28 July 2023 , 14:39
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A teenage mother had to bite through her newborn's umbilical cord as she gave birth scared and alone in her prison cell after no one came to help her.
A prison officer at HMP Bronzefield disabled the call bell to her jail cell after first-time mum Rianna Cleary asked twice for help as she went into labour. Baby Aisha was found dead in the 18 year old's arms by fellow prisoners the next morning when they found the pair covered in blood.
An inquest today slammed both the prison and hospital that looked after her for systematic failings that meant baby Aisha died, with senior coroner for Surrey, Richard Travers, saying she may have survived if her mum had been discovered in labour and transferred to hospital.
During a month-long inquest at Woking Coroner's Court, it was heard that Ms Cleary, a young black woman, was a care leaver and had been treated by authorities as a "gangster" rather than someone who needed help.. She had been sent to the biggest women's prison in the country when she was six months pregnant as she had no bail address.
While behind bars Ms Cleary was told a court order would be made to remove her baby at birth. Giving evidence she said she “wondered at that time if I was being treated differently from [other women in prison] because of my race, because I was young, or because of my past".
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Ms Cleary went into labour inside her prison cell in September 2019 and called an officer on the cell intercom to say she needed a nurse or an ambulance, but no help was called for, the inquest heard. Around half an hour later she called again, despite being in unbearable pain but the call was disconnected in the guard's control room.
Announcing his conclusions at Surrey's Coroner Court in Woking, senior coroner for Surrey, Richard Travers said baby Aisha’s arrival into the world was in the most “harrowing of circumstances”. Her mother was listening to the hearing via video link.
The hearing was told the mum had failed to engage with maternity services and didn't have an ultrasound scan throughout her pregnancy as she was scared her baby would be taken off her when she was born. She even told a prison nurse she would kill herself if her baby was taken away. She had disengaged with maternity care and feared there was no one outside who would be able to care for her child.
On the day before Aisha was born in the early hours, her mum was supposed to have been monitored five times a day, but the nurse on duty admitted she had not been observed as she should have been and this was “unacceptable”. A nurse had tried to get the mum moved to healthcare with the prison but no bed was available. At the time she said: “Tonight could be the night and she could give birth in her cell.”
Harrowing evidence from Ms Cleary was read to the court and revealed the tragic events on the night little Aisha was born and how her calls for help went unanswered. She said: “I called on the bell and asked them to get me a f**king nurse or an ambulance. I just knew I was in a lot of pain. I didn’t understand why he was asking questions. I was so hot I took off my clothes so I was now naked.
“There was blood on the bed, my hands and the wall where I had been holding. I was on all fours on the bed. I was in so much pain I couldn’t scream or call out. I passed out.”
She added: “When I woke up in the cell, I was on the bed, Aisha was between my legs and the cord was still attached. Aisha was purple and didn’t seem to be breathing. I thought I should cut the cord, I didn’t know what to do so I bit through the cord and put the placenta in the bin. I then got into bed with Aisha.”
The coroner slammed prisoner officer Mark Johnson who failed to send Ms Cleary any help. He said Mr Johnson showed a “complete disregard for a prisoner” and his failure meant she did not receive medical assistance with her labour.
Mr Travers said: "Aisha’s mother, Rianna Cleary, was a vulnerable teenager throughout her pregnancy. It is right to acknowledge that, save on a few occasions, she declined offers of ante-natal care. Her refusal to engage with maternity services became more resolute after she had been told that Aisha may be removed at birth. The state agencies and clinicians ought to have understood, and ought to have taken account of the fact, that Ms Cleary’s traumatic background and the prospect of her baby being removed from her were likely to have affected her willingness to engage.
"Ms Cleary’s pregnancy was high-risk and by early September 2019 it was apparent, and it was recognised, that she had become resolutely unwilling to engage with maternity services and that there was a consequential high risk that she might give birth alone in her cell.
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"Despite these risks, the midwifery and obstetric service from St. Peter’s Hospital failed to: give reliable guidance as to the time at which Aisha was likely to arrive, take a joint working approach with the Prison’s healthcare team, arrange a multi-disciplinary team meeting, and ensure that an effective joint plan was in place to ensure that Ms Cleary’s labour was identified and that she was transferred to hospital in a timely manner for Aisha’s delivery.
"Despite these risks, the Prison failed to: put in place an effective plan to ensure that Ms Cleary’s labour was identified and that she was transferred to hospital in a timely manner for Aisha’s delivery, put in place a clear and effective plan to observe and monitor Ms Cleary, open an ACCT when Ms Cleary spoke of self-harm in the context of her pregnancy on the 25th September 2019, implement the extended observations regime that had been directed on the morning of the 26th September 2019, and respond to Rianna Cleary’s request for medical assistance at 8.07pm when she was locked in her cell and in labour, and failed to answer her second cell intercom call made at 8.32pm."
He added: "If Ms Cleary’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."
Janey Starling, co-director of Level Up, who is campaigning for an end to the imprisonment of pregnant women, said: “The coroner found that the clinical care in prison was not equivalent to what she would have been able to access in the community. When a woman is held behind locked doors for sustained periods of time, it never will be. Today’s findings make ‘healthcare reform’ in prisons a thing of the past – now, the Ministry of Justice and Sentencing Council must ensure there are alternatives in place for pregnant women, and that they are no longer trapped in prison.”
“Prison will never be a safe place to be pregnant and it’s long overdue for courts to stop sending pregnant women there. 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.”
Deborah Coles, director at charity Inquest told the Mirror: “Aisha’s mother was a young woman with a history of trauma. She deserved care and support from public services. The fundamental question is why so many agencies failed her, and why was she sent to prison in the first place, not least when pregnant? Inquest evidence has shown that as a vulnerable 18-year-old Black woman, narratives around gangs informed the way she was treated in the community and in prison. She was viewed not as someone in need of care and compassion but as a discipline and control problem.
"Her calls for help went unanswered, and her pain was ignored. 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.”
Naomi Delap, director of the charity Birth Companions, said: "The deeply distressing witness testimony heard in this inquest adds to the considerable weight of evidence showing that prisons are not, and will never be, safe environments for pregnant women. We welcome the Coroner’s conclusion. The prison system, by its very nature, creates significant barriers to healthcare. We’ve been working with pregnant women in prison for 27 years, during which time we’ve seen and heard of other tragic deaths as well as many serious incidents and near misses. Things have to change.
“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.”