Psychiatrist tells of significant care failings at Charlotte Bevan inquest

A psychiatrist has told an inquest there were “significant failings” in the months leading up to a mentally-ill women throwing herself off a cliff while cradling her newborn baby.

Charlotte Bevan walked out of St Michael’s Hospital in Bristol on December 2 last year with Zaani Tiana Bevan-Malbrouck.

Both Ms Bevan, who had schizophrenia, and her four-day-old daughter were later found dead at the bottom of Avon Gorge.

Avon Coroners Court heard the 30-year-old had stopped taking an anti-psychotic drug over concerns about breastfeeding. She later starting taking risperidone after giving birth – but an expert said this could take weeks to have any effect.

Former associate dean of the Royal College of Psychiatrists Laurence Mynors-Wallis told her inquest there were several other warning signs in the run up to the tragedy.

He said an “important contributory failure” had been the lack of a multi-disciplinary care plan – which could have seen her sent to a different unit or been assigned a one-to-one specialist mental health nurse.

He said: “There wasn’t a watertight 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.”

The sixth day of the inquest heard that Ms Bevan had a long history of mental problems and had suffered a drug induced psychosis while at a music festival.

She had been sectioned under the Mental Health Act on four occasions and had self-harmed several times.

After becoming pregnant, she came under the care of the New Horizons team – a specialist unit for women with mental illnesses – before being discharged last July.

Dr Mynors-Wallis said after coming under the care of Bristol North Recovery Team there was clear evidence Ms Bevan was becoming less well.

He told the hearing: “She declined ante-natal classes on September 17 and her behaviour was described as changeable and unstable on October 7.

“When you put all of these together…evidence from different sources shows that Charlotte Bevan was not doing as well as she might. Following these concerns there should have been a multi-disciplinary meeting.”

Dr Mynors-Wallis also questioned whether St Michael’s Hospital had been the ideal place for Ms Bevan to give birth.

He said nurses on the ward had not been trained to deal with “complex” patients like Ms Bevan.

“They may have normalised her behaviour as that of being an exhausted mother,” he added.

Dr Mynors-Wallis said once Ms Bevan was at the hospital though, she could have been assigned a mental health nurse.

After giving birth Ms Bevan was described by Dr Rachel Liebling, a consultant in fetal medicine, as initially being “very happy” before starting to deteriorate.

However, Dr Liebling said at the time it was not felt Ms Bevan needed one-to-one care from a specialist mental health nurse because she was co-operating and had re-started taking her medication again.

“We did talk about whether she should be put on one-to-one basis but we felt she was engaged and not a risk to herself or Zaani. Progress had been made.

“There was a risk that putting a mental health nurse outside her room could disempower her.”

But Dr Mynors-Wallis said it could take two to three weeks for risperidone to start working – and longer to stop psychotic symptoms.

“The presence of mental health nurse (can be beneficial) because they are able to able to spend a lot of time and build up a relationship. It’s in that relationship risk assessment becomes better.”

He also said evidence that Ms Bevan had stopped sleeping and begun to have poor personal hygiene were clear signs she was suffering a relapse.

The hearing was also told, by December 1, transferring Ms Bevan to a specialist mother and baby unit was not possible due to a lack of beds.

Dr Mynors-Wallis said another option could have been for her to go to a psychiatric hospital on her own – although he noted this may have caused her further distress.

But he maintained that things may have been different had Ms Bevan been under the care of a “single special unit”.

In earlier evidence, he said there was a significant risk of relapse for schizophrenics who stopped taking their medication – as there was also for mentally-ill women after giving birth.

However, he said even with hindsight it would have been impossible to predict that Ms Bevan would jump from Avon Gorge while holding her baby.

The hearing heard that Ms Bevan had requested a “doula” during her pregnancy – an experienced woman employed to offer emotional and practical support, during and after childbirth.

Keisha Venn said she first met Ms Bevan on November 25.

“She told me she had stopped taking risperidone, but she said she felt better than ever,” she added.

“She was headstrong, positive and energetic.

“And after Zaani was born, Charlotte told me Zaani was the most gorgeous, sweet thing she had ever seen. She was besotted with her.”

Several other doctors, midwives and nurses have told the inquest they thought Ms Bevan was bonding well with her new daughter.

At one point in her evidence, Dr Liebling broke down in tears before saying: “Zaani was a beautiful baby.

“They looked so happy. Charlotte said to me ‘thank you for making sure she got here safely’.

“She had done so well and been so brave.”

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