Jennifer and Agnes Cahill: Coroner rules homebirth tragedy could have been avoided

A mother who died along with her newborn after a homebirth descended into “chaos” could have been saved, a coroner has ruled.

Coroner Joanne Kearsley, who described the deaths as a “Victorian-aged tragedy” played out in the modern day, found the deaths could have been avoided if not for “catastrophic error” and “gross failings” in basic care.

Jennifer Cahill, 34, gave birth at her Manchester home on June 3, 2024 surrounded by her husband Rob and two midwives.

She died a day later from organ failure after losing around two litres of blood and her daughter, Agnes, survived just four days before she, too, passed away after being delivered not breathing and with the umbilical cord around her neck.

A two week inquest in the Rochdale Coroner’s Court was told how Ms Cahill decided to have a homebirth after a “traumatic” birth experience with her first child, Rudy, at a hospital three years before.

Ms Cahill suffered a postpartum haemorrhage and needed a blood transfusion after losing more than 800ml of blood. Rudy also contracted sepsis after he was born.

The experience left Ms Cahill feeling “unsupported” and she believed this could be rectified during her second labour if she had a homebirth attended by two midwives, with minimal intervention, low lighting, and less noise.

But her previous history with haemorrhaging and the fact she was a carrier of group B strep, which can spread to babies during birth and cause serious infections including sepsis, meningitis, or pneumonia, put her at high risk, the inquest was told.

Ms Cahill’s antenatal care, Ms Kearsley said, “lacked any questions, was based on assumption and was perfunctory”, Manchester News reported.

An important document known as an “out of guidance birth plan” was never completed after Ms Cahill chose a homebirth. This would have informed about the risk of a home birth, identified the dangers and questioned why she wanted to give birth at home.

Rob Cahill previously told the inquest no-one had fully explained the risks of a homebirth to the couple.

The coroner also found the two midwives that attended the birth were inexperienced with high risk births, lacked confidence and did not monitor the baby properly.

She described the lack of monitoring of the baby’s heartbeat, which had been slowing for an hour, a “gross failure”.

Resuscitation equipment had not been checked and an air mask they tried to use for the newborn was broken.

“Mrs Cahill’s blood pressure should have been checked every five minutes and a urine sample taken. But neglectfully, this wasn’t done.”

Manchester University NHS Foundation Trust has apologised and accepted there were “serious failures”.

Kimberley Salmon-Jamieson, the trust’s deputy chief executive, said changes had been made to its home birth service to make it safer.

“We will also study the Coroner’s conclusion very carefully to see if there are any further actions which we should be taking,” she said.

Speaking on behalf of the family, medical negligence lawyer Claire Horton told the BBC the deaths were “entirely avoidable”.

“They were both catastrophically let down by mismanagement before, during and after the birth,” she said.

“Jen was not properly counselled or observed.”

Ms Horton said the family was “deeply saddened” changes were only implemented by the Trust after Ms Cahill and Agnes’ deaths.