Mother, 34, and her newborn baby died from ‘Victorian-age’ failures after she opted to have a home birth

A mother and her newborn baby died in a ‘Victorian-age tragedy’ after she opted to have a home birth, a senior coroner has said. 

Jennifer Cahill, 34, died in 2023 after having a heart attack shortly after giving birth to baby Agnes, Joanna Kersley, senior coroner for Manchester North, heard.

The infant was delivered not breathing, with the umbilical cord around her neck, in the early hours of June 3 last year and died at North Manchester General Hospital aged just three days. 

Ms Cahill had suffered serious bleeding and needed two transfusions following the traumatic hospital birth of her first child, a son, three years earlier.

But medical notes detailing exactly how much blood she lost were not available to midwives when she fell pregnant a second time around.

Now coroner Ms Kersley has warned there is ‘no national guidance’ for home births. She described the events as a ‘Victorian-aged tragedy’ played out in the modern day.

Ms Kersley added that home births are not a specialist service among midwives and there is not a ‘robust framework’ for them. 

‘There is no national guidance to support consistent practice across the country including, for example, details of clinical scenarios where women, following robust assessment, have been considered too high risk to safely receive care in a home setting,’ Ms Kersley said. 

Ms Cahill had suffered serious bleeding and needed two transfusions following the traumatic hospital birth of her first child, a son, pictured, three years earlier

‘The lack of national guidance means there are differing models of care and unlike other specialities home births are not a specialist commissioned service. 

‘There is no national guidance considering the ethical responsibility and proportionality of offering a home birth model under the NHS framework.’

She added there was no stipulation that the risk of death of such a procedure, however small, be discussed beforehand.

Ms Kersley continued: ‘There is no mandated number of deliveries that any midwife (irrespective of the settings in which they are working) must complete once they have qualified as a midwife in order to maintain their registration. 

‘The level of experience of community midwives in conducting deliveries is not information routinely provided to women to inform their decision whether to have a homebirth. 

‘The lack of national data collection means there is no data to evidence the number of women who are transferred in during labour or after birth, maternal or neonatal outcomes, number of women who are considered out of guidance. 

‘There is no national guidance on the model of staffing, training and experience for midwives providing home birth care.’

Ms Cahill suffered a repeat haemorrhage and lost almost half the blood in her body immediately after Agnes’s birth.

Her second baby was delivered not breathing, with the umbilical cord around her neck, in the early hours of June 3 last year and died at North Manchester General Hospital aged three days

Ms Cahill, pictured with her husband Rob, suffered a repeat haemorrhage and lost almost half the blood in her body immediately after Agnes’s birth

The international export manager went into cardiac arrest in the ambulance and died the following day.

Ms Cahill and her baby died after mistakes were made by community midwives, who had had no contact with her previously, while looking after her, the inquest heard.

The hearing was previously told doctors had avoided using the term ‘death’ in meetings with Ms Cahill, and several opportunities were missed to spell out that it would have been safer for baby Agnes to be born in hospital. 

Close friend Katherine Kershaw told the inquest, in Rochdale, that Ms Cahill initially assumed she was a high-risk pregnancy because of the problems she suffered during her first labour, but changed her mind after meeting a hospital consultant.

‘I think she believed the level of blood loss (after the birth of her son) was normal because no one seemed to think it was significant,’ Ms Kershaw, who spoke to Ms Cahill almost daily during her pregnancy, said.

‘She had read or heard somewhere that there was less chance of bleeding at home and that is why she wanted a home birth.’

Expert midwife Abigail Holmes, who is currently director of Midwifery and Neonatal Services at Cardiff and Vale University Health Board, was extremely critical of Mrs Cahill’s ante-natal care and suggested that, had she been properly advised she would not have ‘intentionally put herself or her baby at risk,’ meaning the outcome may have been different.

She said: ‘From what I have seen and read there were no meaningful conversations that took place over the risks of giving birth outside of an obstetrics unit.’

The international export manager went into cardiac arrest in the ambulance and died the following day

Although the amount of home births is falling – they make up for around two per cent of all births in England and Wales – Ms Holmes admitted that the number of high-risk or ‘out of guidance’ deliveries at home was on the rise.

The phenomenon means fewer midwives have direct experience of difficult deliveries at home, the inquest was told.

‘Many midwives are now concerned about high-risk births which they may not be fully trained for,’ Ms Holmes said.

‘Skills like neo-natal resuscitation will be lost if not practised regularly and no amount of mannequins can make up for real-life practice.’

Coroner Joanne Kearsley suggested more direct language needed to be used to make it explicitly clear to women wanting a home birth of the risks involved.

It was assumed that Mrs Cahill would deliver her second child in hospital but there was no conversation had about it.

In February 2024, she informed her community midwife she was considering a home birth – which was found to be linked to trauma from her first pregnancy.

Her pregnancy was judged to be ‘low risk’.

The inquest found there had been a failure in her antenatal care as she was not referred to a senior midwife.

There were also issues with failing equipment and IT connectivity problems when dealing Mrs Cahill.

During the course of labour she received ineffective pain relief and the baby’s foetal heart rate was not monitored properly.

Agnes was born at 6.44am but resuscitation was not conducted effectively due to a split in the bag valve mask – which had not been checked.

A 999 call was made and they were transferred to hospital – but further checks were missed and there was a lack of communication between the midwives and paramedics.

The inquest concluded that Mrs Cahill died as a result of complications arising from the delivery of her second child, contributed to by neglect.

Her cause of death was recorded as multiorgan failure, cardiac arrest and a perineal tear.

Agnes died as a result of complications during birth, such complications contributed to by neglect.

Her causes of death were multi-organ insult following hypoxic ischaemic encephalopathy and cord compression and meconium aspiration syndrome.

Ms Kersley sent her prevention of future deaths report to the Health Secretary and various chief executives of health boards – including the Royal College of Midwives. They have until January 5 to respond.