The mother of a baby who died a week after birth was failed by the NHS trust which did not make her aware of the risks involved with a natural home birth, an inquest was told.
The planned home delivery took place with Edgware Midwives, the designated home birth team at Barnet Hospital which is part of the Royal Free London NHS Foundation Trust.
In his concluding remarks, Mr Walker told the court: “The trust agreed to support Ms Lomas with an unsafe home delivery that was against medical advice and the guidance provided by Royal College of Obstetricians and Gynaecologists (Rcog).
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“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 decelerations 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.”
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He said this resulted in an “absence or delay in interventions and actions”.
The coroner ruled Poppy likely died from a severe hypoxic ischaemic brain event, which happens when the brain lacks oxygen, suffered in the 30 minutes before her birth.
Ms Field said emergency services should have been called around 90 minutes before Poppy was born, when the decelerations were recorded.
Mr Walker said: “To not discuss with Ms Lomas the decelerations and a decision to return to hospital is likely to be a really serious failure to provide basic medical care to Ms Lomas.”
Ms Lomas told the court on Monday that Alice Boardman, who was head midwife at Edgware Midwives and present at Poppy’s birth, actively encouraged her to have a vaginal birth after Caesarean (VBAC) at home.
Guidance from the Rcog states VBACs should take place in a “suitably staffed and equipped delivery suite” and “with resources available for immediate caesarean delivery”.
Poppy’s parents Gemma and Jason Lomas, from Enfield, north London, held hands as Mr Walker gave his concluding remarks on Thursday.
The coroner made four recommendations to the Department of Health and Social Care, including that patients should sign a consent form “clearly” setting out the risks when they choose not to follow medical advice for delivery.
He added multi-disciplinary meetings with the consultant obstetrician, hospital midwives, home delivery midwives and the patient should be held when a patient chooses “an unsafe birth at home” so they are aware of the risks to their baby and themselves.
The coroner also said: “It is a matter of concern that the nationally used expression ‘out of guidance’ is used in these circumstances, when the patient has chosen an unsafe birth at home and in doing so has decided to refuse to consent to the care the hospital recommend for the management of the birth rather than an expression that captures both elements rather than just the Rcog guidance.
“It is a matter of concern that the home delivery kit does not include a pulse oximeter for maternal heart rate.”
Mr Walker told the court it was likely Ms Lomas’s heart rate was believed to be Poppy’s when checks were being carried just before the birth.
After the inquest concluded Ms Lomas read a statement to reporters outside the court, saying: “Today’s finding confirmed what we have lived every single day since losing our precious daughter Poppy.
“We came here for the truth because Poppy’s life mattered and because she deserves to be remembered for more than the circumstances of her death.
“Nothing will ever bring her back but hearing the truth today acknowledged means everything to us.