Baby boy who died at just two days old could have 'possibly' lived longer if his mother had been given a C-section earlier, inquest hears - as hospital apologises and says it 'let the family down'

  • Quinn Lias Parker died in July last year two days after he was born in Nottingham 
  • He could 'possibly' have lived longer if his mother had a C-section earlier on
  • His parents Emmie Studencki and Ryan Parker had an apology from the hospital
  • She asked for an emergency C-section 'and questioned why I couldn't have one' 
  • Quinn's mum's blood dripping on her legs were signs of the placental abruption

A newborn baby who survived for 36 hours could 'possibly' have lived longer if hospital staff had given his mother a C-section earlier, an inquest heard.

Baby Quinn Lias Parker died on July 16 last year, two days after he was born at City Hospital in Nottingham.

Nottingham University Hospital NHS Trust (NUH) apologised to Quinn's parents, Emmie Studencki and Ryan Parker, as they accepted it had 'let the family down'.

Concerned about her heavy bleeding, Ms Studencki said she had been admitted to maternity units run by NUH three times during her pregnancy.

She told Nottingham Coroner's Court that she asked a midwife for an emergency Caesarean section 'and questioned why I couldn't have one'.

An emergency C-section was performed after Quinn's heart rate dropped but when he was born he was 'floppy and pale', the inquest heard.

Quinn Lias Parker died on July 16 last year, just two days after he was born at City Hospital in Nottingham

Quinn Lias Parker died on July 16 last year, just two days after he was born at City Hospital in Nottingham

Quinn was born at 7:08pm on July 14, but he had already suffered severe asphyxia.

He died at 7:55am on July 16 in his 'parents' arms' at the neonatal intensive care unit.

Dr Elizabeth Didcock, assistant coroner for Nottingham and Nottinghamshire, heard evidence from NUH witnesses over four days and came to a conclusion on 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, which occurred days before his birth.

A string of other issues were mentioned surrounding Quinn's death.

Dr Didcock said that a 'very serious placental issue', compromised the pathological examination.

Ms Studencki's placenta was cut by the Nottingham Pathology team after Quinn died.

The asphyxia, or lack of air, was caused by a placental abruption, the inquest heard. 

Dr Didcock said '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 over her legs and pyjamas.

On the morning of July 14 a major haemorrhage from an abruption on admission was recorded. 

Dr Didcock told the inquest that the assessments completed by staff on Ms Studencki's admission and throughout the day 'were not in line with the NUH guideline'.

Dr Didcock 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'.

Mr Parker, from Barrowby, Lincolnshire, voiced his heartbreak prior to the inquest about the lack of information around his son's death.

Had Ms Studencki mum been offered a C-section earlier, the baby could have 'possibly' survived, the coroner said.

The hospital apologised to Quinn's parents, Emmie Studencki and Ryan Parker and issued a 'plan of action' in line with the observations and comments made during the inquest

The hospital apologised to Quinn's parents, Emmie Studencki and Ryan Parker and issued a 'plan of action' in line with the observations and comments made during the inquest

Dr Didcock said: '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'.

She stressed that a discussion with Quinn's parents to discuss the risks would have been necessary.

The heartbroken parents had no information from maternity staff with which to make a decision and were not involved in those discussions, the inquest heard.

Dr Didcock added: 'They [Quinn's parents] were provided with no written information about the possible causes of vaginal bleeding, or antepartum haemorrhage (APH).

'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.'

The NUH has issued a 'plan of action' in line with the observations made during the inquest.

Dr Didcock added: 'I left 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.'

Sharon Wallis, director of midwifery, 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.'