Lack of defined transition pathway between CAMHS and adult services
NHS England received 2 coroners' reports about this hazard between 12 Aug 2025 and 29 Apr 2026.
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 1 specific action.
The story, report by report
Spacing grows with the time between reports.
First warning
Chloe Barber↗
12 Aug 2025 · Paul Marks · City of Kingston Upon Hull and the County of the East Riding of Yorkshire
“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, to ensure a smooth transit and continuity of care.”
Original on judiciary.uk ↗ NHS England responded, stating 1 specific action.Response (PDF) ↗
“The NHS is committed to ensuring that every area across the country commissions a comprehensive mental health offer for children and young people, with a clear focus on supporting young adults as they move from child to adult mental health services. A key priority is ensuring continuity of care and a smooth transition between services.”
Stated timescale: 2024/25
- 9 months later
Raised again · 1st time
Alice Dearden: Prevention of future deaths report (3)↗
29 Apr 2026 · Nicholas Rheinberg · Wiltshire and Swindon
Closely relatedConfidence 0.85 · higha different coroner“commissioning mental health provision for children and adolescents with a strict cut off date of the individual's 18th birthday could be prejudicial to mental health in certain circumstances.”
Original on judiciary.uk ↗ Repeated from the earlier report:mentalhealth
NHS England responded.Response (PDF) ↗
- All reports to NHS England
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.
2025 → 2026Alice Dearden: Prevention of future deaths report (3)9 months after Chloe Barber · different coronerClosely relatedConfidence 0.85 · high
Closely relatedConfidence 0.85 · highBoth reports highlight problems with the transition from child to adult mental health services due to rigid age-based cutoffs.
Chloe Barber · 12 Aug 2025
“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, to ensure a smooth transit and continuity of care.”
Original on judiciary.uk ↗ Alice Dearden: Prevention of future deaths report (3) · 29 Apr 2026
“commissioning mental health provision for children and adolescents with a strict cut off date of the individual's 18th birthday could be prejudicial to mental health in certain circumstances.”
Original on judiciary.uk ↗
Stated action · timescale: 2024/25
“The NHS is committed to ensuring that every area across the country commissions a comprehensive mental health offer for children and young people, with a clear focus on supporting young adults as they move from child to adult mental health services. A key priority is ensuring continuity of care and a smooth transition between services.”
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 NHS England 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 |
|---|---|---|---|---|
| 2025 → 2026 | 0.70 | 0.22 | Closely related · 0.85 | different |
Judge model: nvidia/nemotron-3-super-120b-a12b. How Nemotron did the work · Full methodology.
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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.