A BEREAVED mother is calling for all hospital investigations into baby deaths in Wales to be carried out independently, rather than by staff working in the same hospitals where the tragedies occurred.
Baby Liliwen’s story
Emily Brazier’s daughter, Liliwen Iris Thomas, died just 20 hours after her birth at the University Hospital of Wales in Cardiff. Emily had been given excessive pain medication and unlimited access to Entonox (gas and air) without supervision, leaving her unaware she had given birth.
A lack of checks by midwives meant Liliwen’s birth went undiscovered for a catastrophic period, resulting in the most severe grade of hypoxic brain injury.
To add to the family’s devastation, Emily and her partner, Rhodri Thomas, were told the investigation into their daughter’s death would be conducted by staff at the same hospital. The couple described this as allowing the University Hospital of Wales to “mark its own homework”.
No independent body in Wales
In England, such cases are investigated by the Health Services Safety Investigations Body (HSSIB), which has a dedicated maternity programme. In Scotland, Serious Adverse Event Reviews (SAERs) and Comprehensive Care Reviews (CCR) must include external input from professionals from outside the Health Board.
But in Wales, no equivalent system exists. Investigations are carried out internally, raising concerns about impartiality.
In Liliwen’s case, Coroner Rachel Knight appointed an independent obstetrician to review events. That report identified serious concerns which had not been addressed in the hospital’s own findings.
‘The current system is not fit for purpose’
Emily, from Cardiff, said: “I do not think the current system of investigation in Wales is fit for purpose – are we really expecting medical staff to expose failings by their own colleagues, who they potentially have close relationships with, and for them to disclose failings against their own employer?
“The process felt very biased from the start, and I did not know this was the way investigations were carried out until we lost Liliwen. The current system risks allowing a cover-up culture and could result in negligent staff avoiding accountability.
“We are so grateful to the Coroner for commissioning an external expert, and the report they produced was night and day compared with the hospital’s report. It confirmed everything we had been saying about the effects of pethidine and Entonox on myself and Liliwen, and their role in her death.”
Calls backed by legal support
Lara Bennett, senior associate at law firm Slater and Gordon, who is supporting Emily and Rhodri in action against Cardiff and Vale University Health Board, said: “With the current system of investigations being carried out in the very hospital that is subject to scrutiny, we essentially have a system where they are marking their own homework.
“The difference in evidence produced by the independent expert compared with the University Hospital of Wales really brought this into focus. Families should not have to fight for answers in the way Emily and Rhodri have. Independent investigations would give them confidence they are being supported in their search for justice.”
Emily’s campaign comes as maternity services across Wales are under review following a series of damning reports, most recently into Swansea Bay. Families hope this latest push will lead to real change.
Cardiff and Vale University Health Board has been approached for comment.
The Welsh Government has previously confirmed that maternity services across Wales are subject to an independent review following concerns raised at several health boards, including Swansea Bay.
