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09 October 2015

Joint statement in response to the coroner’s conclusion

NHS England
Bristol Clinical Commissioning Group
University Hospitals Bristol Foundation Trust
Avon and Wiltshire Mental Health Partnership Trust.

"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 birth. 

"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