All of this. And because it's so difficult to 'spot' a serial killer, would be easier if they has devil horns etc, is the very reason why management need to act on concerns. I suspect it was her dad's involvement that meant it all became about Letby being harassed. We had a similar thing years ago where I work. A young male nurse stole morphine from the drugs cupboard, went home and attempted suicide. He lived, but was on ICU for a while. Now that's a straight sackable offence, gross misconduct. But his dad got involved at the disciplinary stage, threatened to sue the hospital for not looking after this chaps welfare and this chap kept his job and was never reported to the NMC. I'm guessing Letbys dad probably made similar threats and therefore instead of properly investigating as they should have done, concerns were dismissed. It's all so wrong.100% I probably didn’t give management enough of a rough ride in that post but I was trying to keep it brief and snappy (actually made myself lol at my own joke there).
I guess again though it’s almost a unique issue with medical murders.. that the same attributes that might make somebody an excellent practitioner in the eyes of management or even patients, are the same attributes that ultimately become suspicious.
You’re prepared to work all the time? You like working nights? You’re obsessed with your work? You’re ALWAYS there in an emergency ()?
You love coming out and making home visits, what a wonderful caring doctor! The creepy cards and possessive nature Letby clearly had over some babies would have been received as weird and unnatural by some and deeply caring and sweet by others. Oh that nurse messaged me on Facebook.. how creepy/how kind and nice that she wants to see how we are. That lovely nurse BA went with the family as the baby was transferred.. how caring and nice. They made her a family friend. If someone as thick as her can be manipulative or abuse the unique vulnerability you’re in in a hospital then anyone probably could. Obviously doesn’t mean you don’t take measures to make sure the pieces of the puzzle are observed more swiftly in the future but it sure is a unique and difficult situation imo.
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I personally think the fact the insulin overdoses weren’t investigated more at the time is all the evidence I need to say “the unit” was incompetent.
There were at least two never events in short succession and as far as we know at this point there was basically no investigation into them despite the results of one being flagged by a third party. I totally get they wouldn’t have thought “serial killer” but even accidental overdoses should be taken seriously and investigated. There’s absolutely no sign that it was Letby in particular who decided not to investigate based on what we’ve heard so far so while she was responsible for the overdose she wasn’t responsible for the lack of investigation.
I understand others don’t agree with that and it’s ok, just trying to explain I’m not pulling it out of my a and I have a reason.
It’s obvious that was a total failure. I don’t think it’s easy to say that they should have thought of incompetence with the insulin or indeed most cases of harm in this trial. Babies aren’t given insane lethal amounts of medicines they are not prescribed by accident. Whilst it might enter your mind because it feels more likely than a killer, it is actually just as inconceivable. Nurses don’t decide who gets insulin. They don’t decide how to administer it. They don’t decide the dose. A baby might be given the wrong dosage of something prescribed or the wrong drug instead of what was prescribed, I guess that’s fairly common. But with this, that’s not what happened at all so they would have had to have looked at that event in isolation and assumed a colleague was intentionally harming a baby. They probably should have but that is human error more than anything. I don’t think there’s any evidence there was some kind of cover up of that information or someone thinking they didn’t want to get “the unit” in trouble for an error. Maybe that will come out at inquiry but I think there was enough opportunity for that to come out at trial. I think it’s human error that they did not link what those levels meant. There is a chance the people that took that information and didn’t take it further will be struck off. In an otherwise unblemished career, I’d find that really sad but understandable.
I don’t think they should have necessarily linked it straight to Lucy for the reasons you said, but the only reasons those levels could have been so high was an administration of insulin as both sides said in court.
I believe even a mistaken administration should have been flagged and fully investigated regardless of the fact Lucy was present in this ward. You’d go in assuming it was a mistake, of course, and in 99.9% cases that’s what it will be but in this case it wasn’t and had they investigated it’s possible they would have made the link to Lucy. They may not have done, we’ll never know that, but the fact it wasn’t even investigated after it happened more than once (even from a “is there some mistake on the paperwork causing this?” perspective) to me is a massive failing. I don’t think they failed purely because they didn’t link it to Letby, I think they failed because it wasn’t investigated properly at all.
Any ward or unit that’s made aware of a mistaken administration of medication and doesn’t investigate to me is incompetent and especially so when it’s got the potential to be as catastrophic as it does in such tiny babies. I would have to say, regardless of Letby, I would expect any person who didn’t take that info further and follow the proper avenues for a never event to be punished.
I think where we differ is where you see an administration for them to see as an error, I’m saying there was none. So they couldn’t investigate something that wasn’t there at all. That baby would have nothing in it’s notes suggesting it needed insulin at that time, there’s no doctor that would have thought so, pharmacy have never written anything up. There’s no other baby that needed insulin at that time with a similar name but even then they’d have had to have needed a fatal dose for this to have been an accident. There is no way to view it as an error of administration at any point. So when they were scratching their junior doctor head about it being exogenous, the conclusion is either someone fatally dosed this child with insulin with no clinical need for any at all let alone a fatal dose with no paper trail of this dose anywhere to be seen, or that the testing was inaccurate or an anomaly somehow. They have to have the knowledge about cpeptide levels to be able to conclude that it cannot be an error of testing and I’m not confident they would necessarily. And that’s a human error. Unfortunately one with devastating consequences. I’m happy to agree to disagree. I can see why you feel how you feel about it.
And the reason given for not acting on the results received back from the lab was that the child had recovered. There's an awful lot of flaws in what happened and I see it as a systemic failure rather than a failure of one single person to act. It's very likely that the C pep and the insulin results weren't returned at the same time, we see that on blood tests all the time, some return later than others, so if each were looked at in isolation by different people, dots clearly weren't joined. It's a massive failure but that's with hindsight.
To me it’s similar thinking when I question why nobody thought of incompetency when it came to Air embolism. But it’s because it’s near enough impossible in the circumstances here. They showed in court that you couldn’t get air in there unless you override the system right? They demonstrated in court how you could override it didn’t they? So once you’re talking about an individual overriding a mechanism to introduce air, you’re never talking about an accident. I see the insulin as similar, there’s no note on that file for a different medicine when the hypo starts, there’s no clinical picture or need for a consultant to have prescribed a normal dose let alone a fatal dose to be administered in a TPN with zero paper work about it. So it’s like expecting people to look for things that can’t have been there as a possibility. It can only have been harm. Then you’d have to reconcile that plain Letby who makes cards for babies and cuddles them and goes salsa dancing with you is actually quite able to poison, maim, watch as babies struggle for breath. Watch them be inflicted with pain and suffering. Make them bleed. Watch you all cope with the fallout. Watch parents on their knees in grief. And do it all again a few days later.
I agree it’s systemic which is why I think the unit was in this case particularly bad. There was obviously a lot of dots not being joined and issues aside from Letby and that was mentioned at the trial (eg the suboptimal care not on her point). Obviously she blew everything up and made it seem even worse but from what I’ve heard even without her I don’t think the unit was providing the correct level of care. This is not defending her of course but does potentially explain part of why she went undetected. And I might change my mind totally when all the inquiry evidence comes out, of course!
I don't think the care on the unit was poor though. Certainly the care massively improved after she left, was much better before she started, and improved again when she was on hols. That tells me the units care was poor only when Letby was around.
Hence my earlier point about hospitals needing to be run by people with formal and impressive qualification in the medical field. The ones who comprehend that patient welfare is sacred & have an understanding of the real medical concerns of the reporting colleagues rather than focussing on the possibility of industrial action which might upset the budget or create adverse PR for them at some stage down the line.
'I'm with the families on this': Health Secretary slams 'insensitive' speculation surrounding child killer Lucy Letby | LBC
The Health Secretary has called for an end to "crass and insensitive" speculation surrounding the innocence of convicted child killer Lucy Letby, telling LBC it's a matter "for the courts to decide".
www.lbc.co.uk
haven't heard from Letby's parents for a while - I particularly like the "their evil daughter"
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I’ll do a new thread…
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New thread
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New thread
Lucy Letby Case #74
Last thread here https://tattle.life/threads/lucy-letby-case-73.46089/ The Thirlwall Inquiry starts on Tuesday 10th September. There is lots of information on the inquiry here https://thirlwall.public-inquiry.uk/ A good starting point is the inquiry terms of reference which details the aims...
tattle.life
Yeah I do agree but sadly I think it's a pipe dream. Before my time, when hospitals were smaller and run by people who cared and knew about patient care, things worked. Trying to run the NHS as a business without the calibre of management required just will never work.
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