Charlotte Bevan inquest: 'Chain of failures' led to gorge fall deaths

Charlotte Bevan was photographed with her partner Pascal Malbrouck and daughter Zaani Tiana shortly after she gave birth

A "chain of failures" led to the death of a vulnerable 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.

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".

Mrs Voisin said health professionals treating Ms Bevan, who had a history of mental illness, should have organised a multi-disciplinary meeting about her care and a proper post-birth plan of action had not been put in place.

CCTV captured Charlotte Bevan leaving the hospital

'Very unwell'

"Once Charlotte gave birth her mental health began to deteriorate and she suffered a relapse which should have been diagnosed and managed appropriately," the coroner said.

"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."

Mrs Voisin added she would be making a Prevention of Further Deaths order to NHS England and other commissioning groups requiring them to respond outlining what action will be taken.

She also intends to seek answers about the provision of mental health services for pregnant women.

Charlotte's mother, Rachel Fortune, read a statement alongside family members and Zaani's father Pascal Malbrouck (left)

The inquest previously heard Ms Bevan, who was 30, had been sectioned under the Mental Health Act four times.

She had stopped taking anti-psychotic medication during her pregnancy over fears she would not be able to breastfeed but later agreed to start taking the drug again after giving birth, when fears about her mental state were raised by doctors.

But an independent expert said by that time it was too late as she had already relapsed.

Ms Bevan and Zaani Tiana vanished from hospital on the evening of 2 December and were caught on CCTV leaving the hospital.

Their bodies were found close to Clifton Suspension Bridge over the following two days.

'Deepest concerns'

Speaking after the inquest, Ms Bevan's mother, Rachel 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."

In a joint statement NHS England, Bristol Clinical Commissioning Group, University Hospitals Bristol Foundation Trust, and the Avon and Wiltshire Mental Health Partnership Trust, expressed their "deepest concerns" to Charlotte and Zaani's family.

"As a health community, we will act on the coroner's findings to ensure that mothers with mental health needs have access to the services and professionals they need to keep them and their babies safe during pregnancy and following the birth.

"We will now consider the coroner's conclusions and recommendations very carefully to see what other actions we can take to improve services for vulnerable mothers, their babies and their wider family."