THE family of a Hereford mum whose body was found nine hours after being granted unescorted leave from a mental health hospital following her baby’s death are calling for lessons to be learned.

Kath Brace was allowed to leave the Mortimer Ward of the Stonebow Unit in Hereford where she had been sectioned under the Mental Health Act.

It was the third time the 32-year-old had been admitted and the second time she had been sectioned following the death of her and fiancé Dan Berry’s one-day-old son Otis, seven months earlier.


During that time, Ms Brace had taken several overdoses. This included once after previously being granted unsupervised leave from the hospital.

Her family said they had tried several times to raise concerns about her care and risk assessment but felt they were not listened to.

Following Ms Brace's death her loved ones instructed specialist lawyers at Irwin Mitchell to support them through an inquest and help establish answers.

Hereford Times: Kath Brace was just 32 when she diedKath Brace was just 32 when she died (Image: Irwin Mitchell)

Her family are now campaigning to improve maternity bereavement care for families, and mental health support in Herefordshire.

It comes after a Root Cause Analysis Report by Hereford and Worcestershire Health and Care NHS Trust, which runs the Stonebow Unit, found that aspects of the trust’s risk assessment and management policy were not applied in Ms Brace's care.

This included the trust's absence leave guidance not being fully applied and “significant risk-related information”, held by Ms Brace's loved ones, was not documented or included in a risk assessment and management of her care.

The jury found that evidence suggested shortcomings in how Ms Brace's risk was assessed when she was granted leave from the unit, and that the Trust’s communication with her family “could have been better”. 

Hereford Times: Kath Brace with her fiance Dan BerryKath Brace with her fiance Dan Berry (Image: Irwin Mitchell)

The jury returned a narrative conclusion, endorsing the findings of the Trust’s own Root Cause Analysis Report that those failings were contributory factors in the lead up to Ms Brace's death.

Aimee Brackfield, a specialist public law and human rights lawyer at Irwin Mitchell, said : “This is a truly tragic case which has left Kath’s family devastated.

“Understandably for the past 18 months they’ve had a number of questions and concerns about the care Kath received and the events leading up to her death.

“While nothing can make up for their loss, we’re pleased that we’ve at least been able to provide them with the answers they deserve.

“However, the inquest and the hospital trust’s own report have identified worrying issues in Kath’s care. It’s vital that lessons are learned to improve patient safety for others.”

A spokesperson for Herefordshire and Worcestershire Health and Care NHS Trust said: "Our deepest condolences go out to Kath’s family and loved ones. We fully accept the findings of the inquest and have conducted a full review in order to find out what has happened and if we can make changes to prevent deaths in the future."

If you are facing similar issues, you can get support from charity INQUEST (click here to visit) and baby loss and bereavement charity Sands (click here to visit), which both helped support Kath and her family.

If you are struggling, the Samaritans are also available 24 hours a day, 365 days a year. Call 116123 for free to speak to a Samaritan, whatever you are going through.