Baby died after "extremely vulnerable" teenage mother gave birth alone in her Surrey prison cell
Aisha Cleary was born in the early hours of September 27 2019 after two calls to prison staff from her mother went unanswered.
A coroner has found that a baby died after an "extremely vulnerable" teenage mother gave birth alone in her Surrey prison cell following "systemic failings" by state agencies,
Aisha Cleary was born in the early hours of September 27 2019 after two calls to prison staff from her mother 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, Surrey Coroner's Court in Woking was told.
The infant's mother Rianna Cleary, who was just 18 when she gave birth, spent time in care and was being exploited by county lines gangs before ending up in HMP Bronzefield jail in August 2019.
She told the inquest she began experiencing pain on September 26 2019 but did not know what it was as she was not expecting to deliver until the following month.
After briefly falling asleep, she woke up in "really serious pain" that evening.
She made two panicked calls to prison staff asking for a nurse and ambulance, but none arrived.
She later fell asleep and delivered the infant during the night after losing blood.
When she woke up, she had to cut its umbilical cord with her teeth.
Her baby was pronounced dead at 9.03am that morning after suffering brain injuries, the inquest heard.
The coroner was unable to ascertain whether she was stillborn or breathing when she was delivered, but if she was alive she would have died within hours.
Prison custody officer (PCO) Mark Johnson, who responded to her first call, said she had been "abusive" and was swearing while asking for a nurse.
He is under disciplinary observation and remains suspended from prisoner-facing duties, charity INQUEST said.
The second call, which she made while her bed, hands and the buzzer were covered in blood, was simply never answered.
Later that night, PCO Katarzyna Rachwal passed as she was in labour but told the hearing "nothing came to my attention and that is why I moved on".
The hearing was told the mother had not been engaging with nurses before the birth because she was worried her baby would be taken away by social services.
She claimed she would take her own life or kill someone else if her baby was removed from her care, the inquest heard.
Senior coroner for Surrey Richard Travers said opportunities were missed to ensure she did not give birth alone in her cell.
He said the prison and midwives at St Peter's Hospital did not do enough to make a plan that would identify the start of Miss Cleary's labour and ensure she was transferred to hospital quickly.
She should have been given a personal adviser and been put on a pathway to help her deliver the infant safely, he added.
The prison also failed to monitor her adequately, support her when she said she would kill herself if the baby was taken away and respond to her calls for help during labour.
The coroner said: "There is clear evidence, not least, of systemic failings which more than minimally contributed to Aisha being delivered in a prison cell without medical assistance and, following delivery, losing the chance of resuscitation and survival.
"If Aisha's mother's labour had been identified and she had been transferred to hospital in a timely manner for Aisha's delivery, there would have been an opportunity for effective steps to have been taken to secure Aisha's survival."
After the inquest, Rianna Cleary, who attended remotely, said in a statement read out by her lawyer Maya Sikand KC: "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.
"The deputy director of Bronzefield wrote one line to me saying 'sorry you gave birth alone' just before the inquest started.
"If it wasn't for this inquest, they would still be blaming me for giving birth alone."
Campaigners have argued pregnant women should not be housed in prisons.
Some countries including Brazil, Ukraine and Mexico do not allow or severely restrict the incarceration of pregnant women.
Charity 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.
"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."
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."
A hearing on whether a prevention of future deaths report is needed will take place at a later date, which was not set.