Investigation reveals woman gave birth in Cheshire Prison toilet block
The inmate didn't know she was pregnant
Last updated 11th Jan 2022
An investigation by the Prisons and Probation Ombudsman (PPO) has found that a prisoner gave birth to a still-born baby in shocking circumstances in a prison toilet, without specialist medical assistance or pain relief.
The 30-year-old mother didn't know she was pregnant and didn't believe she could be.
The PPO investigation report found that fellow prisoners and staff had no suspicion that the woman was pregnant before she gave birth in an emergency on the evening of 18 June 2020 at HMP&YOI Styal in Cheshire. Her roommate, a mother of four herself, only recognised possible signs that she was pregnant in hindsight.
The Ombudsman said that she was satisfied that prison staff did not miss any obvious signs that the inmate was pregnant during her three and a half months at Styal, but that there were missed opportunities to identify that she needed urgent clinical attention in the hours before she gave birth.
The woman, who was in prison for the first time, gave birth to a baby girl – possibly at the stage of 27-31 weeks of gestation – in the toilet of her houseblock. Sue McAllister, PPO, said the woman suffered a “terrifying, painful and traumatic experience” and her roommate and prison staff present were also profoundly affected. “Even at a distance this is a deeply sad and distressing case,” Sue McAllister said.
The investigation found that a prison supervising officer (SO) made three calls to the duty nurse, raising concerns about the inmate, during a period of two hours from shortly before 7pm on 18 June. The nurse, without seeing the patient and with inadequate reference to her medical file, concluded incorrectly that she was bleeding and suffering severe stomach pain as a result of a painful period. The nurse did not go to see the patient.
Sue McAllister’s report said: “We do not consider that (the nurse) should have concluded from the information provided by (the SO) that the woman's situation was a maternity emergency. However, acute abdominal pain can have a variety of causes, some of which are very serious. We consider that the information provided by the SO was sufficient to have caused the nurse to visit the patient, and that she should have done so.
“Regardless of the cause, it is not acceptable that anyone should be in unexplained acute pain for several hours without proper assessment or consideration of pain relief. Had proper triage taken place, the inmate might have given birth in hospital with proper clinical support and medication instead of in a prison toilet with untrained staff.” All the other staff who tried to help the woman and her baby during and after the delivery acted with humanity and to the best of their abilities, the report added.
The Ombudsman said the PPO is not able to say whether the baby could have survived if her mother had been taken to hospital earlier that evening. “We consider that this would need to be determined by a court on the basis of expert evidence commissioned for that purpose.”
The PPO report says that there are a number of reasons why a woman in prison might not know she is pregnant or might deny pregnancy. It is important that prisons do all they can to identify pregnant women and that trauma-informed care is at the heart of their approach.
More could be done to make pregnancy tests available and to explain the risks of not having one if there is any possibility the woman might be pregnant. The report recommends that women are offered a pregnancy test at both the initial and secondary health assessments after arriving at prison.
More could also be done during the secondary health assessment (which takes place a few days after arriving in prison when the woman has had a chance to adjust to her surroundings). The secondary health assessment should allow for discussion about sexual health, menstrual history and contraceptive history.
The report further recommends that nurses in women’s prisons should have training in recognising early labour, and that all staff in women’s prisons need to know what to do in the event of an unexpected birth.
The Prison Service and the NHS have accepted the Ombudsman’s recommendations and produced an action plan setting out how they will be implemented.