Woman Forced to Give Birth Alone in Maximum Security Prison Cell as Nurses Instructed Her Through Door Hatch

A jailed Australian woman who was 36 weeks pregnant was forced to give birth alone in a locked prison cell, despite pleading for help multiple times.

The incident, which took place at Bandyup Women's Prison in the state of Western Australia, put her baby at "unnecessary risk," according to a report conducted by the state's Inspector of Custodial Services, Neil Morgan.

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The report exposed a number of failings including poor communication, staff being slow to act, flawed reporting of the incident and the fact that accommodation for prisoners in the late stage of pregnancy was inadequate.

"I wanted to know how such an event could occur in a 21st Century Australian prison and to prevent it happening again," Morgan said in a statement. "We found that human, procedural and systemic failings had combined to create serious and avoidable risks to both mother and child."

On March 11, at around 5.30 p.m. local time, the woman—identified only as Amy—called from her maximum-security cell to tell staff that she was distressed and possibly in labor. She was taken for a checkup and given paracetamol before being brought back to her cell. However, she became more distressed and gave birth at 7.40 p.m.

Nursing staff had arrived 5 minutes earlier but were forced to communicate with her through a hatch in the door because the only person who had keys to the cell was not present, the BBC reported.

In fact, the nurses did not gain entry to the cell until several minutes after the birth, according to the report. Fortunately, there were no complications and both Amy and her baby were transferred to a hospital later that evening.

The report highlighted how staff were slow to act even though they knew that Amy was in the late stages of pregnancy.

"We listened to recordings of numerous cell calls in which her pain and distress were obvious," Morgan said. "Staff who came to talk to her during this time would also have been very aware of her escalating condition. I find it inexcusable that Amy did not have medical staff with her when giving birth, and that it was only after her child was born that staff called a 'Code Red' emergency.

"This was clearly an emergency well before then. I also find it inexcusable that it took somewhere between seven and 12 minutes for the cell door to be opened after the Code Red was called. In a prison a delay of seven minutes, let alone 12, in responding to a medical emergency could be fatal. In Amy's case, many things could have gone wrong."

The report went on to show how procedural weaknesses played a role in the incident. Communication between staff was poor, cell keys were not readily available and staff shift changes seemed to take priority over caring for Amy.

Morgan also said that there was no proper planning for female prisoners in the late stages of pregnancy at Brandyup, (and indeed other prisons in Australia.) As a result, Amy was in a "wholly unsuitable" cell when she gave birth.

Finally, the report found that the prison downplayed the seriousness of the events when they reported it to head office.

"It is not clear if this was because staff had become desensitized to risk and duty of care, or if it was an attempt to mislead," Morgan said.

The report made a number of recommendations which Western Australia's Department of Justice will respond to on Wednesday.