The inquest into the death of 12-day old Pippa Gillibrand began at Cheshire Coroner’s Court today, Monday.
Pippa’s parents, Victoria and Thomas were in attendance for the hearing, holding a pink toy close to their chests.
The court heard that on August 25, 2024, in the early hours, Victoria awoke with contractions with her husband contacting the labour ward by phone at 5.29am when they felt she was in established labour.
The couple had previously decided upon having a homebirth, believing it to be the safer option due to close monitoring by a dedicated one-to-one team, and the fact that Victoria found Warrington Hospital ‘triggering’ after her father died during her pregnancy.
When Tom called the ward, the couple were informed that the home birth team were already attending another birth.
They were advised that a midwife could come out to them once they finished with the first birth, but if anything changed, they could come into Warrington Hospital.
Evidence heard from Victoria stated that the couple thought it best to wait.
The court heard, though, that Warrington Hospital’s community team were extremely understaffed – an issue that had been raised internally on the Friday.
Plans had been put in place to supply an extra midwife from the hospital to join the community team, but this fell through due to demand at the hospital.
Despite this, when Tom called again at 7.04am to notify the labour ward that Victoria’s waters had broken, they were notified that a midwife could be with them within 30 to 60 minutes.
The couple stated they were not instructed to attend the hospital, issues with staffing or that the hospital was unable to accommodate two home births at the same time.
It was heard that community midwife team leader Eleanor Welding was on call when she received a text message informing her that a second mother requesting a home birth was in labour.
Ms Welding called the couple and spoke to them and decided that Victoria should proceed with a home birth as she was in established labour.
As it did not seem the birth was an emergency at present, but that labour was established, Ms Welding decided a home birth should be proceeded with.
This was due to the fact an ambulance could not be called for and the couple making their own way to hospital could mean Victoria could give birth on route, which would pose a greater risk.
Couple ‘should have been told’ to attend hospital
Ms Welding told the court that ‘with hindsight’ Victoria and Tom should have been told to attend the hospital when they first contacted the ward.
So, by 8.15am the first midwife, Lindsay Yates, arrived at the couple’s home.
Due to the fact the community team only has capacity and equipment for one home birth at a time, Ms Yates did not have the suction machine with her as the hospital only had one.
Not only this, but due to a change over of suppliers of Entonox (gas and air) to the hospital, the incorrect tubing was brought to the home meaning Victoria had no access to pain relief.
After a vaginal examination, Victoria was thought to be 9cm dilated, with Pippa’s heart rate measuring at a safe rate. Victoria was noted as having high blood pressure.
Ms Welding arrived at the home at around 8.51am and proceeded to vaginally examine Victoria, finding her to be 10cm dilated after Ms Yates requested it was rechecked.
Both midwives suffered technical difficulties with their laptops, meaning that Pippa’s heart rate could not be logged in a graph initially and scrap pieces of paper were used instead.
Ms Welding told the court that Pippa’s heart rate should have been checked every five minutes and that Victoria’s blood pressure should have also been closely monitored.
However, the court heard that this practice was not followed due to ‘oversight’ and the fact that the midwives were discussing staffing issues in a separate room. Pippa’s heart rate was instead monitored twice within the first 30 minutes.
When asked if there were missed opportunities to carry out more checks on Pippa and Victoria, Ms Yates answered yes.
A third midwife, Anna Ditchfield, was called to attend and bring the vital equipment to allow Victoria to receive pain relief.
The court heard that Ms Ditchfield was called to the home to allow Ms Yates to return to the hospital and complete other tasks in her leadership role.
Ms Ditchfield, a continuity midwife, had no prior experience in delivering home births and expressed her concerns in being asked to attend multiple times.
“I had never delivered a baby in a home before,” she told the court.
“I’m used to having an emergency button I can use to call for help. Not having that and not having the usual equipment or people outside the room who I can get to help instantly, that was a concern for me.”
Despite this, she was asked to stay and agreed telling the court that no task she was given was out of her ability.
Ms Ditchfield brought the correct equipment, allowing Victoria to finally have access to pain relief inside the birthing pool in her home.
Both Ms Welding and Ms Ditchfield noted struggling to hear Pippa’s heart rate at times, but Victoria was allowed to remain in the pool and had not been advised that she should be transferred to hospital, the court heard.
Shortly before 10am, the midwives were unable to find a heartbeat and an ambulance was called to transfer Victoria to Warrington Hospital.
Pippa was delivered by consultant obstetrician Emmanuel Ekanem at 10.38am, weighing 8lb 5oz. It took six minutes to establish a heartbeat.
Sadly, she was born in ‘poor condition’ and was taken to Liverpool’s Women’s Hospital for cooling therapy.
Over the next few days, Pippa was confirmed to have suffered a severe brain injury due to a lack of oxygen during her delivery.
The family proceeded to take pictures and make memories with Pippa while she was placed on palliative care.
On September 5, 2024, she sadly died at just 12 days old when her life support was turned off.
Giving evidence, Mr Enkanem told the court that had Victoria been asked to attend hospital when the couple first called, Pippa’s chances of survival would have been higher.
Hospital has changed procedures
The court heard that Warrington Hospital has now changed its procedures since Pippa’s tragic death, with mothers now asked to attend hospital if the home birthing team is busy.
A trust report into the issues also showed it does not provide enough equipment for two homebirths to be held simultaneously.
Representing the family, Louise Green asked the coroner to conclude that the failings amounted to neglect.
Ms Green told the court that Victoria and Tom were unable to make an informed decision about the care they would be receiving and may have made the decision to go straight to hospital if they had been told.
Area coroner, Victoria Davies, will conclude the inquest tomorrow, Tuesday.
Prior to the inquest, Tom and Victoria said: “While it will always hurt not knowing her smile, her laugh, her voice, or the milestones we expected to share, we take comfort in knowing she is now at peace, free from pain, and so deeply, deeply loved, not just by us, but by everyone who was fortunate enough to meet her. Pippa will live on in memory of all and be eternally missed beyond all meaning.”
Ali Kennah, chief nurse at Warrington and Halton Teaching Hospitals, said: “Our thoughts and deepest sympathies remain with Mr and Mrs Gillibrand and their family following their devastating loss.
“We were extremely saddened by Pippa’s death and will assist the Coronial investigation in any way we can. We remain available to support Mr and Mrs Gillibrand during this process.”