The babies

Outcome: Died 8 June 2015

Gestation: Twin 2, male; 31+2 weeks, 1.66 kg

Prosecution: Air embolism injected intravenously.

Panel: Panel: died from thrombosis. No evidence of air embolism.

Outcome: Survived

Gestation: Twin 1, female; 31+2 weeks, 1.69 kg (twin sister of Child A)

Prosecution: Air embolism attempt.

Panel: Panel: collapsed from thrombotic emboli originating from a central intravenous catheter, potentially aggravated by maternal anti-phospholipid syndrome. No evidence of air embolism.

Outcome: Died 14 June 2015

Gestation: 30+1 weeks, 800 g, severe intrauterine growth restriction

Prosecution: Air pushed into stomach via NG tube.

Panel: Panel: died following a decision to discontinue respiratory support after inadequate resuscitation; prior signs of intermittent bowel obstruction had gone unrecognised.

Outcome: Died 22 June 2015

Gestation: Term; 37+1 weeks, 3.13 kg, female

Prosecution: Air embolism.

Panel: Panel: died of systemic sepsis, pneumonia and disseminated intravascular coagulation. No evidence of air embolism.

Outcome: Died 4 August 2015

Gestation: Twin 1, male; 29+5 weeks, 1.327 kg (twin brother of Child F)

Prosecution: Air embolism / deliberate bleeding from NG tube.

Panel: Panel: died from massive gastrointestinal haemorrhage due to either intrauterine hypoxia causing ulceration or a congenital vascular lesion. No evidence of air embolism.

Outcome: Survived

Gestation: Twin 2, male; 29+5 weeks, 1.434 kg, borderline IUGR

Prosecution: Exogenous insulin added to TPN bag.

Panel: Panel: prolonged hypoglycaemia caused by sepsis, prematurity, IUGR, loss of intravenous glucose from a tissued line, and poor medical management. The insulin and C-peptide results do not prove exogenous insulin and are within the norm for preterm infants.

Outcome: Survived with severe disabilities

Gestation: 23+6 weeks, 535 g, female

Prosecution: Deliberate over-feeding causing aspiration.

Panel: Panel: vomiting and clinical deterioration due to infection, possibly enterovirus. No evidence to support air injection into the stomach or overfeeding.

Outcome: Survived

Gestation: 34+4 weeks, 2.33 kg, female

Prosecution: Air embolism / airway interference.

Panel: Panel: the deteriorations were due to medical mismanagement of a tension pneumothorax. No evidence of intentional tampering with the endotracheal tube.

Outcome: Died 23 October 2015

Gestation: 27 weeks, 970 g, female, intrauterine growth restriction

Prosecution: Repeated air-in-stomach attacks.

Panel: Panel: died of respiratory complications caused by respiratory distress syndrome and chronic lung disease, complicated by Stenotrophomonas maltophilia colonisation — a likely preventable death. No evidence of air embolism, and evidence that the apnoea alarm was NOT turned off.

Outcome: Survived

Gestation: Twin, female; 32+2 weeks, 1.709 kg

Prosecution: Unspecified act.

Panel: Panel: the deterioration on day 47 of life was due to sepsis. No evidence to support malicious airway obstruction.

Outcome: Transferred, later died of unrelated cause

Gestation: 25 weeks, 692 g, female (footling breech)

Prosecution: Dislodged ET tube; Dr Jayaram's eyewitness account.

Panel: Panel: no evidence of a dislodged endotracheal tube. The deterioration was caused by use of an UNDERSIZED endotracheal tube producing a 94% air leak; the incubator alarms were NOT turned off.

Outcome: Survived

Gestation: Twin 1; 33+2 weeks, 1.465 kg, severe intrauterine growth restriction

Prosecution: Insulin in feeds.

Panel: Panel: hypoglycaemia was due to preterm birth and severe IUGR, and its medical management was inadequate. The insulin and C-peptide results do not prove exogenous insulin and are within the norm for preterm infants.

Outcome: Survived

Gestation: Twin 2, male; 33+2 weeks, 1.703 kg, severe intrauterine growth restriction

Prosecution: Air embolism.

Panel: Panel: the desaturation and bradycardia were caused by apnoea from sepsis or the Eustachian valve. The resuscitation was suboptimal. No evidence of air embolism.

Outcome: Survived

Gestation: Twin 2, male; 34+4 weeks, 1.67 kg, severe IUGR; moderate haemophilia (factor VIII 3%)

Prosecution: Airway interference / injection.

Panel: Panel: the crying was not due to injury or air embolism. The desaturation was due to bleeding — likely spontaneous haemophilia bleeding or bleeding from routine cares — exacerbated by repeated traumatic intubation attempts.

Outcome: Died 23 June 2016

Gestation: Triplet 2, male; 33+2 weeks, 2.02 kg (preterm)

Prosecution: Air into stomach, liver trauma.

Panel: Panel: died from a subcapsular liver haematoma caused by traumatic delivery, causing haemorrhage into the peritoneal cavity and profound shock. Not recognised before death.

Outcome: Died 24 June 2016

Gestation: Triplet 1, male; 33+2 weeks, 2.066 kg (preterm)

Prosecution: Air into stomach.

Panel: Panel: died from a pneumothorax that was suboptimally managed. No evidence of air injection into the stomach or into the intravenous line.

Outcome: Survived

Gestation: 31+3 weeks, 2.076 kg, male

Prosecution: Air into stomach.

Panel: Panel: the deterioration with vomiting was because he was developing early necrotising enterocolitis or sepsis. No evidence to support air injection into the stomach.