Lucy Letby case #21

[stardust1]

So by June 2015 the staff also had suspicions about Letby being linked to everything. So awful that she was enabled to carry on (if guilty)

Mr Myers said: “Miss Letby had been a person identified as a potential link by June 2015.”

Mr Jayaram said: “Yes and other colleagues had noticed the association as well.”

 

[F1Grid]

Is it considered bad practice that the doc never writ down any concerns about the rash? I thought it was drilled in that if you don’t write it down it never happened. It has turned into one word against another because he never noted it down IMO

This is in an arrest situation though, there's lenience given.

 

[CabalofBolorneaise]

It’s a bit concerning that she was identified as a person of interest so early on, but got away with it for another 11 months. Especially when you consider the deliberate insulin poisoning.

Yeah, along with the not writing pertinent info down (eg rash) that could have been used to solidify a link earlier, it really doesn't show the hospital as a whole in a good light, does it?

 

[stardust1]

I've always thought this - plus no pictures. Considering it was something that 'had never been seen before' and so unusual, it seems strange that no one thought to document it properly.

I’m really on the fence with it, so it was never written anywhere but plays a huge part in an AE diagnosis? Idk I am just relating it to my experience my son had a rash, but also had a lot more serious things going on but they still took pics and put it in his notes anyway. At the very least it screams lazy?

 

[avabella]

I’m really on the fence with it, so it was never written anywhere but plays a huge part in an AE diagnosis? Idk I am just relating it to my experience my son had a rash, but also had a lot more serious things going on but they still took pics and put it in his notes anyway. At the very least it screams lazy?

What's that thing called where you 'remember' something that happened, but when lots of people also say they remember it, it begins to be remembered wrongly? I'm sure there's a word for it but I just can't think.

 

[stardust1]

This is in an arrest situation though, there's lenience given.

Yes I know that but even before they thought she was a suspect that rash really should have been documented. It’s a poor excuse from him IMO. I do think she is guilty but he has hardly helped the case
---

What's that thing called where you 'remember' something that happened, but when lots of people also say they remember it, it begins to be remembered wrongly? I'm sure there's a word for it but I just can't think.

I know what you mean. I do personally think she’s guilty but no pictures or documents just a verbal agreement it happened.. really? I could see how the defence could use this to say they are finding something to fit the pattern of an AE.

 

[MmmB777]

The rashes are documented for multiple babies throughout though and many witnesses say they were talked about at the time and have said this under oath in the box. They did try and photograph it at one point but it disappeared like baby Ms. Also they’re being seen and interpreted by different people. He’s said there was not a suspicion of foul play yet but that people saw it was her shifts, she was there or her babies and we know from texts that her friends and colleagues talk about that and Lucy herself acknowledges it several times. Nobody suspected she was killing them yet.

 

[DellaC]

I just hoped after they identified her as 'associated', they ensured that they crossed every T and dotted every I.

It's another one of those frustrating aspects of this case for me and if there are lessons to be learnt then one of them should be the importance of accurate documentation.

 

[Daisydunn15]

I’m really on the fence with it, so it was never written anywhere but plays a huge part in an AE diagnosis? Idk I am just relating it to my experience my son had a rash, but also had a lot more serious things going on but they still took pics and put it in his notes anyway. At the very least it screams lazy?

I can understand the lack of pictures, as they're saying it would have been transient and no time to take a picture during resus. However it's absolutely drilled in that if its not documented it didn't happen, and I know they were busy at the time but afterwards you'd be documenting everything about their presentation that may be significant and you're doing this when things have quietened down and you're no longer in an emergency situation. The nursing notes should document any changes to colour too, baby's chest would have been exposed to everyone in the room would have seen it.

 

[MmmB777]

I can understand the lack of pictures, as they're saying it would have been transient and no time to take a picture during resus. However it's absolutely drilled in that if its not documented it didn't happen, and I know they were busy at the time but afterwards you'd be documenting everything about their presentation that may be significant and you're doing this when things have quietened down and you're no longer in an emergency situation. The nursing notes should document any changes to colour too, baby's chest would have been exposed to everyone in the room would have seen it.

Do you have any ideas for the cause of baby Ms collapse and if it might be related to Letby giving treatment just before?

 

[F1Grid]

I’m really on the fence with it, so it was never written anywhere but plays a huge part in an AE diagnosis? Idk I am just relating it to my experience my son had a rash, but also had a lot more serious things going on but they still took pics and put it in his notes anyway. At the very least it screams lazy?

This baby was actively dead to the point they were asking the parents about stopping CPR. As soon as that happened, the rash went away. There was no time for pictures.

The notes for an arrest follow a specific structure - it has to be an automatic process in the scribe's head, just like everything in CPR that we try and make automatic.

You document how many rounds of CPR, when you're giving drugs (adrenaline), or shocking if appropriate. You document looking for your reversible causes - hypoxia, hypovolaemia, hypo or hyperkalaemia, hypothermia, thrombosis, cardiac tamponade, toxins, tension pneumothorax. This is why we get blood gases, a set of obs, and the heart and lungs are examined during compressions. These are recorded contemporaneously. You do expose the child, but you're looking for something BIG.

If there's none of these reversible causes present, and you don't have a pulse back, you start thinking about stopping. You have a discussion with family, or you ask the rest of the team do they have any objections to stopping. This is documented. Then you document when you stopped and why.

Issue is, the reason baby M arrested isn't one of those reversible causes. They were progressing down that specific structure from what we heard, then.... baby M suddenly got better for no apparent reason. The relevance of that rash was also only recognised once the consultants sat down in June - the art of note writing means down you're writing down relevant things only, I'm not going to write about my patient's 5 cats, or funny looking toe, or a bit of a rash when I don't think it's relevant. In an arrest situation, unless you think that rash is suggestive of anaphylaxis (gives hypoxia and hypovolaemia, which are reversible), or DIC (thrombus, which is reversible), or is due to a local reaction to a transdermal patch (toxins) or suggests surgical emphysema (tension pneumothorax) you're probably going to bypass it.

 

[stardust1]

I can understand the lack of pictures, as they're saying it would have been transient and no time to take a picture during resus. However it's absolutely drilled in that if its not documented it didn't happen, and I know they were busy at the time but afterwards you'd be documenting everything about their presentation that may be significant and you're doing this when things have quietened down and you're no longer in an emergency situation. The nursing notes should document any changes to colour too, baby's chest would have been exposed to everyone in the room would have seen it.

I thought that should be the case. @MmmB777 post above states that there is documentation of it in others babies so I would be more inclined to believe it did happen when you look at the bigger picture but I do still think to not bother even adding it to the notes at a later time is quite bad. I know the hospital isn’t on trial but if LL is found guilty I think it is clear to see there was a good few chances to put a stop to it.

did I read you’re a nurse? If so how common do you find it for things to be missed off the notes? Especially more so in busy times?

 

[mRsKbRoOkS]

The thing that bothers

The rashes are documented for multiple babies throughout though and many witnesses say they were talked about at the time and have said this under oath in the box. They did try and photograph it at one point but it disappeared like baby Ms. Also they’re being seen and interpreted by different people. He’s said there was not a suspicion of foul play yet but that people saw it was her shifts, she was there or her babies and we know from texts that her friends and colleagues talk about that and Lucy herself acknowledges it several times. Nobody suspected she was killing them yet.

That’s what bothers me most about Dr myers discrediting that the rashes occurred, especially in baby As case, when letby her self referenced the rash in her interview.

I have no idea why they didn’t document it at the time, but perhaps they had started to connect the dots but instead of thinking it was intentional, thought it was a whole ward negligence thing, no documentation of the rashes, then negligence can’t be proved? Like they were worried and thought they could handle it without outside interference.


Maybe they were really somewhat trying to cover their arse’s because they didn’t realise they were dealing with potential murderer and if all this was documented and someone starting asking questions then they thought all their jobs would be on the line!

 

[MmmB777]

This baby was actively dead to the point they were asking the parents about stopping CPR. As soon as that happened, the rash went away. There was no time for pictures.

The notes for an arrest follow a specific structure - it has to be an automatic process in the scribe's head, just like everything in CPR that we try and make automatic.

You document how many rounds of CPR, when you're giving drugs (adrenaline), or shocking if appropriate. You document looking for your reversible causes - hypoxia, hypovolaemia, hypo or hyperkalaemia, hypothermia, thrombosis, cardiac tamponade, toxins, tension pneumothorax. This is why we get blood gases, a set of obs, and the heart and lungs are examined during compressions. These are recorded contemporaneously. You do expose the child, but you're looking for something BIG.

If there's none of these reversible causes present, and you don't have a pulse back, you start thinking about stopping. You have a discussion with family, or you ask the rest of the team do they have any objections to stopping. This is documented. Then you document when you stopped and why.

Issue is, the reason baby M arrested isn't one of those reversible causes. They were progressing down that specific structure from what we heard, then.... baby M suddenly got better for no apparent reason. The relevance of that rash was also only recognised once the consultants sat down in June - the art of note writing means down you're writing down relevant things only, I'm not going to write about my patient's 5 cats, or funny looking toe, or a bit of a rash when I don't think it's relevant. In an arrest situation, unless you think that rash is suggestive of anaphylaxis (gives hypoxia and hypovolaemia, which are reversible), or DIC (thrombus, which is reversible), or is due to a local reaction to a transdermal patch (toxins) or suggests surgical emphysema (tension pneumothorax) you're probably going to bypass it.

Very perfectly put and how I see it explained in my head but could never explain in any way! Because it’s now a pinpoint of this case it’s hard to see that at the time this is just a total unknown to them and it’s not explained by any medical pathway they’re looking for. They don’t suspect Letby. They don’t suspect the rash to be an indication of what’s caused the collapse because they’re not aware injection of air is a remote possibility. Or ever remotely seen the results of injection of air ever before. I’m sure nobody wishes it was in the notes more than dr j just to get BM of his case and stop him accusing him of making it up. He has said before about his hurt that he did not make more of a stand later on but until after M and after the meeting, he did not suspect deliberate harm.

 

[Daisydunn15]

Do you have any ideas for the cause of baby Ms collapse and if it might be related to Letby giving treatment just before?

No idea at all, I suppose I'm just waiting to see what any expert witness for the defence may be able to offer as explanation. If they have no alternative theory then the one presented by the prosecution experts must be correct.

Also, while I don't think their prematurity should be blamed for their deaths and completely agree with the points made by people in relation to that, I do think its possible that the state of the unit coupled with their huge vulnerabilities may have played a part in their deaths.

 

[EffingDust]

What's that thing called where you 'remember' something that happened, but when lots of people also say they remember it, it begins to be remembered wrongly? I'm sure there's a word for it but I just can't think.

Mandela effect?

 

[DellaC]

This baby was actively dead to the point they were asking the parents about stopping CPR. As soon as that happened, the rash went away. There was no time for pictures.

The notes for an arrest follow a specific structure - it has to be an automatic process in the scribe's head, just like everything in CPR that we try and make automatic.

You document how many rounds of CPR, when you're giving drugs (adrenaline), or shocking if appropriate. You document looking for your reversible causes - hypoxia, hypovolaemia, hypo or hyperkalaemia, hypothermia, thrombosis, cardiac tamponade, toxins, tension pneumothorax. This is why we get blood gases, a set of obs, and the heart and lungs are examined during compressions. These are recorded contemporaneously. You do expose the child, but you're looking for something BIG.

If there's none of these reversible causes present, and you don't have a pulse back, you start thinking about stopping. You have a discussion with family, or you ask the rest of the team do they have any objections to stopping. This is documented. Then you document when you stopped and why.

Issue is, the reason baby M arrested isn't one of those reversible causes. They were progressing down that specific structure from what we heard, then.... baby M suddenly got better for no apparent reason. The relevance of that rash was also only recognised once the consultants sat down in June - the art of note writing means down you're writing down relevant things only, I'm not going to write about my patient's 5 cats, or funny looking toe, or a bit of a rash when I don't think it's relevant. In an arrest situation, unless you think that rash is suggestive of anaphylaxis (gives hypoxia and hypovolaemia, which are reversible), or DIC (thrombus, which is reversible), or is due to a local reaction to a transdermal patch (toxins) or suggests surgical emphysema (tension pneumothorax) you're probably going to bypass it.

Can someone tag Ben Myers in this?

Fantastic explanation and worded perfectly for us non medical folks.

Thank you.

 

[mRsKbRoOkS]

This baby was actively dead to the point they were asking the parents about stopping CPR. As soon as that happened, the rash went away. There was no time for pictures.

The notes for an arrest follow a specific structure - it has to be an automatic process in the scribe's head, just like everything in CPR that we try and make automatic.

You document how many rounds of CPR, when you're giving drugs (adrenaline), or shocking if appropriate. You document looking for your reversible causes - hypoxia, hypovolaemia, hypo or hyperkalaemia, hypothermia, thrombosis, cardiac tamponade, toxins, tension pneumothorax. This is why we get blood gases, a set of obs, and the heart and lungs are examined during compressions. These are recorded contemporaneously. You do expose the child, but you're looking for something BIG.

If there's none of these reversible causes present, and you don't have a pulse back, you start thinking about stopping. You have a discussion with family, or you ask the rest of the team do they have any objections to stopping. This is documented. Then you document when you stopped and why.

Issue is, the reason baby M arrested isn't one of those reversible causes. They were progressing down that specific structure from what we heard, then.... baby M suddenly got better for no apparent reason. The relevance of that rash was also only recognised once the consultants sat down in June - the art of note writing means down you're writing down relevant things only, I'm not going to write about my patient's 5 cats, or funny looking toe, or a bit of a rash when I don't think it's relevant. In an arrest situation, unless you think that rash is suggestive of anaphylaxis (gives hypoxia and hypovolaemia, which are reversible), or DIC (thrombus, which is reversible), or is due to a local reaction to a transdermal patch (toxins) or suggests surgical emphysema (tension pneumothorax) you're probably going to bypass it.

Or actually what FGrid said

 

[MmmB777]

No idea at all, I suppose I'm just waiting to see what any expert witness for the defence may be able to offer as explanation. If they have no alternative theory then the one presented by the prosecution experts must be correct.

Also, while I don't think their prematurity should be blamed for their deaths and completely agree with the points made by people in relation to that, I do think its possible that the state of the unit coupled with their huge vulnerabilities may have played a part in their deaths.

Well obviously that’s not a ridiculous idea as it’s essentially what BM is going with for a few cases but on the whole I don’t think I’ve ever seen anything to suggest the unit as a whole can create huge and frequent cardiac arrest incidents and such a spike in deaths and that by chance Letby is so often literally right there.
It looks very much like BM has no defence on baby M to me already from the opening statement. The baby was very well by all accounts. And recovered so quickly. I think the preconceptions of neonates being at deaths door really does play into BMs hands as i think if this were almost any other type of patient group, the crimes would be (even more imo) glaringly obvious.

 

[Daisydunn15]

I thought that should be the case. @MmmB777 post above states that there is documentation of it in others babies so I would be more inclined to believe it did happen when you look at the bigger picture but I do still think to not bother even adding it to the notes at a later time is quite bad. I know the hospital isn’t on trial but if LL is found guilty I think it is clear to see there was a good few chances to put a stop to it.

did I read you’re a nurse? If so how common do you find it for things to be missed off the notes? Especially more so in busy times?

I think there have been discrepancies in the way the rash was reported (when it has been) vs what the literature says it should look like. Personally I didn't think their account matched very well, but that could be because the literature is sparse or because they've just not described it well enough, or because it was a different kind of rash

Yeah I'm a nurse but mental health so very different and have missed things off notes loads of times but nothing clinically significant and I think a transient rash immediately prior to and during a collapse is significant. I also tend to put more effort into accurate documentation following an emergency incident, because its a significant event and because I know my notes could be used in court.