“(brief summary of matters of concern) Orlando was caused an irreverseable brain injury…”
Dated 26 Apr 2024, from the coroner for West Sussex, Brighton and Hove. Sent to 4 organisations or people.
A coroner wrote this report after an inquest, to warn the organisations below about a risk of further deaths.
The 56-day response deadline
All responses publishedReplies were due by 21 Jun 2024.
Organisations that receive a report must reply to the coroner within 56 days, saying what they will do or why they will do nothing. We show whether a response is published on judiciary.uk; a reply may have been sent and not yet published.
- Report dated26 Apr 2024
- Deadline21 Jun 2024
- Published on judiciary.uk9 May 2024
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Nursing and Midwifery Council | Response publishedPublished on judiciary.uk in May 2024. |
| Royal College of Obstetricians and Gynaecologists | Response publishedPublished on judiciary.uk in May 2024. |
| Department of Health and Social Care | Response publishedPublished on judiciary.uk in May 2024. |
| NHS Sussex Integrated Care Board | Response publishedPublished on judiciary.uk in May 2024. |
The coroner’s concerns
(brief summary of matters of concern) Orlando was caused an irreverseable 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 intravenousely with no recognition of any potential risk of hyponatremia developing by the midwives or the Doctor on duty.
An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.
- Source
- judiciary.uk, Prevention of Future Deaths reports, 2024-0227
- Added to Minute Book
- 8 Oct 2026
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Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0
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