09 October 2015
Joint statement in response to the coroner’s conclusion
Bristol Clinical Commissioning Group
University Hospitals Bristol Foundation
Avon and Wiltshire Mental Health Partnership
"The deaths of Charlotte and Zaani were tragic and I want to
begin by expressing, on behalf of all the NHS organisations
involved, our deepest condolences to Charlotte and Zaani's
family. We would like to thank them for their kindness and
thoughtfulness to staff during this difficult time and their
commitment to continue working with us to improve services.
"The Coroner has heard that many staff from our mental health
and maternity services did their very best to support and care for
Charlotte before and during her pregnancy and after Zaani's birth.
However, as the coroner has concluded today, there was a chain of
failures which contributed to their deaths.
"As a health community, we will act on the coroner's findings to
ensure that mothers with mental health needs, and their babies,
have access to the services and professionals they need to keep
them and their babies safe during pregnancy, and following the
"Whilst there is more to do, the local NHS has already made
changes to improve the way in which mothers with mental health
needs are cared for and we will now consider the coroner's
conclusions and recommendations very carefully to see what
other actions we can take to improve services for vulnerable
mothers, their babies and their wider family."
Dr Caroline Gamlin, Medical Director NHS England
BACK TO NEWS