Everything on this page attributed to the Panel is taken from the International Expert Panel — Summary Report (February 2025), where Baby H is reviewed as “Baby 8”.
The clinical course
Baby H was a female infant born at 34 weeks and 4 days with a birth weight of 2.33kg, delivered by emergency Caesarean section because of maternal type 1 diabetes with labile glycaemic control. She had respiratory distress syndrome from birth — grunting, subcostal retractions, respiratory and metabolic acidosis — and needed oxygen, but continuous positive airway pressure (CPAP) was not provided until four hours later. BIPAP was started the next day because she was not improving, but no chest X-ray was done. The following day she was intubated and ventilated for desaturation and gasping.
She then developed a life-threatening tension pneumothorax. On the Panel’s reading of the record, the management of it ran as follows:
- The tension pneumothorax was not diagnosed for two and a half hours.
- It was not treated for a further one and a half hours after diagnosis.
- A chest tube was inserted to drain it, but no lateral chest X-ray was performed to check its position. Its malposition led to incomplete evacuation and re-accumulation of the tension pneumothorax.
- Over the next sixteen hours there were four episodes of severe desaturation.
- A second chest tube was inserted, but not until two hours after a check chest X-ray.
- She was ventilated with high pressures (26/5, rate 40/min, Ti 0.45) and continued to deteriorate over the following day with multiple episodes of desaturation.
- Despite poor blood gases and re-accumulation of the pneumothorax, it was not drained; ventilation was increased further, to pressure 26/5, rate 60/min, FiO2 100%.
- A third chest tube was inserted, three hours after a check chest X-ray had shown re-accumulation of the tension pneumothorax.
She finally improved and was transferred to Arrowe Park Hospital.
The prosecution theory
The Crown alleged that Baby H’s clinical deteriorations at around 00.55 and 03.30 on 27 September 2015 were the result of deliberate dislodgement of her endotracheal tube.
What the Panel found
The Panel describes this as a straightforward case: a relatively large preterm infant with respiratory distress syndrome who developed a tension pneumothorax. She had respiratory distress from birth but was not given CPAP until four hours later. Without treatment, the Panel explains, an infant grunts to exert chest pressure in an effort to keep the small air spaces in the lung open — and this can lead to a pneumothorax.
A tension pneumothorax is life-threatening and should be drained immediately. Done promptly and properly, recovery is quick. That is not what happened here. There were repeated and lengthy delays in diagnosis and treatment, and poor placement of chest tubes with ineffectual removal of air from the chest, resulting in re-accumulation of air and continuing clinical deterioration.
In response, high ventilation pressures were used in an attempt to ventilate her — but, the Panel finds, this worsened the situation, because the excessive pressures compromised venous return to the heart and further impaired her circulation and oxygenation. Baby H was subjected to multiple invasive procedures — including at least six intubations, seven chest needles, three chest drains and multiple hand-bagging episodes — and to a prolonged period of illness. There was also delay in transferring her to a higher-level facility.
On the allegation itself, the Panel states that it did not find any evidence to support malicious actions such as endotracheal tube dislodgement on 27 September 2015.
The Panel’s conclusions
- Baby H’s deteriorations were due to medical mismanagement of the tension pneumothorax.
- There was no evidence of intentional tampering with the endotracheal tube.
- One prosecution expert witness recognised that care of the pneumothorax was sub-optimal.
The jury’s verdicts
- Count 1 on Baby H: Not Guilty. The jury returned a verdict of not guilty on this count.
- Count 2 on Baby H: No verdict. The jury could not reach a verdict on the second count. After the full evidence had been adduced, it was not able to agree that the Crown had proved its case to the criminal standard.
Why the verdicts and the Panel finding point the same way
The Crown’s case relied on a pattern argument: one nurse, many babies, many deteriorations. If the pattern is sound, each count ought to persuade the jury. On Baby H it did not. The Panel’s later review supplies a specific reason why: the deteriorations have a documented clinical cause in the record itself — a tension pneumothorax that was diagnosed late, treated late, drained through malpositioned tubes, and then compounded by ventilation pressures that further impaired circulation and oxygenation.
The Panel also records that the sub-optimal care of the pneumothorax was not a point only the defence made: one prosecution expert witness recognised it too.
The failed-verdict cases as a class
Across the indictment, the jury did not convict on Baby H (two counts), Baby J (one count), Baby Q (one count), and Baby N (two counts). In a conviction-safety review, the cases on which the jury did not convict are diagnostic: they show where the pattern argument breaks down. If it breaks down there, a proper review asks whether it also broke down on the convicted cases and was merely not detected at the time. That is relevant context for how a Court of Appeal might evaluate the conviction-carrying cases after CCRC referral.
What the jury did not hear on Baby H
- The Panel’s finding that the deteriorations were due to medical mismanagement of the tension pneumothorax (the Panel reported in February 2025, after the verdicts).
- The Panel’s finding that there was no evidence of intentional tampering with the endotracheal tube.
- The Panel’s account of the delays: two and a half hours to diagnosis, a further one and a half hours to treatment, malpositioned chest tubes, and re-accumulation of the pneumothorax that went undrained.
- The Panel’s finding that the high ventilation pressures used in response worsened her condition by compromising venous return to the heart.