Inquest Finds NHS Trust Failed Mother, Baby Poppy Hope Lomas Died After Enfield Home Birth

An inquest into the death of seven-day-old Poppy Hope Lomas has found that the Royal Free London NHS Foundation Trust failed her mother, Gemma Lomas, by not recognising and appropriately managing complications following a high-risk home delivery. Poppy died on 26 October 2022, a week after her birth at home in Enfield, north London.

The Royal Free London NHS Foundation Trust had agreed to support what the coroner described as an "unsafe home delivery that was against medical advice." Gemma Lomas told Barnet Coroner's Court she had not been informed her pregnancy was high risk and would "never have made a decision to harm my baby or myself."

Lomas explained that a checklist provided by midwives outlined warning signs such as scar pain, prolonged pushing, and foetal heart-rate decelerations. She stated that during labour, she experienced scar pain and pushed for an extended period, with Poppy showing two heart-rate decelerations. These, she argued, should have prompted an emergency response.

Midwife Sasha Field, in a written statement, indicated an ambulance should have been called approximately 90 minutes before birth. However, the inquest heard an ambulance was not summoned until two minutes after Poppy was born, when she showed no signs of life. Senior coroner Andrew Walker concluded that the failure to act on these warning signs constituted a serious lapse in care, stating, "To not discuss deceleration and a return to hospital was likely to be a really serious failure to provide basic medical care."

A subsequent investigation by the Healthcare Safety Investigation Branch, published in April 2023, identified multiple failings. These included a lack of timely and consistent counselling, no single clinician taking responsibility for Lomas's care, and poor communication of risks. Midwives from North Middlesex University Hospital NHS Trust, which was acquired by Royal Free London NHS Foundation Trust in January 2025, reportedly missed critical warning signs during labour, delaying escalation and ambulance calls. The report also highlighted a failure to promptly recognise the baby's critical condition at birth and deviations from resuscitation guidance.

The coroner issued four recommendations to the Department of Health and Social Care, including the introduction of a consent form for mothers choosing an unsafe home birth against medical advice.

Outside the court, Lomas stated, "We came here for the truth because Poppy's life mattered... Nothing will ever bring her back but hearing the truth today acknowledged means everything to us."

A spokesperson for Royal Free London NHS Foundation Trust extended "heartfelt condolences" and stated that following an investigation, measures have been introduced to improve home birth care, including ensuring midwifery teams are aware of guidance on transferring mothers to hospital and improving communication. The trust will review the coroner's recommendations.