The suicide of a new mum who spoke of visions of her baby in the washing machine could not have been prevented, an inquest heard.
Rebecca Kruza, 39, from Folkestone was found hanged at her mother Lyn Richardson's home in Alkham last June.
After experiencing difficulties in conceiving, she he had been overjoyed when she and her partner Simon McPhee fell pregnant with a baby boy.
But the insurance underwriter experienced a traumatic 20-hour labour and then suffered difficulties in breastfeeding, thought to be due to the infant's tongue tie and colic.
She became sleep deprived and sought help, visiting her GP 12 times between March and May for depression and anxiety, before undergoing Cognitive Behavioural Therapy (CBT) and trialling various medications at different dosages.
But today, on the fourth day of her inquest at Sandwich Guildhall, area coroner for north east Kent Alan Blundson said the drugs she took had "minimal effect" of her condition.
Based on the extensive evidence he'd heard, he concluded that Ms Kruza had intended to take her life.
He said: "There was nothing that anybody could have reasonably done to prevent this tragic event."
Despite the verdict, her family still feel she was let down.
Jim Gladman, a solicitor in the clinical negligence department at Switalskis Solicitors who have been representing the family, gave the following statement on behalf of Rebecca’s mother Lyn Richardson and her sister Kathryn Kruza following the conclusion today:
“Our world fell apart on the day we lost Becky.
"She was a beautiful soul who loved life and had every reason to live. Her death was unexpected, shocking and tragically unnecessary.
“We know she was struggling with her mental health after having her baby but she was seeking help from various professionals. We feel that those professionals sadly let her down in her care by failing to liaise between themselves to safeguard Becky and her baby and to send vital referral documents in a timely manner or with urgency.
“Those failures have led to the loss of a much loved and needed daughter, sister, auntie, partner, mother and friend to many.
“Perinatal mother and baby services are in dire straits, and East Kent CCG is in special measures. Up until this year there were no mother and baby units in Kent, and now there are only four beds to serve a population of 1.5 million.
"This leaves mothers and babies struggling with perinatal conditions related to postnatal depression at the mercy of fragmented and inadequate treatment without safeguarding.
“We hoped that the findings of this inquest would help bring about change to see sufficient support given to women experiencing postnatal depression, so that this does not happen again to another mother and family.
“We welcome the coroner’s decision to make enquiries about the referral process to the mother and baby unit, the number of mother and baby unit places available in the area, and plans for increasing them.
“In our grief we, as a family, have anguished endlessly over what we might have done to save Becky.
"We ask that those practitioners involved in her care now reflect on the events leading up to her death and consider how they would act in a similar situation in future.”
Miss Kruza had planned to spend the day with her seven-and-a-half month-old son at her mum 's home in Cleaveland Road, Alkham on the day she died.
The same evening they were due to attend a doctor's appointment to discuss Ms Kruza's medication.
Ms Richardson described her daughter behaviour that day as distracted, edgy, and quieter than usual.
But she put it down to her feelings of apprehension about the impending appointment.
Only two months before in April 2017, Ms Kruza told her mother that she was having dark thoughts. She also spoke of a vision of seeing the baby in a washing machine.
From May she had been attending CBT sessions and it was recorded that during the course of the treatment her symptoms of depression worsened to severe.
On June 16 she admitted to a doctor thoughts of being dead but had no intentions to take her life. She also told an acupuncturist that she "couldn't go on".
Dr Agnieszka Klimowicz, a private psychiatrist with The Priory Group had prescribed Ms Kruza the antidepressant Mirtazapine to help her sleep. The coroner noted the "disconnect" between the private sector and NHS professionals.
Key parts of the hearing focused on whether the new mum had been told she could reduce her medication's if she felt it wasn't having the desired effect.
Ms Kruza's family were particularly concerned by this as a side effect of Mirtazapine can increase suicidal ideation.
Dr Klimowicz told the hearing she had indeed issued the advice to reduce the dosage from 30mg to 15mg if she felt it necessary.
But this advise was not documented in her notes or letter, prompting the family’s advocate, Craig Carr to test her on her account. Mr Blusdon later concluded that Dr Klimowicz's evidence was "unreliable".
Dr Klimowicz also recommended that Ms Kruza was closely monitored by way of weekly appointments and ensured she had the numbers of the crisis team if she felt unsafe.
Nevertheless, Ms Kruza told her mum she was going for a nap, leaving her son in his grandmother's safe hands, and was later found hanged.
Mr Blunsdon said: "I'm satisfied that when Rebecca arrived at her mother's house on June 14, she had then or sometime around then worked out a plan that she would take her own life."
He said he would make enquiries about the referral process to the mother and baby unit, the number of mother and baby unit places available in the the county, and plans for increasing them.
For confidential support on an emotional issue, call Samaritans on 116 123 at any time.