The Derby inquest found that one-day-old Orion Homer died after severe immune hydrops fetalis and failures in continuity of antenatal care. Born at 34 weeks +5 days on 15 October 2023, Orion was critically unwell at delivery and died the next day after unsuccessful interventions. The jury concluded that gaps in community midwifery booking and incomplete sharing of the mother’s rhesus-related medical history prevented timely preparations and possible intrauterine treatment. The senior coroner will issue a Prevention of Future Deaths report to NHS England and the Department of Health.
One-Day-Old Baby Dies After Gaps In Antenatal Care, Inquest Finds
Ellen Roberts was an inmate at HMP Foston Hall when her baby was born premature [HM Inspectorate of Prisons]
An inquest at Derby Coroner's Court has concluded that a one-day-old baby died after pregnancy complications and failures in continuity of antenatal care following the mother's release from custody.
What Happened
Orion Homer was delivered by caesarean section at 01:06 on 15 October 2023 at Royal Derby Hospital at a gestation of 34 weeks and five days. He died in the early hours of 16 October after medical teams were unable to revive him despite several interventions, including a blood transfusion.
High-Risk Pregnancy And Disrupted Care
The baby’s mother, Ellen Roberts, had spent part of her pregnancy in custody at HMP Foston Hall and was released at the end of July 2023 before being recalled to prison on 10 October. Her pregnancy had been classed as high risk because of prior rhesus incompatibility in two earlier pregnancies (one baby required a postnatal transfusion and another required an intrauterine transfusion), as well as maternal substance use and mobility issues.
While in custody Roberts had weekly scans and close contact with prison healthcare and maternity services at Royal Derby Hospital. After her release, prison staff notified local health bodies by email, including Dudley Group NHS Foundation Trust, but administrative and referral processes stalled.
Failures In Community Booking And Information Sharing
The jury found that the Dudley Group Trust required a completed community midwifery booking in its area before arranging scans locally. Because that booking was not completed, no onward referrals were made to tertiary services such as Birmingham Women’s Hospital. The jury said this “rigidity in policy” created a systemic barrier to engaging Roberts with community midwifery care.
When Roberts was recalled to prison on 10 October, prison midwives discovered she had had almost no contact with community antenatal services. An appointment to reinstate care in Derby was arranged, but this came only after she was back in custody.
Orion Homer was born on 15 October 2023 at Royal Derby Hospital [BBC]
Clinical Timeline And Medical Findings
Roberts attended hospital on 14 October reporting reduced fetal movements. After abnormal monitoring readings she was escalated to the labour ward. The inquest heard that clinicians in Derby had only partial information — prior pregnancies and substance misuse — and were not made aware of the full rhesus-related history. Because the neonatal team did not have the full prehistory, they were not able to make all necessary preparations for post-delivery assessment and treatment.
“If Orion had received the treatment planned for him, it is highly unlikely he would have died,” the jury said.
Orion was born gravely unwell and very pale and was not breathing independently. Multiple interventions were attempted, but care was withdrawn at about 04:00 on 16 October when he failed to respond.
Cause And Contributing Factors
The jury concluded Orion’s death was due to complications of severe immune hydrops fetalis arising from untreated immunologic disease related to rhesus incompatibility. They noted that an intrauterine transfusion to treat severe fetal anaemia could have been delivered by around 32 weeks of gestation at the latest and that missing this window likely affected the outcome. The jury also listed premature birth and the mother’s personal circumstances after returning to her home area as contributing factors.
The post-mortem report stated Roberts was enrolled in a methadone programme and had used crack cocaine and heroin in the week before Orion’s death.
Next Steps
Senior Coroner Peter Nieto said he will issue a Prevention of Future Deaths report to NHS England and the Department of Health, citing the lack of a nationally agreed pathway to ensure pregnant prisoners are released with joined-up community care arrangements.
The inquest highlighted both clinical and systemic problems: gaps in administrative processes for community midwifery booking, failures in information-sharing between trusts and hospitals, and the consequences these can have for high-risk pregnancies.
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