We trusted the NHS to care for my wife… they failed us: Grieving husband of mother-of-two who took her own life reveals blunders that led to tragedy

Anyone who knew Abigail Menoret could see she was a devoted mother who adored her two young sons.

‘She was so thoughtful – an incredibly caring person,’ her husband Francois-Marie recalls. ‘It could be just a Thursday at work, or a day back at school, but she’d find some way to make it special. She was a great mother to our boys.’

Those memories are, today, all the more precious for Francois-Marie. Last year, following the birth of their second child, Abigail took her own life.

At the time, the 34-year-old was an inpatient at an NHS psychiatric hospital, receiving treatment for postpartum psychosis.

The serious mental health condition – not to be confused with postnatal depression – affects up to 1,200 women every year in the UK. It causes intense delusions, hallucinations and confusion that come on rapidly in the weeks and months after childbirth.

Abigail had already made several suicide attempts the previous year. And Francois-Marie had raised renewed concerns to staff about her safety in the weeks before her death at Prospect Park Hospital in Reading, Berkshire.

But instead of monitoring her more closely, she was given greater freedom. On September 10 she was able to travel alone to the family’s home in Maidenhead – knowing Francois-Marie and their sons were staying with relatives in France – where she took her own life.

At an inquest into her death, a coroner heard evidence of ‘multiple failures’ in Abigail’s care. And they make for troubling reading.

First, her GP failed to identify the severity of her condition, which is deemed a medical emergency requiring referral to mental health specialists within four hours. This delay in treatment resulted in a dramatic worsening of her symptoms.

Once she was in psychiatric care, however, she saw ‘six or seven’ consultants over 12 months, and all took different approaches to her medication and treatment.

The inquest heard evidence of multiple failings in communication between the hospital and Abigail’s family. And despite the risk she posed to herself, and concerns raised by her family, she was allowed unescorted leave.

Francois-Marie, 35, says: ‘Throughout the 12 months Abigail spent in psychiatric care, I felt like I was the only one who knew how to keep her safe. I almost felt like the lone voice of reason.

‘From early on in her treatment, she said, ‘You’ll never stop me killing myself.’ She always said she’d do it. We had to believe the treatment would get through to her and that we could trust the NHS to care for her, but we were wrong. They failed us.

‘What happened to Abigail is unacceptable and it should not be allowed to happen to any other family.’

Abigail and Francois-Marie both worked in marketing and had their first son in December 2019

Early identification of postpartum psychosis is crucial because, unlike other psychiatric conditions, it can escalate rapidly. In rare cases the delusions are so intense the women pose a risk to their children. They may need a range of treatments, including medication and psychotherapy.

It’s not clear how many cases of maternal suicides are linked to postpartum psychosis, however the number of new mums who take their own lives is rising. It represents a ‘troubling trend’, according to the most recent report from Confidential Enquiry into Maternal Deaths, a group which records and investigates maternal deaths in the UK and Ireland.

Dr Jessica Heron, chief executive of the charity Action On Postpartum Psychosis, says: ‘All suicides due to this condition are preventable. It isn’t helpful that we’re withdrawing more face-to-face routine appointments with health visitors, which are really important in picking up when something isn’t quite right.

‘We also need to train frontline health professionals, including GPs and midwives, in postpartum psychosis awareness, and we need to support our recovering women better.’

Abigail and Francois-Marie both worked in marketing and had their first son in December 2019. She suffered from ‘a bit of baby blues’, Francois-Marie recalls, adding: ‘She’d get tearful and question her mothering abilities, but after some counselling it resolved itself.’

There is thought to be a slightly increased risk of postpartum psychosis in women who have previously had postnatal depression, but it was never mentioned to the couple and Francois-Marie had no concerns after Abigail gave birth to their second son in January 2022.

Abigail eventually she asked her GP for help and was referred to the perinatal mental health team and the trauma team for assessment

Initially everything was fine, but by April Abigail was having problems sleeping, and told Francois-Marie that ‘racing thoughts’ were keeping her awake.

After becoming increasingly agitated and exhausted, eventually she asked her GP for help and was referred to the perinatal mental health team and the trauma team for assessment.

But by August she had still not started any treatment.

‘She got to a point where she was just constantly crying. She had been having some delusions which were quite specific to her childhood and they became bigger. We reduced our world to cope, just focusing on the basics – eating, sleeping and looking after the boys.’

In late August she walked out on Francois-Marie, taking the boys with her.

He says: ‘The delusions had extended to being about me. It had been escalating by the hour. Ultimately she saw me as a danger to her and the boys. It was heartbreaking, and terrifying.’

After leaving the family home, Abigail went to a friend’s house. Realising she was unwell, her friends took her to A&E. It was there she first tried to take her own life and, as a result, was admitted to psychiatric care at the privately run Cygnet Hospital in Harrow, north-west London.

‘The medical team couldn’t tell me anything because Abi didn’t want anything shared with me,’ says Francois-Marie. ‘They also wrongly assumed her symptoms had recently started, which meant they didn’t consider postpartum psychosis.’

Little is known about why postpartum psychosis develops. Most cases emerge within days of birth, but it can come on more gradually.

Unlike postnatal depression, it is not linked to social or financial circumstances or poor support networks.

In November, Abigail was moved to a mother-and-baby unit in north-west London with her young son but, despite a second suicide attempt at Cygnet Hospital, within days of her arrival staff let her out unsupervised.

‘As soon as she left the unit, she tried to take her own life the first opportunity she had. They apologised for misreading the situation. They recognised it was a big mistake.’

Central and North West London NHS Foundation Trust, which runs the unit, said it had ‘strengthened’ its processes for agreeing leave since the incident.

Abigail had appeared to be getting better, but in April 2023 she made another attempt on her life.

‘She had left notes behind, including letters for the boys for the next 20 birthdays. Essentially she admitted she’d been fooling everyone all that time and there was nothing that was going to stop her ending her life.

‘That was a massive step back. It felt like the last eight months had been for nothing.’

Abigail was moved to Prospect Park Hospital in Reading – a general adult psychiatric hospital. But it was ‘chaotic’, Francois-Marie says, adding: ‘We’d been going out into the grounds for a month and a half before it emerged she wasn’t meant to leave the ward. There were no rigorous processes, no one checking what was supposed to be happening. They were taking Abi on face value and not doing a proper assessment, even though we knew she could mask how she was feeling to get what she wanted.’

Prospect Park, like the other hospitals, offered little continuity of care, and she saw several different consultants.

Francois-Marie says: ‘None had enough time with her to develop a relationship and understand what was really going on.’ On multiple occasions he missed meetings about Abigail’s care because they had failed to invite him.

And, most importantly, he raised concerns about the potential risk to Abigail over his plans to take the boys to visit family in France.

‘She’d been pushing for me to go, and that in itself was a red flag,’ he says. ‘I had a meeting with the responsible clinician, and they said it would be taken into account.’

Instead, Abigail was given more freedom.

On September 10, while her family were away, she was permitted an hour of unsupervised leave. She took a taxi home and ended her life.

Francois-Marie was notified she was missing after she failed to return on time.

‘I rang her repeatedly,’ he says. ‘I called our neighbours and asked them to check the house – I was still on the phone with them when they found her. This time, there was no note.’

Abigail was moved to Prospect Park Hospital in Reading – a general adult psychiatric hospital (pictured)

The family were represented at the inquest by Leigh Day solicitor Frankie Rhodes. She said: ‘Failings were highlighted throughout the evidence, but the coroner explicitly said the jury could not attribute them to Abigail’s cause of death. Yet from the beginning she was bounced around different services, which meant her condition got worse and worse.

‘She was desperately trying to get help. It’s still not really clear what the Trust is going to do in future to avoid similar tragic outcomes.’

Francois-Marie is adamant that further efforts are needed to protect women with postpartum psychosis – from better recognition of the condition by GPs to more consistent and robust care by mental health trusts.

‘I know we can’t bring her back,’ he says, ‘but there are changes we can make to the whole system to prevent anyone going through the same thing – and to make sure they are safer than Abi was.’

If you, or someone close to you, is experiencing postpartum psychosis, talk to a midwife, GP, health visitor or dial 111 – if there is an immediate threat to life, call 999. You can also call the Samaritans on 116123.

For support and advice, visit Action On Postpartum Psychosis’ website – app-network.org.