A heartbreaking tragedy unfolded in Manchester when Jennifer Cahill, 34, and her newborn daughter Agnes both died after a home birth went tragically wrong.
Senior coroner Joanna Kersley described the events as a “Victorian-age tragedy” played out in the modern day, highlighting the serious gaps in guidance and support for home births.
Ms Cahill suffered a heart attack shortly after giving birth in June 2023, while baby Agnes was delivered with the umbilical cord around her neck and died three days later at North Manchester General Hospital.
Past Pregnancy Complications Raised the Risk
Jennifer Cahill had previously experienced severe bleeding during the hospital birth of her first child, requiring two blood transfusions.
Unfortunately, detailed medical records of her prior blood loss were not available to midwives during her second pregnancy.
This lack of information meant Ms Cahill was unaware of the full risks, and critical conversations about safer delivery options at a hospital were not held.
Her desire for a home birth was influenced by the belief that bleeding risks would be lower at home.
Coroner Criticizes Lack of National Guidance for Home Births
Coroner Joanna Kersley emphasized the absence of standardized national guidance for home births, stating there is no “robust framework” for midwives or consistent procedures across the country.
She pointed out that home births are not treated as a specialist service within the NHS and that key factors such as experience level, risk discussions, and ethical responsibilities are often left unaddressed.
“There is no mandated number of deliveries that a midwife must complete to maintain registration,” Ms Kersley noted, warning that women cannot make fully informed choices without access to this information.
Failings in Care During Labour
The inquest revealed multiple failings in the care provided to Ms Cahill and baby Agnes.
Community midwives, who had no prior contact with her, managed the birth.
Equipment issues, ineffective pain relief, and poor communication with paramedics all contributed to the tragic outcome.
During delivery, Agnes’s foetal heart rate was not monitored properly, and resuscitation attempts were hampered by a split in the bag valve mask.
A 999 call eventually led to a hospital transfer, but vital checks were missed along the way.
Experts Highlight Growing Risks for Home Births
Expert midwife Abigail Holmes criticized the antenatal care Ms Cahill received, emphasizing that meaningful discussions about home birth risks were missing.
While home births account for just around 2% of deliveries in England and Wales, the number of high-risk home births is rising, meaning fewer midwives have hands-on experience managing complications.
Skills like neonatal resuscitation cannot be fully replaced by simulations, and the inquest heard that midwives may now feel unprepared for high-risk deliveries at home.
Coroner Calls for Clearer Communication
Joanna Kersley suggested that more explicit language is needed to ensure women fully understand the risks of home births.
She noted that Ms Cahill’s pregnancy was assumed to be low risk, and no discussions about hospital delivery took place despite her prior complications.
Preventable Deaths and Recommendations
The inquest concluded that Ms Cahill died due to complications after childbirth, compounded by neglect, while baby Agnes died from complications linked to cord compression and inadequate resuscitation, also contributed to by neglect.
Causes of death were recorded as multiorgan failure and cardiac arrest for Ms Cahill, and multi-organ insult following hypoxic ischaemic encephalopathy for Agnes.
The coroner has sent a Prevention of Future Deaths report to the Health Secretary, NHS trusts, and the Royal College of Midwives, with responses expected by January 5.
A Heartbreaking Reminder of the Need for Reform
This tragedy has shone a stark light on the risks associated with home births and the urgent need for a national framework to guide midwives, inform parents, and prevent avoidable deaths.
Ms Cahill and baby Agnes’s story underscores the importance of clear communication, thorough risk assessment, and consistent standards in maternity care.