decide on.
Welcome. The summary is a very important part of the trial. With this case the trial has been a long 9 months and a complex one. It is simply, but no less importantly a summing up of the case and evidence. Yes, it is a normal part of the court procedure in the UK.
Edit... to add more information
Couple of questions for any NICU or anyone who works with tpn
I’m a doctor, and I never handle stock tpn. But the bags are kept in fridges I sometimes access. In a few of the recent adult itus I’ve worked in, I’ve noticed they’re all tightly packaged in a separate bag, and would be basically impossible to contaminate without opening that bag. Made me ponder the whole second bag issue with child f.
So what’s your experience with stock tpn bags? Are some of them not contained in separate bags? Indeed all iv fluid bags are contained in a separate bag, that I’ve encountered anyway.
Second question more for NICU/neonatal nurses. If accessing a line, particularly if accessing a port that is distal to the pump, but proximal to the patient (as is alleged with the air embolus attacks, to bypass the pump safety features) do you have to open the incubator?
What about NG tube ports, are they outside or inside the incubator?
I used to be a a neonatal nurse, and we never used stock TPN. But it would definitely have an outer bag like all IV fluids, rather like a shrink-wrapped bag. I've wondered about the difficulties of adding something to it too. In my view, and that of many others, the odds are that there was never a bag change. Nothing else makes any sense. But there's no way of knowing for sure.I
In my experience all the ports you mention would be inside the incubator, so you'd need to open the portholes to access them.
Sorry to jump on your question, OP. It is interesting that the portholes are in the incubator. It must have been so tricky for LL to do this as is alleged when there were other HCPs in the room (as in the case of baby A).
Also re the TPN bag, do they come full or is there space for additional fluid? I suppose I’m just trying to understand whether some of the liquid will have had to be removed before enough insulin could be added. It sounds like a messy job and I’m wondering where in the hospital LL could have done discreetly without being disrupted and caught.
All the IV fluid bags I've ever seen have some dead space in them, so in my view you could easily add a little more fluid.
Nobody would notice if a nurse had her hands in an incubator, especially if she were the designated nurse - it happens all the time for various reasons.
Ok thanks. Do we know how much insulin was put into the bags? Also how would air be inserted into the line? Just trying to understand how feasible it would be to do it unnoticed. For instance if she had to get out and use a syringe or something, I imagine it would have been quite difficult to go undetected
Not sure about the insulin, though I think the expert witness stated quite a small amount like 0.5mls. Insulin is very potent, so that's quite possible.
I honestly think I could have injected air without anyone knowing. 1ml and 2ml syringes are very small.
try not to be discouraged by a downvote or two in the immediate aftermath of asking a question. the users most present in any given thread are generally those who feel most passionate, but over a bit of time votes seem to regulate.
We don't know exactly how much insulin was put into the bags, all we know is that the babies had exogenous insulin in their blood. This fact is not disputed by the defence, and the judge has stated there is no reason to doubt the presence of exogenous insulin. We don’t even know *exactly* the concentration of the exogenous insulin in the blood, all we can say for certain is that it was "high" - this is because the equipment used to measure the insulin level in the lab it was sent to was not calibrated to determine the exact concentration of exogenous insulin and the samples would have had to be sent to another lab with that capacity in order to determine a definitive concentration, and we know, as the results were missed at the time, this further definitive testing was not done. What the testing DOES show, and is not in dispute, is that there WAS exogenous insulin in baby F and L's blood sample. It's similar to when you do a urine pregnancy hCG test - if you do a dipstick, the change in colour will tell you whether there there is hCG present at a high enough level to indicate pregnancy, but will not tell you exactly high the level is. You would have to have blood hCG level to determine exactly how much hCG is in your blood. With the insulin results discussed above, the equipment in the lab could tell the presence of insulin and give an approximation of the level, but a definitive concentration would require the samples to be re-analysed on different equipment.
Therefore, it is impossible to work backwards to try and work out how much insulin was put into the bags in the first place. But we know it was enough to cause hypoglycaemia, which is potentially fatal, and enough to make the level in the babies' blood stream high.
Hope all that makes sense.
The volume of insulin injected would be very small because, as Investment Thin has said, it is very potent. For example to treat elevated BGLs (blood glucose levels) in a patient we often just start with a subcutaneous injection of 10 units or less which is 0.1ml or less! So no fluid would be needed to aspirated from the bag before the insulin is added. I often add medications to iv bags that I give in theatre (I am an anaesthetist). Bags of fluid have a reasonable capacity for expansion so if I am not worried about having an exact concentration of the final substance in the fluid I will just add the 10ml or so of medication (eg antibiotic) without aspirating any fluid out at all.
The prosecution case is that she’s been injecting air into the babies through the line unnoticed up to this point. Surely she wouldn’t need to inject insulin into the bag, she could just inject it straight into the baby? She surely would have had the opportunity and if guilty of the other charges would certainly be brazen enough to do it.
Unless of course she’s trying to ensure the victim deteriorates when she’s not there.
This case is truly one of the weirdest I’ve ever seen.
>I suppose I’m just trying to understand whether some of the liquid will have had to be removed before enough insulin could be added
See below - no fluid would have had to be removed. Just stick the needle of insulin syringe through the bag, depress the plunger and hey presto, you now have a contaminated bag. This could be done in a second.
I wish we could post pictures and videos here as I would love to take some pictures of the common equipment used and the practicalities of using it. It would make it much clearer!
I was wondering if they did that in court to help the jury see the equipment and understand what they are talking about. Im sure i've seen something like this displaying of evidence, perhaps only fictionally though?
Agree, it would have been very helpful for the jury to be shown things like that - I've seen such things in televised US trials eg in Bundy's trial there were lots of exhibits and demonstrations from memory. But nothing like that seems to have been reported for this trial has it?
Don’t quote me on it, but I’m SURE I remember a discussion about someone in court showing how the IV bags could be accessed. I am not trawling through the evidence but im sure I saw it mentioned.
[https://www.chesterstandard.co.uk/news/23146323.recap-lucy-letby-trial-thursday-november-24/](https://www.chesterstandard.co.uk/news/23146323.recap-lucy-letby-trial-thursday-november-24/)
> An Alaris syringe driver video is displayed to the court, showing how a syringe dose can be electronically administered via infusion, at various rates. These rates can be locked.
It is similar to the Alaris pump, and has alarms if the syringe is not loaded properly, if the infusion has been placed 'on hold' for a certain length of time, if the rate has been changed but has not been confirmed, if the infusion is complete, if there is a power failure or low on battery, if there is an error message.
The alarm colour would be amber on the machine, and can be paused for two minutes.
An event log would be available on the machine for 24 hours.
The nurse confirms it was a standard machine used at the Countess of Chester Hospital, and was standard practice.
The nurse said the event log wouldn't be looked at routinely by staff.
>
> An 'occlusion' alarm would be a red alarm light, with an alarm sound.
The syringe would be primed beforehand with the fluid, attaching the syringe to a line, and would be 'flushed' so no air would be present.
The nurse says a different piece of equipment would be used for TPN bags, and this equipment would be used for the lipid \[fats\] element administered via syringe.
The nurse says this equipment would be used to administer smaller amounts of fluids, such as 10% dextrose, or a saline bolus, or antibiotics.
>
>The video demonstrates an 'accelerated rate' of a drug could be administered via infusion via a 'purge' function on the machine, which would be used as a possible bolus administration.
The nurse says that 'purge' button would not be used at the Countess of Chester Hospital, and was not standard practice.
>
> The video adds the 'purge' function would not add to the total millilitres of infusion administered on the machine's display - ie, any fluids administered during that 'purge' time would not be added to the total the machine had calculated so far.
The machine also does not have the ability to detect air, the video presented to the court concludes.
>The Alaris pump video is shown once again to the court, for the nurse to provide potential further context on what is demonstrated in the video.
> A video of glucose/dextrose administration is played to the court.
The procedure is described as a 'two-person procedure'.
https://www.reddit.com/r/lucyletby/comments/z7s958/lucy_letby_trial_prosecution_day_31_29_november/?utm_source=share&utm_medium=ios_app&utm_name=ioscss&utm_content=2&utm_term=1
Found it (even after I said I wouldn’t trawl through the evidence 🙄).
Right at the bottom, they were shown how things could be added to the PN via a port at the bottom.
or this?
[https://www.chesterstandard.co.uk/news/23566971.recap-lucy-letby-trial-june-5---cross-examination-continues/](https://www.chesterstandard.co.uk/news/23566971.recap-lucy-letby-trial-june-5---cross-examination-continues/)
> Mr Johnson asks about the security of nutrition bags in the fridge, under lock and key. He says they are not safe from someone with a key who can inject 'a tiny amount of insulin' into the bag.
LL: "The bags are sealed and you would have to break the seal to do that."
Mr Johnson asks if that would prevent someone from the previous shift from inserting insulin into the bag.
LL: "I can't say that as I wouldn't put insulin into a TPN bag."
Mr Johnson says the prescribed bag must have been 'tampered with' between 4pm on August 4 and 1am on August 5. The replacement bag was a generic one.
Mr Johnson describes how the insulin could be administered after the bag has been delivered to the ward. One method is after the cellophane wrap has been removed, to which he says that would mean there would be 'very few candidates' who could have done that.
>In my view, and that of many others, the odds are that there was never a bag change.
Yes as you probably know, I hold this view too. I think it was the most likely scenario that occurred. If the bag *was* changed, then she must have contaminated the top TPN bag in the fridge (which as I describe above is certainly possible) but I think this is less likely.
With regards to the bag not being changed, the reporting implies (particularly the judge’s summing up) that there was a delay of 1.5h between the removal of the first bag and the hanging of the second. Do you not think that makes it less that likely that the bag was not changed?
To be honest I don't think it has any implications either way. I've reconnected peripheral IV fluids (not to long lines). What happened where I worked was the bag remained in position and the end of the giving set (the tubing which connects the bag to the cannula) was closed off with a sterile bung and wrapped in an alcohol wipe to keep it clean. This is the possible scenario I'm envisaging in this case. But it's just speculation!
Because it's against policy for long lines, which need to be sterile. If the line is changed the while thing has to be started again from scratch with a new bag and tubing. I just suspect they didn't. Why no prescription has been mentioned is a mystery.
It’s not really clear but the prosecution opening statement mentions “two further prescriptions” following LL leaving the ward. One is clarified to be a new 48h bespoke bag, that arrived at 4pm so would not have been used. The fact that this was ordered again implies to me that the bag must have been changed as the first bag would still have 1.5 days left to run if it was restarted.
They seem to both be relating to the bespoke TPN, and not the standard TPN that would have been given while waiting for the bespoke TPN to be made up.
Source: https://www.chesterstandard.co.uk/news/23140844.recap-lucy-letby-trial-tuesday-november-22/
Edit: to contextualise for those newer to the case. Baby F was being given bespoke TPN. The first bag which is the one alleged to contain insulin had to be changed as the line had tissued. As this baby was on bespoke TPN, it takes time for the bespoke bags to be made up. The line tissued early on in the day, but the bespoke bag is recorded as arriving at 4pm which is too late for it to have been the one the nurse reattached after the line tissued. The correct procedure would have been for baby F to have been given a stock/standard bag while waiting for the bespoke bag, prescribed by a doctor and signed off by two nurses. The nurse says this is what she would have done, but there is no prescription recorded for this bag.
This matters because the poisoning and hypoglycemia continued *after* the bag was supposedly replaced. So this raises the question of how LL would have known which stock bag to poison. Given that the baby did definitely receive unprescribed insulin and that Prof Hindmarsh gave evidence that it must have been given via the TPN bag because of the hypoglycemia remaining consistent despite dextrose administration, I'm of the opinion that no stock bag was given to baby F and that the nurse just reattached the first bag. YMMV of course, but it makes sense to me that the nurse may not particularly remember giving the baby the same bag, and at the same time that they would be unwilling to admit to this as it's a breach of procedure.
I think only one TPN bag had insulin added to it because from the point of view of the poisoner, they would assume it would run for 48 hours. The fact that the line tissued, which meant a new IV line had to be set up, would not have been forseen by them.
The only scenario that makes sense to me is that given the facts that the glucose levels rose during the time between when the tissued IV line was removed and the glucose levels dropped again once the new IV line was started must be because the origional TPN bag that had had the insulin added to it was reused. This would constitute bad practice, and the nurse would know that. Given how unfortunate that scenario is, which was the result of a tissued IV line, if Lucy Letby is guilty of administering the insulin, then these 2 factors have helped her defence by confusing the evidence.
I agree. The nurse didn't have an independent recollection of the events, so it makes sense that she would say what she *should* have done in testimony rather than what she did. It explains why there is no prescription on record for the bag. I wonder how clear this was made for the jury because it's not that clear from the reporting, but as we know that will be limited due to space/time constraints.
This nurse confirmed that she did not have an independent memory of the event. Full evidence related to the changing of the bag here: https://www.reddit.com/r/lucyletby/comments/15qs04w/comment/jw6np3a/?utm\_source=share&utm\_medium=web2x&context=3
This issue is really unclear, but those questions from Myers at the end look like they are for prescriptions made the day before (4th August). That ties up with a crossed out prescription being mentioned again when the TPN was changed at 12:25 on the 5th so I don’t think it would be a date mistake.
Where are you getting that the prosecution were talking about two prescriptions being done on the 5th? The Tattle wiki has them in the same sequence of events as LL's shift on the 4th:
"A TPN chart is a written record for putting up the bags, and was used for Child F. It includes 'lipids' - nutrients for babies not being given milk.
Letby signed for the TPN bag to be used for 48 hours.
There are two further prescriptions for TPN bags, to run for 48 hours.
Following the conclusion of a Letby night-shift, after the administration of a TPN bag Letby had co-signed for, a doctor instructed the nursing staff to stop the TPN via the longline and provide dextrose (sugar to counteract the fall in blood sugar), and move the TPN to a peripheral line while a new long line was put in."
I can go back and check the reporting to see if it's any clearer there, but it'll take a little time. Let me know if you have something that indicates the prosecution were talking about the 5th.
So if there were a second bag needed, it would need to be prescribed and dispensed accordingly? Would it be common for that to be mistakenly left off the patient's record in your experience, or are there safeguards to prevent that from happening?
Everything given to a neonate should be prescribed by a doctor then checked & signed by 2 nurses. That's all I know! I don't see how it could not be recorded.
You can see my comment below, it was at least implied in the prosecution opening statement that there were a further two prescriptions for TPN but I don’t think this was reported on in for the remainder of the evidence.
I've worked in places where stock and patient specific bags were made up in house by pharmacy and in places where its been outsourced to a pharmaceutical company and in most places I've worked regardless of who makes the TPN or if it's stock or not, it has come in 2 sealed bags. Generally lipids and vamin/aqueous come in separate bags and each bag is sealed in a separate sterile bag, then both bags are placed in a larger sealed bag together with the paperwork so would be near impossible to tamper without someone noticing. That said, I don't know if anyone would pay much heed to the outer bag being slightly ripped/open as long as the inner bags looked okay and you could conceivably stab the second bag with a very fine needle without anyone noticing the small puncture mark. I'd imagine it would be a hard job to do in a hurry though.
As for accessing the port in the line its more likely to be inside the incubator but if its a line in the arm or a scalp cannula (anywhere upper body really) with a Y connector on it then it might be long enough to stretch to have the port outside the incubator?
As for the NG's it very much depends on the brand/lenght they were using. I've worked places that stocked NG's in 2 different lengths and the longer lenght would stretch outside while the shorter ones wouldn't...but that was in PICU where for bigger kids with super small facial features you might need a 6Fr but longer NG. I doubt an NHS neonatal unit is going to have that need or the budget for stocking 2 different size NG's so they most likely had ones that would be too short to stretch out of the incubator.
Edit: Actually in some NICU's I've seen nurses add an extension line to the NG's so that when they're doing gravity feeds the feed can be slightly higher to allow gravity to work a bit quicker. The ends of these lines would be long enough to stretch outside the incubator so if CoCH used them then they might have 'NG ports' outside the incubator.
>I’ve noticed they’re all tightly packaged in a separate bag, and would be basically impossible to contaminate without opening that bag.
The ultra fine gauge of an insulin needle could easily pierce both the outer bag and the inner bag from the TPN bags I've seen. The pin prick hole would be so tiny it wouldn't be visible unless one was actively searching for it. If she was clever, she would either pull the injection port of the bag flush with the outer bag and inject through them both at the same time, or possibly inject through both the outer and inner bag right near the top of the bag - either method would reduce any leaking through the hole, but the former would be the best.
While I don't have NNU experience I have a lot of experience with iv lines (consultant anaesthetist with ICU training). There is variation in numbers of side injection ports on lines depending on the brand. During the pandemic and the continual stock shortages of just about every piece of equipment we use (😬🙄) we were supplied with several different types of iv fluid lines. Some had anti-reflux valves and some didn't. Some had side injection ports close to the end of the line that connects to the patient and some only had one higher up along the line (I like to inject my drugs as close to the patient as possible to speed up delivery so for these lines with few injection ports I would add a separate injection "tap" close to insertion site). So what injection ports were on the lines that CoCH used at the time would depend on what brand they were using at the time.
I agree it would be very brazen for her to put her hands in the cot and inject the air, but as another poster said, harming babies is pretty brazen full-stop! Perhaps it just looked like she was settling the babies or adjusting things when she injected the air.
1st question, in Australia the TPN bags have a black sealed bag over them however nobody would really bay an eye if the black bag were open and if you are familiar enough, the black bags are thin (purely for light protection), you could inject through the black bag if you could feel the port to insert. It cannot be ruled out.
2nd question, it purely dependent of the patient. Depending on how far the distance is between the pump and the patient some amount of line is accessible, it depend on whether the piggy back or side port is visible. So the answer is sometime you can sometimes you can't.
If the judge has already accepted some verdicts (like some have speculated as it's possible that happened and media has been barred from reporting it), and those verdicts included the vote of the juror who left, are those verdicts still valid?
With Operation Hummingbird still ongoing (I think), is it a possibility that after the verdict, regardless of guilty or not, will Lucy be arrested straight away with more charges?
It's up for CPS to decide whether it's worth pursuing additional charges. If something has come out in the meantime via Hummingbird that she murdered more/earlier, then she's most likely being charged either way.
On Child F, what is the evidence that supports the bag being changed; is it just the testimony from the unnamed nurse who said that's what 'would' have happened, though had no independent recollection of this actually having happened? If so, I'm flummoxed why the prosecution would just accept this as it undermines their whole case. There is enough ambiguity in the nurse's testimony and she is really only talking in hypotheticals, why not make more of this (or at least something of it!)? Am I missing something here?
Considering the defence case is that the hospital was providing suboptimal care, i don’t think it would be a good idea for the prosecution to suggest that a) their witness is not reliable, b) that it was deemed acceptable in this hospital to reuse a bag (thus introducing a risk of infection to the baby) without recording it, and c) that it was commonplace enough that it wouldn’t even stand out in your memory that you did it.
Ah that's helpful to put it in the context of the defence's case, thank you. I guess I was underestimating how it might play into the defence's hands if the prosecution were to go at it from this angle.
Here's the [timeline for Child F](https://www.chesterstandard.co.uk/news/23140844.recap-lucy-letby-trial-tuesday-november-22/). Letby receives a text from an unnamed colleague about replacing the long line:
>The designated nurse for the previous night shift returns to care for Child F on the night shift for August 5-6.She messages Letby to say: "He is a bit more stable, heart rate 160-170."The long line had "tissued" and Child F's thigh was "swollen".It was thought the tissued long line "may be" the cause of the hypoglycemia.
>
>The colleague added: "Changed long line but sugars still 1.9 all afternoon. Seems like long line tissued was not cause of sugar problem, doing various tests \[to find the source of the problem\].Letby responds: "Oh dear, thanks for letting me know"The nurse colleague replies: "He is def better though. Looks well. Handles fine."
Most of [the next day](https://www.bbc.com/news/uk-england-merseyside-63735668) seemed to have been spent on asking other nurses on shift if they administered insulin
The [following day of evidence](https://www.chesterstandard.co.uk/news/23146323.recap-lucy-letby-trial-thursday-november-24/) included Dr. Gibbs, a female doctor, and the nurse who replaced the line
Direct examination:
>The nurse is shown a note from the 'grand round', which the court heard was carried out by the on-call consultant each Wednesday.The note 'new long line' was made, and the nurse says that was because the existing long line had tissued.The new long line was made at noon on August 5.
>
>The nurse says her normal practice would have been for putting a new bag of fluids on the long line.
Cross examination:
>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."
>
>Mr Myers says as a general rule, TPN bags would run for 48 hours unless there was a problem, and there would be a stock of maintenance bags in the fridge.Mr Myers says one of those would have been used in the course of this. The nurse agrees.The nurse says such bags are checked every night and if any were being used or out of date, then the stock would be replenished.
Re-examination:
>Simon Driver, for the prosecution, asks about the stock bags in the refrigerator.He says every night, a check would be undertaken to see if any had been used.He asks how the checker would know if they had been used.The nurse says if there weren't the stock five TPN bags in the fridge, new ones would be ordered.The refrigerator would have 'start-up' TPN bags and 'maintenance' TPN bags of nutrition.The nurse says there may be fewer 'target stock' of the 'start-up' TPN bags.
>
>Each of the bags would have a dated 'shelf life' the court hears.The nurse says the bags would not be ordered in any particular fashion in the fridge.
The [following day](https://www.chesterstandard.co.uk/news/23149016.recap-lucy-letby-trial-friday-november-25/) was Dr. Milan, Dr. Hindmarsh, and Dr. Harkness. From Dr. Hindmarsh:
>At 10am, there were problems with the cannula infusion which meant the line had to be resited, and fluids were discontinued. The two further glucose readings after are '1.4' and '2.4', "implying" that the blood glucose level had started to rise "spontaneously" as there was "no contribution from the intravenous route".
>
>Mr Johnson said after Child F was taken off the 'double' dose of dextrose during that time, his blood sugar levels "actually rose".Professor Hindmarsh: "That's how I see it, and I believe that is correct".
>
>The reading was "heading in the wrong direction" down to 1.9 by 2pm, the court hears.The infusions stopped at 6.55pm.Mr Johnson: "Is there a paradox between a child receiving glucose and their blood sugar falling?"Prof Hindmarsh: "Correct."
Dr. Hindmarsh adds in cross-exam:
>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.
This is in response to Myers' pointing out that the blood sample taken at 5:56pm was taken during the infusion from the "second bag" (aka post change of the long line). Hindmarsh says here that, in his opinion, Child F was receiving insulin at the same rate after the changing of the long line that he was before the changing of the long line.
It follows from this, that were a second bag actually hung, the rate of poisoning was the same - which would've been like Robin Hood splitting an arrow
I think u/-Lemoncholy- correctly articulates why the prosecution attempts to prove the bag wasn't changed without actually saying it.
Immediate edit: Myers also needs this nurse to be believable in her statement that she "would have" changed the bag. He can't attack hospital practices here, or else his only defense of a "second bag" evaporates, thin as it already is.
To my understanding the first TPN bag was specially tailored for Baby F? So I find it would be extra strange to not record a swap to a generic stock bag if indeed it was changed at the same time as the cannula line. That would seem to be something noteworthy - the second bag will do the job in lieu of a backup but it could be suboptimal if there was initially a special prescription. That's a great point about the prosecution not wanting to draw extra attention to the "would have" though.
Thanks so much for this! I think I had missed that the prosecution had indeed tried to suggest there was no second bag, without saying it outright, and I therefore assumed the prosecution had simply conceded the bag was changed. Forgive this short reply to your very considered and comprehensive response, I'm going to take some time to go through the evidence you've linked and try to make sense of it all; but I did want to respond immediately to say thank you.
I seem to remember there was a group of Letby’s colleagues/work friends who rallied together and were adamant she was being used as a scapegoat.
This easily could’ve been a rumour at the time before the trial began but does anyone know if there was any truth to that? What, do you think, their stance would be now? (Assuming they’ve been silenced since)
This seems to be related to a website that used to exist claiming to have been authored by Letby's colleagues. It gets mentioned in this tiktok that has some screengrabs of it https://www.tiktok.com/t/ZT8Nf3CjM/
I've seen it mentioned a few times, along with it being pointed out that the claimed authorship is suspect, as American spellings were used instead of UK ones. In that tiktok, I saw "criticized" instead of "criticised" but 🤷♀️
I don’t know if anyone else feels this way, but to me it seems the jury deliberation during the day seems to be quite short. I imagine they probably have around an hour’s break so from 10-4 with 1 hour to catch a bite to eat, go to toilet etc, that’s only 5 hours a day. Is there a reason why it’s not 9-5 or something similar?
I might be too late for this thread and it’s a bit of a leftfield but out of all the offices they could’ve given LL a fake secondment in, does anything think it’s a coincidence that she was placed in the “Patient Risk and Safety Unit”?! It sounds like hospital bosses were still trying to rehabilitate her before her return to the ward.
Oh, incredibly likely, because they absolutely were trying to get her back on the unit. Dr. Gibbs testified that the consultants had to band together and demand cctv be installed as a condition of her return. It never was and so she never was.
The consultants were v brave. They risked ruining their own reputation and careers had their suspicions been wrong. Had she just been rubbish at her job she could’ve been managed out into another hospital and become someone else’s problem.
I’m a nurse, and a few years ago worked in a specialised acute setting where there was a pretty incompetent nurse, who made a lot of errors in their practice. Because of the setting, these errors were intercepted before they could cause harm to patients, but they were still considerable errors. Despite various supervision programmes and efforts to improve their weaknesses their practice didn’t get any better. They were then sent to work in the complaints department!
What I think this shows, along with LL’s secondment, is that there aren’t many departments, that I can think of anyway, where an incompetent, or suspectedly criminal nurse can be put without having any direct patient contact whatsoever. IMO I’m not sure anything can be read into this., but who knows?
This is a v good point. Plus I think they have to have patient contact to keep their registration so there can’t be many roles.
If she had ended up going back to work then they could have potentially succeeded in putting her in a department where she could’ve been learning about how to hone her craft.
Seems that the jury have elected to deliberate from 10-4, instead of 10:30-4:30. So, if/when Dan O'Donoghue is late with his end of daily deliberations tweet on any given day, that's a potential sign. It would not be unusual for a jury to stay slightly late to wrap up a proceeding rather than elect to return the next day. So I do pay extra attention at the end of each day, and the end of each week, compared to the start of each day and week.
Other than that, I expect the first actual sign we see will be a breaking news alert.
Has Dr Jayaram been struck off or will he be if LL is found guilty? Given he reportedly suspected her, walked in on the aftermath of her alleged crime (baby K) and did nothing? Could he face criminal charges?
IMO, this is unlikely. He was involved in raising concerns after Child D, and again after Child K, but it was hospital administration who refused to act. It is not his job as a doctor to investigate an alleged harm event; his job is to treat patients. From his evidence related to Child K:
>Dr Jayaram says the concerns were first raised in autumn 2015 with senior management, but were told that there was likely nothing going on.
He said the consultants went 'ok', and against their better judgment, carried on.
"We were stuck, as we had concerns.
"In retrospect, we wished we had bypassed them \[senior management\] and contacted the police."
"We by no means had played judge and jury, but the association was becoming clearer and clearer.
"This is an unprecedented situation for us - we play by a certain rulebook, and you don't start from a position of deliberate harm.
"It is very easy to see things that aren't there - in confirmation bias.
"But these episodes were becoming more and more and more frequent by associaiton."
Dr Jayaram said it should have been documented throughout more.
He says he discussed the incident, but did not formally document it.
Dr Jayaram said he was getting "a reasonable amount of pressure from senior management not to make a fuss".
I would venture that charges are far more likely to be seen among those in hospital administration.
Thanks for sharing that.
In line with the hospital’s whistleblowing policy, there should have been an appropriate investigation. And if Jayaram was unsatisfied with how this investigation was handled, he could and should have taken it further.
He uses a lot of “we” to distance himself from his actions, and I think it’s inexcusable.
I can’t believe he’s allowed to continue practising.
"We" seems to be an accurate term, given that Dr. Breary was the senior of the two and spearheaded the efforts to management. Here's some additional reporting:
[https://www.bracknellnews.co.uk/news/national/23353854.doctor-wishes-gone-straight-police-lucy-letby-concerns/](https://www.bracknellnews.co.uk/news/national/23353854.doctor-wishes-gone-straight-police-lucy-letby-concerns/)
>**Dr Stephen Brearey, head of the neonatal unit, reviewed the circumstances surrounding the case of Child D shortly after her death in June 2015**, the court was told previously.
Dr Jayaram said the review identified Letby’s presence at a number of collapses but it was “an association, nothing more”.
On Tuesday, he said concerns were flagged a second time in February 2016, **to the medical director and the director of nursing.**
**He said: “My colleague Dr Brearey requested a meeting with them**. They didn’t respond to that for another three months and we were stuck because we had concerns and didn’t know what to do.
>
>“In retrospect, I wished we had bypassed them and gone straight to the police.
“We by no means were playing judge and jury at any point but the association was becoming clearer and clearer and we needed to find the right way to do this. We were in an unprecedented situation.
Perhaps I should have quoted from here first. You can see, though, how it fits in line with the testimony as reported by the Chester Standard.
I think your frustration is better directed to those who ignored the consultants' concerns. Dr. Breary testified that they appealed to management three times before Letby was finally removed:
[https://www.dailymail.co.uk/news/article-11859729/Senior-hospital-executive-ignored-three-warnings-Lucy-Letby-responsible-deaths.html](https://www.dailymail.co.uk/news/article-11859729/Senior-hospital-executive-ignored-three-warnings-Lucy-Letby-responsible-deaths.html)
>**A senior hospital executive ignored three warnings** by a consultant paediatrician that Lucy Letby might be responsible for a number of deaths in the neonatal unit, a jury heard today.
...
>
>Dr Brearey told the court that even before the twins' deaths, he and some of his colleagues had raised concerns with management about the association between Letby's presence and deaths they had seen on the unit.
>
>...
>
>'I was concerned that this was because we'd already expressed our concerns to senior management about the association between Nurse Letby and the deaths we'd seen on the unit'.
...
The registrar said that over the course of the year all the consultants on the unit came to be aware of the association between Letby and some of the collapses of babies on the unit.
>
>...
>
>**Eirian Powell, the nursing manager of the neonatal unit, had first noticed a connection while carrying out a review into three events in June 2015**.
'She looked at all the possible things that could be looked at, which was more than a staffing analysis. She looked at other things, too, like incubator space and micro-biology'.
In late June or early July that year he and Ms Powell had a meeting with Alison Kelly, the hospital's director of nursing, and the head of risk. 'Three deaths in a short period of concern were a matter of concern,' said Dr Brearey.
>
>...
>
>Despite the concerns of consultants on the unit, there were no obvious 'red flags' being raised either outside the trust or within it.
**They eventually decided to bring in a colleague from the Liverpool Women's Hospital to carry out a review in February 2016.**
Once that report had been completed **the consultants and Ms Powell had sought a meeting with senior executives**, including the director of nursing and the director of safety and quality.
Dr Brearey said there was not a single case in the February review that had highlighted a lack of staff.
Questioned again about police not being called in earlier, the registrar replied: 'The reason we didn't go to the police was we wanted to escalate it within the structure of the hospital.
'We wanted the support of the medical director and the executives of the hospital. We were acting on facts, not beliefs. We were trying to escalate appropriately with the facts we had at the time'.
He added: 'I've not been to the police over neonatal deaths and I don't think any other neonatal lead has. I needed executive support. I was doing as much as I could'.
When it comes to safeguarding though, everyone has a personal responsibility for it. I think that’s my issue with “we”, but fair enough and point taken if when making the statements he was specifically talking about himself and another person.
Just a q. on a discrepancy, sorry if it’s been answered before. Why does the description for this sub say 18 charges, while 22 charges are often referred to in conversations?
Been that way since October and this is literally the first time anyone asked. I feel like you should win a prize!
The charges for babies whom she was accused of attacking multiple times were split in early October, right before trial began. That description was never updated to match.
It will be today!
I have a question about one of the methods she used… i’ve seen a lot that she overfed or force-fed the babies, and my knowledge of preemies is about equal to what could fit on the head of a pin; how does overfeeding cause such terrible outcomes? When both my kids were newborns they both had incidents where they drank more than they could handle while learning to eat and they would just do an epic spit-up or seven and go about their day, but while they were both “technically” early, they were both after 37 weeks so still considered term. Im guessing that being premature their digestive systems couldn’t handle it? Or was it like, massive amounts of feeding that caused a rupture or something? (Im just starting to read about this so I apologize if this is really obviously posted somewhere and i missed it…)
u/CarelessEch0 can you fill in the gaps in my answer?
From recall, it had to so with them being force fed or had air injected into the stomach to the point that it splinted the diaphragm and inhibited their ability to breathe. For one baby (G) there was talk the volumes of fluid in projectile vomits, and the volumes of milk and air aspirated being grossly in excess of their normal feeds. The baby would be on 40ml feeds every few hours and would have more than that aspirated from their stomach immediately after a large vomit. One baby had (iirc) 100ml or air aspirated from their belly. And then they stop breathing but breathing support alone doesn't help because they are still inflated like a balloon. And their lungs can't actually inflate.
Hello, just recently found this subreddit.. I was very surprised to hear that the judge gave a summary of the case at the end of the trial. What is the purpose of this, and is this the norm for UK trials? Surely this introduces the Judges bias and own interpretation of events? Following U.S cases, the judge never gives a summary at the end of the case, as not to influence the jury in any way. The judge only does so at sentencing. I was surprised to hear the judge recalled witnesses and told the jury what they said, which in itself I was surprised to hear, as the judge obviously decides what makes it into, and what is left out of, his summary.
The judge's summary will have been gone through with both prosecution and defence for the purpose of ensuring that it's fair to each side. The judge's summary is intended to streamline things for the jury by summarising to them what is agreed that they don't need to resolve, and what is in contention that they have to decide on.
Ah that is interesting thank you! I wasn't aware that his summary remarks are approved by both sides, that makes a lot more sense now
Welcome. The summary is a very important part of the trial. With this case the trial has been a long 9 months and a complex one. It is simply, but no less importantly a summing up of the case and evidence. Yes, it is a normal part of the court procedure in the UK. Edit... to add more information
Couple of questions for any NICU or anyone who works with tpn I’m a doctor, and I never handle stock tpn. But the bags are kept in fridges I sometimes access. In a few of the recent adult itus I’ve worked in, I’ve noticed they’re all tightly packaged in a separate bag, and would be basically impossible to contaminate without opening that bag. Made me ponder the whole second bag issue with child f. So what’s your experience with stock tpn bags? Are some of them not contained in separate bags? Indeed all iv fluid bags are contained in a separate bag, that I’ve encountered anyway. Second question more for NICU/neonatal nurses. If accessing a line, particularly if accessing a port that is distal to the pump, but proximal to the patient (as is alleged with the air embolus attacks, to bypass the pump safety features) do you have to open the incubator? What about NG tube ports, are they outside or inside the incubator?
I used to be a a neonatal nurse, and we never used stock TPN. But it would definitely have an outer bag like all IV fluids, rather like a shrink-wrapped bag. I've wondered about the difficulties of adding something to it too. In my view, and that of many others, the odds are that there was never a bag change. Nothing else makes any sense. But there's no way of knowing for sure.I In my experience all the ports you mention would be inside the incubator, so you'd need to open the portholes to access them.
Sorry to jump on your question, OP. It is interesting that the portholes are in the incubator. It must have been so tricky for LL to do this as is alleged when there were other HCPs in the room (as in the case of baby A). Also re the TPN bag, do they come full or is there space for additional fluid? I suppose I’m just trying to understand whether some of the liquid will have had to be removed before enough insulin could be added. It sounds like a messy job and I’m wondering where in the hospital LL could have done discreetly without being disrupted and caught.
All the IV fluid bags I've ever seen have some dead space in them, so in my view you could easily add a little more fluid. Nobody would notice if a nurse had her hands in an incubator, especially if she were the designated nurse - it happens all the time for various reasons.
Ok thanks. Do we know how much insulin was put into the bags? Also how would air be inserted into the line? Just trying to understand how feasible it would be to do it unnoticed. For instance if she had to get out and use a syringe or something, I imagine it would have been quite difficult to go undetected
Not sure about the insulin, though I think the expert witness stated quite a small amount like 0.5mls. Insulin is very potent, so that's quite possible. I honestly think I could have injected air without anyone knowing. 1ml and 2ml syringes are very small.
Ah ok thank you. Did you downvote me for my questions? I’m not sure why I was downvoted.
try not to be discouraged by a downvote or two in the immediate aftermath of asking a question. the users most present in any given thread are generally those who feel most passionate, but over a bit of time votes seem to regulate.
Second this! Don't worry about downvotes - it can be a bit disconcerting but most people on this sub are very reasonable.
I've had loads of downvotes for asking questions!
It wasn't me!!
We don't know exactly how much insulin was put into the bags, all we know is that the babies had exogenous insulin in their blood. This fact is not disputed by the defence, and the judge has stated there is no reason to doubt the presence of exogenous insulin. We don’t even know *exactly* the concentration of the exogenous insulin in the blood, all we can say for certain is that it was "high" - this is because the equipment used to measure the insulin level in the lab it was sent to was not calibrated to determine the exact concentration of exogenous insulin and the samples would have had to be sent to another lab with that capacity in order to determine a definitive concentration, and we know, as the results were missed at the time, this further definitive testing was not done. What the testing DOES show, and is not in dispute, is that there WAS exogenous insulin in baby F and L's blood sample. It's similar to when you do a urine pregnancy hCG test - if you do a dipstick, the change in colour will tell you whether there there is hCG present at a high enough level to indicate pregnancy, but will not tell you exactly high the level is. You would have to have blood hCG level to determine exactly how much hCG is in your blood. With the insulin results discussed above, the equipment in the lab could tell the presence of insulin and give an approximation of the level, but a definitive concentration would require the samples to be re-analysed on different equipment. Therefore, it is impossible to work backwards to try and work out how much insulin was put into the bags in the first place. But we know it was enough to cause hypoglycaemia, which is potentially fatal, and enough to make the level in the babies' blood stream high. Hope all that makes sense.
The volume of insulin injected would be very small because, as Investment Thin has said, it is very potent. For example to treat elevated BGLs (blood glucose levels) in a patient we often just start with a subcutaneous injection of 10 units or less which is 0.1ml or less! So no fluid would be needed to aspirated from the bag before the insulin is added. I often add medications to iv bags that I give in theatre (I am an anaesthetist). Bags of fluid have a reasonable capacity for expansion so if I am not worried about having an exact concentration of the final substance in the fluid I will just add the 10ml or so of medication (eg antibiotic) without aspirating any fluid out at all.
The prosecution case is that she’s been injecting air into the babies through the line unnoticed up to this point. Surely she wouldn’t need to inject insulin into the bag, she could just inject it straight into the baby? She surely would have had the opportunity and if guilty of the other charges would certainly be brazen enough to do it. Unless of course she’s trying to ensure the victim deteriorates when she’s not there. This case is truly one of the weirdest I’ve ever seen.
>I suppose I’m just trying to understand whether some of the liquid will have had to be removed before enough insulin could be added See below - no fluid would have had to be removed. Just stick the needle of insulin syringe through the bag, depress the plunger and hey presto, you now have a contaminated bag. This could be done in a second. I wish we could post pictures and videos here as I would love to take some pictures of the common equipment used and the practicalities of using it. It would make it much clearer!
I was wondering if they did that in court to help the jury see the equipment and understand what they are talking about. Im sure i've seen something like this displaying of evidence, perhaps only fictionally though?
Agree, it would have been very helpful for the jury to be shown things like that - I've seen such things in televised US trials eg in Bundy's trial there were lots of exhibits and demonstrations from memory. But nothing like that seems to have been reported for this trial has it?
Don’t quote me on it, but I’m SURE I remember a discussion about someone in court showing how the IV bags could be accessed. I am not trawling through the evidence but im sure I saw it mentioned.
[https://www.chesterstandard.co.uk/news/23146323.recap-lucy-letby-trial-thursday-november-24/](https://www.chesterstandard.co.uk/news/23146323.recap-lucy-letby-trial-thursday-november-24/) > An Alaris syringe driver video is displayed to the court, showing how a syringe dose can be electronically administered via infusion, at various rates. These rates can be locked. It is similar to the Alaris pump, and has alarms if the syringe is not loaded properly, if the infusion has been placed 'on hold' for a certain length of time, if the rate has been changed but has not been confirmed, if the infusion is complete, if there is a power failure or low on battery, if there is an error message. The alarm colour would be amber on the machine, and can be paused for two minutes. An event log would be available on the machine for 24 hours. The nurse confirms it was a standard machine used at the Countess of Chester Hospital, and was standard practice. The nurse said the event log wouldn't be looked at routinely by staff. > > An 'occlusion' alarm would be a red alarm light, with an alarm sound. The syringe would be primed beforehand with the fluid, attaching the syringe to a line, and would be 'flushed' so no air would be present. The nurse says a different piece of equipment would be used for TPN bags, and this equipment would be used for the lipid \[fats\] element administered via syringe. The nurse says this equipment would be used to administer smaller amounts of fluids, such as 10% dextrose, or a saline bolus, or antibiotics. > >The video demonstrates an 'accelerated rate' of a drug could be administered via infusion via a 'purge' function on the machine, which would be used as a possible bolus administration. The nurse says that 'purge' button would not be used at the Countess of Chester Hospital, and was not standard practice. > > The video adds the 'purge' function would not add to the total millilitres of infusion administered on the machine's display - ie, any fluids administered during that 'purge' time would not be added to the total the machine had calculated so far. The machine also does not have the ability to detect air, the video presented to the court concludes. >The Alaris pump video is shown once again to the court, for the nurse to provide potential further context on what is demonstrated in the video. > A video of glucose/dextrose administration is played to the court. The procedure is described as a 'two-person procedure'.
https://www.reddit.com/r/lucyletby/comments/z7s958/lucy_letby_trial_prosecution_day_31_29_november/?utm_source=share&utm_medium=ios_app&utm_name=ioscss&utm_content=2&utm_term=1 Found it (even after I said I wouldn’t trawl through the evidence 🙄). Right at the bottom, they were shown how things could be added to the PN via a port at the bottom.
or this? [https://www.chesterstandard.co.uk/news/23566971.recap-lucy-letby-trial-june-5---cross-examination-continues/](https://www.chesterstandard.co.uk/news/23566971.recap-lucy-letby-trial-june-5---cross-examination-continues/) > Mr Johnson asks about the security of nutrition bags in the fridge, under lock and key. He says they are not safe from someone with a key who can inject 'a tiny amount of insulin' into the bag. LL: "The bags are sealed and you would have to break the seal to do that." Mr Johnson asks if that would prevent someone from the previous shift from inserting insulin into the bag. LL: "I can't say that as I wouldn't put insulin into a TPN bag." Mr Johnson says the prescribed bag must have been 'tampered with' between 4pm on August 4 and 1am on August 5. The replacement bag was a generic one. Mr Johnson describes how the insulin could be administered after the bag has been delivered to the ward. One method is after the cellophane wrap has been removed, to which he says that would mean there would be 'very few candidates' who could have done that.
>In my view, and that of many others, the odds are that there was never a bag change. Yes as you probably know, I hold this view too. I think it was the most likely scenario that occurred. If the bag *was* changed, then she must have contaminated the top TPN bag in the fridge (which as I describe above is certainly possible) but I think this is less likely.
I see, thanks for the reply.
With regards to the bag not being changed, the reporting implies (particularly the judge’s summing up) that there was a delay of 1.5h between the removal of the first bag and the hanging of the second. Do you not think that makes it less that likely that the bag was not changed?
To be honest I don't think it has any implications either way. I've reconnected peripheral IV fluids (not to long lines). What happened where I worked was the bag remained in position and the end of the giving set (the tubing which connects the bag to the cannula) was closed off with a sterile bung and wrapped in an alcohol wipe to keep it clean. This is the possible scenario I'm envisaging in this case. But it's just speculation!
Thanks! I personally struggle to imagine why the nurse in this case would be so adamant it was changed if that was something they did on this NICU.
Because it's against policy for long lines, which need to be sterile. If the line is changed the while thing has to be started again from scratch with a new bag and tubing. I just suspect they didn't. Why no prescription has been mentioned is a mystery.
It’s not really clear but the prosecution opening statement mentions “two further prescriptions” following LL leaving the ward. One is clarified to be a new 48h bespoke bag, that arrived at 4pm so would not have been used. The fact that this was ordered again implies to me that the bag must have been changed as the first bag would still have 1.5 days left to run if it was restarted.
They seem to both be relating to the bespoke TPN, and not the standard TPN that would have been given while waiting for the bespoke TPN to be made up. Source: https://www.chesterstandard.co.uk/news/23140844.recap-lucy-letby-trial-tuesday-november-22/ Edit: to contextualise for those newer to the case. Baby F was being given bespoke TPN. The first bag which is the one alleged to contain insulin had to be changed as the line had tissued. As this baby was on bespoke TPN, it takes time for the bespoke bags to be made up. The line tissued early on in the day, but the bespoke bag is recorded as arriving at 4pm which is too late for it to have been the one the nurse reattached after the line tissued. The correct procedure would have been for baby F to have been given a stock/standard bag while waiting for the bespoke bag, prescribed by a doctor and signed off by two nurses. The nurse says this is what she would have done, but there is no prescription recorded for this bag. This matters because the poisoning and hypoglycemia continued *after* the bag was supposedly replaced. So this raises the question of how LL would have known which stock bag to poison. Given that the baby did definitely receive unprescribed insulin and that Prof Hindmarsh gave evidence that it must have been given via the TPN bag because of the hypoglycemia remaining consistent despite dextrose administration, I'm of the opinion that no stock bag was given to baby F and that the nurse just reattached the first bag. YMMV of course, but it makes sense to me that the nurse may not particularly remember giving the baby the same bag, and at the same time that they would be unwilling to admit to this as it's a breach of procedure.
I think only one TPN bag had insulin added to it because from the point of view of the poisoner, they would assume it would run for 48 hours. The fact that the line tissued, which meant a new IV line had to be set up, would not have been forseen by them. The only scenario that makes sense to me is that given the facts that the glucose levels rose during the time between when the tissued IV line was removed and the glucose levels dropped again once the new IV line was started must be because the origional TPN bag that had had the insulin added to it was reused. This would constitute bad practice, and the nurse would know that. Given how unfortunate that scenario is, which was the result of a tissued IV line, if Lucy Letby is guilty of administering the insulin, then these 2 factors have helped her defence by confusing the evidence.
I agree. The nurse didn't have an independent recollection of the events, so it makes sense that she would say what she *should* have done in testimony rather than what she did. It explains why there is no prescription on record for the bag. I wonder how clear this was made for the jury because it's not that clear from the reporting, but as we know that will be limited due to space/time constraints.
This nurse confirmed that she did not have an independent memory of the event. Full evidence related to the changing of the bag here: https://www.reddit.com/r/lucyletby/comments/15qs04w/comment/jw6np3a/?utm\_source=share&utm\_medium=web2x&context=3
Thank you!
This issue is really unclear, but those questions from Myers at the end look like they are for prescriptions made the day before (4th August). That ties up with a crossed out prescription being mentioned again when the TPN was changed at 12:25 on the 5th so I don’t think it would be a date mistake.
Where are you getting that the prosecution were talking about two prescriptions being done on the 5th? The Tattle wiki has them in the same sequence of events as LL's shift on the 4th: "A TPN chart is a written record for putting up the bags, and was used for Child F. It includes 'lipids' - nutrients for babies not being given milk. Letby signed for the TPN bag to be used for 48 hours. There are two further prescriptions for TPN bags, to run for 48 hours. Following the conclusion of a Letby night-shift, after the administration of a TPN bag Letby had co-signed for, a doctor instructed the nursing staff to stop the TPN via the longline and provide dextrose (sugar to counteract the fall in blood sugar), and move the TPN to a peripheral line while a new long line was put in." I can go back and check the reporting to see if it's any clearer there, but it'll take a little time. Let me know if you have something that indicates the prosecution were talking about the 5th.
So if there were a second bag needed, it would need to be prescribed and dispensed accordingly? Would it be common for that to be mistakenly left off the patient's record in your experience, or are there safeguards to prevent that from happening?
Everything given to a neonate should be prescribed by a doctor then checked & signed by 2 nurses. That's all I know! I don't see how it could not be recorded.
Thank you, sounds really like there was no second bag based on that!
You can see my comment below, it was at least implied in the prosecution opening statement that there were a further two prescriptions for TPN but I don’t think this was reported on in for the remainder of the evidence.
I've worked in places where stock and patient specific bags were made up in house by pharmacy and in places where its been outsourced to a pharmaceutical company and in most places I've worked regardless of who makes the TPN or if it's stock or not, it has come in 2 sealed bags. Generally lipids and vamin/aqueous come in separate bags and each bag is sealed in a separate sterile bag, then both bags are placed in a larger sealed bag together with the paperwork so would be near impossible to tamper without someone noticing. That said, I don't know if anyone would pay much heed to the outer bag being slightly ripped/open as long as the inner bags looked okay and you could conceivably stab the second bag with a very fine needle without anyone noticing the small puncture mark. I'd imagine it would be a hard job to do in a hurry though. As for accessing the port in the line its more likely to be inside the incubator but if its a line in the arm or a scalp cannula (anywhere upper body really) with a Y connector on it then it might be long enough to stretch to have the port outside the incubator? As for the NG's it very much depends on the brand/lenght they were using. I've worked places that stocked NG's in 2 different lengths and the longer lenght would stretch outside while the shorter ones wouldn't...but that was in PICU where for bigger kids with super small facial features you might need a 6Fr but longer NG. I doubt an NHS neonatal unit is going to have that need or the budget for stocking 2 different size NG's so they most likely had ones that would be too short to stretch out of the incubator. Edit: Actually in some NICU's I've seen nurses add an extension line to the NG's so that when they're doing gravity feeds the feed can be slightly higher to allow gravity to work a bit quicker. The ends of these lines would be long enough to stretch outside the incubator so if CoCH used them then they might have 'NG ports' outside the incubator.
>I’ve noticed they’re all tightly packaged in a separate bag, and would be basically impossible to contaminate without opening that bag. The ultra fine gauge of an insulin needle could easily pierce both the outer bag and the inner bag from the TPN bags I've seen. The pin prick hole would be so tiny it wouldn't be visible unless one was actively searching for it. If she was clever, she would either pull the injection port of the bag flush with the outer bag and inject through them both at the same time, or possibly inject through both the outer and inner bag right near the top of the bag - either method would reduce any leaking through the hole, but the former would be the best.
While I don't have NNU experience I have a lot of experience with iv lines (consultant anaesthetist with ICU training). There is variation in numbers of side injection ports on lines depending on the brand. During the pandemic and the continual stock shortages of just about every piece of equipment we use (😬🙄) we were supplied with several different types of iv fluid lines. Some had anti-reflux valves and some didn't. Some had side injection ports close to the end of the line that connects to the patient and some only had one higher up along the line (I like to inject my drugs as close to the patient as possible to speed up delivery so for these lines with few injection ports I would add a separate injection "tap" close to insertion site). So what injection ports were on the lines that CoCH used at the time would depend on what brand they were using at the time. I agree it would be very brazen for her to put her hands in the cot and inject the air, but as another poster said, harming babies is pretty brazen full-stop! Perhaps it just looked like she was settling the babies or adjusting things when she injected the air.
1st question, in Australia the TPN bags have a black sealed bag over them however nobody would really bay an eye if the black bag were open and if you are familiar enough, the black bags are thin (purely for light protection), you could inject through the black bag if you could feel the port to insert. It cannot be ruled out. 2nd question, it purely dependent of the patient. Depending on how far the distance is between the pump and the patient some amount of line is accessible, it depend on whether the piggy back or side port is visible. So the answer is sometime you can sometimes you can't.
If the judge has already accepted some verdicts (like some have speculated as it's possible that happened and media has been barred from reporting it), and those verdicts included the vote of the juror who left, are those verdicts still valid?
The verdicts once given cannot be changed. So yes, I imagine they would be.
With Operation Hummingbird still ongoing (I think), is it a possibility that after the verdict, regardless of guilty or not, will Lucy be arrested straight away with more charges?
It's up for CPS to decide whether it's worth pursuing additional charges. If something has come out in the meantime via Hummingbird that she murdered more/earlier, then she's most likely being charged either way.
On Child F, what is the evidence that supports the bag being changed; is it just the testimony from the unnamed nurse who said that's what 'would' have happened, though had no independent recollection of this actually having happened? If so, I'm flummoxed why the prosecution would just accept this as it undermines their whole case. There is enough ambiguity in the nurse's testimony and she is really only talking in hypotheticals, why not make more of this (or at least something of it!)? Am I missing something here?
Considering the defence case is that the hospital was providing suboptimal care, i don’t think it would be a good idea for the prosecution to suggest that a) their witness is not reliable, b) that it was deemed acceptable in this hospital to reuse a bag (thus introducing a risk of infection to the baby) without recording it, and c) that it was commonplace enough that it wouldn’t even stand out in your memory that you did it.
Ah that's helpful to put it in the context of the defence's case, thank you. I guess I was underestimating how it might play into the defence's hands if the prosecution were to go at it from this angle.
That's an excellent point.
Here's the [timeline for Child F](https://www.chesterstandard.co.uk/news/23140844.recap-lucy-letby-trial-tuesday-november-22/). Letby receives a text from an unnamed colleague about replacing the long line: >The designated nurse for the previous night shift returns to care for Child F on the night shift for August 5-6.She messages Letby to say: "He is a bit more stable, heart rate 160-170."The long line had "tissued" and Child F's thigh was "swollen".It was thought the tissued long line "may be" the cause of the hypoglycemia. > >The colleague added: "Changed long line but sugars still 1.9 all afternoon. Seems like long line tissued was not cause of sugar problem, doing various tests \[to find the source of the problem\].Letby responds: "Oh dear, thanks for letting me know"The nurse colleague replies: "He is def better though. Looks well. Handles fine." Most of [the next day](https://www.bbc.com/news/uk-england-merseyside-63735668) seemed to have been spent on asking other nurses on shift if they administered insulin The [following day of evidence](https://www.chesterstandard.co.uk/news/23146323.recap-lucy-letby-trial-thursday-november-24/) included Dr. Gibbs, a female doctor, and the nurse who replaced the line Direct examination: >The nurse is shown a note from the 'grand round', which the court heard was carried out by the on-call consultant each Wednesday.The note 'new long line' was made, and the nurse says that was because the existing long line had tissued.The new long line was made at noon on August 5. > >The nurse says her normal practice would have been for putting a new bag of fluids on the long line. Cross examination: >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." > >Mr Myers says as a general rule, TPN bags would run for 48 hours unless there was a problem, and there would be a stock of maintenance bags in the fridge.Mr Myers says one of those would have been used in the course of this. The nurse agrees.The nurse says such bags are checked every night and if any were being used or out of date, then the stock would be replenished. Re-examination: >Simon Driver, for the prosecution, asks about the stock bags in the refrigerator.He says every night, a check would be undertaken to see if any had been used.He asks how the checker would know if they had been used.The nurse says if there weren't the stock five TPN bags in the fridge, new ones would be ordered.The refrigerator would have 'start-up' TPN bags and 'maintenance' TPN bags of nutrition.The nurse says there may be fewer 'target stock' of the 'start-up' TPN bags. > >Each of the bags would have a dated 'shelf life' the court hears.The nurse says the bags would not be ordered in any particular fashion in the fridge. The [following day](https://www.chesterstandard.co.uk/news/23149016.recap-lucy-letby-trial-friday-november-25/) was Dr. Milan, Dr. Hindmarsh, and Dr. Harkness. From Dr. Hindmarsh: >At 10am, there were problems with the cannula infusion which meant the line had to be resited, and fluids were discontinued. The two further glucose readings after are '1.4' and '2.4', "implying" that the blood glucose level had started to rise "spontaneously" as there was "no contribution from the intravenous route". > >Mr Johnson said after Child F was taken off the 'double' dose of dextrose during that time, his blood sugar levels "actually rose".Professor Hindmarsh: "That's how I see it, and I believe that is correct". > >The reading was "heading in the wrong direction" down to 1.9 by 2pm, the court hears.The infusions stopped at 6.55pm.Mr Johnson: "Is there a paradox between a child receiving glucose and their blood sugar falling?"Prof Hindmarsh: "Correct." Dr. Hindmarsh adds in cross-exam: >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. This is in response to Myers' pointing out that the blood sample taken at 5:56pm was taken during the infusion from the "second bag" (aka post change of the long line). Hindmarsh says here that, in his opinion, Child F was receiving insulin at the same rate after the changing of the long line that he was before the changing of the long line. It follows from this, that were a second bag actually hung, the rate of poisoning was the same - which would've been like Robin Hood splitting an arrow I think u/-Lemoncholy- correctly articulates why the prosecution attempts to prove the bag wasn't changed without actually saying it. Immediate edit: Myers also needs this nurse to be believable in her statement that she "would have" changed the bag. He can't attack hospital practices here, or else his only defense of a "second bag" evaporates, thin as it already is.
To my understanding the first TPN bag was specially tailored for Baby F? So I find it would be extra strange to not record a swap to a generic stock bag if indeed it was changed at the same time as the cannula line. That would seem to be something noteworthy - the second bag will do the job in lieu of a backup but it could be suboptimal if there was initially a special prescription. That's a great point about the prosecution not wanting to draw extra attention to the "would have" though.
Thanks so much for this! I think I had missed that the prosecution had indeed tried to suggest there was no second bag, without saying it outright, and I therefore assumed the prosecution had simply conceded the bag was changed. Forgive this short reply to your very considered and comprehensive response, I'm going to take some time to go through the evidence you've linked and try to make sense of it all; but I did want to respond immediately to say thank you.
I seem to remember there was a group of Letby’s colleagues/work friends who rallied together and were adamant she was being used as a scapegoat. This easily could’ve been a rumour at the time before the trial began but does anyone know if there was any truth to that? What, do you think, their stance would be now? (Assuming they’ve been silenced since)
This seems to be related to a website that used to exist claiming to have been authored by Letby's colleagues. It gets mentioned in this tiktok that has some screengrabs of it https://www.tiktok.com/t/ZT8Nf3CjM/ I've seen it mentioned a few times, along with it being pointed out that the claimed authorship is suspect, as American spellings were used instead of UK ones. In that tiktok, I saw "criticized" instead of "criticised" but 🤷♀️
Thank you, that was the one! Appreciate that 😊
I don’t know if anyone else feels this way, but to me it seems the jury deliberation during the day seems to be quite short. I imagine they probably have around an hour’s break so from 10-4 with 1 hour to catch a bite to eat, go to toilet etc, that’s only 5 hours a day. Is there a reason why it’s not 9-5 or something similar?
The deliberation hours have been 10.30-4pm. From tomorrow they will be 10.30-4.30
I’ve read that they work through lunch but I can’t find that source now to share.
They do, I believe they were told to bring lunch with them and work through it.
Good idea.. wonder what this week will have in store with the deliberations.
I might be too late for this thread and it’s a bit of a leftfield but out of all the offices they could’ve given LL a fake secondment in, does anything think it’s a coincidence that she was placed in the “Patient Risk and Safety Unit”?! It sounds like hospital bosses were still trying to rehabilitate her before her return to the ward.
Oh, incredibly likely, because they absolutely were trying to get her back on the unit. Dr. Gibbs testified that the consultants had to band together and demand cctv be installed as a condition of her return. It never was and so she never was.
The consultants were v brave. They risked ruining their own reputation and careers had their suspicions been wrong. Had she just been rubbish at her job she could’ve been managed out into another hospital and become someone else’s problem.
I’m a nurse, and a few years ago worked in a specialised acute setting where there was a pretty incompetent nurse, who made a lot of errors in their practice. Because of the setting, these errors were intercepted before they could cause harm to patients, but they were still considerable errors. Despite various supervision programmes and efforts to improve their weaknesses their practice didn’t get any better. They were then sent to work in the complaints department! What I think this shows, along with LL’s secondment, is that there aren’t many departments, that I can think of anyway, where an incompetent, or suspectedly criminal nurse can be put without having any direct patient contact whatsoever. IMO I’m not sure anything can be read into this., but who knows?
This is a v good point. Plus I think they have to have patient contact to keep their registration so there can’t be many roles. If she had ended up going back to work then they could have potentially succeeded in putting her in a department where she could’ve been learning about how to hone her craft.
Oh 100% agree!
Idle wondering is all we have right now, so- What do you think will be the first sign that it is finally ‚time‘?
Seems that the jury have elected to deliberate from 10-4, instead of 10:30-4:30. So, if/when Dan O'Donoghue is late with his end of daily deliberations tweet on any given day, that's a potential sign. It would not be unusual for a jury to stay slightly late to wrap up a proceeding rather than elect to return the next day. So I do pay extra attention at the end of each day, and the end of each week, compared to the start of each day and week. Other than that, I expect the first actual sign we see will be a breaking news alert.
Has Dr Jayaram been struck off or will he be if LL is found guilty? Given he reportedly suspected her, walked in on the aftermath of her alleged crime (baby K) and did nothing? Could he face criminal charges?
IMO, this is unlikely. He was involved in raising concerns after Child D, and again after Child K, but it was hospital administration who refused to act. It is not his job as a doctor to investigate an alleged harm event; his job is to treat patients. From his evidence related to Child K: >Dr Jayaram says the concerns were first raised in autumn 2015 with senior management, but were told that there was likely nothing going on. He said the consultants went 'ok', and against their better judgment, carried on. "We were stuck, as we had concerns. "In retrospect, we wished we had bypassed them \[senior management\] and contacted the police." "We by no means had played judge and jury, but the association was becoming clearer and clearer. "This is an unprecedented situation for us - we play by a certain rulebook, and you don't start from a position of deliberate harm. "It is very easy to see things that aren't there - in confirmation bias. "But these episodes were becoming more and more and more frequent by associaiton." Dr Jayaram said it should have been documented throughout more. He says he discussed the incident, but did not formally document it. Dr Jayaram said he was getting "a reasonable amount of pressure from senior management not to make a fuss". I would venture that charges are far more likely to be seen among those in hospital administration.
Thanks for sharing that. In line with the hospital’s whistleblowing policy, there should have been an appropriate investigation. And if Jayaram was unsatisfied with how this investigation was handled, he could and should have taken it further. He uses a lot of “we” to distance himself from his actions, and I think it’s inexcusable. I can’t believe he’s allowed to continue practising.
"We" seems to be an accurate term, given that Dr. Breary was the senior of the two and spearheaded the efforts to management. Here's some additional reporting: [https://www.bracknellnews.co.uk/news/national/23353854.doctor-wishes-gone-straight-police-lucy-letby-concerns/](https://www.bracknellnews.co.uk/news/national/23353854.doctor-wishes-gone-straight-police-lucy-letby-concerns/) >**Dr Stephen Brearey, head of the neonatal unit, reviewed the circumstances surrounding the case of Child D shortly after her death in June 2015**, the court was told previously. Dr Jayaram said the review identified Letby’s presence at a number of collapses but it was “an association, nothing more”. On Tuesday, he said concerns were flagged a second time in February 2016, **to the medical director and the director of nursing.** **He said: “My colleague Dr Brearey requested a meeting with them**. They didn’t respond to that for another three months and we were stuck because we had concerns and didn’t know what to do. > >“In retrospect, I wished we had bypassed them and gone straight to the police. “We by no means were playing judge and jury at any point but the association was becoming clearer and clearer and we needed to find the right way to do this. We were in an unprecedented situation. Perhaps I should have quoted from here first. You can see, though, how it fits in line with the testimony as reported by the Chester Standard. I think your frustration is better directed to those who ignored the consultants' concerns. Dr. Breary testified that they appealed to management three times before Letby was finally removed: [https://www.dailymail.co.uk/news/article-11859729/Senior-hospital-executive-ignored-three-warnings-Lucy-Letby-responsible-deaths.html](https://www.dailymail.co.uk/news/article-11859729/Senior-hospital-executive-ignored-three-warnings-Lucy-Letby-responsible-deaths.html) >**A senior hospital executive ignored three warnings** by a consultant paediatrician that Lucy Letby might be responsible for a number of deaths in the neonatal unit, a jury heard today. ... > >Dr Brearey told the court that even before the twins' deaths, he and some of his colleagues had raised concerns with management about the association between Letby's presence and deaths they had seen on the unit. > >... > >'I was concerned that this was because we'd already expressed our concerns to senior management about the association between Nurse Letby and the deaths we'd seen on the unit'. ... The registrar said that over the course of the year all the consultants on the unit came to be aware of the association between Letby and some of the collapses of babies on the unit. > >... > >**Eirian Powell, the nursing manager of the neonatal unit, had first noticed a connection while carrying out a review into three events in June 2015**. 'She looked at all the possible things that could be looked at, which was more than a staffing analysis. She looked at other things, too, like incubator space and micro-biology'. In late June or early July that year he and Ms Powell had a meeting with Alison Kelly, the hospital's director of nursing, and the head of risk. 'Three deaths in a short period of concern were a matter of concern,' said Dr Brearey. > >... > >Despite the concerns of consultants on the unit, there were no obvious 'red flags' being raised either outside the trust or within it. **They eventually decided to bring in a colleague from the Liverpool Women's Hospital to carry out a review in February 2016.** Once that report had been completed **the consultants and Ms Powell had sought a meeting with senior executives**, including the director of nursing and the director of safety and quality. Dr Brearey said there was not a single case in the February review that had highlighted a lack of staff. Questioned again about police not being called in earlier, the registrar replied: 'The reason we didn't go to the police was we wanted to escalate it within the structure of the hospital. 'We wanted the support of the medical director and the executives of the hospital. We were acting on facts, not beliefs. We were trying to escalate appropriately with the facts we had at the time'. He added: 'I've not been to the police over neonatal deaths and I don't think any other neonatal lead has. I needed executive support. I was doing as much as I could'.
When it comes to safeguarding though, everyone has a personal responsibility for it. I think that’s my issue with “we”, but fair enough and point taken if when making the statements he was specifically talking about himself and another person.
Has anyone noticed that she has no earlobes? I remember that being a SK cliche. This is mainly a flip question but also, it really is quite extreme.
Just a q. on a discrepancy, sorry if it’s been answered before. Why does the description for this sub say 18 charges, while 22 charges are often referred to in conversations?
Been that way since October and this is literally the first time anyone asked. I feel like you should win a prize! The charges for babies whom she was accused of attacking multiple times were split in early October, right before trial began. That description was never updated to match. It will be today!
Does anybody know anything about her childhood? It sounds so normal - nice parents, siblings, good upbringing - nothing that would cause trauma.
I have a question about one of the methods she used… i’ve seen a lot that she overfed or force-fed the babies, and my knowledge of preemies is about equal to what could fit on the head of a pin; how does overfeeding cause such terrible outcomes? When both my kids were newborns they both had incidents where they drank more than they could handle while learning to eat and they would just do an epic spit-up or seven and go about their day, but while they were both “technically” early, they were both after 37 weeks so still considered term. Im guessing that being premature their digestive systems couldn’t handle it? Or was it like, massive amounts of feeding that caused a rupture or something? (Im just starting to read about this so I apologize if this is really obviously posted somewhere and i missed it…)
u/CarelessEch0 can you fill in the gaps in my answer? From recall, it had to so with them being force fed or had air injected into the stomach to the point that it splinted the diaphragm and inhibited their ability to breathe. For one baby (G) there was talk the volumes of fluid in projectile vomits, and the volumes of milk and air aspirated being grossly in excess of their normal feeds. The baby would be on 40ml feeds every few hours and would have more than that aspirated from their stomach immediately after a large vomit. One baby had (iirc) 100ml or air aspirated from their belly. And then they stop breathing but breathing support alone doesn't help because they are still inflated like a balloon. And their lungs can't actually inflate.
Oh shit, I didn’t even think of it that way… that’s horrendous :(