A teacher devastated by the death of her baby took her own life seven months later after NHS mental health services failed.
Kath Brace, 32, and her fiancé Dan Berry were heartbroken when their son Otis passed away at just one day old due to complications in March 2022.
Relatives said Miss Brace’s mental health began to deteriorate seriously after the tragedy.
She was admitted to a mental health hospital, but despite having overdosed while on unaccompanied leave, she was allowed to leave again unaccompanied on October 9, 2022.
Her brother found her body nine hours later in a wooded area a short distance from the Stonebow Unit in Hereford.
Her family said they had tried several times to express their concerns about Miss Brace’s care and risk assessment, but felt they were not heard.
Kath Brace (right), 32, and her fiance Dan Berry (left) were left heartbroken when their son Otis passed away at just one day old due to complications in March 2022.
Relatives said Miss Brace’s (pictured) mental health began to deteriorate seriously after the tragedy.
An inquest jury concluded that NHS failings were “contributing factors” to Miss Brace’s death. Her family is now campaigning for improved maternity bereavement care and mental health support.
Her mother Angie Brace said: ‘Kath went from the upbeat, cheerful person we all knew to someone who really struggled with her mental health.
‘Every time she was admitted to hospital we hoped she would receive the care and support she needed and the long-awaited care plan, which never arrived, to help her get better.
“Every time we tried to raise a concern with the Hospital Trust when Kath was in custody or at home, we felt like they weren’t really listening to us.”
Mrs Brace said the family tried to voice their concerns, especially around their daughter’s previously unaccompanied escape, but felt “excluded and not involved in the process of trying to get her the help she needed”.
“Promises made by one of the doctors responsible for Kath were broken,” he said.
“It’s almost impossible to find the words to describe what the last year has been like and come to terms with what happened.”
Miss Brace and Mr Berry, who met in 2010, were delighted when they found out they were expecting a baby in autumn 2021.
But Miss Brace, who worked at a forestry school, went into premature labor at 33 weeks in March 2022 and her son, Otis, died the next day.
His mother said: ‘His life was good. She had bought a house with her fiancé that they were renovating and were planning to get married. When Kath found out that she was expecting Otis, she felt very blessed and she and Dan faced the future with great hope and excitement.
“However, sadly everything changed when Otis tragically passed away.”
Miss Brace spent almost four weeks in hospital as an informal volunteer patient.
Following an attempted overdose on June 17, she was detained on Mortimer Ward under the Mental Health Act for 10 days.
However, after his release, he continued to struggle with his mental health.
Miss Brace was arrested for a second time on September 15, after another overdose.
On September 24, after being granted unescorted leave from the unit by Mortimer Ward, Miss Brace overdosed. She returned to hospital and was granted leave on October 6, when Mr Berry was so concerned about the condition of her fiancée that he returned her to the ward.
But on October 9 he was again granted unaccompanied leave. He told staff that he planned to go to Hereford to buy a coffee and that he would return in time for a visit from his mother.
However, Miss Brace 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 that some aspects of its risk assessment and management policy were not applied in Miss Brace’s care.
Miss Brace (pictured), who worked at a forestry school, went into premature labor at 33 weeks in March 2022 and her son, Otis, died the following day.
The report said parts of the Trust’s leave of absence guidance were also not fully implemented and that “significant risk-related information” held by loved ones was not documented, it added.
An inquest jury found shortcomings in the way Miss Brace’s risk was assessed when she was granted leave from the unit, and that the Trust’s communication with her family “could have been better”.
Last week, the jury delivered a narrative finding, supporting the findings of the Trust’s own report which concluded that failings were contributing factors in Miss Brace’s death.
Describing her daughter, Mrs Brace said: ‘Kath was a beautiful, loving and caring person inside and out.
‘She was happiest when she helped others, she would do anything to see you smile. Kath’s love for life was contagious.
He added: ‘Kath had a lot to give and it breaks our hearts that she is no longer with us. Our family will forever remain heartbroken. The world is a much darker place without her.
‘We would do anything to get Kath back into our lives, but we know that’s not possible.
‘The only thing we can hope for now is that, by speaking out, we can improve care for others.
“We don’t wish the pain we continue to face daily on anyone.”
Miss Brace’s family is supported by INQUEST charity and Sands baby loss and bereavement charity.
Aimee Brackfield, a specialist public law and human rights solicitor at Irwin Mitchell representing Miss Brace’s family, said after the hearing: “This is a truly tragic case which has left Kath’s family devastated.
‘Understandably, over the past 18 months you have 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 are pleased that we have at least been able to give them the answers they deserve.
‘However, the investigation and the Hospital Trust’s own report have identified worrying issues in Kath’s care. “It is vital that lessons are learned to improve patient safety for others.”
A spokesperson for Herefordshire and Worcestershire Health and Care NHS Trust said: “Our deepest condolences go out to Kath’s family and loved ones.
“We fully accept the conclusions of the investigation and have carried out a full review to find out what has happened and whether we can make changes to prevent future deaths.”
For confidential support, call Samaritans on 116 123, visit samaritans.org or visit https://www.thecalmzone.net/get-support.