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 22 June 2015
Gestation: Term; 37+1 weeks, 3.13 kg, female
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Air embolism.
Method alleged: Injection of air into an IV line.
Prosecution experts: Dr Dewi Evans; Dr Sandie Bohin.
Panel: died of systemic sepsis, pneumonia and disseminated intravascular coagulation. No evidence of air embolism.
Panel conclusion: Baby 4 died of systemic sepsis, pneumonia and disseminated intravascular coagulation (DIC); the mother should have received intrapartum antibiotics for prolonged premature rupture of membranes; there was delay in recognising respiratory distress after birth and in starting antibiotics and treatment; and there was no evidence of air embolism. NICU admission, blood gas and CPAP were delayed by three to four hours and the chest X-ray by six hours. The Panel's reading of the skin discolouration relied on at trial is that it was caused by DIC clotting in the small blood vessels of the skin — and it notes that coagulation defects do not occur with air embolism.
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