Shanice Priestly inquest: Pregnant mother's suicide
A specialist team to help expectant mothers with mental health problems should be set up in north Wales, a coroner said.
It follows the death of Shanice Priestly, 22, from Conwy, who hanged herself when she was eight months pregnant.
A conclusion of suicide was recorded at an inquest on Friday.
"I am not fully persuaded that everything that can be done has been done," said the coroner John Gittins.
Mr Gittins said Betsi Cadwaladr University Health Board must push ahead with plans to establish a perinatal mental health team for new mothers, stating it could be a "huge step forward" to prevent similar deaths.
The two day hearing at Ruthin, Denbighshire, was told Ms Priestly had a long history of depression which began with the birth of her first child in 2010.
She developed an unfounded anxiety her baby could be taken from her because of her mental state.
Her father, Stephen Priestly, was at a meeting four days before his daughter killed herself when she told a social worker she had suicidal thoughts in August 2014.
When asked to indicate on a scale between one and 10 how much she wanted to kill herself, she replied: "10."
"I was disappointed that it wasn't acted on," he said.
During evidence, it emerged Conwy council social worker Lyndsay Reis had just transferred to the adult mental health services and had not undertaken an induction before being assigned to Ms Priestly.
But consultant psychiatrist Stuart Porter said he felt that a suicide risk assessment was of "an acceptable standard".
"It is fraught trying to predict people's behaviour, it is inherently difficult," he said.
A review of mental health support was undertaken following Ms Priestly's death, which led to an action plan being implemented, including ensuring all social workers undergo a full induction when they join mental health services.
Mr Gittins said he would write to Conwy council and the health board to ensure they were put in place.
"Improvements have been made, they are continuing to be made, but I am not fully persuaded that everything that can be done has been done," he said.
After the hearing, Ms Priestly's uncle, Mike Priestly, said: "At this moment in time the family will reserve judgement on whether the lessons will be learned and hope that no other family has to go through what we have."
In a statement, the health board spokesman said: "We are working hard to improve our partnership work in relation to community mental health services. We are also developing a new perinatal mental health service for north Wales."
A council spokesperson said services have been reviewed and improvements implemented with the health board,
"The council looks forward to the implementation of a new perinatal mental health service in north Wales which is a much needed resource for women who suffer mental health issues in pregnancy."