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.

Baby Aisha Cleary was born and died in the prison during the night of September 26, 2019, and was not found until the following morning.

Her mother, 18-year-old Rianna Cleary – a vulnerable care leaver in prison – was left to give birth alone in a prison cell without any care or assistance, which meant “losing the chance of resuscitation and survival".

Rianna was remanded to HMP Bronzefield, the largest women’s prison in Europe, on August 14, 2019 when she was six months pregnant. On August 19 at a meeting in the prison’s Mother and Baby Unit she was told by Camden Social Services that they would be seeking a court order to remove her child at birth.

In her evidence to the inquest, Rianna stated that prison staff told her that she would only get minutes with her baby before the police would take the baby away. This made the mum-to-be so distressed that, on September 25, she told prison officers she would kill herself if that happened. Despite this, no care plan for prisoners at risk of suicide or self-harm (known as an ACCT) was put in place for her by prison or healthcare staff.

After concerns were raised about the risks related to Rianna’s pregnancy, a decision was eventually made by Prison Healthcare staff on the morning of September 26 to place her under extended clinical observations. No such observations were ever carried out. During the inquest, the prison’s Clinical Team Leader, who was supposed to be responsible for Rianna’s clinical observations, accepted that the failure to carry these out were “a total and unacceptable failure in care”.

That same evening, Rianna went into labour at around 8.07pm. She used the intercom in her cell to urgently request a nurse or an ambulance. The call was answered by Prison Officer Mark Johnson, who is currently still under disciplinary investigation and suspended from prisoner-facing duties. No nurse or ambulance were called by Mr Johnson, nor by any other officer on duty, and no-one checked on her in response to her emergency call.

The coroner described this as a “complete disregard for the duties of a prison officer” and concluded that if Mr Johnson had checked Rianna’s cell after her urgent request for assistance, her labour would have been discovered and she would have been transferred to hospital immediately.

Rianna again pressed her emergency cell bell at around 8.32pm but once again the call was not answered.

No one checked on her until prison officers checked the cell by shining a torch through the hatch for 1-2 seconds at around 9.27pm and 4.19am as part of the prison routine. The officers who performed these checks told the inquest that they did not notice anything untoward in Rianna’s cell.

Rianna subsequently gave birth alone in her cell, which she told the inquest was a harrowing experience. She said she did not understand that she was in labour, just that she was in extreme pain; she lost blood and passed out in the early hours of the morning.

At around 8.15am Rianna was awoken by the sound of her cell door being unlocked where she discovered baby Aisha on the bed, who appeared purple and did not seem to be breathing. During the birth the teenager felt compelled to bite through her baby’s umbilical cord as she had no medical or other help.

Nurses attempted to resuscitate Aisha and called an ambulance. At 9.03am, paramedics confirmed that baby Aisha had died.

The coroner’s conclusions

• By early September 2019 there was a recognised risk Rianna could give birth alone in her cell if her labour was not recognised and she was transferred to hospital in a timely manner.  
• Despite those risks, the obstetrics and midwifery services in HMP Bronzefield failed to give any guidance to the prison, to undertake joint working with prison healthcare, to arrange a multidisciplinary meeting, or to ensure that there was an effective joint plan to ensure that Rianna’s labour was identified and that she was transferred to hospital to give birth.  
• The prison failed to put in place a plan to monitor Rianna; to open an ACCT when she spoke of suicide and self-harm in the context of her pregnancy on 25 September; to implement extended observations on Rianna; to respond to Rianna’s requests for medical assistance at 20:07 hours on 26 September (at which time she was already in labour); or to answer second call at 20:32 hours at all.  
• If Rianna’s labour had been identified and she had been transferred to hospital, there was an opportunity to take effective steps to ensure Aisha’s survival.

In her evidence to the inquest, Rianna, a Black woman, asked why her concerns and health needs were ignored and why the prison failed to respond to warning signs and adequately monitor her. She said that she, “wondered at that time if I was being treated differently from [other women in prison] because of my race, because I was young, or because of my past.”

Following the coroner’s conclusions, the bereaved mother added:

“Nothing can change the nightmare I went through or bring Aisha back. However, I am grateful that the coroner has recognised that London Borough of Camden let me down and that the prison as a whole failed me in so many ways.

“I feel so sad knowing that Aisha may have survived if they had helped me. Only one prison officer (Lewis Kirby) 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."

Elaine Macdonald of Broudie Jackson Canter, said: 

“The evidence heard in this inquest about the treatment of such a young and vulnerable pregnant woman has been both distressing and heart-breaking.

“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.  

“The evidence heard confirms that prison is a completely inappropriate and dangerous environment for pregnant women. Sodexo and Ashford and St Peters NHS Trust have failed in significant and multiple ways in this case to provide safe and compassionate care to a young pregnant woman who needed support.

“There was no adequate plan for Aisha's birth and there was no basic emergency response to my client's calls for help. What happened here is utterly unacceptable and there must be changes to how we treat pregnant women in custody.”