HMP Bronzefield baby death: Mother was 'failed' says inspectors

The woman gave birth to the baby at HMP Bronzefield

An 18-year-old inmate who lost her baby at Europe's largest women's prison should never have given birth alone in her cell, according to a critical report from inspectors.

The baby died in September 2019 at HMP Bronzefield in Surrey.

The Prisons and Probation Ombudsman report found a series of failings in the teenager's treatment.

The prison said it was "deeply sorry" and that it would implement recommendations from the report.

The investigation, which was commissioned by the Justice Secretary, found the mother, known as Ms A, pressed her cell bell twice and asked for a nurse, but nobody came.

An hour later, at 21:30 BST, a prison officer shone a torch in her cell and said she did not see anything out of the ordinary.

Ms A told investigators she was on all fours at the time.

'Harrowing'

She described being in constant pain and unable to reach the cell bell.

The teenager then passed out and said when she awoke her daughter had been born but she was not breathing.

A pathologist was unable to determine whether her baby girl was born alive or was stillborn, the report said.

"Ms A gave birth alone in her cell overnight without medical assistance," said the Prisons and Probation Ombudsman, Sue McAllister.

"Overall the healthcare offered to her was not equivalent to that she could have expected in the community."

The report found staff working on her block weren't aware that Ms A was due to give birth imminently, and information sharing between Bronzefield and health agencies was poor.

No-one had a full history of Ms A's pregnancy.

'Fearful of engaging'

The ombudsman set out a raft of recommendations for all the agencies involved, including the prison and Ashford and St. Peter's Hospitals NHS Foundation Trust, which dealt with Ms A during her pregnancy.

Ms A, who was in prison for the first time on a robbery charge, had a troubled childhood, the report stated.

She had refused to engage with most ante-natal care and feared her baby would be taken away.

Ms McAllister said: "We consider that all pregnancies in prison should be treated as high risk.

"There is likely to be a higher percentage of 'avoidant' mothers who have experienced trauma and who are fearful of engaging with maternity care."

• HMP Bronzefield baby death 'subject of 10 investigations'

• My baby died due to errors in prison, says former inmate

• HMP Bronzefield: Newborn baby dies at women's prison

Vicky Robinson, the director of the prison, which is operated by Sodexo Justice Services, said: "This was tragic and extremely sad. We are deeply sorry that this has happened and our thoughts throughout have been with the family.

"A number of recommendations have been made and we have been absolutely dedicated to working closely with all agencies to collectively address these and ensure the actions needed to be taken have been taken."

Following the baby's death, The Ministry of Justice said additional welfare observations for women in their third trimester have been implemented, along with free phone access to NHS pregnancy advice services.

The Deputy Prime Minister and the newly appointed Justice Secretary, Dominic Raab, said improvements had been put in place to ensure that women in custody received the same level of support.

"These events are harrowing, unacceptable and should never happen to any woman or child. My deepest condolences remain with those affected," he said.

Suzanne Rankin, the chief executive of Ashford and St. Peter's Hospitals NHS Foundation Trust, apologised and said further action would be taken following the report.

Follow BBC South East on Facebook, on Twitter, and on Instagram. Send your story ideas to [e-mail].