An inquest into the death of a 14-day-old baby has found missed opportunities in his mother’s NHS care – she said staff failed to act when she tried to raise the issue “something was wrong”.

Orlando Davis passed away on September 24, 2021 in the arms of his parents, Robyn Davis and Jonny Davis, two weeks after he Emergency caesarean section at Worthing Hospital. sussex.

Mrs Davis said she “didn’t feel safe” during the birth.

Coroner Penelope Schofield found Mrs Davies, 28, suffered a seizure during childbirth and a lack of understanding contributed to Orlando’s death.

An inquest found she suffered from a rare condition that staff were “completely unaware of”.

The coroner said: “The failure to recognize the situation was fundamental.”

The coroner added: “Orlando’s death was caused by neglect.”

In November last year, medical negligence law firm CL Medilaw, which represented Orlando’s parents, argued that Orlando “suffered severe hypoxic-ischemic injury at birth as a result of a number of serious errors and delays by the midwives and doctors responsible for his delivery” .

Ms Davies told the Chichester inquest she had previously worked as a midwife at the hospital but left after four or five months due to “pressure, understaffing and a lack of support” from the midwifery team.

She said she chose to give birth at home with a birth pool on the advice of her midwife.

Coroner Ms Schofield recorded narrative conclusions in her post-mortem report, saying: “On September 9, 2021, Robin Davis was in labor at home when she developed hyponatremia during labour.

“Robin’s condition was completely unrecognized during labor and, as a result, she and her son did not receive the clinically required care and attention.

“Midwives and clinicians lacked understanding of this rare condition and therefore the opportunity to treat Robin at home and/or during her subsequent transport to Worthing Hospital was lost.”

The coroner’s conclusion came after a seven-day inquest into Orlando’s death.

Maggie Davies, Chief Nurse, University Hospital Sussex NHS Speaking ahead of the inquest, the Foundation Trust said: “We would like to express our heartfelt condolences to Orlando’s family at this extremely difficult time.

“We will do everything we can to assist the coroner and the family in understanding the circumstances surrounding the tragic death of their baby boy.”

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