A newborn baby died after a teenage girl gave birth alone in a cell in Europe’s largest women’s prison despite calling staff for help, according to a damning report.
The 18-year-old and her lifeless child were not discovered at HMP Bronzefield, in Middlesex, for a full 12 hours after she initially called for a nurse in September 2019, said the watchdog, which found a string of failings in her care.
The mother, known as Ms A, should never have been allowed to give birth without medical assistance at the privately run jail, prisons and probation ombudsman (PPO) Sue McAllister concluded.
Her findings, published on Wednesday, highlighted a catalogue of “troubling weaknesses” in the way the prison and healthcare services handled the mother’s care, and made a slew of recommendations for improvements in handling pregnant prisoners.
Ms A was behind bars for the first time, facing a charge of robbery. The report described her as vulnerable, having had a “traumatic childhood” and she was thought to have a history of drug and alcohol abuse.
She was “sad, angry and very scared” that her baby would be taken away from her, had said she would “kill herself or someone else” if this happened, engaged “minimally or not at all” with the midwifery team at Ashford and St Peter’s Hospitals NHS Trust (ASPH) in Surrey, and all ante-natal care, including refusing to attend appointments for scans.
But staff at the Sodexo-run prison appeared to regard her as “difficult and having a bad attitude”, the report said.
Ms A rang her call bell asking for a nurse just after 8pm on September 26 but one was not sent for. She told inspectors she “gave up” when her subsequent calls less than half an hour later were not answered.
The report said Ms A described being in “constant pain” and ended up having to sit on the toilet before passing out. After delivering the baby, she “managed to bite through the umbilical cord” before wrapping her baby – who was “purple and not breathing” – in a towel. She put the placenta in the bin, tried to wipe up the blood on the floor and got into bed with the baby.
Prison staff did not discover what had happened until after 8am the following day. Ambulance crews were called but the child could not be saved.
A pathologist has been unable to determine whether the baby was born alive or was stillborn, and so far no inquest has taken place.
Ms McAllister said: “Ms A gave birth alone in her cell overnight without medical assistance. This should never have happened.”
Her report found:
- Maternity services at Bronzefield were “outdated and inadequate” and contact with health professionals was limited.
- The care by Ms A’s midwives was “inflexible, unimaginative and insufficiently trauma-informed”.
- A “lack of clarity” about the due date, and staff working on Ms A’s block did not know she might give birth imminently.
- “Several missed opportunities” to carry out checks in the days leading up to the birth which might have led to her labour being discovered.
- The response to her calls for a nurse the day before were “completely inadequate”.
Ms A’s lawyer Elaine Macdonald, of Tuckers Solicitors, branded the failings “truly shocking”, and called for the concerns raised to be “urgently and fully examined”.
Dr Kate Paradine, chief executive of the charity Women In Prison, said the Government must stop putting new mothers and pregnant women behind bars, adding: “Every child deserves to get the best start in life but that will never be in prison.”
Justice secretary Dominic Raab described the events as “harrowing, unacceptable and should never happen to any woman or child” but said “important improvements” have been made to the care received by women in custody.
Prison director Vicky Robinson and hospital trust chief executive Suzanne Rankin both said they were “deeply sorry” for the death and vowed that improvements were being made.
The NHS has since taken over the healthcare budget for maternity services at the prison.