Liliwen Iris THOMAS · Prevention of Future Deaths report

On 20 October 2022 I commenced an investigation into the death of Liliwen Iris THOMAS . The investigation concluded at the end of the inquest on 7th July 2025. The conclusion of the inquest was a narrative as follows:

Box 3:

Liliwen Thomas’s mother was admitted to the University Hospital of Wales for induction of labour on 8th October 2022 at 40+1 weeks. On 9th October she was given analgesia, Entonox and pethidine. Into the early hours of 10th October, Liliwen’s mother was not attended to, or subjected to physical checks/examinations, as regularly enough for her progress to active labour to be recognised. At 02:14 staff attended and found that Liliwen had been delivered unattended. Liliwen was in a very poor condition. She died at 22:40 the same day. A postmortem examination concluded that she died due to asphyxia around the time of her birth exacerbated by the presence of congenital infection and abnormal perfusion of the placenta of which there were no clinical indications identified before birth.

Box 4:

Liliwen died from a hypoxic brain injury following an unattended delivery in hospital. This was contributed to by:

a. Her mother not being attended to as frequently, or subject to as regular physical checks/examinations, as she should have been and her progress to active labour not being recognised;

b. The effects of maternal pethidine administered during labour;

c. Liliwen’s mother suffering an exaggerated pharmacological response to therapeutic doses of the drugs codeine and pethidine in combination with Entonox;

d. The absence of resuscitation at birth;

e. bacterial infection and malperfusion of the placenta.

Liliwen’s cause of death was found to be:

1a Perinatal asphyxia

1b congenital bacterial infection and maternal vascular malperfusion of the placenta

1c

II

The Inquest focused upon:-

a. The learning from Liliwen’s death, surrounding maternal analgesia during induction and labour; and

b. Supervision of mothers being induced and/or labouring under analgesia

(1) Liliwen’s mother was given unlimited Entonox, 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;

(2) Cardiff & Vale Health Board have 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 and increased levels of supervision of mothers under analgesia;

(3) They have seen an escalation in the numbers of women being transferred from the induction ward to the delivery suite as a consequence of reduced analgesia, which would otherwise have masked the transition to active labour; and

(4) The current NICE guidelines on Induction of Labour and Intrapartum Care do not deal explicitly with analgesia levels and supervision.