(To protect the mother’s privacy, we refer to her as ‘Amy’ throughout this review.)
There is not enough appropriate accommodation for women in the late stages of pregnancy
The Department has failed to adequately plan for the large increase in the female prison population, especially for women in the late stages of pregnancy. There is very little specialised accommodation for pregnant women or women with babies. The Bandyup Nursery is often full, as was the case when Amy was in custody. Amy was held in accommodation in Unit 2 which, as the Department now acknowledges, was unsuitable for someone in her condition.
Communication was poor
Amy provided substantial information to many staff to indicate she was in labour. This information was either not passed on to the right people, or was passed on in a way that did not convey the urgency of the situation. When information was passed on, the nurses and the Night Officer in Charge (OIC) did not seek further information in order to make an accurate assessment of what was occurring with Amy. Incomplete information led to poor decision making.
Staff were slow to act
Every person on night shift on 11 March was aware that Amy was in pain and distress for at least an hour before the birth. The situation escalated without staff recognising an emergency situation was developing or taking appropriate action.
Staff had both an individual and a shared responsibility to take action, but failed to do so. Whether this was from a desensitisation of staff to the suffering of Amy, a lack of knowledge or skills, or because each person assumed someone else would take responsibility for responding remains unclear. It was probably a combination of all three.
Record keeping and incident reporting was flawed
This incident raised serious accountability issues in the Department. Staff are not logging all cell calls despite a policy requirement to do so. Incident reporting was not accurate which led to the seriousness of the birth being down played and the incident being wrongfully classified. This should have been a critical incident, but was not initially recorded as such.
It was also difficult to establish a timeline of events because the Department claims that time stamps on records, including CCTV footage, are not synchronised.
It is imperative for the Department to have accurate records so it can investigate incidents and allegations. The flaws in record keeping and incident reporting prevent proper investigations.