EMILY Brazier’s newborn baby girl died after she was left alone during labour, a coroner has found.
The Cardiff mum was sedated and behind a curtain when she gave birth unattended, having fallen into a coma after a bad reaction to painkillers.
Emily Brazier and Rhodri Thomas with their daughter Liliwen[/caption]
The baby died 20 hours after being born[/caption]
Little Liliwen Iris Thomas was born on October 10, 2022, but died just 20 hours later at the University Hospital of Wales in what has been described as “the most tragic case”.
Midwives failed to recognise Emily was in active labour and only found baby Liliwen “between mum’s legs,” hidden beneath a bedsheet, the Pontypridd inquest heard.
Emily was heavily monitored in the lead-up to her labour, as she had a condition which heightened the risk of complications.
She had been admitted for induction on October 8 and was induced the following day.
She was given a cocktail of painkillers, including pethidine, codeine, and gas and air, called Entonox, to ease her labour pains.
Her partner Rhodri Thomas had been asked to return home because of a policy then in place of having no partners on the ward from 9pm to 9am, unless their partner was in active labour.
But staff failed to properly check Emily or carry out a physical exam, missing clear signs she was in active labour and should have been moved to one-to-one care.
She was not checked at all between 1:15a, and 2:14am when a “faint cry for help was heard” and midwives rushed to her, which is when newborn Liliwen was discovered in “poor condition”.
“I vividly remember peeling back the covers and seeing Liliwen there, completely still and lifeless,” Emily previously said.
“I can only describe it as a blood bath. That image will be with me forever.”
“I still have flashbacks and nightmares and have been in counselling since,” she added.
A medical expert’s report, cited by the BBC, concluded that Emily likely experienced an “exaggerated pharmacological response resulting in a coma.”
“During this time, she delivered the baby unattended and was unable to call for help.”
The report added this was “most likely due to sensitivity to codeine and pethidine,” and that her “self-administration of Entonox contributed to Ms Brazier’s inability to respond.”
Doctors immediately attempted resuscitation, but little Liliwen tragically passed away 20 hours later.
A post-mortem revealed she died from a lack of oxygen at birth, a bacterial infection, and problems with the placenta.
The mum was alone when she gave birth[/caption]
University Hospital of Wales in Cardiff[/caption]
Emily was closely monitored throughout her pregnancy.
She was undergoing induction because of low pregnancy-associated plasma protein A (PAPP-A), the same condition she had with her older daughter, Carys.
She was under the care of a consultant during her pregnancy with Liliwen.
Several scans were done over the months to check the baby’s wellbeing.
It was noted that when she gave birth to Carys three years earlier, her labour moved very quickly after she received pethidine and Entonox pain relief.
She was given the same medications for Liliwen’s birth.
‘I am so, so sorry’
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.
The minimum number of midwives that should be available during the day in 24, 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.
Could have been alive today
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.”
Daily nightmare
Emily and Rhodri say they have struggled psychologically in the aftermath of their ordeal.
The mum, who was studying to be a nurse at the time she had Liliwen, even opted against a career as a registered nurse due to the trauma she suffered on a hospital ward.
The couple welcomed their third child, a son named Ellis, in December 2024, but Emily says the grief from the loss of Liliwen continues to cast a shadow over the family’s lives.
“So many happy memories and special family moments are tinged with sadness,” she said.
“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.
“I look at the faces of my living children and long to know what Liliwen would look like now at two-and-a-half years old.
“I will never get over her death, I feel stuck in time. I will never be the same person again.
“Holding your child as they take their last breath, leaving them behind after their last ever cuddle, walking out of the hospital with an empty car seat, there are so many painful memories seared into my brain.
“I have lost my child; it’s every parent’s worst nightmare and we live the nightmare every single day.”
The couple are now pursuing a claim against Cardiff and Vale University Health Board, which manages University Hospital of Wales, supported by the law firm Slater and Gordon.
The hospital has been approached for comment.
Potential pregnancy and birth complications
Most pregnancies progress without a hitch, but some people may experience problems during birth.
Having early and regular midwife appointments helps diagnose, treat, or manage conditions before they become serious.
Here are some complications that may occur:
- Vaginal bleeding: in most cases this isn’t caused by something serious it is very important to check it with your midwife or GP.
- High blood pressure and pre-eclampsia: high blood pressure affects around 10 to 15 per cent of pregnancies. Pre-eclampsia can affect your baby’s growth. In mild pre-eclampsia, there may be no symptoms or signs. Rarely, the illness can develop into severe pre-eclampsia, which can be life threatening for you and your baby.
- Obstetric cholestasis: this is rare and causes a build-up of bile acids in your body, which makes the skin very itchy but without a rash. The symptoms get better when your baby is born.
- Gestational diabetes: this is diabetes that develops during pregnancy and affects up to 18 in 100 people in pregnancy.
- Placenta previa: this happens when the placenta attaches in the lower part of the womb, sometimes completely covering the cervix. This can cause heavy bleeding during pregnancy or at the time of birth, meaning your baby will need to be born by C-section
- Placenta accreta: this is a rare but serious condition when the placenta is stuck to the muscle of your womb and/or to nearby structures such as your bladder.
- Infections: There is a small risk infections can pass on to babies during birth and cause complications. These can include Group B Strep, genital herpes and parvovirus
- Deep vein thrombosis (DVT): this is a clot which can develop in the veins of your leg. A clot can also move to your lungs, and this is known as a pulmonary embolism (PE). Symptoms of this include chest pains and breathlessness. This is a serious condition, which can be life-threatening. There is an increased risk of DVT and PE in women who are, or have recently been, pregnant, and the risk increases after surgery.
Source: NHS
