Baby Orlando Davis Inquest – Scala instructed by CL Medilaw to secure media coverage and interviews for the family and Solicitor, Laura Cook

Orlando Davis, the second baby for Jonny and Robyn Davis, was born by emergency caesarean section at Worthing Hospital (part of University Hospitals Sussex NHS Foundation Trust) on 10th September 2021 but tragically died 14 days later.

An investigation that followed identified concerns in Robyn’s maternity care that failed to monitor her fluid consumption and urine output during labour. There was an excessive imbalance of fluid intake which went unrecognised causing Robyn to develop hyponatraemia leading to seizures. An emergency caesarean section was performed 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 which chronic ongoing health issues and both her and Jonny have been diagnosed with PTSD as a result of their horrendous experience.

Scala were instructed by the couples clinical negligence solicitor, Laura Cook from CL Medilaw, to secure media coverage and interviews for her and the family, who were keen to share their experience in the media.

Prior to the Inquest we spoke to the family and the solicitor to understand the case, the issues to be addressed at the Inquest and what messages the family wanted to communicate. This enabled us to identify what aspects of the case the press would be particularly interested in covering. This included the fact that Robyn was a former midwife at the Trust; the appalling outcome for both Orlando, Robyn and Jonny; the fact that the CQC is an interested party; and the real prospect that the coroner could find that Orlando’s death had been contributed to by ‘Neglect’. We also explored what images and video footage the family wanted to share with the press.

This information was used to draft a media release to circulate ahead of Inquest. As a result of this we were able to secure several pre-inquest interviews to be recorded but embargoed from publication and broadcast until after the inquest conclusion.

Inquest Conclusion

Following the inquest which heard complex medical evidence from a range of parties, Senior Coroner, Penelope Schofield, delivered a narrative conclusion in which she found there were gross failures of care amounting to ‘Neglect’. In addition, she gave a formal commitment to write to the Department of Health and other professional regulatory bodies for midwives and obstetricians to draw their attention to the lack on national guidance with regards to the condition, hyponatraemia. She was alarmed by the evidence she had heard from the medical professionals that they were unaware of the condition as it didn’t form part of their training.

A more detailed analysis of the case can be found  on CL Medilaw’s website - shared to their website.

Media CoverageUsing our extensive and trusted network of media contacts following, we were able to secure our a vast amount of press coverage of the Inquest; over 80 pieces across TV, online, radio and print.

Due to the high level of interest from the press in the Davis Inquest, managing the media was critical to ensure the family were not overwhelmed or felt pressured by them. This was done by securing critical interviews that maximised their visibility to ensure their experience was told diligently and apathetically. Scala helped to secure numerous interviews with Robyn, Jonny and their solicitor Laura Cook.

Additionally, utilising news agencies on a national and regional level expanded the coverage even further, through the use of PA Media and Solent News and Pictures, respectively. This could only be done thanks to Scala’s clear and precise account of the inquest, the background of the hearing and through Cl Medilaw’s prestige in the legal landscape of the UK.

Coverage included major outlets such as:

• BBC – “Parents suffering 'life sentence' after death of son”
• ITV - “Bereaved Sussex mother says midwives failed to act when she raised alarm during labour”
• Sky – “Orlando Davis: 'Neglect' played part in 14-day-old baby's death, inquest finds”
• Daily Telegraph - “My baby died after my midwife colleagues dismissed my concerns during labour. I was gaslit”
• Independent – “Parents living ‘life sentence’ since death of 14-day-old baby boy”
• Mirror Online – “Neglect contributed to death of 14-day-old baby as mum's rare condition unrecognised”
• Mail Online – “Midwives who delivered baby who died two weeks after emergency birth had never heard of rare condition caused by mother drinking seven litres of fluid during labour, leaving son with severe brain damage, inquest hears”

A full list of the extensive press coverage for the inquest can be found via our Coverage Book.

Post-Inquest Press Statements

Statement from Laura Cook, Partner at CL Medilaw:

“The evidence heard throughout this inquest is yet another shocking example of how basic failures in maternity care have led to another tragic death of an otherwise healthy and full term baby. Despite failings being found by HSIB and by independent experts, the Trust’s midwives showed no acceptance of any wrongdoing or that they would have done anything differently, despite such a tragic and shocking outcome to an otherwise healthy, full term and low-risk pregnancy. This only added insult to the family’s distress. 

“The inquest has highlighted an issue with the current practice of many midwives and obstetricians to treat fetal tachycardia by increasing fluids and encouraging hydration. The Coroner is gravely concerned about the lack of education around this and believes Orlando’s death is one death too many. 

“We welcome the Coroners decision to write to the Department of Health and the professional regulatory bodies for midwives and obstetricians to draw their attention to the lack on national guidance. Despite hyponatraemia of the severity seen in Robyn and Orlando being rare, it is nonetheless the case that they should never have got to that point. 

“The Coroner has found there were failings by the midwives to listen to Robyn’s concerns and recognise her deterioration during labour. Thus far, there has been a concerning lack of accountability from those involved in Robyn’s care. 

“We will now continue working with Robyn and Jonny to secure a full admission of liability from UHS NHS Trust for Orlando’s death and the injuries suffered by Robyn through the civil courts.”

Statement from Orlando’s Parents, Robyn and Jonny Davis:

“We have waited an agonising two and a half years for Orlando’s Inquest to take place, a delay that has added to our anguish. We had expected that the Inquest process would reveal the truth and facts about what happened. 

“Instead we’ve heard accounts and evidence from various individuals involved at all levels of our care which was defensive and we feel obscures the true picture. Rather than an attempt at exoneration, this should have been an opportunity for a full and frank appraisal of what happened.  

“What’s scares us, is that this is not an isolated incident and we know of many other families going through this same agony. We are thankful that our birth video threw out any ambiguity. We’re also thankful for our brilliant legal team who have ensured that our heartbreaking experience was properly communicated to the Coroner. 

“Whilst nothing will ever bring Orlando back, we’d like to thank the Senior Coroner for acknowledging that this is a case where there has been a gross failure to provide basic medical attention, and finding that these gross failures amounted to neglect.

“As hard as it is to look forward at this moment, we’re joining the call for a national public inquiry into maternity care across England.” 

CL Medilaw will continue to work with Robyn and Jonny Davis to secure a full admission of liability from the UHS NHS Trust for Orlando’s death and the injuries caused to Robyn who nearly died during childbirth.

The barrister representing the family is Francesca O’Neill at Deka Chambers.