Opportunities missed in postnatal depression killing case, report finds

A watchdog investigating the care of a mother who suffocated her baby while suffering severe postnatal depression has found opportunities to refer her to mental health services were missed.

The Mental Welfare Commission (MWC) also found key information, including her history of postnatal depression when she thought of killing her older children, was “lost” in the GP system.

Erin Sutherland, 37, pleaded guilty on the grounds of diminished responsibility to culpable homicide following the death of her nine-month-old baby Chloe on February 3, 2015, and was jailed for three years, which the judge instructed would only take place if she was deemed fit to leave inpatient psychiatric treatment during that time

The High Court in Edinburgh (pictured) heard she had “severe” postnatal depression when she killed Chloe at her home in Parkhead View, Edinburgh, but was turned down for support by a perinatal mental health team since her daughter was older than six months.

Mental health minister Jamie Hepburn instructed the MWC to carry out an investigation into her care prior to her baby’s death.

In a report published on Thursday, which did not reveal Ms Sutherland’s identity and instead referred to her as Miss OP, the commission found there were “missed opportunities for referral to postnatal and adult mental health services”, and criticised the “very limited communication” between the organisations involved in her treatment.

The report said a pre-birth planning meeting would have highlighted the history, risks and appropriate management plan to all involved and might have reduced the risk of this information being “lost” within the GP system.

The commission has made 14 recommendations – nine for all joint health and social care bodies in Scotland which include ensuring there are clear pathways for access to perinatal mental health experts and urgent assessment by mental health teams as appropriate.

A further recommendation is that areas with perinatal mental health services should ensure women with histories of postnatal depression can be referred until their child is one. This recommendation is also included among the three for the specific health board involved.

The Scottish Government is recommended to prioritise establishing a national managed clinical network for perinatal mental health.

MWC executive director Alison Thomson said: “This is a deeply tragic case. We have not found any single failing or omission which caused or directly contributed to the death.

“However, during the course of our investigation we found several aspects of Ms OP’s care and treatment that should have been better.

“There were a number of factors which, if addressed, would have increased the likelihood of Ms OP receiving appropriate care and treatment for her depression at an earlier stage.

“Ms OP often presented with a good facade and did not express to any care professionals any thoughts of harm to herself or her children. This gave unfounded reassurance to those who were in contact with her.

“The combination of a previous history of thoughts of infanticide in the first postnatal year and deteriorating mental health during a time of stressful life events should have alerted those involved to the need for increased vigilance and support.

“Considering the number of people, agencies and services involved, there was very little communication between them and it is unlikely that anyone really had an overview of what was going on.

“We must learn lessons from this event to reduce the risk of similar events occurring in the future.”

Mental health minister Maureen Watt said her thoughts were with the family involved.

She said: “The report highlights lessons to be learned and it is absolutely imperative that action is taken in response to those lessons.

“The Scottish Government accepts and welcomes the report’s recommendation to establish a managed clinical network for perinatal mental health.

“Work has already been progressing on the creation of a new network and it is currently progressing through the approval process at NHS National Services Scotland. We are clear that we want it to be approved and implemented as soon as possible.

“I fully expect that health boards and health and social care partnerships will give very careful consideration to the lessons highlighted in this report that apply to the quality and provision of the mental health services they provide, including perinatal mental health.

“I expect them all to ensure that all women are given access to the support they need.”

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