Prevention of future deaths report: Jennifer Cahill and Agnes Cahill (7 November 2025)

Summary

In 2023, Jennifer Cahill was pregnant with her second child. Her antenatal care was managed by Manchester Foundation Trust (“MFT”) community midwives. In 2021 her first pregnancy had resulted in complications at the time of delivery. She had a Post Partum Haemorrhage for which she received an iron and also a blood transfusion. She was also positive for Group B Streptococcal.

On the 26 June 2024 an investigation into the deaths of Jennifer and Agnes Cahill was carried out. The Inquests concluded on the 27 October 2025. The conclusion of the Inquests was: Jennifer Rose Cahill died as a result of complications arising from the delivery of her second child, contributed to by neglect. Agnes Lily Wren Cahill died as a result of complications during birth, such complications contributed to by neglect.

The medical causes of death were recorded as: 

• Jen: 1a) Multiorgan failure with disseminated intravascular coagulation 1b) Cardiac arrest due to post-partum haemorrhage 1c) Perineal tear and atony during term delivery.
• Agnes: 1a Multi-organ insult following hypoxic ischaemic encephalopathy 1b. Cord compression and meconium aspiration syndrome leading to pulmonary hypertension.

Content

Key findings

Jen had not made an informed decision to have a home birth and if the out of guidance plan had been completed and all the relevant information provided to her, it is more likely than not she would have given birth in an alternative setting and both Jen and Agnes would have survived.

If the fetal heart rate monitoring had been conducted correctly and every 5 minutes, it was more likely than not an abnormal fetal heart rate would have been noted up to an hour before Agnes was born and an urgent transfer to hospital would have occurred. The coroner found emergency services would have been on scene when Agnes was born and effective resuscitation would have been administered which would likely have prolonged her life. Had this call been made it is more likely than not Jen would have survived as the after care delivered to her would have noted a perineal tear and administered syntemetrine immediately.

The coroner heard evidence that since the deaths, MFT have completely overhauled the home birth service provision. The new service became operational in April 2025. In the six month period within the MFT area of GM they have received requests from 34 women for out of guidance home deliveries. Five of these could not be supported due to safety issues.       

Of the 29 out of guidance home births, 15 (50%) required transfer to hospital for varying degrees of obstetric emergency.

Matter of concerns

1. There is no national guidance in respect of home births. Specifically, robust evidenced based guidance on home birth care, similar to that which is in place for intrapartum care in a hospital setting.
2. There is an increase in the number of women with ‘high risk pregnancies’ requesting home births where required interventions cannot take place or would be significantly delayed and there is no robust framework for midwives supporting home birth care. 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.
3. 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.
4. Even though there is a very small risk of death, this is not something which is discussed with women particularly in relation to maternal death, even if the woman has a recognised risk such as a post-partum haemorrhage. There is no guidance to ensure the risk of death to both mother and baby is discussed with any woman considering a home birth irrespective of being considered high or low risk.
5. NICE guidance on intrapartum care (2023 updated June 2025) Section 1.3.3 only refers to the potential risk of death to a baby. There is no mention in the guidance of risk to the mother.
6. Terminology around pregnancies describes them as ‘high’ or ‘low risk pregnancy’ and leads women to consider that pregnancy encompasses all stages through to delivery of a child. Practice does not personalise or individualise risk so women can fully understand what the level of risk is for them in actually being pregnant, or what the level of risk is for them in giving birth.
7. In order to maintain their skills, there is no set number of deliveries a community midwife must conduct following qualification. 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.
8. No bespoke training needs analysis has been conducted focusing on midwives practicing in home birth teams.
9. 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.
10. The no national guidance on the model of staffing, training and experience for midwives providing home birth care.

See also: NHS England's letter responding the Prevention of Future Deaths report.