NHS failures led to deaths of mother and her newborn baby
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 Bristol’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 yesterday that the frequency of assessments for Ms Bevan was “inadequate”.
Speaking outside Avon Coroner’s Court alongside Ms Bevan’s partner Pascal Malbrouck, hermotherRachel Fortune 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.”
Questions were raised about St Michael’s security and whether the hospital was the right place to send Ms Bevan, given that nurses and midwives were not trained to deal with patients with “complex” mental health issues.
The hearing was told Ms Bevan had been sectioned under the Mental Health Act four times. In 2011, she was
Mentally ill woman was allowed to leave hospital without shoes
found wandering along the M32 intending to jump from a bridge. Two years later, after she had stopped 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 breastfeeding. When doctors raised concerns about her 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 then as the mother 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”.
The motherwas captured on CCTV leaving the maternity ward with her baby. She was last seen crossing the road a