Alonzo Wood: Prevention of Future Deaths Report
Child Death (from 2015)Hospital Death (Clinical Procedures and medical management) related deaths
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Date of report: 18/03/2025
Ref: 2025-0152
Deceased name: Alonzo Wood
Coroners name: Joanne Andrews
Coroners Area: West Sussex, Brighton and Hove
Category: Child Death (from 2015) | Hospital Death (Clinical Procedures and medical management) related deaths
This report is being sent to: Royal College of Obstetricians and Gynaecologists | National Institute for Health and Care Excellence
| REGULATION 28 REPORT TO PREVENT FUTURE DEATHS | |
|---|---|
| THIS REPORT IS BEING SENT TO: 1. The President of the Royal College of Obstetricians and Gynaecologists 2. The Chief Executive of the National Institute for Health and Care Excellence | |
| 1 | CORONER I am Joanne Andrews, Area Coroner, for the coroner area of West Sussex, Brighton and Hove. |
| 2 | CORONER’S LEGAL POWERS I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. |
| 3 | INVESTIGATION and INQUEST On 3 October 2023 I commenced an investigation into the death of Alonzo Christopher Andrew Wood who was born on 23 September 2023. The investigation concluded at the end of the inquest on 26 February 2025. The conclusion of the inquest was: Alonzo Christopher Andrew Wood died on 26 September 2023 at the Royal Sussex County Hospital, Eastern Road, Brighton, from multi organ failure which developed due to a significant hepatic congenital haemangioma identified in utero and that was monitored prior to birth. In the period between 21 September and his birth, a spontaneous bleed occurred which caused him to be critically unwell at delivery and despite treatment he sadly could not recover from the same. The medical cause of Alonzo’s death was recorded as: 1(a) Multi-Organ Failure And 2. Hepatic congenital haemangioma |
| 4 | CIRCUMSTANCES OF THE DEATH At 28 weeks of gestation it was noted on scans that Alonzo had a mass on his liver. He was referred by the Royal Sussex County Hospital in Brighton for specialist review by specialist from Kings College Hospital. A plan was made that Alonzo and his twin sister would be delivered at Kings College Hospital by caesarean section on 28 September 2023 due to Alonzo’s liver condition. On 22 September 2023, Alonzo’s mother attended the Royal Sussex County Hospital for treatment of a common liver condition in pregnancy. As part of the assessment of Alonzo, his twin sister and his mother a CTG was undertaken. There were concerns about the interpretation of the CTG undertaken which resulted in Alonzo’s delivery at the Royal Sussex County Hospital in the early hours of 23 September 2023. There was no evidence that earlier delivery of Alonzo would have prevented his death in this case. |
| 5 | CORONER’S CONCERNS During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. – During the course of the evidence I was informed that the clinicians consider that there is insufficient guidance as to the management actions that should be taken in the event of an abnormal antenatal CTG. In particular, the clinicians indicated that there was no guidance where there has been an abnormal CTG antenatally as to whether delivery should occur and, if so, in what period. As such, the decision making is reliant on individual clinical judgment. |
| 6 | ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe your organisation have the power to take such action. |
| 7 | YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 13 May 2025. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. |
| 8 | COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: · The family of Alonzo Wood · University Hospitals Sussex NHS Foundation Trust · Kings College Hospitals NHS Foundation Trust I am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner. |
| 9 | Joanne Andrews Area Coroner for West Sussex, Brighton and Hove 18 March 2025 |