The Birth Companions Institute responds to the publication of the Prisons and Probation Ombudsman’s report on the death of ‘Baby C’ (published 24th September 2026).
Public statement – 16 October 2026
Following the publication of the Prisons and Probation Ombudsman’s report on the death of ‘Baby C’ (published 24th September 2026) our thoughts are first and foremost with Ms C, and her family.
Baby C died in October 2023, a day after birth. Their mother had been in HMP Foston Hall after being recalled for breaching her licence conditions following a past offence. Her pregnancy was known to be extremely high risk. The Prisons and Probation Ombudsman has found that the pregnancy care she received in the prison was not equivalent to what she could have expected in the community and there were breakdowns and missed opportunities in the way her needs were communicated across multiple agencies. Ms C’s concerns about reduced fetal movements were not escalated as quickly as they should have been.
We are particularly appalled that Ms C was handcuffed within a few hours of giving birth by emergency caesarean section. This was a mother recovering from major surgery, whose baby was critically ill, and who had been assessed as a low risk of escape and to the public. The Ombudsman found that the handcuffs were applied inappropriately, with no clear authorisation and no record of when they were applied. Ms C was restrained again when she was taken back to prison, even though she was still recovering from surgery and her mobility was limited. Restraining a woman in these circumstances is degrading and cannot be justified. It shows a basic failure to recognise her as a new mother in crisis. No woman should be restrained during labour, birth or the postnatal period unless there is clear and significant evidence of risk. Every decision to use restraint must be properly justified, authorised, recorded and reviewed, as set out in the External Escorts Policy Framework.
The tragic death of Baby C also shows how dangerous transitions between prison and the community can be. Ms C had been released from her earlier sentence part-way through her pregnancy, and had only limited antenatal care in the community before she was recalled. When she came back into prison, her urgent need for specialist care wasn’t clearly recorded or followed up on.
We welcome the Ombudsman’s recommendations, including an independent review of midwifery care at Foston Hall, better training for staff on reduced fetal movements, and an end to the restraint of women who have just given birth unless there is a significant, documented risk. But recommendations like these have been made before, and written policy is clear on these issues, it just isn’t translated into practice. The question now is why, after years of reviews, policy frameworks and assurances, women in prison still aren’t getting safe, respectful and equivalent care.
The answer is that prison is not, and cannot be, a safe place to be pregnant. Remand, sentences and recalls send pregnant women with complex needs into prison, and transitions in and out of custody can lead to continuity of care breaking down just when it matters most.
The Chief Medical Officer for England, Professor Sir Chris Whitty, warned last year in his report on the health of people in prison and on probation that “some of the greatest health risks predictably occur during and just after transitions: on arrival in prison; after transfer between prisons and just after release.” For pregnant women, those risks are amplified. Maternity, health and justice services need to work to shared, well-established pathways that make sure care plans, records and referrals follow the woman, so that no one’s pregnancy is lost track of at the prison gate, going in or coming out.
In light of this tragedy, which follows the deaths of Baby A in 2019 and Baby B in 2020, also the subjects of PPO investigations, we are calling on the government and on criminal justice and health agencies to:
• End the use of custody, including remand and recall, for pregnant women and mothers of infants wherever possible, and make sure pregnancy is considered in every decision to recall or remand.
• Put in place strong, coordinated care pathways for pregnant women entering prison on remand, sentence or recall, and for those being released, as the Chief Medical Officer’s findings on transitions demand. That means named responsibility for handover between community and prison maternity services, shared records, and a full antenatal assessment and specialist referral on entry and release from custody.
• Make sure national policy, which prohibits the restraint of women during pregnancy, labour, and recovery after birth unless there is significant, documented risk, is followed in practice in every prison across the women’s estate.
• Implement all of the PPO’s recommendations without delay, and publish how they have been acted on across the whole women’s estate. The omissions in the current training package for staff working with pregnant women in prisons, including the importance of acting on reports of reduced fetal movement, must be addressed immediately.
• Guarantee that every pregnant woman in prison has timely access to specialist maternity care, that there are clear escalation pathways for concerns, and midwifery care is properly supervised and accountable.
Birth Companions is ready to support all agencies involved in this work.