Thought dump

Presenting my thoughts, stories and ideas to the world

15th May 2024

Your Baby's life in their hand: Dr Harkness Baby E.

Jamie Egan

Dr Harkness, a paediatric registrar at the Countess of Chester Hospital in the summer of 2015, is being asked about Baby E on the night shift of August 3. He says they started that shift at about 8.30-9 pm. He explains that working in different hospitals, it is difficult to remember the shift patterns. He explains there would have been a handover period, where he would have read a handover sheet for the various patients and any outstanding conditions those patients had. There would be one sheet for the paediatric ward and one for the neonatal ward. If there were any sick children in A&E, the doctors would have been responsible for attending to them, too. He says the handover period would have lasted about 30 minutes. He says some tasks would have required him to work with Dr Christopher Wood, his colleague, on the night, and some would have been done solo. He says his tasks would have included speaking to nurses and seeing the neonatal unit babies.

He says if there was nothing outstanding happening in the neonatal unit, he would be there at 10-10.30 pm. He says that this night, he was called over at 10 pm, having been called over because Baby E had blood in his vomit. At 10 pm, Letby calls a doctor because she thinks the baby may be vomiting blood. 'Small amounts of blood' - minuscule blood flecks - were spotted when the NG Tube was brought out of Baby E, Harkness recalls.

This was the verbatim message Letby told Harkness at 10 pm. Even if we consider there was blood on Baby E’s mouth at 9 PM, as the mother says, there were no signs of haemodynamic instability at 9 PM, according to the prosecution. “The baby was stable” (TBWS) mantra was in full on mode at 9 PM. Therefore, it was perfectly reasonable for Letby not to overreact at 9 PM. However, at 10 PM, after she removed the nasogastric tube (NG tube) and unequivocally identified blood, she called Harkness.

There is another old saying in medicine: A little blood goes a long way. The saying is to remind juniors of two things: When you see blood, it's likely that you are overestimating the quantity but never the quality. Blood in the wrong place goes a long way to tell you where it's coming from. The over-estimation of the quantity tells you that you still have time to react. If you react on time, you can save a life. Harkness singularly failed to act on time. How do we know this? Because Baby E died not long after that phone call.

The court is shown Dr Harkness's note from 10.10 pm on August 3, which says, 'asked to see the patient (Baby E) regarding gastric bleed.

Harkness assumed that the bleeding was “gastric” (from the stomach). Gastric is his word, not Letby’s.

'Large, very slightly bile-stained aspirate 30mins ago.'

The “aspirate” ( also called residuals) are the contents of the gut drawn from an NG tube. If they are acidic with a Ph of around 4, then they are likely from the stomach.

The note adds: 'Sudden large vomit of fresh blood and 14ml aspirate.'

The doctor is given the opportunity to look through his clinical notes and Lucy Letby's nursing notes from that shift to see the chronology of events that night.

The court is now shown the 10.10 pm note.

He says it is not clear, from his note, how much of the 14ml aspirate contained 'fresh blood'.

It is perfectly clear from his note: “large vomit of fresh blood” and 14 ml aspirate.

He says the fresh blood was what he had witnessed, having been called over to see it. The court hears he did not see the child vomit but saw the fresh blood as a product of it.

This is at 10.10 PM

He notes baby E's blood pressure was 'very good', a CRT (capillary refill time) reading was good, the heart rate was 'normal', and saturation rates were good, with minimal oxygen support.

What does this tell us? If you apply finger pressure to the baby’s toe (usually), the skin will turn white, and as you remove it, the white area will refill with pinkish-coloured blood into capillaries. Hence, capillary refill time. It should be nearly instantaneous. However:

There is little correlation between CRT and blood pressure in neonates. PICU-based studies looking at CRT and central markers of poor cardiac outcome showed a positive predictive value of 93-96% and a negative predictive value of 40-50% to detect a ScVO2 of less than 70%. Blood pressure is a poor marker of outcomes in neonates.

"At that point in time, everything is fine, except for the blood in the aspirate," he tells the court.

Remember? A little blood goes a long way. You have time to stop this Harkness.

Baby E was also 'pink, well perfused', the lungs were 'clear', and the abdomen was 'soft, not distended'.

TBWS. All the more reason, Harkness, to keep it that way.

Dr Harkness notes 'GI bleed? Cause', and tells the court that there is a possible diagnosis for the bleeding, and a plan of action with administration of antibiotics is made.

Antibiotics will make no difference to internal bleeding in the immediate phase.

The note 'close observation' is made, emphasising the designated nurse - Lucy Letby - was to monitor Baby E closely in room 1.

What was there to monitor Harkness? Let’s see if the baby bleeds some more?. Harkness saw blood; He diagnosed a gastrointestinal bleed and called it a large volume.

Dr Harkness says, from his recollection, he does not believe he left the unit as the bleed was 'something unusual' in Baby E, so he does not believe he went very far.

Harkness" presence on the ward will make no difference to internal bleeding in the immediate phase.

For the 11 pm note, he says Letby called him into room 1, where 'Further GI blood loss and desaturation to 70%' is noted.

One hour and still counting. Marking time will make no difference to internal bleeding in the immediate phase.

A '13ml blood-stained fluid from NGT on free drainage' is noted.

Which is catastrophic.

He says he remembers seeing 'fresh, red blood in the tube' with the contents of the stomach. He says the free drainage setup would have allowed the vomit to come out rather than go into the baby's lungs. He says the origin of the blood must have come from somewhere in the oesophageal tract, down to the stomach. It rules out blood coming from the lungs. The saturates 'remained 60-70% in 100% O2', with Dr Harkness saying 'because of Baby E's condition', the oxygen requirement had gone up from 'minimal support'.

Yet more TBWS. The baby was dying

He says baby E was still trying to breathe at this time. The comment 'crying' is added to the note.

Breathing and crying will make no difference to internal bleeding in the immediate phase.

Dr Harkness says the child is still well enough to be awake enough and conscious to cry.

Consciousness will make no difference to internal bleeding in the immediate phase.

He said just the note 'crying' would suggest it was a 'typical cry'.

Another dollop of TBWS.

Dr Harkness says the fact Baby E was crying would mean he would have had to have been taking deep breaths to do so.

Breathing will make no difference to internal bleeding in the immediate phase.

The plan of action was to 'replace losses' - getting fluid back in.

What fluids Harkness? The baby is losing blood. What do we replace it with? Blood.

"Strict fluid balance' - the court hears, 'knowing how much to put back in'.

Cut the crap, Harkness; what about some fresh frozen plasma? O Neg And a cross-match, spun-platelets?

Dr Harkness says he is planning to intubate Baby E and do an x-ray to check Baby E's lungs and abdomen to try to explain why the baby was deteriorating.

Intubation and an x-ray will make no difference to internal bleeding in the immediate phase.

The type of intubation was 'elective', which was not on the level of 'an emergency situation', the court hears.

27 ml of visible GI blood loss and an unknown quantity not visible from a neonate , and it was not an emergency? This sums up the entire culture of the GoGH.

Dr Harkness says he would discuss the result of the x-ray with surgeons at Alder Hey and seek advice from them.

Speaking to surgeons will make no difference to internal bleeding in the immediate phase.

Dr Harkness said he would then have been preparing to intubate and get the equipment ready. Prescriptions are made from 11.28 pm to 11.30 pm for a number of drugs.

A number of drugs will make no difference to internal bleeding in the immediate phase.

A further note, written in retrospect, is made at 1.45 am. He records 'sudden deterioration at 11.40 pm'

One hour and 40 minutes (at least) since Letby called for help.

Prior to that, baby E was still to be 'under close observation' by Lucy Letby.

Blaming Lucy Letby will make no difference to internal bleeding in the immediate phase.

Dr Harkness tells the court he was in the room when the 'sudden deterioration' happened and was there with Lucy Letby and another nurse. Those nurses would have been gathering the drugs to be administered. The notes record 'Brady 80-90bpm, sats 60%, poor perfusion, colour change over the abdomen, purple discoloured patches'.

It hardly matters now what colour the abdomen is because it's too late for Baby E.

He says: "This was a strange pattern over the tummy and abdomen, which didn't fit with the poor perfusion - the rest was still pink, but there were these strange purple patches." He says some of the patches were still pink, but others were purple-blue, which was unusual.

Frankly? Who gives a s**t. Baby E is bleeding out in front of you.

He likens the purple-blue colour to what you would see after going for a swim in cold water and coming out with a 'purple-blue' colour on the lips. Harkness is babbling at this stage. Everyone in the world other than the staff at the CoGH calls that mottling. A clinical sign of shock. The rest of the skin was 'normal colour'.

The abdomen had 'purple patches', which didn't fit with an anatomical part of the body. He says it is difficult to describe in any detail without a photo. He says he has seen this in Baby A before and had not seen it on any other baby outside of the babies in the case. The patches were 'different sizes' and in the region of 1-2cm big - 'not dots'. The areas were 'on the abdomen - not above the chest or below the groin - in the middle section'. The patches 'did not fit with the perfusion' seen. He tells the court if the abdomen was dusky or white, then the whole of the body would gradually take that colour too. He says in the case of an affected blood supply, the blood would be lost from the legs first, and the body would pull the blood 'into the middle of the body'. "But on this occasion, it is the middle where you are seeing these discolouration?"

"Yes."

Dr Harkness confirms he has never seen these discolourations before or since, outside of the babies in this case.

Therefore, Baby A had mottling, a sign of shock. Harkness has never witnessed a mottling before in neonatal shock. Harkness, therefore, has not witnessed shock before, except in Baby A. Harkness clearly does not know what he is doing and certainly shouldn't be in a NICU on his own.

Dr Harkness's notes record 'intubated as an emergency at 11.45 pm'

He says although there were risks associated with this, the 'safer option' for baby E was to do things as an emergency.

Baby E was already in an emergency at 10:10 PM at the minimum, it just that Harkness didn’t know.

An ET tube was inserted, with 'good air and chest movement' recorded, and the tube was recorded to be in the correct place.

Baby E was also 'put on ventilator', with 100% oxygen.

More TBWS.

The saturation readings were '60-70%', and after a morphine bolus was administered, those improved to 80%.

The 'purple discolouration of abdomen remained', it is noted.

Translation: Baby E was still in shock because Harkness did nothing to stop it.

Baby E's blood pressure had dropped but was still in the normal range.

Yet more TBWS.

The plan was to administer further medication, but there was a concern that administering a drug to make the heart beat faster would lead to 'worse bleeding'.

Seriously?

Dr Harkness says 'from his recollection' the blood had settled, and there was no further substantial amount of blood recorded.

Dr Harkness said he and a colleague (Dr Woods no doubt who at least admits he hasn’t a clue) were stood at the end of the incubator, discussing what medication and plans were being put in place for baby E, when Baby E collapsed "in front of our face when we were stood there".

You don’t say?

Dr Harkness recalls the resuscitation efforts began, and Baby E's heart rate recovered at 1.01 am, and the parents had arrived by that time.

He tells the court the blood supply was 'very poor'. He says during CPR, blood was coming out of Baby E's nose and mouth, suggesting the blood pressure was low. He says the sight was "not very nice, particularly".

He’s in the NICU. What does he expect? Disney?

Dr Harkness is asked about the bleeding seen on Baby E.

He says: "I have never seen it in a baby to this extent." He says he had seen the level of blood in a teenager but not relatively, in a baby as small as Baby E.

We already know that.

Dr Harkness is asked about Letby's nursing note made on the night shift of August 3, which refers to Baby E's mum visiting at 10 pm, and she was informed by Letby and Dr Harkness about blood coming from the NG Tube. It refers to 'she was updated by Reg Harkness and contained Baby E'.

The note is shown to the court.

Dr Harkness confirms it was the note shown to him. He does not know what 'contained' meant in the context.

He says he does not remember if the mum was present at that time.

A pathology report for Baby E is shown, with 'PT and APTT readings. Those are two tests for blood clotting measurements. They were 'high, but not enough to be shocked by'.

The readings were 19.5 and 53.6, compared to the normal ranges of '12.5-15' and '26-35' respectively.

TBWS.

News flash: Neonates, especially those born pre-term, are at high risk of bleeding, making this a commonly encountered problem in the Neonatal Intensive Care Unit (NICU).

Standardised PT (prothrombin time) for Small for Gestational age Preterm neonates: 16.60 ± 2.10

And APTT: 51.0 ± 11.0

I agree, not enough for the doctor “to be shocked by” but in a BLEEDING preterm neonate, enough to be shocked by (literally).

Cross-Examination

Mr Myers asks about the sequence of events.

He refers to a police statement Dr Harkness made, where the doctor says: "I was asked to review Baby E by Letby [following the finding of a dirty aspirate].

'Looking at the notes, it was 10 pm-10.30 pm... I only came on at 9 pm.

He described, in the statement, the aspirate, which was largely mucusy.

He said he could not be sure if there was a fleck of blood around Baby E's face on examination.

He could not be sure of the flecks of blood on the baby's face. Was this the flecks of blood the mother saw, but the prosecution claimed only Letby saw? Harkness says here that he too, examined the flecks.

'Baby E looked relatively settled and there was nothing to suggest that was going to change'.

The statement adds: 'However, around half an hour to an hour later there was a large amount of fluid which came up the tube.

'From memory, it was 12-14ml of blood, which for a baby was a substantial amount'.

Baby E brought up further 'fresh blood' in quantities which he had 'not seen in sudden cases since'.

Or before.

Mr Myers asks about the initial stages from the first clinical note, at 10.10 pm.

Dr Harkness confirms he has been asked to review Baby E, following the bile-stained aspirate '30 minutes ago'.

Mr Myers said all of what had happened in the 10.10 pm note had happened by 10.10 pm.

Dr Harkness says this was a 40-minute period of several years ago. He said this was 9.30-10.10 pm.

He said it would 'match up' with the note.

In the police statement, Dr Harkness said he would have been 'bleeped' by Lucy Letby.

He says that would have been the most common approach to be alerted to the nursery room 1.

He said he had seen a dirty aspirate, which may have contained blood flecks and bile.

Mr Myers says the police statement said Baby E had 'nothing dramatic' around the baby's face and could not be sure if there were any blood flecks.

Baby E was 'not in distress' and 'appeared fine'.

Dr Harkness says he does not know if he saw Baby E's mother and does not have a clear recollection. He says it could be the case, looking at the notes provided.

Mr Myers asks if Dr Harkness had 'any particular concerns' from the first reading. Dr Harkness says there wasn't.

IOW. Letby did nothing other than her job.

He agrees the second note, with blood vomit, was 'more concerning' and suggested a gastrointestinal bleed.

Mr Myers asks if such a bleed was 'serious'.

"Potentially," Dr Harkness replies.

Eh.. The baby bled to death. The “potential” came to pass.

Mr Myers suggests that a GI bleed should have led to a blood transfusion.

Dr Harkness says if there were other observations which collated that, he would have done so, but at this point, he would not have done so, as the blood vomit could have had other causes.

I would love to know when and how bleeding is ever anything other than bleeding.

He said a blood transfusion 'may have come up in a conversation' with a fellow doctor (Dr Woods, the only other “fellow doctor” there).

Mr Myers asks why that wasn't documented.

Dr Harkness says he cannot answer that ( (for legal reasons?)

The clinical note for 11 pm is shown to the court, which the court hears refers to the 'large amount of fresh blood'. Dr Harkness was called into the unit.

The '13ml blood-stained fluid' is a 'significant quantity', Dr Harkness confirms.

Mr Myers said this follows other blood which came out earlier, and a typical baby would have had something 'in the region of 120ml' in him at that time.

Dr Harkness agrees.

Mr Myers said there had been 27mls of blood and aspirate taken from him in that time, which was 'up to a quarter' of Baby E's blood.

Dr Harkness agrees.

Mr Myers says the heart rate is 'normal', but the saturation rate is 'low'. He says the heart rate 'should be higher'.

Dr Harkness says: "Not necessary - there are multi factors to that. It's part of a separate conversation with expert witnesses."

In the terminal stage of shock in heart rate cannot rise. Unfortunately, medicine is really, really hard to practice:

Shock can be summarized descriptively as circulatory impairment leading to a state of impaired oxygen delivery to tissues. Normal cellular or tissue oxygenation depends on blood flow, oxygen saturation, transport capacity of the blood, and tissue oxygen demand. If this deficiency is for a short time period, cellular metabolism could be impaired but reversible; however, if prolonged, it may become irreversible. Currently, there is no single direct bedside measure of shock. Various technical and clinical surrogates or biomarkers are used to estimate tissue oxygenation and perfusion in neonates and are discussed elsewhere in more detail in this issue. The challenge is that in the early stages of newborn shock many subtle compensatory mechanisms occur that may mask the degree of circulatory impairment. It may be difficult to appreciate these subtle changes, such that by the time shock becomes clinically obvious, the infant is often in an uncompensated state. Relying solely on BP to determine whether or not an infant is in shock is problematic: when the BP is genuinely low, the patient may be in the uncompensated or even irreversible state, but a normal BP does not necessarily imply a normal flow state, and equally, a low BP can be present in the absence of shock. Each of these factors makes management such a complicated area.

He says it is not as simple as saying one reading should go up in line with others. He says blood pressure was normal, and there were other factors to consider.

Mr Myers says the pairing of heart rate and saturations is 'not normal'. Dr Harkness says it is abnormal in the sense that the heart rate is normal and the saturations rate is abnormal.

Mr Myers asks why a consultation with surgeons was required following x-rays.

Dr Harkness says advice would have been taken from them once the extra results would have been acquired from the x-rays.

While baby E bled to death.

Mr Myers says he could have been dealing with a 'very serious situation indeed'.

Dr Harkness: "Potentially."

Fatally, actually, Dr Harkness.

Dr Harkness says things were "changing", but Child E was still "stable".

TBWS.

Mr Myers: "Are you suggesting that a baby who has lost a quarter of its blood is not an emergency situation?"

Dr Harkness: "What I'm suggesting is there are things to do and there is time to do it."

Except Dr Harkness didn’t “do it”. Life or death are not medical abstractions, they are goals.

Mr Myers says transfusion was not being considered at this point and one of the 'obvious things' to consider.

"It is something you had failed to consider, isn't it?"

Dr Harkness says it was likely considered, but accepts it was not documented at the 11 pm note.

Mr Myers suggests it was a "serious mistake" not to consider blood transfusion.

Dr Harkness: "I disagree."

Mr Myers asks about the staffing levels that night and asks what would have happened if he had been called to the A&E department.

Dr Harkness said he would have contacted the on-call consultant at that time to come over in that instance.

And finally, we get around to the missing consultant!

Mr Myers: "I would suggest you were out of your depth at this point."

"I disagree."

He adds that is "wrong and disrespectful to my ability."

Who cares if the baby’s dead? On no account offend the doctor!

Mr Myers says blood transfusion is not considered.

"But we do have a plan, and we do have a discussion with a consultant."

TBWS.

Mr Myers says the intubation should have happened earlier.

Dr Harkness says there are benefits to an elective intubation compared to an emergency intubation, as the latter could cause stress and complications to the baby.

But bleeding to death wouldn’t? Anyway, who does “elective” intubation outside of an operating theatre?

He said that 'now' this would still have been the course to take in that situation.

The court hears the preparations are made for the intubation during a half hour.

Dr Harkness disagrees with Mr Myers that it was a "delay" and was using his time "appropriately".

"You make more mistakes when you are not taking your time."

Like letting the patient die kind of mistake?

Mr Myers says the blood transfusion is mentioned for the first time at a later note, after 11.40 pm.

Dr Harkness says it would not have been appropriate to give more saline boluses without administrating fresh blood.

Finally! Saline is not the same as blood!

He disagrees a blood transfusion was not considered earlier.

So they took it into consideration but ultimately decided against it.

He says his documentation is not as thorough as it would be now and agrees in hindsight, it should have been documented more clearly.

To show they had decided against it.

The 'skin discolouration' observation is noted, and that it later 'remained' on the abdomen.

The differential diagnosis at this stage is Disseminated Intravascular Coagulation (DIC), but Dr Harkness wouldn’t know because he “hasn’t seen skin discolouration like that before”

A nursing colleague had referred to a 'discoloured abdomen' in a retrospectively written note at 1.30 am.

Mr Myers said Dr Harkness had referred to the discolouration being 'strange' and 'unusual' and 'appearing and disappearing'.

That does not appear in the medical note, Mr Myers says.

Dr Harkness says that observation had "stayed with him", and the clinical note he made at the time was not 'forensic'.

Neither was his thinking.

Mr Myers reads out part of Dr Harkness's statement to the police, referring to the discolouration being on the abdomen.

Dr Harkness says he does not recall the part of the statement of the discolourations' 'path to the body' and said he would not agree with the wording of that. He says he has not been in discussions with anyone in relation to these observations.

Mr Myers said by October 2018 (by the time of his police statement), there had been discussions in the hospital about the skin discolourations.

Dr Harkness said there were discussions to say it was unusual, but refutes any of the details of the discolourations had been discussed.

How is it possible to define unusual without detail?

Mr Myers says Dr Harkness is 'putting details together' from various observations. Dr Harkness:

"No."

Mr Myers says Baby A's skin discolouration, as referred to by Dr Harkness in court earlier in the trial, were not mentioned in the clinical note at the time or the note to the coroner. Mr Myers says the 'red patches' found on Baby A were not mentioned for Baby E. Dr Harkness said the overall discolouration observations were 'similar enough'. Mr Myers refers to Baby E's collapse 'in front of the medical staff'.

Myers says by this point, "there had still been no transfusion."

Dr Harkness said there was no further evidence of bleeding after the second bleed.

Mr Myers: "The reaction to the second haemorrhage was far too slow, wasn't it?"

Dr Harkness: "I disagree."

TBWS.

Mr Myers says a blood transfusion for O-negative blood is noted at 12.50 am on the medical notes.

Dr Harkness says the O-negative blood [a type which can be suitable for all blood transfusions] would be used in this instance, as seeking a specifically matched blood type at this stage would take too long to acquire it from the donor fridge.

The note of 12.36 am - CPR commenced, is mentioned. The transfusion would have followed. Mr Myers says, in 'distressing detail' relayed by Dr Harkness earlier in court, it had been discussed blood coming from baby E's mouth and nose during CPR.

Dr Harkness said blood would 'keep coming out' until the cause of it is found.

Or until anticoagulation stopped it.

Mr Myers says the cause of death would be 'acute blood loss'.

Dr Harkness said that cannot be known without a post-mortem examination.

Yes, it can.

He says the blood loss could be a factor, but it is not 'black and white'.

Yes, it is

Hypovolemic Shock.

The key to successful resuscitation is early recognition and controlled volume expansion with the appropriate fluid. The estimated blood volume of a newborn is 80-85 mL/kg of body weight. Clinical signs of hypovolemic shock depend on the degree of intravascular volume depletion, which is estimated to be 25% in compensated shock, 25-40% in uncompensated shock, and more than 40% in irreversible shock.

If blood loss is confirmed, initial resuscitation with 20 mL/kg of volume expansion should replace a quarter of the blood volume. Blood transfusion is preferred, but in an emergency, colloids or crystalloids can be used. If circulatory insufficiency persists, this dose can be repeated.

Once the first 10 mL/kg of blood volume is replaced, a decision to provide any further volume expansion should prompt the clinician to ascertain the cause of the hypotension and to evaluate the circulatory status. Information regarding central venous pressure (CVP) values in stable, ventilated newborns is limited; therefore, interpretation of readings in ill neonates is challenging. Its role in the management of systemic hypotension is uncertain, but serial measurements through an appropriately placed umbilical venous or other central venous catheter may help to guide volume expansion in suspected hypovolemia. In the absence of CVP, titration against clinical parameters should be completed. Frequent and careful monitoring of the infant's vital signs with frequently repeated assessments and reexamination is mandatory. The use of crystalloid or colloid solutions is appropriate unless the source of hypovolemia is haemorrhage, in which case whole or reconstituted blood is more appropriate.

He said it was 'not his place' to call for a post-mortem examination.

Mr Myers says the blood loss seen would normally be 'fatal'.

Dr Harkness said it could be 'linked'.

Yes, linked to more blood loss.

Mr Myers asks if the actions taken were 'far too slow'.

Dr Harkness: "No."

Yes.

"Would you have admitted it if it was?"

"Yes."

Really?

Prosecution

The prosecution rises to ask about the timing of Dr Harkness 'meeting the mother of Baby E'. Dr Harkness said that would have been the case, based on a nursing note.

The prosecution asked if that was from looking at Letby's note.

Dr Harkness agrees.

The prosecution says Dr Harkness's clinical note does not refer to meeting the family.

Dr Harkness said it could be documented but would depend on the level of detail of the discussion.

Dr Harkness's interview with police from September 2018 is relayed to the court.

Dr Harkness is asked about the skin discolouration and says it is 'similar [between between baby A and Baby E' and is not a rash.

The interview transcript says Baby E's discolouration was 'around the abdomen and chest', with 'purple patches' that 'suddenly come on'.

"It came so quickly not affected by the monitors or anything."

"It was just this purple and pale patches."

He was asked in the police interview if that was symptomatic of other cases, and Dr Harkness said that was not.

Blah Blah. TBWS: It was Letby wot done it. (IWLWDI)

What a load of tosh (my emphasis).

Baby E died from hypovolaemic shock, likely secondary to sepsis with disseminated intravascular coagulopathy. There is no evidence of harm other than the failure to diagnose and treat in an appropriate manner. Some CoGH staff clearly discussed "The Letby rash" and, after the 2018 police interviews, and conspired to include it in evidence. This conclusion is inescapable.


15th May 2024

Worthless.

Jamie Egan


A report from expert witness Dr Dewi Evans in an unrelated civil case was described as "worthless" by a senior judge, jurors in the trial of Lucy Letby have heard.

Manchester Crown Court heard that Dr Evans was criticised over his involvement in an application for permission to appeal against a care order involving two children—a case unconnected to Letby.

The court heard that Dr Evans supported the parents' desire to have increased access to the children being cared for by their grandparents.

Refusing permission last December, Court of Appeal judge Lord Justice Jackson said Dr Evans' report was "worthless" and "makes no effort to provide a balanced opinion". He either knows what his professional colleagues have concluded and disregards it or has not taken steps to inform himself of their views. Either approach amounts to a breach of proper professional conduct. No attempt has been made to engage with the full range of medical information or the powerful contradictory indicators. Instead, the report has the hallmarks of an exercise in 'working out an explanation' that exculpates the applicants. It ends with tendentious and partisan expressions of opinion outside Dr Evans' professional competence and has no place in a reputable expert report. For all those reasons, no court would have accepted a report of this quality even if it had been produced at the time of the trial."

Of course, in court, Evans, an egomaniac with no capacity for self-reflection, said he was "more than happy" to stand by his report" and did not accept either Myers's or Lord Justice Jackson's opinion that his conduct was unprofessional. Evans then lies that he had sent a letter to a firm of solicitors on the subject, which he said was not intended to be used in an appeal. But the kicker was the following remark: "I had no idea it had been sent to the court. I had no idea about this judgment until about two weeks ago."

Most people would take the money and run because money was Evan's game. But no, Doughy went on the warpath after the trial, lashing out against everyone except the consultants.

When referring to management, he said: "They were grossly negligent. I shall write to the Cheshire police and ask them, from what I have heard following the trial, if we should now investigate a number of managerial people concerning corporate manslaughter. The police should also investigate the hospital in relation to criminal negligence.

"Failing to act was grossly irresponsible – let's make it as clear as that. We are talking about a serious emergency. It's grossly irresponsible and, quite frankly, unbelievable that they failed to act sooner."

Evans called for the police investigation after being told about the two-page review in May 2016 ( the RCPCH review of the CoGH Neonatal Unit). By this point, senior doctors had been asking for "urgent" meetings with executives for months to discuss their concerns after five murders and the attempted murder of another five babies.

But nothing appears to have happened until the two-page document was produced in May 2016, effectively clearing Letby of any wrongdoing and blaming other NHS services for the deaths. Letby went on to murder two newborn triplet brothers and attempt to kill a sixth child the following month.

The review, made public for the first time, states: "LL works full time and has a qualification in the speciality. She is, therefore, more likely to be looking after the sickest infant on the unit. LL also works overtime when the acuity or unit is over capacity.

"There are no performance management issues, and there are no members of staff that have complained to me or others regarding her performance. I have found LL to be diligent and have excellent standards within the clinical area."

It goes on to state that there had been a higher death rate in the unit in the year to May 2016 but blamed other NHS services for a number of the mortalities: "The Cheshire and Mersey transport service have been involved in a few of these mortalities, and they may have survived if the service was running adequately.

"Alder Hey children's hospital's failure in facilitating a cot also added to the complexities of these mortalities. If there had been a bed sooner the infant may not have died."

Evans continued: "They were grossly negligent. I shall write to Cheshire police and ask them, from what I have heard following the trial, that I believe that we should now investigate a number of managerial people in relation to corporate manslaughter. The police should also investigate the [hospital] in relation to criminal negligence.

"Failing to act was grossly irresponsible – let's make it as clear as that. We are talking about a serious emergency. It's grossly irresponsible and, quite frankly, unbelievable [that they failed to act sooner]." According to Evans, by this point, senior doctors had been asking for "urgent" meetings with executives for months to discuss their concerns after five murders and the attempted murder of another five babies.

Again, according to Evans, "nothing" happened until the two-page document was produced in May 2016, effectively clearing Letby of any wrongdoing and blaming other NHS services for the deaths.

The review stated: "LL works full time and is qualified in the speciality. She is, therefore, more likely to be looking after the sickest infant on the unit. LL also avails herself to work overtime when the acuity or unit is over capacity.

"There are no performance management issues, and there are no members of staff that have complained to me or others regarding her performance. I have found LL to be diligent and have excellent standards within the clinical area."

It goes on to state that there had been a higher death rate in the unit in the year to May 2016 but blamed other NHS services for a number of the mortalities: "The Cheshire and Mersey transport service have been involved in a few of these mortalities, and they may have survived if the service was running adequately.

"Alder Hey children's hospital's failure in facilitating a cot also added to the complexities of these mortalities. If there had been a bed sooner the infant may not have died."

How true is it that the consultants in the CoGH were beating down management's door to get to the root cause of the rising mortality in their unit?

The gang of four at the CoGH wants the world to believe that a sinister dark force is at work among them. Malevolent and unseen, Letby insinuated her way into a seamless operation. In due course, she became a person of interest as the body count remorselessly rose. Frantic and insistent attempts by the consultants to alert management fell on deaf and cynical ears.

Nothing, of course, could be further from the truth.

There were opportunities and mechanisms galore to stop a murder, but no one except Dr Brearey ever believed there was a "murderer on the ward. The notion is, even now, too ridiculous for words.

From the RCPCH report:

Incident reporting:

4.4.3 If an incident meets the criteria, a serious incident panel is established within two days and chaired by the Medical Director and Director of Nursing. An SBAR report is prepared, and the panel's recommendations are reviewed at the Governance Board and Divisional meetings.

There is a formal Level 2 Root Cause Analysis system for internal Trust reviews

run by the Risk Manager, but this is relatively new and was used in only one of the index cases.

Which one of the "index cases" had this kind of review, and why was not every case followed this way?

4.44: The deaths are reviewed, using case notes, initially by the neonatal lead, senior nurses and the quality facilitator and a report regarding any learning and actions required is completed. Deaths and near misses which are not Serious Incidents are reviewed at the perinatal Mortality and Morbidity (M&M) panel, which is chaired by the Fetal Medicine Consultant and meets around five times a year. The meeting does not include the risk midwife or any external adviser. The M&M death review report template has been updated and improved since February 2016 following the neonatal death review and includes brief findings and actions/learning arising from the incident, together with the names of those present. Minutes from the M&M are circulated to all the paediatric consultants and senior nurses on the neonatal unit for dissemination, but responsibility for follow-up of findings and implementation of lessons learned is not clearly documented. Largely lying with the neonatal lead.

The "neonatal lead" was Dr Brearey. The RCPCH places responsibility for the follow-up of "unexpected" deaths "largely" in his lap. As far as the RCPCH is concerned, deaths are a medical matter, not a managerial matter.

4.4.5 Two of the clusters of deaths were not reported; the current policy indicates that not all deaths need to be submitted as DATIX. If they are expected deaths, and in 2015-6, only 10 of the 13 deaths were reported as incidents on the neonatal incidents summary. The definition of 'expected" was not available but presumed to be used in safeguarding /child death panels, and it was not clear who was responsible for DATIX entry. Other areas in the hospital report well, but the neonatal unit has, for some time, apparently been less systematic in reporting.

This is a severe criticism of Brearey. I certainly cannot read it any other way. Dr Brearey had, for some time, failed to take the deaths of babies seriously enough to report them systematically. Does Dr Brearey have a conflict of interest then in Letby's guilt? If yes, why was he the doctor who initially helped Operation Hummingbird, the Cheshire police investigation into Letby? The first time any copper heard the words "air embolism" had to be from Dr Brearey because he suggested the same to the RCPCH.

4.46 Until early 2016, there was a Risk and Patient Safety Lead, but the role was redesigned when she left the Trust (around the time of the CQC visit), and the post of Risk Midwife was established and filled in May. A Risk Facilitator from Urgent Care covered children's risk, but the Risk Midwife subsequently covered neonatal risk.

4.7. Some of the deaths were reported on the Risk Register and the Review team noted that some were recorded with 'green - low risk of harm status.

4.48 the review of deaths carried out by the (neonatal lead) consultants, which, together with two additional deaths, triggered the unit's reconfiguration in July 2016, did not use a recognised Root Cause Analysis process, nor did it involve the governance lead/risk manager, The staffing grid in particular was not validated. The Risk Manager has conducted a more systematic review of staffing on duty at the time of the deaths and the shift before, but this only includes clinical staff, not cleaners and others with access.

It is clear to anyone who can read that contrary to what the consultants said at the trial, there was at least a half-hearted effort to maintain patient safety at the CoGH. Brearey tried on many occasions to hawk his scientific junk to all takers, but none of them bought it. Eventually, his bizarre "air embolism" theory ends up in court by the hand of the maker of facts, Dewi Evans.

The three initial deaths in June of 2015 were clearly the result of incompetent care. The only doctors in the world who wouldn't see it that way were "expert" witnesses for the prosecution, which had nothing other than this bizarre coterie.

The mainstream media will get to the Letby case; I know this for a fact. They will not show the same fawning reverence for the gang of four nor allow the jury to convict a person without asking themselves the basic question: "How did she do it?" Justice Goss instructed the jury that they did not have to worry about that when reaching their conclusions. How utterly absurd.

In most continental Europe, the long-standing problem of biased experts is partly neutered by the nature of their systems. Only a court service can appoint an expert. Thus, the prosecution avoids any temptation to create the type of fiction we see here. 


15th May 2024

Why neonates won't survive without venous access and constant glucose.

Message to Dr. Dewi Evans

Jamie Egan

1 min read

First, oxygen desaturation events that frequently occur in the NICU setting, most often because of prematurity or respiratory disease, lead to reduced energy stores in neonates. Neonates experiencing multiple oxygen desaturation events are at risk for hypoxia, which refers to an inadequate oxygen supply to the tissues. This leads to a reduced rate of oxidative phosphorylation by aerobic respiration and to reduced adenosine triphosphate (ATP) synthesis. ATP is the energy currency in human biology. Because of the absence of oxygen as a final electron acceptor, the mitochondria cannot sustain the proton gradient required for ATP formation from adenosine diphosphate (ADP) and inorganic phosphate. This leads to a decrease in ATP production and potential disruption.

Second, stressful stimuli, such as procedural pain, can lead to a reduction in energy stores. We explored the effects of tissue damaging procedures (TDPs) on ATP metabolism. After the removal of a central or venous catheter, we found a significant increase in uric acid (UA) and malondialdehyde (MDA) thirty minutes after the painful stimulus.

UA is a downstream product of ATP degradation. MDA is an oxidative stress marker formed by the oxidative degradation of polyunsaturated lipids by reactive oxygen species (ROS). The increase in ATP degradation in response to painful procedures may be because of energy spent through behavioral and physiological reactions to pain, such as crying, facial grimacing, flailing and tachycardia. Increased purine degradation, accompanied by the production of ROS, could contribute to the observed increase in oxidative stress. Alternatively, increased oxidative stress could also result from the increased activity of mitochondrial ATP synthesis, which produces ROS as a byproduct, in order to meet the energy demands of increased ATP utilization. Both the increased ATP utilization and oxidative stress can lead to energy deficit and energy deficit will lead to increased entropy and death. 


15th May 2024

Why did Professor Owen Arthurs Lie to the court in the Letby trial?

Jamie Egan


Here is a link to the paper referred to in court by Professor Owen Arthurs in evidence.

Here's the paper abstract:

The use of postmortem computed tomography (PMCT) is increasing, but the significance of some findings, such as intravascular gas, remains uncertain. In order to correctly interpret the findings, we provide data on a series of cases in whom intravascular gas was noted on PMCT imaging, to assess whether it correlates with clinical features including type of death (traumatic), resuscitation and postmortem interval.

Methods: Children 0-16 years of age who underwent whole-body PMCT as part of their autopsy examination were assessed for the presence and extent of intravascular gas. Demographic details recorded included age, time from death to imaging, associated imaging findings, mode of death, and resuscitation received. Imaging was reviewed by two radiologists, blinded to clinical history and autopsy findings.

Results: 46 children, mean age 2 years (range 0 days–15.5 years) were included in the study. 63% (29/46) of children demonstrated IV gas postmortem. No relationship was demonstrated between IV gas at PMCT and increasing postmortem interval or traumatic death. IV gas was seen more commonly following resuscitation attempts, including intra-osseous needle insertions, although this did not reach statistical significance.

Conclusion: IV gas is commonly identified on PMCT in children and may be related to resuscitation rather than putrefaction or decomposition. A better understanding of IV gas on PMCT will help interpret these findings on future studies.

Let's see how it stacks up beside his evidence.

Professor Owen Arthurs:

Professor Owen Arthurs has been recalled to give evidence in respect of Child C and Child D. 

Professor Arthurs is now giving evidence for Child D and has examined radiograph images as part of his report.

The first one, on June 20, 10.22 pm, is presented to the court, in which there are no abnormalities seen.

A second x-ray image of 'effectively the whole body' is shown to the court on June 21, 1.32 pm.

Professor Arthurs notes two features - the 'obvious one' being the UVC going up towards the heart, which has been pushed in too far.

The 'subtle' observation was a sign of infection in the child's right lung, but the magnitude was 'nothing like' that seen in Child C's case.

The third x-ray image was taken on June 22, 1.51 am, after Child D's first collapse.

The UVC line has been 'withdrawn slightly'.

He explains the UVC is 'in a loop' and is 'almost certain to be outside the body'.

He says there is 'nothing unusual' in the appearance, and the diaphragm 'looks pretty clear', indicating a potential infection looks like it had improved.

Professor Arthurs says it is difficult to gauge between one x-ray and the other, but it would be consistent with an improving picture of a baby in the air throughout that time.

A further x-ray image, taken at Alder Hey Hospital after Child D had died, is shown to the court.

The UVC is still in, and a 'black line' just in front of the spine is a 'striking feature'.

Professor Arthurs says "air is present" on what the court hears is the 'main highway' of the circulation.

Professor Arthurs says the significance of that is that it is an "unusual feature in babies who have died without an explanation".

He adds that the amount of gas is consistent in babies who have died of sepsis, sudden unexpected death in infants, a road traffic collision, and two other babies in the trial.

Another was Child A.

He says one of the other explanations which needs to be considered is deliberate air injection.

 He says the most plausible conclusion was, in the absence of any other explanations, he considered they were 'consistent with, but not diagnositic of, deliberate air administration'.

 He confirms he has never seen this before in his experience.



Cross-Examination

Ben Myers KC, for Letby's defence, is going to ask questions on the baby girl, Child D, first.

He asks if it was correct that, at the postmortem stage, there were normal amounts of gas found in the normal areas, including in the bowel. Professor Arthurs agrees. 

Mr Myers asks about how often gases are found postmortem.



Professor Arthurs says for a quarter of those cases of gases found in the postmortem examinations at Great Ormond Street Hospital; there were gases found in the great vessels areas, for which there was an explanation of postmortem gases. 

He adds if there is 'overwhelming evidence' of infection, that can lead to gases appearing there or potentially gas being redistributed in the body during prolonged resuscitation efforts.

He says the administration of air is one of the explanations.

For Child E

Consultant paediatric radiologist Owen Arthurs is first up in the witness box this morning. He's giving expert evidence on CT scans, X-rays and other images in this case.

Dr Arthurs published a study in 2015 on the prevalence of air postmortem in infants. That study looked at 48 children. Of the 48, six were comparable to this case - but in each of those cases, there were clear explanations for the presence of air in vessels.

He agreed with prosecutor Nick Johnson that it is 'very rare' to find air in vessels without an obvious explanation.

We've gone backwards a little in the timeline (the expert wasn't able to make it to court earlier); Dr Arthurs is discussing the case of Child E. It is alleged that Ms Letby fatally injected air into the bloodstream of the baby in June 2015. The 

court is now being shown a radiograph of Child E. Dr Arthurs agrees there are 'no significant abnormalities' present. Prosecutor Nick Johnson asks if an air embolus would show up on such a radiograph.
 Dr Arthurs says an air embolus is not present, and to see it, there would have to be a lot of air, and the radiograph would have to have been 'done almost immediately' after the injection.

The biggest lie Owens told the court was that his little study had anything to do with X-rays. The study was a case series about using full-body postmortem computerised tomography, as far from an X-ray as an iPhone is from the telegram. A study of 48 cases is too small to mean anything. The median age was two years. None of the paper's 18 citations even mention X-rays.

From the paper: We acknowledge that postmortem changes are not only time-dependent but also depend on multiple factors such as aeration, clothing, and temperature. Children and babies are typically refrigerated within hours after death, and in our study were kept refrigerated at 4–5°C prior to imaging and autopsy. We did not specifically evaluate small collections of gas in soft tissues, where putrefactive gas may have begun to appear, although no such areas were noted. We conclude that following appropriate storage and a relatively short PM interval, it is difficult to ascribe the intravascular gas seen on PM imaging in children to putrefaction.

And: Our study has several limitations apart from postmortem interval. Since we only studied 46 cases in total, some of the statistical trends observed may achieve significance in a larger sample group with greater statistical power. We also did not include significantly decomposed or putrefied cases as a consequence of our referral practice rather than by design. "Resuscitation" following childhood death includes several variables, which we considered to be a single entity for the purposes of this study. However, we acknowledge that there will be a wide spectrum of resuscitation performance, duration and success, and it is possible that differences in approaches taken by first aid from bystanders, compared to vigorous in-hospital resuscitation, may account for the differences seen between cases in this study. We also acknowledge that we do not typically identify intravascular gas on CT in the living following vigorous resuscitation or traumatic deaths therefore, we hypothesise that either gas precipitates out of the bloodstream during the death process (which may be why it is more commonly seen in the right heart and large veins), or is introduced to the body during death (for instance due to penetrating injury or blast trauma). The development of intravascular gas during the perimortem period may be a poor prognostic sign, such as the development of portal venous gas in neonates with necrotising enterocolitis.

13. Conclusion

IV gas is commonly identified on PMCT in children, although this appears to relate more to resuscitation and the presence of IO needles rather than putrefaction with prolonged postmortem interval. A better understanding of IV gas on PMCT will help interpret these findings on future studies.

Owens stated clearly in court that "it is 'very rare' to find air in vessels without an obvious explanation" while quoting his paper, which states the opposite: "The findings of this study have demonstrated that intravascular gas detected on PMCT in children is common and not directly statistically attributable to any of our hypothesised predictive factors."

Arthur's paper uses a unique, non-standard classification for the definition of "air," which he arbitrarily divides into five categories not found in any other medical literature. His paper claims that the method of resuscitation may affect the finding of gas postmortem. His paper states clearly that there is no correlation between the findings of gas postmortem in trauma and non-trauma deaths.

Arthurs also fails to explain that inflammation, as part of the infection, also causes death, which does not always appear on x-rays nor improve over days, particularly in immunocompromised patients. To diagnose and manage sepsis in neonates, clinicians need immunological, biochemical, and sometimes genetic expert information, which Owen Arthurs cannot interpret. Because he lacks the necessary knowledge and insight into applied physiology, he makes fundamental mistakes, such as swallowing and repeating Dewi Evan's nonsense about "splinting diaphragms".

Arthurs also makes a fatal or intentional error when he claims he can determine the location and nature of an object in a two-dimensional X-ray. He cannot. He says that the line in front of the spine was air was unusual and only present in the Letby case series:

1) No one can see "air"; if that were the case, you'd walk into doors as often as through them.

2) Because an X-ray is two-dimensional, a vertical line is, by definition, a length and a width but no depth. He cannot place the line "in front of the spine" without depth. Claiming this in court allowed the morons in the press to write headlines like this. Perhaps that was his intention.

3) Arthur's paper excluded cases controlled for putrefaction and included only patients from his facility. None of the Letby cases went through his facility and, therefore, would have been excluded from his paper.

4) One of the pathologists controlling for Arthurs' paper has only three years of experience, which is insufficient for forensic reliability.

5) Arthurs accepts that autopsy findings are the "gold standard" of pathology but dismisses the autopsy findings in Baby C" 'widespread hypoxic/ischaemic damage to the heart/myocardium' due to lung disease, with maternal vascular under perfusion as a contributary factor" And D: "pneumonia with acute lung injury." which are not casually related to "vascular air embolism"

6) His evidence is contradictory and unclear.

7) He gave evidence about situations in which he had no experience.

8) He failed to provide a scientific method to quantitatively separate air administered accidentally from air administered deliberately, particularly in the context where accidental (iatrogenic) air embolism was a clear and present risk.

9) He failed to reference other bodies of work, which contradicts his conclusions.

10) He states that his work was "peer-reviewed", yet the article provides no links to this.

In conclusion, Owen Arthurs was typical of this trial's "expert" witnesses. He overstated his ability to draw conclusions with the inadequate images the cases provided. He dabbled in areas where he had no expertise. He accepted the absurd conclusions of Dewi Evans and Sandie Bohin without the essential due diligence expected of his profession.

Owens should withdraw his evidence immediately. He should give back his fee for testifying or his fee for producing a frankly quite useless study.


15th May 2024

Why Dewi Evans Diaphragm Splinting is a Myth.

The cause of death for baby C was ‘widespread hypoxic/ischaemic damage to the heart/myocardium’ due to lung disease, with maternal vascular under perfusion as a contributory factor.

This is the one-sentence summary of a detailed pathology report on the death of baby C. If we break it down, widespread means diffuse, not focal or localised, as would be the case with a heart attack. Diffuse changes are normally part of a systemic process, such as infection and inflammation.

Damage to the heart/myocardium means that the cells of the heart, in general, but muscle pump cells in particular, were so damaged they ceased to function adequately, making death inevitable. Lung disease caused this fatal outcome. The lung diseases were respiratory distress syndrome (RDS) and pneumonia, both diagnosed before death. RDS has an extraordinarily high mortality, and the reported mortality of both perinatal and nosocomial pneumonia is still high, ranging from 20%–50%

At 30 weeks, the lung is in the saccular stage. This period develops from 26 to 28 to 32-36 weeks. The saccules enlarge with gestational age to provide a larger, more flexible, efficient end product called the alveolus. The alveolar stage lasts from 32 to 36 weeks of gestational age until more or less 2 years of life. Thus, premature delivery and the start of breathing interrupt the normal development of the alveoli and pulmonary vasculature of these infants, preventing gas exchange. Only after 27 weeks do the terminal Alveoli develop the capacity to readily provide oxygen and remove carbon dioxide. Contrary to Evan's claim that neonatology is much the same as he practised it, newer research provides willing clinicians with deeper insight into the pathology and treatment of immature lungs.

Despite all this knowledge and the facts presented in the case, Dewi Evans invented a new disease while giving evidence. Evans said in court, and not once in any of his written reports that Letby killed baby C by injecting air into the nasogastric tube. Not only is the idea preposterous, but it is also physically impossible, given Baby C's circumstances. Evans committed perjury on the court, proved himself a quack and underscored yet again his profound ignorance of science.

Baby C was under Continuous Positive Airways Pressure (CPAP). CPAP works by different physiological mechanisms but mainly acts to increase the Functional Residual Capacity of the lungs. The application of pressure forces the immature lungs to remain open during expiration when the baby. The lungs, therefore, never fully deflate, and a reserve of air or an air/ oxygen blend remains throughout the respiratory cycle. Gas flowing from the ventilator provides new oxygen and washes out carbon dioxide. It is CPAP that braces (or splints) the entire thoracic cavity, massively reducing the work of breathing required by the neonate.

Newton's third law of motion states that for every action (force) in nature, there is an equal and opposite reaction. Pressurised lungs exert a force on the adjacent diaphragm, which exerts an equal and opposite force on the lungs. CPAP works by splinting the diaphragm!

Of course, it's possible to over-pressurise the lungs, but that would not lead to an unexpected collapse.

If the newborn cannot sustain the extra work of breathing to meet its respiratory needs, respiratory failure follows. This failure may manifest as impaired oxygenation (cyanosis) or ventilation (respiratory acidosis), both present in baby C; then, without prompt intervention, a respiratory arrest is imminent. If respiratory arrest happens, cardiac arrest will follow, which caused the death of baby C.

Is it a mere coincidence that Sandie Bohin is just as stupid about physics as Dewi? Or did they copy each other's homework?

I think we should be told.


15th May 2024

When the numbers do add up.

Jamie Egan


At the climax of the farce that was the Letby trial, M'Lud Goss laid on the lash with gusto. To be fair, what else was he supposed to do? He had his part to play, too.

As an example of how successfully Goss had barred the way to all reason in the trial, he said Letby appeared to have a particular interest in twins. Three pairs of twins and one set of triplets were among her 13 victims and in babies born with vulnerabilities. All the babies, I suspect, were vulnerable, indeed the ones Letby was convicted of. That they were born in an open sewer seems not to pique M'Lud's curiosity about how legions of rampant superbugs impact vulnerability. There is no point at all, I suspect, in getting into the old correlation-causation debate with M'Lud. Letby's victims all happened to be in the highest risk groups for neonatal deaths, but they would say she had the smarts to pick these babies. Confirmation is one of the worst biases.

Death, M'Lud takes a particular interest in twins and even more so in triplets.

Mortality in neonates rises very sharply with falling weight and multiparity. In the U.K., the crude neonatal death rate per 1000 births is 1.8. When I say crude, it really is that. The number 1.8 per 1000 births does not account for anything other than the birth itself. No influences of gestation, weight, parity, place, or picture are highlighted in that number. However, things get a little more interesting when we become a little more granular.

MBBRACE is doing a good job, but its stats are difficult to navigate. Quite rightly, they concentrate on perinatal deaths, which combine stillbirths and early and late neonatal births. At the moment, we are only interested in the latter.

The CoGH had 17 deaths between June 2015 and July 2016, so a year thereabout. According to MBBRACE, 1.8 deaths are expected per 1000 births in that year. According to the RCPCH, the CoGH had 4000 births annually, so we can expect 7 deaths by nature. Previous or future years, like investment warnings, are only a guide. If 7 babies had died on the unit, the performance measured in mortality would be average.

So, we need to account for 10 deaths. How much extra activity would we need to achieve this, by chance?

Let's look at the Prediction of survival for preterm births by weight and gestational age: retrospective population-based study.

From this and other studies, we know that neonatal deaths per 1000 in the U.K. are 1.8.

According to the RCPCH report, the CoGH's admission population was 96% inborn, meaning the chance of cot occupancy was also 96%.

From the United States CDC:

Neonatal deaths per 1000 under 1500g is 178/1000.

Below 1000 grams, 267/1000.

These are absolute numbers and will account for all causes of death in those weight categories.

To move from 1.8 per 1000 to the 2015-2016 CoGH June to July period, we need 10 extra deaths. On average, how many extra deliveries under 1500 grams do we need to achieve this?

178/1000 x 57 = 10.1. Therefore, we need only one extra birth per week to get near that number if the babies are < 1500g.

267/1000 x 38= 10.1 Therefore, we need only one extra birth every 10 days if they are < 1000g.

Yet Dr Brearey said that "acuity and activity increases could not account for the difference in the death rate in the CoGH in this period.

I don't believe him, and the figures above probably mean you shouldn't either.


15th May 2024

When a scream is not a scream.

Biology is the fun science. Furry creatures, microbes that make beer, the birds and the bees and all that. But when push comes to shove, it is just another physics category. Making beer from fermentation primarily involves converting energy from one form to another within a biological system. It is called fermentation, a metabolic process that produces chemical energy stored in sugars and converts it into other chemical energy stored in ethanol. Ethanol moves through the bloodstream to the brain and engages in another exchange of chemical energy, causing the movement of dopamine and serotonin, neurotransmitters associated with pleasure and happiness. Happily for humans, thankfully is not physically quantifiable.

Neither is sound. We can quantify sound in numerous ways, but it brings us no closer to understanding why some people weep from pain listening to Mozart's Mass in C Minor while others weep from a genuine sense of loss and longing. The human mind is as elusive, it seems, as justice itself.

The process of hearing is a complex and intricate system that involves the transformation of sound waves in the air into electrical signals, which are then interpreted by the brain as sound. Something has to create the vibrations of air, to begin with. These waves of air enter the outer ear, which consists of the pinna (the visible part of the ear) and the ear canal. The pinna helps to collect sound waves and funnel them into the ear canal towards the eardrum. The waves reach the eardrum (tympanic membrane) and cause it to vibrate, replicating the original sound source. The vibrations from the eardrum are transmitted to the middle ear, which contains three tiny bones called the ossicles (malleus, incus, and stapes). These bones amplify the sound vibrations and transmit them to the inner ear. These bones are connected to the cochlea, an oval, snail-shaped, fluid-filled structure in the inner ear. The cochlea contains thousands of tiny hair cells sensitive to different sound cycle frequencies. If an object vibrates 20 times per second, it will create a frequency of 20Hertz (Hz), the lowest detectable frequency for a human ear. The upper limit is 20,000 Hz. Progressively smaller hairs vibrate at higher frequencies as the pressure waves move through the cochlea, causing the hair cells to move. This movement of hair cells converts the mechanical energy of sound waves into electrical signals. The electrical signals generated by the hair cells are picked up by the auditory nerve and transmitted to the brain. The auditory nerve carries these signals to various brain parts, including the auditory cortex, where they are processed and interpreted as recognizable sounds.

The best part, though, is the interpretation of sound, which is not much different than our explanation of mottling. The brain processes the electrical signals, allowing us to recognize and understand sounds such as speech, music, noise, etc. This process involves comparing the signals from both ears, which helps determine the direction and distance of the sound source. Even though they come from the same speaker, low frequencies will sound further away. Higher frequencies sound closer. Sound engineers use terms like "muddy" ( 250-500 Hz) and "harsh." 2000-4000 Kz. Boosting a signal at 12000 Hz will make it sound "airy".

But like mottling, it is all perception.

Dr Bohin said that a preterm baby "screamed" for 30 minutes. Apart from the fact that she wasn't there, "scream" is not a medical term; it's an emotive term. Is it the same thing to "scream" at the Beatles as "scream" when we are hurt? Physically, yes, it is. Humans perceive screaming when hearing frequencies around 3000 Hz; we are programmed to do it.

Humans are most sensitive to frequencies ranging from 2000 Hz to 5000 Hz. Specifically, the human ear shows peak sensitivity around 3500 - 4000 Hz, associated with the auditory canal's resonance frequency. A resonance frequency is when an object subject to a sound begins to vibrate at the same frequency as the sound source. A classic example is when the singer shatters a wine glass.

Any sound at that frequency will cause distress in a human, which causes further distress as the resonant energy multiplies itself.

Preterm infants, including those born very prematurely, can produce distinct vocalizations, such as cries. The fundamental frequency (F0) of these cries can vary significantly.

The fundamental frequency of infant cries, including those of preterm infants, is generally higher than that of adult speech. For instance, one study found that the fundamental frequency of spontaneous cries in healthy preterm infants at term-equivalent age was significantly associated with shorter gestational age. However, neither smaller body size at recording nor intrauterine growth retardation (IUGR) was related to increased F0 in preterm infants. This suggests that their smaller body size does not cause the increased F0 of spontaneous cries but might be due to more complicated neurophysiological states owing to their different intrauterine and extrauterine experiences.

The typical frequency range for infant cries is broad, often extending from 250 Hz to 500 Hz in the lower range and can exceed 600 Hz in conditions associated with distress or pathology. 250 -500 Hz. 440Hz is the A below middle C of a piano or the second lowest string on a guitar. Neither of these notes is a "screaming notes."

However, all fundamental tones have harmonics ( overtones) created one octave above and below the fundamental. 500hz will generate overtones at 1000Hz, 1500HZ, 2000 Hz etc. Harmonic frequencies typically have a lower amplitude ( volume) than the fundamental frequency. The fundamental frequency provides the sound with its strongest audible pitch reference and is the predominant frequency in any complex waveform. Harmonics contribute to the timbre or quality of the sound, making it possible to distinguish between different sounds and instruments. While harmonics are present and contribute to the overall sound, they usually have a lower amplitude than the fundamental frequency. Harmonics lose energy as they become higher in pitch.

Harmonics significantly affect a sound's overall loudness by contributing to the total sound pressure level (SPL) and perceived loudness. Their presence and relative levels can influence how loud a sound appears to the listener. The peak sensitivity is around 2,000 to 5,000 Hz. Harmonics that fall within this range can make a sound seem louder in the same way that blue light scattering from skin can make blood appear blue.

Fading harmonics do not lose effect, though. A mother who hears a baby cry at 500 Hz will hear the 7th harmonic at 3500 Hz, much louder than the fundamental frequency, and react to the resonant frequency with great alarm. A gentle moan at 500Hz may as well be a scream at 3500.

It is not physically possible for a preterm baby to cry continuously for 30 minutes because it needs to breathe in between. It is perfectly possible for a mother to feel as if her baby has been crying not just for 30 minutes but for hours. All practising doctors are well aware of this.

Like everything else in the Letby story, 30 minutes is too neat. It is long enough to sound serious, intentional and calculated. But it wasn't Letby who was calculating.

Unless the sound was recorded or measured, we can safely put it down to perception or the wicked desire of an "expert" witness to engage in a little more storytelling.

I look forward to exposing more of Sandie Bohin's irrational brain; it is truly worth the study.


15th May 2024

What value does an X-ray add to autopsy findings?

James Egans


Joe probably doesn't recall his golden moment in politics when he whispered something naughty in Obama's ear. A word most common in use but whose origin remains a mystery got a new lease of life in the Amy Winehouse song "Me and Mr Jones". But Amy merely borrowed the word from everyday Jamaican, where it's pronounced "fuck-ree" and means irritating, bothersome, out of order, and, more importantly, oppression, the inherent corruption of a dominant society. Indeed, because the inherent domination in medicine is the endless "Fck-ree" of consultants who, for the most part, are pretty poorly educated.

Sandie Bohin thinks one can buffer an acid with another acid; Sally Kinsey doesn't know the difference between air and nitrogen. Not many people challenge these idiots; they carry on propagating their stupidity from generation to generation, safe in this knowledge, and when they get caught out, they simply make shit up, which is Doughy's speciality. If you really want to know what many of these people think of you, here's a taster. Remember who's got two thumbs and doesn't give a crap?

Owen Arthurs, that's who. He's a radiologist, a "technician" more than a "physician".

Owen thinks he can see air with his X-ray machine, but like the pink in the mottling and the harmonics in the screams, his world is largely a world of illusion.

X-rays are also electromagnetic radiation with a narrow range of wavelengths ranging from about 0.01 to 10 nanometers (nm), corresponding to frequencies in the range of 30 petahertz to 30 exahertz (3x10^16 Hz to 3x10^19 Hz). So-called "hard" x-rays, commonly used in medical radiography and imaging, have wavelengths between 0.2-0.1 nm (energies between 5-10 keV). Soft X-rays, less desirable for medical diagnostics, have longer wavelengths and lower energies and are more readily absorbed by the body.[

- The specific wavelength of x-rays used in clinical settings depends on the application, with higher energy (shorter wavelength) x-rays used for imaging denser tissues and lower energy (longer wavelength) x-rays used for softer tissues.

There are no nada, zero, zilch medical studies into using X-rays to diagnose air embolism. In fact, when I put the question to Google, I got this answer:

"One of the search results mentions that a forensic scientist noted "striking evidence" from an abdominal x-ray in a case involving Lucy Letby. This suggests that X-rays may provide helpful information in some post-mortem investigations.

Professor Owens can also project himself into the past:

Consultant paediatric radiologist Owen Arthurs is first up in the witness box this morning. In this case, (Baby I) is giving expert evidence on CT scans, X-rays and other images. ( Except there were no CT scans or other images)

Dr Arthurs has said there is evidence of Pneumatosis (gas within the wall of the small or large intestine) on an X-ray from 30 September of Child I

Dr Arthurs has said Child I had a 'normal' bowl, as per her X-ray on 18 October and into 20 October. Looking at an X-ray from 23, there is a 'massive' dilatation of the stomach.

Dr Arthurs says it is 'quite unusual to see babies with this degree of dilatation of the stomach'; he says it can cause 'splits in the diaphragm' and that can lead to 'respiratory complications.'

Asked how much air it would take to generate such images, Dr Arthurs said: 'We don't know, I don't think anybody really knows. Those experiments can't really be carried out, we can't experiment on babies giving them 50 or 100mls of air and taking x-rays.'

He adds, 'I would guess more than 20mls of air".

'When asked, in the absence of another explanation, whether 'someone has deliberately injected air,' Dr Arthurs says, 'I think that stands to reason.'

Except there is another explanation. The real one is that Pneumatosis in a neonatal abdominal X-ray refers to the presence of gas within the walls of the small or large intestine.

Pneumatosis intestinalis is a virtually pathognomonic (diagnostic) radiographic sign of necrotizing enterocolitis (NEC) in neonates. Pneumatosis appears as a "bubbly" or "soap bubble" appearance in the bowel wall on the abdominal X-ray due to the presence of submucosal gas "blebs" or curvilinear lucencies in the subserosal location. The incidence of Pneumatosis in cases of NEC can range from 19% to 98%, though its presence does not always correlate with the clinical severity of the disease. Pneumatosis can also be seen in other conditions like volvulus, ischemic bowel necrosis, and neutropenic colitis, so it is not entirely specific to NEC. Correct identification of Pneumatosis on abdominal X-rays is critical for the early diagnosis and management of NEC in neonates, as it is one of the key radiographic signs of this serious gastrointestinal condition. Therefore, Pneumatosis on a neonatal abdominal X-ray refers to the presence of gas within the intestinal wall, which is a hallmark radiographic finding associated with necrotizing enterocolitis, though it can also occur in other abdominal pathologies.

That's how 99.999% of all known doctors would see it. They wouldn't feel the need to make up numbers for things without empirical data. In fact, doing so is a grave ethical offence.

Guessing correct diagnoses without proper diagnostic reasoning is unethical, as it can lead to improper treatment and harm to the patient. The search results indicate that even when medical students guessed the correct diagnosis, 7% of the time, their reasoning was incorrect.

The proper answer to this question was that Pneumatosis was a finding of common pathology and that the notion of passing 20 ml into a gut over four metres long is plain stupid.

The non-invasive autopsy typically involves CT scanning of the body rather than a traditional invasive autopsy. A small amount of dye is introduced into the coronary arteries through two small incisions to allow scanning of the blood vessels. The CT scan images are then examined by a specialist NHS Consultant Radiologist, who considers the scan results along with any other available information to determine the cause of death. If the CT scan can reveal a clear medical cause of death, an invasive autopsy can usually be avoided. However, in up to 10% of cases, the radiologist may be unable to determine the cause of death from the CT scan alone. In these instances, the coroner may request a limited or complete invasive autopsy by a pathologist. Pathologists can still assist with complex cases by providing additional evidence to supplement the CT scan findings. The non-invasive autopsy is typically performed within 48 hours of death or sooner if there are particular reasons to expedite the process. NHS staff carry out the entire process, including body preparation, scanning, and reporting.

The evidence for the use of this type of autopsy in children is not good.

Are non-invasive or minimally invasive autopsy techniques for detecting cause of death in prenates, neonates and infants accurate?

A systematic review of diagnostic test accuracy.

Abstract:

Objectives: To assess the diagnostic accuracy of non-invasive or minimally invasive autopsy techniques in deaths under 1 year of age.

Design This is a systematic review of diagnostic test accuracy. The protocol is registered on PROSPERO.

Participants: Deaths from conception to one adjusted year of age.

Search methods MEDLINE (Ovid), EMBASE (Ovid), CINAHL (EBSCO), the Cochrane Library, Scopus and grey literature sources were searched from inception to November 2021.

Diagnostic tests Non-invasive or minimally invasive diagnostic tests as an alternative to traditional autopsy.

Data collection and analysis Studies were included if participants were under one adjusted year of age, with index tests conducted prior to the reference standard.

Data were extracted from eligible studies using piloted forms. Risk of bias was assessed using Quality Assessment of Diagnostic Accuracy Studies-2. A narrative synthesis was conducted following the Synthesis without Meta-Analysis guidelines. Vote counting was used to assess the direction of effect.

Main outcome measures Direction of effect was expressed as percentage of patients per study.

Findings: We included 54 direct evidence studies (68 articles/trials), encompassing 3268 cases and eight index tests. The direction of effect was positive for postmortem ultrasound and antenatal echography, although with varying levels of success. Conversely, the direction of effect was against a virtual autopsy. For the remaining tests, the direction of effect was inconclusive.

A further 134 indirect evidence studies (135 articles/trials) were included, encompassing 6242 perinatal cases. The addition of these results had minimal impact on the direct findings yet did reveal other techniques, which may be favourable alternatives to autopsy.

Seven trial registrations were included but yielded no results.

Conclusions Current evidence is insufficient to make firm conclusions about the generalised use of non-invasive or minimally invasive autopsy techniques in relation to all perinatal population groups.

If there is insufficient evidence to make firm conclusions using an entire protocol, there is zero evidence for drawing cartoon conclusions from a few dodgy X-rays.

The British public should be grateful that these people don't sell second-hand cars


15th May 2024

The U.S Marine Corp has a name for it.

Jamie Egan

12 min read

clusterfuck (n.)

"bungled or confused undertaking," 1969, U.S. military slang, from cluster + fuck, probably in the "bungle" sense.

Dr James Smith

The next witness to give evidence in court is Dr James Smith, employed at the Countess of Chester Hospital as a specialist registrar in February 2016. Dr Smith recalls having a memory of Baby K and being notified there would be a delivery of a '25-weeker' baby.

This means that he likely found out about an hour before it happened.

He recalls being present at the birth, and the baby girl was born in 'expected condition'. The Apgar scores of 4, 9 and 9 are 'good'.

No, they're not. An Apgar score of less than five at any time is not good.

When asked about the 'dusky, floppy, no resp effort' note, Dr Smith says the gestation presentation can be variable. Still, a good/reasonable sign is a heart rate, 'no resp effort' is not unexpected, and the baby would present as 'floppy' as medical staff had yet to supply any breathing support.

Apgar scores are the sum of three objective observations assigned to five categories. The score is calculated as follows:

Breathing Effort: If the baby is not breathing, the respiratory score is 0. If respirations are slow and irregular, weak or gasping, the respiratory score is 1. If the infant is crying vigorously, the respiratory score is 2.

Baby K score 0

Heart Rate

Note that heart rate is evaluated with a stethoscope, and it is the most critical part of the score in determining the need for resuscitation. If there is no heartbeat, the heart rate score is 0. If the heart rate is less than 100 beats per minute, the heart rate score is 1. If the heart rate is more than 100 beats per minute, the heart rate score is 2.

Baby K score 1

Muscle Tone: If the infant's muscle tone is loose and floppy without activity, the score for muscle tone is 0. If the infant demonstrates some tone and flexion, the score for muscle tone is 1. The score is two if the infant is in active motion with a flexed muscle tone that resists extension.

Baby K score 0

Grimace Response or Reflex Irritability in Response to Stimulation: If the infant does not respond to stimulation, the reflex irritability response score is 0. If grimacing occurs in response to stimulation, the reflex irritability response score is 1. If the infant cries, coughs, or sneezes on stimulation, the reflex irritability response is 2.

Baby K score 0

Colour: If the infant is pale or blue, the score for colour is 0. If the infant is pink, but the extremities are blue, the score for colour is 1. If the infant is entirely pink, the score for colour is 2Baby K score 0

Baby K had an Apgar score of 1 at one minute, God knows what at five minutes, and it would be another CoGH miracle if it were nine at 10 minutes.

The doctor tells the court full airway breathing resuscitation support would be required, but that would 'not be unexpected' for a baby as premature as Baby K.

Which is why the baby should have been born anywhere other than the CoGH.

In this scenario, Dr Smith describes the procedures he would have taken to stabilise a baby, such as Baby K. He says Baby K's heart rate improved to 100 bpm within two and a half minutes, and she was making respiratory gasps.

The gasps were so influential that:

The decision to intubate is then made. He tells the court that the intubation is "technically difficult" due to the baby's size and can take multiple attempts.

He says Baby K was stabilised after each attempt, and he had no worries about doing the procedure himself without needing to hand it over to the consultant, Dr Ravi Jayaram. He intubated Baby K on the third attempt with a size 2.0 tube. He tells the court if he had seen any signs of trauma, such as bleeding, on Baby K at the time of intubation, he would have passed the procedure on. To the best of his recollection, he did not see any signs of trauma. He tells the court there is nothing in the notes of any sign of trauma at this point.

Seriously? How stupid do these people think we are? There is an opaque plastic tube in the baby's trachea; how can he know what's happening beneath it? The general clinical picture was that Baby K's signs were 'good', the resuscitation 'had gone successfully', and the first blood gas record was 'good—reasonable for the first reading'.

Baby K was like all the other babies in this series. He was intubated at birth on the third attempt. But excellent and stable. A "reasonable" but "good" blood gas. He tells the court that antibiotics would be administered for all babies of this prematurity. Dr Smith tells the court he would have been, to an extent, guided by advice from Arrowe Park Hospital in treating a baby of this prematurity at the Countess of Chester Hospital. Dr Smith says he would not have played any part in connecting Baby K to the ventilator at the neonatal unit following transfer and would not have had any knowledge of how to do so, as nurses would carry out that connection. Dr Smith says he remembers coming back into the neonatal unit early on February 17, probably for labelling blood bottles. He does not recall where the nurses were, but he recalls Dr. Ravi Jayaram giving Baby K breaths via the Neopuff, which was already underway.

He said the readings, while unable to recall what they were precisely, "were not improving", and further measures were to be carried out.

What further measures?

The explanation for a "sudden deterioration" was either the breathing tube being dislodged or blocked. The "correct decision" was for the tube to be removed. Baby K received breathing mask support without a tube. As his oxygen saturation levels improved, he was reintubated. A morphine bolus was administered to help the reintubation process. Dr Smith says he did not see any evidence of trauma, and if there were anything obvious to show that, he would have informed Dr Ravi Jayaram, but he "did not see anything".

So Ravi, after administering a few puffs via a bag, handed the job of re-intubation back to the guy who can't connect a ventilator and who screwed up the first intubation. The prosecution asked if the Countess team followed the advice from Arrowe Park to take x-rays of Baby K to check for tube placement. Dr Smith confirmed they did, and a chest x-ray was carried out. The radiology report said that, from the X-ray, the ET tube and the NG tube were 'in satisfactory position' following the reintubation, while a UVC line required further adjustment. The radiology report also recorded a possible lung infection, which Dr Smith was expecting in Baby k's of Child K's gestational age.

The possible "lung infection is called pneumonia by old-fashioned doctors and is very often fatal.

Dr Smith re-examined Baby K at 6.15 am when it was noted that Baby K had lower saturations and a blood gas reading that was "not good" and "worse than the previous gas." The tube was 'pulled back' to improve the oxygen saturation levels, but the readings had 'not improved'.

So it was the tube, then it wasn't the tube. We put it in, took it out, and shaken it all about. If there was a central line, what was the NG tube for? Don't they know that NG tubes cause apnoea and desaturation?

The decision was then taken to remove the tube from Baby K. 'Bagging' breathing support was provided to stabilise oxygen saturation levels, and Baby K was reintubated once again.

Please put it in, take it out and shake it all about. Baby K had responded 'very quickly' to the 'bagging' support.

Why, then, do you still want to use a tube? Dr Smith says that from the notes, there is nothing to say the tube removed from Baby K was blocked, and his memory has nothing to add to that. A repeat X-ray reported: 'Satisfactory position of the ET tube. NG tube in situ...this would benefit from advancement by 5-10mm. UVC in satisfactory position.'

What X-ray is this? The tube is out now. A lung infection was still suspected for the left lung, which appeared increased in density - 'looking more white', and reduced in volume compared to the right lung. Baby K had pneumonia. If he didn't have it in the womb, he got it in the GoGH because he hasn't been anywhere else. Maybe she got it from all the f@@king about with tubes that never worked.

Dr Smith later wrote a transfer letter to Arrowe Park Hospital summarising the care given to Baby K at the Countess of Chester Hospital, including details of intubations, medication administrations, and a blood result.

And so, after brutalising the baby, she goes to where it should have been at the start.

You can't make this shit up.

Cross-Examination

Benjamin Myers KC, in Lucy Letby's defence, is now asking questions about the events for Baby K. He says Baby K was born in extreme prematurity and asks if there would inevitably be problems with the baby girl's care, particularly about the lungs.

Dr Smith agrees. Dr Smith remembers being in the room when Baby K's resuscitation efforts were taking place, and they were going well. He says neonates with this gestation need a lot of support and resuscitation. He cites a study that found a 75% survival rate for babies of that gestation age.

Mr Myers suggests that the figure could be closer to 40-50% from another study. Dr Smith says he has cited the most recently available study. Mr Myers says a tertiary unit is the most suitable place for treating babies of Baby K's gestational age. Dr Smith says they are more experienced in tertiary units. Still, level 2 units (such as the Countess of Chester Hospital at this time) have the equipment and staff capable of treating babies of this gestational age for the short term.

So why, then, Dr. Smith, if the CoGH was so good, did you need to transfer the baby?

He says the correct thing to do is to contact the level 3 unit in advance to inquire if the transfer is possible before the birth.

He says seeing Baby K's bruising on her hands and feet at birth was not something he had seen frequently in births and was more likely seen by staff at tertiary centres. He said he had asked for an expert opinion on the bruising.

Every doctor should be an expert on bruising; my granny was an expert. Dr Smith says level 2 centres do not look after babies of this prematurity long-term.

Or, in this case, short-term.

He says if mothers of 23-week gestational arrived at the hospital via ambulance, and delivery was imminent, that delivery would take place at the nearest hospital, with a set procedure in place to arrange transport to a tertiary centre when viable. Dr Smith recalls that it would have been better to write his independent notes in addition to Dr Ravi Jayaram's complete notes. He added that he wrote up the transfer letter listing the events and care for Baby K. Mr Myers asked why Dr Jayaram would write up those notes in the first place. Dr Smith says he would also have been on the paediatric unit on that night shift. He says the notes would be' completed' as long as a senior doctor has been involved in writing. He says that 'ideally', he would have written notes up himself, independently.

That is utter bollox. Javi, the jinx, wrote the notes to make it look like he'd done anything, but what did he do apart from a few bag puffs?

Mr Myers asks about the initial intubation process for Baby K. He asks if Dr Jayaram should be the one to do that process as the more senior doctor.

Dr Smith says: "No, not if the baby is stable."

Which she wasn't.

He says the decision to take over could be the 'wrong decision' as the doctor carrying out the procedure would be familiar with the placement of where everything is.

Like the mouth, the pharynx, and the larynx? Mr Myers asks if it's standard practice guidance for babies to be intubated within 15 minutes of birth. Dr Smith says he is unfamiliar with that number and asks Mr Myers where that guidance came from. Dr Smith says he would go with that if that were the standard practice number. He says there are two different numbers for how long it was after birth for intubation to have taken place - one of them is 12 minutes. Dr Smith is asked about lung surfactant, which a note records as being administered at 3 am, and whether that, at about 35 minutes after intubation, is 'too long'.Dr Smith says if good oxygen saturation is recorded at the time and Baby K is stable, that would not be an issue. Still, if guidance is to administer that surfactant five minutes after intubation, that would be considered too long.

The truth is that the consensus recommendation for initial stabilisation of very preterm infants is continuous positive airway pressure (CPAP) rather than routine intubation and surfactant treatment immediately after delivery. This avoids intubation, which will not be necessary for many babies and can cause early lung injury and infection, as in the case of Baby K. Randomised controlled trials and meta-analysis support selecting a CPAP strategy over a prophylactic surfactant treatment.

Dr Jayaram's note is shown to the court and written retrospectively. Dr Smith points out that the note of surfactant administration is recorded as being made at '0245'.Mr Myers asks about inserting a central line, which is done several hours after Baby K was born.

Dr Smith says the procedure requires assistance, is difficult, takes time, requires a sterile environment, and requires a stable baby. It also requires X-rays afterwards.

Dr Smith again makes the case for never having a preterm baby in the CoGH.The 1mm thick line is being put into an umbilical cord line that is 1-2mm thick. In this instance, it is' a non-emergency UVC'.

They are the same thickness in the units that succeed nearly 90% of the time on the first attempt. Mr Myers says this procedure should 'ideally' be performed by a consultant neonatologist at a tertiary centre. Dr Smith says ideally, the baby would be born at a tertiary centre. Still, in these circumstances, the most experienced staff at a level 2 centre, capable of this type of procedure, would carry out the procedure.

Back to the old, well-worn CoGH, self-serving circle to hell. Mr Myers asked if it was 'too long' a period. Dr Smith said a more extended period would not have compromised the baby.

I read that about ten times to understand what Dr. Smith was saying. He's saying that if he hadn't bothered to go near the delivery suite and if Javi the Jinx had never met Baby K, the outcome would have been no different. And you know? I think he's right.

Mr Myers asks if it was 'sub optimal'. Dr Smith says it would depend on the circumstances and the condition of the baby, and in Baby K's case, the 'correct thing to do' was to prioritise the airway and breathing support, and lines could be put in later. Mr Myers asks if the line insertion fell outside the 'golden hour' principle. Dr Smith says there is no difference in the method of the administration of initial medicines - the UVC was one option, but there are others. Dr Smith agrees with Mr Myers the initial administration of antibiotics fell outside the 'golden hour' principle timing. The antibiotics were administered at 4.40 am, according to electronic prescription records, sometime after the first hour of Baby K's birth, which ended at 3.12 am.

Dr Smith adds from a blood test, there was no marker of infection, but it was sub-optimal that the antibiotics and vitamin K (administered at 4.20 am) were not administered in the first hour, and I cannot recall why that was the case. After a short break, Mr Myers is continuing to question Dr Smith. He refers to the intubation attempts made for Child K. Dr Smith says he used a 2.5 tube at first, then a smaller 2.0 tube successfully. Mr Myers asks about an air leak which was reported. Dr Smith says he was aware of this and referenced it in his third statement to the police. Dr Smith does not know what the 3.30 am reading of '94' for air leak means, as it does not correlate to any other readings.

He says Baby K's blood gas record was good, the oxygen Saturation was good, and the oxygen requirement had come down. He does not believe that would mean only 6% (100% minus 94) of oxygen was getting into Child K. He said a large air leak would result in a change to a larger ET tube being considered, but that process would require reintubation. He said knowing there was good oxygenation and gas would reduce the need for reintubation.

He adds that a tertiary neonatologist with more experience with ventilators might give a different opinion, but they would need to be called to provide evidence. Dr Smith also does not know what the 'resistance' figure on the chart signifies. Mr Myers asked about the reintubation of Baby K's tube, which involved a larger tube. Dr. Smith says the first ET tube was working fine, then it was not, and reintubation was required.

The morphine bolus was applied to have "a sedative effect" on Baby K. The desaturation at 6.15 am is referred to. Dr Smith says the ET tube was pulled back, but saturation levels continued to decrease, so it was removed, and bagging commenced. Dr Smith says the saturation levels improved, meaning there "was a problem with the tube."

Mr Myers says pulling the tube back and seeing no change [before the tube's removal] meant there was no problem with the positioning of the tube. Dr Smith says the cause of the tube's movement could have been it 'slipping' from the clamp, which caused this deterioration. Dr Smith says he did not recall any injury/blood/trauma with Baby K, and if he had done so, he would have referred it to Dr Ravi Jayaram and asked them to take over the intubation process. Mr Myers asks if, hypothetically, he had seen blood before intubation and if he would have checked for the source of it.

Dr Smith says it would depend on the amount of blood seen, which would determine how concerned he would be. He said if he had seen blood-stained secretions, he would make a note of it.

As I said, this mess will go back to court only with the proper defendants in the dock


15th May 2024

The unreliable relationship between Insulin, Proinsulin, and C-Peptide in Preterm Neonates.

Jamie Egan


In assessing C-peptide readings in preterm neonates and adults, it is important to recognize that these two populations are inherently different. Comparing C-peptide levels between them can be inaccurate. This is primarily because of the unpredictable clearance of C-peptide in preterm neonates and the need for multiple samples to get reliable results.

The clearance of C-peptide in preterm neonates can be highly unpredictable because of their immature renal function. The kidneys play a vital role in filtering and eliminating substances from the body, including C-peptide. Preterm neonates may have an underdeveloped renal function, which can cause faster clearance rates. This can cause very variable C-peptide levels compared to adults, even in the absence of any underlying medical condition.

Another important consideration is the sample size required to get reliable C-peptide readings in preterm neonates. Because of the variations in clearance rates and potential fluctuations in C-peptide levels, multiple samples are often necessary to get an accurate assessment. This can be challenging with preterm neonates, as obtaining blood samples from them can be more difficult and carry additional diagnostic risks. Therefore, relying on a single C-peptide reading in a preterm neonate may not provide an accurate representation of their insulin production or metabolic status.

In conclusion, comparing C-peptide readings in preterm neonates with those in adults is not accurate because of the unpredictable clearance of C-peptide in preterm neonates and the need for multiple samples to get reliable results. The unique physiology of preterm neonates, including their developing organ systems and immature renal function, contribute to significant differences in C-peptide levels compared with adults. It is essential to consider these factors when interpreting C-peptide readings in preterm neonates and avoid making direct comparisons with adult populations.

It is even more critical when using these measurements as forensic evidence.