Hospital under fire over failings as grieving family demand change across Wales
A BABY girl died after being delivered without assistance while her mother was in a coma at the University Hospital of Wales in Cardiff, an inquest has heard.
Liliwen Iris Thomas passed away just 20 hours after being born on 10 October 2022. Her mother, Emily Brazier, had been left unmonitored for almost an hour after being given high doses of pain relief. A medical expert told the inquest she likely suffered a severe reaction, lost consciousness, and gave birth while unattended.
The hearing in Pontypridd was told there had been a “failure to take adequate care” of Ms Brazier, who had been given 100mg of pethidine and 60mg of codeine, as well as unrestricted access to gas and air. She was not assessed for nearly an hour, despite being in active labour—a stage which requires constant one-to-one monitoring.
Tragically, Liliwen was discovered between her mother’s legs, under a hospital sheet, following a faint cry for help that was heard at 2:14am. A post-mortem found the baby died from a lack of oxygen at birth.
Staffing levels on the maternity ward were described as “exceptionally low” on the night. Only 17 midwives were on shift when the health board’s minimum staffing requirement is 24. Two community midwives were called in to assist.
Ms Brazier had been admitted for an induction on 7 October due to low PAPP-A levels, a condition linked to pregnancy complications. But she was asked to return the next day due to staff shortages. Labour was later induced on 9 October, and she was given pain relief over the course of the evening.
By the early hours of 10 October, she had slipped into unconsciousness—likely due to a heightened sensitivity to the drugs—and gave birth alone.
Abigail Holmes, Head of Midwifery at Cardiff and Vale University Health Board, apologised directly to the family during the hearing. She said: “This is the most tragic case. The impact on our staff has been profound. We are working tirelessly to ensure something like this never happens again.”
The health board has since introduced changes to the way pain relief is administered during labour, and revised protocols for maternity care.
Coroner Rachel Knight described the case as “nothing short of a tragedy” and said it had clearly prompted major reform within the local health board. However, she added that national clinical guidance may still be too vague and confirmed she would be issuing a Prevention of Future Deaths report.
Liliwen’s father, Rhodri Thomas, had not been permitted on the ward at the time of the birth, as hospital rules only allowed partners to be present during active labour—something midwives had failed to recognise in Ms Brazier’s case.
In a statement on behalf of the family, solicitor Lara Bennett said: “This heartbreaking case highlights serious concerns about staffing levels and basic monitoring of vulnerable mothers and babies. Had proper care been given, Liliwen would be alive today. It is vital that the lessons learned here are adopted across all health boards in Wales. Her death must not be in vain.”
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