‘Investigations into baby deaths in Wales must be independent’

Emily Brazier’s daughter Liliwen Iris Thomas died 20 hours after her birth at the University Hospital of Wales, after Emily was given so much pain medication and unlimited access to Entonox (gas and air) without any supervision, resulting in her being unaware she had given birth.

A lack of checks on Emily by midwives meant that Liliwen’s birth went undiscovered for a catastrophic length of time, resulting in the most severe grade of hypoxic brain injury.

To compound the devastation, Emily and her partner Rhodri Thomas were told that the investigation into Liliwen’s death would be conducted by staff at the same hospital – which the bereaved parents believed was essentially enabling the University Hospital of Wales to “mark its own homework”.

In England, investigations into major patient safety concerns such as baby deaths are conducted by the Health Services Safety Investigations Body (HSSIB), and the independent body has further implemented a specific programme to investigate maternity failings, known as The Maternity and Newborn Safety Investigations (MNSI). In Scotland, the Serious Adverse Event Reviews (SAERs) and Comprehensive Care Reviews (CCR) must have external input from clinicians or professionals from a different Health Board.

However, in Wales, there is no such body and cases such as Liliwen’s are looked into by staff employed by the same Health Board who work within the same hospital where the death happened – raising concerns about their impartiality.

Now, Emily is calling for a total change in the process, especially for cases in maternity failings. The Coroner in Liliwen’s case, Rachel Knight, listened to family concerns and appointed an independent obstetrician to prepare a report.. The independent obstetric report identified additional concerns which had not been adequately addressed in the findings of the internal report.

Emily’s campaign comes at a time when maternity services across Wales are being independently reviewed, in response to concerns over the quality of care being delivered across the country, most recently exposed by a report into Swansea Bay.

“I do not think the current system of investigation in Wales is fit for purpose – are we really expecting medical staff to expose failings by their own colleagues, who they

potentially have close relationships with, and for them to disclose failings against their own employer?,” says Emily, from Cardiff.

“The process felt very biased from the start, and I did not know this was the way investigations were carried out until we lost Liliwen. The current system risks allowing a cover up culture and could result in negligent staff avoiding accountability.

“We were really unhappy with the findings of the report by the University Hospital of Wales and we ended up going back to the Health Board with a multitude of questions that needed answering. It didn’t give us justice for Liliwen. We are so grateful to the Coroner for commissioning an external expert, and the report the expert produced really was night and day to the one from the hospital staff.

“We felt vindicated, after two-and-a-half years, and finally the external report was confirmation of all the things we had been saying, that we felt had been brushed aside, about the effects that pethidine and Entonox had upon on myself and Liliwen, and its role in the death of our daughter.

“Rhodri and I have had to fight so hard just to get to the truth of what happened to Liliwen, and it shouldn’t be this way for families. Many families are too tired, too broken, to ask questions or do their own research. They shouldn’t have to fight in any way and should be supported by an independent investigation carried out by external experts. The grief of losing your child is enough to handle without the added grief this process brings.”

Lara Bennett, senior associate at law firm Slater and Gordon, is supporting Emily and Rhodri in action against Cardiff and Vale University Health Board. She echoed Emily’s calls for the introduction of independent investigations.

“With the current system of investigations being carried out in the very hospital that is subject to scrutiny, we essentially have a system where they are marking their own homework. The difference in evidence produced to the Coroner in Liliwen’s case from the independent obstetrics expert, to that in the report from the University Hospital of Wales, has really brought this into focus,” says Lara.

“Families who have endured such trauma should not have to fight for answers in the way Emily and Rhodri have. An independent investigation would really help in achieving this and in families knowing they are being supported in their quest for justice. We wholeheartedly back Emily in her calls for this, and urge the independent review of maternity care in Wales to include this in its scope, as a very effective way in which families can be better supported if tragedy does happen.”