A new-born baby who only survived for 36 hours died as a result of a catalogue of issues that "must be addressed urgently" by the Nottingham University Hospitals Trust (NUH), an inquest heard. Baby Quinn Lias Parker died on July 16 last year, just two days after he was born at the City Hospital.
His mum Emmie Studencki said she had been admitted to Nottingham University Hospital NHS Trust's (NUH's) maternity units three times over concerns of heavy bleeding before baby Quinn Parker was born on July 14 last year. She told the inquest she had asked a midwife for an emergency Caesarean "and questioned why I couldn't have one".
Eventually, after Quinn's heart rate dropped an emergency Caesarean was performed - but when he was born he was "floppy and pale", the inquest heard. Delivery occurred at 7.08pm, by which time Quinn had suffered severe and life threatening asphyxia from which he could not recover. He died just before 7.55am on July 16 in his "parents' arms" at the neonatal intensive care unit.
After four days of hearing evidence from a number of witnesses from NUH, Dr Elizabeth Didcock, assistant coroner for Nottingham and Nottinghamshire, gave a narrative conclusion of the inquest held at the Nottingham Council House on Wednesday (May 11). She agreed with the results of the post-mortem examination, saying that baby Quinn died from multiple organ failure and hypoxia caused by asphyxia, occurring over the hours to days prior to delivery.
It was a string of issues that were mentioned surrounding Quinn's death. However, Dr Didcock went on to say that due to a "very serious placental issue", the pathological examination was compromised. The placenta was cut by the Nottingham Pathology team after Quinn had died.
The asphyxia, or lack of air, was caused by a placental abruption, the inquest heard. Dr Didcock said that "there were signs of marginal or small abruptions prior to the day of delivery" when Quinn's mum was admitted to hospital with blood dripping on her legs and pyjamas.
Evidence of a major haemorrhage from an abruption on admission on the morning of July 14 was also recorded. However, Dr Didcock told the inquest that the assessments completed by staff on admission and throughout the day "were not in line with the NUH guideline".
She added: "Whilst appropriate monitoring was undertaken, no definitive diagnosis was shared with parents until the evening. This meant they had no information upon which to make a decision with maternity staff as to the optimum time and mode of delivery."
The grieving parents told the inquest they felt 'ignored and neglected'. Ryan Parker, of Barrowby in Lincolnshire, voiced his heartbreak about the lack of information around his son's death prior to the inquest.
Had Quinn's mum been offered a C-section, the baby could have 'possibly' survived, said Dr Didcock. "Would that have made a difference to Quinn’s survival, again I cannot say so on a balance of probability, but it is a possibility".
However, she stressed that a discussion with Quinn's parents to discuss the risks involved would have been necessary. The heartbroken parents had no information upon which to make a decision with maternity staff, and were not involved in those discussions.
Dr Didcock added: "They [Quinn's parents] were provided with no written information about the possible causes of vaginal bleeding, or antepartum haemorrhage. Emmie and Ryan are bright, thoughtful and caring parents, and I find they did return to hospital appropriately on each occasion when there was bleeding and/or pain, despite the limited information provided to them."
A 'plan of action' has also been issued by the trust, in live with the observations and comments made during the inquest. Dr Didcock added: "I believe and trust that both will listen and take on the suggestions the family make as to the action plan."
She added: "I let it to them [Quinn's parents] to continue to raise those issues if they feel able, but agree they must be addressed urgently by the Trust. When I consider overall the clinical care provided to Emmie, I find that the lack of careful and repeated risk assessment of APH, led to expectant management rather than active planning, and consideration, of delivery timing.
"There was a delayed recognition of a placental abruption. There was no involvement of parents in decision making in the evolving events of the 14th, and limited reference to, or understanding of, past events to guide management."
Director of Midwifery Sharon Wallis at Nottingham University Hospitals NHS Trust said: “We are deeply sorry and again offer our sincerest condolences to Ms Studencki and Mr Parker for the loss of baby Quinn and apologise that we let the family down. We have already made some changes in response to the family’s feedback and we hope to meet with Ms Studencki and Mr Parker in order to learn more from their experience and concerns to make further improvements.”
