Lucy Letby Case #18

[Tofino]

9m is a massive amount of insulin, they come in 10ml vials. Also 9ml is just what the baby would have had until the TPN stopped, there would have been more in the bag overall. Then there's the potential second bag. You'd notice entire vials of insulin going missing surely!

Well you would think so but nothing would surprise me given what we’ve heard about the unit so far.

What would a fridge stock check process look like? Eg how many vials are kept as standard, how often is stock checked and used vials replenished, (and what is the process to request more vials), do any vials ever get written off for being out of date and what does that process look like?

And whatever the process/policy is, were the staff on that unit following it?

 

[Haveyouanywool]

I think there is some confusion regarding insulin volumes.

The 0.56ml/hr rate is the rate of saline/insulin (or glucose) in a pre-mixed solution in a syringe driver, not the units of insulin.
The first ss shows the tiny units of insulin by volume that a baby requires per hour.
Only a few units extra out of the 10ml vial (100 units) would be required, this would be difficult to stock check accurately.
I’m not very good at explaining but hope that makes it easier.

 

[Daisydunn15]

I think there is some confusion regarding insulin volumes.

View attachment 1767589View attachment 1767590View attachment 1767591

Yeah but she wasn't administering properly. They showed the 10ml insulin vials in the court room and he said 0.56ml/hr so it reads like she's just taken a load straight out of the vial and dumped it in there.

Well you would think so but nothing would surprise me given what we’ve heard about the unit so far.

What would a fridge stock check process look like? Eg how many vials are kept as standard, how often is stock checked and used vials replenished, (and what is the process to request more vials), do any vials ever get written off for being out of date and what does that process look like?

And whatever the process/policy is, were the staff on that unit following it?

Pharmacy did our stock checks, regardless of what was happening on the ward they got done daily, we would have never had the time.

 

[starshine89]

Thanks for that! Would you be able to give colder through a peripheral line? They've confirmed a stock of 5 TPNs all the time although I imagine they need them regularly with neonates.

We would only ever administer TPN through a central line due to the risk of it damaging peripheral lines we would never give it peripherally

But you can get special peripheral made tpn which they change the way it’s made up so it’s essentially more diluted so I’m suprised they gave TPN peripherally

If the tpn came up straight up from aseptic pharmacy where it’s made then it might not have ever gone into the fridge so can go up straight away which I imagine is why the bag could have gone up immediately

 

[Treesy19]

Didn’t someone say last week in court that these bags have like a septum opening on them as well, which self-seals? Or have I imagined that? That would mean someone (she) could easily inject insulin and it not leak and no one would know.

 

[Haveyouanywool]

Yeah but she wasn't administering properly. They showed the 10ml insulin vials in the court room and he said 0.56ml/hr so it reads like she's just taken a load straight out of the vial and dumped it in there.



Pharmacy did our stock checks, regardless of what was happening on the ward they got done daily, we would have never had the time.

No, the 0.56mls an hour was what Baby F had legitimately previously to lower his blood sugar when it was high. That’s obviously the proper saline (or glucose) diluted mixture to deliver x units of per ml but not 0.56mls per hour of an insulin vial, as 10 hrs of that would be 5.6 mls of an insulin vial or 56 units. Baby would be stone dead.
At least that’s my calculations!

 

[crumpets2]

Didn’t someone say last week in court that these bags have like a septum opening on them as well, which self-seals? Or have I imagined that? That would mean someone (she) could easily inject insulin and it not leak and no one would know.

Yes, they have self sealing ports on them. And as they are individually made up they are only kept in bags so they are out of sunlight. Unlike fluids, which also have the same port but have plastic wrapping on them.

 

[Tofino]

Yeah but she wasn't administering properly. They showed the 10ml insulin vials in the court room and he said 0.56ml/hr so it reads like she's just taken a load straight out of the vial and dumped it in there.



Pharmacy did our stock checks, regardless of what was happening on the ward they got done daily, we would have never had the time.

Even if it’s pharmacy’s responsibility to check and maintain stock, the point still stands. If she (or whoever did the deliberate act, even if you don’t think it’s her) took a whole vial then why did nobody notice? Or did someone notice but wrote it off for some other reason. It’s just another example of a missed opportunity of safeguarding those babies from harm if a whole vial did go missing.

But it is possible the units of measurement have also been mixed up in the reporting from what Haveyouanywool posted. (Or not made clear that it’s 0.56ml of fluid per hour not just insulin).

 

[Daisydunn15]

No, the 0.56mls an hour was what Baby F had legitimately previously to lower his blood sugar when it was high. That’s obviously the proper saline (or glucose) diluted mixture to deliver x units of per ml but not 0.56mls per hour of an insulin vial, as 10 hrs of that would be 5.6 mls of an insulin vial or 56 units. Baby would be stone dead.
At least that’s my calculations!

He says the rate would be on the TPN bag and he calculates it based on what the baby had previously been given. So it sounds like his estimated rate is in reference to what would have been in the bag.
Yeah that's so much insulin, even with the dextrose, but then if you're trying to murder you'd use a lot, no?
I don't use insulin much at all, so I'm not clued up but honestly we could have our own tattle expert here and I still don't think they'd make heads nor tails of it with the reporting we've had.

Even if it’s pharmacy’s responsibility to check and maintain stock, the point still stands. If she (or whoever did the deliberate act, even if you don’t think it’s her) took a whole vial then why did nobody notice? Or did someone notice but wrote it off for some other reason. It’s just another example of a missed opportunity of safeguarding those babies from harm if a whole vial did go missing.

But it is possible the units of measurement have also been mixed up in the reporting from what Haveyouanywool posted. (Or not made clear that it’s 0.56ml of fluid per hour not just insulin).

Yup, and pharmacy aren't part of the main ward team, so from my experience they have no issues in raising concerns. We had a book we would use to mark down any discarded meds, say you'd drawn up an injection and used too much saline, you'd need to get rid of the whole lot. But then if she'd done that for insulin we'd have seen it as her trying to cover her tracks. I wonder if you'd know if someone topped up a couple of vials with water.

 

[Haveyouanywool]

Oops, sorry. I have misunderstood that!
Would it be 0.56mls of the TPN an hour?
It can’t be 0.56mls of insulin as that would be 5.6 units an hour. Way too much.

 

[Tofino]

He says the rate would be on the TPN bag and he calculates it based on what the baby had previously been given. So it sounds like his estimated rate is in reference to what would have been in the bag.
Yeah that's so much insulin, even with the dextrose, but then if you're trying to murder you'd use a lot, no?
I don't use insulin much at all, so I'm not clued up but honestly we could have our own tattle expert here and I still don't think they'd make heads nor tails of it with the reporting we've had.



Yup, and pharmacy aren't part of the main ward team, so from my experience they have no issues in raising concerns. We had a book we would use to mark down any discarded meds, say you'd drawn up an injection and used too much saline, you'd need to get rid of the whole lot. But then if she'd done that for insulin we'd have seen it as her trying to cover her tracks. I wonder if you'd know if someone topped up a couple of vials with water.

What’s the shelf life of insulin vials and what happens if not in a fridge? Just speculating if she nicked a vial ahead of time, like days or weeks before (making the paper trail harder), or would that be too risky as she would have to carry it in a pocket.

 

[crumpets2]

Oops, sorry. I have misunderstood that!
Would it be 0.56mls of the TPN an hour?
It can’t be 0.56mls of insulin as that would be 5.6 units an hour. Way too much.

I thought it was the rate of TPN

 

[Haveyouanywool]

What’s the shelf life of insulin vials and what happens if not in a fridge? Just speculating if she nicked a vial ahead of time, like days or weeks before (making the paper trail harder), or would that be too risky as she would have to carry it in a pocket.

I really don’t think she’d need to nick a vial. 10mls would be 100 units. Babies would only need 0.01 - 0.02 units per hour which would be 0.1 in ten hours. That would be 1/1000 of a 100ml vial.

 

[Tofino]

Oops, sorry. I have misunderstood that!
Would it be 0.56mls of the TPN an hour?
It can’t be 0.56mls of insulin as that would be 5.6 units an hour. Way too much.

This is the exact wording from the reporting but the ‘on the TPN bag’ doesn’t make sense to me (but I’m not medical so might make sense to you and others).


Professor Hindmarsh says a rate of about 0.56ml/hr of insulin would have been required to lower Child F's blood sugar levels on the TPN bag.

This was calculated given the insulin level administered to lower Child F's blood sugar levels on July 31.

Mr Johnson: "Would that level have been visible to the naked eye?"

Prof Hindmarsh: "No."

I really don’t think she’d need to nick a vial. 10mls would be 100 units. Babies would only need 0.01 - 0.02 units per hour which would be 0.1 in ten hours. That would be 1/1000 of a 100ml vial.

It was definitely reported the vials were 10ml unless it was a typo. Could they be smaller vials for neonates?


Professor Hindmarsh is shown a 10ml bottle of insulin, which normally comes with an orange, self-sealing cap.

To extract the liquid from the bottle, to administer 'therapeutically', a medical professional would have to use a syringe, the court hears.

Mr Johnson says by 'therapeutically', Professor Hindmarsh means 'legitimately'. Professor Hindmarsh agrees, and says the dose would have to be measured out carefully.

 

[Haveyouanywool]

He says the rate would be on the TPN bag and he calculates it based on what the baby had previously been given. So it sounds like his estimated rate is in reference to what would have been in the bag.
Yeah that's so much insulin, even with the dextrose, but then if you're trying to murder you'd use a lot, no?
I don't use insulin much at all, so I'm not clued up but honestly we could have our own tattle expert here and I still don't think they'd make heads nor tails of it with the reporting we've had.



Yup, and pharmacy aren't part of the main ward team, so from my experience they have no issues in raising concerns. We had a book we would use to mark down any discarded meds, say you'd drawn up an injection and used too much saline, you'd need to get rid of the whole lot. But then if she'd done that for insulin we'd have seen it as her trying to cover her tracks. I wonder if you'd know if someone topped up a couple of vials with water.

Yes, I didn’t use insulin either so got myself a bit confused!
I still think she’d only need to use a tiny amount.

 

[candyland_]

Just catching up with todays updates..
Another baby who was happy and stable until Letby administered care to him. It’s the same pattern each and every time.

 

[Haveyouanywool]

This is the exact wording from the reporting but the ‘on the TPN bag’ doesn’t make sense to me (but I’m not medical so might make sense to you and others).


Professor Hindmarsh says a rate of about 0.56ml/hr of insulin would have been required to lower Child F's blood sugar levels on the TPN bag.

This was calculated given the insulin level administered to lower Child F's blood sugar levels on July 31.

Mr Johnson: "Would that level have been visible to the naked eye?"

Prof Hindmarsh: "No."



It was definitely reported the vials were 10ml unless it was a typo. Could they be smaller vials for neonates?


Professor Hindmarsh is shown a 10ml bottle of insulin, which normally comes with an orange, self-sealing cap.

To extract the liquid from the bottle, to administer 'therapeutically', a medical professional would have to use a syringe, the court hears.

Mr Johnson says by 'therapeutically', Professor Hindmarsh means 'legitimately'. Professor Hindmarsh agrees, and says the dose would have to be measured out carefully.

Yes, the wording is very confusing as it seems to imply they know how much insulin was in the TPN bag, where it shouldn’t have been anyway.
A 10ml vial would normally contain 100 units of insulin (there can be different concentrations). These babies seem to need tiny amounts, starting at 0.01 units (not mls) per kg/hr. I mean, that’s a tiny volume.
I was trying to point out that the professor was talking about mls and not units. So 1 unit would be 0.1 of an ml. So 0.01 units would be 0.001mls. Tiny, tiny.
I didn’t use insulin and I’ve no idea if the concentrations used would be different but that’s the standard.

 

[slingo16]

This is just my understanding from what we’ve read.

They have determined it was deliberate poisoning because of the seriously high insluin / low peptide values from the blood test. can only have been synthetic insluin.

The blood glucose levels show how long the baby was receiving synthetic insluin for - as it went on for 18ish hours the expert has said it must have been a continuous supply so must have been in the bag (I think a single dose would wear off quickly.

The point you make about the insulin binding to the bag so how could it be consistent is an interesting one which has not been reported on but from my understanding I think that’s because typically the doses are so tiny so if it stuck to the bag they might not get enough? But if she did put a large amount in (although 10ml wouldn’t look a lot ?) I imagine it would be a more consistent supply. The same thing happened to Charles Cullen victims, it was an ongoing poisoning of insulin via a bag.

Professor Hindmarsh explains it better than me

For a skin injection, he says the duration of action [for the insulin] of 4-6 hours would not fit with the 17 hours of hypoglaycaemia. It would require multiple injections.

He says an intravenous route "would be the most likely explanation".

The way to do so would be a bolus of insulin - from testing in endrocrinology, the blood sugar level would fall within 90 minutes, then rise back to normal.

To maintain hypoglycaemia "over a protracted period of time" would require multiple insulin boluses "roughly every two hours".

The second route would be via infusion - "probably the most likely way of achieving the blood glucose effect that we have observed".

The infusion would be "continuous", using the bags available, and "fit nicely" with the time course of events

I think I’ve grasped what he’s saying, thanks that makes a lot more sense now

 

[Haveyouanywool]

I really don’t think she’d need to nick a vial. 10mls would be 100 units. Babies would only need 0.01 - 0.02 units per hour which would be 0.1 in ten hours. That would be 1/1000 of a 100ml vial.

ETA: 1/1000 of a 10ml vial!

 

[Tofino]

Yes, the wording is very confusing as it seems to imply they know how much insulin was in the TPN bag, where it shouldn’t have been anyway.
A 10ml vial would normally contain 100 units of insulin (there can be different concentrations). These babies seem to need tiny amounts, starting at 0.01 units (not mls) per kg/hr. I mean, that’s a tiny volume.
I was trying to point out that the professor was talking about mls and not units. So 1 unit would be 0.1 of an ml. So 0.01 units would be 0.001mls. Tiny, tiny.
I didn’t use insulin and I’ve no idea if the concentrations used would be different but that’s the standard.

I looked back earlier to see if it was reported what the actual measurement was when he was given insulin legitimately but it doesn’t say. I presume jury will know that though as they have copies of all the records.

The only thing I’m thinking (but again I am not a medic so may be way off) is that because of how low it dropped (0.8 before treatment commenced) and because prof Hindmarsh said he was having twice as much glucose than a baby normally requires and blood sugars still stayed lowest, would that explain 50 units of insulin per hour? Or would that be more critical even with dextrose.

I don’t think either answer matters btw, because unless we hear otherwise then it wouldn’t surprise me if one or two missing vials would go unnoticed in a failing hospital. And obviously if she didn’t take that much anyway then also not surprising it went unnoticed.