A newborn baby girl died after community midwives failed to properly monitor her heartbeat during a botched home birth over a busy Bank Holiday weekend.
Pippa Gillibrand was delivered after her mother, Victoria, 33, was blue-lighted to hospital after more than five-hours of labour.
But by then it was too late.
The 8lbs 5oz tot had suffered brain damage after being deprived of oxygen during her delivery and died aged 12 days.
An inquest into Pippa’s death, due to open next week, is expected to hear that staff shortages over the August Bank Holiday weekend, in 2024, impacted her care.
Mrs Gillibrand, a public health practice manager, and her husband, Thomas, 34, today said Pippa would be ‘eternally missed’ and that they hoped the inquest would provide answers about why she died.
The couple said: ‘While it will always hurt not knowing her smile, her laugh, her voice, or the milestones we expected to share, we take comfort in knowing she is now at peace, free from pain, and so deeply, deeply loved, not just by us, but by everyone who was fortunate enough to meet her.
‘Pippa will live on in memory of all and be eternally missed beyond all meaning.’
Victoria and Thomas Gillibrand’s baby daughter, Pippa, died aged 12 days
The tot, who was the couple’s first child, died after being starved of oxygen during a botched home birth
The couple, from Warrington, opted for a home birth because they were worried about the state of maternity services and thought it would be safer
Their lawyer, Rebecca Cahill, a specialist clinical negligence associate with JMW solicitors, said evidence will be presented to the inquest to show Pippa’s heart-rate was not monitored correctly, and that there were delays in community midwives attending the couple’s home, in Warrington, Cheshire, because they were dealing with another home birth and couldn’t staff both over the Bank Holiday weekend.
Ms Cahill said: ‘The death of this tiny baby is utterly tragic. Vicky and Tom’s loss is devastating and unimaginable, but to learn that Pippa’s monitoring was not in line with NHS guidelines, and that staff shortages appear to have impacted the care that they received only compounds their loss.
‘They obviously have a number of concerns and so welcome the coroner’s investigation to ensure that no stone is left unturned in trying to find out why Pippa died.’
The inquest will hear that the couple did extensive research prior to Pippa’s birth, and, due to concerns over the current state of hospital maternity services, opted for a home birth because they believed it would be safer.
Although Mrs Gillibrand was diagnosed with Low Pregnancy-Associated Plasma Protein-A (Low PAPP-A), a condition which can affect the growth of the foetus in the womb, at around 16 weeks into her pregnancy, she underwent frequent scans and her consultant agreed she was low-risk and suitable to have her baby at home.
The home birth was carefully planned and, at around 5.30am on Sunday August 25, 2024, Mr Gillibrand, a pharmaceutical technician, contacted the labour ward at Warrington and Halton Hospitals NHS Foundation Trust to say their baby was coming.
But he was allegedly told that the home birth team were already busy with another birth and a midwife would come out to them when they had finished dealing with that arrival.
The inquest is expected to hear that the labour ward asked the homebirth team to call Mrs Gillibrand to triage her care, but no phone call was ever 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
The inquest is expected to hear that staff shortages over the August Bank Holiday weekend, in 2024, impacted Pippa’s care
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 inquest will be told, they 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.
At 9am Mrs Gillibrand was examined and found to be fully dilated, so she was advised to get into the birthing pool.
However, the midwives did not have the correct equipment to give Mrs Gillibrand any gas and air for pain relief, so a third midwife was asked to attend.
She arrived with the gas and air at 9.20am and, although she had never attended a home birth before, she was asked to take over from the first member of staff, who was coming to the end of her shift.
According to guidance, Pippa’s heartbeat should have been monitored every five minutes, for a full minute, from 9am, when Mrs Gillibrand got into the pool.
But the inquest will be told that this didn’t happen even after 9.20am, when problems with Pippa’s heartrate were first recorded.
Despite difficulties listening to her heartbeat, it was another half an hour before an ambulance was called, at 9.50am, when no heartbeat could be detected at all.
Mrs Gillibrand arrived at Warrington Hospital at 10.26am and Pippa was delivered at 10.38am.
But she was in a very poor condition and arrangements were made to immediately transfer her to Liverpool Women’s Hospital for specialist cooling to try and minimise any brain damage.
Sadly, doctors there confirmed she had suffered too severe a brain injury, due to a lack of oxygen during her delivery, to survive. She was made comfortable and died at 12 days old, on September 5.
Ms Cahill said an internal investigation had been carried out by Warrington and Halton Hospitals NHS Foundation Trust which identified a catalogue of issues that will be raised at the inquest.
These include concerns that, instead of monitoring Pippa’s heartbeat midwives spent time organising staff rotas; the home birth risk assessment documentation was not properly completed and Mrs Gillibrand was not made aware of all the risks to her baby prior to going into labour; no senior managers were on call over the Bank Holiday weekend for the midwives to escalate safety concerns; there was not enough equipment available for the community midwives to cope with two home births simultaneously, and records of Mrs Gillibrand’s labour were not completed properly due to problems with the midwives’ laptops and the electronic patient record system.
Pippa’s inquest is scheduled to start at Warrington Coroner’s Court on Monday January 26.
Warrington and Halton Hospitals NHS Foundation Trust was contacted for comment.
