Coroner calls for national maternity guidance to be reviewed following inquest into baby death

An inquest has concluded into the death of baby Poppy Lomas, who died aged 7 days in October 2022 following a planned home birth. The evidence heard raises serious concerns about both the information provided to Poppy’s mother, Gemma Lomas, and the clinical management of the labour itself.

The court heard that she was not properly informed of the risks associated with attempting a vaginal birth after Caesarean (VBAC) in a home setting, having already delivered her first daughter by Caesarean in 2018. Guidance from the Royal College of Obstetricians and Gynaecologists states that VBAC should take place in a suitably staffed and equipped unit where immediate access to emergency care is available. Mrs Lomas told the court that the Edgware Midwives, the designated homebirth team at Barnet Hospital, actively encouraged her to have a VBAC at home.

 

The inquest also identified critical failings during the labour. Evidence showed that signs of fetal distress, including decelerations in the baby’s heart rate, were not appropriately acted upon. A midwife involved in the birth accepted that an ambulance should have been called approximately 90 minutes before Poppy was born, as a report by the Healthcare Safety Investigation Board had found.

 

In his conclusion, HM Senior Coroner Andrew Walker described the failure to inform Mrs Lomas of those decelerations and to offer to transfer her to hospital, as “likely to be a really serious failure to provide basic medical care.”

Beyond the individual failings, the Coroner highlighted systemic concerns. He questioned the use of the term “out of guidance” in maternity care, noting that it fails to reflect situations where patients are not adequately supported to understand and weigh the risks of declining recommended medical care.

 

The coroner issued four recommendations to the Department of Health and Social Care, including clearer written consent, and multi-disciplinary meetings involving consultant obstetricians, hospital and home birth midwives, and the patient where risks and benefits can be clearly explained. The coroner noted that home birth kits may lack essential equipment such as a pulse oximeter.

Gail Waller birth injury solicitor acting for the family said:

“This case is a stark reminder that informed consent is not merely a formality, and that failures in communication and escalation can have devastating consequences. Accountability in maternity care depends not only on individual decision-making, but on systems that ensure risks are clearly explained, understood, and acted upon.

We welcome the Coroner’s recommendations to the Department of Health and hope that changes can be implemented nationally to prevent other families suffering similar tragedies in the future.”

You can read more about the families we have supported here: Coroner Issues Prevention of Future Deaths Report to Warn Mothers About VBAC NHS Risks

 

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