A father whose newborn baby died after an “avoidable” delay in her delivery has accused a hospital trust’s home birth service of playing “Russian roulette” with the lives of mothers and babies.
Warning – this story includes descriptions of a newborn child’s suffering and death
Thomas and Victoria Gillibrand’s baby, Pippa, suffered a severe brain injury and died at just 12 days old, Cheshire Coroner’s court heard.
Ms Gillibrand, 33, had planned to give birth at her home in Warrington, but when she went into labour on 25 August 2024, the home birth team from Warrington and Halton Hospitals NHS Foundation Trust was dealing with another labour.
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There were “missed opportunities” for the trust to abandon the home birth plan and tell Mrs Gillibrand to come into hospital, coroner Victoria Davies said as she delivered her findings.
Speaking outside the court in Warrington on Tuesday, Mr Gillibrand, 34, 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 on that. Our feelings are that Pippa’s death was clearly preventable and it shouldn’t have taken a child’s death for changes to be implemented.”
Mrs Gillibrand, who carried a small toy bought for Pippa with her, added: “Services have been underfunded and stretched for such a long time, that we’re now in a position that we’ve lost our daughter because of the cuts and the services that are currently in situ, and things need to change.”
Mr Gillibrand called Warrington Hospital at about 5.30am on the Sunday of the August bank holiday weekend to tell them his wife was in labour, the inquest heard.
Ms Davies said that, given staffing issues over the weekend, 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”.
A second opportunity to change course came when Mr Gillibrand rang after his wife’s waters broke at about 7am.
Eventually, a midwife arrived at the couple’s home, about 15-20 minutes’ drive from the hospital, at about 8.15am, the inquest heard.
After 9am, Pippa’s heart rate should have been monitored every five minutes but midwives were coping with “competing pressures”, including short staffing and laptops which were not working.
A decision to take Mrs Gillibrand to hospital should have been made after 9.36am, when difficulties in monitoring Pippa’s heart rate became clear, the coroner said.
“Had Pippa been delivered earlier, on the balance of probabilities she would not have died when she did.”
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Mrs Gillibrand was transferred to hospital by ambulance after a decision was made at 10am and Pippa was delivered by forceps.
She was transferred to the neonatal unit and later moved to Liverpool Women’s Hospital but died on 5 September after scans showed she had suffered a “severe irreversible brain injury” due to a lack of oxygen.
Recording a narrative conclusion, Ms Davies said: “Pippa Gillibrand died as a result of a brain injury sustained due to an avoidable delay in her delivery.”
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She said the Warrington hospital trust had since changed its home birth service.
Rebecca Cahill, from JMW solicitors, who represented the family, said the situation “made the homebirth service manifestly unsafe, and the service should have been suspended when Vicky made initial contact”.
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She said the family “were failed from the start”.
Ali Kennah, chief nurse at Warrington and Halton Teaching Hospitals, 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 learned.
“We would again like to extend our deepest condolences to Mr and Mrs Gillibrand for their heartbreaking loss.”
The trust was not immediately available for comment regarding the most recent accusations.
