In a maximum security prison cell on a 33-degree day, a woman was forced to have her baby alone while pleading for help for over an hour to the guards watching through a gap in the locked cell door.

Key points: Prisoner Amy* gave birth a month after arriving at Bandyup Prison

Prisoner Amy* gave birth a month after arriving at Bandyup Prison None of the staff present when she went into labour had a key to her cell

None of the staff present when she went into labour had a key to her cell The prison watchdog has delivered a series of damning findings into her treatment

Those are the disturbing findings released today in a damning assessment from the West Australian prison watchdog into an incident that took place in March this year.

"Amy* gave birth, alone, inside the locked cell," the report summary from inspector of custodial services Neil Morgan said.

"Nursing and custodial staff watched on, and attempted to support her through a hatch in the door, but could offer no physical support."

A pregnancy in prison

The report said Amy had appeared in court earlier in January during the late stages of her pregnancy.

She was granted bail but could not meet the conditions and was taken back into custody. She was then moved to Bandyup Women's Prison in Perth's north-eastern suburbs, on February 17.

The prison opened in 1970 and is the state's only female prison, catering for all levels of security classifications, including maximum security.

Serial killer Catherine Birnie is counted among its most notorious residents.

Bandyup Women's Prison houses WA's most dangerous female inmates. ( ABC News )

The report found Amy was moved to a "cramped cell, in a double-storey unit, on the first flight, up a flight of stairs".

She spent the next 22 days of her pregnancy receiving medical care from prison staff and was transferred to hospital for outpatient care.

A hard labour

According to the report, at 5:30pm on Sunday March 11, Amy called out from her cell.

The report said she used phrases that showed she was distressed and thought she was going into labour.

Timeline of a prison birth: 5:30pm — Amy makes a cell call saying she is "distressed" and in labour. After being taken for a health assessment she is given paracetamol and returned to her cell

— Amy makes a cell call saying she is "distressed" and in labour. After being taken for a health assessment she is given paracetamol and returned to her cell 6:00pm — The prison is locked down

— The prison is locked down 6:30pm — Amy begins a series of cell calls sounding distressed and saying she is in labour

— Amy begins a series of cell calls sounding distressed and saying she is in labour 6:30–7:30pm — Custodial staff intermittently speak to Amy through the cell door

— Custodial staff intermittently speak to Amy through the cell door 7:35pm — Nursing staff arrive and they offer support through the locked cell door

— Nursing staff arrive and they offer support through the locked cell door 7:40pm — Amy gives birth in her cell. Nursing and prison staff offer advice through a cell door hatch

— Amy gives birth in her cell. Nursing and prison staff offer advice through a cell door hatch 7:47–7:52pm — An officer from the gatehouse arrives with keys. Assistance is given Amy and she and her baby are transferred to hospital

She was taken to the prison's health centre for assessment, but while she was there, nurses were not told about her initial cries of pain. She told nurses she had abdominal pain but denied being in labour.

Amy was given some paracetamol and taken back to her cell.

Half an hour later, the prison went into its night lock down.

At 6:30pm, Amy called out again. She was "audibly distressed", indicating she was in labour.

For the next hour, staff talked to Amy through her cell door.

But nursing staff did not assess her until about 7:35pm. The report blamed "poor prioritisation, communication and decision-making".

The report said Amy's distress was by now "palpable" and that she clearly needed help.

But nursing staff could only reach her through a locked cell door, because the only person with her cell keys was a staff member in the gatehouse, a two- to three-minute walk away.

Five minutes later, Amy gave birth to her baby, alone, inside a locked cell.

"Nursing and custodial staff watched on, and attempted to support her through a hatch in the door but could offer no physical support," the report's summary said. "This was obviously a high-risk situation for Amy and her child. "She was in a cell, not in a sterile environment, and none of the standard perinatal checks for a mother and newborn were available. "And staff would have been unable to administer first-aid had it been required."

A 'distressing and degrading' set of events

After Amy had given birth, she had to wait for another 7–12 minutes before the officer from the gatehouse arrived with the keys.

Poor record keeping meant the report could not even put a precise time on the delay for assistance.

Amy and her baby were sent to hospital later that evening.

Professor Morgan said he completed the review to understand how such a "distressing, degrading and high-risk set of events could have happened in a 21st-century Australian prison".

He concluded the situation was avoidable and a result of systemic, procedural and human failings.

They included:

Inadequate infrastructure for women in late stages of pregnancy;

Inadequate infrastructure for women in late stages of pregnancy; Inaction or slow action by some staff;

Inaction or slow action by some staff; Poor communication; and

Poor communication; and Poor processes

WA Prison Officers' Union Secretary Andy Smith agreed it was an unacceptable situation, but said prison officers acted as quickly as possible.

"During night shifts staff do not carry keys as part of tight security measures at the prison," he said.

"Staff had taken the prisoner to the medical centre earlier on and when she was returned, prison officers on duty were told by medical staff that she was not in labour.

"As soon as it was clearly evident she was giving birth, staff acted as quickly as possible."

Code-red emergency was never called

Professor Morgan said there was not enough accommodation for pregnant women in Western Australia's prison system due to a lack of planning and that Amy had been placed in a cell with little or no consideration for her needs.

The Department of Justice has admitted it was not suitable, and had since moved to house women in the late stages of pregnancy in another more suitable unit.

"Every single person on night shift on March 11 was aware that Amy was in pain and distress for at least an hour before the birth," Professor Morgan said. "The situation escalated without anyone apparently realising that an emergency situation was developing or taking appropriate action."

Professor Morgan said it was "inexplicable" nobody called a code red emergency until after the baby was born.

"The response to the code red was also inexplicably slow. It should never have taken 7-12 minutes for the cell door to be opened," he said.

He also said there were major flaws in the record keeping of the incident.

WA Inspector of Custodial Services Neil Morgan has widely criticised the prison's handling of the pregnancy. ( ABC News: Briana Shepherd )

He said staff were not logging "cell calls", the incident was not originally reported as "critical" and that it was impossible to establish a clear timeline of events because time stamps and CCTV vision were not synchronised.

"Pregnant women will continue to come into custody," Professor Morgan concluded.

"The department has a responsibility to ensure the health and safety of the mother and child are not compromised, even if resources are stretched.

"There was no justification for what happened in Amy's case, and it must not be repeated."

WA's Corrective Services Commissioner Tony Hassall apologised for failing Amy and her baby.

"The events that happened to Amy on that night were unacceptable and shouldn't have happened, and clearly every baby, whatever the circumstances of the mother, deserves to be brought into this world in a decent environment and clearly that's not a prison cell," Mr Hassall said.

"I am very sorry to Amy and to the way her baby was brought into the world, and the care that was afforded to her on that night wasn't good enough."

Corrective Services Commissioner Tony Hassall said procedures have changed since the incident. ( ABC News: Lucy McLeod )

Mr Hassall accepted all the findings and recommendations of the review and said that procedures have changed since the incident.

"There were a catalogue of errors, the staff having access to the keys, to some of our procedures locally, to staff training available — right going back to the transfer of Amy to one prison to the other," Mr Hassall said.

"We've got a lot of learning from that, processing improvements at the prison, some training for prison staff and moving forward we are determined to make sure we get those types of things right in the future."

A spokesman for WA's Corrective Services Minister, Francis Logan, said the Minister was appalled to hear of the circumstances.

"[The Minister] has spoken with the department and the Inspector of Custodial Services regarding the review into this matter, and the subsequent changes made at Bandyup including new leadership and training," he said.

*Amy's name has been changed in the report to protect her identity.