23 May 2014 Samarjit Natasha SINGH · Prevention of Future Deaths report The Wirral
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Concerns raised 3 Lack of a Mother and Baby Perinatal Mental Health inpatient unit in the Liverpool City Region View source Lack of a Specialist Community Perinatal Mental Health Service in the Wirral View source Sub-optimal treatment for perinatal mental health issues View source
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
Action
Recruit and establish an additional perinatal mental health midwife post to increase specialist capacity, continuity, cover, teaching and supervision.
View source
Action
Establish an integrated, consultant-led perinatal mental health pathway for Wirral patients by the end of 2014.
View source
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.
View source
Action
Contact NHS England network representatives and discuss commissioning inpatient mother-and-baby units at the next available regional Perinatal Group.
View source
Action
Work with regional perinatal interest groups to agree improvements to the pathway, particularly coordination between Tier 3 and Tier 4 services.
View source
Action
Revise the commissioned Liaison Psychiatry service specification to provide dedicated consultant psychiatrist time for developing and overseeing the perinatal mental health pathway.
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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.
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× 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
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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
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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
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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
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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
Open published response
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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
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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
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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
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations