Call for guidelines to be tightened after newborn death

A coroner has called for guidelines to be tightened following the death of a newborn baby after her mother was left unattended, despite being in a coma due to a reaction to painkillers.

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

An inquest that concluded earlier this month heard there was a "failure to take adequate care" of mother Emily Brazier, who was not checked for an hour after being given a cocktail of painkillers.

The coroner, Rachel Knight, has now published a Prevention of Future Deaths Report calling on the National Institute for Health and Care Excellence (NICE) to address issues raised in the inquest.

The coroner said she believed the current NICE guidelines on induction of labour and childbirth do not deal explicitly with analgesia levels and supervision.

The Chief Executive of NICE must respond to the report by 3 September.

The inquest had heard how Ms Brazier was given 100mg of pethidine, 60mg of codeine and repeatedly used gas and air, but a midwife failed to spot she was in active labour meaning she should have been moved to one-to-one care.

The ward was said to be exceptionally busy at the time.

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

Baby Liliwen was found in a "poor condition" and died 20 hours later, with the cause of death given as asphyxia or a lack of oxygen during birth.

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".

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

The coroner said the health board has taken significant steps to significantly restrict the use of analgesia during induction and labour, including reductions of prescribed doses, allowing only limited access to analgesia on the wards.

There is also increased levels of supervision of mothers under analgesia.

A copy of the Prevention of Future Deaths report has also been sent to the family and to the chief executive of the Welsh NHS.

The coroner suggested the conclusions could be sent to other health boards around Wales.