Evelyn Rae Le Masurier-O’Sullivan

On 23 February 2023, an inquest was opened, and an investigation commenced, into the death of Evelyn Rae Le Masurier-O’Sullivan (“Evie”), who died 23 hours after she was born.

The investigation concluded at the end of the inquest, which was heard over 4 days between 9 and 12 September 2025 and my conclusion was handed down on 16 October 2025.

The medical cause of death was:

1a. Disseminated Intravascular Coagulopathy and Persistent Pulmonary Hypertension of the Newborn. 1b. Sepsis.

The conclusion was as follows:

At around 00:06 on 17 April 2022, when she was less than 10 hours old, Evie became unwell with signs of respiratory distress caused by an infection. A vaginal swab of Evie's mother after her death tested positive for Group B Streptococcus, which was the cause of Evie's infection and the neonatal sepsis which she went on to develop. Evie died as consequence of Disseminated Intravascular Coagulation and Persistent Pulmonary Hypertension of the Newborn, which were secondary to the neonatal sepsis.

Although Evie's mother was seen by a member of the midwifery team at around 00:30 and by a midwife at around 02:30, they did not elicit concerns Evie's parents had about Evie's crying and breathing, and nor did they afford an opportunity for these concerns to be shared. This led to an absence of neonatal assessments being carried out and absence of escalation to the hospital's neonatal team, which contributed to the death. Evie's death was also contributed to by the delay between 08:00 and 10:00 in administering antibiotics. Evie's death was contributed to by neglect.

Evie was born at 14:17 on 16 April 2022 at Croydon University Hospital by a category 3 emergency caesarean section. Evie was born in good condition with her Apgar scores being normal at 1, 5 and 10 minutes after her birth. There were no known risk factors for Group B Streptococcus or sepsis.

In the early hours of the following morning, at or around 00:06 on 17 April 2022, whilst on the post-natal ward, Evie was becoming unwell and began to display symptoms of respiratory distress in the form of an abnormal sound known as grunting. These were the first signs that she had an infection.

Although Evie's mother was seen by a member of the midwifery team at around 00:30 and a midwife at around 02:30, those staff members did not elicit concerns Evie's parents had about Evie's crying and breathing, and nor did they afford an opportunity for these concerns to be shared.

At around 07:00 on 17 April 2022, Evie was observed with signs of respiratory distress, including chest recessions, nasal flaring and some slight grunting. After a neonatal review, she was admitted to the hospital's neonatal unit. The working diagnosis at that time was that Evie was suffering from sepsis. Although antibiotics to treat the suspected sepsis should have been administered within the hour, they were not administered until 10:00.

Evie initially stabilised on the neonatal unit. However, she went on to have an acute deterioration with clinical evidence of pulmonary hypertension and became difficult to oxygenate. Thereafter Evie went on to have a pulmonary haemorrhage and disseminated intravascular coagulation and went into cardiac arrest. Advanced life support resuscitation was performed and although return of spontaneous circulation was achieved on three occasions, Evie could not be stabilised and died at 14:06 on 17 April 2022.

At around 00:06 on 17 April 2022, when she was less than 10 hours old, Evie became unwell with signs of respiratory distress caused by an infection. A vaginal swab of Evie's mother after her death tested positive for Group B Streptococcus, which was the cause of Evie's infection and the neonatal sepsis which she went on to develop. Evie died as consequence of Disseminated Intravascular Coagulation and Persistent Pulmonary Hypertension of the Newborn, which were secondary to the neonatal sepsis.

Although Evie's mother was seen by a member of the midwifery team at around 00:30 and by a midwife at around 02:30, they did not elicit concerns Evie's parents had about Evie's crying and breathing, and nor did they afford an opportunity for these concerns to be shared. This led to an absence of neonatal assessments being carried out and absence of escalation to the hospital's neonatal team, which contributed to the death. Evie's death was also contributed to by the delay between 08:00 and 10:00 in administering antibiotics. Evie's death was contributed to by neglect.