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14 April 2010     Court of Arnhem
Acquittal in case Lucy de Berk

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Gavin Hamilton - The Nurses are Innocent - The Digoxin Poisoning Fallacy

# To whom it may concern

"The Nurses are Innocent - The Digoxin Poisoning Fallacy"
Available in print and in digital format (Dundurn Press, Toronto, November 2011).

It is the true story of an innocent nurse, the daughter of a pediatrician, who was charged with the murder of patients with the heart drug digoxin at the Toronto Hospital for Sick Children, 1980-81. The poisoning theory was based on high digoxin levels on autopsy specimens. She had a good lawyer, so she spent only one week in jail.
The case resulted in a 1½ year Royal Commission of Inquiry (Justice Grange) that was covered almost daily by Canadian national news media (even The New York Times covered the story on at least two occasions). The evidence was circumstantial, so she was not committed for trial. Many in Canada (including Grange) still believe she was guilty, but the facts presented in the book should convince everyone that she is innocent.

The book reads like a novel, but is indexed like a Law journal article, outlining the flaws in the science and in Law. The Foreword was written by one of Canada's foremost medical scientists, Dr. Peter Macklem, the professor of medicine at McGill University at the time when he was called to testify as an expert witness at the Grange Inquiry.

There is an European Law facet to the story - uncovered while the book was in press. A nurse from the Netherlands, Lucia de Berk, was tried and convicted of murdering patients by digoxin poisoning (based on high digoxin readings on autopsy specimens). Her conviction relied on statistical analysis of her presence near the patients at the time of death.

The New York Times, The Guardian and the journal Nature denounced the flawed mathematics of the statistical analysis that convicted her. Editorials as these helped to force a retrial in which she was proclaimed innocent (although many in the Netherlands believed she was guilty).

The scientific arguments presented in "The Nurses are Innocent", proving that high levels in autopsy samples do not indicate digoxin poisoning in a living patient, would be equally valid in the De Berk case.

If there was no digoxin poisoning, how could there have been murders?

I know this information should be valuable in your attempts to clear Lucia de Berk's name – and to eliminate all thoughts that there was any digoxin poisoning at all!

Sincerely,

Gavin Hamilton MD FRCP(C)
London Ontario Canada

Airy business card with shaking hands, grass, tulip, earth globe, statistical graph and formula

# Not only the legal system

by Prof. Richard Gill

10 April 2009

The Dutch legal system has already learnt a very great deal from the case of Lucia de Berk. Moreover, the fact that traditionalists only made things manifestly worse in the subsequent "damage control" has given a lot of career opportunities to a new generation of lawyers.

Also the Dutch scientific world and in particular, the Dutch statistical world, has learnt from the case. The old Dutch mentality that law is for lawyers and proving theorems is for mathematicians is also fading away. Forensic science is hot, multidisciplinary, exciting, challenging and important. Statisticians are meta-disciplinary by nature and by training and can speak with a voice of authority.

What remains is for the medical world to learn. However, as long as they deny that anything went wrong, let alone taking any responsibility, the learning process cannot start.

In my opinion a number of major system-weaknesses, specific to the Dutch situation, were exposed by the case.

  1. The outcome of the first series of court cases was determined essentially by one medical expert, who was vulnerable to gossip, who made a couple of wrong diagnoses so that she herself was amazed when children suddenly died, and who had her brother-in-law further support her statistics based on her own data-gathering. This same person oversaw the internal hospital investigation in the two weeks between the initial catalyzing event and the reporting to the police of 5 murders and 5 attempted murders. The same person was made hospital coordinator and liaison person for the subsequent police investigation. Two extremely hierarchical and powerful organisations (a large hospital and the public ministry) had to be linked up for a murder investigation. It seems to me that the hospital director was responsible for these major errors. An authoritarian manager focussed on processes, not on persons, with a habit of making rapid decisions and never looking back on decisions once made.
  2. In most modern countries where this sort of case arises the first thing that happens is not a police investigation but an independent external medical investigation.
  3. 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. 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". Which shocked my colleague to the core, who could see that a dedicated nursing staff was doing an almost impossible job to the very best of ability. Mismanagement and understaffing, mistakes by specialists and pharmacists, illegible prescriptions, were the order of the day. All professional medical groupings are represented at a monthly meeting with the minister of health. All except… the nurses.

So my recommendations are:

  1. Strengthening of the role and prestige 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, admitting that even after post-mortem examination, the cause of death is still not known in 30% of deaths, and that three people a day die in Dutch hospitals because of avoidable medical errors.
  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.
Cookie agent

# Public Prosecutor's Office in the final round

(author Metta, provisional translation by Marty Hirst)

9 December 2009

No further speculation, just the truth

Today at a meeting in the Courts of Justice in Arnhem came the long expected reversal of Lucia's prosecution. The expectation is that on 17 March 2010 the case will be wound up. Lucia will be cleared of all murders and other incidents.

Public Prosecutor

Public Prosecution Service Solicitor-General Rijkers presented a summary of the conclusions which the Public Prosecution Service derives from the various research reports. He concluded that on the basis of the dossier and previously presented research results the outcome of the lawsuit is obvious, and that the case can now be concluded with a brief substantive handling.
The Solicitor-General indicates further that – the accused had always continued to plead her innocence to the serious accusations made against her. The duration of the revision of this case has also not been as a consequence of the attitude of the accused. She is entitled therefore to a speedy further handling of her case. The same applies moreover to all others directly concerned, in particularly the surviving dependants of the deceased patients.

Investigations

From research by Meulenbelt, Aderjan and Tytgat it is clear that Amber's death was not from digoxine poisoning but of exhaustion and the consequences of a serious and complicated condition. According to Meulenbelt the death of Ahmad was caused by the quantity of sedative medication in combination with his serious medical condition. The poisoning by means of chloralhydrate was possibly caused by giving 1 extra dose of chloralhydrate, which fell within the treatment regime, or by a combination with chloorhexidine which was also prescribed.

Patient Achraf's apnoea could be consistent with his medical condition and breathing problems were also recorded during previous admissions to hospital, according to professor Meulenbelt. Achraf had been admitted for social reasons, because his mother was seriously concerned. There were however actual medical reasons for keeping the child under observation.

The court has presented the question to the Dutch association for pathology and the Dutch association for pediatry whether they would subscribe to the definition for 'murder' or 'incident' which was used in the court of The Hague.

Starting point thereby has always been:

  • sudden and unexpected death or life-threatening incident
  • medically unexplainable
  • presence of the accused

No reply from the association for paediatrics has been forthcoming. The pathologists pointed to the importance of autopsy, because then a better - though certainly not in all cases - indication can be given for clinical events. It would appear that in approximately 20 - 30% of all cases clinical diagnoses are required to be adjusted.

The Public Prosecution Service then stated that in most cases "an important instrument for determining a cause of death - for understandable reasons - was not employed".

It failed thereby to note that in Lucia's case in the two situations wherein, even though autopsy has taken place and in spite of clear indications from autopsy results of death by natural causes, the Public Prosecution Service nevertheless remained fixed to a murder scenario.

Both a hospital doctor and an expert witness even made the vile suggestion that Lucia had selected her victims because she would know that Islamic parents would prohibit autopsy. The children were nevertheless later exhumed and toxicologically examined.

Pleading the case

Stijn Franken emphasised once more in his evidence that a great wrong has been done to Lucia. It wasn't Lucia who was responsible for prescribing large amounts of medication it was the doctors. Amber's condition was worse than was indicated by the doctors who had been treating her. The monitor print-out showed clearly that breathing had stopped before blood circulation. Contrary to that which had been claimed.

Franken believes that Lucia's medical condition demands a rapid conclusion to the case. Nothing, it seems, remains standing in the way of that. A longer lasting trial would economically burden the state unnecessarily.

Lucia

Lucia is trying to pick up the pieces of her life, but the continuing uncertainty persists. Her prison sentence was terrible. But it is even more terrible that her trust in people has decreased. If you can, without cause, from one day to the other, be suspected by everyone of serial murders of children, the elderly, of witchcraft, of arson etc. If family members, friends, colleagues, Uncle Tom Cobbley & all suddenly believe that you have done something so terrible, something you personally consider yourself never ever to be capable of, that you can't even imagine, that is something very difficult to comprehend.

Lucia has paralysis to her right arm. That is permanent, and annoying, cumbersome and painful. It is also terrible that at present she lives beneath the poverty line. Due to her unique legal status she does not qualify for benefits of any kind. Something must be done about that situation as soon as possible too.

Expectation

Today has shown where Public Prosecution Service stands. The finding of truth and not speculation. For this reason no more attention is paid to a rumour that yet another diary quote has been uncovered. Truth is: there were no murders. Truth is moreover that the diaries have all been submitted & examined. Also the Public Prosecution Service is aware that diaries can give speculation a clear reign.

In Lucia's case the facts have now been put straight. The speculation, the (miss)representation is however stubborn and requires a change in attitudes and behaviour.

Public Prosecution Service seems now to be giving the right example. I can only hope that all those who have prosecuted Lucia follow them in thought & deed.

Snow clocks

# The court of Arnhem, no incongruous questions “yet”

Written by Metta, 20 February 2009
Translated by Marty, needs editing
Court of Arnhem

On the 19th of February the court of Arnhem voiced their initial interim decision in Lucia's Judicial Review. After the “criminal-forensic” orientated performance by the Advocate General (AG) mr Brughuis two weeks ago it was clear that the Public Prosecutor (PP) still only wants one thing: Continuation of the witch-hunt. Considering their long list of applications the proceedings could turn into an endless vitriolic conflict. The court did not give the PP the scope. Only a few of the PP's requests are to be included in the investigation. The remaining questions are not considered necessary for the time being.
According to the court there is sufficient factual evidence. It is not expedient in this complex case to do the whole thing all over again superficially. “It's actually all about” the court said delicately, “exhaustive investigations which were by no means lacking in a criminal-forensic approach to the facts and circumstances in the period between 1997 and 2001… The value of revived witness statements, eight to twelve years later, is therefore considered limited. The importance of scientific evaluation of the available material remains undiminished. According to the court this does not however mean that all the evidence plays an equally important role.”

The tone in the courtroom could be described as congenial. There was an appropriate detachment. Some subtle criticism was offered about the manner in which the PP had begun. To do everything all over again was not what the judicial review was meant for. The court wants specifically to follow the line of inquiry along which mr. Knigge has already embarked.

Four events under consideration

The court has decided to consider 4 incidents, namely:

  1. Demise of baby A.Z.
  2. Resuscitation of A. el G.
  3. Poisoning of A.N.
  4. Demise of A.N.

For the investigation of these four cases, that are still called “murders” in the charges, the court requires that that the complete dossier is available to experts. The experts may consult with other experts. The court will request that the commissioner of justice appoints these experts.

Case 1.

In the case of baby A Digoxine was discovered in blood-stained gauzes, which were recovered from the abdominal cavity during the second post-mortem examination. Professors Tytgan and Aderjan will be asked to expand on their report to mr. Knigge. Also to be examined will be the comments made by professor Aderjan concerning the origin and condition of the brain matter. It was thoroughly clarified by the court that the representativeness of the blood-like fluid from the gauzes remains contentious.
Professor Meulenbelt will be required to give his opinion on the comments made by the PP that the trendgraphs do not support the theory of a natural death. The biopsies of organs, where available and if useable, will be sent to the Strasbourg laboratory for testing.

Case 2.

The second case concerns the boy Achraf who suffered a sudden apnoea and had to be resuscitated. Professor Meulenbelt will be asked if the worsening condition of A el G could have occurred without any external intervention.

Case 3.

This case concerns Ahmad, with whom a comatose condition and a high blood level of Chloalhydrate was ascertained. During the argumentation professor Vulto's report was definitive. Professor Meulenbelt will be required to give his opinion on this report. And on an alternative scenario as has been written in professor Derksen's book. “How can the blood level of trichlorethanol at 16.30 be explained?”. And “what do you wish to observe, that in your opinion makes this case so important to the judgement?”

Case 4.

Case 4 concerns Ahmad. One month after the Chloralhydrate incident he dies after an surgical procedure. Request to professor Meulenbelt to asses this in relation to the normal blood tests 45 minutes prior to death.

Searches

The court does not wish to hear any witnesses that the PP might have prepared concerning possible diary entries.

Rehabilitation

The rehabilitation service will only be asked to provide an update on Lucia's condition. Details from the past should not be part of the rehabilitation report.

Comment:

The court's interim judgement looks promising. It was obvious that the preference was for an independent scientific approach. The dossiers are to be thoroughly examined and the experts may make whatever comments they deem appropriate.
This is a totally different approach to the court in Den Haag. There, according to the CEAS, experts were chosen more for their personal notoriety than on any basis of expertise. The medical information was, in many cases, incomplete. And the method of inquiry allowed no room for discussion of any other possible scenarios.

There may remain a certain lack of clarity on some points. In medicine it's not always black or white. The human body does not always react according to the book. Symptoms cannot always be explained. And mistakes can always be made.

# Press Release

13 februari 2009
Isn't it time that "committee Lucia de B" put out an English language press release, something like this:

The traditional legal "witch hunting and burning" season has just opened in the Netherlands: the case of Lucia de B. has been reopened, but instead of following the legal procedure, according to which the judges simply reevaluate the verdict in the light of the new evidence which has been determined by the Supreme Court, the Public Ministry has taken the opportunity to ask to do a new investigation into each of the seven deaths and three other medical incidents. They have hired a commercial forensic science firm who has promised them to get "proof". Of course this "proof" will cost the Dutch tax-payer a lot of money but this is all just a matter of normal business. The reputation of the Dutch justice system is at stake! We cannot allow "guilty" persons to avoid punishment! The "proof" won't be proof in the scientific sense, but it will be complicated enough to confuse the judges and will likely result in the nurse going back to jail. And if not, the Public Prosecution service can always appeal to a higher court…

In the Dutch system you are innocent till "they know" you are guilty. From that point on it is only a matter of time, since "they" will eventually find "proof" sufficient to convince the judges. [In scientific terms: an i.i.d. Bernoulli (p) process with positive p. You go on tossing a two-sided coin and sooner or later it will always come up "heads" yet again.]

They will always get new "convincing legal proof" against you, even if you have managed to prove your innocence and get out of jail in the meantime.

Even important public figures in the legal sphere find this appalling but since we have "trias politica" they cannot say or do anything about it.

[Source: a theoretical scientist who could only speak to us under condition of anonimity – via email Richard Gill]

# Lucia de B. released (for the coming 3-6 months)

2 april 2008 10:45
From the Dutch News
Translated by Corine, unedited

THE HAGUE – Lucia de B., who was sentenced to life in prison has been released. Minister Ernst Hirsch Ballin and secretary of state Nebahat Albayrak of the ministry of Justice have given their permission.

Lucia's prison term has been interrupted, for now for 3 months. After that there will be a review to see if there is a reason to extend this period. The nurse from The Hague was sentenced to life in July of 2006 for 7 murders on hospital patients and 3 attempted murders.

Advice

The decision to release her for now has been based on advice from the top of the Public Prosecutor's office.

They had pointed out to the minister and the secretary of state last week that the advocate-general of the High Court has serious doubts about the safety of De B.'s conviction and will therefore ask for a review of the case.

He also argued that De B. should be released while the case is in review.

Review

Advocate-general G. Knigge is at this point in time preparing the review for the High Court. He is striving to enter this in the proceedings of the highest court in The Netherlands within the month.

De B. was released “suddenly” from prison in Nieuwersluis and is with her partner and daughter, according to her counsel. He is not releasing her address. Her release was so suddenly that she did not even have the opportunity to say goodbye to her fellow inmates.

# Welcome home, update

25 March 2008

Hi Carole

Just to bring you up to date on (non)events here in NL. I heard that Lucia was getting pretty despondent as recently there have only been disappointments.

The "advocate-general" of the Supreme Court is still busy investigating the digoxin question and the statistical question of the "more deaths on the ward before Lucia worked there, than during the time she worked there". This means that the JKZ is again busy providing data for the state's top lawyers, and have as always a monopoly on that. I guess that the outcome of the digoxin research will be that experts' opinions differ, so this will mean that there is no need for a reopening. The conclusion may come at the end of April.

In the meantime the Supreme Court has reported on the possible reopening of another celebrated case, the Deventer Murdercase. Their answer is "no" and they have trotted out the same old formalistic reasons for this. Well, at least they are consistent. New opinions of hundreds of top experts are nothing, since this is not a new "fact", just a new opinion. The only opinion they find worth listening to is the opinions of experts whose evidence was already instrumental in the original conviction. If that expert changes their mind, then … well then it might be interesting. In the Lucia case there is little chance of this since the key experts for the prosecution have already showed themselves to by immune to any argument. Since their reputations already got so tarnished, they are not going to lose the respect of their last friends (high court judges?) by changing their minds, now.

If a court did not provide an expert with highly relevant information this is also no ground for reopening, since the judges' wisdom is indisputible. As long as the judges do not bring this information officially (ie in the context of a retrial) to the attention of their old experts, those old experts, the ones of the formalistic nature, will not make any comments on it. A nicely closed circle.

The government is bringing in a new law which gives the Supreme Court some own new possibility to do actual research into the original facts (rather than just the procedures) in controversial closed cases. One need not expect the Supreme Court to take much of this new opportunity given their past record. In fact, recent laws which were supposed to make judges more accountable have been deliberately sabotaged by the Supreme Court which instructed the judges to take no notice and keep things how they were. This is the wonder of having an independent judiciary. Our parlement members never check to see if the laws they make are being followed, so they are blissfully unaware.

On the up side, there have been reports of the review committee on two other dubious cases, and they were both damning of the police and public ministry and exposed the same old tunnel vision again. Ton Derksen is about to publish a new book (it will come out in a month) in which he analyses the failings of the public ministry in five cases, one of them is Lucia's of course. His original book was focussed on the arguments of the judges but in our system there is no point in criticizing judge's arguments … the only thing that can be criticized is their procedures, and the only ones who can criticise those, is the Supreme Court.

How was Argentina? How is your health?

x Richard

Ceterum censeo Luciam liberandam esse

Lucia de B., a witch trial

# Progress or stagnation

17 February 2008
Written by Metta
Translated by Marty, unedited
Novum & Nova

After publication of the Grimbergen report on the 29th October 2007 it seemed there was some progress in Lucia's case. The report was very clear – the furnishing of proof was unsound and there was evidence of large scale prejudice during the investigation.
The Procurator General of the high court of the Netherlands does not however take up the commission's advice to reopen the case (there is even talk of acquittal). Conversely, the PG of the high court of the Netherlands decides to carry out another enquiry, even after the very extensive Grimbergen Commission enquiry. It's now purely about the academic question of whether or not there is a Novum.
Grimbergen states that due to the latest understanding of the so called Digoxin poisonings – which are now discredited as a form of evidence – a Novum has been created. Novum or no, there is someone who has been imprisoned for over six years because of that unreliable Digoxin story. Worse still – the 6 other murders and 3 attempted murders that have been ascribed to Lucia are also not proven, but must have been just as cunningly carried out as the murder by Digoxin. Those who shout so loudly that, after all, Lucia committed all those other murders too, really should take a closer look at the case judgment. By applying the Chain evidence the judge thought he'd cleverly attached the other 6 murders to Lucia too. Again – if child A was not murdered by Lucia then the other deaths were not murders, but most likely deaths by natural causes.
Because the investigation by the Grimbergen Commission only concentrated on certain aspects of the case it has not emerged that other Nova – new evidence – can be produced. For instance the fact that serious symptoms of illnesses such as chronic diarrhea were not reported but viewed as normal intestinal passings. Or that a possible fatal prescription of medicines or an incorrect diagnosis were not reported.

Suspension; What is the risk of stroke inside prison?

Lucia requested suspension of detention. This was rejected by secretary of state Albayrak after an investigation. Two years ago Lucia suffered a stroke 3 days after the appeal judgment, right out of the blue. The fear that this could happen again during such a stressful period is not irrational. It is in any case more logical than the argumentation from the consultant neurologist, who argued that in scientific literature it is disputed that stress is a risk factor for stroke and attached there on the conclusion that Lucia could just as well remain in custody. Even more surprising is the fact that for such an important recommendation there was never any face to face consultancy.
Lucia remains in Nieuwersluis, with or without the increased risk of stroke.

Stay put where you are and don't you move… beware of the kangaroo-courts!!

Not only Lucia has to remain where she is, the high court also requested that her supporters don't make any “noise”. In the Dutch Jurist's news from this January an article appeared which made reference to a kangaroo-court, a people's tribunal, by a bunch of scientists that let themselves be wound up by the likes of Maarten 't Hart and Richard Gill. The petition for reopening of the case was seen as unwanted meddling into the business of jurists; a citizen, even a scientist, shouldn't meddle in law. Vice versa, apparently a jurist is perfectly entitled, at his own discretion, to apply science in the administration of justice.
It is impossible to call the torch procession on the 5th of January a revolt. It was a dignified gathering that literally gave Lucia a little light in her darkness. The media even did their best in their reports to play down the numbers of participants. Why they spoke of “dozens” of people when there were 122 of us there (excluding the many journalists) is an interesting phenomenon of itself.
Does that have anything to do with the fact that editors will not give their reporters permission to make a program about Lucia? Because even now an editor in chief dares to say “it may look like something else right now, but what about her Canada-past and all that other weird stuff…”

The Monster Trial, poignant theatre.

In the theatre show “Lucy. A Monster Trial” by Hans van Hechten the theme unfounded insinuations was covered in a penetrative manner. For those unfamiliar with the case it would have all been less recognizable, but the ease with which one takes hold of a general representation and shuts oneself off for alternative scenario's was splendidly portrayed by the two judges in the piece. The listened condescendingly to what the young psychologist had to say about the psychological diagnostics and the evidential argumentation, but they didn't falter, they knew netter…

Beyond shame?

For over three years the committee for Lucia has used facts and scientific argumentation to report how Lucia is being unjustly imprisoned. But those involved in the judicial process appear not to want to give way. Worse still; a doctor reads nothing concerning the case, wishes to know nothing about it, while he played an important role in the trial. As far as he was concerned the case was closed for him…

In the medical world there are waiting times due to pressures of work. As a doctor one is ashamed of that. You don't want your patient to have to go through that and a seriously ill patient can usually rely on a fast-track diagnosis and treatment.
Is the Dutch Legal system beyond shame that they allow Lucia to wait for so long?

# Lucia in the marshalling yard of the Digoxin-locomotive

1st January 2008
Written by Metta
Translated by Marty, unedited

The case of Lucia de Berk was, due to the medical, statistical, legal and emotional aspects, extremely complex, but appears now to have been made even more complex because of the PG of the High Court of the Netherlands. Yet another investigation is to take place, even after the Buruma and Grimbergen commissions have already just completed extensive investigations. There are very few people who actually understand what the case of Lucia de Berk is actually about. Wasn't the conclusion of Grimbergen's CEAS (Commission for Evaluation of Closed Cases) that there was evidence of very grave inadequacies?

Transposition from death by natural causes to murder

The core of the case of Lucia remains simply that no murders were committed. Nurses and medical practitioners initially indicated Lucia as a “possible” murderess in a state of collective paranoia. The murder cases were contrived at a later stage using Lucia's shift roster. They were all deaths by natural causes that, sometimes years later, suddenly were made suspicious, purely and simply because Lucia was present.
The court defines a murder in this case as a death that is 1. Unexpected, 2. Unexplainable, 3.
Happened in Lucia's presence. With this criteria the court has created an extremely large playing field. An unlucky person could be innocently hanged while a clever crook laughs up his sleeve from a distance.

Self made statistics

Lucia's case is based on the anxious misgiving that “there really were a lot of deaths in that JKZ”. At least that is what was said to in April 2004 to the new Chef de Clinique, but in hindsight appears not to be corroborated by figures… This assumption later becomes coupled by the JKZ to the fact that Lucia was present a couple of times at a reanimation and death and a story from a so-called friend & colleague concerning “weird things that always happen around Lucia”. The hospital goes and makes its own calculations as to how great the chance would be that Lucia “that often” would be likely to be present at incidents. Later statistical research is carried out by Elffers and De Mulder, which, like the JKZ comes to the conclusion that “it can't be a coincidence”. Professors of statistics, nationally and internationally, have attested to the fact that the statistics were handled in an uninformed and disgraceful manner. One in nine nurses is likely to experience what Lucia did. That is a completely different figure than that Elffers delivered, a one in 324 million chance, that was used as a starting point.

Pseudologica Fantastica

The case against Lucia began with the death of child A on 4th September 2001. The day after the death of A it seemed as if there was an eruption of bottled-up feelings and mistrust, jealousy and condemnation. Strange, because just a few days earlier during her performance interview Lucia was described as a fine colleague, who was good with the children and their parents and reacted adequately in crisis situations. It remains the most bewildering aspect of this case that from one moment to the next everyone believes that Lucia is a mendacious psychopath and how the most fanciful stories were greedily consumed. And that a complete legal system goes along with it as well. Even the fact that Lucia never confessed was used against her as a sign of her mendacity.

Prelude

Three days prior to the death of child A a reanimation took place on a boy who was, according to the doctor in attendance, was only admitted on social grounds. His mother was afraid that, after the death of a sister a year earlier, something might happen to this child too. The children were suffering from a serious hereditary disorder, whereby attacks of apnea may occur. The child has such an attack. Why they later attempted to paint this apnea attack as an attempted murder by Lucia, without any tangible evidence is a mystery. The doctor in attendance X in any case persisted obstinately with her opinion that an apnea attack was, in this situation, unexplainable, while the expert witnesses have their doubts over this. The court had a choice…… and followed the opinion of Dr.X.

Almost immediately after the death of child A this reanimation also becomes suspicious. Much like the way the death of child A suddenly, after internal consultations, becomes suspicious. Initially there was an declaration for a natural death issued for child A. Directly after the death there were no thoughts of murder, let alone murders. As the CEAS explicitly points out there were many arguments for not thinking about murder. The child was seriously ill and, as professor Uges – expert witness in the case – also pointed out, it was more the question what the child didn't die of than what it did considering the serious multiple disorders.

Corpus Delictum?

According to the court Lucia is supposed to have poisoned child A by way of o Digoxin injection. There was no witness, no evidence, but there were raised levels of Digoxin found in blood from swabs. A year after the death the swabs suddenly come to our attention via a police officer. The swabs were apparently recovered from the (previously cleaned out) body cavity of the child during a second post-mortem investigation and contained therefore mainly bodily fluids. The origin of these swabs – THE Corpus Delictum in this case – has always remained unclear.

As was presented by the court the Digoxin evidence functioned as locomotive for the body of evidence in the other ‘murders’. Lucia was supposed to have acted in a similar way in all the other deaths. This broad line of thought is called in legal language chain evidence. It follows the principle of “once a thief, always a thief”. But what if the thief was never a thief in the first place? And, in Lucia's case, there was never any Digoxin poisoning in the first place?

CEAS quotes

The CEAS (Committee for Evaluation of Closed Cases) shows that the Digoxin evidence is flawed in all aspects. They quote the statement from Koren, an expert in the area of Digoxin: “in summary, I am of the opinion that that any attempt to interpret the post mortum levels as proof of poisoning (accidental or deliberate) is untrue and, in all honesty, quite shocking. The idea that a professional in the medical sector would be imprisoned due to such an incorrect interpretation is absolutely unacceptable.”
Moreover, as the commission states: “on the basis of many other arguments it has been shown that baby A.Z. did not die of Digoxin poisoning.” There is, according to the CEAS: “a substantial difference in scientific opinion”, and the commission adds the following: article 457 of the penal code determines in which situations review can be requested. Such is, amongst other things, possible “on the grounds that any detail that was not shown during the hearing of the case and which of itself or in conjunction with previously submitted evidence shows the judgment to appear impossible in a way that serious suspicions exist that were they known, the investigation of the case would have lead (…) to acquittal of the condemned person (…)”

Scientific difference of opinion?

The Attorney General of the high court saw no reason to “without delay” go along with the CEAS's recommendation for a judicial review. Even though a thorough and meticulous investigation lasting a year and a half has been carried out the AG of the high court saw fit to initiate another investigation. That investigation was to direct itself to the number of deaths in the JKZ in a period before Lucia worked there and to the differences of scientific opinion appertaining to the Digoxin poisoning.

In my opinion this is not about differences in scientific opinion at all. The Digoxin investigation in the Lucia case has never been scientific. In the first place, as already stated, the origin and the reliability of the investigative material is very dubious. But also two out of the three test methods employed were incorrect, whilst it was precisely the results of these inaccurate methods of testing that was used as a basis. These two immune-assays cannot differentiate between Digoxin and in the body naturally occurring Digoxin-like chemicals. The other method, the HPLC-MS was recognized – including by expert witness professor de Wolff – as the (only) standard.

Averages from inaccurate methods of testing

The two crude methods gave results of 21 and 25 microgram/liter Digoxin respectively; the good method gave a result of 7 microgram/liter. “The two results from the immune-assays are nicely close together”, the court says, “therefore … we should take an average of these two and we can better ignore the 7 microgram/liter from the fine filter test.” This is how they arrive at a figure of 23 microgram/liter and ‘take some off’ because due to evaporation and contamination the concentration would have risen. The remaining 19 microgram/liter is so far above the 15 microgram/liter that de Wolff indicates as the toxic level. Ergo there is Digoxin poisoning.

Even so they were not really so certain about the oh so nicely close together results from the immune-assays, because in April 2004 the NFI sent material to a lab in Strasbourg asking them to prove a “miracle”. At the end of May the court declares that there is no longer any reason to wait for the results from Strasbourg. There is enough evidence after all…

Report from Strasbourg, a Novum

Three days after the court's judgment, whereby the Digoxin evidence is the most important mainstay of the whole body of evidence, the report arrives from Strasbourg. Only two years later does this actually come out of a drawer at the NFI, through the actions of a journalist from NOVA. At a sitting of the Court of Amsterdam in June 2006 the PP now does wish to add this report to the case files. The court rejects this request and thereby implicitly confirms the advocate's position that the report may serve as a novum.

The result of the test in Strasbourg shows, just like the HPLC-MS, a concentration of 7 microgram/liter in the swab-fluid at a concentration level in the liver of 0 microgram/liter. THE international experts in the field of Digoxin are of the opinion that due to post mortal redistribution (the release of chemicals from tissues after death) there must always be 5 micrograms subtracted per 24 hours after death (in this case it was 50 hours later). There remains therefore only minimal levels of Digoxin. Consequently, according to the experts, there can be no talk of a poisoning here.

Yet, even without these Digoxin scientists, the report from Strasbourg surely proved that they should never have ignored the HPLC, the more accurate method, in favour of the two inaccurate methods. Why did the CEAS not point specifically to these unscientific and false work methods? There isn't in fact any difference in scientific opinion at all, as it may seem at first glance. In this instance the body of evidence has simply been treated very unscientifically.

Digoxin, origin and source

With Digoxin the half life in tissue is not know. What is known is that Digoxin is stored by tissues in very high concentrations (in the hundreds of micrograms). Either the Digoxin is a remnant of pre-operative medication, or that there was in fact Digoxin prescribed in between times due to failing heart function, or that it was administered accidentally makes no difference to the conclusion that there was in fact no poisoning. Where the Digoxin originates from is a completely different question to that of whether Lucia has committed a murder or not. If it weren't for the tragic consequences it would be almost comical to observe how the court made a time-reconstruction whereby the moment of administration by chance coincides with a medical examination. They had forgotten to include the continuous trend-graphs in this reconstruction and only considered the trend-tables that register every 15 minutes.

Alternative scenarios

Because there was so much attention paid to the Digoxin, the clinical records and records from the section report have disappeared way into the background. Stinking diarrhea, a collapsed lung, an enlarged ventricle muscle, fluid on the lungs and brain should have sounded ominous even to a jurist. But it was preferable to attach value to the statement that “the heart operation was a success” and “the child was going to go home”. The remark about going home should however be placed back into its context. It is possible if… and it certainly did not indicate that there were no further problems. Now the possibility of going home is grasped as evidence that the child was doing so well. The same thing appears to have happened with the medical examination three quarters of an hour before death. The court cannot possibly link such an examination with a natural death. people don't die after such an examination… The court is not prepared to accept the notion that death sometimes comes unseen and/or the doctors in this situation had underestimated the situation. Is it medical pride or legal logic that they are not prepared to consider that the child ‘just’ died of the seriousness of her complex defects? Contrary to what everyone had hoped?

Collective hysteria

In the case of Lucia de B. it's primarily about fear. About the fear of all of us missing that there were one, maybe more, murders committed. For the doctors, for the nurses and for the jurists it was no longer the question from which illnesses did the patients suffer and from which of these could they have died. No it was about which deaths could “possibly, maybe after all” have been caused by a murderer's hand.

In September of 2001 a collective hysteria was let loose in the JKZ (Juliana Kinder Ziekenhuis). Instead of the PP distantly and calmly instigating their own investigation they allowed gossip and sensationalism to predominate unchecked. The director of the JKZ went public at an early stage with his suspicions and with that gave out a clear signal: “we, in the JKZ, have captured a serious criminal”. The JKZ played a coordinating role in the investigations, strange when you also take into account the fact that the JKZ was also the complainant. It is noted In the CEAS's report that there was emphatic coaching emanating from within the JKZ. The experts were chosen more by their personality than their scientific arguments. The CEAS uses the expression intuitive feelings. What isn't noted is that a reciprocal influencing existed between the medical practitioners and the jurists. It is all very human in the light of a Great Suspicion. It does mean however that the light went out for Lucia.

Self made forensic psychology

The fact that yet another investigation is now taking place in the same hospital where they previously took up such a position without being open to alternative scenarios, I believe to be (putting it mildly) incomprehensible. In the circle of Pediatricians in Den Haag we have been warned, by way of personal insinuations, against any criticism that may come from our corner. Everyone in the hospital and surrounds must be silent, and is silent too. But everyone also knows that it could very, very easily be different. Only that crazy Lucia…, how she enjoyed her trial! Yes, that is something that jurists, practitioners and journalists are still saying while keeping a straight face. You really shouldn't bother yourself for a person like that?

But even this last non-argument is based on gossip and lies. In the evaluation from that same JKZ was, as has previously been stated, often mentioned how she was a fine colleague, who is good with children, has empathy for the parents and someone who you, as doctor, can rely… The witch-stories, that go around even now, are in no consistent with the report from the Pieter Baan Center. It is evident however in the sensation-psychology in the court room, possibly also coloured by psychologist Ligthart. How dare this so called forensic-specialist psychologist immediately brand this woman as a classic psychopath who even attempted to seduce detectives, without carrying out any kind of thorough examination?

The true heart of this case has remained (or been kept) out of sight due to the restricted nature of the CEAS's questioning. That is: “why could it have been so haunted in the JKZ in September 2001?” And it's there, of all places, that this new investigation is to take place. For a new Ghost-story?

The top-hat?

In the mean time a woman has been imprisoned for the last six years, has suffered a stroke due to all the stress surrounding the appeal judgment from the high court, as a result of which she is semi-paralyzed. That seems to be almost by-the-by these days. We are now after all struggling for the rights of OUR diagnostics, for OUR statistics, for OUR toxicology, for OUR journalism, OUR administration of justice. We're talking about 2008. I wish Lucia a good new-year. You too?

# We didn't do so well……

14 October 2007
Written by Metta
edited by Michaela

In the NOVA TV broadcast on 29th September 2007, Professor Buruma said he feels uncomfortable about the fact that the Grimbergen commission is taking so long. “If this woman was imprisoned while she's innocent, then…”.

In the Hague they apparently think differently about it: they are investigating everything very thoroughly, the case is very complex and there are many, many people involved…
And then for the sensitivities…

If – without any thorough knowledge – you instantaneously speak out to let everyone know that vulnerable children and elderly people fell victim to a terrible monster, then yes, explanations during such a hysterical witch-hunt will become rather difficult and complicated.

There were NO victims – but there certainly was an overstressed reaction on the part of the JK hospital. An overstressed reaction – adopted by the police, the Public Prosecutor's Office and the judges. The information the hospital produced appeared ostensibly scientific and reliable. Physicians, Jurists, the Media and ‘the Public’ were (initially) sympathetic to the hospital, which was a first reaction to these ‘horrible events’. They hadn't – nor were they ever given the opportunity – examined the case histories in their true context and proportions. These people knew and respected each other, which in itself is an agreeable human bonding resource, but in this case it turned out to be a lubricant.


It is astonishing to read that people, who knew nothing of the facts nor of the people involved, developed such a blind hatred for Lucia and even begrudged her a budgerigar in her cell. “It must be true, Lucia is a witch isn't she? The judge has spoken”.

It's also rather worrying that those who are closely involved in the case will not even take the trouble to study newly presented facts.

After all, ‘you shouldn't have to present new studies… We did a good job.’


In a democratic country, can't someone pick up the cause for a fellow human being who has been sentenced to life imprisonment, while there are very strong indications that she is innocent?

The JK hospital, the Leijenburg hospital and the RK hospital pointed their finger at victims by the hand of Lucia, through their diligent searches in service records they labelled people as having been murdered who weren't murdered at all. The deceased people were turned into victims once more, through all the misery of a police investigation, they were not victimised by Lucia! It wasn't her fault that the process of grief was so dramatically disturbed, a process which is still going on, up to the present day.

There are complex, and sometimes grey areas surrounding the deaths in Lucia's case. Under which circumstances is a death ever to be precisely expected or is it totally explicable?

“What exactly happened when this patient was dying? Is it be possible that this patient died due to the administration of a toxin…?” the judge asked.
Yes, possibly, perhaps, maybe, it could have happened, but are there any indications that something like that actually happened?

The Jurist wants to hear a definite yes or no, where as the physician can never give 100% certainty. That tiny percentage of uncertainty , that “yes, but maybe, perhaps” became the hole into which Lucia stumbled… or more derogatively: she fell into a pit which was dug for her.


Ergo: there were no victims, but only children and elderly people who – to our regrets – were seriously ill and who came to die in a hospital, just as many other people die in hospitals. There was this gossip about a woman, about someone who wasn'an average person, who wore short skirts and didn't have a common background. This gossip, in the year 2001, facilitated blaming Lucia for these deaths, even while they – the gossipmongers – were incapable to act in a professional manner. The gossip overhauled into an avalanche of ghostly stories, taking on such proportions that there was no turning back.

The turning point should be Now!!  Even though it is always too late.
With six years and a brain haemorrhage, how much more can a person take?

If Lucia doesn't survive, at least we will know the truth.

# Sorry Lucia……!

16 September 2007
Waiting, waiting, still waiting……
In fact we're only waiting for two words – “Sorry Lucia”.

The Grimbergen Commission examines and deliberates. And the college of PG watches over the health of the Public Prosecutor. Everyone is getting nervous because the commission is taking so long to make their decision. People who have been heard by the commission say that they have had a serious conversation. But otherwise it is not possible to give any indication as to how it will go.


# Public Prosecutor's failures

# a. Flawed statistics

It is now clear to all that gross mistakes were made with the statistic which led to the conclusion that “it cannot be coincidental” Lucia was present at so many incidents. It appears that 1 in 9 nurses experience that many incidents.
Wasn't the cause of all the suspicions in the Juliana Kinder Ziekenhuis because of that many? And haven't expert witnesses said that each death, when looked at individually, could be viewed as a natural death but when viewed “all put together” they must be unnatural. Don't we read in the arrest that there can be no talk of chance and that it can only be Lucia who is responsible for all the suffering.
Sorry Lucia…

# b. No murders – medical data has not been examined

The Grimbergen commission has mainly concerned itself with the points mentioned above. As a medical person I find it amazing, to put it mildly, that there is no place within the remit of the commission's examination for the interpretation of medical data. Lucia's drama begins with the transposition of natural deaths into unnatural deaths.
Sorry Lucia…

# c. The Digoxin evidence is wrong

It has in the meantime been shown that the locomotive, which was supposed to pull all the other evidence along, is unreliable and is now removed. With this the oh so cleverly constructed chain-evidence falls apart.

The evidence that Child A was killed by Lucia with Digoxin has been weakened for a number of reasons. Firstly, the time calculations which were to prove Lucia's involvement, are incorrect. The clinical and pharmacological tests for Digoxin actually showed many imperfections. The tests on the wadding containing stomach fluid (not blood) appeared to be unreliable and the information given to experts concerning the history of illness and post mortem findings was incomplete. On top of this the results gained by incorrect test methods are used in evidence, while results from the golden standard method, as employed in Strasbourg, remain lying in a drawer somewhere. International experts such as Dasgupta and Koren

State that there can be no conclusion, on the basis of these results, that there was any such Digoxin poisoning.
Sorry Lucia…

# d. The compulsion theory is a misleading construction

The Compulsion story and the interpretation of the diaries is also a theme for the commission's examinations. Here too, if you ask me, one can only come to the conclusion that this was a crazy search for a culprit.

In Lucia's diary the word compulsion appears on seven separate days. On one of the days the hospital was able to find a death at which Lucia was present. This concerns patient Z, who was in the terminal stages of cancer and was likely to die of serious complications at any moment. The doctors involved and other experts have stated that her death (as far as it is possible for a doctor to determine) was natural, in other words explainable and expected. A surgeon wrote, after the court case, a letter on his own initiative in which he let the Jurists know that in his opinion there had to be a case of murder here. And, even though he wasn't present at the death and couldn't produce any evidence, with his letter the death of Mrs.Z suddenly became an unnatural death, caused by Lucia.

This is how the diary-word compulsion was linked to an urge to kill.
Sorry Lucia…

As has already been described on this site Lucia has always stated that the word compulsion meant to her the sometimes difficult to suppress urge to read the Tarot cards for patients. She knew that a hospital wasn't the place for this and she was embarrassed by it. But nevertheless she read the cards for her patients now and then because she believed that she could do some good for them by it.

# e. Incorrect image forming

The Public Prosecutors and the Jurists didn't want to believe that the word compulsion referred to the Tarot. It must be the urge to murder. That's why the death of patient Z must be recorded as a murder.

Lucia's interest in the tarot was gratefully used in the image forming. It was one of Lucia's peculiarities that made her, in the eyes of the Public Prosecutor, a strange and dangerous woman. They literally wanted her to be seen as a witch because of a bumper-sticker on her car with “witches on tour”. The fact that the sticker was on the car when she bought it was no longer important. The story remained.
Sorry Lucia…

# f. Persistence of fables

It is almost characteristic of the Lucia case that these (nasty) ‘fables’ stubbornly remain, at all levels, even though they've been proved to be false.

The Canadian police have been able to find absolutely nothing that could point to a criminal past or an arsonist's youth. Yet this is still reported in writings as being the truth and even that it fits perfectly within the profile of a ‘serial hospital killer’. Lucia also has no drugs history or a cross carved into her chest, or a cupboard full of poisons, etc, etc, as is even believed by important functionaries. They are hysterical stories, which apparently are meant to compensate for the fact that there is actually no evidence at all for murder.
The Collaborative story telling, as Professor Wagenaar calls it…

Why has the Public prosecutor never clearly stated in the inquiry that these stories rest entirely on insinuations? Why, last year, in the court in Amsterdam, did an officer of justice refer to “the poison at home”? That has to be slander against a defenceless citizen.
Sorry Lucia…

# g. Disastrous psychology and negation of a report

The Pieter Baan centre has stated clearly that Lucia has no psychopathic signs and there is evidence of a well developed sense of conscience. The examiners in the PBC saw no reason to doubt Lucia's explanation for her writings and her diary notes. Still the more hard-hitting utterances of forensic psychologist Lighthart remain with the Public Prosecutors, Jurists and the public (and writers). At the beginning of the process on a couple of occasions Lighthart observed a silent (on her lawyer's advice) Lucia through a one way screen. He knew immediately that there sat a specially dangerous and deceitful serial killer, one of a kind.
Sorry Lucia…


# A sorry from Lucia

Lucia has asked me to pass on her apologies for not answering all the cards and gifts she receives. She gains a lot of support from all the letter and card writers. But at the moment she is so on edge that she can hardly do anything at all. Once again she wasn't at her daughter's birthday, once again she spent her own birthday alone in her cell.

She does have hope, “it can't be anything else, it's written so clearly on paper.”
But she knows better than anyone how legally 1+1 doesn't always have to add up to 2.


“And if the commission actually decides that the case should be reopened, how long will all that take?”

Maarten 't Hart will, with us, happily stand as surety for Lucia. If later in a report it is shown that there were discrepancies in the Public Prosecutor's investigation there surely can be no reason any more to hold someone on remand for longer than 6 years.

How humane are we in the Netherlands? Are the procedures and the image of the authorities and personalities more important than the lot of a disabled woman in prison?

# Will you go on holiday feeling confident with the Dutch legal system?

21 July 2007

Once again an important decision for Lucia is deferred until after the holidays.
Though this may mean that the members of the commission can go away and enjoy their rest, it's at Lucia's expense. It's her time that is being stolen. For the last six years she's spent her summer holidays in Nieuwersluis prison.

She has become tired and anxious from all the waiting. Her arm and shoulder hurt. It wakes her up at night and she turns and turns about in her bed.

“She walks through the hospital and then it turns into a nightmare”. The nightmare can't be any worse than the one she's already experienced.
With a paralysed right arm and hand to cope with, prison life has become even more oppressive. She needs help with all sorts of things, help that isn't easy to find.


The newspaper De Telegraaf reported that the lawyer, Ton Visser, was considering summary proceedings because Lucia wasn't receiving the treatment that is indicated for her disability.
Physiotherapy was often cancelled these past months and she's had no help with the exercises she should be doing to regain strength in her muscles and, so she hoped, relieve some of the pain.

Luckily there is now a clear agreement that the prison will provide twice weekly therapy and help with the exercises.
But a holiday, no… not for Lucia.

Will it ever be holiday time for Lucia?

How much trust can we have in the Dutch legal system if there is, apparently, no sign at all of any sense of embarrassment in delaying for many months putting to rights this terrible miscarriage of justice.


This week an inquiry was published that showed that 61% of the Dutch population has confidence in the administration of justice in the Netherlands.
Even after the Schiedammer case the disquiet among the population quickly abated, say the Public Prosecutor's Office. There's no mention of Ina Post, Deventer and Lucia. Nor is much made of the 39% of the population that seems to have reason not to have much confidence in the administration of justice.

It is amazing to see how the press haven't said a word on the subject.
In the lobbies it is clear that The Public Prosecutor's Office does not enjoy criticism of its actions from outsiders.
A year and a half ago an insider said, “Den Haag has had more than enough of this, not a single case will be opened”.


On 19th July last, in the NRC newspaper, E.Brouwer wrote a warm plea for how it is still possible to bring (serious) criminals to justice who had previously been mistakenly acquitted.
The PPO understandably feels that this is a good reason to lobby for re-opening to allow justice to be done even years later.
Why then does the PPO have such a problem when it is the other way around? Is this not simply opportunism, unworthy of a judicial power.

The title of the Public Prosecutor's personnel newsletter Opportune appears to be, in this context, a rather sour joke.
The Diepenheimer Goat milker's club wouldn't give its club magazine a name like that.

There is a notion, that is to say talk has been heard, that the College of PG's doesn't want the PPO to be shown to have made mistakes in the Lucia case.
Much less that this was to happen in other cases where a failure of the justice system can clearly be substantiated. Even in the Schiedammer case the ministry of justice continues to stubbornly ignore that there was anything wrong with the PPO's actions.
Who then was responsible for the mistakes and/or carelessness in Lucia's case concerning —

  1. The ‘statistical’ research – the accusation that Lucia was involved with so many deaths
  2. The medical dossier research – the presentation of the case histories
  3. The criteria appertaining to natural or unnatural death
  4. Conveyance of information to experts
  5. Psychological coaching by the research team
  6. Police interviews and investigations
  7. Synchronisation of pharmacological, pathological and clinical data
  8. Application of toxicological know-how and research methods etc.

The Posthumus commission (the Grimbergen triumvirate) was informed both verbally and in writing about what, from an objective point of view, was wrong with the PPO's research methods. It would be an enormous faux pas if the commission, under pressure ‘from upstairs’, was forced to formulate this information in such a way as not to lay any blame with the PPO and for that reason is unable to call for a review. It isn't about who personally was at fault in this wrongful conviction. Each is trying to trip-up the other. That is the essence of collaborative story telling. And the more people who were involved in the process the harder it is to point to where things went wrong.

The only important thing for Lucia is that they admit that there were mistakes made, that she was wrongly convicted.

If, if the commission doesn't request a reopening then the lawyers can draught a request for case-review
It is then, in principle, not about ‘mistakes’ but about a Novum; new information that would show the case in a different light.
Studying this request might take another year, with a lot of manoeuvring again, while it no longer looks like it's about the actual case at all, more about personalities saving face.


Lucia will just have to delay her holiday for a while longer.

The petition for reopening the case has reached nearly 400 signatures. All the University Professor statisticians, except one – who is going to approach a member of parliament – have signed the petition. Many scientist from abroad have also signed the petition, often accompanied by comments worded in no uncertain terms – “A shame!!”

Some doctors and nurses are slowly daring to voice their views, very slowly.

# A Cri du coeur in the “deafening silence”

30 June 2007

It is quiet around Lucia, deafeningly quiet as Menno van Dongen wrote in de Volkskrant.
In legal circles it's also bon ton to be silent whilst a case is being heard. There is no place for outside influences in a court of law.
Lucia has personal experience of how public imagery can influence trials. She was, for example, “a liar”, “too involved”, too thin and too blond.

She would be the last person to say that citizens should be able to force their opinions on judges.


Not disturbing the brooding judicial hen and therefore not displeasuring them would also be desirable. From an objective, scientific viewpoint it's difficult to comprehend this. In the search for the truth it's not about whether it's comfortable for them or not.
In as complex a case as Lucia's one expects that scientific discussions take place that are accessible.
For example the statistician's public debate has shown that professor Elffer's statement “It cannot be coincidence” has damaged the reputation of the science of statistics. Not to mention the impact this had on the whole case and Lucia's life.

However convincing, amicable and sincere an expert witness may be in a court of law, it isn't necessarily the truth.
Science can make mistakes, justice too, history has taught us that. Professor Wolff himself admits that he came to the wrong conclusion because he did not have the correct information, “Lucia could not have administered the Digoxin”.

International Digoxin expert Dasgupta has said the last word – “there was no Digoxin poisoning”.

All things may change, c'est la vie.

Why then is it so difficult to admit this human error, because of which someone in Nieuwersluis has been locked in a cell for nearly six years while innocent. For life. And her loved-ones who have to undergo the imprisonment of a weekly visit as well as the huge void.

Professor Richard Gill has scientifically arrived at the conclusion that Lucia is innocent. Behind, in front or next to him are many Dutch and international scholars. They have signed Gill's petition, see above and in the Links, to get the case reopened as soon as possible.

It is a cri de cour in the deafening silence.


Meanwhile we've been waiting a year for the commission-work for reopening of the case.

Why couldn't they set a time limit for an investigation such as this? A cancer patient would be well within his rights to expect test results within a reasonable time. Of course the investigators have their other work as well, but the commission's chairman has been excused from that for three days a week especially for this investigation. And “more work than expected” could be solved in other ways than with a delay that already is expected to take six months.

The most unfair thing in Lucia's case is that there seems to be a stubborn ‘image’ of Lucia's person.
It's no longer about the content but about the relationships. Moreover, adjacent to this, the most powerful argument wielded against investigating the content of the argumentation any further is “the relative's grief”. What has happened to them is inconceivable. And we find it painful to have to add to that. But won't the eventual rediscovery that it was a case of natural death be easier to bear than the erroneous idea that a mad nurse murdered their loved one for some mysterious reason.

Who was it that held up this terrible scenario to these people, who exhumed the bodies so long after the event without it delivering anything at all?


And now this suffering of the families is to be an argument for letting the case rest?? Double standards is the last thing we expect from justice.
Apparently Lucia must be the reason for all the suffering of the people concerned – even if there is no proof.

Health workers are confronted almost on a daily basis with the ethics of treating medical errors in an honest manner. In the Lucia case there is not talk of grave medical errors.
But the undifferentiated diagnostics and selective information do amount to not acting with medical ethics.

Why is it still so hard to say “I may have been mistaken”. Why is it so difficult to for them to put themselves in the place of that woman, who blond, thin and vocal ended up in a cell for no other reason than that John it heard from Pete, who heard from Mary, who got it from Anne, who heard something about……?

Ah, but, I'm not sure exactly, but it had to be something like that…


Yes, Lucia was a call girl for a couple of years in Canada, but after that she was a good wife and mother who, after years of cleaning jobs, wanted so much to go into nursing.
She didn't have the right diploma and was persuaded to forge a Canadian diploma. Thereafter she had good reports, certificates and performance reports.

She had no poisons in her house, no criminal background, no drugs or alcohol past, no psychopathic nature, etc, etc.
And if you tell this to ‘Insiders in Den Haag’ the answer is “but why did she have so many plastic bags in her house?” Insinuations, insinuations…

If you believe, as we do, that Lucia has a right to justice, then sign our petition.

# Terminal uncertainty

27 May 2007

May is almost over and with it the term that the Grimbergen trio thought they needed for the investigation. The case of Lucia de B. is, of course, complex. A reopening of the case has serious consequences for those involved and the precedent-effect must be taken into account. But can this be allowed to be a reason to ‘vex’ further someone who ‘may’ have been wrongly imprisoned for so many years?

The stroke Lucia suffered came after a long stressful period before the appeal court gave its decision. You can't, of course, charge a high court with causing negligent injury, but… the injury – a right sided paralysis in a young woman – must have been a signal to the jurists that Lucia remains a human being with feelings. It should also be a lesson for government bodies to keep to their word in such situations where people are so dependent on them keeping to a time commitment, because waiting in uncertainty can be deadly.

In addition there has been so much investigative material introduced by us to this case, which clearly and objectively proves that, to put it mildly, there has been a miscommunication and dissemination of incorrect information. How the supplied information judged is something else altogether. Why not then have the dignity – surely fitting of the magistracy – to treat a dependant person, whatever else, with respect and to take her health situation into account? A further adverse effect on Lucia's health would make it impossible for the legal system to be cleared of guilt. Her vulnerability is now evident.


In Utrecht, on the 24th of May, there was a symposium on statistics in lawsuits. It was astonishing for non-jurists to see how few experts enjoy the complete trust of the legal world and other, renowned experts in their field, simple if “non-suitably legally initiated” are barely heard. It shows a certain arrogance to believe that one can judge the merits of non-legal experts and professionals from within the world of lawyers.

During the symposium there was a clear and notable difference between the open discussion that the scientists were having together and the impenetrable stance of the jurists from the PPO. Shouldn't the Jurists from a PPO anno 2007 be more aware of la condition humane, as they may possibly have experienced themselves during their school period in the Beta subjects. Just as vice-versa the Beta's couldn't always translate Plato.

A good judge does not have to be all-knowing, but knows his limitations and the classics.

This implies that a judge cannot always have the clarity to be able to select that which actually adds to the quest for truth during a legal investigation.

In Lucia's trial the judge, in the case of Mrs.Z. for example, selected the only negative medical testimony – which, in addition, just so happened to arrive by letter, unsolicited (?), after the session – together with the statement of a daughter in law. The other six testimonies from physicians concerned, plus those of the nurses and the sons were totally ignored by the judge, rendered unusable as it's called in legal language.


These witnesses pointed to the terminal phase of the illness and the serious symptoms. At that time (1997) there was no doubt in their minds about the manner of death. The surgeon who, years later, was the only one who was so sure that he knew Lucia had committed a murder there as well, strangely enough never reported any such thing at the time.

During the symposium in Utrecht Jurist, and statistical expert for the PPO in Lucia's case, Henk Elffers stated that he hadn't been given access to all the (correct) data. He states that this was certainly of influence when he calculated the obscure number 1 in 342 million. The reason for the mortality rate in the three years prior to Lucia's arrival in the JCH being higher than in the time she worked there is ignored by Elffers. Doesn't it fit in his outline? He says that he had already placed comments in his research back in 2001. Specific circumstances of particular nurses could falsely influence the calculations. According to Elffers these ifs and buts were pushed too much to the background. Notably, at the time he additionally laid down the scenario “if there were colleagues who had it in for Lucia”. Other disciplines remain for the time being outside consideration.

Richard Gill, professor of statistical science, has repeatedly pointed to the influence of the division of day and nightshifts, the disposition of nursing staff and the gravity of illnesses on the statistics of incidents in hospitals. He now shows that it's more common to see nurses involved in a higher than average number of incidents or even involved in fewer incidents than average. In practice we know that in hospitals and care homes something always happens on Hans & Grietje's shift but never on Klaas or Marie's.

This week a child specialist looked through the information concerning child A. He supported our supposition that her state of health was much more critical than the JCH imagined and that it was much more likely that she died of pulmonary-cardiac dysfunction rather than of poisoning. The minimal amount of Digoxin found in the questionable pieces of gauze, the absence of Digoxin in the liver doesn't conforn with acute Digoxin poisoning. Moreover, interaction with the medicine Spirinolacton gives Digoxin a longer half-life. There isn't much exact, scientifically founded data about the secretions of Digoxin. From a recent Polish study it is clear that concentrations of Digoxin in tissue are not 30x as high as in blood, but can be as much as 100x higher than the blood concentrations.


Ergo —
  • The medical data and interpretations were – probably due to fear – selective and therefore misleading.
  • The statistical study was inferior and served only to strengthen the fear-hype.
  • The ‘one & only’ proof – the Digoxin story – is based on an invalid study and produces a result inconsistent with poisoning, but most likely traces back to a remnant of pre-operative administered Digoxin.
  • In the lawsuit no allowance is made for the possibility of medicinal errors or errors of medical assessment. These points shouldn't be allowed to be ignored given the recently published scientific reports regarding this matter.

PS. On Wednesday May 30th there will be a Studium Generale in the Legal Faculty of the University of Nijmegen, dedicated to the Posthumus II commission and the Lucia de B case in particular.

Program
  • 19.00 Hall open and reception + coffee/tea
  • 19.30 Welcoming speech and subject introduction, Ybo Buruma
  • 19.55 Lecture by dr. Ton Derksen
  • 20.20 Lecture by Mr. Stijn Franken
  • 20.45 Panel discussion led by Ybo Buruma
  • 21.30 Closing drinks – Culture cafe

# Wait, wait, wait…

18th May 2007
Hours, days, months, years, etc.

Anybody who has ever had to wait for the results of tests by a serious illness knows that every minute longer that you must wait counts. A doctor is duty-bound not to lose any valuable time. The tests delay must be in accordance with the seriousness of the illness and any possible options for treatment.

Lucia lives “even if in a cell”. The case that is to be considered by the Threesome is very complex and will probably have certain consequences. But it's been nearly a year, of mainly just waiting, since the Court in Amsterdam made its pronouncement.

The judicial system doesn't have to be a ‘curative’ establishment, but couldn't they just make some allowances for the stamina of their clients?

The men of the Threesome will undoubtedly be working conciencously. Perhaps they even individually experience the same impatience as Lucia does, and we do.

There is nothing to report concerning the legal aspects of the case.

On 16th may an editorial appeared in the New York Times that speaks for itself. You can find a copy of the article in a weblog.


On 20th April the following article appeared in the Toronto Star about an “Autopsy of a flawed career”. My attention was drawn to this site with the reference – “As you can see, it's not just in Holland”

In the Netherlands it's, happily, not been all quiet around Lucia. Half way through March there was an article in Medisch Contact by Dirk van der Wedden – Jurist and doctor – about the concept of natural or unnatural death, as the case may be, the way the court handled it. He points out that doctors and nurses, due to their presence at deaths and the applied criteria – unexpected, inexplicable and during Lucia's shift – also run the risk of being stuck on a murder charge.

The moment of death will, in some ways, always be unexpected. With acute disorders that's self-evident, but also with serious disorders the momentum mori isn't a precisely predictable event, which can be experienced by bystanders as “really quite unexpected”. That physicians can't always (be expected to) know how serious a disorder is makes the prediction of a moment of death even more precarious. In any case the fact that a death is medically inexplicable has more to do with the level of knowledge, in general and in particular, of the doctor concerned. Van der Wedden also shows how absurd it is to, by definition, assume the presence of a perpetrator at an unnatural death. Use can be made of the operational duration, especially with toxins. Polonium, as everyone has been able to see, has a very long period before the victim shows any symptoms. It would have been psychologically very unlikely for a woman of Lucia's intellect, in the manner imputed, to have administered all manner of poisons.

In the weekly magazine Intermediair an article appeared on the 25th of April in which the statistical observations on the Lucia case were summarized. Elffers, at the time, based his calculations on the data as presented by the hospital. This data appears to have been incomplete and in some cases incorrect. Statisticians moreover find his calculation that the chance of one in 342 million that Lucia couldn't have been present at the 7 deaths and 2 resuscitations in a four year period unsubstantial.

It is more than surprising that there has been no overt reaction to the article in Medisch Contact from the medical corner. In the corridors there is talk of the “crooked diagnostics” in this case, analogous to Van der Wedden's opinion. But, unlike the statisticians, it appears the physicians are not prepared to engage in public discussion concerning going about with medical facts in a court case. But, as Van der Wedden indicates, it isn't just a case affecting “that Lucy”, but a problem of Jurisdiction in medical affairs in these times. According to him there should be an independent medical physician appended to the bench in this kind of complex case.

The newspapers and TV haven't reported much about the case these last few months. The creed in the present journalism is that there has to be ‘news’ about Lucia. And due to the long duration of the investigation we don't have any ‘news’ If Lucia gets good news the media will undoubtedly want to report it. The fact that she would profit more from journalists getting out there and investigating, to contribute to developments is self-evident, but journalistically it's not an ‘item’.


More and more responses are coming into the website, which for the most part we publish. Almost all of the responses are positive for Lucia.