An inquest into the death of a seven-day-old infant has determined that an NHS trust failed to adequately recognize and manage complications following a high-risk home delivery.
Poppy Hope Lomas passed away on October 26, 2022, just a week after being born at her home in Enfield, located in north London.
The Royal Free London NHS Foundation Trust had consented to support what the coroner described as „an unsafe home delivery that was against medical advice.“ Poppy’s mother, Gemma Lomas, expressed to local media that she felt the home birth team did not respond swiftly enough during critical moments.
„She was so purple, and her head flopped back,“ Lomas recounted. „I remember saying, ‚There’s something wrong.‘ They said, ‚No, she’s fine, the baby’s fine.'“
During her testimony at Barnet Coroner’s Court, Lomas stated that she was not informed of the high-risk nature of her pregnancy and delivery plan, asserting, „I would never have made a decision to harm my baby or myself.“
She mentioned that midwives had provided her with a checklist prior to Poppy’s birth, detailing potential warning signs such as scar pain, prolonged pushing, and abnormalities in the baby’s health. In hindsight, Lomas believes that several of these warning signs were overlooked.
The mother of two indicated that she experienced scar pain during labor, pushed for an extended period, and noted two instances of heart-rate deceleration in Poppy. She asserted that these factors should have triggered an emergency response.
„It broke my heart,“ she said. „I trusted them. They were senior midwives and they were so relaxed.“
Reflecting on the birth, Lomas described a haunting image that remains etched in her memory.
„She had her hands above her head, floating and lifeless, with blood coming out of her mouth,“ she recalled.
When the midwives handed Poppy to her, they reassured her that everything was fine and that they just needed to „get her going“ by rubbing her back. However, Lomas described her newborn as „purple“ and unresponsive.
„She’s gone, she’s gone,“ she said.
Critical Care Failures Identified
In a written statement presented to the court, midwife Sasha Field indicated that an ambulance should have been summoned approximately 90 minutes before the birth, when the baby’s heart rate slowed following a contraction. This finding was also highlighted in a report by the Healthcare Safety Investigation Branch.
However, the inquest revealed that an ambulance was not called until two minutes after Poppy was born, at which point it was evident that she showed no signs of life.
Senior coroner Andrew Walker characterized the failure to act on warning signs as a significant lapse in care.
„To not discuss deceleration and a return to hospital was likely to be a really serious failure to provide basic medical care,“ he stated.
During the proceedings, he suggested that Lomas should not have been placed in a situation to deliver a high-risk baby at home.
„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 noted, while also acknowledging that the midwife had „done the best [she] could in the circumstances.“
Investigation Findings and Recommendations
Poppy was transported to Barnet Hospital, where she underwent therapeutic cooling, a treatment utilized for newborns with brain injuries. She was later transferred to University College London Hospital but tragically passed away a week later.
Lomas was informed that her daughter’s brain injury was so „catastrophic“ that survival was not possible.
A subsequent investigation conducted by the Healthcare Safety Investigation Branch, released in April 2023, identified numerous failings in the care provided. It concluded that maternity teams at the Royal Free London NHS Foundation Trust did not offer Lomas timely and consistent counseling regarding vaginal birth after cesarean (VBAC) and that no single clinician took responsibility for her care.
Poor communication regarding risks meant that Lomas was not adequately supported in making an informed decision about her place of delivery. During labor, midwives from North Middlesex University Hospital NHS Trust failed to recognize key warning signs, including abnormal fetal heart patterns and scar pain, which were not properly acknowledged or acted upon. This resulted in delays in escalation, a failure to call an ambulance when necessary, and inadequate emergency planning.
At the time of birth, the report found a failure to promptly identify that the baby was in critical condition, along with deviations from resuscitation and monitoring protocols.
North Middlesex University Hospital NHS Trust was integrated into the Royal Free London NHS Foundation Trust in January 2025.
The report also pointed out communication failures between NHS trusts and deficiencies in support for the family following Poppy’s death.
The coroner issued four recommendations to the Department of Health and Social Care, including the establishment of a consent form for mothers who opt for what is deemed an unsafe home birth against medical advice.
Seeking Change and Acknowledgment
Outside the court, Lomas expressed, „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.“
She added, „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 the Royal Free London NHS Foundation Trust extended „heartfelt condolences“ to the family, stating, „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.“
Bildquelle: Foto von Alicja Ziajowska auf Unsplash
