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.
Bilirubin trends were used at trial as part of the corroborative clinical picture supporting the prosecution's narrative of unexpected deterioration.
Independent paediatric review of the bilirubin graphs in several indicted cases identifies misreading of the phototherapy thresholds applicable to extremely preterm infants. The thresholds are gestation-specific and weight-specific; readings interpreted as 'unexpected' against full-term thresholds fall well within the expected range for the affected gestational ages. Phototherapy initiation timing in the clinical record is consistent with appropriate management in some cases and with delayed initiation in others — both findings carry implications for the deterioration trajectory that were not foregrounded for the jury.
Bilirubin thresholds are gestation-specific. Readings that look 'unexpected' against full-term thresholds fall within the expected range for extremely preterm infants — and were misread or under-contextualised in the trial picture.
Bilirubin readings were presented as part of the corroborative clinical picture. The gestation-specific phototherapy threshold framework was not foregrounded.
The Panel's case-by-case findings emphasise the importance of gestation-specific clinical-management thresholds when assessing whether a deterioration is anomalous or expected.