Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0152, written 18 Mar 2025. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 18 Mar 2025 |
|---|---|
| Reference | 2025-0152 |
| Deceased | Alonzo Wood |
| Coroner | Joanne Andrews |
| Coroner area | West Sussex, Brighton and Hove |
| Category | Child Death (from 2015) · Hospital Death (Clinical Procedures and medical management) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
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 1 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. CORONER’S CONCERNS 5 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, 2 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. Joanne Andrews Area Coroner for West Sussex, Brighton and Hove 18 March 2025 3
2 responses published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
3rd floor 3 Piccadilly Place Manchester M1 3BN United Kingdom +44 (0)300 323 0140 08 May 2025 Ms Sophie Hills HM Area Coroner Coroners Office Lewes Road Brighton BN2 3QB Sent via email: Our reference: Dear Ms Hills Re: Regulation 28 Prevention of Future Deaths Report (Alonzo Christopher Andrew Wood) I write in response to your regulation 28 report dated 19 March 2025 regarding the very sad death of Alonzo Christopher Andrew Wood. I would like to express my sincere condolences to Alonzo’s family. Our patient safety leads at NICE have discussed the contents of your report and the summary information given relating to the baby death of Alonzo, while considering the relevant published NICE guidance on this topic, in this case Fetal monitoring in labour (NG229). NG229 deals with fetal monitoring in labour and has clear guidance on the interpretation and classification of the cardiotocograph (CTG) in this clinical situation. The emphasis in the guideline is on taking the whole clinical picture into account when making decisions on how to manage the labour, including maternal observations, contraction frequency and labour progress. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian. Responsibility for decisions on the most appropriate treatment stays with individual clinicians. NICE guidelines are a practical tool to be used in conjunction with and not as a substitute for clinical judgement. We will consider reviewing the evidence on antenatal CTG interpretation and actions to be taken as a result however, there is unlikely to be sufficient evidence of the required quality for NICE to produce a guideline in this area. Our patient safety leads will also work with others to see if they can produce a practice guide to inform practitioners. I hope my response is helpful and would like to reiterate my sincere condolences to Alonzo’s family. nice.org.uk | nice@nice.org.uk Yours sincerely, Chief Executive [Insert footer here] 2 of 2
Joanne Andrews His Majesty’s Coroner for West Sussex, Brighton and Hove Coroner’s Office Lewes Road, Brighton, BN2 3BQ 23 April 2025 Dear Ms Andrews Re: Baby Alonzo Christopher Andrew Wood- deceased Your ref: Thank you for your Regulation 28 Report to Prevent Future deaths following the inquest into the death of Baby Alonzo Christopher Andrew Wood on 19th March 2025. The loss of a baby is a devastating tragedy for parents, the wider family, and healthcare professionals involved. We would like to begin by extending our deepest and heartfelt condolences to Alonzo’s family for their profound loss. This response has been developed following input from members of the Royal College of Obstetricians and Gynaecologists (RCOG) Patient Safety Committee and Senior Officers of the College. We recognise and respect the narrative conclusion from the inquest that Alonzo died from multi organ failure which developed due to a significant hepatic congenital haemangioma identified in utero and that was monitored prior to birth. We also recognise the matters of concern as outlined in your letter 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”. The RCOG supports doctors to deliver maternity services through its educational initiatives. This encompasses developing curricula, elevating care standards through clinical guidance, assisting in career advancement through examinations, coordinating professional development initiatives and events, and offering support services to its members. Page 1 of 2 The variability in clinical scenarios in the antenatal period means that strict protocols or exhaustive guidelines, may not cover every situation, underscoring the importance of individualised care plans developed by experienced clinicians. It cannot be emphasised enough that the complexity and variability inherent in clinical practice necessitate reliance on professional judgment to ensure optimal outcomes for both mother and baby. There is no national guidance on the interpretation of antenatal CTG’s. However, the RCOG fully supports and recommends Element 3 of NHS England’s Saving Babies Lives Care Bundle version 2 which recommends the use of computerised CTG (fetal heart monitoring) during antenatal period and states the following (page 21): When the available evidence is inconclusive, SBLCBv2 aims to implement pragmatic best practice care, based upon clinical experience and a recognition of the important human factors. Human error in antepartum CTG interpretation has been identified as a significant root cause of stillbirth and serious brain injury. A failure to meet the Dawes/Redman criteria usually prompts even the most experienced clinician to re-evaluate their clinical assessment. It provides a second line of defence when a less experienced doctor or midwife interprets a CTG. Therefore, with a recognition that the evidence is inconclusive, SBLCBv2 recommends the antepartum use of computerised CTG over and above visualised CTG due to the potential to reduce the risks of human error. Thank you for bringing this to our attention. I hope this is a helpful response to this matter. Yours sincerely, CEO Royal College of Obstetricians and Gynaecologists Page 2 of 2
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