Family Handout/PaA newborn died, when his mother was left unattained from the right and the pain gave birth in a coma after a strong response to the killers, an inquiry heard by an inquiry.
Lillivan Iris Thomas died on 10 October 2022, 20 hours after being born at the University Hospital of Wales in Cardiff.
Pontiprid inquiry heard that mother Emily Brezier’s “failure to take care of adequate care”, which was not checked for an hour after being administered significant doses Pathidine and CodineAnd unrestricted access to gas and air.
One of the causes of death for Lilvan was given as a lack of asphixia or oxygen during birth.
Abigail Holmes, head of Midwifery at Cardiff and Well Health Board, apologized to the family and said that there was a “deep change” after Lilvan’s death.
The coroner’s court heard that Lilvan was found under the sheets between Mummy’s legs on 10 October 2022, when he was found “between the feet of the mother”, at a time when a woman was not in active labor, the wards were not allowed.
This meant that Lilyven’s father, Rodari Thomas, was not present.
Ms. Brezier was booked for an induction due to low on 7 October 2025. Pap-e-level Which meant that there was a danger of complications.
But the next day he had to return due to low staffing levels.
The coroner’s court heard at around 19:30 pm, a discussion began to relieve pain and in the next few hours, Ms. Brezier was used 100mg Pathidine, 60 mg codeine and frequent gas and air (Antonox).
But a midwife failed to present that she was in active labor which means she should have been transferred for one-to-one care.
He was not investigated at all between 01:15 and 02:14, when “was heard fainting for help” and the right reached him.
A report from a medical expert stated that it was likely that Ms. Brezier suffered a “exaggerated medicinal response, resulting in a coma, during which she unattured the child and was unable to call help”.
“This was most likely due to sensitivity to codeine and pethidine,” saying that “Antonox’s self-appreciator contributed to the inability of the Ms. Brezzier”.
The coroner court heard that this happened when the ward was “exceptionally busy”.
The lack of staff was also “so intense that the community had a call to bring the rights”.
At that time, 17 hospital rights were placed on shift, in which two drafts were prepared from two communities – according to the 24 Health Board, there is a minimum number of midwives available during the day.
Family Handout/PaGiving evidence, the head of the Midwifery Ms. Homes, who was not in the post at that time, described it as a “saddest case”.
He said, “Its effect in the form of a staffing body is very felt by every member of our team, regardless of the grade,” he said.
Addressing the family directly, Ms. Homes said: “We are tirelessly trying to ensure that something like this never happens again.
“I know it does not bring your daughter back and I am like that, so forgive.”
Ms. Homes underlined a series of changes made in the health board, which were within a few weeks of Lillven’s death.
These included major changes in the way women relieve pain during both early and active labor.
Coronor Rachel Knight stated that the case was “no less than the tragedy” and it was clear that it had “seismic effect on maternity care” in the health board.
Ms. Knight said that she must be preparing Future death prevention report As she was “worried” that Good guidelines Labor was “not sufficiently clear” on induction.
In a statement, Laraben, a lawyer representing Lilvan’s family, said: “While it has been claimed that the lesson has been taught, and changes have been implemented, the tragic case highlights concerns about understanding and monitoring basic care and monitoring for mothers and babies.
“If it was provided, Lilvan did not face as he had done and would be with his family today.
“It is necessary that policy changes in maternity services implemented by Cardiff and Well University Health Board should be adopted in all Welsh health boards as a direct result of this tragic event.
“Lilyven’s death should not be in vain and maternity care standards in Wales should be improved to ensure that no mother or child suffers again in this way.”
