The missed opportunities to help an Edinburgh mum who went on to suffocate her baby
Erin Sutherland was suffering from severe post-natal depression when she took the life of nine-month old Chloe.
A watchdog's report into the care of a mother who suffocated her baby in Edinburgh says opportunities were missed to offer her mental health treatment.
37-year-old Erin Sutherland was suffering from severe post-natal depression when she took the life of nine-month old Chloe last year.
She'd been turned down for support because her daughter was over six months.
The Mental Welfare Commission found key information, including her history of postnatal depression when she thought of killing her older children, was "lost" in the GP system.
Erin Sutherland, 37, pleaded guilty on the grounds of diminished responsibility to culpable homicide following the death of Chloe on February 3, 2015.
She was sentenced to three years in jail, which the judge said would only take place if she was deemed fit to leave inpatient psychiatric treatment during that time.
The High Court in Edinburgh heard she had "severe" postnatal depression when she killed Chloe at her home in Parkhead View but was turned down for support by a perinatal mental health team since her daughter was older than six months.
Mental health minister Jamie Hepburn instructed the Mental Welfare Commission to carry out an investigation into her care prior to her baby's death.
The commission found there were "missed opportunities for referral to postnatal and adult mental health services", and criticised the "very limited communication" between the organisations involved in her treatment.
The report said a pre-birth planning meeting would have highlighted the history, risks and appropriate management plan to all involved and might have reduced the risk of this information being "lost" within the GP system.
The commission has made 14 recommendations - nine for all joint health and social care bodies in Scotland which include ensuring there are clear pathways for access to perinatal mental health experts and urgent assessment by mental health teams as appropriate.
A further recommendation is that areas with perinatal mental health services should ensure women with histories of postnatal depression can be referred until their child is one. This recommendation is also included among the three for the specific health board involved.
The Scottish Government is recommended to prioritise establishing a national managed clinical network for perinatal mental health.
THe commission's executive director Alison Thomson said: "This is a deeply tragic case. We have not found any single failing or omission which caused or directly contributed to the death.
"However, during the course of our investigation we found several aspects of Ms OP's care and treatment that should have been better."