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Hospital failures led to danger signs in baby Quinn Parker being missed.


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, Nottingham, in July 2021 but he had 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.

His mother, Emmie Studencki, from Barrowby, Lincolnshire, had suffered a number of bleeds in the days before Quinn's birth but hospital checks had not revealed any serious problems.

Assistant coroner for Nottingham and Nottinghamshire, Dr Elizabeth Didcock, said Ms Studencki, and her 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 8am and Quinn's delivery at 7.08pm the situation was reviewed by staff several times but some information about the previous bleeds was not recorded.

The coroner found that, despite episodes of bleeding and severe pain, Ms Studencki and Mr Parker were not included in discussions about Quinn’s medical care. They had earlier told the inquest that they felt "very much excluded" from this.

Because Quinn's heart rate stayed within acceptable parameters, no action was taken until 6:40pm when Ms Studenki's contractions increased.

When her waters broke, a large amount of blood was released and an emergency Caesarean was ordered.

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

Delivering a narrative verdict, Dr Didock 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 (a separation of placenta and uterus) and this diagnosis had been shared with parents.

"I believe, certainly by 3pm, 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."

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

The coroner had already issued a prevention of future deaths order concerning 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.”

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."