An inquest has revealed that a mother whose baby died at a central London hospital one week after a home birth was failed by the NHS trust that encouraged her to deliver at home.
Inquest Findings
Poppy Hope Lomas died at just seven days old at University College Hospital in central London following complications during a home 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.
Senior coroner Andrew Walker told the inquest at Barnet Coroner's Court that 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.
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 (RCOG)."
Risk Factors Ignored
The coroner highlighted several risk factors that were overlooked, including a prolonged rupture of membranes without antibiotic cover, two decelerations around one and a half hours before delivery, slow delivery, and poor condition at birth. He added that there was a failure to recognise and appropriately manage these risk factors, resulting in an absence or delay in interventions and actions.
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.
Midwife's Testimony
In a written statement read out to the coroner, midwife Sasha Field, who was present 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 noted that not discussing the decelerations with Ms Lomas and deciding to return to hospital was likely a serious failure to provide basic medical care.
The court previously heard that Ms Lomas was not informed of the risks involved during home births, despite having given birth to her first daughter Willow by caesarean in 2018. Ms Lomas said 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 Violated
RCOG guidance states that VBACs should take place in a suitably staffed and equipped delivery suite with resources available for immediate caesarean delivery. The trust's failure to adhere to this guidance was a key factor in the coroner's findings.
