Inquest into death of baby finds 'missed opportunities' in care of his pregnant mother

Orlando Davis died 14 days after being born at Worthing Hospital in 2021. Credit: Robyn and Jonny Davis

An inquest into the death of a baby boy who died two weeks after birth in a Sussex hospital has found there were missed opportunities in the care of his mother.

Orlando Davis was born by emergency caesarian section at Worthing Hospital, part of University Hospitals Sussex NHS Foundation Trust, on 10 September 2021 following a normal and low risk pregnancy.

He was born with no heartbeat and his parents were told he had suffered an irreversible brain injury after being starved of oxygen - after his mother Robyn Davis experienced seizures during labour, caused by a rare condition that went "completely unrecognised" by staff.

Orlando died in Robyn and husband Jonny’s arms on 24 September 2021 at 14 days old due to his catastrophic brain injury.

His mother had to be put in an induced coma, but has since recovered. But his parents say his death was avoidable.

Today at the inquest into Orlando's death, senior coroner, Ms Penelope Schofield said a lack of understanding of hyponatremia contributed to neglect of Orlando.

During the inquest, the coroner heard evidence from the midwives and medical staff from University Hospitals Sussex NHS Foundation Trust involved in Mrs Davis’ and Orlando’s care.

The Care Quality Commission (CQC) has also examined the case.

Orlando Davis died at Worthing Hospital in September 2021. Credit: ITV Meridian

Mrs Davis had told the inquest: “I can’t explain the sadness, frustration, anger and complete heartbreak I felt and still feel towards the trust for not keeping us safe.

Mrs Davis continued: “The thing I cannot process is that I have lost my healthy, full-term son. I feel as if my son was taken from me in a circumstance that, in my personal and professional opinion, was completely preventable.

In full the narrative conclusion reads: "On 9th September 2021 Robyn Davis developed hyponatremia during her labour while having a home birth.

"Robyn's condition went completely unrecognised during the period of her labour and therefore she did not receive the care and attention that she and her son, Orlando, clinically required.

"There was a lack of understanding of this rare medical condition by midwives and clinicians and as such there were lost opportunities to treat Robyn both at home and or during her subsequent admission to Worthing hospital.

"Sadly the failure to recognise this condition resulted in Robyn suffering a number of seizures which led to a restriction of oxygen to Orlando before birth and this resulted in him suffering an irreversible brain injury.

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"Orlando sadly died from this injury on 24th September 2021 at the Royal Sussex County Hospital at the age of just 14 days.

"Orlando's death was contributed to by neglect."

Ms Schofield also said she considered a contributing factor to Orlando’s death that there is no guidance of managing hyponatraemia in pregnancy and labour.

“While I appreciate the condition of hyponatraemia is rare, mothers place their lives and those of their newborns in the hands of professionals,” she said.

“While the trust have given evidence learned from Orlando’s death, the risk of hyponatraemia does not seem to form part of training, there still remains an ignorance nationally among professionals.

“Orlando’s death is one death too many.”

The University Hospitals Sussex NHS Foundation Trust which runs Worthing hospital - has offered its condolences to the family.

Chief nurse Maggie Davies said: “We wish to offer our sincere condolences to Orlando’s family once more for the unimaginable heartache and distress caused by the loss of their baby boy.

“As the coroner noted in her findings, hyponatremia is an extremely rare condition which is little understood. We support her view that there is an urgent need for new national guidelines.

“This tragedy has deeply affected everyone involved in the family’s care, and led directly to us introducing new guidance and training within our maternity service.”