Baby died after mum left to give birth alone in one of UK's biggest hospitals
A newborn baby died at a major UK hospital after her mother was left alone to give birth.
An inquest is being held into the death of Liliwen Iris Thomas after her mother Emily Brazier was left unattended for four hours while in labour at the University of Wales Hospital in Cardiff.
Ms Brazier had been admitted to hospital for induced labour on October 8, 2022 at "40+1 weeks", Pontrypidd Coroner's Court heard yesterday.
She was given pethidine and codeine to relieve the pain, but the inquest heard she did not receive enough physical checks and was "not attended to".
Between 1.15am and 2.14am, no one from the midwifery team checked on her, so she cried out for help. The fact "she had moved to active labour was missed", the coroner said.
After a call for help was made, staff arrived and found that Liliwen had been delivered unattended. Liliwen was described as being in a 'very poor condition' and died at 10.40pm that day.
The inquest heard that Cardiff and Vale University Health Board admitted that when Miss Brazier was admitted to hospital there was not a 'full complement' of 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.
Ms Knight said Tuesday's hearing was a 'narrative inquest' to decide if a Regulation 28 report would be issued. A Regulation 28 report is a document issued by a coroner which aims to prevent future deaths by highlighting potential risks identified during an inquest and recommending preventative actions.
The inquest heard that 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 facts at the hearing, Ms Knight said: 'Liliwen died from a hypoxic brain injury following an unattended delivery in hospital'.
Ms Knight added that the death was contributed to by different factors including 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 as perinatal asphyxia (lack of oxygen at birth).
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 across Cardiff and Vale University Health Board and that investment had been made into staff and training.
Miss Brazier previously said how she was 'angry' at being left 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.'
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 in relation to Cardiff and Vale University Health Board.
She said that Liliwen's death had a 'seismic impact on the largest hospital in Wales' (the University of Wales Hospital) and that she was 'satisfied that protocols and guidance have been thoroughly reviewed and that staff within the health board have been significantly retrained'.
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, Ms Knight will draft a Regulation 28 report targeted at the National Institute for Health and Care Excellence so that it can consider the findings made following Liliwen's death. A copy of the draft will be sent to the Chief Executive of NHS Wales.
Following the conclusion of the inquest, Lara Bennett, senior associate at Slater and Gordon, a Cardiff law firm representing Liliwen'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. It is imperative that the policy changes to maternity services implemented by Cardiff and Vale University Health Board as a direct result of this tragic event are adopted across all Welsh health boards.
'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.
'The health board is fully engaged with the inquest process, and it would be inappropriate to comment further until the inquest concludes.'
Following the conclusion of the inquest on Tuesday afternoon, the health board has been asked if it wishes to comment further.
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She said new policies had been put into practice across Cardiff and Vale University Health Board and that investment had been made into staff and training. Miss Brazier previously said how she was 'angry' at being left 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.' 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 in relation to Cardiff and Vale University Health Board. She said that Liliwen's death had a 'seismic impact on the largest hospital in Wales' (the University of Wales Hospital) and that she was 'satisfied that protocols and guidance have been thoroughly reviewed and that staff within the health board have been significantly retrained'. 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, Ms Knight will draft a Regulation 28 report targeted at the National Institute for Health and Care Excellence so that it can consider the findings made following Liliwen's death. A copy of the draft will be sent to the Chief Executive of NHS Wales. Following the conclusion of the inquest, Lara Bennett, senior associate at Slater and Gordon, a Cardiff law firm representing Liliwen'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. It is imperative that the policy changes to maternity services implemented by Cardiff and Vale University Health Board as a direct result of this tragic event are adopted across all Welsh health boards. '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. 'The health board is fully engaged with the inquest process, and it would be inappropriate to comment further until the inquest concludes.' Following the conclusion of the inquest on Tuesday afternoon, the health board has been asked if it wishes to comment further.
