Prevention of Future Deaths reports · 2015
Regulation 28 report to prevent future deaths, reference 2015-0418, written 27 Oct 2015. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 27 Oct 2015 |
|---|---|
| Reference | 2015-0418 |
| Deceased | Charlotte Bevan and Zaani Malbrouck |
| Coroner | Maria Voisin |
| Coroner area | Avon |
| Category | Child Death (from 2015) · Hospital Death (Clinical Procedures and medical management) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text recovered by OCR from a scanned PDF. OCR is imperfect: check anything you rely on against the source PDF. Reproduced verbatim, including the scan's own layout.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1) NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 4. lain Tulley — Chief Executive Avon & Wiltshire Mental Health NHS Trust Jenner House Langley Park Estate Chippenham Wiltshire SN15 1GG | | 1 | CORONER 1 am Maria Voisin, Senior Coroner, for the Area of Avon. 2 | CORONER’S LEGAL POWERS | make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. 3 | INVESTIGATION and INQUEST | On 12" December 2014 | commenced an investigation into the death of: e Charlotte Emily BEVAN, Aged 30, and e Zaani Tiana Bevan Malbrouck, aged 4 days. The investigation concluded at the end of the inquest on 19" October 2015. The conclusion of the inquest for Charlotte was that she died due to 1a) 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 2nd December 2014 at 20.36hrs she walked straight from the hospital to the cliff top 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 i with Charlotte 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's 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 very unwell when she left the hospital | unnoticed with her daughter and went to the cliff top at the Avon Gorge on 2nd i 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. 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 21° November 2014. Charlotte’s mental health deteriorated and on 4" December she left the hospital with Zaani and walked to the cliff top at the Avon Gorge. Both Charlotte and Zaani’s bodies were found subsequently. CORONER’S CONCERNS During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. — 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; and 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. 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 taking steps in relation to ensuring that there are multi- disciplinary meetings in all cases with an appropriate care plan which is then widely circulated. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 29" December 2015. I, the Coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. COPIES and PUBLICATION | have sent a copy of my report to the Chief Coroner and to the following Interested Persons — the family, University Hospitals Bristol NHS Trust and to the LOCAL SAFEGUARDING BOARD. | am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner. 27 October 2015 MN. E. Voisin
1 response published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
24 DEC 208 Avon and Wiltshire [a/Fe3 Mental Health Partnership NHS Trust Chief Executive's Office Maria Voisin ' 4 Senior Coroner ied Dek The Coroner's Court oe ley Parl The Courthouse ippenrem Old Weston Road iltshire Flax Bourton ; SN15 1GG BS48 1UL Tel: 01249 468023 23 December 2015 Dear Ms Voisin | am writing in response to the Prevention of Future Death report you issued to this Trust following 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 Trust for pregnant women and 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 a pathway that can be agreed and implemented Trust wide. This work is well underway with draft algorithms developed that are being consulted on and tested. The pathways are underpinned very 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 the 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 a 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. Yours sincerely if ay i Dr Hayley Richards Acting Chief Executive Chair Trust Headquarters Acting Chiet Anthony Gallagher Jenner House, Langley Park, Chippenham SN15 1GG Dr Hayley Richards We are a teaching, learning and research trust; we aim to inform you about relevant opportunities, unless you tell us otherwise.’
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