Grieving teacher, 32, devastated by the loss of her baby took her own life while on unsupervised leave from mental health hospital – as inquest concludes NHS failures contributed to her death

A teacher left devastated by the death of her baby took her own life seven months later after being rejected by the NHS mental health system.

Kath Brace, 32, and her fiancé Dan Berry were left heartbroken when their son Otis passed away at just one day old after complications in March 2022.

Relatives said Ms Brace’s mental health began to deteriorate seriously after the tragedy.

She was admitted to a psychiatric hospital, but despite taking an overdose while on unescorted leave, she was allowed out unsupervised again on October 9, 2022.

Her body was found nine hours later by her brother in a wooded area just a short distance from The Stonebow Unit in Hereford.

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

Relatives said Ms Brace’s (pictured) mental health began to deteriorate seriously after the tragedy

An inquest jury has concluded that NHS failings were ‘contributing factors’ in the lead-up to Mrs Brace’s death. Her family is now campaigning to improve bereavement and mental health care.

Her mother Angie Brace said: ‘Kath went from being the optimistic and cheerful person we all knew to someone who was really struggling with her mental health.

‘Every time she went to hospital we hoped she would get the care and support she needed and a long-awaited care plan, which never materialised, to help her get better.

‘Every time we tried to raise our concerns with the Hospital Trust while Kath was in prison or at home, we felt like we weren’t really being listened to.’

Ms Brace said the family tried to raise their concerns, particularly about her daughter who had previously gone into hiding on unescorted leave, but felt ‘left out and not involved in the process of getting her the help she needed’.

“The promises of one of Kath’s responsible doctors have been broken,” she said.

“It’s almost impossible to find the words to describe what the past year has been like and what it’s been like coming to terms with what happened.”

Ms Brace and Mr Berry, who met in 2010, were thrilled to learn they were expecting in the fall of 2021.

But Miss Brace, who worked at a forest school, went into premature labor at 33 weeks in March 2022 and her son Otis died the next day.

Her mother said, “Her life was good. She and her fiancé had bought a house that they were renovating, and they were planning to get married. When Kath found out she was expecting Otis, she felt so blessed, and she and Dan looked to the future with so much hope and excitement.

“Unfortunately, that all changed when Otis tragically passed away.”

Miss Brace spent almost four weeks in hospital as an informal volunteer patient.

After attempting an overdose on June 17, she was held at Mortimer Unit for ten days under the Mental Health Act.

However, after her release, she continued to struggle with her 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 ward by Mortimer Ward, Miss Brace overdosed. She returned to hospital and was put on leave on October 6, when Mr Berry became so concerned about his fiancée’s condition that he brought her back to the ward.

But on October 9, she was again given unescorted leave. She told staff she planned to go to Hereford to buy coffee and would return in time for a visit from her mother.

However, Mrs Brace did not return and police were called before her body was found later that day.

A root cause analysis report from Hereford and Worcestershire Health and Care NHS Trust, which runs the Stonebow Unit, found that aspects of their risk assessment and management policies were not applied in Ms Brace’s care.

Mrs Brace (pictured), who worked at a forest school, went into premature labor at 33 weeks in March 2022 and her son Otis died the next day

The report said parts of the Trust’s sick leave guidelines were also not fully applied and “significant risk-related information” from her loved ones was not documented, it added.

An inquest jury found shortcomings in the way Miss Brace’s risk was assessed when she was put on leave from the unit, and that the Trust’s communications with her family ‘could have been better’.

Last week the jury returned a narrative conclusion, endorsing the findings of the Trust’s own report, which concluded that deficiencies were contributing factors in the lead-up to Ms Brace’s death.

Mrs Brace described her daughter: ‘Kath was a beautiful, loving and caring person inside and out.

‘She was happiest when she was helping others, she would do anything to see you smile. Kath’s love for life was infectious.

She added: “Kath had so much to give and it breaks all our hearts that she is no longer with us. Our family will forever be heartbroken. The world is a much darker place without her.

‘We would 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 the care for others.

“The hurt and pain we face every day is something we wouldn’t wish on anyone else.”

Mrs Brace’s family are supported by the INQUEST charity and the baby loss and bereavement charity Sands.

Aimee Brackfield, a specialist public law and human rights lawyer at Irwin Mitchell who is representing Ms 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 they have had a number of questions and concerns about the care Kath received and the events leading to her death.

“While nothing can make up for their loss, we are glad that we were at least able to give them the answers they deserve.

‘However, the inquest and the Hospital Trust’s own report have revealed worrying issues in Kath’s care. It is essential 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 investigation’s findings and have carried out a full investigation to find out what happened and whether we can make changes to prevent future deaths.’