1. Lessons on Maternal Mental Health

3. Causes of maternal death 2011-13

4. Late Maternal Deaths

5. Mental health-related deaths

6. What we already know Epidemiology of perinatal mental illness

7. What we already know Key findings 2006-2008

8. Classification of mental health-related deaths 2009-13

9. Characteristics of the women 2009-2013

10. Method, Timing and Diagnostic Category

11. Method of suicide

12. Method of violent suicide

13. New Learning Point Violent suicide

14. Timing of suicide

15. Timing of suicide

16. Diagnosis

17. Learning Point Pre-existing mental disorder

18. Death of the baby

19. Learning Point Risk to infant/older children

20. Communication Issues

21. Communication between services

22. Learning Point Communication

23. Assessment Issues

24. Booking assessments

25. Lack of recognition of symptom pattern and seriousness

26. Lack of recognition of symptom pattern and seriousness

27. New Learning Point Symptom pattern, escalation and seriousness

28. Precursor thoughts or acts of violent self-harm

29. Precursor thoughts or acts of violent self-harm

30. New Learning Point Precursor thoughts or acts of violent self-harm

31. Estrangement from the infant

32. Estrangement from the infant

33. New Learning Point Estrangement from the infant

34. Red Flag Presentations

35. Grade of assessor

36. Grade of assessor

37. New Learning Point Grade of assessor

38. Management Issues

39. Care by multiple teams

40. Care by multiple teams

41. Learning Point Care by multiple teams

42. Consideration of inpatient care

43. Consideration of inpatient care

44. New Learning Point Consideration of inpatient care

45. Specialised perinatal mental health services

46. New Learning Point Specialised perinatal mental health services

47. Child loss or threat of loss

48. Learning Point Child loss or threat of loss

49. Partner and family involvement

50. Partner and family involvement

51. New Learning Point Partner and family involvement

52. Mental Capacity Issues

53. Mental capacity issues

54. Mental capacity issues

55. New Learning Point Mental capacity issues

56. Organisational Issues

57. Psychiatric returns and reviews

58. New Learning point Psychiatric returns and reviews

59. Key messages

61. Acknowledgements