Children with mental health problems are dying due to NHS treatment failures, coroners across England have said in what psychiatrists and activists have called “deeply worrying” findings.
In the last five years, forensic doctors have issued reports to prevent future deaths in at least 14 cases in which children under the age of 18 have died while being treated by the child and adolescent mental health services (CAMHS).
The most common issues that arise are delays in treatment and a lack of support to help patients transition to adult services when they turn 18.
Medical examiners issue reports to prevent future deaths in extreme cases when it is decided that if changes are not made, another person could die.
Dr. Elaine Lockhart, chair of the Royal College of Psychiatrists’ faculty of child and adolescent psychiatry, said the findings were “deeply worrying” and that each death was a tragedy.
He said too often there were long delays and services were under pressure as demand increased and National Health Service faces a labor shortage.
“In child and adolescent mental health services in England, 15% of consultant psychiatrist positions are vacant,” Lockhart said, calling for more support, investment and planning to increase staffing levels.
Among the cases issued with reports to prevent future deaths are those of:
-
Sky Rollings, who died four days after being admitted to hospital. There was pressure to transfer 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 received six weeks.
-
Mary Bush, who was tested 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 at age 15.
-
Sam Gould, 16, who took his own life in September 2018. A coroner said “systemic weaknesses and failures” in communication between health care agencies likely caused his death.
-
Becky Romero, 15, who died at her home in Bristol. The coroner ruled that she died as a direct result of NHS negligence, because the service that was supposed to help her did not have enough resources.
Tom Madders, director of communications and campaigns for the charity YoungMinds, said: “It goes without saying that when young people seek help for their mental health, they need to be cared for, protected and helped to get better.”
Madders raised concerns about waiting times and a high threshold for treatment. “Some young people start self-harming, dropping out of school or committing suicide before they get help, and those who transition to adult services face a lack of support,” he said. He called for more investment and early intervention.
Another recent case noted by coroners was that of 15-year-old Ellis Murphy-Richards, who committed suicide shortly after leaving a counseling session on September 30, 2020.
At the conclusion of the investigation last year, coroner Sonia Hayes expressed concern 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 criticizing the fact that an NHS worker had to deal with the situation alone and that a psychiatrist had deviated from a plan of care. She said there was no contingency plan to deal with a young man who refused help.
Speaking to The Guardian, Ellis’s mother, Natasha Murphy, said her “honest mistake was trusting CAMHS”. He said that he felt that he would have managed to take care of Ellis and protect him as he had in the previous years. Murphy felt that his son was not taken seriously.
a department of Health and the Social Care spokesperson said: “Every loss of life is a tragedy and the impact on families can be devastating. We are committed to caring for the mental health of children and young people and ensuring they have access to safe and 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 a further 345,000 children and young people would be helped by 2023-24.
