Baby died after unattended mum gave birth in coma

A newborn baby died after her mother was left unattended by midwives and gave birth in a coma following a strong reaction to pain killers, an inquest has heard.

Liliwen Iris Thomas died on 10 October 2022, 20 hours after she was born at the University Hospital of Wales in Cardiff.

The Pontypridd inquest heard there was a "failure to take adequate care" of mother Emily Brazier, who was not checked for an hour after being administered significant doses of pethidine and codeine, and given unrestricted access to gas and air.

A cause of death for Liliwen was given as asphyxia or a lack of oxygen during birth.

Head of Midwifery at Cardiff and Vale health board Abigail Holmes apologised to the family and said that "profound changes" had been made following Liliwen's death.

The coroner's court heard Liliwen was in a "poor condition" when she was found under the sheets "between mum's legs" on 10 October 2022, at a time when partners were not allowed into the ward unless a woman was in active labour.

This meant Liliwen's father, Rhodri Thomas, was not present.

Ms Brazier had been booked in for an induction on 7 October 2025 due to low PAPP-A levels which meant there was a risk of complications.

But she had to return the following day due to low staffing levels.

The coroner's court heard on 9 October at around 19:30, a discussion started around pain relief and over the next few hours, Ms Brazier was given 100mg of pethidine, 60 mg of codeine and repeatedly used gas and air (Entonox).

But a midwife failed to spot she was in active labour meaning she should have been moved to one-to-one care.

She was not checked at all between 01:15 and 02:14 when a "faint cry for help was heard" and midwives rushed to her.

A report by a medical expert said it was likely Ms Brazier suffered an "exaggerated pharmacological response resulting in a coma, during which time she delivered the baby unattended and was unable to summon help".

"This was most likely due to sensitivity to codeine and pethidine," it added, saying the "self-administering of Entonox contributed to Ms Brazier's inability to respond".

The coroner's court heard this happened when the ward was "exceptionally busy".

Staff shortages were also "so acute that there was a call to the community to bring midwives in".

At the time, 17 hospital midwives were on shift, with two drafted in from the community - 24 is the minimum number of midwives that should be available during the day, according to the health board.

Giving evidence, head of midwifery Ms Holmes, who was not in post at the time, described it as "the most tragic case".

"The impact it has had on us as a staffing body has been greatly felt by every member of our team, regardless of grade," she said.

Addressing the family directly, Ms Holmes added: "We are working tirelessly to make sure something like this never happens again.

"I know this doesn't bring your daughter back and I am so, so sorry."

Ms Holmes outlined a series of changes that had been made at the health board, some within weeks of Liliwen's death.

These included major changes to the way pain relief is administered to women during both early and active labour.

Coroner Rachel Knight said the case was "nothing short of a tragedy" and it was clear that it had a "seismic impact on maternity care" in the health board.

Ms Knight said she would be preparing a Prevention of Future Deaths report as she "remained concerned" that NICE guidelines on labour induction were "not sufficiently explicit".

In a statement, Lara Bennett, a solicitor representing Liliwen's family, said: "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."