WARNING: distressing content
A teenage girl who gave birth in prison was found clinging to her dead baby girl after her cries for help were ignored for more than 12 hours.
The pregnant 18-year-old from the UK was in jail for the first time after being remanded for an alleged robbery.
She had not been convicted of any offence. Despite her age and vulnerability, she was placed by herself in the privately run Bronzefield jail in Surrey.
Now the findings on the September 2019 tragedy has been slammed as one of the most disturbing and damning reports ever issued by a prison watchdog.
In the build up to the birth, she feared for her baby's safety.
The day before the teen, named Ms A, went into labour, she told a nurse she would "kill herself" if her baby was to be taken away after birth.
This meant she was put on "extended observations", meaning she should be checked regularly by a nurse day and night.
The checks never happened.
The night she went into labour, the teen pressed the buzzer to ask for a nurse. No medical assistance arrived.
She rang the bell two more times and was ignored. She later begged for an ambulance but gave up after no one came to help her.
Later in the night a guard shone a torch into her cell during a routine roll call. She was on all fours and in constant pain.
By 11pm she was in so much pain she was unable to reach the cell bell after sitting on the toilet.
She eventually passed out before waking up at 2am to find she had delivered her baby.
Unfortunately the baby was purple and not breathing.
She then wrapped the baby in a towel, managing to bite the umbilical cord off.
She tied a loose knot before climbing into bed with her baby.
Only at 8.24am the alarm was raised after two fellow prisoners reported concerns about Ms A.
When the officers entered the cell the discovered blood all over the floor and the mother with her baby under the duvet.
Details of exactly how the full-term baby died are still subject to an inquest.
Its findings were backed by new Justice Secretary Dominic Raab, who blasted: "These events are harrowing, unacceptable and should never happen to any woman or child".
Kate Paradine, CEO of the charity Women in Prison, told the Sun: "This devastating report highlights what we know already: that prison is not a safe place for any pregnant woman or baby.
"Pregnant women are better supported in the community and by planning to build 500 new prison places for women, the Government goes against its own commitment to send fewer women to prison."
Vicky Robinson, director at prison in question said: "This was tragic and extremely sad; nothing we can say or do will change that. We are deeply sorry that this happened and our thoughts throughout have been with the family."
In a devastating summary, Sue McAllister, the Prisons and Probation Ombudsman, said Bronzefield's maternity services were "outdated and inadequate".
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