Orlando Davis

From Baroness Gillian Merron 
Parliamentary Under-Secretary of State for
Patient Safety, Women’s Health and Mental Health 

39 Victoria Street 
London 
SW1H 0EU 

24 July 2024 

Our Ref: 

Penelope Schofield  
Record Office
Orchard Street
Chichester
PO19 1DD
By email: 

Dear Penelope, 

Thank you for your Regulation 28 report to prevent future deaths dated 26/04/24 
about the death of Orlando Nova Davis. I am replying as the newly appointed 
Minister with responsibility for Patient Safety, Women’s Health and Mental Health. 

Firstly, I would like to say how saddened I was to read of the circumstances of 
Orlando’s death, and I offer my sincere condolences to their family and loved ones. 
The circumstances your report describes are deeply concerning and I am grateful to 
you for bringing these matters to my attention.  

The report raises concerns about an irreversible brain injury caused to Orlando 
when his mother suffered a seizure having developed hyponatremia during her 
labour, and how midwifes (in the community and in the hospital, who had cared for 
Orlando’s mother) were unaware of this potential condition developing in birthing 
women.  

Your report states that due to Orlando developing a tachycardia during labour, 
Orlando’s mother was actively encouraged to take in more fluid, yet there was no 
accurate record kept of either input or output of fluid. Again, when in hospital, further 
fluids were given intravenously with no recognition of any potential risk of 
hyponatremia developing by the midwives or the doctor on duty. 

In 2023, NHS Resolution published a report entitled  Recognising and avoiding 
significant maternal and neonatal hyponatraemia. This is a case story which is 
illustrative but based on recurring themes from real life events, to share insights and 
support learning from harm. The report highlights the importance of accurate fluid 
balance monitoring during labour to reduce the chance of a mother experiencing 
hyponatraemia and asked services to consider their local guidance. There was also
a recommendation for trusts to read the Northern Ireland GAIN guideline on 
hyponatraemia in labour and consider whether it could be implemented in their 
services.  

1 

 Current national guidance is informed by The National Institute for Health and Care 
Excellence (NICE). Hyponatraemia is described in a Clinical Skills Summary 
(CKS) which provides primary care practitioners with a readily accessible summary 
of current evidence base and practical advice on best practice, Hyponatraemia 
NICE (2020). This is largely based on expert opinion in the clinical practice 
guideline on diagnosis and treatment of hyponatraemia. 

Many trusts have developed their adult hyponatremia guidelines as a reference for 
the management of hyponatraemia in adults, with further guidance for the 
management of Intravenous fluid therapy in adults in hospital (nice.org.uk) (2017). 
NICE guidance on hyponatraemia specifically in the peripartum period is 
embedded within NICE Guidance (NG229) Fetal monitoring in labour (nice.org.uk) 
(2022) which has been updated and advises not to offer intravenous fluids to treat 
fetal heart rate abnormalities unless the woman is hypotensive or has signs of 
sepsis.  

NICE Guidance (NG235) Intrapartum care (nice.org.uk) (2023) has also been 
updated to include the following:-  

• 1.8.17 Inform the woman that she can drink during labour when she is 

thirsty, but there is no benefit to drinking more than normal. Isotonic drinks 
may be more beneficial than water. [2007, amended 2023]

• 1.8.23 Review bladder care for women at least every 4 hours. This should 

include:

o Frequency of passing urine and bladder sensation
o Fluid balance monitoring if sensation is abnormal or absent, if there is 
an inability to pass urine, or the woman is receiving intravenous fluids 
(including oxytocin)

o Offering to insert a catheter if there are any ongoing concerns over 

the woman’s ability to pass urine. [2023]

• 1.8.47 When starting intravenous oxytocin in the first stage of labour:

o Do not start separate intravenous fluids without a clinical indication 

(for example, the woman is not drinking, is dehydrated, or is 
hypotensive)

o Monitor fluid balance [2023] 

The guidance also advises on the cautious use of intravenous fluids and monitoring 
of fluid balance every four hours and especially if a woman has altered sensation to 
urinate or is receiving intravenous fluids. When a woman chooses to have a low-
dose epidural for pain relief, she is no longer required to have fluids administered 
prior to the procedure (known as pre-loading), or any maintenance fluid infusion. 
This is to limit the likelihood of fluid overload and hyponatraemia. However, the term 
“hyponatraemia” is not used in either of these national guidelines in maternity and 
there is no stand-alone guidance specifically for hyponatraemia in maternity 
services nationally. 

Individual trusts may have developed this based on the guidance from GAIN, 
NHS Resolution’s case reviews and local learning. The Core competency 
framework v2 (2023) was published to guide trusts in developing their training in 
response to local and national learning.  

 Reviews of brain injury cases through programmes such as the Royal College of 
Obstetricians and Gynaecologists (RCOG) Each Baby Counts programme and 
NHS Resolution’s Early Notification programme have identified two clinical areas of 
practice that contribute to avoidable brain injuries:  

1. Failure to identify, escalate and act on signs of foetal deterioration during 

labour, and

2. Failure to adequately manage an impacted foetal head during caesarean 

section. 

To address these issues and accelerate progress towards achieving the National 
Maternity Safety Ambition, the Department of Health and Social Care has 
established a Brain Injury Reduction Programme.  

In 2021-22, the Department provided £5 million to the Royal College of 
Obstetricians and Gynaecologists (RCOG) to lead on Phase 1 and Phase 2 of the 
Brain Injury Reduction Programme. The RCOG subsequently formed a 
collaboration with the Royal College of Midwives (RCM) and the Healthcare 
Improvement Studies (THIS) Institute, which was named the ‘Avoiding Brain Injury 
in Childbirth’ (ABC) collaboration. 

For phase 1, the ABC has developed consensus-building approaches, 
standardised tools, and training to reduce the rate of intrapartum brain injuries. For 
Phase 2, the ABC developed clinical tools and training approaches needed for 
future implementation to standardise the identification and escalation of a 
deteriorating baby.  

A national pilot for the tools and training approaches commenced in May. The pilot 
will help inform a full national rollout of the programme. At the 2024 Spring Budget, 
£9m over three years was committed to roll out the Brain Injury Reduction 
Programme across maternity units in England following successful completion of 
the pilot. This will provide maternity services with the tools and training to reduce 
brain injuries in childbirth. 

The Nursing and Midwifery Council's standards of proficiency for midwives 
represent the knowledge, skills and attributes that all midwives must demonstrate 
at the point of registration and reflect what the public, women and families can 
expect midwives to know and be able to do in order to provide the best and safest 
care possible. 

The standards are grouped under six domains, and domain four sets out the 
midwife’s role in first line assessment and management of complications and 
additional care needs. Standard 6.69 states that midwives must "recognise, 
assess, plan, and respond to pre-existing and emerging complications and 
additional care needs for women and newborn infants, collaborating with, 
consulting and referring to the interdisciplinary and multiagency team as 
appropriate. 

The NHS in England is working in collaboration with national partners and 
providers of maternity care, towards the national ambition to halve the rates of 
stillbirth, neonatal and maternal mortality, and intrapartum brain injury by 2025.

 Several initiatives are underway including how we learn from incidents with the 
introduction of the Perinatal Safety Incident Reporting Framework (2020), the 
ongoing reporting from MBRRACE-UK, and thematical reviews by MNSI, the 
Maternity and Neonatal Safety Investigations programme. To date, there has 
not been any thematical reviews pertaining to hyponatraemia in maternity 
services.  

I hope this response is helpful and demonstrates my sincere desire to improve 
care for patients so we can avoid such tragedies from occurring. Thank you for 
bringing these important concerns to my attention.  

Yours sincerely, 

BARONESS GILLIAN MERRON

Ms Penelope Schofield 
Senior Coroner 
County Records Office 
HM Coroners Office 
Orchard Street 
Chichester 
West Sussex 
PO19 1DD 

21 June 2024 

Dear Madam 

NHS Sussex 
Wicker House 
High Street 
Worthing 
BN11 1DJ 

Tel: 

E-mail: 

Website: www.sussex.ics.nhs.uk  

I write in response to your Regulation 28 report and your covering letter dated 26.04.2024, 
setting out your concerns after hearing evidence at the Inquest touching on the death of 
Orlando Nova Davis. 

I wish to begin by extending my sincere condolences to  Orlando’s family. This must have 
been an extremely difficult time for them, and I hope that my response provides them and 
you with assurances that NHS Sussex Integrated Care Board has taken action to address 
the issues set out in your Regulation 28 report. 

HM Coroner’s concerns 

The matters of concern are that;  

Orlando was caused an irreversible brain injury when his mother suffered a seizure 
having developed hyponatremia during her labour. The concern is that the midwifes 
(in  the  community  and  in  the  hospital,  who  had  cared  for  Orlando’s  mother)  were 
completely unaware of this potential condition developing in birthing women. 
In this case due to Orlando developing a tachycardia during labour Orlando’s mothers 
was actively encouraged to take in more fluid yet there was no accurate record kept 
of  either  input  or  output  of  fluid.  Again,  when  in  hospital  further  fluids  were  given 
intravenously with no recognition of any potential risk of hyponatremia developing by 
the midwives or the Doctor on duty. 

Our Response 

NHS  Sussex  Integrated  Care  Board  (‘the  ICB’)  is  the  lead  commissioner  for  maternity 
services provided by University Hospitals Sussex NHS Foundation Trust (“UHSx”) and East 
Sussex Healthcare NHS Trust (“ESHT”).  NHS Sussex ICB works in partnership with Surrey 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Heartlands ICB  and  with  Kent  and  Medway ICB  who  are the  lead commissioners for the 
maternity services provided by Surrey and Sussex NHS Foundation Trust and Maidstone 
and  Tunbridge  Wells  NHS  Trust  who  also  provide  some  maternity  services  for  parts  of 
Sussex.   

As part of our commissioning role, we seek assurance about the quality and delivery of the 
maternity services provided and we work together with our partners, including service user 
representatives and including those where other ICBs are the lead commissioners, to share 
learning and to make improvements for the people of Sussex.   

We also have a Local Maternity & Neonatal system (LMNS). The purpose of the LMNS, is 
stated below:  
‘As the maternity arm of NHS Sussex, Sussex LMNS oversees perinatal clinical quality with 
the  ICB  quality  and  contracting  teams,  playing  a  key  role  in  quality  oversight,  ensuring 
integrated  oversight  and  action’.(Sussex  LMNS  Perinatal  Quality  Surveillance  Operating 
Model, (1st approved April 2022))    

We seek to disseminate any learning from the reports and the recommendations from any 
maternity investigation as widely as we can across Sussex maternity practitioners. We have 
a clinical shared learning forum for maternity investigations where reported serious incidents 
and actions are discussed. This is a monthly meeting which brings together clinicians from 
the perinatal multi-disciplinary team across the LMNS.  

HSIB  attended  the  learning  forum in  September  2022,  and  confirmed  from  investigations 
they  had  undertaken  nationally,  that  the  improvement  areas  being  progressed  regarding 
awareness and education around hyponatraemia, were being targeted appropriately.  

There are two particular issues that arise from HM Coroners concerns regarding the care of 
  and  Orlando  Nova  Davis  during  labour.    The  first  is  regarding  the  failure  of  the 
midwives to monitor fluid balance and to record the fluids accurately during labour  in the 
community and in Hospital, although we are advised by UHSx that the guidance at the time 
did not require accurate monitoring of fluid balance during labour,   and the second is the 
lack of knowledge and education amongst both doctors and midwives in relation to the rare 
complication of hyponatraemia in labour.   

We can confirm that by November 2022, both Trusts, UHSx and ESHT, had put in place 
policies  with  regards  fluid  management  and  hyponatraemia  in  labour.    Training  and 
education  related  to  the  accuracy  of  fluid  management  and  the  risk  of  hyponatraemia  in 
labour, has also been developed and has been delivered at both Trusts.   

Both Trusts are also auditing compliance with the completion of fluid balance charts, and we 
have requested another audit is completed before the end of the year.   A leaflet has been 
developed  advising  mothers  about  fluid  intake  in  early  labour.    The  leaflet  has  been 
published  by  UHSx and  a  publication  is being  considered by  ESHT  for inclusion on  their 
website.   

 
 
 
 
 
 
 
 
 
 NHS  Sussex  continues  to  oversee  further  improvements,  including  further  fluid  balance 
audits covering all birth settings and being shared with NHS Sussex following completion,  
through its perinatal quality surveillance arrangements.   

In order to enable the learning to be shared more widely with other Integrated Care Systems, 
our  work  on  hyponatraemia  and  fluid  balance  in  labour  was  shared  with    the  Regional 
Maternity  Team  at  NHS  England  in  2022,  as  part  of  the  perinatal  quality  surveillance 
processes, put in place following the Ockenden Review.  

I hope that we have provided you and Orlando’s family with some assurance that NHS 
Sussex ICB has taken steps to address the concerns outlined in your report and that we 
are continuing to take action to prioritise patient safety in our maternity departments. 

Thank you for raising this matter with me and please contact me if I can be of any further 
assistance. 

Yours sincerely, 

Chief Nursing Officer  

On behalf of NHS Sussex

From the Chief Executive and Registrar 

Penelope Schofield 
Senior Coroner for West Sussex, Brighton and Hove  

By email to: 

21 June 2024  

Dear Ms Schofield  

Private and confidential  

The late Orlando Davis – NMC response to Regulation 28 Prevention of Future 
Deaths report  

Thank you for sending your Regulation 28 Prevention of Future Deaths (PFD) report 
made  under  paragraph  7,  Schedule  5,  of  the  Coroners  and  Justice  Act  2009  and 
Regulations  28  and  29  of  the  Coroners  (Investigations)  Regulations  2013  to  us  for 
review.  I write to provide a response on behalf of the Nursing and Midwifery Council 
(NMC).   

I’d like to begin by offering my sincere condolences to Master Orlando Davis’s family 
for their great loss. I’d also like to assure you and them that I take the concerns you 
have raised in the Regulation 28 PFD report very seriously.  I set out below the steps 
we will take to respond to the concerns raised. In summary:  

1.  We  are  carrying  out  Fitness  to  Practise  (FtP)  investigations  and  will  take 
appropriate action to protect the public and uphold standards where we identify 
concerns relating to professionals on our register. 

2.  We have shared the PFD report with the General Medical Council (GMC) so 

they can take appropriate action which falls within their remit. 

3.  We  will  develop  and  publish  a  scenario  to  inform  student  midwives  and 
midwives about hyponatraemia for the start of the next academic year and raise 
awareness with our education colleagues.  

 
 
 
  
  
  
  
  
  
 
  
  
  
 
 
 
 
 
 
 
 Background  

I  note  that  your  investigation  into Orlando’s death  concluded  that  there had been a 
complete lack of awareness or understanding of hyponatraemia by those who cared 
for  Mrs  Davis  (Orlando’s  mother)  when  she  suffered  a  seizure  during  labour.  You 
indicated that it is that lack of understanding which led to Mrs Davis being encouraged 
to take in more fluid during labour, ultimately causing Orlando to develop a tachycardia 
as there was no recognition by the midwives or the doctor on duty of the potential risk 
of  hyponatraemia  developing;  and  lastly  but  not  least,  the  failure  to  keep  accurate 
records of either input or output of fluid.   

As a result, you have raised the following concerns:  

1.  The  concern  that  midwives  (in  the  community  and  in  the  hospital)  were 
completely unaware of this potential condition developing in birthing women.  

2.  No accurate records were kept of either input or output fluid and there was no 
recognition of any potential risk of hyponatraemia developing by the midwives 
or the doctor on duty.  

Our function 

The NMC is the independent regulator of more than 808,000 nurses and midwives in 
the  UK  and  nursing  associates  in  England.  We’re  here  to  protect  the  public  by 
upholding high professional nursing and midwifery standards, which the public has a 
right  to  expect.  We’re  continuing  to  improve  the  way  we  regulate,  enhancing  our 
support for colleagues, professionals, and the public, and working with our partners to 
influence the future of health and social care.  

The over-arching objective of the NMC in exercising its functions "is the protection of 
the public" (Article 3(4) of the Order) and Article 3(4A) provides that:   

"The pursuit by the Council of its over-arching objective involves the pursuit of the 
following objectives:  

(a) to protect, promote and maintain the health, safety and wellbeing of the public;  

(b) to promote and maintain public confidence in the professions regulated under  
this Order; and  

(c) to promote and maintain proper professional standards and conduct for members 
of those professions."  

Our  core  role  is  to  regulate.  We  set  and  promote  high  education  and  professional 
standards for nurses and midwives across the UK, and nursing associates in England 
and  quality  assure  their  education  programmes.  We  maintain  the  integrity  of  the 

2 

 
 
   
  
  
 
 
  
 
  
  
  
  
  
 register of those eligible to practise. And we investigate concerns about professionals 
– something that affects very few people on our register every year. 

To regulate well, we support nursing and midwifery professionals and the public. We 
create  resources  and  guidance  that  are  useful  throughout  professionals’  careers, 
helping them to deliver our standards in practice and address challenges they face. 
We  work  collaboratively  so  everyone  feels  engaged  and  empowered  to  shape  our 
work.  

We work with our partners to address common concerns, share our data, insight, and 
learning,  to  influence  and  inform  decision-making  and  help  drive  improvement  in 
health and social care for people and communities.   

It falls within our remit to take appropriate steps to ensure that registered midwives 
have the skills and knowledge they need to deliver safe, kind, and effective midwifery 
care  for  women  giving  birth  and  newborn  infants.  I  have  explained  in  further  detail 
below how our standards and processes  apply in relation to the concerns you have 
raised.  

Standards for Midwives 

Our standards of proficiency apply to all NMC midwives. They should be read with 
our standards for education and training, which set out our expectations regarding 
provision of all pre-registration and post-registration NMC approved midwifery 
education programmes. These standards apply to all approved education providers 
and are set out in three parts including the standards framework for nursing and 
midwifery education, the standards for student supervision and assessment, and the 
programme standards, which are the standards specific for each pre-registration or 
post-registration programme.  

Midwifery students are assessed to ensure they are proficient in providing safe, 
effective, and kind care that improves the health and wellbeing of the women and 
newborn infants in their care. Proficiencies are the knowledge, skills, and behaviours 
that midwives need to join our register and practise.   

We do not specify a list of diseases or conditions that professionals need to know or 
be able to provide care in respect of. This is because it would not be possible to 
keep such a list up to date and complete. We rely on our Approved Education 
Institutions (AEIs) to develop evidence-based curricula which reflect local practice 
contexts and the population. 

I set out below the relevant sections within the domains of the Standards of 
proficiency for midwives that are most relevant to this case.   

Under Domain 1, midwives are required to understand and apply the principles of 
courage, integrity, transparency, and the professional duty of candour, recognising 

3 

 
 
  
 
 
  
  
  
 
 
 
 and reporting any situations, behaviours, or errors that could result in sub-standard 
care, dysfunctional attitudes and behaviour, ineffective team working, or adverse 
outcomes. Midwives are also required to understand the importance of effective 
record keeping, and maintain consistent, complete, clear, accurate, secure, and 
timely records to ensure an account of all care given is available for review by the 
woman and by all professionals involved in care.  

Under Domain 4, midwives are required to demonstrate knowledge and 
understanding of pre-existing, current and emerging complications and additional 
care needs that affect the woman, including their potential impact on the woman’s 
health and wellbeing; and the ability to recognise and provide any care, support or 
referral that may be required because of any such complications or needs.   

They should also demonstrate knowledge, understanding, and the ability to 
recognise complications and additional care needs regarding embryology and foetal 
development, adaptation to life and the newborn infant.   

They must be able to use evidence-based, best practice approaches to respond 
promptly to signs of compromise and deterioration in the woman, foetus, and 
newborn infant, and to make clinical decisions based on need and best practice 
evidence, and act on those decisions.  

Under Domain 6, midwives are required to demonstrate the ability to use evidence-
based communication skills when communicating and sharing information with the 
woman, newborn infants and families that takes account of the woman’s needs, 
views, preferences, and decisions, and the needs of the newborn infant by actively 
listening, recognising and responding to verbal and non-verbal cues, and responding 
to women’s questions and concerns with kindness and compassion.  

They are particularly required under Domain 6 to: 

•  keep, and securely store, effective records for all aspects of the continuum of 
care  for  the  woman,  newborn  infant,  partner  and  family  by  presenting  and 
sharing  verbal,  digital  and  written  reports  with  individuals  and/or  groups, 
respecting confidentiality; by clearly documenting the woman’s understanding, 
input,  and  decisions  about  her  care  and 
informing  and  updating 
interdisciplinary and multiagency colleagues about changes in care needs and 
care planning, and update records accordingly.  

• 

respond  to  any  questions  and  concerns  and  recognise  the  woman’s  own 
expertise  of  her  own  pre-existing  conditions,  demonstrate  the  ability  to 
measure  and  record  vital  signs  for  the  woman  and  newborn  infant,  using 
technological  aids  where  appropriate,  and  implement  appropriate responses 
and decisions, demonstrate the ability to work in partnership with the woman 
to assess and provide care and support across the continuum that ensures the 
safe administration of medicines. 

4 

 
 
  
  
  
  
  
 
 
 • 

recognise,  assess,  plan,  and  respond 
to  pre-existing  and  emerging 
complications  and  additional  care  needs  for  women  and  newborn  infants, 
collaborating  with,  consulting  and  referring  to  the  interdisciplinary  and 
multiagency  team  as  appropriate  and  a  prompt  call  for  assistance  and 
escalation as necessary.   

•  monitor  deterioration  using  evidence-based  early  warning  tools,  respond  to 
signs of infection, sepsis, blood loss including haemorrhage, and meconium-
stained  liquor,  keep  accurate and  clear records,  including  emergency  scribe 
sheets, 

•  work 

in  partnership  with 

the 
the  woman  and 
interdisciplinary and/or multiagency team to plan and implement midwifery care 
for  women  and  newborn  infants  as  appropriate  to implement  necessary 
interventions when physical complications occur. 

in  collaboration  with 

We only approve courses of midwifery education once we are satisfied that the 
course provider has met the standards of education and training that we have set as 
being necessary for midwives to achieve our standards of proficiency. This is the 
framework prescribed by our legislation which gives us assurance that newly 
qualified midwives entering the NMC register will be able to deliver safe, effective, 
respectful, kind, compassionate, person-centred midwifery care.  

We do not refer to hyponatraemia specifically in our standards. Our standards are 
high level and outcome focused. This is because we believe the detail is better 
situated within curricula to reflect that evidence changes and practice experiences 
and assessment can be developed accordingly. We will develop and publish a 
scenario to inform student midwives and midwives about this condition for the start of 
the next academic year and raise awareness with our education colleagues.  

Continued Practice and Revalidation  

To maintain registration with the NMC, every nurse, midwife and nursing associate 
on our register must 'revalidate' every three years. This is to ensure they remain 
capable of safe and effective practice. The revalidation process requires nursing and 
midwifery professionals to demonstrate that they have practised for at least 450 
hours, obtained at least 35 hours of continuing professional development, including 
20 hours of participatory learning, reflected on their practice and obtained five pieces 
of practice related feedback.  

Revalidation encourages nurses, midwives and nursing associates to promote 
lifelong learning. It requires professionals to reflect on their practice and how the 
Code applies to their day-to-day work. This is how we ensure that those on our 
register continue to maintain the knowledge and skills required for safe and effective 

5 

 
 
 
 
 
  
 
  
  
 
 care in the UK. Links to our revalidation guidance can be found here: What is 
revalidation? - The Nursing and Midwifery Council (nmc.org.uk).  

The NMC Code and Fitness to Practise 

Paragraph 10 of The Code sets out our expectations in relation to record keeping 
including that registrants must keep clear and accurate records relevant to their 
practice. Specifically, registrants must:  

1.  complete records at the time or as soon as possible after an event, recording 

if the notes are written some time after the event; 

2.  identify any risks or problems that have arisen and the steps taken to deal 
with them, so that colleagues who use the records have all the information 
they need; 

3.  complete records accurately and without any falsification, taking immediate 
and appropriate action if you become aware that someone has not kept to 
these requirements;   

4.  attribute any entries you make in any paper or electronic records to yourself, 
making sure they are clearly written, dated and timed, and do not include 
unnecessary abbreviations, jargon or speculation;  

5.  take all steps to make sure that records are kept securely;   
6.  collect, treat and store all data and research findings appropriately. 

We will investigate alleged breaches of the Code when we become aware of them. 
In appropriate circumstances we enforce the standards set out in the Code through 
fitness to practise proceedings. Fitness to practise proceedings can result in a range 
of outcomes, ranging from the provision of advice to the registrant by the NMC to 
removal of the registrant from the register.  

We are taking steps to investigate the concerns raised in relation to this incident to 
establish whether we need to take any regulatory action to protect the public and 
maintain our regulatory standards. Further information about our fitness to practise 
processes can be found here: How we regulate and the types of concerns we look 
into - The Nursing and Midwifery Council (nmc.org.uk).  

We recognise the impact that FtP proceedings can have on families, which is why we 
have a Public Support Service (PSS) to help support people through the process and 
understand how the investigation process works. Through it, our public support officers 
can answer individual questions or provide one-to-one meetings and help explain the 
different decisions that could be made. We have been engaging with Orlando’s family 
through the investigation process. More information about our PSS can be found here 
NMC public support service - The Nursing and Midwifery Council 

The PFD report mentions that there was also a doctor on duty who failed to recognise 
the  potential  risk  of  hyponatraemia.    Whilst  our  statutory  remit  does  not  extend  to 
doctors, we have shared this information with the GMC in accordance with our fitness 

6 

 
 
 
  
 
 
  
 
 to  practise  information  handling  guidance  (ftp-information-handling-guidance.pdf 
(nmc.org.uk)) in case they need to carry out further investigations. 

Conclusion  

We take the concerns you raise in the PFD report and the circumstances leading to 
Orlando’s death very seriously. We are committed to taking steps that are within our 
powers  to  address  the  concerns  raised.  We  will  do  this  by  taking  specific  action  to 
address any fitness to practise concerns we identify in relation to professionals on our 
register, sharing necessary information with the General Medical Council so they can 
take  any  action  required  to  protect  the  public,  and  developing  a  scenario  to  inform 
student  midwives  and  midwives  about  hyponatraemia  to  raise  awareness  of  the 
condition.  

I hope this provides reassurance that we are taking appropriate action to address the 
concerns you have raised.  Once again, I offer my heartfelt condolences to Orlando’s 
family.  If  you  have  any  further  questions  concerning  this  case  or  the  steps  we  are 
taking, please do not hesitate to contact us.   

Yours sincerely   

Chief Executive and Registrar  

cc:  

7

Penelope Schofield 
Her Majesty’s Senior Coroner for West Sussex, Brighton and Hove 
Parkside Chart Way, 
Horsham 
RH12 1XH 

15 July 2024 

Dear Ms Schofield, 

Re: Baby Orlando Nova Davis - deceased 
Your ref: 02182-2021 

Thank you for your Regulation 28 Report to Prevent Future deaths following the inquest into 
the death of Baby Orlando Nova Davis dated 26 April 2024. 

The loss of a baby is a devastating tragedy for parents, the wider family, and healthcare 
professionals involved. We would like to begin by extending our deepest and heartfelt 
condolences to Orlando’s family for their profound loss. 

This response has been developed following input from members of the RCOG Patient 
Safety Committee and Senior Officers of the College.  

We recognise and respect the narrative conclusion from the inquest that Orlando died of 
irreversible brain injury when his mother suffered a seizure having developed hyponatremia 
during her pregnancy.  

We also recognise the matters of concern as outlined in your letter as follows, “in particular 
that the midwives (in the community and in the hospital, who had cared for Orlando’s 
mother) were completely unaware of this potential condition developing in birthing women. 
In this case due to Orlando developing a tachycardia during labour, Orlando’s mother was 
actively encouraged to take in more fluid yet there was no accurate record kept of either 
input or output of fluid. Again when in hospital further fluids were given intravenously with 
no recognition of any potential risk of hyponatremia developing by the midwives or the 
Doctor on duty.” 

The Royal College of Obstetricians and Gynaecologists (RCOG) plays a vital role in supporting 
maternity services through its educational initiatives. This encompasses developing 
curricula, elevating care standards through clinical guidance, assisting in career 
advancement through examinations, coordinating professional development initiatives and 
events, and offering support services to its members. Our commitment lies in improving 
maternity safety, working alongside partners such as Maternity and Newborn Safety 

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 Investigation (MNSI), NHS England, the Royal College of Midwives, National Institute of 
Clinical Excellence (NICE), and policymakers to realise this objective. 

Training in the assessment of maternal and fetal wellbeing is a core component of the RCOG 
curriculum and is a key component of the MRCOG examinations that all obstetrics and 
gynaecology trainees must pass before achieving their Certificate of Completion of Training 
(CCT) in obstetrics and gynaecology and entry to the specialist register. Evidence of 
undertaking training to demonstrate  fetal monitoring  interpretation skills is also a 
requirement of all O&G trainees to ensure they have the basic understanding of fetal 
monitoring principles. RCOG does not have independent guidelines for intrapartum care and 
fetal monitoring and recommends use of NICE guidance(1, 2) on this topic. 

NICE guideline1 (NG229): Fetal monitoring in labour states in point 1.5.11 that “if there are 
any concerns about the baby's wellbeing, be aware of the possible underlying causes and 
start 1 or more of the conservative measures based on an assessment of the most likely 
cause(s) and advises do not offer intravenous fluids to treat fetal heart rate abnormalities 
unless the woman is hypotensive or has signs of sepsis”.  

NICE guideline2 (NG235): Intrapartum care alludes to hydration in labour in 1.8.17 by advice 
to inform the woman that she can drink during labour when she is thirsty, but there is no 
benefit to drinking more than normal.  It does suggest (1.8.23) to review bladder care for 
women at least every 4 hours. This should include fluid balance monitoring if bladder 
sensation is abnormal or absent, if there is an inability to pass urine, or the woman is 
receiving intravenous fluids (including oxytocin).  

The Obstetric Anaesthesia Association has a Quick Reference Handbook for Obstetric 
Emergencies3, which addresses severe and non-severe hyponatraemia (2-9a and 2-9b) 
management plans, including signs, drugs and critical changes. However, there is a need for 
increased awareness amongst health care professionals in maternity and midwifery around 
accurate fluid balance monitoring and an earlier detection of hyponatremia in labour and 
postnatal period. As there is little known about hyponatraemia in pregnancy, the UK 
Obstetric Surveillance System4 (UKOSS) which is a joint initiative between the National 
Perinatal Epidemiology Unit and the Royal College of Obstetricians and Gynaecologists, has 
run a study to determine the incidence, risk factors and maternal/neonatal outcomes of 
peripartum hyponatraemia in obstetric patients in the UK. The results are not yet available.  

The Regulation and Quality Improvement Authority has also published a Guideline for the 
Prevention, Diagnosis and Management of Hyponatraemia in Labour and the Immediate 
Postpartum Period. (2017)5 

The RCOG is committed to improving the standard of care provided for women by working 
collaboratively with all stakeholders and in response to this matter, the RCOG will approach 
NICE to suggest an addendum to their Intrapartum care guideline: NG235 along the 
following lines: 

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 “Every woman in labour faces a heightened risk of hyponatremia, characterized by blood 
serum sodium levels below 130 mmol/L, particularly dilutional hyponatremia, also known as 
water intoxication. Long labour, excessive water intake or intravenous fluid administration 
and oxytocin use in labour can increase the risk of hyponatremia. Some of the early signs 
include headache, anorexia, nausea, lethargy, and apathy progressing to disorientation, 
agitation, seizures, depressed reflexes, coma, respiratory arrest and noncardiogenic 
pulmonary oedema.  

The occurrence of significant hyponatremia can be prevented by closely monitoring oral and 
intravenous fluid input and output, and promptly addressing positive fluid balance. Fluid 
balance charts should be used alongside the partograms in all low risk and high-risk women. 
The neonatal team should be informed about infants born to mothers or parents with 
hyponatremia, and consideration should be given to performing paired cord blood 
sampling.” 

In terms of actions to be taken, copies and publications, the RCOG would like to suggest that 
the Royal College of Midwives is also sighted on this concern. 

I hope this is a helpful response in this matter.  

Yours sincerely, 

CEO Royal College of Obstetricians and Gynaecologists 

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 References:  

1.  NICE guideline [NG229]: Fetal monitoring in labour. Published: 14 December 2022 

2.  NICE guideline [NG235]: Intrapartum care. Published: 29 September 2023 

3.  The Obstetric Anaesthesia Association- Quick Reference Handbook for Obstetric 

Emergencies 

4.  UK Obstetric Surveillance System (UKOSS) study  Peripartum Hyponatraemia in 

Pregnancy 

5.  RQIA (Regulation and Quality Improvement Authority), Guideline for the Prevention, 

Diagnosis and Management of Hyponatraemia in Labour and the Immediate 
Postpartum Period. 

6.  NHS Resolution, Case story -Understanding the risk of maternal and neonatal 

hyponatraemia 

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