“5 (1) Liliwen’s mother was given unlimited Entonox, as well as routine doses of pethidine…”
Dated 8 Jul 2025, from the coroner for South Wales Central. Sent to 1 organisation or person.
A coroner wrote this report after an inquest, to warn the organisations below about a risk of further deaths.
The 56-day response deadline
All responses publishedReplies were due by 2 Sep 2025.
Organisations that receive a report must reply to the coroner within 56 days, saying what they will do or why they will do nothing. We show whether a response is published on judiciary.uk; a reply may have been sent and not yet published.
- Report dated8 Jul 2025
- Deadline2 Sep 2025
- Published on judiciary.uk16 Jul 2025
- Today27 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| National Institute for Health and Care ExcellenceNamed in the report as “NICE” | Response publishedPublished on judiciary.uk in July 2025. |
Some responses were published as scans, so their text was read automatically. Check the wording against the original before you quote it.
The coroner’s concerns
5 (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; Coroner’s Office, The Old Courthouse, Courthouse Street, Pontypridd, CF37 1JW 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.
An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.
- Source
- judiciary.uk, Prevention of Future Deaths reports, 2025-0352
- Added to Minute Book
- 8 Oct 2026
- Reuse
- We show short extracts and link to the original. We don’t host the full report.
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Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0
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