The parents of a baby who died at Nottingham City Hospital say they have to live with the pain of “never knowing what truly happened” because potential evidence was destroyed when staff dissected the placenta.
Quinn Lias Parker was born on July 14 2021 but died two days later.
Parents Emmie Studencki and Ryan Parker have spoken out after more details about what happened were made public in a Coroner’s report.
After Quinn’s birth, Ms Studencki’s placenta was sent from the maternity unit to pathology at Nottingham City Hospital, where it was dissected – meaning it was cut up for examination.
The placenta is a vital organ which develops in a mother’s uterus during pregnancy, providing oxygen and nutrients to the growing baby.
After birth, the placenta typically detaches and follows the baby out of the uterus. When a baby is born in good health placentas are usually medically disposed of by hospital staff.
A coroner has since said the dissection of Ms Studencki’s placenta meant the post-mortem examination – which is carried out to determine what caused Quinn’s death – was compromised.
At the time, the hospital and the organisation which runs it – Nottingham University Hospitals Trust – was already under increased scrutiny after its maternity units were rated ‘inadequate’ by the Care Quality Commission (CQC).
The couple says “disturbingly” their experience was not an isolated event at the trust.
This is confirmed by the newly-published Coroner’s report, which reveals there were ‘a number’ of other cases at the trust where the placenta has been “disposed of and/or interfered with”.
The hospital says news of Quinn’s death was not passed on to pathology before the procedure and the dissection would not have happened if the information had arrived sooner.
The hospital trust’s Director of Midwifery apologised and says after Quinn’s death the organisation changed the way staff examine placentas and introduced an electronic alerting system to notify pathology staff if a baby dies after birth.
Ms Studencki and Mr Parker said the first time they were made aware of the placenta being cut up was in court during Quinn’s inquest.
The couple added their trust in NUH to operate safely and respect families had been “painfully torn apart”.
They said: “This raises serious concerns about the Trust’s willingness to address a matter which we were made aware in court is disturbingly not an isolated event.
“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.
“No parent should have information withheld about their child’s death when they so desperately need answers.
“We have never received an apology for how we were treated.”
The coroner’s report – a mechanism known as a ‘Prevention of Future Deaths Report’ – was issued to the trust to try to prevent similar incidents in future.
It was first made public last month and outlines concerns with the way the placenta was “cut into/dissected after Quinn’s death without discussion with the Coroner”.
It was written by Dr Elizabeth Didcock, Assistant Coroner for Nottinghamshire – and was issued to NUH before Quinn’s inquest began in April 2022.
The Coroner said the dissection of the placenta undermined the investigation, which will “likely lead to a lack of learning from such deaths, and therefore a risk that similar deaths will occur in the future”.
Dr Didcock 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 a post-mortem examination.
Dr Didcock added: “It is not clear to me exactly how the placenta was cut into after Quinn’s death without discussion with the Coroner.
“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.”
The inquest, held in April, returned a narrative verdict and heard Quinn died following multiple organ failure. Ms Studencki had been previously admitted to the hospital a number of times after suffering bleeding.
In its response to Dr Didcock’s prevention of future deaths report, NUH said in the case of all neonatal intensive care unit (NICU) admissions, the placenta is automatically sent to the pathology department for examination and “a standard approach is used to dissect the placenta and gain material for histological examination”.
But it added: “It is the case that Quinn had actually died prior to the dissection of the placenta commencing and that had the laboratory been informed of the death earlier the examination would not have been started.”
Following a series of baby deaths and injuries at the trust across the City Hospital and Queen’s Medical Centre, a large-scale review into maternity services at both hospitals started in September and has seen around 1,000 families and members of staff share their experiences.
It is being led by midwife and healthcare expert Donna Ockenden.
Quinn’s parents added: “We encourage as many families as possible to join us and the Ockenden review. Ensuring safe care is the only thing we can now do for Quinn.”
Richard Baker, a former assistant coroner and barrister, explained how ordinarily, a placenta is disposed of after a baby is born.
But if the baby is unlikely to survive – as the Coroner states in Quinn’s case – the placenta must be preserved for the pathologist.
Mr Baker said he had “never seen a case where after a baby has died, someone has dissected a placenta”.
He said: “The placenta is important from a post-mortem perspective because you can look at it and determine the type of haemorrhage there has been.
“When a post-mortem is carried out the placenta is always examined by the paediatric pathologist, internally and externally.
“If it has been dissected before the pathologist has seen it, it interferes with the ability of the pathologist to examine it.
“It could damage the placenta in a way that it’s impossible to work out what happened.
“Nobody should interfere with the body unless that’s been accepted and agreed by the Coroner.”
A midwife not employed by Nottingham University Hospitals Trust, asked to remain anonymous said that in the case of an unexpected baby death, “it is essential that the placenta is kept intact and stored appropriately”.
They said: “The examination of it is a vital part of the Coroner’s process.
“All midwives and obstetricians should / would be aware of the importance of this.”
Sharon Wallis, Director of Midwifery at Nottingham University Hospitals NHS 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 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.”