Story Highlight
– Inquest found NHS trust failed to manage home delivery risks.
– Baby Poppy Hope Lomas died after high-risk home birth.
– Mother felt warning signs were ignored during labor.
– Emergency response was delayed; ambulance called too late.
– Coroner issued recommendations for safer home birth practices.
Full Story
An inquest into the tragic death of a newborn has highlighted critical failures within an NHS trust following a home birth deemed high-risk. Poppy Hope Lomas, who was only seven days old when she passed away on 26 October 2022, suffered complications after her delivery at the family home in Enfield, north London. The Royal Free London NHS Foundation Trust has faced scrutiny for their role in the incident, which was described by the coroner as an “unsafe home delivery that was against medical advice.”
During the proceedings at Barnet Coroner’s Court, Poppy’s mother, Gemma Lomas, shared her distressing experience with the court, expressing her belief that the midwives failed to act upon clear warning signs during labour. “She was so purple, and her head flopped back,” Lomas recollected, conveying her growing concern as the situation escalated. Despite her pleas, the midwives assured her that everything was fine, stating, “the baby’s fine.”
Gemma Lomas revealed that she was not adequately informed about the high-risk nature of her pregnancy, nor the potential dangers of a home birth. She stated, “I would never have made a decision to harm my baby or myself,” underscoring her desire for a safer birthing environment. Prior to Poppy’s birth, midwives had provided her with a checklist of warning signs to be vigilant for, including scar pain and anomalies in the baby’s health. In hindsight, Lomas believes that numerous indicators of distress during labour went unacknowledged.
The bereaved mother recounted experiencing severe scar pain and prolonged pushing, in addition to noticing Poppy’s heart rate abnormalities. “It broke my heart,” she said, lamenting her trust in the senior midwives, who appeared complacent in their handling of the situation. The traumatic moment of birth remains etched in her memory, as she described the horrifying image of her daughter: “She had her hands above her head, floating and lifeless, with blood coming out of her mouth.”
When midwives eventually handed Poppy to her, they insisted that she merely needed stimulation and reassured her mother that “everything was fine.” However, Lomas vividly remembers her newborn as “purple” and unresponsive, leading her to cry out, “She’s gone, she’s gone.”
Midwife Sasha Field, in a statement to the court, asserted that emergency services should have been alerted approximately 90 minutes before Poppy’s birth, as the baby’s heart rate had exhibited troubling patterns. This crucial point was echoed in a prior report from the Healthcare Safety Investigation Branch. Unfortunately, an ambulance was only called two minutes after Poppy was born, by which time it was clear she was not alive.
Senior coroner Andrew Walker characterised the lack of timely intervention as a significant failure in medical care. He remarked that the failure to communicate about the baby’s heart rate when complications arose represented an egregious oversight. He also indicated that Lomas shouldn’t have been placed in a scenario where a high-risk birth occurred at home without the necessary medical apparatus that would typically be available in a hospital setting. However, he complemented the midwife, stating she had “done the best [she] could in the circumstances.”
Following the birth, Poppy was taken to Barnet Hospital where she underwent therapeutic cooling — a procedure for newborns experiencing brain injuries. Sadly, she was later transferred to University College London Hospital, but died a week after her traumatic delivery. Lomas was informed that Poppy’s brain injury was so severe that survival was impossible.
An investigation conducted by the Healthcare Safety Investigation Branch in April 2023 identified numerous deficiencies in the care given to Lomas before and during delivery. The investigation revealed that maternity teams from the Royal Free London NHS Foundation Trust failed to provide adequate counselling regarding the risks of having a vaginal birth after a caesarean (VBAC). Furthermore, the investigation found a lack of ownership over Lomas’s care from the medical staff, resulting in insufficient communication about risks, and leaving her unable to make an informed decision regarding her birthing option.
The report highlighted a significant failure in the response to warning signs during labour, including those identifying abnormal fetal heart patterns and scar pain. These warning indicators were not adequately addressed, leading to a delay in seeking emergency assistance. Additionally, there were failures in recognising the baby’s critical state at birth and deviations from established guidelines for resuscitation and monitoring.
North Middlesex University Hospital NHS Trust, which was later acquired by the Royal Free London NHS Foundation Trust in January 2025, was also implicated in the report. It flagged instances of poor communication between different NHS trusts and deficiencies in family support following the tragic loss of Poppy.
In response to the inquest, the coroner issued four recommendations to the Department of Health and Social Care that included the mandating of a consent form for mothers who decide to proceed with home births against medical advice.
Outside the courtroom, Lomas spoke of the emotional weight of the proceedings, stating: “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 a fervent hope that her daughter’s story would lead to meaningful changes, preventing similar tragedies for other families in the future.
Acknowledging the family’s loss, a spokesperson for the Royal Free London NHS Foundation Trust extended “heartfelt condolences” and noted that measures have been implemented to enhance care for women opting for home births. These improvements include ensuring midwifery teams are educated about protocols for transferring expectant mothers to hospitals and enhancing communication among clinicians involved in care. It was promised that the trust will thoroughly review the concerns raised during the inquest and respond appropriately to the coroner’s recommendations.
Our Thoughts
The tragic death of Poppy Hope Lomas highlights several critical safety failures that could have been addressed to prevent this incident. Key lessons include the importance of effective risk assessment and communication regarding high-risk pregnancies. The Royal Free London NHS Foundation Trust did not appropriately manage the mother’s complications or recognize significant warning signs during labor, breaching health and safety principles under the Health and Safety at Work Act 1974, which mandates adequate risk management and care provision.
Essential failings included the delay in calling an ambulance despite evident fetal distress and the lack of a clear emergency plan for high-risk home births, contravening the Maternity Services Guidelines under the Care Quality Commission. The absence of a formal consent process for high-risk home births was also noted, which could have ensured that the mother was fully aware of the potential dangers, aligning with the requirement for informed consent under the Mental Capacity Act 2005.
To prevent similar incidents, it’s crucial to enhance training for midwives in recognizing and responding to distress signals, ensure clear communication between trusts, and implement robust protocols for emergency care during home births.
