Jennifer Cahill, 34, and her newborn daughter Agnes Lily died following a home birth in Prestwich, north of Manchester, in June last year. A coroner described the events as ‘a Victorian-age nightmare’ after a ‘gross failure’ in medical care.
Cahill suffered a haemorrhage due to 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. Agnes was delivered not breathing with the umbilical cord around her neck and died four days later at North Manchester General Hospital.
The inquest at Rochdale Coroner’s Court heard that Cahill’s pregnancy was high-risk because she had a postpartum haemorrhage after her first child in 2021. She had been advised to have a hospital birth, but the dangers of a home birth were not fully explained. Manchester University NHS Foundation Trust accepted that she should have been referred to a senior midwife to discuss risks.
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. Holmes said: ‘A woman can only make an informed decision if she has been informed, and that includes the risk of death.’
The inquest also revealed that the two community midwives attending the birth had worked 12-hour shifts and were awake for over 30 hours. Vital notes, including blood pressure and the baby’s heart rate, were not properly recorded, with the latter scrawled on an incontinence pad that was later thrown away.
