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

Orlando Davis died on 24 September 2021, in the arms of his parents, Robyn and Jonny Davis, two weeks after being born by emergency Caesarean section at Worthing Hospital, West Sussex.

Mrs Davis said she did not “feel safe” during labour.

Coroner Penelope Schofield found a lack of understanding contributed to Orlando’s death after Mrs Davis, 28, suffered seizures while giving birth.

She had a rare condition which went “completely unrecognised” by staff, the inquest found.

The coroner said: “Failure to recognise this condition was fundamental.”

“Orlando’s death was contributed to by neglect,” the coroner added.

In November last year, medical negligence law firm CL Medilaw, representing Orlando’s parents, argued he “suffered a severe hypoxic ischaemic insult during his birth as a result of a number of alleged serious failings and delay by the midwives and doctors responsible for his delivery”.

Mrs Davis told the inquest in Chichester 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.

Recording a narrative conclusion at the inquest, the coroner Ms Schofield said: “On 9 September 2021, Robyn Davis developed hyponatraemia during her labour while having a home birth.

“Robyn’s condition went completely unrecognised during the period of her labour and, therefore, did not receive the care and attention her and her son 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 Robyn both at home and or during her subsequent submission to Worthing Hospital.”

The coroner’s findings come after seven days of proceedings looking into Orlando’s death.

Maggie Davies, chief nurse of the University Hospitals Sussex NHS Foundation Trust, had said ahead of the inquest: “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.”

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