I was thinking before I read about her questioning the fluid bag. Could someone form the previous shift nor have put insulin into the fluid bags and then the effect happen when Lucy was on shift? Especially if it was only 90 minutes after her shift started then couldn’t, if the insulin spiked fluid was going in slowly had an effect after that amount of time?
Or if the insulin is diluted anyway(?) then she or someone else could have diluted them incorrectly?
The fluid boluses the only thing I could think is if she was setting up a line and got pulled away before finishing the set up and someone else saw, attached and started it without checking, then maybe the babies would’ve got an air bolus via that? I know certain drip pumps are clever and can usually pick up on air but I’m sure if the whole line is full of air they don’t?