Paragraphs 7 & 8 read: "On August 30 last year , she went with her son and daughter to Southall station, west London, where she told a railway worker: 'I'm taking my children to see the fast trains.'"
"She clutched Aman Raj in her arms and held Simran's hand as she leapt in front of a speeding Heathrow Express train. Her husband Manjit arrived at the scene moments too late to save his family."
Paragraph 13 reads: "In July 2005, anti-depressants prescribed to Mrs Sidhu were changed repeatedly, without explanation. A social worker appointed as "care co-ordinator", responsible for Mrs Sidhu's medical and social needs, had little knowledge of anti-depressant medication."
Tragic mistakes in case of mother who jumped under train
A mother who flung herself under a train with her two young children had told doctors and social workers that she could not cope, a report has revealed.
Navjeet Sidhu, 27, was being treated for depression when she killed herself, her daughter Simran, five, and her son Aman Raj, 23 months. Yet, despite her warnings, professionals in charge of her care failed to discuss it or draw up a care plan, as recommended in NHS guidelines.
A secret inquiry into the lapses, conducted by West London Mental Health Trust, identified 11 areas "where it was felt that the case could have been managed differently, or where practice could and should be improved".
The inquiry report, completed in March and released to The Sunday Telegraph under the Freedom of Information Act, provides the first confirmation that Mrs Sidhu was treated for depression.
While it concludes that the tragedy could not have been predicted, it also highlights a series of mistakes which affected the quality of care.
It says that in the last six weeks of her life, "there was no formal case discussion [between mental health doctors, social services and the primary care team], although there were concerns about Mrs Sidhu's mental state and her own concerns about her ability to cope with the children".
On August 30 last year, she went with her son and daughter to Southall station, west London, where she told a railway worker: "I'm taking my children to see the fast trains."
She clutched Aman Raj in her arms and held Simran's hand as she leapt in front of a speeding Heathrow Express train. Her husband Manjit arrived at the scene moments too late to save his family.
In a further tragic twist, Mrs Sidhu's mother, Satwant Kaur Soghi, 56, took her own life at the same spot in February. An inquest into all four deaths is expected next month.
Unhappy in her arranged marriage, Mrs Sidhu was first treated for depression in 2002 and came back for further help in 2004. She underwent counselling and was advised to seek marriage guidance from Relate, although there is no evidence that she did so. She returned for treatment in 2005, three months before her death.
In May 2005, a senior hospital doctor took 11 days to refer the case to social services. The delay was described by the inquiry panel, whose chairman was Trevor Farmer, the trust's associate director of local services, as "seemingly inappropriate".
The same doctor - who is not named in the released version of the report - left "fairly illegible" entries in the patient's notes and wrongly recorded Aman Raj's age as 18 years, instead of 18 months. He was also criticised for using a risk-assessment system he had developed himself and with which his colleagues were not familiar.
In July 2005, anti-depressants prescribed to Mrs Sidhu were changed repeatedly, without explanation. A social worker appointed as "care co-ordinator", responsible for Mrs Sidhu's medical and social needs, had little knowledge of anti-depressant medication.
The social worker was unsupervised, because her supervisor only worked during school term times and no arrangement had been made to provide cover.
Sophie Corlett, the policy director of Mind, the mental health charity, said that there had been "serious" lapses in Mrs Sidhu's care, of a kind all too common in the overstretched mental health system.
She added: "People's health deteriorates when they are not getting the care they should be getting. It's not often that it leads to something so extreme. Only when it leads to a death do people seem to take it seriously."
Himmat Singh Sohi, a family friend and the president of Southall's Sikh temple, called for a further inquiry into Mrs Sidhu's treatment. He said: "The NHS should take more care, so that other families do not have to go through the same ordeal."
|23 February 2006: For six months she grieved for her daughter and grandchildren. Then she killed herself on the same rail line where they died|
|2 September 2005: I'm taking children to see trains, said suicide leap mother|