Overview

• The inquest found that Liliwen Iris Thomas died from a hypoxic brain injury after her mother was left unattended for four hours during induced labour at Cardiff’s University Hospital of Wales.
• Assistant Coroner Rachel Knight identified perinatal asphyxia and a bacterial placental infection as the primary medical causes contributing to the newborn’s death.
• Cardiff and Vale University Health Board admitted it had only 17 midwives on duty when 24 were required, leading to failures in monitoring and support.
• The coroner decided against issuing a Prevention of Future Deaths report for the health board after local policy reviews and retraining but warned that learning may not reach other NHS maternity units.
• A Regulation 28 report will be sent to the National Institute for Health and Care Excellence to drive national adoption of the inquest’s safety recommendations.