Children O and P — the Panel's findings: a birth-injury liver haematoma and a mismanaged pneumothorax
The prosecution’s claim: The Crown's pathology expert Dr Andreas Marnerides interpreted post-mortem liver findings on Child O as consistent with deliberately inflicted blunt impact. The interpretation was that the observed hepatic injury could not adequately be explained by the resuscitation efforts alone.
Prosecution claim
The Crown's pathology expert Dr Andreas Marnerides interpreted post-mortem liver findings on Child O as consistent with deliberately inflicted blunt impact. The interpretation was that the observed hepatic injury could not adequately be explained by the resuscitation efforts alone.
Counter-evidence
The Shoo Lee Panel reached a different conclusion on the same material — and it is not the resuscitation-trauma reading either. The Panel finds that Child O died from a subcapsular liver haematoma caused by a traumatic, extremely rapid delivery: a birth injury, which bled into the peritoneal cavity. It regards blunt inflicted trauma as implausible, and it does not attribute the haematoma to cardiopulmonary resuscitation. It notes separately that the blind needle aspiration of the abdomen carried out during the resuscitation may have caused additional injury — a parenchymal haematoma and a laceration — but that this was not the cause of death. For Child P the Panel's finding has nothing to do with the liver at all: Child P died from a pneumothorax that was suboptimally managed, and the Panel found no evidence of air injected into the stomach or into an IV line. The Crown's unified 'deliberate harm across the triplets' reading survives neither finding.
Key point: The Panel's cause of death for Child O is a birth injury — a subcapsular liver haematoma caused by an extremely rapid delivery. Not inflicted blunt trauma, and not chest compressions. For Child P it is a pneumothorax that was suboptimally managed.
What the jury heard
Dr Marnerides presented the liver findings as consistent with deliberate blunt impact. The prosecution's narrative connected the finding to air-embolism-pattern evidence on the other triplets to produce a unified theory of deliberate harm across the triplet set. The obstetric record — an extremely rapid delivery — was not put to the jury as the origin of the liver injury.
What the Panel says
The Panel attributes Child O's subcapsular liver haematoma to a traumatic, extremely rapid delivery — a birth injury — with haemorrhage into the peritoneal cavity. It considers blunt inflicted trauma implausible and does not attribute the haematoma to CPR. The blind needle aspiration performed during the resuscitation may have caused additional injury (parenchymal haematoma and laceration) but is not the cause of death. For Child P the Panel finds death from a suboptimally managed pneumothorax, with no evidence of air injection into the stomach or an IV line.
What independent experts add
- The Panel's Child O finding places the fatal injury at the delivery itself — before the period in which the Crown alleged deliberate harm.
- The Panel treats the blind needle aspiration of Child O's abdomen during resuscitation as a possible source of additional injury, not as the cause of death — a distinction the Crown's causation case never had to confront.
- Child P's Panel finding — a mismanaged pneumothorax, with no evidence of air injected into the stomach or an IV line — is a failure-of-care finding, and it is unrelated to the liver pathology relied on for Child O.
- Post-mortem findings in newborns are difficult to interpret without the obstetric and clinical record of what was done to the baby; the Panel's re-reading works forward from the delivery record, which the trial pathology did not.
- The pathology strand is one of the most examinable parts of the conviction for the CCRC: the physical material is preserved and can be reviewed in a way the insulin samples and skin-sign descriptions cannot.