Angus Jonathan Labofski WEST · Prevention of Future Deaths report

On 20th February 2015 I commenced an investigation into the death of Angus Jonathan Labofski WEST aged 27 days. The investigation concluded at the end of the Inquest on 1st April 2016. The conclusion of the Inquest was Natural Causes, the cause of death being (1)(a) Hypoxic-ischaemic encephalopathy

Angus Jonathan Labofski WEST was born at York District Hospital on 24th January 2015. It became apparent that he may have brain damage which necessitated him ultimately being transferred to the Neonatal Unit at The General Infirmary, Leeds, where he was noted to be perfect before he became unwell and had no infections and for reasons which are not clear, he became asphyxiated which led to him suffering severe hypoxic-ischaemic encephalopathy which caused his death to be confirmed at Martin House Children’s Hospice, Boston Spa, at 1424 hours on 20th February 2015.

[BRIEF SUMMARY OF MATTERS OF CONCERN]
(1) After the baby was born the placenta was not retained. Within a short time after his birth he became unwell and despite all efforts his death was confirmed. It was likely that a post mortem examination would be needed to determine the cause of death. It would have been of assistance to the Pathologist to be able to examine the placenta to show the possibility of a toxoplasmosis infection; to establish if relevant the possibility of placental abruption and to establish if the umbilical cord was kinked, trapped or in any way damaged which could have caused or contributed to the death. I therefore recommend and request that when it is foreseeable that at birth or shortly thereafter, the baby’s condition is poor and is deteriorating which may lead to death, then the placenta and all its appendages should be retained and be made available to the Pathologist for further examination.