A woman gave birth to a stillborn baby in a prison toilet without specialist medical care or pain relief after a nurse wrongly said her stomach cramps were the result of a “painful period”, a watchdog report has found.
An investigation by the Prisons and Probation Ombudsman reveals that the woman, known as Ms B, was in unexplained acute pain for several hours before and while giving birth to a baby girl – possibly at the stage of 27-31 weeks of gestation – in the toilet of her houseblock on the evening of 18 June 2020 at Styal Prison in Cheshire.
Ms B, who was in prison for the first time, suffered a “terrifying, painful and traumatic experience” and her roommate and prison staff present were also profoundly affected, Ombudsman Sue McAllister said, describing the case as “deeply sad and distressing”.
The 30-year-old did not know she was pregnant and did not believe she could be, and fellow prisoners and staff had no suspicion that she was pregnant before she gave birth.
Ms McAllister said that she was satisfied that prison staff did not miss any obvious signs that Ms B 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 investigation found that a prison supervising officer made three calls to the duty nurse, raising concerns about Ms B, during a period of two hours from shortly before 7pm.
The nurse, without seeing Ms B 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, and there was no need for her to see her.
“We do not consider that (the nurse) should have concluded from the information provided by (the supervising officer) that Ms B’s situation was a maternity emergency. However, acute abdominal pain can have a variety of causes, some of which are very serious,” said Ms McAllister.
“We consider that the information provided by the supervising officer was sufficient to have caused the nurse to visit Ms B, and that she should have done so.”
Prison officers contacted healthcare staff about Ms B three times and they did not come to see her. It wasn’t until shortly after 9pm, when Ms B was on labour in the toilet, that the duty nurse came and delivered the baby, who showed no signs of life.
The Ombudsman said it was not able to say whether the baby could have survived if Ms B had been taken to hospital earlier that evening, and that this would need to be determined by a court on the basis of expert evidence.
“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,” she added.
“Had proper triage taken place, Ms B 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 Ms B and Baby B during and after the delivery acted with humanity and to the best of their abilities, the report added.
It comes after a report published by the Ombudsman in September found that another female prisoner whose baby died during childbirth, at Bronzefield jail, was left to give birth alone in her cell despite calling for help multiple times.
Dr Kate Paradine, chief executive of Women in Prison, said: “This is the second report into the death of a baby in prison in six months and another example of a catastrophic failure of healthcare in prisons.
“This should never have happened. Prisons are not safe for women, especially if they are pregnant, and they simply do not have access to healthcare that is equivalent to in the community.”
The report states that there are a number of reasons why a woman in prison might not know she is pregnant or might deny pregnancy, and that it is important that prisons do “all they can” to identify pregnant women.
It recommends that women are offered a pregnancy test at both the initial and secondary health assessments after arriving at prison, and that nurses in women’s prisons should have training in recognising early labour, while all staff need to know what to do in the event of an unexpected birth.
A spokesperson from Spectrum Community Health, the private firm that runs healthcare at Styal Prison, said it accepted the report’s findings and that it was “fully committed” to ensure that “lessons are learnt and that recommendations in the report are acknowledged and actioned following this tragic incident”.
“We extend our deepest condolences to Ms B for the distress and sad loss that she has experienced,” they added.
An NHS spokesperson said: “We send sincere condolences to Ms B on the tragic loss of her baby.”
They said the NHS had already taken “prompt action” on the recommendations so that pregnancy tests were offered to all women when they arrive in prison as well as ensuring staff undertake training to identify early signs of labour and know what to do in the event of an unexpected birth.
The prisons minister, Victoria Atkins, said: “The tragic events detailed in this report should quite simply never happen to any woman or child, and my deepest sympathies remain with the mother.”
She said the report’s recommendations had been implemented, but that there was “clearly much more to do” to ensure expectant mothers in prison get the same support as those in the community.