A coroner concluded Jennifer and Agnes suffered what should have been a ‘Victorian-aged tragedy’ played out in the modern day
A devastating home birth which resulted in the deaths of both a mother and her newborn baby was caused by “neglect”, “catastrophic error” and “gross failures to provide basic care”, a coroner has ruled.
Jennifer Cahill, 34, passed away in hospital on June 3, 2024, the day after the delivery of her second child, Agnes, at the family home she shared with her husband, Robert Cahill, in Prestwich. Little Agnes also tragically died in hospital just four days later.
On Monday (October 27), following a two-week inquest into their deaths, the coroner concluded the family had suffered what should have been a “Victorian-aged tragedy” unfolding in the modern day. The mother and daughter were transported to hospital separately after a series of complications arose.
Agnes was born not breathing, with the umbilical cord wrapped around her neck. Shortly after, Mrs Cahill started losing an estimated two litres of blood, the M.E.N. reports.
Mrs Cahill’s death was attributed to multi-organ failure resulting from cardiac arrest, brought on by postpartum haemorrhage, according to the pathologist who gave evidence on October 17. Agnes died from multi-organ failure following hypoxia after umbilical cord compression.
Rochdale Coroners’ Court heard Coroner Joanne Kearsley’s conclusion yesterday. She determined there were “gross failures” to provide basic care in the antenatal care of Mrs Cahill, and in the care both she and baby Agnes received during delivery.
Ms Kearsley called it a “catastrophic error and gross failure to provide basic medical care” that the “most important document” – an out-of-guidance birth plan – was never completed after Mrs Cahill chose to have a home birth.
Such a plan would have allowed for a more accurate assessment of the risks of a home birth, identified potential dangers and examined why Mrs Cahill chose to have a home birth.
Ms Kearsley said Mrs Cahill’s antenatal care “lacked any questions, was based on assumption and was perfunctory”.
The coroner also said it was a “gross failure to provide basic medical care” that heart rate checks on Agnes were not completed every five minutes as Mrs Cahill’s labour progressed. Had these measures been done appropriately, midwives would have realised that Agnes was struggling for air, as the cord was wrapped around her neck for around an hour before the birth.
Neglect was found to be a contributing factor in both Agnes’ and Mrs Cahill’s deaths.
