Latest news with #Regulation28
Daily Mirror
09-07-2025
- Health
- Daily Mirror
Baby died after mum left to give birth alone in one of UK's biggest hospitals
A coroner ruled that Liliwen Iris Thomas died as a result of a 'hypoxic brain injury following an unattended delivery' after her mother Emily Brazier delivered her without any midwives present at University of Wales Hospital 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.
Wales Online
08-07-2025
- Health
- Wales Online
Baby died after mother was left to give birth alone in Wales' biggest hospital
Baby died after mother was left to give birth alone in Wales' biggest hospital An inquest into the death of Liliwen Iris Thomas heard her mother was left alone for an hour. She managed to cry for help and it was discovered that her baby daughter had already been born Emily Brazier, Rhodri Thomas and their baby daughter Liliwen who died hours after being born (Image: Slater and Gordon ) A newborn baby died after her mother was left alone to give birth in Wales' biggest hospital without supervision from a midwife or any medical professional, an inquest has heard. Liliwen Iris Thomas was born at the University of Wales Hospital but died just hours later after her mother, Emily Brazier, was left unattended in labour. An inquest into the death of Liliwen was held at Pontypridd Coroner's Court on Tuesday, July 8. The assistant coroner for South Wales Central, Rachel Knight, explained that Miss Brazier was admitted to hospital for an induced labour on October 8, 2022, at '40+1 weeks'. Miss 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. For the latest Cardiff news, sign up to our newsletter here . Evidence read in the hearing revealed that, during the early hours of October 10, 2022, Miss Brazier was not attended to by anyone from the midwifery team for almost an hour between 1.15am and 2.14am, the point when she made a cry for help, and that "the fact she had moved to active labour was missed". 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. Article continues below 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. Emily, Rhodri and Liliwen in hospital (Image: Slater and Gordon ) 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. Article continues below
Sky News
22-04-2025
- Sport
- Sky News
Open water swimming events without regulation 'risk future deaths', warns coroner
Open water swimming events without regulation are putting people's lives at risk, according to a new report following a keen swimmer's death in Sunderland. The warning comes following a coroner's report into the death of Joel Kenneth Ineson, 55, who drowned at Hetton Lyons Park on 1 June 2023 after suffering a cardiac event during an organised open water swim. David Place, senior coroner for the City of Sunderland, found his death was accidental and wasn't caused by safety issues at the event. However, in a report aimed at preventing future deaths, Mr Place warned that the growing popularity of open water swimming was not matched by sufficient oversight or regulation. "Mr Ineson was a keen participant in organised open water swimming events with safety at the forefront of his mind," wrote Mr Place. "[He had] a reasonable expectation that appropriate safety measures would be in place" and was charged a small fee for entry. The report found, however, that there was "uncertainty and confusion" around who was responsible for safety precautions at the event. This led, found the report, to "some participants not receiving a specific safety briefing, a lack of knowledge of the competency [of] every participant and no understanding as to who was in the water and how many people were in the water at any one time". Open water swimming events are not regulated by any UK body and as such, there is no specific health and safety guidance. Event organisers aren't required to carry out pre-session safety briefings, risk assessments, signing in and out of the water systems, emergency plans or organiser training, according to the report. Mr Place is now calling on the government to strengthen regulations around open water swimming events. He sent the warning - known as a Regulation 28 report - to the Secretary of State for Culture, Media and Sport and to the chief executive of the Health and Safety Executive. They have until 5 June to respond, setting out what action they propose to take or explaining why none is planned.
Yahoo
22-04-2025
- Sport
- Yahoo
Open water swimming events without regulation 'risk future deaths', warns coroner
Open water swimming events without regulation are putting people's lives at risk, according to a new report following a keen swimmer's death in Sunderland. The warning comes following a coroner's report into the death of Joel Kenneth Ineson, 55, who drowned at Hetton Lyons Park on 1 June 2023 after suffering a cardiac event during an organised open water swim. David Place, senior coroner for the City of Sunderland, found his death was accidental and wasn't caused by safety issues at the event. However, in a report aimed at preventing future deaths, Mr Place warned that the growing popularity of open water swimming was not matched by sufficient oversight or regulation. "Mr Ineson was a keen participant in organised open water swimming events with safety at the forefront of his mind," wrote Mr Place. "[He had] a reasonable expectation that appropriate safety measures would be in place" and was charged a small fee for entry. The report found, however, that there was "uncertainty and confusion" around who was responsible for safety precautions at the event. This led, found the report, to "some participants not receiving a specific safety briefing, a lack of knowledge of the competency [of] every participant and no understanding as to who was in the water and how many people were in the water at any one time". Read more from Sky News: Open water swimming events are not regulated by any UK body and as such, there is no specific health and safety guidance. Event organisers aren't required to carry out pre-session safety briefings, risk assessments, signing in and out of the water systems, emergency plans or organiser training, according to the report. Mr Place is now calling on the government to strengthen regulations around open water swimming events. He sent the warning - known as a Regulation 28 report - to the Secretary of State for Culture, Media and Sport and to the chief executive of the Health and Safety Executive. They have until 5 June to respond, setting out what action they propose to take or explaining why none is planned.
Wales Online
22-04-2025
- Wales Online
Coroner calls for wild swimming regulation after death of man, 55
Coroner calls for wild swimming regulation after death of man, 55 Joel Kenneth died after suffering a cardiac event while taking part in an organised open-water swim Hetton Lyons Park in Sunderland (Alamy/PA) A coroner has urged the government to take action after a 55-year-old man drowned at an open water swimming event. Joel Kenneth Ineson died at Hetton Lyons Park in Sunderland on June 1 2023 after suffering a cardiac event while taking part in an organised open water swim. At the conclusion of an inquest held on April 4, David Place, senior coroner for the City of Sunderland, recorded a conclusion of accidental death. The medical cause of death was given as drowning, with diffuse myocardial scarring as a contributing factor. In a formal report aimed at preventing future deaths, Mr Place warned that the growing popularity of open water swimming was not matched by sufficient oversight or regulation. He said Mr Ineson had a 'reasonable expectation that appropriate safety measures would be in place' at the event, which was organised, well attended and charged participants a small fee. Article continues below Although the safety issues raised were not found to have caused Mr Ineson's death, Mr Place said there was a risk of further fatalities unless changes were made. He wrote: 'The evidence highlighted uncertainty and confusion with regard to responsibility for aspects of safety measures. 'Some participants did not receive a safety briefing, there was a lack of knowledge about the competency of swimmers, and no understanding of how many people were in the water at any one time.' Article continues below 'It became clear in evidence that the activity does not require a licence from the Adventure Activities Licensing Authority and can be undertaken and/or organised by anyone without regulation.' The report also noted an absence of formal requirements around risk assessments, emergency plans, sign-in/out procedures, and organiser training. Mr Place sent the warning – known as a Regulation 28 report – to the Secretary of State for Culture, Media and Sport and to the chief executive of the Health and Safety Executive. They have until June 5 2025 to respond, setting out what action they propose to take or explaining why none is planned.
