'Hospital played Russian roulette with our baby's life'

The parents of a baby who died after an "avoidable delay" in suspending a home birth said a hospital had played "Russian roulette with babies' lives".

Pippa Gillibrand was born at Warrington Hospital in Cheshire on 25 August 2024 but died on 5 September that year after suffering a major brain injury.

Her parents, Victoria and Tom Gillibrand, had opted for a home birth after being told they would be under the care of experienced midwives from the hospital trust - which did not happen due to "staffing pressures".

Warrington and Halton Teaching Hospitals NHS Foundation Trust said it was "truly sorry" and had since "strengthened" its home birth services.

Speaking outside Cheshire Coroners' Court in Warrington, Pippa's father Tom 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."

Coroner Victoria Davies concluded that not only should Victoria's home birth have been cancelled - but when midwives struggled to measure Pippa's heart rate, she should have been immediately transferred to hospital.

Davies said: "It is likely that, had either of these taken place, her mother would have been assessed in hospital earlier and the need for urgent delivery would have been identified earlier.

"Had Pippa been delivered earlier, on the balance of probabilities she would not have died when she did."

She delivered the conclusion: "Pippa Gillibrand died as a result of a brain injury sustained due to an avoidable delay in her delivery."

The inquest heard Tom had called the hospital at 05:30 BST to say his wife's labour had begun and called again shortly after 07:00 to say her waters had broken.

Davies said both calls were "missed opportunities" to cancel the home birth.

The court heard "inexperienced midwives" were "scrambled together" and attended the family home, about a 20-minute drive from Warrington Hospital, at 08:15.

Pippa's heart rate should have been monitored every five minutes from about 09:00 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 09.36, after difficulties in monitoring the heart rate became apparent, a decision should have been made to transfer Victoria to hospital, where it was likely that a need for urgent delivery would have been identified.

The decision to transfer her to hospital was taken at 10:00 and Pippa was delivered in a "poor condition" using forceps.

After she was resuscitated in the hospital's neonatal unit, she was transferred to Liverpool Women's Hospital where the extent of her brain injury meant palliative care was provided.

Speaking outside court, carrying a small teddy the family had placed in Pippa's incubator, Victoria, 33, said: "We were sold this birth where we had highly trained midwives that were going to be taking really close care of us.

"We were told that if we needed to come in that we would be alerted.

"We were told that if there was even a slightest concern that we would be transferred to hospital.

"Obviously that trust that we put in to the maternity service is, ultimately, trust that has been failed and that's not the kind of birth that we received."

She added: "Our lives will always have almost like a cloud looming over in the sense of Pippa not being here."

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 also died after complications with a home birth.

She said she planned to write to the Health Secretary Wes Streeting, NHS England and the National Institute for Health and Care Excellence to raise concerns about the lack of national guidance for home birth services.

Ali Kennah, chief nurse at Warrington and Halton Teaching Hospitals, said: "We remain truly sorry for the failures in the care that Mrs Gillibrand and Pippa received, and we fully accept the coroner's findings.

"Since this tragedy occurred, we have strengthened our home birth service and have fully implemented all recommendations from an independent review. We will continue to make sure that all lessons are learnt."

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