A vulnerable 18-year-old whose baby died after her calls for help were ignored as she gave birth alone in a prison cell was not provided with bereavement support – but the prison guards who failed to get her medical assistance were offered counselling, the Observer can reveal.

The details were buried in a devastating report from a prison watchdog published last week that described how the teenager was found in bed cradling her dead baby more than 12 hours after pressing her cell bell and telling staff at the privately run HMP Bronzefield that she needed an ambulance.

It has also emerged since the report’s publication that those who ignored her calls for assistance remain working at the prison in Ashford, Surrey.

The young woman, in prison for the first time, was on remand facing a charge of robbery. She went into labour, and records show that on the evening of 26 September 2019 she called for help three times but none came.

By 11pm she was in constant pain and unable to reach her cell bell. After passing out, she came round to find her baby girl was there but not breathing. She bit through the umbilical cord and tried to wipe the blood from her cell before climbing into bed.

The prisons and probation ombudsman Sue McAllister listed a catalogue of failures and found maternity services at Bronzefield were “outdated and inadequate”.

Despite overnight checks by guards, the baby’s death was discovered only after two prisoners raised the alarm. A nurse was called but failed to resuscitate the infant. Staff were later offered support from external counsellors.

But, shockingly, the PPO report found: “Police and coroner involvement immediately after Baby A’s death, and a lack of understanding by the prison of the role of the local child death review team, meant Ms A did not receive the routine bereavement and practical support that would normally be provided.”

McAllister said Ms A was regarded as having a “bad attitude” rather than a vulnerable 18-year-old who refused care because she was frightened her baby would be taken away.

She even told a nurse she would “kill herself” if her baby was taken into care but the prison failed to step up monitoring.

Deborah Coles, the executive director of the charity Inquest, said: “Their view of her as a difficult woman informed her treatment – both during the pregnancy and the subsequent ignoring of cell bells. The further complete contempt of her case in not providing bereavement counselling is indicative of a wider culture at Bronzefield, which is supposed to be a trauma-informed prison.”

Ms A had entered the prison on 14 August 2019, with a nurse noting she had “asthma, a chest infection and looked pregnant”. Seven months earlier she had been assigned “looked after child” status by Camden social services in London.

Coles said: “The key question we need to ask is why she was in prison in the first place – she could and should have been kept safely in the community.” The report revealed Ms A was released on bail on 17 October 2019 but it is unclear as to why she was not granted bail in the first instance.

It has also come to light that another prisoner from HMP Bronzefield gave birth to a full-term stillborn baby in an ambulance on the way to hospital in December 2017.

The cases raise vital questions about the safety of pregnant prisoners and their unborn babies.

One new mother who served half of a six-month sentence while pregnant told the Observer: “It’s an extremely toxic place. I suffered with depression and cried every day. I worried the stress would cause a miscarriage.”

Olivia, who was sentenced for a first-time offence at eight weeks pregnant, declined to name the prison but described the experience that left her suffering from PTSD. She said: “The toilet was open inside my shared cell, which was hard when you are dealing with morning sickness. I was asked to clean the loos, and heavily pregnant women were forced to sweep the floor – it’s just not a safe place for pregnant women.”

On one occasion when she had a bleed she requested a nurse but was given no privacy. “She wanted me to open my legs with the cell door wide open and male guards standing outside,” she recalled. “I was terrified I’d lost the baby and had to wait five days to see a midwife.”

The organisations Level Up, Women In Prison, and Birth Companions have launched a petition calling for the end to the imprisonment of pregnant women.

Kate Paradine, chief executive of WIP, said: “The government can prevent another tragedy and strengthen the law to stop imprisoning pregnant women, to ensure that the sentencing guidelines which require courts to consider pregnancy and the best interests of children in sentencing decisions, are consistently applied.”

The latest Ministry of Justice figures show 31 women gave birth during a prison sentence in the year to March 2021. While 28 gave birth in hospital and none were born in cells, three were delivered en route to hospital.

The MoJ says improvements have been made since the death of Ms A’s baby. These include all women having free phone access to local NHS pregnancy advice services and increased monitoring in the third trimester.

Vicky Robinson, director at HMP Bronzefield, said the prison had been working to implement a raft of recommendations made by the ombudsman. She confirmed an internal inquiry and disciplinary investigations had taken place, and appropriate steps had been taken with staff.

She said: “We are deeply sorry this happened and our thoughts throughout have been with the family … We take this matter extremely seriously and are committed to providing the best care possible.”

A spokesperson for the Judicial Office said: “Decisions as to granting or refusing bail are made by the court on a case-by-case basis. When determining whether to grant bail, magistrates and judges are guided by the relevant statutory provisions and case law.”