22 April 2024

This is a media release by Irwin Mitchell, reshared by INQUEST

• Family Instructs Lawyers To Establish Answers At Inquest Into 32-Year-Old Forest School Teacher’s Death
• Woman Struggled With Mental Health Following Tragic Death Of One-Day-Old Baby Son
• Hospital Trust Investigation Finds Absence Leave Guidance Not Fully Applied And “Significant Risk-Related Information Held By Family Not Included In Care Plan”

The family of a mum whose body was found nine hours after being granted unescorted leave from a mental health hospital following her baby’s death are calling for lessons to be learned. 

Kath Brace, aged 32, was allowed to leave the Mortimer Ward of the Stonebow Unit in Hereford where she had been sectioned under the Mental Health Act. 

It was the third time Kath, of Hereford, had been admitted and the second time she had been sectioned following the death of her and fiancé Dan Berry’s one-day-old son Otis, seven months earlier. During that time Kath had taken several overdoses. This included once after previously being granted unsupervised leave from the hospital. 

Her family said they had tried several times to raise concerns about Kath’s care and risk assessment but felt they were not listened to. 

Following the former Forest School teacher’s death, her loved ones instructed specialist lawyers at Irwin Mitchell to support them through an inquest and help establish answers. 

Kath’s family have now spoken for the first time about their loss. They’re also campaigning to improve maternity bereavement care for families, and mental health support in Herefordshire. 

It comes after a Root Cause Analysis Report by Hereford and Worcestershire Health and Care NHS Trust, which runs the Stonebow Unit, found that aspects of the Trust’s 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 or included in a risk assessment and management of her care, the report added. 

An inquest has found that Kath died following the loss of her son Otis, when her mental health deteriorated. 

The jury found that evidence suggested shortcomings in how Kath’s risk was assessed when granted her 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 Root Cause Analysis Report that 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 after the hearing: “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 and Dan, who met in 2010, found out they were expecting in the autumn of 2021. Kath went into premature labour at 33 weeks in March 2022. Baby Otis tragically died the following day following complications. 

Kath’s mental health started to deteriorate following Otis’ death. She spent nearly four weeks in hospital as an informal voluntary patient in May 2022. 

Following an overdose attempt, on 17 June, 2022, Kath was detained on the Mortimer Ward under the Mental Health Act for 10 days. 

However, 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 15 September, 2022, following a further overdose. On 24, September, 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 6 October, when Dan was so concerned about his fiancée’s condition that he returned her to the ward.

On 9 October, 2022, 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 scheduled visit by her mum, Angela Brace. 

However, Kath did not return, and police were called. Her body was found, by her brother, in a wooded area, only a short distance from the Stonebow Unit, nine hours later that day. 

After the hearing Kath’s mum Angie 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.

“Her life was good. She had bought a house with her fiancé 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 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’s family were also supported through the hearing by the charity INQUEST. For more information visit www.inquest.org.uk

Kath and her family also received help from the baby loss and bereavement charity Sands. Visit www.sands.org.uk for more information. 

ENDS 

Notes to Editors

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