Orlando Davis
26 Apr 2024 · Coroner Penelope Schofield · West Sussex, Brighton and Hove
The coroner's concerns
1. lack of awareness of hyponatremia in birthing women
“the midwifes (in the community and in the hosptial, who had cared for [the deceased]'s mother) were completely unaware of this potential condition developing in birthing women”
2. irreversible brain injury
“[the deceased] was caused an irreverseable brain injury when his mother suffered a seizure having developed hyponatremia during her labour”
3. inaccurate fluid intake and output recording
“no accurate record kept of either input or output of fluid”
4. failure to recognise hyponatremia risk
“no recognition of any potential risk of hyponatremia developing by the midwives or the Doctor on duty”