“The Perinatal Mental Health Service was established across the Health Board around 5…”
Dated 19 Mar 2025, from the coroner for North Wales (East and Central). Sent to 1 organisation or person.
A coroner wrote this report after an inquest, to warn the organisations below about a risk of further deaths.
The 56-day response deadline
All responses publishedReplies were due by 14 May 2025.
Organisations that receive a report must reply to the coroner within 56 days, saying what they will do or why they will do nothing. We show whether a response is published on judiciary.uk; a reply may have been sent and not yet published.
- Report dated19 Mar 2025
- Deadline14 May 2025
- Published on judiciary.uk26 Mar 2025
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Betsi Cadwaladr University Health Board | Response publishedPublished on judiciary.uk in March 2025. |
The coroner’s concerns
– 1. The Perinatal Mental Health Service was established across the Health Board around 5 years ago. It was accepted in evidence that there is insufficient awareness of the Service by health professionals including midwives, health visitors and GP’s. Whilst attempts have been made to raise awareness and encourage direct referrals to the Service (rather than via the Single Point of Access) this remains inadequate. If health professionals are unaware of the Service then mothers-to-be and mothers who require assistance will not be fully supported. 2. There are only 2 temporary perinatal health visitors across the 3 Health Board areas and not one in the Eastern area of the Health Board. By not having permanent perinatal health visitors acros all three Health Board areas then those who need to access support will suffer 3. The Single Point of Access meetings which occur on a daily basis by way of triaging referrals do not provide written records of the discussions had and decisions made. This means that there is no written justification for decisions made or written actions and therefore these discussions and decisions do not form part of any health record for the patient which would be relevant to the overall management of the patient. 4. I am concerned that deaths will occur into the future as awareness of the Service is not at all adequate to health professionals, the Service is not adequately staffed and records of meetings and decisions made in the Single Point of Access are not documented.
An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.
- Source
- judiciary.uk, Prevention of Future Deaths reports, 2025-0153
- Added to Minute Book
- 8 Oct 2026
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Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0
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