A mother whose baby died when she gave birth alone in her prison cell has urged ministers to stop sending pregnant women to jail.
Aisha Cleary was born at HMP Bronzefield in Surrey in the early hours of September 27 2019, but died at 9.03am that morning.
An inquest held earlier this year heard two calls to prison staff from her mother Rianna Cleary, who was just 18 when she gave birth, went unanswered.
A prison officer also walked past her cell with a torch when she was on her hands and knees in labour but did not stop and help, the hearing was told.
Senior coroner for Surrey Richard Travers said at the end of the inquest in Woking that there is “clear evidence” of “systemic failings” by state agencies which “more than minimally contributed” to the baby’s death.
However, he has been criticised by charities after deciding not to order a prevention of future deaths report, which a coroner can issue when they believe action must be taken to prevent such deaths, in the case.
Rianna Cleary said: “When it comes to prison, what’s written on a piece of paper is never what happens in practice.
“The way the prisons are run, it is all about power and control. They will never be caring places.
“Prison officers do not always follow policy. Look what happened to me when I pressed my cell bell twice – nobody came.
“And I still don’t know whether the prison officer who refused me medical help has been sacked.
“The system is cruel and will never be a safe place to have a baby.
“Everybody now accepts that all pregnancies in prison are high risk, so why was I sent there?
“This is why I now support the campaigns of Level Up and No Births Behind Bars to stop sending pregnant women to prison.”
Selen Cavcav, senior caseworker at charity Inquest, said: “We are disappointed that the coroner has decided not to issue a prevention of future deaths report following this inquest which exposed one of the most damning failures in our prison system.
“We have no faith that the changes which have been made by the prison will save further lives.
“There is a depressingly huge gap between policy and what happens behind closed doors.
“There is no reliable system for checking how these changes are implemented and essentially no proper accountability when policies and procedures are completely ignored like they were when Rianna was pregnant in prison.”
Naomi Delap, director of charity Birth Companions said: “It is dangerous to assume that promised improvements, and better written policies, can address the deep, systemic issues flagged by Aisha’s death.
“Fundamental change is needed if we are to prevent the deaths of more women and infants, and this decision from the coroner is a missed opportunity to drive that change.”