Death of a baby - Investigation into the care of Ms OP

The Mental Welfare Commission today published an investigation into the care of Ms OP, a mother who suffocated her baby while profoundly affected by postnatal depression.

The death of her baby on 3 February 2015 was the subject of a police investigation and court case. Ms OP was convicted of culpable homicide. Psychiatric reports prepared for the court case concluded that she was profoundly affected by postnatal depression at the time of the offence.

Ms OP had experienced postnatal depression during a previous pregnancy.

The Commission was asked by the former Minister for Sport, Health Improvement and Mental Health, Jamie Hepburn, to carry out a full investigation into the care of Ms OP prior to the baby's death, and to make recommendations as appropriate.

The Commission's key findings include:

• very limited communication between the different agencies involved in Ms OP's care and treatment,
• missed opportunities for referral to postnatal mental health services (PNMHS) and to adult mental health services,
• a pre-birth planning meeting would have highlighted the history, risks and appropriate management plan to all involved and might have reduced the risk of this information being 'lost' within the GP system,
• following an assessment in November 2013, there was no further contact with a psychiatrist. Ms OP's discharge by the community psychiatric nurse from the postnatal mental health service in August 2014 was not discussed with anyone else in the team in advance.

The Commission makes a range of recommendations - nine for all joint health and social care bodies in Scotland; three for the specific health board involved, health board C, one for Scottish Government, and one for the Royal College of General Practitioners Scotland. The recommendation for Scottish Government is that priority should be given to establishing a national managed clinical network for perinatal mental health.

Alison Thomson, Executive Director (Nursing), Mental Welfare Commission, said:

"This is a deeply tragic case. 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.

"There were a number of factors which, if addressed, would have increased the likelihood of Ms OP receiving appropriate care and treatment for her depression at an earlier stage.

"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.

"Considering the number of people, agencies and services involved, there was very little communication between them, and it is unlikely that anyone really had an overview of what was going on.

"We must learn lessons from this event to reduce the risk of similar events occurring in the future."