A coroner said future deaths could occur if no action is taken
A report to prevent future deaths has been published(Image: Derby Telegraph)
Future deaths may occur unless action is taken by a number of local healthcare authorities following the death of a woman in a Derbyshire river earlier this year, a coroner has said
Hannah Booth was found to have drowned in the Goyt River on January 6 after sending a text message that morning implying that she intended to take her own life.
The 42-year-old’s death came less than one year after the birth of her daughter in July 2024, and she had subsequently been diagnosed with postnatal depression.
Months earlier, on November 25 last year, Hannah had a consultation with a GP at Sett Valley Medical Centre in New Mills due to concerns over lack of sleep, bonding with her daughter and isolation from new mums.
Due to self-harm concerns, an urgent referral was made to the perinatal mental health services because of Hannah’s low mood, which was triaged by the perinatal mental health services and treated as routine.
There had been no further liaison with the GP regarding her reasons for considering the referral urgent.
Hannah was given an appointment for an assessment on December 16, which resulted in her being put on a waiting list for a full ‘core’ assessment.
She was offered nursery nurse support and the opportunity to attend a reflective programme.
Although Hannah did not appear to want to engage with the reflective programme, she did contact the perinatal mental health services to speak to a nurse due to her concerns about bonding.
Her last contact with anyone from perinatal mental health services was on December 24.
On December 27, however, Hannah contacted expressing concerns about her daughter’s development.
She was offered a face-to-face appointment with them on January 6, and later that day she sent a detailed text message to her health visitor expressing her anxieties about her daughter’s development – and concerns that she might have had a negative impact on that development.
Hannah’s January 6 appointment was brought forward four days to January 2, and the record of that text message was placed in her baby’s electronic patient records on SytmOne rather than on Hannah’s.
Hannah placed a further call to the health visitors on December 30, and spoke to a health visitor the following day, on December 31. The appointment for January 2 remained.
Later on December 31, Hannah, her partner and her daughter saw a different GP (from the one who made the referral to perinatal mental health) within Sett Valley.
Hannah raised concerns about the health and development of her daughter, and the GP examined and observed the baby, discussing Hannah’s concerns and attempting to reassure her.
Up until this point in the consultation, the GP had been documenting and considering only the baby’s notes, however, the consultation shifted in focus to Hannah, due to her anxiety, and so her notes were then consulted.
It was then evident that there had been a previous referral to the perinatal mental health services, however the GP was unaware of any previous contact with the health visitor service about the same concerns.
The contact had not been shared with Sett Valley, and Sett Valley did not use the same note recording system as the health visitors, SystmOne, so they did not have access to that information within the notes.
The notes relating to the consultation on December 31 were made by the GP on the baby’s patient records rather than Hannah’s.
The perinatal mental health services were not informed of this consultation and, as users of SystmOne, they did not have access to this information from the notes.
During the planned home visit on January 2 and during a telephone call ahead of that visit, Hannah raised similar developmental concerns regarding her baby.
These concerns were noted in the baby’s patient records and not Hannah’s. Hannah’s contact with the health visitors was not raised or shared with any other service.
Then, on January 6, Hannah sent a text message to her partner, evidencing her intention to take her own life and echoing her previously raised concerns that she had detrimentally affected her daughter’s development. She was later found to have drowned in the river.
Derby and Derbyshire Coroner, Susan Evans, has now published a Prevention of Future Deaths report following Hannah’s death, stating that the investigation into her death revealed “matters giving rise to concern.”
She added: “In my opinion, there is a risk that future deaths could occur unless action is taken.”
The coroner listed three matters of concern, adding that the 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.
She added: “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.
“Had [they] known about Hannah’s increasing frequency of contact with services… it would have prompted further contact with Hannah and prompted a review of risk and support offered. They did not know and there was no further contact.”
The report was sent to Sett Valley Medical Centre, Derbyshire Community Health Services NHS Foundation Trust, Derbyshire Healthcare NHS Foundation Trust, NHS Derby & Derbyshire Integrated Care Board and NHS England, who have a duty to respond to the report by February 3.
DerbyshireLive has contacted the above bodies for a statement after the report was published earlier this week.
A Sett Valley Medical Centre spokesperson said: “Our thoughts and deepest sympathies are with Hannah’s family and friends at this profoundly difficult time. We remain dedicated to working closely with other healthcare providers to ensure the highest level of care and support for our patients.”
A spokesperson for the NHS Derby and Derbyshire Integrated Care Board said: “We extend our sincere sympathies to the family and friends of Hannah Booth following their tragic loss. We will consider the findings of the Prevention of Future Deaths report carefully and reflect on any lessons identified.”