Overview
- Coroner Joanne Kearsley told the hearing that newborn Agnes died from hypoxia, while the cause of Jennifer Cahill’s death has not yet been determined.
- Midwife Andrea Walmsley said vital signs were not entered into the new HIVE electronic system during labour and were later reconstructed from memory after being scribbled on an incontinence pad that was discarded.
- Walmsley testified she had never performed a neonatal resuscitation, the baby’s breathing mask did not fit, and resuscitation equipment had not been checked beforehand.
- Community midwife Caroline Nixon acknowledged that an ‘out of guidance’ referral should have been made due to the pregnancy’s high‑risk status and after Jennifer declined Group B strep testing, noting a culture of avoiding “against medical advice” language.
- The court heard on‑call community midwives had just completed 12‑hour shifts, faced limited backup and infrequent exposure to deliveries, and described the scene as “absolute chaos” when the baby was born not breathing.