I agree, reading a big wall of text makes me skim read.
The things I think defence will raise regarding the lines. I'm going to paraphrase some articles, some A&P and try and explain what I think will drive a big hole in Baby A (forgive me if I'm wrong about which baby)
I'm also back on the fence and wobbling round like a weeble. Leaning to guilty but KENT. The thing that sways me to guilty is as always the statistics and data about her presence, which leaves me kind of weeding out what I think are the medical failings
This might not have happened fellas but
In ITU and I've since learnt, in PICU the lines you insert in to the major vessels need priming with saline. The line insertion itself can leave miniscule pockets of air in the vein or I guess arterially in UAC, often resolved by further flushing with saline, and apart from thrombisis of the blood clot variety, embolism (full stop) is why you always keep something running through these lines, if you cant run bulk you run a blood thinning miniscule solution. (this is in adult but the same risk applies) ...lines have air in them pre application. I'm really really scared the clearly inexperienced Reg fucked up and didn't prime the line and tried to insert dry. I can't blame LL for this at the moment. There's also the question of 5 applications, one of which was possibly advanced too far. Funny how the line along the spine showing non radio opaque something (yes, yes, they say it's air, but bowel obstruction reads as air, some liquids like a blood filled cavity can read as air, holes can read as air..all they know is it isn't showing radio opaqueness and they think it might be air) and that's also the possible pathway of a mis inserted line, whereas it's not definite this is where injected air would coalesce.
This is all just me thinking out loud, but the Reg, I believe also whipped the line out during resus...so I'm concerned a misplaced line was moved backwards quickly leaving a vacuum in which multiple embolism were released in to or at least coalesced due to backward pressure.
Most of all if that line wasn't in the right place at any one time we're looking at cardiac tamponade, which I'm not sure we'll see on xray on a neonate. There are a lot of difficulties with spotting lines on Xray, many trusts have started using radio opaque guide wires which are left until xray then removed or they use injectable die. This is clearly heard in court when one expert suddenly realised the catheter wasn't where she thought it was. Normalising risking this in a tiny baby is sooooo fucked up. I think the consultant issues may be more widespread than Kent. Why oh why aren't they calling consultants after failed lines and acidotic babies? Arrogance? Fear?
Without knowing for sure this child didn't have underdeveloped lungs we can't know if CPR caused a pneumothorax/air bubble. I know the actual experts will have probably gone through all of this while coming to their own conclusions, but Kent shows us how far apart case notes and actuality can be and how protective staff are of their poor practice.
Now I'm going to be that person who begs everyone to read the Kent document, I have a friend partially involved in this situation. I would quite happily go slap that consultant. Her Grandson died having been discharged WAY early, underweight and not thriving, it's recorded as a SIDS.
So none of this is what I believe happened, just what could have happened but in the face of what seems to me to be medical arrogance and lies we might not get that far.
Once again, this is stuff that goes through my head because I don't know what happened . I'm going to take a closer look at baby D for my own satisfaction too. Something's not right there.
Once more for those at the back -----insulin deaths = guilty. A and D ..hmmmmm....
EDIT :chuckling at my dissing big walls of text, then I post this shit waffle
Edit No 2, Dye not die