Today, the Healthcare Safety Investigation Branch has published its second full investigation report to support a new learning culture around mistakes in the NHS. The investigation reviewed the transition of care from child and adolescent to adult mental health services to understand how variations in the transition impacts the safe and effective care of young people. As a result of the investigation a number of recommendations have been made to national NHS organisations to make the transition smoother and safer for young people.

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.

It is estimated that more than 25,000 young people transition from child and adolescent to adult mental health services each year, and research has identified that few of those receive an ‘ideal’ transition. There is limited information available to determine how many young people experience severe mental health problems and need crisis support or take their own lives shortly after being discharged from child and adolescent mental health services or following transition from child and adolescent to adult mental health services.

Research suggests that, between 16 and 18 years old, young people are going through significant change and are potentially at their most vulnerable psychologically. Despite this, this is currently the age that young people are either transitioned to adult mental health services, or discharged if they do not meet the criteria for adult mental health services. 

Chief Investigator, Keith Conradi, whose experience includes six years as the chief investigator of the Air Accident Investigation Branch, said: “Young people’s mental health has received considerable national interest in recent years, with particular attention paid to how young people are supported in transition to adult services. Experts have documented the elements of a safe and effective transition for many years however, many young people still do not have a positive experience and, as a result, disengage from services. 

“I believe this is a very important issue of increasing significance for young people today and I am pleased to publish our second report. The report is the culmination of many months of rigorous and independent investigation, working closely with those involved in the care of this young person, who sadly died by suicide, as well as relevant organisations and subject matter experts. We undertook this investigation with the sole purpose of learning and have made six safety recommendations to three national NHS organisations with the intention of preventing future, similar events. In addition, we also made two safety observations which also warrant attention. We will publish organisational responses to our recommendations in the coming months on our website.”

ENDS

Notes to editors: 

The Healthcare Safety Investigation Branch’s role is to investigate safety incidents for the sole purpose of learning and improving patient safety across the healthcare sector without attributing blame or liability. The intention is to build on HSIB’s work and strengthen its independence – via legislation currently at draft Bill stage – which would see the creation of a statutory Health Service Safety Investigations Body, independent of the NHS and arm’s length from Government. Its creation is inspired by the airline industry, where a learning culture has led to dramatic improvements in safety.

As a result of the investigation the Healthcare Safety Investigation Branch identified the following key findings:

  • Young people using child and adolescent mental health services would benefit from a flexible, managed transition to adult mental health services which has been carefully planned with the young person, provides continuity of care and follow-up after transition. A duration of shared-care would help to ensure readiness and continuity for the young person.

  • Young people and their families may also benefit from the use of tools in their transition planning to allow for structured conversations and to empower them to ask questions and take ownership of their diagnosis, needs and treatment.

  • In the acute and mental health trusts visited, there were no standardised methods or tools used to manage transition. However, we did find that acute trusts were more likely to plan transition over a longer period of time and to use tools to bring some standardisation to the process.

  • There is evidence that moving to a flexible model which has the capacity to provide mental health services up to the age of 25, can minimise some of the barriers and reduce the risks associated with transition.

  • Research suggests that young people want flexible services which do not have strict 'cut-off' points. Flexible services are especially important for young people with emotional problems, complex needs, mild learning disability, attention deficit hyperactivity disorder, and autism spectrum disorder, for whom there are limited available services in the adult mental health setting.

  • Significant efforts are being taken to improve early intervention services for young people. Research indicates that early intervention reduces the impact on both the young person and subsequently the NHS through improved outcomes and a reduction in the need for longer-term resources. 

The Healthcare Safety Investigation Branch has made the following six safety recommendations to three national NHS organisations with the intention of preventing future, similar events:

  1. It is recommended that within the long-term plan; NHS England works with partners to identify and meet the needs of young adults who have mental health problems but do not meet the current criteria for access to adult mental health services. 
  2. It is recommended NHS England require Clinical Commissioning Groups to demonstrate the budget identified for current children and young people’s services - those delivering care up to the age of 18 – is spent only on this group.
  3. It is recommended NHS England and NHS Improvement ensure transition guidance, pathways or performance measures, require structured conversations to take place with the young person transitioning to access their readiness, develop their understanding of their condition and empower them to ask questions. NHS England and NHS Improvement must ensure the effectiveness is robustly evaluated. 
  4. It is recommended within the long-term plan; NHS England requires services to move from aged based transition criteria towards more flexible criteria based on an individual’s needs.
  5. It is recommended NHS England and NHS Improvement work with commissioners and providers of mental health services to ensure that the care of a  young person before during and after transition is shared in line with best practice, including joint agency working. 
  6. It is recommended the Care Quality Commission extend its remit of its inspections to ensure the whole care pathway, from child and adolescent mental health services to adult mental health services, is examined.

And 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:

  1. It may be beneficial for NHS England to consider developing a method to identify where clinical commissioning groups spend on child and adolescent mental health services per capita is lower than reasonably expected.  
  2. It may be beneficial for both child and adolescent mental health service and adult mental health service clinicians to be trained in safe and effective transitions from child and adolescent to adult mental health services.

HSIB undertook this investigation with the sole purpose of learning.

HSIB became operational on 1st April 2017 and more details can be found www.hsib.org.uk

Please contact media@hsib.org.uk for interviews or if you have further queries.