Post-mortem findings — reviewed and reinterpreted
Prosecution claim
In several cases, post-mortem findings were cited as supporting specific mechanisms of harm — liver injury, gastric over-distension, skin patterns consistent with air embolism.
Counter-evidence
The Panel's case-by-case review concludes that in every case, post-mortem findings are explicable without deliberate harm. Liver findings in the case of Child O, for example, are consistent with cardiopulmonary resuscitation effort — vigorous chest compressions routinely produce hepatic injury in neonates. Gastric findings are explicable by the routine use of CPAP and bag-mask ventilation. No finding unique to deliberate harm was identified.
No post-mortem finding in any indicted case is unique to, or even highly specific for, deliberate harm.
What the jury heard
Post-mortem findings were presented as corroborating the Crown's mechanism of harm, case by case.
What the Panel says
The Panel's line-by-line review concludes every finding is compatible with natural causes or standard resuscitation effort. CPR-related hepatic injury is well described in neonatal practice.
What independent experts add
- Neonatal pathologists emphasise that CPR on a very small baby commonly produces findings that lay observers misread as trauma.
- Gastric over-distension is routine with bag-mask ventilation and CPAP.