The clinical context
On the Panel’s summary of the record, Baby I was born at 27 weeks and 970 g, female, with intrauterine growth restriction, after premature rupture of membranes at Liverpool Women’s Hospital. She was treated for mild respiratory distress syndrome with respiratory support, and with antibiotics for sepsis from day 1 of life, and was fed both intravenously and enterally by oral tubing.
She developed bradycardias, respiratory distress and an elevated white count, leading to the first of five transfers between four hospitals on day 12 of life. She went on to develop chronic lung disease, abdominal distension, and recurrent episodes of apnoea, desaturation and bradycardia requiring resuscitation and ventilation. She had viscous, gelatinous secretions from her airway and mouth that were associated with frequent blockages of her endotracheal tube, and “sticky stools”. A registrar described the secretions in these terms: “It’s not unusual for babies on breathing support to get secretions but it was a bit unusual for them to be so stubborn at being removed.” Testing for cystic fibrosis was sent. She had an episode of lung collapse. At two and a half months she had an episode of severe apnoea, bradycardia, desaturation and heart block, and died.
The prosecution theory
The Crown’s case was that each collapse was a discrete criminal event. It was alleged that air was injected into Baby I’s stomach via a nasogastric tube, leading to recurrent episodes of abdominal distension, “splinting” of the diaphragm and respiratory arrest; that on 13 October 2015 the apnoea alarm was deliberately turned off, delaying the response to a collapse; and that on 15 October 2015 air was injected into her intravenous tubing, causing air embolism and death. The repeated nature of the collapses was argued as pattern evidence of a repeated criminal act.
What the Panel found: an untreated airway colonisation
The Panel read the same record as describing a very preterm, growth-restricted infant with respiratory distress syndrome and chronic lung disease. Critically, the Panel notes that Stenotrophomonas maltophilia was detected in surveillance cultures taken from her endotracheal tube.
On the Panel’s account, S. maltophilia is a multiresistant opportunistic pathogen that can colonise the airway in “biofilms” that are resistant to antibiotics and generally impossible to clear in patients with chronic lung disease. The thick secretions it produces can block endotracheal tubes and interfere with ventilation in the small airways of these vulnerable infants, which, together with other factors such as chronic lung disease, lead to recurrent episodes of apnoea, desaturation, bradycardia, respiratory failure and collapse. The colonisation would have further compromised Baby I’s ventilatory capacity.
The Panel records, in terms, that Baby I was not treated for S. maltophilia.
The abdominal distension
The distension that the Crown attributed to injected air is given a different reading in the Panel report. The Panel concluded that the initial abdominal distension was likely due to sepsis causing ileus, or to lactose intolerance — noting that there was a family history and that her stools were positive for reducing substances.
On the radiology, the Panel makes a point of sequence rather than of interpretation: the repeated abdominal X-rays showing intestinal gaseous distension were all taken after resuscitation, and the air was likely introduced by bagging. That is a timing-of-imaging problem, and it applies to every one of the films relied on. See our related page on resuscitation trauma as an alternative explanation and the NG-tube air-injection mechanism.
The apnoea alarm
On the allegation that the apnoea alarm was deliberately silenced, the Panel found positive evidence to the contrary. A nurse explained why the alarm had not sounded: “The apnoea alarm goes off if there is a 20 second period of no breaths, but because she was gasping and it was less than 20 seconds, it hadn’t gone off.” On that evidence, the alarm behaved exactly as designed. The Panel’s conclusion is that there is evidence the apnoea alarm was not turned off.
Air embolism
On the final allegation — that air was injected into her intravenous tubing, causing death — the Panel is direct: there is no evidence that air embolism was involved, and no evidence of air causing splinting of the diaphragm.
The Panel’s conclusions on Baby I
- Baby 9 died of respiratory complications caused by respiratory distress syndrome and chronic lung disease, complicated by S. maltophilia colonisation.
- The doctors failed to respond to surveillance warnings about S. maltophilia, did not recognise the diagnosis, and did not treat her with the appropriate antibiotics. This was “a likely preventable death”.
- There is no evidence of air causing splinting of the diaphragm or of air embolism.
- There is evidence that the apnoea alarm was not turned off.
Source: International Expert Panel — Summary Report (February 2025), “Baby 9”. Read the Panel report (PDF). For how to read it, see how to read the Panel report.
Why this specific case matters
Baby I’s case was evidentially significant for the Crown because its pattern-of-repeated-collapse structure was used as a particularly strong inference of criminal intent: “this could not keep happening by accident”. The Panel’s reading supplies a mechanism under which it could keep happening — an untreated, antibiotic-resistant airway colonisation in an infant with chronic lung disease, producing exactly the recurrent apnoea, desaturation, bradycardia and collapse that the record describes.
That reading also carries a second-order point that a pattern argument cannot absorb. The Panel does not describe Baby I’s death as unavoidable natural tragedy: it describes a clinical failure to act on the unit’s own surveillance cultures. A differential diagnosis that was available on the notes at the time was neither recognised nor treated. Repeated collapses are pattern evidence of a criminal act only once the natural and iatrogenic explanations have been positively excluded, and on the Panel’s reading of Baby I that exclusion was not done.
What the Panel’s report adds
The Panel’s report was published in February 2025, after the 2023 convictions, so none of the following was before the jury in this form:
- The S. maltophilia surveillance-culture finding, and the Panel’s conclusion that it was never treated.
- The mechanism by which that colonisation, in an infant with chronic lung disease, produces recurrent apnoea, desaturation, bradycardia and collapse.
- The Panel’s point that the repeated abdominal X-rays showing gaseous distension were all taken after resuscitation, with air likely introduced by bagging.
- The Panel’s reading of the abdominal distension as sepsis-related ileus or lactose intolerance.
- The Panel’s finding that there is evidence the apnoea alarm was not turned off, and no evidence of air embolism.
The Panel’s report forms part of the post-conviction material now before the CCRC. It has not been tested in court, and no court has ruled on it. Lucy Letby’s convictions currently stand.