Parents speak out after death of newborn daughter due to serious medical failings

The heartbroken parents of four-day-old Etta Lili Stockwell-Parry, who died in July 2023 following what a coroner described as “serious failures to provide basic medical care,” are calling for urgent improvements in maternity care to prevent further tragedies.

Laura and Tristan Stockwell-Parry shared their devastating story in an emotional interview on Y Byd ar Bedwar, S4C’s current affairs programme, which aired earlier this week and is available on S4C Clic and BBC iPlayer with English subtitles.

The couple, from north Wales, have spoken for the first time following an inquest that concluded negligence by Betsi Cadwaladr University Health Board contributed to the death of their daughter.

Etta passed away on July 7, 2023, just four days after her birth at Ysbyty Gwynedd.

“Everything during the pregnancy was normal,” said Laura Stockwell-Parry. “There were no signs of complications. We were told ‘happy baby, happy baby until she was born.’”

Immediate resuscitation

Etta required immediate resuscitation after birth and was admitted to the Special Care Baby Unit at Ysbyty Gwynedd before being transferred to Arrowe Park Hospital near Liverpool. Etta suffered severe hypoxic brain injury due to lack of oxygen during birth. After four days of critical care, her life support was withdrawn.

In October 2023, Betsi Cadwaladr Health Board provided the family with a serious incident report.

The report concluded that multiple failures occurred in the care of Laura and Etta during the pregnancy and birth. One of the most significant was that midwives failed to notice, on three separate occasions, that Etta was not growing in the womb.

It also emerged that mistakes were made while monitoring Etta’s heartbeat before birth – with the mother’s heartbeat mistakenly recorded instead of the baby’s.

“That did scare me because it was 43 minutes… that’s a long time. It’s something quite basic,” said Laura.

The report also stated that there was a significant delay before recording Etta’s temperature after she was born, and that the doctors should have used another airway device to assist her breathing at the time.

‘Clear neglect’

The coroner’s findings in May 2025 confirmed several breaches of basic medical standards, stating, “This was one of the most distressing cases I have dealt with. There was clear neglect.”

The episode of Y Byd ar Bedwar also uncovered serious ongoing concerns from mothers and maternity staff at Ysbyty Gwynedd, months after a critical inspection report from Healthcare Inspectorate Wales (HIW) identified urgent patient safety risks.

The HIW report, published in June following an unannounced inspection in February, warned that “urgent action” was needed to address patient safety concerns in the hospital’s maternity unit. While inspectors acknowledged that staff treated women and their families with kindness and respect in a clean environment, they raised serious concerns about inadequate staff communication, which they said undermines the ability to deliver safe and effective care.

The report also revealed alarming gaps in mandatory training completion among medical staff:

Only 44% had completed training on measuring fetal growth.

62% had completed fetal heart monitoring training.

Just 14% had completed basic life support training.

Staff also reported feeling that their wellbeing was not a priority, and said staffing levels were often insufficient to feel safe in the unit.

Low morale

Y Byd ar Bedwar heard from staff working at the Maternity Unit at Ysbyty Gwynedd, who described low morale within the department and said they had seen little change in the months since the Healthcare Inspectorate Wales (HIW) visit.

The programme also spoke to mothers who received care at the unit after the inspection. They said the same concerns raised in the HIW report – particularly poor communication among staff – remain unresolved.

One mother, Leanne Lovell from Caernarfon, gave birth to her daughter Elsi at Ysbyty Gwynedd just a month after the inspection. Her experience was marred by confusion over her medical notes, resulting in staff passing incorrect information between themselves.

Leanne had gone 11 days past her due date but was almost sent home after a doctor mistakenly believed she was only one day overdue.

“I just keep thinking, ‘what if I’d gone home?’” said Leanne. “The whole experience was stressful. It didn’t make me feel comfortable, happy, or safe.

“There are lives involved—little children. I definitely wouldn’t want to go back there. It was chaotic, inconsistent, and I didn’t feel like I was in a safe place.”

Profound impact

Angela Wood, Executive Director of Nursing and Midwifery Services at Betsi Cadwaladr University Health Board, said: “We wish to express our deepest sympathies and heartfelt condolences to Mr and Mrs Stockwell-Parry following the heartbreaking loss of baby Etta. We fully acknowledge the profound impact this tragedy has had on their family, and our thoughts are with them during this incredibly difficult time.

“Since this tragic event in July 2023, we have conducted a comprehensive review of the care provided and taken decisive action to address the issues identified. We are committed to learning from this experience and have introduced a range of measures to enhance our training and clinical oversight, ensuring the best possible care for both mothers and babies.

“Delivering safe, compassionate care remains our highest priority, and we are dedicated to maintaining the utmost standards across all our maternity services.

“We encourage anyone with concerns to reach out to us directly so we can thoroughly investigate and support them.”

She added: “We welcome the report from Health Inspectorate Wales into our Maternity Unit at Ysbyty Gwynedd and are pleased that it recognises the dedication of our staff in treating women with kindness and respect.

“We are particularly encouraged by the positive feedback from women using our services, especially their appreciation for the support they have received during their maternity journey. We are also pleased that this report acknowledges our specialist bereavement service and our Rainbow Clinic, which provides vital care for women following pregnancy loss.

“The Inspectorate’s feedback is valuable and provides us with a welcome opportunity to make further improvements. An improvement plan was promptly put in place in response to their findings and we remain on track to complete all of the remaining actions by the end of July.

“We remain fully committed to ensuring the highest standards of care for women and families using our maternity services across North Wales.”