Coroner finds gross failings in community midwifery and Manchester hospital care contributed to death of Jen and Agnes Cahill

Mrs Cahill had opted for a home birth following a stressful labour with her first child three years previously at North Manchester General Hospital during the Covid pandemic.

After her son's birth, she suffered a postpartum haemorrhage, losing more than 800ml of blood. She also needed intravenous antibiotics during the delivery as she was positive for Group B streptococcal infection (GBS).  Shortly after his birth, her son showed signs of a developing infection and was also given antibiotics.   

Senior Coroner for Manchester North Ms Joanne Kearsley said in her verdict that although Mrs Cahill was considering a home birth, it was not a 'fixed view'. Midwives and doctors employed by MFT therefore failed to provide her with sufficient information to be able to make an informed decision about the safest birth option, which, considering her previous delivery, should have been at hospital.

The MFT has previously admitted that had Mrs Cahill been taken to hospital earlier in her labour, she and her daughter would likely not have died.

Evidence during the inquest heard described the significant differences between what treatment which can be provided during delivery at home and at hospital, particularly in Mrs Cahill's case, only two doses of Syntometrine (to prevent postpartum haemorrhage) can be given at a home and intravenous antibiotics can only be given in hospital during the delivery. Also, at home continuous mechanical monitoring of the fetal heart rate cannot be carried out.

The coroner expressed her concern that it was unlikely most women understood the more limited role and experience of community midwives who attend home births, compared to hospital midwives.

Most of a community midwife's role concerns antenatal and postnatal support, with no national guidelines around how many births a community midwife should attend to maintain her competency levels. They would also be expected to only attend women at low risk in the delivery, whereas Mrs Cahill should have been considered high risk for the delivery, even if monitoring her pregnancy before the birth was initially considered low risk and manageable by midwife care. She should have been encouraged to give birth in hospital.

One of the midwives who attended Mrs Cahill had very limited experience of intrapartum care and neither were experienced in resuscitating a baby, which contributed to Agnes' death.

The trust failed to advise Mrs Cahill at various midwifery and obstetric appointments of the risks of a home birth, considering her situation, and once she did opt for a home birth, she should have been referred to a senior midwife to put in place an Out of Guidance plan to detail what would happen if things went wrong during the birth, which, tragically, they did.

Additionally, there were three occasions later in her ante natal care under midwives when Mrs Cahill should have been referred to a consultant obstetrician for review, which did not happen.

Scant attention was given to what had happened in Mrs Cahill's first delivery, or to reassure her that giving birth in hospital in the second pregnancy would be safer for the baby. She was not given enough information to help her understand the risks.

In her verdict, the coroner highlighted that the gross failure of FHR monitoring of Agnes by the community midwives probably contributed more than minimally to her death, in that effective resuscitation from the moment she was born was not given and had ambulance crews been on scene earlier, it would likely have at least prolonged her life.  

The coroner also criticised the midwives' failures to assess or treat Jen after the birth of Agnes, when she started to bleed.

She said the gross failure to call ambulance earlier in the delivery likely also made more than minimal contribution to the death of Jen, in that had she been in a hospital setting much sooner, she would likely have been saved.

Also, she noted that the length of time it takes ambulance crews to extract a patient to transfer them to hospital during or immediately after delivery is generally not understood. This is information that is relevant to choice of birth setting.  

Mrs Cahill's family told the press following the conclusion that it was deeply distressing that the MFT had only put in place improvements to its home birth care in response to the terrible tragedy of Jen and Agnes' death.

Claire Horton, representing the family at inquest and in an ongoing clinical negligence claim, told the press that although national guidelines highlight the importance of allowing women to choose how they want to give birth, it is the fundamental responsibility of every hospital to give women all the information relevant to their own health and the available services, so they make the right and safe choice.

In this terrible case, that simply did not happen.

The coroner will now prepare a Prevention of Future Deaths report.

Read the full report on the inquest by the Manchester Evening News and by the BBC.

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