WEBVTT - The Experts 0:00:00.080 --> 0:00:04.559 Before we begin, please be aware this episode contains discussions 0:00:04.600 --> 0:00:09.080 around infant deaths and other difficult topics. Please take care 0:00:09.200 --> 0:00:09.880 while listening. 0:00:13.920 --> 0:00:19.079 Now you'll presumably know the background of the Lucy let 0:00:19.120 --> 0:00:21.960 Be issue the miscarriage. 0:00:21.360 --> 0:00:22.000 As I view it. 0:00:23.160 --> 0:00:27.400 Member of Parliament David Davis is sitting behind a rectangular table. 0:00:28.080 --> 0:00:31.880 Beside him. To his right is Lucy Letb's current lawyer, 0:00:32.320 --> 0:00:36.320 Mark McDonald, to his left one of the world's most 0:00:36.479 --> 0:00:39.040 distinguished neonatal experts. 0:00:39.560 --> 0:00:44.240 And today what we're here to do is to present 0:00:44.440 --> 0:00:50.599 a report which is the idea, the genesis, the. 0:00:50.560 --> 0:00:53.279 Creation of Dr. Shoo Lee, who's sitting next to. 0:00:53.240 --> 0:00:57.280 Me in front of the panel waiting anxiously to hear 0:00:57.320 --> 0:01:02.720 this report. Are a gaggle of media newspapers, TV broadcasters, 0:01:03.200 --> 0:01:06.000 and in keeping with the times, a number of podcasters, 0:01:06.560 --> 0:01:10.560 all their microphones and cameras squarely focused on the group 0:01:10.600 --> 0:01:12.200 of people sitting before them. 0:01:12.640 --> 0:01:15.960 Well, thank you, sir David. My name is Shoo Lee, 0:01:16.880 --> 0:01:19.280 and I'm here to share with you the findings of 0:01:19.319 --> 0:01:23.720 the International Expert Panel on the Lucy Latvi case. But 0:01:23.840 --> 0:01:26.160 before I start, I'd like to share the syncrithies and 0:01:26.240 --> 0:01:30.960 condolences of members of the International Expert Panel with families 0:01:31.000 --> 0:01:36.800 of the affected infants. We understand their stress and their anguish, 0:01:36.840 --> 0:01:40.759 and our work is not meant to cause more distress. Rather, 0:01:41.440 --> 0:01:44.720 it is meant to give them comfort and assurance in 0:01:44.800 --> 0:01:50.040 knowing the truth about what really happened. We know that 0:01:50.120 --> 0:01:52.400 they want to know the truth, and that is why 0:01:52.440 --> 0:01:54.400 we are here to tell the truth. 0:01:57.360 --> 0:02:01.400 The truth when it comes to Lucy let Be the 0:02:01.520 --> 0:02:05.680 truth is not an easy place to land. There are 0:02:05.720 --> 0:02:09.040 some who are sure they know the court for one, 0:02:09.240 --> 0:02:11.440 has sent her away for the rest of her life. 0:02:12.080 --> 0:02:15.120 In the mind of the judge, the jury and the prosecutor, 0:02:15.720 --> 0:02:19.520 she is one of the worst serial killers in UK history. 0:02:20.280 --> 0:02:23.880 But as more and more information beyond what the juries 0:02:23.880 --> 0:02:27.720 have heard comes out, more and more people are starting 0:02:27.720 --> 0:02:31.200 to wonder if the truth might actually be one of 0:02:31.240 --> 0:02:32.359 a wrongful conviction. 0:02:34.240 --> 0:02:41.400 There is overwhelming evidence that the conviction is unsafe and 0:02:41.480 --> 0:02:44.880 if Dr Shoo Lee and the Panel are correct, no 0:02:45.040 --> 0:02:49.360 crime was committed. If no crime was committed, that means 0:02:49.400 --> 0:02:51.480 that a thirty four you old woman is currently sitting 0:02:51.560 --> 0:02:53.519 in prison for the rest of her life for a 0:02:53.639 --> 0:02:55.079 climate just never happened. 0:02:56.680 --> 0:03:01.160 I'm Amanda Knox and from Vespucci and iheartpod casts This 0:03:01.480 --> 0:03:05.840 is Doubt The Case of Lucy let Be Episode nine. 0:03:06.520 --> 0:03:24.080 The experts. On the surface, Lucy has run out of options. 0:03:24.120 --> 0:03:27.280 Nearly every level available to her in the UK court 0:03:27.320 --> 0:03:31.239 system has turned down the opportunity to rehear her case, 0:03:32.000 --> 0:03:35.800 but Lucy's lawyer Mark McDonald is hopeful that the UK's 0:03:35.840 --> 0:03:39.520 Criminal Case Review Commission will consider a new review. 0:03:40.040 --> 0:03:42.200 What I do know is that the CCRC had taken 0:03:42.280 --> 0:03:44.400 us very seriously. They've already got a team in place, 0:03:44.480 --> 0:03:47.800 They're ready to go. They've watched this conference. I've made 0:03:47.800 --> 0:03:50.280 sure they've had a link to this, They've watched the presentation, 0:03:50.920 --> 0:03:53.840 they've got this report. They're going to get the final 0:03:53.920 --> 0:03:58.760 report that they've seen what you've all seen. I'm hoping 0:03:58.800 --> 0:04:01.560 they're going to take this very seriously until we met 0:04:01.800 --> 0:04:04.000 very quickly, and we will be back in the compable 0:04:04.520 --> 0:04:04.960 very soon. 0:04:05.400 --> 0:04:09.680 The panel comprises fourteen very experienced and well known experts 0:04:09.720 --> 0:04:13.520 from highly prestigious institutions in six countries around the world, 0:04:14.040 --> 0:04:19.960 including Canada, the United States of America, Japan, Germany, Sweden, 0:04:20.120 --> 0:04:25.599 and the United Kingdom. They include ten neonatologists, one pediatric surgeon, 0:04:26.160 --> 0:04:31.880 one pediatric infectious disease specialists, one senior neonatal intensive canness 0:04:31.920 --> 0:04:33.680 and one other pediatric specialists. 0:04:34.680 --> 0:04:38.880 These experts were not paid for their time. In fact, Dr. 0:04:38.920 --> 0:04:43.200 Shoo Lee, a veteran neonatologist who lives in Canada, paid 0:04:43.240 --> 0:04:45.640 for his own trip to the UK to be part 0:04:45.680 --> 0:04:46.799 of this press conference. 0:04:47.320 --> 0:04:49.840 I decided that, you know, it was necessary to do this, 0:04:49.920 --> 0:04:51.839 even though there would be a cost to pay for 0:04:51.880 --> 0:04:54.040 me personally. I also recognized that there was going to 0:04:54.080 --> 0:04:56.520 be a lot of pressure because this was such a 0:04:56.600 --> 0:04:59.240 high profile case, in the sense that there would be 0:04:59.279 --> 0:05:02.760 public in backlash. There will be people on both sides arguments, 0:05:02.760 --> 0:05:06.920 and I'll be open to attas, etc. But if in 0:05:06.960 --> 0:05:12.240 fact this woman is innocent of the crimes that she's accused, 0:05:13.640 --> 0:05:15.640 I think you'll be all with it, and I'm prepared 0:05:15.680 --> 0:05:16.400 to pay that price. 0:05:20.160 --> 0:05:24.159 Now retired, Dr. Shoo Lee spends his days farming on his spot 0:05:24.160 --> 0:05:27.719 of land in Alberta, Canada. When he talks about farming, 0:05:27.839 --> 0:05:30.599 it sounds like something he's been doing all his life. 0:05:31.040 --> 0:05:34.360 Last day was wheat the year before there was canola, 0:05:34.440 --> 0:05:36.479 and we're actually bringing cattle on to the farm this year. 0:05:36.880 --> 0:05:39.920 I enjoy being a farmer. I love to see things grow, 0:05:40.080 --> 0:05:41.599 just like I love to see my babies grow. 0:05:42.160 --> 0:05:45.359 But it's when the conversation turns to neonatology that you 0:05:45.480 --> 0:05:50.839 see his expertise really come alive. Calm, warm and precise. 0:05:51.320 --> 0:05:54.279 He carries decades of knowledge with him, and when it 0:05:54.320 --> 0:05:56.880 comes to the Lucy let Bee case, he knows the 0:05:56.920 --> 0:06:01.120 details almost by heart. I ask him how he first 0:06:01.200 --> 0:06:02.160 became involved. 0:06:04.600 --> 0:06:07.200 I caught an email from a lawyer in the UK 0:06:08.440 --> 0:06:10.560 asking me if I would look at a case, and 0:06:10.880 --> 0:06:14.560 I was busy during harvest, and I ignored it initially 0:06:14.600 --> 0:06:17.640 because how often does one get a email from a 0:06:17.720 --> 0:06:20.880 lawyer in the UK. But then two weeks later, after 0:06:20.960 --> 0:06:23.839 my harvest, it was there again, and so I decided 0:06:23.920 --> 0:06:27.560 to answer our curiosity, and I realized that, in fact, 0:06:27.640 --> 0:06:30.200 this was genuine. What a lawyer told me was that 0:06:30.279 --> 0:06:32.599 they had used a paper that had written in nineteen 0:06:32.640 --> 0:06:36.560 eighty nine to convict her. And that stirred my attention 0:06:36.800 --> 0:06:41.560 because I don't normally do medical legal cases, but in 0:06:41.600 --> 0:06:43.760 this case, because they used my paper, I was curious 0:06:43.800 --> 0:06:47.880 about what they actually said. So I agreed to look 0:06:47.920 --> 0:06:52.920 at the case without committing to actually participating in the process. 0:06:53.440 --> 0:06:56.080 You may remember earlier in this series we heard how 0:06:56.080 --> 0:07:00.960 the prosecution's medical expert, doctor Dowie Evans, on a research 0:07:01.000 --> 0:07:05.040 paper doctor Lee published in nineteen eighty nine. In court, 0:07:05.200 --> 0:07:09.480 it was cited as evidence suggesting that unusual skin discolouration 0:07:09.760 --> 0:07:14.240 seen on some of the babies could indicate air embolism. 0:07:14.640 --> 0:07:18.280 For doctor Lee, that was the moment this case stopped 0:07:18.320 --> 0:07:22.080 being distant news. If his research had been used to 0:07:22.120 --> 0:07:27.240 support that conclusion, he needed to understand exactly how. 0:07:27.400 --> 0:07:29.600 So they asked me to look specifically at the skin 0:07:29.680 --> 0:07:34.720 discolorations and whether the interpretation of the prosecution doctors were accurate. 0:07:35.080 --> 0:07:36.520 And when I looked at it, I realized that it 0:07:36.680 --> 0:07:41.480 wasn't because what they had interpreted wasn't what I wrote about. 0:07:42.280 --> 0:07:45.040 And so I appeared at the appeal and I explained 0:07:45.040 --> 0:07:48.760 that to the judges, and unfortunately my testimony was disallowed 0:07:49.240 --> 0:07:53.600 because in the British legal system you can only present 0:07:53.760 --> 0:07:57.280 evidence at appeal that could not have been presented at 0:07:57.280 --> 0:08:01.040 the original trial, and at the original trial, since they 0:08:01.040 --> 0:08:04.239 did not call me, they lost their chance and therefore 0:08:04.400 --> 0:08:09.160 my evidence was inivisible. So her appeal was rejected, and 0:08:09.200 --> 0:08:13.280 I was a little concerned because, as far as I 0:08:13.360 --> 0:08:16.160 was concerned, the evidence that was used to convictor on 0:08:16.320 --> 0:08:22.920 the air embolism and skin discolouration was inaccurate. So potentially 0:08:22.960 --> 0:08:24.239 this is an unsafe conviction. 0:08:25.000 --> 0:08:28.320 With his evidence dismissed by the court, his work might 0:08:28.320 --> 0:08:31.880 have ended there, but it didn't sit easily with him. 0:08:32.559 --> 0:08:35.760 If the medical conclusions presented at trial were wrong in 0:08:35.800 --> 0:08:40.080 this one case, what about the others? Doctor Lee felt 0:08:40.080 --> 0:08:42.160 he had a responsibility to find out. 0:08:42.720 --> 0:08:44.560 On the one hand, I could be selfish and say, well, 0:08:44.600 --> 0:08:46.360 this is not my problem anymore. I did my part. 0:08:47.280 --> 0:08:49.840 On the other hand, I felt compelled to do it 0:08:49.920 --> 0:08:53.880 because if in fact this was wrong, a young woman 0:08:53.920 --> 0:08:56.240 would be in jail for the rest of her life 0:08:56.320 --> 0:09:00.200 without possibility of appeal or parole, which means she to 0:09:00.240 --> 0:09:04.600 die in prison. That is a horrible consequence to contemplate, 0:09:05.360 --> 0:09:10.600 and I think, I think I would lack humanity if 0:09:10.640 --> 0:09:15.319 I didn't find out whether or not that conviction based 0:09:15.320 --> 0:09:18.440 on the medical evidence was correct. I would do this 0:09:18.679 --> 0:09:22.360 only on condition that we would publish our results and 0:09:22.400 --> 0:09:24.600 make it public, regardless of whether we felt. 0:09:24.400 --> 0:09:26.120 She was innocent or guilty. I just wanted to get 0:09:26.240 --> 0:09:28.079 the truth, so. 0:09:28.800 --> 0:09:31.000 He agreed to look at the rest of the medical 0:09:31.000 --> 0:09:34.800 evidence in the case. But what that meant in practice 0:09:35.320 --> 0:09:37.040 was an enormous undertaking. 0:09:37.440 --> 0:09:39.800 So for each case, because some of the cases were 0:09:39.880 --> 0:09:42.800 very long and baby stayed in the hospital for months, 0:09:42.960 --> 0:09:46.280 it's hundreds and hundreds of pages of material, and then 0:09:46.360 --> 0:09:49.920 hundreds and hundreds of pages of laboratory results and medical 0:09:50.000 --> 0:09:52.640 charting from binesses in the unit and a Hoart rate, 0:09:52.679 --> 0:09:54.800 blood pressure, all that kind of stuff. So it was 0:09:54.880 --> 0:09:56.160 a great deal of material. 0:09:57.000 --> 0:10:00.360 Doctor Lee knew this wasn't something one person should be 0:10:00.440 --> 0:10:04.040 reviewing alone. To get through the mountain of evidence and 0:10:04.080 --> 0:10:06.840 to do it properly, he turned to the panel we 0:10:06.920 --> 0:10:11.480 mentioned earlier, bringing together those fourteen medical experts from around 0:10:11.559 --> 0:10:14.559 the world to examine the case alongside him. 0:10:14.720 --> 0:10:17.240 And we not only had new netologists, we also had 0:10:17.280 --> 0:10:23.199 one infectious disease expert, and we had a mediafic surgeon 0:10:23.240 --> 0:10:25.680 because some of the cases involved trauma, and so he 0:10:25.720 --> 0:10:27.800 wanted to be sure that we covered all the bases 0:10:27.800 --> 0:10:32.440 of a multidisciplinary team that had parensic experience, that had 0:10:32.520 --> 0:10:36.439 pathological experience, surgical, obstetric and new needle. 0:10:36.520 --> 0:10:37.760 So that was the team. 0:10:38.160 --> 0:10:41.960 The panel divided the work between them, assigning each baby's 0:10:42.000 --> 0:10:44.960 case to two experts to review independently. 0:10:45.440 --> 0:10:47.840 Each case was then assigned to two members of the 0:10:47.880 --> 0:10:51.120 team randomly, and they were asked to look at the 0:10:51.240 --> 0:10:56.000 cases independently without consulting each other initially, and we asked 0:10:56.040 --> 0:10:59.839 them to look at the medical records without referring to 0:11:00.240 --> 0:11:05.200 the prosecution witnesses or to the court transcripts. In others, 0:11:05.280 --> 0:11:08.199 just take the chart and tell us what you think 0:11:08.640 --> 0:11:10.760 was the cause of injury or death in this baby, 0:11:11.120 --> 0:11:14.319 so that they were biased by other opinions. 0:11:14.880 --> 0:11:19.560 Only after they had reached their own conclusions independently were 0:11:19.559 --> 0:11:22.160 they asked to review the evidence presented at trial. 0:11:22.679 --> 0:11:26.000 They were then asked to look at the prosecution witnesses 0:11:26.120 --> 0:11:28.439 reports to see whether or not it would change their minds, 0:11:28.520 --> 0:11:31.280 and if it did not, then they completed their report. 0:11:31.720 --> 0:11:34.640 Even though we divided up the work amount fourteen people, 0:11:35.080 --> 0:11:37.000 it still took us four months to get through all 0:11:37.000 --> 0:11:37.559 that material. 0:11:37.840 --> 0:11:39.800 It was a lot of work. Nobody paid us to 0:11:39.840 --> 0:11:40.800 do any of this, you know. 0:11:41.440 --> 0:11:43.560 I think it was doctor Dowie Evans who said that 0:11:43.600 --> 0:11:45.640 within a few minutes he had decided that one of 0:11:45.679 --> 0:11:49.920 the cases was a murder. And I'm impressed that he 0:11:50.000 --> 0:11:51.559 was able to do that because we couldn't. 0:11:54.360 --> 0:11:57.480 After months of work and with more than a dozen 0:11:57.600 --> 0:12:01.800 medical experts reviewing the evidence, the reports finally came back. 0:12:02.600 --> 0:12:06.720 The panel compared their conclusions for each baby, but even 0:12:06.800 --> 0:12:10.240 then there was still more work to do in verifying 0:12:10.280 --> 0:12:11.240 the conclusions. 0:12:11.480 --> 0:12:14.120 If the two reports on each baby agreed with each other, 0:12:14.800 --> 0:12:19.000 then that was accepted as the final result. If there 0:12:19.080 --> 0:12:22.559 was a disagreement between the two reports, then a third 0:12:22.800 --> 0:12:23.959 member was brought in. 0:12:24.600 --> 0:12:26.640 And then a consensuship was achieved. 0:12:27.440 --> 0:12:32.160 We found that there was unanimous opinion that there was 0:12:32.200 --> 0:12:36.000 no male seasons. In others, there was good reasons why 0:12:36.200 --> 0:12:41.400 each of the babies either died or suffered injury. There's 0:12:41.440 --> 0:12:45.360 a logical explanation for what happened to each baby. In others, 0:12:45.440 --> 0:12:49.680 you don't have to invoke murder to understand why the 0:12:49.720 --> 0:12:50.240 baby died. 0:12:51.040 --> 0:12:53.640 But by this point there was no clear way to 0:12:53.760 --> 0:12:58.400 put those findings back before a court, so instead, along 0:12:58.440 --> 0:13:02.199 with MP David Davies and Lucy's current lawyer, Mark McDonald, 0:13:02.679 --> 0:13:06.600 the panel decided to make their conclusions public. A press 0:13:06.600 --> 0:13:10.200 conference was organized in London and doctor Lee traveled to 0:13:10.240 --> 0:13:11.880 the UK to present the report. 0:13:12.600 --> 0:13:14.720 When I went to the UK, there was an additional 0:13:14.760 --> 0:13:17.480 burden in that I was actually coming to the UK 0:13:17.600 --> 0:13:20.680 where the majority of the opinion now was at that time, 0:13:20.840 --> 0:13:23.760 was that she was guilty. So therefore to step into 0:13:23.800 --> 0:13:26.200 the arena and say she is not, and here's why 0:13:26.240 --> 0:13:29.600 we think she is not is a huge task, right 0:13:30.480 --> 0:13:33.319 so it was unclear to me what the public reaction 0:13:33.480 --> 0:13:36.400 would be, but I felt that it needed to be done. 0:13:37.720 --> 0:13:41.079 In a room packed with journalists in London, doctor Lee 0:13:41.200 --> 0:13:45.040 stepped up to present the panel's findings. He began by 0:13:45.120 --> 0:13:48.400 laying out how the team had grouped the cases, placing 0:13:48.440 --> 0:13:51.800 the deaths and injuries into six medical categories. 0:13:53.120 --> 0:13:57.960 First embolism caused for injection of air into the intraveners system. 0:13:58.320 --> 0:14:01.840 Two splinting of die fram causper injection of air into 0:14:01.880 --> 0:14:08.000 the nasogastric tube. Three dislodged nastric and doctor killed you 0:14:08.559 --> 0:14:16.280 causing collapse. Four hypoglycemia casper injection of insulin, five trauma 0:14:16.320 --> 0:14:20.640 to the abdomen or gaestri intestinal tract, and sixth overfeeding. 0:14:21.760 --> 0:14:24.920 Doctor Lee did not go over every case the panel 0:14:24.960 --> 0:14:25.680 had examined. 0:14:26.200 --> 0:14:30.240 Mart McDonald lawyer, said, why don't we focus on the 0:14:30.240 --> 0:14:33.960 fatalities because the most important cases. Second, there were some 0:14:34.040 --> 0:14:40.160 cases that were shall we say, very obvious in terms 0:14:40.200 --> 0:14:42.800 of the causes of death or egregious in terms of 0:14:42.800 --> 0:14:46.040 the accusations that we felt that they needed to be highlighted. 0:14:46.480 --> 0:14:47.920 So those were the two conditions. 0:14:49.600 --> 0:14:52.280 The first case Doctor Lee brought up was Baby A, 0:14:53.160 --> 0:14:56.560 or as he called him, Baby one, citing the cause 0:14:56.600 --> 0:14:58.880 of death argued by the prosecution. 0:14:58.960 --> 0:15:02.800 Maybe one died from injection of air into the intravenous line, 0:15:03.040 --> 0:15:04.680 causing air embolism. 0:15:04.960 --> 0:15:08.800 This case, in particular had already drawn doctor Lee's attention. 0:15:09.720 --> 0:15:13.240 It was the prosecution's conclusion in that death and the 0:15:13.280 --> 0:15:16.440 way his research had been used to support it that 0:15:16.520 --> 0:15:18.880 it first led him to speak at the appeal. 0:15:19.440 --> 0:15:22.800 And so on the day of the collapse. Actually, BBA 0:15:23.320 --> 0:15:27.240 had two central cathetists, and these are lines that are 0:15:27.280 --> 0:15:32.440 placed into the large veins for venus access. Right now, 0:15:32.520 --> 0:15:35.480 Normally when you put in central catheteris like this, we 0:15:35.520 --> 0:15:39.320 would infuse the lines together with anticoagulants to prevent them 0:15:39.320 --> 0:15:44.440 from clotting, because central lines are notorious for clotting and 0:15:44.480 --> 0:15:45.440 causing trombus. 0:15:45.520 --> 0:15:49.240 Right a thrombus is simply a blood clot that forms 0:15:49.280 --> 0:15:52.800 inside a blood vessel or medical line, blocking the normal 0:15:52.840 --> 0:15:56.920 flow of blood, something doctors work carefully to prevent in 0:15:57.040 --> 0:15:58.080 fragile newborns. 0:15:58.480 --> 0:15:58.680 Now. 0:15:58.720 --> 0:16:02.360 In BBA, the risk of trombosis was further increased because 0:16:02.360 --> 0:16:06.400 the mother had something called antiphospholipid syndrome, which is a 0:16:06.400 --> 0:16:10.000 condition in which the immune system mistakenly creates antibodies to 0:16:10.040 --> 0:16:13.280 attack tissues in the mother's body and can trigger blood 0:16:13.320 --> 0:16:15.640 cloths to form in the arteries and veins. 0:16:16.040 --> 0:16:21.800 You see, although Baby A didn't have antiphospholipid syndrome, antibodies 0:16:21.800 --> 0:16:24.960 from the mother can cross the placenta and enter the 0:16:24.960 --> 0:16:29.880 baby's bloodstream, increasing the risk of dangerous blood clots. In 0:16:29.960 --> 0:16:33.520 Baby A's case, that risk may have been compounded by 0:16:33.520 --> 0:16:36.200 the fact that the catheterl lines had been left in 0:16:36.280 --> 0:16:40.080 place without infusion for an extended period of time. 0:16:40.480 --> 0:16:43.320 The lines were left uneffused for four hours. Clot forms 0:16:43.400 --> 0:16:45.480 very quickly. You don't need four hours of form a 0:16:45.560 --> 0:16:49.080 clock right. It forms in minutes, and if you leave 0:16:49.120 --> 0:16:52.040 a line left for four hours, you're almost begging the 0:16:52.080 --> 0:16:54.120 trumbus the form. On top of that, it did not 0:16:54.160 --> 0:16:57.040 anticoagulate the line and it did not infuse it. So 0:16:57.360 --> 0:16:59.520 after four hours you're going to get a trumpets. I mean, 0:16:59.560 --> 0:17:01.640 it's no question about it. And then after that day 0:17:01.680 --> 0:17:05.199 somebody started the infusion and shortly, very shortly after the 0:17:05.240 --> 0:17:07.440 infusion was started and the baby collapsed. 0:17:08.240 --> 0:17:11.560 According to doctor Lee, on top of the risk factors 0:17:11.640 --> 0:17:16.640 already present, allowing blood to sit in an unmaintained catheter 0:17:16.760 --> 0:17:20.880 line creates the conditions for a clot to form. Once 0:17:20.920 --> 0:17:25.120 the line is flushed or infusion restarts, that clot can 0:17:25.160 --> 0:17:26.119 break free. 0:17:26.080 --> 0:17:28.159 And when the trumpus breaks off, it can go to 0:17:28.440 --> 0:17:32.040 an archy, supplying a critical structure in a brain, for example, 0:17:32.080 --> 0:17:34.080 O in a hut that causes sudden collapse and death. 0:17:36.359 --> 0:17:39.440 Doctor Lee also pointed to findings in the post mortem 0:17:39.520 --> 0:17:43.560 that suggested a recent clotting event, evidence, he says, is 0:17:43.640 --> 0:17:48.000 consistent with a thrombus traveling through the bloodstream shortly before death. 0:17:48.880 --> 0:17:51.639 But the detail that first drew him into this case, 0:17:52.240 --> 0:17:55.600 the one tied to his own research, was something else 0:17:55.920 --> 0:18:00.680 entirely the unusual skin discolouration seen on the baby. 0:18:03.480 --> 0:18:06.439 Now, then there's this matter of these patchy skin discolorations. 0:18:06.760 --> 0:18:09.119 Because a lot of was made about the during the 0:18:09.160 --> 0:18:12.239 trial saying that these were very unusual skin discolorations. They 0:18:12.280 --> 0:18:15.600 were consistent of what I had written in nineteen eighty nine. Uh, 0:18:15.640 --> 0:18:18.840 and they seemed to be migrating and moving, and therefore 0:18:19.080 --> 0:18:21.920 this was a diagnostic of embolism. 0:18:22.520 --> 0:18:23.679 Unfortunately, that's not correct. 0:18:23.720 --> 0:18:27.040 The only skin discoloration there is diagnostic of air embolism 0:18:27.160 --> 0:18:28.240 is something called the Lee sign. 0:18:29.160 --> 0:18:32.879 You heard that right, The Lee sign, as in Dr. 0:18:32.920 --> 0:18:37.000 Shoo Lee. The clinical sign was literally named after him, 0:18:37.400 --> 0:18:40.000 and in the case of baby A, it sits right 0:18:40.080 --> 0:18:43.720 at the center of the debate over what happened. Doctor 0:18:43.800 --> 0:18:46.720 Lee first identified what would become known as the Lee 0:18:46.880 --> 0:18:51.240 sign in nineteen eighty after observing a dramatic and previously 0:18:51.400 --> 0:18:54.840 undocumented pattern of skin discoloration on a newborn. 0:18:55.240 --> 0:18:57.800 Basically, the O trees appear on the skin, and it's 0:18:57.840 --> 0:19:01.480 like a tree that fans up and it starts approximately 0:19:01.680 --> 0:19:03.800 and then moves this toilely, so you can see like 0:19:03.840 --> 0:19:05.960 a Christmas tree lighting up on a duck baby. 0:19:06.680 --> 0:19:10.000 That discovery eventually led to the nineteen eighty nine paper, 0:19:10.560 --> 0:19:14.840 the paper doctor Dowwie Evans cited at trial, But according 0:19:14.840 --> 0:19:18.240 to doctor Lee, what was described in his research was 0:19:18.280 --> 0:19:23.080 something very specific the marks discussed in court were patchy. 0:19:23.800 --> 0:19:27.040 The Lee sign, he says, looks nothing like that. 0:19:27.320 --> 0:19:30.400 Nothing patchy about it at all. These are very clear vessels. 0:19:30.440 --> 0:19:33.320 You can see the bloodvessels very clearly superimposed on the 0:19:33.440 --> 0:19:34.120 dark background. 0:19:34.480 --> 0:19:40.040 So at the press conference, doctor Lee, in no uncertain terms, 0:19:40.080 --> 0:19:44.200 revealed that doctor Evans had misunderstood his research. 0:19:45.960 --> 0:19:49.639 The prosecution in part based the allegation on the paper 0:19:49.680 --> 0:19:52.560 that I had written in nineteen eighty nine where I. 0:19:52.560 --> 0:19:54.840 Described fifty seven cases. 0:19:54.720 --> 0:19:57.280 That about ten percent of them has skinned discolourations of 0:19:57.320 --> 0:20:01.000 different kinds. At that time, I did not distinguished between 0:20:01.160 --> 0:20:06.919 arterial and venous air embolism, and in this particular case, 0:20:07.280 --> 0:20:10.359 the allegation is that she injected air into the venus 0:20:10.359 --> 0:20:13.600 system into the veins. And in the new paper that 0:20:13.640 --> 0:20:15.879 I had published in December of twenty twenty four in 0:20:15.920 --> 0:20:20.920 the American Journal of Parentetology, we actually separated the cases 0:20:21.240 --> 0:20:25.880 with arterial venus embolism from the cases with venus embolism, 0:20:26.520 --> 0:20:28.800 and what we found was that in the cases where 0:20:29.000 --> 0:20:33.200 air was injected into the veins, there were no cases 0:20:34.080 --> 0:20:39.160 of Patche's skin discolourations ever described in the literature. So 0:20:39.440 --> 0:20:43.000 the notion that these babies can be diagnosed with air 0:20:43.000 --> 0:20:47.080 embolism because they collapsed and had these skin discolourations. Has 0:20:47.200 --> 0:20:51.960 no evidence. In fact, right, none of this actually has 0:20:52.000 --> 0:20:54.320 ever been described. If this is true, it'll be the 0:20:54.320 --> 0:20:56.440 first case ever described, but it's never been. 0:20:57.720 --> 0:21:00.680 We of course wanted to ask doctor Abbas about this 0:21:01.000 --> 0:21:04.160 and so much more, but he has repeatedly turned down 0:21:04.200 --> 0:21:08.080 our requests for an interview. In other media, we know 0:21:08.240 --> 0:21:12.560 that doctor Evans is aware of doctor Lee's response. In fact, 0:21:12.880 --> 0:21:17.000 in one documentary called Conviction, we can see doctor Evans 0:21:17.080 --> 0:21:20.879 watching the press conference. Despite the author of the papers 0:21:20.960 --> 0:21:26.000 explaining the issues with doctor evans diagnosis, doctor Evans refuses 0:21:26.080 --> 0:21:31.040 to accept that he is wrong. Now in court, prosecutors 0:21:31.040 --> 0:21:35.439 pointed to one clear pattern in the collapses that Lucy 0:21:35.600 --> 0:21:39.760 let Be happened to be on shift, that when doctor 0:21:39.880 --> 0:21:44.240 Lee looked at the cases, he noticed another pattern, one 0:21:44.280 --> 0:21:48.880 that had received far less attention. Many of the babies 0:21:48.920 --> 0:21:53.520 involved weren't isolated cases at all. They were part of 0:21:53.720 --> 0:21:55.680 multiple births. 0:21:56.880 --> 0:21:59.359 Now Baby A had a twin called Baby B. 0:22:00.119 --> 0:22:02.640 Now this twin suffered the same thing in the sense 0:22:02.680 --> 0:22:05.880 that the baby also had sudden collapse within the first 0:22:05.920 --> 0:22:09.000 two days of life. But the baby survived right, So 0:22:09.040 --> 0:22:13.200 there was no pathology, et cetera. But there are common things. 0:22:13.320 --> 0:22:17.120 Number One, the baby had a similar character. Number two, 0:22:17.520 --> 0:22:20.440 they had the same mother, and as I said earlier, 0:22:20.720 --> 0:22:24.879 the mother has anti fossil lipid syndrome. And so I 0:22:24.920 --> 0:22:28.919 think that there's a commonality why these multiple babies, just 0:22:29.119 --> 0:22:33.159 you know, twins, triplets had problems because they had a 0:22:33.320 --> 0:22:36.639 similar pathology or something underlying it. 0:22:36.680 --> 0:22:38.600 In other words, that in fact. 0:22:38.560 --> 0:22:41.600 Created the conditions for these things to happen. And so 0:22:41.680 --> 0:22:44.320 it happened to one baby, it was more likely actually 0:22:44.320 --> 0:22:46.440 to happen to another because it's the same condition they's 0:22:46.480 --> 0:22:47.360 affecting the babies. 0:22:48.160 --> 0:22:51.080 So, after laying out the medical evidence surrounding Baby A, 0:22:51.840 --> 0:22:56.879 the obvious question followed. If not air embolism, then what 0:22:57.200 --> 0:23:02.080 actually caused the baby's sudden collapse. Doctor Lee brings up 0:23:02.160 --> 0:23:05.960 a few possibilities, from the high risk of thrombosis as 0:23:05.960 --> 0:23:10.399 we heard earlier, to malpractice. A post mortem on the 0:23:10.440 --> 0:23:13.960 baby showed that there was in fact a thrombic event 0:23:14.440 --> 0:23:17.359 and an IV had been inserted into the baby in 0:23:17.480 --> 0:23:21.840 order to infuse medicine, but that IV had penetrated the 0:23:21.920 --> 0:23:24.880 vein and had come out into the tissues. 0:23:24.760 --> 0:23:27.440 And so the infusion was not going into the circulation, 0:23:27.560 --> 0:23:30.399 was going into tissues, and so the air was getting 0:23:31.440 --> 0:23:35.320 swollen because the infusion was coming out. And so because 0:23:35.359 --> 0:23:38.879 of this, they removed the IV and replaced it with 0:23:38.920 --> 0:23:43.119 an unbelica venus catheter, but their first insertion was malpositions, 0:23:43.200 --> 0:23:44.760 and so they had to replace it again. 0:23:46.000 --> 0:23:49.240 Doctor Lee never says that he is sure how Baby 0:23:49.240 --> 0:23:52.600 A died, but he is sure it wasn't from an 0:23:52.600 --> 0:23:56.760 air embolism. But Baby A was not the only baby 0:23:56.880 --> 0:23:58.840 that this cause of death was given to. 0:23:59.600 --> 0:24:02.960 It was especially concerning because in many of these babies, 0:24:03.640 --> 0:24:06.399 Doctor Evans contended that the babies were stable and then 0:24:06.400 --> 0:24:09.439 they suddenly collapsed and died, and therefore it can be 0:24:09.480 --> 0:24:12.560