Overview
- A pathologist told Rochdale Coroner’s Court the mother died from multi‑organ failure following cardiac arrest caused by postpartum haemorrhage.
- Paramedics and midwives described the baby being born unresponsive with the cord around her neck and meconium present, with faulty or ill‑fitting resuscitation equipment reported.
- Evidence detailed delayed recognition of heavy bleeding, estimated blood loss of about two litres and a cardiac arrest in the ambulance before hospital transfer.
- Records for key observations were entered hours later from recollection, and staff cited difficulties using the newly introduced HIVE electronic maternity system.
- Manchester University NHS Foundation Trust accepted a missed referral for senior midwife review after the mother chose a home birth, and police documented her post in a private home‑birth Facebook group.