Charlotte Bevan and Zaani Malbrouck
PFD Report
All Responded
Ref: 2015-0418
All 1 response received
· Deadline: 22 Dec 2015
Coroner's Concerns (AI summary)
There was no mandatory multi-disciplinary team meeting or widely circulated care plan for pregnant women with known mental health conditions, risking fragmented and uncoordinated care.
View full coroner's concerns
In the circumstances it is my statutory duty t report to you: _ It was not stated in evidence that in all cases when a lady with a known mental health condition becomes pregnant that there is a multi-disciplinary team meeting to include all or some of the following professionals: GP, midwife, obstetrician, consultant psychiatrist; care co-ordinator; social services; any others to be deemed appropriate_ It was not stated in evidence that and an appropriate care plan involving all agencies and professionals is drawn up and then widely circulated to those professionals who are involved with the care and treatment of the patient That group to include; GP, midwife; obstetrician; consultant psychiatrist; care co-ordinator, social services; and any others to be deemed appropriate.
Responses
Action Planned
A consultant perinatal psychiatrist has been tasked to review individual pathway arrangements against NICE guidelines, aiming to agree and implement a Trust-wide pathway. The Trust also plans to prepare and issue a vignette of Charlotte's care as a reflective training exercise, emphasizing multi-disciplinary working and care planning. (AI summary)
A consultant perinatal psychiatrist has been tasked to review individual pathway arrangements against NICE guidelines, aiming to agree and implement a Trust-wide pathway. The Trust also plans to prepare and issue a vignette of Charlotte's care as a reflective training exercise, emphasizing multi-disciplinary working and care planning. (AI summary)
View full response
Dear Ms Voisin am writing in response to the Prevention of Future Death report you issued to this Trustfollowing the inquest into the death of Charlotte Bevan deceased. At our December Critical Incident Overview Group meeting, we examined the perinatal pathways in place across the Trustfor pregnant womenand noted that there was variability, and more variability than canbe accounted for by the different commissioning arrangements and service delivery models As such; Dr Kathryn Bundle, Consultant Perinatal Psychiatrist has been tasked to review the individual pathway arrangements against the NICE guidelines for antenatal and post-natal mental health care; with the aim of agreeing pathway that can be agreed and implemented Trust wide_ This work is well underway with draft algorithms developed that are consulted on and tested. The pathways are underpinned much by multi-disciplinary care planning and co-ordination that you found missing in Charlotte's care and require the undertaking of multi-disciplinary team meetings and the revision and updating of care plan as part of that process_ In addition, although we have not found the need to revise our existing policies, systems and procedures in light of Charlotte's and Zaani's deaths we do plan to prepare and issue in the New Year vignette of Charlotte's care that can be shared with all teams as a valuable reflective training exercise. This will place emphasis on the importance of multi-disciplinary working and care planning: This vignette will be issued with prominence via our internal safety alert system , that requires positive confirmation that action has been taken: Implementation of change will be monitored via our supervision and appraisal processes_ Finally, we will of course continue to work with NHS England to help them review the commissioning model for perinatal mental health services _ If you require further information, please do not hesitate to let me know.
Sent To
- Avon and Wiltshire Mental Health NHS Trust
Response Status
Linked responses
1 of 1
56-Day Deadline
22 Dec 2015
All responses received
About PFD responses
Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Report Sections
Investigation and Inquest
On 12th December 2014 commenced an investigation into the death of: Charlotte Emily BEVAN, Aged 30, and Zaani Tiana Bevan Malbrouck; aged 4 days The investigation concluded at the end of the inquest on 19"h October 2015. The conclusion of the inquest for Charlotte was that she died due to Ia) Multiple Injuries with Section 3 of the Record of Inquest Form reading as follows: Charlotte Bevan had schizophrenia and was under the care of the mental health service. On 28th November 2014,she gave birth to her daughter at St Michaels Hospital, after which her mental health began to deteriorate. Charlotte left the hospital unnoticed on the Tuesday Znd December 2014 at 20.36hrs she walked straight from the hospital to the cliff at the Avon Gorge_ At the time she left the hospital she was suffering with a psychotic relapse that had not been diagnosed Her body was recovered from the base of the cliff at the Avon Gorge on 3rd December 2014, her death was confirmed at 21.17hrs_ The narrative conclusion for Charlotte found based on the evidence was as follows: Charlotte had schizophrenia, and was under the care of the mental health service In early 2014 she became pregnant: There was a failure by her care coordinator who was managing Charlotte from July 2014 to develop a therapeutic relationship with Chariotte during this high risk period and to involve a psychiatrist in her care and treatment: There was a failure to hold a multidisciplinary team meeting to develop a care plan for Charlotte at all, but especially when concerns were raised by the midwives during her pregnancy, and later when it was known that she had stopped taking her Risperidone; (a fact which was reported on 14th November 2014). In addition there was a failure to arrange a face to face meeting with a psychiatrist and Charlotte when she stopped her Risperidone,which Was a missed opportunity in managing Charlotte'$ care: Once Charlotte gave birth on 28th November 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 unwell when she left the hospital unnoticed with her daughter and went to the cliff top at the Avon Gorge on 2nd December 2014, her intention Is unclear but she was found dead at the base of the cliff, That chain of failures contributed to Charlotte's death: and top very
In relation to Zaani her cause of death was recorded as 1a) Head Injury. Section 3 of the Record of Inquest form read as follows: Zaani Bevan-Malbrouck was born at St Michaels Hospital on 28th November 2014. On 2nd December 2014 she was taken from the hospital by her mother who had schizophrenia and was at the time suffering with a psychotic relapse that had not been diagnosed Her Mother took her straight to the cliff top at the Avon Gorge; her body was recovered on 4th December 2014 amongst shrubbery growing from the cliff face, about 40 feet from the base of the cliff. Her death was confirmed at 15.02 hrs_ And the conclusion as to death of Zaani based upon the evidence was a narrative which read as follows: Zaani was 4 days old when she was taken by her Mother from St Michaels Hospital to the cliff top at the Avon Gorge; Her Mother had schizophrenia and was suffering with a relapse following her birth. Her Mother"'s intention is unclear but Zaani was found dead on the cliff face on 4th December 2014. Her death was contributed to by a chain of failures in her Mothers care_
In relation to Zaani her cause of death was recorded as 1a) Head Injury. Section 3 of the Record of Inquest form read as follows: Zaani Bevan-Malbrouck was born at St Michaels Hospital on 28th November 2014. On 2nd December 2014 she was taken from the hospital by her mother who had schizophrenia and was at the time suffering with a psychotic relapse that had not been diagnosed Her Mother took her straight to the cliff top at the Avon Gorge; her body was recovered on 4th December 2014 amongst shrubbery growing from the cliff face, about 40 feet from the base of the cliff. Her death was confirmed at 15.02 hrs_ And the conclusion as to death of Zaani based upon the evidence was a narrative which read as follows: Zaani was 4 days old when she was taken by her Mother from St Michaels Hospital to the cliff top at the Avon Gorge; Her Mother had schizophrenia and was suffering with a relapse following her birth. Her Mother"'s intention is unclear but Zaani was found dead on the cliff face on 4th December 2014. Her death was contributed to by a chain of failures in her Mothers care_
Circumstances of the Death
These are explained within section 3 above but briefly Charlotte who had a history of schizophrenia gave birth to Zaani on 218' November 2014. Charlotte's mental health deteriorated and on 4ih December she left the hospital with Zaani and walked to the top at the Avon Gorge_ Both Charlotte and Zaani's bodies were found subsequently.
Action Should Be Taken
In my opinion action should be taken to prevent future deaths and believe you have the power to take such action: would ask that you look into steps in relation to ensuring that there are multi-disciplinary meetings in all cases with an appropriate care plan which is then widely circulated
Inquest Conclusion
Charlotte Bevan had schizophrenia and was under the care of the mental health service. On 28th November 2014,she gave birth to her daughter at St Michaels Hospital, after which her mental health began to deteriorate. Charlotte left the hospital unnoticed on the Tuesday Znd December 2014 at 20.36hrs she walked straight from the hospital to the cliff at the Avon Gorge_ At the time she left the hospital she was suffering with a psychotic relapse that had not been diagnosed Her body was recovered from the base of the cliff at the Avon Gorge on 3rd December 2014, her death was confirmed at 21.17hrs_ The narrative conclusion for Charlotte found based on the evidence was as follows: Charlotte had schizophrenia, and was under the care of the mental health service In early 2014 she became pregnant: There was a failure by her care coordinator who was managing Charlotte from July 2014 to develop a therapeutic relationship with Chariotte during this high risk period and to involve a psychiatrist in her care and treatment: There was a failure to hold a multidisciplinary team meeting to develop a care plan for Charlotte at all, but especially when concerns were raised by the midwives during her pregnancy, and later when it was known that she had stopped taking her Risperidone; (a fact which was reported on 14th November 2014). In addition there was a failure to arrange a face to face meeting with a psychiatrist and Charlotte when she stopped her Risperidone,which Was a missed opportunity in managing Charlotte'$ care: Once Charlotte gave birth on 28th November 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 unwell when she left the hospital unnoticed with her daughter and went to the cliff top at the Avon Gorge on 2nd December 2014, her intention Is unclear but she was found dead at the base of the cliff, That chain of failures contributed to Charlotte's death: and top very
In relation to Zaani her cause of death was recorded as 1a) Head Injury. Section 3 of the Record of Inquest form read as follows: Zaani Bevan-Malbrouck was born at St Michaels Hospital on 28th November 2014. On 2nd December 2014 she was taken from the hospital by her mother who had schizophrenia and was at the time suffering with a psychotic relapse that had not been diagnosed Her Mother took her straight to the cliff top at the Avon Gorge; her body was recovered on 4th December 2014 amongst shrubbery growing from the cliff face, about 40 feet from the base of the cliff. Her death was confirmed at 15.02 hrs_ And the conclusion as to death of Zaani based upon the evidence was a narrative which read as follows: Zaani was 4 days old when she was taken by her Mother from St Michaels Hospital to the cliff top at the Avon Gorge; Her Mother had schizophrenia and was suffering with a relapse following her birth. Her Mother"'s intention is unclear but Zaani was found dead on the cliff face on 4th December 2014. Her death was contributed to by a chain of failures in her Mothers care_
In relation to Zaani her cause of death was recorded as 1a) Head Injury. Section 3 of the Record of Inquest form read as follows: Zaani Bevan-Malbrouck was born at St Michaels Hospital on 28th November 2014. On 2nd December 2014 she was taken from the hospital by her mother who had schizophrenia and was at the time suffering with a psychotic relapse that had not been diagnosed Her Mother took her straight to the cliff top at the Avon Gorge; her body was recovered on 4th December 2014 amongst shrubbery growing from the cliff face, about 40 feet from the base of the cliff. Her death was confirmed at 15.02 hrs_ And the conclusion as to death of Zaani based upon the evidence was a narrative which read as follows: Zaani was 4 days old when she was taken by her Mother from St Michaels Hospital to the cliff top at the Avon Gorge; Her Mother had schizophrenia and was suffering with a relapse following her birth. Her Mother"'s intention is unclear but Zaani was found dead on the cliff face on 4th December 2014. Her death was contributed to by a chain of failures in her Mothers care_
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.