Daisy French
9 Nov 2017 · Coroner Louise Slater · South Yorkshire (West)
This report repeats 1 earlier warning, and was raised again 2 times later. See the linked reports.
The coroner's concerns
1. communication breakdown between CAMHS and adult services
“The communication/information sharing between CAMHS and Adult Services”
2. inappropriate transition of care from CAMHS to adult services
“Transition of care from CAMHS to Adult services”
3. inconsistent service provision for 16-18 year olds
“Out of hour's provision for 16 to 18 years”
4. placement of minor in adult crisis facility
“Placement of an under 18 year old in a Crisis house for adults”
5. return to unsupervised supported living after mental health assessment
“Returning an under 18 year old to a supported living setting following a mental health act assessment where no staff are on duty at the premises”
Linked reports
Closely relatedConfidence 0.85 · high
Earlier report
“[the deceased] was aged just 18 when admitted to an acute psychiatric ward that cared for adults aged 18-”
This report
“Placement of an under 18 year old in a Crisis house for adults”
Closely relatedConfidence 0.80 · moderate
This report
“Out of hour's provision for 16 to 18 years. (During working hours they are considered children and therefore are the responsibility of CAMHS,”
Later report
“The inquest was told that the provision of mental health services post 16 varies widely across the country.”
Closely relatedConfidence 0.90 · high
This 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:”
Later 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,”
Responses
2017-0264-Response-by-Department-of-Health.pdf ↗· Department of Health and Social Care
Stated action · 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.”
2017-0264-Response-by-Sheffield-Health-and-Social-Care.pdf ↗· Department of Health and Social Care
Stated action
“SC NHS FT will work with local commissioners on the benchmarking exercise”