A newborn baby died after the mother was left to give birth alone by midwives and doctors, an inquest told.
Liliwen Iris Thomas was born at the University of Wales Hospital but died just hours later after her mother’s cries for help were ignored during labour.
An inquest into the death of Liliwen was held at Pontypridd Coroner’s Court on Tuesday. The assistant coroner for South Wales Central, Rachel Knight, explained that Emily Brazier was admitted to hospital for an induced labour on October 8, 2022, at ’40+1 weeks’.
Ms Brazier was given pethidine and codeine for pain relief, however she was ‘not attended to or subjected to physical checks regularly enough’, the inquest heard.
The mother was not attended to by anyone from the midwifery team for almost an hour during the early hours of October 10, which is when she cried for help, and ‘the fact she had moved to active labour was missed’.
Staff eventually came to find that Liliwen had been delivered unattended. The newborn was described as being in a ‘very poor condition’ and died later that same day.
The heartbroken mother previously said how she was ‘angry’ at being left completely alone during childbirth. She said she remembered ‘being in a cycle of puffing gas and air, passing out, and repeating’.
She added: ‘So many happy memories and special family moments are tinged with sadness. I dread family events and Christmas as Liliwen will never be there, she will always be the missing piece, her death should never have happened and that’s hard to live with.’
Liliwen Iris Thomas (centre) died after her mother, Emily Brazier (right), was left to give birth alone by midwives and doctors, an inquest told. The father, Rhodri (left), was not present during the birth due to the hospital’s strict visiting hours rules
The inquest heard that Cardiff and Vale University Health Board admitted that when Ms Brazier was admitted to hospital there not enough midwives on duty, with only 17 present when the required number was 24. Two on-call midwives then arrived for duty to take the number up to 19.
Liliwen’s father Rhodri was not present during his daughter’s birth because partners were not allowed on the ward during that time due to the hospital having strict rules about visitors overnight between 9pm and 9am.
Summing up at the hearing, Ms Knight said: ‘Liliwen died from a hypoxic brain injury following an unattended delivery in hospital’.
She added that the death was a culmination of the mother ‘not being attended to as frequently as she should have been’, ‘the absence of resuscitation at birth’, and ‘a bacterial infection of the placenta’.
The official cause of death, as recorded by Dr Andrew Bamber following an investigation, was given aa a lack of oxygen at birth, known medically as perinatal asphyxia.
Abigail Holmes, director of midwifery and neonatal services at the University of Wales Hospital, told the hearing that Liliwen’s death represented ‘the most tragic case I’ve ever been involved with’.
She said new policies had been put into practice and that investment had been made into staff and training.
Dr Rachel Liebling, a consultant obstetrician and specialist in fetal and maternal medicine, said failings by the health board ‘more than minimally’ contributed to the death of Liliwen.
Ms Knight concluded the inquest by offering her condolences to Liliwen’s family and said that, having read extensive evidence, she had decided not to issue a Regulation 28 Prevention of Future Deaths report.
She said that Liliwen’s death had a ‘seismic impact on the largest hospital in Wales’ and was ‘satisfied that protocols and guidance have been thoroughly reviewed and that staff within the health board have been significantly retrained’.
The official cause of death, as recorded by Dr Andrew Bamber following an investigation, was given aa a lack of oxygen at birth, known medically as perinatal asphyxia
The inquest heard that Cardiff and Vale University Health Board admitted that when Ms Brazier was admitted to hospital there not enough midwives on duty
However, Ms Knight added that she ‘remains concerned’ that the learning from this case might not have reached other health boards across England and Wales.
Therefore a report will be rafted to target the National Institute for Health and Care Excellence so that it can consider the findings made following Liliwen’s death.
Following the conclusion of the inquest, Lara Bennett, senior associate at Slater and Gordon, a Cardiff law firm representing the baby’s family, said: ‘This case is truly shocking and Emily, Rhodri and their family have been left absolutely devastated by Liliwen’s death.
‘To have to relive the trauma again at the inquest, and to hear how their beloved baby was failed, has been hugely distressing. Liliwen and Emily were abandoned at a time when their care should have been the hospital’s top priority.
‘While it is claimed that lessons have been learned, and changes have been implemented, this tragic case highlights concerns regarding understaffing on maternity wards and the absence of basic care and monitoring for mothers and babies at their most vulnerable.
‘Had this been provided, Liliwen would not have suffered as she did and would be with her family today.’
‘Liliwen’s death must not be in vain and the maternity care standards across Wales must be improved to ensure no mother or baby ever suffers in this way again.’
On Tuesday, a spokesperson for Cardiff and Vale University Health Board, said: ‘Our sincere thoughts and heartfelt condolences remain with Liliwen’s family during this incredibly difficult time.’
