Luan Macauley Hart died shortly after his birth on May 18, 2024, at the Queen Elizabeth Hospital in King’s Lynn.

An inquest opening at Norfolk Coroner’s Court recorded a provisional cause of death as hypoxic ischaemic encephalopathy (HIE), a serious brain injury caused by lack of oxygen to the brain.

But at a recent review at the court, counsel for the family, Kerry Nicholson, told the court the pathologist “doesn’t seem to have been aware of the cord issue around Luan’s neck” when carrying out the post-mortem.

Norfolk Coroner's Court, at County Hall in Norwich. (Image: Newsquest)

The hearing, scheduled for this week, was adjourned due to outstanding witness statements, with a full inquest now expected sometime after May.

The court heard the inquest will examine the medical cause of death and the events immediately surrounding Luan’s delivery, including risk assessment, staff handovers and antenatal care.

Miss Nicholson also highlighted findings from a Maternity and Newborn Safety Investigations (MNSI) report, which identified concerns about “the first hour of care and the improvements needed to be made”.

There were resuscitation attempts after Luan’s birth, and questions remain over the standard of care he received during that critical period.

A key issue is expected to be cardiotocography (CTG) monitoring - used to track foetal heart rate and contractions during labour.

CTG monitoring can indicate foetal distress or oxygen deprivation, helping guide urgent clinical decisions during labour.

Queen Elizabeth Hospital (Image: Newsquest)

The family’s legal team has requested full disclosure of the CTG results, describing them as “a central issue to the inquest”.

“It would be helpful to have the actual results there so witnesses are able to refer to them and provide a better explanation to the court,” Miss Nicholson said.

An extensive external review has already taken place following Luan’s death, and a wider investigation remains ongoing.

The Coroners' Courts Support Service helps bereaved families and witnesses attending Norfolk Coroner’s Court. If you are a bereaved family member or a witness please get in touch by calling 0300 111 2141 or emailing helpline@ccss.org.uk

© Eastern Daily Press