'Chain of failings' before death of Charlotte Bevan and newborn baby


A series of failings contributed to the death of a mentally ill woman who jumped off a cliff while holding her newborn baby, a coroner has ruled.

Charlotte Bevan walked out of St Michael's Hospital in Bristol on a cold December night last year with her four-day-old daughter Zaani Tiana - with just a thin pair of slippers on her feet.

Zaani and her mother, who had a long history of mental illness and had been sectioned four times, were found dead at the bottom of Avon Gorge, close to Clifton Suspension Bridge.

The double inquest heard that in the weeks running up to the deaths 30-year-old Ms Bevan had stopped taking her anti-psychotic medication.

Coroner Maria Voisin said there had been a "chain of failings" in the run-up to the tragedy.

Delivering a narrative conclusion, she said officials should have organised a multi-disciplinary meeting, and that a proper care plan post-birth had not been put in place.

Mrs Voisin also said she would be making a Prevention of Further Deaths Order - and would write to NHS England about the provisions to mental health services for pregnant women.

Mrs Voisin said: "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 a 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 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."