A coroner has condemned a 'gross failure' in care that led to the deaths of a mother and her newborn daughter during a home birth in Prestwich, Greater Manchester. Jennifer Cahill, 34, and her baby Agnes Lily died in June last year after a delivery described as a 'Victorian-age nightmare'. The inquest at Rochdale Coroner's Court heard that vital notes, including blood pressure readings and the baby's heart rate, were scrawled on a spare incontinence pad and later thrown away.
Ms Cahill, an international export manager, suffered a severe haemorrhage after a tear between her vagina and anus, losing five pints of blood. She went into cardiac arrest in the ambulance and died from multiple organ failure the next day. Baby Agnes was delivered not breathing, with the umbilical cord wrapped around her neck, and died four days later at North Manchester General Hospital.
The inquest heard that Ms Cahill's pregnancy was high-risk due to a previous postpartum haemorrhage, and she had been advised to give birth in hospital. However, the dangers of a home birth were not fully explained, and she believed there was less chance of bleeding at home. Expert midwife Abigail Holmes criticised the advice given, stating that phrases like 'out of guidance' were used instead of 'against medical advice', and the risk of death was not explicitly raised.
The two community midwives attending the birth, Julie Turner and Andrea Walmsley, had worked 12-hour shifts and been awake for over 30 hours. They were unaware of the couple's birth plan due to a communication failure. The coroner noted that the midwives' effectiveness was affected by a 'lack of understanding and confidence'. Manchester University NHS Foundation Trust has accepted that Ms Cahill should have been referred to a senior midwife to discuss risks.
