Care of postnatal depression killer 'should have been better'
A mother who suffocated her baby while suffering from postnatal depression did not receive adequate treatment for her illness, a report has found.
Health professionals dealing with Erin Sutherland were responsible for a series of failures, according to the Mental Welfare Commission for Scotland.
Mental health experts, GPs and health visitors failed to detect the extent of the mother-of-three's depression.
It made 14 recommendations to improve postnatal mental health care.
The report follows a court case last year in which Sutherland admitted the culpable homicide of her nine-month-old daughter Chloe.
Psychiatric reports submitted to the court found that Sutherland, referred to in the reports only as Ms OP, was "profoundly" affected by postnatal depression.
The commission was asked by former mental health minister Jamie Hepburn to carry out a full investigation into her care before Chloe's death in Edinburgh.
It concluded that, had the failures in her care been addressed, Sutherland would have received appropriate care and treatment at an earlier stage.
Alison Thomson, executive director (nursing) of the Mental Welfare Commission said the case was "deeply tragic".
She said: "We have not found any single failing or omission which caused or directly contributed to the death.
"However, during the course of our investigation we found several aspects of Ms OP's care and treatment that should have been better."
The report reveals that Sutherland was in hospital for four weeks with post-natal depression following the birth of her second child
It said a psychiatrist's letter identifying risks in her previous pregnancy should she become unwell again were "not sufficiently highlighted".
Following the birth of her third child, she appeared to display no outward signs of suffering such severe depression.
Ms Thomson said: "Ms OP 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."
Other findings of the report include:
- There was "very little communication" between the people, agencies and services involved in Sutherland's care
- There were "missed opportunities" to refer her to the perinatal mental health services (PNMHS)
- One GP told Sutherland he could not refer her to PNMHS because her baby was over six months old
- Another GP did refer her to PNMHS. But it did not receive the letter until a week later - the day after Sutherland suffocated her baby
- She was seen by six different GPs which created difficulty in ensuring "continuity of care"
- Concerns about the resources within the PNMHS were not adequately addressed in a review by the local NHS board
Recommendations outlined by the commission include ensuring that women with "significant histories" can be referred to perinatal mental health services until their child is one year old.
They suggest large doctors surgeries nominate a "go-to" GP with a particular interest in perinatal health - in a bid to minimise inconsistencies.
National clinical network
The commission has called on the NHS board to review the remit and staffing of the PNMHS.
And it has told the Scottish government that priority should be given to establishing a national clinical network for perinatal mental health.
Minister for Mental Health, Maureen Watt, said it was "absolutely imperative" that lessons were learned from the issues highlighted in the report.
She added: "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."