1. Messages for Mental Health

2. The women who died

3. The women who died

4. The women who died

5. Timing of deaths by suicide

6. Underlying diagnosis

7. Repeated recommendations

8. Communication of previous history

9. Communication of previous history

10. Red Flags

11. Red Flags

12. Red Flags

13. Amber Flags

14. Amber Flags

15. Forward Planning

16. Crisis, liaison and home treatment team training

17. Crisis, liaison and home treatment team training

18. New messages for care

19. Multiple adversities

20. Multiple adversities

21. Judgements based on diagnosis or social adversity

22. Judgements based on diagnosis or social adversity

23. Avoidance of care

24. Self-harm

25. Gatekeeping

26. Gatekeeping

27. Care of women in prison

28. Care of women in prison

29. Prescribing issues – de-prescribing

30. Prescribing issues – de-prescribing

31. Prescribing issues - propranolol

32. Adequacy of mental health returns

33. Good care

34. What have we learned?

35. What have we learned? Routine good clinical care

36. What have we learned? Routine good organisational care

37. What have we learned? Distinctiveness of perinatal mental health care