Everything on this page attributed to the Panel is taken from the International Expert Panel — Summary Report (February 2025), where Baby D is reviewed as “Baby 4”.
The clinical course
Baby D was a female infant born at 37 weeks and 1 day, with a birth weight of 3.13kg. She was delivered by emergency Caesarean section for failed induction of labour after prolonged premature rupture of the membranes. Her Apgar scores were 8 at one minute and 9 at five minutes. At twelve minutes she became pale and floppy and needed respiratory support with bag and mask.
She was admitted to the neonatal unit three and a half hours later. On admission she was cold, blue and dusky, and had respiratory distress, polycythaemia and infection — high white cell and neutrophil counts. Her first blood gas, taken four hours after birth, showed a high CO2 and respiratory acidosis. Continuous positive airway pressure (CPAP) was started nearly four hours after birth. She was electively intubated after three attempts, and ventilated. Her chest X-ray showed pneumonia.
The following day she developed fever, deteriorating blood gases and increasing metabolic acidosis. The next day she was mottled, with dark brown and black tracking lesions across the trunk and two evolving purpuric-looking patches on the abdomen. She had prolonged coagulation times, a raised CRP, and repeated episodes of apnoea and desaturation, until her final collapse and death.
The prosecution theory
The Crown’s case was that Baby D was a stable infant who died from an injection of air into her intravenous line, causing an air embolism that produced her collapse, the patchy discolorations of her skin, and her death.
What the Panel found: the skin discolorations were caused by DIC
The Panel’s starting point is the research published in December 2024 by Zhou and Lee (Am J Perinatol 2024 Dec 27, doi: 10.1055/a-2508-2733), which showed that patchy skin discolorations have never been reported in infants with venous air embolism, including intravenous air injection. When air is injected into the veins, the air bubbles must first traverse the lungs, where they are filtered out by a vast bed of small blood vessels. In infants there is a hole in the heart — the foramen ovale — which normally closes shortly after birth, so it is possible for bubbles to escape through the hole into the arterial system; but Zhou and Lee reported no patchy skin discolorations in infants with intravenous injection of air.
What Baby D did have was a documented, worsening infection. She continued to deteriorate after admission with fever, intolerance of CPAP removal, deteriorating blood gases, increasing metabolic acidosis, a raised CRP, and repeated episodes of apnoea and desaturation. She developed prolonged coagulation times, which the Panel reads as indicating that the infection was going out of control and causing early disseminated intravascular coagulation (DIC).
DIC causes coagulation within the blood vessels, a coagulation defect, and bleeding. Coagulation defects do not occur with air embolism. The Panel’s explanation of the skin signs is therefore direct: the patchy skin discolorations were caused by DIC producing clotting in the small blood vessels of the skin, which compromised blood flow and, together with hypoxia, triggered dilation and contraction of the small vessels in the skin — resulting in the patches of discoloration, the purpuric patches and the tracking lesions.
The delays in her care
The Panel identified failures of care that preceded and shaped the deterioration:
- The mother should have been given antibiotics for prolonged premature rupture of the membranes.
- Admission to the neonatal unit, the first blood gas and CPAP were all delayed by three to four hours.
- The chest X-ray was delayed by six hours.
Those delays, the Panel found, subjected the infant to unnecessary acidosis and high CO2, and delayed antibiotic treatment.
The Panel’s conclusions
- Baby D died of systemic sepsis, pneumonia and disseminated intravascular coagulation.
- The mother should have received intrapartum antibiotics.
- There was delay in recognising respiratory distress after birth, and in starting antibiotics and treatment.
- There was no evidence of air embolism.
Why this case is important
The Crown’s case described Baby D as “a stable infant” before her collapse. The clinical record the Panel reviewed describes an infant who was cold, blue and dusky on admission, with a high white cell count, a chest X-ray showing pneumonia, and a mother who had had prolonged premature rupture of membranes without antibiotics.
The single sign on which the air-embolism reading rested — the discoloured skin — is the sign the Panel attributes to DIC, and the Panel notes that the coagulation defect Baby D actually had is a finding that air embolism does not produce. On this case, the Panel is not offering a competing possibility; it is stating a cause of death and recording that there was no evidence for the mechanism alleged at trial.