Overview
- Senior coroner Joanne Kearsley concluded that Jennifer Cahill, 34, and her newborn, Agnes, died from delivery complications contributed to by neglect.
- The report warns there is no national guidance for home births, highlighting gaps on eligibility criteria, staffing models, training requirements, equipment checks and consistent data.
- Inquest findings detailed failures in antenatal and intrapartum care, including no senior referral, poor fetal monitoring, a split bag‑valve mask that undermined resuscitation, and weak communication with paramedics.
- Kearsley found Cahill was not given the information needed for an informed choice, saying she would likely have delivered in hospital and both would have survived.
- The notice was sent to the Health Secretary and multiple health bodies, with responses due by 5 January 2026, as reporting notes home births make up about 2% of deliveries with higher‑risk requests reportedly increasing.