Child I
The prosecution’s theory: Repeated air-in-stomach attacks.
Outcome: Died 23 October 2015
Gestation: 27 weeks, 970 g, female, intrauterine growth restriction
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Prosecution theory
Repeated air-in-stomach attacks.
Method alleged: Multiple air-in-stomach events by NG tube over weeks.
Prosecution experts: Dr Dewi Evans; Dr Sandie Bohin.
Panel view (Feb 2025)
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.
Pathology
Panel conclusion: Baby 9 died of respiratory complications caused by respiratory distress syndrome and chronic lung disease, complicated by Stenotrophomonas maltophilia colonisation. The Panel found that the doctors failed to respond to surveillance warnings about S. maltophilia, did not recognise the diagnosis and did not treat her with the appropriate antibiotics — stating in terms that this was 'a likely preventable death'. S. maltophilia is a multi-resistant opportunistic pathogen that colonises the airway in biofilms; the resulting thick, viscous secretions blocked her endotracheal tube and interfered with ventilation, driving the recurrent apnoea, desaturation, bradycardia and collapse. The Panel found no evidence of air causing splinting of the diaphragm or of air embolism; the abdominal distension was likely sepsis-related ileus or lactose intolerance, and the repeated X-rays showing intestinal gaseous distension were all taken after resuscitation, with air likely introduced by bagging. On the alarm allegation the Panel found positive evidence the apnoea alarm was NOT turned off — a nurse explained it only sounds after 20 seconds without breaths, and she was gasping.
Natural-cause alternatives identified
- Respiratory distress syndrome and chronic lung disease — the Panel's stated cause of death
- Stenotrophomonas maltophilia airway colonisation (detected on surveillance cultures, never treated)
- Sepsis-related ileus or lactose intolerance explaining the abdominal distension
- Air introduced by bagging during resuscitation explaining the gaseous distension on X-ray
What the jury did not hear
- The Panel's conclusion that she died of respiratory complications of RDS and chronic lung disease, complicated by S. maltophilia colonisation.
- That S. maltophilia was detected on surveillance cultures and never treated — which the Panel calls 'a likely preventable death'.
- That the repeated abdominal X-rays showing gaseous distension were all taken AFTER resuscitation.
- That the Panel found evidence the apnoea alarm was NOT turned off: it only triggers after 20 seconds without breaths, and she was gasping.
Key primary sources
- International Expert Panel — Summary Report (February 2025), Panel Baby 9: https://lucyletbyinnocence.com/shoo-lee/International%20Expert%20Panel%20-%20Summary%20Report.pdf
- R v Letby sentencing remarks (August 2023)
Read the full long-form analysis →
Sources:
- Court of Appeal judgment (May 2024) and sentencing remarks — judiciary.uk
- Shoo Lee International Expert Panel Report (February 2025) — lucyletbyinnocence.com
- Per-baby trial evidence archive — lucyletbyinnocence.com
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