Thrombosis in preterms — an underconsidered natural-causes explanation
Prosecution claim
Several indicted collapses were attributed at trial to air embolism as the cause of sudden deterioration with skin colour changes. The framing treated air embolism as the leading explanation for circulatory events with mottled skin appearance.
Counter-evidence
Thrombosis in extremely preterm infants is a well-documented natural cause of sudden circulatory collapse. Central venous catheters are a specific risk factor — and every indicted baby who had a central line was, by definition, at elevated thrombotic risk. Antiphospholipid syndrome in the mother (documented in some of the indicted pregnancies) further elevates neonatal thrombotic risk. Twin-to-twin transfusion syndrome and selective intrauterine growth restriction are also associated with in-utero and perinatal thrombotic events. Several Panel reviewers specifically identify thrombotic events as a plausible, and in the case of Child E likely, alternative explanation for the observed deterioration. A proper differential-diagnosis workup on each suspicious collapse would include imaging and laboratory testing for thrombosis. Much of that workup was not done at the time, and where post-mortem material exists it has not been systematically re-examined with a thrombotic hypothesis in view until the Panel's 2025 review.
A central-line-in-place preterm baby who collapses is at risk of thrombosis as a first-line diagnosis. Air embolism should be much further down the differential, not at the top of it.
What the jury heard
Air embolism was presented as the leading explanation for collapses with skin-mottling; thrombosis was not systematically developed as an alternative.
What the Panel says
Case-by-case review identifies thrombotic events as plausible or likely alternative diagnoses in multiple indicted cases. The case of Child E in particular is noted as consistent with natural pathology potentially including thrombosis.
What independent experts add
- Central venous catheters are a recognised independent risk factor for neonatal thrombosis, especially in extremely preterm infants.
- Maternal antiphospholipid syndrome, documented in some of the indicted pregnancies, elevates neonatal thrombotic risk.
- Sarah Hawkins's long-form analyses on this site identify the APS dimension in specific cases.
- Acute thromboembolic events in neonates can present with skin mottling that has been misread by less paediatrically-experienced observers as suggestive of air embolism.
- No post-mortem imaging suitable for detecting intravascular thrombosis was systematically obtained across the indicted cases.