Samarjit Singh

From Dr Dan Poulter MP
Parliamentary Under Secretary of State for Health

Department
Richmond House
of Health 79 Whitehall
Lond
POCS 864237 ewer
Mr André Rebello OBE Tel: 020 7210 4850

HMSenior Coroner for the Wirral
Coroner’s Office |
St George’s Hall ;
St George’s Place i
Liverpool \
LI 1JJ

21 3UL 201%

5

Der rr Cbshho,

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 of her 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 of a wider

network of services that provide care for this patient group and the commissioning of the
‘specialist’ (local) and ‘specialised’ (national) pathway is a responsibility shared between

NHS England, Clinical Commissioning Groups and Local Authorities.

As local Perinatal Mental Health Services are commissioned by Clinical Commissioning
Groups, we are unable to provide a response to the first of your 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 of patients needing treatment is
low 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
a regional, rather than local, basis. This ensures that those very specialised qualifications,
clinical skills and experience required to treat the patient group can. be maintained and that
the service can be commissioned cost-effectively, making best use of public funds. If there
were to be a Mother and Baby unit in every major city, the use of the service by that city’s
population would be minimal and clinicians would quickly lose their specialist knowledge
and skills because of infrequent use. It would also be inefficient because of the low demand.

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’s 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’s parity of esteem
initiative - the principle by which mental health must be given equal priority to physical
health.

To this end, I have copied this correspondence to Jane Cummings who is Chief Nursing
Officer for England to draw her attention to this important issue and so that she can consider
how awareness can be raised with CCGs through their current work programme.

I hope that this response is helpful and I thank you for bringing the circumstances of Mrs
Singh‘s death to our attention.

Buk Wi,

DR DAN POULTER

NHS

: Wirral Clinical Commissioning Group

Ref: WCCG/PN/CCIJS/

NHS Wirral Clinical Commissioning Group.

24" June 2014 Old Market House
Hamilton Street

Birkenh
Mr André Rebello ; m atta
St George's Hall f CH41 5AL

St George’s Place
Liverpool i
L1 1JJ i

Your Ref: DR 01441/2012
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 1 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 Conyissioni ich sits with NHS England. NHS
England has.set up Strategic Clinical Networks or ll had been appointed as Clinical
Network Lead (Maternity Services) for Cheshire & Merseyside Strategic Clinical Network for Maternit
Children & Young People; we are in the process of contacting a along ‘(h

to ensure that your second concern, regarding the commissioning of inpatient units, is
discussed at the next available regional Perinatal Group, and that the commissioning of these units is
discussed in light of this incident and the risks highlighted. We will. continue to work with NHS England
to ensure a partnership approach to this issue, with the aim of achieving seamless patient care across
the whole pathway.

In response to notification of the serious incident, and pending the outcome of the full investigation by
all partners, in March 2013 a 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

Tel: 0151 651 0011
WICGG .InTouch@nhs.net

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 (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 1 | 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).

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 1 | Specialist skills and capacity | Led by Specialist Perinatal Health Visitor
within Health Visiting.
Clinical Networks e NHS England have set up a regional_Perinatal

Interest Group which is chaired by |
(WUTH)
e 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.

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:

e 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.

e 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.

e Additional Consultant Psychiatrist input to be recruited to provide authority and clinical
leadership to the team and would develop and co-ordinate the Wirral Perinatal MH pathway.

Progress made to date

NHS England has set up a regional Perinatal Interest Group aie
and a 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 15" 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 midwives 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 APT, which is due to go out for tender with a new service starting in April
2015.

Actions in Progress

We are currently revising the service specification for the Liaison Psychiatry service commissioned for
Wirral patients. This will include provision for dedicated consultant psychiatrist time to develop and
oversee the perinatal mental health pathway.

It is acknowledged that progress has not been made as quickly as originally anticipated, and as
required by the gravity of this case. As such, following this Regulation 28 notice, the CCG can provide
assurance to the Coroner and to all parties involved that the development of an integrated pathway
will become a high priority for the CCG during 2014/15. We will require this integrated pathway to be
in place, led by the Consultant Psychiatrist, by the end of the calendar year 2014.

| 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.

’

.

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

Yours sincerely

Acting Chair
NHS Wirral Clinical Commissioning Group

Chair: Dr Phil Jennings
Chief Clinical Officer: Dr Abhi Mantgani