Alfie Lydon

I am R Brittain, Assistant Coroner for Inner London North.

INVESTIGATIONS and INQUESTS An investigation into the death of Alfie Lydon (date of birth 28/2/24) was opened on 26/3/24, following his death on 12/3/24. An inquest was opened on 18/4/24 and concluded on 27/6/25. The conclusion reached was that Alfie died from natural causes.

Alfie was admitted to hospital on 6/3/24 after being found profoundly unwell at home. He was subsequently transferred to another hospital for intensive care support but sadly died on 12/3/24 from a then unknown cause. A post mortem examination demonstrated that he died from the consequences of a viral infection. Prior to his admission to hospital, concerns had been raised by Alfie’s parents to the community midwife team regarding the adequacy of his feeding and increasing lethargy. On two occasions midwives discussed Alfie with the neonatal team at the local hospital but admission was not felt to be necessary. These discussions were not documented by the hospital doctors who took the calls and, on one occasion, not documented by the midwife who made the call. As such, it was difficult  to  identify  who  provided  advice  to  the  midwives  and  the  rationale  for  the decision-making process. Ultimately, given the overwhelming nature of the infection Alfie suffered from, I concluded that it was not likely earlier admission would have prevented his death.

During the course of this inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN following the inquest into Alfie’s death were as follows:

1. I heard evidence that the vast majority of hospital Trusts do not have processes in place to document external calls from midwives to hospital teams. Concerns were raised that this can result in a lack of continuity and escalation of care, particularly with regards to parental concerns.

The hospital Trust involved has taken steps to document such calls now but this is undertaken on paper, which is subsequently uploaded to the hospital records. They plan to implement an electronic solution but not for some time. There is a concern that a lack of contemporaneous, accurate and immediately available documentation of discussions between community and hospital teams could result in deaths in future similar circumstances. Given that this is not simply a local issue, this concern warrants raising at a national level.

ACTION COULD BE TAKEN In my opinion action could be taken to prevent future deaths and I believe that the addressees have the power to take such action.