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Aisha Cleary: Inquest finds serious failings contributed to death of baby in prison cell at HMP Bronzefield

A Coroner has today concluded that the death of an 18-year-old Black woman’s full-term baby in a prison cell in Surrey was contributed to by serious operational and systemic failings.

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 she “arrived into the world in the most harrowing of circumstances” given that her mother, Rianna Cleary – a vulnerable teenage care leaver – was left to give birth alone in a prison cell without any care or assistance.

Rianna Cleary was represented by Maya Sikand KC and Tom Stoate of Doughty Street Chambers Inquests and Public Inquiries Team, instructed by Elaine Macdonald of Broudie Jackson Canter Solicitors and supported by INQUEST senior caseworker Selen Cavcav.

After learning that Social Services would seek a court order to remove the child immediately after its birth, Rianna informed prison officers – a day before the birth - that she told she would kill herself if this happened.

The Coroner concluded that the lack of appropriate care plan put in place for Rianna by prison or healthcare staff (ie ACCT for prisoners at risk of suicide or self-harm) was a “significant missed opportunity” to engage with and monitor her. His conclusions were as follows:

  • 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.

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.

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.”

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

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.”

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.”

The case was covered by the Independent, Channel 4, The Guardian, SkyNews and others.

For further enquiries, please contact our Senior Civil Clerk Sian Wilkins