Source · Prevention of Future Deaths

Liliwen Thomas

Ref: 2025-0352 Date: 8 Jul 2025 Coroner: Rachel Knight Area: South Wales Central 1 response identified · 1 indexed addressee View PDF

AI-generated concerns summaryThe coroner noted that current NICE guidelines on Induction of Labour and Intrapartum Care do not explicitly address analgesia levels and supervision during labour, which was a factor in a mother becoming comatose.

Date 8 Jul 2025

56-day deadline 3 Sep 2025 stated in the report

Responses identified 1 of 1

Child Death (from 2015) Hospital Death (Clinical Procedures and medical management) related deaths Wales prevention of future deaths reports (2019 onwards)

Coroner's concerns

AI summary

The coroner noted that current NICE guidelines on Induction of Labour and Intrapartum Care do not explicitly address analgesia levels and supervision during labour, which was a factor in a mother becoming comatose.

View full coroner's concerns

(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;

Phone/Ffôn (01443) 281100 Fax/Ffacs (01443) 485862 (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.

Responses

1 respondent

National Institute for Health and Care Excellence

Other

Letter dated 1 Sep 2025 PDF

AI-classified response stance Action Planned

AI-generated response summary

• NICE stated it would consider updating recommendations in its guidelines on inducing labour (NG207) and intrapartum care (NG235). • This consideration will include the optimum frequency of clinical assessments for women requiring increasing pain relief. • NICE will also consider updating the pain relief section of its intrapartum care guideline to discuss combination therapies and monitoring requirements.

View full response

Dear Ms Knight Re: Regulation 28 Prevention of Future Deaths Report (Liliwen Iris Thomas) write in response to your regulation 28 report dated 8 July 2025 regarding the sad death of Liliwen Iris Thomas. would Iike to express my sincere condolences to Liliwen's family have asked the patient safety leads at NICE to carefully consider the content of report with respect to the areas for which NICE is responsible, and with specific regard to the NICE guidelines on induction of labour and intrapartum care_ can confirm that we will consider updating the recommendations in our guidelines on inducing labour (NG2OZ) and intrapartum care (NG235) as a result of the issues raised in your report: This will include the following specific considerations: NG207 recommendation 1.5.4. What is the optimum frequency of clinical assessments (including vaginal assessments) in women before active labour, and where women require increasing levels of pain relief during labour? 2 NG235 recommendation 1.6. We consider updating the pain relief section to discuss the use of combination therapies and at what point further monitoring is required. 3 NG207 recommendation 1.5.6-8 in We will also consider if these recommendations need updating: Given that some of the matters of concern relate to policies and practices within Cardiff and Vale University Health Board, these are not areas that we can comment on, but understand that you have also shared your report with the Health Board. Once we have concluded our review and decided on any updates needed to our guidance, we will write to you once more with the outcome. hope that the information above is helpful and would like to reiterate my sincere condolences to Liliwen's family_

Report sections

Investigation and inquest

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, 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:

Phone/Ffôn (01443) 281100 Fax/Ffacs (01443) 485862 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

Circumstances of the death

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

Copies sent to

as well as , Chief Executive of NHS Wales

Inquest conclusion

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, 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:

Phone/Ffôn (01443) 281100 Fax/Ffacs (01443) 485862 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

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Report details

Reference: 2025-0352
Date of report: 8 July 2025
Coroner: Rachel Knight
Coroner area: South Wales Central

Responses identified

Responses identified 1 of 1

All listed responses identified

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 3 Sep 2025 (stated in the report).

Sent to

NICE

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk.

Contains public sector information licensed under the Open Government Licence v3.0.