The very last thing Rianna Cleary remembers earlier than she handed out within the early hours of 27 September 2019, alone and within the throes of labour ache, was a scene involving a rooster leg within the movie Killer Joe, which was exhibiting on the TV display in her jail cell.
Cleary was 18 on the time – a particularly susceptible care leaver, she had felt judged harshly by the system ever since her being pregnant had been confirmed earlier within the 12 months.
When she was lastly present in her cell in HMP Bronzefield in Surrey, the largest ladies’s jail in Europe, greater than 12 hours after she tried and did not summon assist by repeatedly urgent her cell bell, her child daughter, who she named Aisha, had been born however was exhibiting no indicators of life. Aisha was lined in meconium, the primary faeces of a new child, was not shifting and had a tinge of blue on her lips. There was blood in every single place – on Cleary, on her mattress, on her sink and on the partitions. With no different strategy to sever it, Cleary had bitten by her umbilical twine.
Workers tried to resuscitate Aisha however there have been no neonatal masks obtainable, solely grownup ones that didn’t match her tiny face. She was pronounced useless at 9.03am, earlier than mom and child had been taken by ambulance to hospital.
It was solely a matter of days earlier than the surprising information leaked, first revealed within the Guardian. On the time, Surrey police mentioned the demise was “unexplained”. Eleven separate inquiries had been subsequently launched and, on 28 July, an inquest, presided over by the senior Surrey coroner Richard Travers, concluded that “systemic failings” contributed to Aisha’s demise. After listening to knowledgeable medical proof, the coroner discovered that it was “unascertainable” whether or not Aisha died shortly after delivery or had been stillborn.
It took nearly 4 years for the inquest to get below approach. About 50 witnesses gave proof – from the jail, from Camden council the place Cleary had been in care, from Ashford and St Peter’s hospitals NHS basis belief (which offered midwifery providers within the jail), in addition to numerous specialists and most powerfully Cleary herself, whose witness assertion was learn out in courtroom. Cleary, now 22, attended the windowless coroner’s courtroom each day of the month-long case, listening intently. Finally, a complete account of how she and her child had been failed has been made public.
Cleary had difficulties in her youth. She mentioned in her witness assertion that her mom had drug issues and so she solely noticed her sometimes. She lived together with her father from the age of 4, with help from her mom’s mom – her nan. Each championed her and supported her when she took half in sports activities resembling tennis and judo. At 14, the demise of her nan affected her “actually badly”. She was excluded from mainstream training and despatched to dwell in a care dwelling in Wales by social providers.
In 2016, she was sentenced to a interval in a safe unit in Bristol after committing quite a lot of offences. She was launched in 2017, however that 12 months her father went to jail. “Every thing continued to snowball very badly for me. I didn’t have anyplace to dwell completely and I saved getting arrested,” she mentioned. It was suspected that she was being exploited by county traces drug gangs and at one level she was discovered by police in a home utilized by addicts in Northampton.
In February 2019, she came upon that she was pregnant after being arrested and brought to a police station, the place a take a look at was carried out. She was dwelling in a hostel and felt that from that second numerous professionals began planning for the child, leaving her feeling “overwhelmed” and denied a chance to consider what she needed.
Later that 12 months, in August, she pleaded responsible to a theft cost and, distressed by her remedy within the hostel, requested to be remanded in jail whereas awaiting sentence. She thought she may get extra assist and help behind bars, however her hopes had been dashed when she acquired a letter from Camden social providers. Fairly than seeing her as a sufferer of exploitation, the letter was crucial of her way of life and “prison historical past”. “We will probably be going to courtroom as soon as your child is born to attempt to make sure your youngster is protected. This might imply that your youngster will probably be eliminated out of your care,” it acknowledged.
A letter from social providers 5 months earlier had accused Cleary of “going lacking and never partaking with providers”. She was criticised for her lack of cooperation with professionals and for failing to attend antenatal appointments and scans. However, she informed one jail officer, after she had been informed that her child could be taken away from her at delivery there appeared little level in going together with what social providers needed. She mentioned one officer informed her she would get simply 5 minutes together with her child and that police could be there to take the kid away.
“I felt like no one was attempting to grasp me or what was happening for me,” she mentioned in her witness assertion. “This made me defensive and I put up limitations. I didn’t perceive why they had been saying these items to me … I felt like they had been unfairly judging me and never giving me an opportunity earlier than she was even born. I felt like I used to be being requested to surrender on my youngster and motherhood.” She continued: “They didn’t assume I could possibly be a ok mom.”
She felt different pregnant ladies within the jail had been being handled extra favourably than her and weren’t being threatened with having their infants eliminated. Cleary, who’s black, “questioned at the moment if I used to be being handled in a different way from them due to my race, as a result of I used to be younger or due to my previous. I felt like I used to be trapped and had nowhere to go.”
As her being pregnant progressed, so did her sense of concern and hopelessness. Shortly earlier than she gave delivery, two inmates had flagged to jail officers that Cleary was upset and crying and was threatening to throw herself down the steps as a result of she didn’t need her child to be taken away from her.
Through the day of 26 September, Cleary skilled cramping pains and an pressing have to urinate however was unsure whether or not she was in labour or not, partly as a result of she had been given wildly various due dates of a while between August and November.
She dozed off in her locked cell, waking up in agony round 8pm. At 8.07pm she tried to summon assist by urgent her buzzer. The decision was answered and she or he managed to get out the phrases: “Get me a fucking nurse or an ambulance.” The officer requested why she wanted medical help however Cleary was in an excessive amount of ache to clarify. The dialog didn’t formally finish and the officer then took one other name. At 8.32pm, she tried once more to summon help, however this time her buzzer went unanswered. She mentioned that by the point an officer, a lady new to nighttime obligation, shone a torch into her cell a number of hours later she was on all fours in acute misery. The officer’s proof acknowledged that “nothing caught my consideration, so I moved on”.
Cleary is believed to have misplaced consciousness a while after 1.40am, when the movie Killer Joe began screening. She recalled reducing the umbilical twine together with her enamel after Aisha was born and wrapping her in a towel. She tried and did not wipe away the blood that was everywhere in the cell. “Finally I gave up attempting to scrub it,” she mentioned.
An officer unlocked Cleary’s cell door at about 8.30am however didn’t seem to note that there was a child within the cell, nor that it was lined with blood. It was two inmates who lastly raised the alarm a short time later.
At one level within the inquest, jail officer Lewis Kirby spoke on to Cleary throughout the courtroom room: “Rianna, I simply wish to cross on my honest condolences to you and your loved ones for what’s occurred. I’m actually sorry for what you will have been by.” He was the one witness to supply any type of condolences to Cleary through the dwell proof.
In his conclusions, the coroner recognized a collection of failings by Ashford and St Peter’s hospitals NHS basis belief and HMP Bronzefield, together with not making a correct plan to switch Cleary to hospital when she went into labour.
The inquest, he mentioned, had been “a distressing investigation into the demise of a new child child who on any view arrived into the world in probably the most harrowing of circumstances”. NGOs resembling Beginning Companions, Stage Up and Inquest have condemned the case and referred to as for an finish to the incarceration of pregnant ladies.
There was quite a lot of official remorse expressed within the days for the reason that inquest concluded. The prisons minister, Damian Hinds, mentioned the federal government continued to “prolong our deepest and most heartfelt sympathies”, Ashford and St Peter’s hospitals mentioned they had been “deeply sorry”, and Sodexo, which has a contract with the Ministry of Justice to run HMP Bronzefield, mentioned it was “actually sorry”. All spoke of quite a lot of enhancements which were made since Aisha Cleary’s demise, together with specialist mom and child workers in each ladies’s jail, further welfare checks and higher well being and antenatal help. Since then, greater than 100 infants have been born to ladies in jail.
Many various providers operated within the jail on the time, private and non-private – nurses had been employed by Sodexo, GPs by Cimmaron, psychological well being providers by North West London NHS basis belief, together with the midwifery providers offered by Ashford and St Peter’s. Nobody service had an entire overview of Cleary’s case. A number of failures had been recognized in the middle of the inquest and at instances it appeared that Cleary’s fellow prisoners had grasped what was happening higher than the professionals.
In her testimony, Cleary described what occurred to her in her cell in HMP Bronzefield as “the worst and most terrifying and degrading expertise of my life. I’m nonetheless struggling to come back to phrases with what occurred.”
Whereas system-wide failures usually grow to be extra obvious with the advantage of hindsight, in Cleary’s case the alarm was sounded a number of instances earlier than she gave delivery. One officer wrote: “Her danger of giving delivery in cell will increase by the week.” A medical skilled additionally issued a warning earlier than the delivery: “Tonight could possibly be the evening we will probably be caught out.”
The earlier 12 months, Cleary had been described by one social employee as “sceptical of execs” and with “a harsh understanding of the truth of the world”.
That statement is much more true now than when it was written.