The mental health watchdog has exposed a string of missed opportunities to prevent a mother from suffocating her baby daughter while in the grip of postnatal depression.
Erin Sutherland, 37, admitted culpable homicide after her nine-month-old daughter Chloe died at their home in Parkhead View, Sighthill, in February last year.
A critical report published today by the Mental Welfare Commission (MWC) found NHS staff simply accepted Sutherland’s “good facade” without question and failed to consider her previous history, in which the mother-of-three had admitted thinking about killing her older children.
There was poor communication between health professionals looking after Sutherland, who may have missed out on follow-up care because flaws in the GP records system meant she was not referred for perinatal mental health care when she was eligible.
It follows a damning report last week into the death of Evie Douglas, who took her own life days after being discharged from outpatient care at the Royal Edinburgh Hospital.
The ombudsman highlighted failings in communication and follow up care for the 21-year-old, who died at her flat in Canonmills in November 2014.
Referring to Sutherland, Alison Thomson, MWC executive nursing director, said: “This is a deeply tragic case.
“There were a number of factors which, if addressed, would have increased the likelihood of Ms OP [Sutherland] receiving appropriate care and treatment for her depression at an earlier stage.
“She 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.” Sutherland was jailed for three years, which she will serve in a psychiatric hospital unless she is deemed well enough for prison.
The case heightened calls for mental health services for new mums to be extended beyond the current six-month cut-off offered by NHS Lothian.
Tillie Mabbutt, from the PANDAS Foundation, which offers support for pre- and post-natal depression, said: “Given that postnatal depression can affect a mother within the first year of giving birth, a six-month cut off for specialist care from the Perinatal Mental Health Service simply does not provide the help and support that mothers need.
“Once more, if the service is unable to extend the support past six months postnatally then a more robust and fit-for-purpose procedure for care needs to be provided.”
The commission has made 14 recommendations for improving perinatal mental health – nine for all joint health and social care bodies in Scotland, three for NHS Lothian and one for the Scottish Government.
Professor Alex McMahon, of NHS Lothian, said: “Our sincere condolences and sympathies are with the family of baby A [Chloe]. This was a tragic case and one that prompted us to take immediate action.
“These actions have now all been implemented and I would also like to reassure patients and their relatives that lessons have been learned.”
Maureen Watt, Mental Health Minister, said: “This is a tragic case, and first and foremost our thoughts must be for the family involved. I would like to thank the MWC for this diligent report, which was carried out at the request of Scottish ministers.
“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.”