The clinical context
On the Panel’s summary of the record, Baby N was a twin boy born at 34 weeks and 4 days weighing 1.67 kg, with severe intrauterine growth restriction, delivered by emergency Caesarean section. His mother was a haemophilia carrier.
He had mild respiratory distress syndrome, a reduced factor VIII of 3% — moderate haemophilia — and raised coagulation times (PT 15.4, APTT 69.7). This is the central fact of his case, and it is a fact about the baby, not about his mother: he had a diagnosed bleeding disorder, and moderate haemophilia can cause spontaneous bleeding.
Twelve hours after birth he desaturated, looked dusky, was unsettled, and had increased work of breathing. When a doctor saw him he was screaming and had subcostal recession, but he settled after half an hour.
On day 13 he became mottled and had five episodes of desaturation, followed by an episode of profound desaturation. Intubation was attempted three times but abandoned because of blood in the oropharynx and trauma from the repeated attempts. A chest X-ray showed right patchy consolidation consistent with infection and oedema. Intravenous factor VIII was given. Intubation was then attempted a further five times, by registrars, consultants and an anaesthetist, without success. A laryngeal mask was used. A team from Alder Hey arrived 11 hours after the onset of the profound desaturation and intubated him. He was transferred there, given factor VIII, and recovered.
The prosecution theory
It was alleged that the initial screaming episode was due to inflicted injury, or to injection of air into his intravenous system causing pain. It was further alleged that the later desaturation and bleeding were caused by trauma inflicted by thrusting a nasogastric tube into the back of his throat.
What the Panel found: the screaming
The Panel considers the screaming episode unlikely to be due to inflicted injury, because an injury of the intensity required to cause 30 minutes of screaming would itself have caused bleeding.
It is also not, on the Panel’s reading, air embolism: crying due to air embolism is of short duration, being a response to hypoxia as the infant gasps and cries for air, and it either resolves quickly or the infant collapses. Crying is usually associated with discomfort from hunger, hypothermia, hypoxia and pain.
What the Panel found: the bleeding
The Panel concludes that the desaturation was most likely due to bleeding from haemophilia — either spontaneously, or from routine cares — causing blood and secretions to pool in the oropharynx and obstruct the airway. Moderate haemophilia can cause spontaneous bleeding. The Panel adds that it is unclear whether a haemophilia nursing protocol was used by the unit to prevent inadvertent trauma from standard nursing care procedures.
On the specific allegation of an NG tube thrust into the throat, the Panel is direct about what the record would have to show. If that had happened, the infant would have cried or screamed, and there would be evidence of lacerations in the pharynx, oesophagus and vocal cords. None were reported by the intubating physicians — the very doctors who were repeatedly looking directly at his airway.
The trauma that was inflicted
The Panel does find inflicted trauma in Baby N’s case. It attributes it to the treatment, not to an assault: trauma was “most certainly inflicted” during the repeated intubation attempts — eight of them — which aggravated the bleeding and caused swelling of the epiglottis.
The Panel is explicit about how this should have been handled. In a haemophilia patient, intubation should be performed by an experienced individual. It is inappropriate to allow junior doctors to try and then progress up the chain to senior doctors. The patient should not have been subjected to eight intubation attempts. And the referral to Alder Hey, and the transfer, should have been done much sooner — not 11 hours after the initial desaturation.
The Panel’s conclusions on Baby N
- The crying was not due to injury or air embolism.
- The subsequent episode of desaturation was due to bleeding, likely spontaneously from haemophilia or from routine cares, and exacerbated by repeated traumatic intubation attempts.
Source: International Expert Panel — Summary Report (February 2025), “Baby 14”. Read the Panel report (PDF). For how to read it, see how to read the Panel report.
Why this specific case matters
Baby N is the case in which the alleged mechanism and the innocent explanation leave different marks — and the record contains one set of marks and not the other. An NG tube driven into the throat of a baby with a bleeding disorder would have torn the pharynx, oesophagus and vocal cords. Eight failed intubation attempts in a baby with a bleeding disorder would aggravate bleeding and swell the epiglottis. It is the second picture that the notes describe.
The rest of the Panel’s reading follows from the diagnosis nobody disputes. Baby N had moderate haemophilia with a factor VIII of 3% and deranged clotting times. Bleeding into the airway of such an infant, whether spontaneous or provoked by ordinary nursing care, is the expected natural history of the condition — and it is what the Panel says happened.
The Panel’s report has not been tested in court, and no court has ruled on it. It forms part of the post-conviction material now before the CCRC. Lucy Letby’s convictions currently stand.
What the Panel’s report adds
The Panel reported in February 2025, after the 2023 trial. None of the following was before the jury in this form:
- The Panel’s conclusion that the desaturation was bleeding from moderate haemophilia, spontaneous or from routine cares, obstructing the airway.
- The point that a nasogastric tube thrust into the throat would have left lacerations of the pharynx, oesophagus and vocal cords — and that none were reported by the intubating physicians.
- The Panel’s finding that trauma was “most certainly inflicted” during the eight intubation attempts, aggravating the bleeding and causing epiglottic swelling.
- That in a haemophilia patient intubation should be done by an experienced operator, and that escalating attempts up the seniority chain — eight of them — was inappropriate.
- That it is unclear whether the unit used a haemophilia nursing protocol to prevent inadvertent trauma from routine care.
- That the referral and transfer to Alder Hey should have happened far sooner than 11 hours after the profound desaturation.