Alonzo Wood

I am Joanne Andrews, Area Coroner, for the coroner area of West Sussex, Brighton and Hove.

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

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.

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.

In my opinion action should be taken to prevent future deaths and I believe your organisation have the power to take such action.