Inadequate transition pathway from CAMHS to adult services
Department of Health and Social Care received 2 coroners' reports about this hazard between 9 Nov 2017 and 12 Aug 2025.
They came from 2 different coroners in 2 coroner areas. A similar concern was raised again 1 time after the first warning.
A published response was found for 1 of the 1 earlier reports, stating 2 specific actions.
The story, report by report
Spacing grows with the time between reports.
“During the course of the inquest the evidence revealed matters giving raise to concern. The MATTER OF CONCERN for the Secretary of State to consider is as follows:”
Original on judiciary.uk ↗ Department of Health and Social Care responded, stating 2 specific actions.Response (PDF) ↗Response (PDF) ↗
“SC NHS FT will work with local commissioners on the benchmarking exercise”
“the NHS in Sheffield has taken a number of measures to address the concerns raised. This includes training for staff on transitions; the opening of a Section 136 suite at Sheffield Children's Hospital; and the employment of a Mental Health Liaison Consultant to commence in January 2018. In addition, an information sharing agreement is to be drawn up between NHS organisations in Sheffield.”
Stated timescale: January 2018
- 7 years 9 months later
Raised again · 1st time
Chloe Barber↗
12 Aug 2025 · Paul Marks · City of Kingston Upon Hull and the County of the East Riding of Yorkshire
Closely relatedConfidence 0.90 · higha different coroner“Evidence was heard at inquest from several expert witnesses that concern exists and continues to exist nationwide that there is not necessarily any clearly defined pathway that assists young persons making the transition between Childhood and Adolescent Mental Health Service (CAMHS) and adult psychiatric services,”
Original on judiciary.uk ↗ Repeated from the earlier report:Evidenceinquestconcern
Department of Health and Social Care responded.Response (PDF) ↗
- All reports to Department of Health and Social Care
Each row is one judged link between an earlier and a later report. Open a row to read both quotes, found word for word in the originals.
2017 → 2025Chloe Barber7 years 9 months after Daisy French · different coronerClosely relatedConfidence 0.90 · high
Closely relatedConfidence 0.90 · highBoth reports highlight problems with the transition of young people from CAMHS to adult mental health services. The earlier report focuses on local communication and out‑of‑hours arrangements, while the later report notes a nationwide lack of a defined pathway.
Daisy French · 9 Nov 2017
“During the course of the inquest the evidence revealed matters giving raise to concern. The MATTER OF CONCERN for the Secretary of State to consider is as follows:”
Original on judiciary.uk ↗ Chloe Barber · 12 Aug 2025
“Evidence was heard at inquest from several expert witnesses that concern exists and continues to exist nationwide that there is not necessarily any clearly defined pathway that assists young persons making the transition between Childhood and Adolescent Mental Health Service (CAMHS) and adult psychiatric services,”
Original on judiciary.uk ↗
Stated action
“SC NHS FT will work with local commissioners on the benchmarking exercise”
Stated action · timescale: January 2018
“the NHS in Sheffield has taken a number of measures to address the concerns raised. This includes training for staff on transitions; the opening of a Section 136 suite at Sheffield Children's Hospital; and the employment of a Mental Health Liaison Consultant to commence in January 2018. In addition, an information sharing agreement is to be drawn up between NHS organisations in Sheffield.”
No specific action could be extracted with a verified quote.
- Each report's concerns were extracted by Nemotron 3 Nano on Nebius Token Factory, each with a quote copied from the report.
- Concerns from reports to Department of Health and Social Care at least six months apart were compared by meaning (Qwen3 embeddings) and wording (TF-IDF).
- The closest pairs were judged by Nemotron 3 Super with reasoning on. Only identical or closely related, with confidence of at least 0.70, are shown.
- Every quote was checked by code as an exact substring of the original text. Names of staff and family are redacted, and the deceased are named by report title only.
| Link | Meaning | Wording | Judge | Coroner |
|---|---|---|---|---|
| 2017 → 2025 | 0.80 | 0.33 | Closely related · 0.90 | different |
Judge model: nvidia/nemotron-3-super-120b-a12b. How Nemotron did the work · Full methodology.
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Other chains for Department of Health and Social Care
This shows that a similar concern was raised again after an earlier report. It does not say why, and it is not a finding about any organisation or person. To report an error, see the corrections route.