2 May 2023

Before HM Senior Coroner for Surrey, Richard Travers
Surrey Coroner’s Court, Woking
Scheduled 2 May – 1 June 2023

Aisha Cleary was born during the night of 26 September 2019. She was found dead on the morning of 27 September after her mother, a highly vulnerable 18 year old care leaver, gave birth alone in a prison cell in HMP Bronzefield in Ashford, Surrey – the largest women’s prison in Europe.

Now an inquest will open into her death after her mother persuaded the coroner to examine the circumstances of Aisha’s death and whether any failures in the care provided to Aisha’s mother or to Aisha contributed to her death. The coroner will hear the evidence of expert pathologists and a consultant obstetrician to determine whether Aisha was born alive or stillborn.

Aisha’s mother was remanded to HMP Bronzefield on 14 August 2019, arriving with a Prison Escort Record stating that she was six months pregnant. On 19 August she was told by social services that they would be seeking a court order to remove her child at birth. She did not engage consistently with maternity services.

During the evening of 26 September, Aisha’s mother went into labour. At around 8.07pm Aisha’s mother used the intercom in her cell to request medical attention. No nurse or ambulance was called, and no-one checked on her. Aisha’s mother pressed her cell bell again at around 8.32pm, but the call was not answered.

At around 9.27pm and 4.19am, Aisha’s mother’s cell was checked by prison officers as part of a routine roll count, but on neither occasion was anything untoward noticed in her cell. At around 8.15am a prison officer did the morning unlock and did not notice that the cell had significant amounts of blood on the floor and walls.

At around 8.21am, two prisoners alerted prison staff to blood in Aisha’s mother’s cell. A prison officer who then attended discovered that Aisha’s mother had given birth during the night.

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

The inquest, which is planning to hear evidence from approximately 50 witnesses (including social services, community and prison midwifery services, prison healthcare staff and officers and former prisoners, as well as expert evidence), will also examine issues including:

• Aisha’s mother’s status in relation to any relevant state agencies, when she became pregnant with Aisha;
• The care (including clinical care) offered or provided to Aisha’s mother in relation to her pregnancy from February to the 14 August 2019 by relevant services;
• The care (including clinical care) and support offered or provided to Aisha’s mother in relation to her pregnancy, and how this was managed after she was detained in custody at HMP Bronzefield on the 14 August 2019 including the adequacy of the response to cell bells;
• Information sharing between relevant agencies and services; and
• What Aisha’s prospects of survival would or may have been if Aisha’s mother had been provided different treatment and care at any time in the course of her pregnancy, labour, or delivery of Aisha.

Aisha’s death has been investigated by the Prisons and Probation Ombudsman (PPO), Sue McAllister. 

In the PPO Report, Ms McAllister commented: “Ms A gave birth alone in her cell overnight without medical assistance. 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”. 

The PPO has made wide-ranging recommendations for national improvement and learning for caring for pregnant prisoners. The coroner will also examine what changes have been made to maternity services in HMP Bronzefield, and more widely, since Aisha’s death, to determine whether a Report to Prevent Future Deaths must be issued.

Deborah Coles, Director at INQUEST, said: "A teenager giving birth alone in a prison cell, her calls for help ignored, is deeply shocking. This inquest must examine how she and her baby were so badly failed by multiple state agencies with responsibility for their welfare, health  and safety."  

ENDS

NOTES TO EDITORS

For more information please contact Leila Hagmann on [email protected]. 

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 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.

Relevant case

• 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.