Keith Conradi, HSIB chief investigator, is pleased to publish the second HSIB investigation report and safety recommendations.  

Young people’s mental health has received considerable national interest in recent years. However, despite this attention there has been very little change towards what experts believe a safe and effective transition should look like. In this report we have investigated how young people are supported in the transition from children and adolescent mental health services to adult services.  

Many young people, including those who participated in this investigation, do not have a positive experience of transition and, as a result, may disengage from services putting their health and wellbeing at risk.  

The report is the culmination of many months of rigorous and independent investigation, working closely with those involved in the care of the young person, whose story we share, who sadly died by suicide. His story is echoed across the country. Our investigators also engaged with relevant organisations and subject matter experts.  

HSIB is independent. We do not investigate on behalf of the families, staff, organisations or regulators. This independence enables us to make public safety recommendations to the healthcare sector, both within and outside the NHS. 

 Our investigations make robust safety actions and safety recommendations for the organisations investigated as well as other similar bodies who can make changes to improve patient safety. 

 In publishing this report, we have made six safety recommendations to three organisations and two safety observations. We will publish their response to our recommendations on our website in the coming months.