## Inquest Reveals Baby’s Tragic Death After Mother Left Alone in Wales’ Largest Hospital
An inquest has determined that a newborn baby, Liliwen Iris Thomas, died after her mother was left to give birth by herself at the University Hospital of Wales in Cardiff, with no midwife or medical professional present. The harrowing events that unfolded have prompted calls for sweeping changes in maternity care, and have exposed ongoing concerns about staffing levels and policies at one of Wales’ most prominent healthcare institutions.
On 8 October 2022, Emily Brazier arrived at the University Hospital of Wales to be induced at just over 40 weeks pregnant. According to proceedings at Pontypridd Coroner’s Court on 8 July 2025, Ms Brazier received pain relief but was not monitored or checked by medical staff as often as guidelines recommend. Crucially, evidence presented at the inquest indicated that between 1:15am and 2:14am on 10 October, she was left entirely unsupervised. During this period, Ms Brazier’s quiet move into active labour was missed.
When Ms Brazier eventually managed to raise the alarm, staff rushed to her side—but their intervention came too late. Her newborn daughter had already arrived. Liliwen was found in a critical condition and tragically died later that evening at 10:40pm. According to the official post-mortem, the cause of her death was perinatal asphyxia, a condition arising from a lack of oxygen during birth.
Testimony at the inquest revealed the hospital was operating significantly below recommended staffing levels at the time, with just 17 midwives present instead of the projected minimum of 24. Only after calling in two additional staff did the number rise to 19, still falling short of requirements for a busy maternity ward.
A further layer to the tragedy was that Liliwen’s father, Rhodri Thomas, was not allowed to be present for the birth. At the time, strict overnight visitor policies prohibited partners from staying on the ward between 9pm and 9am, leaving Ms Brazier to face the ordeal alone.
Assistant Coroner Rachel Knight noted that several failings contributed to Liliwen’s death: lack of sufficient monitoring, the absence of immediate resuscitation, and the presence of a bacterial infection in the placenta. “Liliwen died from a hypoxic brain injury following an unattended delivery in hospital,” Ms Knight stated. She added that these events had a “seismic impact on the largest hospital in Wales”, prompting a comprehensive review of protocols and additional staff training within Cardiff and Vale University Health Board.
Despite these changes, Ms Knight stopped short of issuing a Regulation 28 Report—a formal notice designed to prevent further deaths within the same trust—stating she was satisfied that the health board had responded robustly to the tragedy. However, she expressed concern that the lessons might not yet be shared widely enough and instead directed a draft Regulation 28 report towards the National Institute for Health and Care Excellence, hoping for broader reform.
Liliwen’s parents, through their legal representatives at Cardiff firm Slater and Gordon, described the inquest and its revelations as “absolutely devastating.” In a statement, they said: “Liliwen and Emily were abandoned at a time when their care should have been the hospital’s top priority. Had basic care and proper monitoring been in place, we believe Liliwen would be with us today. We hope her death leads to lasting change.”
Addressing the hearing, Abigail Holmes, director of midwifery and neonatal services at the hospital, described Liliwen’s death as “the most tragic case I’ve ever been involved with.” She confirmed that both staffing and training have received renewed investment since the incident.
Following the conclusion of the inquest, Cardiff and Vale University Health Board extended its sympathies to the family and emphasised its commitment to the ongoing review process, declining to comment further until all proceedings are formally closed.
This case has highlighted the vital, and often under-reported, role that inquests play in uncovering systemic issues and prompting meaningful improvement within the NHS. Open and transparent reporting of such tragedies is not only important to the bereaved, but often acts as the catalyst for critical change in health and safety practices, potentially saving lives in the future.
The events surrounding Liliwen’s death have reignited debate on the adequacy of maternity services across Wales, drawing attention to the human impact of staffing shortfalls and policy decisions. Campaigners, healthcare professionals, and bereaved families alike stress the importance of learning urgent lessons—to ensure such heartbreak is never repeated.