Lucia de Berk two years on, by Richard Gill This April will be the second anniversary of Lucia de Berk's acquittal. Unfortunately, the chances of this kind of thing occurring again have not yet been eliminated. The Royal Dutch Academy of Sciences, the Supreme Court and the Court of Arnhem requested that expert reports (after redaction) be made publicly available for scientific research and to enable lessons to be learnt for the future. This mainly concerns reports made by toxicologist Professor Meulenbelt and his team. For the first time in the case a multidisciplinary team of medical researchers studied the complete files of three key cases: Achmed, Achraf and Amber. The result was overwhelming: the deaths and other incidents fitted perfectly within the children's 'natural' overall clinical picture. The action taken by nurses in emergency situations was extremely professional. Unfortunately their excellent work was negated by practitioners' medical errors (diagnostic mistakes, errors of medication, communication failures). In Autumn 2001 a thorough examination carried out by the Health Care Inspectorate (IGZ) into the medical situation of Amber and other children proved that there were no suspicious circumstances. Nine months before Amber's death, in September 2001, the medical staff was already working on linking Lucia's presence with several of the 'incidents'. Lack of communication between medical specialists and the hospital's management then played a role in converting an error of medication made by a specialist into a suspicious incident in which Lucia had been involved. This report ended up in a drawer somewhere and was, I presume unknown to police or judges, never even requested. This confidential report, conducted by independent external medical experts, was something that should have taken place right at the start. (Background: At the end of 2000, the rumour mill was working against Lucia, following the transfer of one of her former colleagues. And in autumn 2000, she reported her own concerns about the number of deaths during her shifts to her managers. The head nurse already had it in for her, personal contacts between head nurses, directors, doctors, did the rest.) Legally it is quite possible that the JKZ's statement concerning five suspicious deaths and resuscitations was a "malicious declaration". The JKZ knew that these five cases were caused by avoidable medical errors of which they were already aware, both ordinary human errors made by doctors, and errors caused by poor organisation (transference between physicians and to nursing staff). Yet a serious charge was filed and their making a connection to one particular nurse was a distraction to the police. The hospital headed straight for "vigilantism", especially later when they began guiding the police and the judicial inquiry. All medical information was filtered by the "chef de clinic" (head paediatrician) who was responsible internally for 'managing' the crisis. Despite the fact that this same person had also filed accusations, and that these accusations concerned their own patients and even their own diagnostic errors. And even though others in the hospital management strongly discouraged this decision due to the awareness of a psychiatric disorder suffered by the pediatrician (under treatment for major depression). Personal connections between senior medical staff and senior figures in the Hague's legal circles (judges, prosecutors) may have also contributed to making the process that had already been set in motion irreversible. Only in 2004 when the head paediatrician was unable to testify personally in court due to mental illness - that had not happened up to that point, and would later never take place - were insiders aware that all may not have been as it seemed. The rest - the study by Metta de Noo and Ton Derksen - is of course history. The image we are therefore left with of the situation within JKZ in this period reminds me of the situation in Rotterdam's Maasstad Hospital, where director Paul Smits presided over a similar chaotic situation and managed turn a bad situation into a disaster. In England, the 'Annual Research Conference of the College of Nursing' gave me the opportunity to present a lecture about the case against Lucia. I detect (as an Englishman) a strong cultural difference between Anglo-Saxon countries and the Netherlands, with respect to openness about these kinds of disasters. I fear that the Dutch peace-loving and stick-to-what-you-know mentality is no longer of these times. I see a connection between this subject and a series of recent articles in NRC about the medical culture in the Netherlands (eg, "Why are surgeons so arrogant?" Mara Simons, Opinion, January 19, 2012). I hope that nurses are now more than ever aware of how easily they can be a victim of a nineteenth-century regents-mentality. A new Lucia-case could arise again tomorrow. Clusters of events are the rule rather than exception. Gossip and slander too. How is one to protect oneself against it? Richard Gill, Professor of Mathematical Statistics, Leiden University Research areas: forensic statistics, misuse of statistics in society, medical statistics and epidemiology. Investigates the origins and causes of the case of Lucia de B.