A mother whose baby died after she gave birth alone in her prison cell called for a ban on jailing pregnant women as an inquest concluded.
Rianna Cleary spoke out as a senior coroner ruled against ordering a prevention of future deaths report to stop similar tragedies happening again.
Following the announcement, Ms Clearly said: “The system is cruel and will never be a safe place to have a baby.”
But two panicked calls from her 18-year-old mother to prison staff asking for a nurse and ambulance went unanswered, the court heard.
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, it was said.
Ms Cleary spent time in care and was being exploited by county lines gangs before ending up inside.
Senior coroner for Surrey Richard Travers said Aisha “arrived into the world in the most harrowing of circumstances”.
He added there is “clear evidence” of “systemic failings” by state agencies which “more than minimally contributed” to the baby’s death.
But while the evidence he received at Surrey Coroner’s Court in Woking did give rise to a “number of issues” creating a risk of other deaths, on Tuesday he said his concerns had now been addressed by the prison and other interested parties.
Ms Cleary told reporters: “I have lost Aisha forever, so the most important thing is that no pregnant woman ever goes through what I did again.
“I understand that the senior coroner is not making a prevention of future deaths report because of all the changes that have been made since Aisha died. But 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, of the charity Inquest, added: “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.
“Prison is a disproportionate, inappropriate, and dangerous response to women in conflict with the law, let alone those who are pregnant.
“We must urgently dismantle women’s prisons and redirect resources to holistic, gender responsive community services. Only then can we end the deaths of women and their babies in prison.”
Solicitor Elaine Macdonald, of Broudie Jackson Canter, said: “While significant changes have been made to policy relating to perinatal care in prisons in general, which must be acknowledged, it remains to be seen whether prisons, including HMP Bronzefield, will implement the changes sufficiently.”
Janey Starling, co-Director of Level Up, added: “The only way to prevent further deaths of babies in prison is to end the imprisonment of pregnant women.”
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.
“While there is still more to be done to make sure expectant mothers in prison get the same care as those in the community, these changes will reduce the chances of such a tragedy happening again.”