Chris and Joe (short for Joanne) Bingley were the definition of wedded bliss; they had a lovely home, they had a good monthly income and, most importantly of all, they were very much in love.
"It’s a statutory regulation for health visitors to assess for mental health problems — but Joe’s health visitor never asked the relevant questions. I know, because I’ve seen the questionnaire and none of the mental health questions have been ticked"
So it made sense that they began trying for children immediately. However, after two miscarriages in the space of two years, Joe was understandably unhappy.
Speaking to a British newspaper, Chris explained: "It was absolutely horrendous. Joe was crying all the time."
Tellingly, Joe’s medical records — which Chris accessed after her death — reveal that she was suffering from post-natal depression. Chris had no idea that women could develop this after a miscarriage, let alone that this was what his wife was suffering from.
"I knew she was very down, but her health visitor said we needed something to take her mind off it. We threw ourselves into gardening, and Joe seemed to improve."
A year later, the couple were overjoyed that Joe was pregnant again - and it proved to be a case of third time lucky. Their daughter Emily was born on 18th February 2010 and, at first, all seemed well.
Why weren't the right questions asked?
"There’s a ten per cent chance that any woman will get post-natal depression. For someone who has suffered before — like Joe following the miscarriages — there’s a 50 percent chance of having it again, so that alone should have set off alarm bells for those monitoring her pregnancy.
"It’s a statutory regulation for health visitors to assess for mental health problems — but Joe’s health visitor never asked the relevant questions. I know, because I’ve seen the questionnaire and none of the mental health questions have been ticked.
"Had they bothered to ask, they may have discovered that Joe’s mother, grandmother and aunt had all suffered from post-natal depression."
"Joe ended up being connected to a breast pump for most of the day. By the time I got there in the evening, her chest was battered and bruised. She looked as if she’d been in a fight and was in a desperate state"
The pressure of breastfeeding
On top of Joe's post-natal depression, the new mum was struggling under the pressures of breastfeeding; she was finding it difficult to nurse her daughter and the overwhelming mantra of 'breast is best' was making her more and more upset.
"Joe was struggling with breastfeeding, and she and Emily went back into hospital to get help. She stayed two nights and came out much happier.
"For a couple of weeks things seemed fine, but then Emily started screaming for hours on end at night. Joe wasn’t producing enough milk and Emily was hungry and losing weight.
"Joe was beside herself and returned to hospital... Her medical records say she was stressed and tearful. They suspected she was suffering from post-natal depression, but she was never referred for any kind of mental health help, only help with breastfeeding.
"The hospital seemed only to focus on the breastfeeding issue, not the mental health one. That’s the breastfeeding lobby for you.
"Joe ended up being connected to a breast pump for most of the day. By the time I got there in the evening, her chest was battered and bruised. She looked as if she’d been in a fight and was in a desperate state."
"I questioned why no one had suggested that she bottle-feed the baby. The midwife said that unless Joe or I specifically asked for advice on bottle-feeding, then they weren’t allowed to raise the subject.
"I asked if we could do bottle-feeding as well as breastfeeding — and that night, for the first time in ten days, Joe fed her baby in her arms with a bottle, and Emily fell asleep.
"We cried with relief. I don’t blame the midwives — they were fantastic. It’s the hospital and their policies that I blame, putting her physical health ahead of her mental health."
It was obvious that Joe wasn't coping...
A solution to the pressure of breastfeeding had been found but, when Joe came home four days later, it was obvious to Chris and her family that she still needed help.
"My parents came over three or four days a week. I was doing the midnight feed and the 4 am feed, then would go to work at 6.30am and come home around 7 pm and do whatever I could to help.
"I was scared as hell because she was talking not just about killing herself, but taking Emily with her"
"But it was obvious that Joe wasn’t coping, and things came to a head on the Easter weekend. On the Friday evening she collapsed on the floor and was crying inconsolably. It took me six hours to get her into bed, and I couldn’t get anything out of her other than uncontrollable weeping.
"The next morning she wouldn’t get out of bed. I encouraged her to go to her GP, who diagnosed post-natal depression and prescribed anti-depressants. She seemed to pick up a little, but it was only on the surface."
Things took an alarming turn just ten days before Joe died, when the new mother expressed a desire to kill herself - and take her baby daughter with her.
Chris explained: "I got a call from my sister-in-law. Joe had spoken to her about wanting to drive the car into a brick wall or over a cliff with Emily in it because she couldn’t see a way out.
"I was horrified. Joe and I went to the GP together the next day and I had to listen as she reeled off eight or nine ways she had considered killing herself: jumping off a building, taking tablets, using a knife …
"I was scared as hell because she was talking not just about killing herself, but taking Emily with her."
After a consultation with their GP, it was decided - much to the despair of husband Chris - that Joe would be treated at home, rather than taken to a Mother And Baby Psychiatric Unit.
And, from that point on, Joe's condition rapidly deteriorated.
Joe's condition deteriorates...
On the day before she died, Chris came home, just as a health visitor was leaving, to find his wife in floods of tears, pacing the room and saying "Emily doesn't need me… I'm useless".
He couldn’t understand how anyone could think she was fit to be cared for at home.
The next morning, at 7.30am, Chris woke to find that Joe was gone.
"I raced to the car and went to all the places she might have been — the park, the woods, up and down the roads. But she wasn’t anywhere.
"I came home and called the police, who sent someone round. And as the police officer was asking me to describe what Joe looked like, there was a newsflash on the radio that the trainline was closed and that someone had killed themselves. I knew then. You don’t want to believe it, but I knew.
"There was a newsflash on the radio that the trainline was closed and that someone had killed themselves. I knew then"
"Around an hour later, another policeman arrived and confirmed it. I went into complete meltdown. I collapsed. Joe’s mum turned up and I had to break the news to her, too."
After Chris had time to grieve, anger quickly settled in; why hadn't more been done to protect his wife? He began to seek answers, asking Dr Margaret Oates - a leading expert on post-natal depression - to conduct an investigation into his wife's death.
He soon discovered that Joe is not the first person to have been allowed to slip through the cracks.
This isn’t the first time it’s happened,’ Chris says.
"Yorkshire and Humberside is a failing NHS trust. There have been 19 previous independent investigations showing recurring failures in the treatment and care of patients with depression, like Joanne, though not all were post-natal.
"One of the directors of the crisis team even said to me: “Guidelines are only guidelines — we don’t need to follow them.”
The Joanne Bingley Memorial Trust
Chris has since given up his job to care for Emily full-time and has set up the Joanne Bingley Memorial Foundation, which is focusing on working towards de-stigmatising, educating and stimulating open discussion about postnatal depression.
"[I'm] determined to make a big bloody noise about the changes that need to be made for women suffering from post-natal depression."
Carol McKenna, chief officer of NHS Greater Huddersfield Clinical Commissioning Group (CCG), said: "Joanne’s death was a terrible tragedy and our sympathies go out to her family, who may well find things particularly difficult at this time of year.
"The circumstances surrounding Joanne’s death and the care and treatment she received were examined carefully by the coroner, who concluded that the dramatic decline in Joanne’s condition could not have been foreseen and there were no ongoing system failures.
"Since Joanne’s death, the local NHS has had close and frequent contact with Mr Bingley, who has been involved in work to devise and implement an action plan to strengthen services for women with severe post-natal depression."
SOME FACTS ON POST-NATAL DEPRESSION
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1 in 2 mums suffer from the Baby Blues
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15% of mums suffer from Postnatal Depression with their first child
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The normal risk factor is 3% of mums suffer from Severe Postnatal Depression with their first child
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The risk factor doubles to 6% with the first child, if there is a family history of postnatal depression or a history of mental illness,
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But the risk factor is 50%, if you suffered postnatal depression with your first child or have a previous history of mental illness, i.e. there is 1 in 2 chance of it recurring during or following pregnancy and you suffering severe postnatal depression
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1 in 500 suffer from Puerperal Psychosis and present a danger to themselves and their babies.
WHAT CAN YOU DO TO HELP?
"One of the most valuable things you can do is talk. It’s not a subject people want to talk openly about, or start a conversation about, but once someone else has presented them with the opportunity and given permission; then they feel free to speak – so go on talk and help someone."
The foundation needs corporate sponsors and volunteers to help mentor, fund raise and share their experiences online. It has also set up a petition to end the postcode lottery in perinatal healthcare.
Visit The Joanne Bingley Memorial Foundation to find out more