Nottingham placenta error hampered baby death probe - coroner

A coroner says an investigation into the death of a newborn baby at a hospital was compromised by the way the placenta was dealt with.

Quinn Lias Parker was born at Nottingham's City Hospital in July 2021 but died two days later from multiple organ failure.

It later emerged the placenta was dissected by pathology staff when it should have been preserved.

Hospital bosses said procedures had since been revised.

It heard the baby's mother Emmie Studencki had been previously admitted to hospital a number of times after suffering bleeding.

But more details about what happened with the placenta have been made public in a coroner's report seen by the Local Democracy Reporting Service.

After Quinn's birth, Ms Studencki's placenta was sent from the hospital's maternity unit to pathology, where it was dissected - meaning it was cut up for examination. 

But Dr Elizabeth Didcock, assistant coroner for Nottinghamshire, said the dissection meant the post-mortem examination was compromised.

In a prevention of future deaths report, she detailed how Quinn was born in a "poor condition" and there was a "high probability that he would not survive" and therefore "thought needed to be given to the preservation of the placenta" to ensure it could be used in an examination.

"It is not clear to me exactly how the placenta was cut into after Quinn's death without discussion with the coroner," she said.

"What is clear is that the outcome has been highly detrimental to the independent investigation by the coroner and other agencies investigating the circumstances of this case.

"This death follows a number of similar early neonatal deaths in Nottingham, where the placenta has not been retained, and therefore key information regarding placental pathology has been lost."

In a joint statement, Quinn's father Ryan Parker and Ms Studencki said: "Let's be clear, this is the destruction of an organ, the prevention of a conclusive post-mortem and a significant challenge to the coroner's ability to investigate the cause of our son's death.

"The trust denied us a full post-mortem into our son's death."

Nottingham University Hospitals NHS Trust said news of Quinn's death was not passed on to pathology staff before the procedure, and the dissection would not have happened if the information had arrived sooner.

Sharon Wallis, director of midwifery at the trust, said: "We offer our sincere condolences to Ms Studencki and Mr Parker for the loss of baby Quinn.

"We are deeply sorry that we let them down with the care and communication that we provided both before and after Quinn's birth.

"We have changed the way we examine placentas, which includes introducing a longer 'stop' moment of four days, and an electronic alerting system to notify pathology if a baby sadly dies.

"In addition, we have increased the number of consultants on our labour suite, increased the number of consultant reviews and we have implemented a system to ensure women and families are reassessed for risk after each consultant review."