A newborn baby who died after midwives called to carry out a home birth over a busy Bank Holiday weekend failed to check her heart rate regularly was a victim of neglect, an inquest heard today.
Pippa Gillibrand was delivered weighing 8lbs 5oz after her mother, Victoria, 33, was rushed to hospital following more than five hours of labour.
Tragically she had suffered severe brain damage after being deprived of oxygen during her delivery and died aged just 12 days.
Today an inquest heard that Mrs Gillibrand and her pharmaceutical technician husband Tom, 34, had opted for a home birth in the belief they would be ‘closely monitored’ during labour.
Her own father had died during her pregnancy and she found attending Warrington Hospital ‘triggering’, the public health practice manager said in a statement to the hearing.
When Mr Gillibrand rang the birthing suite at around 5.30am on August 25, 2024, to say her contractions had begun, he was told midwifery staff were at another home birth and the couple could come into hospital ‘if we wanted to’.
Crucially, however, they were not told there was only a single home birth team for the area, she said – or that there were ‘staffing issues’ with it being a Bank Holiday weekend.
At 7am they rang the unit again and felt ‘calmed’ at being told midwives would be at their house within the hour.
Victoria and Thomas Gillibrand’s baby daughter, Pippa, died aged 12 days after a botched home birth, an inquest was told
Pippa, 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 in the belief they would be ‘closely monitored’ during labour
However when two midwives arrived at their home in Warrington, Cheshire, from around 8.25am, neither had a vital piece of equipment to enable gas and air to be delivered, the inquest heard.
Instead of checking the foetal heartrate every five minutes – as recommended by guidelines once established labour has begun – the pair discussed ‘staffing issues’ in a side room, Cheshire Coroner’s Court was told.
Problems connecting their laptops to the hospital computer network meant readings were taken on ‘scraps of paper’, she added.
At around 9.50am ‘panicking’ midwives became concerned about Pippa’s heartbeat, and Mrs Gillibrand was rushed to hospital by ambulance for an emergency delivery.
Giving evidence today, Ms Welding agreed that she and fellow midwife Lindsay Yates had spent time setting up equipment and discussing staffing levels.
As a result, Pippa’s heart rate was not checked at five-minute intervals for around half an hour.
But she said Mrs Gillibrand appeared to be ‘coping well’ when she arrived at the house, and that when they resumed regular monitoring at about 9.30am there was no cause for concern.
Ms Welding – a senior midwife who was team leader for the five-strong home birth team – said she had flagged staffing concerns to management before the weekend.
Pippa’s parents Thomas and Victoria Gillibrand attended her inquest in Warrington today
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 at their home, in Warrington
Mrs Gillibrand, pictured towards the end of her pregnancy, in August 2024
The inquest heard that staff shortages over the August Bank Holiday weekend, in 2024, impacted Pippa’s care
She added that ‘with hindsight’, Pippa’s parents ought to have been told to come into hospital when Mr Gillibrand first rang the birthing unit.
However Ms Welding said that once she arrived at the couple’s home, labour was so advanced that it would have been a greater ‘risk’ to transfer her to hospital.
Ms Yates, a team leader on the community midwife service who did not normally attend home births, was asked to help out due to the staffing shortage.
She said the gap in foetal heartrate monitoring was down to setting up equipment and moving Mrs Gillibrand into a birthing pool.
Asked by coroner Victoria Davies whether there were ‘missed opportunities’ to carry out more checks, she answered: ‘Yes.’
Ms Yates then had to return to her duties at the hospital, with newly-qualified colleague Anna Ditchfield joining Ms Welding.
Ms Ditchfield – who finally brought the missing equipment with her – told the hearing she wasn’t ‘comfortable’ as she had never delivered a baby at home.
But she said nothing she was asked to do was outside her ‘competence’.
Senior midwife Eleanor Welding (pictured), who attended the home birth, told the inquest she had warned managers of staffing difficulties before the Bank Holiday weekend
Community midwife Lindsay Yates (pictured), who also attended the home birth, accepted there were ‘missed opportunities’ to carry out more checks on Pippa’s heart rate
Emmanuel Ekanem, the on-call consultant obstetrician who delivered Pippa, agreed that had her mother been asked to attend hospital when Mr Gillibrand first rang, her chances of survival would have been greater.
The inquest heard the trust has overhauled its home birth service since Pippa’s tragic death.
Expectant mothers who have booked a home birth are now asked to attend hospital if the team is already busy.
In legal submissions on behalf of the family, Louise Green asked the coroner to conclude that the failings amounted to neglect.
Pippa was delivered at 10.38am after which it took the neonatal team six minutes to establish a heartbeat.
She was transferred to Liverpool Women’s Hospital where tests established she had suffered a severe brain injury due to a lack of oxygen during her delivery.
An internal investigation by Warrington and Halton Hospitals NHS Foundation Trust later identified a catalogue of issues.
On the eve of the hearing, Pippa’s parents said she would be ‘eternally missed’ and that they hoped the inquest would provide answers about why she died.
‘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,’ they said.
‘Pippa will live on in memory of all and be eternally missed beyond all meaning.’
Ali Kennah, chief nurse at Warrington and Halton Hospitals NHS Foundation Trust, has previously said it was ‘extremely saddened by Pippa’s death’.
The coroner is due to give her conclusion on Tuesday.