28 July 2023

Before HM Senior Coroner for Surrey, Richard Travers
Surrey Coroner’s Court, Woking
Evidence 3 May – 31 May 2023
Concluded 28 July 2023

A coroner has today concluded that serious operational and systemic failings contributed to the full-term baby of an 18-year-old Black woman "being delivered in a prison cell without medical assistance and... losing the chance of resuscitation and survival".

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

Concluding the month-long inquest into Aisha’s death the Senior Coroner for Surrey, Richard Travers, stated that Aisha “arrived into the world in the most harrowing of circumstances” given that her mother, Rianna Cleary – a vulnerable teenage care leaver in prison – was left to give birth alone in a prison cell without any care or assistance.

There were 196 pregnant women in prison during the 12-month period from April 2022 to March 2023. Campaigners are calling for an end to the imprisonment of pregnant women.

Rianna Cleary was excluded from mainstream education and taken into care as a young teenager. She moved frequently and lived in placements across London and in Wales.

Rianna presented to Camden Social Services in October 2018, but was not accepted to be a former relevant child by London Borough of Camden until the end of July 2019, which only happened after a solicitor helped her and threatened legal action against the council.

Being a former looked after child is a status which entitles a person to specific services and support, such as a Personal Advisor when you are over the age of 18.

In evidence to the inquest, Camden’s Head of Safeguarding and Quality Assurance accepted that Camden had become involved in a debate with Haringey as to who was responsible for her.

They said Rianna, “as a very vulnerable young woman, was not central to decision making” between the two boroughs’ Social Services departments “which will have left her feeling unwanted and uncared for”.

The London Borough of Camden also accepted that the delay in agreeing to support Rianna as a former relevant child “took too long” and “presented her with further rejection, a lack of hope in the system and a further difficult battle – just to have her basic needs met”.

Rianna did not have support from a Personal Adviser until after Aisha’s death, which the coroner concluded contributed to the failure to help her engage in care. The coroner stated Rianna had been “let down” by Camden Social Services.

Rianna realised she was pregnant after being arrested whilst living in a supported hostel in Camden. On 14 August 2019, she was remanded to HMP Bronzefield, the largest women’s prison in Europe.

Rianna arrived with a Prison Escort Record stating that she was six months pregnant. On 19 August, at a meeting in HMP Bronzefield’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.

Rianna was given a letter, written in legal jargon, confirming this – which the coroner stated was unnecessarily judgmental and negative about Rianna, and further contributed to her difficulties in engaging with social services.

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. Rianna became so distressed at the prospect of her baby being removed that, on 25 September, 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 – which the coroner concluded was a “significant missed opportunity” to engage with and monitor Rianna.

Realising she was not going to get the help she needed in prison, Rianna tried to apply for bail, but her Offender Manager at the prison, Carleigh Marshall, refused to help her get a bail hostel address to go to. During the inquest, and in her evidence to the Prison and Probation Ombudsman, the Offender Manager referred to Rianna as a “gangster”.

INQUEST research has found that racial stereotyping is an experience shared by many Black people in prison, which contributes to deaths.

In her evidence to the inquest, Rianna 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.”

The coroner was strongly critical of the midwifery care provided to Rianna by Ashford & St Peter’s Hospital Trust while she was a prisoner in HMP Bronzefield.

He found that the approach of the Lead Safeguarding Midwife, Sarah Legg, was “highly inappropriate and unprofessional; and “probably made matters worse” in terms of Rianna’s engagement. He noted that no effective plan was put in place for Rianna for some three weeks in September 2019, despite the obvious risks.

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 26 September to place her under extended clinical observations. No such observations were ever carried out – despite there being a 24-hour nursing station on Rianna’s wing in the prison, and observations being carried out on other prisoners during that night.

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” to Rianna and baby Aisha.

During the evening of 26 September, 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 found Mr Johnson to be a dishonest and unreliable witness. The coroner 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.

Despite being barely able to walk across her cell in labour, Rianna again pressed her emergency cell bell at around 8.32pm. This call was not answered, and the inquest heard evidence that it was simply disconnected in the prison communications room at 8.45pm.

The prison officer in the Central Control Room could offer no explanation for this failure, and the coroner was unable to conclude on the evidence why this failure occurred.

The prison’s Deputy Director, Vicky Robinson, admitted in her evidence at the inquest that the prison’s response to Rianna calling for help by her cell bell was “wholly and completely inadequate.”

At around 9.27pm and 4.19am, Rianna’s cell was checked extremely briefly by prison officers, who shone a torch through the hatch as part of a routine roll count. Each check lasted 1- 2 seconds before the officers moved on to the next cell.

The officers who did undertake 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. Rianna 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, a prison officer unlocked Rianna’s cell. He did not enter the cell or address Rianna and told the inquest that he did not notice the blood on the walls and floor of the cell.

Rianna was eventually woken by the sound of her cell being unlocked. She discovered baby Aisha on the bed, who appeared purple and did not seem to be breathing. Rianna felt compelled to bite through her baby’s umbilical cord as she had no medical or other help, and placed her placenta in the bin as she did not know what else to do.

Over 12 hours since she first rang the cell bell, and a few minutes after her cell was unlocked, at 8.21am, two other prisoners had to alert prison staff to the fact that Rianna needed assistance. Following this, a prison officer attended and discovered that Rianna had given birth alone during the night.

Nurses attended and attempted to resuscitate Aisha (without access to a paediatric resuscitation equipment), and called an ambulance. At 9.03am, paramedics confirmed that baby Aisha had died.

Ruth Mason, the expert Consultant Obstetrician and Gynaecologist instructed by the coroner, said that if a midwife had been present during Rianna’s labour and if Aisha was alive when it started, it is more than likely that Aisha would have survived. The coroner agreed with this conclusion.

As part of the inquest, the coroner considered whether Aisha was stillborn or took an independent breath before she died. While the coroner found that Aisha had air in her lungs, he found the evidence was not sufficient to confirm whether or not it was a stillbirth – concluding that it was possible Aisha had been born alive.

In what is understood to be the first time a coroner has deliberated on coronial powers and duties where it is unclear whether a baby was stillborn, the coroner agreed with Rianna’s legal team’s submissions – despite opposition from all the State interested persons – that Article 2 of the European Convention on Human Rights was engaged where it was possible that Aisha had been born alive, and where there was “ample evidence that serious systemic failures” had contributed to her death.

The coroner also rejected an argument made by Sodexo, the Ministry of Justice and Ashford & St Peter’s NHS Foundation Trust, that Aisha’s death should be treated as a stillbirth, and that the coroner had no jurisdiction to make the critical conclusions he went on to do.

The coroner concluded:

• 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; and
  
  
• 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.

Following the coroner’s conclusions, Rianna Cleary said: “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.

This includes the conclusions that the safeguarding midwife in prison was ‘inappropriate and unprofessional’, that prison healthcare let me down, and that the prison officer Mark Johnson who ignored my request for medical assistance when I rang my cell bell is a dishonest witness who showed ‘complete disregard for his duties as a prison officer’.

I really cannot believe Officer Johnson still has not been disciplined and is still employed by the prison.

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."

Deborah Coles, Director at INQUEST, said: “These conclusions are a shocking and damning inditement of the utter failure to keep Aisha and her mother safe, both long before and during her deeply traumatic time in prison.

Aisha’s mother was a young woman with a history of trauma. She deserved care and support from public services. The fundamental question is why so many agencies failed her, and why was she sent to prison in the first place, not least when pregnant?

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.

The death of a baby in a prison cell is unconscionable and it is an indictment of the society we live in that a young woman can be failed so catastrophically by so many services. Prison is a disproportionate, inappropriate, and dangerous response to women in conflict with the law, let alone those who are pregnant.

For too long we have ignored recommendations from inquests and reviews. We need to dismantle prisons and redirect resources to holistic, gender responsive community services. Only then can we end the deaths of women and their babies in prison.”

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.”

Janey Starling, Co-Director of Level Up, said: “Prison will never be a safe place to be pregnant and it’s long overdue for courts to stop sending pregnant women there. There are plenty of other countries that do not send pregnant women to prison, including Italy, Brazil and Mexico, yet the UK lags behind.

“Since the death of Baby Aisha in 2019, a coalition of mothers, midwives and medical experts have joined forces to demand an end to the imprisonment of pregnant women. It’s time for the government to listen to the experts and end the imprisonment of pregnant women. When a mother is supported in her community, she is able to tackle the issues that swept her up into crime in the first place and get the support to give her child the best start in life, and herself the best future.”

Naomi Delap, Director of Birth Companions, said: “It’s not enough to promise improvements in care that we all know will be impossible to deliver. The government can, and must, end the imprisonment of pregnant women and mothers of infants. This is far from a radical position. 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.

“This tragic case also highlights the urgent work needed to improve the way local authorities support girls in their care, and women whose unborn babies and infants are subject to care proceedings. It is clear that support for Rianna was not well managed as she moved from child to adult services. Care was fragmented when she became pregnant and attention shifted to her baby, and support was further compromised when she entered the prison system. This picture is all-too common.

“If the government ends the use of custody for pregnant women and mothers of infants; if it prioritises services that address the root causes of offending; and delivers better support for girls and women in local authority care; it will break intergenerational cycles of disadvantage and deliver huge benefits for women, their families and society."

ENDS

NOTES TO EDITORS

For further information please contact Lucy McKay on [email protected] or 020 7263 1111

See the full document of the coroner's conclusions for more information.

The family is represented by INQUEST Lawyers Group members Elaine Macdonald of Broudie Jackson Canter Solicitors, and Maya Sikand KC and Tom Stoate of Doughty Street Chambers. The family is supported by INQUEST senior caseworker Selen Cavcav. 

Other Interested persons represented are Sodexo Justice Services, the Ministry of Justice, the London Borough of Camden, Ashford & St Peter’s Hospitals NHS Foundation Trust, University College London Hospital NHS Foundation Trust, Central and North West London NHS Foundation Trust, NHS England, Prison Officer Lewis Kirby and Prison Officer Mark Johnson.  

About INQUEST  
INQUEST is the only charity providing expertise on state related deaths and their investigation, founded by bereaved people in 1981. Their specialist casework includes death in police and prison custody, immigration detention, mental health settings and deaths involving multi-agency failings, including Grenfell and Hillsborough.   
 
INQUEST’s policy, parliamentary, campaigning and media work is grounded in the day to day experience of bereaved people. Please refer to INQUEST the organisation in all capital letters in order to distinguish it from the legal hearing.   

www.inquest.org.uk | @INQUEST_ORG on Twitter and Instagram  

About Level Up 

Level Up is a UK feminist group campaigning for an end to the imprisonment of pregnant women and new mothers, whose petition is supported by over 11,000 people. In 2022, Level Up coordinated an open letter to the Sentencing Council to demand specific sentencing guidelines for pregnant women and new mothers, which was signed by the country's leading maternal health experts. www.welevelup.org/ | @we_level_up  

About Birth Companions 

Birth Companions is a national charity specialising in the needs and experiences of pregnant women and mothers of infants in the criminal justice system. www.birthcompanions.org.uk 

BACKGROUND  

According to HMPPS data, there were 196 pregnant women in prison during the 12-month period from April 2022 to March 2023.  

There were 44 births in the year April 2022 to March 2023 for women in prison with nearly all (43) taking place at a hospital. The other birth either took place in the prison or in transit to hospital (place of birth not disclosed to protect individual privacy). 

The Sentencing Council recently announced that they will be consulting on a new mitigating factor relating to pregnancy in sentencing guidelines this September. 

In 2019, the Royal College of Midwives released a statement on perinatal women in the criminal justice system stating that “prison is no place for pregnant women." 

The Prisons and Probation Ombudsman (PPO) published an anonymised report on the death of Aisha Cleary ('Baby A') in September 2022. The then Ombudsman, Sue Mcallister, said: “This should never have happened”, noting that “[i]n many ways the situation for pregnant women in Bronzefield was symptomatic of a national absence of policies and pathways for pregnant women in custody”. See the Media Release. 

Other relevant cases: 

• Baby Brooke Leigh was born to Louise Powell, 31, who was unaware that she was 30-32 weeks pregnant when she gave birth on a prison toilet on 18 June 2020 at HMP & YOI Styal in Cheshire. The clinical evidence indicates that had Louise been properly assessed Baby Brooke may have survived. Louise had also been calling for help, but was ignored. See media release.  
• Natasha Chin, 39, was found unresponsive in her cell in HMP Bronzefield on 19 July 2016, less than 36 hours after entering the prison. An inquest found neglect and systemic failures by prison and healthcare providers contributed to her death. The inquest also considered the prisons response to cell bell calls, after staff failed to respond when Natasha rang her cell bell due to a system fault. 
• Michelle Barnes, 33, took her own life in her cell in HMP Low Newton on 16 December 2015, just three days after giving birth. Michelle had returned to prison from hospital after the birth. The day before she died, she had been told that she would not be allowed back to hospital and that her baby would be taken into care. The coroner hearing her inquest found very serious failures contributed to her death.  See media coverage.