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Investigation and inquest
On 03 March 2025, I commenced an investigation into the death of Poppy Hope LOMAS aged 7 days.
The medical cause of death was:-
Cause of death 1a - Hypoxic- Ischaemic Encephalopathy
Cause of death 1b - Peripartum Hypoxic Ischaemic Episode
How, when and where:-
Poppy Hope LOMAS died in University College hospital on the 26th October 2022 aged 7 days.
Conclusion:-
Poppy died when an accumulation of risk factors were not recognised during a high risk delivery at home.
Circumstances of the death
Poppy Hope LOMAS died in University College hospital on the 26th October 2022 aged 7 days.
The Trust agreed to support Mrs Lomas with an unsafe home delivery that was against medical advice and the guidance provided by the Royal College of Obstetricians and Gynaecologists.
The home delivery midwives worked against a background of an accumulation of risk factors including:- a prolonged rupture of the membranes without antibiotic cover, two episodes of deceleration at around one and a half hours before delivery, the slow delivery and poor condition at birth.
There was a failure to recognise and appropriately manage these risk factors:- The prolonged rupture of membranes without intravenous antibiotic cover, two episodes of deceleration heard around one and a half hours before delivery, the slow delivery of Poppy's head, the fresh bleeding from her nose and mouth, the slow delivery of her body and her poor condition at birth.
This resulted in a lack of recognition of these multiple deviations from the normal position during this time and subsequent absence of delay in interventions and actions.
It is likely that the cause of Poppy's death was caused by a severe hypoxic ischaemic event suffered in the 30 minutes before her birth, most likely an acute foetal bradycardia.
It is likely that during the period of approximately 30 minutes prior to Poppy's birth, the maternal heart rate was thought to be Poppy's when the foetal heart was checked, and this is a known difficulty when monitoring foetal heart-rate during intermittent auscultation.
To not discuss with Mrs Lomas the decelerations and a decision to return to hospital is likely to be a really serious failure to provide basic medical care to Mrs Lomas.
Poppy was taken to hospital in a poor condition following delivery in a pool at her home and despite medical attention could not recover from the consequences of the hypoxic ischaemic event.
Coroner’s concerns
The below matters all fall within the purview of NHS England and the Department of health and Social Care and the National Institute for Health and Care Excellence.
It is a matter of concern that where the patient has chosen to have an unsafe birth at home and has decided to refuse to consent to the care the hospital recommend for the management of the unsafe birth, that consideration is not given to the patient signing a consent form that clearly sets out the risks.
It is a matter of concern that where the patient has chosen to have an unsafe birth at home consideration is not given to holding a Multi-Disciplinary Team Meeting with the consultant obstetrician, hospital midwives & community midwives and the patient, to ensure that the patient receives an understanding of the risks to the baby and to themselves..
It is a matter of concern that the nationally used expression “Out of Guidance” is used in these circumstances, which may fail to convey the gravity of the decisions being taken, rather than an expression that captures all elements:- in particular that the delivery is against medical advice, the Royal College of Obstetricians and Gynaecologists guidance and that as a consequence it is an unsafe delivery.
It is a matter of concern that the Home Delivery kit does not include a pulse oximeter for maternal heart rate.
Information checked against the published report and official responses