Serious systemic failings contributed to the death of a newborn baby in a cell at Europe’s largest women’s prison, a coroner has concluded. Rianna Cleary, who was 18 at the time, gave birth to her daughter Aisha alone in her prison cell at HMP Bronzefield, in Surrey, on the night of 26 September 2019. The care-leaver was on remand awaiting sentence after pleading guilty to a robbery charge. The inquest into the baby’s death heard that Cleary’s calls for help when she was in labour were ignored, she was left alone in her cell for 12 hours and bit through the umbilical cord to cut it. The senior coroner for Surrey, Richard Travers, said Aisha “arrived into the world in the most harrowing of circumstances”. He concluded it was “unascertained” whether she was born alive and died shortly after or was stillborn. Cleary realised she was pregnant after being arrested while living in a supported hostel in Camden, London. She was remanded to HMP Bronzefield on 14 August 2019, arriving with a record stating she was six months pregnant. On 19 August, she was told by social services that they would be seeking a court order to remove her child at birth. At 8.07pm on the night of the birth, Cleary used the intercom in her cell to urgently request a nurse or an ambulance. The call was answered by the prison officer Mark Johnson, who did not call for medical help. He is under disciplinary investigation and suspended from prisoner-facing duties. When she called for help a second time, the call was disconnected in the prison communications room. A staff member doing a night patrol did not notice anything untoward in the cell, although the following morning it was found covered in blood. In a devastating witness statement read to the court, Cleary described going into labour alone as “the worst and most terrifying and degrading experience of my life”. She said: “I didn’t know when I was due to give birth. I was in really serious pain. I went to the buzzer and asked for a nurse or an ambulance twice.” Cleary passed out and when she woke up she had given birth. “The cord was still attached. The placenta was on the floor. I bit the cord and tied it and put the placenta in the bin. I sat there holding her.” Cleary’s cell was unlocked at 8.15am and at 9.03am paramedics confirmed that baby Aisha had died. In her statement, Cleary questioned whether she had been failed so badly because she was a young, black woman. “I 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,” she said. The coroner identified failings by both the prison and Ashford and St Peter’s hospitals NHS foundation trust, which was providing maternity care. He found that the prison failed to put in place an effective plan to ensure Cleary’s labour was identified, and failed to respond to her calls for help. He also found that the midwifery and obstetrics team at the trust failed to give reliable guidance about when the baby would arrive and to ensure an appropriate plan would be in place. He described the approach of one midwife dealing with Cleary’s care as “highly inappropriate and unprofessional”. The inquest heard that Cleary had experienced childhood trauma, struggled in her early teenage years to engage with education and was at risk of exploitation. Aisha’s death was investigated by the prisons and probation ombudsman (PPO), Sue McAllister. In her report, she said the mother “gave birth alone in her cell overnight without medical assistance. This should never have happened.” McAllister noted that in many ways “the situation for pregnant women in Bronzefield was symptomatic of a national absence of policies and pathways for pregnant women in custody”. From April 2022 to March 2023, there were 196 pregnant women in prison. Campaigners are calling for an end to the imprisonment of pregnant women. After the inquest verdict, Cleary said: “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.” Deborah Coles, the director of 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. “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.” A spokesperson for HMP Bronzefield said: “We are truly sorry that Ms Cleary gave birth alone in her cell and continue to extend our sincere condolences for the sad and tragic death of Aisha. In the four years that have passed, our priority has been to implement effective and positive changes in the prison. We will now review these in light of the coroner’s conclusions, as we continue to improve support for pregnant women in our care.” Julie Smith, the chief executive at Ashford and St Peter’s hospitals NHS foundation trust, said: “We are deeply sorry to Ms Cleary for the devastating loss of her baby, Aisha, and the impact this has had. “Following Aisha’s death, we immediately launched a full serious incident investigation and have implemented subsequent recommendations from the prison and probation ombudsman report. We will continue to work with the coroner’s conclusion alongside the prison authorities and their healthcare team. “The ASPH maternity team pride themselves on providing the highest level of care and are deeply distressed by the death in such tragic circumstances of Aisha.”