Parents want answers following tragic death of their 12-day-old baby

Victoria and Thomas Gillibrand's baby Pippa died after a carefully planned home birth resulted in her suffering a severe brain injury due to a lack of oxygen during her delivery.

Concerned about reports of staff shortages and safety concerns in maternity services prior to Pippa’s delivery and after carrying out extensive research, Victoria and Thomas believed the labour and their baby would be more closely monitored by a dedicated one-to-one home birth team and that a home birth was the safer option.  

Following Pippa’s death, an investigation was initiated by the Trust, with several concerns being highlighted, including:

• The risk assessment for a homebirth was not fully completed; there was no documented discussion regarding a small risk of serious medical problems for the baby, compared to planning the birth in other settings for mothers having their first baby.  There was also no discussion of a plan to continue labour on the midwife led unit when the homebirth team were already called out to a homebirth.  This meant Victoria was not fully informed of all the risks when she was planning her homebirth.
• The Trust’s homebirth service can safely provide resources for one homebirth. If any further homebirths occur at the same time the assumption is that the labouring mother will receive care on the midwife led unit. This was not documented in Trust guidance. This meant that Victoria was not invited to attend hospital when the homebirth team were initially not available to provide one to one care at home.
• There were no bleep holders or senior managers on call to escalate safety concerns to or get advice from. Awareness of the whole maternity service was not recognised due to the high acuity on the labour ward, with no escalation of safety concerns when the maternity service was under pressure outside of the hospital setting.
• The Trust does not provide enough equipment for two homebirths to be held simultaneously.
• There was no risk assessment done when Victoria’s husband, Tom, first called the labour ward.  It was not the role of the labour ward coordinator to triage telephone calls from mothers requesting the homebirth team to attend.  There was no follow up telephone call to Victoria from the homebirth team due to them being at another homebirth, which led to a missed early opportunity to assess Victoria and Pippa’s wellbeing.
• Pippa’s wellbeing was not assessed in line with national and Trust Guidelines.  When Victoria was assessed as being in the second stage of labour, intermittent auscultation was not performed every 5 minutes, only recorded twice in the first 30 minutes.  This was due to the midwifery team focusing on other activities, such as the staffing issues and setting up the homebirth equipment. 
• There was a delay in recognition of difficulties to auscultate Pippa’s heart rate due to the staff’s previous positive experiences at homebirths which led to a delay with subsequent actions.
• There was incomplete documentation of the advice and care given during telephone calls, at Victoria’s home and during the events of her labour. This was due to a very busy labour ward and poor connectivity of the laptops in the homebirth setting, which meant staff were initially unable to document in the electronic patient record system and document Pippa’s heart rate on the partogram; there was no alternative method for documentation available for staff to be able to effectively capture vital information regarding Pippa’s wellbeing. This did not support clinical oversight or risk assessment during labour.

Rebecca Cahill, specialist clinical negligence senior associate with JMW, representing the family, said: “The death of this tiny baby is utterly tragic. Vicky and Tom’s loss is devastating and unimaginable, but to learn that Pippa’s monitoring was not in line with NHS Guidelines, and that staff shortages appear to have impacted the care that they received only compounds their loss.

 “They obviously have a number of concerns and so welcome the coroner’s investigation to ensure that no stone is left unturned in trying to find out why Pippa died.”

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Source: Warrington Guardian, 24 January 2026