Poppy Lomas
30 Apr 2026 · Coroner Andrew Walker · North London
This report repeats 1 earlier warning. See the linked reports.
The coroner's concerns
1. unsafe home birth without consent form
“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”
2. lack of multidisciplinary meeting
“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”
3. misleading terminology
“the nationally used expression "Out of Guidance" is used in these circumstances, which may fail to convey the gravity of the decisions being taken”
4. missing pulse oximeter in kit
“the Home Delivery kit does not include a pulse oximeter for maternal heart rate”
Linked reports
Closely relatedConfidence 0.85 · high
Earlier report
“The inquest heard that new CTG machines incorporate maternal ECG or pulse oximetry, which alerts staff to investigate when MHR and FHR appear the same.”
This report
“It is a matter of concern that the Home Delivery kit does not include a pulse oximeter for maternal heart rate.”