Baby of prisoner died after pregnancy complications, inquest jury finds
A one-day-old baby born to a Derbyshire prisoner died from pregnancy complications worsened by gaps in his mother's contact with maternity services after her release. An inquest jury ruled the death was likely preventable had planned treatment been given.
Orion Homer was born at Royal Derby Hospital on 15 October 2023, at 34 weeks and five days' gestation, and died the following day. His mother, Ellen Roberts, was an inmate at HMP Foston Hall and was taken to hospital after noticing reduced foetal movement.
An inquest at Derby Coroner's Court heard Roberts had spent part of her pregnancy in prison in June and July 2023, was released at the end of July, then recalled to custody on 10 October. Her pregnancy was classed as high risk due to a history of rhesus incompatibility, a condition where the mother's immune system attacks the baby's red blood cells. In two earlier pregnancies she and her babies had different rhesus blood types; one baby needed a transfusion after birth and another received one in the womb. Drug use and mobility issues added to the risk assessment.
While in prison, Roberts received weekly scans and stayed in close contact with prison medical staff and maternity services at Royal Derby Hospital. After her release, emails were sent to health bodies including the Dudley Group NHS Foundation Trust in the West Midlands, but prison staff could not arrange scans at Royal Derby Hospital because the trust required a full booking with local community midwives first. Access to antenatal care depended on Roberts completing that booking herself, and the trust did not refer her to Birmingham Women's Hospital.
The jury found that rigid policy created a systemic barrier to engaging Roberts with community midwifery care. When she returned to custody on 10 October, prison midwives discovered she had had almost no contact with community antenatal services, and a new appointment in Derby was only booked for the following week.
Orion died from complications of severe immune hydrops fetalis caused by untreated immunisation disease. The jury said it was highly unlikely he would have died had he received the treatment that had been planned for him. Premature birth and Roberts' personal circumstances after returning home were also listed as contributing factors. A post-mortem report noted Roberts was on a methadone programme and had used crack cocaine and heroin in the week Orion died.
Senior coroner Peter Nieto said he would issue a Prevention of Future Deaths report to NHS England and the Department of Health, citing the lack of a nationally agreed pathway to ensure pregnant prisoners leave custody with joined-up care.
