Sebastian Clark · Prevention of Future Deaths report

On the 31st May 2017 an Inquest was opened into the death of baby Sebastian Clark. The investigation was concluded at the end of the inquest on the 16th and 17th January 2019. The conclusion was a narrative one and read:

Sebastian Clark died on the 12th March 2017 following his birth on the 8th March 2017 at the Kingston Hospital. He died from 1a Multi-organ failure and hypoxic ischaemic encephalopathy and 1b acute chorioamnionitis. These are natural causes. His mother had a prolonged rupture of her membranes and developed a chorioamnionitis. The severe effect on Sebastian went unrecognized until he collapsed in utero and whilst he was initially resuscitated he had suffered catastrophic brain injury.

Sebastian Clark died from multiorgan failure and hypoxic ischaemic encephalopathy subsequent to an acute chorioamnionitis infection in his mother. No screening for streptococcal infection was undertaken.

1. I heard evidence that suggested that screening for streptococcal infection in women who were in labour would potentially benefit infants in detecting and interrupting ascending chorioamnionitis infections such as the one that arose in Sebastian Clark. I heard evidence that there was no national programme for such screening in England.
2. Kingston Hospital had subsequently developed a guidance note entitled “Pyrexia and Suspected Chorioamnionitis” in an effort to reduce the prospect of a further death locally. It seemed to me that a policy such as this should be considered by you in an effort to reduce or prevent future deaths. I attach a copy of that document for your information.