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........

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