Chichester Coroner to hear inquest into death of 14 day old Orlando
Orlando Davis, the second baby for Jonny and Robyn Davis, was born by emergency caesarean section at Worthing Hospital (part of University Hospitals Sussex NHS Foundation Trust) on 10th September 2021 but tragically died 14 days later.
An investigation that followed identified concerns in Robyn’s maternity care that failed to monitor her fluid consumption and urine output during labour.
There was an excessive imbalance of fluid intake which went unrecognised causing Robyn to suffer seizures necessitating an emergency caesarean section to deliver Orlando, who was starved of oxygen, and Robyn was put in an induced coma in intensive care for several days.
Robyn has been left which chronic ongoing health issues and both her and Jonny have been diagnosed with PTSD as a result of their horrendous experience.
Jonny and Robyn are being represented by our clinical negligence Solicitor and birth injury claims specialist, Laura Cook, who is advising them in relation to the inquest and a civil claim against the hospital. They hope that the inquest will reveal exactly what happened on the lead up to Orlando’s death. It will be the first time that they will hear directly from key individuals responsible for Robyn and Orlando’s care.
Inquest to hear evidence of poor care
In addition to the concerns over fluid balance, there is evidence that Robyn’s condition had deteriorated during labour, losing the ability to converse and lacking consciousness for extended periods of time, which was attributed to ‘hypnobirthing’ by the midwives, despite this never being part of her birth plan.
The inquest will also hear evidence regarding the monitoring of Orlando’s heart rate during the labour, both by the midwives whilst Robyn remained at home, and by the hospital midwives and obstetric staff once continuous monitoring by CTG had commenced in hospital.
HSIB has identified that there were abnormalities in Orlando’s heart rate that should have been responded to much sooner, and there is evidence of incorrect CTG interpretation by the hospital midwives.
The inquest, which was originally to be heard in October 2022, was delayed following the announcement of an independent investigation by the Nursing and Midwifery Council (NMC) into the practice of several of the midwives involved in Orlando’s delivery. There has also been significant delay caused by the coronial process, with several pre-inquest hearings and allocation of the case to different coroners. This delay has caused considerable further stress and anguish for Robyn and Jonny.
What do the family want to learn from Orlando’s inquest?
Above all else, the family are looking for answers on the events that led up to Orlando’s death. They believe that there is stark evidence of gross failures of care provided to Robyn whilst in labour with Orlando.
It will be alleged on behalf of Robyn and Jonny that those failures were both individual and systemic in nature, and were allowed to occur within a culture that did not appear to hold patient safety in sufficiently high regard.
There is also evidence likely to be heard that the organisation did not create or have in place proper or robust systems to protect patient safety.
The couple are also shocked about the failings in education for Worthing Hospital staff regarding the importance of fluid balance monitoring in a labouring woman, hyponatremia and the lack of learning from previous, similar cases.
“This was a completely normal and healthy pregnancy that ended so tragically. Whilst we have not yet heard the live evidence that will be given at the inquest, records seen to date show what appears to be a basic lack of safe maternity care provided by this Trust. Nothing can ever compensate for the loss of a child, and Robyn and Jonny will suffer lasting damage of their own. It is hoped that the inquest will provide them with some answers and, in turn, accountability from Worthing for what went so badly wrong. We are pleased that the Coroner is holding a full and open hearing to seek justice for Orlando. At CL Medilaw we represent many parents and families that have lost babies, or whose babies have suffered life changing brain injuries, at both this and other NHS Trusts across the country and we fully support the calls for a wholesale national review of NHS maternity services.”
The current state of maternity care across England
England is in the midst of a crisis in maternity care. Maternity wards are continually falling in CQC rating standards. In February this year Worthing Hospital was downgraded to ‘requires improvement’ for safety.
The public are repeatedly hearing of similar stories of tragic deaths and brain injuries, for both mothers and babies, in wards around the country. It was widely reported at the end of 2023 that CQC records showed it deemed two-thirds (67%) of wards not to be safe enough, up from 55% last autumn, according to a BBC analysis.
The CQC are, unusually, an Interested Party at Orlando’s inquest, as are the NMC and HSIB. It’s worth noting that CQC prosecutions for failures in maternity care are rare. There have been only two cases the CQC brought against an NHS maternity unit. The most recent one being the against Nottingham University Hospitals (NUH) NHS Trust over the death of Baby Wynter Andrews for which they were fined £800,000. At Wynter’s inquest the Coroner made a finding of ‘neglect’, a finding that is also available to the Coroner in this case to make.
Inquest delays compound family's distress
The turmoil the Davis family has been through cannot be overstated. Following the horrendous death of Orlando, parents Robyn and Jonny have fought for 2.5 years to reach an inquest.
Initially receiving push back about the need for an inquest which, when finally granted, has had 3 Coroner’s overseeing the case at different stages.
The family have been left to oversee this emotionally draining case while having two children at home – Dixie, 3 (she will turn 4 in May), and Nova, the couple’s 2-month-old baby girl who was born in January this year. This is on top of their PTSD diagnosis, which Robyn and Jonny continue to battle with.
The impact of this entire ordeal on their life cannot be overstated.
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