A chain of “significant failures and missed opportunities” contributed to the death of a mentally ill mother who walked out of hospital days after giving birth and jumped off a cliff cradling her baby.
Charlotte Bevan was able to leave the city’s St Michael’s Hospital on 2 December last year without shoes and carrying four-day-old Zaani Tiana Bevan-Malbrouck, despite having a long history of severe mental illness and self-harm. The pair were found dead two days later at the bottom of Avon Gorge.
The double inquest into their deaths concluded on 9 October that the frequency of assessments for Ms Bevan was “inadequate”.
Speaking outside Avon Coroner’s Court alongside Ms Bevan’s partner Pascal Malbrouk, her mother Rachel Fortune said the deaths were a tragic event which had proved difficult for everybody concerned.
She said: “Following on from what has been said and heard in evidence, the family would urge the commissioners to fund a dedicated perinatal mental health service.”
A psychiatrist had told the hearing it was “significant” that a multi-disciplinary meeting featuring specialist mental health experts and social services had not been set up in the months before the double tragedy. One to one nursing was considered but ruled out.
Questions were raised about security procedures at St Michael’s and whether the hospital was the right place to send Ms Bevan, given that nurses and midwives were not trained to deal with “complex” patients with mental issues.
The hearing was also told Ms Bevan had been sectioned under the Mental Health Act four times. In 2011 she was found wandering along the M32 intending to jump from a bridge. Two years later after stopping taking her medication she stabbed herself in the breast.
Ms Bevan also stopped taking anti-psychotic medication in the weeks before her death over fears about being able to breastfeed. When doctors raised fears about Ms Bevan’s mental condition she agreed to resume taking her medication after giving birth. However, an independent expert told the hearing that it was too late by this point as Ms Bevan had already relapsed.
The 30-year-old had been described as a “beautiful, joyful and headstrong person” and the court heard Ms Bevan’s intentions after leaving the hospital were “unclear”.
Ms Bevan had been captured on CCTV leaving the maternity ward of St Michael’s cradling her baby. She was last seen crossing the road a short time later in front of Bristol’s Suspension Bridge.
Avon coroner Maria Voisin (corr) returned two narrative verdicts and said Ms Bevan had suffered an “undiagnosed psychotic relapse”.
The coroner also said she would be making a Prevention of Further Deaths Order and will write to NHS England and local commissioning groups regarding provision to mental health services for pregnant women.
Mrs Voisin said: “There was a failure … to develop a therapeutic relationship witg Charlotte during this high risk period and to involve a psychiatrist in her care and treatment.
“There was a failure to hold a multi-disciplinary team meeting to develop a care plan for Charlotte at all, but especially when concerns were raised during her pregnancy and when it was known she had stopped taking [her medication].”
Mrs Voisin also said Ms Bevan’s relapse was not managed properly and that no appropriate care plan was put in place.
She said: “That chain of failures contributed to Charlotte’s death. Zaani’s death was contributed to by a chain of failures in her mother’s care.”
Dr Caroline Gamlin, from NHS England South and South West, said: “We will act on the coroner’s findings to ensure that mothers with mental health needs and their babies have access to the services and professionals they need to keep them and their babies safe during pregnancy and following birth.”
Dr Gamlin said that while there was “more to do” the local NHS had already made changes to improve the way mothers with mental health needs are cared for.
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