London inquest opens into death of four-day old Sebastian Clark


At an Inquest at West London Coroner’s Court, HM Coroner Dr Sean Cummings will examine evidence and review witness statements received from those involved in the events that led to the death of baby Sebastian Clark following his delivery.

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 was brain dead, unable to breathe on his own and that providing further intensive care would 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.

Kingston Hospital NHS Trust have 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 almost two years after the events 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.”

Sebastian’s family hope that the Inquest will provide further information and insight into the tragic events which unfolded at the Kingston Hospital Maternity Unit. Specifically, they believe that:

Staff failed to listen to their concerns: On numerous occasions, Alison and Justin asked staff about the need to carry out a caesarean section. However, on each occasion their request was dismissed and warning signs about the health of Sebastian were therefore ignored.

Earlier delivery would have saved Sebastian’s life: There were numerous occasions during Alison’s time in the Maternity Unit when her condition should have been escalated by various members of the medical team. However, a failure to action any of these opportunities ultimately meant that any chance of providing life-saving earlier delivery was missed.
Alison and Justin Clark have issued the following statement:

“Sebastian, known as Sebby, is our much loved first born child. He was a fiercely strong, 8lb 9oz, auburn, wavy haired beauty. He continues to provide us with great joy and pride and will forever do so. He has opened us up to a new level of love. However, his death has shattered our lives and we will never be the same; part of us will always be with Sebastian wherever he may be. Sebastian was a completely healthy little boy up until the point of labour. Ultimately, we feel that a lack of care and treatment led to his death. We believe there was an utter failure in fetal monitoring, wellbeing and escalation of care and, if this had not been the case, our son would still be alive today. What happened to him was entirely avoidable.”