Writings on Lucia

Lucia: who did do it, then?

This letter by me published by Dutch magazine 'Nursing', April 2012, -- here's a rough English translation -- summarizes what we now know about the causes of the case: namely a kind of subconscious mass conspiracy by a number of medical specialists at JKZ to connect their own errors and other unexpected mishaps to Lucia.
This process started at least nine months before the "unexpected" death of baby Amber in the early hours of 4 September, 2001. One piece of evidence for this (there is lots more): within 24 hours of Amber's death, the hospital director reported five unnatural deaths at his hospital over the last year to the police and to the Dutch national health inspectorate. Yet none of the other deaths had previously been thought in any way to be unusual - at least, not officially. There had been no reports of incidents to the authorities. Even Amber's death was first registered as natural, this was only converted to unnatural later in the day.
It took JKZ's director less than fifteen minutes, from the time he was informed on the afternoon of 4 September of the latest death, to report the five unnatural deaths to police and to the health inspectorate. Within a day, Lucia was put on "non-active". All staff was informed of the upcoming police investigation and of the implication of an (unnamed) nurse. A press conference was held in which it was also mentioned that the murder investigation (by the hospital???) was being extended to other hospitals at which the same nurse had been earlier employed. Coincidentally, hospitals at this very moment in the process of being merged with JKZ.
Implication: four dossiers were ready and waiting. The doctors had simply been waiting for one more, and the time between the death and informing the director, was simply used to complete the last dossier.
During these few hours a number of important medical facts about Amber's death were altered on the patient's dossier by the specialists concerned: most crucially, the sequence of events leading to death. Lung failure before heart failure, suggestive of a natural death by exhaustion, was changed into heart failure before lung failure, suggestive of poisoning. Yet at the trial, the hospital director and most (but not all!) specialists claimed that there had been no suspicion at all of anything, or of anyone, till the death of Amber.
Interestingly, the investigation by the Dutch national Health Inspectorate (IGZ), at the same time as a police investigation and then a murder trial was going on, found no evidence of anything remarkable! Their report has never been made public. Even the mere fact of their investigation seems completely unknown.
Also interestingly, the media has totally ignored all this news. Presumably, the Dutch population is "Lucia-tired" - this story won't sell newspapers or generate large viewing numbers on TV.
The Dutch medical community, and people in the upper echelons of "justice" still believe "she did it". The legal system got the blaim (but also takes any credit: "she got freed, didn't she?"). The medical world looks the other way.
I sent a copy of my letter to the directors of Haga hospital, to Haga's lawyer, and to the coordinator of research at Haga (who had earlier been forbidden by her bosses to communicate with me). I was expecting at least a response from the lawyer, but nothing came.

Lessons from Lucia

Lucia interviewed (in English) on CBC

Learning from Lucia, slides from my lecture at ATSTATS 2010, video of the lecture

"Learning from Lucia" is the title of many talks I am giving these days. I believe that there is so much of value that we can learn from understanding the Lucia case, which in one sense was concluded with the "not guilty" verdict given at her retrial in 2010, but in another sense is still completely open: what really did happen? Why was there ever a case at all?
Below is my present list of recommendations. In my opinion a number of "system faults" were exposed by the catastrophe, some of them specific to the Dutch situation (with its specific and fascinating culture, history, ...).

Actually, the Dutch legal system has already learnt a great deal. The same goes for the Dutch scientific world and in particular, the statistical world and the world of forensic science. What remains is for the medical world to learn. However, as long as it denies any responsibility, that learning process cannot start, and unfortunately that is definitely still the case.

Here are some of the hard facts of the case and the hard facts of the Dutch situation.

1) The fact that there was a case at all (2001) and the outcome of the first round of court cases (Supreme Court, 2006) was - it seems to observers with access to the dossiers and who study the reports of CEAS (judicial review committee reporting to the Public Ministry), of the Advocate General to the Supreme Court, of Prof Meulenbelt to the court in Arnhem and of the conclusions of that court itself - strongly determined by the interation between the chef-de-clinique of the Juliana Children's Hospital, a well-known and respected paediatrician, and the director of that hospital. Their actions were influenced by malicious gossip about Lucia, and moreover we now know that the paediatrican was mistaken in some diagnoses, so that she herself could well have been surprised when some of her patients suddenly died. Her brother-in-law, a theoretical computer scientist with no experience whatever in applied statistics, supported her amateur statistical conclusions based on her own data-gathering (the data of the amazing coincidence of Lucia so often being on duty whenever strange things happened). These were the statistics at the outset of the case.

Together these two persons reported a number of deaths and other incidents to the police as being highly suspicious. Each medical dossier was accompanied by the chief paediatrician's one-page summary explaining why the incident was suspicious. She was made hospital coordinator and laison person for the subsequent police investigation, yet she never gave witness to the court of appeal, and only briefly at the lower court.

Two extremely hierarchical and powerful organisations (a large hospital and the public ministry) had to be linked up for a murder investigation.

So we have some medical errors and, It seems to me some, some managerial errors. The hospital director was responsible for a number of very far-reaching decisions. The fact that the hospital had become aware of a serial killer in the nursing staff, and a suspect had been suspended from duty, was communicated in a succession of three internal memos to the hospital staff and in a press conference, including TV appearance, before the police had started an investigation; before any external investigation had taken place at all. To this day, hospital staff is forbidden to talk about the affair to outsiders (the board of the the Dutch society of paediatricians has also forbidden discussion of the case by its members). The director was an authoritarian manager; perhaps necessarily so, since at the time he was charged with the merger of three badly functioning hospitals in a bad financial situation. He was focussed on processes and on the reputation of his hospital(s). He is known for, and proud of, making rapid criticial decisions and never looking back on decisions once made; see the interview with him (in Dutch) in Skipr, the Dutch magazine for health care managers.

These two key persons consider that they acted completely properly and state they would do exactly the same again if the same circumstances arose again today -- which further underlines the point I am trying to make: the "integrity" of the system in which these individual human beings were embedded needs to be investigated, since it so easily allowed the chance interaction of their personalities together with some bad luck to spark a catastrophe - of which they too are the victims. And by the way, such medical and managerial personalities are not rare, nor - as I will explain - is the "run of bad luck" which hit Lucia.

Compare this with an investigation into an air disaster. The direct cause might be the chance mechanical failure of some bolt or electrical failure of some wiring followed by some errors of judgement of pilots faced with what seems like a dangerous situation. My wife usually says: "I know why the plane came down: because of gravity"; but sometimes she lays the blame on the hubris of man(kind). These are two extremes of causation, and since we cannot do anything about either they are not really interesting, however true; we should look somewhere in between the immediate and the ultimate root cause. The point of investigations into air disasters is to make air travel safer for you and me in the future, and for pilots and maintenance engineers too for that matter, by uncovering opportunities to improve training or maintenance procedures or emergency procedures or engineering standards.

So at this stage, we have just found that some persons took some in retrospect unfortunate decisisions when confronted with a chance situation which to them appeared sinister. These things happen, and with the benefit of hindsight it is all so easy. But I am not talking about blame. I want to understand.

2) In most modern countries where this sort of case arises the very first thing that happens is not a police investigation following a press-release, but a *confidential* and *independent* medical investigation.

3) In most modern countries, whenever statistical data like this is involved, an external professional statistician is involved. And the first thing that that person does is to go back to the original data, I mean back to original hospital records and back to the persons who gathered and compiled the data. How did they do it, what definitions did they use, what were they looking for? As Willem van Zwet had always said: when you see such extreme data as the little contingency table of shifts of Lucia and shifts with incidents which led to Elffers' infamous "one in 342 million" the first thing you can be sure of as a statistician is that the data is wrong. He turns out to have been completely right. A better number might be something like "one in a hundred".

4) In the UK and in many other modern countries the nursing staff is much better organized and harder to ignore. Florence Nightingale? In NL, nurses have only had a single organisation representing them for a couple of years. They are largely ignored in hospital management decisions and certainly by medical specialists. They are less well-paid and consequently less-well educated than in quite a few other countries. A colleague of mine was in hospital for 6 weeks with a severe heart condition and took great care to note exactly what medication he was supposed to be having and what he actually got. He was given the wrong pills on 8 occasions. He told this to his heart-surgeon who exclaimed "oh those careless sluts". This shocked my colleague to the core, since he could see that a dedicated and overworked nursing staff was doing an almost impossible job to the very best of their ability. Mismanagement and understaffing, mistakes by specialists and pharmacists, illegible prescriptions, were the order of the day.

So my recommendations are:

1) Strengthening of the role and prestige (hence improvement of level of education, level of training, hence level of salary) of nursing staff in hospitals.

2) More scientific diagnostic reporting ("differential diagnostics"). In the medical-legal situation the medical specialist must discard his role of God who knows the right decision to make and never makes a mistake (in life and death situations), and adopt a more humble scientific attitude, concordant with the facts that even after post-mortem examination cause of death is not really known in 30% of deaths, and that three people a day die in Dutch hospitals because of avoidable medical errors (compare this to two a day in road accidents). But admitting individual medical errors is taboo. In the Lucia case, none were admitted, but finally many were revealed. This problem is so severe (for the many victims of medical errors) that from June 16, 2010, a new "code of practice" has been introduced, which allows medical practitioners to apologize for mistakes, without thereby admitting legal responsibility!

3) External and independent and confidential medical investigations in Lucia scenarios, before calling in the police. Probably this will often need non-Dutch speaking experts and more openness concerning health care in hospitals.

4) In the court situation, written scientific expert evidence needs to be put into the public domain as far as possible, so that the scientific methodology used can be openly discussed in the scientific community.

5) A multidisciplinary and in particular statistical and epidemiological analysis should be made of data on medical incidents at JKZ, say 1995--2005. We can be pretty certain that there was no serial killer active during this period, yet we know that over time there were huge oscillations in the numbers of incidents on at least one particular ward. But no professional statistician has ever had access to more than the most summary of biased summary statistics (no professional statistician was ever heard in court or consulted by the hospital or police).

Just like sun-spots, earthquakes, or volcanic eruptions, long periods of almost total quiescence were interspersed with short bursts of intense activity: unexplained clusters of events. This phenomenon is seen world-wide. It has numerous times led to wild-goose-chase murder investigations which always end up ruining quite a few lives, even if at the end of the day there is no reason whatever to suppose that anybody did anything wrong at all. In fact, some investigators (who have built an academic career with lucrative media opportunities out of HCSKs or "Health Care Serial Killers), report a world wide epidemic.

Simultaneously to studying patterns of incidents at JKZ one should study patterns in nurses' shifts, so that we finally known what is the "normal situation", or more precisely, "a" normal situation. One thing that is for sure, is that the time pattern of a nurse's shifts doesn't look anything like the outcome of a homogenous Poisson process. Thus even if shifts and events are unrelated (which for many good reasons is not true either) we are going to see over-dispersion in the numbers of incidents experienced by each nurse, since time itself is a hidden confounder. Since the mean is low but the variance is rather large, many nurses will experience no events at all over long periods of time, while just a few will experience "surprisingly" many. All experienced nurses know this as an empirical fact of nursing life.

It is so important to study this scientifically and empirically and in a multidisciplinary framework, not just to gain knowledge into a fascinating but never studied phenomenon, but also in order to protect hospital workers by avoiding future red-herring-witch-hunts generated by ignorance and prejudice and the irrelevant statistics of amateur statisticians. We have seen in the cases of Sally Clarke, Lucia de Berk, O.J. Simpson, and in so many others, that when lawyers and medics pretend to be able to do statistics, truth flies out of the window. Lord Rutherford said "if you need statistics, you did the wrong experiment". I beg to submit that "if they use statistics in court, someone will be screwed".

I reported my recommendations, and requested scientific collaboration, in an email to the chairman of the board of Haga (pdf), Autumn 2010. The response was a notice from a lawyer acting on behalf of Haga hospital, that (civil) legal action would be taken against me for slander of one of Haga hospital's respected medical specialists, unless I acceded to certain demands. My (university's) lawyer's advice was to yield to just one of Haga's demands, namely to remove statements by me on various internet discusson blogs concerning this person, which might be seen to be too personal and hence beyond the bounds of propriety. However, I stood on my position that the information which I had disseminated was in the public interest and that I had had no intention whatsoever of harming that person's reputation. I refused to sign a declaration that I would never ever publish material on these "personal" aspects of the case. Discussions with my lawyers and Haga's lawyers and the long process of getting my offending comments removed from other people's blogs and discussion fora, cost the Dutch taxpayer a large amount of money (though probably peanuts for Haga hospital). The final letter from Haga's lawyers was the statement that Haga would immediately take legal action against me anytime one of my - by now removed - allegations was repeated on internet, or published in any other ways, by third parties. Interestingly, one and a half years later, my earlier postings were cited in their entirety by third parties, who also informed Haga and Haga's lawyers of their actions. However there has been no response from Haga hospital.

Nurse Lucia de Berk, victim of gossip and bad statistics

The Dutch nurse Lucia de Berk has been completely exhonerated. Not only is there no proof that she committed any murders, there is no reason whatsoever to suppose that any of the deaths and other incidents with which she was connected were in any way unnatural. Lucia had been given a life sentence for seven murders and three attempted murders of patients in her care. Statistical reasoning played a central role in her case, first explicitly but later, after an appeal court confirmed the sentence, implicitly: it was converted into irrefutable medical evidence, in a completely circular and seemingly unbreakable chain of legal reasoning. An official judicial review committee uncovered many irregularities in the handling of the case, in which the rapid response of hospital authorities led to tunnel-vision and bias from the earliest stages of the case. A new medical investigation commissioned by the supreme court has removed the linch-pin of the prosecution case, the only death “proven” to be a murder, and “proven” to have been committed by Lucia, on its own merits. There is no reason now not to suppose that this was a natural death. Evidence of any wrong-doing in any of the cases is totally nonexistent. There was however the usual amount of medical blunders and mistaken diagnoses, but at least the professional behaviour of the nurses was exemplary. The statistical evidence - which is all that remains - has been totally discredited. The data was seriously biased, a meaningless statistic was computed, and the model used was completely inappropriate. A cluster of incidents on this hospital ward was actually a common occurrence. The presence of Lucia at many of the incidents in one cluster was not terribly unlikely, though striking enough to have drawn attention to her. Neither shifts nor incidents occur uniformly at random. Half of the incidents were repeated events associated with a small number of particularly sick children. Shifts and incidents are not independent of one another, since a more observant nurse notices problems with a patient earlier than a less careful nurse. Lucia had more weekend shifts than most of the nurses (lesser qualified part-timers, trainees, and temporary employees), while incidents typically occurred in the weekends. Neither fact is surprising, both facts were never reported.

I have written more on the case on my pages Lying Statistics Damn Nurse Lucia de B, and you can also find much information (Dutch and English) at www.luciadeb.nl

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(Last updated: 15 December 2014).