Mental health staff and social services committed multiple failures but could not be held responsible for the deaths of a mother and child who laid in the path of a train in Riddlesdown, a coroner has ruled.

Doctors, nurses and social workers did not properly assess the risk of harm to Donna Oettinger, 41, and her three-year-old son Zaki, but probably could not have prevented their deaths, South London Coroner's Court was told today.

Miss Oettinger, described as a loving mother who suffered from "crippling anxiety" and panic attacks, took the toddler to Riddlesdown station and laid on the rails cradling him in her arms on March 22, 2013.

Selena Lynch, senior coroner for Croydon, highlighted five "significant" failures by South London and Maudsley (SLAM) NHS Trust and Croydon Council in her conclusion this morning.

Those included doctors not reassessing Miss Oettinger's suicide risk after she took a near-fatal overdose in December 2012 and social workers never visiting Zaki after his mother's psychiatrist flagged up concerns about him.

But the coroner said: "There was no clue of the horrors that were to follow.

"No one could have foreseen the events of March 22, not the healthcare professionals and certainly not the family."

Ms Lynch also urged for the deaths not to overshadow Miss Oettinger and Zaki's previously happy and loving relationship.

Directly addressing Miss Oettinger's devastated mother Carol in court, the coroner said: "What happened that day represents just a fraction of their lives. Zaki was a happy and bubbly child.

"He was very well-loved and wouldn't have had time to understand what was happening to him.

"Those 'what if?' questions are futile and to continue to ask 'what if?' will keep you under a shadow. Zaki and Donna deserve to be remembered as they were in very happy and healthy times."

Your Local Guardian:

Miss Oettinger and Zaki were pronounced dead at Riddlesdown station

During a two-day inquest, the court heard SLAM had treated Miss Oettinger for depression and anxiety as a community patient for four months before her death.

She had been plagued by fears that a six-month spell of cocaine use had damaged her brain and devastated to learn that Mohamed El Shaer, Zaki's father, had a secret wife and child in his native Egypt.

She was prescribed anti-depressants and placed on a waiting list for cognitive behavioural therapy, but her mental health continued to deteriorate and she became "convinced she would never get better".

In the five months before her death, she twice held a neck to her throat and threatened to kill herself and, on a separate occasion, had to be physically restrained from jumping in front of a train at East Croydon.

In December 2012, while visiting a friend in Rotherham, she took an overdose of medication in a suicide bid.

Her life was only saved because her friend checked her bedroom and found her.

The court heard Paul Willison, a community mental health worker who assessed Miss Oettinger in Rotherham after she left intensive care, recommended to SLAM she be offered urgent and intensive home treatment.

But a SLAM nurse who saw Miss Oettinger in the following days failed to speak to Mr Willison and doctors on the Croydon Mood, Anxiety and Personality Disorder team, which treated her, never reassessed her suicide risk.

The nurse, Elizabeth Oduntan, said: "'It's something I would usually do, but I can't remember why I didn't contact Rotherham." Asked if she should have, she replied: "Yes, if I had the time."

The coroner said: "This was a failure of some magnitude, compounded and continued by the rest of the team for some weeks after. They failed to do another risk assessment and did not report the overdose to children's services."

Ms Lynch criticised SLAM for its failure to arrange a care co-ordinator for Miss Oettinger or to contact her when she did not turn up to an appointment, which it is thought she never received notice of.

She also highlighted the failure of Croydon Council's Children in Need service to act upon a referral from Dr Hermanth Rao, Miss Oettinger's psychiatrist, over concerns about how her mental illness may be affecting him.

The coroner said: "We know effectively it was ignored. Nothing happened. If a social worker had gone to see the family, who knows what might have happened."

But Ms Lynch added: "The failures can't be said to have caused or contributed to her death or that of Zaki. Some or all of the actions that were not taken might have made a difference but that is purely speculative."

Your Local Guardian: Donna and Zaki Oettinger

Miss Oettinger had been in a seven-year relationship with Zaki's father

She recorded a conclusion of suicide for Miss Oettinger's death, who she said had "diminished responsibility" but sufficient capacity to understand her actions. She recorded Zaki's death as unlawful killing.

The coroner also urged that the deaths should not worsen the stigma of mental illness. She said: "It is important to recognise that what happened to Donna and Zaki is very much out of the ordinary.

"If stigmatisation was to grow as as a result of this case, it would be a tragedy."

Miss Oettinger's family accepted the coroner's conclusions but said they remained "deeply concerned" about shortcomings in the mental health sector, in particular the two-year waiting list for the Croydon Integrated Psychological Therapies Service, to which doctors felt she would be best suited.

Bridget Hughes, the family's solicitor, said: "This cannot be right. The family calls for better funding for this service in particular.

"Nothing will bring Donna and Zaki Oettinger back, but it is hoped that something may be learned from this family’s experiences given the detailed investigation that has since taken place."

A statement issued by SLAM this afternoon said: "We would like to offer our sincere condolences to the family of Donna and Zaki Oettinger.

"A full investigation was carried out following her death and a number of significant internal changes have been made within the community mental health teams at SLaM.

"The IAPT (Improving Access to Psychological Therapies) service has been recommissioned and waiting times have been reduced from six months to approximately four weeks.

"Additional roles have been developed to ensure mental health services work more closely with children and families services and further."

A spokesman for Croydon Council said: "The council would like to express its sincere condolences to the family at this difficult time. Lessons have been learned as a result of this tragic case, and since 2013, we have carried out a thorough review of how we process referrals.

"While we now await the publication of the serious case review, it would be inappropriate to comment any further at this time."

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