Sad failings which resulted in baby dying at Bronzefield prison

Work with offenders looks at the detail of today’s report by the Prisons and Probation Ombudsman

The Prisons and Probation Ombudsman (PPO), Sue McAllister, has today published a devastating report into the death of a baby at HMP Bronzefield two years ago in September 2019.

The PPO was extremely critical of the fact that an (un-named) vulnerable 18 year old woman (Ms A) was allowed to give birth alone in her cell.

A pathologist has been unable to determine whether the baby (Baby A) was born alive or was stillborn, and no inquest has so far been held. However, the PPO report has been published to draw attention to a range of troubling weaknesses in the way Bronzefield and healthcare services handled the mother’s care.

Sue McAllister’s report makes recommendations for improvements in dealing with pregnant prisoners at Bronzefield, particularly those like Ms A who are fearful of engaging with maternity care. The report’s findings are relevant more widely across the prison service, and to health professionals working in women’s prisons.

Ms A's case 

Ms A had a troubled and traumatic childhood and was in prison for the first time, facing a charge of robbery. She was vulnerable – “sad, angry and very scared” that her baby would be taken away from her. She engaged “minimally or not at all” with the midwife team from Ashford and St Peter’s Hospitals NHS Trust (ASPH) and all ante-natal care, including refusing to attend appointments for scans.

However, the report concluded that while there was a commitment at senior prison manager level to delivering trauma-informed care at Bronzefield, “we saw little practical evidence of this in the healthcare for Ms A. Ms A 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.”

Sue McAllister said:

“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.”

The PPO found that information sharing within and between the prison and health agencies was poor and the approach to managing Ms A was uncoordinated and no one responsible for her care had a full history of her pregnancy.

“She was a challenging person to manage but we found that the midwives’ approach to her care was inflexible, unimaginative and insufficiently trauma-informed and that 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).”

One of the key problems was a lack of clarity about Ms A’s estimated delivery date. In the days leading up to Baby A’s birth, the PPO chronicled several missed opportunities to increase observations on Ms A that might have led to her labour being discovered.

Tragically, staff working on Ms A’s house block on 26/27 September did not know that Ms A might give birth imminently and did not respond properly to her request for a nurse.

The PPO concluded that Prison healthcare staff were not sufficiently involved in maternity care in general and in Ms A’s maternity care in particular.

Ms McAllister said that the community model of care is led by and centred on midwives who can be contacted directly and at any time by pregnant mothers but that this model just does not work in a prison context. The PPO called maternity services at Bronzefield “outdated and inadequate” and pointed out that midwifes visit only twice a week and that the obstetrician holds only eight clinics a year and the women in prison do not have direct access to them.

In conclusion, the PPO argues that all pregnancies in prison should be treated as high risk by virtue of the simple fact that women are locked behind a door for a significant amount of time. She also points out that there is likely to be a higher percentage of ‘avoidant’ mothers who have experienced trauma and who are fearful of engaging with maternity care.

The PPO’s report has prompted a new petition to the Justice Secretary asking for the law to be strengthened so that judges legally have to consider the health of pregnant women and their babies, and avoid sending them to prison at all costs. You can see the petition, jointly launched by three charities, Level Up, Women in Prison and Birth Companions on this site.