"the death cause findings"
Why would they do that, the findings were natural causes and one inconclusive .
The situation is simple, the jury believed Dr Marnerides at arms length contradictions of all 6 coroner's office findings, which takes a stretch of the imagination, to believe any coroner's office could be so incompetent.
However we are where we are, at this juncture, future developments may show things in a different light.
Summary of Pathology
Child A
Original pathology: The case was referred to the coroner and the cause of Child A's death was 'unascertained' at the time.
Reviewing pathology (Dr Andreas Marnerides): Dr Marnerides said it appeared Child A, a twin boy, died as a result of an injection of air into his bloodstream.
He reviewed tissue samples from Child A. The medic says from his review, he found 'globules' in the veins in the lungs and brain tissue that were most likely air, he said this air 'most likely went there while this baby was alive'
Child C
Original pathology: The cause of death was ‘widespread hypoxic/ischaemic damage to the heart/myocardium’ due to lung disease, with maternal vascular under perfusion as a contributory factor.
Reviewing pathology (Dr Andreas Marnerides):
The prosecution added an independent pathologist said the skin colour changes in Child C were likely caused by prolonged unsuccessful resuscitation.
Child C had pneumonia, but the pathologist concluded Child C died as a result of having an excessive quantity of air injected into his stomach via the nasogastric tube (NGT).
Child D
Original pathology: The coroner gave the cause of death as "pneumonia with acute lung injury."
Reviewing pathology (Dr Andreas Marnerides): The “likely explanation” for the death of Child D, a girl, was an air embolism into her circulation.
Child E
The parents did not wish to have a post-mortem, the consultant did not deem one necessary, and the coroner's office agreed.
Child I
Original pathology: The cause of death was given by the coroner as Hypoxic ischaemic damage of brain and chronic lung due to prematurity and 1b. Extreme prematurity. All loops of bowel showed significantly dilated lumen due to increased air content – in layman’s terms they were expanded like a partially inflated balloon. There was no sign of NEC (bowel necrosis) or any other bowel problem.
Reviewing pathology (Dr Andreas Marnerides):
Child I, received an excessive injection of air into her stomach, he said.
Child O
Original pathology:
A post-mortem examination found free un-clotted blood in the peritoneal (abdominal)space from a liver injury. There was damage in multiple locations on and in the liver. The blood was found in the peritoneal cavity. He certified death on the basis of natural causes and intra-abdominal bleeding.
He observed that the cause of this bleeding could have been asphyxia, trauma or vigorous resuscitation.
Reviewing pathology (Dr Andreas Marnerides):
Dr Andreas Marnerides, the reviewing pathologist, thought that the liver injuries were most likely the result of impact type trauma and not the result of CPR.
He thought that the excess air via the NGT was likely to have led to stimulation of the vagal nerve which has an effect on heart rate and would have compromised Child O's breathing.
He could not say whether it was either of these factors in isolation or in combination which caused Child O's death.
He certified the cause of death to be “Inflicted traumatic injury to the liver and profound gastric and intestinal distension following acute excessive injection or infusion of air via a naso-gastric tube” and air embolus.
Child P
Original pathology: A post-mortem examination had the coroner concluding Child P died from Sudden Unexpected Postnatal Collapse but he was unable to identify the underlying cause. He certified the cause of death as “prematurity”.
Reviewing pathology (Dr Andreas Marnerides):
Dr Marnerides said: “In my view, the cause of death was inflicted traumatic injury to the liver, profound gastric and intestinal distension following acute excessive injection/infusion of air via a naso-gastric tube and air embolism due to administration into a venous line.”