The last thing Rianna Cleary remembers before she passed out in the early hours of 27 September 2019, alone and in the throes of labour pain, was a scene involving a chicken leg in the film Killer Joe, which was showing on the TV screen in her prison cell.
Cleary was 18 at the time – an extremely vulnerable care leaver, she had felt judged harshly by the system ever since her pregnancy had been confirmed earlier in the year.
When she was finally found in her cell in HMP Bronzefield in Surrey, the biggest women’s prison in Europe, more than 12 hours after she tried and failed to summon help by repeatedly pressing her cell bell, her baby daughter, who she named Aisha, had been born but was showing no signs of life. Aisha was covered in meconium, the first faeces of a newborn, was not moving and had a tinge of blue on her lips. There was blood everywhere – on Cleary, on her bed, on her sink and on the walls. With no other way to sever it, Cleary had bitten through her umbilical cord.
Staff attempted to resuscitate Aisha but there were no neonatal masks available, only adult ones that did not fit her tiny face. She was pronounced dead at 9.03am, before mother and baby were taken by ambulance to hospital.
It was only a matter of days before the shocking news leaked, first revealed in the Guardian. At the time, Surrey police said the death was “unexplained”. Eleven separate inquiries were subsequently launched and, on 28 July, an inquest, presided over by the senior Surrey coroner Richard Travers, concluded that “systemic failings” contributed to Aisha’s death. After hearing expert medical evidence, the coroner found that it was “unascertainable” whether Aisha died shortly after birth or had been stillborn.
It took almost four years for the inquest to get under way. About 50 witnesses gave evidence – from the prison, from Camden council where Cleary had been in care, from Ashford and St Peter’s hospitals NHS foundation trust (which provided midwifery services in the prison), as well as various experts and most powerfully Cleary herself, whose witness statement was read out in court. Cleary, now 22, attended the windowless coroner’s court every day of the month-long case, listening intently. At last, a comprehensive account of how she and her baby were failed has been made public.
Cleary had difficulties in her early life. She said in her witness statement that her mother had drug problems and so she only saw her from time to time. She lived with her father from the age of four, with support from her mother’s mother – her nan. Both championed her and supported her when she took part in sports such as tennis and judo. At 14, the death of her nan affected her “really badly”. She was excluded from mainstream education and sent to live in a care home in Wales by social services.
In 2016, she was sentenced to a period in a secure unit in Bristol after committing a number of offences. She was released in 2017, but that year her father went to prison. “Everything continued to snowball very badly for me. I didn’t have anywhere to live permanently and I kept getting arrested,” she said. It was suspected that she was being exploited by county lines drug gangs and at one point she was found by police in a house used by addicts in Northampton.
In February 2019, she found out that she was pregnant after being arrested and taken to a police station, where a test was done. She was living in a hostel and felt that from that moment various professionals started making plans for the baby, leaving her feeling “overwhelmed” and denied an opportunity to think about what she wanted.
Later that year, in August, she pleaded guilty to a robbery charge and, distressed by her treatment in the hostel, asked to be remanded in prison while awaiting sentence. She thought she might get more help and support behind bars, but her hopes were dashed when she received a letter from Camden social services. Rather than seeing her as a victim of exploitation, the letter was critical of her lifestyle and “criminal history”. “We will be going to court once your baby is born to try to ensure your child is safe. This could mean that your child will be removed from your care,” it stated.
A letter from social services five months earlier had accused Cleary of “going missing and not engaging with services”. She was criticised for her lack of cooperation with professionals and for failing to attend antenatal appointments and scans. But, she told one prison officer, after she had been told that her baby would be taken away from her at birth there seemed little point in going along with what social services wanted. She said one officer told her she would get just five minutes with her baby and that police would be there to take the child away.
“I felt like nobody was trying to understand me or what was going on for me,” she said in her witness statement. “This made me defensive and I put up barriers. I didn’t understand why they were saying these things to me … I felt like they were unfairly judging me and not giving me a chance before she was even born. I felt like I was being asked to give up on my child and motherhood.” She continued: “They did not think I could be a good enough mother.”
She felt other pregnant women in the prison were being treated more favourably than her and were not being threatened with having their babies removed. Cleary, who is black, “wondered at that time if I was being treated differently from them because of my race, because I was young or because of my past. I felt like I was trapped and had nowhere to go.”
As her pregnancy progressed, so did her sense of fear and hopelessness. Shortly before she gave birth, two inmates had flagged to prison officers that Cleary was upset and crying and was threatening to throw herself down the stairs because she did not want her baby to be taken away from her.
During the day of 26 September, Cleary experienced cramping pains and an urgent need to urinate but was not sure whether she was in labour or not, partly because she had been given wildly varying due dates of some time between August and November.
She dozed off in her locked cell, waking up in agony around 8pm. At 8.07pm she tried to summon help by pressing her buzzer. The call was answered and she managed to get out the words: “Get me a fucking nurse or an ambulance.” The officer asked why she needed medical assistance but Cleary was in too much pain to explain. The conversation did not formally end and the officer then took another call. At 8.32pm, she tried again to summon assistance, but this time her buzzer went unanswered. She said that by the time an officer, a woman new to night duty, shone a torch into her cell several hours later she was on all fours in acute distress. The officer’s evidence stated that “nothing caught my attention, so I moved on”.
Cleary is thought to have lost consciousness some time after 1.40am, when the film Killer Joe started screening. She recalled cutting the umbilical cord with her teeth after Aisha was born and wrapping her in a towel. She tried and failed to wipe away the blood that was all over the cell. “Eventually I gave up trying to clean it,” she said.
An officer unlocked Cleary’s cell door at about 8.30am but did not appear to notice that there was a baby in the cell, nor that it was covered with blood. It was two inmates who finally raised the alarm a short while later.
At one point in the inquest, prison officer Lewis Kirby spoke directly to Cleary across the court room: “Rianna, I just want to pass on my sincere condolences to you and your family for what’s happened. I’m truly sorry for what you have been through.” He was the only witness to offer any kind of condolences to Cleary during the live evidence.
In his conclusions, the coroner identified a series of failings by Ashford and St Peter’s hospitals NHS foundation trust and HMP Bronzefield, including not making a proper plan to transfer Cleary to hospital when she went into labour.
The inquest, he said, had been “a distressing investigation into the death of a newborn baby who on any view arrived into the world in the most harrowing of circumstances”. NGOs such as Birth Companions, Level Up and Inquest have condemned the case and called for an end to the incarceration of pregnant women.
There has been a great deal of official regret expressed in the days since the inquest concluded. The prisons minister, Damian Hinds, said the government continued to “extend our deepest and most heartfelt sympathies”, Ashford and St Peter’s hospitals said they were “deeply sorry”, and Sodexo, which has a contract with the Ministry of Justice to run HMP Bronzefield, said it was “truly sorry”. All spoke of a number of improvements that have been made since Aisha Cleary’s death, including specialist mother and baby staff in every women’s prison, extra welfare checks and better health and antenatal support. Since then, more than 100 babies have been born to women in prison.
Many different services operated in the prison at the time, public and private – nurses were employed by Sodexo, GPs by Cimmaron, mental health services by North West London NHS foundation trust, along with the midwifery services provided by Ashford and St Peter’s. No one service had a complete overview of Cleary’s case. Multiple failures were identified in the course of the inquest and at times it seemed that Cleary’s fellow prisoners had grasped what was going on better than the professionals.
In her testimony, Cleary described what happened to her in her cell in HMP Bronzefield as “the worst and most terrifying and degrading experience of my life. I am still struggling to come to terms with what happened.”
While system-wide failures often become more apparent with the benefit of hindsight, in Cleary’s case the alarm was sounded several times before she gave birth. One officer wrote: “Her risk of giving birth in cell increases by the week.” A medical professional also issued a warning before the birth: “Tonight could be the night we will be caught out.”
The previous year, Cleary had been described by one social worker as “sceptical of professionals” and with “a harsh understanding of the reality of the world”.
That observation is even more true now than when it was written.
