What was meant to be a joyful and intimate home birth turned into a heartbreaking tragedy for Victoria and Tom Gillibrand.
Their daughter, Pippa, died just 12 days after birth, leaving the couple and their families devastated.
The inquest into her death has revealed a series of mistakes and oversights that contributed to the newborn’s death, which authorities have now described as neglect.
Choosing a Home Birth for Comfort and Safety
Victoria, 33, and her husband Tom, 34, a pharmaceutical technician, had chosen a home birth because Victoria felt hospital visits were emotionally triggering following the death of her own father during her pregnancy.
They were assured they would be closely monitored throughout labor, giving them reassurance that the process would be safe.
However, when Mr. Gillibrand called the Warrington Hospital birthing unit at 5:30 a.m. on August 25, 2024, to report that contractions had started, he was told the midwives were attending another home birth.
He was offered the option of coming to the hospital, but crucial details were not shared—there was only one home birth team for the area, and it was a busy Bank Holiday weekend with staffing issues.
Critical Delays and Missing Equipment
The couple called again at 7 a.m., and were told midwives would arrive at their home within the hour.
But when two midwives finally reached their Warrington home at 8:25 a.m., they lacked essential equipment, including the means to administer gas and air.
Instead of monitoring Pippa’s heart rate every five minutes as guidelines recommend, the midwives spent time discussing staffing problems and dealing with technical issues, recording data on scraps of paper due to laptop connectivity issues.
By 9:50 a.m., the midwives became concerned about Pippa’s heart rate, prompting an emergency ambulance transfer to hospital.
Pippa had already suffered severe brain damage from oxygen deprivation during labor.
Staff Challenges and Missed Opportunities
Senior midwife Ms. Welding admitted she had raised staffing concerns before the Bank Holiday weekend, but acknowledged that the couple should have been advised to come to the hospital when they first called.
She noted, however, that once at the home, Victoria’s labor was so advanced that transferring her could have posed additional risks.
Ms. Yates, called in due to staff shortages, explained that gaps in monitoring occurred while setting up equipment and moving Victoria into a birthing pool.
She confirmed that opportunities to carry out more checks were missed.
When newly qualified midwife Anna Ditchfield arrived with the missing equipment, she admitted she was not fully comfortable with home deliveries, though she acted within her competence.
Consultant obstetrician Emmanuel Ekanem confirmed that if Victoria had gone to the hospital at the first call, Pippa’s chances of survival would likely have been higher.
A Service Overhaul After Tragedy
Since Pippa’s death, Warrington and Halton Hospitals NHS Foundation Trust has overhauled its home birth procedures.
Expectant mothers now must attend hospital if the home birth team is already busy, aiming to prevent a repeat of this devastating incident.
Louise Green, representing the family, asked the coroner to conclude that the failings amounted to neglect.
Pippa was born at 10:38 a.m., with the neonatal team taking six minutes to establish a heartbeat.
Tests at Liverpool Women’s Hospital confirmed severe brain injury from oxygen deprivation during delivery.
Parents Remember Their Daughter
On the eve of the hearing, Pippa’s parents shared a heartfelt tribute: “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.”
Ali Kennah, chief nurse at the Trust, expressed deep sorrow over Pippa’s death.
The coroner is scheduled to deliver her conclusion on Tuesday.
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