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.
Clinical-chart records including arterial blood-gas values, lactate trends, and oxygen saturation were used by the Crown's experts to describe deteriorations as sudden, unexpected, and more consistent with deliberate harm than with natural causes.
Natural clinical deterioration in critically unwell neonates produces characteristic blood-gas and lactate trajectories: rising lactate (reflecting anaerobic metabolism during tissue hypoxia), falling pH (metabolic acidosis), rising pCO2 (respiratory failure), falling base excess, and eventual oxygen-saturation instability. These trajectories are documented in the UK National Neonatal Research Database as the standard pattern for NEC, sepsis, overwhelming IVH, and cardiovascular collapse. The specific trajectories presented at trial are, on independent Panel review, consistent with natural deterioration rather than abrupt iatrogenic or deliberate events. A deliberate air embolism, by contrast, would typically show a characteristic abrupt-onset pattern rather than the evolving metabolic picture documented in the clinical charts.
The chart tells a story. The story the charts tell in these cases is of critically ill preterm infants decompensating along recognised natural-cause trajectories — not of abrupt, iatrogenic events.
The jury was shown selected blood-gas and chart values and asked to weigh the Crown's expert interpretation of them. The full reference-distribution context — what these values look like in natural-cause deterioration — was not systematically presented.
The Panel's case-by-case review walks through the blood-gas and lactate trajectories in the indicted cases and concludes they are compatible with natural-cause deterioration. The Panel's specific point is that the chart trajectories do not require a deliberate-harm hypothesis to explain them.