An inmate gave birth alone in her unsterile West Australian prison cell in circumstances the prison’s inspector has described as “distressing, degrading and high risk”.

The woman indicated to staff at Bandyup women’s prison just over two hours before she gave birth on 11 March that she believed she was going into labour.

She was taken to the health centre for assessment but information from the initial call was not passed on to the nurses, and while she complained of abdominal pain, she denied being in labour.

She was given paracetamol and returned to her cell, but after the night lockdown she called out again, audibly distressed, and indicated she was in labour.

Staff talked to her through her cell door, but due to poor management, communication and decision-making, nursing staff didn’t arrive to assess her for around an hour.

When they arrived they couldn’t access the cell because the only person with keys, a senior staff member in the gatehouse, didn’t arrive until between seven and 12 minutes after she gave birth.

Inspector of custodial services Neil Morgan said cascading and intersecting failures put the woman and her baby at high risk.

“It was the result of systemic, procedural and human failings,” Morgan said in a report on Wednesday.

These included inadequate infrastructure for women in late stages of pregnancy, inaction or slow action by some staff, poor communication and poor processes.

“We find it inexplicable that nobody called a code-red emergency until after the baby was born,” Morgan said.

“The response to the code red was also inexplicably slow.”