Independent paediatric-pathology re-reading — CCRC submission

Summary of the independent paediatric-pathology re-reading of the post-mortem material filed with the October 2025 CCRC application. The re-reading addresses, on the cases with preserved post-mortem material: Child O's liver findings (resuscitation-associated injury, not deliberate trauma); Child E's bleeding (coagulopathy and stress ulceration, not deliberate trauma); the air-embolism-hypothesis cases (no intravascular gas finding on any post-mortem imaging or histology); and the NEC differential on multiple 'air in stomach' counts. The overall conclusion is that post-mortem findings are compatible with natural pathology and do not require deliberate-harm explanations.

Last updated 2026-04-22

14 min read

Context

The October 2025 CCRC application includes independent paediatric-pathology re-readings of the post-mortem material in the cases on which physical pathology evidence exists. This page summarises the principal conclusions of that re-reading.

The Child O liver findings

The Crown’s pathologist interpreted post-mortem liver findings on Child O as consistent with deliberate blunt impact. Independent paediatric pathologists read the same findings as consistent with vigorous neonatal resuscitation — a well- documented pattern of sub-capsular haematoma, parenchymal contusion and capsular tear seen in term neonates after prolonged CPR. See our resuscitation trauma analysis.

The Child E bleeding

Upper-GI bleeding in a preterm infant can arise from stress ulceration, coagulopathy or mucosal injury from NG-tube insertion. Independent paediatric pathology re-reading identifies natural causes as sufficient to explain the observed bleeding in Baby E’s case without any deliberate act being posited. See our Baby E deep-dive.

The air-embolism cases

No post-mortem imaging or histology demonstrated the intravascular gas pattern that air embolism would produce, on any of the cases where air embolism was alleged. The Crown’s theory was an inference from clinical signs, not a confirmed pathology finding. Independent pathology review therefore finds no evidence supporting the air-embolism mechanism.

The NEC differential

Across multiple “air in stomach” counts, the post-mortem bowel findings are compatible with evolving NEC — the pneumatosis intestinalis, portal venous gas, and bowel-wall changes characteristic of NEC pathology. Independent paediatric pathology identifies NEC as the primary differential on these cases. See our NEC natural pathology evidence page.

The overall conclusion

Across the cases on which preserved post-mortem material is available for independent review, the finding is that pathology is compatible with natural pathology and does not require deliberate-harm explanations. This is consistent with the Panel’s overall conclusion.

Read alongside

Evidence: post-mortem findings, Evidence: resuscitation trauma, Evidence: NEC natural pathology, CCRC application summary.