Yahoo News 'Chain Of Failures' Before Mum And Baby Died
A mentally ill mother fell off a cliff and died with her newborn baby after a "chain of failures" by mental health professionals, a coroner has ruled.
Charlotte Bevan, 30, vanished from St Michael's Hospital in Bristol with her four-day-old daughter Zaani Tiana Bevan Malbrouck on 2 December last year.
Ms Bevan, who suffered from schizophrenia and depression, was seen carrying the child out of the hospital in a blanket at 8.36pm.
She was filmed on CCTV leaving the maternity unit, wearing just hospital slippers and no coat.
Their bodies were found by search teams in the Avon Gorge on 3 and 4 December.
Coroner Maria Voisin said there had been a "chain of failures" that contributed to her death.
Among the failures was the lack of an appropriate mental healthcare plan for Charlotte, especially after she fell pregnant.
After the inquest, Ms Bevan's mother, Rachel Fortune, called for the creation of a dedicated perinatal mental health service.
The inquest was told that Ms Bevan had previously been sectioned four times and had stopped taking anti-psychotic medication due to fears about breastfeeding.
She agreed to start taking the drug again after giving birth when concerns were raised about her deteriorating mental health.
An independent expert, Dr Laurence Mynors-Wallis, earlier told the hearing he believed there had been "significant failings" in her care.
He said "with hindsight" Ms Bevan's relapse "could have been identified sooner" and there had been a "lack of a clear care plan" in place.
Health professionals who had assessed her also told the inquest they did not believe she was a risk to herself or her baby.
Dr Rachael Liebling, a consultant obstetrician at the hospital, said she felt the steps the teams were taking were adequate.
These included regular reviews of her mental state, and the decision to go back on her medication.
Mrs Voisin concluded: "Charlotte was very unwell when she left the hospital unnoticed with her daughter and went to the cliff top at Avon Gorge.
"Her intention is unclear but she was found dead at the base of the cliff. 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."
In a statement by University Hospitals Bristol NHS Foundation Trust said: "As a health community, 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 the birth."
