UK Inquiry Tracker

Thomas Hoskin

PFD Report Historic (No Identified Response) Ref: 2022-0115

Date of Report 22 April 2022

Coroner Lydia Brown

Coroner Area West London

Response Deadline ✓ from report 17 June 2022

Child Death (from 2015) Hospital Death (Clinical Procedures and medical management) related deaths

Judiciary.uk Report PDF

Coroner's Concerns (AI summary)

There is a critical lack of specific guidelines for the optimal management of fatal fetal infection, leaving clinicians without assistance in situations like circulatory collapse at birth.

View full coroner's concerns

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.

Sent To

National Institute for Health and Care Excellence

Response Status

Linked responses 0 of 1

56-Day Deadline 17 Jun 2022

About PFD responses

Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.

Source: Courts and Tribunals Judiciary

Report Sections

Investigation and Inquest

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

Circumstances of the Death

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.