The senior coroner in Surrey announced yesterday that he will not be making any recommendations to prevent future deaths, following the death of baby Aisha Cleary in HMP Bronzefield.

Baby Aisha Cleary was born and died in the prison during the night of 26 September 2019, and was not found until the following morning. Earlier this year, a ‘distressing’ and ‘heartbreaking’ inquiry heard how serious operational and systemic failings contributed to the death of a full-term baby in a cell at HMP Bronzefield.

Since Aisha’s death, NHS England and the Ministry Of Justice (MOJ) have accepted that all pregnancies in prison are “high risk”, echoing the finding of the Prisons and Probation Ombudsman, Sue McAllister.

Concluding the month-long inquest into Aisha’s death the coroner stated that Aisha “arrived into the world in the most harrowing of circumstances” given that her mother, Rianna Cleary – a Black teenage care leaver – was left to give birth alone in a prison cell without any care or assistance, despite asking for help and pressing her cell bell twice.

The senior coroner stated that while the evidence he received at the inquest hearing did give rise to concerns on his part that circumstances creating a risk of other deaths may still continue, his concerns had now been addressed by the prison and other interested parties.

Rianna Cleary, Aisha’s mother, said:

I have lost Aisha forever, so the most important thing is that no pregnant woman ever goes through what I did again.

I understand that the Senior Coroner is not making a Preventing Future Deaths Report because of all the changes that have been made since Aisha died. But when it comes to prison, what's written on a piece of paper is never what happens in practice. The way the prisons are run, it is all about power and control. They will never be caring places.

Prison officers do not always follow policy – look what happened to me when I pressed my cell bell twice – nobody came. And I still don’t know whether the prison officer who refused me medical help has been sacked.

The system is cruel and will never be a safe place to have a baby. Everybody now accepts that all pregnancies in prison are high risk, so why was I sent there? This is why I now support the campaigns of Level Up and No Births Behind Bars to stop sending pregnant women to prison.

Elaine Macdonald of Broudie Jackson Canter, said: 

While significant changes have been made to policy relating to perinatal care in prisons in general, which must be acknowledged, it remains to be seen whether prisons, including HMP Bronzefield, will implement the changes sufficiently.

It is staggering that, prior to Aisha’s death, there was no policy in place to care for pregnant women in prison. The previous MBU policy was overly focused on the rules and processes around MBU admissions and not on looking after pregnant women.

Additionally, the cell bell failures in this case had catastrophic consequences (despite expectations on response being in place) and whilst we note that Bronzefield has upgraded its cell call system, only time will tell whether prison officers are adhering to it.