Cara Guthrie, instructed by Claire Horton of Fieldfisher, represented Rob Cahill, the widower of Jen Cahill and the father of Agnes Cahill, at the inquest into their deaths.
Jen had a postpartum haemorrhage after she gave birth to Agnes at home in June 2024. There was a delay in recognising that she was bleeding and, once her condition deteriorated, difficulties in her extricating her from the house. She died in hospital the next day. Agnes suffered a severe hypoxic episode in the lead up to her birth, she required neonatal resuscitation at home and she also died in hospital aged four days old. Going into the inquest, Jen’s family felt that she had not been advised properly about the risks of a home birth.
The inquest took place from 13-23 October 2025, with 8 full days of evidence. There were five interested parties. HM Senior Coroner for Manchester North, Ms Joanne Kearsley, gave her ruling on 27 October 2025, finding that:
- the community midwife and ST4 obstetrician who discussed home birth with Jen did not explore why she wanted a home birth and so did not have a full discussion with her;
- it was a catastrophic error that no referral was made to a senior midwife and that an out of guidance personalised care plan for a home birth was not prepared;
- Jen should have been referred back to the obstetricians for further discussion on two occasions;
- Jen had not given informed consent to a home birth;
- there were many shortcomings in the care provided to Jen by the midwives during her labour, including inappropriate fetal heart rate monitoring, and to Agnes during her resuscitation;
- there was a gross failure by the midwives to provide basic medical care to Jen after Agnes was born; and
- there was a lack of urgency on the part of the paramedics in transferring Jen to hospital.
She found that with appropriate antenatal care and the provision of complete information, Jen would not have chosen to give birth at home and neither Jen nor Agnes would have died.
She also found that their deaths were contributed to by neglect in that there was inappropriate fetal heart rate monitoring in the second stage of labour resulting in the ambulance crew not being present when Agnes was born.
In her concluding remarks the Coroner identified her concerns about the information that is not currently provided to pregnant women who are considering a home birth and her intention to write to the relevant professional bodies about this.
Jen and Agnes’ family, and those representing them, hope that there will be changes to the way home birth services are delivered nationally as a result of their deaths.
The link to the Coroner’s ruling is available here.
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