Baby died after "gross failure to provide basic medical attention to mother".

A two-week-old baby died because a “gross failure to provide basic medical attention” meant a blood disorder was not identified in his mother, a senior coroner has ruled.

Orlando Davis suffered a fatal brain injury when he was born by emergency caesarean section at Worthing Hospital, part of University Hospitals Sussex NHS Foundation Trust, in September 2021.

An inquest at Chichester heard that Orlando’s mother, Robyn Davis, 28, had worked as a midwife at the hospital for about four months before leaving because of “stress, poor staffing and lack of support” and “did not feel safe” during her labour.

She had opted for a home birth after being told that it was a low-risk pregnancy. The inquest heard that she was rushed to hospital after complications arose during the birth, where she suffered seizures before being placed in a coma for three days.

Robyn Davies claimed that midwives failed to act when she tried to raise fears that “something was wrong” and raised concerns about her fluid intake and the position of the baby, with staff telling her to take her “midwifery hat off.”

Her son was born with no heartbeat and brain damage and died in intensive care at the Royal Sussex County Hospital in Brighton.

West Sussex senior coroner, Penelope Schofield, told the inquest that staff failed to spot that Mrs Davis had developed hyponatraemia, a medical term for a low level of sodium in the bloodstream, which led her to have seizures and starved her unborn son of oxygen./more

The coroner ruled that there was a “lack of inquiry or investigation” into Davis’s claims and a lack of awareness about the condition. Penelope Schofield added that “the lives of mothers and their children were at risk” unless national guidance was issued.

She told the court: “Robyn’s condition went completely unrecognised during the period of her labour and, therefore, did not receive the care and attention she and her son clinically required. The failure to recognise this condition was fundamental and had catastrophic consequences.”

She added that she would write a prevention of future death report to raise awareness about the condition.

Robyn Davis had told the hearing how she was “haunted” by having to make the decision to let Orlando die after they were told that it was in their child’s “best interest”.

She said: “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.”

Chief nurse at the University Hospitals Sussex NHS Foundation Trust, Maggie Davies, offered the family condolences for the “unimaginable heartache and distress caused by the loss of their baby boy” and supported the call for an urgent review of guidelines on hyponatraemia.