The clinical record, as the Panel sets it out
The Panel records Baby E (its Baby 5) as a 29+5 week, 1,327 g, male infant, the first of twins, born by semi-elective caesarean section for twin-twin transfusion syndrome with oligohydramnios. His antenatal ultrasound showed dilated small bowel loops and absent or reversed end-diastolic flow. He is the twin brother of Baby F, whose count was prosecuted on the insulin evidence rather than on an air-embolism theory.
He required bagging at birth and continuous positive airway pressure for apnoea. He showed signs of infection — low white cell and neutrophil counts and a high blood sugar — which were treated with antibiotics and insulin. His chest x-ray was clear.
Four days later, the Panel records this sequence:
- Respiratory distress (desaturation, chest recession, an oxygen requirement) and bilious aspirates from the nasogastric tube — but the abdomen was soft and not distended.
- Two episodes of massive gastrointestinal bleeding, with at least 25% of his estimated total blood volume aspirated from the nasogastric tube.
- He was given normal saline. Forty minutes later he suddenly deteriorated — desaturation, poor perfusion, a heart rate of 80–90 per minute, and purple patches of discolouration over the abdomen.
- An hour later he collapsed again and died despite resuscitation efforts.
The prosecution theory
As the Panel summarises the conviction: it was alleged that Baby E died from inflicted trauma causing upper gastrointestinal haemorrhage, and from intravenous injection of air causing air embolism resulting in collapse, patchy discolorations of the skin and death.
What the Panel actually concluded
The Panel’s conclusions on Baby 5 are four:
- Baby 5 died from massive gastrointestinal haemorrhage, due to either intrauterine hypoxia causing stomach or intestinal ulceration, or a congenital vascular lesion.
- Emergency blood transfusion should have been given much earlier.
- There was no evidence of air embolism.
- A post-mortem should have been requested.
The Panel’s reasoning:
- He was a high-risk infant before he was born. He was preterm, had twin-twin transfusion with oligohydramnios, and his antenatal ultrasound showed reversed end-diastolic flow and dilated small bowel loops. The Panel’s reading of those findings: blood was being sucked out of the fetus at the end of each cardiac cycle, and the intestines were likely damaged before birth.
- The bleeding has a natural explanation. The two episodes of massive gastrointestinal haemorrhage were, in the Panel’s view, most likely due to in-utero hypoxia causing stomach or small-intestinal ulceration with erosion into an intestinal blood vessel — or to a vascular abnormality such as a Dieulafoy’s lesion, which can cause life-threatening haemorrhage.
- The blood loss was fatal, and probably worse than recorded. The 25% blood-volume loss measured from the nasogastric aspirate was likely an underestimate, because more blood was likely lost into the intestines. Since a 20% blood loss causes shock, and Baby E lost much more, the Panel describes this as fatal.
- The transfusion came too late. The Panel states that emergency transfusion with group O negative blood should have been given immediately, earlier during resuscitation.
- The skin signs are not diagnostic of air embolism. Patchy skin discolourations are caused by dilation and contraction of small blood vessels in the skin in response to hypoxia, which occurs in many conditions. The Panel cites Zhou and Lee (December 2024), who reported that non-specific localised patchy skin discolourations have not been reported in infants with venous air embolism, including intravenous injection of air, and that only Lee’s sign and Liebermeister’s sign are diagnostic of air embolism.
- The alleged act is difficult to reconcile with the timeline. The Panel observes that if air were deliberately infused through a central venous line to cause air embolism, the line would have to be reinfused with fluid to prevent detection — yet collapse from air embolism occurs instantaneously. The Panel doubts this could be achieved quickly enough before other staff on the unit responded to the collapse.
Why this case is important
The Crown’s case on Baby E required two deliberate acts: one to produce the bleeding, one to produce the collapse. The Panel’s reading requires neither. It identifies a single natural process — a massive gastrointestinal haemorrhage in an infant whose intestines were likely already damaged in utero — that accounts for the bleeding, the shock, and the death. It also identifies a treatment failure: the emergency transfusion that, on the Panel’s reading, should have been given much earlier.
That is a materially different case from the one the jury was asked to decide. It does not turn on doubt about the Crown’s theory; it states a positive cause of death and a positive care failing.
The post-mortem that was never requested
The Panel’s fourth conclusion on Baby E is that a post-mortem should have been requested. It was not. The consequence is that the specific pathology the Panel points to — ulceration eroding into an intestinal blood vessel, or a congenital vascular lesion such as a Dieulafoy’s lesion — was never looked for. The absence of a post-mortem finding is therefore a gap in the record, not evidence that the natural explanation is unavailable. It is one of the questions now before the CCRC.
Sources
- International Expert Panel — Summary Report (February 2025), Panel Baby 5 (Child E).
- Zhou Q, Lee SK. Am J Perinatol, 27 December 2024. doi: 10.1055/a-2508-2733 — cited by the Panel on the skin signs.