An inquest into the unlawful killing of twins by their depressed mother at a their home in Margate was unforeseeable.
Samantha Ford drowned 23-month old Chloe and Jake on Boxing Day in 2018 following the breakdown of her marriage to Steve Ford.The pair met in 2004 before moving to Dubai and then Doha, Qatar, until they moved back to Kent in February 2018 before separating in the autumn.
Samantha Ford moved to Margate so she could be close to her parents and brother.
In the weeks leading up to the deaths of her children, Samantha Ford had been in touch with doctors and nurses on several occasions.
Coroner Christopher Sutton-Mattocks concluded there was no inclination that the children were going to be harmed and there were no failings made by healthcare staff.
Among the communication between Ford and healthcare staff:
December 7th 2018: Samantha Ford spoke to several health workers through the NHS 111 phone service about how she was feeling. Nobody believed there was any immediate risk to the children.
December 14th: A letter warning of suicidal thoughts was sent to her doctors surgery in Charing by a mental health team who had spoken to Ford.
December 21st: Her GP was not aware of the letter when Ford spoke to him over the phone. Dr Robert Immelman told the inquest he did not believe she was 'irritated' or 'distressed'. The surgery has since tightened up the procedure.
Chloe and Jake Ford spent Christmas Day with their father but were then returned to their mother on Boxing Day.
Samantha Ford undressed both of the children, put them in the bath and held them under the water.
She then removed them from the bath, dressed them in nappies and baby grows and placed them in bed.
Afterwards Ford then attempted to take her own life.
Coroner Christopher Sutton-Mattocks said: "I make it clear that in my judgement there was no foreseeability that this tragic outcome was likely, in fact the opposite. Throughout the period Samantha Ford's family, friends, estranged husband or medical practitioners had no incline at all that the lives of the twins were at risk. They were concerned about the risk of Samantha's safety and risk of suicide."
Statement from Steven Ford, father of Chloe and Jake Ford following the inquest
“On Boxing Day 2018 my beautiful children Chloe and Jake were killed by their mother, Samantha. The last two years have been agonising. I miss them so much and this is something I will never get over as long as I live.
"Samantha and her family have attempted to use the inquest process to point to failings in the NHS which she says should have acted to prevent her from killing Chloe and Jake. I am disappointed that it has taken two years to reach this point. It was clear from the beginning the health services did not fail my children or Samantha in anyway.
"I am very pleased with the outcome of the inquest. The coroner completely rejected the unfounded calls on behalf of Samantha to make a Prevention of Future Deaths Report. Having examined Samantha’s interactions with the NHS in great detail, the coroner found that there were no failings or faults on the part of the health services that could be said to have contributed to their deaths.
"I do not consider this to be a win in any way. It is simply a prevention of additional injustice caused by Samantha’s and her familys continued attempts to find someone to blame for her actions. Samantha was to blame for the death of Chloe and Jake. No one else.
"I appreciate that this is a difficult outcome for Samantha’s family to hear. It is my sincere hope that they finally accept it.
"I am very grateful to the coroner for pressing ahead with the inquest in the face of the logistical challenges caused by the present health emergency.
"I can finally grieve in peace."
Parents of Samantha Ford concerned following the inquest
"The deaths of our grandchildren Chloe and Jake was the worst pain that any family could ever endure, we will never recover from the loss of their precious lives.
"We remain concerned that there were missed opportunities for Chloe and Jake. Although Samantha repeatedly sought help (speaking to 14 different professionals throughout November and December) she was only seen face to face on two occasions and the only solution appeared to be to prescribe her more and more medication.
"We can only hope that the support networks that are in place to help people suffering the mental distress endured by Samantha will be strengthened to ensure that this can never happen to another family."
Ford was jailed for 10 years in August 2019 at a psychiatric unit after admitting manslaughter by diminished responsibility.
18 months since the deaths of Chloe and Jake, Samantha Ford is still being treated in that unit.