Coroner slams midwives who never heard of fatal newborn condition

A senior coroner has issued a warning after hearing that midwives caring for an expectant mother were 'completely unaware' of the condition that led to the death of her newborn baby.

Penelope Schofield said she was 'concerned' healthcare professionals failed to spot Robyn Davis had developed hyponatraemia, which caused her seizures and starved baby Orlando of oxygen.

She said there was 'no recognition of any potential risk' about the condition, which is caused by a lower than normal level of sodium in the bloodstream, developing in Mrs Davis, herself a trained midwife who had worked alongside the team.

Now, the senior coroner for West Sussex, Brighton and Hove has written to the Nursing and Midwifery Council and Royal College of Obstetricians and Gynaecologists to improve understanding about it.

At the inquest into Orlando's death in March Mrs Davis accused her ex-workmates of negligence over the death of her newborn son.

She said she 'never felt safe' when her concerns her labour was going wrong were repeatedly brushed aside during her home birth.

She ended up having to be rushed by ambulance to Worthing Hospital, West Sussex, where she suffered seizures and an emergency C-section had to be carried out.

What is hyponatraemia?

Hyponatremia occurs when the concentration of sodium in your blood is abnormally low. 

Sodium is an electrolyte, and it helps regulate the amount of water that's in and around your cells.

When the sodium in your body to become diluted, your body's water levels rise, and your cells begin to swell. This swelling can cause many health problems, from mild to life-threatening.

Hyponatremia treatment is aimed at resolving the underlying condition. 

Depending on the cause of hyponatremia, you may simply need to cut back on how much you drink. In other cases of hyponatremia, you may need intravenous electrolyte solutions and medications.

Source: Mayo Clinic 

Mrs Davis was placed in a coma and the previously healthy baby boy was born with no heartbeat and brain damage having been starved of oxygen on September 10, 2021.

He tragically passed away in intensive care at the Royal Sussex County Hospital in Brighton just 14 days later, despite it being initially assessed as a 'low risk' pregnancy.

Orlando was the second child of graphic designer Jonny Davis, 30 and 28-year-old Mrs Davis, of Steyning, West Sussex, who have since had another baby but suffer from post-traumatic stress from the experience.

At the inquest in Chichester it was heard the trained midwife's worries about her baby's position and fluid consumption were ignored as she drank four litres of water and her condition deteriorated at home, but was told to take her 'midwifery hat off'.

In a narrative conclusion Mrs Schofield ruled Orlando's death had been 'contributed to by neglect' in which there was a 'gross failure to provide basic medical attention'.

Now, in a Prevention of Future Deaths report, she said evidence heard at the inquest revealed 'matters giving rise to concern'.

'In my opinion there is a risk that future deaths could occur unless action is taken,' she wrote.

'Orlando was caused an irreversible 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 hospital, 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 tachycardia during labour, Orlando's mother 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 intravenously with no recognition of any potential risk of hyponatremia developing by the midwives or the doctor on duty.'

She continued: '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.'

The coroner reminded them they are legally required to reply within 56 days.

Mrs Davis had told the hearing how she was 'haunted' by having to make the decision to let baby Orlando die.

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She said she and her husband suffered 'complete heartbreak' when they were told it was in their baby's 'best interest' to die.

'I could not understand that Orlando was this catastrophically ill that meant he was going to die,' she said.

'I just can't explain the sadness, frustration, anger and complete heartbreak I felt and still feel towards the Trust for not keeping us safe.

'As a parent, I can't explain how horrendous hearing the news that it's in your child's best interest to die.

'To also be faced with agreeing to end your child's life is the biggest scar you could ever imagine, we knew it was the best thing we could do for him but it doesn't make it remotely easier.

'We had to make terrible decisions as to when and how Orlando would die.

'We then watched our son pass away, which took around 24 hours.

'This is the hardest thing I think could possibly ever happen to a human being and I am haunted psychologically in so many ways from this, and I can honestly say hand on heart my life is ruined because of this.

'I just had to keep telling myself that I know for Orlando it was the kindest thing we could have agreed to, as his daily condition was deteriorating where he was unable to take feeds, he even aspirated within his first week of life due to his inability to control his airways and lack of suck/swallow reflex.

'Everyone could tell his life would not be comfortable, pain free or happy, and his life expectancy was so very poor.

'May my beautiful son rest in peace.'