The father of a newborn baby who died following what a coroner described as an "avoidable" delay in her delivery has accused a hospital trust of playing "Russian roulette" with the lives of mothers and infants. Thomas Gillibrand made the emotional statement outside Cheshire Coroner's Court after an inquest into the death of his daughter, Pippa, who lived for just twelve days.
Coroner Identifies Critical Failures in Home Birth Service
Coroner Victoria Davies delivered a narrative conclusion stating that Pippa Gillibrand died as a result of a severe brain injury sustained due to a preventable delay in her delivery. The inquest heard that Victoria Gillibrand, aged 33, had planned a home birth at the family's residence in Warrington on August 25, 2024. However, the home birth team from Warrington and Halton Hospitals NHS Foundation Trust was already attending another labour when Mrs Gillibrand went into labour.
Missed Opportunities to Suspend Service and Transfer to Hospital
Ms Davies identified several critical failures in the care provided. She found there were "missed opportunities" for the trust to suspend its home birth service and advise Mrs Gillibrand to attend hospital instead. The first opportunity arose when Thomas Gillibrand initially called the hospital at approximately 5:30 am on the August bank holiday Sunday to report his wife was in labour. A second chance was missed when he called again around 7:00 am after her waters had broken.
A midwife eventually arrived at the couple's home, located a 15 to 20-minute drive from Warrington Hospital, at about 8:15 am. The inquest was told that from 9:00 am onwards, Pippa's heart rate should have been monitored every five minutes, but this vital procedure was not carried out. Coroner Davies attributed this lapse to "competing pressures" faced by the midwives, including short staffing and malfunctioning laptops.
Critical Delay in Decision to Transfer
The coroner stated that by 9:36 am, after difficulties in monitoring the fetal heart rate became apparent, a decision should have been made to transfer Victoria Gillibrand to hospital immediately. Had this transfer occurred promptly, it is likely that the need for an urgent delivery would have been identified. "Had Pippa been delivered earlier, on the balance of probabilities she would not have died when she did," Ms Davies concluded.
A decision to transfer was finally made at 10:00 am. Mrs Gillibrand was taken to hospital by ambulance, where Pippa was delivered by forceps. The newborn was transferred to the neonatal unit and later moved to Liverpool Women's Hospital. Tragically, scans revealed she had suffered a severe and irreversible brain injury due to oxygen deprivation. Pippa died on September 5, 2024.
Family's Heartbreaking Statement and Call for Change
Speaking outside the court, Thomas Gillibrand, aged 34, expressed the family's profound grief and anger. "The trust seems to have played Russian roulette with the innocent lives of mothers and babies," he said. "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."
Victoria Gillibrand, who carried a small toy purchased for Pippa, added her voice to the call for systemic reform. "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," she stated.
Coroner to Escalate Concerns to National Bodies
Coroner Victoria Davies announced her intention to write to Health Secretary Wes Streeting, NHS England, and the National Institute for Health and Care Excellence (NICE). She aims to raise significant concerns about the lack of comprehensive national guidance for home birth services across the NHS. Ms Davies noted that a prevention of future deaths report had been issued by a Manchester coroner the previous year following another home birth tragedy, yet she was not aware of any subsequent national guidance being issued.
She highlighted that the Warrington trust had since remodelled its home birth service. However, at the time of Pippa's birth, the community midwives on the team assisted with only around three labours per year. The coroner stated she was not assured the wider issue had been resolved and would issue her own report focusing on the lack of guidance and problems with data collection.
Legal and Trust Response to the Tragedy
Rebecca Cahill, the solicitor from JMW who represented the Gillibrand family, said the conclusion made it clear the family "were failed from the start." She emphasised, "The circumstances arising on August 25 2024 made the homebirth service manifestly unsafe, and the service should have been suspended when Vicky made initial contact."
Ali Kennah, chief nurse at Warrington and Halton Teaching Hospitals NHS Foundation Trust, offered a formal apology. "We remain truly sorry for the failures in the care that Mrs Gillibrand and Pippa received, and we fully accept the coroner's findings," she said. "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."
