14 November 2023

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

The senior coroner in Surrey announced this week 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, an inquest found that serious operational and systemic failings contributed to her death. 

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

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.  

After an inquest, coroners can issue recommendations on the Prevention of Future Deaths (PFDs) to organisations, local authorities, government agencies or person in order to try and stop similar deaths.

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.

Campaigners are continuing to call for an end to the imprisonment of pregnant women.

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.”

Selen Cavcav, Senior Caseworker at INQUEST, said:We are disappointed that the coroner has decided not to issue a Prevention of Future Deaths report following this inquest which exposed one of the most damning failures in our prison system.

We have no faith that the changes which have been made by the prison will save further lives. There is a depressingly huge gap between policy and what happens behind closed doors.  

There is no reliable system for checking how these changes are implemented and essentially no proper accountability when policies and procedures are completely ignored like they were when Rianna was pregnant in prison.

INQUEST knows this only too well. Prison is a disproportionate, inappropriate, and dangerous response to women in conflict with the law, let alone those who are pregnant. 

We must urgently dismantle women’s 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: “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 focussed 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.”

Janey Starling, Co-Director of Level Up, said: "The only way to prevent further deaths of babies in prison is to end the imprisonment of pregnant women. There are no amount of reforms that will ever make prison a safe place for pregnant women when they remain trapped behind several sets of locked doors, inherently harsh conditions where care is substandard, and at the mercy of prison officers decision-making.

Since Aisha’s death, the Prison Ombudsman, NHS and Ministry of Justice have declared that all pregnancies in prison are high-risk. So why can courts still send pregnant women there? Without a change in our court system, it is only a matter of time before another death like this happens.

The government must stop sending pregnant women to prison. Courts are effectively sentencing women to high-risk pregnancies, if not emergency births and stillbirths. This urgently has to stop.” 

Naomi Delap, Director of Birth Companions, said: “The systems interrogated in this inquest - prison, maternity, and local authority social care services – are in crisis. It is dangerous to assume that promised improvements, and better written policies, can address the deep, systemic issues flagged by Aisha’s death.


Fundamental change is needed if we are to prevent the deaths of more women and infants, and this decision from the coroner is a missed opportunity to drive that change. We are not confident that women and babies are safe. There is a real risk that more lives will be lost.” 



For further information please contact Leila Hagmann on [email protected] or 020 7263 1111.

Rianna 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 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. It provides services in HMP Bronzefield and HMP Foston Hall, as well as supporting women in the community after release from prison. www.birthcompanions.org.uk @brthcompanions 


According to HMPPS data, there were 196 pregnant women in prison during the 12-month period from April 2022 to March 2023.. One in three pregnant women in prison are being held on remand awaiting trial, it has now been uncovered. 

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 is currently consulting on whether to add a new mitigating factor for pregnancy, childbirth and postnatal care (amongst other proposals). Their consultation runs until 30 November and is an opportunity to reduce the number of pregnant women sentenced to imprisonment.

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.

Previous press releases

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.