Letby Case (part 2)

[OneFrenchEgg]

www.mumsnet.com/talk/_chat/4652340-lucy-letby-court-case?reply=121815754

follow up, remember rules around discussion of active cases

I’ve been following the trial and I just can’t get my head around this and what would drive someone to do such a thing

the blood tests with the insulin reading though is definitely conclusive that someone did something

because we aren’t getting the transcripts it’s hard to try to follow it closely to form accurate judgements

in the star Hobson trial the local paper did daily transcripts

Yes, and what's more nothing should ever be added to PN on a ward. It's extremely poor practice.

The port is there to allow additions in a pharmacy clean room and is usually covered with a seal - either the original one from when the bag itself was manufactured or a new one attached in the pharmacy - before issue.

I can't begin to guess what has happened here and wouldn't like to speculate even if it was appropriate to do so.

Sorry to butt in

Whilst you're waiting for Pharmicistquestions reply you might be interested to look at Prof Hindmarsh's evidence from yesterday on the ChesterStandard Live feed

He covered all this in great detail - there's one post on the live feed that gives all the blood sugars between 11ish and 9pm

It starts with a little blip when the BS rose slightly whilst the iv was tissued at midday but then the dropped very low again once the TPN started again and was like that all afternoon until it was taken down at around 7pm. BS was back to normal by 9pm

He's of the opinion that there were 2 bags similarly contaminated

Elsewhere it was reported he'd estimated the amount of insulin to be x17 the previous therapeutic dose in both bags

He's of the opinion that there were 2 bags similarly contaminated

And to the same degree. One bespoke bag and one stock bag with apparently similar insulin levels.

Was LL on shift when the bag was changed?

Nope she went off duty at about 7am

Ok so practically speaking how does a stock bag then get infused with similar quantities of insulin and end up with the same baby.

According to a pp would be possible to inject with insulin in the supply cupboard, but not possible to determine that bag would then go to a specific baby.

It's impossible unless she went back to the ward at lunchtime. Or had an accomplice. Neither of which I believe to be the case.

So [shrug]

I really need to understand the differential markers between natural and synthetic insulin. Any medical info gratefully received.

Endogenous (natural) insulin contains C-peptide. Exogenous (synthetic) does not.

Hyperinsulinaemia with low C-peptide is an indicator of administration of synthetic insulin.

Here www.medscape.com/viewarticle/432906_6

Thanks for the reply. I did see that evidence, and it's rather thrown the cat among the pigeons! If he's correct, there would have to have been more insulin given well after Lucy Letby went home. The only other explanation would be that the same bag of TPN was used all along, but that would be terrible practice and I can't believe they'd do that.

I personally think poor practice was at play with the TPN bag. Chester are not coming out of this well at all but I firmly believe, possibly for the very first time in this trial that Child F was murdered. I’m not saying LL is responsible

still lots more to come in this trial

Thanks for starting the second thread.

Let’s say you have 4 stock bags in the fridge and you tamper with one of them. You’ve a pretty good chance that the same baby is going to get the tampered bag. Or… maybe it’s the thrill that (if the bags WERE tampered with) you don’t know who is getting sick next?

I don’t know.

Having worked in NICU/NNU & other departments I am horrified by this case

There's no way Child F was targeted with a stock bag, at least not by anybody not on shift when it was put up. Apart from the random chance involved, nobody would have known his long line was going to need to be replaced & hence the bag changed.

So maybe it was the trill of not knowing who would get what. Who knows. It’s awful.

Child F survived. Thinking back to the opening statement, I think there is at least one other insulin case to come though, but I'm not sure.

So - do I understand the process correctly? For legitimately giving a baby insulin.

The insulin vials are kept in a fridge on the ward. Saline bags too? The insulin is put in to the saline by a nurse? And then the bag is hung up immediately and pumped into the baby by a different piece of kit, which infuses it at a different rate to the TPN kit?

Such a shame that they didn't keep the TPN bags, but I suppose they didn't really know what had happened until they got the blood test back a week later with those strange levels.

I wonder whether this is the point where they really began to suspect foul play. It seems like the first hard evidence of deliberate wrongdoing... by someone.

Yes the vials of insulin are kept in a locked fridge in a lockable Treatment Room -

[acts as both a clean relatively quiet space to concentrate on preparing medication and as a stockroom for medication, bags of fluids, needles, syringes, drip-sets, etc where everything is easily to hand]

The saline soln is kept in locked cupboards in same room - in the distant past pre Allit it was kept on open shelves but is now locked away to prevent tampering.

The nurse measures the tiny amount of insulin in a special small 1ml syringe and adds it to the saline, labels it with the baby's name and amount of insulin

Locks up, takes the saline+insulin to the baby and attaches it to one of the iv lines via the 'insulin pump' adjusted to the correct rate. The final part of the task is to sign the medication/fluid chart to confirm that the infusion has been started and by whom. .And return the keys to the shift-leader!

Any TPN being given doesn't really come into performing the task legitimately - other than the insulin and TPN - and other medication wh deteriorates at room temperature are stored in the same locked fridge. Plus a different separate iv access would be used in giving them.

The treatment room at CoC has apparently been upgraded since 2015 so videos of it cannot be shown to the jury. Also not sure if there is now CCTV in there

Sorry that was very long and excessively detailed

It's worth adding that all medication for children is checked & signed for by 2 nurses. It isn't necessarily checked in the room where bags & medication are kept, as that would mean 2 nurses leaving the clinical area. Where I worked we checked all infusions in the same room as the babies. We also kept a small amount of fluids in the room for use that day.

I've never worked anywhere where the treatment room was actually locked despite all of them being lockable. Drug cupboards are sometimes locked, sometimes not. Same with the fridges. Keys are passed around more readily than cookies and you don't always know who has them at a particular point of a shift. I don't know if CoC were stricter on any of that than any of the places I've worked but I've worked on quite a few wards at a few different hospitals and all were the same.

(I'm not necessarily agreeing with the culture around keys & locks, simply stating my experience.)

Yes absolutely - 2 nurses/2 signatures! And after being so long-winded

I got a bit distracted typing my post thinking about how to make the process safer/less open to malicious intent particularly wrt to locking saline bags away if you can 'borrow the keys' and do exactly the same thing as if they were on an open shelf

So much is down to vital and essential trust in colleagues and ill-intent being so very rare - it's almost 30 years since Allit's offences, a life-time ago before many younger nurses were born. Shipman 'scandal' nearly 20 years ago too

I read somewhere that CoC were keen on bedside CCTV around this time but it was strongly resisted by staff because of the trust issue - not sure if it was commonplace at other hospitals or was in response to suspicions/other things going wrong

It must have been an awful place to work not just the babies dying but also the lack of trust

Thank you so much for the explanations. They are really helpful.

Cctv in the treatment room sounds like an excellent idea though - as patients wouldn't be in there and no privacy concerns that way?