PFD report

Samarjit Natasha SINGH · Prevention of Future Deaths report

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Issued 23 May 2014•The Wirral

Report record

Published report and response evidence

This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.

View original report
Concerns
3

Raised in this report

Recipients
3

Named on the report

Responses found
2

Of 3 recipients

Stated actions
9

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised3

  1. Lack of a Mother and Baby Perinatal Mental Health inpatient unit in the Liverpool City Region
    Part of recurring concern: Insufficient psychiatric inpatient bed capacityPart of recurring concern: Unreliable specialist perinatal mental-health service provision
  2. Lack of a Specialist Community Perinatal Mental Health Service in the Wirral
    Part of recurring concern: Unreliable access to specialist mental health treatment for serious mental illnessPart of recurring concern: Unreliable specialist perinatal mental-health service provision
  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 An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.8

  1. Action

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

    Stated by Department of Health and Social CareStated completedThe respondent said that this action was complete when they made their response on 23 May 2014.
  2. Action

    Work with the Royal College to develop quality standards for specialised perinatal mental health services.

    Stated by Department of Health and Social CareStated in progressThe respondent said that this action was in progress when they made their response on 23 May 2014.
  3. Action

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

    Stated by NHS Wirral Clinical Commissioning GroupStated completedThe respondent said that this action was complete when they made their response on 23 May 2014.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.3

  1. Position

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

    Stated by Department of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do 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 ”

Is this part of a recurring concern?

Yes — Insufficient psychiatric inpatient bed capacity; Unreliable specialist perinatal mental-health service provision.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do 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 ”

Is this part of a recurring concern?

Yes — Unreliable access to specialist mental health treatment for serious mental illness; Unreliable specialist perinatal mental-health service provision.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do 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 ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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

Work with the Royal College to develop quality standards 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

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

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

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

Other statements in published responses

These actions and other statements could not be clearly connected to one concern in this report.

Recipient-stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.1

  1. 1

    Continue working with NHS England toward a partnership approach supporting seamless care across the perinatal mental health pathway.

    Stated by NHS Wirral Clinical Commissioning GroupStated in progressThe respondent said that this action was in progress when they made their response on 23 May 2014.

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

Continue working with NHS England toward a partnership approach supporting seamless care across the perinatal mental health pathway.

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

Data last updated 7 September 2026