Pippa Gillibrand

Parliamentary Under-Secretary of State for   
Women’s Health and Mental Health 

39 Victoria Street 
London 
SW1H 0EU 

19 March 2026 

HM Coroner Victoria Davies 
Area Coroner for Cheshire 

Dear Ms Davies, 

Thank you for the Regulation 28 report of 27 January 2026 sent to the Secretary of State / 
the Department of Health and Social Care about the death of Pippa Gillibrand. I am replying 
as the Minister with responsibility for Women’s Health and Mental Health. 

Firstly, I would like to say how saddened I was to read of the circumstances of Pippa’s death, 
and I offer my sincere condolences to Victoria and her family. The circumstances your report 
describes  are  deeply  concerning  and  it  is  a  tragedy  that  Pippa  died  from  a  brain  injury 
sustained due to an avoidable delay in her delivery. This should never have happened.  

You raise concerns over the lack of national guidance for home births, particularly the model 
of care, as well as concerns that there is no national or local collection of data around home 
births. In preparing this response, my officials have made enquiries with NHS England  to 
ensure we adequately address your concerns, and I understand there is work underway to 
develop national standards and a clear framework for homebirth services. As operational 
responsibility  for  issuing  guidance  and  collecting  data  around  home  births  sits  with  NHS 
England,  they  will  be  issuing  a  substantive  response  addressing  the  specific  matters  of 
concern raised. 

All women deserve access to safe care during childbirth. All staff should receive training that 
is tailored to their specific setting, including homebirths and how to manage emergencies at 
point of care. NHS England will speak further to what action is being taken to ensure this is 
the case, but I want to say how sorry I am that this did not happen for Victoria and Pippa. I 
understand that NHS England has written to all services and systems asking them to review 
their service provision, to prevent future tragedies and ensure that women can safely deliver 
babies across all settings.  

It is not acceptable that problems are not always identified effectively or quickly enough such 
as in the case of Victoria and Pippa, and issues such as these  are why the Secretary of 
State  asked  Baroness  Amos  to  carry  out  a  national  independent  investigation  in  NHS 
maternity and neonatal care. The investigation will help us understand the systemic issues 
behind why so many women, babies and families experience unacceptable  care, and the 
final report and recommendations are due to be published in June 2026.  

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 The government is also setting up a National Maternity and Neonatal Taskforce, chaired by 
the  Secretary  of  State  for  Health  and  Social  Care. The Taskforce  will address the 
recommendations  of  the investigation by developing a  new  national  action  plan  to  drive 
improvements across maternity and neonatal care.  

Thank you for bringing these concerns to my attention, and I am sorry again for the failings 
in  care  experienced  by  Victoria  which  led  to  the  tragic  loss  of  baby  Pippa. This  is  not 
acceptable and we are taking your concerns very seriously.   

Yours sincerely,  

PARLIAMENTARY UNDER-SECRETARY OF STATE FOR 
WOMEN’S HEALTH AND MENTAL HEALTH 

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Classification: Official 

To: 

Trust Chief Nurses 

Trust Directors of Midwifery 

cc. 

ICB Chief Nurses  

ICB Directors of Midwifery 

NHS England 

Wellington House 

133-155 Waterloo Road 

London 

SE1 8UG 

26 November 2025 

Dear colleagues, 

Urgent review of homebirth services following Prevention of Future 
Deaths report 

We are writing to bring to your immediate attention the Prevention of future deaths report 

issued by the Senior Coroner for Manchester North after the tragic deaths of Jennifer Cahill 

and her child Agnes Cahill following a homebirth. The report raises a number of concerns 

and we are asking you to urgently review the safety and quality of your homebirth services. 

We would like you to consider the following issues which were highlighted in this case: 

The operational running of your service: including how it ensures that prompt midwifery 

care is available 24 hours a day; that staff are properly equipped, trained, prepared and 

skilled for providing birth and neonatal care in a home setting; that staff have senior multi-

disciplinary support available to them at all times and have sufficient rest periods; and that 

potential transfer and extraction processes are clear and planned for each birth. 

Care planning and risk assessment: including systematic assessment of complexity and 

risk; how the multidisciplinary team (MDT) ensures a personalised approach to women in 

planning care in light of any identified issues (particularly when homebirth is not 

recommended); how the MDT continues to maintain good communication at all stages of 

care with women and between all teams including ambulance services; and how dynamic 

risk assessment is managed and responded to throughout pregnancy, birth and the 

postnatal period.   

Publication reference: PRN02255  

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 Governance and oversight: including how governance is structured to ensure robust 

oversight of homebirth services by the whole organisation, so the executive board has 

appropriate oversight; that there is an audit programme that covers outcomes and clinical 

and operational guidance and leads to continual improvement; and that there is 

comprehensive homebirth guidance including standard operating procedures for all stages 

and aspects of care.  

Trusts have a continuing responsibility to offer homebirth as a choice for women. Where this 

review identifies concerns, please take prompt action to address them to ensure your 

homebirth service remains safe and high quality. While no formal response is required, we 

expect that the outcome of the review be reported to your Trust board and that you contact 

your regional NHS England team immediately if you identify any safety concerns requiring 

urgent attention. 

Yours sincerely, 

Chief Midwifery Officer for England 

Regional Chief Midwife, South East 

NHS England  

Copyright © NHS England 2025 

2 

8

Victoria Davies 
Area Coroner for Cheshire 
The West Annexe 
Town Hall 
Sankey Street 
Warrington 
Cheshire 
WA1 1UH 

National Medical Director  
NHS England  
Wellington House 
133-155 Waterloo Road  
London 
SE1 8UG 

5th March 2026  

Dear Coroner, 

Re: Regulation 28 Report to Prevent Future Deaths – Pippa Isobel Waller 
Gillibrand who died on 5th September 2024.  

Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 27th 
January 2026 concerning the death of Pippa Isobel Waller Gillibrand on 5th September 
2024. In advance of responding to the specific concerns raised in your Report, I would 
like to express my deep condolences to Pippa’s parents, wider family and loved ones. 
NHS England is keen to assure the family and yourself that the concerns raised about 
Pippa’s care have been listened to and reflected upon.   

Your Report raised the concerns that there is currently no national guidance in respect 
of home births and the model of care, nor is there a national or local collection of data 
around home births, such as the numbers resulting in transfer to hospital, or involving 
injury to mother or baby. Such information would enable expectant parents to make 
an informed choice as to the risks of a home birth.  

HM  Coroner  may  already  be  aware  that  NHS  England  previously  received  a 
Regulation 28 Report dated 5 November 2025 from Joanne Kearsley, Senior Coroner 
for  the  Manchester  North  area.  This  Report  raised  very  similar  concerns  to  those 
raised in this case, and NHS England responded to the Report on 24 December 2025. 
For completeness, and for the benefit of Pippa’s family, NHS England has responded 
to  your  Report  in  full.  However,  there  is  an  element  of  duplication  in  terms  of  the 
information  which  was  provided  by  NHS  England  on  24  December  2025.  No 
disrespect is intended to the Coroner or family in this regard. 

On 26 November 2025, NHS England wrote to all NHS maternity providers in England 
asking them to urgently review the safety and quality of their homebirth services. In 
particular, we urged them to consider the following issues: 

•  The  operational  running  of  their  service:  including  how  it  ensures  that 
prompt  midwifery  care  is  available  24  hours  a  day;  that  staff  are  properly 
equipped, trained, prepared and skilled for providing birth and neonatal care in 
a  home  setting;  that  staff  have  senior  multi-disciplinary  support  available  to 

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 them at all times and have sufficient rest periods; and that potential transfer and 
extraction processes are clear and planned for each birth. 

•  Care  planning  and  risk  assessment:  including  systematic  assessment  of 
complexity  and  risk;  how  the  multidisciplinary  team  (MDT)  ensures  a 
personalised  approach  to  women  in  planning  care  in  light  of  any  identified 
issues  (particularly  when  homebirth  is  not  recommended);  how  the  MDT 
continues  to  maintain  good  communication  at  all  stages  of  care  with  women 
and  between  all  teams  including  ambulance  services;  and  how  dynamic  risk 
assessment is managed and responded to throughout pregnancy, birth and the 
postnatal period.   

•  Governance and oversight: including how governance is structured to ensure 
robust  oversight  of  homebirth  services  by  the  whole  organisation,  so  the 
executive board of each NHS Trust has appropriate oversight; that there is an 
audit programme that covers outcomes and clinical and operational guidance 
and leads to continual improvement; and that there is comprehensive homebirth 
guidance including standard operating procedures for all stages and aspects of 
care.  

The National Institute for Heath and Care Excellence (NICE) uses available evidence 
to  develop  guidance  to  improve  health  and  social  care,  including  the  Guideline  on 
Intrapartum Care (published 29 September 2023 and updated on 14 November 2025). 
While not dedicated to homebirths, the guidance does cover the care of women and 
their  babies  during  labour  and  immediately  after  birth  in  all  settings  and  addresses 
issues around planning the place of birth. 

We  acknowledge  that  the  current  intrapartum  care  guidance  does  not  provide 
sufficient clarity to women, staff and services as to how to safely support requests for 
and  the  provision  of  homebirth  services.  NHS  England  will  continue  working  with 
partners  including  NICE,  the  Royal  College  of  Midwives,  the  Royal  College  of 
Obstetrics and Gynaecology, the Nursing & Midwifery Council, Maternity & Newborn 
Safety Investigations, the Care Quality Commission, and the General Medical Council 
to  develop 
to  consistently  support 
commissioners, providers and women and families.  

that  enable  services 

further  resources 

In  December  2025,  NHS  England  convened  partner  organisations  and  their 
representatives, and initiated work to develop resources that rapidly close this gap in 
the  guidance.  We  already  expect  maternity  provider  Trusts  to  have  operating 
procedures  in  place  for  planning  births  at  home,  and  this  should  include  potential 
transfer processes. We have written to all maternity providers on 26th November 2025 
reminding them of those expectations and the action to be taken. A copy of this letter 
has  been  included  with  the  response  to  the  Coroner.  Where  Trusts  may  not  have 
appropriate operating procedures for planning births at home and managing high-risk 
pregnancies, we would expect this to be identified and escalated using the Perinatal 
Quality  Oversight  Model  (2025).  This  model  provides  a  structured  approach  for 
identifying and responding to safety concerns across Trusts, Integrated Care Boards 
(ICBs), and neonatal operational delivery networks.  

3

 
 
 
 
 
 
 
 We  agree  that  women  should  be  informed  about  all  material  risks,  as  has  been 
established through the Montgomery v Lanarkshire Health Board judgment of the UK 
Supreme Court. Health professionals must take “reasonable care to ensure that the 
patient is aware of any material risks involved in any recommended treatment and of 
any reasonable alternative or variant treatments”. 

For all women, communication around risk should be personalised. Donna Ockenden, 
in her review of the maternity services at Shrewsbury and Telford Hospital NHS Trust, 
made it clear that staff must ensure that women undergo a risk assessment at each 
contact  throughout  the  pregnancy  pathway  and  that  “risk  assessment  must  include 
ongoing  review  of  the  intended  place  of  birth.”  NHS  England  asked  Trusts  to 
implement this at the time. All pregnant women should also be offered a personalised 
care  and  support  plan  where  such  information  is  recorded,  alongside  the  decisions 
they make about their care. 

The  General  Medical  Council  (GMC)  has  issued  guidance  around  decision  making 
and consent, to support healthcare professionals in their conversations with patients 
and  service  users  to  help  share  the  information  needed  to  make  decisions  and  to 
ensure informed consent is given. 

The  Royal  College  of  Midwives  (RCM)  has  separately  issued  guidance  around 
informed  decision  making  and  care  outside  of  guidance.  The  Nursing  &  Midwifery 
Council (NMC) has also issued principles for supporting women's choices in maternity 
care.  Employing  Trusts  are  responsible  for  ensuring  that  their  midwives  and 
obstetricians practice in line with this guidance. 

The NMC also maintains standards of proficiency for all midwives, which represent the 
skills,  knowledge and attributes  they must demonstrate.  While the number  of  births 
attended is not alone a reliable indicator of a midwife’s fitness to practice intrapartum 
care,  we  will  work  with  the  NMC  to  consider  the  requirements  for  post-registration 
standards,  that  have  a specific  focus  on homebirths,  as  part  of the development  of 
resources mentioned above. 

Midwives providing care at home must be able to respond to developing emergencies 
on their own, sometimes without the support of multi-disciplinary teams and immediate 
access to hospital facilities, until additional assistance is provided from the ambulance 
service. Such midwives are expected to undergo regular training in this. NHS England 
will  work  with  other  organisations  to  ensure  that  multi-disciplinary  team  training 
simulation  for  obstetric  emergencies  includes  at  least  one  scenario  starting  in  a 
community/homebirth setting, in addition to the yearly training competency required 
by all NHS midwives within the NHS England » Core competency framework version 
two (2023). 

Following the meeting with national stakeholders in December 2025, ongoing work is 
taking  place  to  develop  resources  that  will  fill  the  current  gap  in  the  guidance.  We 
anticipate that those resources will touch  upon all the matters of concern you have 
raised, including: 

•  safe working practices. 
•  midwifery competence, training and education. 

4

 
 
 
 
 
 
 
 
 risk assessment and care planning. 

• 
•  clinical care standards, IT and equipment. 
• 

transfer of care including working with ambulance services, escalation and 
multi-disciplinary team involvement.  
informed decision making, communication and public information. 

• 
•  personalised approaches to planning care, particularly when homebirth is 

not recommended. 

•  provision  of  comprehensive  homebirth  guidance,  including  standard 

operating procedures for all stages and aspects of care. 

We acknowledge that this does not provide evidence of the number of women who 
have been transferred from home to hospital during labour or after birth, or of their and 
their baby’s outcomes. We will explore whether existing data gathering systems can 
be updated to provide regular reporting on outcomes associated with homebirths and 
will go out to tender to develop a longer-term solution to this evidence gap.  

Local actions 

Cheshire  and  Merseyside  Integrated  Care  Board  (ICB)  have  advised  us,  via  NHS 
England’s North West Regional Team, that the Local Maternity and Neonatal System 
(LMNS) has contacted Warrington & Halton Hospitals NHS Foundation Trust’s Deputy 
Director of Nursing & Care regarding this case. They have scheduled a meeting with 
the  Chief  Nurse  at the  Trust  where  they  will  discuss  the  actions taken by the Trust 
since the incident. The LMNS have already raised the Trust’s workforce model with 
them  and  will  be  supporting  them  with  further  work  on  this  as  a  result  of  their  own 
diagnostic  report.  Should  the  Coroner  require  further  information  regarding  the 
outcome of this meeting, we recommend contacting ICB / LMNS or Trust directly. 

As  part  of  the  Warrington  and  Halton  Hospitals  (WHH)  enhanced  perinatal 
surveillance,  known  locally  as  ‘Joint  Oversight  and  Support’  (JOS),  the  LMNS  will 
review  individual  guidelines  associated  with  homebirths,  including  training  needs 
analysis, home birth guidelines, escalation, guidelines in relation to midwifery staffing 
and  management  of  the  homebirth  service,  including  a  review  of  the  Whole  Time 
Equivalent midwifery workforce and on call requirements. 

I  would  also  like  to  provide  further  assurances  on  the  national  NHS  England  work 
taking place around the Reports to Prevent Future Deaths. All reports received are 
discussed  by  the  Regulation  28  Working  Group,  comprising  Regional  Medical 
Directors,  and  other  clinical  and  quality  colleagues  from  across  the  regions.  This 
ensures that key learnings and insights around events, such as the sad death of Pippa, 
are shared across the NHS at both a national and regional level and helps us to pay 
close attention to any emerging trends that may require further review and action.   

Thank you for bringing these important patient safety issues to my attention and please 
do not hesitate to contact me should you need any further information.  

5

 
 
 
 
 
 
 
  
 
 
 
 Yours sincerely,  

National Medical Director  
NHS England  

6

3rd floor 
3 Piccadilly Place 
Manchester 
M1 3BN 
United Kingdom 

11 March 2026   

Victoria Davies  
HM Area Coroner   
Cheshire Coroner’s Court  
Museum Street  
Warrington  
Cheshire   
WA1 1JX  

Dear Ms Davies,    

Re: Regulation 28 report to prevent future deaths in respect of Pippa Isobel Waller 
GILLIBRAND  

I write in response to the sad death of Pippa Isobel Waller Gillibrand. I would like to express my 
sincere condolences to Pippa’s family.    

Patient safety leads at NICE have carefully considered your report with respect to the areas for 
which NICE is responsible, and I have addressed each point in turn.  

1.  There is no national guidance in respect of home births  

Home birth is covered in NICE’s guideline on intrapartum care (NG235). The risks and benefits 
of home birth compared to birth in an alongside midwifery unit, freestanding midwifery unit and 
hospital are covered, with information for counselling detailed in tables 6 to 9. The 
guideline provides comprehensive guidance on intrapartum care, including (but not limited to) 
home births. The guideline covers:  

•  Eligibility. Home birth might be considered for women with low-risk, uncomplicated 
pregnancies. This includes those without medical or obstetric complications and 
differentiates in terms of risk factors between nulliparous and multiparous women 
(recommendation 1.3.1).  

• 

Informed Choice. Women should be supported to make informed decisions about their 
place of birth. This includes discussing risks, benefits, and available support 
(recommendation1.3.3-5).  

•  Midwife Support. Care during home birth should be provided by trained midwives, with 

access to emergency transfer protocols if complications arise.  

nice.org.uk | nice@nice.org.uk 

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 Within the guideline, medical conditions and other factors that may affect the choice of planned 
place of birth are not given as contraindications to home birth but indicate where care in an 
obstetric unit would be expected to reduce risk to the mother or the baby. There are also 
recommendations that support further discussion with an appropriately trained senior or 
consultant midwife and/or a senior or consultant obstetrician (if there are obstetric issues) if 
such a discussion is wanted by the midwife or the woman. See recommendations 1.3.9 to 
1.3.11 and tables 6 to 9.  

NICE’s guideline on intrapartum care covers assessment in the first stage of labour in any 
setting, including the observations of the mother and the unborn baby that should led to the 
transfer of the woman to obstetric-led care, noting also that multiple risk factors may increase 
the urgency of the transfer, particularly if they have a cumulative effect. The guideline notes the 
more frequent observations of the mother and the unborn baby that should be undertaken in the 
second stage.  

We therefore conclude that the subject of home births is appropriately covered in the current 
guidelines. The recommendations guide clinical practice and support women to make an 
informed choice about their care based on discussions with trained staff about the risks and 
benefits.   

a.  There is no guidance on the training that a midwife should undergo to ensure they 

are competent to manage a home birth  

Training of midwives and the attainment and assessment of competencies are not within NICE’s 
remit. I recommend that you address these concerns to the organisations responsible for 
training and regulation of midwives (such as the Nursing and Midwifery Council (NMC) and NHS 
England’s Workforce, Training and Education Directorate).  

b.  There is no guidance on the number of deliveries a midwife should support to 

attain or maintain their midwifery skills  

Please see the response to point 2 above.  

c.  There is no guidance on the threshold for transfer to hospital from a home birth.  

We do not agree. The intrapartum care guideline (NG235, recommendations 1.8.11-12 and 
1.8.20) lists the observations of the mother and the unborn baby that should lead to the transfer 
of the woman to obstetric led care, noting also that multiple risk factors may increase the 
urgency of the transfer, particularly if they have a cumulative effect. The guideline notes that 
more frequent observations of the mother and the unborn baby that should be undertaken in the 
second stage.  

However, it is also the case that local and patient specific factors (such as geography, distance 
from the obstetric unit, the availability of support and other factors) need to be taken into 
account when deciding on the need for patient transfer.  

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 d.  There is no guidance on safe staffing and equipment levels for home birth  

NICE’s guideline on safe midwifery staffing for maternity settings (NG4) covers safe midwifery 
staffing in all maternity settings, including at home and in the community.   

It aims to improve maternity care by giving advice on monitoring staffing levels and actions to 
take if there are not enough midwives to meet the needs of women and babies in the service. It 
provides recommendations on organisational requirements; setting the midwifery establishment; 
assessing differences in the number and skill mix of midwives needed and the number of 
midwives available; and monitoring and evaluating midwifery staffing requirements. The 
guideline also provides recommendations on assessing the skill mix of available maternity staff 
against care requirements.   

We provide several tools and resources to assist NHS commissioning bodies to implement our 
recommendations. For intrapartum care (NG235), these include a tabulated comparison of the 
different places of birth containing an estimate of the risks to the mother and the baby. There is 
also a link to endorsed resources produced by NHS England that support the implementation of 
the recommendations in this guideline.   

Further, the Royal College of Midwives have just published a safe staffing document with 
recommendations Safe staffing = safe care - Royal College of Midwives (RCM) 

e.  There is no guidance on ‘supervision which should be provided during a home 

birth’.  

We are unclear what this refers to. If this relates to ‘support’ for the attending midwives rather 
than supervision, we believe this is a concern about professional support and supervision, which 
is outside of NICE’s remit. As discussed above the NMC and RCM, will be better placed 
to consider the report and respond   

f.  There is no system for back-up should electronic systems fail  

Responsibility for managing the delivery of NHS care rests with the appropriate 
commissioning body. We believe, therefore, that NHS England (NHSE) is best placed to 
consider this point.  

g.  There is no Information which should be provided to expectant parents around the 

risks of home birth or the experience of the team to enable them to make an 
informed choice (about whether to have a home birth).  

NICE provides a number of tools and resources to support NG235, including a tabulated 
comparison of the different places of birth. This includes an estimate of the risks to the mother 
and the baby. There is also a link to endorsed resources produced by NHSE that support the 
implementation of recommendations in the NICE guideline on intrapartum care. These include 
the statement that ‘Very few mothers die or are injured as a result of birth, wherever they have 
their baby. Few babies die or are injured as a result of the birth itself, wherever the baby is 
born’  

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 It is, however, true that NICE does not provide information on the required experience of the 
midwifery team for supporting home births, but this is outside our role. This is an issue for 
the NMC and the RCM to consider.     

2.  There is no national or local collection of data around home births.  

The Maternity Services Dataset (MSDS) collated by NHSE is a national source for homebirth 
statistics in England. It records the planned and actual place of birth, including home 
births. The Office for National Statistics Birth Registrations also records place of birth, which 
includes home births.   

MBRRACEUK: Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries 
across the UK, collects data for maternal deaths, perinatal deaths, and serious maternal 
morbidity, but does not publish routine statistics on home births or maintain a dataset designed 
to analyse homebirth trends. However, if a maternal or perinatal death occurred following a 
home birth, the place of birth would be captured as part of the case record. Maternity and 
Newborn Safety Investigations (MNSI) collects data on serious incidents – this includes 
homebirth incidents when reported, but it does not track home births nationally.  

NICE does not collect routine data around home births. This is likely to be commissioned 
by NHSE and supported by the Healthcare Quality Improvement Partnership (HQIP). These 
organisations will be better placed to respond to the concerns raised here.    

Finally, we note that the Royal College of Obstetricians and Gynaecologists have not been 
identified as an interested party in your report. You may find it helpful to appraise them of this 
case and seek their views.     

I hope that the information above is helpful in clarifying the guidance that we have published 
that is of relevance to the circumstances of this very sad event. I also hope that the suggestions 
of other organisations who may be able to comment is useful.    

I would like to reiterate my sincere condolences to the family of Pippa Gillibrand.   

Yours sincerely,  

Chief Executive  

 CBE MD FRCS FRCEM  

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