Mother of child that died from problems of pure residence delivery was not made conscious of the dangers, inquest informed

The mother of a baby that died a week after a natural home birth was not made aware of the risks by her local NHS Trust, an inquest has heard. 

Poppy Home Lomas was just seven days old when she died at University College Hospital, central London, on October 26, 2022.

She died following complications during a home birth, which her mother said she was encouraged to have.

A coroner concluded that Poppy likely died from a severe hypoxic ischaemic brain event, which happens when the brain lacks oxygen, suffered in the 30 minutes before her birth.

Barnet Coroner’s Court heard Gemma Lomas was not properly consulted about the risks surrounding the natural delivery of her second child, having delivered her first daughter Willow via caesarean section. 

The planned home delivery took place with Edgware Midwives, the designated home birth team at Barnet Hospital, which is part of the Royal Free London NHS Foundation Trust.

The inquest heard Alice Boardman, who was head midwife at Edgware Midwives, had encouraged a vaginal birth after caesarean (VBAC) at home but failed to explain the potential risks.

Senior coroner Andrew Walker said the Royal Free London NHS Foundation 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’.

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 said this resulted in an ‘absence or delay in interventions and actions’.

After the inquest concluded on Thursday, Ms Lomas read a statement to reporters outside the court, 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 added: ‘Poppy was our daughter, she was loved beyond words and she will never be forgotten.’

The inquest had heard Ms Lomas was not told of the risks involved with delivering naturally at her home, having already given birth to her first daughter Willow by caesarean section in 2018.

The inquest previously heard Ms Lomas was not told of the risks involved with delivering naturally at her home, having already given birth to her first daughter Willow by Caesarean in 2018.

Ms Lomas described how midwives were slow to react when Poppy was born ‘blue and floppy’. Doctors from University College Hospital in London later discovered the baby girl had been ‘starved of oxygen’ for ‘around seven to eight minutes’.

In a witness statement read out by her lawyer, Teresa Hargreaves, Ms Lomas said: ‘The midwife placed Poppy on my chest and said, “There’s your baby”.

‘Poppy was blue and floppy. There was blood coming out of her mouth and her head fell back. That’s a horrific memory that sticks in my mind, being handed my dead baby.

‘I said “there’s something wrong” but the midwives moved very slowly, there was no sense of urgency.’

Ms Lomas told the court on Monday that Alice Boardman, who was 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 VBACs should take place in a ‘suitably staffed and equipped delivery suite’ and ‘with resources available for immediate caesarean delivery’.

In her statement, Ms Lomas said: ‘I immediately trusted Alice. She was young and I felt like she was really advocating for me. She was very upbeat and said: “Let’s go for this.”

‘VBACs were something they did every day. She said they’d just delivered a lady with a VBAC with twins.

‘She said that, because of my previous C-section, I’d have to “jump through a few hoops” and speak to their consultant.

‘I was very much led to believe that the conversation I’d be having with their consultant was just a tick box exercise and there was no good reason I could not have a VBAC at home.’

Poppy was rushed to hospital after the midwives, who are the designated home birth team at Barnet Hospital, told Mr Lomas to ring 999.

After the Poppy’s brain was scanned, Dr Giles Kendall, a consultant neonatologist, described the scan as ‘one of the worst that he’d seen in his career’, according to Ms Lomas’s statement.

Dr Kendall believed Poppy had been ‘starved of oxygen for a long time’, Ms Lomas said, while Ms Boardman estimated it to be around seven to eight minutes.

Ms Lomas told reporters she was ‘encouraged’ by medical staff to give birth at home, adding she ‘would have never made decisions to harm myself or my baby’.

She said: ‘I was encouraged to do what we did. I would have never made decisions to harm myself or my baby in any capacity.

‘So I think moving forward for women and, you know, families, having the right information presented to them, in a good way, will make the decisions easier.’

Poppy’s parents Gemma and Jason Lomas, from Enfield, north London, held hands as Mr Walker gave his concluding remarks on Thursday.

The coroner made four recommendations to the Department of Health and Social Care, including that patients should sign a consent form ‘clearly’ setting out the risks when they choose not to follow medical advice for delivery.

He added 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 to their baby and themselves.

The coroner also said: ‘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 told the court it was likely Ms Lomas’s heart rate was believed to be Poppy’s when checks were being carried just before the birth.

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.’