The mother of a baby who tragically died from complications during a natural home birth has told an inquest that 'Nothing will ever bring her back.' Poppy Hope Lomas was rushed to hospital when her heart rate dropped during what was described as an 'unsafe home birth.' Her mother, Gemma Lomas, insisted that midwives encouraged her to have the home birth. Poppy was just seven days old when she died at University College Hospital, central London, on October 26, 2022.
Details of the Case
The planned home delivery was conducted by Edgware Midwives, the designated home birth team at Barnet Hospital, part of the Royal Free London NHS Foundation Trust. Senior coroner Andrew Walker told the inquest at Barnet Coroner's Court, north London, that the trust agreed to support Ms. Lomas with an 'unsafe home delivery that was against medical advice' and failed to address 'an accumulation of risk factors.'
Coroner's Findings
In his concluding remarks, Mr. Walker stated: 'The trust agreed to support Ms. Lomas with an unsafe home delivery that was against medical advice and the guidance provided by the Royal College of Obstetricians and Gynaecologists. The home delivery midwives worked against a background of an accumulation of risk factors including a prolonged rupture of the membranes without antibiotic cover, two decelerations around one and a half hours before delivery, the slow delivery and poor condition at birth. There was a failure to recognise and appropriately manage these risk factors.' He noted that this resulted in an 'absence or delay in interventions and actions.'
Midwife's Testimony
Midwife Sasha Field, who was present at Poppy's birth, testified that an ambulance should have been called when she heard the baby's heart rate slow down after a contraction. She said emergency services should have been called around 90 minutes before Poppy was born, when the decelerations were recorded. Mr. Walker commented: 'To not discuss with Ms. Lomas the decelerations and a decision to return to hospital is likely to be a really serious failure to provide basic medical care to Ms. Lomas.'
Lack of Risk Communication
The inquest heard that Ms. Lomas was not informed of the risks associated with delivering naturally at home, especially since she had given birth to her first daughter, Willow, by Caesarean in 2018. Ms. Lomas told the court that Alice Boardman, head midwife at Edgware Midwives and present at Poppy's birth, actively encouraged her to have a vaginal birth after Caesarean (VBAC) at home. Guidance from the Rcog states that VBACs should take place in a 'suitably staffed and equipped delivery suite' with 'resources available for immediate caesarean delivery.'
Coroner's Recommendations
The coroner made four recommendations to the Department of Health and Social Care. These include requiring patients to sign a consent form 'clearly' setting out the risks when they choose not to follow medical advice for delivery. He also recommended that multi-disciplinary meetings with the consultant obstetrician, hospital midwives, home delivery midwives, and the patient should be held when a patient chooses 'an unsafe birth at home' so they are aware of the risks. Additionally, he expressed concern about the use of the term 'out of guidance' and suggested a more precise expression. He also noted that the home delivery kit should include a pulse oximeter for maternal heart rate, as it was likely that Ms. Lomas's heart rate was mistaken for Poppy's during checks.
Family's Statement
After the inquest, Ms. Lomas read a statement outside the court: 'Today's finding confirmed what we have lived every single day since losing our precious daughter Poppy. We came here for the truth because Poppy's life mattered and because she deserves to be remembered for more than the circumstances of her death. Nothing will ever bring her back but hearing the truth today acknowledged means everything to us. We trusted the professionals who were guiding us and Poppy should have had the safest possible start in her life. Our hope is that by hearing Poppy's story lessons will be learned and changes will be made so that no other family has to endure the pain that we will carry for the rest of our lives.' She added: 'Poppy was our daughter, she was loved beyond words and she will never be forgotten.'
Trust's Response
A spokesperson from the Royal Free London NHS Foundation Trust said: 'Our heartfelt condolences remain with Poppy Lomas's family at this incredibly difficult time and we are profoundly sorry for their loss. Following an investigation, we have introduced a number of measures to improve care for women delivering their baby at home. This includes ensuring midwifery teams are aware of the guidance around transferring mothers to hospital and improving communication between clinicians and women. We will carefully review all the matters raised by the coroner and will respond to him in due course.'
