Baby who died following botched home birth while midwives were stretched over Bank Holiday weekend was victim of ‘neglect’, inquest told

A newborn baby who died after midwives called to perform a home birth over a busy Bank Holiday weekend failed to regularly check his heart rate was the victim of neglect, an inquest heard today.

Pippa Gillibrand was born weighing 8lbs 5oz after her mother Victoria, 33, was rushed to hospital after more than five hours of labor.

Tragically, she suffered severe brain damage due to lack of oxygen during birth and died at just 12 days old.

Mrs Gillibrand and her pharmaceutical technician husband Tom, 34, opted for a home birth in the belief they would be ‘closely monitored’ during the birth, an inquest heard today.

Her own father died during her pregnancy and she found going to Warrington Hospital ‘triggering’, the director of public health practice told the hearing.

When Mr Gillibrand called the birthing suite at around 5.30am on August 25, 2024, to say he was experiencing contractions, he was told midwife staff were at another home birth and the couple could come to the hospital ‘if we wanted’.

But most importantly, she said, they were not told there was only one home birth team in the area or that there were ‘staffing issues’ due to it being a bank holiday weekend.

They called the unit again at 7am and felt ‘calmed’ when they were told the midwives would be at their home within an hour.

Pippa, the couple’s first child, died after being deprived of oxygen during a failed home birth

The couple, from Warrington, chose to have a home birth in the belief they would be ‘closely monitored’ during the birth.

But the inquest heard that when the two midwives arrived at their home in Warrington, Cheshire, at around 8.25am, they did not have vital equipment to deliver gas and air.

Cheshire Coroner’s Court was told the pair were discussing ‘staff issues’ in the next room after labor began, rather than checking the fetal heart rate every five minutes as guidelines recommend.

He added that problems connecting laptops to the hospital’s computer network meant readings were done on ‘pieces of paper’.

At around 9.50am ‘panicked’ midwives became concerned about Pippa’s heartbeat and Ms Gillibrand was taken to hospital by ambulance for an emergency delivery.

Giving evidence today, Ms Welding acknowledged that she and fellow midwife Lindsay Yates spent time setting up equipment and discussing staffing levels.

As a result, Pippa’s heart rate was not checked at five-minute intervals for approximately half an hour.

But he said Ms Gillibrand appeared to be in “good shape” when she arrived home and there was no cause for concern when they resumed regular monitoring around 9.30am.

Ms Welding, a senior midwife who is team leader in a five-person home birth team, said she had raised concerns about staffing with 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 to have Pippa delivered to their home in Warrington.

Ms. Gillibrand, in a photo taken in August 2024, near the end of her pregnancy

The inquest heard staff shortages over the August Bank Holiday weekend in 2024 affected Pippa’s care.

He added that “in hindsight” Pippa’s parents should have been told to come to the hospital when Mr Gillibrand first called the maternity unit.

But when she arrived at the couple’s home, Ms Welding said the labor was so far along that it would be a greater ‘risk’ to transport her to hospital.

Mrs Yates, a team leader for the community midwife service who does not normally attend home births, was asked to help due to staff shortages.

He said the gap in fetal heart rate monitoring was due to the installation of equipment and moving Ms. Gillibrand to the birthing pool.

Asked by coroner Victoria Davies whether there were ‘missed opportunities’ for further checks, he replied: ‘Yes.’

Miss Yates then had to return to her duties at the hospital and Miss Welding was joined by her newly qualified colleague Anna Ditchfield.

Miss Ditchfield, who finally brought the missing equipment with her, told the hearing she was ‘not at ease’ as she had never delivered a baby at home.

But he said nothing he was asked to do was beyond his ‘competence’.

Senior midwife Eleanor Welding (pictured), who attended the home birth, said she had warned managers about staff shortages ahead of the bank holiday weekend.

Community midwife Lindsay Yates (pictured), who also attended the home birth, admitted there were ‘missed opportunities’ to have Pippa’s heart rate checked further

Emmanuel Ekanem, the on-call obstetrician who delivered Pippa, admitted her mother would have had a better chance of survival if she had been asked to go to hospital when Mr Gillibrand first called.

The inquest heard the trust has overhauled its home birth service since Pippa’s tragic death.

Expectant mothers who book a home birth are now asked to go to the hospital if the team is already busy.

In legal submissions made on behalf of the family, Louise Green asked the coroner to conclude the faults amounted to negligence.

Pippa was born at 10.38am and it took six minutes for the neonatal team to detect a heartbeat.

She was transferred to Liverpool Women’s Hospital, where tests revealed she had suffered a serious brain injury due to lack of oxygen during birth.

An internal investigation by Warrington and Halton Hospitals NHS Foundation Trust subsequently identified a catalog of problems.

On the eve of the hearing, Pippa’s parents said she would be “forever missed” and they hoped the inquest would provide answers as to why she died.

‘While it always hurts not to know her smile, her laugh, her voice, or the milestones we’ve been waiting to share, we take comfort in knowing that she is now at peace, free of pain, and loved so deeply not only by us, but by everyone lucky enough to meet her,’ they said.

‘Pippa will live on in her memory and will be forever missed beyond all meaning.’

Ali Kennah, chief nurse at Warrington and Halton Hospitals NHS Foundation Trust, previously said he was “extremely saddened by Pippa’s death”.

The coroner is expected to announce his conclusion on Tuesday.