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.