Alonzo Christopher Andrew Wood · Prevention of Future Deaths report

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 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.