Thomas Hoskin · Prevention of Future Deaths report

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

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.

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.