UK - Healthcare worker arrested on suspicion of murder/attempted murder of a number of babies, 2018

[Angleterre]

I have just read the review, from the link quoted above. Two things stood out to me;
1) Unobstructed observation was difficult on the unit ("Direct visability from one area to another was poor" RCPCH Review, page 10).
2) Toxicology, electrolyte and blood glucose samples were not taken at postmortem, BECAUSE THE CHILDREN DIED IN HOSPITAL.
I cannot believe that this was accepted practice, as it eliminates a full investigation of cause of death. I hope UK authorities change this now.

I haven’t had the time to read this yet but I will take up your point at number 2.
I too cannot believe that this was the case as it is normal procedure to take blood samples for post mortem wether they died in hospital or not so I am astounded by this fact . What was the point of the post mortem if they didn’t take bloods ? It makes no sense to me having been to so many post mortems including those of children.
Now the UK law is that If a person is in hospital or they have seen a Dr within the last 7 days, a post mortem is not necessary but it is up for discussion if it’s felt that one is needed or the family request one.
So I’m wondering if what they mean and have got mixed up about in the wording of this report is that no post mortem was required because they were in hospital and ergo no toxicology was performed because there was no PM. If not then I am speechless... I can’t wait to see the evidence supporting the arraignment of LL . It’s an unusual one that’s for sure and I’m not saying this is the case at all as I don’t have access to the evidence but as others have said, I sure hope that LL isn’t being made the scapegoat for these poor children’s deaths . I can’t believe that would be the case because otherwise I don’t know how the case would have passed the CPS threshold test for charging.
Mmmmm ( scratching my head )!

 

[Slixcon]

Of course it's possible they've got something rather more concrete than that in relation to one or more of the deaths, but in terms of what that could be nothing really makes sense in my mind.

They almost certainly have something concrete. Otherwise they wouldn't have suddenly decided to charge her now, two years after she first became a person of interest.

If she'd been virtually caught in the act then I feel like they would have done more than move her to administrative duties and only have her arrested two years after the alleged killings.

As far as I know they haven't revealed why she was moved to administrative duties, for all we know it could have been for an entirely unrelated reason.

The other possibility would be that they had evidence of her misappropriating drugs

She wouldn't have been charged with murder if this was the case.

There were a lot of deaths, she was around for a lot of them, the deaths seemed odd, she was a bit weird, but that's exactly the sought of circumstances and reasoning that has lead to those miscarriages of justice.

I think you are massively underestimating the competence of the seasoned team of investigators who are working on this case. If you and I are both aware of enormity of the charges brought against the accused, charges which will undoubtedly have done irreparable damage to her reputation and ultimately ruined her life, then surely the experienced investigators know this as well. By bringing her to trial the police are not only putting her future on the line, but also their reputation. Could you imagine the outcry if it was determined in the court of law that she was innocent, that, after two years and three arrests, the police had simply honed in on a convenient scapegoat for major structural failings at the hospital? It would be inconceivable for the police to have pursued this particular line of enquiry with such perseverance, with such tenacity, if they did not have an extremely compelling reason for believing that she indeed committed these unspeakably malicious crimes. Innocent until proven guilty, of course, but the behaviour of the police in this case leads me to believe that there is a very high chance she will be convicted.

 

[Angleterre]

They almost certainly have something concrete. Otherwise they wouldn't have suddenly decided to charge her now, two years after she first became a person of interest.



As far as I know they haven't revealed why she was moved to administrative duties, for all we know it could have been for an entirely unrelated reason.



She wouldn't have been charged with murder if this was the case.



I think you are massively underestimating the competence of the seasoned team of investigators who are working on this case. If you and I are both aware of enormity of the charges brought against the accused, charges which will undoubtedly have done irreparable damage to her reputation and ultimately ruined her life, then surely the experienced investigators know this as well. By bringing her to trial the police are not only putting her future on the line, but also their reputation. Could you imagine the outcry if it was determined in the court of law that she was innocent, that, after two years and three arrests, the police had simply honed in on a convenient scapegoat for major structural failings at the hospital? It would be inconceivable for the police to have pursued this particular line of enquiry with such perseverance, with such tenacity, if they did not have an extremely compelling reason for believing that she indeed committed these unspeakably malicious crimes. Innocent until proven guilty, of course, but the behaviour of the police in this case lead me to believe that there is a very high chance she will be convicted.

@Slixcon
A Very well written and well worded post and the way in which you have broken down each part of Supernovae’s post and answered individual points that they made is truly excellent because it makes it very clear and precise for the reader. Thank you

 

[dotr]

FWIW..
This is the case in Canada that i referenced early on this thread, involving a nurse who was arrested for killing a number of babies and who was ultimately found innocent. The true culprit was a compound found in the seals IV and syringes used. rbbm.

SUSAN NELLES CASE - falsely accused nurse from Sick Kids Hospital - Burlington Post 07MAR01
''SUSAN NELLES CASE

"Decision in Nelles case a defining moment"
David Allan Harris B.A., LL.B., Published in the Burlington Post on March 7, 2001

''Susan Nelles was one of those clients. She was charged with four counts of first degree murder in connection with the death of four babies who were patients under her care on the cardiac ward at the Hospital for Sick Children and who died from poisoning alleged to have been caused by the deliberate administration of massive overdoses of the drug digoxin.

Judge David Vanek presided over her preliminary hearing, which occupied forty-one days of evidence from over one hundred witnesses and four days of argument by counsel.

During the preliminary hearing, Crown counsel announced that there were not just four, but 24, babies who had died on the cardiac ward in the same time frame, and in suspiciously similar circumstances. Those circumstances surrounding the twenty additional deaths were admitted as "similar fact evidence"' for purposes of the preliminary inquiry.

In return, Cooper prepared a chart and with the consent of the Crown, filed it as an exhibit. The chart contained a list of the nurses who were on duty on each of the days when the 24 babies died. This chart disclosed that Nelles was on duty on most but not all of the days when babies died and that another nurse was on duty on all of the days when babies had died. Nelles was not, however, on duty on the day of the death of one of the four babies included in the charges of murder laid against her. This was critical since both the Crown and the defence assumed that one person was responsible for killing all four babies. If Nelles did not kill one, it followed that she could hardly be found guilty of killing the others.

In the end Judge Vanek found that the evidence did not reach the threshold required to justify committal for trial and he directed that Susan Nelles be discharged on all four charges of murder. Following this decision, the Government of Ontario appointed a Royal Commission of Inquiry under Mr. Justice Grange of the Ontario Court of Appeal to examine the circumstances the extraordinary number of deaths at the Hospital.

These hearings took well over a year to complete. At the conclusion, the Commissioner's report contained statements expressly agreeing with Judge Vanek's decision in the preliminary hearing and generally approving of his handling of the charges against Susan Nelles.''

The baby killer at Toronto's Sick Kids was rubber - Macleans.ca
''The real culprit for a wave of deaths in the early 1980s was a compound found in seals on IVs and syringes''

''So what really happened to those children? A cluster of factors, according to Hamilton. They were very sick, and it took only the tiniest of nudges—natural or deliberate—to push them across death’s threshold. And that push was coming with increasing force. MBT, a chemical compound in the rubber seals used in IV lines and disposable plastic syringes, was leeching into the contents of those devices, bringing chances of life-threatening anaphylactic shock—which is how Hamilton, a radiologist from London, Ont., encountered it—and of death by accumulated toxins. The problem grew, unseen, as the era of unit-dose syringes dawned around 1980. Designed to eliminate overdose errors, prepackaged unit doses had three-year shelf lives—all the longer for the MBT to leech into the contents.

The smallest, most fragile patients, the cardiac babies, were most at risk: more injections, more transfusions, more poison, more chances of crossing the threshold. And if circumstances were cruelly conspiring against the children, so too were they taking aim at the accused nurses. The tests used to measure the digoxin levels in the autopsied babies were less than useless.''

 

[Whitehall 1212]

They almost certainly have something concrete. Otherwise they wouldn't have suddenly decided to charge her now, two years after she first became a person of interest.

As far as I know they haven't revealed why she was moved to administrative duties, for all we know it could have been for an entirely unrelated reason.

She wouldn't have been charged with murder if this was the case.

I think you are massively underestimating the competence of the seasoned team of investigators who are working on this case. If you and I are both aware of enormity of the charges brought against the accused, charges which will undoubtedly have done irreparable damage to her reputation and ultimately ruined her life, then surely the experienced investigators know this as well. By bringing her to trial the police are not only putting her future on the line, but also their reputation. Could you imagine the outcry if it was determined in the court of law that she was innocent, that, after two years and three arrests, the police had simply honed in on a convenient scapegoat for major structural failings at the hospital? It would be inconceivable for the police to have pursued this particular line of enquiry with such perseverance, with such tenacity, if they did not have an extremely compelling reason for believing that she indeed committed these unspeakably malicious crimes. Innocent until proven guilty, of course, but the behaviour of the police in this case leads me to believe that there is a very high chance she will be convicted.

I am going to play devils advocate here!

TIMELINE (for reference)

January 2015 to July 2016 - The Countess of Chester Hospital experienced a greater number of deaths in its neo-natal unit than would normally be expected.

August 2016 - the hospital commissioned an independent review by The Royal College of Paediatric and Child Health (RCPCH). The review raised concerns about gaps in medical and nursing rotas, insufficient staffing levels for a level 2 neonatal unit and inadequate arrangements for investigating neonatal deaths.

May 2017 - the hospital contacted Cheshire Police to raise their concerns. Cheshire Police commenced enquiries.

Prior to July 2017 - LL was moved to non-clinical administrative duties (exact date not available)

July 2017 - LL suspended from The Countess of Chester Hospital.

3rd July 2018 - LL was arrested on suspicion of eight murders and six attempted murders. She was interviewed and subsequently bailed.

June 2019 - LL was arrested for a second time. She was also arrested for a further three attempted murders. Once again she was interviewed and bailed.

10th November 2020 - LL was charged with eight murders and nine attempted murders.

It is not beyond the realms of possibility that there is no smoking gun. Maybe a significant degree of the circumstantial evidence comes from collective links identifying LL's duties and actions at the material times and medical and forensic evidence which may be subject to different interpretation.

If the links between the alleged offences are a key feature of the evidence, then the time period of thirty-two months, from the police being called in to the charges, may have been necessary to thoroughly investigate each individual offence and to ultimately tip the balance in favour of the CPS authorising the charges.

The neonatal hospital environment is one where death, together with life threatening and limiting conditions and invasive procedures are not uncommon.

The reality of the operational environment along with the departmental concerns highlighted in the RCPCH review, lends the possibility that a nurse doing their job under great pressure, with limited support, could make a series of unintentional minor errors with major consequences. Indeed they may not be aware of their errors as there was poor post incident debrief and little time to reflect in the hot house environment.

I don't doubt the skill, dedication and tenacity of the detectives. However, there are two key factors which make this investigation unusually challenging:

1. The pressurised environment, in terms of specialised life giving care and where death is inevitable

2. The potential for NHS 'management/reputational interests' to come into play

Considering your thoughts that the police must be entirely satisfied about the robustness of their investigation for fear of an outcry if LL is not convicted and the subsequent clamour of 'scapegoat' and 'cover up'.

Would public confidence in the police and the justice system be significantly undermined if a suspect was arrested more than once over a 2 1/2 year investigation and whose name, job role, workplace, residential location and alleged yet highly emotive crimes were identified by the police, and who ultimately was not charged but released with no further action?

Could pressure have been bought to bear upon the CPS by higher powers, beyond the police, to assuage concerns about a significant loss of confidence in the justice system and the NHS being undermined if nothing was seen to be done? Contentious I know, but there are dark arts! With Covid-19 we live in very challenging times where confidence in the NHS, medical science and the rule of law is being questioned every day in the media and on the streets. Disquiet in the functions of state are seen to be 'unhelpful' when dealing with a pandemic.

I sincerely hope that the evidence is compelling beyond all reasonable doubt after being tested thoroughly in court or that LL admits her guilt and explains her actions. Anything less and the wound may always be infected.

Sources:

Timeline of the Chester hospital baby deaths investigation

Hospital probe report after death rate rise for high risk babies

Police investigating baby deaths at Chester hospital rearrest nurse

 

[Kemug]

I wonder why LL didn't just resign in 2017, having been moved to administrative duties, and go to work with babies somewhere else?

 

[Angleterre]

I am going to play devils advocate here!

TIMELINE (for reference)

January 2015 to July 2016 - The Countess of Chester Hospital experienced a greater number of deaths in its neo-natal unit than would normally be expected.

August 2016 - the hospital commissioned an independent review by The Royal College of Paediatric and Child Health (RCPCH). The review raised concerns about gaps in medical and nursing rotas, insufficient staffing levels for a level 2 neonatal unit and inadequate arrangements for investigating neonatal deaths.

May 2017 - the hospital contacted Cheshire Police to raise their concerns. Cheshire Police commenced enquiries.

Prior to July 2017 - LL was moved to non-clinical administrative duties (exact date not available)

July 2017 - LL suspended from The Countess of Chester Hospital.

3rd July 2018 - LL was arrested on suspicion of eight murders and six attempted murders. She was interviewed and subsequently bailed.

June 2019 - LL was arrested for a second time. She was also arrested for a further three attempted murders. Once again she was interviewed and bailed.

10th November 2020 - LL was charged with eight murders and nine attempted murders.

It is not beyond the realms of possibility that there is no smoking gun. Maybe a significant degree of the circumstantial evidence comes from collective links identifying LL's duties and actions at the material times and medical and forensic evidence which may be subject to different interpretation.

If the links between the alleged offences are a key feature of the evidence, then the time period of thirty-two months, from the police being called in to the charges, may have been necessary to thoroughly investigate each individual offence and to ultimately tip the balance in favour of the CPS authorising the charges.

The neonatal hospital environment is one where death, together with life threatening and limiting conditions and invasive procedures are not uncommon.

The reality of the operational environment along with the departmental concerns highlighted in the RCPCH review, lends the possibility that a nurse doing their job under great pressure, with limited support, could make a series of unintentional minor errors with major consequences. Indeed they may not be aware of their errors as there was poor post incident debrief and little time to reflect in the hot house environment.

I don't doubt the skill, dedication and tenacity of the detectives. However, there are two key factors which make this investigation unusually challenging:

1. The pressurised environment, in terms of specialised life giving care and where death is inevitable

2. The potential for NHS 'management/reputational interests' to come into play

Considering your thoughts that the police must be entirely satisfied about the robustness of their investigation for fear of an outcry if LL is not convicted and the subsequent clamour of 'scapegoat' and 'cover up'.

Would public confidence in the police and the justice system be significantly undermined if a suspect was arrested more than once over a 2 1/2 year investigation and whose name, job role, workplace, residential location and alleged yet highly emotive crimes were identified by the police, and who ultimately was not charged but released with no further action?

Could pressure have been bought to bear upon the CPS by higher powers, beyond the police, to assuage concerns about a significant loss of confidence in the justice system and the NHS being undermined if nothing was seen to be done? Contentious I know, but there are dark arts! With Covid-19 we live in very challenging times where confidence in the NHS, medical science and the rule of law is being questioned every day in the media and on the streets. Disquiet in the functions of state are seen to be 'unhelpful' when dealing with a pandemic.

I sincerely hope that the evidence is compelling beyond all reasonable doubt after being tested thoroughly in court or that LL admits her guilt and explains her actions. Anything less and the wound may always be infected.

Sources:

Timeline of the Chester hospital baby deaths investigation

Hospital probe report after death rate rise for high risk babies

Police investigating baby deaths at Chester hospital rearrest nurse

Yes I can see your point of view and I sincerely hope that is not the case because I would severely question how it all passed the threshold test .
I don’t know if you recall the days when Police decided who to prosecute and you didn’t run everything by the CPS and you just charged with consultation of the custody Sgt? In those days I can see it happening but now .... nope because the standard that the CPS hold are so highly weighted in favour of there being a 90% plus realistic chance of conviction that I don’t see how it would have passed the threshold test.

 

[Whitehall 1212]

Yes I can see your point of view and I sincerely hope that is not the case because I would severely question how it all passed the threshold test .
I don’t know if you recall the days when Police decided who to prosecute and you didn’t run everything by the CPS and you just charged with consultation of the custody Sgt? In those days I can see it happening but now .... nope because the standard that the CPS hold are so highly weighted in favour of there being a 90% plus realistic chance of conviction that I don’t see how it would have passed the threshold test.

Thanks for your reply Angleterre.

Some of my comments were contentious, but aimed at highlighting that there may sometimes be other players at work for whatever reason.

I do recall way back when I would have a discussion with the Custody Sergeant before writing out the charge sheet. Then again nearly all my experience has been in liaising with the mainstream CPS and more recently the SFD.

I'm interested as to where the notion of a 90%+ realistic chance of conviction comes from regarding the evidential test?

The Code for Crown Prosecutors (26/10/18), describes the evidential stage (4.6 to 4.8, inclusive). Whilst it is essentially an objective test, numerical probability of success is not a feature.

4.6 Prosecutors must be satisfied that there is sufficient evidence to provide a realistic prospect of conviction against each suspect on each charge*.

Extract from section 4.7, below in bold

This is a different test from the one that the criminal courts themselves must apply. A court may only convict if it is sure that the defendant is guilty.

Crown Prosecutors that I have discussed cases with have expressed their view of success in rather more pragmatic terms.

The Code for Crown Prosecutors | The Crown Prosecution Service

I have been looking at case histories for the convictions of Beverley Allitt, Benjamin Geen and Colin Norris.

Allitt (1993) was clearly guilty, the evidence was significant and red flags of psychiatric disorders since childhood were very evident.

The evidence against Geen (2006) and Norris (2008) appears to be solely circumstantial, with different possible explanations for medical anomalies. Both are continuing to challenge their convictions.

A repeated observation is raised insulin levels, with the assertion that injecting insulin has resulted in death from the effects of hypoglycemia.

Interestingly neonatal hypoglycemia is a very common metabolic condition. Neonates on level 2 neonatal intensive care units are at greater risk if the condition is not identified and managed in a timely way. Just a consideration if high insulin levels were identified in the case of LL.

Hypoglycaemia on the Neonatal Unit

 

[Angleterre]

Thanks for your reply Angleterre.

Some of my comments were contentious, but aimed at highlighting that there may sometimes be other players at work for whatever reason.

I do recall way back when I would have a discussion with the Custody Sergeant before writing out the charge sheet. Then again nearly all my experience has been in liaising with the mainstream CPS and more recently the SFD.

I'm interested as to where the notion of a 90%+ realistic chance of conviction comes from regarding the evidential test?

The Code for Crown Prosecutors (26/10/18), describes the evidential stage (4.6 to 4.8, inclusive). Whilst it is essentially an objective test, numerical probability of success is not a feature.

4.6 Prosecutors must be satisfied that there is sufficient evidence to provide a realistic prospect of conviction against each suspect on each charge*.

Extract from section 4.7, below in bold

This is a different test from the one that the criminal courts themselves must apply. A court may only convict if it is sure that the defendant is guilty.

Crown Prosecutors that I have discussed cases with have expressed their view of success in rather more pragmatic terms.

The Code for Crown Prosecutors | The Crown Prosecution Service

I have been looking at case histories for the convictions of Beverley Allitt, Benjamin Geen and Colin Norris.

Allitt (1993) was clearly guilty, the evidence was significant and red flags of psychiatric disorders since childhood were very evident.

The evidence against Geen (2006) and Norris (2008) appears to be solely circumstantial, with different possible explanations for medical anomalies. Both are continuing to challenge their convictions.

A repeated observation is raised insulin levels, with the assertion that injecting insulin has resulted in death from the effects of hypoglycemia.

Interestingly neonatal hypoglycemia is a very common metabolic condition. Neonates on level 2 neonatal intensive care units are at greater risk if the condition is not identified and managed in a timely way. Just a consideration if high insulin levels were identified in the case of LL.

Hypoglycaemia on the Neonatal Unit

I may be getting mixed up here but I think I have read something about high insulin levels in relation to LL but I can’t be 100% certain

re the CPS - it’s during personal discussions
I have a very close friend who is the deputy crown prosecutor for the country .... say no more about that !

 

[Whitehall 1212]

I may be getting mixed up here but I think I have read something about high insulin levels in relation to LL but I can’t be 100% certain

re the CPS - it’s during personal discussions
I have a very close friend who is the deputy crown prosecutor for the country .... say no more about that !

Gotcha Thanks

 

[beforethegladness]

Good question @Kemug. I wonder if perhaps LL had 'burn out', really common in nursing, and a way for her to still be employed by the Trust was to take on a less physically demanding/not 12 hour shifts based admin role. Burn out can lead to 'compassion fatigue'.

I wonder why LL didn't just resign in 2017, having been moved to administrative duties, and go to work with babies somewhere else?

 

[MsBetsy]

Good question @Kemug. I wonder if perhaps LL had 'burn out', really common in nursing, and a way for her to still be employed by the Trust was to take on a less physically demanding/not 12 hour shifts based admin role. Burn out can lead to 'compassion fatigue'.

I wonder how many infants experienced similar heart or lung collapses, or how many died under similar circumstances since the time she was removed from her position of direct care.

 

[Whitehall 1212]

I wonder how many infants experienced similar heart or lung collapses, or how many died under similar circumstances since the time she was removed from her position of direct care.

Cause/effect analysis is a superb tool when implemented correctly. However, it is easy though to fall into the trap of consciously or unconsciously being emotionally attached to an outcome and finding the cause of causes that support the effect and disregarding those that don't.

In this case the increased deaths occurred when the neonatal unit was operating at level 2 status as a Neonatal Intensive Care Unit (NICU), with a higher proportion of compromised neonatal patients.

Once the increased mortality was identified and the hospital commissioned the independent review, the NICU was downgraded to the lower level 1 neonatal unit status with patients requiring NICU support being transferred to a NICU at another hospital.

Therefore, a cause/effect study would not be comparing like with like on one of the most relevant factors., namely the medical status of the patient.

 

[Parker Knoll]

A closed meeting is being held this Friday by the NMC to discuss LL fitness to practice.

 

[MsBetsy]

Cause/effect analysis is a superb tool when implemented correctly. However, it is easy though to fall into the trap of consciously or unconsciously being emotionally attached to an outcome and finding the cause of causes that support the effect and disregarding those that don't.

In this case the increased deaths occurred when the neonatal unit was operating at level 2 status as a Neonatal Intensive Care Unit (NICU), with a higher proportion of compromised neonatal patients.

Once the increased mortality was identified and the hospital commissioned the independent review, the NICU was downgraded to the lower level 1 neonatal unit status with patients requiring NICU support being transferred to a NICU at another hospital.

Therefore, a cause/effect study would not be comparing like with like on one of the most relevant factors., namely the medical status of the patient.

Oh, that's right, I had forgotten about that. I'm just curious to know in general how many babies die unexpectedly from collapse who are difficult to resuscitate and have the mottled skin right afterwards.

Apparently it was an unusual amount in this case, since the hospital requested an investigation.

 

[MsBetsy]

A closed meeting is being held this Friday by the NMC to discuss LL fitness to practice.

Is there a source for this information? Is this to determine whether or not her license will be renewed? TIA.

 

[Tortoise]

Is there a source for this information? Is this to determine whether or not her license will be renewed? TIA.

I've found this statement from the Nursing and Midwifery Council (more to read at link provided) :

A virtual interim order hearing, overseen by an independent fitness to practise panel, has been scheduled to take place on Friday 20 November.

It’s likely that part or all of this hearing will take place in private due to the ongoing criminal proceedings. This will be decided by the Panel at the start of the hearing.

An outcome of this hearing will be published on our website shortly after the hearing has concluded.

NMC comment on nurse charged with murder

 

[Kitkat28]

I may be getting mixed up here but I think I have read something about high insulin levels in relation to LL but I can’t be 100% certain

re the CPS - it’s during personal discussions
I have a very close friend who is the deputy crown prosecutor for the country .... say no more about that !

Are there many “natural” reasons for high insulin levels which then lead to patients dying? It seems to be a common theme with nurses who are suspected of causing harm .

 

[pickle26]

Liverpool Crown Court today 18th Nov 2020

 

[meanmaryjean]

I've found this statement from the Nursing and Midwifery Council (more to read at link provided) :

A virtual interim order hearing, overseen by an independent fitness to practise panel, has been scheduled to take place on Friday 20 November.

It’s likely that part or all of this hearing will take place in private due to the ongoing criminal proceedings. This will be decided by the Panel at the start of the hearing.

An outcome of this hearing will be published on our website shortly after the hearing has concluded.

NMC comment on nurse charged with murder

In the US- such hearings are also open to the public and documentation is housed FOREVER in the licensing agency's archives- also accessible to the public.

I do have a question for a Brit- a page or so back there was a mention of it being a 'Level 2 NICU'. In the US- that is not high acuity. If a smallish hospital has monitoring equipment and a pediatrician on-call, they can be considered Level 2. ( By comparison, US 'Level 4' is for the sickest of the sick, uber-preemies, complex cardiac defects, specialty surgical services) So I wonder if it is different in the UK?