‘Chain of failures’ verdict in Bevan inquest

There were a “chain of failures” and “missed opportunities” in managing Charlotte Bevan’s care before she fell to her death with her new-born baby, a coroner has ruled.

Recording a narrative conclusion on the final day of an eight day inquest, Avon coroner Maria Voisin said Bevan suffered from an “undiagnosed psychotic relapse” leading to her death in December last year.

Bevan, who had schizophrenia, walked out of the maternity ward of St Micheal’s Hospital on December 2 with her four-day-old baby Zaani Tiana in just her t-shirt and slippers. Their bodies were found the following day at the foot of the Avon Gorge.

The coroner found failures in the care system to:

• Hold a multidisciplinary meeting to assess Bevan’s risk before giving birth
• Draw up a care plan for Bevan after she gave birth
• Arrange a meeting with a psychiatrist after it emerged Bevan had stopped taking her anti-psychotic medication
• Recognise Bevan’s relapse following her daughter’s birth

Ms Voisin said the above failures “contributed” to Bevan’s death. She said she would be writing to the NHS and Avon and Wiltshire Mental Health Partnership to make recommendation to prevent future deaths.

Following the inquest, Bevan’s mother Rachel Fortune called on the NHS to fund a “dedicated perinatal mental health service”.

A joint statement from NHS England, Bristol Clinical Commissioning Group, University Hospitals Bristol Foundation Trust and Avon and Wiltshire Mental Health Partnership Trust said they would “consider the coroner’s conclusions very carefully”.

The inquest had previously heard how Bevan had stopped taking her anti-psychotic medication, resperidone, a month before she gave birth.

She suffered from mental health problems since the age of 15, when her father died, but had been “stabilised” on risperidone, which she feared would affect her breastfeeding.

The court heard that on the occasions in the past when she stopped taking her medication she had been sectioned more than once, self harmed and had attempted to take her own life.

She was considered a “high-risk” mental health patient by many of the professionals who helped look after her.

But, the court heard, appropriate plans were not drawn up during the months before her giving birth and her relapse in hospital, triggered by her stopping taking her medication, went undiagnosed.

Ms Voisin said in her conclusion: “Once Charlotte gave birth on November 28, 2014, her mental health began to deteriorate and she suffered a relapse which should have been diagnosed and managed appropriately by those responsible for her mental health.

“That failure was contributed to by the fact there was no plan. Charlotte was therefore very unwell when she left the hospital unnoticed with her daughter and went to the cliff top at the Avon Gorge on December 2.

“Her intention is unclear, but she was found dead at the base of the cliff. That chain of failures contributed to her death.”