Background
We have launched an investigation into deaths associated with perinatal mental health concerns. The perinatal period that will be considered by the investigation includes pregnancy through to 12 months after birth.
The investigation will examine how serious mental health concerns are identified and risk is assessed, how women access care pathways, and what support is available to them. There will also be a specific focus on healthcare inequalities and understanding how vulnerable women are supported to access mental health care.
Intelligence review
There have been several recent national inquiries and reviews, including Amos (2026) and Ockenden (2026) relating to maternity services, however the subject of perinatal mental health was not explored fully as part of these reviews.
Death from psychiatric causes continues to be the leading cause of death in women during the late postpartum period (6 weeks to 12 months after childbirth) (MBRRACE-UK, 2025). The safety concerns in this area are well known, however variation in access and provision of services continues to be reported.
Summary of investigation
The investigation will examine how a woman’s need for mental health support is recognised and accessed during the perinatal period when a woman maybe at risk of death from psychiatric causes, by understanding:
- how serious mental health concerns are recognised and how risk is assessed
- the pathways available for women experiencing serious mental health concerns and how they access them
- how vulnerable women are supported to access care and how healthcare inequalities are addressed.
Get involved
We are keen to hear from anybody with an interest in this subject matter. This includes patients, families, carers and health and care professionals who may wish to share their experience.
If you would like to speak to us about this investigation before we publish the final report, please email investigations@hssib.org.uk. Please help us to respond to your email by including details about your interest in the investigation, such as your relevant experience, role, or how you would like to contribute to our work.