Hannah Booth

Headquarters
Ash Green Learning Disability Centre
Ashgate Road
Ashgate
Chesterfield
S42 7JE

Ms. Susan Evans
Area Coroner for Derby and Derbyshire
St. Katherine’s house
St. Mary’s Wharf
Mansfield road
Derby
DE1 3TQ

Date: 26 January 2026

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.

Yours Sincerely

, Chief Executive

Derbyshire Community Health Services NHS Foundation Trust

Corporate Services 
Ashbourne Centre 
Kingsway Site 
Kingsway 
DERBY 
DE22 3LZ 

20 January 2026 

Susan Evans 
HM Area Coroner for Derby and Derbyshire 
Town Hall 
Rose Hill 
Chesterfield 
Derbyshire 
S40 1LP 

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. 

Trust Headquarters, Ashbourne Centre, Kingsway Hospital, Derby DE22 3LZ  
Tel: 01332 623700  

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 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. 

Yours sincerely  

CHIEF EXECUTIVE 

Enc. Action Plan

Susan Evans 
HM Area Coroner 
Derby and Derbyshire Coroner’s Service  
St Katherine’s House 
St Mary’s Wharf  
Mansfield Road 
Derby  
DE1 3TQ 

National Medical Director  
NHS England  
Wellington House 
133-155 Waterloo Road  
London 
SE1 8UG 

23rd January 2026  

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 

                                                                                                                       
 
 
 
 
 
  
 
  
 
 
 
 
  
 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.  

Yours sincerely,  

National Medical Director  
NHS England

Derby and Derbyshire Integrated Care Board 
First Floor 
The Council House 
Corporation Street 
Derby 
DE1 2FS 

15 January 2026 

PRIVATE AND CONFIDENTIAL 
Ms Susan Evans 
HM Area Coroner for Derby and Derbyshire 
St Katherine’s House 
St Mary’s Wharf 
Mansfield Road 
Derby 
DE1 3TQ 

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. 

Yours sincerely 

Executive Director of Outcomes (Medical) 
Derby and Derbyshire ICB, Lincolnshire ICB, Nottingham and Nottinghamshire ICB

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