Overview
- The inquest at Barnet Coroner’s Court, which concluded Thursday, found Poppy likely suffered a severe lack‑of‑oxygen brain injury in the 30 minutes before birth after the trust backed an unsafe home delivery.
- The coroner cited prolonged rupture of membranes without antibiotics, recorded heart rate drops about 90 minutes before delivery, a slow delivery and poor condition at birth, and said staff failed to act on these risks.
- He said the trust supported a vaginal birth after a previous caesarean at home, against guidance that such births occur in hospital, and that Gemma Lomas was not properly warned about the risks.
- A midwife present, Sasha Field, said an ambulance should have been called when decelerations were heard about 90 minutes before delivery and that returning to hospital should have been discussed.
- The coroner urged the Department of Health and Social Care to require clear risk consent forms, team reviews for planned unsafe home births, clearer wording than “out of guidance,” and pulse oximeters in home kits, and the trust said it has begun improvements and will respond.