9 Dec 2025 Hannah Louise Booth · Prevention of Future Deaths report Derby and Derbyshire
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Concerns raised 4 Failure to record or cross-reference information relevant to both mother and baby in both records View source Lack of a single electronic patient record accessible to all services View source Lack of shared policies, guidance and understanding about information relevant for sharing between services View source Failure to escalate and share increasing contact with health visitors with perinatal mental health services View source See 1 more concern
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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.
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 Sett Valley Medical Centre; that does not assign responsibility.
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.
” 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 Sett Valley Medical Centre; that does not assign responsibility.
PFD Monitor interpretation Lack of a single electronic patient record accessible to all services
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.
” 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 Sett Valley Medical Centre; that does not assign responsibility.
PFD Monitor interpretation Lack of shared policies, guidance and understanding about information relevant for sharing between services
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.
” 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 Sett Valley Medical Centre; that does not assign responsibility.
PFD Monitor interpretation Failure to escalate and share increasing contact with health visitors with perinatal mental health services
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.
” 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 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
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 Provide team training on using EMIS interoperability to view SystemOne within two months.
Verbatim wording from the response “At the Significant Event Meeting the Practice discussed the fact that we have the ability to view SystemOne but this ability is quite limited as only the patient’s most recent entries can be viewed. Staff would need to have a reason to access this information as it is not feasible to check this for every patient. We as a practice refer patients to a number of other services which use different IT systems such as Mental Health Services, Hospitals and Community services. It was agreed that we will provide training for the team on using the interoperability function in EMIS to view SystemOne and this training will be given within 2 months of this Response.” Source location Response from Sett Valley Medical centre
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 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
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 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
Open published response
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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 Developing interoperability between EMIS and SystmOne is the responsibility of the NHS Derby and Derbyshire Integrated Care Board as service commissioner.
Verbatim wording from the response “The development of the ability for electronic GP medical record systems such as SystemOne and EMIS to communicate with each other and allow sharing of clinical information, is not within the control of any individual GP practice, including ours. This is a matter that falls under the responsibility of the service commissioners at Derbyshire-wide level, specifically the NHS Derby & Derbyshire Integrated Care Board (ICB), which is responsible for commissioning services, including general practice, in the area. Individual practices, including ours, have no authority to determine the specifications of such services, nor are they involved in the due diligence processes related to the Information Management and Technology (IM&T) aspects of these systems.” Source location Response from Sett Valley Medical centre
Open published response
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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 Changing from EMIS to SystmOne would significantly increase risk across integrated primary-care and community services.
Verbatim wording from the response “The Practice provides primary care medical services via a Personal Medical Services (PMS) contract commissioned by NHSE England (“NHSE”) and the Derby and Derbyshire Integrated Care Board (ICB). It is part of a Primary Care Network (“PCN”) comprising 8 practices serving approximately 60,000 patients across North Derbyshire, all of which use the EMIS software system. EMIS and SystmOne are the most commonly used electronic GP medical record software systems in the UK. EMIS is used by over 50% of GP practices in the UK and by all 8 practices in our PCN. Whilst most practices in Derbyshire use SystemOne, all Practices in the High Peak area use EMIS. It is vital for effective and safe working across the Practices and for our patients to have access to the shared PCN services including the home visiting service, pharmacy team, social prescribers and others.” Source location Response from Sett Valley Medical centre
Open published response
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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 Continuing to share only clinically relevant contacts is considered safer and sufficient; emailing every consultation would burden the perinatal mental health team.
Verbatim wording from the response “With regards to sharing ongoing information with the perinatal mental health team it was discussed whether clinicians should request for the secretarial team to email any consultations relating to mental health (not just a deteriorating condition) and the perinatal mental health team can decide whether this is relevant to the care they are providing to the patient. However, it was felt that emailing every consultation to the perinatal team would put an unsafe burden on the perinatal team and we as a Practice consider that it is better and safer for us to continue with our normal practice of sharing only relevant contacts if we feel it is clinically indicated. This is consistent with the hundreds of other specialities/patient groups that we consult with.” Source location Response from Sett Valley Medical centre
Open published response
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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 Interoperability specifications and related information-technology due diligence are outside the Practice’s authority and control.
Verbatim wording from the response “The development of the ability for electronic GP medical record systems such as SystemOne and EMIS to communicate with each other and allow sharing of clinical information, is not within the control of any individual GP practice, including ours. This is a matter that falls under the responsibility of the service commissioners at Derbyshire-wide level, specifically the NHS Derby & Derbyshire Integrated Care Board (ICB), which is responsible for commissioning services, including general practice, in the area. Individual practices, including ours, have no authority to determine the specifications of such services, nor are they involved in the due diligence processes related to the Information Management and Technology (IM&T) aspects of these systems.” Source location Response from Sett Valley Medical centre
Open published response
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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 The Practice does not consider a policy or guidance on relevant information sharing capable of assisting with this concern.
Verbatim wording from the response “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.” Source location Response from Sett Valley Medical centre
Open published response
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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 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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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations