Overview

• Coroner heard that baby Agnes was born unresponsive with the cord around her neck and meconium present, with her cause of death recorded as hypoxia four days later.
• Midwives described a disordered resuscitation where a mask did not fit and one practitioner lacked prior home neonatal resuscitation experience, and an investigation found the efforts fell short of national guidelines.
• Key observations from the final hours of labor were not entered contemporaneously and were later reconstructed from memory, with staff citing unfamiliarity with the newly introduced HIVE electronic system.
• Evidence highlighted concerns about postpartum care for Jennifer Cahill, including delayed recognition of haemorrhage, an initial failure to give syntometrine, significant blood loss, and subsequent collapse during transfer to hospital.
• Manchester University NHS Foundation Trust acknowledged a referral to a senior midwife should have been made to discuss risks, while Rob Cahill said he was not told the home birth was outside guidance, and police obtained a statement about a related Facebook post to be presented to the inquest.