A MOTHER whose child was found dead after she gave birth alone in her cell in HM Prison Bronzefield, the largest women’s prison in Europe, should never have been remanded in the first place, the Bishop of Gloucester, the Rt Revd Rachel Treweek, said this week.
The independent investigation by the Prisons and Probation Ombudsman (PPO) into the death of “Baby A” was published last week. It highlights a catalogue of failings, including calls from the baby’s mother, Ms A, which went unanswered during the night of the birth. The situation for pregnant women in Bronzefield is “symptomatic of a national absence of policies and pathways for pregnant women in custody”, it says, and the Prison Service “must take this opportunity to improve the outcomes for pregnant prisoners so that this tragic event is not repeated”.
Ms A gave birth on the night of 26 September 2019. The report notes that she had a “traumatic childhood”, and was known to local authority children’s services from birth: “Years of trauma meant she struggled to form relationships of trust with agencies attempting to engage with her.”
Before being remanded to Bronzefield, charged with robbery on 14 August 2019, she had refused all maternity care in the community, and was thought to be misusing alcohol and drugs. Once in prison, she refused to attend appointments for scans. Although she told a nurse that she would kill herself or someone else if her baby was taken from her, she was not put under suicide monitoring. On the night of the birth, she should have been checked by a nurse three times a day, and at least twice during the night, but this did not happen.
She rang for a nurse on the evening of 26 September, but none was called. A second call was disconnected. Routine checks on her cell took place, but it was not until two prisoners alerted staff to blood in her cell that it was discovered that she had given birth during the night. Nurses attempted to resuscitate Baby A, but paramedics confirmed that the baby had died. A pathologist was unable to determine whether Baby A was born alive or was stillborn. Before Ms A left for hospital by ambulance, the prison chaplain baptised Baby A in the cell.
Ms A described being on all fours when a torch was shone into her cell during the night. In constant pain by 11 p.m. she ended up sitting on the lavatory, unable to get to the cell bell to ring for help again. After giving birth alone, she had to bite through the umbilical cord and got into bed with the baby, who was purple and not breathing.
Among the failings identified in the report are poor information-sharing — no one had a full history of Ms A’s pregnancy — and “outdated and inadequate” maternity services at the prison. There was no paediatric or neonatal emergency equipment in the prison, and no staff were trained in neonatal resuscitation.
“Ms A was a vulnerable young woman with a complex history who found it difficult to trust people in authority,” the report says. “She was afraid (with reason) that her baby would be taken away from her immediately after birth and she refused to engage with maternity services. 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). . .
“We consider that all pregnancies in prison should be treated as high risk by virtue of the fact that the woman is locked behind a door for a significant amount of time. In addition, there is likely to be a higher percentage of ‘avoidant’ mothers who have experienced trauma and who are fearful of engaging with maternity care.”
Birth Companions, a charity dedicated to helping mothers and babies facing inequalities and disadvantage, said that the case “adds to the considerable evidence showing that prisons are not safe for pregnant women and their babies. . . In numerous other cases, there have been serious incidents, near misses, and adverse outcomes for women and their babies.” It has joined forces with two other charities, Level Up and Women in Prison, to launch a campaign to end the imprisonment of pregnant women.
On Monday, Bishop Treweek, who is the Bishop for Prisons, agreed with the campaign call, but cautioned against focusing solely on the question of pregnancy rather than exploring the “underlying issues” raised in the report: “Here was a woman who clearly had got a difficult story, she had got mental-health issues, she clearly didn’t trust people . . . and she was pregnant. . . How could we say that prison was the right place for her to be?. . .
“I would say that, fundamentally, prison is not a place where women who are pregnant should be and where babies should be born. . . Let’s look at the woman’s story and let’s understand what the issues are and then let’s ask, What is the best way to be providing rehabilitation for that woman? And, actually, it’s hard to see how the answer to that is going to be prison.”
It had been known, ever since the 2006 Corston report on vulnerable women in the criminal-justice system, that “the vast majority of women who find themselves being sentenced and going to prison . . . have a number of complex needs,” she said. “A large proportion of women should not be in prison. . . Approximately 60 per cent of all women who go to prison have been abused themselves, and most of those women . . . are not a danger to other people. . .
“We know that women’s centres in the community and all forms of community intervention who work holistically with women building trust, relationship — we know that then the rate of reoffending is very low.”
The PPO report had emphasised the urgent need for joined-up working, she said. There had been great hopes when the Female Offender Strategy was published in 2018, but it had been “very slow to be implemented”.
The PPO report notes that a failure to respond to prisoners’ calls was a “long-standing issue” at the prison, and noted similarities between Ms A’s experience and a previous unexpected birth at the prison in 2017. “Plans for a maternity pathway were referred to as being ‘under development’ for a significant period of time,” it says. “We asked to see these plans, but none were provided.” It lists recommendations made after a 2015 investigation into the death of a new mother in HM Prison Low Newton.
Bishop Treweek said that she had prayed for Ms A, Baby A, and all those involved in the case. “I found myself praying hope,” she said. “And for that child, trusting that that child is held in God’s love.”