Bereaved mother says midwives failed to act when she raised alarm during labour

The mother of a baby who died after being born by emergency Caesarean section did not feel “safe” during labour as she claimed midwives failed to act when she tried to raise fears that “something was wrong”, an inquest has heard.

Orlando Davis was born at Worthing Hospital, part of University Hospitals Sussex NHS Foundation Trust, on September 10 2021, but died 14 days later.

His parents, Robyn and Jonny Davis, from Steyning, West Sussex, are suing the hospital in a separate case assisted by birth injury claims specialist Laura Cook, of CL Medilaw.

The solicitors for the couple, who have two other children, claim there was “a basic lack of safe maternity care” provided for Orlando and his mother, who used to work as a midwife.

A spokesman for the firm said medics had “failed” to monitor Mrs Davis’s fluid consumption and urine output during labour “despite identified concerns”.

He said: “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 with chronic ongoing health issues, and both her and Jonny have been diagnosed with PTSD as a result of their horrendous experience.”

He added that the family are hoping to identify what led Orlando to suffer a fatal brain injury, what action could have been taken to avoid his death, and what learnings have been made since.

Coroner Penelope Schofield told the hearing in Chichester: “I appreciate the family are incredibly angry and distressed, as one would expect, following the death of their son, Orlando.

“This is not a rehearsal of the civil proceedings, and I have to take into account the impact this case will have, not only on the family but on the witnesses whose careers may be at risk.”

In a statement read to the court, Mrs Davis, 28, told the hearing she had previously worked as a midwife at the hospital but had left after four or five months because of the levels of “stress, poor staffing and lack of support” for the midwifery team.

She said she had opted for a home birth with a birthing pool following the advice of her midwife.

Mrs Davis said she felt she had not been listened to by the midwives when she raised concerns about her fluid intake and the position of the baby.

She said: “I proceeded to keep saying ‘Something is wrong’. It felt like I was trapped, that, although I knew I was declining so rapidly, I was unable to think how I could help myself, such as asking to go to hospital.

“Every time I said something was wrong the midwives never investigated this further.”

The inquest heard that, as complications arose during the labour, Mrs Davis was transferred to hospital as she began to suffer seizures, which led to her being placed in a coma.

Mrs Davis came out of the coma after three days but said it was not until she was transferred to see her son the following day that she found out how seriously ill he was.

She said: “I could not stop crying and having panic attacks. I could not understand that Orlando was this catastrophically ill that he was going to die.

“I 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 that 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 can ever imagine.”

She said she had been “haunted psychologically” at having watched her son die, and added: “My life is ruined because of this. I just keep telling myself that for Orlando it is the kindest thing we could do.”

Mrs Davis continued: “The thing I cannot process is that I have lost my healthy, full-term son. I feel as if my son was taken from me in a circumstance that, in my personal and professional opinion, was completely preventable.

“This is agony to live with. This is because I can’t help but relive the moments of constantly expressing something wasn’t right during labour multiple times.

“It is also a sickening feeling that no-one picked up on how poorly I was for hours and hours despite expressing it.”

Lawyer Ms Cook said ahead of the hearing: “This was a completely normal and healthy pregnancy that ended so tragically.

“Records seen to date show what appears to be a basic lack of safe maternity care provided by this Trust.”

Chief nurse Maggie Davies, of the University Hospitals Sussex NHS Foundation Trust, said ahead of the hearing: “We wish to offer our heartfelt condolences to Orlando’s family at this hugely difficult time.

“We will be doing all we can to assist the coroner and the family to understand the circumstances surrounding the tragic loss of their baby boy.”