NHS trust ‘failed to warn mum of home birth risks’ before week-old baby Poppy died

A coroner found that the Royal Free London NHS Foundation Trust failed to inform Poppy Lomas’s mother of the risks involved in a home birth

The mother of a baby who died a week after birth was let down by the NHS trust which failed to inform her of the dangers associated with a natural home birth, an inquest heard.

Poppy Hope Lomas passed away at just seven days old at University College Hospital in central London after complications during a home birth her mum said she was urged to have. The planned home delivery occurred with Edgware Midwives, the designated home birth team at Barnet Hospital which forms part of the Royal Free London NHS Foundation Trust, reports the Mirror.

The trust agreed to support Poppy’s mother Gemma Lomas with an “unsafe home delivery that was against medical advice” and failed to address “an accumulation of risk factors,” senior coroner Andrew Walker told the inquest at Barnet Coroner’s Court in north London.

In his concluding remarks, Mr Walker told the court: “The trust agreed to support Ms Lomas with an unsafe home delivery that was against medical advice and the guidance provided by Royal College of Obstetricians and Gynaecologists (Rcog).”

“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 added this resulted in an “absence or delay in interventions and actions”.

According to the coroner, Poppy most likely died from a severe hypoxic ischaemic brain event – sustained in the 30 minutes prior to her birth – which happens when the brain is deprived of oxygen.

In a written statement read to the coroner on Tuesday, the inquest was told that midwife Sasha Field, who attended Poppy’s birth, said an ambulance ought to have been summoned when she detected the baby’s heart rate dropping after a contraction – approximately 90 minutes before she was delivered.

Mr Walker stated: “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.”

Ms Lomas was not informed of the dangers associated with home births, having previously delivered her first daughter Willow via Caesarean in 2018, the court heard earlier. Ms Lomas revealed on Monday that Alice Boardman, who served as head midwife at Edgware Midwives and was present at Poppy’s birth, actively urged her to have a vaginal birth after Caesarean (VBAC) at home.

Guidelines from the RCOG specify that VBACs should occur in a “suitably staffed and equipped delivery suite” and “with resources available for immediate caesarean delivery”. Poppy’s parents Gemma and Jason Lomas, from Enfield, north London, clasped hands as Mr Walker delivered his closing remarks on Thursday.

The coroner put forward four recommendations to the Department of Health and Social Care, including that patients should sign a consent form “clearly” outlining the dangers when they opt not to follow medical guidance for delivery.

He also stated that multi-disciplinary meetings involving the consultant obstetrician, hospital midwives, home delivery midwives and the patient should take place when a patient selects “an unsafe birth at home” so they understand the risks to their baby and themselves.

The coroner also stated: “It is a matter of concern that the nationally used expression ‘out of guidance’ is used in these circumstances, when the patient has chosen an unsafe birth at home and in doing so has decided to refuse to consent to the care the hospital recommend for the management of the birth rather than an expression that captures both elements rather than just the Rcog guidance.

“It is a matter of concern that the home delivery kit does not include a pulse oximeter for maternal heart rate.”

Mr Walker informed the court it was probable Ms Lomas’s heart rate was mistaken for Poppy’s during checks conducted just before the birth.

Ms Lomas delivered a statement to journalists outside the court following the inquest, saying: “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 continued: “Poppy was our daughter, she was loved beyond words and she will never be forgotten.”

A representative from the Royal Free London NHS Foundation Trust commented: “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.”

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