An inquest has heard that a ‘gross failure’ to provide basic medical care led to the deaths of a mother and her newborn daughter during a home birth in Prestwich, Greater Manchester. Jennifer Cahill, 34, and her daughter Agnes Lily died within days of each other in June last year, following a delivery described by the coroner as a ‘Victorian-age nightmare’.
Cahill, an international export manager, suffered a haemorrhage after giving birth at home, losing almost half the blood in her body from a tear between her vagina and anus. She went into cardiac arrest in the ambulance and died from multiple organ failure the next day. Agnes was born 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 was told that Cahill’s pregnancy had been high-risk because she had a postpartum haemorrhage after her first child. She had been advised to deliver in hospital, but her husband Rob said the dangers of a home birth were not fully explained. An expert midwife, Abigail Holmes, criticised the advice given, stating that ‘softer, kinder words’ such as ‘out of guidance’ were used instead of ‘against medical advice’, and the risk of death was not explicitly raised.
Manchester University NHS Foundation Trust has accepted that Cahill should have been referred to a senior midwife to discuss risks. The inquest also heard that the two community midwives who attended the birth, Julie Turner and Andrea Walmsley, had worked 12-hour shifts before delivering the baby and were awake for over 30 hours. Vital notes, including blood pressure readings and the baby’s heart rate, were not properly recorded; one set of notes was even scrawled on a spare incontinence pad that was later thrown away.
