A damning report outlines the failures leading up to the discovery of a teenager holding her dead newborn baby in a prison cell in the largest women’s prison in Europe.
The investigation report into the death of the teen prisoner’s baby was published by the Prisons and Probation Ombudsman today, two years after the horror incident in September 2019, at HMP Bronzefield in Ashford, Middlesex.
According to Guardian reports, the baby’s death triggered 11 separate inquiries.
A summary of the case outlines the timeline of ‘Miss A’s’ pregnancy, from when she found out she was pregnant whilst in police custody, in February of 2019 to when she was remanded to HMP Bronzefield, on 14 August 2019.
Shortly after her arrival in the cells a midwife in prison determined that Ms A was 32 weeks pregnant, which would make her expected delivery date from 24 September to 14 October.
While this was earlier than originally expected, the midwife did not recalculate this.
Ms A was said to have engaged “minimally or not at all” with the midwife team and all antenatal care, including refusing to attend appointments for scans.
In September, Ms A told a nurse that she would kill herself or someone else if her baby was taken away from her after birth; a comment that prompted the nurse to discuss with an officer on duty whether it would be necessary to begin Prison Service suicide and self-harm monitoring.
While they decided against this, Ms A was put on ‘extended observations' by the deputy head of healthcare on September 26. This meant she should have been checked by a nurse a minimum of twice during the day and twice at night.
However, this did not happen.
Ms A rang her cell bell shortly after 8pm that evening and asked for a nurse, though she did not say why. The officer who took the call handed over the information to a colleague, who spoke to Ms A on the phone but cannot remember the conversation.
“No nurse was called for Ms A. 9. Ms A pressed her cell bell again at 8.32pm. The call was not answered on the house block and was diverted to the permanently staffed communications room,” the report continued.
“At 8.45pm the call was connected and immediately disconnected. Ms A did not press her cell bell again.”
Ms A’s cell was checked twice over the course of the night, but neither of the officers who carried out these checks noticed anything untoward, including blood, in her cell. It wasn’t until 8.21am the next morning that an officer investigated and discovered Ms A had given birth during the night.
Shortly after 9am paramedics confirmed her baby had died. Ms A was taken by ambulance to ASPH and returned to the prison that evening, where she was placed in the prison’s inpatient unit.
The pathologist was unable to determine whether Baby A was born alive or was stillborn.
The report outlined how the teenager “appeared to have been regarded as difficult and having a ‘bad attitude’ rather than as a vulnerable 18-year-old, frightened that her baby would be taken away”.
Prisons and Probation ombudsman Sue McAllister told the Guardian that Ms A should never have been left in a position where she was forced to give birth alone without medical assistance.
The director of HMP Bronzefield called the incident “tragic and extremely sad”.
“We are deeply sorry that this happened and our thoughts throughout have been with the family. In the two years which have passed, we have cooperated fully with the PPO investigation,” she said.
Dr Kate Paradine, CEO of the charity Women in Prison, in 2019 pleaded that "all mothers should have the right to give birth in dignity."
She said: “But time and time again, we hear of situations where this isn’t happening, with mothers regularly being denied access to the vital health and maternity care necessary to give birth safely.
"This has devastating consequences not only for the baby and mother, but also for the rest of the family they are separated from."
She added: "Many mothers are imprisoned for being homeless, not having money to pay their bills and not having access to adequate mental health care and substance misuse support.
"Instead of sending these women to prison, the government needs to urgently prioritise investment in community support services like women’s centres, housing and health care.
Deputy prime minister and justice secretary, Dominic Raab also commented on the incident, which he said was “harrowing and unacceptable”.
“We have already implemented the recommendation in the Prisons and Probation Ombudsman’s report. 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,” he said.
Publication of the report has prompted the organisation of a petition by organisations Level Up, Women In Prison and Birth Companions, calling for an end to the imprisonment of pregnant women. The groups’ calls have been echoed by the Royal College of Midwives and academics in the field.
