A young mother who jumped to her death while holding her newborn baby wasn’t offered support because she was considered ‘middle class and articulate’.
UK mum, Charlotte Bevan, 30, vanished from St Michael’s Hospital in Bristol with her four-day-old daughter, Zaani Tiana Bevan Malbrouck, in her arms.
She walked off the maternity ward and threw herself into Avon Gorge in November 2014 still cuddling Zaani around 40 minutes after leaving the hospital, reports Daily Mail.
A report released today said staff felt ‘intimidated’ by Ms Bevan who healthcare professionals described as ‘quite angry and strong’ and ‘quiet fierce’.
This was compounded by Ms Bevan’s ‘intelligence and assertiveness’ which made it more difficult to identify potential risk, the report said.
The finding of the serious case review was one of eight issues surrounding the care of the new mum by agencies including NHS England, Avon and Wiltshire Mental Health Partnership NHS Trust, and Bristol Clinical Commissioning Group.
The report said: ‘When a mental health professional attempted to discuss possible child protection issues with CB, the professional described the experience as; ‘It was as if the shutters went down’.
‘It was difficult – ‘I was in her home she had a way of gazing quite fierce.’
‘When confronted with this unpredictability or hostility many professionals ‘backed off’ from the confrontation, leaving the issue for another time or other professional to handle without a clear documented plan of how to address these issues.
‘This was compounded by what Case Group members described as CB’s intelligence and assertiveness.
‘One professional described CB as ‘middle class’, ‘articulate’. This made it more difficult for professionals to identify the potential risk.
‘When challenged by professionals CB was able to counter their suggestions with cogent arguments.
‘For example, CB declined offered support from the local children’s centre and the Health Visitor accepted CB’s argument that she had lots of friends with young babies so did not require further support.’
The inquest at Flax Bourton near Bristol in 2015 heard ‘caring and creative’ Charlotte had started to suffer from low moods following the death of her father in 2000.
Charlotte, of Clifton, Bristol, was sectioned or admitted to hospital a number of times over the following years, and admitted hearing voices.
She was prescribed risperidone – a drug mainly used to treat schizophrenia – in 2010 after an ‘acute psychotic episode’.
While she was continually prescribed medication, the inquest heard she stopped taking it months before Zaani was born on November 28, 2014.
Community midwives raised concerns – as did her mum Rachel Fortune – but experts failed to conclude she was relapsing, the inquest heard.
CCTV footage captured the new mother leaving the ward in a t-shirt and hospital slippers with her baby wrapped in a blanket at 8.36pm, on December 2.
A search and rescue party started scouring the Avon Gorge on December 3 and found Charlotte’s body near the A4, and her daughter was found the next day.
In a narrative conclusion, Avon Coroner Maria Voisin said Ms Bevan had suffered an ‘undiagnosed psychotic relapse’ and a ‘chain of failures’ contributed to the deaths.
A serious case review was launched, and concluded with the release of a 45-page report today.
Among the eight ‘key findings’, report writers found a difficulty in balancing the needs of a pregnant user, with the needs of an unborn child.
The report said professionals had access to support and supervision but it wasn’t always consistent.
It added: ‘This means the possible risks to an unborn child may not be recognised compared to the more immediate needs of the adult.’
The report also said current practice doesn’t identify a ‘lead clinician’ to manage complex cases.
It added some professionals ‘may feel intimidated by unpredictable and hostile service users’ which makes them ‘less confident’.
Rachel Fortune, Charlotte’s mother, who contributed to the review, said today: ‘As you can quite clearly see from the report, no single thing, action or person was to blame.
‘This was a particularly difficult case to manage as long-term ill mental health and pregnancy came together.
‘It’s our hope now that any families and individuals facing such difficulties will have a multi-agency team with accountable clinicians in each service, as they now do in Bristol.’
Statistics of PND
A recent study found that two in five women aren’t aware that perinatal depression was an illness, and almost 50 per cent of women didn’t know what symptoms to look for.
PANDA’s helpline also reports that 60 per cent of mothers feel like they’re not living up to their own expectations as a parent.
Annual data from PANDA’s National Helpline identifies that nearly 60% of callers are affected by the feeling of not meeting their own expectations as a parent.
The 2016 PANDA facts:
•Three in five people are not aware of perinatal anxiety as an illness and almost half do not know what signs to look for
•Anxiety is at least as common as depression during the perinatal period
•There has been an increase in understanding and compassion in the community with 80% of people believing perinatal depression and anxiety is not a sign of weakness
•92% of people believe that perinatal depression and anxiety does not stop a woman from being a good mother
•Nearly 60% of callers report a lowered mood, with symptoms including hopelessness, lacking motivation and loss of joy, while over 65% report feeling anxious, panicked, agitated, angry and irritable
•Two out of five callers have not been diagnosed with a mental illness, meaning they have ‘slipped through the cracks’ in the system and have only received critical intervention and support via the PANDA Helpline.
Signs can include…
persistent, generalised worry,
development of obsessive or compulsive behaviours,
abrupt mood swings,
feeling constantly tired,
withdrawing from friends,
feeling constantly sad or crying for no reason
having thoughts of death or suicide.
The free National Perinatal Anxiety and Depression Helpline can be reached on 1300 726 306, Monday-Friday 10am-5pm EST. OR contact Lifeline 13 11 14.
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