Coroner says 14-day-old child’s demise was ‘midwives’ neglect’

A senior coroner, who previously ruled that the death of a 14-day-old baby was ‘contributed to by midwives’ neglect’, has now written to medical bodies urging them to take preventative action.

Penelope Schofield, senior coroner for West Sussex, Brighton and Hove, has penned a message to the Nursing and Midwifery Council and Royal College of Obstetricians and Gynaecologists

She has urged the medical bodies to improve the training around a rare condition that ‘still remains an ignorance nationally among professionals’ and led to the tragic death of baby Orlando in 2021.

During a home birth gone wrong, midwives failed to spot that Robyn Davies, 28, had developed a rare condition called hyponatraemia which caused her seizures and starved her baby of oxygen.

Orlando had no heartbeat when he was born by emergency C-Section at 2.37am on September 10 and tragically passed away two weeks later in intensive care at the Royal Sussex County Hospital in Brighton.

The coroner ruled that midwives were ‘completely unaware’ of the condition that led to the death of the newborn baby.

She said there was ‘no recognition of any potential risk’ associated with hyponatraemia – which is caused by a lower than normal level of sodium in the bloodstream.

At the inquest into Orlando’s death in March this year, grieving mother Mrs Davis – herself a trained midwife – accused her ex-workmates of negligence.

She said she ‘never felt safe’ and her concerns about the labour going wrong were repeatedly brushed aside during the home birth.

The inquest in Chichester heard that Mrs Davis was told to take her ‘midwifery hat off’.

The young mother ended up being rushed by ambulance to Worthing Hospital, West Sussex, where she was placed in a coma.

Her previously healthy baby boy Orlando was born with no heartbeat and brain damage having been starved of oxygen.

He tragically passed away in intensive care at the Royal Sussex County Hospital in Brighton just 14 days after he was born, despite it being initially assessed as a ‘low risk’ pregnancy.

Orlando was the second child of Mrs Davis and her husband Jonny Davis, 30, who works as a graphic designer. 

The couple have since had another baby but suffer from PTSD since losing their son.

Senior coroner Mrs Schofield ruled Orlando’s death had been ‘contributed to by neglect’ in which there was a ‘gross failure to provide basic medical attention’.

Now, in a Prevention of Future Deaths report, she said evidence heard at the inquest revealed ‘matters giving rise to concern’.

Mrs Schofied wrote that she was concerned about there being no guidance on how to manage hyponatraemia in pregnancy and labour. 

She wrote: ‘In my opinion there is a risk that future deaths could occur unless action is taken,’ she wrote.

‘Orlando was caused an irreversible brain injury when his mother suffered a seizure having developed hyponatremia during her labour.

‘The concern is that the midwifes (in the community and in the hospital, who had cared for Orlando’s mother) were completely unaware of this potential condition developing in birthing women.

‘In this case due to Orlando developing a tachycardia during labour Orlando’s mothers was actively encouraged to take in more fluid yet there was no accurate record kept of either input or output of fluid.

‘Again when in hospital further fluids were given intravenously with no recognition of any potential risk of hyponatremia developing by the midwives or the Doctor on duty.’

She added: ‘In my opinion action should be taken to prevent future deaths and I believe you (and/or your organisation) have the power to take such action.’

The coroner reminded the medical bodies that they are legally required to reply within 56 days.

The devastated young mother previously told the hearing how she was ‘haunted’ by having to make the decision to let baby Orlando die.

Mrs Davis said she and her husband suffered ‘complete heartbreak’ when they were told it was in their baby’s ‘best interest’ to die.

She said: ‘I could not understand that Orlando was this catastrophically ill that meant he was going to die.

‘I just can’t explain the sadness, frustration, anger and complete heartbreak I felt and still feel towards the Trust for not keeping us safe.

‘As a parent, I can’t explain how horrendous hearing the news that it’s in your child’s best interest to die.

‘To also be faced with agreeing to end your child’s life is the biggest scar you could ever imagine, we knew it was the best thing we could do for him but it doesn’t make it remotely easier.

‘We had to make terrible decisions as to when and how Orlando would die.

‘We then watched our son pass away which took around 24 hours.’

Recalling the tragic event, Mrs Davis said:  ‘This is the hardest thing I think could possibly ever happen to a human being and I am haunted psychologically in so many ways from this, and I can honestly say hand on heart my life is ruined because of this.

‘I just had to keep telling myself that I know for Orlando it was the kindest thing we could have agreed to, as his daily condition was deteriorating

‘Everyone could tell his life would not be comfortable, pain free or happy, and his life expectancy was so very poor.’

She adds: ‘May my beautiful son rest in peace.’