Poppy Lomas

I am Mr Andrew Walker, HM Senior Coroner for the coroner area of North London.

I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013.

I have a duty to send a copy of your response to the Chief Coroner. In  accordance  with  the  Chief  Coroner’s  Publication  Policy,  you  should  send  me  any representations regarding publication of your response. These representations should be made at the same time as the response is provided. I will pass any representations received to the Chief Coroner for a decision. Please note any links to webpages included in the response will not be checked for sensitive information prior to publication, as the information is already online . The names of those who do not respond to PFD reports are regularly published on the Chief  Coroner’s webpages Non-responses to Prevention of Future Death (PFD) reports – Courts and Tribunals Judiciary.

SUMMARY OF CORONER’S CONCERN: 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. The support that can be provided by the Trust to the patient in these circumstances. The absence of a consent process when such a patient chooses not to follow medical advice and the Royal College of Obstetricians and Gynaecologists guidance, and chooses an unsafe birth. The contents of the Home Delivery kit used by midwives in these circumstances.