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Tragic circumstances unfolded when a newborn baby passed away after her mother was reportedly left unattended by midwives during birth. Liliwen Iris Thomas tragically died on October 10, 2022, just 20 hours after being born at the University Hospital of Wales in Cardiff. The inquest revealed that there was a failure in providing proper care to mother Emily Brazier, who was left unchecked for an hour after receiving significant doses of painkillers and having access to gas and air without restrictions. The cause of death for baby Liliwen was determined to be asphyxia, resulting from a lack of oxygen during birth.
Following the heartbreaking incident, Abigail Holmes, the Head of Midwifery at Cardiff and Vale health board, extended her apologies to the family and announced significant changes have been implemented in response to Liliwen’s death. The coroner’s court heard that Liliwen’s father, Rhodri Thomas, was not present at the time of her birth as partners were only allowed in the ward if the woman was in active labor. Emily Brazier had originally been scheduled for an induction due to low PAPP-A levels, signaling a risk of complications, but had to return the next day due to inadequate staffing levels.
During the discussion on October 9, concerning pain relief, Ms. Brazier was administered 100mg of pethidine, 60mg of codeine, and frequently used gas and air. Unfortunately, a midwife failed to recognize that she was in active labor, neglecting to provide the necessary one-to-one care. The tragic event unfolded when the ward was exceptionally busy, leading to staff shortages and a call for community midwives to assist. The incident highlighted concerns over understaffing on maternity wards and the lack of basic care and monitoring for vulnerable mothers and babies.
As the investigation continued, it was noted that substantial changes had been made within weeks of the tragic incident at the health board. Coroner Rachel Knight labeled the case as a “seismic impact on maternity care,” stressing the need for stricter adherence to guidelines in labor induction procedures. A solicitor representing Liliwen’s family emphasized the importance of adopting the policy changes across all Welsh health boards to prevent similar tragedies from occurring in the future. The family’s hope is that Liliwen’s death will spur improvements in maternity care standards across Wales to ensure the safety and well-being of all mothers and babies
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