Quinn Parker: Failures led to danger signs being missed

Quinn Parker lived for 36 hours after delivery by emergency Caesarean section

A series of mistakes contributed to the death of a baby two days after being born, an inquest has found.

Quinn Parker was delivered by emergency Caesarean section at City Hospital in Nottingham in July 2021 but suffered oxygen starvation in the womb.

Nottingham Coroner's Court heard his parents were not consulted properly nor told to look out for danger signs.

The coroner said it was a "possibility" that earlier intervention could have changed the outcome.

Emmie Studencki, from Barrowby in Lincolnshire, had suffered a number of bleeds in the days before Quinn's birth but hospital checks had revealed no serious problems.

Quinn Parker's parents said they felt 'very much excluded' from his care

But Dr Elizabeth Didcock, assistant coroner for Nottingham and Nottinghamshire, said Ms Studencki - and partner Ryan Parker - were not given clear information on possible danger signs.

Ms Studencki then suffered a major haemorrhage on 14 July and was rushed to hospital.

Between her admission at just before 08:00 BST and Quinn's delivery at 19:08, the situation was reviewed by staff several times but some information about the previous bleeds was not recorded.

Despite episodes of bleeding and severe pain, Ms Studencki and Mr Parker were not included in discussions for treatment, the coroner found.

They had earlier said they felt "very much excluded" from Quinn's care.

'Balanced discussion'

Because Quinn's heart rate stayed within acceptable parameters, no action was taken until 18:40 when Ms Studenki's contractions increased.

When her waters were broken, large amounts of blood were released and the emergency Caesarean was ordered.

Dr Didcock said the evidence pointed to the placenta coming away from the lining of the womb up to two days before hospital admission.

Delivering her narrative verdict, she said: "Earlier delivery would have been achieved I find, on balance, if the significance of the bleeding and pain had been clearly identified as an abruption [separation of placenta and uterus], and this diagnosis had been shared with parents.

"I believe certainly by 15.00 hours.... a balanced discussion of options would have led parents to request and ensure a Caesarean section.

"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."

'Let family down'

Dr Didcock said staff in the neonatal intensive care unit did what they could but the damage had been done.

Additionally the coroner had already issued a prevention of future deaths order over the dissection of the placenta immediately afterwards, which hindered the subsequent post mortem.

In a statement, Ms Studencki and Mr Parker said: "We have always believed that Quinn's death was the result of a tragic failure to provide safe and timely care.

"Our view remains painfully this way after hearing Dr Didcock's findings.

"We must now place our faith in NUH to change. A change that will allow us to forgive. A change that will allow our little boy Quinn to rest in peace."

Director of Midwifery at Nottingham University Hospitals NHS Trust, Sharon Wallis, 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."

The inquest took place against the backdrop of a major investigation into failings at Nottingham's two maternity units going back to about 2010.

A review into maternity services at the trust is currently under way, after being announced by the Department of Health and Social Care in July, while relatives of other babies who died have also called for a public inquiry.