Serious case review after deaths


Published: Friday 5th December 2014 by The News Editor

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A serious case review is expected to take place following the deaths of a mother and her newborn baby girl who went missing from a maternity hospital.

Charlotte Bevan, 30, who suffered from mental health issues, vanished from Bristol maternity hospital with Zaani Tiana Bevan Malbrouck at around 9pm on Tuesday.

CCTV images showed Ms Bevan walking in hospital slippers with her four-day-old daughter wrapped in a blanket through the hospital without being stopped.

The charity worker passed three nurses standing around a vending machine and a reception desk before leaving with her daughter in cold weather.

A police helicopter located Ms Bevan’s body two miles away on the Avon Gorge on Wednesday night, while Zaani’s body nearby was found by search teams the following day.

University Hospitals Bristol NHS Foundation Trust has launched an investigation into the care mother and baby received to establish if anything could have been done to prevent the double tragedy.

Today Bristol City Council said it anticipated Bristol Safeguarding Adults Board and Bristol Safeguarding Children Board would launch a serious case review into the case.

“This is a truly tragic incident and our deepest sympathies are with all of Charlotte’s family and friends,” said John Readman, strategic director for people at the council.

“We fully anticipate an independent Serious Case Review, which would look closely at the circumstances of this case and the role of all agencies involved, including health, mental health and social services.

“Its findings would be published once complete.”

Ms Bevan’s partner Pascal Malbrouck, Zaani’s father, left mother and baby at the hospital at about 8pm on Tuesday.

Nurses checked on them at about 8.30pm but raised the alarm at 9.05pm when they returned to find Ms Bevan and baby Zaani missing.

Ms Bevan, who lived in Clifton, is believed to have suffered from schizophrenia, depression and severe sleep deprivation since giving birth.

A walker alerted police after spotting a pair of white hospital slippers and a multi-coloured baby blanket on a cliff edge fence by Clifton Observatory on Wednesday.

Ms Bevan’s body was discovered at around 10.30pm that night, while the body of baby Zaani was located nearby following an intensive search operation on Thursday.

Speaking at a press conference overlooking the Avon Gorge, Detective Chief Inspector Simon Crisp said neither death was being treated as suspicious.

“This is a dreadful, awful, frustrating business and our thoughts are with the family at this time,” Mr Crisp, of Avon and Somerset Police, said.

He said he was unable to comment on whether Ms Bevan should have been more carefully monitored by hospital staff.

University Hospitals Bristol NHS Foundation Trust has launched a review of the care Ms Bevan and Zaani received while at St Michael’s Hospital.

Babies at the unit wear tags for identification purposes only and patients are allowed to come and go on the ward, a spokeswoman confirmed.

CCTV cameras monitoring the ward and public areas are not monitored, though footage can be played back in real time or at a later date.

Standard discharge procedure states mother and baby must be confirmed as fit by a midwife or doctor, with computer and handheld notes also completed.

Midwives ensure mother and baby go home with post birth notes, including medication and details of any side effects, in suitable transport including a car seat for baby.

Ms Bevan was expected to be discharged from the unit a few days after her disappearance and the spokeswoman said there was “no indication” she was planning to leave.

” We cannot stop any mother leaving the hospital unless there are legal restrictions on her movements,” the spokeswoman added.

Ms Bevan’s mother Rachel Fortune, 59, issued a statement thanking all hospital staff and mental healthcare teams past and present.

“My beautiful daughter and granddaughter are now at peace,” she said. “The family would like to thank all the friends of Pascal, Charlotte and Zaani, some of whom we have only met today.

“We would also like to say thank you for all the messages from everyone.”

Friends described Ms Bevan, who had attended Wells Cathedral School, as part of a “happy couple” and described her disappearance as “out of character”.

Hours before she disappeared, Ms Bevan posted a self-help video on her Facebook page called Get Through Positive and Negative Thinking Rough Patches.

Earlier this month she uploaded happy pictures of herself with her baby bump, smiling with Mr Malbrouck, on the social networking site.

Rachael Dobson, co-founder and chief executive of Pandas, a charity which supports families suffering from pre and postnatal illnesses, described the case as “deeply saddening”.

“It is deeply saddening, this tragedy of the death of Charlotte Bevan and her baby daughter, and my thoughts are with her family and friends at this difficult time,” Mrs Dobson said.

“Postnatal depression affects as many as one in seven new mums, along with the same amount suffering antenatal depression.

“We should be in a society where we can talk about our feelings and our mental health and let everyone know It’s OK not to be OK.”

Published: Friday 5th December 2014 by The News Editor

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