Bronzefield infant death: Woman left to give birth alone in prison cell despite calling for help, report finds
A woman whose baby died during childbirth at Bronzefield jail was left to give birth alone in her cell despite calling for help multiple times, a new investigation reveals.
A damning report by the Prison and Probation Ombudsman highlights a series of failings in the care for Ms A, 18, who lost her newborn child on 27 September 2019 at HMP Bronzefield, Europe’s largest women’s jail.
It details a disturbing series of events that culminated with the young woman, who cannot be named, being in “constant pain” on the night of 26 September and eventually passing out while giving birth.
She had rung her cell bell twice in the evening, first at 8:07pm and again 25 minutes later, asking to see a nurse, but no one tended to her. She then ended up having to sit on the toilet and not being able to get to the cell bell to call for help again, according to the report.
After delivering the baby, Ms A had to bite through the umbilical cord herself before trying to wipe up the blood on the floor, investigators said.
The young woman is then said to have put the placenta in the waste bin and got back into bed with her baby, a girl, who was “purple and not breathing” and whom she had wrapped in a towel. Prison staff did not discover what had happened until shortly after 8am the following morning.
A pathologist has been unable to determine whether Baby A was born alive or was stillborn, and no inquest has so far been held.
Sue McAllister, the ombudsman, said Ms A was failed by an “inflexible, unimaginative and insufficiently trauma-informed” approach to care and “outdated and inadequate” maternity services at HMP Bronzefield.
The report describes Ms A, who was in prison for the first time, facing a charge of robbery, as a “very vulnerable young women with a complex history”, who has a lack of trust for people in authority as a result of her “traumatic childhood”.
The ombudsman found that information sharing within and between the prison and health agencies was “poor” and that the approach to managing the 18-year-old was “uncoordinated”, with no one responsible for her care having a full history of her pregnancy.
“Ms A gave birth alone in her cell overnight without medical assistance. This should never have happened. Overall, the healthcare offered to Ms A in Bronzefield was not equivalent to that she could have expected in the community,” Ms McAllister said.
It says she had been “sad, angry and very scared” that her baby would be taken away from her, and subsequently engaged “minimally or not at all” with the midwife team at the local NHS Trust and all ante-natal care, including refusing to attend appointments for scans.
The report concludes that while there is a commitment to delivering trauma-informed care at Bronzefield, there was “little practical evidence” of this in the healthcare for Ms A. It found that she 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.
Investigators found that in the days leading up to Baby A’s birth there were several missed opportunities to increase observations of Ms A that might have led to her labour being discovered, with staff unaware that she might give birth imminently. They said the response to her request for a nurse on 26 September “completely inadequate”.
It comes as another woman, Louise Powell, told BBC Newsnight how her baby died during childbirth “due to errors” made after she went into labour in HMP Styal last year.
Data published in July shows there were on average 26 pregnant women in prison per week in the nine months to March 2021. Research by the Nuffield Trust found that in 2017-18, just over one in ten women giving birth during a prison sentence did so before they reached hospital.
Chief executive of Women in Prison, Dr Kate Paradine, told The Independent the lower levels of care provided to pregnant women in prison compared to those in the community risked the safety and wellbeing of both mothers and their babies.
The charity is spearheading a campaign, along with charities Level Up and Birth Companions, calling for a new statutory duty for judges to consider pregnancy and the health of the mother and child when sentencing – and for prison sentences for women to be avoided at all costs.
“When women are supported in the community, children can get the best start in life, including easy access to antenatal and postnatal healthcare,” Dr Paradine said.
Elaine Macdonald of Tuckers Solicitors, who represents Baby A’s mother, known as Ms A, said the failings identified were “truly shocking”.
“A vulnerable young woman giving birth alone in a prison cell should never have happened, and the number of significant concerns raised about her treatment while in custody need to be urgently and fully examined,” she added.
The Ministry of Justice said that since the death at HMP Bronzefield, it had made some “important improvements” to care for women in custody, including putting £500,000 towards a new prison officer role specialising in supporting pregnant and new mothers, and providing all women with free phone access to local NHS pregnancy advice services.
Deputy prime minister and justice secretary Dominic Raab said: “These events are harrowing, unacceptable and should never happen to any woman or child. My deepest condolences remain with those affected.”
Vicky Robinson, director at HMP Bronzefield said: “This was tragic and extremely sad; nothing we can say or do will change that. We are deeply sorry that this happened and our thoughts throughout have been with the family.”
She added that the prison was “cooperating fully” with the PPO investigation and took the matter “extremely seriously”.