The double inquest, that was opened last week to look into the death of Charlotte Bevan and her child, has been closed this afternoon. Last December Bevan was seen on CCTV leaving St Michael’s Hospital in Bristol with her four year old new born girl.
After a missing persons report was filed, and with authorities on the look out, she was found dead days later at the bottom of a cliff at Avon Gorge, with her daughter also dead at the scene.
The inquest was opened to look into hospital security and negligence before and after the incident to see if anything could have been prevented or stopped.
Dr Laurence Mynors-Wallis stated that the “lack of multi-disciplinary care plan” was an “important contributory factor” to allowing the incident to take place. There were said to me multiple warning signs that the 30-year-old mother was not at ease after she had stopped taking an anti-psychotic drug over concerns about breastfeeding.
Charlotte Bevan suffered from schizophrenia so should have been a higher priority, especially as post natal depression is often a negative aspect of child birth.
At the inquest, Dr Mynors-Wallis, the former associate dean of the Royal College of Psychiatrists, said:
“There wasn’t a waterproof care plan in place. A care plan is core to delivering the interventions that are needed for people with mental illnesses, especially those who are going through childbirth – which is a stressful experience.
“It is important as well because she would be coming into contact with a series of professionals who aren’t experts in mental health.”
A coroner concluded that a “chain of failures” and “missed opportunities” contributed to the death of Ms Avon and her newly born daughter.
The family of Ms Bevan called for a dedicated perinatal mental health service.