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A mother who lost her baby a week after an “unsafe” home birth that went against medical advice was failed by the NHS, an inquest has found.
Poppy Hope Lomas was seven days old when she died at University College hospital in London on 26 October 2022 after complications during a home birth that, according to her mother, was encouraged by midwives at Barnet hospital.
An inquest into Poppy’s death at Barnet coroner’s court concluded that she probably died from a lack of oxygen reaching her brain in the 30 minutes before she was born.
The senior coroner Andrew Walker said the Royal Free London NHS foundation trust had agreed to support Poppy’s mother, Gemma Lomas, with an “unsafe home delivery that was against medical advice” and had failed to address “an accumulation of risk factors”.
After the inquest concluded on Thursday, Lomas said outside the court: “Nothing will ever bring her back, but hearing the truth today acknowledged means everything to us.
“We trusted the professionals who were guiding us,” she said, adding that she hoped lessons would be learned.
She previously told the inquest that midwives had actively encouraged her to have a vaginal birth at home, despite the risks because she had given birth to her first daughter, Willow, by caesarean section in 2018.
Guidance from the Royal College of Obstetricians and Gynaecologists says vaginal births after caesarean (VBACs) should take place in a “suitably staffed and equipped delivery suite” and “with resources available for immediate caesarean delivery”.
“I was encouraged to do what we did,” Lomas said. “I would have never made decisions to harm myself or my baby in any capacity.”
In England and Wales, about one in 50 births take place at home, but they are recommended only for low-risk pregnancies.
Last year, experts told the Guardian that mothers must be given clearer warnings on the potentially fatal dangers of giving birth at home.
This came after a coroner ruled that a mother and daughter from Greater Manchester had died after a home birth owing to “a gross failure” in care. The inquest heard that the dangers of a home birth had not been fully explained, and phrases such as “out of guidance” had been favoured, rather than “against medical advice”.
In his closing remarks at the inquest into Poppy’s death, the coroner also flagged concerns about the use of the expression “out of guidance”. He made recommendations that multi-disciplinary meetings involving the parents should be held when they choose “an unsafe birth at home”, and that they should sign a consent form clearly explaining the risks.
A Royal Free London NHS foundation trust spokesperson offered their “heartfelt condolences” to Poppy’s family.
“Following an investigation, we have introduced a number of measures to improve care for women delivering their baby at home,” they said, which included better communication and ensuring midwives were aware of the guidance on transferring mothers to hospital.
They added that the trust would respond to the issues raised by the coroner in due course.
