Hannah Booth

IN THE CHESTERFIELD CORONER’S COURT

BEFORE HIS MAJESTY’S CORONER FOR DERBY & DERBYSHIRE

THE INQUEST TOUCHING THE DEATH OF HANNAH LOUISE BOOTH

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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

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.

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.