Everything on this page attributed to the Panel is taken from the International Expert Panel — Summary Report (February 2025), where Child C is reviewed as “Baby 3”.
The clinical picture at birth
Child C was born at a gestational age of 30 weeks and 1 day. His intrauterine growth had been extremely poor: his birth weight was 800g, against an average birth weight at 30 weeks’ gestation of around 1.4kg, and there had been reversed end-diastolic (abnormal) blood flow. On the Panel’s reading he was therefore at high risk of intrauterine demise, of stillbirth, and — if liveborn — of multiple immediate, short-term and long-term complications. The Panel considered the decision to deliver him at a non-tertiary unit to be questionable.
He was cold on admission to the neonatal unit. He had low white cell and platelet counts, which the Panel notes are consistent with severe intrauterine growth restriction (IUGR) and not necessarily with infection. He developed respiratory distress syndrome and was given surfactant. His chest X-rays showed respiratory distress syndrome — not pneumonia — and showed that the surfactant had been administered mainly into the right lung.
The prosecution theory
The Crown’s mechanism on Child C was that Lucy Letby deliberately injected air into him through his NG tube, in a quantity sufficient to cause his collapse.
What the Panel found: three days of missed bowel obstruction
Over the three days after birth, the Panel found, Child C showed multiple clinical signs of intermittent bowel obstruction:
- No bowel opening from birth.
- Dark bilious aspirates.
- Bilious vomit.
- Intermittent stomach and small-bowel distension.
- Recurrent crying.
In the Panel’s assessment, an absence of bowel movements together with dark bile aspirates and vomiting is a clear indication for an urgent surgical opinion. That did not happen. Instead, despite feeds being contraindicated, he was given a 0.5ml nasogastric feed. He collapsed with a major apnoea fifteen minutes later.
The resuscitation
Two nurses commenced resuscitation, one of whom was extremely inexperienced and had never performed cardiac compressions before. The medical registrar who was called made three unsuccessful attempts at intubation before the consultant arrived. The Panel’s finding is that Child C would appear to have had ineffective ventilation for at least twenty minutes, which would have produced marked respiratory and metabolic acidosis and made the subsequent resuscitative efforts less likely to succeed. He received seven boluses of adrenaline, three of saline, two of sodium bicarbonate and one of calcium gluconate.
Following discussion with his parents, a decision was made to stop active resuscitation but to continue ventilation until he was baptised. He lived for five hours after ventilatory support was withdrawn.
What the post-mortem showed
The post-mortem showed an aberrant descending colon with persistence of the mesentery — a membrane that normally disappears in fetal life, thereby fixing the colon to the back of the peritoneal cavity. With a persisting mesentery, the descending colon is mobile and displaced to the right, with the potential for transmesenteric (internal) herniation of small bowel to the left of the descending colon, causing an obstruction that could be intermittent. In other words, the post-mortem identified an anatomical basis for exactly the intermittent obstruction his notes had been describing for three days.
The post-mortem also showed widespread hypoxic-ischaemic damage to the heart, lung immaturity, and other changes consistent with severe IUGR.
The Panel’s opinion
The Panel’s opinion is that Child C did not respond adequately to prolonged resuscitation because of inadequate resuscitation for twenty minutes following an acute episode of apnoea. Recovering respiratory distress syndrome, and severe growth restriction with myocardial ischaemia, would have added further to the likelihood of a poor response to resuscitation. The apnoeic attack itself was, in the Panel’s view, likely precipitated by severe pain due to a further episode of acute small-bowel obstruction precipitated by feeding.
On the prosecution mechanism, the Panel is direct: the suggestion that the multiple signs of intestinal obstruction could be caused by injection of air through the nasogastric tube is untenable.
The Panel’s conclusions
- Child C died because of a decision to discontinue respiratory support and resuscitative effort in the face of a poor response, following inadequate resuscitation for at least twenty minutes after an acute episode of apnoea.
- The clear prior signs of intermittent bowel obstruction that warranted urgent surgical opinion and investigation had gone unrecognised.
Why this case is structurally important
Child C was one of the earliest indicted cases — his death came only days after Child A’s. If the Crown’s narrative is right, his case is early evidence of a pattern of deliberate harm. If the Panel’s reading is right, his case is something else entirely: a severely growth-restricted infant delivered in a non-tertiary unit, whose documented signs of surgical bowel obstruction were not acted on, who was fed when feeding was contraindicated, and who was then inadequately resuscitated for twenty minutes.
The two readings are not variations on a theme. The Panel does not say the mechanism is unproven or hard to establish; it says the prosecution’s explanation for the abdominal signs is untenable, and it identifies specific failures of care in their place.