Great article again. Two things that could have increased the risk of necrotizing enterocolitis (NEC) in that unit in a specified time period that have more to do with bad management than a bad nurse:
(1) poor breast feeding rates in the neonatal unit. This is a major risk factor for NEC in the NICU. Is the Countess of Chester recognised as a "baby friendly" unit?
(2) overuse of co-amoxiclav in antenatal women at risk of preterm labour. This is a known risk factor for NEC and neonatal death (HR of 14x for mortality from NEC). Known = known in the literature which doesn't stop bad obstetricians giving it out.
I would look at those two factors around that time at that hospital if I were on the defence team.
UPDATE: CoC claims to be "baby friendly" accredited. It would be worth trying to get hold of one of these team members to see if the neonatal unit was an active participant, or they were still running old-school formula based doctrines. https://www.coch.nhs.uk/all-services/infant-feeding
In 2015 the midwives in COCHospital were recognized an award. That seems to go against the analyses by Dr. James Egan, that bad care in the maternity ward could have caused premature babies in worse condition (than if the care had been top-notch).
Clipping:
"Pregnant women in Chester can be assured they are receiving the best maternity care available as the Countess of Chester Hospital's midwifery management team has won a top award." Crowned Team of the Year at the Royal College of Midwives (RCM) 2015 Annual Midwifery Awards, the midwives were recognized for their dynamism, commitment and enthusiasm, competing against shortlisted hospitals from Blackpool and Manchester. They were also recognized for their ability to work in a unique way within a contemporary maternity service and as having an appropriate skill mix and an innovative and consistently high quality approach to the provision of care to women, their babies and families."
P.S. As we can see a hand wash sink is next to incubator 1.
Aug 27, 2023Liked by Mr Law, Health and Technology
"During cross examination he undermined his own ‘expert evidence’ first by telling the jury that not everything could be learned from training videos, and then by admitting he had not only never used in clinical practice the Phillips monitors he had been taking them through - but that he had actually never seen one at all." It's as if the prosecution did not really want an expert witness. This is farce, though tragic.
Even more tragic: he was the expert witness. The whole investigation, the whole trial, revolved around Dr. Dewi Evans. He came with these innovative ideas how to murder babies. The prosecution apparently lapped it up - like police had done before.
If I remember correctly one of the MD's was asked about a value on a piece of equipment in use in the NICU. He answered that he had no idea "I only use the equipment, I did not design it, how should I know what it means."
In case anyone else finds this of interest: there was a letter in the BMJ in 2002, signed by Dr Dewi Evans, alongside Prof Roy Meadow (the "expert" involved in Sally Clark's wrongful conviction) and a number of other signatories, complaining about having been reported to the GMC - see https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1122077/ .
I’m not sure which of these articles this comment belongs to. But since this article is The Incredible Dr Dewi Evans, how about one for The Incredible Police Investigation. What concerns me is how it was decided which cases Dr Evans should look into when it was finally decided by the CoCH powers that something was amiss at the NICU.
When the police investigation eventually got going it seems by Dr Brearey’s own admission that it was he who researched and produced the case files for the police. Yet he was quite clearly a compromised individual. For one thing he was clearly amongst the possible suspects and for another thing also amongst the group of accusers of Nurse Lucy Letby. The police couldn’t have found anyone with a more profound conflict of interests to ask to ‘help out’ in the initial stage of their investigation than Dr Brearey.
If it was really thought that a murderer was at large amongst the members of staff, then wouldn’t the normal course of action be for the police to ‘ring fence’ the unit, ie shut it down to prevent further incidents, and then to seize all case files, notes and documents throughout the whole unit as being potential evidence. After that bring in some trusted and completely independent medical experts to examine everything from scratch. Also, by ‘independent experts’ I don’t mean someone who has managed to inveigle himself upon the police and who also stands to gain pecuniary interest, but I mean an independent team of experts! Plurality being essential for accountability.
From what has been admitted by Dr Brearey and Dr Evans...
Dr Brearey chose more than 30 medical case files of death or near death collapse to hand to the police (so 31 or more serious cases).
The police handed them to Dr Dewi Evans, who whittled them down to the 15 for which he was unable to find a natural cause (despite the PM results for 6 being exactly that, and despite there being loads of relevant literature about medical risks to neonates).
To the 15 were added another two, again from Dr Brearey who discovered the so called insulin cases. Dr Evans then handed the 17 cases back to the police to work with.
Is it possible to design a more flawed or biased investigation?
Why were the 16 or more discarded cases not investigated for other causes, since 13 or 14 of them clearly exceeded the expectations of only ‘2 or 3 cases’ that the unit usually had per year? (A team sweeping the unit for pathogens would seem like a sensible start).
Statistics were incorrectly used, same as in de Lucia de Berk case, a neonatal nurse from The Netherlands. She was in prison for seven years, also based on a "gut feeling', being on shift when a death occurred too often, having taken hospital papers, being in the process of writing a pot-boiler located in a hospital, and statistics improperly applied.
Dr. Gill wrote an email to the judge presiding over the Letby case, pointing to the incorrect use of statistics by the Chester PD. Next he was visited by a few member of his local Dutch PD (two cars, lights on), bringing him a threatening letter from Chester PD. Apparently writing the email was illegal under UK law.
Dr. Breary was known as a bully by all who worked in the ward, and also by parents.
This case needs to be brought back into the court room with a cracking defence team and expert medicals giving testimony surely these experts should be vetted before giving expert statements
A trip from Wales to Chester can be as short as 1/4 mile but I believe Evans lives in Carmarthen so a good 3-4 hour drive across country so he must have believed to be worth considerable effort and money. Turns out it was!
Just another comment from the Chester Standard report: ‘Ben Myers KC, defending, says Dr Evans has prepared a "large number of reports" over the years, and air emboluses feature in "a number of them" - "literally dozens". Dr Evans agrees.’ Sounds like Evans has a tendency to diagnose air embolism when he can’t think of anything else. Can anyone identify these ‘literally dozens’ of cases?
Does anyone know anything about Dr Evans’s career? I tried looking him up on the GMC register but there is only a Dewi Arwyn Evans qualified in 1954 and not registered since 2009. I don’t think that can be him, somebody qualified in 1954 would be at least 90 by now.
Where is he on the GMC register in that case. I’ve checked again and can only find one Dewi Evans qualified in London 1954 so clearly not him. I was just checking to see if he has maintained his licence to practice as that would at least demonstrate ongoing CPD and annual appraisal. But I can’t find another Dewi Evans. Is he registered under a different name?
https://uk.linkedin.com/in/dewi-evans-211194a3 on LinkedIn is him. The photo is him. Retired (sort of) in 2009 is him. 1954 on the GMC Register must be a typo or error. The whole Lucy Letby case seems to have one error after another running through it. Poor Lucy.
He is David Richard Evans. Qualified 1971. Full registration 1972. Registered with licence to practice until August 2015. Registered without licence to practice between August 2015 and July 2019. Registered with licence to practice since. It appears he had no licence to practice during the period of the investigation. Legally there was no requirement for him to have one but I would have expected it.
Great article again. Two things that could have increased the risk of necrotizing enterocolitis (NEC) in that unit in a specified time period that have more to do with bad management than a bad nurse:
(1) poor breast feeding rates in the neonatal unit. This is a major risk factor for NEC in the NICU. Is the Countess of Chester recognised as a "baby friendly" unit?
(2) overuse of co-amoxiclav in antenatal women at risk of preterm labour. This is a known risk factor for NEC and neonatal death (HR of 14x for mortality from NEC). Known = known in the literature which doesn't stop bad obstetricians giving it out.
https://pubmed.ncbi.nlm.nih.gov/22933088/
I would look at those two factors around that time at that hospital if I were on the defence team.
UPDATE: CoC claims to be "baby friendly" accredited. It would be worth trying to get hold of one of these team members to see if the neonatal unit was an active participant, or they were still running old-school formula based doctrines. https://www.coch.nhs.uk/all-services/infant-feeding
In 2015 the midwives in COCHospital were recognized an award. That seems to go against the analyses by Dr. James Egan, that bad care in the maternity ward could have caused premature babies in worse condition (than if the care had been top-notch).
Clipping:
"Pregnant women in Chester can be assured they are receiving the best maternity care available as the Countess of Chester Hospital's midwifery management team has won a top award." Crowned Team of the Year at the Royal College of Midwives (RCM) 2015 Annual Midwifery Awards, the midwives were recognized for their dynamism, commitment and enthusiasm, competing against shortlisted hospitals from Blackpool and Manchester. They were also recognized for their ability to work in a unique way within a contemporary maternity service and as having an appropriate skill mix and an innovative and consistently high quality approach to the provision of care to women, their babies and families."
P.S. As we can see a hand wash sink is next to incubator 1.
"During cross examination he undermined his own ‘expert evidence’ first by telling the jury that not everything could be learned from training videos, and then by admitting he had not only never used in clinical practice the Phillips monitors he had been taking them through - but that he had actually never seen one at all." It's as if the prosecution did not really want an expert witness. This is farce, though tragic.
Even more tragic: he was the expert witness. The whole investigation, the whole trial, revolved around Dr. Dewi Evans. He came with these innovative ideas how to murder babies. The prosecution apparently lapped it up - like police had done before.
If I remember correctly one of the MD's was asked about a value on a piece of equipment in use in the NICU. He answered that he had no idea "I only use the equipment, I did not design it, how should I know what it means."
Check out this case from 2015…another judge was critical of Dr E…. https://www.casemine.com/judgement/uk/5a8ff87360d03e7f57ec0ab6/amp
In case anyone else finds this of interest: there was a letter in the BMJ in 2002, signed by Dr Dewi Evans, alongside Prof Roy Meadow (the "expert" involved in Sally Clark's wrongful conviction) and a number of other signatories, complaining about having been reported to the GMC - see https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1122077/ .
I’m not sure which of these articles this comment belongs to. But since this article is The Incredible Dr Dewi Evans, how about one for The Incredible Police Investigation. What concerns me is how it was decided which cases Dr Evans should look into when it was finally decided by the CoCH powers that something was amiss at the NICU.
When the police investigation eventually got going it seems by Dr Brearey’s own admission that it was he who researched and produced the case files for the police. Yet he was quite clearly a compromised individual. For one thing he was clearly amongst the possible suspects and for another thing also amongst the group of accusers of Nurse Lucy Letby. The police couldn’t have found anyone with a more profound conflict of interests to ask to ‘help out’ in the initial stage of their investigation than Dr Brearey.
If it was really thought that a murderer was at large amongst the members of staff, then wouldn’t the normal course of action be for the police to ‘ring fence’ the unit, ie shut it down to prevent further incidents, and then to seize all case files, notes and documents throughout the whole unit as being potential evidence. After that bring in some trusted and completely independent medical experts to examine everything from scratch. Also, by ‘independent experts’ I don’t mean someone who has managed to inveigle himself upon the police and who also stands to gain pecuniary interest, but I mean an independent team of experts! Plurality being essential for accountability.
From what has been admitted by Dr Brearey and Dr Evans...
Dr Brearey chose more than 30 medical case files of death or near death collapse to hand to the police (so 31 or more serious cases).
The police handed them to Dr Dewi Evans, who whittled them down to the 15 for which he was unable to find a natural cause (despite the PM results for 6 being exactly that, and despite there being loads of relevant literature about medical risks to neonates).
To the 15 were added another two, again from Dr Brearey who discovered the so called insulin cases. Dr Evans then handed the 17 cases back to the police to work with.
Is it possible to design a more flawed or biased investigation?
Why were the 16 or more discarded cases not investigated for other causes, since 13 or 14 of them clearly exceeded the expectations of only ‘2 or 3 cases’ that the unit usually had per year? (A team sweeping the unit for pathogens would seem like a sensible start).
https://www.youtube.com/watch?v=8MTv_EKKNLw
https://www.bbc.com/news/uk-66120934
Statistics were incorrectly used, same as in de Lucia de Berk case, a neonatal nurse from The Netherlands. She was in prison for seven years, also based on a "gut feeling', being on shift when a death occurred too often, having taken hospital papers, being in the process of writing a pot-boiler located in a hospital, and statistics improperly applied.
Dr. Gill wrote an email to the judge presiding over the Letby case, pointing to the incorrect use of statistics by the Chester PD. Next he was visited by a few member of his local Dutch PD (two cars, lights on), bringing him a threatening letter from Chester PD. Apparently writing the email was illegal under UK law.
Dr. Breary was known as a bully by all who worked in the ward, and also by parents.
That poor, poor girl…
This case needs to be brought back into the court room with a cracking defence team and expert medicals giving testimony surely these experts should be vetted before giving expert statements
A trip from Wales to Chester can be as short as 1/4 mile but I believe Evans lives in Carmarthen so a good 3-4 hour drive across country so he must have believed to be worth considerable effort and money. Turns out it was!
Just another comment from the Chester Standard report: ‘Ben Myers KC, defending, says Dr Evans has prepared a "large number of reports" over the years, and air emboluses feature in "a number of them" - "literally dozens". Dr Evans agrees.’ Sounds like Evans has a tendency to diagnose air embolism when he can’t think of anything else. Can anyone identify these ‘literally dozens’ of cases?
Does anyone know anything about Dr Evans’s career? I tried looking him up on the GMC register but there is only a Dewi Arwyn Evans qualified in 1954 and not registered since 2009. I don’t think that can be him, somebody qualified in 1954 would be at least 90 by now.
Would this be the same Dewi Evans, once of Singleton Hospital in Swansea?
Councillor Kevin Edwards :-
www.cllrkevinedwards.blogspot.com
doesn't much like him, nor the company he keeps
Right person but wrong YOB. His LinkedIn profile says he went to Cardiff Medical School
(Bachelor’s Degree) 1966 - 1971 after being at Carmarthen Grammar School from 1960 to 1966, so he was born in about 1948.
Where is he on the GMC register in that case. I’ve checked again and can only find one Dewi Evans qualified in London 1954 so clearly not him. I was just checking to see if he has maintained his licence to practice as that would at least demonstrate ongoing CPD and annual appraisal. But I can’t find another Dewi Evans. Is he registered under a different name?
Dewi is short for Dewydd which is a Welsh form of David.
https://uk.linkedin.com/in/dewi-evans-211194a3 on LinkedIn is him. The photo is him. Retired (sort of) in 2009 is him. 1954 on the GMC Register must be a typo or error. The whole Lucy Letby case seems to have one error after another running through it. Poor Lucy.
He is David Richard Evans. Qualified 1971. Full registration 1972. Registered with licence to practice until August 2015. Registered without licence to practice between August 2015 and July 2019. Registered with licence to practice since. It appears he had no licence to practice during the period of the investigation. Legally there was no requirement for him to have one but I would have expected it.
Dr. Evans (retired) has a business as an "expert for hire".
When he heard about the Lucy Letby case he inserted himself by offering the Cheshire police his (paid) services.
He has proven to have little knowledge about the latest developments in neonatal care - for preemies smaller than ever.
Yet he played a big part in getting nurse Lucy convicted.