Children with mental health problems are dying because of failings in NHS treatment, coroners across England have said in what psychiatrists and campaigners have called “deeply concerning” findings.
In the last five years coroners have issued reports to prevent future deaths in at least 14 cases in which under-18s have died while being treated by children’s and adolescent mental health services (CAMHS).
The most common issues that arise are delays in treatment and a lack of support in helping patients transition to adult services when they turn 18.
Coroners issue reports to prevent future deaths in extreme cases when it is decided that if changes are not made then another person could die.
Dr Elaine Lockhart, the chair of the Royal College of Psychiatrists’ faculty of child and adolescent psychiatry, said the findings were “deeply concerning” and every death was a tragedy.
She said there were too often lengthy delays and services were under strain as demand rises and the NHS faces workforce shortages.
“In child and adolescent mental health services in England, 15% of consultant psychiatrist posts are vacant,” Lockhart said, calling for more support, investment and planning to grow staff levels.
Among the cases issued with reports to prevent future deaths were those of:
Sky Rollings, who died four days after being admitted to hospital. Pressure was applied for her to be transferred after she turned 18 and no longer qualified for child and adolescent mental health services (CAMHS). Instead of receiving the standard six-month transition, the college student was given six weeks.
Mary Bush, who was assessed three weeks later than she should have been. There was a delay in Mary receiving psychological therapy, and she was still on the waiting list at the time of her death aged 15.
Sam Gould, 16, who took her own life in September 2018. A coroner said “systemic weaknesses and failings” in communication between healthcare agencies probably caused her death.
Becky Romero, 15, who died at her home in Bristol. The coroner ruled she died as a direct consequence of neglect by the NHS, because the service that was supposed to help her did not have enough resources.
Tom Madders, the director of communications and campaigns at the charity YoungMinds, said: “It goes without saying that when young people seek help for their mental health they should be looked after, kept safe and helped to get better.”
Madders raised concerns over waiting times and a high threshold for treatment. “Some young people start to self-harm, drop out of school or become suicidal before they get help, and those who transition into adult services face a lack of support,” he said. He called for more investment and early intervention.
Another recent case flagged by coroners was that of Ellis Murphy-Richards, 15, who killed himself shortly after walking out of a counselling session on 30 September 2020.
Concluding the inquest last year, the coroner Sonia Hayes raised concerns about the care the transgender teenager received hours before his death. He had tried to take his own life the night before.
Hayes sent a report to prevent future deaths criticising the fact that an NHS worker had had to deal with the situation alone and that a psychiatrist had deviated from a care plan. She said there was no contingency plan being in place to deal with a young person who refused help.
Speaking to the Guardian, Ellis’s mother, Natasha Murphy, said her “honest mistake was trusting CAMHS”. She said she felt she would have managed to look after Ellis and protect him as she had over the previous few years. Murphy felt her son was not taken seriously.
A Department of Health and Social Care spokesperson said: “Every loss of life is a tragedy and the impact on families can be devastating. We are committed to looking after children and young people’s mental health and ensuring they have access to safe, appropriate care.”
The department said that through the NHS long-term plan it was providing an extra £2.3bn a year to expand mental health services, meaning 345,000 more children and young people would be helped by 2023-24.
In the UK and Ireland, Samaritans can be contacted on 116 123 or email jo@samaritans.org or jo@samaritans.ie. In the US, the National Suicide Prevention Lifeline is 1-800-273-8255. In Australia, the crisis support service Lifeline is 13 11 14. Other international helplines can be found at www.befrienders.org.
