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: Transferred, later died of unrelated cause
Gestation: 25 weeks, 692 g, female (footling breech)
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Dislodged ET tube; Dr Jayaram's eyewitness account.
Method alleged: Deliberate dislodgement of the endotracheal tube.
Prosecution experts: Dr Dewi Evans; Dr Jayaram (treating consultant witness).
Panel: no evidence of a dislodged endotracheal tube. The deterioration was caused by use of an UNDERSIZED endotracheal tube producing a 94% air leak; the incubator alarms were NOT turned off.
No fatal outcome. Panel conclusion: there is no evidence to support a dislodged endotracheal tube; the clinical deterioration was caused by the use of an undersized endotracheal tube; the initial intubation was traumatic and poorly supervised; and the consultant did not understand the basics of resuscitation, air leak, mechanical ventilation, or how commonly used equipment such as the Neopuff and capnograph work. Baby 11 needed a size 2.5 tube but was intubated with a size 2, producing a 94% air leak — so only about 6% of each breath entered the lung. That explains the two findings the consultant treated as sinister: bagging with the Neopuff failed to move the chest because its pressure-limiting safety feature could not overcome the leak, and the capnograph read negative because CO2 could not build up in the tube. The Panel also found positive evidence that the incubator alarms were NOT turned off — a nurse (not Letby) stated she 'immediately became aware of the alarms sounding'.
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