Child A

Pathology

Panel conclusion: Baby 1 died from thrombosis; there was no evidence of air embolism. The mother had anti-phospholipid syndrome (not charted in the medical records), which can pass antibodies across the placenta and predispose the newborn to thromboembolism. The post-mortem showed a recent non-occluding thrombus in the liver, indicating a recent thrombotic event. On the day of the collapse two central catheters were left without infusion for up to four hours — which predisposes to thrombosis — and the collapse came shortly after infusion restarted in the most central line. The Panel's reading is that a thrombus from the catheter tip likely migrated to an artery supplying the brain stem, causing sudden collapse and inability to resuscitate. On the skin discolouration relied on at trial, Zhou and Lee (Am J Perinatol, Dec 2024) found patchy skin discolouration has never been reported in infants with venous air embolism.