![](\"https:\/\/www.europesays.com\/uk\/wp-content\/uploads\/2025\/11\/1_HVR_MEN_021125_jencahillmarianna.jpg\")
The deaths of Jen Cahill and her daughter, Agnes, after a tragic home birth were contributed to by ‘neglect’, \u2018catastrophic error\u2019 and \u2018gross failures to provide basic care\u2019(Image: MEN\/Handout\/2025 Getty Images)<\/p>\nSPECIAL REPORT: After the deaths of Jen Cahill and her newborn daughter Agnes, a Manchester court heard of catastrophic errors and fatal misunderstandings in maternity care.The deaths of Jen Cahill and her daughter, Agnes, after a tragic home birth were contributed to by ‘neglect’, \u2018catastrophic error\u2019 and \u2018gross failures to provide basic care\u2019(Image: MEN\/Handout\/2025 Getty Images)<\/p>\n
The room falls silent. All except for the gentle rustling of tissues being clutched in their plastic packets.<\/p>\n
It\u2019s an agonising wait for an apprehensive, full courtroom. But that wait is only 20 minutes before the final chapter of this case<\/a> begins.<\/p>\n Others in this courtroom have been waiting more than a year for answers.<\/p>\n Senior coroner Joanne Kearsley files through the door and sits at her bench, raised in front of the crowded court packed with the family and friends of a beloved mother and her newborn baby.<\/p>\n I\u2019ve spent seven years as a reporter covering Ms Kearsley\u2019s cases at Rochdale<\/a> Coroners\u2019 Court, and have long seen her spending her days as a stoic leader of proceedings. She\u2019s unflappable in her questioning of deaths caused by injustice, kind in supporting families through their most difficult moments.<\/p>\n But three hours later, I watch as the coroner fights tears as she tries to speak \u2013 recording the unfathomable loss of that tiny baby girl, Agnes, and her mother, Jen Cahill, aged just 34.<\/p>\n \u201cRob,\u201d her voice wavered, addressing Jen\u2019s husband and Agnes\u2019 dad.<\/p>\n \u201cI think it will be hard for any of us to ever understand, and I cannot find the words to describe the absolutely horrific nightmare<\/a> you endured in a very short space of time on June 3, 2024, and in the days that followed.\u201d<\/p>\n Then, a crushing blow.<\/p>\n \u201cAs the situation is today, I cannot help but worry that unless change is made, then another family will potentially endure the agony which Rob and Jen\u2019s family has faced.\u201d<\/p>\n Jen knew some of the concerns associated with choosing to give birth at home, with her medical history putting her at higher risk during delivery.<\/p>\n And she was cared for by Manchester University NHS<\/a> Foundation Trust (MFT) \u2013 the largest trust of hospitals in England.<\/p>\n If these deaths can happen to a family under the care of one of the most well-resourced trusts in the country, what comes next?<\/p>\n Jen and Agnes died after a tragic birth at their family home in Prestwich<\/a> in the early hours of that June morning.<\/p>\n After a long and difficult labour through the night, Agnes was born not breathing, with the umbilical cord around her neck.<\/p>\n Jen suffered a perineal tear, two postpartum haemorrhages, and went into cardiac arrest.<\/p>\n On Monday, October 26, 2025, the coroner determined that both deaths in the following days were contributed to by ‘neglect’, \u2018catastrophic error\u2019 and \u2018gross failures to provide basic care\u2019<\/a>.<\/p>\n Jen Cahill knew some of the risks of delivering her second child. The first time, Jen suffered a postpartum haemorrhage, an episiotomy, a tear, and lost enough blood to warrant a transfusion.<\/p>\n She was also a carrier of group B strep, which can spread to babies during delivery and cause problems like meningitis.<\/p>\n Her first child went on to develop sepsis after being born, recovering later.<\/p>\n She felt midwives often had too many mothers to help. She felt she was left alone during a long and painful labour, where her first baby was known to be large and in a very position in the womb.<\/p>\n Jen and her husband shared fears that staff attending to her during the labour kept changing \u2013 meaning they had to explain information multiple times, creating confusion.<\/p>\n The court heard that Jen thought that having two midwives present through a birth at home, just attending her, could avoid the things that previously \u2018traumatised her\u2019.<\/p>\n Jen also knew that she had been advised a number of times by midwives and doctors to have a hospital birth for her second child.<\/p>\n She would have faster emergency help if she had another haemorrhage. She would also have IV medications that would help stop bleeding and guard against strep, not available for a home birth.<\/p>\n But the inquest revealed that Jen had received mixed messages of just how at risk she was.<\/p>\n During an appointment, one consultant \u2018correctly\u2019 graded Jen\u2019s pregnancy as low risk. The doctor decided Jen would be cared for by community midwives as the pregnancy progressed \u2013 rather than care by consultants if she had been a high risk.<\/p>\n The consultant gave evidence that she \u2018assumed that the patient understands, whilst her pregnancy could be a low risk, she may be at a \u2018high risk\u2019 in terms of the delivery\u2019.<\/p>\n Doctors and midwives also gave evidence that the priority in discussions around where to give birth is often on giving women the freedom to choose.<\/p>\n For Jen, that\u2019s how ultimately fatal confusion and misunderstanding grew.<\/p>\n \u201cOne can see why this misunderstanding arises since many women may understand the term \u2018pregnancy\u2019 to incorporate the entire process from pregnancy through to labour and delivery of a child,\u201d said the coroner.<\/p>\n \u201cThis is incorrect. Pregnancy and labour are distinct processes and carry different risks.<\/p>\n \u201cIn Jen\u2019s case there was no risk attached to her being pregnant, the risk to Jen was in respect of the delivery of her child.\u201d<\/p>\n Jen was not inflexible about the home birth and \u2018there is no suggestion that she was reckless\u2019, said the coroner.<\/p>\n She had indicated she would go to hospital if the home delivery service wasn\u2019t available when she went into labour, and was taking a maternity bag out with her in case it started while she was out of the house.<\/p>\n However, the coroner determined: \u201cJen believed that the description being given to her, in general terms, was that she had a low risk pregnancy.<\/a><\/p>\n \u201cJen was aware of a described risk of infection to her baby as she was a group B strep carrier that she was also aware of [the consultant\u2019s advice for preventative medication] due to her previous postpartum haemorrhage.<\/p>\n \u201cBut beyond these risks, I do not consider Jen viewed her pregnancy or more importantly the delivery of a child as one where there was an overtly increased risk.\u201d<\/p>\n A plan required in higher-risk delivery cases going against doctors’ advice was never done. The in-depth, two-hour discussion should have created a plan \u2018crucial\u2019 for both the woman and attending midwives.<\/p>\n \u201cAn \u2018out of guidance\u2019 care plan\u2026 should be an opportunity to explore fully with a woman what has happened in any previous pregnancies, to explain why certain advice was being given and to explore options on all topics as well as any worries or concerns a woman has,\u201d said the coroner.<\/p>\n Jen was never invited to discuss with a doctor \u2018her reasons for wanting a home-birth; of other venues that were available for labour and delivery in addition to the option of hospital; an exploration of any fears that she had which were influencing her decision-making around a home-birth\u2019.<\/p>\n \u201cThis meant that the personalised risks associated with Jen having a home-birth were not fully explored,\u201d added the coroner<\/p>\n \u201cFrom the time Jen indicated she was considering a home-birth in February 2024, her antenatal care lacked any active inquiries, was based on assumptions made by midwives and was perfunctory.<\/p>\n \u201cThe most critical of appointments with a senior midwife to complete the most important guidance document, an out of guidance care plan, was simply overlooked and forgotten.<\/p>\n \u201cThis was a catastrophic error and a gross failure to provide basic medical care.\u201d<\/p>\n Jen was also never advised of the instability of home birth services. Pregnant women are not advised of how thin on-call staffing can be overnight, when Jen went into labour, the court heard.<\/a><\/p>\n They are also not told the background of the midwives who might be sent out to assist them during their labour. In Jen\u2019s case, the two midwives had both done 12-hour shifts before the home birth.<\/p>\n One of those attending midwives, who had never resuscitated a baby, told the court \u2018we\u2019re not trained\u2019 for that rare combination of higher risk home birth \u2013 with all home births only making up a very small percentage of births in general.<\/p>\n The midwife gave evidence that concerns had frequently been raised to senior leaders at the Manchester hospital trust about the rising numbers of higher-risk women opting for home births.<\/a>And just like Jen, the two midwives found themselves blind to risks. Neither had ever been informed prior to their arrival at the Cahill home of the documented concerns about complications for Jen during the delivery of her child.<\/p>\n \u201cI heard a lot of evidence in relation to the increase of home births and the right of a woman to choose where she has her child,\u201d said the coroner.<\/p>\n \u201cBut I also heard of a complete absence of any national guidance, and the incredibly difficult position this is placing many trusts, and more importantly the increasing challenges for community midwives.\u201d<\/p>\n The deaths of Jen and Agnes have prompted \u2018a huge overhaul\u2019 of maternity services in the Manchester.<\/p>\n Kimberley Salmon-Jamieson, Deputy Chief Executive and Chief Nursing Officer for MFT, said: “The trust accepted at an early stage that there were serious failures in the care provided to Mrs Cahill and Agnes for which we are truly sorry.\u201d<\/p>\n The trust said it is \u2018committed to learning\u2019 to \u2018make services safer\u2019, explaining that the \u2018homebirth service has been remodelled\u2019, shaped by internal and independent investigations. The trust says it will also be examining the inquest conclusion for further actions.<\/p>\n But it’s change that, devastatingly, wouldn\u2019t have happened without these deaths<\/a>. Change that, worryingly, can\u2019t be done elsewhere, said the coroner.<\/p>\n The court heard from Professor Edward Johnstone, the clinical head of division for maternity services, and Esme Polshaw, the head of midwifery, at the trust.<\/p>\n National data about the safety, complications and outcomes surrounding home births is so lacking and out of date that \u2018women cannot make an informed choice\u2019 about the safety of home births<\/a>, they said.<\/p>\n \u201cThe evidence available is quite out of date. And it is very difficult as a lay person to find that information and make that judgement,\u201d said Prof Johnstone.<\/p>\n “I don’t think there’s a national leadership recognition [that a similar overhaul needs to be made across the country].”<\/p>\n In their view, some areas in England should not be providing home birth services at all.<\/p>\n![](\"https:\/\/www.europesays.com\/uk\/wp-content\/uploads\/2025\/11\/5_Jennifer-Cahill.jpg\")
Jennifer Cahill(Image: MEN\/UGC)<\/p>\n![](\"https:\/\/www.europesays.com\/uk\/wp-content\/uploads\/2025\/11\/0_210125northman8.jpg\")
(Image: Manchester Evening News)<\/p>\n![](\"https:\/\/www.europesays.com\/uk\/wp-content\/uploads\/2025\/11\/1_STR_121216_CORONER.jpg\")
Senior coroner Joanne Kearsley(Image: Rochdale)<\/p>\n
![](\"https:\/\/www.europesays.com\/uk\/wp-content\/uploads\/2025\/11\/6_210125northman6.jpg\")
North Manchester General Hospital was the location of Jen’s first birth, and where she and Agnes were rushed to after the tragic home birth(Image: Manchester Evening News)<\/p>\n