Hannah Booth
PFD Report
All Responded
Ref: 2025-0615
All 5 responses received
Coroner's Concerns (AI summary)
Fragmented IT systems and poor information sharing between and within services meant crucial mental health information about the mother was not readily accessible or understood.
View full coroner's concerns
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 CONTROLLED 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.
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 CONTROLLED 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.
Responses
Action Taken
Derbyshire Healthcare NHS Foundation Trust has audited GPs not using SystmOne and added an 'alert' to patient records for awareness. They have drafted an information leaflet for GPs about different electronic record systems and added an additional page to e-referral documents for contextual information sharing. (AI summary)
Derbyshire Healthcare NHS Foundation Trust has audited GPs not using SystmOne and added an 'alert' to patient records for awareness. They have drafted an information leaflet for GPs about different electronic record systems and added an additional page to e-referral documents for contextual information sharing. (AI summary)
View full response
Dear Ma’am
Re: Regulation 28 response: an inquest touching the death of Hannah Booth
May I first begin on behalf of the Trust by conveying my condolences to the family of Hannah for their loss.
Below the Trust has responded to matters that are within its control and relate to the Trust as set out in your Regulation 28 report dated 9 December 2025:
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.
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.
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.
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.
Action plan oversight The actions are detailed within an action plan which I append to this letter for ease and assistance and are being overseen through the Trust’s established clinical governance and patient safety arrangements, with progress monitored and assurance provided through those governance forums.
I hope that the above information provides you and the family of Hannah the reassurance that the Trust takes learning very seriously and continually seeks to improve. I am mindful that some of the actions detailed in this letter have not yet been completed and with that, I have requested that an update be sent to you, and the family of Hannah, if they would like continued communications from the Trust, in August 2026.
Re: Regulation 28 response: an inquest touching the death of Hannah Booth
May I first begin on behalf of the Trust by conveying my condolences to the family of Hannah for their loss.
Below the Trust has responded to matters that are within its control and relate to the Trust as set out in your Regulation 28 report dated 9 December 2025:
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.
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.
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.
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.
Action plan oversight The actions are detailed within an action plan which I append to this letter for ease and assistance and are being overseen through the Trust’s established clinical governance and patient safety arrangements, with progress monitored and assurance provided through those governance forums.
I hope that the above information provides you and the family of Hannah the reassurance that the Trust takes learning very seriously and continually seeks to improve. I am mindful that some of the actions detailed in this letter have not yet been completed and with that, I have requested that an update be sent to you, and the family of Hannah, if they would like continued communications from the Trust, in August 2026.
Action Taken
Sett Valley Medical Centre has implemented screen alerts on mother/child notes where the mother is under perinatal care and ensures these patients are discussed at monthly MDT and child safeguarding meetings. They also completed suicide prevention training and plan to request acknowledgement of referrals from the perinatal team. (AI summary)
Sett Valley Medical Centre has implemented screen alerts on mother/child notes where the mother is under perinatal care and ensures these patients are discussed at monthly MDT and child safeguarding meetings. They also completed suicide prevention training and plan to request acknowledgement of referrals from the perinatal team. (AI summary)
View full response
IN THE CHESTERFIELD CORONER’S COURT
BEFORE HIS MAJESTY’S CORONER FOR DERBY & DERBYSHIRE
THE INQUEST TOUCHING THE DEATH OF HANNAH LOUISE BOOTH
__________________________________________________________
RESPONSE TO REGULATION 28 – SETT VALLEY MEDICAL CENTRE __________________________________________________________
1. H.M. Coroner Evans for the Coroner Area of Derby & Derbyshire has made a Regulation 28 Report – Action to prevent deaths dated 9 December 2025 (“the Regulation 28 Report”) concerning the death of Hannah Louise Booth (“the Deceased”). This arises from the Inquest of 2 December 2025 which concluded on 8 December 2025 (“the Inquest”).
2. Sett Valley Medical Centre (“the Practice”) respond in accordance with Regulation 29 of the Coroners (Investigations) Regulations 2013 (“the Response”).
3. H.M. Coroner Evans’ concerns are set out in bold italics, with the Practice’s Response below: The MATTERS OF CONCERN are as follows: (brief summary of matters of concern) 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.
The Practice held a Significant Event Meeting on 12 January 2026 to discuss the Regulation 28 Report.
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. 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. 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. 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. 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. 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.
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.
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 SystemOne 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. EMIS is also used by the local provider of outpatient services 3V Healthcare Limited, so in the community clinicians at outpatient appointments have access to the patients’ EMIS notes, which improves safety for patients accessing those services. The Practice is integrated into all the PCN services. Changing over to SystemOne would significantly increase risk in many of these areas.
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.
As such in respect of this Concern we consider we cannot proactively do anything as it is a commissioning issue.
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. We do not consider that a policy or guidance can be of assistance here. As stated above, the Practice’s ability to view SystemOne is limited but we will provide training for the team on using the interoperability function in EMIS to view SystemOne within 2 months of this Response. A screen alert is now added to a patient's records when they are referred to the perinatal mental health team. The alert is put on the notes of both the mother and their children under 2yrs. In addition, all patients referred to the perinatal mental health team will be discussed at our MDT meetings and at the monthly child safeguarding meeting with the health visitors. As above, we are also writing to the perinatal and health visitor teams to ask them to inform us about referrals but cannot say when/if this will occur or whether it will be possible. We have discussed the issue of sharing ongoing information with the perinatal mental health team but we consider that emailing every consultation to the perinatal team would put an unsafe burden on the perinatal team and 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.
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.
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
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.
4. The main measures to be implemented as a result of the Significant Event Meeting are: Screen alerts on notes of mother/children under 2 where mother is under the care of the perinatal team (this has already been implemented); Patients under the care of the perinatal team to be discussed at practice monthly MDT meetings and child safeguarding meetings with the health visitors (this has already been implemented); Asking the perinatal team to send acknowledgement of receipt of our referral including whether it has been accepted as urgent or routine. We will write to them within 2 weeks of this Response Asking the Health Visitor team to inform the practice if they have referred a mother to the Perinatal Team. We will write to them within 2 weeks of this 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.
Dated this 29th day of January 2026
Signed:
Dr Blackburn, on behalf of Sett Valley Medical Centre, Hyde Bank Road, New Mills SK22 4BP
BEFORE HIS MAJESTY’S CORONER FOR DERBY & DERBYSHIRE
THE INQUEST TOUCHING THE DEATH OF HANNAH LOUISE BOOTH
__________________________________________________________
RESPONSE TO REGULATION 28 – SETT VALLEY MEDICAL CENTRE __________________________________________________________
1. H.M. Coroner Evans for the Coroner Area of Derby & Derbyshire has made a Regulation 28 Report – Action to prevent deaths dated 9 December 2025 (“the Regulation 28 Report”) concerning the death of Hannah Louise Booth (“the Deceased”). This arises from the Inquest of 2 December 2025 which concluded on 8 December 2025 (“the Inquest”).
2. Sett Valley Medical Centre (“the Practice”) respond in accordance with Regulation 29 of the Coroners (Investigations) Regulations 2013 (“the Response”).
3. H.M. Coroner Evans’ concerns are set out in bold italics, with the Practice’s Response below: The MATTERS OF CONCERN are as follows: (brief summary of matters of concern) 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.
The Practice held a Significant Event Meeting on 12 January 2026 to discuss the Regulation 28 Report.
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. 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. 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. 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. 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. 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.
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.
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 SystemOne 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. EMIS is also used by the local provider of outpatient services 3V Healthcare Limited, so in the community clinicians at outpatient appointments have access to the patients’ EMIS notes, which improves safety for patients accessing those services. The Practice is integrated into all the PCN services. Changing over to SystemOne would significantly increase risk in many of these areas.
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.
As such in respect of this Concern we consider we cannot proactively do anything as it is a commissioning issue.
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. We do not consider that a policy or guidance can be of assistance here. As stated above, the Practice’s ability to view SystemOne is limited but we will provide training for the team on using the interoperability function in EMIS to view SystemOne within 2 months of this Response. A screen alert is now added to a patient's records when they are referred to the perinatal mental health team. The alert is put on the notes of both the mother and their children under 2yrs. In addition, all patients referred to the perinatal mental health team will be discussed at our MDT meetings and at the monthly child safeguarding meeting with the health visitors. As above, we are also writing to the perinatal and health visitor teams to ask them to inform us about referrals but cannot say when/if this will occur or whether it will be possible. We have discussed the issue of sharing ongoing information with the perinatal mental health team but we consider that emailing every consultation to the perinatal team would put an unsafe burden on the perinatal team and 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.
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.
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
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.
4. The main measures to be implemented as a result of the Significant Event Meeting are: Screen alerts on notes of mother/children under 2 where mother is under the care of the perinatal team (this has already been implemented); Patients under the care of the perinatal team to be discussed at practice monthly MDT meetings and child safeguarding meetings with the health visitors (this has already been implemented); Asking the perinatal team to send acknowledgement of receipt of our referral including whether it has been accepted as urgent or routine. We will write to them within 2 weeks of this Response Asking the Health Visitor team to inform the practice if they have referred a mother to the Perinatal Team. We will write to them within 2 weeks of this 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.
Dated this 29th day of January 2026
Signed:
Dr Blackburn, on behalf of Sett Valley Medical Centre, Hyde Bank Road, New Mills SK22 4BP
Action Planned
NHS England has invested £20 million to connect care records across England by March 2026 and is updating its Healthy Child Programme guidance to include requirements for information sharing and record keeping related to maternal and family health. Regional Chief Nurses will cascade this updated guidance to Trusts. (AI summary)
NHS England has invested £20 million to connect care records across England by March 2026 and is updating its Healthy Child Programme guidance to include requirements for information sharing and record keeping related to maternal and family health. Regional Chief Nurses will cascade this updated guidance to Trusts. (AI summary)
View full response
Dear Coroner, Re: Regulation 28 Report to Prevent Future Deaths – Hannah Louise Booth who died on 6 January 2025.
Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 9 December 2025 concerning the death of Hannah Louise Booth on 6 January 2025. In advance of responding to the specific concerns raised in your Report, I would like to express my deep condolences to Hannah’s family and loved ones. NHS England is keen to assure the family and yourself that the concerns raised about Hannah’s care have been listened to and reflected upon.
Your Report raises the following concerns:
1. If perinatal mental health services had 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.
2. There was no single electronic patient record accessible to all services as the perinatal mental health and the health visitors did not use the same electronic patient record.
3. There are no policies, guidance or any shared understanding between services of what might be relevant information to be shared and when.
4. There are no policies or guidance regarding when information potentially relevant to both mother and baby should be placed in both records and cross referenced.
Single Electronic Patient Record 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.
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 National Medical Director NHS England Wellington House 133-155 Waterloo Road London SE1 8UG
23rd January 2026
care has been delivered, and will enable seamless access to information across all care settings, including primary, acute and community services.
Perinatal Mental Health Support and Guidance
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.
Healthcare professionals are encouraged to seek advice from their local specialist perinatal mental health team as required to support assessment, risk management, and care planning. All healthcare systems are expected to have clear and documented local perinatal mental health pathways in place.
The National Institute of Health and Care Excellence (NICE) has published guidance on antenatal and postnatal mental health (NICE QS115), which recommends routine enquiry about emotional wellbeing at every antenatal and postnatal contact, recognising that risk can change over time. Where a red flag is identified, urgent discussion with the Specialist Perinatal Community Mental Health Team is required, with crisis services accessible outside of normal working hours where necessary. All assessments, identified risks and actions taken are to be documented.
Sharing of information between services
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.
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.
We are therefore working across the health system to support greater integration and awareness of record sharing between providers. We are also working with the SCR Programme to support wider access to relevant patient information.
At present, Integrated Care Boards (ICBs) are responsible for the commissioning, implementation and integration of primary care solutions.
The newly published Fit for the future: 10 year Health Plan for England, which sets out the government’s plan for healthcare in England over the next 10 years, also includes a commitment to give patients a ‘single, secure and authoritative account of their data
– a single patient record – to enable more coordinated, personalised and predictive care’. Alongside this, the 10 year Health Plan emphasises working towards the Single Patient Record (SPR) with the Maternity First approach, which prioritises the perinatal period. The SPR introduces new concepts such as being able to ‘red flag’ a contact with a health visitor, which then becomes part of the same medical record seen by the GP.
Placing relevant information in both mother and baby records
In regard to your concern that there are no policies or guidance that advise when information potentially relevant to both mother and baby should be placed in both records or cross referenced, the current position is that parents and children must have their own separate records which should not be merged (NHS Records Management Code of Practice).
Clinical information that impacts care should be documented in the record where it supports ongoing care and decision making. If information in one record (e.g. the mother’s mental health) is relevant to another record (e.g. safeguarding a baby’s welfare), clinicians should either document that it has been shared (and with whom and why) in both records, or provide a summary/cross reference in the other record based on clinical need and consent. Discussions regarding consent and confidentiality and decisions about information sharing should also be clearly documented.
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.
Maternal health information being hidden in the baby’s records is a known risk that the ‘Born Digital’ ambitions for the 10 year Health Plan aims to address. This includes the introduction of a link between mother and baby from the first maternity booking. By forming this link at the start of the SPR, this should ensure that the mother-baby relationship is treated as a single clinical entity, allowing a clinician viewing either record to make alterations or updates for relevant health markers.
Another new development is to include The Personal Child Health Record (The Red Book) in the NHS App as part of the SPR, thus allowing any flags entered into the Red Book to flag into the mother’s record as well, subject to the usual governance and safeguarding requirements.
Sharing of information by Health Visitors
The Department of Health and Social Care (DHSC) is due to publish refreshed Healthy Child Programme guidance in early February 2026. Thei current guidance highlights the importance of continuity of care by a named health visitor, particularly during the antenatal and immediate postnatal period. This can help to mitigate against contact being seen in isolation, as the health visitor develops a relationship with and an understanding of the individual family’s needs, building a holistic picture. This
continuity of care also supports earlier identification, combining the assessment skills of the health visitor and the confidence of the parent(s) to share concerns.
Health professionals have a legal duty to share patient information where they consider it to be in the patient’s best interests. This is essential for safe coordinated clinical care. The Healthy Child Programme guidance reflects these requirements to share information as well as those related to record keeping.
The guidance also includes a High Impact Area on Supporting Maternal and Family Health, which sets out the heightened risks during the antenatal and postnatal period, expectations around working in partnership with other services, continuity of care with midwifery services and the importance of assessing maternal (and paternal) mental health at every contact.
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.
Regional Oversight
NHS England’s Midlands Region have been informed by Derby and Derbyshire ICB that they are committed to working with NHS England on the areas that extend beyond their organisational influence. In particular, the matter of concern related to the cross-referencing of information in the records of mother and baby, which will have a national impact.
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.
Thank you for bringing these important patient safety issues to my attention and please do not hesitate to contact me should you need any further information.
Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 9 December 2025 concerning the death of Hannah Louise Booth on 6 January 2025. In advance of responding to the specific concerns raised in your Report, I would like to express my deep condolences to Hannah’s family and loved ones. NHS England is keen to assure the family and yourself that the concerns raised about Hannah’s care have been listened to and reflected upon.
Your Report raises the following concerns:
1. If perinatal mental health services had 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.
2. There was no single electronic patient record accessible to all services as the perinatal mental health and the health visitors did not use the same electronic patient record.
3. There are no policies, guidance or any shared understanding between services of what might be relevant information to be shared and when.
4. There are no policies or guidance regarding when information potentially relevant to both mother and baby should be placed in both records and cross referenced.
Single Electronic Patient Record 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.
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 National Medical Director NHS England Wellington House 133-155 Waterloo Road London SE1 8UG
23rd January 2026
care has been delivered, and will enable seamless access to information across all care settings, including primary, acute and community services.
Perinatal Mental Health Support and Guidance
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.
Healthcare professionals are encouraged to seek advice from their local specialist perinatal mental health team as required to support assessment, risk management, and care planning. All healthcare systems are expected to have clear and documented local perinatal mental health pathways in place.
The National Institute of Health and Care Excellence (NICE) has published guidance on antenatal and postnatal mental health (NICE QS115), which recommends routine enquiry about emotional wellbeing at every antenatal and postnatal contact, recognising that risk can change over time. Where a red flag is identified, urgent discussion with the Specialist Perinatal Community Mental Health Team is required, with crisis services accessible outside of normal working hours where necessary. All assessments, identified risks and actions taken are to be documented.
Sharing of information between services
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.
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.
We are therefore working across the health system to support greater integration and awareness of record sharing between providers. We are also working with the SCR Programme to support wider access to relevant patient information.
At present, Integrated Care Boards (ICBs) are responsible for the commissioning, implementation and integration of primary care solutions.
The newly published Fit for the future: 10 year Health Plan for England, which sets out the government’s plan for healthcare in England over the next 10 years, also includes a commitment to give patients a ‘single, secure and authoritative account of their data
– a single patient record – to enable more coordinated, personalised and predictive care’. Alongside this, the 10 year Health Plan emphasises working towards the Single Patient Record (SPR) with the Maternity First approach, which prioritises the perinatal period. The SPR introduces new concepts such as being able to ‘red flag’ a contact with a health visitor, which then becomes part of the same medical record seen by the GP.
Placing relevant information in both mother and baby records
In regard to your concern that there are no policies or guidance that advise when information potentially relevant to both mother and baby should be placed in both records or cross referenced, the current position is that parents and children must have their own separate records which should not be merged (NHS Records Management Code of Practice).
Clinical information that impacts care should be documented in the record where it supports ongoing care and decision making. If information in one record (e.g. the mother’s mental health) is relevant to another record (e.g. safeguarding a baby’s welfare), clinicians should either document that it has been shared (and with whom and why) in both records, or provide a summary/cross reference in the other record based on clinical need and consent. Discussions regarding consent and confidentiality and decisions about information sharing should also be clearly documented.
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.
Maternal health information being hidden in the baby’s records is a known risk that the ‘Born Digital’ ambitions for the 10 year Health Plan aims to address. This includes the introduction of a link between mother and baby from the first maternity booking. By forming this link at the start of the SPR, this should ensure that the mother-baby relationship is treated as a single clinical entity, allowing a clinician viewing either record to make alterations or updates for relevant health markers.
Another new development is to include The Personal Child Health Record (The Red Book) in the NHS App as part of the SPR, thus allowing any flags entered into the Red Book to flag into the mother’s record as well, subject to the usual governance and safeguarding requirements.
Sharing of information by Health Visitors
The Department of Health and Social Care (DHSC) is due to publish refreshed Healthy Child Programme guidance in early February 2026. Thei current guidance highlights the importance of continuity of care by a named health visitor, particularly during the antenatal and immediate postnatal period. This can help to mitigate against contact being seen in isolation, as the health visitor develops a relationship with and an understanding of the individual family’s needs, building a holistic picture. This
continuity of care also supports earlier identification, combining the assessment skills of the health visitor and the confidence of the parent(s) to share concerns.
Health professionals have a legal duty to share patient information where they consider it to be in the patient’s best interests. This is essential for safe coordinated clinical care. The Healthy Child Programme guidance reflects these requirements to share information as well as those related to record keeping.
The guidance also includes a High Impact Area on Supporting Maternal and Family Health, which sets out the heightened risks during the antenatal and postnatal period, expectations around working in partnership with other services, continuity of care with midwifery services and the importance of assessing maternal (and paternal) mental health at every contact.
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.
Regional Oversight
NHS England’s Midlands Region have been informed by Derby and Derbyshire ICB that they are committed to working with NHS England on the areas that extend beyond their organisational influence. In particular, the matter of concern related to the cross-referencing of information in the records of mother and baby, which will have a national impact.
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.
Thank you for bringing these important patient safety issues to my attention and please do not hesitate to contact me should you need any further information.
Action Planned
Derby and Derbyshire ICB is working to remove barriers to information sharing by establishing system-wide information governance agreements and applying for Section 251 agreements by Q1 26/27. The ICB will also work with partner Trusts to ensure relevant guidance on information sharing and cross-referencing mother and baby notes is provided by Q1 26/27. (AI summary)
Derby and Derbyshire ICB is working to remove barriers to information sharing by establishing system-wide information governance agreements and applying for Section 251 agreements by Q1 26/27. The ICB will also work with partner Trusts to ensure relevant guidance on information sharing and cross-referencing mother and baby notes is provided by Q1 26/27. (AI summary)
View full response
Dear Madam
HANNAH BOOTH: REGULATION 28 REPORT RESPONSE
I am writing in response to the Regulation 28 Report dated 9 December 2025, following the inquest into the death of Hannah Louise Booth. The Regulation 28 Report was addressed to Sett Valley Medical Centre, Derbyshire Community Health Services NHS Foundation Trust, Derbyshire Healthcare NHS Foundation Trust, NHS Derby and Derbyshire Integrated Care Board (DDICB), and NHS England.
At the outset, and in the knowledge that this report will be read more widely, I want to extend my personal condolences to the family of Hannah Booth and reiterate the ICB’s condolences.
Derby and Derbyshire ICB Response
We acknowledge the Matters of Concern you raise and have taken them seriously. We have considered whether there are improvements which we as an integrated care board can make as part of our statutory responsibilities. Discussions have taken place between the ICB and relevant system partners and providers, including with the two Foundation Trusts also referenced in this Report.
DDICB notes the coronial concern around difficulties encountered because different IT systems were being used for record keeping in different services; essentially a lack of a shared patient record between health visitor teams and primary care providers. We acknowledge and recognise this difficulty at scale, which is compounded in this case by differences in commissioning arrangements (primary care is commissioned by the NHS ICB, whereas health visiting is commissioned by Derbyshire County Council).
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
primary and secondary healthcare use. Our current expectation is that S251 agreements will be approved by relevant national bodies in Q1 26/27.
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.
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.
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.
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.
HANNAH BOOTH: REGULATION 28 REPORT RESPONSE
I am writing in response to the Regulation 28 Report dated 9 December 2025, following the inquest into the death of Hannah Louise Booth. The Regulation 28 Report was addressed to Sett Valley Medical Centre, Derbyshire Community Health Services NHS Foundation Trust, Derbyshire Healthcare NHS Foundation Trust, NHS Derby and Derbyshire Integrated Care Board (DDICB), and NHS England.
At the outset, and in the knowledge that this report will be read more widely, I want to extend my personal condolences to the family of Hannah Booth and reiterate the ICB’s condolences.
Derby and Derbyshire ICB Response
We acknowledge the Matters of Concern you raise and have taken them seriously. We have considered whether there are improvements which we as an integrated care board can make as part of our statutory responsibilities. Discussions have taken place between the ICB and relevant system partners and providers, including with the two Foundation Trusts also referenced in this Report.
DDICB notes the coronial concern around difficulties encountered because different IT systems were being used for record keeping in different services; essentially a lack of a shared patient record between health visitor teams and primary care providers. We acknowledge and recognise this difficulty at scale, which is compounded in this case by differences in commissioning arrangements (primary care is commissioned by the NHS ICB, whereas health visiting is commissioned by Derbyshire County Council).
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
primary and secondary healthcare use. Our current expectation is that S251 agreements will be approved by relevant national bodies in Q1 26/27.
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.
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.
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.
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.
Action Taken
Derbyshire Community Health Services NHS FT has incorporated guidance into their Perinatal Mental Health SOP for cross-referencing child and parent records when information is relevant to parental mental health, and implemented an auto-consultation function in SystmOne for this purpose. Locality Managers have been briefed, and a one-page document on record keeping has been shared with staff. (AI summary)
Derbyshire Community Health Services NHS FT has incorporated guidance into their Perinatal Mental Health SOP for cross-referencing child and parent records when information is relevant to parental mental health, and implemented an auto-consultation function in SystmOne for this purpose. Locality Managers have been briefed, and a one-page document on record keeping has been shared with staff. (AI summary)
View full response
Dear Ms. Evans I am writing in response to the Regulation 28 Report dated 9 December 2025, following the inquest into the death of Ms. Hannah Booth. May I first begin on behalf of the Trust by conveying my condolences to the family of Hannah for their loss. At the conclusion of the Inquest, you identified three areas of corner; firstly, difficulties encountered because different IT systems were being used for record keeping in different services. Essentially a lack of a single patient record. The second area of concern was a lack of shared understanding of what is relevant information and needs to be made available to other services. The third area of concern was that relevant notes being made in records of baby and not repeated in notes of the mother. I would like to assure you that we take the outcome of this inquest extremely seriously and we have undertaken a review as a Trust and also discussed this matter with Derbyshire Healthcare NHS Foundation Trust (DHCFT) Perinatal Mental Health team to ensure we can work more collaboratively moving forward. We have consequently agreed to some actions. I will address each issue you have highlighted in turn. Different IT systems. Lack of a single patient record:
The Trust has given careful consideration to the coroner’s first area of concern relating to the absence of a single, shared electronic patient record across organisations using different IT systems. 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. Within Derbyshire, the majority of NHS provider services, including DCHS, utilise SystmOne as their electronic patient record system. The Trust does not have the authority to mandate the system used by independent GP practices or to require system-wide interoperability across different platforms. 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. The Trust provides a universal Health Visiting Service for all children and young people aged 0-5 years residing within the Trust’s area. Health visiting is not a referral-based service. Every child within this age range is open to the Health Visiting Service by default, and this remains the case even where contact is declined by parents or carers. As such, all GP practices are aware that any child registered at their surgery will be known to the Health Visiting Service. Where GP practices use SystmOne, they are able to access the Health Visiting record directly, subject to appropriate role-based access and information governance permissions. For GP practices using alternative clinical systems, awareness of the child’s health visiting involvement is maintained through established professional communication routes. In addition, the Trust operated a GP liaison model whereby each GP practice is linked with a named Health Visitor, and regular liaison meetings take place at least every 8 weeks. These meetings support information sharing, professional dialogue, and discussion of relevant clinical cases. 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. Lack of shared understanding of what is relevant information and needs to be made available to other services: On the 20th of January 2026, senior representatives from the Health Visiting Service (DCHS) and the Perinatal Mental Health Service (DHCFT) met to consider the coroner’s concerns, with a specific focus on information sharing between services.
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. It was further agreed that where a patient is already open to the Perinatal Mental Health Service, relevant contextual information identified by the Health Visiting Service, such as repeated contacts relating to parental concerns of child development, should be proactively shared via the advice line. This approach is intended to support a more holistic understanding of the family’s circumstances and ensure that emerging concerns are considered within the wider clinical picture. 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: The purpose of the advice line When and how it should be used. The types of information and concerns that should be shared. This infographic will include practical examples of concerns raised by parents that would warrant contact with the Perinatal Mental Health Service. Once finalised, it will be circulated and made available to all Health Visiting Staff. 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). 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. In addition, the Perinatal Mental Health Service shared information about its multidisciplinary team (MDT) meetings and agreed that the Health Visiting Service could contribute to these discussions where appropriate. This will further support shared understanding, improve collaborative working, and ensure families receive coordinated and appropriate support. The Health Visiting staff have also been offered the opportunity to observe MDT meetings as a learning opportunity. These meetings are held weekly and involve consultants, psychiatrists, perinatal mental health staff, and now health visitors, to discuss complex cases. The Perinatal Mental Health Service will also be invited to attend Health Visiting Service preceptorship sessions, which are structured support and development sessions for newly qualified health visitors. The team has agreed to deliver a session outlining their role, referral pathways, and how our service can effectively engage with them. This will be delivered as a discussion-based session incorporating case examples and a question-and-answer element. Additionally, the Perinatal Mental Health service will attend Health Visiting locality meetings on an ad hoc basis and
contribute to selected annual skills development days. Dates for these sessions are to be agreed and will be discussed further at the meeting on the 23rd of February 2026. 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. 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 the sharing of relevant information. Relevant notes being made in records of baby and not repeated in notes of the mother: 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. In response to the coroner’s concerns raised, the service has taken steps to clarify expectations for staff and to strengthen record keeping within parental records. Where information arises in the context of child contact but is also relevant to parental mental health, staff are required to ensure this information is cross-referenced and documented in both the child’s and the parent’s records. This ensures that relevant information is visible and accessible to professionals reviewing either record, and reduces the risk of important contextual details being missed. 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. 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. Locality Managers have been briefed on the findings of the inquest and the learning identified. Strengthening documentation within parental records has been identified as
a priority area for education and professional development, and this will be reinforced through training and supervision. 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. We hope that the above goes some way to address your concerns, and we thank you for the opportunity to review our systems and processes to improve patient care. If you require any further information, please do not hesitate to contact us.
The Trust has given careful consideration to the coroner’s first area of concern relating to the absence of a single, shared electronic patient record across organisations using different IT systems. 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. Within Derbyshire, the majority of NHS provider services, including DCHS, utilise SystmOne as their electronic patient record system. The Trust does not have the authority to mandate the system used by independent GP practices or to require system-wide interoperability across different platforms. 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. The Trust provides a universal Health Visiting Service for all children and young people aged 0-5 years residing within the Trust’s area. Health visiting is not a referral-based service. Every child within this age range is open to the Health Visiting Service by default, and this remains the case even where contact is declined by parents or carers. As such, all GP practices are aware that any child registered at their surgery will be known to the Health Visiting Service. Where GP practices use SystmOne, they are able to access the Health Visiting record directly, subject to appropriate role-based access and information governance permissions. For GP practices using alternative clinical systems, awareness of the child’s health visiting involvement is maintained through established professional communication routes. In addition, the Trust operated a GP liaison model whereby each GP practice is linked with a named Health Visitor, and regular liaison meetings take place at least every 8 weeks. These meetings support information sharing, professional dialogue, and discussion of relevant clinical cases. 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. Lack of shared understanding of what is relevant information and needs to be made available to other services: On the 20th of January 2026, senior representatives from the Health Visiting Service (DCHS) and the Perinatal Mental Health Service (DHCFT) met to consider the coroner’s concerns, with a specific focus on information sharing between services.
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. It was further agreed that where a patient is already open to the Perinatal Mental Health Service, relevant contextual information identified by the Health Visiting Service, such as repeated contacts relating to parental concerns of child development, should be proactively shared via the advice line. This approach is intended to support a more holistic understanding of the family’s circumstances and ensure that emerging concerns are considered within the wider clinical picture. 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: The purpose of the advice line When and how it should be used. The types of information and concerns that should be shared. This infographic will include practical examples of concerns raised by parents that would warrant contact with the Perinatal Mental Health Service. Once finalised, it will be circulated and made available to all Health Visiting Staff. 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). 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. In addition, the Perinatal Mental Health Service shared information about its multidisciplinary team (MDT) meetings and agreed that the Health Visiting Service could contribute to these discussions where appropriate. This will further support shared understanding, improve collaborative working, and ensure families receive coordinated and appropriate support. The Health Visiting staff have also been offered the opportunity to observe MDT meetings as a learning opportunity. These meetings are held weekly and involve consultants, psychiatrists, perinatal mental health staff, and now health visitors, to discuss complex cases. The Perinatal Mental Health Service will also be invited to attend Health Visiting Service preceptorship sessions, which are structured support and development sessions for newly qualified health visitors. The team has agreed to deliver a session outlining their role, referral pathways, and how our service can effectively engage with them. This will be delivered as a discussion-based session incorporating case examples and a question-and-answer element. Additionally, the Perinatal Mental Health service will attend Health Visiting locality meetings on an ad hoc basis and
contribute to selected annual skills development days. Dates for these sessions are to be agreed and will be discussed further at the meeting on the 23rd of February 2026. 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. 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 the sharing of relevant information. Relevant notes being made in records of baby and not repeated in notes of the mother: 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. In response to the coroner’s concerns raised, the service has taken steps to clarify expectations for staff and to strengthen record keeping within parental records. Where information arises in the context of child contact but is also relevant to parental mental health, staff are required to ensure this information is cross-referenced and documented in both the child’s and the parent’s records. This ensures that relevant information is visible and accessible to professionals reviewing either record, and reduces the risk of important contextual details being missed. 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. 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. Locality Managers have been briefed on the findings of the inquest and the learning identified. Strengthening documentation within parental records has been identified as
a priority area for education and professional development, and this will be reinforced through training and supervision. 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. We hope that the above goes some way to address your concerns, and we thank you for the opportunity to review our systems and processes to improve patient care. If you require any further information, please do not hesitate to contact us.
Sent To
- Derbyshire Community Health Services NHS Foundation Trust
- Derbyshire Healthcare NHS Foundation Trust
- NHS Derby & Derbyshire Integrated Care Board
- NHS England
Response Status
Linked responses
5 of 5
All responses received
About PFD responses
Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Report Sections
Investigation and Inquest
On 10 January 2025 I commenced an investigation into the death of Hannah Louise BOOTH aged 42. The investigation concluded at the end of the inquest on 08 December 2025. The conclusion of the inquest was that: On the 6th of January 2025 Hannah Booth was found to have drowned in the Goyt River. She had sent a message earlier that morning evidencing her intention to take her own life. She had given birth to her daughter on 15th of July 2024 and had subsequently been diagnosed with post-natal depression. She had expressed unfounded concerns regarding maternal bonding, the health and development of her baby and that she herself might be detrimentally affecting that development. Her concerns remained, and were echoed in her final message, despite reassurance from healthcare professionals that there was no evidential basis for any of them.
Circumstances of the Death
1. Hannah Booth became pregnant after having IVF and gave birth to her daughter on the 15th of July 2024. She described the birth as traumatic. She was diagnosed with post-natal depression. She had a previous history of an eating disorder, and her mother had died after taking her own life.
2. On the 25th of November Hannah had a consultation with a GP at Sett Valley Medical centre due to her concerns regarding lack of sleep, bonding with her daughter and her isolation from other new mums. Hannah spoke of thoughts of self-harm however had no specific intentions or suggestions of self-harm and said she would not leave her daughter who relied on her for feeding. An urgent referral was made to the perinatal mental health CONTROLLED services because of Hannah’s low mood, her persistent inability to sleep, alongside her intrusive thoughts about death as well as her family and eating disorder history.
3. The referral was triaged by the perinatal mental health services, and it was treated as routine. There had been no further liaison with the GP regarding her reasons to have considered the referral urgent. Hannah was given an appointment for an initial focused assessment on 16th December, the result of which was to place her on a waiting list for a full ‘core’ assessment. She was offered nursery nurse support and the opportunity to attend a reflective programme looking at bonding and attachment. Hannah did not appear to want to engage with the reflective programme although she did contact the perinatal mental health services to speak to a nursery nurse due to her concerns around bonding. Her last contact with anyone from perinatal mental health services was on 24th December.
4. However, Hannah did contact the single point of contact for her health visitor on 27th December expressing concerns about her daughter’s development. She was offered a face-to-face appointment with them on 6th January 2025. Later the same day she sent a detailed text message to her health visitor expressing her anxieties about her daughter’s development and concerns that she might have had a negative impact on that development. Hannah’s appointment for 6th January was brought forward to the 2nd. The record of that text message was placed in her baby’s electronic patient records on SytmOne rather than on Hannah’s.
5. Hannah placed a further call to the single point of access for the health visitors on 30th January and spoke to a health visitor the following day, 31st December. The appointment for 2nd January remained.
6. The same day, 31st December, Hannah, her partner and her daughter saw a different GP (from the one that made the referral to perinatal mental health) within Sett Valley. Hannah raised concerns about the health and development of her daughter. The GP examined and observed the baby, discussed Hannah’s concerns and sought to reassure Hannah. It is evident that Hannah needed to be reassured more than once and appeared anxious. Up until this point in the consultation the GP had been documenting and considering only baby’s notes, however, the consultation shifted in focus to Hannah, due to her anxiety, and so her notes were then consulted. It was then evident that there had been a previous referral to the perinatal mental health services. The GP was unaware of any previous contact with the health visitor service about the same concerns. The contact had not been shared with Sett valley and Sett Valley did not use the same note recording system as the health visitors, SystmOne, and so did not have access to that information within the notes. The notes relating to the consultation on 31st were made by the GP on the baby’s patient records rather than Hannah’s. The perinatal mental health services were not informed of this consultation and as users of SystmOne, they did not CONTROLLED have access to this information from the notes.
7. During the planned home visit by a health visitor on the 2nd of January 2025 and during a telephone call ahead of that visit, Hannah raised essentially the same developmental concerns regarding her baby. These concerns were noted in baby’s patient records and not Hannah’s. Hannah’s contact with the health visitors was not raised or shared with any other service.
8. On the 6th of January 2025 Hannah sent a text message to her partner evidencing her intention to take her own life and echoing her previously raised concerns that she had detrimentally affected her daughter’s development. She was later found to have drowned in the river.
2. On the 25th of November Hannah had a consultation with a GP at Sett Valley Medical centre due to her concerns regarding lack of sleep, bonding with her daughter and her isolation from other new mums. Hannah spoke of thoughts of self-harm however had no specific intentions or suggestions of self-harm and said she would not leave her daughter who relied on her for feeding. An urgent referral was made to the perinatal mental health CONTROLLED services because of Hannah’s low mood, her persistent inability to sleep, alongside her intrusive thoughts about death as well as her family and eating disorder history.
3. The referral was triaged by the perinatal mental health services, and it was treated as routine. There had been no further liaison with the GP regarding her reasons to have considered the referral urgent. Hannah was given an appointment for an initial focused assessment on 16th December, the result of which was to place her on a waiting list for a full ‘core’ assessment. She was offered nursery nurse support and the opportunity to attend a reflective programme looking at bonding and attachment. Hannah did not appear to want to engage with the reflective programme although she did contact the perinatal mental health services to speak to a nursery nurse due to her concerns around bonding. Her last contact with anyone from perinatal mental health services was on 24th December.
4. However, Hannah did contact the single point of contact for her health visitor on 27th December expressing concerns about her daughter’s development. She was offered a face-to-face appointment with them on 6th January 2025. Later the same day she sent a detailed text message to her health visitor expressing her anxieties about her daughter’s development and concerns that she might have had a negative impact on that development. Hannah’s appointment for 6th January was brought forward to the 2nd. The record of that text message was placed in her baby’s electronic patient records on SytmOne rather than on Hannah’s.
5. Hannah placed a further call to the single point of access for the health visitors on 30th January and spoke to a health visitor the following day, 31st December. The appointment for 2nd January remained.
6. The same day, 31st December, Hannah, her partner and her daughter saw a different GP (from the one that made the referral to perinatal mental health) within Sett Valley. Hannah raised concerns about the health and development of her daughter. The GP examined and observed the baby, discussed Hannah’s concerns and sought to reassure Hannah. It is evident that Hannah needed to be reassured more than once and appeared anxious. Up until this point in the consultation the GP had been documenting and considering only baby’s notes, however, the consultation shifted in focus to Hannah, due to her anxiety, and so her notes were then consulted. It was then evident that there had been a previous referral to the perinatal mental health services. The GP was unaware of any previous contact with the health visitor service about the same concerns. The contact had not been shared with Sett valley and Sett Valley did not use the same note recording system as the health visitors, SystmOne, and so did not have access to that information within the notes. The notes relating to the consultation on 31st were made by the GP on the baby’s patient records rather than Hannah’s. The perinatal mental health services were not informed of this consultation and as users of SystmOne, they did not CONTROLLED have access to this information from the notes.
7. During the planned home visit by a health visitor on the 2nd of January 2025 and during a telephone call ahead of that visit, Hannah raised essentially the same developmental concerns regarding her baby. These concerns were noted in baby’s patient records and not Hannah’s. Hannah’s contact with the health visitors was not raised or shared with any other service.
8. On the 6th of January 2025 Hannah sent a text message to her partner evidencing her intention to take her own life and echoing her previously raised concerns that she had detrimentally affected her daughter’s development. She was later found to have drowned in the river.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.