PFD report

Hannah Louise Booth · Prevention of Future Deaths report

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Issued 9 Dec 2025•Derby and Derbyshire

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
4

Raised in this report

Recipients
5

Named on the report

Responses found
5

Of 5 recipients

Stated actions
45

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 raised4

  1. Failure to record or cross-reference information relevant to both mother and baby in both records
    Part of recurring concern: Unreliable cross-referencing of related patient records
  2. Lack of a single electronic patient record accessible to all services
    Part of recurring concern: Electronic patient records failing to make relevant clinical information available and actionablePart of recurring concern: Unreliable access to relevant clinical records for safe care
  3. Lack of shared policies, guidance and understanding about information relevant for sharing between services
    Part of recurring concern: Failure to communicate clinically important information reliably between care servicesPart of recurring concern: Unreliable inter-agency information sharing for coordinated carePart of recurring concern: Unreliable multi-agency communication procedures
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.27

  1. Action

    Document telephone advice-line discussions in the relevant parent’s health record when information concerns parental mental health.

    Stated by Derbyshire Community Health Services NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 15 December 2025.
  2. Action

    Reinforce parental-record documentation standards through staff training and supervision.

    Stated by Derbyshire Community Health Services NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 15 December 2025.
  3. Action

    Use the Perinatal Mental Health Service advice line for consultation and proactively share relevant contextual information about patients already receiving its care.

    Stated by Derbyshire Community Health Services NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 15 December 2025.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.11

  1. Position

    Resolving the absence of a unified patient record requires system-wide and national action overseen by NHS England, rather than action by an individual Trust.

    Stated by Derbyshire Community Health Services NHS Foundation TrustRedirects 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

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. ”

Is this part of a recurring concern?

Yes — Unreliable cross-referencing of related patient records.

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 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. ”

Is this part of a recurring concern?

Yes — Electronic patient records failing to make relevant clinical information available and actionable; Unreliable access to relevant clinical records for safe care.

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 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. ”

Is this part of a recurring concern?

Yes — Failure to communicate clinically important information reliably between care services; Unreliable inter-agency information sharing for coordinated care; Unreliable multi-agency communication procedures.

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

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. ”

Is this part of a recurring concern?

Yes — Failure to communicate clinically important information reliably between care services; Unreliable coordination and escalation between care providers and mental health services.

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

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
Page 3 · response
Published 15 December 2025

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

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
Page 4 · response
Published 15 December 2025

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

Use the Perinatal Mental Health Service advice line for consultation and proactively share relevant contextual information about patients already receiving its care.

Verbatim wording from the response

“During this meeting, it was agreed that the Perinatal Mental Health Service should be utilised by the Health Visiting Service as an advice and consultation resource, in addition to the existing formal referral pathways. Health Visitors are able to contact the Perinatal Mental Health Service advice line to discuss concerns, seek professional advice, or share relevant information without the need to submit a formal referral.”

Source location

Response from Derbyshire Community Health Service NHS Foundation Trust
Page 3 · response
Published 15 December 2025

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

Update Health Visiting Service standard operating procedures to formalize information-sharing expectations and use of the Perinatal Mental Health Service advice line.

Verbatim wording from the response

“As a result of this discussion, the Health Visiting Service is in the process of updating its Standard Operating Procedures to reflect the agreed approach to information sharing and the use of the Perinatal Mental Health Service advice line. This update will provide clear, consistent guidance to staff and reinforce expectations regarding early consultation and sharing of relevant information.”

Source location

Response from Derbyshire Community Health Service NHS Foundation Trust
Page 4 · response
Published 15 December 2025

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

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
Page 4 · response
Published 15 December 2025

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

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
Page 4 · response
Published 15 December 2025

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

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
Page 4 · response
Published 15 December 2025

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

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
Page 5 · response
Published 15 December 2025

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

Develop and circulate an infographic explaining the advice line, appropriate use, and information to share, with practical examples for Health Visiting staff.

Verbatim wording from the response

“To support clarity and consistency in practice, the Perinatal Mental Health Service has agreed to develop an infographic for Health Visiting staff. This will provide clear, accessible guidance on:”

Source location

Response from Derbyshire Community Health Service NHS Foundation Trust
Page 3 · response
Published 15 December 2025

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

Add contextual-information-sharing guidance to the electronic referral document for professionals.

Verbatim wording from the response

“Information leaflet to GP’s on referral The Perinatal CMHT has drafted an information leaflet for GPs setting out that this Trust and the GP practice use different electronic patient record systems, highlighting the impact of this and detailing risk mitigation. This leaflet will be sent to GPs on receipt of a referral from them if they do not have the same electronic patient record. An additional page has been added to the e-referral document for professionals regarding the sharing of contextual information around the patient. A patient will also be informed that their GP is not on the same electronic patient record so that they too are aware that information sharing is not automatic at the time of their appointment.”

Source location

Response from Derbyshire Healthcare NHS Foundation Trust
Page 1 · response
Published 15 December 2025

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

Share identified non-SystmOne GP practices with Perinatal CMHT clinicians and administrators.

Verbatim wording from the response

“SystmOne ‘alert’ Following the conclusion of the Inquest, the Perinatal CMHT has undertaken an audit of GP’s within its catchment area who do not use the same electronic patient record, SystmOne and have shared this information with all clinicians and administrators internally for awareness. To ensure continuing knowledge internally of GP’s who do not use SystmOne, the Trust is in the process of adding an ‘alert’ onto patients’ medical records as a reminder / notification. The Trust has taken this specific action wider than the Perinatal CMHT to include the High Peak CMHT / CRHT as that is the geographical area that the Trust covers where GP’s do not have SystmOne; in other areas GP’s do have SystmOne.”

Source location

Response from Derbyshire Healthcare NHS Foundation Trust
Page 1 · response
Published 15 December 2025

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

Add alerts to patient records identifying GP practices that do not use SystmOne.

Verbatim wording from the response

“SystmOne ‘alert’ Following the conclusion of the Inquest, the Perinatal CMHT has undertaken an audit of GP’s within its catchment area who do not use the same electronic patient record, SystmOne and have shared this information with all clinicians and administrators internally for awareness. To ensure continuing knowledge internally of GP’s who do not use SystmOne, the Trust is in the process of adding an ‘alert’ onto patients’ medical records as a reminder / notification. The Trust has taken this specific action wider than the Perinatal CMHT to include the High Peak CMHT / CRHT as that is the geographical area that the Trust covers where GP’s do not have SystmOne; in other areas GP’s do have SystmOne.”

Source location

Response from Derbyshire Healthcare NHS Foundation Trust
Page 1 · response
Published 15 December 2025

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

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
Page 2 · response
Published 15 December 2025

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

Draft an information leaflet explaining different electronic records, their impact, and risk mitigation.

Verbatim wording from the response

“Information leaflet to GP’s on referral The Perinatal CMHT has drafted an information leaflet for GPs setting out that this Trust and the GP practice use different electronic patient record systems, highlighting the impact of this and detailing risk mitigation. This leaflet will be sent to GPs on receipt of a referral from them if they do not have the same electronic patient record. An additional page has been added to the e-referral document for professionals regarding the sharing of contextual information around the patient. A patient will also be informed that their GP is not on the same electronic patient record so that they too are aware that information sharing is not automatic at the time of their appointment.”

Source location

Response from Derbyshire Healthcare NHS Foundation Trust
Page 1 · response
Published 15 December 2025

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

Send the electronic-record information leaflet to GPs when referring patients from practices using different systems.

Verbatim wording from the response

“Information leaflet to GP’s on referral The Perinatal CMHT has drafted an information leaflet for GPs setting out that this Trust and the GP practice use different electronic patient record systems, highlighting the impact of this and detailing risk mitigation. This leaflet will be sent to GPs on receipt of a referral from them if they do not have the same electronic patient record. An additional page has been added to the e-referral document for professionals regarding the sharing of contextual information around the patient. A patient will also be informed that their GP is not on the same electronic patient record so that they too are aware that information sharing is not automatic at the time of their appointment.”

Source location

Response from Derbyshire Healthcare NHS Foundation Trust
Page 1 · response
Published 15 December 2025

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

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
Page 2 · response
Published 15 December 2025

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

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
Page 2 · response
Published 15 December 2025

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

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
Page 4 · response
Published 15 December 2025

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

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
Page 5 · response
Published 15 December 2025

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

Develop the Single Patient Record to provide unified access to patient information across care settings.

Verbatim wording from the response

“Work is also progressing to develop a Single Patient Record (SPR). The SPR aims to provide a clear, unified view of a patient’s health and care history, regardless of where”

Source location

Response from NHS England
Page 1 · response
Published 15 December 2025

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 Summary Care Record Programme to support wider access to relevant patient information.

Verbatim wording from the response

“NHS England is aware of the challenges in sharing medical records between providers and the variability between areas using different technologies. We are also aware that use of the SCR is variable across different care settings.”

Source location

Response from NHS England
Page 2 · response
Published 15 December 2025

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

Publish perinatal mental health care pathway guidance and provide supporting e-learning resources for healthcare staff.

Verbatim wording from the response

“The NHS has expanded specialist perinatal mental health support and access has more than doubled (113%) from 31,163 patients in March 2020 to 66,468 in October 2025. NHS England previously published guidance on perinatal mental health care pathways in May 2018, to support all healthcare professionals working across the wider perinatal mental health pathway in identifying cases requiring specialist input. This is supported by e-learning resources for all staff, including modules for health visitors and a broader perinatal mental health resource covering risks to parents.”

Source location

Response from NHS England
Page 2 · response
Published 15 December 2025

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

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
Page 3 · response
Published 15 December 2025

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

Provide £20 million investment to connect care records across England by March 2026.

Verbatim wording from the response

“NHS England recognises the challenge of separate systems being used by different health and social care organisations. New initiatives and systems are being designed to integrate records. NHS England has invested £20 million to connect care records across England by March 2026. This will facilitate the safe and secure exchange of electronic health data across different systems, devices and applications. It is also expected that this will improve the information available to health and social care staff.”

Source location

Response from NHS England
Page 1 · response
Published 15 December 2025

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

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
Page 2 · response
Published 15 December 2025

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 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
Page 2 · response
Published 15 December 2025

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

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
Page 2 · response
Published 15 December 2025

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

Resolving the absence of a unified patient record requires system-wide and national action overseen by NHS England, rather than action by an individual Trust.

Verbatim wording from the response

“The Trust notes that the absence of a single, unified patient record across all NHS and GP settings is a longstanding national issue, overseen by NHS England. Any substantive resolution to this issue would require system-wide and national action, rather than action by an individual NHS Trust.”

Source location

Response from Derbyshire Community Health Service NHS Foundation Trust
Page 2 · response
Published 15 December 2025

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

Configuration and interoperability of clinical record systems across NHS providers and GP practices fall outside the Trust’s direct control and remit.

Verbatim wording from the response

“The Trust acknowledges that variations in clinical IT systems across NHS organisations can present challenges to the timely sharing of patient information. However, the configuration, interoperability and alignment of clinical record systems across NHS providers and GP practices are determined at a national and system level and sit outside the direct control and remit of the Trust.”

Source location

Response from Derbyshire Community Health Service NHS Foundation Trust
Page 2 · response
Published 15 December 2025

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

Existing universal health visiting, professional communication, GP liaison and record-access arrangements address local information-sharing needs despite the absence of a single record.

Verbatim wording from the response

“Notwithstanding these system-level constraints, the Trust has robust arrangements in place to ensure that children and young people receive universal health visiting services, and GP practices are aware of and able to engage with those services.”

Source location

Response from Derbyshire Community Health Service NHS Foundation Trust
Page 2 · response
Published 15 December 2025

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

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
Page 3 · response
Published 15 December 2025

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

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
Page 3 · response
Published 15 December 2025

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

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
Page 2 · response
Published 15 December 2025

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

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
Page 3 · response
Published 15 December 2025

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

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
Page 4 · response
Published 15 December 2025

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

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
Page 5 · response
Published 15 December 2025

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

NHS England does not mandate IT infrastructure, so it cannot require a single electronic patient record across providers.

Verbatim wording from the response

“Historically, different care settings have adopted different clinical systems to maintain a clinical record; some areas have adopted the same electronic patient record (such as SystmOne), whereas other areas have adopted shared care records which can provide access to records from different care settings. The GP record is available via GP Connect, the Summary Care Record and the Medical Interoperability Gateway (MIG), but the availability and content does vary across England. NHS England does not mandate IT infrastructure.”

Source location

Response from NHS England
Page 2 · response
Published 15 December 2025

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

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
Page 2 · response
Published 15 December 2025

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.18

  1. 1

    Continue joint working between Health Visiting and Perinatal Mental Health Services, including a scheduled progress review and agreement of further actions.

    Stated by Derbyshire Community Health Services NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 15 December 2025.
  2. 2

    Incorporate Perinatal Mental Health Service links and the agreed infographic into the Health Visiting Service induction pack for new starters.

    Stated by Derbyshire Community Health Services NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 15 December 2025.
  3. 3

    Brief Locality Managers on the inquest findings and identified learning.

    Stated by Derbyshire Community Health Services NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 15 December 2025.
  4. 4

    Add investigation and inquest learning to the agenda for the next stakeholder event.

    Stated by The TrustStated completedThe respondent said that this action was complete when they made their response on 15 December 2025.
  5. 5

    Inform patients when their GP uses a different electronic patient record system.

    Stated by The TrustStated plannedThe respondent said that this action was planned when they made their response on 15 December 2025.
  6. 6

    Audit local GP practices to identify those using different electronic patient record systems.

    Stated by The TrustStated completedThe respondent said that this action was complete when they made their response on 15 December 2025.
  7. 7

    Write to the health visitor team requesting notification when it refers a mother to perinatal mental health services.

    Stated by Sett Valley Medical CentreStated plannedThe respondent said that this action was planned when they made their response on 15 December 2025.
  8. 8

    Complete suicide-prevention training for the whole practice team and discuss increased use of safety plans and patient resources.

    Stated by Sett Valley Medical CentreStated completedThe respondent said that this action was complete when they made their response on 15 December 2025.
  9. 9

    Discuss all patients referred to perinatal mental health services at monthly practice MDT and child safeguarding meetings with health visitors.

    Stated by Sett Valley Medical CentreStated completedThe respondent said that this action was complete when they made their response on 15 December 2025.
  10. 10

    Arrange appropriate maternal follow-up, considering continuity of care and communication with relevant clinicians.

    Stated by Sett Valley Medical CentreStated plannedThe respondent said that this action was planned when they made their response on 15 December 2025.
  11. 11

    Write to the perinatal mental health team requesting referral acknowledgement and confirmation of acceptance and urgency.

    Stated by Sett Valley Medical CentreStated plannedThe respondent said that this action was planned when they made their response on 15 December 2025.
  12. 12

    Support greater integration and awareness of record sharing across the health system.

    Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 15 December 2025.
  13. 13

    Discuss all Reports to Prevent Future Deaths through the Regulation 28 Working Group and share learning across national and regional NHS services.

    Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 15 December 2025.
  14. 14

    Cascade updated Healthy Child Programme guidance through Regional Chief Nurses to highlight it to Trusts.

    Stated by NHS EnglandStated plannedThe respondent said that this action was planned when they made their response on 15 December 2025.
  15. 15

    Raise the coronial concerns through provider quality assurance meetings.

    Stated by NHS Derby and Derbyshire Integrated Care BoardStated completedThe respondent said that this action was complete when they made their response on 15 December 2025.
  16. 16

    Create system-wide information governance agreements to remove barriers to information sharing.

    Stated by NHS Derby and Derbyshire Integrated Care BoardStated in progressThe respondent said that this action was in progress when they made their response on 15 December 2025.
  17. 17

    Regularly report concern-related outputs through ICB quality oversight arrangements and strengthen those arrangements through clustering.

    Stated by NHS Derby and Derbyshire Integrated Care BoardStated plannedThe respondent said that this action was planned when they made their response on 15 December 2025.
  18. 18

    Apply for Section 251 agreements enabling information sharing for primary and secondary healthcare.

    Stated by NHS Derby and Derbyshire Integrated Care BoardStated in progressThe respondent said that this action was in progress when they made their response on 15 December 2025.

Recipient positions A position is what a recipient says about a concern when they do not describe a specific action.1

  1. 1

    Integrated Care Boards are responsible for commissioning, implementing and integrating primary care solutions.

    Stated by NHS EnglandRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.

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 joint working between Health Visiting and Perinatal Mental Health Services, including a scheduled progress review and agreement of further actions.

Verbatim wording from the response

“Both services have committed to ongoing joint working and have scheduled a follow-up meeting on the 23rd of February 2026 to review progress and agree further actions.”

Source location

Response from Derbyshire Community Health Service NHS Foundation Trust
Page 3 · response
Published 15 December 2025

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

Incorporate Perinatal Mental Health Service links and the agreed infographic into the Health Visiting Service induction pack for new starters.

Verbatim wording from the response

“Finally, links to the Perinatal Mental Health Service and the agreed infographic will be incorporated into the Health Visiting Service induction pack for all new starters. This induction resource provides comprehensive information on policies, procedures, and key contacts, and will be updated to ensure that new staff are aware of the service, how to access advice, and the importance of timely and appropriate information sharing.”

Source location

Response from Derbyshire Community Health Service NHS Foundation Trust
Page 4 · response
Published 15 December 2025

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

Brief Locality Managers on the inquest findings and identified learning.

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
Page 4 · response
Published 15 December 2025

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

Add investigation and inquest learning to the agenda for the next stakeholder event.

Verbatim wording from the response

“Dissemination of learning The learning identified as part of the Trust’s Patient Safety Incident investigation and the inquest has been added to the agenda for the next stakeholder event.”

Source location

Response from Derbyshire Healthcare NHS Foundation Trust
Page 2 · response
Published 15 December 2025

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

Inform patients when their GP uses a different electronic patient record system.

Verbatim wording from the response

“Information leaflet to GP’s on referral The Perinatal CMHT has drafted an information leaflet for GPs setting out that this Trust and the GP practice use different electronic patient record systems, highlighting the impact of this and detailing risk mitigation. This leaflet will be sent to GPs on receipt of a referral from them if they do not have the same electronic patient record. An additional page has been added to the e-referral document for professionals regarding the sharing of contextual information around the patient. A patient will also be informed that their GP is not on the same electronic patient record so that they too are aware that information sharing is not automatic at the time of their appointment.”

Source location

Response from Derbyshire Healthcare NHS Foundation Trust
Page 1 · response
Published 15 December 2025

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

Audit local GP practices to identify those using different electronic patient record systems.

Verbatim wording from the response

“SystmOne ‘alert’ Following the conclusion of the Inquest, the Perinatal CMHT has undertaken an audit of GP’s within its catchment area who do not use the same electronic patient record, SystmOne and have shared this information with all clinicians and administrators internally for awareness. To ensure continuing knowledge internally of GP’s who do not use SystmOne, the Trust is in the process of adding an ‘alert’ onto patients’ medical records as a reminder / notification. The Trust has taken this specific action wider than the Perinatal CMHT to include the High Peak CMHT / CRHT as that is the geographical area that the Trust covers where GP’s do not have SystmOne; in other areas GP’s do have SystmOne.”

Source location

Response from Derbyshire Healthcare NHS Foundation Trust
Page 1 · response
Published 15 December 2025

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

Write to the health visitor team requesting notification when it refers a mother to perinatal mental health services.

Verbatim wording from the response

“We will also write to the perinatal mental health team asking them to inform us of the outcome of referrals and whether a patient has been accepted. Similarly we will write to the health visitor team asking them to inform us when they refer a patient to the perinatal mental health team as we currently are not aware unless the patient informs us.”

Source location

Response from Sett Valley Medical centre
Page 2 · response
Published 15 December 2025

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

Complete suicide-prevention training for the whole practice team and discuss increased use of safety plans and patient resources.

Verbatim wording from the response

“5. We hope the above proposed measures are constructive and useful. The whole practice team also completed suicide prevention training on 7 January 2026. This has refreshed everyone's awareness of how to support patients, and we discussed increasing the use of safety plans and resources available to patients.”

Source location

Response from Sett Valley Medical centre
Page 5 · response
Published 15 December 2025

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

Discuss all patients referred to perinatal mental health services at monthly practice MDT and child safeguarding meetings with health visitors.

Verbatim wording from the response

“Going forwards all patients referred to the perinatal mental health team will be discussed at our MDT meetings, so all members of the team are aware and at the monthly child safeguarding meeting with the health visitors.”

Source location

Response from Sett Valley Medical centre
Page 2 · response
Published 15 December 2025

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

Arrange appropriate maternal follow-up, considering continuity of care and communication with relevant clinicians.

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
Page 5 · response
Published 15 December 2025

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

Write to the perinatal mental health team requesting referral acknowledgement and confirmation of acceptance and urgency.

Verbatim wording from the response

“We will also write to the perinatal mental health team asking them to inform us of the outcome of referrals and whether a patient has been accepted. Similarly we will write to the health visitor team asking them to inform us when they refer a patient to the perinatal mental health team as we currently are not aware unless the patient informs us.”

Source location

Response from Sett Valley Medical centre
Page 2 · response
Published 15 December 2025

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

Support greater integration and awareness of record sharing across the health system.

Verbatim wording from the response

“NHS England is aware of the challenges in sharing medical records between providers and the variability between areas using different technologies. We are also aware that use of the SCR is variable across different care settings.”

Source location

Response from NHS England
Page 2 · response
Published 15 December 2025

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

Discuss all Reports to Prevent Future Deaths through the Regulation 28 Working Group and share learning across national and regional NHS services.

Verbatim wording from the response

“I would also like to provide further assurances on the national NHS England work taking place around the Reports to Prevent Future Deaths. All reports received are discussed by the Regulation 28 Working Group, comprising Regional Medical Directors, and other clinical and quality colleagues from across the regions. This ensures that key learnings and insights around events, such as the sad death of Hannah, are shared across the NHS at both a national and regional level and helps us to pay close attention to any emerging trends that may require further review and action.”

Source location

Response from NHS England
Page 4 · response
Published 15 December 2025

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

Cascade updated Healthy Child Programme guidance through Regional Chief Nurses to highlight it to Trusts.

Verbatim wording from the response

“The updated guidance will be published on the gov.uk website and will be available to all 0-19 health commissioners, providers and practitioners, educators, and regulators. NHS England will ensure this guidance is cascaded via our Regional Chief Nurses to ensure Trusts are highlighted to the updated guidance.”

Source location

Response from NHS England
Page 4 · response
Published 15 December 2025

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

Raise the coronial concerns through provider quality assurance meetings.

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
Page 2 · response
Published 15 December 2025

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

Create system-wide information governance agreements to remove barriers to information sharing.

Verbatim wording from the response

“Resolving these issues are a priority for us. As an ICB we are already working at speed to remove existing barriers to information sharing. This includes the creation of system-wide information governance agreements, and application for Section 251 agreements to share information for”

Source location

Response from Nottingham and Nottinghamshire Integrated Care Board
Page 1 · response
Published 15 December 2025

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

Regularly report concern-related outputs through ICB quality oversight arrangements and strengthen those arrangements through clustering.

Verbatim wording from the response

“Delivery of outputs in relation to these concerns, will be regularly reported into the ICB through our established quality oversight arrangements, which will be maintained and strengthened as part of current ICB Clustering arrangements.”

Source location

Response from Nottingham and Nottinghamshire Integrated Care Board
Page 2 · response
Published 15 December 2025

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

Apply for Section 251 agreements enabling information sharing for primary and secondary healthcare.

Verbatim wording from the response

“Resolving these issues are a priority for us. As an ICB we are already working at speed to remove existing barriers to information sharing. This includes the creation of system-wide information governance agreements, and application for Section 251 agreements to share information for”

Source location

Response from Nottingham and Nottinghamshire Integrated Care Board
Page 1 · response
Published 15 December 2025

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

Integrated Care Boards are responsible for commissioning, implementing and integrating primary care solutions.

Verbatim wording from the response

“At present, Integrated Care Boards (ICBs) are responsible for the commissioning, implementation and integration of primary care solutions.”

Source location

Response from NHS England
Page 2 · response
Published 15 December 2025

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