The father of a baby girl who died following a botched home birth today accused the NHS of playing ‘Russian roulette’ with her life.
Thomas Gillibrand, 34, said the death of his newborn daughter, Pippa, was ‘preventable’ and she’d been ‘taken’ from him and his wife, Victoria, 33, because of a catalogue of failings with the home birth service at their local hospital.
Cheshire Coroner’s Court heard how staffing shortages over a Bank Holiday weekend meant there were not enough midwives on duty and those that arrived at the couple’s home were inexperienced and delivered, on average, just three babies each a year.
They failed to properly monitor Pippa’s heart-rate because they were distracted by staffing and IT issues, which delayed an ambulance being called, an inquest was told.
By the time Mrs Gillibrand arrived at Warrington Hospital and Pippa was delivered it was too late.
She had been deprived of oxygen and she died of a severe brain injury aged just 12 days.
Speaking after a coroner ruled Pippa’s death was avoidable, Mr Gillibrand, a pharmaceutical technician, said: ‘The Trust seems to have played Russian roulette with the innocent lives of mothers and babies.
‘Tragically, we are the family that took the bullet. Pippa’s death was clearly preventable. It is vital for her legacy that she does not die in vain.
‘Changes have to be made to prevent this from happening again.’
Mr and Mrs Gillibrand with their newborn daughter, Pippa. Her death was ‘avoidable,’ a coroner has ruled
The tot, who was the couple’s first child, died after being starved of oxygen during a botched home birth
Mr and Mrs Gillibrand (right) spoke alongside their lawyer Rebecca Cahill (left), of JMW Solicitors, following the hearing at Cheshire Coroner’s Court
His wife, a public health practice manager, added: ‘Baby loss is one of the worst things anybody could ever go through, but then to find out that that loss was preventable, that there’s been failings and missed opportunities along the way, it’s just absolutely shattered our lives.’
Victoria Davies, senior coroner for Cheshire, said she would be writing to the Health Secretary to warn that a lack of national guidance on home births was putting babies’ lives at risk.
She said Pippa’s death occurred just over three months after that of another mother and baby, Jennifer and Agnes Cahill, in a similar botched home birth, in nearby Prestwich, Greater Manchester.
Although the coroner who presided over their inquests wrote to Wes Streeting highlighting the lack of national guidance in November, Ms Davies said nothing had been done.
She said she was ‘not assured the issue has been resolved’ and would be writing again to the Department of Health and Social Care, along with NHS England and the National Institute of Clinical Excellence (NICE) to warn more mother and baby deaths would occur unless guidance on home births was put in place urgently.
The court heard that Mrs Gillibrand went into labour in the early hours of Sunday August 25, 2024, and at around 5.30am Mr Gillibrand contacted the labour ward at Warrington and Halton Teaching Hospitals NHS Foundation Trust to say their baby was coming.
He was told that the home birth team was already busy with another birth and a midwife would come out to them when they had finished dealing with that arrival.
The labour ward contacted the homebirth team and asked them to call Mrs Gillibrand to triage her care, but no phone call was made.
The couple, who married in June 2023, were excited to welcome their first child and had done extensive research before planning for Pippa to be delivered by community midwives at their home, in Warrington, Cheshire
Mrs Gillibrand, pictured towards the end of her pregnancy, in August 2024
Victoria and Thomas Gillibrand’s baby daughter, Pippa, died aged 12 days
Jennifer Cahill (pictured) with her son died alongside her newborn daughter, Agnes, in June 2024 during a home birth – three months before Pippa’s death, in August the same year
Instead, Mr Gillibrand called the labour ward again at 7.40am to say his wife’s waters had broken.
He was told a midwife would be with them within the hour, but that they could also come to hospital if they preferred.
Crucially, the couple were never instructed to attend the hospital or informed that there were not enough midwives to accommodate two home births at the same time.
Eventually, the first midwife arrived to help the couple at 8.15am, followed by a second at 8.51am and a third at 9.20am.
At 9am Mrs Gillibrand was examined as being fully dilated and assessed to be in established labour, so was advised to get into the birthing pool.
According to national guidelines, Pippa’s heart-rate should have been monitored every five minutes from then on, but this did not happen because the midwives were ‘distracted’ trying to sort out staffing pressures and problems with their laptops, which were not connecting to the hospital’s electronic notes system.
Although Pippa’s heartrate was recorded as being normal at 9am, 9.15am and 9.30am, by 9.36am it could only be heard intermittently and eventually at 10am a decision was made to call an ambulance.
Mrs Gillibrand was rushed to Warrington Hospital, where Pippa was delivered by forceps in a very poor condition, not breathing and with no heartbeat, 38 minutes later.
Doctors managed to resuscitate her and she was transferred to Liverpool Women’s Hospital for specialist treatment.
But she had suffered a severe brain injury due to a lack of oxygen during her delivery and died at 12 days old, on September 5.
Ms Davies said the couple should have been advised that the Trust could only cope with one home birth at a time and told to come into hospital when they first called at 5.30am.
Another ‘missed opportunity’ occurred when they called back at 7.40am and midwives took the decision to go out to the couple’s home, in Appleton, near Warrington, instead of again advising them to attend the labour ward.
The court heard two of the three midwives who attended the home birth were community midwives, who only delivered, on average, three home births a year.
Ms Davies said: ‘You wouldn’t want a surgeon operating on you who only performs a procedure three times a year, so I cannot understand why we are asking midwives to be in the same position.’
Recording a narrative verdict, she stopped short of concluding that there had been ‘gross failures’ in Pippa’s care or that her death was ‘contributed to by neglect.’
However, the coroner concluded Pippa would have lived without ‘avoidable’ delays in her delivery .
‘In light of the staffing issues, including that the home birth team were already at another birth, Pippa’s mother should have been advised to attend hospital rather than continue as a home birth,’ Ms Davies said.
‘Once difficulties became apparent in monitoring Pippa’s heart rate from 9.36am, a decision should have been made shortly after for transfer for hospital.
‘It is likely that, had either of these taken place, her mother would have been assessed in hospital earlier and the need for urgent delivery would have been identified earlier.
‘Had Pippa been delivered earlier, she would not have died when she did. Pippa died as a result of a brain injury sustained due to an avoidable delay in her delivery.’
The coroner also said she would be highlighting the need for better data collection on home births so parents could make more informed choices about the risks associated with them, as opposed to a hospital delivery.
Clutching a pink toy bunny that the couple had placed with Pippa in her incubator during her short life, Mrs Gillibrand urged Mr Streeting to take action on home births.
‘This is a national issue,’ she said. ‘The NHS needs to act on maternity care. Everybody is born and every family deserves a safe experience.
‘Services have been underfunded and stretched for such a long time that we’re now in a position where we’ve lost our daughter because of the cuts. Things need to change.’
She said the couple, who now have a four-month-old son, Rory, had been fundraising for Liverpool Women’s Hospital ever since Pippa’s death.
‘In the aftermath of Pippa, we weren’t living, we were just existing,’ Mr Gillibrand added.
‘Rory will never replace Pippa, we will always miss her, but with our son we’ve started to feel the happiness that we never thought was possible again.’
Rebecca Cahill, a specialist clinical negligence lawyer with JMW Solicitors, who represented the couple at the inquest, said: ‘What is clear from today’s conclusion is that the family were failed from the start.
‘If anything positive can be taken from this dreadful loss, it is that the Trust recognises the failings in care, and changes have already been implemented which, we hope, will ensure this does not happen to another baby and another family.’
The court heard that Warrington and Halton Hospitals NHS Foundation Trust has overhauled its home birth service since Pippa’s tragic death, with expectant mothers now asked to attend hospital if the home birth team is already busy.
Chief nurse Ali Kennah said: ‘We remain truly sorry for the failures in the care that Mrs Gillibrand and Pippa received, and we fully accept the coroner’s findings.
‘Since this tragedy occurred, we have strengthened our home birth service and have fully implemented all recommendations from an independent review. We will continue to make sure that all lessons are learnt.
‘We would again like to extend our deepest condolences to Mr and Mrs Gillibrand for their heartbreaking loss.’
