Alice Dearden: Prevention of future deaths report (3)
29 Apr 2026 · Coroner Nicholas Rheinberg · Wiltshire and Swindon
This report repeats 1 earlier warning. See the linked reports.
The coroner's concerns
1. lack of continuity in mental health services at age 18
“Evidence received at the above inquest suggested that 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.”
2. self-harm and overdose
“[the deceased] suffered from mental health difficulties as a result of anorexia nervosa and emotionally unstable personality disorder. Her conditions resulted in acts of self-harm which included overdoses.”
3. loss of faith in mental health services
“[the deceased] did not respond well to the transfer from CAMHS to Adult Mental Health services, she lost faith in the process of mental health delivery and as a result her mental health suffered.”
Linked reports
Closely relatedConfidence 0.85 · high
Earlier report
“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.”
This report
“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.”