Source · Prevention of Future Deaths
Thomas Hoskin
Ref: 2022-0115
Date: 22 Apr 2022
Coroner: Lydia Brown
Area: West London
Responses identified: 0 / 1
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There is a critical lack of specific guidelines for the optimal management of fatal fetal infection, leaving clinicians without assistance in situations like circulatory collapse at birth.
Date
22 Apr 2022
56-day deadline
17 Jun 2022
Responses identified
0 of 1
Coroner's concerns
There is a critical lack of specific guidelines for the optimal management of fatal fetal infection, leaving clinicians without assistance in situations like circulatory collapse at birth.
View full coroner's concerns
It was brought to the Court’s attention that the focus of guidelines relate to maternal infection, which is rarely life-threatening, but not to the optimal management of fetal infection which can be fatal or life changing. For Thomas, the evolving infection caused fetal circulatory collapse at birth and he could not be resuscitated.
There appear to be no specific guidelines available to assist clinicians in this difficult situation and it was agreed by the independently instructed expert and the clinicians who gave evidence that this would be a helpful development.
There appear to be no specific guidelines available to assist clinicians in this difficult situation and it was agreed by the independently instructed expert and the clinicians who gave evidence that this would be a helpful development.
Report sections
Investigation and inquest
On 24 September 2019 I commenced an investigation into the death of Thomas Hoskin, newborn. The investigation concluded at the end of the inquest on 21 March 2022. The conclusion of the inquest was Medical cause of death 1a Congenital pneumonia 1b Placental acute chorioamnionitis with fetal inflammatory response 1c Maternal ascending genital tract infection due to Group B Streptococcus Conclusion Natural causes
Circumstances of the death
Thomas' mother presented to West Middlesex University Hospital in labour at term on 8 April 2019. During the course of her labour, there were clear signs of Thomas having an acute infection. Obstetric input was not requested as early as it could have been as the 2 clinicians were known to be in theatre, but other staff were working within the hospital and earlier senior input could have been obtained. There was no clear evidence that this would have led to an earlier delivery of Thomas, due to the number of factors presenting at the time that all had to be balanced and no one course of action was risk free. Thomas was delivered by forceps and his condition at birth was unexpectedly extremely poor and despite active resuscitation with all appropriate staff, he did not survive but died in hospital on 9 April 2019 shortly after his birth.
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Report details
- Reference
- 2022-0115
- Date of report
- 22 April 2022
- Coroner
- Lydia Brown
- Coroner area
- West London
Responses identified
Responses identified
0 of 1
1 response not yet linked
Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 17 Jun 2022.
Sent to
- National Institute for Health and Care Excellence