No investigation on baby's death 'shameful' - parents

The CQC said it could not investigate due to legal limitations.

The parents of a baby who died in hospital have said the care watchdog should be "ashamed" after it decided not to criminally investigate his death.

Orlando Davis died 14 days after being born by emergency caesarean at Worthing Hospital in West Sussex on 10 September 2021.

The Care Quality Commission (CQC) said it understood "how difficult it was for Orlando's family to hear the news", but insisted there was "not enough time to commence and conclude a criminal investigation".

Dr Maggie Davies, chief nurse at University Hospitals Sussex NHS Foundation Trust, said they had "cooperated fully" with the independent investigation into what happened.

The parents blasted the CQC's decision as "shameful".

In March, a coroner ruled that neglect contributed to Orlando's death as clinicians failed to address his mother's rare condition in labour.

Parents Robyn and Jonathan Davis, from Steyning, West Sussex, asked the care watchdog to criminally investigate their son's death.

However, the CQC said it was prevented from investigating by a law that prosecution cases can only be brought within three years of an alleged offence.

"Investigations to establish a case for prosecution take significant time to gather sufficient evidence to determine whether there has been a failing by the trust rather than an individual, and to prove there has been a breach of the regulations to the criminal standard - beyond reasonable doubt," said a CQC spokesperson.

The body said it previously asked the government to review the Health and Social Care Act 2008 which prescribes the three-year prosecution limit.

'Parents deserve better'

Mr and Mrs Davis say that delays at the coroners court and by the University Hospitals Sussex NHS Foundation Trust caused time to elapse.

"When a crime is possibly committed it should be investigated regardless of a timeframe, especially when this relates to a baby's death," the parents said.

"To not do so should be a crime in itself for allowing such incidents to happen without proper review."

The CQC should be "ashamed", they added. "Grieving parents deserve better".

The NHS trust said it had also heard from other families "affected by events related to poor care".

At an inquest in March, senior coroner Penelope Schofield found Orlando's death was caused by a type of brain damage.

But she concluded this was contributed to by neglect, after medical staff failed to recognise that Mrs Davis had developed hyponatremia - a lower than normal level of sodium in the bloodstream - during labour.

Mrs Davis, a former midwife, told the inquest she had not been listened to when she raised concerns about her fluid intake and the position of the baby.

She began suffering seizures and was placed in a coma as complications arose during the birth.

Mrs Davis said she was "haunted psychologically" at having to watch her son die.

'We will not be the last'

Vowing to challenge the CQC's decision not to criminally investigate Orlando's death, Mr and Mrs Davis said it had added to their "ongoing grief and pain".

"We are not the only families going through this with the CQC and unless change is made, we will not be the last," the parents said.

In June, the families of nine babies who died at hospitals run by the University Hospitals Sussex NHS Foundation Trust over a three-year period called for a public inquiry into the standard of its maternity care.

The trust said at the time it had recruited more midwives and "changed" how it supported families, with outcomes now better "than most other trusts in the country".