Poppy Hope Lomas: Baby died after NHS trust failed to warn mother of home birth risks, coroner finds

The NHS trust failed to inform the mother of the risks of a natural home birth after her baby died a week after birth, a coroner found.

Poppy Hope Lomas was just seven days old when she passed away following complications during a home birth at University College Hospital in central London on October 26, 2022, which she said her mother had encouraged her to do.

The planned home birth was facilitated by Edgware Midwives, Barnet Hospital’s designated home birth team, operating as part of the Royal Free London NHS Foundation Trust.

Senior coroner Andrew Walker, who chaired the inquest into the baby’s death at Barnet Coroner’s Court in north London, said the trust agreed to support Poppy’s mother, Gemma Lomas, in an “unsafe home delivery that was against medical advice” and failed to address the “accumulation of risk factors”.

In his closing address, Mr Walker told the court: “Midwives delivering home births worked against an accumulation of risk factors such as prolonged rupture of membranes without antibiotic cover, two decelerations around an hour and a half before birth, slow labor and poor condition at birth.

“There was a failure to recognize and appropriately manage these risk factors.”

He said this had led to “a lack or delay in response and actions”.

The coroner ruled that Poppy probably died from a severe hypoxic-ischemic brain event, which occurs when there is a lack of oxygen in the brain within 30 minutes before birth.

Midwife Sasha Field, who was present at Poppy’s birth, said in her written statement read by the coroner on Tuesday that an ambulance should have been called when she heard the baby’s heartbeat slowing down after the contraction.

Ms Field said emergency services should have been called about 90 minutes before Poppy was born, when slowdowns were recorded.

Mr Walker said: “Failing to talk to Ms Lomas about the slowdowns and the decision to return to hospital would probably be a truly serious failure to provide basic medical care to Ms Lomas.”

The inquest previously heard that Ms Lomas, who gave birth to her first daughter Willow by caesarean section in 2018, was not informed about the risks of giving birth naturally at home.

Ms Lomas told the court on Monday that Alice Boardman, who was head midwife at Edgware Midwives and was present at Poppy’s birth, had actively encouraged her to have a vaginal birth after a caesarean section (VBAC) at home.

The Rcog’s guidance states that VBACs should be carried out “in a suitably staffed and equipped birthing room” and with “available resources for emergency caesarean delivery”.

Poppy’s parents Gemma and Jason Lomas, from Enfield, north London, held hands as Mr Walker made his closing speech on Thursday.

The coroner made four recommendations to the Department of Health and Social Care, including that patients sign a consent form that “clearly” states the risks if they choose not to follow medical advice for birth.

He added that multidisciplinary meetings are held with the consultant obstetrician, hospital midwives, and home birth midwives, and that when the patient chooses “unsafe birth at home” they need to be aware of the risks to the patient’s baby and themselves.

The coroner also said: “It is concerning that the nationally used phrase ‘unguidance’ is used in these circumstances where the patient has opted for an unsafe home birth and in doing so has decided to refuse to consent to the hospital’s recommended care for the management of the birth, rather than just the Rcog guidance but a statement that encompasses both elements.”

“It is concerning that the home delivery kit does not include a pulse oximeter that measures the mother’s heart rate.”

Mr Walker told the court it was believed Ms Lomas’s heart rate was likely Poppy’s when the checks were being carried just before the birth.

After the inquest concluded, Ms Lomas read a statement to reporters outside court, saying: “Today’s finding confirmed what we have experienced every day since we lost our precious daughter Poppy.

“We came here to find out the truth because Poppy’s life mattered and she deserves to be remembered for more than the circumstances of her death.

“Nothing will bring him back but it means a lot to us to hear the truth acknowledged today.

“We trusted the professionals who guided us and ensured Poppy had the safest possible start to her life.

“Our hope is that by listening to Poppy’s story, lessons will be learned and changes will be made so that no other family has to endure the pain we will carry for the rest of our lives.”

He added: “Poppy was our daughter, loved beyond words and will never be forgotten.”

A spokesman for the Royal Free London NHS Foundation Trust said: “We offer our sincere condolences to Poppy Lomas’ family at this incredibly difficult time and are deeply saddened by their loss.

“Following an investigation we have taken a number of measures to improve the care of women giving birth at home.

“This includes ensuring midwifery teams are aware of guidance on transferring mothers to hospital and improving communication between clinicians and women.

“We will carefully consider all matters raised by the coroner and will respond to him in due course.”