A father has accused a hospital trust's home birth service of playing "Russian roulette" with the lives of mothers and babies, following the tragic death of his newborn daughter due to what a coroner ruled was an "avoidable" delay in delivery.
Coroner Highlights Missed Opportunities in Home Birth Plan
Thomas and Victoria Gillibrand's baby, Pippa, died at just 12 days old after suffering a severe brain injury from a lack of oxygen during birth. Cheshire Coroner's Court heard that the infant's death may have been prevented if staff from Warrington and Halton Hospitals NHS Foundation Trust had acted differently.
Coroner Victoria Davies stated there were "missed opportunities" to abandon the home birth plan and advise Mrs Gillibrand to come into hospital earlier. She emphasised that, given staffing issues over the August bank holiday weekend in 2024, including the home birth team being occupied with another labour, Pippa's mother should have been directed to hospital from the outset.
Timeline of Failures Leading to Tragedy
The inquest revealed a series of critical errors. Mr Gillibrand called Warrington Hospital at around 5.30am on 25 August 2024 to report his wife was in labour. Despite this early alert, no immediate action was taken to switch to a hospital birth.
A second chance arose when Mr Gillibrand rang again after his wife's waters broke at approximately 7am, but again, the opportunity was missed. A midwife eventually arrived at the couple's home in Warrington, about a 15-20 minute drive from the hospital, at 8.15am.
After 9am, Pippa's heart rate should have been monitored every five minutes, but midwives faced "competing pressures" such as short staffing and malfunctioning laptops. The coroner noted that a decision to transfer Mrs Gillibrand to hospital should have been made by 9.36am, when difficulties in monitoring became apparent.
Ms Davies concluded, "Had Pippa been delivered earlier, on the balance of probabilities she would not have died when she did."
Family's Heartbreaking Account and Call for Change
Speaking outside the court in Warrington, Mr Gillibrand, 34, expressed his anguish, saying, "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, 33, who carried a small toy bought for Pippa, 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."
Hospital Response and Ongoing Reforms
Rebecca Cahill, the family's solicitor from JMW solicitors, criticised the situation, stating it "made the homebirth service manifestly unsafe, and the service should have been suspended when Vicky made initial contact." She affirmed that the family "were failed from the start."
Ali Kennah, chief nurse at Warrington and Halton Teaching Hospitals, offered an apology, saying, "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 learned."
The trust extended its deepest condolences to the Gillibrand family for their heartbreaking loss. However, it was not immediately available for comment regarding the recent accusations of playing "Russian roulette" with patient safety.
This case underscores broader concerns about maternity care and resource allocation within the NHS, prompting calls for systemic improvements to prevent similar tragedies in the future.
