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 relied on Dr Evans's retrospective interpretation of the clinical records as evidence that deliberate harm had occurred. The reasoning moved backward from collapse to alleged deliberate act, with the contemporaneous clinical notes then read through that interpretive frame.
The contemporaneous clinical notes — written in real time by the clinicians on duty during and immediately after each event — do not themselves contain findings of deliberate harm. They record: clinical signs observed, interventions performed, the patient's response, and the clinical team's impressions at the time. Where they do identify a cause of deterioration, they generally identify a natural cause: sepsis, respiratory distress, feed intolerance, NEC, prematurity-related instability. The deliberate-harm reading is a retrospective overlay applied years later by an expert working forensic-from-hypothesis. A blinded re-reading of the contemporaneous notes by the Shoo Lee Panel reaches the opposite conclusion from Dr Evans's retrospective overlay.
The contemporaneous notes record what the treating team was actually thinking at the time. They are written by people whose professional duty is to identify and treat whatever is wrong. They do not, in their own words, record deliberate harm.
Contemporaneous notes were adduced in evidence but were framed through Dr Evans's retrospective interpretation. The jury was not systematically walked through a blinded reading of what the notes say in their own terms.
A blinded case-by-case review of the clinical record, as conducted by the Panel, produces different conclusions from the Crown's retrospective reading. The Panel identifies natural causes sufficient to explain each deterioration.