“The placenta, a key organ required for a full paediatric post mortem in an early neonatal…”
Dated 21 Nov 2022, from the coroner for Nottingham City and Nottinghamshire. Sent to 1 organisation or person.
A coroner wrote this report after an inquest, to warn the organisations below about a risk of further deaths.
The 56-day response deadline
Dates unclearOrganisations that receive a report must reply to the coroner within 56 days, saying what they will do or why they will do nothing. We show whether a response is published on judiciary.uk; a reply may have been sent and not yet published.
The date on the report comes after the day judiciary.uk put it online, so we can’t work out when replies were due.
- Report dated21 Nov 2022
- Published on judiciary.uk6 Oct 2022
Watch this report
We’ll email you when a response is published on judiciary.uk, or when the 56 days to reply end with none published there yet. Free, and you can stop with one click.
Responses from each recipient
| Sent to | Response |
|---|---|
| Nottingham University Hospitals NHS TrustNamed in the report as “Nottingham University Hospital NHS Trust” | Response published, not yet matchedA response is published with this report. We haven’t yet matched it to the organisation it’s from, so it may be this one’s. |
The coroner’s concerns
– 1. The placenta, a key organ required for a full paediatric post mortem in an early neonatal death, has been interfered with such that the Paediatric Pathologist, is limited in his conclusion as to the likely cause of death. In some ways the placenta is akin to an organ for the purposes of a paediatric post mortem- Loss of an organ at any post mortem examination, may well undermine the ability of the pathologist to carry out a full and proper examination. Decisions surrounding interference with, or disposal of, the placenta should be made in a careful and considered manner, with thought given to an early discussion with the coroner as would happen if organ donation is being considered. This did not happen in this case. 2. Unfortunately, there have been a number of cases in Nottingham where the death of a baby shortly after the birth was anticipated, but the placenta was disposed of and/or interfered with prior to the death being reported to the coroner. This undermines the coronial investigation resulting in limited findings and therefore limited conclusions at inquest. This will likely lead to a lack of learning from such deaths, and therefore a risk that similar deaths will occur in the future. It may also deprive the parents of significant information when considering whether future pregnancies may be at greater risk with the consequent need for appropriate management and planning. 6 3. The Nottinghamshire Coronial service has to date worked collaboratively with all local Trusts, but particularly with NUH NHS Trust, to ensure key staff understand the importance of retaining the placenta in an early neonatal death. This has not led to the actions necessary to achieve a full and proper examination of the placenta in repeated paediatric post mortems in this jurisdiction.
An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.
- Source
- judiciary.uk, Prevention of Future Deaths reports, 2022-0287
- Added to Minute Book
- 8 Oct 2026
- Reuse
- We show short extracts and link to the original. We don’t host the full report.
Something wrong, such as a date or who it was sent to? Report a mistake
Is this report about someone close to you? You can ask us to remove names from our pages.
Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0
Ask about this report
AISummaries and questions, with page references. Pro and above.
Sign in to use