Women should not have ‘unlimited' medication in labour, coroner warns

Telegraph

17-07-2025

A coroner said women should not have unrestricted access to medication in labour, after the death of a newborn.
Liliwen Thomas died of a lack of oxygen 20 hours after she was born in hospital to a mother in a painkiller-induced coma, without midwives in attendance.
Emily Brazier, Liliwen's mother, 'effectively became comatose' after taking prescribed painkillers and self-administering gas and air, said Rachel Knight, the coroner.
Ms Knight called for a review of national guidelines for pain relief in childbirth following the incident.
The coroner expressed concern that Ms Brazier had 'unlimited' access to gas and air and was not supervised by midwives or doctors when she gave birth at the University Hospital of Wales, in Cardiff, in October 2022.
An inquest heard that Ms Brazier was admitted to the hospital's induction ward on Oct 8 while more than 40 weeks pregnant. She was given gas and air, and pethidine – an opioid similar to morphine – on Oct 9.
Into the early hours of Oct 10, the inquest heard, Ms Brazier 'was not attended to or subjected to physical checks and examinations regularly enough for her progress to active labour to be recognised'.
As a result of the gas, air and other pain relief, Ms Brazier slipped into a coma and delivered Liliwen. The baby's father, Rhodri Thomas, was not present as Ms Brazier was not considered to be in active labour.
At 2.14am, medics attended and found Liliwen had been born unattended and was in a 'very poor condition' under the sheets between her mother's legs. Liliwen died about 20 hours later from perinatal asphyxia – a lack of oxygen.
'Risk of future deaths'
Ms Knight said she feared more babies could die in childbirth in similar circumstances.
She wrote a Prevention of Future Death report for the National Institute for Health and Care Excellence (Nice), which publishes advice for the NHS, to raise concerns about mothers' unrestricted access to gas and air while unsupervised.
She said that there was not sufficient guidance for healthcare professionals surrounding painkillers and supervision.
Ms Knight said: 'In my opinion, there is a risk that future deaths will occur unless action is taken.
'Liliwen's mother was given unlimited Entonox [gas and air], as well as routine doses of pethidine and codeine.
'The result was that she effectively became comatose for a period of time, during which she delivered Liliwen.'
Gas and air is the most common pain relief method during labour in the UK, with 76 per cent of women using it, according to a 2022 survey.