Father Condemns NHS Trust After Baby's Death in Home Birth Tragedy
A grieving father has accused an NHS trust of 'playing Russian roulette' with the lives of mothers and babies following the tragic death of his newborn daughter. The heartbreaking case emerged during an inquest at Cheshire Coroner's Court, which examined the circumstances surrounding the passing of baby Pippa Gillibrand.
Avoidable Delay Led to Fatal Brain Injury
Victoria Gillibrand, 33, had planned to give birth to her daughter at the family home in Warrington on August 25, 2024. However, the inquest heard there was an 'avoidable delay' in delivery that resulted in Pippa suffering a severe brain injury. The newborn was transferred to Liverpool Women's Hospital but tragically died on September 5, just twelve days old.
Coroner Victoria Davies delivered a narrative conclusion stating: 'Pippa Gillibrand died as a result of a brain injury sustained due to an avoidable delay in her delivery.' The coroner identified multiple missed opportunities where Warrington and Halton Hospitals NHS Foundation Trust should have suspended their home birth service and advised Mrs. Gillibrand to attend hospital instead.
Systemic Failures and Staffing Issues
The inquest revealed concerning details about the circumstances surrounding the delayed delivery:
- When Mr. Gillibrand first called Warrington Hospital at approximately 5:30am to report his wife was in labour, the home birth team was already attending another birth
- A second call at around 7am after Mrs. Gillibrand's waters broke presented another opportunity to suspend the service that was not taken
- A midwife eventually arrived at the family home between 8:15am and 8:20am, despite the property being just 15-20 minutes from the hospital
- From 9am onwards, Pippa's heart rate should have been monitored every five minutes, but this did not occur due to competing pressures including short staffing and malfunctioning equipment
- The coroner determined that from 9:36am, a decision should have been made to transfer Mrs. Gillibrand to hospital where urgent delivery would likely have been identified as necessary
Coroner Davies stated unequivocally: 'Had Pippa been delivered earlier, on the balance of probabilities she would not have died when she did.'
Family's Heartbreaking Testimony
Speaking outside the Coroner's Court in Warrington, Pippa's father Thomas Gillibrand, 34, expressed his family's devastation: '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 purchased for Pippa during the proceedings, 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.'
National Guidance Concerns and Previous Warnings
The coroner revealed she plans to write to Health Secretary Wes Streeting, NHS England, and the National Institute for Health and Care Excellence (NICE) to raise concerns about the lack of national guidance for home birth services. This follows a prevention of future deaths report issued by a Manchester coroner last year after similar tragedies.
Ms. Davies noted that despite previous warnings following the deaths of Jennifer Cahill and her child Agnes Lily Wren Cahill during a home birth, she was 'not aware any national guidance had been issued since that report' and remained 'not assured the issue had been resolved.'
Rebecca Cahill from JMW solicitors, representing the Gillibrand family, stated: 'What is clear from today's conclusion is that the family were failed from the start. 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.'
The inquest heard that Warrington and Halton Hospitals NHS Foundation Trust has since remodelled its home birth service. However, at the time of Pippa's birth, community midwives on the team assisted with approximately three labours annually, highlighting potential issues with maintaining adequate expertise and response capabilities in low-volume services.
