Series of failings uncovered after baby death in young women's prison
The 18-year-old inmate should never have given birth alone in her cell, according to the watchdog's report
A newborn baby died after an 18-year-old gave birth alone in her cell in Europe's largest women's prison, according to a 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 HMP Bronzefield in Middlesex, prisons and probation ombudsman (PPO) Sue McAllister said.
Ambulance crews were called to the scene in September 2019 but the child did not survive. Police launched an investigation, treating the death as "unexplained".
No less than 10 separate investigations were launched into the incident, with the PPO conducting the overarching probe.
According to the watchdog's report, published on Wednesday, a pathologist has been unable to determine whether the baby was born alive or was stillborn, and so far no inquest has taken place.
The findings highlight a catalogue of "troubling weaknesses" in the way the prison and healthcare services handled the mother's care and makes a series of recommendations for improvements in handling pregnant prisoners.
Ms A had a "traumatic childhood" and was in prison for the first time, facing a charge of robbery. The findings said she was regarded as vulnerable, "sad, angry and very scared" that her baby would be taken away from her.
She 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.
According to the report, staff at Bronzefield appeared to regard her as "difficult and having a 'bad attitude', rather than as a vulnerable 18-year old, frightened that her baby would be taken away".
Ms McAllister said: "Ms A gave birth alone in her cell overnight without medical assistance. This should never have happened."
All pregnancies in prison should be treated as "high risk" because the women are "locked behind a door for a significant amount of time", she said, adding that there was likely to be a higher percentage of "avoidant" mothers who were "fearful of engaging with maternity care".
Prisoners do not have direct access to their midwives, compared to pregnant women who are not in custody.
The report found maternity services at Bronzefield were "outdated and inadequate" with limited visits from health professionals.
Although Ms A was considered a "challenging person to manage", the approach to her care by midwives was found to be "inflexible, unimaginative and insufficiently trauma-informed", while there was no plan for dealing with a pregnant woman who refused to accept the usual procedures.
There was also "lack of clarity" about the due date, and staff working on Ms A's block did not know she might give birth imminently.
In the days leading up to the birth, there were "several missed opportunities" to increase observations which might have led to her labour being discovered, the findings said, adding that the response to her request for a nurse the day before was "completely inadequate".
Justice Secretary Dominic Raab described the events as "harrowing, unacceptable and should never happen to any woman or child", adding: "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."
The Ministry of Justice (MoJ) stressed it was exceptionally rare for a woman to give birth in prison. Since the death, women have been given phone access to advice services, offered social services support and welfare checks are being carried out for pregnant women in their third trimester, the department said.
The NHS has since taken over the healthcare budget for maternity services at the prison, increased its budget in this area by 87%, put an ultrasound scanner inside the jail as part of a range of improvements, a spokeswoman said.
Prison director Vicky Robinson said Sodexo was "deeply sorry" the incident occurred and was "absolutely dedicated" to working with all other bodies involved to address the recommendations and "ensure the actions that needed to be taken have been taken".
The hospital trust's chief executive, Suzanne Rankin, said: "We are deeply sorry for the devastating loss Ms A experienced and the lifelong impact this will have.
"The ASPH maternity team pride themselves on providing the highest level of care and are deeply distressed by the death in such tragic circumstances of Baby A."
The trust made a series of changes in light of the death - including providing training and dedicating more staff and resources to this area of care - and will take "further action" as a result of the PPO report, she added.