Coroner’s conclusions of ‘serious failings’ in death of a newborn baby show we need an end to pregnancy in prisons

The inquest into death of baby Aisha Cleary came to a close on Friday 28 July. Aisha died in 2019 after being born in her 18-year-old mother Rianna’s cell in HMP Bronzefield, Europe’s largest women’s prison. The coroner concluded that serious systematic failings contributed to her death, with the inquest revealing that Rianna’s calls for help during labour went ignored and she was left alone in her cell for 12 hours.

Last year we joined colleagues at Level Up to call attention to the fact that women in prison are 7 times more likely to experience a stillbirth than those in the general population. They also have far poorer experiences of pregnancy and birth which leaves them, and their babies, at risk of life-long harm.

With Friday’s news highlighting yet more serious maternity safety failing, we support calls for the UK to follow the examples of other countries, including Brazil, Russia, Ukraine, and Mexico, in ending the incarceration of pregnant women. Often their imprisonment provides unnecessary and avoidable barriers to appropriate healthcare.

Every woman, no matter their circumstance, should have access to quality maternity care, which is why we’re joining Birth Companions in calling for an end to imprisoned pregnancy.

Rianna Cleary and her baby were failed on multiple fronts. Evidence given showed the prison did not have a good plan to identify Rianna's labour and did not respond to her calls for help. The midwifery and obstetrics team in charge of her care failed to give reliable guidance and arrange an appropriate plan of care. Senior coroner for Surrey, Richard Travers, said of the case that Aisha “arrived into the world in the most harrowing of circumstances.”

Rianna’s case further shows that inadequate care is being provided to these women who often come from the most deprived backgrounds and will be more likely to experience a high-risk pregnancy. 

Kath Abrahams, Tommy’s Chief Executive, said:

We cannot simply write these families off. These women and their babies are amongst the most vulnerable in society and need specific, personalised care during pregnancy to reduce the unacceptable rates of stillbirth and neonatal harm occurring within the prison system.

Being pregnant in prison has now repeatedly been shown to have serious safety failings. This is why Tommy’s, along with many other organisations, has made the decision to co-sign a letter written by charity Birth Companions, laid out below, in a call to end the use of prisons for pregnant women and mothers of infants.

Letter by Birth Companions, co-signed by Tommy's

First published 28 July 2023

Today, the coroner gave his decision in the inquest into the tragic death of Aisha Cleary, born in her mother’s prison cell in 2019.

Speaking in the Surrey Coroner’s Court, HM Senior Coroner Richard Travers noted significant failings in the care provided to Aisha’s mother by social services, healthcare, and the prison, including a stark lack of consideration for her mental health needs. Mr Travers said that while he was unable to ascertain whether Aisha died shortly after birth, or was stillborn, it was clear there had been real opportunities to identify the fact that her mother Rianna was in labour, and that, had she been transferred to hospital when she called for medical assistance, Aisha would have been given clinical care that may have ensured her survival.

We urge the government to learn the lessons from this awful case, which illustrates the huge risks posed by the prison system. Prison will never be a safe or appropriate place to hold pregnant or postnatal women.

The death of Aisha, also known as ‘Baby A,’ whose 18-year-old mother’s calls for help went ignored by the prison when she went into labour, has already led the NHS to categorise all pregnancies in prison as high risk due to the nature of the environment.

As organisations and academics working across maternity and the criminal justice system, we are all too aware of the severity of these risks, for both mother and baby. It is not enough for the government to promise improvements in care that we all know will be impossible to deliver. They can, and must, end the use of prison for 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.

Commenting on the inquest's decision, Naomi Delap, Director of 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.

Kath Abraham, Tommy's Chief Executive, said:

Tommy’s believes everyone should have equitable access to good maternity care, no matter who they are or where they live. We’re working to make maternity care safer for all, and that must include women in prison. They can’t be ignored simply because they’re out of sight.