A mother whose baby died during a natural home birth was not properly informed about the risks involved.

On October 26, 2022, Poppy Hope Lomas tragically passed away at University College Hospital in central London. Her mother, Gemma Lomas, spoke at the inquest and expressed her grief, stating that nothing can bring her baby back. Poppy was only seven days old when she died, and her death was the result of complications from a home birth that her mother insists she was encouraged to have by the midwives.

The planned home birth was carried out by Edgware Midwives, the designated home birth team at Barnet Hospital, which is part of the Royal Free London NHS Foundation Trust. During the inquest at Barnet Coroner's Court in north London, Senior Coroner Andrew Walker revealed that the trust had agreed to support Gemma with an unsafe home delivery, against medical advice. He also noted that there were multiple risk factors that were not addressed properly, leading to Poppy's death.

Poppy's parents, Gemma and Jason Lomas, held hands as Mr. Walker gave his concluding remarks. He stated that the midwives had worked under the pressure of an accumulation of risk factors, including a prolonged rupture of membranes without proper antibiotic cover, decelerations in the baby's heart rate before delivery, and a slow and poor condition at birth.

Mr. Walker also mentioned that there was a failure to recognize and manage these risk factors, resulting in a delay in taking necessary actions. One of the midwives present at Poppy's birth, Sasha Field, admitted that an ambulance should have been called when she heard the baby's heart rate drop after a contraction.

She also stated that emergency services should have been called 90 minutes before Poppy was born when the decelerations were recorded. Mr. Walker expressed his concern that the midwives did not discuss these issues with Gemma and failed to make the decision to return to the hospital.

The inquest heard that Gemma was not informed about the risks involved in delivering naturally at home, even though she had previously given birth via Caesarean in 2018. According to Gemma, Alice Boardman, the head midwife at Edgware Midwives, actively encouraged her to have a vaginal birth after Caesarean at home. However, guidance from the Royal College of Obstetricians and Gynaecologists (Rcog) states that VBACs should be carried out in a well-equipped delivery suite with immediate access to a Caesarean if needed.

In his four recommendations to the Department of Health and Social Care, Mr. Walker suggested that patients should sign a consent form clearly stating the risks when they choose not to follow medical advice for delivery. He also recommended that multi-disciplinary meetings be held with the consultant obstetrician, hospital midwives, home delivery midwives, and the patient when a patient chooses an unsafe home birth.

He also expressed his concern about the use of the term "out of guidance" in these situations and recommended that it be changed to better reflect the patient's decision. Additionally, he noted that the home delivery kit should include a pulse oximeter for monitoring the mother's heart rate. After the inquest concluded, Gemma read a statement to reporters outside the court, stating that the truth about Poppy's death means everything to her and her family.

She also expressed her hope that lessons will be learned, and changes will be made to prevent other families from experiencing the pain they have endured. She lovingly remembered Poppy as their daughter, who will never be forgotten. The Royal Free London NHS Foundation Trust expressed their condolences to Poppy's family and stated that they have taken measures to improve care for women delivering their babies at home.

They have also promised to review all the issues raised by the coroner and respond accordingly.