This investigation followed the Healthcare Safety Investigation Branch being notified of an 18-year-old who died by suicide shortly after transitioning from child and adolescent to adult mental health services. The investigation identified possible issues regarding the transition process.
report is the culmination of many months of rigorous and independent investigation,
working closely with the organisations involved in the incident, as well as
relevant organisations, and subject matter experts.
A series of different methodologies were used which included: review of records, policies and procedures, and practice relating to transitioning of young people into adult services, and the identification of the needs of individual young people and the response to those needs.
A focus group
involving up to 14 young people who had either transitioned from CAMHS to AMHS
or were in the process of transitioning provided the investigation with a lived
experience of the issues and concerns for young people and where services were
not meeting their needs.
- It is recommended that NHS England ensure its ‘long term plan’ (2021-2026) meets the needs of young adults who do not meet the criteria for adult mental health services.
- It is recommended that NHS England require Clinical Commissioning Groups to demonstrate that budget identified for children and young people’s services is spent only on this group.
- It is recommended that NHS England ensure that transition guidance, pathways or performance measures require structured conversations to take place with the young person transitioning in order to assess their readiness, develop their understanding of their condition, and empower them to ask questions. NHS England must then ensure that the effectiveness of this is robustly evaluated.
- It is recommended that NHS England ensure its Five Year Forward Plan (2021 – 2026) requires services to move from aged-based transition criteria towards more flexible criteria based on an individual’s needs.
- It is recommended that NHS England require Clinical Commissioning Groups to ensure that providers of mental health services share the care of a young person before, during and after transition, in line with best practice until flexible transitions are available
- It is recommended that the Care Quality Commission extend the remit of its inspections to ensure that the whole care pathway, from child and adolescent mental health services to adult mental health services, is examined.
Two safety observations were also made. These are made when there is insufficient or incomplete information on which to make a definitive recommendation for action, although findings are deemed to warrant attention:
- It may be beneficial for NHS England to consider developing a method to identify where CCGs spend on CAMHS per capita is lower than reasonably expected.
- It may be beneficial for both CAMHS and AMHS clinicians to be trained in safe and effective transitions from CAMHS to AMHS.
Download the report below
View the statement from our Chief Investigator here
View our media release here