Chloe Barber
12 Aug 2025 · Coroner Paul Marks · City of Kingston Upon Hull and the County of the East Riding of Yorkshire
This report repeats 1 earlier warning, and was raised again 1 time later. See the linked reports.
The coroner's concerns
1. lack of clearly defined pathway for transition between CAMHS and adult psychiatric services
“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, to ensure a smooth transit and continuity of care.”
2. no clear guidelines for depot preparation administration of antipsychotics
“Concern was expressed by professional witnesses and experts that there are no clear guidelines about where and by whom depot preparations of antipsychotic may be administered.”
3. uncertainty about aftercare provision under s117
“There was considerable uncertainty and ignorance about the provision of aftercare pursuant to s117 of the Mental Health Act 1983 amongst some healthcare workers and social workers, who should in any event be closely liaising with each other as well as with other allied professionals.”
Linked reports
Closely relatedConfidence 0.90 · high
Earlier report
“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:”
This report
“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,”
Closely relatedConfidence 0.85 · high
This 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.”
Later 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.”
Responses
2025-0421-Response-from-Department-for-Health-and-Social-Care.pdf ↗· Department of Health and Social Care
2025-0421-Response-from-NHS-England.pdf ↗· NHS England
Stated action · 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.”