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An inquest into the death of a woman who overdosed on prescribed and non-prescribed medicines as she tried to cope with psychological problems after giving birth found she could have been saved if she had been referred to the perinatal mental health service.  

In her report to Betsi Cadwaladr University Health Board (BCUHB), the assistant coroner for North Wales Kate Robertson said at no stage did any healthcare professional refer 27-year-old Leanne Marie Carroll to the service despite her anxiety and worsening obsessive compulsive disorder.

She died on June 29, 2024, “from the excessive consumption of prescribed and non-prescribed medications” having given birth to her first child about eight months earlier.

The inquest concluded health professionals including “midwives, health visitors and GPs” have “insufficient awareness” of the perinatal mental health service.

The inquest also heard Ms Carroll went to her GP for help and was referred to the community mental health team in March 2024 as well as an OCD support group.

However, the inquest concluded “death was due to misadventure where Leanne had not been referred to the perinatal mental health service either during her pregnancy or at any point up to her death”.

In her report, Robertson said: “Whilst attempts have been made to raise awareness and encourage direct referrals to the (perinatal mental health service), this remains inadequate. If health professionals are unaware of the service then mothers-to-be and mothers who require assistance will not be fully supported.”

The inquest heard there were no permanent perinatal health visitors working across all three health board areas which had just two temporary visitors and none in the eastern area of the board.

“By not having permanent perinatal health visitors across all three health board areas, then those who need to access support will suffer,” the report said.

It added no written records of any discussions and decisions were made, which meant they did not “form part of any health record for the patient which would be relevant to the overall management of the patient”.

Warning deaths could occur in future unless awareness of the perinatal mental health service improves, Robertson gave BCUHB until May 14 to outline what action it has taken or intends to take.