The Prisons and Probation Ombudsman (PPO) for England and Wales yesterday published its 50-page report on the incident, which took place nearly two years ago at privately-run HMP Bronzefield in the south of England.

INQUEST, a charity focused on state-related deaths, said the damning report “exposes the inhumane treatment of a young woman in need” and reflects the “systemic neglect of women’s health”.

It remains unclear whether the baby, known as Baby A, was born alive or was stillborn, and no inquest has so far been held.

However, the PPO report highlights a number of failings in the way prison authorities and healthcare services handled the care of the vulnerable 18-year-old mother, Ms A.

Prisons and probation ombudsman Sue McAllister said: “Ms A gave birth alone in her cell overnight without medical assistance. This should never have happened. Overall, the healthcare offered to Ms A in Bronzefield was not equivalent to that she could have expected in the community.”

According to the report, Ms A “appeared to have been regarded [by the prison and healthcare system] as difficult and having a ‘bad attitude’ rather than as a vulnerable 18-year old, frightened that her baby would be taken away”.

“She was a challenging person to manage but we found that the midwives’ approach to her care was inflexible, unimaginative and insufficiently trauma-informed and that there was no plan for dealing with a pregnant woman who refused to accept the usual procedures (which focused on her baby rather than on her),” the report states.

Among its recommendations is that the prison “should commission a local investigation into the failure to respond to Ms A’s request for a nurse and to answer her cell bell on the night of 26 September 2019 and consider whether disciplinary action is appropriate”.

Deborah Coles, director of INQUEST, said: “This harrowing report exposes the inhumane treatment of a young woman in need. It is further evidence of the inability and inappropriateness of prisons for keeping people facing serious trauma safe, and in this case their newborn babies.

“The findings reflect the broader issues of systemic neglect of women’s health, shown by ever rising self-harm and continued deaths of women in prison. Yet still the government plans to build 500 more prison places for women, when the reality is that this could happen again tomorrow.”

Elaine Macdonald of Tuckers Solicitors, who represents Ms A, said: “The failings identified in this report are truly shocking. A vulnerable young woman giving birth alone in a prison cell should never have happened, and the number of significant concerns raised about her treatment while in custody need to be urgently and fully examined.”