Overview

• A consultant had advised Jennifer Cahill to deliver in hospital with active management because of a prior severe postpartum haemorrhage and Group B Strep history.
• Despite being classed high risk, she pursued a home birth after referral under trust policy, and her community midwife told the inquest an out-of-guidance escalation to a senior midwife should have been made.
• The attending midwife said the baby was born not breathing, with meconium and the cord around her neck, and acknowledged she had never previously resuscitated a newborn.
• The infant was taken to hospital and died from hypoxia three days later, while Jennifer suffered catastrophic bleeding, arrested in the ambulance, and died the next day from multiple organ failure.
• Her husband testified that terms such as “out of guidance” and “against advice” were not communicated to the couple during the pregnancy.