A seven-day-old baby died after an “unsafe” home birth that was encouraged by midwives despite being against medical advice, an inquest has concluded. Poppy Hope Lomas died at University College Hospital in London on 26 October 2022 after complications during a home birth supported by Barnet Hospital midwives.
The senior coroner for Barnet, Andrew Walker, ruled that the Royal Free London NHS Foundation Trust had agreed to an “unsafe home delivery that was against medical advice” and failed to address “an accumulation of risk factors”. He found that Poppy probably died from lack of oxygen in the 30 minutes before birth.
The mother, Gemma Lomas, had previously given birth by Caesarean section in 2018, making her a high-risk candidate for a vaginal birth after caesarean (VBAC). National guidance recommends VBACs take place in a fully staffed delivery suite with immediate access to emergency Caesarean. Lomas told the inquest that midwives actively encouraged the home birth, saying she would never have chosen it if the risks had been clearly explained.
The coroner also criticised the use of the phrase “out of guidance” instead of “against medical advice”, and recommended that parents who choose an unsafe home birth should attend a multi-disciplinary meeting and sign a consent form outlining the risks. A trust spokesperson offered condolences and said measures had been introduced to improve communication and ensure midwives follow transfer guidelines.
