Baby C

OFFICIAL - FOR PUBLIC RELEASE
Independent investigation into
the death of Baby C, the child of
a prisoner at HMP Foston Hall,
on 16 October 2023
A report by the Prisons and Probation Ombudsman
Third Floor, 10 South Colonnade Email: mail@ppo.gov.uk T l 020 7633 4100
Canary Wharf, London E14 4PU Web: www.ppo.gov.uk
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
© Crown copyright, 2026
This report is licensed under the terms of the Open Government Licence v3.0. To view this licence,
visit nationalarchives.gov.uk/doc/open-government-licence/version/3
Where we have identified any third-party copyright information you will need to obtain permission
from the copyright holders concerned.
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
The Prisons and Probation Ombudsman aims to make a significant contribution to safer,
fairer custody and community supervision. One of the most important ways in which we
work towards that aim is by carrying out independent investigations into deaths, due to any
cause, of prisoners, young people in detention, residents of approved premises and
detainees in immigration centres.
If my office is to best assist His Majesty’s Prison and Probation Service (HMPPS) in
ensuring the standard of care received by those within service remit is appropriate, our
recommendations should be focused, evidenced and viable. This is especially the case if
there is evidence of systemic failure.
Baby C died at the Royal Derbyshire Hospital on 16 October 2023, just over 24 hours after
they were born. The baby’s mother, Ms C, was admitted to hospital from HMP Foston Hall
around seven hours before the birth. I offer my condolences to Ms C and her partner.
Ms C was in prison for just four days when she was admitted to hospital, having been 34
weeks pregnant when she was recalled to prison having breached her licence for a
previous sentence. Her pregnancy was high-risk, and she had limited contact with
maternity services in the community.
The clinical reviewers found that the pregnancy related care Ms C received at Foston Hall
was not equivalent to that which she could have expected to receive in the community.
Information about Ms C’s high-risk pregnancy was not fully shared with relevant prison
staff and clinical records lacked detail. The prison midwife was working in isolation, with
little accountability or direct supervision. Following Ms C’s recall, the prison midwife should
have completed and recorded a full antenatal assessment and escalated her care to
appropriate hospital specialists. There was also a delay in admitting Ms C to hospital
before she gave birth, when she reported reduced fetal movement.
Just a few hours after she gave birth, prison bed watch staff inappropriately handcuffed Ms
C.
This version of my report, published on my website, has been amended to remove the
names of staff and prisoners involved in my investigation.
Adrian Usher
Prisons and Probation Ombudsman May 2025
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Contents
Summary ......................................................................................................................... 1
The Investigation Process ................................................................................................ 3
Background Information ................................................................................................... 5
Key Events ....................................................................................................................... 7
Findings ......................................................................................................................... 15
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Summary
Events
1. On 10 October 2023, Ms C was returned to prison, having breached her release
licence, and was taken to HMP Foston Hall. She was approximately 34 weeks
pregnant.
2. Ms C had a history of high-risk pregnancies, due to having a rare blood group. She
also had a history of substance misuse and was prescribed methadone (an opiate
substitute).
3. At around 11.15am on 14 October, Ms C told a nurse that her baby’s movements
had reduced. At around 4.00pm, she reported that the baby had not moved since
the morning. Foston Hall contacted the Pregnancy Assessment Unit (PAU) for
advice and Ms C was taken to hospital.
4. At 1.06am on 15 October, Ms C gave birth to Baby C. The baby had to be
resuscitated, was noted to have numerous health complications and was unlikely to
survive.
5. At 6.05am on 16 October, Baby C died.
Findings
6. The clinical reviewers found that Ms C’s general nursing care was equivalent to that
she could expect to receive in the community. They concluded that the standard of
pregnancy care was not equivalent. Ms C’s high-risk pregnancy and limited
antenatal care in the community meant that she should have been urgently
assessed by a fetal medicine consultant and/or a senior obstetrician. An urgent
appointment was not made, and the first time Ms C went to hospital was when she
gave birth.
7. Recording of midwifery care and observations at Foston Hall was poor with multiple
different records used, which meant that information was not always accessible to
those who needed it. Not all staff who worked with Ms C had received HMPPS
training on pregnancy and perinatal care in prisons, and the training package
available had some notable omissions.
8. On the day of her admission, Ms C’s reduced fetal movements were not escalated
as quickly as they should have been.
9. Handcuffs were inappropriately applied to Ms C within a few hours of her giving
birth.
Recommendations
• NHS England should commission an independent review of the standard of
midwifery care provided at HMP Foston Hall. The review should include the
standard of midwifery documentation; the nature and content of clinical contacts;
Prisons and Probation Ombudsman 1
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
referrals completed, communication and escalation pathways; and supervision of
midwifery care at HMP Foston Hall.
• The Head of Healthcare should review the prison medical record to ensure that key
information regarding a pregnancy and any associated care plans are easily
accessible to all healthcare staff.
• NHS England should ensure that all relevant community and hospital records are
provided for the purpose of a PPO investigation following the death of a baby.
• The Head of Healthcare should ensure that nurse prescribers are adequately
informed regarding antidepressant medication, including what is safe to use in
pregnancy, and the risks associated with immediately stopping prescribed
medication.
• The Head of Healthcare should ensure that all bereaved prisoners who request
antidepressant medication are seen by a GP and/or nurse prescriber in a timely
manner.
• The Governor should ensure that all required observations, comments and
summaries are recorded in a prisoner’s Pregnancy Support Plan, in line with
national and local guidelines.
• The Prison Group Director for the Women’s Estate should review the current
training package for staff working directly with pregnant prisoners, to ensure they
receive training to equip them with the required skills and knowledge to care for
pregnant prisoners safely. This training should include the importance of fetal
movements and escalation pathways if a prisoner reports reduced fetal movements.
• The Governor should ensure that local policy regarding Hospital Escorts – Prisoners
Under Escort to Give Birth is revised to include guidance to staff following a birth,
including that:
• Prisoners who have given birth are not restrained in hospital unless there are
significant indicators of high risk of escape or to the public; and
• The escort risk assessment is reviewed and revised before the prisoner returns
from hospital, giving consideration to information about their current health and
mobility.
Prisons and Probation Ombudsman 2
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
The Investigation Process
10. HMPPS notified us of Baby C’s death on 16 October 2023.
11. The investigator issued notices to staff at HMP Foston Hall informing them of the
investigation and asking anyone with relevant information to contact her. No one
responded.
12. The investigator visited Foston Hall on 23 October. She introduced herself to Ms C
and explained the remit of the investigation. The investigator visited the remand unit
and prison healthcare. She obtained copies of relevant extracts from Ms C’s prison
and medical records. She also obtained the HMPPS Early Learning Review, Post
Incident Initial Review Report completed by Practice Plus Group, and relevant
extracts from Ms C’s Probation Service records.
13. NHS England commissioned a clinical reviewer to review Ms C’s physical and
mental healthcare at the prison and a consultant midwife to review Ms C’s midwifery
and obstetric care at Foston Hall. The investigator, together with the clinical
reviewers, interviewed eleven members of prison and healthcare staff at Foston
Hall. In addition, the investigator interviewed the Deputy Head of Dudley and
Sandwell Probation Delivery Unit, and three officers from other establishments that
undertook bed watch duties. The remit of this investigation does not include a
review of the care Ms C received in the community or in hospital.
14. The investigator met Ms C again via a video link on 7 November to hear about her
experience. The investigator and clinical reviewers attempted to meet with Ms C
before she was released from prison but, due to her ongoing physical health issues,
were unable to do so. They attempted to engage with her after she was released
from prison, but Ms C did not attend a planned meeting, or respond to subsequent
phone calls.
15. We informed HM Coroner for Derbyshire of the investigation. The Coroner gave us
the results of the post-mortem examination. We have sent the Coroner a copy of
this report.
16. The investigator also contacted Ms C’s partner to explain the investigation and to
ask if he had any matters he wanted us to consider. Ms C and her partner asked
some questions outside the remit of our investigation, but asked the following
questions relating to Ms C’s time at Foston Hall and Baby C’s death:
• Why were restraints applied to Ms C shortly after giving birth and again in the
labour ward before she returned to Foston Hall?
• Why some bed watch staff made inappropriate and offensive comments?
• Did Baby C have to be resuscitated after their birth?
17. Baby C’s parents received a copy of the initial report. They did not identify any
factual inaccuracies. The solicitor representing Baby C’s parents wrote to us raising
a number of questions that do not impact on the factual accuracy of this report. We
have provided clarification by way of separate correspondence to the solicitor.
Prisons and Probation Ombudsman 3
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
18. The prison also received a copy of the report. They did not identify any factual
inaccuracies. We have issued a revised version of the clinical review report.
Prisons and Probation Ombudsman 4
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Background Information
HMP Foston Hall
19. HMP Foston Hall is a closed women’s prison serving courts in the Midlands. It holds
remanded and sentenced women. Practice Plus Group provides primary and
mental healthcare services.
20. NHS England are responsible for commissioning maternity services in prisons,
including midwifery services. Commissioning arrangements vary across the country,
however women in prison have access to community midwifery services at all
women’s prisons. Diagnostic and obstetric services are available onsite or at local
NHS Trusts subject to need. Health Visiting Services are commissioned by the
Local Authority for the prison with health providers providing onsite care as
appropriate.
21. At the time that Ms C was at Foston Hall, a midwife was employed to work 15 hours
a week at the prison; she was employed by University Hospitals Derbyshire and
Burton (UHDB). One midwife provided most of the midwifery care at Foston Hall.
During Ms C’s custody in June 2023, the midwife was on leave therefore midwifery
care was provided by her colleagues from the midwifery team at UHDB (known as
the Juno Team, who provide primary and secondary maternity care).
HM Inspectorate of Prisons
22. The most recent full inspection of Foston Hall was in November 2021. Inspectors
found a deterioration in the regime and the provision of purposeful activity, and that
safety outcomes were poor. Inspectors found that the support offered to newly
arrived women was not good enough.
23. Inspectors noted that pregnant women received care from the local Trust’s midwife
who supported mothers through their pregnancy and postnatal period. The local
midwife services prepared mothers to give birth and provided birthing plans and
separation packs. The midwife visited the prison each week and discussed with the
lead GP and a local nurse specialist the detoxification of pregnant women who
misused substances. Two prison officers with appropriate training worked closely
with the midwife to support these women. However, inspectors reported that not all
staff knew the expected date of delivery for women in their care which did not meet
expectations.
24. There was an established pathway to refer women to the Birth Companions charity
which supported women during pregnancy and when they were separated from
their babies. Women had access to support and counselling which reflected
national guidance on support with miscarriage and bereavement.
25. Inspectors returned to Foston Hall in August 2022, to undertake a review of
progress. They found that support for new arrivals had improved.
Prisons and Probation Ombudsman 5
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Independent Monitoring Board
26. Each prison has an Independent Monitoring Board (IMB) of unpaid volunteers from
the local community who help to ensure that prisoners are treated fairly and
decently. In its latest annual report, for the year to November 2023, the IMB
reported that a new Governor took up post in October 2023 and that significant
number of new staff had started. Training, mentoring and induction had been
prioritised. The IMB noted that the regime was less restricted than the previous
year.
27. IMB members reported that healthcare providers faced challenges with recruitment
and retention, particularly the mental health team. They found that there was an
increasingly joined up approach to perinatal care.
Prisons and Probation Ombudsman 6
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Key Events
28. On 1 June 2023, Ms C was charged with theft and a breach of bail and remanded to
HMP Foston Hall. On 21 July, she was sentenced to 12 months imprisonment. Due
to the length of time she had been on remand, and time monitored by an electronic
curfew, she was released the same day. On 22 September, Ms C was recalled to
custody as she had failed to attend probation appointments, reside as directed and
for poor behaviour. She was arrested on 10 October and returned to Foston Hall.
29. Ms C has several physical health conditions, a long history of substance misuse
and was prescribed methadone (an opiate substitute). She had previously given
birth to four children, all of whom had survived.
1 June to 21 July 2023
30. When Ms C first arrived in custody on 1 June 2023, a test confirmed she was
pregnant. A nurse completed her initial health screen and recorded Ms C’s clinical
observations, which were all normal. A urine test confirmed that Ms C was positive
for using opiates, methadone and cocaine, and an alcohol assessment showed that
she was drinking at a harmful level. Ms C disclosed that she had used heroin and
crack.
31. On 2 June, Ms C told a mental health nurse that she was diagnosed with Post
Traumatic Stress Disorder (PTSD - a mental health condition caused by very
stressful, frightening or distressing events) and Emotionally Unstable Personality
Disorder (EUPD - this is a pervasive pattern of unstable and intense interpersonal
relationships, self-perception, and moods. Impulses are poorly controlled). Ms C
was referred for a mental health assessment.
32. A Registered Midwife (RM) recorded that she had arranged an antenatal scan for
Ms C on 9 June. The RM did not see Ms C in person on this date, and a full
antenatal assessment was not completed.
33. During this time at Foston Hall, the substance misuse team monitored Ms C every
day.
34. On 4 June, a mental health nurse assessed Ms C. She told the nurse that she was
focussed on her baby and hoped to be released from court when she next
appeared. The nurse noted that Ms C should be reassessed after her next court
appearance, to determine what support she may need with her pregnancy, but that
she was currently coping well. She also provided Ms C with information about
taking methadone while pregnant.
35. On 7 June, a nurse recorded in Ms C’s medical record that a potentially clinically
significant red cell antibody had been detected. She documented that the prison
midwife was to review Ms C. Later that morning, another RM met Ms C, as the
previous RM was on leave. The RM recorded clinical observations and that Ms C
gave consent for blood and urine tests. She recorded details about Ms Cs previous
pregnancies and deliveries.
Prisons and Probation Ombudsman 7
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
36. On 9 June, Ms C attended the local hospital for her pregnancy scan. The expected
date of delivery was confirmed as 21 November, making her 16 weeks pregnant. A
GP at Foston Hall noted that Ms C’s fetal RHD screen (a blood test to identify fetal
rhesus disease status, a condition where antibodies in a pregnant woman’s blood
destroy her baby’s blood cells) showed an abnormal result. He sent an urgent task
to the RM to make her aware of the need for enhanced fetal screening.
37. After she returned from her scan, Ms C told staff that she had been advised by the
hospital to have the pregnancy terminated as she had a history of deep vein
thrombosis, she was a drug user, and because she had a rare blood type and a
potential she could have rhesus disease. (This condition had been detected in two
earlier pregnancies for Ms C.) Ms C told staff that she wanted to keep the baby.
38. On 14 June, a nurse recorded in Ms C’s medical record that she had seen the
prison midwife and been told that her baby had an increased risk of Down’s
Syndrome. (A scan on 28 June confirmed that this risk was low.) Later, an RM
recorded that Ms C was upset about the diagnostic testing and she advised her that
if she continued with the pregnancy there was a high chance that intrauterine
transfusions (a medical procedure where substances are introduced directly into the
uterus) would be required, as with her previous pregnancies, and that those
appointments would be arranged at short notice as they would be directly related to
her blood results.
39. On 16 June, Ms C met a mental health nurse. They discussed the possibility that
the baby would potentially have additional needs. The nurse noted that Ms C was
calm and relaxed and trying to process this news. Ms C asked if she could restart
antidepressant medication and the nurse advised her to book a GP appointment.
40. On 19 June, Ms C attended an appointment in the fetal medicine department at
Royal Derby Hospital. She had blood tests and was advised she would have to wait
for the results and a follow up appointment. The next day, Foston Hall held a
multidisciplinary perinatal meeting attended by prison and healthcare staff. They
discussed Ms C’s pregnancy and the concerns around her baby’s health. They
recorded that Ms C was waiting for her test results. The RM was assigned to liaise
with the antenatal team to establish a plan for Ms C.
41. On 21 June, an RM recorded that Ms C was generally well. They discussed the
normal pattern for fetal movements and the RM provided Ms C with information on
normal fetal movement pattern and fetal development. Ms C asked to start
antidepressants as she said she was a ‘bit up and down’.
42. On 22 June, Ms C did not attend an appointment with the GP. It is likely this
appointment was to discuss antidepressant medication, but it is not recorded in the
health records what the purpose of this appointment was.
43. On 27 June, Ms C attended an appointment with the fetal medicine team. When she
returned to Foston Hall, Ms C told the nurse that she had received positive news at
the hospital, and she showed him a scan of the baby. The next day, an RM
recorded in Ms C’s medical record that there was a strong possibility of the need for
intrauterine transfusions, and Ms C would need regular scans to ensure that any
fetal anaemia was detected early.
Prisons and Probation Ombudsman 8
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
44. On 29 June, Ms C met a GP at Foston Hall and said that she was struggling with
her mood and was not sleeping. The GP recorded that she would prescribe
sertraline (an antidepressant).
45. On 6 July, Ms C attended hospital for a scan and met a specialist drug and alcohol
midwife. In an email forwarded by the hospital midwife to the prison midwife, it was
noted that during Ms C’s hospital appointment she disclosed she had been
experiencing some withdrawal symptoms in the evenings. The specialist midwife
suggested a small increase in Ms C’s methadone to reduce the negative impact
withdrawal symptoms could have either on the baby’s growth, or the possibility that
this could trigger miscarriage/premature labour. (This was implemented later that
week.)
46. On 14 July, Ms C attended an outside hospital appointment for a scan. She told a
nurse on her return to Foston Hall that she was concerned about the continuity of
her antenatal care as she could soon be released from prison when she next
attended court. The RM was notified.
47. On 17 July, the RM recorded that the recent scan results showed there was no
evidence of hydrops fetalis (severe swelling in an unborn baby).
48. On 19 July, the RM completed a maternity assessment and recorded no concerns.
Ms C asked the RM to contact the hospital to transfer her care if she was released
from court and the RM emailed the hospital to alert them to her possible release
from Foston Hall. The RM recorded that she sent an email to Ms C’s local hospital
and Royal Derby Hospital to update plans.
49. On 21 July, Ms C appeared in court and was sentenced to 12 months in prison. Due
to the time she had spent on remand, she was released directly from court.
50. On 26 July, Ms C contacted the RM to say she was concerned about her baby’s
movements and that she was not on the correct dose of methadone. The RM
advised her to contact the Pregnancy Assessment Unit (PAU) at her local hospital
and gave Ms C their telephone number. There was no further contact from Ms C to
the RM before her return to custody.
10 October 2023 - return to custody
51. At around 3.30pm on 10 October, Ms C arrived at Foston Hall having been arrested
following her recall. The reception process was completed, and staff noted that Ms
C was approximately 34 weeks pregnant and did not raise any concerns. Ms C
reported that she had only attended one midwifery appointment in the community
since her release in July.
52. An officer, the Pregnancy, Mother and Baby Liaison Officer (PMBLO – the key
purpose of the role is to enable early identification, contact and signposting to
support services for pregnant women and mothers) met Ms C in Reception. She
noted that Ms C was in good spirits. The officer recorded that the expected date of
delivery was 21 November, and they discussed arranging authorisation to visit for
Ms C’s birthing partner in case of an early labour. The officer contacted the RM to
advise her that Ms C was back in custody and arranged for an appointment with the
RM the next day.
Prisons and Probation Ombudsman 9
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
53. At 3.37pm, a nurse completed the initial health screen and noted Ms C’s physical
and mental health history. All clinical observations were within the normal range. Ms
C said that she no longer received a methadone prescription and was buying
approximately 40mls a day. She reported using opiates and benzodiazepines daily.
Ms C tested positive for methadone, cocaine and benzodiazepines. Ms C said that
she never drank alcohol. She told the nurse that the baby was moving well and that
she had no concerns. Ms C said that she had only attended one antenatal
appointment in the community since her discharge from court. Ms C disclosed she
was awaiting a hip and knee replacement and the nurse noted she had a constant
limp and used crutches to help her mobilise.
54. At 4.10pm, an advanced nurse practitioner (they can assess, diagnose, manage,
and care for patients with complex clinical issues) met Ms C. The nurse detailed Ms
C’s substance misuse history and noted some signs of withdrawal. She started Ms
C on a methadone maintenance programme and pregnancy vitamins. (Ms C’s
methadone prescription was 10mls each morning, evening and night for the first two
days, increasing to 15mls morning, evening and 10mls at night. Between 13-23
October, Ms C was prescribed 20mls each morning and evening.) Ms C told the
nurse that she had engaged with her antenatal care in the community but went on
to say that ‘they’ll say I haven’t’.
55. Ms C arrived with a supply of sertraline, but the nurse did not prescribe it as it was
not recorded on Ms C’s summary care record (an electronic summary of key clinical
information), and she wanted to check it was safe to prescribe during pregnancy.
An appointment was booked for Ms C to meet the prison midwife the following day.
The nurse created a care plan for the management of Ms C’s substance misuse.
The nurse recorded that Ms C needed crutches due to hip problems.
56. Staff allocated Ms C a single cell on the induction unit. A Pregnancy Support Plan
was started, and Ms C signed a compact giving permission to share relevant
information about her pregnancy with other organisations. Because Ms C was in her
third trimester, prison staff were to observe her hourly and record comments each
morning and afternoon. (Staff completed the observations, but most of the
conversations were left blank).
11-13 October
57. At 8.25am, an HCA completed Ms C’s secondary health screen. He noted her
medical history, including Ms C’s pregnancy, and that she had Hepatitis C (an
infectious disease affecting the liver, often acquired through intravenous drug use)
but could not start treatment until after the birth.
58. At around 9.30am, another HCA, substance misuse team, assessed Ms C. The
HCA recorded that Ms C showed no signs of toxicity and all her clinical
observations were within the normal range.
59. At 2.10pm, the RM met Ms C and recorded that she had not had any antenatal care
since 8 August. The RM noted that Ms C showed signs of drug withdrawal and
looked ‘very thin’. She made an appointment for Ms C with the hospital fetal
medicine team for 18 October. The RM noted that Ms C’s pregnancy was high risk
and confirmed that she had the contact details for the PAU on her in-cell phone.
She also recorded that they discussed vigilance on fetal movements. There was no
Prisons and Probation Ombudsman 10
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
mention of rhesus immunisation or an antenatal care plan in the RM’s medical
record entry. Although Ms C consented to having blood and urine samples taken
there is no evidence in her medical record to confirm that these were taken and
there are no subsequent results recorded.
60. At around 3.50pm, a psychosocial substance misuse recovery worker, who is also
the perinatal lead for that team, met Ms C and introduced herself as her key worker.
Ms C said she was feeling the effects of withdrawal and asked for her methadone to
be increased. The recovery worker explained that it could not be increased at that
time (she did not record why) but that hopefully she should start to feel better.
61. At 5.00pm, the prison pharmacist completed a medicines reconciliation review and
confirmed that Ms C could be prescribed sertraline. However, there is no evidence
in Ms C’s medical record that it was prescribed to her.
62. At around 8.50am on 12 October, an HCA assessed Ms C, who told her that she
was not sleeping and felt stressed and worried about the baby. Ms C said she was
experiencing cold sweats, felt sick and had back ache. The HCA encouraged Ms C
to continue taking her symptomatic medication for nausea and general aches and
recorded that all her clinical observations were normal. The HCA assessed Ms C
again in the afternoon, and although she reported still feeling achy said she felt
better than she had earlier. All Ms C’s clinical observations were within normal
parameters.
63. On 13 October, a multi-disciplinary team meeting was held (where pregnant
prisoners are discussed); this is not recorded in Ms Cs health records. However, at
this meeting, the Operational Head of Perinatal Health completed a Mother Care
and Management Plan (MCMP) for Ms C as the PMBLO was on annual leave.
There is no record of who attended this meeting. In the MCMP, Ms C’s details and
EDD were recorded and that social services and the prison midwife had been
informed she had arrived at Foston Hall. In the healthcare section, the Operational
Head of Perinatal Health noted that Ms C was detoxing and had been referred for a
prescription of aspirin. No mental health needs were identified, and it was noted that
Ms C would receive support from Birth Companions (a charity to support pregnant
women and mothers in prison) each Tuesday. There was nothing recorded about
Ms C having a high-risk pregnancy in the healthcare or additional comment
sections.
64. In the afternoon, an HCA completed a substance misuse assessment and noted
that Ms C had no signs of sedation or toxicity. Ms C reported that she had achy
bones and had been sick. She was advised to ask for symptomatic medication.
Events from 14 October
65. At around 11.15am, Ms C told a nurse that the baby’s movements had reduced. He
advised her to monitor the movements and if they continued to reduce or stop then
she should contact the healthcare team and they may need to escalate to the PAU.
The nurse told Ms C that she would be checked again later that afternoon when she
collected her methadone. The nurse recorded in Ms C’s medical record that her
clinical observations were normal, although she was showing mild withdrawal
symptoms.
Prisons and Probation Ombudsman 11
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
66. At around 4.00pm, the nurse completed the planned welfare check with Ms C. She
told him that she was concerned as she had not felt any movements since the
morning, and she had some lower chest wall pain. The nurse recorded that he
obtained Ms C’s consent and examined her stomach. He noted that he thought the
baby’s foot was positioned under Ms C’s ribcage and he told her that this may have
been the cause of her discomfort. An HCA contacted the PAU, and the midwife that
he spoke to also spoke directly to Ms C. She was advised to attend the hospital.
67. At 6.15pm, Ms C left Foston Hall by car, escorted by two prison officers. Prison staff
completed an escort risk assessment, which noted that Ms C was a low risk of
escape and low risk to the public, and that at least one of the escorting officers had
to be female. Healthcare staff noted that they did not have any medical objection to
restraints being applied but that Ms C was a ‘pregnant prisoner’. Ms C was not
restrained.
68. At around 6.40pm, Ms C arrived at the Royal Derbyshire Hospital, and staff at the
PAU assessed her.
69. Foston Hall attempted to telephone Ms C’s mother, her nominated next of kin, to
inform her that she had been taken to hospital, but the calls were not answered. Ms
C provided her partner’s telephone number, and he was informed of the situation.
70. At 7.45pm, two officers from other prisons arrived to take over the bed watch.
Officers from Foston Hall gave a handover to these staff, which was noted in the
Person Escort Record (PER - a document that accompanies all prisoners when
they move between police stations, courts, hospitals, and prisons which sets out the
risks they pose).
71. At 11.15pm, after a period of assessment and monitoring at the hospital, a doctor
told Ms C that her baby would have to be delivered by caesarean section. Around
an hour later, she was taken into theatre.
72. At 1.06am on 15 October, Baby C was delivered by caesarean section, but was not
breathing. Hospital staff started neonatal resuscitation and after 25 minutes they
established a heartbeat. Baby C was moved to intensive care. The baby had
numerous health problems, and hospital staff recorded that the baby was unlikely to
survive.
73. The bed watch staff were traumatised by events. They contacted Foston Hall to ask
if they could be replaced. At 2.30am, two officers from Foston Hall took over the
bed watch duty. Ms C was able to visit her baby in intensive care before moving to
a ward.
74. At 7.20am, when day shift staff took over from the night bed watch staff, they found
that the current bedwatch staff had applied standard handcuffs. There is no record
of who applied restraints, at what time, or whether this was authorised by a
manager. The Head of Safety and Equalities later told us that a CM (the duty night
manager) had authorised use of handcuffs.
75. At 8.15am, the bedwatch staff contacted The Head of Safety and Equalities and a
CM, as a nurse on the maternity ward had raised concerns with the bed watch staff
Prisons and Probation Ombudsman 12
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
about Ms C being in handcuffs. They authorised that the restraints were removed
immediately.
76. Hospital staff kept Ms C informed about Baby C’s health and treatment and prison
staff continued to provide support. Ms C was able to visit her baby in the neonatal
care unit and was told that if Baby C stabilised they might be moved to Queen
Elizabeth Hospital in Nottingham. (This did not happen as Baby C was not well
enough to be transferred.) Foston Hall arranged a taxi for Baby C’s father to travel
to the hospital. He was allowed to stay with Ms C throughout her time in hospital.
77. At 3.45pm, the prison chaplain and the hospital chaplain blessed Baby C. The
Operational Head of Perinatal Health arranged for photographs to be taken of Baby
C (at Ms C and her partner’s request), and foot and handprints were taken. Over
the next few hours, Baby C underwent several clinical procedures.
78. At 6.05am on 16 October, Baby C died.
Care for Ms C following Baby C’s death
79. While Ms C was in hospital her partner was allowed to remain with her. As well as
the support she received from Foston Hall bed watch officers, she was visited
regularly by various staff, including the Operational Head of Perinatal Health, an
RM, and the PMBLO. Ms C told the investigator that she was very grateful for the
support she received.
80. On 19 October, Ms C was discharged from hospital and escorted back to the
prison; handcuffs were applied. The PMBLO authorised additional vapes, PIN
phone credit and writing materials so Ms C could maintain contact with her partner
when she returned to Foston Hall. SAND, a baby loss helpline number, was added
to her in-cell phone contacts. Ms C asked the PMBLO to tell her friends on the wing
that her baby had died, as she did not want to face questions on her return. The
PMBLO arranged for fresh bedding and clothes for Ms C when she arrived back at
Foston Hall and, at her request, Ms C was allocated a single cell.
81. A nurse met Ms C on her return and noted that she was tearful, but grateful to have
had the opportunity to spend time with her baby. The nurse recorded that she had
referred Ms C to the mental health team, and that she could contact the healthcare
team at any time for support. Ms C asked for her anti-depressant medication to be
prescribed.
82. Ms C continued to receive regular contact from the mental health team and the
prison chaplain to support her with her bereavement, as well as support from wing
staff. In addition, Ms C had regular contact with Birth Companions.
83. The PMBLO and RM helped Ms C plan the funeral arrangements. Birth
Companions supported Ms C during these arrangements and provided an outfit for
Baby C. The PMBLO left her role in mid-November but ensured that Ms C was
made aware of her departure in good time and that all information was handed over
to the new PMBLO.
84. Baby C’s funeral was held on 29 November, and the prison contributed to the costs,
in line with national guidance. Ms C attended. At her request, prison staff also
Prisons and Probation Ombudsman 13
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
attended the service. Foston Hall also held a blessing ceremony in the prison
chapel on 15 December.
Support for prisoners and staff
85. The staff care team and trauma risk management (TRiM) were made available to
staff who were involved with Ms Cs care and most said they felt well supported.
However, the RM did not feel supported by Foston Hall or the Royal Derbyshire
Hospital. The RM said she felt that she had done her best to care for Ms C but felt
pulled between the prison and hospital and felt that ‘nothing was good enough’.
Post-mortem report
86. The pathologist concluded that Baby C died from meconium aspiration (occurs
when a new born breathes a mixture of meconium and amniotic fluid into the lungs
around the time of delivery), leading to hypoxic ischaemic encephalopathy (a lack of
oxygen to the brain before or shortly after birth), causing fetal distress (a baby’s
heart rate gets faster or slower before birth and is a sign they may not be getting
enough oxygen) and hydrops fetalis (severe swelling in an unborn baby).
87. Toxicology tests showed that Baby C had a very low concentration of total morphine
(which is morphine itself and its metabolites), which may reflect medical intervention
or the prior exposure to a compound containing or metabolised to morphine (such
compounds include morphine sulphate, heroin, and codeine). The pathologist noted
that a review of Baby C’s medical notes would determine if morphine or a
compound metabolised to morphine was administered during his care.
88. There was evidence of exposure to methadone. The concentration of methadone
was very low; however, some respiratory depressant and sedative effects could not
be ruled out.
Prisons and Probation Ombudsman 14
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Findings
Clinical care
89. The clinical reviewers found that the general nursing care, including Ms C’s physical
health and management of her substance misuse, were equivalent to that she could
expect to receive in the community. However, they concluded that the standard of
pregnancy care was not equivalent. The clinical reviewers have made
recommendations not directly related to Baby C’s death, which we have not
included in our report, but which the Head of Healthcare will need to address.
Prison midwifery care – return to HMP Foston Hall
90. The clinical reviewers found that despite the RM’s awareness of Ms C’s rhesus
isoimmunisation and the extremely high-risk nature of this condition, there was no
specific mention of the rhesus isoimmunisation and the implications for the unborn
baby in her documentation on Ms C’s medical record. There was no evidence that a
full antenatal assessment had been completed when she returned to Foston Hall in
October, neither had information been formally passed to prison staff (including
healthcare staff) about the high-risk nature of her pregnancy. The clinical reviewers
considered these to be significant omissions by the midwife as, on her return to
prison on 10 October, Ms C required urgent referral back to the fetal medicine team
at the hospital without delay.
91. The consultant midwife clinical reviewer considered that arrangements should have
been made for Ms C to be seen urgently when she returned to Foston Hall,
particularly as she had had limited antenatal care in the community after she was
discharged from prison in July. The RM contacted the hospital, and an appointment
was made for 18 October, despite the high-risk circumstances of her pregnancy.
The details of the RM’s call to the hospital are not recorded in the medical record.
The clinical reviewers concluded that the RM should have escalated Ms C’s care to
a consultant or senior obstetrician and discussed Ms C’s pregnancy with her line
manager or another senior midwife.
Prison midwifery care – record keeping and service provision
92. The clinical reviewers found that, overall, the entries made in Ms C’s prison medical
record by the RM were very limited and lacked detail. There was no template for
recording a full antenatal check and the RM did not use sufficient detail using free
text. The RM did not document a full antenatal assessment when Ms C returned to
prison and although she assessed the fetal heart rate, the results were not
recorded. The RM explained at interview that she was required to record her
contacts on three different systems: SystmOne (prison medical record), Lorenzo
(UHDB - hospital record) and the patient’s own handheld maternity records. The
clinical reviewers found that the requirement to document clinical care/findings in
three separate locations was a significant concern and the recording of pregnancy
care on the prison medical record was not fit for purpose.
93. The investigation identified that much of the communication described by prison
and healthcare staff, including the prison midwife, relied on conversations,
telephone calls and emails. There was an over-reliance on individual contacts and
Prisons and Probation Ombudsman 15
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
established relationships between staff, with little documentation on the prison or
medical records. A lack of recorded and accessible information to those who
needed to understand Ms C’s pregnancy was a potential risk.
94. At the time Ms C was at Foston Hall, the midwife was contracted to work 15 hours a
week at the prison. We understand that consideration is being made to increase this
to 25 hours a week. We were given conflicting information about what cover was
provided when the RM was on leave or absent from work. The RM said that when
she is in Foston Hall she meets weekly with all pregnant prisoners in the second
trimester onwards (14 – 26 weeks pregnant). She said the Juno Team provide
support when she is on leave as/when requested by the pregnant prisoners. During
Ms C’s first period at Foston Hall, between 1 June – 21 July (Ms C was recorded as
16 weeks pregnant on 9 June), the RM made entries in Ms C’s medical record on
28 June, 6 July (added by a healthcare administrator), 17, 18 and 19 July. Another
RM made entries on 7, 14 and 21 June. None of these entries refer to Ms C’s
pregnancy being high risk.
95. The clinical reviewers found that the RM was working in isolation at Foston Hall,
with little accountability and no direct supervision. We make the following
recommendations:
NHS England should commission an independent review of the standard of
midwifery care provided at HMP Foston Hall. The review should include the
standard of midwifery documentation; the nature and content of clinical
contacts; referrals completed, communication and escalation pathways; and
supervision of midwifery care at HMP Foston Hall.
The Head of Healthcare should review the prison medical record to ensure
that key information regarding a pregnancy and any associated care plans are
easily accessible to all healthcare staff.
96. Despite the clinical reviewers repeated and escalated requests for access to Ms C’s
relevant maternity hospital records from UHDB, and Baby C’s neonatal records,
they were not provided until the PPO’s initial report was issued for consultation
(they never received Ms Cs hand held maternity records). The clinical reviewers
said that this hindered their review of the care received which then necessitated
amendments to their clinical review report. We make the following recommendation:
NHS England should ensure that all relevant community and hospital records
are provided for the purpose of a PPO investigation following the death of a
baby.
Reduced fetal movements on 14 October
97. When Ms C told a nurse that the baby’s movements had reduced, he did not think it
was necessary to contact the prison midwife and/or the PAU. The clinical reviewers
noted that fetal movements are the single most important indicator of fetal wellbeing
and any reduction in fetal movements should cause concern and should prompt
immediate escalation to the PAU for review. The nurse is not a midwife, and he did
not have the expertise to decide not to escalate Ms C’s report of reduced fetal
movements to a midwife and/or PAU.
Prisons and Probation Ombudsman 16
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
98. The nurse recorded in Ms C’s medical record that he had examined her. In
interview, the nurse clarified that he did not examine Ms C, but when she lifted her
top, with her permission, he felt her abdomen with his hand and gave an opinion
that he thought her discomfort could be because the baby’s foot was pushing up if
the head was engaged.
99. The clinical reviewers raised their concerns about the nurse’s actions immediately
after his interview. They noted that all registered nursing staff must recognise the
limitations of their professional registration and practice within their scope of
professional practice. The clinical reviewers referred the nurse to the Nursing and
Midwifery Council (NMC - independent regulator for nurses and midwives in the UK,
and nursing associates in England). As these concerns are now being investigated
by the NMC we do not make a separate recommendation.
Medication
100. Ms C was prescribed an anti-depressant (sertraline) when she was previously at
Foston Hall. When she returned to Foston Hall on 10 October, a nurse recorded
that Ms C had arrived with this medication but that it was not recorded on her
summary care record, and she incorrectly noted that there were prescribing risks as
Ms C was pregnant.
101. The clinical reviewers found that the prescribed anti-depressant, which is safe
during pregnancy, was abruptly discontinued, contrary to best practice. This was
despite Ms C having been recalled to prison, at an advanced stage of pregnancy,
and that she was exhibiting opiate withdrawal symptoms. The sudden cessation of
anti-depressant medication can lead to a return of symptoms and/or the possibility
of a ‘psychiatric emergency’ and can potentially be dangerous to the baby’s health
during the third trimester of pregnancy. The nurse did not seek immediate advice on
prescribing sertraline during pregnancy.
102. On 19 October, when Ms C returned to Foston Hall after the birth of Baby C, during
her re-admission assessment, she asked to be prescribed her anti-depressant and
an appointment was booked with the prison GP. This appointment was not for five
days. Ms C was bereaved and had a history of depression. The clinical reviewers
concluded that the management of Ms C’s anti-depressant medication was of a
poor standard. We make the following recommendation:
The Head of Healthcare should ensure that nurse prescribers are adequately
informed regarding antidepressant medication, including what is safe to use
in pregnancy, and the risks associated with immediately stopping prescribed
medication.
The Head of Healthcare should ensure that all bereaved prisoners who
request antidepressant medication are seen by a GP and/or nurse prescriber
in a timely manner.
Supporting pregnant prisoners
103. Supporting Women Experiencing Pregnancy, Mother and Baby Units, and Maternal
Separation from Children up to the Age of Two in Women’s Prisons – Operational
Guidance issued on 20 September 2021 and re-issued on 17 May 2023, together
Prisons and Probation Ombudsman 17
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
with the Policy Framework issued in September 2021, provide guidance for prison
staff at all levels and is a reference for prisons to develop their own local policies
and partnerships with other agencies. The guidance sets out that a trauma-informed
responsive person-centred approach should be taken and based on the individual’s
specific circumstances and needs.
104. Pregnant Mother and Baby Liaison Officers are required to meet with a pregnant
prisoner within five days of their arrival. The PMBLO met Ms C in Reception on the
day she arrived and informed the midwife and social services, which was in line with
guidance and good practice. She ensured wing staff were aware of the need to
monitor Ms C hourly, using the Pregnancy Support Plan, as she was in her third
trimester. Staff completed the observations hourly, but the requirement to write a
comment/summary each morning and afternoon by wing staff were not completed,
and these omissions were not identified during quality assurance checks. We make
the following recommendation:
The Governor should ensure that all required observations, comments and
summaries are recorded in a prisoner’s Pregnancy Support Plan, in line with
national and local guidelines.
Training
105. There is an eLearning training package, HMP Pregnancy and Perinatal Care in
Prisons, which takes around 45 minutes to complete. This training has three
modules and a course evaluation form: Supporting pregnancy in Prisons; An
Introduction to Mother and Baby Units in Prison and; Mother and Baby Unit, which
staff working in female prisons are expected to complete but is not mandatory.
There is no other training which we identified for staff working with pregnant
prisoners, beyond this eLearning package. Many staff we spoke to during our
investigation were aware there was an online training package, but not all had
completed it. The PMBLO had completed this training, but the perinatal lead for the
substance misuse team had not.
106. We were told that after the death of Baby C, the RM supplied posters which
included information on ‘red flags’ during pregnancy, including reduced fetal
movements, and which were displayed around the prison. However, many of the
staff did not know where these posters were and could not describe the content or
purpose of the posters and they did not know who the posters were aimed at (e.g.
staff or prisoners). No communication or further training regarding the information
on these posters was provided.
107. The investigator completed the eLearning and found that the information provided
does not include information on reduced fetal movements, a high-risk indicator for
any pregnancy.
108. We therefore make the following recommendations:
The Prison Group Director for the Women’s Estate should review the current
training package for staff working directly with pregnant prisoners, to ensure
they receive training to equip them with the required skills and knowledge to
care for pregnant prisoners safely. This training should include the
Prisons and Probation Ombudsman 18
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
importance of fetal movements and escalation pathways if a prisoner reports
reduced fetal movements.
Restraints, security and escorts
109. The Prison Service has a duty to protect the public when escorting prisoners
outside prison, such as to hospital. It also has a responsibility to balance this by
treating prisoners with humanity. The level of restraints used should be necessary
in all the circumstances and based on a risk assessment, which considers the risk
of escape, the risk to the public and takes into account the prisoner’s health and
mobility. A judgment in the High Court in 2007 made it clear that prison staff need to
distinguish between a prisoner’s risk of escape when fit (and the risk to the public in
the event of an escape) and the prisoner’s risk when suffering from a serious
medical condition. It said that medical opinion about the prisoner’s ability to escape
must be considered as part of the assessment process and kept under review as
circumstances change.
110. Foston Hall’s Local Security Strategy, Hospital Escorts – Prisoners Under Escort to
Give Birth states that physical restraints must not be applied during the escort to the
hospital and may be applied on the return journey if the child is not present. In
addition, on 12 November 2021, Foston Hall issued a Staff Information Notice that
stated any pregnant prisoner would not be restrained when attending a medical
appointment and that there must be significant evidence to inform a decision to
apply restraints. Both instructions formed part of the escort risk assessment booklet
that travelled with prison staff to the hospital.
111. When Ms C was discharged to hospital the escort risk assessment notes that her
escape risk was low and that she was a low risk to the public. Other than identifying
that Ms C was pregnant, there were no other comments about other physical issues
which were pertinent when assessing Ms C’s level of escape risk, including her
poor mobility. In line with policy, restraints were not used when Ms C went to
hospital.
112. The bed watch occurrence log shows that restraints were applied on 15 October,
only hours after Ms C had given birth. We were not able to determine exactly when
restraints were applied. The Head of Safety and Equalities said that this was a
mistake and speculated that it may have been because the duty manager was used
to working within the male prison estate and had not experienced working with
pregnant women.
113. When Ms C was returned to Foston Hall, restraints were applied. Ms C told the
investigator that she was told that restraints would not be applied until they were at
the entrance of the hospital, but said they were applied in the ward. At 1.40pm,
there is an entry in the bedwatch log ‘cuffs to be applied’ and Ms C arrived back at
Foston Hall at 2.50pm. There was no entry made in the bed watch log as to the
specific time/place restraints were applied and no indication that the escort risk
assessment was reviewed or revised.
114. We recognise that many factors must be considered in determining whether
restraints should be applied. However, Ms C had undergone a caesarean section,
and her baby was gravely ill; she also had physical health needs which restricted
her movement, which were not recorded. She was assessed as a low risk of escape
Prisons and Probation Ombudsman 19
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
and to the public. The decision to restrain her at any point, especially within hours of
giving birth, was not proportionate to her risk and was not in accordance with the
pregnant prisoner protocol. We note that the current policy refers to ‘pregnant’
women, which could have caused confusion in Ms C’s situation as she was no
longer pregnant when restraints were applied. We therefore make the following
recommendation:
The Governor should ensure that local policy regarding Hospital Escorts –
Prisoners Under Escort to Give Birth is revised to include guidance to staff
following a birth, including that:
• Prisoners who have given birth are not restrained in hospital unless
there are significant indicators of high risk of escape or to the public;
and
• The escort risk assessment is reviewed and revised before the prisoner
returns from hospital, giving consideration to information about their
current health and mobility.
Staff conduct during bed watch
115. Ms C told the investigator that hospital bed watch staff did not behave appropriately,
and she made several allegations about their conduct. The staff involved were not
from Foston Hall, but staff from other prisons who had volunteered to undertake bed
watch duties (when a prison do not have sufficient staff to complete the role
internally).
116. We told the prisons where these officers are based about the allegations, and they
subsequently conducted local investigations. As a result, two staff were given
advice and guidance, and one officer received a verbal warning. We are satisfied
that the respective prisons have taken appropriate action.
Inquest
117. The inquest into Baby C’s death concluded on 25 September 2026. The medical
cause of death was recorded as: 1a Meconium Aspiration leading to Hypoxic
Ischaemic Encephalopathy (occurs when a newborn aspirates meconium, a thick
and sticky substance from the first bowel movements, into the airway which can
lead to a lack of oxygen and blood flow), 1b Foetal Distress (usually due to
insufficient oxygen or nutrient supply during late pregnancy or labour), 1c Immune
Hydrops Fetalis, 1d Haemolytic disease of the foetus and newborn (where the
mother’s antibodies attack foetal red blood cells, leading to anaemia and jaundice),
and 2 Prematurity at 34+5 weeks.
118. The Coroner concluded that Baby C died due to complications of severe immune
hydrops fetalis because of untreated haemolytic disease. The Coroner found that if
Baby C had received the in-utero treatment that had been planned for him when it
was assessed as needed, it is highly unlikely that he would have died.
119. The Coroner also found that Baby C's death was contributed to by Baby C's
mother's personal circumstances and difficulties after returning to her home area
Prisons and Probation Ombudsman 20
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
which likely affected her ability to engage and therefore probably more than
minimally contributed to Baby C's death.
Prisons and Probation Ombudsman 21
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Third Floor, 10 South Colonnade Email: mail@ppo.gov.uk T l 020 7633 4100
Canary Wharf, London E14 4PU Web: www.ppo.gov.uk
OFFICIAL - FOR PUBLIC RELEASE