A grieving teacher left devastated by the death of her newborn baby took her own life months later following failings at a hospital which 'contributed' to her suicide.
Kath Brace and her fiance Dan Berry were left heartbroken when their son Otis died at just a day old following complications in March 2022. Family members said Kath's mental health began to severely deteriorate following the tragedy, which led to her being admitted to a mental health hospital seven months later.
Despite taking an overdose after being granted unescorted leave from The Stonebow Unit in Hereford, Kath was later allowed out unsupervised again. Nine hours later her body was found by her brother in a wooded area only a short distance from the facility on October 9, 2022.
The 32 year old's family said they had tried several times to raise concerns about Kath's care and risk assessment but felt they were not listened to. An inquest jury has also since ruled the NHS Trust's failings were "contributory factors in the lead up to Kath's death".
Kath's family have now spoken for the first time about their loss and campaigning to improve maternity bereavement care and mental health support. Her mum Angie Brace said: "Kath was a beautiful, loving and caring person inside and out. She was at her happiest when helping others, she would do anything to see you smile. Kath's love of life was infectious.
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"Her life was good. She had bought a house with her fiance which they were renovating and were planning on marrying. When Kath found out she was expecting Otis she felt so blessed, and she and Dan were facing the future with so much hope and excitement. However, sadly that all changed when Otis tragically passed away.
Kath Brace's family has spoken out (Irwin Mitchell / SWNS)
Kath and her fiancé Dan Berry lost a child (Irwin Mitchell / SWNS)"Kath went from being the optimistic and upbeat person we all knew to one who really struggled with her mental health. Each time she went into hospital we hoped that she would receive the care and support she needed and long awaited care plan, that was never forthcoming, to help her get better. However, even once back home we remained concerned for Kath.
"Each time we tried to raise any concerns with the Hospital Trust when Kath was either detained or at home, we felt like we weren't really listened. We tried and tried to make our voice heard, especially around Kath absconding previously on unescorted leave, but we felt shut out and not involved in the process of trying to get her the help she needed.
"The promises made by one of Kath's responsible clinicians were broken. Kath even needed to rely on support from charities, like Sands, to feel heard and listened to. It's almost impossible to find the words to describe what the last year or so and coming to terms with what happened has been like. Kath had so much to give and it breaks all our hearts she's no longer with us. Our family will forever remain heartbroken.
"The world is a much darker place without her. We'd do anything to have Kath back in our lives, but we know that's not possible. All we can hope for now is that by speaking out we can improve care for others. We wouldn't wish the hurt and pain we continue to face daily on anyone else."
Kath and Dan, who met in 2010, had been delighted when they found out they were expecting in the autumn of 2021. Kath, who worked at Forest School, went into premature labour at 33 weeks in March 2022 - but baby Otis tragically died the following day. Kath's mental health started to deteriorate and she spent nearly four weeks in hospital as an informal voluntary patient that May.
Following an overdose attempt on June 17 Kath was detained on the Mortimer Ward under the Mental Health Act for 10 days. owever, following her release, Kath continued to struggle with her mental health. Her and Dan postponed their wedding that August having already postponed on two previous occasions because of Covid.
She was detained for a second time on September 15, following a further overdose. On September 24, after she was granted unescorted leave from Mortimer Ward, Kath took an overdose and attempted to hang herself, the Hospital Trust report said. Kath returned to hospital and was granted leave on October 6, when Dan was so concerned about his fiance's condition that he returned her to the ward.
On October 9, Kath was granted unescorted leave and she told staff she planned to go into Hereford to buy a coffee and would return in time for a visit by her mum However, Kath did not return, and police were called before her body was found later that day.
A root cause analysis report by Hereford and Worcestershire Health and Care NHS Trust, which runs the Stonebow Unit, found aspects of their risk assessment and management policy were not applied in Kath's care. Elements of the Trust's absence leave guidance were not fully applied and "significant risk-related information" held by Kath's loved ones was not documented, it added.
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An inquest jury also found shortcomings in how Kath's risk was assessed when she was granted leave from the unit, and that the Trust's communication with Kath's family "could have been better".
The jury returned a narrative conclusion, endorsing the findings of the Trust's own report those failings were contributory factors in the lead up to Kath's death. Aimee Brackfield, a specialist public law and human rights lawyer at Irwin Mitchell representing Kath's family, said: "This is a truly tragic case which has left Kath's family devastated.
Understandably for the past 18 months they've had a number of questions and concerns about the care Kath received and the events leading up to her death. While nothing can make up for their loss, we're pleased that we've at least been able to provide them with the answers they deserve. However, the inquest and the Hospital Trust's own report have identified worrying issues in Kath's care.It's vital that lessons are learned to improve patient safety for others."
Kath's family were also supported by the charity INQUEST and the baby loss and bereavement charity Sands.
Herefordshire and Worcestershire Health and Care NHS Trust has been approached for comment.
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