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Sat, 26 Aug, 2023 - 10:30

Rónán Collins

The ward clinical nurse manager (formerly ‘sister’) looked aggrieved when I suggested we should send a blood test for c-peptide which, if low, can be a marker of externally given insulin, when I came across a patient with unexplained low blood glucose on our ward a number of years ago.

This was shortly after I had come back having completed my training in Leeds.

The senior nurse seemed offended at any inference that the patient might have been given insulin by a member of staff accidently.

Prof Rónán Collins, now a consultant geriatrician at Tallaght University Hospital, was among clinicians at Leeds General Infirmary who raised concerns about deaths on the wards — concerns which ultimately led to the conviction of nurse Colin Norris. File picture

I diplomatically explained that it was and should be a routine part of the clinical investigations of low blood glucose; that insulin could have been given by accident on a ward where some patients were diabetic; that a patient could have given it to themselves as a suicide attempt; that, in any case, it was a busy ward with lots of “comings and goings”, and that, in an era of staff shortages, things were often more rushed with more opportunity for error and that we did not know all our doctors and nurses well any more, with many temporary staff on 'bank' or locum shifts.

I kept the possibility of a premeditated and deliberate act of harm to myself.

The Colin Norris case

Some three years prior as a medical registrar at Leeds General Infirmary, I was called one night to the orthopaedic ward to assess a woman in her 80s who was unwell and drowsier than normal following hip surgery.

The nursing staff and I quickly deduced she was hypoglycaemic (low blood sugar) and, having assessed for infection, blood loss, clot to lungs, and stroke, we were satisfied that a long day fasting and post-surgery was the likely cause of the low blood sugar. Two doses of intravenous replacement seemed to solve the matter.

Ethel Hall, one of the four women murdered by nurse Colin Norris. File picture: West Yorkshire Police/PA

About a week later, I was called again to the orthopaedic ward to assess an unresponsive older lady post-hip surgery with quite a low blood sugar.

On this occasion, it took some effort and repeated administrations of glucose over some hours to try restore normal levels.

The situation puzzled and interested me and I gave a steroid in case of an undiagnosed deficiency and broad-spectrum antibiotics in case of infection, and I sent a number of blood tests, including one for endogenous (naturally produced by the body) pro-insulin levels in case the lady had a rare insulin-producing tumour called an ‘insulinoma’.

I was at the top of my top of my game, I thought. How naïve I was.

An obviously thoughtful — and more distanced — biochemistry laboratory scientist received my request and obviously thought: “Insulinoma! Not a chance.”

Instead, and more appropriately, they performed a test for a protein called c-peptide. This protein is elevated in insulinoma and naturally induced states of hypoglycaemia. More pertinently in the situation perhaps, low sugar states can also be produced by surreptitiously-given insulin.

Alarm bells rang...

The next morning, I brought the case to the attention of my supervising consultant who exclaimed, in some surprise, that she’d had a similar case on that ward a few weeks back.

The lab scientist called me later that day to tell me the c-peptide was low — evidence that insulin had been given to the patient. He asked me to check was the lady diabetic or could there have been an error? Were there other patients in adjacent beds on insulin?

There were not.

There had also been rumblings of concern about unexpected deaths across city in our more famous sister hospital St Jimmy’s. Alarm bells rang as the pennies dropped.

What followed was an extensive police investigation with a meticulous cross-city examination of all staff rotas with everyone interviewed.

There was a review of unexplained deaths and exhumations of bodies for forensics. There was a pervasive atmosphere of suspicion and fear on our wards.

'Angel of death' convicted

The rest is matter of the Newcastle Crown Court record and, in 2008 a nurse, Colin Norris — subsequently dubbed “the angel of death” in the tabloid press — was convicted on four counts of murder and one attempted murder.

There were six other suspicious deaths uncovered that could not be investigated sufficiently due to the bodies having been cremated.

The case shocked me and opened my eyes to the fact that I was working in a very large and busy hospital, with lots of patient and staff movements, with lots of potential for miscommunication and error and an opportunity, if someone was so inclined, for malevolence.

I asked the detective at the court case what had prompted such actions.

He felt the psychopathology could have potentially originated by witnessing a loved one dying badly and the subsequent actions, in the detective’s opinion, were motivated by a belief that this was a version of “involuntary euthanasia” and a humane and morally correct course of action for these frail, suffering and vulnerable older people.

An alternative body of testimony at the court case suggested Norris was a cruel individual and disliked older people. When sentencing him to life imprisonment with a minimum of 30 years to be served, the judge remarked:

I have absolutely no doubt, you are a thoroughly evil and dangerous man.

Norris has always maintained his innocence and an episode of the BBC's Panorama series, The Innocent Serial Killer?, raised concerns about the safety of the conviction.

The foreman of the jury that convicted Norris even spoke out on his belief years later that there had been a miscarriage of justice. A case review in 2013 upheld the conviction but it remains under appeal still. If the appeal is successful, this would be the greatest miscarriage of justice since the Birmingham Six.

What was not disputed, however, was that Ethel Hall was murdered by an injection of insulin at Leeds General Infirmary.

The recent case of Lucy Letby, found guilty of the murder of seven babies and attempted murder of six more at the Countess of Cheshire Hospital, again brings into the spotlight a potential for malevolence from healthcare staff.

Although a highly unusual occurrence, one must reluctantly accept that evil people with complex psychopathology do exist in healthcare, though perhaps much less so than in other walks of life — or at least we would hope so.

Harold Shipman arriving at Ashton-Under-Lyne police station in Greater Manchester on September 7 1998 when he was arrested in connection with the death of 81-year-old Kathleen Grundy. In January 2000, the GP was found guilty of murdering 15 patients under his care. Picture: PA/EDI

Rare cases like those of Norris, Lucy Letby, and the notorious GP Harold Shipman evoke, at one level, the almost Victorian curio quality of a Sweeney Todd (himself believed to have been in the surgical trade) and, on another level, a revulsion of those breaking a most sacred trust, the trust between protector and vulnerable, healer and sick.

Beneficence and sanctuary in health settings is an expected value in our society, exemplified by a public presumption of Hippocratic oath taking but maybe at times taken for granted, lazily so and even negligently so.

The reported actions of hospital management in the Letby case are self-preserving at best, possible criminally negligent at worst.

Calls by Dr Stephen Brearey, the lead consultant at the neonatology unit in which Letby was allowed to continue practice murder, despite raising his concerns early with management, are not likely to lead to anything meaningful in terms of any serious culture change in the NHS management and in their relationship with clinicians.

A few insignificant dragoons will be sent to face the cannons, and the NHS management machine, its reputation, and any potential for making the honours list will be defended.

Nurse Lucy Letby was convicted of murdering seven babies and attempting to kill six others between June 2015 and June 2016 — despite concerns being raised by clinicians as early as 2015. File picture: Cheshire Constabulary/PA

A dangerous component of the problem here is the antipathy — if not adversity — between management and clinicians in Britain currently. This was something I witnessed first-hand in Leeds, when no less than the professor of medicine raised concerns about a serious patient safety episode during the four-hour trolley wait campaign, only to be brushed aside with the nonchalance of Lord Raglan on the hill at Balaclava.

What then do we learn from such rare and shocking cases?

Well they happen and in the first instance there must be both curiosity and rigour in our scientific understanding of unexplained deaths. The past organ retention cases have much damaged society’s and our clinically important relationship with the science of pathology.

Forensic pathology such as CSI may be popular on TV, but a scientifically curious post-mortem is now a rarity. Many of us in medicine wonder what half the people who “died of Covid” actually died of.

In September 2001, an inquiry examining the deaths of at least 466 people issued adverts seeking to trace the relatives of more than 80 former patients of Harold Shipman. File picture: PA

We also need action to accompany our increased understanding that we all now work in more diverse and busy clinical settings, where there are frequent changes in personnel, where mistakes can and will happen and where rarely and unfortunately staff can be inadvertently abusive of patients and, more rarely, malevolent towards them.

Clinical settings must have a governance structure that accounts for this, that encourages more team working and peer support, that is adequately resourced to minimise error and its work practices designed to reduce stress and empathy burnout among staff.

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Most importantly perhaps is a need to affirm by design that our healthcare settings exist to serve the health of our patients and not government policy, the reputation of the institution, the needs of its individual staff or managers.

The culture of a health service must reflect this in every facet of its operations. It is the most sacred of trusts.