A Coroner has ruled that neglect by an NHS trust contributed to the death of a 14-day old baby

The inquest into the death of 14-day old Orlando Davis, has found that that there were missed opportunities in the care of his Mother, Robyn, with the Coroner concluding that neglect contributed to his death.

Orlando, the second baby of Jonny and Robyn Davis, was born by emergency caesarean section at Worthing Hospital, part of University Hospitals Sussex NHS Foundation Trust on 10 September 2021, following a period of poor maternity care provided by midwives and clinicians employed by the Trust.

The evidence heard throughout the inquest is yet another shocking example of how basic failures in maternity care have led to another tragic death of an otherwise healthy and full-term baby.

Failings and shortcomings

Despite failings being found by HSIB and by independent experts, the Trust’s midwives showed no acceptance of any wrongdoing or that they would have done anything differently, despite such a tragic and shocking outcome to an otherwise healthy, full-term and low-risk pregnancy. This only added insult to the family’s distress.

In her verdict, Senior Coroner Penelope Schofield found that there was a sequence of shortcomings that amount to a gross failure to provide basic medical attention, but for which Orlando’s death would have been prevented. Her recorded verdict was that “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” She concluded that Orlando’s death was contributed to by neglect.

The inquest has highlighted an issue with the current practice of many midwives and obstetricians to treat fetal tachycardia by increasing fluids and encouraging hydration.

The Coroner is gravely concerned about the lack of education around this and believes Orlando’s death is one death too many.

Robyn and Orlando facing each other
Laura Cook

We welcome the Coroner’s decision to write to the Department of Health and the professional regulatory bodies for midwives and obstetricians to draw their attention to the lack of national guidance. Despite hyponatraemia of the severity seen in Robyn and Orlando being rare, it is nonetheless the case that they should never have got to that point.

No accountability or full admission of liability

The Coroner has found there were failings by the midwives to listen to Robyn’s concerns and recognise her deterioration during labour. There has been a concerning lack of accountability from those involved in Robyn’s care.

We will continue working with Robyn and Jonny to secure a full admission of liability from UHS NHS Trust for Orlando’s death and the injuries suffered by Robyn through the civil courts.

Davis family statement

We have waited an agonising two and a half years for Orlando’s inquest to take place, a delay that has added to our anguish.

We had expected that the inquest process would reveal the truth and facts about what happened. Instead, we’ve heard accounts and evidence from various individuals involved at all levels of our care which was defensive and we feel obscures the true picture.

Rather than an attempt at exoneration, this should have been an opportunity for a full and frank appraisal of what happened.

What scares us, is that this is not an isolated incident and we know of many other families going through this same agony.

We are thankful that our birth video threw out any ambiguity. We’re also thankful for our brilliant legal team who have ensured that our heart-breaking experience was properly communicated to the Coroner.

Whilst nothing will ever bring Orlando back, we’d like to thank the Senior Coroner for acknowledging that this is a case where there has been a gross failure to provide basic medical attention and finding that these gross failures amounted to neglect.

As hard as it is to look forward at this moment, we’re joining the call for a national public inquiry into maternity care across England.

Jonny and Robyn Davis both kissing their son Orlando
Orlando Davis' feet

Keep up to date with everything going on

Join our mailing list