text: A mother who cradled her three-year-old son while she lay down in front of a train killed them both after finding out her husband had a second family in Egypt, an inquest has heard. Depressed Donna Oettinger, 41, had sought urgent psychiatric help in the months before she and her son Zaki died on train tracks in south London in March 2013, Croydon Coroner's Court heard. She had attempted to kill herself three months before the tragedy but was unable to receive the treatment recommended to her by doctors. Depressed Donna Oettinger, 41, had sought urgent psychiatric help in the months before she and her son Zaki died on train tracks in south London in March 2013, Croydon Coroner's Court heard.  Ms Oettinger had starting suffering depression after going to Zaki's father, Mohammed El Shaer, in Egypt, and discovering he had another family, an inquest heard . Her mental health had declined after discovering Zaki's father, an Egyptian national who could not travel to the UK, had a second family. She also was using cocaine regularly for six months and became convinced she had caused lasting damage and her anxiety worsened, the inquest heard. After visiting a psychiatrist in November Zaki was referred to social services, although the case was not reviewed. It meant the family and Zaki's safety was never assessed by the authority. A coroner has today ruled that doctors and social services in charge of looking after Ms Oettinger, made five 'significant' failures in the months before she and her young son lay in the path of a train in March 2012. But at the end of a three day inquest into their deaths, coroner Selena Lynch said that despite the family slipping under social services' radar 'nothing could have be done' to foresee the deaths. A coroner has ruled that doctors and social services in charge of looking after Ms Oettinger, made five 'significant' failures. But at the end of a three day inquest into their deaths, coroner Selena Lynch said that despite the family slipping under social services' radar 'nothing could have be done' to foresee the deaths . Ms Lynch concluded at the end of a three-day inquest that Ms Oettinger, who suffered chronic anxiety, unlawfully killed her son. She said: 'Donna Oettinger suffered from depression and had suicidal ideas. 'She had taken a significant overdose and had been seen by a number of professionals. 'The failures that I have identified, are in some respects quite significant, but can't be said to have caused or contributed to her death or Zaki's.' She said some of the measures now in place might have made a difference, but added: 'I think it is unlikely that Donna Oettinger would have been admitted to hospital or prevented from being alone with her child. 'Whether there might have been some improvement in her condition it is impossible to say.' The Coroner identified five separate failures by doctors and nurses at the South London and Maudsley NHS Foundation Trust and Croydon child protection services, who first came into contact with Ms Oettinger in late 2012. Her mental health had declined after discovering Zaki's father, an Egyptian national who could not travel to the UK, had a second family. She also was using cocaine regularly for six months and became convinced she had caused lasting damage and her anxiety worsened, the inquest heard . Ms Oettinger took an overdose of tablets while visiting a friend in Rotherham, South Yorkshire, on December 13 2012. A social worker in Rotherham advised doctors back in Croydon that she should be cared for by a Home Treatment Team (HTT) However the request was not met. After a follow up appointment back in London a few days later no-one liaised with Rotherham and Ms Oettinger was not reassessed. Doctors decided that instead of treating her at home she would benefit from her own 'care coordinator'. But a miscommunication meant this never happened. As a result the Trust failed to check on Ms Oettinger's condition when she missed a number of appointments in early 2013. The pair died around a month after her last missed appointment. Zaki's grandmother, Carol Oettinger, wept as the the Coroner recorded her daughter's death as suicide and the unlawful killing of Zaki. The coroner said: 'With respect to Donna Oettinger the only appropriate conclusion in this case is a matter of law I conclude to be one of suicide.' With respect to Zaki, she said: 'His mother was suffering from an anxiety disorder. The conclusion for Zaki, again as a matter of law, must be one of unlawful killing.' At the end of the hearing the Coroner pleaded that the horrific nature of Zaki's death and its link to Ms Oettinger's health didn't undo work to end stigma around mental illness. She said: 'It's important to recognise what happened to Donna and Zaki is very much out of the ordinary. '[But] I fear that the stigma of depression and mental illness will grow as a result of events such as these. 'The circumstances of these deaths are extremely upsetting, even for the experienced professionals who dealt with the events of March 22 2013. 'But they represent a tiny fraction of Donna and Zaki's lives. The mother and baby were seen lying on the tracks at a south London station, before their deaths . 'Zaki was a happy child who was very much loved by all those around him and wouldn't have had any time at all to understand what happened to him. 'The events that day do not define them as people. 'Don't let anyone tell you that suicide can always be prevented. They are wrong. Zaki and Donna deserve to be remembered as they were in happier and healthier times.' Speaking after the hearing, Bridget Hughes, Solicitor to the Oettinger family at Kingsley Napley LLP said: 'The Oettinger family is devastated by the loss of Donna and dear Zaki. No one could have fought harder than Donna's mother, Carol, to try and get the care her daughter desperately needed when she became ill. 'The Coroner has heard that there were serious shortcomings in care at the Croydon Mood Anxiety and Personality Disorder Team (MAP) which was managed by the South London & Maudsley NHS Foundation Trust. 'These shortcomings permeated through from community psychiatric nurse to consultant level. The service, fragmented in design, was chaotic in its implementation. 'In the family's view, this contributed to Donna's deepening despair and distress. '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.'
target: Donna and Zaki Oettinger died on train tracks in south London in 2013 .
  Inquest heard mother had taken an overdose three months earlier .
  She hoped for home psychiatric help, but was later told not available .
  A coroner has recorded she unlawfully killed her son and killed herself .
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