A baby’s life should have been saved after his mother developed a rare condition during labour.

Orlando Davis died after medical staff dismissed his mother’s pleas for help despite her being a trained midwife.

Mum Robyn Davies developed a rare condition which led to her having seizures which restricted oxygen to her unborn child.

Baby Orlando’s death was “contributed to by neglect”, a coroner concluded.

Senior coroner Penelope Schofield said: “Orlando’s death was one death too many.

“Robyn felt she was not being listened to. Sadly, this resulted in her suffering a number of seizures leading to lack of oxygen to Orlando.

"His death was contributed to by neglect. In my view, there was a missed opportunity to notice her deteriorating condition before she started fitting."

The inquest into baby Orlando’s death heard that mum Robyn, 28, from Steyning, had planned a home birth after a low-risk second pregnancy.

As complications arose during the labour, Mrs Davis was transferred to hospital as she began to suffer seizures, which led to her being placed in a coma.

Orlando was born by emergency Caesarean section in September, 2021.

Mrs Davis came out of the coma after three days but said it was not until she was transferred to see her son the following day that she found out how seriously ill he was.

Orlando died 14 days later in parents Robyn and Jonny Davis's arms at the Royal Sussex County Hospital.

Mrs Davis said in a statement read to the inquest that she had previously worked as a midwife but left after four or five months due to the level of “stress, poor staffing and lack of support”.

She added that she felt she had not been listened to by the midwives when she raised concerns about her fluid intake and the position of the baby.

She said: “I proceeded to keep saying ‘Something is wrong’. It felt like I was trapped, that, although I knew I was declining so rapidly, I was unable to think how I could help myself, such as asking to go to hospital.

“Every time I said something was wrong the midwives never investigated this further.”

“I could not stop crying and having panic attacks. I could not understand that Orlando was this catastrophically ill that he was going to die.

“I can’t explain the sadness, frustration, anger and complete heartbreak I felt and still feel towards the Trust for not keeping us safe.

“As a parent I can’t explain how horrendous hearing that news that it’s in your child’s best interest to die; to also be faced with agreeing to end your child’s life is the biggest scar you can ever imagine.”

The inquest into his death concluded that this was contributed to by neglect. The coroner expressed concern about a lack of knowledge of hyponatraemia, a rare condition which Mrs Davis experienced.

Even though there was a missed opportunity to transfer Mrs Davis to hospital earlier, the coroner said it was unlikely her hyponatraemia would have been picked up.

The coroner recorded a narrative conclusion, telling the family: "On September 9, 2021 Robyn Davis developed hyponatremia during her labour while having a home birth.

"Robyn’s condition went completely unrecognised during the period of her labour and therefore she did not receive the care and attention that she and her son, Orlando, clinically required.

"There was a lack of understanding of this rare medical condition by midwives and clinicians and as such there were lost opportunities to treat Robyn both at home and or during her subsequent admission to Worthing hospital.

"Sadly the failure to recognise this condition resulted in Robyn suffering a number of seizures which led to a restriction of oxygen to Orlando before birth and this resulted in him suffering an irreversible brain injury.

"Orlando sadly died from this injury on September 24, 2021 at the Royal Sussex County Hospital at the age of just 14 days.

"Orlando's death was contributed to by neglect."

In a statement, University Hospital Sussex NHS Foundation Trust chief nurse Maggie Davies said: “We wish to offer our sincere condolences to Orlando’s family once more for the unimaginable heartache and distress caused by the loss of their baby boy.

“As the coroner noted in her findings, hyponatremia is an extremely rare condition which is little understood. We support her view that there is an urgent need for new national guidelines.

“This tragedy has deeply affected everyone involved in the family’s care and led directly to us introducing new guidance and training within our maternity service.”