A coroner has raised concerns about mental healthcare for new mothers after a woman jumped off a cliff clutching her baby girl following a “chain of failures” by medical staff.
Charlotte Bevan, who had a history of mental illness, walked out of St Michael’s hospital in Bristol on a December night wearing a pair of thin slippers and carrying her four-day-old daughter, Zaani Tiana, wrapped in a blanket.
Her inquest heard that by the time hospital staff warned police that she was missing, Bevan, 30, had already plunged into the Avon Gorge with her child.
Bevan, who had schizophrenia and depression and had been sectioned four times, had stopped taking medication so that she could breastfeed her child, the inquest was told.
The coroner, Maria Voisin, said that a proper care plan had not been put in place after Bevan gave birth and officials should have organised a multi-disciplinary meeting to discuss how the young mother should be looked after.
Delivering a narrative verdict, in which the circumstances of a death are recorded without attributing the cause to a named individual, Voisin said she would write to NHS England about the provision of mental health services for pregnant women. She said she would also be writing to Avon and Wiltshire Mental Health Partnership NHS trust, and the Bristol clinical commissioning group.
The coroner continued: “There was a failure ... to develop a therapeutic relationship with 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 [the anti-psychotic medication] risperidone.
“Once Charlotte gave birth, her mental health began to deteriorate and she suffered a relapse, which should have been diagnosed and managed appropriately. That failure was contributed by the fact there was no care plan.
“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.”
During the inquest, Zaani’s father, Bevan’s partner Pascal Malbrouck, claimed she had been given contradictory advice about stopping her medication.
Malbrouck said he spent visiting hours with his partner and new baby and raised his concerns with nurses. “On the day of the birth she was happy but then became worse and worse and worse,” Malbrouck said.
“I could see she was more and more unresponsive. She didn’t talk much. She was texting me at three and four in the morning telling me: ‘I can’t sleep, I want to go home.’
Bevan told him she had slept for just five hours in the three days after the birth. On the night she went missing he left to allow her to sleep. “I went to see the nurse and said: ‘Please keep an eye on Zaani and Charlotte.’ ”
After the inquest, Charlotte’s family – who are working with the NHS to improve care – called for a dedicated perinatal unit for mothers with mental health issues.
Her mother, Rachel Fortune, who was accompanied by Malbrouck, said: “This has been a very difficult time for everybody who knew Charlotte and Zaani and has been involved with this tragic event. The families would urge the commissioners to fund a dedicated perinatal mental health service.”
Caroline Gamlin, south-west medical director for the NHS, read a statement on behalf of NHS England, Avon and Wiltshire Mental Health Partnership NHS trust, Bristol clinical commissioning group, and University Hospitals Bristol NHS foundation trust, who were all involved in Bevan’s care.
She said: “The coroner has heard that many staff from our mental health and maternity services did their very best to support and care for Charlotte before and during her pregnancy, and after Zaani’s birth. However, as the coroner has concluded today, there was a chain of failures which contributed to their death.
“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 their births.
“Whilst there is more to do, the local NHS has already made changes to improve the way in which mothers with mental health needs are cared for.
“We will now consider the coroner’s conclusion and recommendations very carefully to see what other actions we can take to improve services for vulnerable mothers and their families.”
