Dear Ms Andrews

Re: Baby Alonzo Christopher Andrew Wood- deceased Your ref:

Thank you for your Regulation 28 Report to Prevent Future deaths following the inquest into the death of Baby Alonzo Christopher Andrew Wood on 19th March 2025.

The loss of a baby is a devastating tragedy for parents, the wider family, and healthcare professionals involved. We would like to begin by extending our deepest and heartfelt condolences to Alonzo’s family for their profound loss.

This response has been developed following input from members of the Royal College of Obstetricians and Gynaecologists (RCOG) Patient Safety Committee and Senior Officers of the College.

We recognise and respect the narrative conclusion from the inquest that Alonzo died from multi organ failure which developed due to a significant hepatic congenital haemangioma identified in utero and that was monitored prior to birth.

We also recognise the matters of concern as outlined in your letter 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”.

The RCOG supports doctors to deliver maternity services through its educational initiatives. This encompasses developing curricula, elevating care standards through clinical guidance, assisting in career advancement through examinations, coordinating professional development initiatives and events, and offering support services to its members.

The variability in clinical scenarios in the antenatal period means that strict protocols or exhaustive guidelines, may not cover every situation, underscoring the importance of individualised care plans developed by experienced clinicians. It cannot be emphasised enough that the complexity and variability inherent in clinical practice necessitate reliance on professional judgment to ensure optimal outcomes for both mother and baby.

There is no national guidance on the interpretation of antenatal CTG’s. However, the RCOG fully supports and recommends Element 3 of NHS England’s Saving Babies Lives Care Bundle version 2 which recommends the use of computerised CTG (fetal heart monitoring) during antenatal period and states the following (page 21):

When the available evidence is inconclusive, SBLCBv2 aims to implement pragmatic best practice care, based upon clinical experience and a recognition of the important human factors. Human error in antepartum CTG interpretation has been identified as a significant root cause of stillbirth and serious brain injury. A failure to meet the Dawes/Redman criteria usually prompts even the most experienced clinician to re-evaluate their clinical assessment. It provides a second line of defence when a less experienced doctor or midwife interprets a CTG. Therefore, with a recognition that the evidence is inconclusive, SBLCBv2 recommends the antepartum use of computerised CTG over and above visualised CTG due to the potential to reduce the risks of human error.

Thank you for bringing this to our attention. I hope this is a helpful response to this matter.

Dear Ms Hills

Re: Regulation 28 Prevention of Future Deaths Report (Alonzo Christopher Andrew Wood)

I write in response to your regulation 28 report dated 19 March 2025 regarding the very sad death of Alonzo Christopher Andrew Wood. I would like to express my sincere condolences to Alonzo’s family.

Our patient safety leads at NICE have discussed the contents of your report and the summary information given relating to the baby death of Alonzo, while considering the relevant published NICE guidance on this topic, in this case Fetal monitoring in labour (NG229).

NG229 deals with fetal monitoring in labour and has clear guidance on the interpretation and classification of the cardiotocograph (CTG) in this clinical situation. The emphasis in the guideline is on taking the whole clinical picture into account when making decisions on how to manage the labour, including maternal observations, contraction frequency and labour progress.

When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian.

Responsibility for decisions on the most appropriate treatment stays with individual clinicians. NICE guidelines are a practical tool to be used in conjunction with and not as a substitute for clinical judgement.

We will consider reviewing the evidence on antenatal CTG interpretation and actions to be taken as a result however, there is unlikely to be sufficient evidence of the required quality for NICE to produce a guideline in this area. Our patient safety leads will also work with others to see if they can produce a practice guide to inform practitioners.

I hope my response is helpful and would like to reiterate my sincere condolences to Alonzo’s family.

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