Jeff Antwis

“Following an urgent referral by [the deceased]'s GP to (the then) Shropshire CAMHS on the 10th January 2017 a timely response was made with an initial appointment with a mental health practitioner taking place on the 12th. A further appointment was arranged for the 25th January (an earlier date clashed with an existing medical appointment) and in the meantime [the deceased] was given a miracle question to complete.”

“[the deceased] answered the miracle question indicating that he wished to die. He passed it to his mother who immediately contacted the mental health practitioner who in turn referred it and the initial assessment to a consultant physiatrist for review. The consultant physiatrist did not consider the matter urgent and arranged for a routine medical review for the 17th March 2017.”

“Independent expert evidence from a child and adolescent consultant physiatrist indicated that [the deceased] should have been offered an urgent medical review appointment for the 27th January 2017 (i.e. within 7 days of the internal referral to the consultant physiatrist) and not, as a routine appointment, the 17th March 2017. It cannot be said that such earlier appointment would have addressed [the deceased]'s problems and altered his wish to die but it is it possible that earlier intervention may have lifted his”

“Other matters of concern arose from the evidence. The mental health practitioner: a) Was aware of the deliberate self-harm protocol but not its content. b) Carried out a risk assessment on a subjective basis without reference to any known definition e.g. serious or significant. c) Had no mechanism for referring back to the consultant physiatrist appointment, whether she agreed with the request or not.”

“As stated [the deceased] had a diagnosis of asperger's syndrome with autistic spectrum disorder. Concerns were raised to what extent these conditions have may have masked [the deceased]'s suicidal ideation on presentation and to what extent, if it is the case, they were recognized.”

“From evidence given at the inquest it is clear that the provision of child and adolescent mental health service is in transition, having moved from Shropshire CAMHS to part of South Staffordshire and Shropshire NHS Trust. Certain actions are already being taken and these concerns are raised so that a holistic approach can be taken and fed in to what is already an ongoing wider review.”