A mother who tragically lost her baby seven days after giving birth at home was not warned of the risks of home birth, an inquest has heard.
Poppy Hope Lomas Died After Complications
Poppy Hope Lomas died at University College Hospital in central London following complications during the birth. The planned home delivery took place with Edgware Midwives, the designated home birth team at Barnet Hospital, part of the Royal Free London NHS Foundation Trust.
The trust agreed to support 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.
Coroner’s Findings
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 the 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.”
He added: “There was a failure to recognise and appropriately manage these risk factors.” This resulted in an “absence or delay in interventions and actions.”
Cause of Death
According to the coroner, Poppy likely died from a severe hypoxic ischaemic brain event, suffered in the 30 minutes before her birth, which occurs when the brain lacks oxygen.
In a written statement read out to the coroner on Tuesday, the inquest heard that midwife Sasha Field, who was at Poppy’s birth, said an ambulance should have been called when she heard the baby’s heart rate slow down after a contraction – around 90 minutes before she was born.
Mr Walker said: “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 Disclosure
Ms Lomas was not told of the risks involved during home births, having already given birth to her first daughter Willow by Caesarean in 2018, the court previously heard. Ms Lomas said 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.”
