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 23 October 2015
Gestation: 27 weeks, 970 g, female, intrauterine growth restriction
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Repeated air-in-stomach attacks.
Method alleged: Multiple air-in-stomach events by NG tube over weeks.
Prosecution experts: Dr Dewi Evans; Dr Sandie Bohin.
Panel: died of respiratory complications caused by respiratory distress syndrome and chronic lung disease, complicated by Stenotrophomonas maltophilia colonisation — a likely preventable death. No evidence of air embolism, and evidence that the apnoea alarm was NOT turned off.
Panel conclusion: Baby 9 died of respiratory complications caused by respiratory distress syndrome and chronic lung disease, complicated by Stenotrophomonas maltophilia colonisation. The Panel found that the doctors failed to respond to surveillance warnings about S. maltophilia, did not recognise the diagnosis and did not treat her with the appropriate antibiotics — stating in terms that this was 'a likely preventable death'. S. maltophilia is a multi-resistant opportunistic pathogen that colonises the airway in biofilms; the resulting thick, viscous secretions blocked her endotracheal tube and interfered with ventilation, driving the recurrent apnoea, desaturation, bradycardia and collapse. The Panel found no evidence of air causing splinting of the diaphragm or of air embolism; the abdominal distension was likely sepsis-related ileus or lactose intolerance, and the repeated X-rays showing intestinal gaseous distension were all taken after resuscitation, with air likely introduced by bagging. On the alarm allegation the Panel found positive evidence the apnoea alarm was NOT turned off — a nurse explained it only sounds after 20 seconds without breaths, and she was gasping.
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