A mother whose baby died after she gave birth alone in her prison cell is waiting for a coroner’s ruling on whether a prevention of future deaths report is needed to stop similar tragedies happening again.

Aisha Cleary was born at HMP Bronzefield jail in Surrey in the early hours of September 27 2019, but died at 9.03am that morning.

The inquest into the infant’s death earlier this year was told 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 inquest heard.

Senior coroner for Surrey Richard Travers said at the end of the inquest that there is “clear evidence” of “systemic failings” by state agencies which “more than minimally contributed” to the baby’s death.

He heard live evidence at Surrey Coroner’s Court in Woking on Monday about whether sufficient steps had been taken to ensure a similar death cannot happen again.

The coroner said there is a “number of issues” he needs to think about before coming to a decision on prevention of future deaths, on a date to be fixed.

A decision is likely to take several weeks, the PA news agency understands.

If ordered, any prevention of future deaths report will be published online.

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.”