\n<\/p>\n
W<\/span>hen Jennifer Cahill went into labour with her second child at home in summer last year, she thought that the delivery, assisted by two midwives and with her husband by her side, would be a relatively simple one. Within 24 hours, however, she was dead, and her newborn daughter was fighting for her life after experiencing \u201chorrors that should be consigned to a Victorian-age nightmare\u201d.<\/p>\n Cahill, 34, who was an international export manager, died after her baby, Agnes Lily, was born in the early hours of 3 June last year at her home in Prestwich, north of Manchester.<\/p>\n She suffered a haemorrhage and lost <\/strong>five pints of blood, or almost half the blood in her body, owing to a tear between her vagina and anus. She was taken to hospital, but went into cardiac arrest in the ambulance, and died from multiple organ failure the next day.<\/p>\n Agnes was delivered not breathing, with the umbilical cord wrapped around her neck, and also died at North Manchester general hospital four days later.<\/p>\n On Monday, Rochdale coroner\u2019s court heard that the mother and daughter died owing to \u201ca catastrophic error and a gross failure to provide basic medical care\u201d, which started when Cahill first considered a home birth.<\/p>\n About one in 50 births in England and Wales takes place at home. However, they are recommended only for low-risk pregnancies.<\/p>\n Cahill\u2019s pregnancy was considered high-risk because she had suffered a postpartum haemorrhage after giving birth to her first child in 2021. She had been advised to have her second baby in hospital because of this, the inquest heard, but her husband, Rob, told the court that the dangers of a home birth had not been fully explained.<\/p>\n The court heard that Cahill, while knowing that the pregnancy had been high-risk, had not been properly advised on the benefits of having Agnes in hospital, and that if she had, it was likely that she would not have delivered her daughter at home.<\/p>\n Manchester University NHS foundation trust, which runs the hospital, has accepted that after deciding on a home birth, Cahill should have been referred to a senior midwife, so that the risks could be discussed.<\/p>\n Her friend told the inquest that she did not believe Cahill had understood her pregnancy to be high-risk, despite having needed a blood transfusion after delivering her first child.<\/p>\n \u201cI think she believed the level of blood loss was normal because no one seemed to think it was significant,\u201d Katherine Kershaw told the court. \u201cShe had read or heard somewhere that there was less chance of bleeding at home and that is why she wanted a home birth.\u201d<\/p>\n Also giving evidence, the expert midwife Abigail Holmes, director of midwifery and neonatal services at Cardiff and Vale University Health Board, was critical of the advice that Cahill had received.<\/p>\n \u201cFrom 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,\u201d she said.<\/p>\n The inquest heard that phrases such as \u201cout of guidance\u201d were favoured, rather than \u201cagainst medical advice,\u201d and the risk of death was not explicitly raised.<\/p>\n \u201cIt is more conducive to a healthy relationship with a pregnant woman for softer, kinder words rather than more forceful language,\u201d Holmes told the inquest.<\/p>\n \u201cBut we have to be clear about what we are saying. A woman can only make an informed decision if she has been informed, and that includes the risk of death. It should have been made clear to Jen that she was high risk for a delivery at home.\u201d<\/p>\n The inquest heard that both of the community midwives who attended Cahill\u2019s home, Julie Turner and Andrea Walmsley, for reasons the court could not ascertain, had not seen or been aware of a thorough birth plan devised by the Cahills prior to Jennifer going into labour.<\/p>\n The inquest heard that both women had worked 12-hour shifts before delivering the baby and had been awake for more than 30 hours by the time the delivery was finished. They had tried their best to help Cahill but their effectiveness was affected by a \u201clack of understanding and confidence\u201d in what she had wanted due to a failure in communication from others.<\/p>\n Vital notes, such as Cahill\u2019s blood pressure readings and the baby\u2019s heart rate, were not properly recorded, with the latter at one point scrawled on to a spare incontinence pad, which was later thrown away.<\/p>\n \u201cWe were always concerned about the hours we were sent out for but that\u2019s the way it was,\u201d Walmsley said, after being asked why she had not raised the fact that she may be unsafe to work.<\/p>\n \u201cWe know what it\u2019s like working for the NHS; things are either ignored or you\u2019re sticking your head above the parapet and going to get shot at.\u201d<\/p>\n She described thinking that Cahill\u2019s birth plan, once she saw it, was \u201cthe most intense birth file that I have ever read\u201d, and said the requests for very low lighting and voices to be kept to a whisper meant she felt \u201cfrightened\u201d of speaking.<\/p>\n The midwife, who told the inquest she had never dealt with a postpartum haemorrhage in a home setting before, said that she was unaware of Cahill\u2019s symptoms of anaemia and pre-eclampsia until after her death.<\/p>\n Walmsley also told the inquest that prior to the birth she was very concerned that Cahill had refused some medication and observations, including a syntometrine injection, which would have helped prevent excessive bleeding.<\/p>\n The inquest previously heard that during her pregnancy, Cahill had refused some hospital tests and interventions, including a second test for Group B Strep, which she had carried during her first pregnancy. Her son had contracted sepsis after being born, from which he later recovered.<\/p>\n \u201cI honestly felt that I would be thrown out if I said the wrong thing,\u201d Walmsley told the court.<\/p>\n Turner told the inquest that while Cahill was in the birthing pool, she had struggled with contractions, saying: \u201cI can\u2019t do this,\u201d or: \u201cI really want to do this. I want to be a warrior, why would my body do this.\u201d<\/p>\n She said there was \u201cunease in the office\u201d about home birth requests. \u201cPeople were nervous about being on call and some people would do anything to get out of being on call,\u201d Turner said. \u201cThere were more women with complex birth plans and people were nervous about that.\u201d<\/p>\n Rob Cahill told the inquest that his wife had opted for a home birth because she had not felt supported during her first delivery, which she had found \u201chighly stressful\u201d.<\/p>\n \u201cThere was no one midwife assigned to Jen. There seemed to be lots of midwives coming and going,\u201d he said. \u201cJen did not feel she had been fully supported. It was a tricky time because of Covid and there were lots of restrictions.\u201d<\/p>\n After the inquest\u2019s conclusions the coroner, Joanne Kearsley, described Agnes\u2019s birth and the mother and daughter\u2019s deaths as \u201chorrors that should be consigned to a Victorian-age nightmare\u201d, and stated that she would personally be writing to numerous medical and midwifery organisations to recommend changes.<\/p>\n Rob Cahill thanked the emergency services who had tried to save his wife and daughter and praised the proposed changes, but said he was \u201cdeeply saddened that these changes have only came in after Jen and Agnes\u2019 deaths\u201d.<\/p>\n","protected":false},"excerpt":{"rendered":" When Jennifer Cahill went into labour with her second child at home in summer last year, she thought that the delivery, assisted by two midwives and with her husband by her side, would be a relatively simple one. Within 24 hours, however, she was dead, and her newborn daughter was fighting for her life after<\/p>\n","protected":false},"author":1,"featured_media":31119,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[51],"tags":[631,5189,314,1039,8407,456,4644,4611,1229,18166],"class_list":{"0":"post-31118","1":"post","2":"type-post","3":"status-publish","4":"format-standard","5":"has-post-thumbnail","7":"category-health","8":"tag-baby","9":"tag-birth","10":"tag-deaths","11":"tag-failure","12":"tag-gross","13":"tag-home","14":"tag-led","15":"tag-mother","16":"tag-nhs","17":"tag-prestwich"},"_links":{"self":[{"href":"https:\/\/naijaglobalnews.org\/index.php?rest_route=\/wp\/v2\/posts\/31118","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/naijaglobalnews.org\/index.php?rest_route=\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/naijaglobalnews.org\/index.php?rest_route=\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/naijaglobalnews.org\/index.php?rest_route=\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/naijaglobalnews.org\/index.php?rest_route=%2Fwp%2Fv2%2Fcomments&post=31118"}],"version-history":[{"count":0,"href":"https:\/\/naijaglobalnews.org\/index.php?rest_route=\/wp\/v2\/posts\/31118\/revisions"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/naijaglobalnews.org\/index.php?rest_route=\/wp\/v2\/media\/31119"}],"wp:attachment":[{"href":"https:\/\/naijaglobalnews.org\/index.php?rest_route=%2Fwp%2Fv2%2Fmedia&parent=31118"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/naijaglobalnews.org\/index.php?rest_route=%2Fwp%2Fv2%2Fcategories&post=31118"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/naijaglobalnews.org\/index.php?rest_route=%2Fwp%2Fv2%2Ftags&post=31118"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}