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An inquest examining the death of a newborn baby has revealed significant shortcomings by an NHS trust in handling complications arising from a high-risk home birth. The infant, Poppy Hope Lomas, passed away on 26 October 2022, just seven days after being delivered at her family’s home in Enfield, north London. The investigation highlighted failures in recognizing and responding appropriately to warning signs during the delivery process.
Poppy’s mother, Gemma Lomas, expressed concerns over the care she and her baby received from the home birth team supported by the Royal Free London NHS Foundation Trust. Despite Poppy’s visibly distressed condition—described by her mother as “so purple” with her head flopped back—the staff reassured her that everything was fine. Gemma recounted, “I remember saying, ‘There’s something wrong.’ They said, ‘No, she’s fine, the baby’s fine.’” She also stated to Barnet Coroner’s Court that she had not been adequately informed about the high-risk nature of her pregnancy and birth, insisting that she “would never have made a decision to harm my baby or myself” if she had known. Prior to the birth, midwives gave her a checklist including potential warning signs such as scar pain, prolonged pushing, and abnormalities in the baby’s health; however, Gemma believes several of these were overlooked.
During labor, Gemma experienced scar pain, prolonged pushing, and Poppy’s heart rate slowed on two occasions, all of which should have triggered urgent medical intervention. Despite the presence of senior midwives, these critical warning signs were not acted upon with the necessary urgency. The mother described the heartbreaking moment of birth, recalling, “She had her hands above her head, floating and lifeless, with blood coming out of her mouth.” Although midwives reassured Gemma that they just needed to stimulate her baby by rubbing her back, Poppy remained unresponsive. Gemma’s anguish is evident as she recalls the moment she realized, “She’s gone, she’s gone.”
Evidence presented during the inquest included a statement from midwife Sasha Field, who acknowledged that an ambulance should have been called about 90 minutes before the birth when fetal heart decelerations were first detected. Official reports by the Healthcare Safety Investigation Branch also identified this failure. However, emergency services were only contacted two minutes after Poppy was born, by which time it was clear she showed no signs of life. Senior coroner Andrew Walker condemned this delay, 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 questioned whether it was appropriate for Gemma, a high-risk mother, to give birth at home instead of in a hospital environment with immediate access to necessary equipment. While acknowledging the midwife’s efforts under difficult circumstances, he stressed the importance of proper planning for such births.
Following delivery, Poppy was transferred to Barnet Hospital and treated with therapeutic cooling, a process used for newborns who have suffered brain injury. She was later moved to University College London Hospital but tragically died a week later. Gemma was informed that Poppy’s brain injury was so severe it was unsurvivable. The Healthcare Safety Investigation Branch’s April 2023 report identified multiple care failings, including inconsistent and untimely vaginal birth after cesarean (VBAC) counselling, lack of clear clinical responsibility, and poor communication regarding risks involved. Throughout labor, vital warning signs were missed or inadequately acted upon by midwives, contributing to delays in escalation and emergency response.
In response to the findings, the coroner made several recommendations to the Department of Health and Social Care, notably suggesting the introduction of a consent form for mothers who choose to proceed with home births deemed unsafe by medical professionals. Outside the court, Gemma voiced her desire for truth and change: “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.” She expressed hope that sharing Poppy’s story would lead to lessons learned and prevent other families from suffering similar loss.
A spokesperson for Royal Free London NHS Foundation Trust extended “heartfelt condolences” to the family and confirmed that improvements had been implemented based on the investigation’s findings. These measures include better awareness among midwifery teams regarding hospital transfers and enhanced communication between clinicians and expectant mothers. The trust pledged to carefully consider all issues raised by the coroner and respond accordingly
Read the full article from The BBC here: Read More
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