A review into the death of a Bristol mother who fell to her death with her four-day-old baby has found that mental health staff caring for her were over-stretched and under-resourced.
Charlotte, who had schizophrenia, walked out of the doors of St Michael's Hospital in Bristol into the icy night - wearing slippers on her feet.
The bodies of Charlotte Bevan and her daughter Zaani were found in the Avon Gorge two days after they went missing in December 2014. It was a case that shocked the nation.
The Serious case review, commissioned by Bristol Safeguarding Children Board, has found that improvements can be made within safeguarding organisations. But despite this, no clear act caused the death of Charlotte Bevan and Zaani Tiana Bevan-Malbrouck.
The 45 page case review was published yesterday, and the main theme underlying the report is that staff were under huge pressure and suffering from a lack of resources.
Charlotte, who had schizophrenia, had a long history of suffering from mental illnesses and had been sectioned four times.
Despite a system being in place for entry into the ward, mothers were allowed free access throughout the hospital allowing Charlotte to leave the ward with Zaani "unnoticed and unchallenged".
What were the key findings in the report?
The report lists eight key findings to help improve mental health care for pregnant women and their babies.
Once the maternity ward staff noticed that Charlotte and Zaani were missing there was a quick response by the staff who contacted the police.
But there was "missed opportunities" as the model of support provided was inconsistent.
Charlotte's mother, Rachel Fortune, contributed to the review saying that "no single thing, action or person was to blame". She said that the report published allows for "clear, constructive learning".
What has changed in mental healthcare for new mothers since December 2014?
A new control system for entry and exit out of the ward where Charlotte was staying has been installed - anyone wanting to enter or leave must be buzzed out by staff.
A new mental health service is operating in the area for pregnant women and new mothers who are at high risk of a mental health problem.
This new system identifies and supports those at risk, but it also supports other mental health professionals involved in their care. Since it launched in February, 89 women have already been referred to it.
Dr Leanne Hayward is the consultant for the new community perinatal service.
The NHS bodies involved are reviewing their practices, and significant change has happened, but one factor must be taken into consideration, that although you can significantly reduce the risk, you can't eliminate it.
If you or someone you know is suffering from mental health problems, there is advice and support available.