Family photoThe mother of a newborn baby who suffered extensive brain damage during a home birth has told an inquest “inexperienced” midwives were “scrambled together” due to staffing shortages.
Pippa Gillibrand was 12 days old when her life support was turned off due to the damage caused by a lack of oxygen during labour.
Her mother Victoria told Cheshire Coroners Court the midwives’ focus “was not on me and baby” and that they did not carry out proper checks during the August 2024 delivery attempt.
The lead midwife told the inquest that home service should have been suspended on the day Pippa was born.
Eleanor Welding, team leader at Warrington and Halton Hospitals NHS Trust’s community midwives service, acknowledged that “earlier in labour we should have suspended the home birth service” because the team was already dealing with another home birth.
She admitted trust policy and a lack of equipment did not allow for simultaneous home births, which she said were “very unusual”.
Louise Green, acting on behalf of Pippa’s family, told the inquest there had been “gross failings of basic medical care”.
Family handoutIn a statement read to the inquest, mother Victoria described how, after the labour had progressed, she was asked to stand up “for five to ten minutes” because the midwives could not get a heart reading.
“There was a look between the two midwives that sparked concern”, she said.
She was taken to Warrington Hospital by ambulance where doctors were able to deliver and resuscitate the baby.
After transfer to Liverpool Women’s Hospital, Ms Gillibrand said doctors told her “a lack of oxygen” had led to organ damage and a scan showed “extensive brain damage” which led to a decision for Pippa to be put on end-of-life care.
Emmanuel Ekanem, the on-call consultant who delivered Pippa at Warrington, agreed under questioning that if he had been aware there were concerns about her heart rate she would have been delivered earlier.
He agreed an earlier delivery would have meant her outcome and chance of survival would have been better.
The hearing was told midwives on the home birth team would typically attend “about three home births a year”.
First home birth
Green said the family was “not in a position to make an informed decision about the care that Pippa and, by extension Victoria, would receive because they had not been told that there was no second home birth team available, nor adequate equipment, nor that all of the individuals attending would not be part of the home birth team.
The inquest heard Welding and midwife Anna Ditchfield did not monitor Pippa’s heart rate at the appropriate intervals because Welding said they were “completing other tasks”, which she later acknowledged could have been completed by just one member of the team.
The court heard Ditchfield had never worked on a home birth before and had expressed concerns about being part of the delivery team.
“I’m used to having an emergency buzzer that I can [use to] call for help.
“So not having that and my usual equipment, that was a concern for me,” Ditchfield said.
She denied that the home birth was “outside [her] competence”.
The inquest also heard heart readings were written on “a piece of paper” because of computer problems preventing the team from adding them into the trust’s online partogram system, where they could be tracked.
A “paperless” policy meant the trust’s midwives no longer had access to paper partograms, Welding said, adding that the policy had since been amended.
Welding agreed under questioning by Ms Green that “proper monitoring didn’t happen” due to “inexperienced staff”, time being spent setting up equipment and laptop connectivity problems.
The trust’s Deputy Director of Midwifery Tina Moors agreed the home birth team had “the least day-to-day” experience of childbirth in comparison to the trust’s other midwives, but said the service had since been “completely remodelled”.
She said they were now “open and honest with women” adding: “We let them know there’s potential we can’t provide a home birth service if we’re unable to facilitate it because of staffing”.
The inquest is due to conclude on Tuesday.
