A newborn baby died in a prison cell after its teenage mother was left alone overnight without any medical assistance, according to an investigation that found “troubling” weaknesses in her care.
The prisons and probation ombudsman Sue McAllister said the 18-year-old woman should never have been allowed to give birth on her own at HMP Bronzefield in Middlesex, Europe’s largest women’s prison.
The woman, known only as Ms A, twice rang her cell bell asking for a nurse on the night she gave birth but no medical assistance was provided. Ambulance crews were called the following morning after two prisoners alerted staff to blood in the teenager’s cell.
The child did not survive and police opened an investigation, treating the death as "unexplained". No less than 10 separate investigations were launched into the death with Ms McAllister conducting the overarching probe.
Ms McAllister said Ms A, who was in prison for the first time on a robbery charge, appeared to have been regarded as difficult and having a “bad attitude” rather than as a vulnerable, “very scared” 18 year old, frightened that her baby would be taken away.
Care branded 'outdated and inadequate'
“She was afraid (with reason) that her baby would be taken away from her immediately after birth and she refused to engage with maternity services,” said Ms McAllister
Despite being a challenging prisoner to manage, the ombudsman said the midwives’ approach to the teenager’s care was “inflexible, unimaginative and insufficiently trauma-informed.”
The day before the baby died on September 26, 2019, Ms A told a nurse that she would kill herself or someone else if her baby was taken from her after birth. But neither the nurse, nor the officer she told considered it necessary to put her on suicide or self-harm watch.
Ms McAllister said this response was “completely inadequate.” This was compounded by “outdated and inadequate” maternity services at Bronzefield with the result that Ms A received care that was “not equivalent to that she could have expected in the community.”
Although the ambulance arrived promptly, there was no paediatric or neonatal emergency equipment in the prison and no staff were trained in neonatal resuscitation.
She added: “None of the multiple record systems involved spoke to each other, none of the separate records contained sufficient information on their own for proper oversight and no one person had access to them all.”
Ms McAllister said all pregnancies in prison should be treated as "high risk" because the women are "locked behind a door for a significant amount of time", adding that there was likely to be a higher percentage of "avoidant" mothers who were "fearful of engaging with maternity care".
Prisoners do not have direct access to their midwives, compared to pregnant women who are not in custody.
Dr Kate Paradine, chief executive of Women in Prison, which is part of a campaign calling for an end to jail for pregnant women, said: "This devastating and distressing report shows prison is not a safe place for any pregnant woman or baby, and begs the question why she was there in the first place.
"The Government must ensure a tragedy like this doesn’t happen again and reverse its decision to build 500 new prison places for women. Instead, we can invest in community solutions such as Women’s Centres, which provide an anchor for women to tackle the root causes that sweep them into crime.”
'Harrowing and unacceptable'
Dominic Raab, the Justice Secretary, described the events as "harrowing, unacceptable and should never happen to any woman or child", adding: "We have put in place important improvements to the care received by women in custody, and across government we must make sure that expectant mothers in prison get the same support as those in the community."
The Ministry of Justice (MoJ) stressed it was exceptionally rare for a woman to give birth in prison. Since the death, women have been given phone access to advice services, offered social services support and welfare checks are being carried out for pregnant women in their third trimester, the department said.
The NHS has since taken over the healthcare budget for maternity services at the prison, increased its budget in this area by 87 per cent, put an ultrasound scanner inside the jail as part of a range of improvements, a spokeswoman said.