Recurring concern

Unreliable specialist perinatal mental-health service provision

First to latest report 23 May 2014 — 13 Oct 2025

Reports that mention this concern
4
Times this concern has been raised
6
Stated actions linked to this concern
9

What this concern includes

Includes failures in the dedicated specialist perinatal mental-health service, including staffing and capacity, urgent visits, specialist assessment, referral arrangements and provision of appropriate care for women and their babies where these directly impair service reliability.

What is not included
  • Excludes generic mental-health service capacity, staffing or access deficiencies without a specialist perinatal mental-health connection.
  • Excludes failures in general community mental-health services unless they directly concern the specialist perinatal service's referral, support or urgent-care interface.
  • Excludes maternity, neonatal or obstetric care failures where specialist perinatal mental-health service provision is not the deficient condition.
  • Excludes failures occurring after appropriate specialist perinatal mental-health care has been reliably provided, unless the service-provision process itself remains deficient.

Reports and published responses 4 reports

See individual reports that have raised this concern, and the actions taken in response

  1. Hampshire, Portsmouth and Southampton

    AI-generated summary

    Abigail Eleanor Ann Jelly · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Abigail Eleanor Ann Jelly, a 34-year-old mother of two experiencing post-natal depression, died on 12 November 2024 after intentionally harming herself, causing fatal blood loss. The report identified concerns about inadequate perinatal mental-health training, limits on urgent specialist visits, insufficient engagement with her parents, and wider failings in professional curiosity, escalation, decision-making and risk assessment.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Unavailability of urgent visits by the specialist perinatal team

    Wider context from the report

    “The Perinatal Team are expert in assisting patients such as Abigail. However, they are not commissioned to complete urgent visits and must refer patients to the community mental health teams who lack the specialist training and who are likely, due to the reasons outlined above, unaware of the perinatal red flags. I am concerned that women in need will not receive the appropriate mental health care and that there is a risk of future deaths. ”

    Source location

    Abigail Eleanor Ann Jelly · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    The Perinatal Team is not commissioned to complete urgent visits and must refer patients to Community Mental Health Teams.

    Verbatim wording from the response

    “As you state, the Perinatal Team are expert in assessing patients such as Abigail. However, they are not commissioned to complete urgent visits and must refer patients to the Community Mental Health Teams. This is an arrangement that is common in most parts of the country. The important issue is the drawing on specialist perinatal expertise when needed, through very close working between the Crisis Resolution Home Treatment Teams (CRHTs) and the specialist Perinatal Team.”

    Source location

    Response from Hampshire and Isle of Wight Healthcare
    Page 1 · response
    Published 14 October 2025

    Open published response

  2. North Wales (East and Central)

    AI-generated summary

    Leanne Marie Carroll · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Leanne Marie Carroll, aged 27, died on 29 June 2024 after excessive consumption of prescribed and non-prescribed medications. She had experienced anxiety and deteriorating OCD following the birth of her first child and had been referred to mental health support, but not to the Perinatal Mental Health Service. The report raises concerns about inadequate awareness and staffing of that service and the lack of written records of Single Point of Access discussions and decisions.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Insufficient awareness of the Perinatal Mental Health Service among health professionals

    Wider context from the report

    “1. The Perinatal Mental Health Service was established across the Health Board around 5 years ago. It was accepted in evidence that there is insufficient awareness of the Service by health professionals including midwives, health visitors and GP’s. Whilst attempts have been made to raise awareness and encourage direct referrals to the Service (rather than via the Single Point of Access) this remains inadequate. If health professionals are unaware of the Service then mothers-to-be and mothers who require assistance will not be fully supported. ”

    Source location

    Leanne Marie Carroll · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Inadequate staffing of the Perinatal Mental Health Service

    Wider context from the report

    “4. I am concerned that deaths will occur into the future as awareness of the Service is not at all adequate to health professionals, the Service is not adequately staffed and records of meetings and decisions made in the Single Point of Access are not documented. ”

    Source location

    Leanne Marie Carroll · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Deliver and disseminate perinatal mental health awareness training across relevant Health Board teams.

    Verbatim wording from the response

    “Currently, mandatory perinatal mental health training is delivered to midwifery colleagues, student health visitors, obstetricians and gynaecologists, Community Mental Health Teams (CMHT’s) and Home Treatment Teams (HTT). As extended members of the team, specialist perinatal health visitors provide training relating to the “Ask, Assess and Act Assessment Framework” whilst promoting the role of the Perinatal Mental Health Service. In addition, Institute of Health Visiting perinatal training is offered six times per year to the Health Visiting Teams, and members of the Mental Health Perinatal Team have undertaken train the trainer modules to disseminate this training further across the Health Board.”

    Source location

    Response from BCUHB
    Page 1 · response
    Published 26 March 2025

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Integrate perinatal mental health awareness training across the acute mental health care pathway, including inpatient services.

    Verbatim wording from the response

    “Moving forwards, the long-term plan is to integrate perinatal mental health training across the whole of the mental health acute care pathway to include in-patient services in addition to HTT, Psychiatric Liaison, and CMHTs. This is being processed through the Mental Health and Learning Disabilities Training and Development Group and it is expected that the perinatal awareness training will be fully ratified at the end of July 2025.”

    Source location

    Response from BCUHB
    Page 2 · response
    Published 26 March 2025

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Develop perinatal mental health training for North Wales GPs covering illness recognition, assessment, support and referral.

    Verbatim wording from the response

    “Alongside this, the Health Board’s Perinatal Consultant Psychiatrist, ████████, is leading on the development of training for GPs across North Wales. This training intends to increase knowledge of perinatal mental illness and the role and referral process for access to perinatal mental health assessment and support. ████████ is in the process of liaising with GP colleagues with the aim of having initial training dates agreed by the beginning of September 2025.”

    Source location

    Response from BCUHB
    Page 2 · response
    Published 26 March 2025

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Review Health Visiting Services and wider perinatal provision to identify access gaps and make recommendations.

    Verbatim wording from the response

    “With regard to Perinatal Health Visitors and the equity of access across North Wales, I can confirm that a review of Health Visiting Services at the Health Board that relate to wider perinatal services will be undertaken to determine whether gaps in service are evident. This will include consideration of access to specialist Perinatal Mental Health Services and the Mental Health Perinatal Service Manager will be involved within this process. An action plan will be developed to address any identified areas of need in order to ensure that there is equitable and appropriate access to perinatal services. Consideration will be given to the role and function of the Perinatal Health Visitor posts currently in place in the central and west areas on a temporary basis. This review will be undertaken with recommendations for the Health Board to consider by the end of July 2025.”

    Source location

    Response from BCUHB
    Page 2 · response
    Published 26 March 2025

    Open published response

  3. East London

    AI-generated summary

    Ms Aleksandra Markowska · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Ms Aleksandra Markowska was found unresponsive on 30 September 2021 after jumping from 21 Gardner Close, and her death was pronounced at the scene. The inquest concluded that she took her own life while suffering from pregnancy-related depression and anxiety, after seeking help but not receiving a review by a perinatal psychiatrist. The principal concern was the lack of direct access for BPAS patients experiencing pregnancy-related mental health decline to perinatal psychiatry teams.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Lack of direct access for BPAS patients with pregnancy-related mental health decline to perinatal psychiatry teams

    Wider context from the report

    “The British Pregnancy Advisory Service (BPAS) is a charity whose services are often commissioned by the NHS. As a charity, BPAS does not have direct access to NHS perinatal psychiatrists. Referrals would have to be made either via the patient's GP or via an unwieldy safeguarding concern (as happened in this case). Referrals via the GP are not possible where the patient does not wish their identity to be revealed. It is a matter of concern that there is no direct access for BPAS patients who are suffering from pregnancy related mental health decline, to peri-natal psychiatry teams. Direct and confidential access to peri-natal psychiatry teams may reduce the risk of future deaths. ”

    Source location

    Ms Aleksandra Markowska · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  4. The Wirral

    AI-generated summary

    Samarjit Natasha SINGH · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Samarjit Natasha Singh developed postnatal depression after giving birth to her son and had acts of deliberate self-harm and a threat of self-harm. On 4 December 2012, she was found in cardiac arrest following hanging and sustained an irreversible hypoxic brain injury; she died the following day. The report identified concerns about the absence of a Specialist Community Perinatal Mental Health Service and a Mother and Baby Perinatal Mental Health inpatient unit in the Liverpool City Region.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Lack of a Mother and Baby Perinatal Mental Health inpatient unit in the Liverpool City Region

    Wider context from the report

    “Mrs Singh suffered from severe postnatal depression following the birth of her son. Clearly she needed to be with her son whilst she was being treated for her perinatal mental health issues, given his needs. 1. There was no Specialist Community Perinatal Mental Health Service in the Wirral to meet both her son’s and her needs. The treatment that was available was sub-optimal. 2. There is not a Mother and Baby Perinatal Mental health—in-patient Unit in the Liverpool City Region serving the needs of Lancashire, Merseyside and East Cheshire. 50% of referrals from this area to the Manchester Unit decline because it is too far from family and support networks but more relevantly from older sibling children who remain in the family home ”

    Source location

    Samarjit Natasha SINGH · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Lack of a Specialist Community Perinatal Mental Health Service in the Wirral

    Wider context from the report

    “Mrs Singh suffered from severe postnatal depression following the birth of her son. Clearly she needed to be with her son whilst she was being treated for her perinatal mental health issues, given his needs. 1. There was no Specialist Community Perinatal Mental Health Service in the Wirral to meet both her son’s and her needs. The treatment that was available was sub-optimal. 2. There is not a Mother and Baby Perinatal Mental health—in-patient Unit in the Liverpool City Region serving the needs of Lancashire, Merseyside and East Cheshire. 50% of referrals from this area to the Manchester Unit decline because it is too far from family and support networks but more relevantly from older sibling children who remain in the family home ”

    Source location

    Samarjit Natasha SINGH · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Develop and nationally consult on a specification for specialised perinatal mental health services.

    Verbatim wording from the response

    “NHS England has had responsibility for commissioning the ‘Specialised’ element of this pathway (Mother and Baby in-patient Units) since April 2013. A specification for these specialised perinatal services was developed by the NHS England specialised perinatal Clinical Reference Group, which comprises representatives from across the country with both clinical members and patients/Carers. The specification was subject to national consultation and NHS England work with the Royal College to develop quality standards.”

    Source location

    2014-0239-Response-by-Department-of-Health
    Page 1 · response
    Published 23 May 2014

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Contact NHS England network representatives and discuss commissioning inpatient mother-and-baby units at the next available regional Perinatal Group.

    Verbatim wording from the response

    “With regards to the second point that you raise, the commissioning of mother and baby units is within the commissioning responsibility of Specialised Commissioning, which sits with NHS England. NHS England has set up Strategic Clinical Networks and ████████ had been appointed as Clinical Network Lead (Maternity Services) for Cheshire & Merseyside Strategic Clinical Network for Maternity Children & Young People; we are in the process of contacting ████████ along with ████████ to ensure that your second concern, regarding the commissioning of inpatient units, is discussed at the next available regional Perinatal Group, and that the commissioning of these units is discussed in light of this incident and the risks highlighted. We will continue to work with NHS England to ensure a partnership approach to this issue, with the aim of achieving seamless patient care across the whole pathway.”

    Source location

    2014-0239-Response-by-Wirral-Clinical-Commissioning-Group
    Page 1 · response
    Published 23 May 2014

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Recruit and establish an additional perinatal mental health midwife post to increase specialist capacity, continuity, cover, teaching and supervision.

    Verbatim wording from the response

    “• an additional Perinatal Midwife should be recruited as a secondment opportunity for 6-12 months on a rolling basis from within existing workforce to skill up all midwives and to allow for postnatal appointments to be given, continuity of care, annual leave, teaching and clinical supervision to be undertaken. Thus supporting the Tier 2 provision and allowing post natal care to be also given.”

    Source location

    2014-0239-Response-by-Wirral-Clinical-Commissioning-Group
    Page 3 · response
    Published 23 May 2014

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Include specialist-staffing requirements in the new IAPT service specification and inform providers that perinatal clinicians must liaise with other professionals involved in care.

    Verbatim wording from the response

    “The provision for urgent access to psychological therapies was already included in IAPT Provider contracts; however, this case has been raised and discussed with the IAPT providers, who have been informed of the need to liaise with the other professionals who are likely to be involved with the other professionals involved in the lady’s care. The requirement for specialist staff has been included within the new specification for IAPT, which is due to go out for tender with a new service starting in April 2015.”

    Source location

    2014-0239-Response-by-Wirral-Clinical-Commissioning-Group
    Page 3 · response
    Published 23 May 2014

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Establish an integrated, consultant-led perinatal mental health pathway for Wirral patients by the end of 2014.

    Verbatim wording from the response

    “It is acknowledged that progress has not been made as quickly as originally anticipated, and as required by the gravity of this case. As such, following this Regulation 28 notice, the CCG can provide assurance to the Coroner and to all parties involved that the development of an integrated pathway will become a high priority for the CCG during 2014/15. We will require this integrated pathway to be in place, led by the Consultant Psychiatrist, by the end of the calendar year 2014.”

    Source location

    2014-0239-Response-by-Wirral-Clinical-Commissioning-Group
    Page 3 · response
    Published 23 May 2014

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Regional commissioning and the Manchester Mother and Baby Unit are considered sufficient for North West demand, with neighbouring units available when necessary.

    Verbatim wording from the response

    “Mother and Baby Units fall under this category of service and are therefore commissioned on a regional, rather than local, basis. This ensures that those very specialised qualifications, clinical skills and experience required to treat the patient group can be maintained and that the service can be commissioned cost-effectively, making best use of public funds. If there were to be a Mother and Baby unit in every major city, the use of the service by that city’s population would be minimal and clinicians would quickly lose their specialist knowledge and skills because of infrequent use. It would also be inefficient because of the low demand.”

    Source location

    2014-0239-Response-by-Department-of-Health
    Page 2 · response
    Published 23 May 2014

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Commissioning mother and baby units is the responsibility of NHS England’s Specialised Commissioning, not the CCG.

    Verbatim wording from the response

    “With regards to the second point that you raise, the commissioning of mother and baby units is within the commissioning responsibility of Specialised Commissioning, which sits with NHS England. NHS England has set up Strategic Clinical Networks and ████████ had been appointed as Clinical Network Lead (Maternity Services) for Cheshire & Merseyside Strategic Clinical Network for Maternity Children & Young People; we are in the process of contacting ████████ along with ████████ to ensure that your second concern, regarding the commissioning of inpatient units, is discussed at the next available regional Perinatal Group, and that the commissioning of these units is discussed in light of this incident and the risks highlighted. We will continue to work with NHS England to ensure a partnership approach to this issue, with the aim of achieving seamless patient care across the whole pathway.”

    Source location

    2014-0239-Response-by-Wirral-Clinical-Commissioning-Group
    Page 1 · response
    Published 23 May 2014

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Clinical Commissioning Groups commission local perinatal mental health services and should address concerns about Wirral provision.

    Verbatim wording from the response

    “Specialised Perinatal Mental Health Services (Mother and Baby Units) are a part of a wider network of services that provide care for this patient group and the commissioning of the ‘specialist’ (local) and ‘specialised’ (national) pathway is a responsibility shared between NHS England, Clinical Commissioning Groups and Local Authorities.”

    Source location

    2014-0239-Response-by-Department-of-Health
    Page 1 · response
    Published 23 May 2014

    Open published response

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

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Data last updated 7 September 2026