PFD report

Orlando NOVA DAVIS · Prevention of Future Deaths report

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Issued 26 Apr 2024•West Sussex, Brighton and Hove

Report record

Published report and response evidence

This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.

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Concerns
3

Raised in this report

Recipients
4

Named on the report

Responses found
4

Of 4 recipients

Stated actions
9

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised3

  1. Lack of awareness of hyponatremia developing in birthing women
  2. Failure to recognise the risk of hyponatremia when giving intravenous fluids
    Part of recurring concern: Unsafe intravenous fluid management
  3. Failure to keep accurate records of fluid input and output
    Part of recurring concern: Unreliable recording of fluid balance information
Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

Actions described in response An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.7

  1. Action

    Oversee further fluid-balance audits across all maternity birth settings and receive the results through perinatal quality surveillance arrangements.

    Stated by NHS Surrey and Sussex Integrated Care BoardStated in progressThe respondent said that this action was in progress when they made their response on 9 May 2024.
  2. Action

    Request completion of an additional fluid-balance compliance audit before the end of the year.

    Stated by NHS Surrey and Sussex Integrated Care BoardStated completedThe respondent said that this action was complete when they made their response on 9 May 2024.
  3. Action

    Share NHS Sussex’s hyponatraemia and labour fluid-balance work with NHS England’s Regional Maternity Team to disseminate learning across Integrated Care Systems.

    Stated by NHS Surrey and Sussex Integrated Care BoardStated completedThe respondent said that this action was complete when they made their response on 9 May 2024.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.4

  1. Position

    At the time, applicable guidance did not require accurate fluid-balance monitoring during labour.

    Stated by NHS Surrey and Sussex Integrated Care BoardDisputes the concernThe respondent disagreed with part of the concern or the basis for it.

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Lack of awareness of hyponatremia developing in birthing women

Wider context from the report

“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 hosptial, 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 tachicardia 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. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to recognise the risk of hyponatremia when giving intravenous fluids

Wider context from the report

“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 hosptial, 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 tachicardia 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. ”

Is this part of a recurring concern?

Yes — Unsafe intravenous fluid management.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to keep accurate records of fluid input and output

Wider context from the report

“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 hosptial, 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 tachicardia 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. ”

Is this part of a recurring concern?

Yes — Unreliable recording of fluid balance information.

Open source report

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Oversee further fluid-balance audits across all maternity birth settings and receive the results through perinatal quality surveillance arrangements.

Verbatim wording from the response

“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.”

Source location

Response from NHS Sussex
Page 2 · response
Published 9 May 2024

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Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Request completion of an additional fluid-balance compliance audit before the end of the year.

Verbatim wording from the response

“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.”

Source location

Response from NHS Sussex
Page 2 · response
Published 9 May 2024

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Share NHS Sussex’s hyponatraemia and labour fluid-balance work with NHS England’s Regional Maternity Team to disseminate learning across Integrated Care Systems.

Verbatim wording from the response

“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 process, put in place following the Ockenden Review.”

Source location

Response from NHS Sussex
Page 3 · response
Published 9 May 2024

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Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Share information about the doctor’s potential failure to recognise hyponatraemia with the General Medical Council.

Verbatim wording from the response

“2. We have shared the PFD report with the General Medical Council (GMC) so they can take appropriate action which falls within their remit.”

Source location

Response from NMC
Page 1 · response
Published 9 May 2024

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Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Investigate the concerns about the incident through fitness-to-practise processes to determine whether regulatory action is needed.

Verbatim wording from the response

“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.”

Source location

Response from NMC
Page 1 · response
Published 9 May 2024

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Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Develop and publish a hyponatraemia scenario for student midwives and midwives, and raise awareness of it with education colleagues before the next academic year.

Verbatim wording from the response

“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.”

Source location

Response from NMC
Page 1 · response
Published 9 May 2024

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Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Approach NICE to suggest an addendum to the Intrapartum care guideline addressing hyponatraemia risks, fluid balance monitoring and related neonatal notification.

Verbatim wording from the response

“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:”

Source location

Response from Royal College of Obstetricians and Gynaecologists
Page 2 · response
Published 9 May 2024

Open published response

Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

At the time, applicable guidance did not require accurate fluid-balance monitoring during labour.

Verbatim wording from the response

“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.”

Source location

Response from NHS Sussex
Page 2 · response
Published 9 May 2024

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Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

The GMC is responsible for considering whether further investigation or action is required concerning the doctor involved.

Verbatim wording from the response

“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”

Source location

Response from NMC
Page 6 · response
Published 9 May 2024

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Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Hyponatraemia need not be specified in NMC standards because high-level standards and provider curricula are considered sufficient, although a scenario will be developed.

Verbatim wording from the response

“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.”

Source location

Response from NMC
Page 3 · response
Published 9 May 2024

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Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

The statutory remit does not extend to doctors, so the NMC cannot take regulatory action concerning the doctor involved.

Verbatim wording from the response

“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”

Source location

Response from NMC
Page 6 · response
Published 9 May 2024

Open published response

Other statements in published responses

These actions and other statements could not be clearly connected to one concern in this report.

Recipient-stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.2

  1. 1

    Commit £9 million over three years to support national rollout of the Brain Injury Reduction Programme after successful pilot completion.

    Stated by Department of Health and Social CareStated plannedThe respondent said that this action was planned when they made their response on 9 May 2024.
  2. 2

    Establish the Brain Injury Reduction Programme to accelerate progress towards reducing avoidable intrapartum brain injuries.

    Stated by Department of Health and Social CareStated completedThe respondent said that this action was complete when they made their response on 9 May 2024.

Recipient positions A position is what a recipient says about a concern when they do not describe a specific action.1

  1. 1

    The College does not issue independent intrapartum care or fetal monitoring guidelines and therefore recommends using NICE guidance.

    Stated by Royal College of Obstetricians and GynaecologistsOutside remitThe respondent said that this matter was outside its role or authority.

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Commit £9 million over three years to support national rollout of the Brain Injury Reduction Programme after successful pilot completion.

Verbatim wording from the response

“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.”

Source location

2024-0227 Response from Department of Health and Social Care
Page 3 · response
Published 9 May 2024

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Establish the Brain Injury Reduction Programme to accelerate progress towards reducing avoidable intrapartum brain injuries.

Verbatim wording from the response

“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:”

Source location

2024-0227 Response from Department of Health and Social Care
Page 3 · response
Published 9 May 2024

Open published response

Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

The College does not issue independent intrapartum care or fetal monitoring guidelines and therefore recommends using NICE guidance.

Verbatim wording from the response

“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 guidance¹,² on this topic.”

Source location

Response from Royal College of Obstetricians and Gynaecologists
Page 2 · response
Published 9 May 2024

Open published response
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Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026