Dear Mr Rebello_ We are writing in response to the Regulation 28 report received in relation to Samarjit Natasha Singh, on behalf of NHS Wirral CCG. The response primarily focusses on Point of your report; namely: There was no Specialist Community Perinatal Mental Health service in the Wirral to meet both her son's and her needs: The treatment that was available was sub-optimal. With regards to the second point that you raise, the commissioning of mother and baby units is within the commissioning responsibility of Specialised Commissioning_which sits with NHS England NHS England has set up Strategic Clinical Networks and had'been appointed as Clinical Network Lead (Maternity Services) for Cheshire & Merseyside Stratedic Clinical Network for Maternity Children & Young People; we are in the process of contacting along withl_ to ensure that your second concern, regarding the commissioning of inpatient units, is discussed at the next available regional Perinatal Group, and that the commissioning of these units is discussed in light of this incident and the risks highlighted. We will continue to work with NHS England to ensure partnership approach to this issue, with the aim of achieving seamless patient care across the whole pathway In response to notification of the serious incident, and pending the outcome of the full investigation by all partners; in March 2013 working group' was established to review the current perinatal mental health pathway on Wirral, It was ascertained that there had been a wide number of individuals and teams involved in the care of perinatal women, including: consultant psychiatrist; staff grade psychiatrist perinatal specialist midwife, clinical consultant specialist nurse_ perinatal mental health midwife, specialist perinatal midwife After reviewing guidance issued by the Joint Commissioning Panel for Mental Health (2012) on commissioning perinatal mental health services, the working group undertook a gap analysis against existing service provision: Table. reviewing current provision against Joint Commissioning Panel for: Mental Health (2012) on key commissioning principles for perinatal mental health services National guidance Local provision Group 24th RUmgR

Tier 4 Specialised in patient mother Commissioned regionally by NHS England with beds and baby units available in a Mother and Bay Unit in Manchester: Tier 3 Specialised community Teams providing input individually, but not in a co-ordinated perinatal mental health teams way Tier 3 Parenting and infant mental In place between CWP and Local Authority health teams Tier 3 Clinical psychological Led by (in hours- CWP) and the Liaison services linked to maternity Psychiatric team (out of hours CWP): hospitals Tier 2 Specialist skills and capacity One Perinatal Midwife and a Perinatal Health Visitor (WUTH within Maternity services and Community Trust) Tier 2 Specialist skills and capacity Consultant Psychiatrist and Staff grade psychiatrist and within general adult services specialist nurse within Liaison Psychiatry _ Tier Specialist skills and capacity IAPT providers are to provide an urgent response to within IAPT perinatal women but there is no requirement for specialist skills. Shortly out to tender for IAPT services and will be requiring staffing complement to include specialist skills within this area)_ Tier Specialist skills and capacity There are no identified GPs with specialist skills within within general practice and primary care Support within the extended primary care the extended primary care team is led by Specialist Perinatal Midwives team Tier Specialist skills and capacity Led by Specialist Perinatal Health Visitor within Health Visiting: Clinical Networks NHS England have set up regional Perinata Interest Group which is chaired by kWUTH) Merseyside Special Interest Group which is chaired byl Wirral CCG is working with both of these Chairs and their groups to agree how to improve the provision for the perinatal pathway particularly between Tier 3 services and those of Tier 4_ Despite these individuals coming together in a multiagency special interest group chaired by an Adult Psychiatrist; along with representation other mental health services, midwifery providers and family nurse partnerships, it was clear that there had been a lack of cO-ordination and integration of pathway: The most significant gaps appear to be the lack of cO-ordination between tiers, the single Perinatal Midwife, and the lack of identified specialist skills within primary care_ As such, the working group made the following priority recommendations to the CCG:

an additional Perinatal Midwife should be recruited as a secondment opportunity for 6-12 months on a rolling basis from within existing workforce to skill up all midwives and to allow for postnatal appointments to be given, continuity of care, annual leave, teaching and clinical supervision to be undertaken: Thus supporting the Tier 2 provision and allowing post natal care to be also given_ All individuals involved in perinatal care to be part of a co-ordinated, integrated pathway, and for full understanding of each professional's role within a woman's care. Additional Consultant Psychiatrist input to be recruited to provide authority and clinical leadership to team and would develop and co-ordinate the Wirral Perinatal MH pathway Progress made_to date NHS England has set up regional Perinatal Interest Group which is chaired and Merseyside Special Interest Group which is chaired by Wirral CCG is working with both of these Chairs and their groups to agree how to improve the provision for the perinatal pathway particularly between Tier 3 services and those of Tier 4 The additional post of a perinatal mental health midwife was approved by the CCG Operational Group on 15th October 2013; this post has now been recruited to (May 2014) and is employed by Wirral University Teaching Hospital. In total there are now two perinatal mental health midwivves employed. These posts will provide further support and will be on a rotational basis from the existing workforce in order to skill up all midwives in this specialised area, and to provide full cover throughout the year_ The provision for urgent access to psychological therapies was already included in IAPT Provider contracts; however , this case has been raised and discussed with the IAPT providers, who have been informed of the need to liaise with the other professionals who are likely to be involved with the other professionals involved in the lady's care_ The requirement for specialist staff has been included within the new specification for IAPT, which is due to go for tender with a new service starting in April
2015. Actions in Progress are currently revising the service specification for the Liaison Psychiatry service commissioned for Wirral patients_ This will include provision for dedicated consultant psychiatrist time to develop and oversee the perinatal mental health pathway: It is acknowledged that progress has not been made as quickly as originally anticipated, and as required by the gravity of this case. As such; following this Regulation 28 notice, the CCG can provide assurance to the Coroner and to all parties involved that the development of an integrated pathway will become high priority for the CCG during 2014/15. We will require this integrated pathway to be in place, led by the Consultant Psychiatrist; by the end of the calendar year 2014. hope that this response provides you with assurance that the CCG has identified that there is potential to improve the pathway for care of perinatal women, and has taken steps to start to address this: As a CCG we are committed to continuing and enhancing the pace of this piece of work, with the aim of an integrated pathway for the mental health care of perinatal women by 2015. the out We

Please do not hesitate to contact me should you require any further information

From Dr Dan Poulter MP Parliamentary Under Secretary of State for Health Department Richmond House of Health 79 Whitehall POCS 864237 London SWIA 2NS Tel: 020 7210 4850 Mr Andre Rebello OBE HMSenior Coroner for the Wirral Coroner' s Office 0537 St George's Hall L 4 JUL 2014 21JUL 2014 St George's Place Liverpool X #1 GONER Ll IJJ Qev N Qusekko Thank you for your letter to Jeremy Hunt about the death of Mrs Samarajit Singh: I am responding on his behalf; Your report advised that Mrs Singh committed suicide while suffering post natal depression, some 12 weeks after the birth ofher son. You raised two matters of concern in this case;
1. There are no specialist community perinatal health services in the Wirral and the treatment available was inadequate 2 There is no mother and baby perinatal mental health inpatient unit in the Liverpool City region: Specialised Perinatal Mental Health Services (Mother and Baby Units) are a part ofa wider network of services that provide care for this patient group and the commissioning of the 'specialist' (local) and *specialised' (national) pathway is a responsibility shared between NHS England, Clinical Commissioning Groups and Local Authorities. As local Perinatal Mental Health Services are commissioned by Clinical Commissioning Groups, we are unable to provide a response to the first ofyour concerns but I note you have sent a copy of your report to the commissioners in the Wirral who should be able to address this point: NHS England has had responsibility for commissioning the 'Specialised' element of this pathway (Mother and Baby in-patient Units) since April 2013.A specification for these specialised perinatal services was developed by the NHS England specialised perinatal Clinical Reference Group; which comprises representatives from across the country with both clinical members and patients/Carers The specification was subject to national consultation and NHS England work with the Royal College to develop quality standards

Specialised' services are those services where the incidence ofpatients needing treatment is and where the specialised qualifications, skills and experience required to treat the condition are scarce and in high demand. These services are often categorised as high cost and low volume_ Mother and Baby Units fall under this category of service and are therefore commissioned on regional, rather than local, basis This ensures that those very specialised qualifications, clinical skills and experience required to treat the patient group can be maintained and that the service can be commissioned cost-effectively, making best use of funds. If there were to be a Mother and Baby unit in every major city, the use of the service by that city' $ population would be minimal and clinicians would quickly lose their specialist knowledge and skills because of infrequent use. It would also be inefficient because of the low demand: The relevant Regional Unit for this particular speciality is based in Manchester but is open to, and used by, the whole population of the North West: The Unit has 10 beds which is sufficient to satisfy the needs of the North West'$ population, cost effectiveness and most importantly ensures clinically qualified, skilled and experienced interventions Additionally, it should be noted that the commissioning arrangements through NHS England ensure that; should a particular Regional Unit have no vacant beds at the time of need, or a patient does not wish to attend that particular Regional Unit; a bed in a neighbouring Regional Unit may be utilised However; I have noted your concerns and agree there is a need for strong linkage between the physical and mental health aspects of care in line with the government' $ parity of esteem initiative the principle by which mental health must be given equal priority to physical health: To this end, [ have copied this correspondence to Jane Cummings who is Chief Nursing Officer for England to draw her attention to this important issue and s0 that she can consider how awareness can be raised with CCGs through their current work programme. that this response is helpful and I thank you for bringing the circumstances of Mrs Singh*s death to our attention: 6 his DR DAN POULTER low public Ihope