The coroner has concluded that serious operational and systemic failings led to the death of Baby Aisha Cleary, who was born in HMP Bronzefield without medical assistance in 2019.
Aisha’s mother, Rianna Cleary, a vulnerable teenage care leaver in prison, was left to give birth alone in her cell without any care or assistance. A young woman with a history of trauma, Rianna faced difficulties accessing support services as a former looked after child, leaving her feeling unwanted and uncared for.
During the inquest, it was revealed that Camden Social Services delayed accepting Rianna as a former relevant child, depriving her of crucial support services. The lack of a Personal Advisor until after Aisha’s death further contributed to the failure to help Rianna engage in care.
We support campaigners, like Birth Companions, who are advocating for an end to the imprisonment of pregnant women, especially those with vulnerable backgrounds, to prevent similar tragedies in the future. The coroner criticised Camden Social Services for letting Rianna down, and the entire situation highlights the need for improved support systems for vulnerable individuals.
In this particular situation, HMP Bronzefield had no care plan for prisoners at risk of suicide or self-harm (known as an ACCT) in place, nor was a plan put in place by healthcare staff – which the coroner concluded was a “significant missed opportunity” to engage with and monitor Rianna.
Not getting the help she needed in prison, Rianna tried to apply for bail, but her Offender Manager at the prison refused to help her get a bail hostel address to go to. During the inquest, and in her evidence to the Prison and Probation Ombudsman, the Offender Manager referred to Rianna as a “gangster”.
Research by the charity Inquest has found that racial stereotyping is an experience shared by many Black people in prison, which contributes to deaths. As an 18-year-old Black woman, narratives around gangs informed the way Rianna 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.
In her evidence to the inquest, Rianna asked why her concerns and health needs were ignored and why the prison failed to respond to warning signs and adequately monitor her. She said that 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.”
The evidence heard in this inquest about the treatment of a young and vulnerable pregnant woman has been shocking, upsetting and heart-breaking. It’s also a damning indictment of the state’s failure to keep a young vulnerable woman safe; and she was failed by many agencies. Rianna has shown incredible courage in bringing this case to light. As a young pregnant woman with a history of trauma, Rianna should have been treated with appropriate care and support. There was no adequate care plan for Aisha’s birth and no basic emergency response to her calls for help. Rianna giving birth alone should never have happened.
The adequate response to this tragedy should be swift changes to how we treat pregnant women in custody, and to question why a young woman in Rianna’s situation was sent to prison in the first place, not least when pregnant.
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”.
Two babies are known to have died in women’s prisons in the past four years: one at Bronzefield in October 2019, and one at Styal prison in June 2020. That’s two babies too many.
For too long recommendations from inquiries and reviews have been ignored. We need to take a hard look at our prison system, ensure it is fit for purpose, direct adequate resources where needed, and start taking a race and gender responsive community services approach. The death of a baby in prison should never happen.