Necrotising enterocolitis — the alternative diagnosis, and where the Panel actually finds it
The prosecution’s claim: The Crown's case on several counts, particularly those involving abdominal distension, 'air in stomach' and rapid gastrointestinal deterioration, framed the findings as consistent with deliberate injection of air via nasogastric or other routes.
Prosecution claim
The Crown's case on several counts, particularly those involving abdominal distension, 'air in stomach' and rapid gastrointestinal deterioration, framed the findings as consistent with deliberate injection of air via nasogastric or other routes.
Counter-evidence
Necrotising enterocolitis (NEC) is a devastating bowel disease of premature infants and one of the leading causes of neonatal death and morbidity on NICUs worldwide. The clinical presentation of evolving NEC includes abdominal distension, bilious aspirate, temperature instability, and rapid circulatory collapse — the constellation of findings prosecuted as 'air in stomach' in several indicted cases. The Shoo Lee Panel's NEC finding, however, is specific rather than sweeping. For Child Q the Panel concludes the picture is early NEC or sepsis, and that the '++ air' aspirated from the nasogastric tube was most likely introduced by the bagging that preceded the aspiration. NEC is not the Panel's conclusion elsewhere — for Child I it expressly rejects NEC, attributing the death instead to respiratory complications of RDS and chronic lung disease complicated by an untreated Stenotrophomonas maltophilia colonisation. The general point survives the correction: 'air in stomach' is not a diagnosis, NEC is one of its commonest causes in extremely preterm infants, and NEC was not rigorously excluded before a criminal cause was adopted.
Key point: 'Air in stomach' is not a diagnosis. It is a radiological observation with multiple causes — including a bag-and-mask resuscitation performed minutes earlier. Where the Panel does find NEC, it says so: in Child Q, as early NEC or sepsis.
What the jury heard
The prosecution's narrative framed 'air in stomach' findings as a specific deliberate-harm pattern attributable to tampering with nasogastric lines. NEC was mentioned as a clinical reality but not systematically developed as a competing diagnosis for the specific indicted collapses.
What the Panel says
For Child Q the Panel concludes the picture is early NEC or sepsis, and that the air aspirated from the nasogastric tube was most likely introduced by the bagging that preceded it — not injected. NEC is not the Panel's conclusion in the other cases, and it expressly rejects NEC for Child I. Its per-baby findings differ case by case: thrombosis, sepsis, haemorrhage, pneumothorax, hypoglycaemia, untreated infection, failures of care.
What independent experts add
- NEC pathogenesis is multifactorial: prematurity, gut immaturity, gut-flora imbalance, feed tolerance, and infection all contribute.
- NEC incidence rises substantially in units under epidemic or outbreak pressure — exactly the Countess of Chester's 2015-16 situation.
- The radiographic features of evolving NEC — pneumatosis intestinalis, portal venous gas, free intraperitoneal gas — can be misread as 'air in stomach' by a non-paediatric-radiologist eye.
- Where the Panel does reach a bowel diagnosis it is case-specific: early NEC or sepsis in Child Q, and unrecognised intermittent bowel obstruction in the days before Child C's death.
- Private Eye's M.D. column has written about the NEC differential on the Letby counts in multiple 2024-2025 instalments.