Jennifer Cahill and her newborn daughter Agnes Lily died after a home birth that a coroner described as a 'Victorian-age nightmare' marked by a 'catastrophic error and a gross failure to provide basic medical care'. The 34-year-old international export manager suffered a severe haemorrhage following the delivery at her home in Prestwich, north of Manchester, on 3 June last year.
Cahill lost five pints of blood due to a tear between her vagina and anus. She went into cardiac arrest in the ambulance and died from multiple organ failure the following day. Her daughter Agnes, who was delivered not breathing with the umbilical cord wrapped around her neck, died four days later at North Manchester General Hospital.
Rochdale Coroner's Court heard that Cahill's pregnancy was high-risk because she had suffered a postpartum haemorrhage after her first child in 2021. She had been advised to give birth in hospital, but her husband told the court the dangers of a home birth were not fully explained. An expert midwife testified that phrases such as 'out of guidance' were used instead of 'against medical advice', and the risk of death was never explicitly raised.
The inquest heard that the two community midwives attending the birth had worked 12-hour shifts and been awake for over 30 hours. Their effectiveness was hindered by a failure to see the Cahills' birth plan, and vital notes, including the baby's heart rate, were not properly recorded, with some scribbled on an incontinence pad that was later thrown away. Manchester University NHS Foundation Trust has accepted that Cahill should have been referred to a senior midwife to discuss risks.
