Damning report into case of woman left alone to give birth in jail cell at Bandyup

Bandyup Women's Prison, Middle Swan. Picture: David Baylis
Bandyup Women's Prison, Middle Swan. Picture: David Baylis

THE Inspector of Custodial Services, Neil Morgan, has released a damning assessment about the treatment of a prisoner at Bandyup Women’s Prison who was left alone pleading for help while she gave birth in a locked cell.

On March 11, despite pleading for help multiple times for over an hour, Amy* gave birth alone in a locked cell at 7.40pm.

Staff observed events through a hatch in the cell door, but the door was not unlocked until several minutes after the birth.

On releasing a summary of his report into the birth, Mr Morgan said he wanted to know how such a distressing, degrading and potentially fatal event could occur in a 21st century Australian prison.

“We found that human, procedural and systemic failings combined to create serious and avoidable risks to both mother and child,” he said.

“First, staff were slow to act even though they knew Amy* was in the late stages of pregnancy.

“We listened to recordings of numerous cell calls in which her pain and distress were obvious.

“Staff who came to talk to her during this time would also have been very aware of her escalating condition.

“I find it inexcusable that Amy* did not have medical staff with her when giving birth, and that it was only after her child was born that staff called a code red emergency.

“This was clearly an emergency well before then.”

Mr Morgan said it was also inexcusable it took up to 12 minutes for the cell door to be opened after the code red was called.

“In a prison a delay in responding to a medical emergency could be fatal,” he said.

“This was obviously a high risk situation for Amy* and her child.

“She was in a cell, not a sterile environment, and none of the standard perinatal checks for the mother and the newborn were available.

“In Amy’s case, many things could have gone wrong.”

Mr Morgan said procedural weaknesses also played a role.

“Communication between staff was poor, cell keys were not readily available, and staff shift changes seemed to take priority over caring for Amy*,” he said.

“On top of this, records were incomplete.

“Staff had not bothered to log cell calls from Amy and other distressed women, in clear disregard of local orders.

“Finally, the prison downplayed the seriousness of the events when reporting to head office.

“It is not clear if this was because staff had become desensitised to risk and duty of care, or if it was an attempt to mislead.”

Mr Morgan also drew attention to long-term failures in strategic planning for women in prison.

“In the last decade planning for female prisoners in general has been poor,” he said.

“It follows that there has been no proper planning for women in the late stages of pregnancy, whether at Bandyup or other prisons.

“As a result Amy* was in a wholly unsuitable cell when she gave birth.

“Pregnant women will continue to come into custody and the Department of Justice has an obligation to ensure the health and safety of mothers, unborn children and babies.”

Mr Morgan said the Department had accepted the report’s findings and had agreed that improvements are needed to infrastructure, operational processes, staff culture and training.

A number of measures have been implemented but many remain a ‘work in progress’.

Amy* is not her real name.