Necrotising enterocolitis — the alternative diagnosis on multiple counts
Prosecution claim
The Crown's case on several counts, particularly those involving abdominal distension, 'air in stomach' and rapid gastrointestinal deterioration, framed the findings as consistent with deliberate injection of air via nasogastric or other routes.
Counter-evidence
Necrotising enterocolitis (NEC) is a devastating bowel disease of premature infants. It is one of the single leading causes of neonatal death and morbidity on NICUs worldwide. The clinical presentation of evolving NEC includes abdominal distension, bilious aspirate, temperature instability, and rapid circulatory collapse — the exact constellation of findings prosecuted as 'air in stomach' in multiple indicted cases. The Panel's case-by-case review identifies evolving NEC as a plausible, and in several cases likely, alternative diagnosis for collapses charged as deliberate harm. NEC is also substantially more common in units under the kinds of stresses the Countess of Chester neonatal unit was under in 2015–16: outbreak conditions, staffing pressures, infants below unit designation. In no indicted case was NEC rigorously excluded using the structured differential-diagnosis approach a modern UK NICU would apply.
'Air in stomach' is not a diagnosis. It is a radiological observation with multiple causes. NEC is one of the most common of them in extremely preterm infants — and NEC was not systematically excluded before a criminal cause was adopted.
What the jury heard
The prosecution's narrative framed 'air in stomach' findings as a specific deliberate-harm pattern attributable to tampering with nasogastric lines. NEC was mentioned as a clinical reality but not systematically developed as a competing diagnosis for the specific indicted collapses.
What the Panel says
The Panel reviewing the cases case-by-case identifies evolving NEC as a plausible or likely diagnosis for several collapses charged as 'air in stomach'. The Panel's conclusion — no medical evidence of deliberate harm in any case reviewed — incorporates the NEC re-reading across multiple counts.
What independent experts add
- NEC pathogenesis is multifactorial: prematurity, gut immaturity, gut-flora imbalance, feed tolerance, and infection all contribute.
- NEC incidence rises substantially in units under epidemic or outbreak pressure — exactly the Countess of Chester's 2015–16 situation.
- The radiographic features of evolving NEC — pneumatosis intestinalis, portal venous gas, free intraperitoneal gas — can be misread as 'air in stomach' by a non-paediatric-radiologist eye.
- A blinded paediatric-pathology review of the post-mortem bowel material in the relevant cases would, on the Panel's framework, include NEC as a primary differential.
- Private Eye's M.D. column has written about the NEC differential on the Letby counts in multiple 2024–2025 instalments.