Dr Wilkinson On Lucy Letby, Cases A, D & K

Añadido: 2026-05-27

[00:00:00]First question uh then um can you tell us a bit about your background and how much experience you have working with children and neonates?

[00:00:11]>> Um my background is um basically I went to Liverpool Medical School from 1977 to 82 >> right >> and then during that time I decided I wanted to do anesthetics for various reasons. Uh and then I went to um the aisle of man for my um first job as a doctor. So my house job so pre-registration job after passing kind of a postgrad exams I went up to Newcastle as a senior registar um for two and a half years and then I got a consulting job on the aisle back on the aisle of man >> right >> and I started that in 1990 and I spent exactly 30 years in that post. I think you were alert quite early to the idea that the Lucy Leppy case might be a miscarriage of justice >> when the retrial happened. That was in 2024. So I kind of followed that one on a bit more closely than the original tribe because of my you know background as an anist and quite a bit a few things about that case didn't kind of ring true and >> and then when I heard she'd got another whole life sentence for attempted murder in such a ridiculous case that was when I took interest and then I remember being on the cruise with my wife and I emailed Ben Meyers from the from the cruise in the meds somewhere and I just said, "Look, I've been following this a bit and it's like such an unbelievable um unbelievably ridiculous case to me as an antheist."

[00:01:46]Uh, you know, to be to for a consultant to say that he caught a nurse red-handed and didn't tell anybody for ages. And he said she the only explanation for the tube coming out was because he, you know, that there was no there was no other explanation other than deliberate exubation. She tried to kill the baby, tried to harm the baby. And I said it was so laughable if it wasn't so serious that I emailed Ben Myers and said, "Look, I think she's innocent from what I've heard of this, you know, and it's like unbelievable."

[00:02:15]>> Anyway, I didn't expect a reply. I got a reply the next day saying basically, "Oh, thanks for your email. Um, but I can't comment obviously, but I'll pass it on to a new lawyer." So that I got that m I think I got that email in like July 24 just after the trial finished the retrial. So that was when I took started to take a big interest >> and then I emailed Mark McDonald a few couple of times got no reply from him and it was about that case and I just voiced my concerns about that case and why I thought it just didn't make any sense at all really. But I got no reply back from him. And then shortly after that is when I became really interested in starting looking at the other cases.

[00:02:56]And then I joined the 19 nurses group.

[00:02:59]And then I went to a meeting in Heraford and then another one in Manchester. And so from the from kind of July 24, that's when I kind of got really interested uh in the case.

[00:03:09]>> So that's a little bit about my um kind of how I became involved. Anyway, >> but as I say during the first trial, I didn't really follow it that closely >> because I just assumed >> with it being such a big case, such a a long it it it didn't just start the with the first trial in 2020 uh two, it started the end of 2022. It had been kind of rumbling on for years before that >> and the first I heard I think was in 2018 or 19 with the first second arrest.

[00:03:47]>> Um so I knew it was kind of rumbling on and there was you know there was something going on in Chester >> nurse had been accused of he had kind of multiple murders and attempted murders but so it just seemed to go on for so long. It just seemed at the time to me to be surely the police wouldn't have brought a case if there was no evidence.

[00:04:08]You know, I kind of didn't really get that interested for that reason. I just thought she must be guilty.

[00:04:14]>> Okay, >> that's a little bit about the background of how it became involved. Anyway, >> okay then. And so I'm curious um as you've had an interest in several other miscarriages of justice >> at this point in terms of your knowledge and understanding of the case. Um would you say this is a particularly flawed investigation or weak case? Would you say >> in terms of um yeah miscarriage of justice? This one now looking back with all the information I've got now is the most shocking and most clear-cut obvious miscarriage of justice I've ever seen in like over 50 years. And that's going back to the 70s with the Irish cases, you know, the Birmingham six, Guilford 4, and all the other cases from since then. I spent uh just by co just diverging slightly in 2003 I spent about eight or nine months trying to write a book with um a man in in the states who' spent 22 years on death row and he'd been accused of rape and murder um and was given the death penalty >> and I tried to write his book and we got to the stage of getting it published and then it was kind of pulled at the last second. I think he was getting sued or something. can't I've never got I've never really got to the bottom of why it didn't get published but his name is Nick Harris so that so that's just an example of the interest I've had in miscarriage of justice but even going on to recent cases like Peter Sullivan >> um who was released about a year ago after 38 years in prison and and of course the Andrew Malinson rape case those sort of case I'm still following cases like that now but Lucy's case to me Lucy's case as I say is it's so obviously a glaring miscarriage of justice >> for like numerous reasons. Um, >> so it's still kind of shocking to me that it actually she was found guilty of anything, you know, because I honestly feel there's no evidence at all. I can't imagine any case where it's so obvious that someone's innocent than this one, >> right?

[00:06:18]>> Not just in I mean, she's got all these charges. So if she'd only been found guilty of one charge, she probably still would have got a whole life sentence.

[00:06:27]Um, so but when there's been so many and in all of them, there's no to me that they're all they're all absolutely not laughable because it's more ser it's too serious for that. But it it's so obvious that's what I'm saying that she's innocent.

[00:06:43]>> Okay.

[00:06:44]>> Yeah.

[00:06:45]And like what I must have learned something in all these years of looking into miscarriage of justice and and being a a doctor, you know, I'm not kind of just I haven't gone completely mad, you know, just and not doing this for any other reason that >> maybe I think one big reason maybe is that my I've got three daughters. The youngest one's two years older than Lucy. She's 38 now. The oldest one's 42.

[00:07:08]>> And the youngest one was going to do nursing at one point. And the thought of it being in Lucy's position now was >> so horrifying, you know.

[00:07:16]>> Yeah.

[00:07:16]>> And it could have been anybody, I think.

[00:07:18]I just can't understand how it's happened.

[00:07:22]>> It's hard for me.

[00:07:23]>> Baby A uh was diagnosed or potential diagnosed uh suspected sepsis. Um can you describe what sepsis is uh to the average person?

[00:07:35]>> Of all the cases, well, not not of all the cases. some of the cases this one it it wasn't that obvious that there was there was didn't seem to be severe sepsis anyway >> right okay >> so that that's it's not really the best case to describe a case of sepsis but >> in answer to your question I think sepsis is um is basically a condition where the body seems to I don't think we know why it kind of like overreacts in in response to an infection usually a bacterial infection >> so it's like I mean to me it's not that the definition of it is is that basically it's it's a um the kind of the body's response to infection which for some reason seems to become more extreme and is can can become life-threatening >> um and the body somehow reacts to infection uh in a way that um results in release of certain um chemicals into the blood which attack the body's the whole body's um tissues. So it can result in um so for example you can get a patient say with pneumonia and so they develop a cough and they coughing up probably sputum and they have a temperature and the pulse goes up maybe and they feel unwell and they might be drowsy and struggling to breathe all you get all the symptoms from the infection itself like that. But in some cases the infection doesn't just it's not just localized to the lungs where it starts.

[00:09:08]So it gets into the bloodstream and then you get kind of what called septasemia and the patient becomes more ill and I've seen patients over the years adults usually but I've seen a few children as well which I'll mention in a second but you so the patient comes into hospital and they're often like really ill so they developing multiple organ failure and it so that the it spread it converts from pneumonia it becomes a more serious lung condition in some ways called adult respiratory distress syndrome. Um so you get generalized inflammation of the lungs and then also they can develop kidney failure, renal failure. Um they can get blood clotting disorders um called DIC disseminated intravascular coagulation. Um they can some some patients even get like liver failure and it can affect the heart as well and the circulation the circulatory system. So you get um the patient's uh blood pressure drops. Uh there's reduced blood flow to the major organs. Um and basically I can just visualize quite a lot of patients over the years that that I've seen and my colleague saw and you you just know with some of these patients when they come in, you get this horrible sinking feeling that whatever you do, >> they're probably going to die. you know, >> okay, >> and you tell the families often, you know, it's really bad. You know, they've got multiple organ failure. They're going to end up on a ventilator. They're probably going to need diialysis or renal support. Um, you know, we're going to have to give clotting factors to stop the blood from from bleeding everywhere. Um, and it's just a horrible condition. And I thought about this during my career of like 38 years in in hospital medicine, 38 years in need. My impression was at the end of it all when I retired >> I I to got the feeling that the prognosis from severe septic shock. So we talked about sepsis first. Um if that goes on to the extreme I mean you can have sepsis and not be too ill, you know. So you get some antibiotics and you maybe if you go into hospital you might get some inus fluids um and often it just resolves and you make a full recovery and that's it.

[00:11:33]>> But some patients, the ones I'm talking about now, they they're the other end of the scale. So they've got life-threatening um septic shock.

[00:11:41]>> Okay. And my feeling still is now that I'm sure there's loads of papers that will probably prove that I'm talking absolute rubbish, but my impression of seeing the a lot of these patients is that the outlook's still awful. You know, there still a lot of these patients are going to die wherever they are, I think. And no matter what drugs you give them to support circulation, however you ventilate them or or or give them renal support or whichever antibiotics you've got, the outlook is still awful. you know that's a fact and the other thing is with children uh I wrote a book about my career and I've mentioned this in the book about the awful feeling you get when these when you see these patients and just as I'll just kind of give you a little example so I can think of maybe not that many over the years but maybe say 12 with maninga cockal septasemia children so these patients have got the worst um sepsis this septic shock that you could imagine. So they come in and they might have been well say 6 hours before or maybe yeah maybe six hours before but often say 24 hours before they might have complained about a bit of a headache or just feeling unwell or vomiting or not being feeling hungry or just generally you know lazing around and no energy and just not well. And then the mom might take the temperature and then that's high. So she might go to the GP um and it's there might be non-specific signs at first. So it might just be a general viral infection you know that children get and there might be no skin rash at that point and then maybe you know an hour or two before they come to hospital they develop the rash that most people know about that the non- blanching particular rash. So when you press on it or you you know or you can put a glass over it you know when you press down and it's still there. It doesn't go like other rashes. So this is bleeding into the skin particular rash.

[00:13:41]Um and it's kind of associated with severe sepsis and in particular mining cockal uh sepmia.

[00:13:49]So some of these patients just have mining coakal septasemia on its own.

[00:13:53]Others have menitis as well. So they might have the neck stiffness and they might photoophobia you know they kind of can't look at the lights um and they might have the headaches and they might have convulsions some of these children.

[00:14:05]>> So anyway but in so what I'm saying is you get patients who come in like that in that condition. So they might be drowsy, they might be unconscious. Uh they're breathing very fast. Uh they've got this rash, they might be cyanosed, sort of hypoxic because they've got lung involvement as well. They've got this adult, it's the adult respiratory distress. The similar thing in children.

[00:14:28]Um they might the mom might say they haven't had a wee, you know, past urine, they haven't had a wee for a day all day or small baby, they've had no wet nappies for a day or so. So they're dehydrated. They might have kidney failure. Anyway, when you see them, you just heart sinks because you know that the chances of of them surviving are minuscule, you know, and I'm still just picture a few now, you know, and they just go downhill so rapidly in in front of your eyes really and then they just um in, you know, so you get some lions in, you give them antibiotics as fast as you can, obviously introvenous, antibiotics, give them some fluids. Uh you might need some inotropes which are drugs drugs to support the circulation.

[00:15:11]Put them on a ventilator. Uh you know you do all the all that immediate um resuscitation but often like whatever you do they just die you know and often within minutes or an hour or two. So that's the ultimate extreme of sepsis when you get that overwhelming um you know and with with with sepsis you the white cell count. So the white cells are the main cells in the body. I think the neutrfils and the lymphosytes that that um that try to fight the infection and try to um you know to to combat the infection the bacteria and often you get a very high white cell count. But in very severe cases, sometimes you get the you get the white cell count back and it's like, you know, the normal say four to 10 and often they come in with 20 30,000, but sometimes they have like three or so they hardly got any white cells, >> which is even worse because they're so the body's um defense mechanism is so overwhelmed by the infection that they've got no they haven't got any white cells really fighting the infection. And it's basically in those cases the outlook's even worse, but the outlook's terrible anyway.

[00:16:27]>> So that that's a little example of um just a brief overview, I think, of sepsis. Um from cases that aren't that bad to ones where there's basically it's just it's almost certain that some of these patients are going to die when they come in. And I've seen patients die with um I remember one man who came in an adult, he died um within an hour or two of come to hospital and at the postmortm we never really found anything but everything fitted with severe overwhelming sepsis but we never actually found any cause for it.

[00:17:01]>> So you know he may have had some there was no evidence he was immuno compromised in any way. You know he didn't have some condition where he's more prone to infection you know like he wasn't on chemotherapy drugs. he didn't have some kind of leukemia or so he didn't have um uh you know he didn't have AIDS. There was nothing nothing to suggest that he might have a but we still didn't find anything um at postmortm. So that that's always been a mystery as to what happened to him. But it was obvious that he had overwhelming sepsis and died from it.

[00:17:33]>> So I don't know whether that's that's very helpful but it's just >> yeah know it's a good description I think. Yeah. Good description.

[00:17:40]>> Yeah. So that's just a um but the cases of the maninga cockal septtoacemia children I mean any doctor who's involved with that you never forget those cases cuz they're so awful you know like these are these are fitting healthy children who are >> you know who but if you do get them early um then and you get it inven antibiotics into them quickly then they're going to do they often do really well you know they make full recoveries after a bit of stormy time you know, in hospital. Um, but sometime once it's gone beyond a certain point, I've always had the feeling that we're going to do everything we can obviously, but the outcome's almost certainly going to be the same anyway, you know.

[00:18:23]>> So, so that's a little bit about that.

[00:18:25]Yeah.

[00:18:26]So, in terms of the Lucy Letby cases, um just off the top of your head, I'm not sure if you'll be able to remember each case, but um >> maybe Baby D. Would that be kind of an example of >> Yeah, Baby D was um just by co well not coincidence but I follow uh Chris Morris's channel a lot you know Lucy let the analysis and he's in our little WhatsApp group as well just just by coincident coincidence but >> so I'm in touch with him anyway I watched that baby D one and also I should I should say now because I'm not part of you know Shulie's team or anything I haven't got access to Um, I've got access to anything really that anyone else can get access to, you know. So, I go to the third wall inquiry and read things from there that go that they put out um transcripts from there. Some of the transcripts I've seen on various videos on YouTube and I've read all the, you know, I read the the newspaper reports and so on, but I haven't got the full I obviously I haven't got case notes. I haven't got the nursing records, chest X-rays, blood results for every case.

[00:19:36]So, a lot of it's I'm basing a lot of what I think and what I say on um on information which is not complete, >> right?

[00:19:46]>> So, like Mark McDonald's team of experts, they're going to have everything I would imagine. you know they >> so but anyway from my impression about a lot of these cases was that the the impression my impression was that the impression the experts gave to the jury >> and the court you know the judge and the the barristers there was that a lot of these babies were doing well >> you know there was there was like total almost to shock when they suddenly collapsed I suspect Ed, a lot of these babies weren't as stable as the expert witnesses were making out to the jury.

[00:20:26]That was my impression, even though I haven't got all the notes just from what I'd read.

[00:20:32]But when I saw Chris Morris's um I think I think it was Lucy Leby analysis, Chris's video channel. When I saw the one baby D, I was like literally shocked because that that baby um that was the case I think where the mom hadn't had the antibiotics for the premature rupture of membranes.

[00:20:54]>> Um and the baby was born with obvious severe sepsis, you know, so had pneumonia. So when I saw that when I saw that and I got the I got the a bit more of the picture of what actually that baby was like >> and then I went to Shoul Le's um uh the press conference the second press conference where he was he presented his findings with the the summary of the findings with the panel and I looked at their their findings I was I couldn't believe it because that baby to me even within you know within a few hours it was obvious that that baby was going to well say obvious it was likely that baby was going to die wherever it was in the whichever however good the intensive care unit was >> okay >> however skilled and experienced the neonatlogists were >> it was unlikely to survive because it was so ill even when it was born So when I saw that, when I when I watched it, I was like like horrified, you know, that the jury had been told that I think one of the experts said it was doing really well, you know, and I thought, God, it was like from the from the minute it was born, it was it was really ill to me.

[00:22:19]>> So I was literally like shocked. Uh, and I just couldn't believe it really, you know, and I still can't believe it now when I when I look at at Shoul Le's um, report on that baby baby D. But other ones weren't very well either, you know, and there was obvious signs of infection maybe or so that was now that's that was bad enough to me when I saw that. I thought this is like unbelievable. But when I heard people like Martin Pitman talking um who's an obstitrician and then I realized again from Chris Morris >> that the amount of obstetric input into the trial the first trial was like absolutely minuscule. It was hardly there was hardly any mention of and now Chris has been through it all and he said uh you know he went through day by day you know he went through the trial and he's got a list of all the people who were giving evidence and I think there was hardly anything you know there was maybe a half a day with a bit of obstetric discussion and then there's a report read out by an obstatrician which took not very long an hour or two maybe and that was it there was nothing else but Martin Pitman describes how not just Martin I've heard another very wellrespected um professor of obstetrics speak in Manchester I think it was last November at the meeting 19 nurses meeting >> and he said the same you know there was literally very little um obstetric input into the whole trial that's that that's when I became even more convinced than I already had been when I saw the baby D and and I looked into it a bit more and got a bit more information on that I just couldn't believe it you know how how anybody can could think that baby was doing reasonably well, you know, and how anybody could be surprised when the baby suddenly died is a mystery to me because >> yeah, >> it was obvious that the outlook was terrible. You know, >> probably from the probably from the first >> I think I think at birth, if I'm I might be wrong on this, I think the condition of birth was good, reasonable, you within minutes.

[00:24:28]>> I think within minutes, I think I think the dad was holding the baby if I got this right and suddenly the baby kind of be um I think stopped breathing or you start to struggle to breathe. And from then on it was all downhill you know >> very rapidly became got to the stage where it was obvious to me just reading what I have read that the chances of survival were almost non-existent.

[00:24:51]>> But in spite of that the impression to the jury was that it was doing the baby was doing quite well you know.

[00:24:57]>> Mhm.

[00:24:57]>> So that's that's when I got the biggest shock of all when I when I read about that case.

[00:25:03]>> Right. Okay. And I think um Dr. Bowen uh seems like maybe a slightly bizarre comment, but she said maybe the way the father was holding the baby might have uh >> contributed to that cl.

[00:25:16]>> Yeah, I I remember reading that as well.

[00:25:18]Um I mean even if the even if the dad wasn't holding the baby properly, which I which I doubt anyway, even if that was the case, that doesn't explain exactly everything that happened after that. You know, As I say, there was a steady when not a steady and rapid decline to the extent where the baby was so ill it was never going to survive anyway. So I think I think again Dr. Bone did point out that the baby was born in good condition which was >> true. I think it was the after scores were were all right, you know.

[00:25:55]>> Mhm.

[00:25:56]>> But that's irrelevant anyway because minutes after that >> it's the the condition of the baby started to deteriorate and there was a steady downhill path from there that I could see anyway.

[00:26:07]>> Um so to to even say the baby's born in good condition is like totally irrelevant.

[00:26:13]>> Just because you're born in good condition doesn't mean that it doesn't mean it's it's got no bearing on what happens after that. You know, >> some babies are born in terrible condition and they get resuscitated and they do well. You know, >> my my uh my first grandchild, I we got called in. It's a long story.

[00:26:33]Don't have preeacclampsia.

[00:26:35]Um she basically she came into hospital and they were worried about your blood pressure and a few other things. So they kept her in overnight and we got a call at like 3:00 in the morning went flying in and she was and she she rang up to say she was going for se urgent section and luckily they had her on a monitor on a the CTG um monitor and suddenly the uh the baby's heart rate decreased and there was signs of fetal distress.

[00:27:04]So we call it so the baby was like coming to harm you know while still in the uterus. So, she was rushed into theater and then we sat outside waiting.

[00:27:14]This is about 4:00 in the morning. Um, and we were both, you know, wife and I were both quite worried, but about an hour later, they came out and said, "Oh, you know, it's all over now. Baby's fine.

[00:27:27]Needed a bit resuscitation."

[00:27:30]>> So, we never got the full story that night, but the next morning at half eight, I was in theater with the uh obstitrician who'd been looking after Madora. had a list with him and I said to him, he hadn't been on that night.

[00:27:43]His colleague had been on, but he knew about it because he he found out as soon as he came in the next morning and I said, "What uh what was it trace like?"

[00:27:51]Cuz the trace suddenly changed as you rushed in the theater. Um and he I'll not tell you what he said, but he was he said it wasn't good, you know, terrible really. So, and I found out and then when he came out, I found out later when when my grandson was born, he was very flat, you know, he wasn't it was a real emergency. He wasn't breathing. Uh he wouldn't he didn't breathe. He needed assistance with that. Wasn't intubated.

[00:28:16]So, he was given inflation breaths and and I think his heart rate was very slow when he was born. So, basically what I'm saying is he was in terrible condition when he was born.

[00:28:25]>> Okay. But within within like five minutes he's he was fine and then he's like he's 15 now you know. So the app what I'm saying about the appgar scores is baby D's appars were reasonable >> and for the first few minutes his condition was u was all right but from then on it was just terrible.

[00:28:45]>> Um so anyway the jury might have I'm not saying they did but the jury might have got the impression that this baby was born in good condition. So, you know that he might have been expected to do well, but that's not that doesn't always happen. So, unfortunately.

[00:28:59]>> Yeah. Okay. Then, and a theory that's recently come out about baby A is that perhaps um when there was an attempt to put in a breathing tube into this baby, um they may have accidentally sort of put it in the food pipe um or esophagus.

[00:29:17]Um, yeah. And we know that was a problem on the unit in terms of this Noah Robinson case before.

[00:29:23]>> Yes.

[00:29:24]>> Yeah. I've um I just watched a video by um made by Dr. Ellen Storm who which I thought was to to be honest with you, I never even I never thought about a possible esophageal incubation and it may not have happened anyway. We know that. All she was doing was raised concerns that it was possible because of the timing of the way things happened.

[00:29:49]Um so she was Ellen's a um she's not a consultant but she's very experienced uh um pediatrician neatlogist. She's an SAS doctor I think. So, not not a consultant, but I was very impressed with the with the video and she's done kind of an analysis of uh the baby a um case and she just I think the first video she did, I don't think she mentioned that as possible cause she talked about um you know the possible I mean the Lucille Ley was convicted of um deliberately of murdering the baby with an air embulus. That's what she was convicted of. But um Ellen looked at other possibilities and she's kind of analyzed them really very cleverly I thought you know um and she talked about things like the baby had a couple of lines in um umbilical vein catheter and a long line peripheral long line and she talked about complications from the lines. um Shoul Le's team later on they decided I called him I say his team I mean his the experts that he kind of um got together to look into the cases independently to see what they thought they thought that they they even they don't know what happened you know but they wonder whether the baby may have had a brain stem um stroke of a CVA cardiovascular accident and they wonder whether the the mother had uh this antifphospholippid syndrome which makes the mother prone to thrombosis or blood clots >> and there was actually a blood clot in the liver at postmortem. So they wondered whether a bit of that blood clot had broken off or a bit of a clot had come from one of the lines which hadn't had any fluids going through for a few hours, four hours I think. So there may have been clot at the end of the line and that maybe gone off and found its way. It would be a tiny little thrombus and it went up in got a maybe got across to the left side of the heart through the fammen of um and went up to the and ended up in the in a an artery supply in the brain stem and maybe give the baby a brain stem stroke which would explain why the baby suddenly stopped breathing.

[00:32:15]I'm I'm not a um you know obviously not a neonatlogist and I haven't had that much in involvement with neonates but to me that didn't quite and I could be wrong but my thought here is if the baby had a brain stem sudden stroke it was certainly going to die you know stop breathing from that and it would die from that eventually but I don't think it it might have had a sudden cardiac arrest even but I think with resuscitation oxygen you know oxygenation um some adrenaline, some CPR, I think the baby would probably have survived for a while anyway. I don't think it would have been but this baby wasn't weren't able to resuscitate it from that that event. So I wasn't but I could be wrong there. That was just my thought.

[00:32:58]I'm not sure why you would suddenly just literally die on the spot from that.

[00:33:02]>> Right. Okay.

[00:33:03]>> Could be because if your brain I've come across many patients who sadly end up brain dead.

[00:33:10]>> They they they might have a cardiovascular collapse. Well, they do they do have a cardiovascular collapse, but once you resuscitate them, they come back and then they stabilize out and then then you do brain death tests and then you either turn the ventilator off because they they're dead. You know, the heart's still beating but the brain, you know, the brain dead or you take them to the theater and then you do an organ retrieval and these are the patients that donate organs, you know, which are transplanted in to other patients. So that so those patients are actually brain dead. You know, they've had a um their whole brain stem's infed. The whole brain's inficted, but there's still a heart still beating. So that didn't quite >> I didn't quite >> That baby died from a brain stem infar, you know, wasn't able to be resuscitated. That didn't quite ring true. But anyway, >> what I'm saying is I don't think we'll ever know for sure what he died from.

[00:34:08]But but there's no evidence for an air embism. I know that and that's what Shulie said as well. But >> Ellen took it bit further and she looked at other possible complications from the lines like pericardial tamponard. So the line goes through uh and damages the lining of the heart and it causes blood to go into the pericardial sack around the heart. Um and that's a well recognized cause of a sudden um cardiac arrest tamponard. It's not common but it can happen you know usually a traumatic injury um or say a stabbing or something that that a lot of those patients might die from tampon uh and it's one of the four H's and four T's that we think about when there ever there's a cardiac arrest. So she talks about that as a possibly as a complication of the line.

[00:34:55]Um and then she talks about many other things but that was in the first video she did I think and I don't think there was any mention there of possible esophageal incubation but in another video that she did um that's when she talked about this. So I kind of my you know when I kind of um suddenly became interested when she said that because I haven't even thought about that >> but when it when the timing of it you know the baby was had an apnea episode didn't stop breathing it was I think was like 9 weeks premature anyway so that that could happen um and she questions whether so I think there was the so the treatment for that is to open the airway obviously um and to put face mask on and to gently ventilate with the 100% oxygen. Um, and often the baby just usually the baby just starts breathing again. You know, the the neonatal nurses would do that.

[00:35:54]Um, any of the doctors would be able to do that. But in this this baby um the baby stopped breathing and then I think the pulse rate went down and then the baby was incubated and I haven't got the exact timeline. I haven't been able to and I don't think anyone knows the exact timeline but >> the baby shortly after that the baby basically never the ECG complexes became quite small um and she mentioned about possible tamponard that can happen in tamponard but basically basically the patient had a cardiac arrest and in spite of I think seven doses of adrenaline and you know numerous cycles of of CPR um the baby wasn't resuscitated. Ellen wonders whether it possibly an esophageal incubation >> right >> now I don't know but it's certainly you know it whenever you incubate someone and things don't start going downhill rapidly so the oxygen levels start dropping um the you saturation's dropping uh maybe the ventil things with the ventilator the pressures are quite high Um anyway, if you any if if things don't go the way they should do once you've intubated someone, you should think immediately, is this tube in the right place?

[00:37:14]>> And Ellen talks a bit about that, you know, she talks about one example where she said she'd seen the tube go through the cords. It was definitely in and the midwife the um the neonatal nurse I think was with it. She said, "Take it out." And she said, "No, no, it's in."

[00:37:28]And she said, "Just take it out." You know, and so she she did take it out and then she put the face mask on and oxygenated. the stats came back up and it's like it was a lesson for her you know she said if you got any doubt I mean my book's called if in doubt and that comes from if in doubt take it out that's where the just by coincidence and so if you have any doubt about where the tube's in the right place you should take it out now you asked so that was just a possible another thing that I hadn't thought about and surely panic I don't think they mentioned it either so it was just an interesting Um, well, it it's it's a good suggestion. There's a possible cause, but I don't think we'll ever know really.

[00:38:12]>> Okay.

[00:38:13]>> So, it's a case where there's reasonable doubt, I guess.

[00:38:16]>> Well, I I think so, but we're never going to know now, but I think for Dr. Evans, it was him, I think, that said this was a and Dr. Bone agreed that it was um a likely um air embolism.

[00:38:30]>> Yeah.

[00:38:30]>> I mean, I don't think they even said likely. I think they were doctor certain that's what it was >> but there was no real evidence for that.

[00:38:38]I mean it talked about skin rashes which weren't documented at the time and they came out later and I think um in some of the cases might have been that one um I think it was that one where I saw some transcript where um Ben Meyers was saying that he'd he hinted that Dr. Jamm had used almost the exact phrase that Chulie used in his 199 about the flitting flitting skin rash and the pink >> vessels on a on a gray background or you know >> and it was in Dr. Ben Meyers was hinting that um Dr. J Ram he said it seemed to him that he took the almost the exact wording and imposed it >> on his own >> two and a half years later >> what happened >> now I'm not saying he did that >> but he told Dr. Evans he told Dr. Evans you know you heard me did you hear me say that when I was given evidence because Dr. evidence was listening to the evidence apparently. But anyway, um so what that was a thing that just came up came up recently with me anyway that there was another potential I'm not we're not saying it happened because we don't we'll never know but it was another thing that I think even do even Shelina's panel didn't really pick up on >> but they've got more information than I have obviously they've got the records have better timings I'm just kind of going on bits and pieces that I'm reading and hearing you know So it's difficult for you know difficult for me but but even when you can't get exact information you can't get the precise timings and you can't get the exact I mean you know I wasn't there obviously for anything and even if I intubated somebody I wouldn't say I saw the tube go through the cords I felt the compliance of the chest and it felt normal if it's in the esophagus you would expect it might be a bit harder to ventilate both sides of the chest were moving nicely. The saturations were they stayed up for a few minutes after I put the tube in, which would suggest it's in the right place. There was carbon dioxide coming out on the cap. You know, I wouldn't write all that stuff down.

[00:40:52]I'd just say I incubate the patient. And usually I just leave it at that and say the tube I know the tube's in the right place. It's not down the right main bronus. It's not in the esophagus. Um, so the fact that they didn't do that, I'm not criticizing them for that. Mhm.

[00:41:06]>> How could they know that now we're all everyone's scrutinizing every single move they made >> and wondering now was a tube in the esophagus, you know? So, I'm not criticizing them for that.

[00:41:16]>> I'm just saying that we've all put tubes in. I've put many tubes in >> and they've gone in the esophagus. Um, and I haven't recognized it for a while, you maybe a minute or two then I've realized. So, everyone's done, every anistthetist, every pediatrician neonatlogist.

[00:41:30]I think probably everyone's put a tube in the esophagus and it's not that on its own that's not going to um that's not the I wouldn't say it doesn't matter because you can cause trauma by putting the tube in and there it's not >> is it more how you react to it >> how you react to it it's how quickly you recognize it there's just been a case here um which has been in the national press so it's not confidential but there was an awful case here about I think it was it was just after six months after I retired. In fact, I used to say to my uh old ODPs, you know, the the theater uh our persistence in theater, I used to say to them now and then, I want to want to retire soon. I want to get out before I end up in trouble. you know, always have this nightmare concern of harming a patient >> and they get charged with manslaughter because they put a tube in your esophagus or you do something, you know, you put a line in and you hit an artery and the patient subclavian artery that bleed into the chest and die from that or anything, you know, you give the wrong drug, which I've done before, you know, and they have a massive um anaphylactic reaction, say, you know, all kinds of, you know, you it's it's d it's can be worrying >> happen in every job don't they >> yeah but in anesthetics you can you know cause like serious uh >> you know >> yeah that's true yes it's a double-edged sword isn't it yeah >> so I used to say I want to you know at least when I'm out of it I can't get >> in trouble for something like that you know anyway six months after that I retired that very thing happened here >> okay >> and four of my ex-colagues were charged with manslaughter over a possible tube in the esophagus.

[00:43:18]>> Okay.

[00:43:19]>> And you know, I went to the I went to the inquest and I went to the court case and as I suspected, it was the the case was basically thrown out eventually, but they still had to go through a couple of years of of worry, you know, and um you know, all the stress and of of that case hanging over them. M >> so anyway um I think can't remember what your original question was but esophageal incubations do happen as you mentioned the Noah Robinson case >> but fortunately um in most cases the anesthetist recognizes it you know and and corrected >> but there have been awful cases where it hasn't been recognized you know and the patients ended up either dead or they've had massive um awful brain hypoxy for so long that they end up with a um with with a massive brain injury and maybe die, you know, months or years later.

[00:44:13]>> Mhm.

[00:44:13]>> Um so it's it's um it's a one of the maybe the worst or one of the worst anesthetic uh complications you can have.

[00:44:25]>> Um so that's a bit about esophagy and incubation.

[00:44:29]Uh but the baby uh aid case as I say that's just the thing that recently I came across Ellen Storms um which I thought was was interest very interesting and and very good you know.

[00:44:41]>> So thinking about the baby case then uh I think uh there's quite a bit of well quite a few alternative explanations there. Um looking at Dr. Bowen's testimony. Uh firstly, she was quite categoric in saying that she thought the baby died from their embism and then she also said she thought it was the only plausible explanation. So I'm wondering what's your take on it being the only plausible.

[00:45:10]>> Yeah. I mean, I think one of the another thing I haven't I've never been able to get to the bottom of this, but this whole thing about the skin rashes, you know, that that played a big part in the trial, I think, because without the skin rash uh evidence, there wouldn't be any, as far as I can see, there was nothing to suggest that this was an air embolis anyway. the the skin rash thing kept creeping in, you know, that it was a kind of unusual rash. And I've seen comments from a few people saying that we've never se I've never seen anything like this before or since. This rash was so unusual.

[00:45:53]>> Mhm.

[00:45:54]>> Um but at the time when these babies did um have these so-called collapses or you know when they needed resuscitating then from what I can gather and I could be wrong again but there was nothing written in the notes about you know they said oh the patient stopped breathing and we they might have said you know the patient was bagged and there was no response or they were incubated and then then the baby had the pulse slowed and they had a cardiac arrest and we gave adrenaline and then we did it you know all that might be documented but as far as I can see there was no thing there was nothing not a separate node or a node as part of the account of the resuscitation saying there was an unusual skin rash which we I'd never seen before >> and it was like a mockled it's generalized skin rash but it was it was blue or or gray or white but there was some pink areas in it you know >> which which was what Shulie talked about in his paper from 1989 >> which was a totally different thing anyway it was about um these were babies premature babies on high pressure ventilation. Um, who the air was getting in through the lungs with probably microscopic damage to the lungs and air was getting in and so there was air bubbles in the circulation from that. It wasn't a wasn't a someone coming along and getting a syringe full of air and squirting it in when no one was looking.

[00:47:25]>> A different mechanism altogether.

[00:47:27]Anyway, >> so that was that was um as far as I can see that wasn't mentioned, you know. Mhm.

[00:47:37]>> And then and then suddenly so but the point I'm getting at is I've never been able to be clear about who it was that first came up with this Shulie paper which was caught a lot during the trial.

[00:47:49]us.