I fail to see how the weighting of evidence is not heavily in favour of contemporaneous notes in an event 8 years prior to the trial. I mislaid a book some months ago, not located yet. Over weeks I have remembered putting it in some place, only to find on carefully checking that I did not do so.
2) Were any blood sugars or electrolytes checked on the baby? Was the baby hypoglycemic?
3) Is there a site where Xrays for Baby A?
4) Why were antibiotics started?
5) The baby had RDS...how much oxygen was needed? The baby had a lactate checked. Why? Is that standard? Did the baby ever have a blood gas? What was the PCO2?
6) What is a "long line UVC?" A UVC is a UVC. It's not in the US ever referred to as long. We also place PICC lines which some refer to as long lines...placed in a peripheral vein and threaded centrally. There are not UVCs though.
7) There was an xray when the line was originally placed...was it in place or not? Do we have the xray?
8) It is inexplicable that the doc pulled the UVC as this code commenced. It was venous access! It was a place to give emergency drugs even if not perfectly sited. If he pulled the line how did they give code meds?
Apparently Dr Owen Arthurs expert radiologist examined cXR postmortem and said he found a "line of gas just in front of the spine". ..."in absence of any other explanation (he had said this documented in road accidents & sepsis) this appearance is consistent with, but not diagnostic of air being administered". I would think 30 mins of CPR on a tiny baby might be akin to a road accident & sepsis also possible.
But looking for his reference I found this article by a Dr Owen J Arthurs et al in Pediatric Radiology 45, 491-500, 2015
[Indications, advantages and limitations of perinatal postmortem imaging]
Discussing use of radiography, ultrasound, CT and MRI - "There is limited direct evidence on the diagnostic utility of any of these techniques apart from postmortem MRI ..."
1. Included by Dr E as a murder - no evidence at all.
Thank you, so much, for explaining this so well, with so much detail, in a way even I (think!) I fully understand.
I had amazing midwives, but a couple of doctors who displayed an arrogance that was staggering. This included, with my first baby, whacking up the syntocynon while I was already in too much pain to speak and couldn't interject, I'd warned them of familial problems- even a tragedy of a baby dying soon after birth- with it and the demonstrable effect on my baby's heart rate. I also was jabbed with additional anticoagulants while near active labour and consequently lost almost two litres of blood.
You've done an amazing job here. Poor, poor Lucy. I hope she knows what amazing people she has calling this out
Do we know which type of long line was inserted? Was it inserted through the umbilical vein or peripherally? Can we confirm the lumen was only 1mm. Has anyone actually tried pushing air through a plastic tube with a 1mm lumen? It can’t be easy.
The long lines described in the evidence were all umbilical (UVC). UVC are a common cause for air in the abdominal cavity as you essentially have an open track for the air to pass into the blood vessels. That air can be a source for infection. The other issue is infection itself - while nurses will usually follow a strict aseptic technique when changing the infusion bags connected to the long line, many of the pathogens you are going to encounter that will get onto the long line sheath and surrounding areas inside the cot create pockets of gas as they breed and grow. This is why air pockets in, through, and outside the bowels is a sign for NEC - the bacteria causing NEC creates this gas - NOT a nurse with a syringe
Further, why did expert witness (Prof Kinsey) flat out contradict the agreed evidence by testifying that the twins A & B did not have APS? Apparently there are no agreed clinical testing standards for neonatal APS, so if you test it comes up negative! Yet there is medical literature to say neonates can inherit APS or acquire passive APL antibodies from mother across the placenta. This is like Admiral Nelson using his blind eyes and seeing no ships!
From Dan O'Donoghue's Twitter thread “Dr Marnerides, who leads the forensic children's pathology service at Guy's and St Thomas' Hospitals, is now in witness box. He reviewed tissue samples from Child A, who the Crown say was murdered by Ms Letby in June 2015 via air injection. The medic says from his review, he found 'globules' in the veins in the lungs and brain tissue that were most likely air, he said this air 'most likely went there while this baby was alive'”. Apart from the fact that ‘most likely’ doesn’t sound like beyond reasonable doubt, can anyone explain how a venous air embolism gets from the inferior vena cava into the cerebral or pulmonary veins. It should end up in the pulmonary arterial system. Perhaps I’m stupid and it can get there or Mr O’Donoghue has got it wrong. However it can get there from high pressure respiratory therapy in the neonate due to alveolar leakage https://pubmed.ncbi.nlm.nih.gov/98984/. Baby A was on CPAP and then intubated. Has anybody considered this?
I fail to see how the weighting of evidence is not heavily in favour of contemporaneous notes in an event 8 years prior to the trial. I mislaid a book some months ago, not located yet. Over weeks I have remembered putting it in some place, only to find on carefully checking that I did not do so.
So many neonatologist questions.
1) How preterm was Baby A, what was the weight?
2) Were any blood sugars or electrolytes checked on the baby? Was the baby hypoglycemic?
3) Is there a site where Xrays for Baby A?
4) Why were antibiotics started?
5) The baby had RDS...how much oxygen was needed? The baby had a lactate checked. Why? Is that standard? Did the baby ever have a blood gas? What was the PCO2?
6) What is a "long line UVC?" A UVC is a UVC. It's not in the US ever referred to as long. We also place PICC lines which some refer to as long lines...placed in a peripheral vein and threaded centrally. There are not UVCs though.
7) There was an xray when the line was originally placed...was it in place or not? Do we have the xray?
8) It is inexplicable that the doc pulled the UVC as this code commenced. It was venous access! It was a place to give emergency drugs even if not perfectly sited. If he pulled the line how did they give code meds?
Oh...and other than the non-expert saying air embolus, do any xrays from Baby A show air in the heart or elsewhere?
Apparently Dr Owen Arthurs expert radiologist examined cXR postmortem and said he found a "line of gas just in front of the spine". ..."in absence of any other explanation (he had said this documented in road accidents & sepsis) this appearance is consistent with, but not diagnostic of air being administered". I would think 30 mins of CPR on a tiny baby might be akin to a road accident & sepsis also possible.
But looking for his reference I found this article by a Dr Owen J Arthurs et al in Pediatric Radiology 45, 491-500, 2015
[Indications, advantages and limitations of perinatal postmortem imaging]
Discussing use of radiography, ultrasound, CT and MRI - "There is limited direct evidence on the diagnostic utility of any of these techniques apart from postmortem MRI ..."
1. Included by Dr E as a murder - no evidence at all.
2. At trial - absolutely reasonable doubt.
My good god.
Thank you, so much, for explaining this so well, with so much detail, in a way even I (think!) I fully understand.
I had amazing midwives, but a couple of doctors who displayed an arrogance that was staggering. This included, with my first baby, whacking up the syntocynon while I was already in too much pain to speak and couldn't interject, I'd warned them of familial problems- even a tragedy of a baby dying soon after birth- with it and the demonstrable effect on my baby's heart rate. I also was jabbed with additional anticoagulants while near active labour and consequently lost almost two litres of blood.
You've done an amazing job here. Poor, poor Lucy. I hope she knows what amazing people she has calling this out
Do we know which type of long line was inserted? Was it inserted through the umbilical vein or peripherally? Can we confirm the lumen was only 1mm. Has anyone actually tried pushing air through a plastic tube with a 1mm lumen? It can’t be easy.
The long lines described in the evidence were all umbilical (UVC). UVC are a common cause for air in the abdominal cavity as you essentially have an open track for the air to pass into the blood vessels. That air can be a source for infection. The other issue is infection itself - while nurses will usually follow a strict aseptic technique when changing the infusion bags connected to the long line, many of the pathogens you are going to encounter that will get onto the long line sheath and surrounding areas inside the cot create pockets of gas as they breed and grow. This is why air pockets in, through, and outside the bowels is a sign for NEC - the bacteria causing NEC creates this gas - NOT a nurse with a syringe
In the agreed evidence:
Both twins A and B are said to have antiphospholipid syndrome.
Mum said to have a prior to pregnancy ‘blood condition’, being treated and monitored during pregnancy.
At collapse of both twins (and death of baby A) very unusual lopsided skin discolouration observed.
Medics discussed if APL syndrome a contributing factor, considering the obvious genetic link. (Consulted Gt Ormand St and Alder Hey)
Could thrombosis have played a part?
Further, why did expert witness (Prof Kinsey) flat out contradict the agreed evidence by testifying that the twins A & B did not have APS? Apparently there are no agreed clinical testing standards for neonatal APS, so if you test it comes up negative! Yet there is medical literature to say neonates can inherit APS or acquire passive APL antibodies from mother across the placenta. This is like Admiral Nelson using his blind eyes and seeing no ships!
From Dan O'Donoghue's Twitter thread “Dr Marnerides, who leads the forensic children's pathology service at Guy's and St Thomas' Hospitals, is now in witness box. He reviewed tissue samples from Child A, who the Crown say was murdered by Ms Letby in June 2015 via air injection. The medic says from his review, he found 'globules' in the veins in the lungs and brain tissue that were most likely air, he said this air 'most likely went there while this baby was alive'”. Apart from the fact that ‘most likely’ doesn’t sound like beyond reasonable doubt, can anyone explain how a venous air embolism gets from the inferior vena cava into the cerebral or pulmonary veins. It should end up in the pulmonary arterial system. Perhaps I’m stupid and it can get there or Mr O’Donoghue has got it wrong. However it can get there from high pressure respiratory therapy in the neonate due to alveolar leakage https://pubmed.ncbi.nlm.nih.gov/98984/. Baby A was on CPAP and then intubated. Has anybody considered this?