Orlando Davis

I am Penelope SCHOFIELD, Senior Coroner for the coroner area of West Sussex, Brighton and Hove

On 08 October 2021 I commenced an investigation into the death of Orlando Nova DAVIS aged 14 Days. The investigation concluded at the end of the inquest on 14 March 2024. The conclusion of the inquest was a Narrative Conclusion namely: On 9th September 2021  [REDACTED] (Orlando’s mother) developed hyponatremia during her labour while having a home birth. [REDACTED]’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 [REDACTED] both at home and or during her subsequent admission to Worthing hospital. Sadly the failure to recognise this condition resulted in [REDACTED] suffering a number of seizures which led to a restriction of oxygen to Orlando before birth and this resulted in him suffering an irreversible brain injury. Orlando sadly died from this injury on 24th September 2021 at the Royal Sussex County Hospital at the age of just 14 days. Orlando’s death was contributed to by neglect.

The circumstances of Orlando’s death are set out in the narrative conclusion above.

During the course of the investigation my inquiries revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows: (brief summary of matters of concern) Orlando was caused an irreverseable brain injury when his mother suffered a seizure having developed hyponatremia during her labour. The concern is that the midwifes (in the community and in the hosptial, who had cared for Orlando’s mother) were completely unaware of this potential condition developing in birthing women. In this case due to Orlando developing a tachicardia during labour Orlando’s mothers was actively encouraged to take in more fluid yet there was no accurate record kept of either input or output of fluid. Again when in hospital further fluids were given intravenousely with no recognition of any potential risk of hyponatremia developing by the midwives or the Doctor on duty.

In my opinion action should be taken to prevent future deaths and I believe you (and/or your organisation) have the power to take such action.