Latest news with #EmilyBrazier
Yahoo
18-07-2025
- Health
- Yahoo
Call for guidelines to be tightened after newborn death
A coroner has called for guidelines to be tightened following the death of a newborn baby after her mother was left unattended, despite being in a coma due to a reaction to painkillers. Liliwen Iris Thomas died on 10 October 2022, 20 hours after she was born at the University Hospital of Wales in Cardiff. An inquest that concluded earlier this month heard there was a "failure to take adequate care" of mother Emily Brazier, who was not checked for an hour after being given a cocktail of painkillers. The coroner, Rachel Knight, has now published a Prevention of Future Deaths Report calling on the National Institute for Health and Care Excellence (NICE) to address issues raised in the inquest. Baby died after unattended mum gave birth in coma NHS staff want 'dehumanising' corridor care to end The coroner said she believed the current NICE guidelines on induction of labour and childbirth do not deal explicitly with analgesia levels and supervision. The Chief Executive of NICE must respond to the report by 3 September. The inquest had heard how Ms Brazier was given 100mg of pethidine, 60mg of codeine and repeatedly used gas and air, but a midwife failed to spot she was in active labour meaning she should have been moved to one-to-one care. The ward was said to be exceptionally busy at the time. Ms Brazier was not checked at all between 01:15 and 02:14 when a "faint cry for help was heard" and midwives rushed to her. Baby Liliwen was found in a "poor condition" and died 20 hours later, with the cause of death given as asphyxia or a lack of oxygen during birth. A report by a medical expert said it was likely Ms Brazier suffered an "exaggerated pharmacological response resulting in a coma, during which time she delivered the baby unattended and was unable to summon help". The Head of Midwifery at Cardiff and Vale health board Abigail Holmes has previously apologised to the family and said that "profound changes" had been made following Liliwen's death. The coroner said the health board has taken significant steps to significantly restrict the use of analgesia during induction and labour, including reductions of prescribed doses, allowing only limited access to analgesia on the wards. There is also increased levels of supervision of mothers under analgesia. A copy of the Prevention of Future Deaths report has also been sent to the family and to the chief executive of the Welsh NHS. The coroner suggested the conclusions could be sent to other health boards around Wales. Too few consequences for NHS underperformance - Miles Couple feel vindicated by critical maternity care report Dad demands changes over maternity service failures
Times
17-07-2025
- Health
- Times
Use of gas and air in labour ‘should be reviewed' after baby death
Official guidelines on pain relief during childbirth should be reviewed, a coroner said, after a baby died while her mother had 'unlimited' access to gas and air. Liliwen Thomas died after her mother was left unattended by midwives and gave birth while in a coma. At an inquest into the infant's death, Rachel Knight, an assistant coroner for South Wales, called for a review of national guidelines on the use of gas and air during labour. Liliwen Thomas, who died 20 hours after being born, with her parents Emily Brazier and Rhodri Thomas PA The inquest was told that Emily Brazier was left with unlimited access to the pain relief while on a hospital induction ward. Medical staff were said to have failed to notice that Brazier had progressed to active labour and she was left unattended by midwives. Her newborn baby died 20 hours later owing to a lack of oxygen during birth. Knight said that she feared that more babies could die in similar circumstances. She has now written to the National Institute for Health and Care Excellence (Nice) — which publishes advice for the NHS — expressing concerns around pain relief and noting that current official guidelines do not offer clear advice. • My nightmare giving birth — and Britain's maternity scandal Gas and air is the most common method administered during labour in the UK — a 2022 survey found that more than 75 per cent of women used it on maternity wards. The survey also found that it was common practice for women to have unrestricted access to the pain relief. The inquest heard that Brazier was admitted to the University Hospital of Wales in Cardiff for induction in 2022, while she was more than 40 weeks pregnant. Because she was not in active labour when admitted, the unborn child's father, Rhodri Thomas, was not present. Brazier was given gas and air the next day along with pethidine, an opioid similar to morphine. However, in the early hours of the day after that, Brazier 'was not attended to or subjected to physical checks and examinations regularly enough for her progress to active labour to be recognised'. At around 2am, medical staff found that Liliwen had been born unattended and was in a 'very poor condition' under the sheets between her mother's legs. She died about 20 hours later from perinatal asphyxia — a lack of oxygen. In her prevention of future deaths report, Knight said that the current Nice guidelines failed to deal explicitly with 'pain relief levels and supervision'. She added her concern that pain relief appeared to 'mask' when women moved into active labour. However, she noted that the Cardiff & Vale Health Board had taken steps 'to significantly restrict the use of analgesia during induction and labour, including reductions of prescribed doses, allowing only limited access to analgesia on the wards and increased levels of supervision of mothers under analgesia'. Nice has until September 3 to respond to the coroner's concerns. In a statement after the inquest, Lara Bennett, the lawyer representing the parents, said that the case highlighted 'concerns regarding understaffing on maternity wards and the absence of basic care and monitoring for mothers and babies at their most vulnerable'.
Telegraph
17-07-2025
- Health
- Telegraph
Women should not have ‘unlimited' medication in labour, coroner warns
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.
BBC News
16-07-2025
- Health
- BBC News
Call for guidelines to be tightened after newborn death
A coroner has called for guidelines to be tightened following the death of a newborn baby after her mother was left unattended, despite being in a coma due to a reaction to Iris Thomas died on 10 October 2022, 20 hours after she was born at the University Hospital of Wales in inquest that concluded earlier this month heard there was a "failure to take adequate care" of mother Emily Brazier, who was not checked for an hour after being given a cocktail of coroner, Rachel Knight, has now published a Prevention of Future Deaths Report calling on the National Institute for Health and Care Excellence (NICE) to address issues raised in the inquest. The coroner said she believed the current NICE guidelines on induction of labour and childbirth do not deal explicitly with analgesia levels and Chief Executive of NICE must respond to the report by 3 inquest had heard how Ms Brazier was given 100mg of pethidine, 60mg of codeine and repeatedly used gas and air, but a midwife failed to spot she was in active labour meaning she should have been moved to one-to-one ward was said to be exceptionally busy at the Brazier was not checked at all between 01:15 and 02:14 when a "faint cry for help was heard" and midwives rushed to Liliwen was found in a "poor condition" and died 20 hours later, with the cause of death given as asphyxia or a lack of oxygen during birth.A report by a medical expert said it was likely Ms Brazier suffered an "exaggerated pharmacological response resulting in a coma, during which time she delivered the baby unattended and was unable to summon help".The Head of Midwifery at Cardiff and Vale health board Abigail Holmes has previously apologised to the family and said that "profound changes" had been made following Liliwen's coroner said the health board has taken significant steps to significantly restrict the use of analgesia during induction and labour, including reductions of prescribed doses, allowing only limited access to analgesia on the is also increased levels of supervision of mothers under analgesia.A copy of the Prevention of Future Deaths report has also been sent to the family and to the chief executive of the Welsh coroner suggested the conclusions could be sent to other health boards around Wales.
The Sun
09-07-2025
- Health
- The Sun
Baby girl died hours after midwives ‘dosed mum up on painkillers then left her to give birth alone'
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. 4 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." Two mums and 56 babies died 'needlessly' at 'appalling' NHS trust where staff 'tick boxes and fob patients off with paracetamol' "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. 4 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
