Coroner’s Investigation Into The Death Of A New Born Baby Compromised

It has been reported recently that a Coroner’s investigation into the death of a baby boy at Nottingham City Hospital was severely compromised by the way the baby’s placenta was handled by the hospital.

The BBC has reported that baby Quinn Lias Parker was born via emergency Caesarean at Nottingham’s City Hospital in July 2021.

Sadly, he suffered oxygen starvation in the womb and died from multiple organ failure two days later.

Due to the circumstances of Quinn Parker’s death, an inquest was held in April. More details on what happened to the placenta have been made public in a Coroner’s report.

After the birth, her placenta was sent to the pathology unit, where it was dissected by pathology staff, meaning that it was cut up for examination. However, it should have been preserved, and the dissection of the placenta meant that the post-mortem examination was compromised.

The Coroner highlighted that:

The outcome is now such that the Coroner’s inquest was severely compromised, and this has led to a detrimental effect on the inquest process. The Coroner can no longer use their full ability to investigate the death of Quinn because the organ that was vital to the whole process has been destroyed.

The Coroner highlighted that Quinn’s death followed a number of similar early neonatal deaths in Nottingham where the placenta had also not been retained, therefore losing key information regarding placental pathology.

In response, the Trust said that news of Quinn’s death was not passed on to pathology staff before the dissection took place and that, if the information had arrived sooner, the dissection would not have happened.

The Trust has confirmed that, as a result, they have changed the way placentas are examined, introducing a longer ‘stop’ moment of four days, and an electronic alerting system to notify the pathology department if a baby dies.

Due to the Trust’s actions, the family has been let down, and will never know the real reason for Quinn’s death and whether the oxygen starvation was due to the separation of the placenta.

The outcome of the inquest showed on the balance of probabilities, earlier delivery by the staff could have increased the chances of Quinn’s survival. However, without the key piece of evidence (the placenta), the parents will never know.

What is an inquest?

An inquest is the Coroner’s investigation and is the process by which the Coroner seeks to establish who has died, how, when, and where.

An inquest is a public Court hearing held by the Coroner. The inquest might be held with a jury, depending on the circumstances of the death.

The inquest does not involve prosecution and defence. Rather, the purpose of it and the Coroner’s role is to discover the facts of the death.

Importance of an inquest

The importance of inquests to bereaved family members is significant. The process can be difficult for families because it is often an unknown experience and people have little idea of where to start.

The Coroner’s role is not to apportion blame but to investigate the circumstances and causes of a death. When a death has occurred following medical treatment the Coroner will often call the doctors and nurses involved to Court as witnesses. The Coroner will ask questions of these witnesses and the family may do so if they wish. The Coroner will also consider any relevant policies and guidelines which may have been followed.

Sometimes an inquest may show that something could be done to prevent deaths from occurring in similar circumstances. In this situation, the Coroner can draw this to the attention of people or organisations that may be able to take preventative steps in the future.

In these circumstances, they are obliged to provide the Coroner with details of how they have addressed these issues and these details should also be made available to surviving family members.

Due to the Trust’s actions, the family has been let down, and will never know the real reason for Quinn’s death and whether the oxygen starvation was due to the separation of the placenta. The outcome of the inquest showed on the balance of probabilities, earlier delivery by the staff could have increased the chances of Quinn’s survival, however without the key piece of evidence (the placenta), the parents will never know.

Following the death of a loved one, under suspicious circumstances, it always helps when a thorough investigation is carried out. This ensures that the families have full answers and then closure following the death. Unfortunately, in the case of Quinn and his family, they will never get the chance to raise these questions and have their side of the story heard.

Post-Mortems and the importance of evidence for an Inquest

A post-mortem is required to provide more information about the cause of death and forms a key part of a Coroner’s investigation for an inquest.

During the procedure, organs can be removed for examination and a diagnosis can sometimes be made by doing so. Some organs will need to be examined in close detail during the process.

In order to properly investigate all possibilities, it is vital that the organs remain preserved for the pathologist to then properly be able to carry out a full post-mortem.