Home birth service played ‘Russian roulette’ with lives, father says

The father of a newborn baby who died after an “avoidable” delay in her delivery has said a hospital’s home birth service played “Russian roulette” with the lives of mothers and babies.

Victoria Gillibrand, 33, had planned to give birth to baby Pippa at her home in Warrington, but when she went into labour on August 25 2024, the home birth team were attending another labour, an inquest at Cheshire Coroner’s Court was told.

Coroner Victoria Davies found there were “missed opportunities” for Warrington and Halton Hospitals NHS Foundation Trust to suspend the home birth service and tell Mrs Gillibrand to come into hospital.

Pippa died on September 5, at 12 days old, after suffering a severe brain injury due to the “avoidable delay” in delivery, the coroner’s court was told.

Ms Davies said she planned to write to the 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.

Speaking outside the coroner’s court in Warrington on Tuesday, Pippa’s father Thomas Gillibrand, 34, said: “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 bought for Pippa with her, 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.”

The inquest, which began on Monday, heard Mr Gillibrand called Warrington Hospital at about 5.30am on the Sunday of the August bank holiday weekend to tell them his wife was in labour.

Delivering her findings, the coroner said: “In light of the staffing issues, including that the home birth team were already at another birth, Pippa’s mother should have been advised to attend hospital rather than continue as a home birth.”

She said there was another missed opportunity to suspend the home birth service when Mr Gillibrand rang a second time, at about 7am, after his wife’s waters broke.

The inquest heard a midwife arrived at the couple’s home, about 15 to 20 minutes’ drive from the hospital, at about 8.15am.

After 9am, Pippa’s heart rate should have been monitored every five minutes but that was not done because midwives were dealing with “competing pressures”, including short staffing and laptops which were not working, the court was told.

The coroner found that from 9.36am, after difficulties in monitoring the heart rate became apparent, a decision should have been made to transfer Mrs Gillibrand to hospital, where it was likely that a need for urgent delivery would have been identified.

She said: “Had Pippa been delivered earlier, on the balance of probabilities she would not have died when she did.”

The inquest heard Mrs Gillibrand was transferred to hospital by ambulance after a decision was made at 10am and Pippa was delivered by forceps.

She was transferred to the neonatal unit and later moved to Liverpool Women’s Hospital but died on September 5 after scans showed she had suffered a “severe irreversible brain injury” due to a lack of oxygen.

Recording a narrative conclusion, Ms Davies said: “Pippa Gillibrand died as a result of a brain injury sustained due to an avoidable delay in her delivery.”

She said the Warrington hospital trust had since remodelled its home birth service, but at the time the community midwives on the team assisted with around three labours a year.

Ms Davies said a prevention of future deaths report had been issued by a Manchester coroner last year following the deaths of Jennifer Cahill, 34, and her child Agnes Lily Wren Cahill, who died after complications with a home birth.

But she said she was not aware any national guidance had been issued since that report and was not assured the issue had been resolved.

She said she would issue her own report to raise concerns about the lack of guidance for home birth services and around data collection.

Rebecca Cahill, from JMW solicitors, who represented the family, said: “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.”