9 Dec 2025 Hannah Louise Booth · Prevention of Future Deaths report Derby and Derbyshire
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Concerns raised 1
Failure to record or cross-reference information relevant to both mother and baby in both records View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
Derbyshire Community Health Services NHS Foundation Trust NHS Derby and Derbyshire Integrated Care Board NHS England Sett Valley Medical Centre The Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 14
Derbyshire Community Health Services NHS Foundation Trust
Document telephone advice-line discussions in the relevant parent’s health record when information concerns parental mental health.
View source
Derbyshire Community Health Services NHS Foundation Trust
Require staff to cross-reference relevant parental mental-health information in both child and parent records.
View source
Derbyshire Community Health Services NHS Foundation Trust
Use the SystmOne auto-consultation function to create parent-record entries referencing relevant information from child contacts.
View source
Derbyshire Community Health Services NHS Foundation Trust
Incorporate documentation and cross-referencing guidance into the Trust’s Perinatal Mental Health standard operating procedure.
View source
Derbyshire Community Health Services NHS Foundation Trust
Reinforce parental-record documentation standards through staff training and supervision.
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Derbyshire Community Health Services NHS Foundation Trust
Share a one-page document with all staff clarifying expected record-keeping standards for parental mental health.
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The Trust
Discuss developing guidance with DCHS on when health visitors should cross-reference medical notes for babies and mothers.
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Sett Valley Medical Centre
Add screen alerts to the records of mothers referred to perinatal mental health services and their children under two.
View source
Sett Valley Medical Centre
Document significant maternal mental-health concerns identified during appointments for children of mothers receiving perinatal mental-health care in the mother’s record and send consultation notes to the perinatal team.
View source
Sett Valley Medical Centre
Add a note to the child’s record directing clinicians to the mother’s notes when significant maternal mental-health concerns are identified.
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NHS England
Encourage specialist perinatal mental health teams to include record keeping in training for the wider perinatal pathway.
View source
NHS Derby and Derbyshire Integrated Care Board
Provide providers with guidance on recording information relevant to mother and baby and sharing information about frequent service access.
View source
NHS Derby and Derbyshire Integrated Care Board
Request discussion of recording information in both mother’s and baby’s notes at the next local maternity network meeting.
View source
NHS Derby and Derbyshire Integrated Care Board
Work with NHS England on cross-referencing information in mother and baby records.
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AI-generated summary
Hannah Louise Booth · 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
Hannah Louise Booth, who had been diagnosed with post-natal depression after giving birth in July 2024, drowned in the Goyt River on 6 January 2025 after sending a message evidencing her intention to take her own life. The report identified concerns about information sharing between services, including different record systems, incomplete records, and relevant information about Hannah being recorded only in her baby’s records. Increasing contact about her baby’s development was not shared with perinatal mental health services or recognised as potentially indicating that Hannah was struggling.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to record or cross-reference information relevant to both mother and baby in both records
Wider context from the report “This inquest has exposed important issues with information sharing between services and also within services. Those issues are:
• Difficulties encountered because different IT systems were being used for record keeping in different services. Essentially a lack of a single patient record.
• A lack of a shared understanding of what is relevant information and needs to be made available to other services.
• Relevant notes being made in records of baby and not repeated in notes of the mum.
Further detail:
1. Sett Valley, the health visitors and perinatal mental health services all had information about Hannah that was potentially relevant to her mental health, but none had the whole picture. It was evident that had those within the perinatal mental health services known about Hannah’s increasing frequency of contact with services about her baby’s development, it would have prompted further contact by them with Hannah and prompted a review of risk and support offered. They did not know and there was no further contact.
2. There was no single electronic patient record accessible to all services. Whilst the perinatal mental health and health visitors used SystmOne, Sett Valley did not. The health visitor had not informed Sett Valley about the contact Hannah had had with them on 27th December so that the GP seeing Hannah on 31st did not know that Hannah was beginning to make increased contact with services about her concerns and did not share any information about that consultation with other services.
3. There was increasing contact with health visitors that was not escalated to or shared with perinatal mental health. The significance of the increased contact, to Hannah’s mental health, did not appear to have been understood. The concerns raised at each contact around her baby’s development were dealt with at face value with exploration and examination of her baby’s development and reassurances given to Hannah regarding the particular concerns raised. The evidence revealed that it was not the individual concerns raised that were relevant to Hannah’s mental health but the fact that she was making more frequent contact which suggested she was struggling. There are no policies, guidance or any shared understanding between services of what might be relevant information to be shared and when.
4. Within both Sett Valley and health visitor records there was potentially important information relevant to Hannah’s mental health recorded only within her baby’s records. At any future appointments concerning Hannah the relevant medical history available on her record would have been incomplete. It also meant that whilst the perinatal mental health services had access to the health visitor notes in relation to Hannah (because they both used SystmOne), even had they had cause to look at Hannah’s notes they would still not have had all relevant information. There are no policies or guidance regarding when information potentially relevant to both mother and baby should be placed in both records or cross referenced. This appears to be particularly important in the perinatal period.
” Source location Hannah Louise Booth · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Document telephone advice-line discussions in the relevant parent’s health record when information concerns parental mental health.
Verbatim wording from the response “It has also been agreed that advice line discussion will take place via telephone and that these conversations should be documented within the mother/father’s health record, rather than child record, where the information relates specifically to parental mental health (for both services).” Source location Response from Derbyshire Community Health Service NHS Foundation Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Require staff to cross-reference relevant parental mental-health information in both child and parent records.
Verbatim wording from the response “The Health Visiting Service recognises the importance of clear and accurate documentation to ensure that relevant information is accessible to all professionals involved in family care. The established principle remains that information relating to a parent’s mental health should be documented within the specific parent’s health record, while information relating specifically to the child should be recorded in the child’s record.” Source location Response from Derbyshire Community Health Service NHS Foundation Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Use the SystmOne auto-consultation function to create parent-record entries referencing relevant information from child contacts.
Verbatim wording from the response “To support this in practice, an auto-consultation function has been implemented within SystmOne. This functionality enables clinicians to promptly create an entry within the parent’s record that references relevant information arising from a child contact, supporting consistent and timely documentation and strengthening the visibility of parental mental health information.” Source location Response from Derbyshire Community Health Service NHS Foundation Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Incorporate documentation and cross-referencing guidance into the Trust’s Perinatal Mental Health standard operating procedure.
Verbatim wording from the response “Best practice guidance on documentation and cross-referencing between child and parent records will be formally incorporated into the Trust’s Perinatal Mental Health Standard Operating Procedure. This will provide clear, consistent guidance and support improved documentation standards.” Source location Response from Derbyshire Community Health Service NHS Foundation Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Reinforce parental-record documentation standards through staff training and supervision.
Verbatim wording from the response “Locality Managers have been briefed on the findings of the inquest and the learning identified. Strengthening documentation within parental records has been identified as” Source location Response from Derbyshire Community Health Service NHS Foundation Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Share a one-page document with all staff clarifying expected record-keeping standards for parental mental health.
Verbatim wording from the response “A one-page document clarifying the expected standard of record keeping about parental mental health has been shared with all staff via team meetings, which took place during the week commencing 26th January 2026. Further information will be shared with all staff when the perinatal mental health team infographic is available to disseminate.” Source location Response from Derbyshire Community Health Service NHS Foundation Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Discuss developing guidance with DCHS on when health visitors should cross-reference medical notes for babies and mothers.
Verbatim wording from the response “Working alongside DCHS
Further, and in addition, the Trust is currently discussing with Derbyshire Community Health Services NHS FT (‘DCHS’) the development of Guidance regarding when DCHS’ health visitors will cross reference the medical notes for baby and mum.” Source location Response from Derbyshire Healthcare NHS Foundation Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Add screen alerts to the records of mothers referred to perinatal mental health services and their children under two.
Verbatim wording from the response “As a Practice we are constantly assessing risk on an individual patient basis and we share relevant information with those services if and when deemed necessary. We discussed how perinatal mental health is a specific, small, cohort of patients who are known to be at increased risk of mental health problems who can deteriorate rapidly, and it was agreed that it would be useful to know which patients are under the specialist team. We considered how to make all staff aware that a patient is under the care of the perinatal mental health team and a decision was made to add an alert to a patient's records when they are referred to the perinatal mental health team. A screen alert is now put on the notes of both the mother and their children under 2yrs.” Source location Response from Sett Valley Medical centre
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Document significant maternal mental-health concerns identified during appointments for children of mothers receiving perinatal mental-health care in the mother’s record and send consultation notes to the perinatal team.
Verbatim wording from the response “At the Significant Event Meeting it was agreed that in circumstances where a child whose mother is under the perinatal mental health team is seen and there are significant concerns about the mother’s mental health, the clinician should document this in the mother’s notes and ask” Source location Response from Sett Valley Medical centre
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Add a note to the child’s record directing clinicians to the mother’s notes when significant maternal mental-health concerns are identified.
Verbatim wording from the response “the secretary team to send consultation notes to the perinatal mental health team. This has already been implemented. The clinician will also arrange appropriate follow up for the mother, considering continuity of care and communicate with relevant clinicians within the team if appropriate. It was also agreed that a note should be added to the child's record to please see the mother’s notes as we are not able to document in the child's record about the mother’s health due to patient confidentiality.” Source location Response from Sett Valley Medical centre
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Encourage specialist perinatal mental health teams to include record keeping in training for the wider perinatal pathway.
Verbatim wording from the response “Following this case, NHS England via the regional Perinatal Mental Health networks will encourage specialist perinatal mental health teams to include record keeping as a component of their training to the wider pathway, to help support staff to understand their experiences for documenting assessments, risks, red flags, information sharing and consent.” Source location Response from NHS England
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide providers with guidance on recording information relevant to mother and baby and sharing information about frequent service access.
Verbatim wording from the response “DDICB is committed to ensuring that providers understand their obligations to share information between providers, where that information relates to the delivery of patient care. We note the coronial concern around the lack of policy or guidance relating to the recording of information potentially relevant to both mother and baby; and guidance relating to information sharing between healthcare providers in the case of a pattern of more frequent access to services.” Source location Response from Nottingham and Nottinghamshire Integrated Care Board
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Request discussion of recording information in both mother’s and baby’s notes at the next local maternity network meeting.
Verbatim wording from the response “The ICB will work with Derbyshire Community Health Services NHS Foundation Trust, and Derbyshire Healthcare NHS Foundation Trust, to ensure relevant guidance is provided in these areas by Quarter 1 of the 26/27 financial year. The coronial concerns have been raised with both organisations in quality assurance meetings in the last month and we have also requested that the issue of recording information in both mother’s and baby’s notes is discussed at the next local maternity network meeting for shared learning.” Source location Response from Nottingham and Nottinghamshire Integrated Care Board
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Work with NHS England on cross-referencing information in mother and baby records.
Verbatim wording from the response “DDICB notes that some of the matters of concern extend substantially beyond the borders of our organisational influence. We are committed to work with NHS England on these areas; in particular, the matter of concern related to cross-referencing of information in records of mother and baby, which will have a national impact.” Source location Response from Nottingham and Nottinghamshire Integrated Care Board
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Confidentiality prevents documenting the mother’s health information in the child’s record, requiring a cross-reference instead.
Verbatim wording from the response “the secretary team to send consultation notes to the perinatal mental health team. This has already been implemented. The clinician will also arrange appropriate follow up for the mother, considering continuity of care and communicate with relevant clinicians within the team if appropriate. It was also agreed that a note should be added to the child's record to please see the mother’s notes as we are not able to document in the child's record about the mother’s health due to patient confidentiality.” Source location Response from Sett Valley Medical centre
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Some concerns, particularly cross-referencing mother and baby records, extend beyond the ICB’s organisational influence and require work with NHS England.
Verbatim wording from the response “DDICB notes that some of the matters of concern extend substantially beyond the borders of our organisational influence. We are committed to work with NHS England on these areas; in particular, the matter of concern related to cross-referencing of information in records of mother and baby, which will have a national impact.” Source location Response from Nottingham and Nottinghamshire Integrated Care Board
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Concerns raised 1
Failure of allergy information to automatically cross-populate between records View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Glennis CONNELLY · 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
Glennis CONNELLY died at home on 11 November 2022 from end-stage renal failure due to tubulo-interstitial nephritis caused by tazocin, despite a previously identified allergy to the drug. The principal concerns were that this allergy was not recorded in the hospital records at Queens Hospital Burton upon Trent and that electronic patient records across the same trust did not automatically share allergy information.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure of allergy information to automatically cross-populate between records
Wider context from the report “Although the Queens Hospital Burton Upon Trent and the the Royal Derby Hospital are governed by the same hospital trust, they have different electronic patient records. Entries made by the renal team at the Royal Derby Hospital are not automatically visible to medical staff at the Queens Hospital, "allergies" do not automatically cross populate despite entries being made on the Lorenzo system and the GP records being updated on 6th & 12th February 2020.
” Source location Glennis CONNELLY · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement the unified electronic patient record across Trust sites, with staged rollout underway and allergy functionality planned for the first phase.
Verbatim wording from the response “Whilst the incident was multifactorial, the unification of the EPR systems is something the Trust is working hard to remedy. As noted, the Trust currently has two enterprise wide systems which include all patient administrative and clinical functionality, appointments, waiting lists, test results, medications, emergency care, maternity and clinical noting.” Source location Response from Derby and Burton NHS
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How this respondent action was interpreted
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PFD Monitor interpretation Establish a multidisciplinary allergy working group to ensure robust systems for managing allergies and alerts.
Verbatim wording from the response “4. Setting up an allergy working group” Source location Response from Derby and Burton NHS
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The Trust cannot extend an existing EPR across all sites because of contractual, technical, support-life and specialist-function constraints.
Verbatim wording from the response “Implementing an entirely new system is not a small undertaking. It is important to get this right for the five hospital sites now and into the future. These EPR systems are not created by the Trust, but rather bought under contracting arrangements with their associated contractual periods, support and shelf life. As was heard at inquest, it has not been possible to extend one of the existing systems to the whole site as they need to function effectively across all specialisms. In the case of one system it is reaching the end of its support life. Any system has to be then integrated into the wider Trust in a safe way, operating alongside our other systems.” Source location Response from Derby and Burton NHS
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How this respondent position was interpreted
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PFD Monitor interpretation The Care Quality Commission will assess the incident and determine whether further regulatory action is needed.
Verbatim wording from the response “Where there is any death or serious injury at a provider or service registered by the CQC, the CQC will consider this in line with their specific incident guidance to identify if a patient has suffered avoidable harm or they were placed at significant risk of avoidable harm. This includes when there are issues relating to digital systems, and a specific incident review would consider the role of the system, as well as the registered providers involved.” Source location Response from DHSC
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How this respondent position was interpreted
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PFD Monitor interpretation The University Hospitals of Derby and Burton NHS Foundation Trust will address specific local actions in its separate response.
Verbatim wording from the response “I understand that the University Hospitals of Derby and Burton NHS Foundation Trust will be separately responding to the report and commenting on specific local action in their response.” Source location Response from DHSC
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23 Jan 2019 Tyrone GIVANS · Prevention of Future Deaths report Inner North London
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Concerns raised 1
Failure to maintain single, accurate NOMIS and SystmOne records View source
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
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Tyrone GIVANS · 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
Tyrone Givans, who was homeless, profoundly deaf and had a history of alcohol and drug use, was remanded into custody at HMP Pentonville after being arrested for assault. The jury concluded that he hanged himself in his cell, although his intentions were unclear. Principal concerns included Spice use in prison, duplicated prison and healthcare records that prevented access to earlier assessments, and inadequate recognition and support of his deafness and disabilities.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to maintain single, accurate NOMIS and SystmOne records
Wider context from the report “2. A past spelling error meant that there were two sets of NOMIS prison records for Mr Givans. This meant that there were then two sets of SystmOne healthcare records .
This meant that staff did not have access to records of the assessments conducted before 8 February 2018. However, later consultations were not paused to make enquiries about this. The nature of the IT error was discovered after Mr Givans’ death, but at the time, staff did not seem to recognise the significance of having no earlier records.
Evidence was given that NOMIS in its present form is unsatisfactory and does not lend itself to human intervention. The jury found that the IT system was unfit for purpose.
” Source location Tyrone GIVANS · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Run a monthly report to identify and merge duplicate prisoner records created by differing name spellings.
Verbatim wording from the response “You have raised the issue that when the name of a prisoner who has previously been in custody is spelt differently, a new record, which will not contain all the information about the prisoner, is created. At HMP Pentonville a monthly report is now run to identify any such cases and merge the records. Because NOMIS and SystmOne are separate IT platforms, designed and operated by separate government departments, the level of connectivity is limited. However, there are good local working practices now in place which encourage communication between prison and health teams. I understand that Care UK are also writing to you about this.” Source location 2019-0028-Response-by-HM-Prison-and-Probation-Service
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Share learning about duplicate medical records with clinical teams through national and regional quality-assurance meetings.
Verbatim wording from the response “Care UK has shared the learning from the inquest, including the existence of the anomaly which can cause the creation of more than one set of medical records for the same patient (for example” Source location 2019-0028-Response-by-Care-UK
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Remind clinicians to review relevant records thoroughly and query missing records or other anomalies.
Verbatim wording from the response “Clinicians have also been reminded to thoroughly review relevant records and to query apparently missing records or other anomalies. In addition, at HMP Pentonville, the structure of the clinics has been altered to minimise interruption and disruption by other patients, which transpired as a concern through GP evidence in the inquest. All healthcare reception staff at HMP Pentonville have attended a 3 day NHS England run reception screening course titled “Reducing Deaths in Custody”.” Source location 2019-0028-Response-by-Care-UK
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7 Aug 2014 Vijay Sonagara · Prevention of Future Deaths report Inner South London
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Concerns raised 3
Failure to incorporate temporary medical records into the permanent file View source Unavailability of potentially relevant information from separate medical records to treating doctors View source Failure to amalgamate or cross-reference medical records held under different hospital numbers View source
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
Vijay Sonagara · 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
Vijay Sonagara, who had alcoholic liver disease, underwent routine surgery for repair of an inguinal hernia on 8 February 2013. His condition deteriorated rapidly, and he died at St Thomas’ Hospital on 22 February 2013 after developing decompensated alcoholic liver disease requiring intensive care. The concerns were that medical records were held under different hospital numbers and in a temporary file, were not amalgamated or cross-referenced, and contained potentially relevant information that was unavailable to his treating doctors.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to incorporate temporary medical records into the permanent file
Wider context from the report “My concerns are therefore as follows:
(1) Mr Sonagara had two different sets of medical records under two different hospital numbers that were not amalgamated or cross referenced.
(2) In addition a third temporary file of medical records was not incorporated into the permanent file .
(3) Potentially relevant information contained in the second and third set of records was not available to Mr Sonagara’s treating doctors.
” Source location Vijay Sonagara · Prevention of Future Deaths report
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 Unavailability of potentially relevant information from separate medical records to treating doctors
Wider context from the report “My concerns are therefore as follows:
(1) Mr Sonagara had two different sets of medical records under two different hospital numbers that were not amalgamated or cross referenced.
(2) In addition a third temporary file of medical records was not incorporated into the permanent file.
(3) Potentially relevant information contained in the second and third set of records was not available to Mr Sonagara’s treating doctors .
” Source location Vijay Sonagara · Prevention of Future Deaths report
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 Failure to amalgamate or cross-reference medical records held under different hospital numbers
Wider context from the report “My concerns are therefore as follows:
(1) Mr Sonagara had two different sets of medical records under two different hospital numbers that were not amalgamated or cross referenced .
(2) In addition a third temporary file of medical records was not incorporated into the permanent file.
(3) Potentially relevant information contained in the second and third set of records was not available to Mr Sonagara’s treating doctors.
” Source location Vijay Sonagara · Prevention of Future Deaths report
Open source report
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.