The child was born in Bronzefield prison in Ashford, Middlesex, in September 2019 to an 18-year-old woman from Camden who had been remanded in custody for the first time on a robbery charge after suffering a “troubled and traumatic” childhood.
But the birth took place without medical assistance despite the pregnancy being high risk because of an “inflexible, unimaginative” response by midwives, a lack of co-ordination in managing the teenager’s care, and the failure of health and prison staff to share information.
There were also “missed opportunities” to detect her going into labour and a “completely inadequate” failure to send a nurse in response to a call for help from the woman using her cell bell.
A second call shortly afterwards was initially unanswered and then disconnected and, although two routine checks were made on the woman’s cell overnight, her labour and the birth were not detected until the following morning when a prison officer entered her cell to be told that the baby had died.
There was no neonatal or paediatric equipment in prison and an attempt to use oxygen to revive the baby, which looked lifeless and had a blue tinge, failed when the adult mask used was too big.
Disclosing details of the tragedy in a report on the child’s death, Sue McAllister, the prisons and probation ombudsman, said it should “never have happened”. She added: “Information sharing between the prison and health agencies was poor and the approach to managing Ms A was unco-ordinated and no one responsible for her care had a full history of her pregnancy.
“The midwives’ approach to her care was inflexible, unimaginative and insufficiently trauma-informed and there was no plan for dealing with a pregnant woman who refused to accept the usual procedures (which focused on her baby rather than on her).”
Ms McAllister’s report makes a number of recommendations for improvements and urges the prison service to “improve the outcomes for pregnant prisoners so that this tragic event is not repeated”.
Justice Secretary Dominic Raab said: “These events are harrowing. We have implemented the recommendations.”