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Charlotte Bevan inquest: 'Chain of failures' led to gorge fall deaths Charlotte Bevan inquest: 'Chain of failures' led to gorge fall deaths
(35 minutes later)
A "chain of failures" and missed opportunities led to the death of a mother who jumped off a cliff with her four-day-old baby, a coroner has ruled.A "chain of failures" and missed opportunities led to the death of a mother who jumped off a cliff with her four-day-old baby, a coroner has ruled.
Charlotte Bevan, who had schizophrenia, walked out of St Michael's Hospital in Bristol last December with her daughter Zaani Tiana Bevan-Malbrouck.Charlotte Bevan, who had schizophrenia, walked out of St Michael's Hospital in Bristol last December with her daughter Zaani Tiana Bevan-Malbrouck.
Their bodies were found days later at the bottom of Avon Gorge.Their bodies were found days later at the bottom of Avon Gorge.
In a narrative conclusion, Avon Coroner Maria Voisin said Ms Bevan had suffered an "undiagnosed psychotic relapse".In a narrative conclusion, Avon Coroner Maria Voisin said Ms Bevan had suffered an "undiagnosed psychotic relapse".
Speaking after the inquest, Ms Bevan's mother, Rachel Fortune, said Charlotte and Zaani's death was a tragic event which had proved difficult for everybody who knew them. Mrs Voisin said health professionals treating Ms Bevan should have organised a multi-disciplinary meeting about her care and a proper post-birth plan of action had not been put in place.
She added: "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." She added she would be making a Prevention of Further Deaths order to NHS England and would seek answers about the provisions to mental health services for pregnant women.
Ms Bevan's mother, Rachel Fortune, described Charlotte and Zaani's death as a tragic event which had proved difficult for everybody who knew them.
Speaking after the inquest, she 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."