Surrey: Baby of teen mum who gave birth alone in prison cell died after 'systemic failings', coroner finds
A prison officer walked past聽Rianna Cleary's cell with a torch when she was on her hands and knees in labour but did not stop and help, Surrey Coroner's Court is told.
Friday 28 July 2023 22:59, UK
A baby girl who died after her mother gave birth alone in a prison cell may have survived if prison and hospital staff had acted differently, a coroner has found.
A prison officer walked past Rianna Cleary's cell with a torch when she was on her hands and knees in labour but did not stop and help, Surrey Coroner's Court was told.
Systemic failings contributed to the "chance of resuscitation and survival" being lost, Coroner Richard Travers said.
Ms Cleary, who was 18 when she gave birth to Aisha at HMP Bronzefield in the early hours of 27 September 2019, had spent time in care.
She had also been been exploited by county lines gangs before entering the jail the month before.
She had been reluctant to talk to medical staff because she was worried her baby would be taken away by social services, Surrey Coroner's Court heard.
Ms Cleary began to feel pain on 26 September but was confused because her due date was not until the following month, she told the inquest.
After briefly falling asleep, she woke up in "really serious pain" that evening.
She made two panicked calls to prison staff asking for a nurse and an ambulance, but they did not arrive.
After falling asleep she delivered the infant during the night after losing blood.
When she woke up, she had to cut the infant's umbilical cord with her teeth.
Her baby was pronounced dead at 9.03am that morning after suffering brain injuries, the inquest heard.
The coroner was unable to ascertain whether Aisha was stillborn or breathing when she was delivered.
Prison custody officer (PCO) Mark Johnson, who responded to her first call, said she had been "abusive" and was swearing while asking for a nurse.
He is under disciplinary observation and remains suspended from prisoner-facing duties, charity INQUEST said.
The second call, which Ms Cleary made while her bed, hands and the buzzer were covered in blood, was never answered.
Later that night, PCO Katarzyna Rachwal passed as she was in labour but told the hearing "nothing came to my attention and that is why I moved on".
Coroner Travers said the prison, on the southwest edge of London, and St Peter's Hospital in Surrey, did not do enough to make a plan that would identify the start of Miss Cleary's labour and ensure she was transferred to hospital quickly.
She should also have been given a personal adviser, he added.
The coroner said: "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.
"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."
After the inquest, Rianna Cleary, who attended remotely, said in a statement read out by her lawyer Maya Sikand KC: "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.
"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."
Meanwhile, a woman who was sent to prison while six months pregnant said she went into labour while locked in her cell.
The woman, whose identity Sky News is protecting, said her call bell, which she had been pressing since 5.30am, was "ignored".
She did not get to hospital until 11am, she added.
Prisons minister Damian Hinds said: "Aisha's death was appalling. We continue to extend our deepest and most heartfelt sympathies to her mother and family.
"We have since made important improvements to the care received by pregnant women, including specialist mother and baby staff in every women's prison, extra welfare checks and better health and antenatal support."
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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.
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"The prison system, by its very nature, creates significant barriers to healthcare.
"The government can, and must, end the imprisonment of pregnant women and mothers of infants."