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: Survived
Gestation: Twin 2, male; 34+4 weeks, 1.67 kg, severe IUGR; moderate haemophilia (factor VIII 3%)
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Airway interference / injection.
Method alleged: Airway interference or injection.
Prosecution experts: Dr Dewi Evans; Dr Sandie Bohin.
Panel: the crying was not due to injury or air embolism. The desaturation was due to bleeding — likely spontaneous haemophilia bleeding or bleeding from routine cares — exacerbated by repeated traumatic intubation attempts.
No fatal outcome. Panel conclusion: the crying was not due to injury or air embolism, and the subsequent episode of desaturation was due to bleeding, likely spontaneously from haemophilia or from routine cares, exacerbated by repeated traumatic intubation attempts. Baby 14 had moderate haemophilia (factor VIII 3%) with raised coagulation times, and moderate haemophilia can cause spontaneous bleeding. The Panel notes that if a nasogastric tube had been thrust into his throat as alleged, the infant would have cried or screamed and there would be lacerations in the pharynx, oesophagus and vocal cords — none were reported by the intubating physicians. Trauma was, however, 'most certainly inflicted' during the eight intubation attempts, which aggravated the bleeding and caused epiglottic swelling. The Panel adds that in a haemophilia patient intubation should be done by an experienced operator, not escalated up from junior doctors, and that transfer to Alder Hey should have happened far sooner than 11 hours.
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