A deeply concerning inquest has revealed critical failings in the care provided to Gemma Lomas by the Royal Free London NHS Foundation Trust, ultimately contributing to the tragic death of her newborn daughter, Poppy Hope Lomas.

Baby's Death Following Home Birth

Poppy died just seven days after her birth on October 26, 2022, at University College Hospital in London, following complications arising from a planned home birth. The inquest, held at Barnet Coroner’s Court, established that Gemma Lomas was not adequately informed about the inherent risks associated with a vaginal birth after a previous caesarean section (VBAC), particularly when attempting this at home.

Unsafe Home Delivery Supported

The evidence presented highlighted a pattern of concerning decisions, including the encouragement of a home VBAC by Alice Boardman, then head midwife at Edgware Midwives, without a thorough explanation of the potential dangers. The Trust agreed to support a home delivery deemed ‘unsafe’ and contrary to medical advice issued by the Royal College of Obstetricians and Gynaecologists (RCOG).

Critical Delays and Risk Factors

Midwives failed to recognize and appropriately manage a build-up of risk factors during labor, including a prolonged rupture of membranes without antibiotic protection, decelerations in the fetal heart rate, a slow delivery process, and Poppy’s poor condition immediately after birth. This resulted in a critical delay in necessary interventions, potentially depriving Poppy of vital oxygen.

Distressing Birth Account

Testimony revealed that when Poppy was born, she was described as ‘blue and floppy’ with blood coming from her mouth, and Ms. Lomas felt an alarming lack of urgency from the attending midwives. Doctors later determined Poppy had been deprived of oxygen for approximately seven to eight minutes.

Mother's Trust and Grief

Ms. Lomas felt a strong sense of trust in Alice Boardman, who presented the home VBAC as a routine and achievable option, downplaying the potential complications. Following the inquest’s conclusion, Gemma Lomas expressed her profound grief and the importance of uncovering the truth surrounding her daughter’s death.

Call for Change

Ms. Lomas stated that Poppy’s life mattered and deserved to be remembered for more than the circumstances of her passing. She voiced a desperate hope that lessons would be learned from Poppy’s tragic story, leading to changes in practice to prevent similar heartbreak for other families. The coroner, Andrew Walker, explicitly stated that the Trust’s actions constituted a failure to provide safe care, and that the accumulation of risk factors was not adequately addressed.