Poppy Lomas

Parliamentary Under-Secretary of State for   
Women’s Health and Mental Health 

39 Victoria Street  
London  
SW1H 0EU  

25 June 2026 

HM Coroner Andrew Walker  
North London 

Dear Mr Walker,  

Thank you for the Regulation 28 report of 30th April 2026 sent to the Department of Health 
and Social Care about the death of Poppy Hope Lomas. I am replying as the Minister with 
responsibility for Women’s Health.  

Firstly,  I  would  like  to  say  how  saddened  I  was  to  read  of  the  circumstances  of  Poppy’s 
death, and I offer my sincere condolences to her family and loved ones. The circumstances 
your report describes are concerning and I am grateful to you for bringing these matters to 
my attention.  

The  report  raises  concerns  about  consideration  not  being  given  to  holding  a  multi-
disciplinary  team  meeting  with  the  patient  to  ensure  that  the  patient  receives  an 
understanding of the risks to the baby and to themselves, when the patient chooses to have 
an unsafe birth at home. It also raises concerns over patients not being given consent forms 
that  clearly  set  out  the  risks  of  choosing  to  have  unsafe  births  at  home.  The  report  also 
raises concerns around the use of the expression ‘out of guidance’ in these circumstances, 
as  it  may  not  convey  that  the  delivery  is  against  medical  advice,  and  against  the  Royal 
College of Obstetricians and Gynaecologists (RCOG) guidance – and is therefore an unsafe 
delivery.  

All women deserve access to safe care during childbirth, and all staff should receive training 
that  is  tailored  to  their  specific  setting,  including  homebirths  and  how  to  manage 
emergencies at point of care. NHS England has written to all services and systems asking 
them to review their service provision, to prevent future tragedies and ensure that women 
can safely deliver babies across all settings.    

In preparing this response, my officials have made enquiries with NHS England to ensure 
we adequately address your concerns, and I understand there is work underway to develop 
national standards and a clear framework for homebirth services. As responsibility for the 
specific matters of concern you have raised sits with NHS England, they will be issuing a 
substantive response addressing each of these concerns. 

It is unacceptable that there was a failure to recognise and appropriately manage the risk 
factors  during  the  delivery,  and  the  subsequent  absence  and  delay  in  interventions  and 
actions. It is also unacceptable that the decelerations and a decision to return to hospital 

17 
   
 
 
 
 
 
 
 
 
 
 
  
  
 
 
 
 were not discussed with Mrs Lomas. I recognise that it is a known difficulty to monitor the 
foetal heart rate during intermittent auscultation and I am extremely saddened that during 
the 30 minutes before Poppy’s birth, the maternal heart rate was mistakenly thought to be 
Poppy’s. 

I recognise that there were a number of factors which impacted the care Mrs Lomas and 
Poppy  received,  which  is  why  Baroness  Amos  is  carrying  out  a national  independent 
investigation in NHS maternity and neonatal care. The investigation will help us understand 
the  systemic  issues  behind  why  so  many  women,  babies  and  families  experience 
unacceptable care,  and the final 
to  be 
published in June 2026.   

recommendations are  due 

report  and 

The government has also set up a National Maternity and Neonatal Taskforce, chaired by 
the  Secretary  of  State  for  Health  and  Social  Care. The Taskforce  will  address the 
recommendations  of  the investigation by developing  a  new  national  action  plan  to  drive 
improvements across maternity and neonatal care.   

I hope this response is helpful. Thank you for bringing these concerns to my attention.   

Yours sincerely,  

18

Mr. Andrew Walker 
Barnet Coroner’s Court 
29 Wood Street 
Barnet  
EN5 4BE 

National Medical Director  
NHS England  
Wellington House 
133-155 Waterloo Road  
London 
SE1 8UG 

18th June 2026  

Dear Mr. Andrew Walker, 

Re: Regulation 28 Report to Prevent Future Deaths – Poppy Hope Lomas who 
died on 26th October 2022.  

Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 30th 
April  2026  concerning  the  death  of  Poppy  Hope  Lomas  on  26th  October  2022.  In 
advance of responding to the specific concerns raised in your Report, I would like to 
express my deep condolences to Poppy’s parents and family. NHS England is keen 
to assure the family and yourself that the concerns raised about Poppy’s care have 
been listened to and reflected upon.   

Your Report raises the following concerns: 

1.  That patients who decide to have a home birth and decide to refuse the care 
recommended by the hospital for the management of the unsafe birth, do not 
have to sign a consent form clearly setting out the risks. 

2.  When  a  patient  chooses  to  have  an  unsafe  birth  at  home  that  a  Multi-
Disciplinary Team meeting is not held with the patient to ensure that the patient 
understands the risks to the baby and themselves. 

3.  The  use  of  the  term  “Out  of  Guidance”,  used  nationally,  fails  to  convey  the 
gravity of the decision being taken, and that it is against medical advice.  

On 26 November 2025 the Chief Midwifery Officer wrote to all NHS maternity providers 
in  England  asking them  to  urgently  review  the  safety  and  quality  of  their  homebirth 
services. NHS Trusts were urged to consider the following issues:  

a)  The operational running of their service: including how it ensures that prompt 
midwifery  care  is  available  24  hours  a  day;  that  staff  are  properly  equipped, 
trained, prepared and skilled for providing birth and neonatal care in a home 
setting; that staff have senior multi-disciplinary support available to them at all 
times and have sufficient rest periods and that potential transfer and extraction 
processes are clear and planned for each birth. 

b)  Care  planning  and  risk  assessment:  including  systematic  assessment  of 
complexity  and  risk;  how  the  multidisciplinary  team  (MDT)  ensures  a 

                                                                                                                       
 
 
 
 
 
  
 
 
 
  
 
 
 
 
 
 personalised  approach  to  women  in  planning  care  in  light  of  any  identified 
issues  (particularly  when  homebirth  is  not  recommended);  how  the  MDT 
continues  to  maintain  good  communication  at  all  stages  of  care  with  women 
and  between  all  teams  including  ambulance  services;  and  how  dynamic  risk 
assessment is managed and responded to throughout pregnancy, birth and the 
postnatal period.   

c)  Governance and oversight: including how governance is structured to ensure 
robust  oversight  of  homebirth  services  by  the  whole  organisation,  so  the 
executive board  has appropriate  oversight; that there  is  an audit programme 
that  covers  outcomes  and  clinical  and  operational  guidance  and  leads  to 
continual improvement; and that there is comprehensive homebirth guidance 
including standard operating procedures for all stages and aspects of care.  

d)  The National Institute for Heath and Care Excellence (NICE) uses evidence-
based  recommendations  to  develop  clinical  guidance  to  improve  health  and 
social  care.  While  not  dedicated  to  homebirths,  the  NICE  guideline  on 
intrapartum  care  (2023),  outlines  the  care  of  women  and  their  babies  during 
labour and immediately after birth in all settings and addresses issues around 
planning place of birth. 

We have noted concerns raised by Coroners in previous Prevention of Future Deaths 
reports  relating  to  homebirths,  that  this  current  intrapartum  care  guidance  does  not 
provide  sufficient  clarity  to  women,  staff  and  services  as  to  how  to  safely  support 
requests  for  and  provision  of  home  birth  services,  particularly  when  significant  risk 
factors have been identified. 

As  a  result,  NHS  England  has  started  work  with  partners  including  NICE,  Royal 
College  of  Midwives,  Royal  College  of  Obstetrics  and  Gynaecology,  Nursing  & 
Midwifery  Council,  Maternity  &  Newborn  Safety  Investigations,  Care  Quality 
Commission, and the General Medical Council to develop further resources to close 
this gap.  

By autumn 2026, we anticipate setting out the minimum standards that providers and 
commissioners of maternity services will be expected to meet to support the delivery 
of a safe, effective, equitable and personalised home birth service. The standards will 
include the use of appropriate and clear language in discussing women’s preferences, 
including review of the term “Out of Guidance”. The standards will also include detail 
on the assessment of safety and risk required, and the need for multi-disciplinary team 
working in the formulation of care plans and their documentation. This will also include 
consideration of the use of consent forms which are not currently used in maternity 
services  for  any  place  of  birth.  It  will  also  include  reference  to  the  standardised 
equipment required for clinical care provided during homebirth. 

There  are  other  national  guidance  and  reviews  relevant  to  the  concerns  you  have 
raised, which I would like to draw to your attention:  

 
 
 The standards of care in relation to sharing information have in part been established 
through the Montgomery Judgement at the UK Supreme Court. Health professionals 
must take “reasonable care to ensure that the patient is aware of any material risks 
involved in any recommended treatment and of any reasonable alternative or variant 
treatments”.  In  addition,  communication  around  risk  should  be  personalised  (NICE 
Shared Decision-Making Guideline, 2021 and NICE Intrapartum care guideline, 2023).  

One  of  the  immediate  and  essential  actions  that  arose  from  the  first  report  of  the 
Independent Review of Maternity Services at Shrewsbury and Telford Hospitals was 
that:  

All women must be formally risk assessed at every antenatal contact so that they have 
continued access to care provision by the most appropriately trained professional.  

Risk assessment must include ongoing review of the intended place of birth, based on 
the developing clinical picture. 

Following  publication  of  the  first  report  in  December  2020,  NHS  England  asked  all 
trusts to assure themselves that this was in place in their services. There then followed 
two  further  assurance  processes  led  by  the  regional  teams  to  assess  that  this  was 
being undertaken and support any necessary changes to practice.    

The Three year delivery plan for maternity and neonatal services (2023) which states 
that  all  women  should  be  “offered  personalised  care  and  support  plans”,  where  all 
information  is  recorded,  including  “a  risk  assessment  updated  at  every  contact, 
including when the woman is in early or established labour." 

The Royal College of Midwives has also issued guidance on Informed decision Making 
(2022). They recommend that midwives “support women’s informed decision making” 
including by not providing “any care without first receiving consent”, and document the 
information given and the discussions had with the woman. 

The RCM document on Care Outside Guidance (2022) discusses Personalised Care 
and  Support  Plans  and  sets  out  that  decisions  about  care  should  be  “documented, 
implemented and shared with the multi-disciplinary team”. Those decisions should be 
based  on  gaining  and  documenting  informed  consent  from  the  service  user,  using 
evidence and assessments of risks and benefits. 

The  General  Medical  Council’s  guidance  on  Decision  Making  and  Consent  (2020), 
supports  healthcare  professionals  in  their  conversations  with  patients  and  service 
users ensuring informed consent is given. As a minimum, clinicians, should keep an 
accurate record of “information leading to a decision in a patient’s record (which) will 
inform their future care”. The guidance states that while a patient can give consent 
verbally clinicians “should make sure this is recorded in their notes”. 

The  Nursing  &  Midwifery  Council’s  Principles  for  supporting  women's  choices  in 
maternity care (2025) includes that midwives should “document discussion(s) about 
care  in  the  maternity  records  and  what  information  has  been  given  to  the  woman”. 
Midwives should provide care that is based on informed consent and adhere to the 
NMC Code of Conduct (2015). 

 Trusts are responsible for ensuring midwives and obstetricians practice in line with this 
guidance and the new homebirth standards will take these documents into account to 
ensure greater clarity and alignment of advice across all organisations. 

Regional Response 

NHS  England’s  London  regional  team  have  liaised  with  the  Trust  regarding  this 
Report.  They  shared  the  report  on  the  maternity  investigation  undertaken  by 
Healthcare Safety Investigation Branch (HSIB) in relation to Poppy’s death. As a result 
of that investigation an action plan has been devised to address the concerns.  

Actions the Trust intend to take include: 

•  To  ensure  staff  are  supported  to  recognise  when  to  transfer  a  patient  to  the 

hospital from a homebirth or standalone birthing unit. 

•  To provide training to community midwives on providing care for mothers with 

a high-risk pregnancy in a low-risk birth setting. 

•  Updating local guidance regarding the care of  Vaginal Birth After Caesarean 
(VBAC) patients in a low risk setting, including the management of the second 
stage of labour. 

•  To establish a pathway for early recognition and escalation to consultant/senior 

midwife of women requesting to birth outside of guidance. 

•  To ensure that birth plans for mothers who are birthing outside of guidance at 
home explicitly detail all aspects of the management of labour and birth and the 
indications for transferring to the maternity unit. 

•  To ensure that clinicians are supported to recognise and take timely action on 
adverse  clinical  findings  when  mothers  are  birthing  outside  of  guidance  at 
home, via specialised training for community midwives. 

I  would  also  like  to  provide  further  assurances  on  the  national  NHS  England  work 
taking place around the Reports to Prevent Future Deaths. All reports received are 
discussed  by  the  Regulation  28  Working  Group,  comprising  Regional  Medical 
Directors,  and  other  clinical  and  quality  colleagues  from  across  the  regions.  This 
ensures  that  key  learnings  and  insights  around  events,  such  as  the  sad  death  of 
Poppy, are shared across the NHS at both a national and regional level and helps us 
to  pay  close  attention  to  any  emerging  trends  that  may  require  further  review  and 
action.   

Thank you for bringing these important patient safety issues to my attention and please 
do not hesitate to contact me should you need any further information.  

Yours sincerely,  

 
 
  
 
  
 National Medical Director   

NHS England

RESPONSE TO A REPORT TO PREVENT FUTURE DEATHS 
REGULATION 29 OF THE CORONERS (INVESTIGATIONS) REGULATIONS 
2013 

Please do not include any living persons’ names in this document, in 
accordance with the Chief Coroner’s PFD Publication Policy (2026). 

THIS RESPONSE IS BEING SENT TO: 

The Senior Coroner, Andrew Walker, for the Coroner Area of North London in 
response to a ‘REPORT TO PREVENT FUTURE DEATH REGULATION 28’ following 
an inquest into the death of [NAME OF DECEASED] that concluded on 30 April 2026. 

1. 

RESPONDENT 

In line with our duty under Regulation 29 of the Coroners (Investigations) 
Regulations 2013, the National Institute for Health and Care Excellence 
provides this response within 56 days (plus any extension granted) of the 
date of the Report to Prevent Future Deaths. 

2.  DATE OF RESPONSE 18 June 2026 

3.  CONFIRMATION OF CORONER’S MATTERS OF CONCERN 

The MATTERS OF CONCERN were identified in the report are as follows: 

1.  The use of expressions that may minimise the detail of the risks taken by 
patients who elect, following a Caesarean birth, to have a vaginal birth at 
home.   

2.  The support that can be provided by the Trust to the patient in these 

circumstances.   

3.  The absence of a consent process when such a patient chooses not to 
follow medical advice and the RCOG guidance, and chooses an unsafe 
birth. 

4.  The contents of the Home Delivery kit used by midwives in these 

circumstances. 

13 
 
 
 
 
 3. 

DETAILS OF ACTION TAKEN, how has the concern been addressed. 
[If no action is proposed please explain why here]. 

Please note that any links to webpages included in the response will not be 
checked for sensitive information prior to publication, as the information is 
already online. 

Matter 1 

The National Institute for Health and Care Excellence (NICE) has considered 
the comments made regarding the term 'birth outside of guidance'. This term 
has been chosen carefully to reflect the sensitivities around discussions where 
women have felt in the past that their care has been paternalistic and choice 
has been removed, and we therefore do not feel that amendments to the 
language within NICE guidance are appropriate. 

NICE is unable to make recommendations on expressions used by NHS staff 
as these should be case relevant and part of a professional skill set.  

NICE guideline NG235 section 1.3 provides recommendations regarding the 
planned place of birth. We do not feel these should be reconsidered as a result 
of this very sad case. 

Matters 2 and 3 

Although these matters of concern appear to be for the NHS Trust to consider, 
and HM Coroner has not requested any further national guidance be produced 
in this area, I have provided full details below of the NICE guidance that exists, 
which I hope is of use. 

All NICE guidance referred to is available in full on www.nice.org.uk    

Home birth is covered in NICE’s guideline on intrapartum care (NG235). The 
risks and benefits of home birth compared to birth in an alongside midwifery 
unit, freestanding midwifery unit and hospital are covered, with information for 
counselling detailed in tables 6-9. The guideline provides comprehensive 
guidance on intrapartum care, including (but not limited to) home births. The 
guideline covers:  

Eligibility - home birth might be considered for women with low-risk, 

• 
uncomplicated pregnancies. This includes those without medical or obstetric 
complications and differentiates in terms of risk factors between nulliparous 
and multiparous women (recommendation 1.3.1).  

• 
Informed Choice: Women should be supported to make informed 
decisions about their place of birth. This includes discussing risks, benefits, 
and available support (recommendation1.3.3-5).  

• 
Midwife Support: Care during home birth should be provided by trained 
midwives, with access to emergency transfer protocols if complications arise.  

Within the guideline, medical conditions and other factors that may affect the 
choice of planned place of birth are not given as contraindications to home 
birth but indicate where care in an obstetric unit would be expected to reduce 
risk to the mother or the baby. There are also recommendations that support 
further discussion with an appropriately trained senior or consultant midwife 
and/or a senior or consultant obstetrician (if there are obstetric issues) if such 
a discussion is wanted by the midwife or the woman. See recommendations 

14 1.3.9 to 1.3.11 and tables 6-9. 

Intrapartum care (NG235) covers assessment in the first stage of labour in any 
setting, including the observations of the mother and the unborn baby that 
should lead to the transfer of the woman to obstetric-led care, noting also that 
multiple risk factors may increase the urgency of the transfer, particularly if they 
have a cumulative effect. The guideline notes the more frequent observations of 
the mother and the unborn baby that should be undertaken in the second stage.  

We have considered the information provided in the report, and would comment 
that it should be standard practice, if a patient decides not to follow advice 
given, that the healthcare professional should document the discussion, any 
professional concerns and care planned that is acceptable to the patient. NICE 
cannot give recommendations on alternative care where our recommendations 
are not followed; this would need to be addressed by the professional in the 
specific circumstances. 

The support that the NHS trust can provide to the patient in these 
circumstances is covered in the Royal College of Midwives guideline Care 
Outside Guidance. 

This refers to the development of a personalised care plan, informed consent, 
and the duties of a midwife to support women within the framework of the 
Human Rights Act. It does not fall within NICE’s remit as the guideline was 
produced by the Royal College of Midwives.  

At NICE we feel that it would be legally difficult to produce a specific document 
recording when a patient chose not to take the advice given, but as noted 
above, professionals are advised to document discussions and decisions on 
preferred care. 

In current NICE guidance, our recommendations guide clinical practice and 
support women to make informed choices about their care based on 
discussions with trained staff about the risks and benefits. There is insufficient 
evidence to suggest that a change to the current NICE recommendations is 
justified. 

Matter 4 

The specific contents of home delivery kits issued to midwives for use during 
home births is not a matter for NICE. Other organisations such as the RCM 
and specialist societies are better placed to make recommendations in this 
area.  

4.  DETAILS OF FURTHER ACTION PROPOSED 

Please note that any links to webpages included in the response will not be 
checked for sensitive information prior to publication, as the information is 
already online. 

No further action proposed by NICE. 

15 
 
 
 
 SIGNATURE 

Chief Executive  

National Institute for Health and Care Excellence  

16