Recipient

NHS Wirral Clinical Commissioning Group

First report 23 May 2014•Latest report 23 May 2014

Recipient record

Reports, concerns and published responses

Health and care · Clinical commissioning group. This page brings together reports naming this recipient and response statements clearly connected to concerns raised in those reports.

Reports: 1
Published responses: 100%
Concerns addressed: 3
Stated actions: 7

Reports over time

Reports naming this recipient by issue year.

Evidence profile

Report topics

Share of this recipient’s reports compared with all other recipients.

100%published responses found

7stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

Statements from NHS Wirral Clinical Commissioning Group linked to the concerns in each report. Select any concern, action or position to view the source wording.

23 May2014
The Wirral
Concerns raised3
1. Lack of a Mother and Baby Perinatal Mental Health inpatient unit in the Liverpool City Region
2. Lack of a Specialist Community Perinatal Mental Health Service in the Wirral
3. Sub-optimal treatment for perinatal mental health issues
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 6
1. Action
  Recruit and establish an additional perinatal mental health midwife post to increase specialist capacity, continuity, cover, teaching and supervision.
  Stated completed
2. Action
  Establish an integrated, consultant-led perinatal mental health pathway for Wirral patients by the end of 2014.
  Stated planned
3. Action
  Include specialist-staffing requirements in the new IAPT service specification and inform providers that perinatal clinicians must liaise with other professionals involved in care.
  Stated completed
1. Action
  Contact NHS England network representatives and discuss commissioning inpatient mother-and-baby units at the next available regional Perinatal Group.
  Stated in progress
2. Action
  Work with regional perinatal interest groups to agree improvements to the pathway, particularly coordination between Tier 3 and Tier 4 services.
  Stated in progress
3. Action
  Revise the commissioned Liaison Psychiatry service specification to provide dedicated consultant psychiatrist time for developing and overseeing the perinatal mental health pathway.
  Stated in progress
Respondent positions 1
1. Position
  Commissioning mother and baby units is the responsibility of NHS England’s Specialised Commissioning, not the CCG.
  Redirects responsibility
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. The report was sent to NHS Wirral Clinical Commissioning Group; that does not assign responsibility.
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 ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Wirral Clinical Commissioning Group; that does not assign responsibility.
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 ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Wirral Clinical Commissioning Group; that does not assign responsibility.
PFD Monitor interpretation
Sub-optimal treatment for perinatal mental health issues
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 ”
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
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
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 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
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
Work with regional perinatal interest groups to agree improvements to the pathway, particularly coordination between Tier 3 and Tier 4 services.

Verbatim wording from the response
“Clinical Networks | • NHS England have set up a regional Perinatal Interest Group which is chaired by ████████ (WUTH)”

Source location
2014-0239-Response-by-Wirral-Clinical-Commissioning-Group
Page 2 · 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
Revise the commissioned Liaison Psychiatry service specification to provide dedicated consultant psychiatrist time for developing and overseeing the perinatal mental health pathway.

Verbatim wording from the response
“We are currently revising the service specification for the Liaison Psychiatry service commissioned for Wirral patients. This will include provision for dedicated consultant psychiatrist time to develop and oversee the perinatal mental health pathway.”

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
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

Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026

Reports, concerns and published responses

Reports over time

Concerns raised3

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

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

Sub-optimal treatment for perinatal mental health issues

Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised.6

Respondent positions A position is what this recipient says about the concern when it does not describe a specific action.1

Actions described in response 6

Respondent positions 1