HMP Bronzefield baby death followed systemic failings - inquest

A baby died after her "vulnerable" 18-year-old mother gave birth alone in a jail cell following "systemic failings" by state agencies, a coroner has said.

Aisha Cleary's mother Rianna Cleary made two calls to staff that went unanswered before her baby was born on 27 September 2019 at HMP Bronzefield.

The teen had to cut the umbilical cord with her teeth, the inquest heard.

Senior coroner Richard Travers said opportunities were missed to ensure she did not give birth alone in her cell.

The coroner was unable to ascertain whether the baby was stillborn or breathing when she was delivered, but said if she had been alive she would have died within hours.

Ms Cleary's case led to demonstrations calling for an end to imprisoning pregnant women and new mothers.

Mr Travers said: "There is clear evidence, not least, of systemic failings which more than minimally contributed to Aisha being delivered in a prison cell without medical assistance and, following delivery, losing the chance of resuscitation and survival.

"If Aisha's mother's labour had been identified and she had been transferred to hospital in a timely manner for Aisha's delivery, there would have been an opportunity for effective steps to have been taken."

Ms Cleary had been in care and had been exploited by county lines gangs before she was jailed in August 2019, the inquest heard.

Before the birth, Ms Cleary had not been engaging with nurses because she was worried her baby would be taken away, the inquest was told.

Ms Cleary told the hearing she began to experience pain on 26 September 2019, but did not know what it was because she did not expect to deliver until the following month.

She had fallen asleep before she woke in "really serious pain" and made two calls to staff asking for a nurse and ambulance, but none arrived.

She later fell asleep and delivered her baby during the night after losing blood.

Prison custody officer Mark Johnson, who responded to her first call, said she had been "abusive" and was swearing while asking for a nurse. He is under disciplinary observation and remains suspended from prisoner-facing duties, the charity Inquest said.

Ms Cleary's second call was never answered.

The inquest heard Ms Cleary was on her hands and knees in labour when a prison officer walked past her cell with a torch but did not stop to help.

Aisha was pronounced dead the next morning after suffering brain injuries, the inquest heard.

After the inquest, Ms Cleary, who attended remotely, said in a statement: "I feel so sad knowing that Aisha may have survived if they had helped me.

"Only one prison officer who didn't even do anything wrong said sorry to me directly.

"The deputy director of Bronzefield wrote one line to me saying 'sorry you gave birth alone' just before the inquest started.

"If it wasn't for this inquest, they would still be blaming me for giving birth alone."

Her lawyer, Elaine Macdonald, of Broudie Jackson Canter, said: "My client has shown incredible strength and courage to attend every single day of this inquest. She has seen the men who failed to respond to her on the night that Aisha was born and heard their inadequate explanations. Only one of them has apologised to her."

After the hearing, Deborah Coles, director of Inquest, said Aisha's mother had a history of trauma and deserved care and support from public services.

She said: "Inquest evidence has shown that as a vulnerable 18-year-old black woman, narratives around gangs informed the way she was treated in the community and in prison. She was viewed not as someone in need of care and compassion but as a discipline and control problem. Her calls for help went unanswered, and her pain was ignored."

Ms Coles said the death of a baby in a prison cell was "unconscionable", adding: "Prison is a disproportionate, inappropriate, and dangerous response to women in conflict with the law, let alone those who are pregnant."

Citing government data, Inquest said there were 196 pregnant women in prisons in England and Wales from April 2022 to March 2023.

The charity posted the coroner's conclusions on its website.

Janey Starling, co-director of gender justice campaign Level Up, said prison was not safe for pregnant women and it was "long overdue" that courts should stop sending pregnant women there. She said plenty of other countries did not send pregnant women to prison, including Italy, Brazil and Mexico, but the UK "lags behind."

Naomi Delap, director of Birth Companions, said the government must end imprisonment of pregnant women and mothers of infants, adding: "In the vast majority of cases the imprisonment of pregnant and postnatal women is unnecessary and avoidable. It is a choice made by the legal system in this country."

Prisons Minister Damian Hinds said: "We have since made important improvements to the care received by pregnant women, including specialist mother and baby staff in every women's prison, extra welfare checks and better health and antenatal support. While there is still more to be done to make sure expectant mothers in prison get the same care as those in the community, these changes will reduce the chances of such a tragedy happening again."

A hearing on whether a prevention of future deaths report is needed will take place at a later date.

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