Lucy Letby - have you changed your mind pt. 5

[Typicalwave]

New thread

Part 4 here - https://www.mumsnet.com/talk/_chat/5400564-lucy-letby-have-you-changed-your-mind-thread-4?utm_campaign=thread&utm_medium=app_share

Originally started by @kittybythelighthouse

I'd say that ambition is necessary but not sufficient for this sort of accomplishment. I'd see ambition itself as a neutral quality.

I agree that there must be very able people with no appetite for these roles. I'm sure we all know examples in our own line of work.

However, if we are to ask to have our judgement taken seriously, submitting our work, publicly and repeatedly, to the scrutiny of our peers, is a way to offer some guarantees of our capacity and seriousness. Of course, not everyone wants to do this.

But it is what Lee, Chase and so many others expressing concerns about the case have done, and what Evans has not done. There's just no metric by which Evans could be described as world-leading.

Dewi cant even recognise the fairly obvious symptoms of Addisons or if he can he certainly doesn’t believe a GP should be able to.

For an academic maybe, but I don’t think Dewi Evans has ever claimed to be an academic? On the flip side you could also argue that for all the time Shoo Lee has spent publishing his hundreds of papers he has not been working fully clinically and therefore has been getting less first hand experience of all the various ways that neonates can present and behave in different circumstances.

I do not believe that world leading is a meaningful descriptor in medicine anyway, but the only metrics that people are using to attribute it (published work, shiny appointments) definitely do not necessarily make someone more competent for these purposes.

This is quite an assertion - can you back it up?

Robbie Powell.

Right, but can you tell me how you are confident to assert that “Dewi cant even recognise the fairly obvious symptoms of Addisons or if he can he certainly doesn’t believe a GP should be able to”?

I like Neena Modi's take on this: that you need a combination of hands-on experience and research expertise. There's a good interview with her and related discussion at www.reddit.com/r/LucyLetbyTrials/comments/1kh7tof/is_lucy_letby_innocent_motive_method_extended/

That's obviously the case for the charges against Lucy Letby. Venous air embolism in premature neonates is a rare phenomenon. You're not going to find someone with a clinical history of dealing with such things. Hepatitic subcapsular hematoma is rare. Monochorionic triplets are extremely rare. Twin births to a mother with APS? Not so common.

One thing we heard far too much of in the trial was, "something I had never seen before". The range of possible occurrences, especially with premature children, just isn't a subset of any doctor's previous clinical experience, however talented and industrious that doctor.

Academia can be an ivory tower endeavour, but in medicine it's marked by two things that keep it grounded. One is the requirement for many academics to act as clinicians - hence the prevalence of teaching hospitals and university hospitals. Another is the strong tradition of sharing case reports in academic journals - so that we should expect those with a higher profile, academically, to be better informed about phenomena across different cases than anyone focused purely on practice.

I would want the combination of relevant hands-on experience and academic excellence in a fraught case like this, and that is what we have on Lee's panel. One does not exclude the other. It is hard to argue that the prosecution expert witnesses had this combination.

Have a research yourself and make up your own mind.
I certainly do not believe writing a supportive letter to a GP practise who very obviously failed Robbie and tried to cover it up, telling said GP practise that they did nothing wrong, after said child had visited Dewi’s hospital on numerous occasions, and Dewi’s name was on the child’s hospital records as a Treating consultant, but Dewi claims it was a ‘mistake’ and that he’d never met he child, is indicative of Dewi being a medical professional I could trust to diagnose (of even be honest about ) anything.

@rubbishatballet - its a fair point that doctors need hands on experience. However, like all practicing professionals they also need to keep up to date with the literature and - crucially - understand it. Evans misinterpreted the literature with significant consequences in this trial. Practicing professionals are also expected to know their limitations - if you are acting as an expert in a complex trial you need to bring in those with expertise outwith your own yet Dewi didn't bring in an obstetrician and he is not himself a neonatologist. TBH the latter should have precluded him from being the lead expert and anyone less self aggrandising would not have put themselves forward for a case beyond their expertise in the first place.

However the world needs different sorts of doctors. I once spoke to the medical fellow at college when I was an undergrad. He was usually allowed to recruit 3 undergrad medics a year (every few years it would be his turn to get 4). His rationale was that he would select one who was likely to go into high level research ("and maybe find a cure for cancer") one who was likely to be a senior consultant/surgeon and one who would make a "damn good GP". WHen he had a fourth he'd probably go for the latter again. In my year he was pretty spot on - one is a very distinguished medical researcher, one a leading surgeon and one a GP.

Dewi Evans qualified before neonatology was a distinct subspecialty of paediatrics, but spent many years working in neonatology and was instrumental in developing neonatal services in Wales.

Plus there were two other neonatologists who reviewed his findings and were in agreement with them.

This thread by Svilena Dimitrova (who is far from a friend of the prosecution) is quite interesting on what a neonatologist is https://x.com/neodoc11/status/1966181180161552695?s=46&t=nMIEPJTrX8mdRDt3kgBsag

He didn’t bring in an obstetrician, but then I don’t think he considered obstetric issues to be a factor in any of the causes of death/harm? He did definitely decline to offer an opinion several times in court though, and instead deferred to other experts.

Yes, Evans didn't make a judgement on baby K, which was not a case where a medical opinion made a difference. It was, as the judge commented at retrial, primarily a question of whether or not you found Dr Jayaram's testimony reliable.

Similarly, Evans deferred to Hindmarsh on insulin cases.

Dr Dimitrova is of course correct that one should not judge clinical practice purely by academic standards. But I don't find her position particularly different from Neena Modi's.

I am sure there are many, many retired practitioners of related specialisms, like Evans, who are capable of giving an accurate and honest account of the state of medical knowledge on relevant issues, unlike Evans. You won't find me arguing that many careful and competent professionals couldn't have made a far far better fist of it than he.

My primary objection to Evans is to his avowedly, obviously, unscientific approach. And because he has offered arguments for murder that he claims to draw from the scientific literature and evidence base, it's obviously a sensible step to engage experts who can demonstrate that they in fact know and understand that literature and evidence base as well as anyone.

Let us remember too that new scientific research constitutes new evidence for the Court of Appeal, so that one would obviously seek out experts familiar with the most recent developments in their fields and capable of conducting such research themselves.

If I understand her correctly, Dr Dimitrova has argued that the standards and reporting at Chester fell so far short of normal expectations that direct reporting of Chester medics to police and a case built on exposing their misconduct is appropriate. In this case one would, legally, look at standards applicable to the consultants' peers practicing medicine in the UK - that's the expected measure. Whether that's a useful strategy for Lucy Letby legally, I don't know. But the distinction is fair

Still, in terms of expert witnesses for a court case based on medical murder, a combination of recent relevant experience and academic expertise is obviously what's required.

I just think it's funny how Mark Mcdonald just so happens to have the world's best in everything. Do you really believe that or do you think he might be slightly exaggerating there? Even if Shoo Lee is world leading it still doesn't mean much in the grand scheme of things because something like air embolism is so rare. The staff who worked on the unit have seen far more air embolism symptoms than Shoo Lee ever has in real life. They all saw the weird rashes. Even one of the parents saw it. What have the panel said these rashes were down to if not air embolism? I must've missed it.

Why do you think the discolourations were caused by air embolism?

Where's Dewi Evans evidence (and those who agreed with him) that the rashes came from air embolism??...Oh yeah, Dr Shoo Lees paper...............

It would have been really helpful if those weird rashes were properly documented or photographed to help with differential diagnoses, as might be considered good medical practise.

It would also have been helpful if there was some consistency in how they were described, because I've seen various descriptions, all different, and all recounted in retrospect, years down the line.

Also, it would have been helpful to have what a "rash" is defined. Personally a rash to me is evidence of skin irritation. Reddening, possibly raised, itching perhaps.

What seems to be described here are transient and moving episodes of skin discolouration, probably more marked because premature babies have less fat and substance and so changes in temperature and circulation cause a more marked difference.

Never mind the whole issue of venous versus arterial air embolism, and the fact that these "rashes" are not always observed in such cases, nor considered to be diagnostic, which was actually conceded during the trial, but still proved pivotal in people's misunderstanding of it all.

It's just a shambles.

Because excess air was found in the babies' systems and there was nothing else to account for the rashes?

Air found post-mortem does not prove air embolism, and it's a common finding in infants after failed CPR.

"Patchy skin discolorations are caused by dilation and contraction of small
blood vessels in the skin in response to hypoxia, which can occur in many conditions.", as Lee's panel observed.

None of the events at Chester has been established by scientific analysis and review to have been air embolism. So no, the doctors there wouldn't count as expert in this phenomenon in infants. One acquires expertise in such rare phenomenona through study of case reviews, as Lee has done.

If Drs Jayaram, Evans or Bohin believe they have evidence of air embolism in any of these infants, they are free to submit a case report for scientific scrutiny by their peers. They appear not to have done so.

You appear to have missed quite a lot here somehow, yes.

The panel gives a number of explanations for the discolorations in their reports: hypoxia, compromised blood flow, shock (at the press conference). You're under no obligation to read them but those who wish to can find the reports, as well as the full video of the press conference, at:

lucyletbyinnocence.com/#shoolee

Air found post-mortem does not prove air embolism, and it's a common finding in infants after failed CPR.

Put it together with the rashes that had never been seen before by any of the staff and it very much points towards that. If it was common the whole unit wouldn't have been stumped by what was going on.

"Patchy skin discolorations are caused by dilation and contraction of small
blood vessels in the skin in response to hypoxia, which can occur in many conditions.", as Lee's panel observed.

"Many conditions" how conveniently vague. And yet somehow none of the consultants had ever come across such rashes before.

None of the events at Chester has been established by scientific analysis and review to have been air embolism. So no, the doctors there wouldn't count as expert in this phenomenon in infants. One acquires expertise in such rare phenomenona through study of case reviews, as Lee has done.

Yes and his findings matched what was happening at Chester.

Are you saying that many conditions (including hypoxia, shock, and anything compromising blood flow) don't cause patchy discolorations?

Is that a position you want to defend?

These were specific rashes that weren't seen before (I just listened to this part of the audiobook by Moritz and Coffey) not run of the mill common discolorations. If they weren't rare no one would need to rely on Lee's paper would they? Are you saying air embolism doesn't cause rashes?

They can't just decide that it means someone deliberately caused air embolisms though....well they can and it can convict someone, but there's a very, very real possibility that it's then going to fall apart on appeal, which is why normally the prosecution are far more careful with what they present in court......

OK, I’ll try again. Why are you associating air embolism with a rash?

Lee’s paper showed that skin discolouration was characteristic of arterial air embolism, not venous, and there’s no evidence whatsoever that any of the babies had arterial air emboli. That was the misinterpretation to which he objected once he realised.

And where’s the contemporaneous evidence that these rashes had never been seen before by anyone on the unit? If that were the case, would you not have expected it to have been investigated at the time? Rashes generally point to infection, and given that we know the unit had a sewage problem, alarm bells should have been ringing.

The "specific" there really doesn't apply. If you read the descriptions of rashes from the time, none of them even match the Lee and Tanswell paper. The only matches are the ones that weren't noted at the time, and were described by the doctors years later, after reading the paper.

Nobody was talking about a rash that looked like what was described by Lee and Tanswell at the unit at the time. That's not surprising, because we know none of the children had the pulmonary arterial embolism caused by high pressure oxygenation that caused it.

Venous air embolism doesn't cause the particular rashes later described by the doctors to match Lee and Tanswell, no. There's no scientific work or observation out there to say it does. That effect has simply never been noted in infants known to have venous air embolism. It was a huge mistake on the part of the prosecution.