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The family of a mother and baby who died after a 'chaotic' home birth said they were both 'catastrophically let down by mismanagement' after a coroner ruled the tragedy was caused by 'neglect' and 'gross failures to provide basic care'. Jen Cahill's family issued statements on Monday after the conclusion of a two week-long inquest hearing. Mrs Cahill, 34, died in hospital on June 3, 2024, after giving birth at her family home in Prestwich , near Bury , which she shared with her husband, Robert Cahill, and their first child. Their second child, baby Agnes, sadly also died in hospital four days later. A coroner said the family had endured a 'Victorian-aged tragedy' played out in modern times as she hit out at 'gross failures' to provide basic antenatal care to Mrs Cahill and blasted the care she and Agnes received during the delivery. All coroner Joanne Kearsley's comments were directed at Manchester University NHS Foundation Trust (MFT). Join the Manchester Evening News WhatsApp group HERE In a statement, Mrs Cahill's family said they had been 'devastated to learn, in detail, all the times in which the MFT failed in their care for Jen and Agnes'. But they said they hope the coroner's findings and recommendations 'result in positive and sustainable changes in the approach to management of home births across the National Health Service'. The family acknowledged changes made by the trust but said they were 'deeply saddened' it took the tragedy for them to be implemented. Mrs Cahill, her family added, was 'a wonderful person' who would have been 'exceptional as Agnes' mummy'. In a separate statement to the Manchester Evening News , Mrs Cahill's mother, Cecily Howick, said the deaths were 'entirely avoidable'. She said they were both 'catastrophically let down by mismanagement before, during and after the birth' and added: "Jen was not properly counselled or observed. She and Agnes died because of a lack of basic care within a system which was not optimally set up to deal with obstetric emergency in the home. "We hope these findings lead to meaningful and lasting national change. Home birth services can only be delivered safely if they are resourced and managed correctly. "Jen was an outstanding young woman and we will never know what Agnes could have gone on to achieve." The family's statement, in full, read: "Our family would like to thank all the people who attempted to save Jen and Agnes. We welcome Ms Kearsley's findings and hope that the recommendations result in positive and sustainable changes in the approach to management of home births across the National Health Service. "We acknowledge the comprehensive changes made by Manchester University NHS Foundation Trust (MFT) to their homebirth service and hope that these improvements are sustainable. We are however deeply saddened that these changes have only been implemented following Jen and Agnes' deaths. "We have also been devastated to learn, in detail, all the times in which the MFT failed in their care for Jen and Agnes. "The MFT has admitted that Jen should have been advised that she needed to be transferred to hospital earlier in her labour and this would have likely prevented Jen and Agnes' deaths. The MFT has also admitted that monitoring of Agnes' fetal heart rate was not performed correctly and failed to detect the fetal hypoxia that ultimately caused Agnes' death. "The MFT has also admitted that the resuscitation attempted on Agnes was not performed correctly. The resuscitation was ineffective due to a combination of equipment failings and poor technique. "The MFT has also admitted that they failed to complete standard post-partum observations and care for Jen, in turn, not recognising signs or taking measures to mitigate the post-partum haemorrhage that caused her death. Ultimately, the MFT's neglectful care contributed to both Jen and Agnes’ deaths. "We would like to thank Cara Guthrie our barrister for her outstanding representation. Our family appreciates beyond measure the way in which she has determinedly advocated for Jen and Agnes over the last two weeks. We would also like to thank Claire Horton and her team at Fieldfisher for their exceptional legal support. "Lastly, we would like to thank Elle Bartlett and Karen Armsden who conducted the initial six-month investigation on behalf of the Maternity and Newborn Safety Investigations (MNSI) that drew the coroner's attention to the scale of the issues in the care provided to Jen and Agnes. "Jen was a truly wonderful person and we’re sure that Agnes would have been as exceptional as her mummy. They are dearly loved and deeply missed." Claire Horton, a medical negligence lawyer at Fieldfisher Manchester, said: "National guidelines highlight the importance of allowing women to choose how they want to give birth, but it is the fundamental responsibility of every hospital to give those women all the information relevant to their own health and the services available so that they make the right and safe choice. "The inquest heard that Jen was not given the information she needed to enable her to make the safest choice. It has been devastating for the family to hear evidence that had Jen been transferred to hospital earlier in her labour and given birth in hospital, both she and Agnes would likely have survived. "The hospital trust has said that as a result of this tragedy, it has overhauled its home birth service. But the overriding need is to deliver essential training to medical staff and ensure it is effective."
