A newborn baby died after an 18-year-old inmate gave birth alone in her cell following a series of failings and “inadequate” care in Europe’s largest women’s prison, according to a watchdog.

Ambulance crews were called to HMP Bronzefield in Middlesex in September 2019 but the baby did not survive.

A police investigation was subsequently launched, treating the death as “unexplained”.

Sue McAllister, prisons and probation ombudsman (PPO), said the mother, known as Ms A, should not have been allowed to give birth without medical assistance in her cell.

“Ms A gave birth alone in her cell overnight without medical assistance. This should never have happened,” she said.

At least 10 separate investigations were launched into the baby’s death, with the PPO conducting the overarching probe.

There has not yet been an inquest into the death and a pathologist could not determine whether the baby was born alive or was stillborn, the watchdog said in its report, published on Wednesday.

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It said its findings highlight a catalogue of “troubling weaknesses” in the way the prison and healthcare services dealt with the mother and made a series of recommendations on how to improve the handling of pregnant prisoners.

The watchdog discovered Ms A had a “traumatic childhood” and was in prison for the first time.

She was regarded as vulnerable, “sad, angry and very scared” that her baby would be taken away from her.

Ms A also refused to attend appointments for scans and engaged “minimally or not at all” with the midwifery team at Ashford and St Peter’s Hospitals NHS Trust (ASPH) in Surrey.

The staff at Bronzefield thought Ms A was “difficult and having a ‘bad attitude’ rather than as a vulnerable 18-year-old, frightened that her baby would be taken away”, the report said.

It found the maternity services at Bronzefield were “outdated and inadequate” with limited visits from health professionals.

And though Ms A was believed to be a “challenging person to manage”, the approach to her care by midwives was found to be “inflexible, unimaginative and insufficiently trauma-informed”, and they were also not prepared to deal with a pregnant woman who refused to accept the usual procedures.

There was also a “lack of clarity” surrounding Ms A’s due date, with staff working her block not knowing she could give birth imminently.

The report added that there were “several missed opportunities” to increase observations in the days leading up to the birth, which may have prevented her going into labour alone, and the response to Ms A’s request for a nurse the day before was “completely inadequate”.

Justice Secretary Dominic Raab described the incident as “harrowing, unacceptable and should never happen to any woman or child”.

He added: “We have put in place important improvements to the care received by women in custody, and across government, we must make sure that expectant mothers in prison get the same support as those in the community.”

The Ministry of Justice (MoJ) said it was exceptionally rare for a woman to give birth in prison.

Female inmates have since been provided with phone access to advice services, social services support and welfare checks for pregnant women in their third trimester, the department said.

The NHS, which is now in charge of the healthcare budget for maternity services at the prison, has increased its budget in this area by 87% and put an ultrasound scanner inside the jail as part of a range of improvements, a spokeswoman said.

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