Post-mortem findings — reviewed and reinterpreted
The prosecution’s claim: In several cases, post-mortem findings were cited as supporting specific mechanisms of harm — liver injury, gastric over-distension, skin patterns consistent with air embolism.
Prosecution claim
In several cases, post-mortem findings were cited as supporting specific mechanisms of harm — liver injury, gastric over-distension, skin patterns consistent with air embolism.
Counter-evidence
The Panel's case-by-case review concludes that the post-mortem findings are explicable without deliberate harm in every case in which they were relied on. For Child O, the Panel's conclusion is a birth injury: a subcapsular liver haematoma caused by a traumatic — extremely rapid — delivery, bleeding into the peritoneal cavity. It does not attribute that haematoma to cardiopulmonary resuscitation, and it regards blunt inflicted trauma as implausible; it notes separately that the blind needle aspiration of the abdomen performed during the resuscitation may have caused additional injury — a parenchymal haematoma and a laceration — but that this was not the cause of death. Gastric gas findings are explicable by bag-and-mask ventilation given before the films were taken. For Child D, the skin discolouration recorded at post-mortem is attributed to disseminated intravascular coagulation — and coagulation defects do not occur with air embolism. No finding unique to deliberate harm was identified.
Key point: No post-mortem finding in any indicted case is unique to, or even highly specific for, deliberate harm.
What the jury heard
Post-mortem findings were presented as corroborating the Crown's mechanism of harm, case by case.
What the Panel says
The Panel's line-by-line review finds a natural cause, a birth injury or a failure of care behind each death rather than deliberate harm. For Child O it identifies a subcapsular liver haematoma caused by a traumatic, extremely rapid delivery — a birth injury — and not chest compressions; the blind needle aspiration attempted during the resuscitation may have added further injury but did not cause the death. For Child D the skin discolouration is attributed to disseminated intravascular coagulation, a coagulation defect that does not occur with air embolism. For Child E, no post-mortem was requested at all — the Panel says one should have been.
What independent experts add
- For Child O the Panel's finding is a birth injury — a subcapsular liver haematoma from an extremely rapid delivery, bleeding into the peritoneal cavity. It considers blunt inflicted trauma implausible and does not attribute the haematoma to CPR.
- The blind needle aspiration of Child O's abdomen during resuscitation may, on the Panel's reading, have caused additional injury (a parenchymal haematoma and a laceration) — but it is not the cause of death.
- Gastric over-distension is routine with bag-mask ventilation and CPAP; for Child G every X-ray showing gaseous distension was taken after bag-and-mask ventilation had been given.
- For Child D the Panel attributes the skin discolouration to disseminated intravascular coagulation, and points out that coagulation defects do not occur with air embolism.
- No post-mortem was carried out on Child E, whose death the Panel attributes to a massive gastrointestinal haemorrhage; the Panel states a post-mortem should have been requested.