A nurse at a women’s jail failed to visit an inmate three times before the prisoner gave birth to a stillborn baby in the lavatory, an investigation has found.
Doctors said the baby could have been saved if the inmate – Louise Powell, 31 – had been taken to hospital when she began to give birth to her baby, Brooke, on the evening of June 18 2020.
Instead, she gave birth to a baby girl up to 31 weeks old in the lavatory of her houseblock in Styal prison, Cheshire.
Sue McAllister, the prisons and probation ombudsman, described it as a “terrifying, painful and traumatic experience”.
“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,” said Ms McAllister.
She added that had proper triage taken place, Ms Powell “might have given birth in hospital with proper clinical support and medication instead of in a prison toilet with untrained staff”.
It is the second death of a baby within the female prison estate, after a newborn baby died at HMP Bronzefield, in Surrey, in September 2019.
Ms Powell, in jail for the first time on charges of assault, claimed on arrival at the prison in March 2020 that she could not be pregnant because she did not have sexual relationships with men. She declined a pregnancy test offered by the examining nurse.
Nearly four months later, however, at around 1pm on June 18, she started to have severe pains and lost blood. A supervising officer at the prison made three calls to the duty nurse between 6.45pm and 8.09pm, raising concerns about the woman who believed she was having a bad period.
However, the watchdog said that, without seeing her, the nurse concluded incorrectly that she was bleeding and suffering severe stomach pain as a result of a painful period. The nurse did not go to see Ms Powell.
By 9pm, two prison officers realised she must be in labour and an ambulance was called.
A consultant obstetrician commissioned by the watchdog said that if Ms Powell had been taken to hospital by 7.30pm or 8pm, doctors would have been able to provide expert help with the delivery. She said that assuming the baby was alive during labour, the outcome “would have been different”.
Ms McAllister said that she was satisfied that prison staff did not miss any obvious signs that Ms Powell was pregnant while at Stya. However, she said there were missed opportunities to identify that she needed urgent clinical attention in the hours before she gave birth.
“We consider that the information provided by the supervising officer was sufficient to have caused the nurse to visit, and that she should have done so,” said the ombudsman.
All the other staff who tried to help Ms Powell and her baby during and after the delivery acted with humanity and to the best of their abilities, the report added.
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.
“We have already implemented the report’s recommendations and important improvements have been made to the care received by pregnant women in custody. We are also looking at how we can better screen for pregnancy in jails so no woman falls through the cracks.
“But there is clearly much more to do to ensure expectant mothers in prison get the same support as those in the community – something I will continue to prioritise.”