Senior Coroner to investigate the death of 14 day old Orlando Davis

Baby Orlando was the second child of Robyn and Jonny Davis and was born at Worthing Hospital, part of University Hospitals Sussex NHS Foundation Trust, on 10 September 2021 following a normal and low risk pregnancy.

Orlando suffered a severe hypoxic ischaemic insult during his birth as a result of a number of alleged serious failings and delay by the midwives and doctors responsible for his delivery. Orlando sadly passed away in Robyn and Jonny’s arms on 24th September 2021 at 14 days old due to his catastrophic brain injury.

Nursing and Midwifery Council probe delays the inquest

The inquest into Orlando’s death is due to be heard in Spring 2024 in Horsham and is listed for a five day hearing before Senior Coroner, Ms Penelope Schofield. It was originally to be heard in October 2022 but 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, it has been significantly delayed, causing further stress and anguish for Robyn and Jonny.

Emergency caesarean section

Following an investigation by the Healthcare Safety Investigation Branch (recently renamed the Health Services Safety Investigations Body, HSSIB) one of the key concerns in Robyn Davis’ maternity care surrounds the failure to monitor her fluid consumption and urine output during labour. There was an excessive imbalance of fluid intake which went completely unrecognised and caused Robyn to suffer seizures, necessitating an emergency caesarean section to deliver Orlando, who was starved of oxygen, and Robyn to be put in an induced coma in intensive care for several days.

During the course of the Inquest, the Coroner, Ms Penelope Schofield, will hear evidence from the midwives and medical staff from University Hospitals Sussex NHS Foundation Trust involved in Mrs Davis’ and Orlando’s care to determine how Orlando, an otherwise healthy and full term baby boy, died under their care. The Care Quality Commission (CQC) has also examined the case and will be a party to the inquest.

Ongoing distress

The family have waited over two years for answers as to how Orlando died and have been subjected to continually re-living these tragic events at three Pre-Inquest Review hearings and a last minute adjournment of the inquest itself during the course of the delay.

We have been incredibly distressed by the delay of the inquest considering Orlando passed away over 2 years ago and we still have no explanation as to why my son died and why I ended up in a coma for 3 days and have been left with chronic ongoing health issues. We demand answers as to how a catastrophic chain of failings occurred across both the community and hospital setting within Worthing that day and night with errors involving a minimum of 6 members of staff. We can only hope for swift case progression from now onwards, given we have a very experienced Coroner, Penelope Schofield, taking over our case. I am also pleased to say that Penelope made the decision to not delay the inquest any further and it will hopefully take place in Spring 2024. Our family want to hear directly from each individual involved as to how and why this happened. We hope learning can come from our case and that this does not keep happening to any further families because our lives have been turned upside down and these consequences will be a life time sentence for us.

CL Medilaw represent Robyn and Jonny Davis

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 the Trust 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 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.

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