Midwife had 'grave concerns' for mother and newborn baby before fatal fall
Published 01/10/2015 | 12:17
A midwife had "grave concerns" for the welfare of a mother and newborn baby three days before they left a hospital and fell to their deaths, an inquest has heard.
Charlotte Bevan, 30, vanished from St Michael's Hospital in Bristol with her four-day-old daughter Zaani Tiana Bevan Malbrouck on December 2 last year.
The new mother, who had stopped taking anti-psychotic medication to breastfeed, carried Zaani outside in a blanket at 8.36pm, when temperatures were 3C (37.4F).
Hospital staff did not raise the alarm to police until 9.14pm, by which time the mother and baby had reached Clifton Observatory - a 30-minute walk away.
Search teams later located the bodies of Ms Bevan and Zaani, who suffered fatal injuries consistent with a fall, on the Avon Gorge below.
Avon Coroner's Court heard community midwife Alison Woozley contacted staff at the hospital on November 29, after hearing Ms Bevan had given birth.
"I was aware that Charlotte had her baby and I phoned the ward to speak to the midwife who was looking after Charlotte," she told the inquest.
"I said 'have you read the plan of care for Charlotte?'. The midwife said 'oh, I'm not sure if there's a plan'.
"I said 'I suggest you look for it, I have met Charlotte in the community and I have grave concerns for her well-being and her ability to care for a baby'.
"I said to the midwife under no circumstances was Charlotte to be discharged from the ward without consultation with an obstetrician and a psychiatrist.
"The midwife later phoned me back and said she had seen the plan. She thanked me for flagging it up."
Ms Woozley said she was concerned about Ms Bevan, from Clifton, following three meetings she had with her prior to the birth of Zaani.
During the final appointment, on November 18, she met with Ms Bevan and Zaani's father, Pascal Malbrouck.
"I purposefully read aloud from the notes that Charlotte had stopped taking risperidone," she said.
"Pascal's jaw hit the floor. He looked really surprised and was really concerned.
"I expressed my concerns, the plan was clear that Charlotte was to be on 5mg of risperidone once a day.
"She became very, very angry, she was right in my face. She was saying 'I know my rights as a woman, how dare you tell me what to do'.
"I felt really sorry for Pascal, I felt she was really shouting at him, I could hear he was concerned and distressed.
"She was a very articulate, intelligent, imposing woman."
Ms Woozley brought a colleague into the room and Ms Bevan's behaviour switched to being "meek and sweet", she said.
"I was extremely concerned for Charlotte's well-being but also for the well-being of the baby, my anxiety was how she could look after a baby," she said.
"I had a sense of foreboding."
Ms Woozley then contacted the doctor managing Ms Bevan's medication, her GP, and First Response, which provides preventative services to help families.
The inquest heard Zaani was born at 6.16pm on November 28, weighing 3.34kg.
Midwife Sarah Grey said: "She behaved like a normal mum of a newborn baby, she coped very well with labour.
"She obviously fell in love immediately with her baby, she responded beautifully to her baby. She expressed no concerns at all.
"It was a lovely atmosphere in the room."