Inmate's baby died due to pregnancy complications

The one-day-old baby of a Derbyshire prisoner died due to pregnancy complications and gaps in contact with maternity services while his mother was living in the community, an inquest jury has ruled.

Orion Homer was born at 01:06 on 15 October 2023 at Royal Derby Hospital at 34 weeks plus five days' gestation. He died the following day.

An inquest at Derby Coroner's Court heard his mother, Ellen Roberts, was a prisoner at HMP Foston Hall and was taken to the hospital on 14 October after she raised concerns about reduced foetal movement.

Senior coroner Peter Nieto read out the jury's narrative conclusion and said he would escalate their findings to NHS England.

Roberts had spent some of her pregnancy in prison in June and July 2023, before she was released at the end of July but recalled on 10 October, the jury inquest heard.

The jury heard Roberts' case had been classed as "high risk" due to previous positive rhesus pregnancies, where the mother's immune system attacks the baby's red blood cells.

Roberts had two previous pregnancies in which she and her babies had different rhesus blood types, jurors were told. One baby required a post-birth transfusion, while another had an intrauterine transfusion.

Her pregnancy was also classed as high risk due to her drug use and mobility issues.

The inquest heard she had weekly scans while in prison and was in close contact with prison medical staff and maternity services at Royal Derby Hospital, as well as a number of support agencies for substance misuse and mental health.

On her release from prison, various emails were sent to a number of health bodies including Dudley Group NHS Foundation Trust in the West Midlands.

The jury, in their conclusion, said prison staff could not book scans at Royal Derby Hospital just before her release as the Dudley Group Trust needed a full booking with the community midwives in their area for her to do so.

The jury said access to antenatal services was reliant on completion of a booking by Roberts and the NHS trust in turn did not make any referrals to Birmingham Women's Hospital as a result.

"The rigidity in policy created a systemic issue of engaging Orion's mother in community midwifery care within the Dudley Group," the jury said.

On her recall to prison on 10 October 2023, prison midwives found Roberts had next to no contact with antenatal services in the community and the process to get her seen regularly again in Derby was started with an appointment that was booked for the following week.

Roberts was taken to the hospital on 14 October after she raised concerns about reduced foetal movement. After abnormal readings following monitoring, she was escalated to the labour ward.

The inquest heard the only information shared about her was her previous pregnancies and substance misuse. "No concerns were raised about rhesus pregnancies" and medics had a "lack of prehistory", the jury was told.

This meant medics in Derby were "not able to make the necessary preparations" for post-delivery assessment and treatment by the neonatal team.

Orion was born on 15 October via caesarean section. He was described by a neonatal consultant as "gravely unwell and very pale" when he was born and was not breathing by himself.

Care was withdrawn at about 04:00 on 16 October after Orion failed to respond to a number of medical interventions, including a blood transfusion.

The jury said the option for an intrauterine transfusion - which delivers donor red blood cells directly into an unborn baby's circulation to treat severe foetal anaemia - could have been delivered by the 32nd week of pregnancy at the latest.

Orion died due to "complications of severe immune hydrops fetalis due to non-treated immunistic disease", the jury said.

"If Orion had received the treatment planned for him, it is highly unlikely he would have died," they said.

"His death was contributed to by Orion's mother's personal circumstances and difficulties after she re-entered her home area which might have affected the ability to engage [with midwives] and have therefore probably more than minimally contributed to Orion's death."

Premature birth was also listed as a contributing factor.

The post-mortem report said Roberts was in the methadone programme and had used crack cocaine and heroin during the week of Orion's death.

Senior coroner Peter Nieto said he would be issuing a Prevention of Future Deaths Report to NHS England and the Department for Health.

He said this was due to the "lack of a national agreed pathway" for the release of pregnant prisoners to "ensure they leave custody with joined-up care".

Listen to BBC Radio Derby on Sounds and follow BBC Derby on Facebook, on X, or on Instagram. Send your story ideas to eastmidsnews@bbc.co.uk or via WhatsApp on 0808 100 2210.