Overview
- After a two-week inquest, Rochdale Coroners' Court on 27 October 2025 ruled that the deaths of Jennifer Cahill, 34, and her newborn, Agnes, were contributed to by neglect.
- The coroner called the absence of an out-of-guidance birth plan a catastrophic error that undermined proper risk assessment for the chosen home birth.
- The inquest found fetal heart-rate checks were not performed every five minutes, so midwives missed signs of distress as the umbilical cord was around Agnes's neck for about an hour.
- The recorded causes of death were multi-organ failure due to cardiac arrest following postpartum haemorrhage for Mrs Cahill and multi-organ failure from hypoxia after umbilical cord compression for Agnes.
- Manchester University NHS Foundation Trust admits multiple failures, including delayed hospital transfer advice, incorrect monitoring, ineffective neonatal resuscitation, and missed post-partum observations, and the family is calling for wider national change.