Inquest Delivers Verdict of Neglect in Tragic Newborn Death Following Home Birth
A newborn baby who tragically passed away after midwives attending a home birth over a busy Bank Holiday weekend failed to conduct regular heart rate checks has been identified as a victim of neglect, according to findings presented at an inquest today. Pippa Gillibrand was delivered weighing 8lbs 5oz after her mother, Victoria Gillibrand, aged 33, was urgently transported to hospital following more than five hours of labour. Devastatingly, the infant had sustained severe brain damage due to oxygen deprivation during her delivery and died at just twelve days old.
Couple's Belief in Close Monitoring Led to Home Birth Decision
The inquest heard that Mrs Gillibrand and her husband Tom, a 34-year-old pharmaceutical technician, had chosen a home birth under the assumption they would receive close and attentive monitoring throughout the labour process. In a statement to the hearing, Mrs Gillibrand explained that attending Warrington Hospital felt triggering as her own father had died during her pregnancy. When Mr Gillibrand contacted the birthing suite at approximately 5.30am on August 25, 2024, to report the onset of contractions, he was informed that midwifery staff were engaged with another home birth and advised they could come into hospital if we wanted to.
Critically, the couple were not made aware that there was only a single home birth team covering the area or that significant staffing issues existed due to the Bank Holiday weekend. At 7am, they called the unit again and felt reassured upon being told midwives would arrive at their home within the hour. However, when two midwives reached their residence in Warrington, Cheshire, around 8.25am, neither possessed a crucial piece of equipment required to administer gas and air, the inquest was told.
Systemic Failures and Missed Monitoring Opportunities
Instead of adhering to guidelines recommending foetal heart rate checks every five minutes once established labour had commenced, the midwives discussed ongoing staffing challenges in a side room, Cheshire Coroner's Court heard. Technical difficulties connecting laptops to the hospital network meant vital readings were recorded on scraps of paper. By approximately 9.50am, the midwives became alarmed about Pippa's heartbeat, prompting an emergency ambulance transfer to hospital for delivery.
Giving evidence, senior midwife Eleanor Welding acknowledged that she and colleague Lindsay Yates had dedicated time to setting up equipment and conversing about staffing levels. Consequently, Pippa's heart rate was not monitored at the required intervals for around thirty minutes. Ms Welding, who led the five-member home birth team, stated she had previously raised staffing concerns with management ahead of the weekend. She conceded that, with hindsight, the parents should have been directed to hospital during the initial phone call.
Staffing Shortages and Inexperienced Personnel
Ms Yates, a community midwife service team leader not typically assigned to home births, was enlisted to assist due to the staffing shortage. She attributed the monitoring gap to equipment setup and moving Mrs Gillibrand into a birthing pool. When questioned by coroner Victoria Davies about missed opportunities for additional checks, Ms Yates responded affirmatively. Subsequently, Ms Yates returned to hospital duties, with newly-qualified midwife Anna Ditchfield joining Ms Welding.
Ms Ditchfield, who finally brought the missing equipment, testified she felt uncomfortable as she had never before delivered a baby at home, though she asserted all tasks fell within her competence. Emmanuel Ekanem, the on-call consultant obstetrician who delivered Pippa, agreed that had Mrs Gillibrand been advised to attend hospital initially, the infant's survival chances would have been significantly higher.
Trust Overhauls Home Birth Service Following Tragedy
The inquest was informed that Warrington and Halton Hospitals NHS Foundation Trust has since completely overhauled its home birth service in response to Pippa's death. Expectant mothers who book a home birth are now instructed to attend hospital if the team is already occupied. An internal trust investigation identified a catalogue of issues, and in legal submissions, family representative Louise Green urged the coroner to rule that the failings constituted neglect.
Pippa was delivered at 10.38am, after which the neonatal team took six minutes to establish a heartbeat. She was transferred to Liverpool Women's Hospital, where tests confirmed a severe brain injury from oxygen deprivation during delivery. Ahead of the hearing, Pippa's parents expressed that she would be eternally missed and hoped the inquest would provide answers. Ali Kennah, chief nurse at the trust, stated the organisation was extremely saddened by Pippa's death. The coroner is scheduled to deliver her formal conclusion on Tuesday.
