Lucy Letby is a nurse who worked in the neonatal intensive care unit at the Countess of Chester Hospital. She was accused, tried and convicted of murdering seven infants, and attempting to murder seven others.
I encourage you to look into these cases, as they are, quite clearly, absurd. Quite clearly, the correct explanation of these deaths and injuries is a combination of the known fact that sick babies can die, with chronic incompetence, arrogance and understaffing in the relevant intensive care unit. Unfortunately this was compounded by biased and incompetent expert advice to the investigation and court.
A panel of international experts, with much more convincing qualifications than those of the expert witnesses at trial, concluded that:
- There was no medical evidence to support malfeasance causing death or injury in any of the 17 cases in the trial.
- Death or injury of affected infants were due to natural causes or errors in medical care.
- There were problems related to the medical care of patients at the Countess of Chester Hospital neonatal unit.
- There were problems related to teamwork and inter-disciplinary collaboration at the Countess of Chester Hospital neonatal unit.
To give you a flavor of the absurdity, consider the case of baby K. A jury convicted Letby of attempted murder, of which more below. The judge said, in his sentencing:
… only you know the reason or reasons for your murderous campaign. … It was another shocking act of calculated, callous cruelty.
Now let us look at the evidence, reviewed by the international panel of experts. They identify baby K as “baby 11”. I’ll summarize, and then quote their conclusions in full.
In summary: baby K needed an endotracheal (breathing) tube. It was placed incompetently by the unit doctors, and the tube was too small. The doctors noticed that air wasn’t getting into the baby’s lungs as it should, but failed to understand that this was because they had put in a tube that was too small. Instead they concluded that Letby had displaced the tube, for which there was no evidence.
Here are the full conclusions of the international panel:
CONVICTION
The consultant alleged that Baby 11’s first episode of clinical deterioration was caused by deliberate dislodgment of her endotracheal tube, since bagging failed to move the chest and carbon dioxide was not detected by capnography. He alleged that the incubator alarms were deliberately turned off to prevent prompt rescue response because he did not hear the alarms when he entered the room.
PANEL OPINION
Baby 11 required a size 2.5 ETT [EndoTracheal Tube]. Instead, she was traumatically intubated with a size 2 ETT, with a resulting 94% air leak. As a result, ventilation was ineffective because 94% of the air was leaking out and only 6% was entering the lung. Effective gas exchange could not occur and mechanical ventilation could not generate sufficient pressure to keep the small air spaces in the lung open. This led to gradual collapse of the small air spaces in the lung and deteriorating gas exchange. When the tipping point was reached, the infant decompensated, desaturated and collapsed. Bagging to reopen the collapsed small air spaces in the lung requires relatively high pressures. With a 94% air leak, bagging with the Neopuff, which has a safety feature to limit air pressures, did not generate sufficient pressure to move the chest. Capnography did not work because the device measures build-up of carbon dioxide in the endotracheal tube during expiration, but with 94% air leak, the carbon dioxide could not build-up sufficiently to trigger measurement. There is no evidence to support dislodgement of the endotracheal tube. The consultant stated that he did not hear the alarms, but a nurse (not LL) stated that “When I returned to the unit, I immediately became aware of the alarms sounding from Baby 11’s incubator.”
CONCLUSIONS
- There is no evidence to support a dislodged endotracheal tube.
- The clinical deterioration was caused by use of an undersized endotracheal tube.
- The initial intubation was traumatic and poorly supervised.
- The consultant did not understand the basics of resuscitation, air leak, mechanical ventilation, and how equipment that were commonly used in the unit work, e.g. Neopuff and capnograph.
- There is evidence that the incubator alarms were not turned off.