Coroner in home birth risks warning after tragedy

10 DANGERS UNCOVERED IN PREVENTION OF FUTURE DEATHS REPORT FOLLOWING INQUEST

- By HELENA VESTY

THE deaths of a mother and baby following a home birth has uncovered 10 risks that could lead to more women and newborns losing their lives if no action is taken, a coroner has warned.

The damning list finds fundamental absences in maternity care - including that there is ‘no national guidance’ for home births; that the risk of death is not discussed with pregnant women even when they carry that risk; and that there is no national guidance on staffing, training and experience for midwives providing home birth care.

Jennifer and Agnes Cahill died after a traumatic birth at their home in Prestwich on June 3, 2024. After a long and difficult labour through the night, Mrs Cahill’s second child was born not breathing, with the umbilical cord around her neck.

Jen suffered a perineal tear, two postpartum haemorrhages, and went into cardiac arrest. She died the following day, while Agnes died in hospital four days later.

Mrs Cahill’s cause of death was multi-organ failure due to cardiac arrest, due to postpartum haemorrhage. Agnes died from multi-organ failure, following hypoxia after umbilical cord compression.

On October 26, 2025, following a two-week inquest, senior coroner Joanne Kearsley determined that both deaths were contributed to by ‘neglect; ‘catastrophic error’ and ‘gross failures to provide basic care’

Following the inquest, the coroner issued a prevention of future death report, detailing an extensive list of 10 reasons more women could die if no action is taken.

The coroner identified that there is ‘no national guidance in respect of home births, especially evidenced-based guidance on home birth care, which does exist for births in hospitals.