(To protect the mother’s privacy, we refer to her as ‘Amy’ throughout this review.)
On 11 March 2018, Amy and her baby were put at unnecessary risk. This risk was not recognised by local staff or the Department. It was caused by cascading failures, predominately due to inaction and poor communication.
These failures were compounded by inadequate infrastructure to support women in their late stages of pregnancy, a problem that has been brewing for over a decade. Amy was housed in a unit that was inappropriate for a pregnant woman. Her cell was located upstairs, and the retrofitted double bunk made the cell so cramped it was difficult for emergency aid to be provided.