Emily BrazierA mum whose daughter died at just 20 hours old after she was left on her own during labour has said major changes are needed to stop more deaths.
Liliwen Iris Thomas died on 10 October 2022 at Cardiff’s University Hospital of Wales due to a lack of oxygen when Emily Brazier gave birth alone and in a coma after a reaction to pain medication.
Emily said Liliwen’s death “must not be in vain” and wants all health boards to change their policies on pain relief in labour and induction.
The Welsh government said there were “mechanisms in place for learning to be shared”.
Emily, 33 from Cardiff, said she felt the inquest gave her family “some justice”.
She added: “For the coroner to say that this should not have happened and that she should be here is something we needed to hear.”
The harrowing details of Liliwen’s birth are “seared into” Emily’s mind – she was alone in the induction suite of the maternity unit, where women stay during the early stages of labour.
“I was just puffing on gas and air, I couldn’t move, I couldn’t press a call bell, I couldn’t open my eyes, it was as if I was trapped in my own body.”
Emily had been given significant amounts of pethidine and codeine with no-one monitoring her use of gas and air.
“I just thought ‘someone will come and help me – surely, someone will help me.’ But nobody did.”
Emily’s partner Rhodri Thomas, 41, was not with her because of Cardiff and Vale health board’s policy at the time did not allow partners on the ward overnight, unless their partner was in active labour.
Hospital records show nobody checked on Emily for an hour during which time she gave birth to Liliwen as she drifted in and out of a coma and she woke up to see “so much blood and a baby lying there”.
Emily said, when Rhodri arrived, no-one told him of the seriousness of the situation and the first thing she said to him was: “I don’t know if our baby is alive.”
The following hours were filled with visits from family members who “said hello and goodbye” to Liliwen after it became clear she would not survive.
Emily still feels “unbelievable guilt” about her life support machine being switched off and Liliwen died in her father’s arms.
The health board said it sent its “deepest sympathies” to the family and was “fully committed to learning from this tragic event”.
It added: “In response to the concerns raised, we have implemented robust changes to staffing, escalation protocols and psychological support for both families and staff.”
A spokesperson added the board would “welcome the opportunity to meet with Liliwen’s family to share the actions taken”.
Now, the family want changes to maternity care, as well as changes they believe could help all families whose relative suffers death or injury in the NHS.
Liliwen’s inquest heard fundamental changes had been made at the health board since 2022, including only allowing women to use gas and air under supervision, reducing doses of other painkillers and reassessing their induction processes.
Emily said this must now be implemented at all health boards by the Welsh government.
“It feels like every other week there are more cases about baby injury or death and maternity services are on their last legs,” she said.
“If they can implement the changes that Cardiff and Vale have, it’s a step closer to this not happening again.”
The family are also concerned that Liliwen’s death was investigated by an officer within the health board.
“For families it just leaves an element of bias – of cover ups – it just doesn’t sit well and it doesn’t help the grieving process,” Emily said.
She wants an independent body set up to deal with cases across Wales – something that already happens in England through the HSSIB or MSNI in maternity cases.
Another avenue for change could be through a review of NICE guidance on pain relief in labour – something raised by Coroner Rachel Knight in a Prevention of Future Death report following Liliwen’s inquest.
NICE, the body that issues guidance across the NHS in Wales and England, has until 3 September to respond.
“It feels like Liliwen’s death won’t be in vain if we can achieve the change that we feel is needed,” said Emily.
“Then I can say I have done everything in her name and to think that this will not happen to another family is a sense of justice for us as well.”
Emily BrazierThe Welsh government said patient safety was “paramount” and it was aware of the findings at Cardiff and Vale health board.
It added: “An independent assessment of all Welsh maternity and neonatal services began in July to assess how all maternity services are performing against national guidelines.”
The family’s lawyers, Slater and Gordon are still negotiating a claim against the health board and senior associate Lara Bennett called Liliwen’s death “absolutely tragic and… entirely avoidable”.
She added that it was “vital” that all health boards in Wales adopted the new policies to ensure the mistakes that led to Liliwen’s death are not allowed to happen again.
If you have been affected by the issues raised in this story you can visit the Action Line for details of organisations who can offer support.
