Baby death investigation finds ‘missed opportunity’ in caring for pregnant mother

A coronial inquest into the death of a two-week-old baby boy who died in a Sussex hospital has found that care for his mother was missed.

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

He was born without a heartbeat and suffered irreversible brain damage after his mother, Robin Davis, suffered a seizure and starvation of oxygen due to a rare condition that went “completely unnoticed” by staff during childbirth, his parents told reporters. I was told.

Orlando is survived by Robin and her husband. Johnny’s arm on September 24, 2021, at 14 days old, due to a catastrophic brain injury.

His mother had to go into a coma, but has since recovered. But his parents insist his death was avoidable.

At the inquest into Mr Orlando’s death today, senior coroner Ms Penelope Schofield said a lack of understanding of hyponatremia contributed to Mr Orlando’s neglect.

During the inquest, the coroner heard evidence from Mrs Davies and midwives and medical staff at University Hospitals Sussex NHS Foundation Trust who were involved in Orlando’s treatment.

The Care Quality Commission (CQC) also investigated the matter.

Mrs Davies told the inquest: “I cannot explain the sadness, regret, anger, and complete heartbreak I felt and continue to feel for the trust that failed to keep us safe.

Mrs. Davis continued: “What I cannot accept is that I lost my healthy, full-term son. In my personal and professional opinion, my son was taken from me in circumstances that were completely preventable. I feel it.

The full conclusion of the story reads: “On September 9, 2021, Robin Davis developed hyponatremia during labor during a home birth.

“During the birth, Robyn’s condition was completely unrecognized and, as a result, she and her son Orlando did not receive the care and attention they clinically needed.

“There was a lack of understanding of this rare condition among midwives and clinicians, which meant they missed the opportunity to treat Robin either at home or during his subsequent stay at Worthing Hospital.

“Sadly, failure to recognize this condition resulted in Robin having multiple seizures and Orlando’s oxygen supply being restricted before birth, resulting in him suffering irreversible brain damage. became.

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“Orlando sadly passed away from his injuries on September 24, 2021, at the Royal Sussex County Hospital, aged 14 days.

“Orlando’s death was caused by neglect.”

Ms Schofield also said a lack of guidelines for managing hyponatremia during pregnancy and delivery may have been a contributing factor to Orlando’s death.

“We understand that symptoms of hyponatremia are rare, but mothers are putting their lives and the lives of their newborns in the hands of professionals,” she says.

“While the Trust has provided evidence of lessons learned from Orlando’s death, the risk of hyponatremia does not appear to be part of training and remains nationally ignorant among professionals.

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

University Hospitals Sussex NHS Foundation Trust, which runs Worthing Hospital, expressed its condolences to the family.

Chief nurse Maggie Davis said: “We would like to once again extend our deepest condolences to Orlando’s family for the unimaginable heartache and pain caused by the loss of their baby boy.”

“As the coroner pointed out in her findings, hyponatremia is an extremely rare but poorly understood condition. We echo her view that new national guidelines are urgently needed. I support it.

“This tragedy has had a profound impact on everyone involved in the family’s care and has directly led to us introducing new guidance and training to our maternity services.”