The Daily Telegraph - Saturday
‘Every single one of them had the opportunity to do something different – and they didn’t’
A couple relive the threeyear fight for justice after the death of their newborn son – with the heartbroken mother insisting midwives ignored her pleas for help
A FEW hours into her labour with her second child, former midwife Robyn Davis began to feel drowsy and confused, as though she was drunk, and repeatedly told midwives she felt sure something was wrong.
But every time she raised concerns, they were brushed aside. The midwives attending her birth were former colleagues and friends of hers, they were relaxed and insisted there was nothing to worry about.
Robyn grew increasingly panicked as her questions were dismissed. In a two-hour video which she had set up to record what she thought would be the birth of her child at home, midwives are caught on camera telling her things like: “You need to stop worrying and take off your midwife hat – pretend you know nothing.”
Hours later, Robyn was in a coma and her baby son Orlando was in intensive care with a severe brain injury caused by oxygen starvation. He died 14 days later.
An inquest this week concluded that neglect had “contributed” to his death. Midwives and doctors had failed to notice that Robyn had developed the rare and potentially fatal condition hyponatraemia during labour, where an imbalance of fluids alters blood sodium levels.
“I was gaslit,” Robyn, 28, says. “I trusted these people so much that at one point I felt it must be me going insane. I kept voicing my concerns but they shot them down without carrying out any observations [health checks].
“Normally I would have stood my ground, but I was too poorly to question it. I felt maybe I should just be quiet, because if they were so sure nothing was wrong then it must be me being crazy. I was totally powerless.”
When we meet in their bungalow in West Sussex, Robyn and her husband Jonny, 30, who works in graphic design, describe their life as “picture perfect” before Orlando died.
The couple met in Brighton as teenagers in 2012, when they were 17 and 19, through a mutual love of music (Jonny played in bands, while Robyn was studying drumming). After several happy years together, they got engaged in 2017, around the same time as Robyn got her first job as a midwife.
She had loved studying midwifery at the University of Brighton and enjoyed her placement at Worthing Hospital, which was rated as outstanding by the Care Quality Commission. After graduating with first-class honours, she was delighted to get a position within the same trust.
But on her very first shift, she realised everything felt wrong. The department was understaffed, meaning there was little support for newly qualified midwives.
On her first day, Robyn was left alone in charge of a woman having a baby prematurely. The baby’s heartrate didn’t look good and there was no interpreter to help her speak to the woman, who had poor English.
“I ran out to get help but there was no-one there,” she says. “When I did find people they said they were too busy. I was completely on my own and out of my depth. Often I was too busy to give the care I wanted to give. On postnatal ward, I could be looking after 10 women and their babies. My anxiety levels were so high, knowing there was so much more I should be doing but just couldn’t. Throughout the time I worked there, I was made to feel I shouldn’t be asking questions. I would come home and cry.”
Robyn handed in her notice after four months and, when her request to transfer was refused, she quit the profession and retrained as a teacher, working primarily in nurseries caring for babies. She and Jonny married in 2019 and had a daughter, Dixie, in May 2020.
Although strict lockdown restrictions in place at the time prevented Robyn from being able to have a homebirth she wanted or attend hospital with her husband until her labour was advanced, she describes the birth as “textbook” – it was straightforward and she delivered Dixie quickly in a home-from-home birthing room at Worthing Hospital without requiring pain relief or medical assistance.
Despite her experiences as a midwife a few years earlier, Robyn had felt confident giving birth at Worthing.
“I knew it well, I knew the staff, which I thought was a positive, I knew I was low-risk and felt sure I could advocate for myself because of my training,” she recalls. “In the end, we had a wonderful experience.”
When she discovered she was pregnant again when her first child was just eight weeks old, Robyn was surprised but delighted.
Again, the pregnancy was largely straightforward and midwives were happy for her to have a homebirth. When she went into labour on Sept 9, 2021, she was excited and looking forward to meeting her son.
But things began to go wrong while she was labouring at home. Robyn and Jonny repeatedly told the attending midwives she hadn’t been able to pass urine when she tried to go to the lavatory. Robyn said the baby felt “stuck” and questioned if he was in the right position. In hindsight, they believe his unusual position may have blocked her bladder, preventing her from being unable to urinate.
She kept saying she felt unwell and was unnaturally tired, finding it harder and harder to speak as time passed.
But every time she questioned if everything was OK, her concerns were dismissed.
When the baby’s heart rate became raised on multiple occasions – which can be a sign something is wrong – midwives urged Robyn to drink more and stay hydrated. In fact, each of the seven midwives and two doctors the couple saw during her 16-hour labour said the same. The message that Robyn had not been able to go to the lavatory was not passed on between staff changing shifts.
By the evening, midwives became concerned enough about the baby’s heartbeat to transfer her to hospital by ambulance that evening, Robyn had drunk 4 litres of water. In hospital, a lack of communication between staff meant another 3 litres of fluid were pumped into her intravenously.
Not long afterwards, Robyn violently vomited two litres of liquid. By the time a doctor decided a C-section was necessary, Robyn was too delirious to sign the consent form. All she could say was: “Help me.”
As Jonny bent down beside her with the form to try to encourage her to sign it, he saw Robyn’s eyes roll back into her head. She let out a scream and began convulsing violently.
What happened next is a blur to the couple – many details they have only found out much later during investigations and the inquest. They know the closest operating theatre was shut for a clean so Robyn had to be taken to another floor.
There were delays as the lift wasn’t working properly. At one point, a member of staff had to sit on the trolley to restrain Robyn during a seizure. It was some time before she was stable enough for doctors to perform an emergency C-section. Orlando was born without a heartbeat.
“He was born dead,” Robyn interjects. “They told me he was born in ‘poor condition’ but that downplays it.” After around 20 minutes of resuscitation, medics revived
Orlando’s heartbeat but he was severely brain damaged, paralysed from the head down and couldn’t swallow on his own. He was transferred to the neonatal intensive care unit 15 miles away at the Royal Sussex County Hospital in Brighton.
Robyn was placed in an induced coma for three days. When she woke, she was still experiencing the effects of hyponatraemia, including confusion and paranoia.
“No one had told me how ill my son was,” she says. “When I was finally able to see him, I went into the room smiling because I was excited to meet him and the doctor had to take me very gently to one side and explain there was nothing they could do for him.
“I started screaming. I was devastated. I became very angry that people had met my son, had touched him, before I could. I felt really upset I’d been away from him for so long.”
Orlando’s parents were told palliative care was the only option.
“The doctors told us there was a choice of withdrawing food, stopping clearing his airway or reducing his oxygen supply,” says Robyn. “Can you imagine how awful it is being asked to choose how you want your child to die? It goes against every single instinct you have as a parent.”
The decision was made with the medical team to withdraw all treatment. Orlando was introduced to his big sister. He passed away in his parents’ arms the following morning.
After three years of delays and the couple’s long fight for justice, at this week’s inquest the coroner did not, as they had hoped, conclude it was a case of gross negligence manslaughter.
Instead came a narrative verdict which noted that the failure of staff to recognise Robyn’s declining condition during labour was “fundamental”, that there were “lost opportunities” to treat her both at home and in hospital, and that Orlando’s death was “contributed to by neglect”.
While University Hospitals Sussex NHS Foundation Trust has offered its “sincere condolences” for the couple’s loss, there has been no apology for the events that led to Orlando’s death.
Robyn says: “In my training, I was taught that if you make a mistake, you hold your hands up to it,” she says.“I don’t claim these people wanted what happened to happen, but they didn’t do anything to stop it. Every single one of them had the opportunity to do something different – and they didn’t.”
In fact, when one midwife was questioned at the inquest as to whether she would do anything differently if she could go back in time, knowing as she did now that the events had led to Orlando’s death, she said no. “I’m haunted by that – not only as a midwife, but as a friend,” Robyn adds quietly. She hasn’t spoken to any of her former colleagues or friends from the hospital since Orlando was born.
At both the inquest and in the official statement the Trust has released since, it has emphasised how hyponatraemia is “an extremely rare condition which is little understood”.
Robyn believes this deflects from a failure to carry out basic midwifery care. “I wasn’t taught about hyponatraemia – it is rare – but I was taught that you need to be really vigilant about monitoring fluid input and output during labour,” she adds.
The inquest took place when the couple’s third child, Nova, was just nine weeks old. She was born via a planned C-section at in Brighton, where Robyn said the couple’s anxieties were taken seriously and they received very good care.
As a result of Orlando’s birth, Robyn incurred injuries, including lasting damage to her pelvic floor and bladder. She cannot stand for long or lift anything heavy and has had to leave her job.
“The thing I was really good at was working with children but I just can’t now,” she says. “It is too triggering. I find it so hard to be around little boys knowing we should have a two-yearold at home.”
Both she and Jonny have been diagnosed with PTSD, anxiety and depression following Orlando’s death and have spent thousands of pounds on therapy.
The couple are also suing the Trust in a civil case. The Trust says it has since implemented training for staff in hyponatraemia and the coroner is recommending national guidelines be put in place.
“I’m glad that there is learning happening that will hopefully help people in future, but my son wasn’t born to be a learning curve, he should be at home thriving,” she adds.
Asked what justice they would like to see, the couple say they can’t imagine what justice could look like.
“All these people who were involved in our care, they get to go home at the end of the day and carry on with their lives,” Robyn adds. “Our lives will never be the same again. Every day I wake up with the knowledge that my son is dead – for us it is a life sentence. I put all my trust in these people to keep me and my baby safe. They failed us.”
‘Can you imagine how awful it is being asked to choose how you want your child to die?’