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 Babies A and B, monochorionic twins, deteriorated as a direct result of deliberate harm by Lucy Letby acting on consecutive shifts.
The Panel's findings for these twins are specific, and neither is air embolism. Child A, it concludes, died from thrombosis: the mother had anti-phospholipid syndrome, a recent non-occluding liver thrombus was found at post-mortem, and catheters had been left unperfused for up to four hours. Child B collapsed from thrombotic emboli arising from a central intravenous catheter that was kinked and had not been heparinised, potentially aggravated by the same maternal anti-phospholipid syndrome; her D-dimer was 6219 and her platelets 103. There is, in other words, a shared explanation for two consecutive collapses in twins — the mother's clotting disorder, plus the lines in the babies' veins — and it is not a nurse working consecutive shifts. Monochorionic twins are in general at elevated risk of shared placental pathology, and sequential deterioration in twins who share a placenta and a maternal exposure is not anomalous.
Sequential deterioration in twins whose mother has anti-phospholipid syndrome, and who both have central lines, is not the signature of deliberate harm. The Panel's finding is thrombosis in Child A, and catheter-related thrombotic emboli in Child B.
The twin pregnancy was acknowledged, but the maternal anti-phospholipid syndrome, the catheters left unperfused, and the kinked, non-heparinised central line were not developed as a unifying natural-cause explanation for two sequential collapses.
The Panel concludes that Child A died from thrombosis and that Child B collapsed from thrombotic emboli from a kinked, non-heparinised central catheter — both potentially aggravated by maternal anti-phospholipid syndrome. It found no evidence of air embolism in either baby.