Dear Madam 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.

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.

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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

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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

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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.

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• 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 woman and in collaboration with the 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.

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

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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

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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.

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

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:

“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.

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.

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:-
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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]
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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]
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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.