A series of failings contributed to the death of a mentally ill woman who jumped off a cliff while holding her newborn baby, a coroner has ruled.
Charlotte Bevan walked out of St Michael's Hospital in Bristol on a cold December night last year with her four-day-old daughter Zaani Tiana - with just a thin pair of slippers on her feet.
Zaani and her mother, who had a long history of mental illness and had been sectioned four times, were found dead at the bottom of Avon Gorge, close to Clifton Suspension Bridge.
The double inquest heard that in the weeks running up to the deaths 30-year-old Ms Bevan had stopped taking her anti-psychotic medication.
Coroner Maria Voisin said there had been a "chain of failings" in the run-up to the tragedy.
Delivering a narrative conclusion, she said officials should have organised a multi-disciplinary meeting, and that a proper care plan post-birth had not been put in place.
Mrs Voisin also said she would be making a Prevention of Further Deaths Order - and would write to NHS England about the provisions to mental health services for pregnant women.
Mrs Voisin said: "There was a failure ... to develop a therapeutic relationship with Charlotte during this high risk period and to involve a psychiatrist in her care and treatment.
"There was a failure to a hold a multi-disciplinary team meeting to develop a care plan for Charlotte at all, but especially when concerns were raised during her pregnancy and when it was known she had stopped taking risperidone.
"Once Charlotte gave birth her mental health began to deteriorate and she suffered a relapse which should have been diagnosed and managed appropriately.
"That failure was contributed by the fact there was no care plan.
"Charlotte was very unwell when she left the hospital unnoticed with her daughter and went to the cliff top at Avon Gorge.
"Her intention is unclear but she was found dead at the base of the cliff.
"That chain of failures contributed to Charlotte's death.
"Zaani's death was contributed to by a chain of failures in her mother's care."
Avon Coroner's Court heard that Ms Bevan's mental problems started when she was 15 following the sudden death of her father from a brain tumour.
The hearing was also told she later began experimenting with drugs and suffered a drug-induced psychosis while at a music festival before being diagnosed with schizophrenia.
As part of her condition, she often heard voices and believed they were real.
In 2011, she was found walking barefoot down the M32 with the intention of killing herself and two years ago she seriously self-harmed after suddenly stopping taking risperidone, the inquest heard.
Her inquest was told that in her medical notes a list of relapse indicators included stopping medication, poor hygiene and no sleep.
Ms Bevan became pregnant in the early part of last year - and her initial care was later deemed "as a good standard" by an independent expert.
However, after being transferred to the Bristol North Recovery Team she was assigned a care co-ordinator who only worked on a part-time basis and had no experience of working with complex, mentally ill patients.
In a report, former associate dean of the Royal College of Psychiatrists Laurence Mynors-Wallis said the care co-ordinator, Deborah Evans, lacked support.
And Dr Mynors-Wallis said Ms Bevan's care plan was "not watertight" as it should have been and there were a number of warning signs that Ms Bevan's case should have been discussed at a multi-disciplinary meeting.
"She was a high-risk patient who had no proper support for her care at a time when she should have had a face-to-face meeting with a doctor and a psychiatrist," he added.
In late October Ms Bevan stopped taking risperidone over fears she may not be able to breastfeed - and midwives raised concerns about her behaviour.
But after giving birth to Zaani on November 28, Ms Bevan was described as being a doting mother and doctors said she had bonded well with her baby.
However, as the hours continued her behaviour became increasingly erratic and she became paranoid.
On the morning before Ms Bevan disappeared, fetal medicine consultant Dr Rachel Liebling said there had been a notable change in her patient's appearance and she was becoming suspicious of others and had only slept for an hour.
"On Tuesday morning ... I was more worried. The room smelt strongly of old blood and she looked unkempt," she previously told the inquest.
However, Dr Liebling added she felt that Ms Bevan's deterioration had not been "rapid" enough to assign a mental health nurse. The inquest heard such a person would have been likely to have sat outside the door of Ms Bevan's room when they were not providing one-to-one care.
In his report, Dr Mynors-Wallis said it was likely nursing staff at St Michael's may not have realised how unwell Ms Bevan was becoming and normalised her behaviour to that of "an exhausted mother" rather than having a relapse.
Six minutes after her boyfriend, and father of her child, Pascal Malbrouck visited Ms Bevan she was captured on CCTV walking out of the maternity unit holding her baby.
Around half an hour later, she was seen passing a security camera while walking towards Clifton Suspension Bridge.
Her body was later found in Avon Gorge on December 3, while Zaani's body was found the following day.
But despite a number of failings, coroner Mrs Voisin said there was no way anyone could have predicted that Ms Bevan would suddenly leave the maternity ward before jumping into Avon Gorge.
Previously, the inquest had heard that despite a deterioration in her condition Ms Bevan was complying with doctors and on the day she vanished had started taking her medication again - although evidence was given that the drug can take weeks to work properly.
Following the conclusion of the eight-day inquest, health bosses offered their deepest condolences to Ms Bevan's family.
A joint statement by NHS England, Bristol Clinical Commissioning Group, University Hospitals Bristol Foundation Trust and Avon and Wiltshire Mental Health Partnership NHS Trust said: "The Coroner has heard that many staff from our mental health and maternity services did their very best to support and care for Charlotte before and during her pregnancy and after Zaani's birth.
"However, as the coroner has concluded today, there was a chain of failures which contributed to their deaths.
"As a health community, we will act on the coroner's findings to ensure that mothers with mental health needs, and their babies, have access to the services and professionals they need to keep them and their babies safe during pregnancy, and following the birth.
"While there is more to do, the local NHS has already made changes to improve the way in which mothers with mental health needs are cared for and we will now consider the coroner's conclusions and recommendations very carefully to see what other actions we can take to improve services for vulnerable mothers, their babies and their wider family."
Avon and Wiltshire Mental Health Partnership NHS Trust also said it would carefully look at the coroner's conclusions.
A spokesman said: "We will review the areas of care offered to Charlotte in an effort to ensure that any recommended improvements are made."
Speaking afterwards, Ms Bevan's mother Rachel Fortune called for improvements to be made in services for pregnant women with mental health issues.
In a short statement outside the coroner's court in Flax Bourton, she said: "This has been a very difficult time for everyone who knew Charlotte and Zaani. Following from what has been heard in evidence, we would urge commissioners to fund a dedicated perinatal mental health service."