Systemic failings by state agencies contributed to the death of a Black baby whose “extremely vulnerable” teenage mother gave birth alone in her prison cell, a coroner has ruled.
Rianna Cleary, who was 18 years old at the time, gave birth to Aisha in the early hours of 27 September 2019 without any medical help after two calls to prison staff at HMP Bronzefield went unanswered.
A prison officer also walked past her cell with a torch when she was on her hands and knees in labour but did not stop and help, Surrey Coroner’s Court in Woking was told.
On the night she went into labour, Ms Cleary – who was exploited by county lines gangs before ending up in HMP Bronzefield jail – was in extreme pain but did not know what was causing it as she was not due to give birth until the following month.
She later fell asleep and delivered the infant alone during the night. When she woke up, she was forced to bite off her own baby’s umbilical cord with her teeth.
Aisha was found dead in the cell in the morning after suffering brain injuries, the inquest heard. The coroner was unable to determine whether she was stillborn or breathing when she was delivered, but if she was alive she would have died within hours.
The hearing was told the mother had not been engaging with nurses before the birth because she was worried her baby would be taken away by social services. She had claimed she would take her own life if her baby was removed from her care.
Richard Travers, senior coroner for Surrey, found that the prison and midwives at St Peter’s Hospital did not have proper plans to care for Ms Cleary and her baby in the run-up to her going into labour.
The prison also failed to monitor her adequately, support her when she said she would kill herself if the baby was taken away, and respond to her calls for help during labour.
“There is clear evidence, not least, of systemic failings which more than minimally contributed to Aisha being delivered in a prison cell without medical assistance and, following delivery, losing the chance of resuscitation and survival,” Mr Travers said.
“If Aisha’s mother’s labour had been identified and she had been transferred to hospital in a timely manner for Aisha’s delivery, there would have been an opportunity for effective steps to have been taken to secure Aisha’s survival.”
Speaking after the inquest, Ms Cleary said that “nothing can change the nightmare I went through or bring Aisha back”.
“I feel so sad knowing that Aisha may have survived if they had helped me,” she added.
“Only one prison officer, 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.”
Although race was not considered as a potential factor, Ms Cleary questioned whether she was mistreated because of her ethnicity in a statement read out during the inquest.
“I want this inquest to give me some answers,” she said. “Was I treated differently because I am a young, Black woman? Why was I left to give birth on my own? Why did no one answer my cell bell when I was desperately seeking help?”
In official statements given shortly after Aisha’s death, a prison supervisor entrusted with Ms Cleary’s care described her as being like a “gangster”. However, she was unable to justify her use of such language when challenged by the coroner and Ms Cleary’s barrister during the inquest proceedings.
When asked by the coroner whether that was an appropriate word to use, she replied: “No.” Her barrister then asked whether she had used the term because Ms Cleary was Black, but she denied this.
Last year, Black, Asian and minority ethnic women prisoners recounted their experiences of racial discrimination at the hands of staff members – with some inmates reporting that they had been inappropriately described using terms such as “gangster”.
Racial disparities in maternal and baby health outcomes across the UK reflect the tragedy of Aisha’s case.
The court heard how a prison officer walked past Ms Cleary’s cell with a torch when she was on her hands and knees in labour but did not stop to help— (The Independent)
Black and mixed-race babies are statistically more likely to die following birth, according to figures from the Office for National Statistics (ONS), with research pointing to systemic racism as a cause of these inequalities.
The charity INQUEST, which is supporting Ms Cleary, believes race may have played a part in how the young mother was treated.
Deborah Coles, INQUEST’s director, told The Independent: “INQUEST’s research has found a lack of meaningful consideration of the race or ethnicity of those who die in prison, and the potential role of racism or discrimination in ombudsman investigations, coroner’s inquests and reports.
“This is an unacceptable oversight which renders clear issues of racism and discrimination invisible. It puts the onus on bereaved families and their legal representatives to highlight the evidence.
“Our research and casework evidence patterns of neglectful treatment of racialised people in prison, whose pain and distress is frequently ignored or seen as attention-seeking, aggressive or manipulative. Without investigating and considering these issues, how can they be properly addressed?”
The tragic case of Aisha has renewed concerns about pregnant women being in prison. Protesters gathered outside the coroner’s court after the hearing.
Janey Starling, co-director of Level Up, a women’s rights campaign group, told The Independent: “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.
“It’s time for the government to listen to the experts and end the imprisonment of pregnant women.”
There were 196 pregnant women in prison during the 12-month period from April 2022 to March 2023.
