May 2026: Thirlwall Inquiry report delayed to at least September 2026 · six-baby inquests relisted to 2027 · CCRC review active · Shoo Lee Panel: no medical evidence of deliberate harm.
Outcome: Died 8 June 2015
Gestation: Twin 2, male; 31+2 weeks, 1.66 kg
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Air embolism injected intravenously.
Method alleged: Injection of air into an IV line causing fatal venous air embolism.
Prosecution experts: Dr Dewi Evans (lead); Dr Sandie Bohin. Both cited the Lee & Tanswell 1989 paper.
Panel: died from thrombosis. No evidence of air embolism.
Panel conclusion: Baby 1 died from thrombosis; there was no evidence of air embolism. The mother had anti-phospholipid syndrome (not charted in the medical records), which can pass antibodies across the placenta and predispose the newborn to thromboembolism. The post-mortem showed a recent non-occluding thrombus in the liver, indicating a recent thrombotic event. On the day of the collapse two central catheters were left without infusion for up to four hours — which predisposes to thrombosis — and the collapse came shortly after infusion restarted in the most central line. The Panel's reading is that a thrombus from the catheter tip likely migrated to an artery supplying the brain stem, causing sudden collapse and inability to resuscitate. On the skin discolouration relied on at trial, Zhou and Lee (Am J Perinatol, Dec 2024) found patchy skin discolouration has never been reported in infants with venous air embolism.
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