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 14 June 2015
Gestation: 30+1 weeks, 800 g, severe intrauterine growth restriction
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Air pushed into stomach via NG tube.
Method alleged: Forced air insufflation into the stomach via nasogastric tube causing diaphragmatic splinting.
Prosecution experts: Dr Dewi Evans; Dr Sandie Bohin.
Panel: died following a decision to discontinue respiratory support after inadequate resuscitation; prior signs of intermittent bowel obstruction had gone unrecognised.
Panel conclusion: Baby 3 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 20 minutes after an acute episode of apnoea. The Panel further found that clear prior signs of intermittent bowel obstruction — which warranted an urgent surgical opinion and investigation — had gone unrecognised. His intrauterine growth had been extremely poor (800 g at 30+1 weeks, against an average of about 1.4 kg).
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