Overview
- Cheshire coroner Victoria Davies recorded a narrative conclusion that Pippa Gillibrand died from a brain injury caused by an avoidable delay in her delivery.
- She found missed opportunities to suspend the home-birth service and advise hospital attendance when the team was already at another birth, including during 5:30am and 7am calls.
- Required five-minute fetal heart-rate checks were not done for about 30 minutes as midwives faced staffing pressures, missing gas-and-air equipment and laptop problems.
- A transfer decision was made at about 10am; Pippa was delivered at 10:38am and died 12 days later after scans showed severe irreversible hypoxic injury.
- The trust says it has remodelled its home-birth service, and the coroner will contact the Health Secretary, NHS England and NICE over the lack of national guidance and data as the family call the death preventable.