Hannah Booth
15 Dec 2025 · Coroner Susan Evans · Derby and Derbyshire
The coroner's concerns
1. lack of a single patient record
“This inquest has exposed important issues with information sharing between services and also within services”
2. increased contact not escalated to perinatal mental health
“There was increasing contact with health visitors that was not escalated to or shared with perinatal mental health”
3. information recorded only in baby's records
“Within both Sett Valley and health visitor records there was potentially important information relevant to [the deceased]'s mental health recorded only within her baby's records”