I first became interested in the Lucy Letby (LL) case when my wife referred me to a 10 hour podcast entitled: “The Case of LL; The Facts – Crime Scene 2 Court Room”, https://www.youtube.com/watch?v=_OA0ukO7D7c. Since, I have searched for further background to this case. Richard Gill’s website raises issues around imbalance between the prosecution and the defence, or lack of it! Also, there was toxic atmosphere at the Countess of Chester (CC) neonatal unit and LL reported problems. I worked for over 25 years anaesthetizing children down to 500g, in addition to adult anaesthesia, as well as expert witness experience. I also spent 6 months attached to a Neonatal Unit. The question of whether LL committed the alleged crimes is a difficult one to answer as (a) no one actually witnessed her doing the alleged crimes, (b) there is no obvious motive, (c) the actions would be very hard to achieve and (iv) there are other alternative explanations that were not explored by the court case, or at least the 10 hour transcript.
The Countess of Chester baby unit: The main purpose of the unit was a nursey to look after and feed babies too small and fragile to leave hospital, born at the CC. There was a small 4 bedded-neonatal unit in addition to the 4 nursery rooms. LL probably wanted to gain neonatal experience hence her involvement with the 17 cited cases.
Neonates and vulnerability: Small preterm babies easily deteriorate and die. Their organs are still developing and without the advent of neonatal units in the 1980s most would die. It is only today that a baby born prematurely before 28 to 32 weeks has a good chance of survival.
Staffing levels, staff experience and standard of care: LL was only 25 years old at the time and had only been a neonatal nurse for a few years. That is not very long and she lacked experience! She still needed further training in Liverpool to advance her career. Yet, she seemed to be one of the most senior neonatal nurses (band 5) on the unit and nowhere in the transcript do we find an older, more senior or experienced colleague other than a charge nurse who managed the duties and was not hands on. Similarly, it appears that medical cover was by paediatricians who also covered the wards and there was no doctor solely on duty for the unit. Therefore, when compared to other bigger units (i.e. Alder-Hey) the level of care was limited, so it would not be surprising if a baby deteriorates, and that happens with “prems”, outcomes are not as good. So, the evidence suggests that the CC was not up to standard, and it was an overflow unit for Alder-Hey. The CC neonatal unit has since been closed down. So were the cited incidents and deaths really due to LL or a result of a poorly supported / under-funded unit looking after sick neonates that should have been elsewhere?
The prosecution case focused on a number of methods of harming babies allegedly used by LL: (i) Distending the stomach by giving too much feed or (ii) injecting air into the stomach, (iii) injecting air into the circulation causing sudden collapse, (iv) traumatising the airway and causing bleeding, (v) dislodged tracheal and chest tubes, and (vi) adding insulin to the intravenous feed. The discussion of the pathophysiology of these mechanisms was disjointed and difficult to follow. However, the connection of LL to the sudden deteriorations and deaths in 7 seemed very compelling. However, I have to take issue with a number of the prosecution’s assertions.
(i) Over-distending the stomach with feed to an extent to cause collapse and projectile vomiting. I don’t have any experience of tube feeding prems, but projectile vomiting can be a reaction to bad / infected milk? Was LL in hurry to feed the baby? I find it hard to believe this was an attempt at murder.
(ii) Most obvious was the air in the stomach and intestines at post mortem. LL must have injected air via the gastric feeding tube, or how else did it get there? Well anyone who works in theatre or resuscitation knows during mask ventilation, which all these babies had (i.e. Neopuff), that it is very easy to blow up the stomach and intestines with air / anaesthetic gases, especially if one’s technique is not perfect. I regularly had to pass a suction catheter to empty the stomach of gas at the start of surgery to deflate the stomach and improve ventilation. I even did a study on the carbon dioxide levels that often reached the level of expired gas. However, the role of the Neopuff as a potential cause was never mentioned. So what is more likely, LL injected the air or the air got there through resuscitative efforts by stressed staff.
(iii) Some of the babies suddenly collapsed and developed a strange rash on the abdomen. Some recovered rapidly. This was said to be due to LL injecting air into the circulation. Air was found to be in the blood vessels at post mortem in some deaths. The premature baby can revert to a foetal circulation (by passing the lungs) when they become unstable and this can take time to treat (revert back). Sometimes “persistent foetal circulation” manifests itself during anaesthesia until the ductus closes fully. Point not mentioned in the case but could explain the above. Also, chest compression would cause significant sucking in of air to the heart if intravenous access lines were left open to air during the resuscitation after injecting a drug (adrenaline). LL sent a Datex about a line being left uncapped by one of the doctors. So there are other explanations and mechanisms by which air could have entered the circulation.
(iv) One of the cases had trauma to oral airway and significant blood loss, I think this was one of the twins with Haemophilia, a blood clotting disorder. LL was accused of traumatising the airway. I cannot imagine how. The likely explanation would be repeated intubation attempts, not an attempt to murder the baby by LL. I recall up to seven attempts as the neonate was difficult to intubate!
(v) LL was also accused of dislodging an endotracheal tube and a chest drain which lead to deterioration in two patients. Preterm babies are very small, endotracheal tubes can easily move and become dislodged however carefully one secures them, particularly if the neck is flexed or extended! Similarly, with chest drains, the baby had bilateral drain presumably as a result of premature lungs, and one drain became dislodged / was not working and a third drain was needed. These things happen so just because LL was present does not automatically mean it was her fault. Then there was the incident with deliberate liver injury, which equally could have occurred during chest compressions by someone else?
(vi) The addition of insulin to intravenous feeds has already been mentioned by Gill from a biochemistry and reliability of blood test perspective. I don’t fully understand this one. One baby was receiving regular intravenous nutrition made up in sealed bags from pharmacy. The baby had unexplained hypoglycaemia. For three bags it persisted and when LL was not on duty the hypoglycaemia resolved. Blood were analysed insulin and C peptide. Hypoglycaemia is common in preterm babies because their mechanisms to maintain blood glucose levels are immature (i.e. glycogen stores in the liver). The child may have had an infection as Gill says there was virus circulating. That being said it difficult to image how LL managed to injected the correct and same amount of insulin into a sealed bag on three separate occasions. There is a rigid nursing protocol involving two nurses when a new bag is put up to maintain sterility. Then there was a further insulin contaminated Dextrose infusion in a second baby. BTW, LL was not the only nurse present for both these cases.
Hence, I find it very difficult to accept the verdict that Lucy Letby was responsible for all 7 deaths and a further 6 attempts at murder. I think that her case needs to be reviewed by someone with a better understanding of neonatal medicine and how a premature baby unit is run.
I am a coauthor of the report of the Royal Statistical Society https://rss.org.uk/news-publication/news-publications/2022/section-group-reports/rss-publishes-report-on-dealing-with-uncertainty-i/. It is deeply distressing that the police investigation into the case of Lucy Letby and the subsequent trial made all of the mistakes in our book. The jury was never told how the police investigation arrived at that list of “suspicious” events and how it was further narrowed down to the list of charges. This is a case in which a target was painted around a suspect by investigators. We call it confirmation bias, in statistics. It is also often referred to as the Texas sharpshooter paradox.
Thanks to amateurs who report their work on Twitter and YouTube, we now know how the list of charges in the Lucy Letby case evolved. It is utterly scandalous that this history was not revealed to the court. Here is the broad picture.
Doctors reported Lucy to the police, against the wishes of the hospital board.
They told the police the exact period she had been on the ward and gave them the files on all deaths in that period and on some of the incidents: namely, exactly and only those “arrests” at which Lucy had been present.
What qualifies as an incident, what is an arrest?
There is no medical category “arrest, resuscitation” under which such events are logged in hospital administration. Probably there were about five times as many such events when Lucy was not on duty, but nobody has ever looked. There is no medical definition of such an event. No formal criteria.
“Unexpected, unexplained, sudden” are also not defined in any formal way. Nor is “stable”.
Next the absolutely unqualified, long retired, paediatrician Dewi Evans, who has a business helping out in civil child custody cases, went through those medical files looking for anomalies about which he could fantasise a murder or murder attack. His ideas that milk was injected into the stomach or air into the veins were far fetched, and later not confirmed by any other evidence. On the contrary, the actual evidence certainly contradicts the idea that Lucy Letby actually attacked any child. He never gave alternative medical explanations, as would have been the obligation of a forensic scientist. All the deaths had had a post-mortem and a coroner’s report. Every single event on the charge sheet has absolutely normal explanation. Lucy was never seen doing anything wrong.
The medical experts for the prosecution merely confirmed Evans’ diagnosis, they also did not do the job of a forensic scientist.
The defence had no experts. They had brought in one paediatrician. But at the pre-trial hearing he said he wasn’t qualified in endocrinology, toxicology, etc etc etc.
This was Texas sharpshooter, big time. Plus utterly incompetent defence.
Note: [20 August 2023] This post is incomplete. It needs a prequel: the history of medical investigations into two “unexplained clusters” of deaths at the neonatal ward of the Countess of Chester Hospital. It needs many sequels: statistical evidence; how the cases were selected (the Texas sharpshooter paradox) and the origin of suspicions that a particular nurse might be a serial killer; the post-it note; the alleged insulin poisonings; the trouble with sewage backflow and the evidence of the plumber; the euthanasias. For the medical material, the site to visit is the magnificent https://rexvlucyletby2023.com/.
Lucy Letby, a young nurse, has been tried at Manchester Crown Court for 7 murders and 15 murder attempts on 17 newborn children in the neonatal ward at Countess of Chester Hospital, Chester, UK, in 2015 and 2016.
She was found:– Guilty of 7 counts of murder (against 7 babies) – Guilty of 7 counts of attempted murder (against 6 babies) – Not guilty on 2 counts of attempted murder (against 2 of the 6 babies she *was* found guilty of attempting to murder). No decision was reached on 6 counts of attempted murder against 6 different babies. However, 2 of those 6 she was also found guilty of a different count of attempted murder. [Thanks to the commenter who corrected my numbers.]
The prosecution dropped one further murder charge just before the trial started, on the instruction of the judge. Several groups of alleged murders and murder attempts concern the same child, or twin or triplet siblings. All but one child was born pre-term. Several of them, extremely pre-term.
I’m not saying that I know that Lucy Letby is innocent. As a scientist, I am saying that this case is a major miscarriage of justice. Lucy did not have a fair trial. The similarities with the famous case of Lucia de Berk in the Netherlands are deeply disturbing.
The image below summarizes findings concerning the medical evidence. This was not my research. The graphic was given to me by a person who wishes to remain anonymous, in order to disseminate the research now fully documented on https://rexvlucyletby2023.com/, whose author and owner wishes to remain anonymous. Note that the defence has not called any expert witnesses at all (except for one person: the plumber). Possibly, they had not enough funds for this. Crowd-sourcing might be a smart way of getting the necessary work done for free, to be used at a subsequent appeal. That’s a dangerous tactic, and it seems to me that the defence has already taken a foolish step: they admitted that two babies received unauthorised doses of insulin, and their client was obliged to believe that too.
This blog post started in May 2023 as a first attempt by myself to blog about a case which I have been following for a long time. The information I report here was uncovered by others and is discussed on various internet fora. Links and sources are given below, some lead to yet more excellent sources. Everything here was communicated to the defence, but they declined to use it in court. Maybe they felt their hands were bound by pre-trial agreement between the trial parties as to what evidence would be brought to the attention of the jury, which witnesses, etc.
An extraordinary feature of UK criminal prosecution law is that if exculpatory evidence is in the possession of the defence, but not used in court, then it should not be used at a subsequent appeal, whether by the same defence team or a new one. This might explain why the defence team would not even inform their client of their knowledge of the existence of evidence which exonerated her. Even though, it is also against the law that they did not, as far as we know, disclose evidence which they had which was in her favour. The UK law on criminal court procedure is case law. New judges can always decide to depart from past judges’ rulings.
A very important issue is that the rules of use of expert evidence is that all expert evidence must be introduced before the trial starts. It is strictly forbidden to introduce new expert evidence once the trial is underway.
UK criminal trials are tightly scripted theatre. The jury is of course incommunicado, very close to its verdict, and I do not aim to influence the jury or their verdict. I aim to stimulate discussion of the case in advance of a likely appeal against a likely guilty verdict. I wish to support that small part of the UK population who are deeply concerned that this trial is going to end in an unjustified guilty verdict. Probably it will, but that will not be the end. So much information has come out in the 9 months of the trial so far, that a serious fight on behalf of Lucy Letby is now possible. Public opinion crystallised long ago against Lucy. It can be made fluid again, and maybe it can even be reversed, and this is what must happen if she is to get a fair re-trial.
As a concerned scientist who perceives a miscarriage of justice in the making, I attempted to communicate information not only to the defence but also to the prosecution, to the judge (via the clerk of the court), and to the Director of Public Prosecutions. That was a Kafkaesque experience which I will write about on another occasion. Personally, I tend to think that Lucy is innocent. That was however not my reason for attempting to contact the authorities. As a scientist, it was manifestly clear to me that she was not getting a fair trial. Science was being abused. I tried to communicate with the appropriate authorities. I failed to get any response. Therefore I had to “go public”.
Here is a short list of key medical/scientific issues, originally copied from an early version of the incredible and amazing website https://rexvlucyletby2023.com/, with occasional slight rephrasing and some small, hopefully correct, additions by myself. That site presents full scientific documentation and argumentation for all of the claims made there.
Air embolism cannot be determined by imaging, and can only be determined soon after death, and requires the extraction of air from the circulatory system, and analysis of the composition of the air using gas chromatography.
The coroner found a cause of death in 5 out of 7 of the alleged murder cases. Two of them appeared to be, in part, related to aggressive CPR, two appeared to be due to undiagnosed hypoxic-ischemic encephalopathy and myocarditis, one of the infants received no autopsy, and the other infant was determined to have died due to prematurity. It is highly unusual for the cause of death to be altered years after the fact and using methodology that is not supported by the coroner’s office.
The two claims of insulin poisoning are not supported by the testing conducted, and the infants (who are still alive and well) did not have dangerously low or dangerously high blood glucose levels for any period of time. There are many physiological reasons that could explain their low blood glucose during the whole period. In one of the two cases, assumptions are being made on the basis of one test taken at a single time point, clearly inconsistent with the other medical readings, and contravening the manufacturer’s own instructions for use (see image below). The report detailing the conclusions from that single test violates the code of practice of the forensic science regulator. Moreover, it appears that some numerical error has been made in the necessary calculation, resulting in an outcome which is physiologically impossible (or the person responsible did not know about the so-called “hook effect”). The mismatch between C-peptide and insulin concentration does not prove that the excess insulin found must have been synthetic insulin. There are many other biological explanations for a mismatch. No testing was done to determine the origin of the insulin. Similarly, there are many innocent explanations for the detection of some insulin in a feeding bag.
The air embolism hypothesis is confusing because it fails to explain why some children apparently perished and others did not, and it has not been supported by the minimal necessary measurements.
In at least one case, Lucy is blamed with causing white matter brain injury. This claim is utterly dishonest. The infant who experienced this brain injury was born at 23 weeks gestation, and white matter brain injury is associated with such early births. Further, there is sufficient evidence that demonstrates that enterovirus and parechovirus infection has been linked to white matter brain injury in neonates, resulting in cerebral palsy.
At the time of the collapses and deaths of the infants, enterovirus and parechovirus had been reported in other hospitals. There is a history of outbreaks of these viruses in neonatal wards in hospitals around the world. They especially harm preterm infants who do not yet have a functioning immune system. It is reported that many parents of the infants were concerned that their ward had a virus (as was Lucy) and that Dr Gibbs denied this was so. To date we have seen no evidence to show they did any viral testing, and if they did what the results were.
Then a fact pertaining to my own scientific competence.
Both prosecution and defence were warned long ago about the statistical issues in such cases. Both have responded that they are not going to use any statistics. They are also not using the services of any statistician. Seems the RSS report https://rss.org.uk/news-publication/news-publications/2022/section-group-reports/rss-publishes-report-on-dealing-with-uncertainty-i/ has had the opposite effect to that intended. Amusingly, the same thing happened in the case of Lucia de Berk. At the appeal the prosecution stopped using statistics. She was convicted solely on the grounds of “irrefutable medical scientific evidence”. (Here, I’m quoting from the words both spoken by the judges and written down on the first page of their > 100 page report of the reasons and reasoning which had led to their unshakable conviction that Lucia de Berk was guilty. The longest judge’s summing up in Dutch legal history). I was one of the five coauthors of the RSS report. We were a “task force”, formally commissioned by the “Statistics and the Law” section of the society. I consider it the most important scientific work of my career. It took us two years to put together. We started the work in 2020; we had seen the Lucy Letby trial on the horizon since 2017 when police investigations started and the suspect being investigated was already common knowledge.
The UK does not have anything like that because a jury of ordinary folk are the ones who (legally) determine guilt or innocence. This is a clever device which makes fighting a conviction very difficult; no one can know what arguments the jury had in their mind, no one knows what, if anything, was the key fact that convinced them of guilt. Ordinary people are convinced by what seems to be a smoking gun, they then see all the other evidence through a filter. This is called “confirmation bias”. In the Lucy Letby case, the smoking gun was probably the post-it note, and the insulin then seems to clinch the matter. The prosecution cross-examination convinces those who already believe Lucy is guilty that she moreover is constantly lying. More on all this in later posts, I hope.
Back to the insulin. Here are the instructions on the insulin testing kit used for the trial, taken from this website http://pathlabs.rlbuht.nhs.uk/ccfram.htm, the actual file is http://pathlabs.rlbuht.nhs.uk/insulin.pdf. Notice the warning printed in red. Yes, it was printed in red, that was not something I changed later. (All this is not my discovery; the person who uncovered these facts wishes to remain anonymous).
The toxicological evidence used in the trial violates the code of practice of the UK’s Forensic Science Regulator (see link below). It should have been deemed inadmissible. Instead, the defence has not disputed it, and thereby obliged their own client Lucy to agree that there must have been a killer on the ward. The jury are instructed to believe that two babies were given insulin without authorization, endangering their lives. (The two babies in question are still very much alive, to this day. Probably now at primary school.)
The defence stated to me that they cannot inform Lucy of the alternative analysis of the insulin question. It appears to me that this violates their own code of practice. Do they feel bound by the weird rules of UK’s criminal prosecution practice? Their client, Lucy Letby, is herself essentially merely a piece of evidence, seized by the police from what they believe is a scene of crime. No one may tamper with it during the duration of her own trial, which is lasting 10 months! I think this constitutes an appalling violation of basic human rights. The UK laws on contempt of court are meant to guarantee a fair trial. But in the case of a 10-month trial on 22 charges of murder and attempted murder, they are guaranteeing an unfair trial.
Lucy’s solicitor refused to pass on a friendly personal letter of support to Lucy or to her parents because she had not instructed him to do so. Should one laugh or cry about that excuse? I have the impression that he is not very bright and that he may have been convinced she is guilty. If so, I hope he is changing his mind. In the UK, the solicitor does all the legwork and communication between the client and the defence team. The barrister does the cross-examinations and the court theatrics, but probably never builds up a personal relationship with his client. Lucy has been all this time prison, in pre-trial detention, far from Manchester or Hereford. This might explain the extraordinarily weak defence which has been put up so far. But it might be deliberate.
One must take into account the fact that funding for legal support is meagre. The prosecution has been working on the case for 6 or so years, with unlimited resources. The defence has had a relatively very short time, with very limited resources. Probably the solicitor and the barrister already put in many more hours than they are paid for. There are no funds for expensive scientific witnesses. It is very possible that the defence team well understands that they cannot put up a serious defence during the 9 to 10 months of the trial, but that precisely this time period, with a huge number of revelations being made outside the trial, material for a serious defence during an appeal has been “crowd-sourced”. It seems to me that this mass of high-quality independent scientific work provides plenty of grounds for an appeal, in the case that the jury hands down a guilty verdict.
At a pre-publication meeting of stake-holders held to gain feedback on our report, a senior West Midlands police inspector told me “we are not using statistics because they only make people confused”. Lucy’s sollicitor and barrister knew well in advance of our report, were even given names of excellent UK experts whom they could consult, but did not bother to contact one of them. No statistics in our courts please, we are British! Yet the UK has the best applied statisticians and epidemiologists in the world.
Article in “Science” about my work on serial killer nurses
https://www.bbc.co.uk/sounds/play/m001k7vt?partner=uk.co.bbc&origin=share-mobile “The UK’s forensic science used to be considered the gold standard, but no longer. The risk of miscarriages of justice is growing. And now a new Westminster Commission is trying to find out what went wrong. Joshua talks to its co-chair, leading forensic scientist Dr Angela Gallop CBE, and to criminal defence barrister Katy Thorne KC.”
Criminal Procedure Rules and Criminal Practice Directions
New expert evidence cannot be admitted once a trial is in progress
“The courts have indicated that they are prepared to refuse leave to the Defence to call expert evidence where they have failed to comply with CrimPR; for example by serving reports late in the proceedings, which raise new issues (Writtle v DPP  EWHC 236). See also: R v Ensor  1 Cr. App. R.18 and Reed, Reed & Garmson EWCA Crim. 2698″. This quote comes from https://www.cps.gov.uk/legal-guidance/expert-evidence. Note, a judge is always allowed to break with precedence. The rule is not actually a permanent rule, it is merely a description of current practice. Current practice evolves when and if a new judge sees fit to break with precedence. Obviously, he would have to come up with good legal reasons why he believes he has to do that. It’s his prerogative, his free choice. That’s the essence of case law, aka common law.
There has been much concern about health issues associated with the breeding of short-muzzled pedigree dogs. The Dutch government commissioned a scientific report Fokken met Kortsnuitige Honden (Breeding of short-muzzled dogs), van Hagen (2019), and based on it rather stringent legislation, restricting breeding primarily on the basis of a single simple measurement of brachycephaly, the CFR: cranial-facial ratio. Van Hagen’s work is a literature study and it draws heavily on statistical results obtained in three publications: Njikam (2009), Packer et al. (2015), and Liu et al. (2017). In this paper, I discuss some serious shortcomings of those three studies and in particular, show that Packer et al. have drawn unwarranted conclusions from their study. In fact, new analyses using their data lead to an entirely different conclusion.
The present work was commissioned by “Stichting Ras en Recht” (SRR; Foundation Justice for Pedigree dogs) and focuses on the statistical research results of earlier papers summarized in the literature study Fokken met Kortsnuitige Honden (Breeding of short-muzzled – brachycephalic – dogs) by dr M. van Hagen (2019). That report is the final outcome of a study commissioned by the Netherlands Ministry of Agriculture, Nature, and Food Quality. It was used by the ministry to justify legislation restricting breeding of animals with extreme brachycephaly as measured by a low CFR, cranial-facial ratio.
An important part of van Hagen’s report is based on statistical analyses in three key papers: Njikam et al. (2009), Packer et al. (2015), and Liu et al. (2017). Notice: the paper Packer et al. (2015) reports results from two separate studies, called by the authors Study 1 and Study 2. The data analysed in Packer et al. (2015) study 1 was previously collected and analysed for other purposes in an earlier paper Packer et al. (2013) which does not need to be discussed here.
In this paper, I will focus on these statistical issues. My conclusion is the cited papers have many serious statistical shortcomings, which were not recognised by van Hagen (2019). In fact, a reanalysis of the Study 2 data investigated in Packer et al. (2015) leads to conclusions completely opposite to those drawn by Packer et al., and completely opposite to the conclusions drawn by van Hagen. I come to the conclusion that the Packer et al. study 2 badly needs updating with a much larger replication study.
A very important question is just how generalisable are the results of those papers. There is no word on that issue in van Hagen (2019). I will start by discussing the paper which is most relevant to our question: Packer et al. (2015).
An important preparatory remark should be made concerning the term “BOAS”, brachycephalic obstructive airway syndrome. It is a syndrome, which means: a name for some associated characteristics. “Obstructed airways” means: difficulty in breathing. “Brachycephalic” means: having a (relatively) short muzzle. Having difficulty in breathing is a symptom sometimes caused by having obstructed airways; it is certainly the case that the medical condition is often associated with having a short muzzle. That does not mean that having a short muzzle causes the medical condition. In the past, dog breeders have selected dogs with a view to accentuating certain features, such as a short muzzle: unfortunately, at the same time, they have sometimes selected dogs with other, less favourable characteristics at the same time. The two features of dogs’ anatomies are associated, but one is not the cause of the other. “BOAS” really means: having obstructed airways and a short muzzle.
Packer et al. (2015) reports findings from two studies. The sample for the first study, “Study 1”, 700 animals, consisted of almost all dogs referred to the Royal Veterinary College Small Animal Referral Hospital (RVC-SAH) in a certain period in 2012. Exclusions were based on a small list of sensible criteria such as the dog being too sick to be moved or too aggressive to be handled. However, this is not the end of the story. In the next stage, those dogs who actually were diagnosed to have BOAS (brachycephalic obstructive airway syndrome) were singled out, together with all dogs whose owners reported respiratory difficulties, except when such difficulties could be explained by respiratory or cardiac disorders. This resulted in a small group of only 70 dogs considered by the researchers to have BOAS, and it involved dogs of 12 breeds only. Finally, all the other dogs of those breeds were added to the 70, ending up with 152 dogs of 13 (!) breeds. (The paper contains many other instances of carelessness).
To continue with the Packer et al. (2015) Study 1 reduced sample of 152 dogs, this sample is a sample of dogs with health problems so serious that they are referred to a specialist veterinary hospital. One might find a relation between BOAS and CFR (craniofacial ratio) in that special population which is not the same as the relation in general. Moreover, the overall risk of BOAS in this special population is by its construction higher than in general. Breeders of pedigree dogs generally exclude already sick dogs from their breeding programmes.
That first study was justly characterised by the authors as exploratory. They had originally used the big sample of 700 dogs for a quite different investigation, Packer et al. (2013). It is exploratory in the sense that they investigated a number of possible risk factors for BOAS besides CFR, and actually used the study to choose CFR as appearing to be the most influential risk factor, when each is taken on its own, according to a certain statistical analysis method, in which already a large number of prior assumptions had been built in. As I will repeat a few more times, the sample is too small to check those assumptions. I do not know if they also tried various simple transformations of the risk factors. Who knows, maybe the logarithm of a different variable would have done better than CFR.
In the second study (“Study 2”), they sampled anew, this time recruiting animals directly mainly from breeders but also from general practice. A critical selection criterium was a CFR smaller than 0.5, that number being the biggest CFR of a dog with BOAS from Study 1. They especially targeted breeders of breeds with low CFR, especially those which had been poorly represented in the first study. Apparently, the Affenpinscher and Griffon Bruxellois are not often so sick that they get referred to the RVC-SAH; of the 700 dogs entering Study 1, there was, for instance, just 1 Affenpinscher and only 2 Griffon Bruxellois. Of course, these are also relatively rare breeds. Anyway, in Study 2, those numbers became 31 and 20. So: the second study population is not so badly biased towards sick animals as the first. Unfortunately, the sample is much, much smaller, and per breed, very small indeed, despite the augmentation of rarer breeds.
Now it is important to turn to technical comments concerning what perhaps seems to speak most clearly to the non-statistically schooled reader, namely, Figure 2 of Packer et al., which I reproduce here, together with the figure’s original caption.
In the abstract of their paper, they write “we show […] that BOAS risk increases sharply in a non-linear manner”. They do no such thing! They assume that the log odds of BOAS risk , that is: log(p/(1 – p)), depends exactly linearly on CFR and moreover with the same slope for all breeds. The small size of these studies forced them to make such an assumption. It is a conventional “convenience” assumption. Indeed, this is an exploratory analysis, moreover, the authors’ declared aim was to come up with a single risk factor for BOAS. They were forced to extrapolate from breeds which are represented in larger numbers to breeds of which they had seen many less animals. They use the whole sample to estimate just one number, namely the slope of log(p/(1 – p)) as an assumed linear function of CFR. Each small group of animals of each breed then moves that linear function up or down, which corresponds to moving the curves to the right or to the left. Those are not findings of the paper. They are conventional model assumptions imposed by the authors from the start for statistical convenience and statistical necessity and completely in tune with their motivations.
One indeed sees in the graphs that all those beautiful curves are essentially segments of the same curve, shifted horizontally. This has not been shown in the paper to be true. It was assumed by the authors of the paper to be true. Apparently, that assumption worked better for CFR than for the other possible criteria which they considered: that was demonstrated by the exploratory (the author’s own characterisation!) Study 1. When one goes from Study 1 to Study 2, the curves shift a bit: it is definitely a different population now.
There are strange features in the colour codes. Breeds which should be there are missing, and breeds which shouldn’t be there are. The authors have exchanged graphs (a) and (b)! This can be seen by comparing the minimum and maximum predicted risks from their Table 2.
Notice that these curves represent predictions for neutered dogs with breed mean neck girth, breed ideal body condition score (breed ideal body weight). I don’t know whose definition of ideal is being used here. The graphs are not graphs of probabilities for dog breeds, but model predictions for particular classes of dogs of various breeds. They depend strongly on whether or not the model assumptions are correct. The authors did not (and could not) check the model assumptions: the sample sizes are much too small.
By the way, breeders’ dogs are generally not neutered. Still, one-third of the dogs in the sample were neutered, so the “baseline” does represent a lot of animals. Notice that there is no indication whatsoever of statistical uncertainty in those graphics. The authors apparently did not find it necessary to add error bars or confidence bands to their plots. Had they done so, the pictures would have given a very, very different impression.
In their discussion, the authors write “Our results confirm that brachycephaly is a risk factor for BOAS and for the first time quantitatively demonstrate that more extreme brachycephalic conformations are at higher risk of BOAS than more moderate morphologies; BOAS risk increases sharply in a non-linear manner as relative muzzle length shortens”. I disagree strongly with their appraisal. The vaunted non-linearity was just a conventional and convenience (untested) assumption of linearity in the much more sensible log-odds scale. They did not test this assumption and most importantly, they did not test whether it held for each breed considered separately. They could not do that, because both of their studies were much, much too small. Notice that they themselves write, “we found some exceptional individuals that were unaffected by BOAS despite extreme brachycephaly” and it is clear that these exceptions were found in specific breeds. But they do not tell us which.
They also tell us that other predictors are important next to CFR. Once CFR and breed have been taken into account (in the way that they take it into account!), neck girth (NG) becomes very important.
They also write, “if society wanted to eliminate BOAS from the domestic dog population entirely then based on these data a quantitative limit of CFR no less than 0.5 would need to be imposed”. They point out that it is unlikely that society would accept this, and moreover, it would destroy many breeds which do not have problems with BOAS at all! They mention, “several approaches could be used towards breeding towards more moderate, lower-risk morphologies, each of which may have strengths and weaknesses and may be differentially supported by stakeholders involved in this issue”.
This paper definitely does not support imposing a single simple criterion for all dog breeds, much as its authors might have initially hoped that CFR could supply such a criterion.
In a separate section, I will test their model assumptions, and investigate the statistical reliability of their findings.
Now I turn to the other key paper, Liu et al. (2017). In this 8-author paper, the last and senior author, Jane Ladlow, is a very well-known authority in the field. This paper is based on a study involving 604 dogs of only three breeds, and those are the three breeds which are already known to be most severely affected by BOAS: bulldogs, French bulldogs, and pugs. They use a similar statistical methodology to Packer et al., but now they allow each breed to have a different shaped dependence on CFR. Interestingly, the effects of CFR on BOAS risk for pugs, bulldogs and French bulldogs are not statistically significant. Whether or not they are the same across those three breeds becomes, from the statistical point of view, an academic question.
The statistical competence and sophistication of this group of authors can be seen at a glance to be immeasurably higher than that of the group of authors of Packer et al. They do include indications of statistical uncertainty in their graphical illustrations. They state, “in our study with large numbers of dogs of the three breeds, we obtained supportive data on NGR (neck girth ratio: neck girth/chest girth), but only a weak association of BOAS status with CFR in a single breed.” Of course, part of that could be due to the fact that, in their study, CFR did not vary much within each of those three breeds, as they themselves point out. I did not yet re-analyse their data to check this. CFR was certainly highly variable in these three breeds in both of Packer et al.’s studies, see the figures above, and again in Liu et al. as is apparent from my Figure 2 below. But Liu et al. also point out that anyway, “anatomically, the CFR measurement cannot determine the main internal BOAS lesions along the upper airway”.
Another of their concluding remarks is the rather interesting “overall, the conformational and external factors as measured here contribute less than 50% of the variance that is seen in BOAS”. In other words, BOAS is not very well predicted by these shape factors. They conclude, “breeding toward [my emphasis] extreme brachycephalic features should be strictly avoided”. I should hope that nowadays, no recognised breeders deliberately try to make known risk features even more pronounced.
Liu et al. studied only bulldogs, French bulldogs and pugs. The CFRs of these breeds do show within breed statistical variation. The study showed that a different anatomical measure was an excellent predictor of BOAS. Liu et al. moreover explain anatomically and medically why one should not expect CFR to be relevant for the health problems of those races of dogs.
It is absolutely not true that almost all of the animals in that study have BOAS. The study does not investigate BOS. The study was set up in order to investigate the exploratory findings and hypotheses of Packer et al. and it rejects them, as far as the three races they considered were concerned. Packer et al. hoped to find a simple relationship between CFR and BOAS for all brachycephalic dogs but their two studies are both much too small to verify their assumptions. Liu et al. show that for the three races studied, the relationship between measurements of body structure and ill health associated with them, varies between races.
In contradiction to the opinion of van Hagen (2019), there are no “contradictions” between the studies of Packer et al. and Liu et al. The first comes up with some guesses, based on tiny samples from each breed. The second investigates those guesses but discovers that they are wrong for the three races most afflicted with BOAS. Study 1 of Packer et al. is a study of sick animals, but Study 2 is a study of animals from the general population. Liu et al. is a study of animals from the general population. (To complicate matters, Njikam et al., Packer et al. and Liu et al. all use slightly different definitions or categorisations of BOAS.)
Njikam et al. (2009), like the later researchers in the field, fit logistic regression models. They exhibit various associations between illness and risk factors per breed. They do not quantify brachycephaly by CFR but by a similar measure, BRA, the ratio of width to length of the skull. CFR and BRA are approximately non-linear one-to-one functions of one another (this would be exact if skull length equalled skull width plus muzzle length, i.e., assuming a spherical cranium), so a threshold criterium in terms of one can be roughly translated into a threshold criterium in terms of the other. Their samples are again, unfortunately, very small (the title of their paper is very misleading).
Their main interest is in genetic factors associated with BOAS apart from the genetic factors behind CFR, and indeed they find such factors! In other words, this study shows that BOAS is very complex. Its causes are multifactorial. They have no data at all on the breeds of primary interest to SRR: these breeds are not much afflicted by BOAS! It seems that van Hagen again has a reading of Njikam et al. which is not justified by that paper’s content.
Fortunately, the data sets used by the publications in PLoS ONE are available as “supplementary material” on the journal’s web pages. First of all, I would like to show a rather simple statistical graphic which shows that the relation between BOAS and CFR in Packer et al.’s Study 2 data does not look at all as the authors hypothesized. First, here are the numbers: a table of numbers of animals with and without BOAS in groups split according to CFR as a percentage, in steps of 5%. The authors recruited animals mainly from breeders, with CFR less than 50%. It seems there were none in their sample with a CFR between 45% and 50%.
BOAS versus CFR group
Table 1: BOAS versus CFR group
This next figure is a simple “pyramid plot” of percentages with and without BOAS per CFR group. I am not taking into account the breed of these dogs, nor of other possible explanatory factors. However, as we will see, the suggestion given by the plot seems to be confirmed by more sophisticated analyses. And that suggestion is: BOAS has a roughly constant incidence of about 20% among dogs with a CFR between 20% and 45%. Below that level, BOAS incidence increases more or less linearly as CFR further decreases.
Be aware that the sample sizes on which these percentages are based are very, very small.
Could it be that the pattern shown in Figure 3 is caused by other important characteristics of the dogs, in particular, breed? In order to investigate this question, I, first of all, fitted a linear logistic regression model with only CFR, and then a smooth logistic regression model with only CFR. In the latter, the effect of CFR on BOAS is allowed to be any smooth function of CFR – not a function of a particular shape. The two fitted curves are seen in Figure 4. The solid line is the smooth, the dashed line is the fitted logistic curve.
This analysis confirms the impression of the pyramid plot. However, the next results which I obtained were dramatic. I added to the smooth model also Breed and Neutered-status, and also investigated some of the other variables which turned up in the papers I have cited. It turned out that “Breed” is not a useful explanatory factor. CFR is hardly significant. Possibly, just one particular breed is important: the Pug. The differences between the others are negligible (once we have taken account of CFR). The variable “neutered” remains somewhat important.
Here (Table 2) is the best model which I found. As far as I can see, the Pug is a rather different animal from all the others. On the logistic scale, even taking account of CFR, Neckgirth and Neuter status, being a Pug increases the log odds ratio for BOAS by 2.5. Below a CFR of 20%, each 5% decrease in CFR increases the log odds ratio for BOAS by 1, so is associated with an increase in incidence by a factor of close to 3. In the appendix can be seen what happens when we allow each breed to have its own effect. We can no longer separate the influence of Breed from CFR and we cannot say anything about any individual breeds, except for one.
(CFRpct – 20) * (CFRpct < 20)
Breed == “Pug”:TRUE
*** p < 0.001; ** p < 0.01; * p < 0.05
Table 2: A very simple model (GLM, logistic regression)
The pug is in a bad way. But we knew that before. Packer Study 2 data:
Table 3: The Pug almost always has BOAS. The majority of non-Pugs don’t.
The graphs of Packer et al. in Figure 1 are a fantasy. Reanalysis of their data shows that their model assumptions are wrong. We already knew that BOAS incidence, Breed, and CFR are closely related and naturally they see that again in their data. But the actual possibly Breed-wise relation between CFR and BOAS is completely different from what their fitted model suggests. In fact, the relation between CFR and BOAS seems to be much the same for all breeds, except possibly for the Pug.
The paper Packer et al. (2015) is rightly described by its authors as exploratory. This means: it generates interesting suggestions for further research. The later paper by Liu et al. (2017) is excellent follow-up research. It follows up on the suggestions of Packer et al., but in fact it does not find confirmation of their hypotheses. On the contrary, it gives strong evidence that they were false. Unfortunately, it only studies three breeds, and those breeds are breeds where we already know action should be taken. But already on the basis of a study of just those three breeds, it comes out strongly against taking one single simple criterion, the same for all breeds, as the basis for legislation on breeding.
Further research based on a reanalysis of the data of Packer et al. (2015) shows that the main assumptions of those authors were wrong and that, had they made more reasonable assumptions, completely different conclusions would have been drawn from their study.
The conclusion to be drawn from the works I have discussed is that it is unreasonable to suppose that a single simple criterion, the same for all breeds, can be a sound basis for legislation on breeding. Packer et al. clearly hoped to find support for this but failed: Liu et al. scuppered that dream. Reanalysis of their data with more sophisticated statistical tools shows that they should already have seen that they were betting on the wrong horse.
Below a CFR of 20%, a further decrease in CFR is associated with a higher incidence of BOAS. There is not enough data on every breed to see if this relationship is the same for all breeds. For Pugs, things are much worse. For some breeds, it might not be so bad.
Study 2 of Packer et al. (2015) needs to be replicated, with much larger sample sizes.
Liu N-C, Troconis EL, Kalmar L, Price DJ, Wright HE, Adams VJ, Sargan DR, Ladlow JF (2017) Conformational risk factors of brachycephalic obstructive airway syndrome (BOAS) in pugs, French bulldogs, and bulldogs. PLoS ONE12 (8): e0181928. https://doi.org/10.1371/journal.pone.0181928
Njikam IN, Huault M, Pirson V, Detilleux J (2009) The influence of phylogenic origin on the occurrence of brachycephalic airway obstruction syndrome in a large retrospective study. International Journal of Applied Research in Veterinary Medicine7(3) 138–143. http://www.jarvm.com/articles/Vol7Iss3/Nijkam%20138-143.pdf
Packer RMA, Hendricks A, Volk HA, Shihab NK, Burn CC (2013) How Long and Low Can You Go? Effect of Conformation on the Risk of Thoracolumbar Intervertebral Disc Extrusion in Domestic Dogs. PLoS ONE8 (7): e69650. https://doi.org/10.1371/journal.pone.0069650
Table 4: A more complex model (GAM, logistic regression)
The above model (Table 4) allowing each breed to have its own separate “fixed” effect is not a success. That certainly was presumably the motivation to make “Breed” a random, not a fixed, effect in the Packer et al. publication, because treating breed effects as drawn from a normal distribution and assuming the same effect of CFR for all breeds disguises the multicollinearity and lack of information in the data. Many breeds, most of them contributing only one or two animals, enabled the authors’ statistical software to compute an overall estimate of “variability between breeds” but the result is pretty meaningless.
Further inspection shows that many breeds are only represented by 1or 2 animals in the study. Only five are in something a bit like reasonable numbers. These five are the Affenpinscher, Cavalier King Charles Spaniel, Griffon Bruxellois, Japanese Chin and Pug; in numbers 31, 11, 20, 10, 32. I fitted a GLM (logistic regression) trying to explain BOAS in these 105 animals and their breed together with variables CFR, BCR, and so on. Still then, the multicollinearity between all these variables is so strong that the best model did not include CFR at all. In fact: once BCS (Body Condition Score) was included, no other variable could be added without almost everything becoming statistically insignificant. Not surprisingly, it is good to have a good BCS. Being a Pug or a Japanese Chin is disastrous. Cavalier King Charles Spaniel is intermediate. Affenpinscher and Griffon Bruxellois have the least BOAS (and about the same amount, namely an incidence of 10%), even though the mean CFRs of these two species seem somewhat different (0.25, 0.15).
Had the authors presented p-values and error bars the paper would probably never have been published. The study should be repeated with a sample 10 times larger.
This work was partly funded by “Stichting Ras en Recht” (SRR; Foundation Justice for Pedigree dogs). The author accepted the commission by SSR to review statistical aspects of MAE van Hagen’s report “Breeding of short-muzzled dogs” under the condition that he would report his honest professional and scientific opinion on van Hagen’s literature study and its sources.
Note: the present post reproduces the text of our new preprint https://arxiv.org/abs/2104.00333, adding some juicy pictures. Further editing is planned, much reducing the length of this blog-post version of our story.
Summary: We analyse data from the final two years of a long-running and influential annual Dutch survey of the quality of Dutch New Herring served in large samples of consumer outlets. The data was compiled and analysed by Tilburg University econometrician Ben Vollaard, and his findings were publicized in national and international media. This led to the cessation of the survey amid allegations of bias due to a conflict of interest on the part of the leader of the herring tasting team. The survey organizers responded with accusations of failure of scientific integrity. Vollaard was acquitted of wrongdoing by the Dutch authority, whose inquiry nonetheless concluded that further research was needed. We reconstitute the data and uncover important features which throw new light on Vollaard’s findings, focussing on the issue of correlation versus causality: the sample is definitely not a random sample. Taking into account both newly discovered data features and the sampling mechanism, we conclude that there is no evidence of biased evaluation, despite the econometrician’s renewed insistence on his claim.
Keywords: Data generation mechanism, Predator-prey cycles, Feedback in sampling and measurement, Consumer surveys, Causality versus correlation, Questionable research practices, Unhealthy research stimuli.
In surveys intended to help consumers by regularly publishing comparisons of a particular product obtained from different consumer outlets (think of British “fish and chips” bought in a large sample of restaurants and pubs), data is often collected over a number of years and evaluated each year by a panel, which might consist of a few experts, but might also consist of a larger number of ordinary consumers. As time goes by, outlets learn what properties are most valued by the panel, and may modify their product accordingly. Also, consumers learn from the published rankings. Panels are renewed, and new members presumably learn from the past about how they are supposed to weight the different features of a product. Partly due to negative reviews, some outlets go out of business, while new outlets enter the market, and imitate the products of the “winners” of previous years’ surveys. Coming out as “best” boosts sales; coming out as “worst” can be the kiss of death.
For many years, a popular Dutch newspaper (Algemene Dagblad, in the sequel AD) published two immensely influential annual surveys of two particularly popular and typically Dutch seasonal products: the Dutch New Herring (Dutch: Hollandse Nieuwe) in June, and the Dutch “oliebol” (a kind of greasy, currant-studded, deep-fried spherical doughnut) in December. This paper will study the data published by the newspaper on its website of 2016 and 2017—the last two years of the 36 years in which the AD herring test operated. This data included not only a ranking of all participating outlets and their final scores (on a scale of 0 to 10) but also numerical and qualitative evaluations of many features of the product being offered. A position in the top ten was highly coveted. Being in the bottom ten was a disaster.
For a while, rumours had been circulated (possibly by disappointed victims of low scores!) that both tests were biased. The herring test was carried out by a team of three tasters, whose leader Aad Taal was indeed consultant to a wholesale company called Atlantic (based in Scheveningen, in the same region as Rotterdam), and who offered a popular course on herring preparation. As a director at the Dutch ministry of agriculture he had earlier successfully managed to obtain the European Union (EU) legal protection for the official designation “Dutch New Herring”. Products may only be sold under this name in the whole EU only if meticulously prepared in the circumscribed traditional way, as well as satisfying strict rules of food safety. It is nowadays indeed sold in several countries adjacent to the Netherlands. We will later add some crucial further information about what actually makes a Dutch New Herring different from the traditionally prepared herring of other countries.
Enter econometrician Dr Ben Vollaard of Tilburg University. Himself partial to a tasty Dutch New Herring, he learnt in 2017 from his local fishmonger about the complaints then circulating about the AD Herring Test. The AD is based on the city of Rotterdam, close to the main home ports of the Dutch herring fleet in past centuries. Tilburg is somewhat inland. Not surprisingly, consumers in different regions of the country seem to have developed different tastes in Dutch New Herring, and a common complaint was that the AD herring testers had a Rotterdam bias.
Vollaard decided to investigate the matter scientifically. A student helped him to manually download the data published on their website on 144 participating outlets in 2016, and 148 in 2017. An undisclosed number of outlets participated in both years, and initial reports suggested it must be a large number. Later we discovered that the overlap consisted of only 23 outlets. Next, he ran a linear regression analysis, attempting to predict the published final score for each outlet in each year, using as explanatory variables the testing team’s evaluations of the herring according to various criteria such as ripeness and cleaning, together with numerical variables such as weight, price, temperature, and laboratory measurements of fat content and microbiological contamination. Most of the numerical variables were modelled by using dummy variables after discretization into a few categories. A single indicator variable for “distance from Rotterdam’’ (greater than 30 kilometres) was used to test for regional bias.
The analysis satisfyingly showed many highly significant effects, most of which are exactly those that should have been expected. The testing team gave a high final score to fish which had a high fat content, low temperature, well-cleaned, and a little matured (not too little, not too much). More expensive and heavier fish scored better, too. Being more than 30 km from Rotterdam had a just significant negative effect, lowering the final score by about 0.5. Given the supreme importance of getting the highest possible score, 10, a loss of half a point could make a huge difference to a new outlet going all out for a top score and hence position in the “top ten” of the resulting ranking. However, just because outlets in the sample far from Rotterdam performed a little worse on average than those close to Rotterdam, can have many innocent explanations.
But Vollaard went a lot further. After comparing the actual scores to linear regression model predicted scores based on the measured characteristics of the herring, Vollaard concluded:
Everything indicates that herring sales points in Rotterdam and the surrounding area receive a higher score in the AD Herring Test than can be explained from the quality of the herring served.
That is a pretty serious allegation.
Vollaard published this analysis as a scientific paper Vollaard (2017a) on his university personal web page, and the university put out a press release. The research drew a lot of media attention. In the ensuing transition from a more or less academic study (in fact, originally just a student exercise) to a press release put out by a university publicity department, then to journalists’ newspaper articles adorned with headlines composed by desk editors, the conclusion became even more damning.
Presumably stimulated by the publicity that his work had received, Vollaard decided to go further, now following up on further criticism circulating about the AD Herring Test. He rapidly published a second analysis, Vollaard (2017b), on his university personal web page. His focus was now on the question of a conflict of interest concerning a connection between the chief herring tester and the wholesale outlet Atlantic. Presumably by contacting outlets directly, he identified 20 outlets in the sample whose herring, he believed, had been supplied by that company. Certainly, his presumed Atlantic herring outlets tended to have rather good final scores, and a few of them were regularly in the top ten.
We may surmise that Vollaard must have been disappointed and surprised to discover that his dummy variable for being supplied by Atlantic was not statistically significant when he added it to his model. His existing model (the one on the basis of which he argued that the testing team was not evaluating outlets far from Rotterdam using their own measured characteristics) predicted that Atlantic outlets should indeed, according to those characteristics, have come out exactly as well as they did! He had to come up with something different. In his second paper, he insinuated pro-Atlantic bias by comparing the amount of variance explained by what he considered to be “subjective” variables with the amount explained by the “objective” variables, and he showed that the subjective (taste and smell, visual impression) evaluations explained just as much of the variance as the objective evaluations (price, temperature, fat percentage). This change of tune represents a serious inconsistency in thinking: this is cherry-picking in order to support a pre-gone conclusion.
In itself, it does not seem unreasonable to judge a culinary delicacy by taste and smell, and not unreasonable to rely on reports of connoisseurs. However, Vollaard went much further. He hypothesized that “ripeness” and “microbiological state” were both measurements of the same variable; one subjective, the other objective. According to him, they both say how much the fish was “going off”. Since the former variable was extremely important in his model, the latter not much at all, he again accused the herring testers of bias and attributed that bias to conflict of interest. His conclusion was:
A high place in the AD Herring Test is strongly related to purchasing herring from a supplier in which the test panel has a business interest. On a scale of 0 to 10, the final mark for fishmongers with this supplier is on average 3.6 points higher than for fishmongers with another supplier.
He followed that up with the statement:
Almost half of the large difference in average final grade between outlets with and without Atlantic as supplier can be explained by a subjective assessment by the test team of how well the herring has been cleaned (very good/good/moderate/poor) and of the degree of ripening of the herring (light/medium/strong/spoiled).
The implication is that the Atlantic outlets are being given an almost 2 point advantage based on a purely subjective evaluation of ripeness.
The AD defended itself and its herring testers by pointing out that the ripeness or maturity of a Dutch new herring, evaluated by taste and smell, reflects ongoing and initially highly desirable chemical processes (protein changing to fat, fat to oil, oil becoming rancid). Degree of microbiological activity, i.e., contamination with harmful bacteria, could be correlated with that, since dangerous bacterial activity will tend to increase with time once it has started, and both processes are speeded up if the herring is not kept cold enough, but it is of a completely different nature: biological, not chemical. It is caused by carelessness in various stages of preparation of the herring, insufficient cooling, and so on. It is obviously not desirable at all. AD also pointed out that one of the Atlantic outlets must have been missed, which actually in the first of the two years had scored very badly. This could be deduced from the numbers of those outlets, and the mean score of the Atlantic-supplied outlets, both reported by Vollaard in his papers.
The newspaper AD complained first to Vollaard and then to his university. With the help of lawyers, a complaint was filed with the Tilburg University committee for scientific integrity. The committee rejected the complaint, but the newspaper took it to the national level. Their lawyers hired the second author of this paper, Richard Gill (RDG), in the hope that he would support their claims. He requested Vollaard’s data-set and also requested that the outlets in the data-set be identified, since one major methodological complaint of his was that Vollaard had not taken account of possible autocorrelation by combining samples from two subsequent years, with presumably a large overlap, but without taking any account of this. Vollaard reluctantly supplied the data but declined to identify the outlets appearing twice or even inform us how many such outlets there were. With the help of AD however, it was possible to find them, and also locate many misclassified outlets. RDG wrote an expert opinion in which he argued that the statistical analysis did not support any allegations of bias or even unreliability of the herring test.
Vollaard had repeatedly stated that he was only investigating correlations, not establishing causality, but at the same time his published statements (quoted in the media), and his spoken statements on national TV, make it clear that he considered that his analysis results were damming evidence against the test. This seemed to RDG to be unprofessional, at the very least. RDG moreover identified much statistical amateurism. Vollaard analysed his data much as any econometrician might do: he had a data-set with a variable of interest and a number of explanatory variables, he ran a linear regression making numerous modelling choices without any motivation and without any model checking. He fit a completely standard linear regression model to two samples of Dutch new herring outlets, without any thought to the data generating mechanism. How were outlets selected to appear in the sample?
According to the AD, there were actually 29 Atlantic outlets in Vollaard’s combined sample. Note, there is some difficulty in determining this number. A given outlet may obtain some fish from Atlantic, some from other suppliers, and may change their suppliers over the course of a year. So the origin of the fish actually tasted by the test team cannot be determined with certainty. We see in Table 1 (according to AD), that Vollaard “caught” only about two thirds of the Atlantic outlets, and misclassified several more.
Atlantic by Vollaard
Not Atlantic by Vollaard
Atlantic by AD
Not Atlantic by AD
Table 1: Atlantic- and not Atlantic-supplied outlets tested over two years as identified by Vollaard and the AD respectively.
At the national level, the LOWI (Landelijk Orgaan Wetenschappelijk Integriteit — the Dutch national organ for investigating complaints of violation of research integrity) re-affirmed the Tilburg University scientific integrity committee’s “not guilty” verdict. Vollaard was not deliberately trying to mislead. “Guilty” verdicts have an enormous impact and imply a finding, beyond a reasonable doubt, of gross research impropriety. This generally leads to termination of university employment contracts and to retraction of publications. They did agree that Vollaard’s analyses were substandard, and they recommended further research. RDG reached out to Vollaard suggesting collaboration, but he declined. After a while, Vollaard’s (still anonymized) data sets and statistical analysis scripts (written in the proprietary Stata language) were also published on his website Vollaard (2020a, 2020b). The data was actually in the form of Stata files; fortunately, it is nowadays possible to read such files in the open source and free R system. The known errors in the classification of Atlantic outlets were not corrected, despite AD’s request. The papers and the files are no longer on Vollaard’s webpages, and he still declines collaboration with us. We have made all documents and data available on our own webpages and on the GitHub page https://github.com/gaofengnan/dutch-new-herring.
RDG continued his re-analyses of the data and began the job of converting his expert opinion report (English translation: https://gill1109.com/2021/06/01/was-the-ad-herring-test-about-more-than-the-herring/) into a scientific paper. It seemed wise to go back to the original sources and this meant a difficult task of extracting data from the AD’s websites. Each year’s worth of data was moreover coded differently in the underlying HTML documents. At this point he was joined by the first author Fengnan Gao (FG) of the present paper who was able to automate the data scraping and cleaning procedures — a major task. Thus, we were able to replicate the whole data gathering and analysis process and this led to a number of surprises.
Before going into that, we will explain what is so special about Dutch New Herring, and then give a little more information about the variables measured in the AD Herring Test.
Dutch New Herring
Every nation around the North Sea has traditional ways of preparing North Atlantic herring. For centuries, herring has been a staple diet of the masses. It is typically caught when the North Atlantic herring population comes together at its spawning grounds, one of them being in the Skagerak, between Norway and Denmark. Just once a year there is an opportunity for fishers to catch enormous quantities of a particular extremely nutritious fish, at the height of their physical condition, about to engage in an orgy of procreation. The fishers have to preserve their catch during a long journey back to their home base; and if the fish is going to be consumed by poor people throughout a long year, further means of conservation are required. Dutch, Danish, Norwegian, British and German herring fleets (and more) all compete (or competed) for the same fish; but what people in those countries eat varies from country to country. Traditional local methods of bringing ordinary food to the tables of ordinary folk become cultural icons, tourist attractions, gastronomic specialities, and export products.
Traditionally, the Dutch herring fleet brought in the first of the new herring catch in mid-June. The separate barrels in the very first catch are auctioned and a huge price (given to charity) is paid for the very first barrel. Very soon, fishmongers, from big companies with a chain of stores and restaurants, to supermarket chains, to small businesses selling fish in local shops and street markets are offering Dutch New Herring to their customers. It’s a traditional delicacy, and nowadays, thanks to refrigeration, it can be sold the whole year long (the designation “new” should be removed in September). Nowadays, the fish arrives in refrigerated lorries from Denmark, no longer in Dutch fishing boats at Scheveningen harbour.
What makes a Dutch new herring any different from the herring brought to other North Sea and Baltic Sea harbours? The organs of the fish should be removed when they were caught, and the fish kept in lightly salted water. But two internal organs are left, a fish’s equivalent to our pancreas and kidney. The fish’s pancreas contains enzymes which slowly transform some protein into fat and this process is responsible for a special almost creamy taste which is much treasured by Dutch consumers, as well as those in neighbouring countries. See, e.g., the Wikipedia entry for soused herring for more details, https://en.wikipedia.org/wiki/Soused_herring. According to a story still told to Dutch schoolchildren, this process was discovered in the 14th century by a Dutch fisher named Willem Beukelszoon.
The AD Herring Test
For many years, the Rotterdam-based newspaper Algemene Dagblad(AD) carried out an annual comparison of the quality of the product offered in a sample of consumer outlets. A small team of expert herring tasters paid surprise visits to the typical small fishmonger’s shops and market stalls where customers can order portions of fish and eat them on the premises (or even just standing in a busy food market). The team evaluated how well the fish has been prepared, preferring especially that the fish have not been cleaned in advance but that they are carefully and properly prepared in front of the client. They judged the taste and checked the temperature at which it is given to the customer: by law it may not be above 7 degrees. A sample was sent to a lab for a number of measurements: weight, fat percentage, signs of microbiological contamination. They are also interested in the price (per gram). An important, though subjective, characteristic is “ripeness”. Expert tasters distinguish Dutch new herring which has not ripened (matured) at all: green. After that comes lightly matured, well matured, too much matured, and eventually rotten.
This information was all written down and evaluated subjectively by each team member, then combined. The team averaged the scores given by its three members (a senior herring expert, a younger colleague, and a journalist) to produce a score from 0 to 10, where 10 is perfection; below 5.5 is a failing grade. However, it was not just a question of averaging. Outlets which sold fish which was definitely rotten, definitely contaminated with harmful bacteria, or definitely too warm got a zero grade. The outlets which took part were then ranked. The ten highest ranking outlets were visited again, and their scores possibly adjusted. The final ranking was published in the newspaper, and put in its entirety on internet. Coming out on top was like getting a Michelin star. The outlets at the bottom of the list might as well have closed down straight away. One sees from the histogram below, Figure [fig:1], that in 2016 and 2017, more than 40% of the outlets got a failing grade; almost 10% were essentially disqualified, by being given a grade of zero. The distribution looks nicely smooth except for the peak at zero, which really means that their wares did not satisfy minimal legal health requirements.
It is important to understand how outlets were chosen to enter the test. To begin with, the testing team itself automatically revisited last years’ top ten. But further outlets could be nominated by individual newspaper readers, indeed, they could be self-nominated by persons close to the outlets themselves. We are not dealing with a random sample, but with a self-selecting sample, with automatically a high overlap from year to year.
Over the years, there had been more and more acrimonious criticism of the AD Herring Test. As one can imagine, it was mainly the owners of outlets who had bad scores who were unhappy about the test. Many of them, perhaps justly, were proud of their product and had many satisfied customers too. Various accusations were therefore flung around. The most serious one was that the testing team was biased and even had a conflict of interest. The lead taster gave courses on the preparation of Dutch New Herring and led the movement to have the “brand” registered with the EU. There is no doubting his expertise, but he had been hired (in order to give training sessions to their clients) by one particular wholesale business, owned by a successful businessman of Turkish origin, which as one might imagine lead to jealousy and suspicion. Especially since a number of the retail outlets of fish supplied by that particular company often (but certainly not always) appeared year by year in the top ten of the annual AD Herring Test. Other accusations were that the herring tasters favoured businesses in the neighbourhood of Rotterdam (home base of the AD). As herring cognoscenti know, people in various Dutch localities have slightly different tastes in Dutch New Herring. Amsterdammers have a different taste from Rotterdammers.
In the meantime, under the deluge of negative publicity, the AD announced that they would now stop their annual herring test. They did hire a law company who on their behalf brought an accusation of failure of scientific integrity to Tilburg University’s “Commission for Scientific Integrity”. The law firm moreover approached one of us (RDG) for expert advice. He was initially extremely hesitant to be a hired gun in an attack on a fellow academic but as he got to understand the data and the analyses and the subject, he had to agree that the AD had some good points. At the same time, various aggrieved herring sellers were following up with their own civil action against the AD; and the wholesaler whose outlets did so well in the test, also started a civil action against Tilburg University, since its own reputation was damaged by the affair.
Here is the main result of Vollaard’s first report.
No surprises here. The testing team prefers fatty and larger herring, properly cooled, mildly matured, freshly prepared in view of customers on-site, and well-cleaned too. We have a delightful amount of statistical significance. There are some curious features of Vollaard’s chosen model: some numerical variables (“temp” and “fat”) have been converted into categorical variables by presumably arbitrary choice of cut-off points, while “weight” is taken as numerical. Presumably, this is because one might expect the effect of temperature not to be monotone. Nowadays, one might attempt fitting low-degree spline curves with few knots. Some categories of categorical variables have been merged, without explanation. One should worry about interactions and about additivity. Certainly one should worry about model fit.
We add to the estimated regression model also R’s standard four diagnostic plots in Fig. 2. Dr Vollaard apparently did not carry out any model checking.
Model validation beyond Vollaard’s regression analysis
There are some serious statistical issues. There seem to be a couple of serious outliers. The error distribution seems to have a heavier than normal tail. But we also understand that some observations come in pairs — the same outlet evaluated in two subsequent years. The data set has been anonymized too much. Each outlet should at the least have been given a random code so that one can identify the pairs and take account of possible dependence from one year to the next, easy to do by simply estimating the correlation from the residuals, and then doing a generalized linear regression with an estimated covariance matrix of the error terms.
Inspection of the outliers led us to realize that there is a serious issue with the observations which got a final score of zero. Those outlets were essentially disqualified on grounds of gross violation of basic hygiene laws, applied by looking at just a couple of the variables: temperature above 12 degrees (the legal limit is 7), and microbiological activity (dangerous versus low or none). The model should have been split into two parts: a linear regression model for the scores of the not-disqualified outlets; and a logistic regression model, perhaps, for predicting “disqualification” from some of the other characteristics. However, at least it is possible to analyse each of the years separately, and to remove the “disqualified” outlets. That is easy to do. Analysing just the 2017 data, the analysis results look a lot cleaner; the two bad outliers have gone, the estimated standard deviation of the errors is a lot smaller, the normal Q-Q plot looks very nice.
There is another big issue with this data and these analyses which needs to be mentioned, and if possible, addressed. How did the “sample” come to be what it is? A regression model is at best a descriptive account of the correlations in a given data set. Before we should accuse the test team of bias, we should ask how the sample is taken. It is certainly not a random sample from a well-defined population!
Some retail outlets took part in the AD Herring Test year after year. The testing team automatically included last years’ top ten. Individual readers of the newspaper could nominate their own favourite fish shop to be added to the “sample”, and this actually did happen on a big scale. Fish shops which did really badly tended to drop out of future tests and, indeed, some of them stopped doing business altogether:
The “sample” evolves in time by a feedback mechanism.
Everybody could know what the qualities were that the AD testers appreciated, and they learnt from their score and their evaluation each year what they had to do better next year, if they wanted to stay in the running and to join the leaders of the pack. The notion of “how a Dutch New Herring ought to taste”, as well as how it ought to be prepared, was year by year being imprinted by the AD test team on the membership of the sample. New sales outlets joined and competed by adapting themselves to the criteria and the tastes of the test team.
The same newspaper did another annual ranking of outlets of a New Year’s Dutch traditional delicacy, actually, a kind of doughnuts (though without a hole in the middle) called oliebollen. They are indeed somewhat stodgy and oily, roughly spherical, objects, enlivened with currants and sprinkled with icing sugar. The testing panel was able to taste these objects blind. It consisted of about twenty ordinary folk and every year, part of the panel resigned and was replaced with fresh persons. Peter Grünwald of Centrum Wiskunde & Informatica, the national research institute for mathematics and computer science in the Netherlands, developed a simulation model which showed how the panel’s taste in oliebollen would vary over the years, as sales outlets tried to imitate the winners of the previous year, while the notion of what constitutes a good oliebol was not fixed. Taking the underlying quality to be one-dimensional, he demonstrated the well-known predator-prey oscillations (Angerbjorn et al., 1999). Similar lines of thinking have appeared in the study of, e.g., fashion cycles, see e.g. Acerbi et al. (2012), where the authors propose a mechanism for individual actors to imitate other actors’ cultural traits and preferences for these traits such that realistic and cyclic rise-and-fall patterns (see their Figure 4) are observed in simulated settings. A later study, Apriasz et al. (2016), divides a society into two categories of “snobs” and “followers”, where followers copy everyone else and snobs only imitate the trend of their own and go against the followers. As a result, clear recurring cyclic patterns (see their Figures 3 and 4) similar to the predator-prey cycle arise under proper parameter regimes.
The AD was again engaged in a legal dispute with disgruntled owners of low ranked sales outlets, which eventually led to this annual test being abandoned too. In fact, the AD forbade Grünwald to publish his results. We have made some initial simulation studies of a model with higher dimensional latent quality characteristics, which seems to exhibit similar but more complex behaviour.
New analyses, new insights
It turns out that the correlation between the residuals of the same outlet participating in two subsequent years is large, about 0.7. However, their number (23) is fairly small, so this has little effect on Vollaard’s findings. Taking account of it slightly increases the standard errors of estimated coefficients. However, we also knew that according to AD, many outlets were incorrectly classified by Vollaard, and since he did not wish to collaborate with us, we returned to the source of his data: the web pages of AD. This enabled us to play with the various data coding choices made by Vollaard and to try out various natural alternative model specifications. As well as this, we could use the list of outlets certified by AD and Atlantic as having actually supplied the Dutch new herring tested in 2016 and 2017.
First, it is clear from the known behaviour of the test team that a score of zero means something special. There is no reason to expect a linear model to be the right model for all participating outlets. The outlets which were given a zero score were essentially disqualified on objective public health criteria, namely temperature above 12 degrees and definitely dangerous microbiological activity. We decided to re-analyse the data while leaving out all disqualified outlets.
Next, there is the issue of correlation between outlets appearing in two subsequent years. Actually, this turned out to be a much smaller proportion than expected. So correction for autocorrelations hardly makes a difference, but on the other hand, it is easily made superfluous by dropping all outlets appearing for the second year in succession. Now we have two years of data, in the second year only of “newly nominated” outlets.
Going back to the original data published by AD, we discovered that Vollaard had made some adjustments to the published final scores. As was known, the testing team revisited the top ten scoring outlets, and ranked their product again, recording (in one of the two years) scores like 9.1, 9.2, … up to 10, in order to resolve ties. In both years there were scores registered such as 8– or 8+, meant to indicate “nearly an 8” or “a really good 8”, following Dutch traditional school and university test and exam grading. The scores “5″, “6″, “7″, “8”, “9”, “10” have familiar and conventional descriptions “unsatisfactory” or insufficient, “satisfactory” or sufficient, “good”, “very good, “excellent”. Linear regression analysis requires a numerical variable of interest. Vollaard had to convert “9–” (almost worthy of the qualification “very good”) into a number. It seems that he rounded it to 9, but one might just as well have made it 9–𝞮 for some choice of 𝞮, for instance, 𝞮 = 0.01, 0.03, or 0.1.
We compared the results obtained using various conventions for dealing with the “broken” grades, and it turned out that the choice of value of 𝞮 had major impact on the statistical significance of the “just significant” or “almost significant” variables of main interest (supplier; distance). Also, whether one followed standard strategies of model selection based on leaving out insignificant variables has a major impact on the significance of the variables of most interest (distance from Rotterdam; supplier). The size of their effects becomes a little smaller, standard errors remain large. Had Vollaard followed one of several common model selection strategies, he could have found that the effect of “Atlantic” was significant at the 5% level, supporting his prior opinion! As noted by experienced statistical practitioners such as Winship and Western (2016), in linear regression analysis where multicollinearity is present, the regression estimates are highly sensitive to small perturbations in model specification. In our data-set, what should be unimportant changes to which variables are included and which are not included, as well as unimportant changes in the quantification of the variable to be explained, keep changing the statistical significance of the variables which interested Vollaard the most — the results which led to a media circus, societal impact, and reputational damage to several big concerns, as well as to the personal reputation of the chief herring tester Aad Taal.
Having “cleaned” the data by removing the repeat tests, and removing the outlets breaking food safety regulations, and using the AD’s classification, the size of the effects of being an Atlantic-supplied outlet, and of being distant from Rotterdam, are smaller and hardly significant. By varying 𝞮, they change. On leaving out a few of the variables whose statistical significance is smallest, whether the two main variables of interest are significant changes again. The size of the effects remains about the same: Atlantic supplied outlets score a bit higher, outlets distant from Rotterdam score a bit lower, when taking account of all the other variables in the way chosen by the analyst.
By modelling the effects of so many variables by discretization, Vollaard created multicollinearity. The results depend on arbitrarily chosen cut-offs, and other arbitrary choices. For instance, “weight” was kept numerical, but “price” was made categorical. This could have been avoided by assuming additivity and smoothness and using modern statistical methodology, but in fact the data-set is simply too small for this to be meaningful. Trying to incorporate interaction between clearly important variables caused multicollinearity and failure of the standard estimation procedures. Different model selection procedures, and nonparametric approaches, end up with finding quite different models, but do not justify preferring one to another. We can come up with several excellent (and quite simple) predictors of the final score, but we cannot say anything about causality.
Vollaard’s analyses confirmed what we knew in advance (the “taste” of the testers). There is no reason whatsoever to accuse them of favouritism. The advantage of outlets supplied by Atlantic is tiny or non-existent, certainly nothing like the huge amount which Vollaard carelessly insinuated. The distant outlets are typically new entrants to the AD Herring Test. Their clients like the kind of Dutch new herring which they have been used to in their region. Vollaard’s interpretation of his own results obtained from his own data set was unjustified. He said he was only investigating correlations, but he appeared on national TV talk shows to say that his analyses made him believe that the AD Herring Test was severely biased. This caused enormous upset, financial and reputational damage, and led to a lot of money being spent on lawyers.
Everyone makes mistakes and what’s done is done, but we do all have a responsibility to learn from mistakes. The national committee for investigating accusations of violation of scientific integrity (LOWI) did not find Vollaard guilty of gross misdemeanour. They did recommend further statistical analysis. Vollaard declined to participate. No problem. We think that the statistical experiences reported here can provide valuable pedagogical material.
In our opinion, the suggestion that the AD Herring Test was in any way biased cannot be investigated by simple regression models. The “sample” is self-recruiting and much too small. The sales outlets which join the sample are doing so in the hope of getting the equivalent of a Michelin star. They can easily know in advance what are the standards by which they will be evaluated. Vollaard’s purely descriptive and correlational study confirms exactly what everyone (certainly everyone “in the business”) should know. The AD Herring Test, over the years that it operated, helped to raise standards of hygiene and presentation, and encouraged sales outlets to get hold of the best quality Dutch New Herring, and to prepare and serve it optimally. As far as subjective evaluations of taste are concerned, the test was indubitably somewhat biased toward the tastes valued by consumers in the region of Rotterdam and The Hague, and at the main “herring port” Scheveningen. But the “taste” of the herring testers was well known. Their final scores fairly represent their public, written evaluations, as far as can be determined from the available data.
The quality of the statistical analysis performed by Ben Vollaard left a great deal to be desired. To put it bluntly, from the statistical point of view it was highly amateurish. Economists who self-publish statistical reports under the flag of their university on matters of great public interest should have their work peer-reviewed and should rapidly publish their data sets. His results are extremely sensitive to minor variations in model choice and specification, to minor variations in quantifications of verbal scores, and there is not enough data to investigate his assumption of additivity. Any small effects found could as well be attributed to model misspecification as to conscious or unconscious bias on the part of the herring testers. We are reminded of Hanlon’s razor “never attribute to malice that which is adequately explained by stupidity”. In our opinion, in this case, Ben Vollaard was actually a victim of the currently huge pressure on academics to generate media interest by publishing on issues of current public interest. This leads to immature work which does not get sufficient peer review before being fed to the media. The results can cause immense damage.
Statisticians in general should not be afraid to join in societal debates. The total silence concerning this affair from the Dutch statistical society, which even has an econometric chapter, was a shame. Fortunately, the society has recently set up a new section devoted to public outreach.
A huge amount of statistical analyses are performed and published by amateurishly matching formal properties of a data-set (types of variables, the shape of the data file) to standard statistical models with no consideration at all given to model assumptions and to checks of model assumptions. Vollaard’s data-set can provide a valuable teaching resource, and we have published a version with (English language) description of the variables. We have made two versions available: Vollaard’s data-set put together by his student, but now with outlets identified, and the newly constituted data set with Atlantic-supplied outlets according to the AD, which is as well available in our GitHub repository https://github.com/gaofengnan/dutch-new-herring.
It would be interesting to add to the data some earlier years’ data, and investigate whether scores of repeatedly evaluated outlets tended to increase over the years. At the very least, it would be good to know which of the year 2016 outlets were repeat participants.
Just before we are about to submit this article, we become aware of Vollaard and van Ours (2021), in which Dr Ben Vollaard made the same accusations with essentially the same false arguments.
More study must be done of the feedback processes involved in consumer research panels.
Conflict of interest
The second author was paid by a well-known law firm for a statistical report on Vollaard’s analyses. His report, dated April 5, 2018, appeared in English translation earlier in this blog, https://gill1109.com/2021/06/01/was-the-ad-herring-test-about-more-than-the-herring/. He also reveals that the best Dutch New Herring he ever ate was at one of the retail outlets of Simonis in Scheveningen. They got their herring from the wholesaler Atlantic. He had this experience before any involvement in the Dutch New Herring scandals, topic of this paper.
Anders Angerbjorn, Magnus Tannerfeldt, and Sam Erlinge. Predator–prey relationships: arctic foxes and lemmings. Journal of Animal Ecology, 68(1):34–49, 1999. https://www.jstor.org/stable/2647297
Rafał Apriasz, Tyll Krueger, Grzegorz Marcjasz, and Katarzyna Sznajd-Weron. The hunt opinion model—an agent based approach to recurring fashion cycles. PloS one, 11(11):e0166323, 2016. https://doi.org/10.1371/journal.pone.0166323
Deze Apeldoornse wetenschapper redt onschuldige zusters uit de gevangenis: ‘De mens wil helaas niet in toeval geloven’
Wetenschapper Richard Gill uit Apeldoorn zorgde er mede voor dat Lucia de Berk werd vrijgesproken. Datzelfde kreeg hij voor elkaar bij een vergelijkbare zaak in Italië en nu gaat hij voor de hattrick in Engeland. Wat drijft hem?
Anne Boer 28-05-22, 08:00
Pure wetenschappelijke nieuwsgierigheid, dat is wat hem drijft, zegt de internationaal vermaarde wiskundige Richard Gill uit Apeldoorn. Als expert op het terrein van statistieken werkte Gill (70) voor het Openbaar Ministerie en het Internationaal Strafhof. Bijna zes jaar is hij gepensioneerd en staat hij te boek als emeritus professor in de statistiek aan de Universiteit Leiden.
Met zijn kennis over het gebruik van statistieken heeft hij vanuit zijn werkkamer de onschuld kunnen aantonen van twee verpleegkundigen die waren veroordeeld voor seriemoorden: de Nederlandse Lucia de Berk en de Italiaanse Daniela Poggiali. Nu zet hij zich in voor de vrijlating van verpleegkundige Ben Geen uit Engeland.
Alle drie zouden tijdens hun werk patiënten hebben gedood. Lucia de Berk werd zelfs veroordeeld voor zeven moorden. De bewijslast was vooral gebaseerd op statistieken. Als Lucia werkte, zouden er meer patiënten overlijden dan tijdens de diensten van haar collega’s. Het bleek klinkklare onzin, zoals Gill het fijntjes verwoordt. ,,Kwestie van roddel en achterklap, zoeken naar een zondebok om de reputatie van het ziekenhuis te redden en aannames, terwijl er helemaal geen moord is gepleegd.’’
De mens wil helaas niet in toeval geloven, we willen een oorzaak hebben. Daarom geloven we ook in duivels en goden
Statistisch bewijs speelt een grote rol in onderzoek, ook naar seriemoordenaars in de medische wereld. ,,Maar dan moet je de cijfers wel goed interpreteren’’, vindt Gill. ,,Als er ogenschijnlijk veel mensen overlijden in een ziekenhuis, moet je eerst goed kijken naar de oorzaak. Zijn er misschien meer patiënten dan anders? Zijn ze zieker dan in andere perioden? Is de methode van registreren aangepast? Zijn er wijzigingen in de staf? Als je meteen kijkt welke verpleegkundige aanwezig was, sla je bovendien de belangrijkste vragen over: is er sprake van moord of is het medisch falen of zelfs natuurlijk overlijden?’’
Dat raakt volgens Gill meteen aan een ander pijnlijk punt. ,,Een ziekenhuis is een plek waar mensen doodgaan, maar vaak is de doodsoorzaak niet duidelijk. Dat kan leiden tot clusters van verdachte overlijdens. Je moet wel weten welke doden je telt, anders zoekt de politie bewijs voor beweringen.’’
Volgens Gill moet je altijd in gedachten houden dat er een goede, onschuldige reden kan zijn voor een gebeurtenis. ,,Kijk vooral hoe vaak iemand werkt. Fulltime verpleegkundigen maken meer doden mee dan parttimers. Als iemand fulltime werkt en ook nog gepassioneerd bezig is met haar of zijn vak, is de kans nog groter dat die persoon aanwezig is als iemand overlijdt, dan iemand die een paar dagen per week werkt of strikt de uren werkt die in het rooster staan.”
Nooit mag je volgens hem een rare samenloop van omstandigheden uitsluiten. ,,Die gebeuren, ook zonder moord. Beroemd is het voorbeeld van een Amerikaans stel dat op één dag in twee verschillende loterijen de hoofdprijs won. Hoe groot is de kans dat zoiets gebeurt? Het gebeurde toch echt. De mens wil helaas niet in toeval geloven, we willen een oorzaak hebben en zoeken een zondebok. Daarom geloven we ook in duivels en goden.’’
Richard Gill is geboren in Engeland. Zijn vader was ook wetenschapper. De liefde brengt hem in 1974 op 23-jarige leeftijd naar Nederland. Hij is zes jaar eerder op vakantie als een blok gevallen voor een dochter van een Nederlandse vriend van zijn vader. Beide vaders werken voor Wavin uit Hardenberg. Na wat omzwervingen belandt Gill begin jaren 80 in Apeldoorn, om er nooit meer weg te gaan. Hij woont in een oud herenhuis, in een zee van weelderig groen. Dit was het ouderlijk huis van zijn vrouw. Om financieel het hoofd boven water te houden, werkt hij extra hard om snel carrière te kunnen maken.
De medische wereld komt al vroeg op zijn pad. Na een studie wiskunde in Cambridge promoveert hij op onderzoek naar de vraag hoelang kankerpatiënten bij bepaalde behandeling overleven. Zijn rekenmethode blijkt een uitkomst en wordt inmiddels ook op andere terreinen toegepast. ,,Het kwam toevallig op mijn bord. Ik had geen onderwerp en mijn promotor haalde dit onderwerp uit zijn la. Het heeft veel impact gehad en de methode wordt nog massaal gebruikt.’’
Zijn vrouw, die historicus is, wijst hem al in een vroeg stadium op de zaak Lucia de Berk, die later veroordeeld zou worden voor zeven moorden in een ziekenhuis. ,,Zij sprak van een heksenjacht en wilde dat ik ernaar keek, zeker toen het ook een heksenproces werd, zoals ze dat noemde. Ze wees me erop dat statistiek als bewijs werd gebruikt en ik er dus wel iets van zou moeten vinden. Ik wilde niet. Er waren al ervaren statistici bij betrokken, ook mensen die ik kende.’’
Toen er in 2006 een boek over deze zaak verscheen, ging Gill overstag. ,,Ik werd door een collega op het boek gewezen. Ik wist werkelijk niet wat ik las, was er echt ondersteboven van. Voor mij was zonneklaar dat het vonnis niet deugde en de rechters de cijfers verkeerd hadden geïnterpreteerd.’’
De rest is geschiedenis. Gill hielp aantonen dat de cijfers de beschuldiging niet konden onderbouwen en Lucia werd na 6,5 jaar onterechte celstraf in 2010 volledig vrijgesproken.
Als hij in 2014 over een gelijksoortige situatie in Italië leest, besluit hij direct weer in actie te komen. Dit keer wordt een verpleegkundige (Daniela Poggiali) verdacht van zestig moorden. Gill belt zijn collega Julia Mortera van de Roma Tre-universiteit en samen bieden ze hun hulp aan. Met succes, ook deze verpleegkundige is na een eerdere veroordeling tot levenslange gevangenisstraf sinds oktober op vrije voeten.
Statistiek is de wetenschap en de techniek van het verzamelen, bewerken, interpreteren en presenteren van gegevens. Statistische methoden worden gebruikt om grote hoeveelheden gegevens – bijvoorbeeld over het koopgedrag van mensen, de huizenmarkt of het aantal doden in de zorg – om te zetten in bruikbare informatie.
,,De statistiek in deze zaak was totaal amateuristisch, het deugde niet. De aanklagers beweerden dat er meer sterfgevallen waren als Daniela werkte. Tot het moment dat ze werd gearresteerd: toen daalde het plotseling. Wij ontdekten dat het sterftecijfer bij alle personeelsleden hoog was. Daniela was vaak al voor het begin van haar ingeroosterde dienst aanwezig en bleef vaak ook nog helpen nadat haar dienst voorbij was. Daardoor was ze vaker aanwezig als een patiënt stierf. Dat het aantal doden daalde nadat Daniela werd gearresteerd, is simpel te verklaren. Het nieuws over de ‘moordzuster’ was breed uitgemeten in de media. Als gevolg daarvan trok het ziekenhuis minder patiënten. Minder patiënten betekent ook minder sterfgevallen.’’
Gill doet nu onderzoek naar de zware beschuldigingen tegen de Engelse verpleegkundige Ben Geen. Dat gebeurt op verzoek van zijn advocaat. Het is vooralsnog een heel lastige kluif, vooral omdat het rechtssysteem in Engeland anders in elkaar zit. Opnieuw is Gill ervan overtuigd dat de verdachte geen moorden heeft gepleegd en dat het recht moet zegevieren.
Uit deze zaken heeft hij belangrijke lessen getrokken die hij wil overbrengen aan iedereen die wereldwijd betrokken is bij de rechtspraak, van advocaten tot rechters en van officieren van justitie tot juryleden. Samen met andere experts schrijft hij een handleiding hoe statistiek in de rechtbank kan worden gebruikt, met name bij strafprocessen tegen zogeheten seriemoordenaars in de gezondheidszorg. Dat gebeurt onder supervisie van het gezaghebbende instituut Royal Statistical Society. Het boek moet later dit jaar verschijnen.
Je kunt aannemen dat een hond vier poten heeft, maar niet dat alles met vier poten een hond is. Als op die manier naar Lucia was gekeken, was ze nooit veroordeeld
De boodschap die hij heeft, is in hoofdlijnen simpel: gebruik statistische gegevens pas als je je ervan hebt verzekerd dat ze kloppen en gebruik ze goed. ,,Benoem alle factoren. Trek niet te snel conclusies. Vraag onafhankelijke experts om hulp. Onderzoek alle mogelijkheden.’’ Volgens Gill is niet alleen expertise van professionals nodig, maar ook dat rechters en advocaten worden geschoold in een goede interpretatie van statistieken.
Hij geeft een simpel voorbeeld. ,,Je kunt aannemen dat een hond vier poten heeft, maar niet dat alles met vier poten een hond is. Je mag aannemen dat iemand uit Peru Spaans spreekt, maar niet iedereen die Spaans spreekt komt uit Peru. Als op die manier naar Lucia was gekeken, was ze nooit veroordeeld.’’
Kenmerkend vindt Gill dat de verdachten die hij hielp, allemaal opvallende mensen zijn. Ze werkten hard, hadden een duidelijke mening, stootten daardoor waarschijnlijk ook leidinggevenden voor het hoofd en eindigden uiteindelijk als zondebok. ,,Het heeft me echt getroffen hoeveel ze gemeen hebben. Ben Geen wilde legerarts worden en was enorm gedreven in zijn werk. Hij zag zijn werk als meer dan een baan en deed veel extra als het kon. Hij botste ook met managers omdat het ziekenhuis voortdurend tegen grenzen aanliep.’’
Als expert op het terrein van statistieken werkte Gill ook voor het Openbaar Ministerie (moordzaak Tamara Wolvers) en het Internationaal Strafhof (moordaanslag president Libanon). Inmiddels is hij al bijna zes jaar gepensioneerd, maar tijd om zich te vervelen, heeft hij niet. Er ligt nog voor jaren werk op zijn bordje. Puzzels die hij graag helpt oplossen.
Daarnaast zijn er veel onderwerpen waar hij graag in zou willen duiken, zoals de geruchtmakende Deventer moordzaak, die hem al jaren mateloos intrigeert. ,,Ik houd het nog steeds voor mogelijk dat de veroordeelde Ernest Louwes onschuldig is. Met name de dna-sporen op de blouse van de vermoorde weduwe vind ik interessant. Dna is ook statistisch bewijs en statistiek vertelt ons hoe je met onzekerheden moet omgaan. Er zijn inmiddels nieuwe moleculairbiologische methoden om veel meer uit een spoor te halen.’’
Gill helpt Kamerlid Pieter Omtzigt met het analyseren van data over uithuisplaatsingen als gevolg van het toeslagenschandaal. ,,We maken een tijdlijn om oorzaak en gevolg in beeld te krijgen. Ik heb dus eigenlijk helemaal geen tijd meer om nog meer verpleegkundigen achter de tralies vandaan te halen’’, zegt hij met een glimlach.
Als er toch weer een zaak van een vermeende moordzuster op zijn pad komt, zal hij waarschijnlijk moeilijk ‘nee’ kunnen zeggen. Hij geniet van het puzzelen en wil voorkomen dat het leven saai wordt. De tekst op de achterkant van zijn trui spreekt wat dat betreft misschien wel boekdelen: ‘Keep calm, en deze opa lost het wel op’. Want ja. Gill, vader van drie kinderen, is opa en zijn vijf kleinkinderen logeren graag bij hem en zijn vrouw in Apeldoorn.
Een van de vele puzzels die hem al jaren bezighoudt en soms zelfs uit zijn slaap haalt, moet hij van zichzelf oplossen: de zaak José Booij, die achttien jaar geleden werd geconfronteerd met de uithuisplaatsing van haar zes weken oude baby Julia-Lynn.
,,Een onvoorstelbaar en afschuwelijk verhaal. Zij is vermalen door het systeem en daar compleet aan onderdoor gegaan. Ik ben het contact met José verloren, maar nog steeds in het bezit van een doos met persoonlijke spullen van haar, zoals kindertekeningen, diploma’s, dagboeken en krantenknipsels over haar strijd voor haar kind tot de hoogste rechtsorganen in Nederland en Europa aan toe. Wellicht leeft Julia-Lynn nu onder een andere naam en wellicht weet ze haar geboortenaam niet eens. Ik wil dat ze weet wie haar moeder is. Dat die nooit heeft opgegeven. Daar heeft ze recht op. Ik hoop haar ooit te vinden en de spullen van haar moeder te kunnen geven. En weet je, ook deze vrouw is een bijzonder mens, anders dan anderen.’
More than ten years ago I started writing a book on Dutch miscarriages of justice in which I had been involved. I wanted to explore the personality issues in three such cases. In each case, it seemed to me that aspects of the character of the main protagonist led to them being something of a scapegoat of a system under great stress. Some trigger events caused a bad situation to become an utter disaster. Authorities made mistakes and could not admit them, so errors were compounded, and there was no going back, no way to change path any more.
In recent posts, I have told a lot of the story of José Booij. It’s time to start writing about Lucia de Berk and Kevin Sweeney.
Concerning Lucia de Berk there already is an enormous literature. The case started in 2001, seemed to be closed with Lucia in jail for life by 2006 (conviction by the lower court at the first trial in 2003, appeal to higher court failed in 2004, cassation – appeal to the supreme court – failed in 2006) but at that time also a strong movement burst into the public view, calling for a judicial review and a retrial. Lucia was fully exonerated in 2010. The role of statistics in the case is well known though controversial since at the 2004 appeal, she was convicted “on the grounds of incontrovertible medical scientific evidence only”. A “statistical probability calculation” (such as the infamous calculation leading to the spectacular 1 in 342 million) played no part at all in the court’s conclusion, according to her judges.
Yet many things have still not been said in public about the case, except perhaps in literary form. In my future book, I want to say things I have said many times before in ephemeral blog posts, and other removed or hidden web pages.
Concerning Kevin Sweeney, not much has been written at all. He sat out his sentence for the murder of his wife and keeps a low profile.
The title of this blog might refer to the very, very famous trials of Amanda Knox in the case of the murder of Meredith Kercher. However, I am writing about a case that is much less known outside of Italy (neither victim nor alleged murderer was a rich American girl). This is the case of Daniela Poggiali, a nurse suspected by the media and accused by prosecution experts of having killed around 90 patients in a two-year killing spree terminated by her arrest in April 2014. She has just been exonerated after a total of three years in prison with a life sentence as well some months of pre-trial detention. This case revolved around statistics of an increased death rate during the shifts of a colourful nurse. I was a scientific expert for the defence, working with an Italian colleague, Julia Mortera (Univ. Rome Tre), later assisted by her colleague Francesco Dotto.
Piet Groeneboom and I worked together on the statistics of the case of Lucia de Berk, see our paper in Chance [Reference]. In fact, it was remarkable that the statistical community in the Netherlands got so involved in that case. A Fokke and Sukke cartoon entitled “Fokke and Sukke know it intuitively” had the exchange “The probability that almost all professors of statistics are in agreement … is obviously very small indeed”.
Indeed, it wasn’t. That was one of the high points of my career. Another was Lucia’s final acquittal in 2010, at which the judges took the trouble to say out loud, in public, that the nurses had fought heroically for the lives of their patients; lives squandered, they added, by their doctors’ medical errors.
At that point, I felt we had learnt how to fight miscarriages of justice like that, of which I rapidly became involved in several. So far, however, with rather depressing results. Till a couple of months ago. This story will not have much to do with mathematics. It will have to do with simple descriptive statistics, and I will also mention the phrases “p-value” and “Bayes’ rule” a few times. One of the skills of a professional statistician is the abstraction of messy real-world problems involving chance and data. It’s not for everybody. Many mathematical statisticians prefer to prove theorems, just like any other mathematician. In fact, I often do prefer to do that myself, but I like more being able to alternate between the two modes of activity, and I do like sticking my nose into other people’s business, and learning about what goes on in, for instance, law, medicine, or anything else. Each of the two activity modes is a nice therapy for the frustrations which inevitably come with the other.
The Daniela Poggiali case began, for me, soon after the 8th of April, 2014, when it was first reported in international news media. A nurse at the Umberto I hospital in the small town of Lugo, not far from Ravenna, had been arrested and was being investigated for serial murder. She had had photos of herself taken laughing, close to the body of a deceased patient, and these “selfies” were soon plastered over the front pages of tabloid media. Pretty soon, they arrived in The Guardian and The New York Times. The newspapers sometimes suggested she had killed 93 patients, sometimes 31, sometimes it was other large numbers. It was suspected that she had used Potassium Chloride on some of those patients. An ideal murder weapon for a killer nurse since easily available in a hospital, easy to give to a patient who is already hooked up to an IV drip, kills rapidly (cardiac arrest – it is used in America for executions), and after a short time hard to detect. After death, it redistributes itself throughout the body where it becomes indistinguishable from a normal concentration of Potassium.
Many features of the case reminded me strongly of the case of Lucia de Berk in the Netherlands. In fact, it seemed very fishy indeed. I found the name of Daniela’s lawyer in the online Italian newspapers, Google found me an email address, and I sent a message offering support on the statistics of the case. I also got an Italian statistician colleague and good friend, Julia Mortera, interested. Daniela’s lawyer was grateful for our offer of help. The case largely hinged on a statistical analysis of the coincidence between deaths on a hospital ward and Daniela’s shifts there. We were emailed pdfs of scanned pages of a faxed report of around 50 pages containing results of statistical analyses of times of shifts of all the nurses working on the ward, and times of admission and discharge (or death) of all patients, during much of the period 2012 – 2014. There were a further 50 pages (also scanned and faxed) of appendices containing print-outs of the raw data submitted by hospital administrators to police investigators. Two huge messy Excel spreadsheets.
The authors of the report were Prof. Franco Tagliaro (Univ. Verona) and Prof. Rocco Micciolo (Univ. Trento). The two are respectively a pathologist/toxicologist and an epidemiologist. The epidemiologist Micciolo is a professor in a social science department, and member of an interfaculty collaboration for the health sciences. We found out that the senior and more influential author Tagliaro had published many papers on toxicology in the forensic science literature, usually based on empirical studies using data sets provided by forensic institutes. Occasionally, his friend Micciolo turned up in the list of authors and had supplied statistical analyses. Micciolo describes himself as a biostatistician. He has written Italian language textbooks on exploratory data-analysis with the statistical package “R” and is frequently the statistician-coauthor of papers written by scientists from his university in many different fields including medicine and psychology. They both had decent H-indices, their publications were in decent journals, their work was mainstream, useful, “normal science”. They were not amateurs. Or were they?
Daniela Poggiali worked on a very large ward with very many very old patients, many suffering terminal illnesses. Ages ranged from 50 up to 105, mostly around ninety. The ward had about 60 beds and was usually quite fully occupied. Patients tended to stay one to two weeks in the hospital, admitted to the hospital for reasons of acute illness. There was on average one death every day; some days none, some days up to four. Most patients were discharged after several weeks in the hospital to go home or to a nursing home. It was an ordinary “medium care” nursing department (i.e., not an Intensive Care unit).
Some very simple statistics showed that the death rate on days when Poggiali worked was much higher than on days when she did not work. A more refined analysis compared the rate of deaths during the hours she worked with the rate of deaths during the hours she was not at work. Again, her presence “caused” a huge excess, statistically highly significant. A yet more refined analysis compared the rate of deaths while she was at work in the sectors where she was working with the rate in the opposite sectors. What does this mean? The ward was large and spread over two long wings of one floor of a large building, “Blocco B”, probably built in the sixties.
Between the two wings were central “supporting facilities” and also the main stairwell. Each wing consisted of many rooms (each room with several beds), with one long corridor through the whole building, see the floor plan below. Sector A and B rooms were in one wing, first A and then B as you you went down the corridor from the central part of the floor. Sector C and Sector D rooms were in the other wing, opposite to one another on each side of the corridor. Each nurse was usually detailed in her shifts to one sector, or occasionally to the two sectors in one wing. While working in one sector, a nurse could theoretically easily slip into a room in the adjacent sector. Anyway, the nurses often helped one another, so they often could be found in the “wrong sector”, but not often in the “wrong wing”.
Tagliaro and Micciolo (in the sequel: TM) went on to look at the death rates while Daniela was at work in different periods. They noticed that it was higher in 2013 than in 2012, even higher in the first quarter of 2014, then – after Daniela had been fired – it was much, much less. They conjectured that she was killing more and more patients as time went by, till the killing stopped dead on her suspension and arrest
TM certainly knew that, in theory, other factors might be the cause of an increased death rate on Poggiali’s shifts. They were proud of their innovative approach of relating each death that occurred while Daniela was at work to whether it occurred in Daniela’s wing or in the other. They wrote that in this way they had controlled for confounders, taking each death to provide its own “control”. (Similarly, in the case of Lucia de B., statistician Henk Elffers had come up with an innovative approach. In principle, it was not a bad idea, though all it showed was that nurses are different). TM did not control for any other confounding factors at all. In their explanation of their findings to the court, they repeatedly stated categorically that the association they had found must be causal, and Daniela’s presence was the cause. Add to this that their clumsy explanation of p-values might have misled lawyers, journalists and the public. In such a case, a p-value is the probability of what you see (more precisely, of at least what you see), assuming pure chance. That is not the same as the probability that pure chance was the cause of what you see – the fallacy of the transposed conditional, also known as “the prosecutor’s fallacy”.
Exercise to the reader: when is this fallacy not a fallacy? Hint: revise your knowledge of Bayes’ rule: posterior odds equals prior odds time likelihood ratio.
We asked Tagliaro and Micciolo for the original Excel spreadsheets and for the “R” scripts they had used to process the data. They declined to give them to us, saying this would not be proper since they were confidential. We asked Daniela’s lawyer to ask the court to ask for those computer files on our behalf. The court declined to satisfy our request. We were finally sent just the Excel files by the hospital administration, a week before we were called to give evidence. Fortunately, with a combination of OCR and a lot of painstaking handwork, a wealthy friend of Daniela’s lawyer had already managed to help us get the data files reconstructed. We performed a lot of analyses with the help of a succession of students because extracting what we needed from those spreadsheets was an extraordinarily challenging issue. One kept finding anomalies that had to be fixed in one way or another. Even when we had “clean” spreadsheets, it still was a mess.
Next, we started looking for confounding factors that might explain the difference between Daniela and her colleagues, which certainly was striking and real. But was it perhaps entirely innocent?
First of all, simple histograms showed that death rates on that ward varied strongly by month, with big peaks in June and again in December. (January is not high: elderly people stay home in January and keep themselves warm and safe). That is what one should expect. The humid heat and air pollution in the summer; or the damp and cold and the air pollution in the winter, exacerbated by winter flu epidemics. Perhaps Daniela worked more at bad times than at good times? No. It was clear that sectors A+B were different from C+D. Death rates were different, but also the number of beds in each wing was different. Perhaps Daniela was allocated more often to “the more difficult” sections? It was not so clear. Tagliaro and Micciolo computed death rates for the whole ward, or for each wing of the ward, but never took account of the number of patients in each wing nor of the severity of their illnesses.
Most interesting of all was what we found when we looked at the hour of the time of death of patients who died, and the minute of the time of death of patients who died. Patients tended to die at times which were whole hours, “half past” was also quite popular. There was however also a huge peak of deaths between midnight and five minutes past midnight! There were fewer deaths in a couple of hours soon after lunchtime. There were large peaks of deaths around the time of handover between shifts: 7:00 in the morning, 2:00 in the afternoon, 9:00 in the evening. The death rate is higher in the morning than in the afternoon, and higher in the afternoon than at night. When you’re dying (but not in intensive care, when it is very difficult to die at all) you do not die in your sleep at night. You die in the early morning as your vital organs start waking up for the day. Now, also not surprisingly, the number of nurses on a ward is largest in the morning when there is a huge amount of work to do; it’s much less in the afternoon and evening, and it’s even less at night. This means that a full-time nurse typically spends more time in the hospital during morning shifts than during afternoon shifts, and more time during afternoon shifts than during night shifts. The death rate shows the same pattern. Therefore, for every typical full-time nurse, the death rate while they are at work tends to be higher than when they are not at work!
Nurses aren’t authorized to officially register times of death. Only a doctor is authorized to do that. He or she is supposed to write down the time at which they have determined the patient is no longer alive. It seems that they often round that time to whole or half hours. The peak just after midnight is hard to explain. The date of death has enormous financial and legal consequences. The peak suggests that those deaths may have occurred anywhere in a huge time window. Whether or not doctors come to the wards on the dot at midnight and fill in forms for any patients who have died in the few hours before is hard to believe
What is now clear is that it is mainly around the hand-over between shifts that deaths get “processed”. Quite a few times of death are so hard to know that they are shunted to five minutes past midnight; many others are located in the hand-over period but might well have occurred earlier.
Some nurses tend to work longer shifts than others. Some conscientiously clock in as early as they are allowed, before their shift starts, and clock out as late as they can after their shift ends. Daniela was such a nurse. Her shifts were indeed statistically significantly longer than those of any of her colleagues. She very often stayed on duty several hours after the official end of the official ten-minute overlap between shifts. There was often a lot to do – one can imagine often involving taking care of the recently deceased. Not the nicest part of the job. Daniela was well known to be a rather conscientious and very hard worker, with a fiery temper, known to play pranks on colleagues or to loudly disagree with doctors for whom she had a healthy disrespect.
Incidentally, the rate of admissions to Umberto I hospital tumbled down after the news broke of a serial killer – and the news broke the day after the last day the serial killer was at work, together with the publication of the lurid “selfie”. The rate of deaths was slowly increasing over the two years up to then, as was in fact also the rate of admissions and the occupancy of the ward. A hospital getting slowly more stressed? Taking on more work?
If one finds a correlation between X and Y, it is a sound principle to suppose that it has a causal explanation. Maybe X causes Y, maybe Y causes X, … and maybe W causes both X and Y, or maybe X and Y both cause Z and there has been a selection on the basis of Z. In the case of Lucia de B., her association between inexplicable incidents and her presence on the ward was caused by her, since the definition of “unexpected and inexplicable incident” included her being there. She was already known to be a weird person, and it was already clear that there were more deaths than usual on her ward. The actual reason for that was a change of hospital policy, moving patients faster from intensive care to medium care so that they could die at home, rather than in the hospital. If she was not present, then the medical experts always could come up with an explanation for why that death, though perhaps a bit surprising at that moment, was expected to occur soon anyway. But if Lucia was there then they were inclined to believe in foul play because after all there were so many incidents in her shifts.
Julia and I are certain that the difference between Daniela’s death rates and those of other nurses is to a huge extent explainable by the anomalies in the data which we had discovered and by her long working hours.
Some residual difference could be due to the fact that a conscientious nurse actually notices when patients have died, while a lazy nurse keeps a low profile and leaves it to her colleagues to notice, at hand-over. We have been busy fitting sophisticated regression models to the data but this work will be reported in a specialist journal. It does not tell us more than what I have already said. Daniela is different from the other nurses. All the nurses are different. She is extreme in a number of ways: most hours worked, longest shifts worked. We have no idea how the hospital allocated nurses to sectors and patients to sectors. We probably won’t get to know the answer to that, ever. The medical world does not put out its dirty washing for everyone to see.
We wrote a report and gave evidence in person in Ravenna in early 2015. I did not have time to see the wonderful Byzantine mosaics though I was treated to some wonderful meals. I think my department paid for my air ticket. Julia and I worked “pro deo“. In our opinion, we totally shredded the statistical work of Tagliaro and Micciolo. The court however did not agree. “The statistical experts for the defence only offered a theoretical discourse while those of the prosecution had scientifically established hard facts”. In retrospect, we should have used stronger language in our report. Tagliaro and Micciolo stated that they had definitively proven that Daniela’s presencecaused 90 or so extra deaths. They stated that this number could definitely not be explained as a chance fluctuation. They stated that, of course, the statistics did not prove that she had deliberately murdered those patients. We, on the other hand, had used careful scientific language. One begins to understand how it is that experts like Tagliaro and Micciolo are in such high demand by public prosecutors.
There was also toxicological evidence concerning one of the patients and involving K+ Cl–, but we were not involved in that. There was also the “selfie”, there was character evidence. There were allegations of thefts of patients’ personal jewellery. It all added up. Daniela was convicted of just one murder. The statistical evidence provided her motive: she just loved killing people, especially people she didn’t like. No doubt, a forensic psychologist also explained how her personality fitted so well to the actions she was alleged to have done.
Rapidly, the public prosecution started another case based largely on the same or similar evidence but now concerning another patient, with whom Daniela had had a shouting match, five years earlier. In fact, this activity was probably triggered by families of other patients starting civil cases against the hospital. It would also clearly be in the interest of the hospital authorities to get new criminal proceedings against Daniela started. However, Daniela’s lawyers appealed against her first conviction. It was successfully overturned. But then the court of cassation overturned the acquittal. Meantime, the second case led to a conviction, then acquittal on appeal, then cassation. All this time Daniela was in jail. Cassations of cassations meant that Daniela had to be tried again, by yet another appeal court, for the two alleged murders. Julia and I and her young colleague Francesco Dotto got to work again, improving our arguments and our graphics and our formulations of our findings.
At some point, triggered by some discussions with the defence experts on toxicology and pathology, Julia took a glance at Tagliaro’s quite separate report on the toxicological evidence. This led to a breakthrough, as I will now explain.
Tagliaro knew the post-mortem “vitreous humour” potassium concentration of the last patient, a woman who had died on Daniela’s last day. That death had somehow surprised the hospital doctors, or rather, as it later transpired, it didn’t surprise them at all: they had already for three months been looking at the death rates while Daniela was on duty and essentially building up a dossier against her, just waiting for a suitable “last straw”! Moreover, they already had their minds on K+ Cl-, since some had gone missing and then turned up in the wrong place. Finally, Daniela had complained to her colleagues about the really irritating behaviour of that last patient, 73-year-old Rosa Calderoni.
“Vitreous humour” is the transparent, colourless, gelatinous mass that fills your eyeballs. While you are alive, it has a relatively low concentration of potassium. After death, cell walls break down, and potassium concentration throughout the body equalises. Tagliaro had published papers in which he studied the hourly rate of increase in the concentration, using measurements on the bodies of persons who had died at a known time of causes unrelated to potassium chloride poisoning. He even had some fresh corpses on which he could make repeated measurements. His motivation was to use this concentration as a tool to determine the PMI (post-mortem interval) in cases when we have a body and a post-mortem examination but no time of death. In one paper (without Micciolo’s aid) he did a regression analysis, plotting a straight line through a cloud of points (y = concentration, x = time since death). He had about 60 observations, mostly men, mostly rather young. In a second paper, now with Micciolo, he fitted a parabola and moreover noted that there was an effect of age and of sex. The authors also observed the huge variation around that fitted straight line and concluded that the method was not reliable enough for use in determining the PMI. But this did not deter Tagliaro, when writing his toxicological report on Rosa Calderoni! He knew the potassium concentration at the time of post-mortem, he knew exactly when she died, he had a number for the natural increase per hour after death from his first, linear, regression model. With this, he calculated the concentration at death. Lo and behold: it was a concentration which would have been fatal. He had proved that she had died of potassium chloride poisoning.
Julia and Francesco used the model of the second paper and found out that if you would assume a normal concentration at the time of death, and take account of the variability of the measurements and of the uncertainty in the value of the slope, then the concentration observed at the time of post-mortem was maybe above average, but not surprisingly large at all.
Daniela Poggiali became a free woman. I wish her a big compensation and a long and happy life. She’s quite a character.
Aside from the “couleur locale” of an Italian case, this case had incredibly much similarity with the case of Lucia de Berk. It has many similarities with quite a few other contested serial killer nurse cases, in various countries. According to a NetFlix series, in which a whole episode is devoted to Daniela, these horrific cases occur all the time. They are studied by criminologists and forensic psychologists, who have compiled a list of “red flags” intended to help warn hospital authorities. The scientific term here is “health care serial killer”, or HCSK. One of the HCSK red flags is that you have psychiatric problems. Another is that your colleagues think you are really weird. Especially when your colleagues call you an angel of death, that’s a major red flag. The list goes on. These lists are developed in scientific publications in important mainstream journals, and the results are presented in textbooks used in university criminology teaching programs. Of course, you can only scientifically study convicted HCSKs. Your sources of data are newspaper reports, judges’ summings up, the prosecution’s final summary of the case. It is clear that these red flags are the things that convince judges and jurors to deliver a guilty verdict. These are the features that will first make you a suspect, which police investigators will look for, and which will convince the court and the public of your guilt. Amusingly, one of the side effects of the case of Lucia de Berk was contributing a number of entries to this list, for instance, the Stephen King horror murder novels she had at home which were even alleged to have been stolen from the library. Her conviction for the theft of several items still stands. As does Daniela’s: this means that Daniela is not eligible for compensation. In neither case was there any real proof of thefts. Amusingly, one of the side effects of the case of Lucia de Berk was contributing a number of entries to this list. Embarrassingly, her case had to be removed from the collections of known cases after 2011, and the criminologists and forensic psychologists also now mention that statistical evidence of many deaths during the shifts of a nurse is not actually a very good red flag. They have learnt something, too.
Interesting is also the incidence of these cases: less than 1 in a million nurses killing multiple patients per year, according to these researchers. These are researchers who have the phenomenon of HCSKs as their life work, giving them opportunities to write lurid books on serial murder, appear in TV panels and TV documentaries explaining the terrible psychology of these modern-day witches, and to take the stand as prosecution witnesses. Now, that “base rate” is actually rather important, even if only known very roughly. It means that such crimes are very, very unusual. In the Netherlands, one might expect a handful of cases per century; maybe on average 100 deaths in a century. There are actually only about 100 murders altogether in the Netherlands per year. On the other hand, more than 1000 deaths every year are due to medical errors. That means that evidence against a nurse suspected of being a HCSK would be very strong indeed before it should convince a rational person that they have a new HCSK on their hands. Lawyers, judges, journalists and the public are unfortunately perhaps not rational persons. They are certainly not good with probability, and not good with Bayes’ rule. (It is not allowed to be used in a UK criminal court, because judges have ruled that jurors cannot possibly understand it).
I am still working on one UK case, Ben Geen. I believe it is yet another example of a typical innocent HCSK scare in a failing hospital leading to a typical unsafe conviction based largely on the usual red flags and a bit of bad luck. At least, I see no reason whatsoever to suppose that Ben Geen was guilty of the crimes for which he is sitting out a life sentence. Meanwhile, a new case is starting up in the UK: Lucy (!) Letby. I sincerely hope not to be involved with that one.
Time for a new generation of nosy statisticians to do some hard work.
Covadonga Palacio, Rossella Gottardo, Vito Cirielli, Giacomo Musile, Yvane Agard, Federica Bortolotti, and Franco Tagliaro. Simultaneous analysis of potassium and ammonium ions in the vitreous humour by capillary electrophoresis and their integrated use to infer the post mortem interval (PMI). Medicine, Science and the Law, 61(1 suppl):96–104, 2021. https://journals.sagepub.com/doi/abs/10.1177/0025802420934239
Nicola Pigaiani, Anna Bertaso, Elio Franco De Palo,Federica Bortolotti, and Franco Tagliaro. Vitreous humor endogenous compounds analysis for post-mortem forensic investigation. Forensic science international, 310:110235, 2020. https://doi.org/10.1016/j.forsciint.2020.110235
Francesco Dotto, Richard D. Gill and Julia Mortera (2022) Statistical Analyses in the case of an Italian nurse accused of murdering patients. Submitted to “Law, Probability, Risk” (Oxford University Press), accepted for publication subject to minor revision; preprint: https://arxiv.org/abs/2202.08895