Parents call for change at the end of Inquest into four-day old Sebastian Clark’s ‘avoidable’ death

Following the conclusion of the Inquest at West London Coroner’s Court into the death of baby Sebastian Clark, parents Justin and Alison have implored the NHS to change, and improvements to be implemented to avoid the mistakes surrounding Sebastian’s birth being repeated, as well as providing greater support to grieving parents.

Having heard the evidence received from those involved in the events that led to the death of baby Sebastian Clark following his delivery, HM Coroner Dr Sean Cummings concluded that there were lamentable failures, inadequate and complacent management and a group and collective failure to appreciate the developing emergency until it was too late.

Sebastian was born with a devastating brain injury on 8 March 2017 due to damage caused during labour at Kingston Hospital. On 9 March, Sebastian and his mother Alison were transferred to St George’s Hospital, where Sebastian continued to deteriorate. Alison and her husband Justin were informed that their son had likely brain damage, was unable to breathe on his own and that providing further intensive care may only delay death and prolong his suffering. 

On 12 March, Sebastian’s parents took the heart-breaking decision to turn off Sebastian’s life support machine. Sebastian breathed for over four hours unaided and died peacefully in his parents' arms.

Speaking after the Inquest, Tim Deeming of Tees Law, representing the family, said:

“Whilst Justin and Alison are relieved that the Inquest is over, they are understandably devastated as his death has shattered their lives.

“Sebby was a completely healthy little boy up until the delivery and the multiple failings, complacent management and lack of fundamental care caused his death. It was entirely avoidable and as the Coroner heard today the hospital did not intervene early enough.”

Tim Deeming went on to say:

“Not only is this case incredibly sad, what makes it even harder is that the support provided after his death by the NHS was negligible. Anyone suffering as Justin and Alison did should, as a matter of course, receive prompt and appropriate support and counselling and we are calling on the NHS to ensure that sufficient funding is in place at every hospital to provide this for families.

“Nothing will bring Sebby back and the end of the Inquest is the start of another part of the grieving process to come to terms with such information. We have a duty to ensure that there is a lasting legacy for Sebby and we would ask that Kingston and other hospitals reconsider the availability of centralised monitoring given that it can save lives, and hope that the Department of Health can review the availability of testing for group B strep.”

Prior to the Inquest, but almost two years after Sebastian’s death, Kingston Hospital NHS Trust apologised and admitted that substandard care led to Sebastian’s poor condition at birth and his subsequent death.

Ann Radmore, the Trust’s Chief Executive, wrote to the family on 9 January 2019 saying, “I would like to offer you my sincere apologies that the treatment and care provided by the Trust immediately prior to and during Sebastian’s delivery fell below a standard that you were entitled to expect. We recognise that this substandard care led to Sebastian’s poor condition at birth, and tragically, his death.”

The Clark family has specifically requested that the media does not contact them and have asked that any enquiries be directed to Tim Deeming at Tees Law. He is happy to provide further background information.