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.
The Crown alleged Child I's repeated deteriorations were caused by deliberate harm by Lucy Letby across multiple occasions over a period of weeks.
The Panel's conclusion on Child I is neither of the readings that dominated the trial. It is not NEC, and it is not air embolism. The Panel finds that Child I died of respiratory complications of respiratory distress syndrome and chronic lung disease, complicated by colonisation with Stenotrophomonas maltophilia that was never treated — and it describes this as 'a likely preventable death'. It found no evidence of air embolism. It also found evidence that the apnoea alarm had not been turned off, which removes one of the concrete factual planks the Crown built on. The tragedy the Panel describes is a baby with severe chronic lung disease carrying an untreated infection: a failure of care, and a death that need not have happened.
Child I's death, on the Panel's finding, was 'a likely preventable death' — respiratory complications of RDS and chronic lung disease, complicated by a Stenotrophomonas maltophilia colonisation that was never treated. Not NEC. Not air embolism.
The Crown framed each deterioration as a discrete deliberate event, presented in sequence to suggest a pattern, and the jury heard that an alarm had been silenced. The natural-cause trajectory — an infant with RDS and chronic lung disease carrying an untreated infection — was not put to them as the unifying alternative explanation.
The Panel concludes Child I died of respiratory complications of RDS and chronic lung disease, complicated by an untreated Stenotrophomonas maltophilia colonisation — 'a likely preventable death'. It does not find NEC, it found no evidence of air embolism, and it found evidence that the apnoea alarm was not turned off.