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Charlotte Bevan: ‘no single thing, action or person was to blame’
A review of the care service provided to a mother who died with her baby has been published.
The Serious Case Review, commissioned by Bristol Safeguarding Children Board, found that improvements can be made in safeguarding organisations, although there is no clear act that had caused the tragic death of Charlotte Bevan and her newborn baby Zaani in December 2014.
The review found much good practice but highlighted “missed opportunities” when identifying the “less obvious safeguarding cases” as well as the absence of a “lead clinician across services,” leading to Charlotte’s “undiagnosed psychotic relapse” ending in tragedy.
is needed now More than ever
Rachel Fortune, Charlotte’s mother, said that “there is clear constructive learning” to be had following the review and that “no single thing, action or person was to blame” for her daughter and granddaughter’s death.
“This was a particularly difficult case to manage as long-term ill mental health and pregnancy came together,” Rachel said.
The review found that the “possible risks to an unborn child may not be recognised compared to the more immediate needs of the adult.”
“Limited resources” are placing professionals under mounting pressure, the report also found, especially in light of increased public expectations regarding children’s safety.
Indeed, the coroner’s report from October 2015 pointed to a “chain of failings” in Charlotte’s care.
The review concluded that there are “number of significant systemic issues” in the care service afforded to mothers suffering from ill mental health, and their babies.
If you or someone you know is suffering from mental health problems, there is a range of advice and help available.
Call Safeguarding – First Response on 0117 903 6444 in working hours, the police on 101 out-of-hours or, if you think there is immediate danger to someone, call 999.
www.nhs.uk/mentalhealth, visit your GP or call NHS 111.
Samaritans – Call 116 123
Read more: Grieving family speak as mum and baby found
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