Inquest Reveals Failures in Care After Newborn's Death
An inquest into the death of seven-day-old Poppy Hope Lomas concluded that the Royal Free London NHS Foundation Trust failed to appropriately recognise and manage complications following a high-risk home birth.
Poppy died on 26 October 2022, one week after being born at her home in Enfield, north London.
The coroner noted that the NHS trust had agreed to support what was described as "an unsafe home delivery that was against medical advice." Poppy's mother, Gemma Lomas, expressed to BBC London her belief that the home birth team did not respond promptly to emerging complications.
"She was so purple, and her head flopped back,"Gemma recalled.
"I remember saying, 'There's something wrong.' They said, 'No, she's fine, the baby's fine.'"
At Barnet Coroner's Court, Lomas stated she was not informed that her pregnancy and planned birth were high risk and said,
"I would never have made a decision to harm my baby or myself."
She explained that midwives had provided a checklist before birth outlining warning signs such as scar pain, prolonged pushing, and abnormalities in the baby's health, which she believes were overlooked.
Lomas, a mother of two, described experiencing scar pain during labour, extended pushing, and noted two heart-rate decelerations in Poppy, all of which she said should have triggered an emergency response.
"It broke my heart,"she said.
"I trusted them. They were senior midwives and they were so relaxed."
Describing the birth, Lomas recounted a distressing image:
"She had her hands above her head, floating and lifeless, with blood coming out of her mouth."
She said the midwives handed Poppy to her, assuring her that everything was fine and that they only needed to "get her going" by rubbing her back. However, she described her newborn as "purple" and unresponsive.
"She's gone, she's gone,"Lomas said.
Serious Failures in Medical Response
Midwife Sasha Field, in a written statement read to the court, acknowledged that an ambulance should have been called approximately 90 minutes before birth when the baby's heart rate slowed following a contraction. This finding was also noted in a report by the Healthcare Safety Investigation Branch.
Despite this, the inquest heard that an ambulance was only summoned two minutes after Poppy was born, once it was evident she showed no signs of life.
Senior coroner Andrew Walker described the failure to act on warning signs as a serious lapse in care, stating,
"To not discuss deceleration and a return to hospital was likely to be a really serious failure to provide basic medical care."
He further suggested that Lomas should not have been placed in a position to deliver a high-risk baby at home, adding,
"There was an argument you should not have been put in a position to deliver a high-risk birth without the necessary equipment available at hospital."He also noted that the midwife had "done the best [she] could in the circumstances."
Poppy was transported to Barnet Hospital where she underwent therapeutic cooling, a treatment for newborns with brain injuries. She was later transferred to University College London Hospital but died a week after birth.
Lomas was informed that Poppy's brain injury was so severe it was unsurvivable.
Investigation Identifies Multiple Failings
A subsequent investigation by the Healthcare Safety Investigation Branch, published in April 2023, identified numerous failings in the care provided.
The report found that maternity teams from the Royal Free London NHS Foundation Trust did not provide timely and consistent vaginal birth after caesarean (VBAC) counselling, and no single clinician assumed responsibility for Lomas's care.
Poor communication of risks resulted in Lomas not being fully supported to make an informed decision regarding her place of birth.
During labour, midwives missed critical warning signs, including abnormal fetal heart patterns and scar pain, which were not properly recognised or acted upon. This led to delays in escalation, failure to call an ambulance when necessary, and inadequate emergency planning.
At birth, the report identified failures to promptly recognise Poppy's critical condition and deviations from resuscitation and monitoring guidelines.
The coroner issued four recommendations to the Department of Health and Social Care, including the introduction of a consent form for mothers who choose to proceed with home births considered unsafe against medical advice.
Family Seeks Truth and Change
Outside the court, Gemma Lomas said,
"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."
A spokesperson for Royal Free London NHS Foundation Trust extended "heartfelt condolences" to the family and stated,
"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."
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