A senior coroner has issued a warning after hearing that midwives caring for an expectant mother were “completely unaware” of the condition that caused her newborn baby to die.
Penelope Schofield said she was “concerned” because health professionals failed to detect that Robyn Davis had developed hyponatremia, causing seizures and depriving baby Orlando of oxygen.
He said there was “no potential risk recognised” about the condition, which is caused by a lower than normal level of sodium in the bloodstream, which developed in Ms Davis, a trained midwife who had worked alongside the team.
Now the chief coroner for West Sussex, Brighton and Hove has written to the Nursing and Midwifery Council and the Royal College of Obstetricians and Gynecologists to improve understanding.
At the inquest into Orlando’s death in March, Ms Davis accused her former co-workers of negligence over the death of her newborn son.
Coroner Penelope Schofield said she was “concerned” that health professionals failed to detect that Robyn Davis had developed the rare condition of hyponatraemia.
Roby Davis ended up having an emergency C-section and the previously healthy baby was born with no heartbeat and brain damage from lack of oxygen in 2021.
She said she “never felt safe” when her concerns that the birth was going wrong were repeatedly ignored during the home birth.
She ended up having to be rushed by ambulance to Worthing Hospital, West Sussex, where she suffered seizures and had to have an emergency caesarean section.
Ms. Davis was placed in a coma and the previously healthy baby was born without a heartbeat and with brain damage from lack of oxygen on September 10, 2021.
She tragically passed away in intensive care at the Royal Sussex County Hospital in Brighton just 14 days later, despite initially being assessed as having a “low risk” pregnancy.
Orlando was the second child of graphic designer Jonny Davis, 30, and Mrs Davis, 28, from Steyning, West Sussex, who have since had another baby but suffer post-traumatic stress from the experience.
The inquest in Chichester heard that the trained midwife’s concerns about her baby’s position and fluid intake were ignored as he drank four liters of water and his condition deteriorated at home, but she was told to remove the “midwifery hat.”
In a narrative conclusion, Ms Schofield ruled that Orlando’s death had been “contributed to negligence” in which there was “a serious lack of basic medical care”.
Now, in a report on Preventing Future Deaths, he said evidence heard at the inquest revealed “matters of concern”.
“In my opinion, there is a risk of future deaths unless action is taken,” he wrote.
‘Orlando suffered an irreversible brain injury when his mother suffered a seizure while developing hyponatremia during childbirth.
‘The concern is that the midwives (in the community and at the hospital, who had cared for Orlando’s mother) were completely unaware of this possible condition developing in women giving birth.
‘In this case, because Orlando developed tachycardia during childbirth, Orlando’s mother was actively encouraged to drink more fluid, but no accurate record of fluid intake or output was kept.
Father Jonny Davis held his son Orlando, who suffered an irreversible brain injury when his mother Robyn suffered a seizure, having developed hyponatremia during childbirth.
The couple says they suffer from post-traumatic stress disorder since the death of their son, Orlando, in 2021
“Again, when I was in hospital, more fluids were given intravenously without any potential risk of hyponatremia being recognized by the midwives or doctor on duty.”
He continued: “In my opinion, measures must be taken to prevent future deaths and I believe that you (and/or your organization) have the power to take such measures.”
The coroner reminded them that they are legally required to respond within 56 days.
Mrs. Davis had told the hearing that she was “obsessed” by having to make the decision to let baby Orlando die.
She said she and her husband suffered “complete distress” when they were told that dying was best for their baby.
“I couldn’t understand that Orlando was so catastrophically ill that it meant he was going to die,” she said.
‘I simply cannot explain the sadness, frustration, anger and utter anguish I felt and continue to feel towards the Trust for not keeping us safe.
‘As a father, I cannot explain how horrendous it is to hear the news that the best thing for your child is to die.
‘Having to also face accepting to end your son’s life is the biggest scar you can imagine, we knew it was the best thing we could do for him, but that doesn’t make it even remotely easier.
‘We had to make terrible decisions about when and how Orlando would die.
‘Then we watched our son die, which lasted about 24 hours.
“This is the hardest thing I think could happen to a human being and this psychologically torments me in so many ways, and I can honestly say with the whole palm of my heart that my life is ruined because of this.
“I had to keep telling myself that I know that for Orlando it was the kindest thing we could have accepted as his daily condition was deteriorating and he was unable to feed himself, even hoovering during his first week of life due to his inability to control his airways and lack of suck/swallow reflex.
‘Everyone could tell that their life would not be comfortable, pain-free or happy, and their life expectancy was very poor.
‘May my beautiful son rest in peace.’
The newborn died two weeks later in intensive care at the Royal Sussex County Hospital in Brighton (pictured)