Recurring concern

Unsafe transition and continuity of care from child to adult healthcare

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First reported 17 Dec 2014•Latest report 12 Aug 2025

Definition

What this concern includes

Includes failures of the dedicated transition and continuity process from child to adult healthcare, including transition pathways, transfer planning, timing and best-interests consideration, information exchange, allocation to appropriate adult services and effective adult follow-up or review.

Not included

Excludes generic shortages or inadequacy of adult services where no child-to-adult transition or continuity failure is identified.
Excludes routine transfers between adult services or unrelated care transitions.
Excludes isolated clinical treatment, assessment or review failures occurring after a safe transition unless they directly show that the adult continuity-of-care arrangement was not established.
Excludes generic communication, staffing, commissioning or documentation deficiencies unless they are specifically part of the child-to-adult transition and continuity process.

Reports: 7
Individual concerns: 10
Date range: 2014–2025
Stated actions: 27

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Reports about this concern sent to each recipient.

Department of Health and Social Care4

NHS England2

East London NHS Foundation Trust1

Hywel Dda University LHB1

Royal College of Psychiatrists1

Sheffield Children'S NHS Foundation Trust1

Sheffield Teaching Hospitals NHS Foundation Trust1

Concerns and responses across reports

Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.

12 Aug2025
East Riding and Hull
Concerns raised1
1. Lack of a clearly defined transition pathway between CAMHS and adult psychiatric services
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 4
1. Action
  Release funding to healthcare systems to transform young adult mental health pathways.
  Stated by NHS EnglandStated completed
2. Action
  Finalise a Personalised Care Framework setting minimum standards for secondary mental health services across children’s and adult services.
  Stated by NHS EnglandStated in progress
3. Action
  Strengthen North East and Yorkshire pathways for young people transitioning from CAMHS to adult mental health services using personalised care approaches.
  Stated by NHS EnglandStated in progress
1. Action
  Hold regional discussions to reinforce assurance that transitions follow relevant NICE guidance.
  Stated by NHS EnglandStated completed
AI-generated summary

Chloe Louise Barber · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Chloe Louise Barber, who had a history of self-harm and multiple overdoses and had been detained under the Mental Health Act, was found at home on 3 November 2021 and was confirmed dead at 17:05. The report identified concerns about transition pathways between CAMHS and adult psychiatric services, guidance on administering depot antipsychotic preparations, and understanding of section 117 aftercare responsibilities.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Lack of a clearly defined transition pathway between CAMHS and adult psychiatric services
Wider context from the report
“1. Evidence was heard at inquest from several expert witnesses that concern exists and continues to exist nationwide that there is not necessarily an clearly defined pathway that assists young persons making the transition between Childhood and Adolescent Mental Health Service (CAMHS) and adult psychiatric services, to ensure a smooth transit and continuity of care. ”
Source location
Chloe Louise Barber · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Release funding to healthcare systems to transform young adult mental health pathways.

Verbatim wording from the response
“The NHS is committed to ensuring that every area across the country commissions a comprehensive mental health offer for children and young people, with a clear focus on supporting young adults as they move from child to adult mental health services. A key priority is ensuring continuity of care and a smooth transition between services. Funding was released to healthcare systems in 2022/23 to transform and focus”

Source location
Response from NHS England
Page 1 · response
Published 13 August 2025
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Finalise a Personalised Care Framework setting minimum standards for secondary mental health services across children’s and adult services.

Verbatim wording from the response
“NHS England is also finalising a new ‘Personalised Care Framework’ which sets out the minimum expected standards of care for people needing secondary mental health services. The Framework will apply to both CYP and Adult services, meaning a greater level of consistency in the offer across both services, giving young people transitioning between CYP and adult care will have greater clarity about what they should expect from their care.”

Source location
Response from NHS England
Page 4 · response
Published 13 August 2025
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Strengthen North East and Yorkshire pathways for young people transitioning from CAMHS to adult mental health services using personalised care approaches.

Verbatim wording from the response
“Within the North East and Yorkshire Region, work is underway to strengthen pathways for young people transitioning from CAMHS into adult mental health services using personalised care approaches. The priority is to ensure a safe, seamless transition with continuity of care. Alongside this, section 117 aftercare, and ensuring personalised, consistent and appropriate support for all those entitled to it, is an identified area of focus within regional discussions and planned work.”

Source location
Response from NHS England
Page 4 · response
Published 13 August 2025
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Hold regional discussions to reinforce assurance that transitions follow relevant NICE guidance.

Verbatim wording from the response
“NHS England’s case managers work across inpatient providers and the wider health system in accordance with the National Institute for Health and Care Excellence (NICE) guidance on the transition of young people from child to adult services. We recognise that transition remains a key area of focus across ICBs, adult mental health services and the broader system. This priority was also reflected in the NHS England Improvement Plan following the independent investigation by NICE Health and Social Care Consulting into West Lane Hospital, published in March 2023, which highlighted the need for robust transition processes. In 2023, regional discussions were held to reinforce the importance of NHS England, NHS providers and local authorities being assured that transitions are completed in line with the relevant NICE guidance.”

Source location
Response from NHS England
Page 4 · response
Published 13 August 2025
Open published response
15 Apr2024
West Sussex, Brighton and Hove
Concerns raised2
1. Lack of national guidance and support for the multi-agency transition approach
2. Lack of a recognised multi-agency transition pathway with clear risk, accountability and support arrangements
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Axel Price · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Axel Price, who had recently turned 18, died by a ligature at some time between 15 and 23 April 2021 after discharge from hospital and Police custody into temporary accommodation. The report identified concerns about unclear agency responsibility and inadequate support during his transition from child and adolescent mental health services to adult services, including failures relating to discharge planning, risk assessment, capacity assessment and ongoing engagement.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Lack of national guidance and support for the multi-agency transition approach
Wider context from the report
“This case identified that there is a lack of clear understanding of the risk or accountability between the agencies when a young person transitions from CAMBS services at the age of 18 to adult services. The expert who provided evidence in this case said that this was a well-recognised problem and whilst services across the country had tried to address this, there was a lack of national guidance and provision. In this particular case Axel was particularly vulnerable. He was born Yasmin Price but identified as a male from a young age. He had struggled emotionally during his teens and had indulged with alcohol and drugs. He had been detained on a number of occasions due to his mental health. At the age of 18 he transitioned to adult services but there was a lack of a recognised pathway for him. In the lead up to his death he had been discharged from a mental health provision following his arrest for criminal offences. He was then discharged from the hospital and subsequently the Police station to temporary accommodation. There was little shared understanding between agencies of how Axel should best be supported and therefore he appeared to fall between the services. Substantial changes have been made locally by Sussex Partnership Foundation NHS Trust around the transition of those from CAMBS to Adult health services but looking at other Prevention of Future Death Reports this is not just a local issue. There is a lack of national guidance and support in relation to the multi-agency approach that is needed to support those young people transitioning to adult health and social care services. Unless this is addressed nationally, sadly other deaths will occur. ”
Source location
Axel Price · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Lack of a recognised multi-agency transition pathway with clear risk, accountability and support arrangements
Wider context from the report
“This case identified that there is a lack of clear understanding of the risk or accountability between the agencies when a young person transitions from CAMBS services at the age of 18 to adult services. The expert who provided evidence in this case said that this was a well-recognised problem and whilst services across the country had tried to address this, there was a lack of national guidance and provision. In this particular case Axel was particularly vulnerable. He was born Yasmin Price but identified as a male from a young age. He had struggled emotionally during his teens and had indulged with alcohol and drugs. He had been detained on a number of occasions due to his mental health. At the age of 18 he transitioned to adult services but there was a lack of a recognised pathway for him. In the lead up to his death he had been discharged from a mental health provision following his arrest for criminal offences. He was then discharged from the hospital and subsequently the Police station to temporary accommodation. There was little shared understanding between agencies of how Axel should best be supported and therefore he appeared to fall between the services. Substantial changes have been made locally by Sussex Partnership Foundation NHS Trust around the transition of those from CAMBS to Adult health services but looking at other Prevention of Future Death Reports this is not just a local issue. There is a lack of national guidance and support in relation to the multi-agency approach that is needed to support those young people transitioning to adult health and social care services. Unless this is addressed nationally, sadly other deaths will occur. ”
Source location
Axel Price · Prevention of Future Deaths report
Page 2 · concerns
Open source report
26 Mar2024
South Yorkshire (Western)
Concerns raised2
1. Lack of a transfer protocol or pathway for transition from childhood to adulthood
2. Lack of an effective review process for adults
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 5
1. Action
  Operate an agreed cross-trust transition pathway covering records, individual plans, transfer information and attendance at the first adult appointment.
  Stated by Sheffield Children'S NHS Foundation Trust and Sheffield Teaching Hospitals NHS Foundation TrustStated completed
2. Action
  Provide specialist transition-team support, including multidisciplinary discussions and assistance with initial adult appointments or inpatient ward visits for young people with complex needs.
  Stated by Sheffield Children'S NHS Foundation Trust and Sheffield Teaching Hospitals NHS Foundation TrustStated completed
3. Action
  Run a monthly transition clinic for hydrocephalus patients aged 14 and over, with extended appointments covering clinical review and transition preparation.
  Stated by Sheffield Children'S NHS Foundation Trust and Sheffield Teaching Hospitals NHS Foundation TrustStated completed
1. Action
  Formalise the transition process in a written pathway clarifying how young people with shunts move from children’s to adult services.
  Stated by Sheffield Children'S NHS Foundation Trust and Sheffield Teaching Hospitals NHS Foundation TrustStated planned
2. Action
  Participate in the regional innovator project to standardise developmentally appropriate transition care, including defined roles, staff training, personalised plans and patient tracking.
  Stated by Sheffield Children'S NHS Foundation Trust and Sheffield Teaching Hospitals NHS Foundation TrustStated completed
Respondent positions 1
1. Position
  Routine shunt reviews are not clinically required after transition; patients remain able to seek advice about symptoms or concerns.
  Stated by Sheffield Children'S NHS Foundation Trust and Sheffield Teaching Hospitals NHS Foundation TrustDisputes the concern
AI-generated summary

Craig John BURFIELD · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Craig Burfield was admitted for surgery for bladder stones on 20 February 2023 and underwent surgery on 23 February 2023. He did not regain consciousness from the anaesthetic and died on 24 February 2023 at Northern General Hospital, Sheffield, following clots in his hydrocephalus shunt and cerebral sinus that caused brain swelling. The report raised concerns that shunt care did not continue into adulthood and that there were no effective transition, transfer, or review pathways for adults with such needs.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Lack of a transfer protocol or pathway for transition from childhood to adulthood
Wider context from the report
“During evidence from the family and ████████, author of the internal investigation, it became clear that although Craig had received care for the shunts implanted as a consequence of his hydrocephalus as a young person, this did not continue as an adult. Also, there was no process for review of patients such as Craig. ████████ gave evidence that there remained no transfer protocol or pathway in place as children move into adulthood as at the current date nor an effective review process for adults at the present time. In evidence she stated that it was important that a clear pathway, including for transitions between childhood and adulthood, was in place and a failure to have such clear pathways and protocols such that people who needed care could easily access it could potentially be fatal. ”
Source location
Craig John BURFIELD · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Lack of an effective review process for adults
Wider context from the report
“During evidence from the family and ████████, author of the internal investigation, it became clear that although Craig had received care for the shunts implanted as a consequence of his hydrocephalus as a young person, this did not continue as an adult. Also, there was no process for review of patients such as Craig. ████████ gave evidence that there remained no transfer protocol or pathway in place as children move into adulthood as at the current date nor an effective review process for adults at the present time. In evidence she stated that it was important that a clear pathway, including for transitions between childhood and adulthood, was in place and a failure to have such clear pathways and protocols such that people who needed care could easily access it could potentially be fatal. ”
Source location
Craig John BURFIELD · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Operate an agreed cross-trust transition pathway covering records, individual plans, transfer information and attendance at the first adult appointment.

Verbatim wording from the response
“We acknowledge that the arrangements for transition have not been as robust as they could have been, and we have been working hard to address this. The current transition process is reflected in the SCFT and STHFT Transition Policy and the Cross Trust Transition pathway which have been agreed between the two organisations (enclosed). The Cross Trust Transition pathway details the process followed by both organisations and includes:”

Source location
Response from Sheffield Teaching Hospitals
Page 1 · response
Published 15 April 2024
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Provide specialist transition-team support, including multidisciplinary discussions and assistance with initial adult appointments or inpatient ward visits for young people with complex needs.

Verbatim wording from the response
“To support the transition process there are specialist transition teams at SCFT and STHFT; these teams work closely together to support young people with complex healthcare needs who are transitioning from child to adult healthcare. For patients with complex needs the Transition Teams facilitate a multi-disciplinary team discussion with the receiving specialities to ensure appropriate arrangements are in place. Where appropriate the STH Transition Team would also support with the initial appointment(s) in adult services and where there are likely to be inpatient admissions, arrange visits to the relevant wards.”

Source location
Response from Sheffield Teaching Hospitals
Page 1 · response
Published 15 April 2024
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Run a monthly transition clinic for hydrocephalus patients aged 14 and over, with extended appointments covering clinical review and transition preparation.

Verbatim wording from the response
“For young people with shunts SCFT runs a monthly transition clinic where all hydrocephalus patients 14 years old and over are seen by clinical nurse specialists. The more complex hydrocephalus patients or those with other neurological conditions are followed up in a Consultant Neurosurgeon’s clinic and they will start to discuss transition with them from around 14 years old as per the SCFT and STHFT Transition Policy. These visits require longer appointment times as they cover a hydrocephalus check and discuss preparation for transition. At the last appointment before transition the patient is provided with contact details for the Neurosurgical secretaries so that they know who to contact if they have any concerns about their symptoms between appointments in the adult service.”

Source location
Response from Sheffield Teaching Hospitals
Page 2 · response
Published 15 April 2024
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Formalise the transition process in a written pathway clarifying how young people with shunts move from children’s to adult services.

Verbatim wording from the response
“Following the concern raised by Craig’s inquest, we will formalise the process with a written pathway so that it is clear to both SCFT and STHFT what process these young people will follow when transitioning to adult services. This will be complete by September 2024.”

Source location
Response from Sheffield Teaching Hospitals
Page 2 · response
Published 15 April 2024
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Participate in the regional innovator project to standardise developmentally appropriate transition care, including defined roles, staff training, personalised plans and patient tracking.

Verbatim wording from the response
“Early in 2023 the South Yorkshire & Bassetlaw Acute Federation Trust Paediatric Innovator Programme was established, which includes a project on standardising developmentally appropriate healthcare for young people with chronic or complex conditions transitioning from paediatric to adult secondary care. This is a provider collaboration between STHFT, SCFT, Barnsley Hospital NHS Foundation Trust, Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust and The Rotherham NHS Foundation Trust. It is one of nine national provider collaborative innovators.”

Source location
Response from Sheffield Teaching Hospitals
Page 2 · response
Published 15 April 2024
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Routine shunt reviews are not clinically required after transition; patients remain able to seek advice about symptoms or concerns.

Verbatim wording from the response
“There is no clinical requirement for the routine review of shunts, however during appointments both before and after transfer, patients and/or their families are made aware of the signs and symptoms of a blocked shunt and what action they should take. If, following transition, a decision is made that further routine follow-up is not required, the patient will stay active on the neurosurgery pathway. Patients will be provided with contact details, so that the patient and family are aware of who to contact, including the Consultant’s secretary, for non-urgent enquiries or the on-call Neurosurgeon for urgent enquiries.”

Source location
Response from Sheffield Teaching Hospitals
Page 2 · response
Published 15 April 2024
Open published response
16 Jan2022
Bedfordshire and Luton
Concerns raised2
1. Inadequate transition arrangements for individuals with high functioning autism reaching adulthood
2. National gap in transition services for individuals with high functioning autism
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 12
1. Action
  Review the serious incident report and transition policy and protocols with relevant CAMHS staff.
  Stated by East London NHS Foundation TrustStated completed
2. Action
  Identify CAMHS service users approaching adulthood monthly and discuss their transition planning at multidisciplinary team meetings.
  Stated by East London NHS Foundation TrustStated completed
3. Action
  Include transition-policy performance monitoring in CAMHS supervisors’ monthly clinical supervision.
  Stated by East London NHS Foundation TrustStated completed
1. Action
  Conduct quarterly transition audits, including cross-team audits, to identify improvements, share learning and promote better transitions.
  Stated by East London NHS Foundation TrustStated in progress
2. Action
  Revamp the Bedford and Luton Transition Policy with current protocols and joint CAMHS and adult mental health input, then review and reinforce it after completion.
  Stated by East London NHS Foundation TrustStated planned
3. Action
  Increase transition-support staffing for autistic young people through a dedicated worker, an additional worker and two further support workers.
  Stated by East London NHS Foundation TrustStated completed
4. Action
  Appoint a Strategic Transitions Lead to provide cross-agency leadership and maintain robust transition pathways.
  Stated by East London NHS Foundation TrustStated completed
5. Action
  Participate in the multi-agency task group identifying transition gaps across local authority and health services.
  Stated by East London NHS Foundation TrustStated in progress
6. Action
  Outline a proposal to establish a strategic multi-agency transitions forum to the three named local authorities by 31 March.
  Stated by East London NHS Foundation TrustStated planned
7. Action
  Establish a comprehensive mental health support offer for people aged 0–25 in every area, without age-based thresholds and adapted to young adults’ needs.
  Stated by NHS EnglandStated planned
8. Action
  Ensure NHS services make reasonable adjustments to better meet autistic people’s needs.
  Stated by NHS EnglandStated planned
9. Action
  Prioritise transition within the Learning Disability and Autism Programme and work with partner agencies on an effective cross-system response to young people experiencing difficulty or crisis.
  Stated by NHS EnglandStated in progress
Respondent positions 1
1. Position
  ELFT is responsible for responding directly regarding Luke’s transition arrangements to adult mental health services.
  Stated by NHS EnglandRedirects responsibility
AI-generated summary

Luke Richard WILDEN · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Luke Richard WILDEN was a vulnerable adult with high functioning autism and ADHD who, after turning 18, was not effectively transitioned from child to adult mental health services or provided with an appropriate social care package. He moved to independent living on 2 January 2020, experienced declining mental health and drug misuse, and was found deceased in his flat on 22 May 2020 after being discharged from psychiatric inpatient care. The principal concerns were inadequate transition arrangements within ELFT and a possible wider national gap in services.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Inadequate transition arrangements for individuals with high functioning autism reaching adulthood
Wider context from the report
“Transition arrangements within ELFT for individuals with high functioning autism were inadequate when Luke turned 18 and, as a result, he was not transferred to the appropriate adult mental health team for continued treatment and to enable provision of an appropriate adult social care package, including suitable accommodation for him. Whilst I understand that changes have been made within ELFT in order to address this gap in services, I am concerned that these may still not be sufficient. Furthermore, I am concerned that this gap in services may also exist on a national level. ”
Source location
Luke Richard WILDEN · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
National gap in transition services for individuals with high functioning autism
Wider context from the report
“Transition arrangements within ELFT for individuals with high functioning autism were inadequate when Luke turned 18 and, as a result, he was not transferred to the appropriate adult mental health team for continued treatment and to enable provision of an appropriate adult social care package, including suitable accommodation for him. Whilst I understand that changes have been made within ELFT in order to address this gap in services, I am concerned that these may still not be sufficient. Furthermore, I am concerned that this gap in services may also exist on a national level. ”
Source location
Luke Richard WILDEN · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Review the serious incident report and transition policy and protocols with relevant CAMHS staff.

Verbatim wording from the response
“I understand that you heard oral evidence at the inquest into Mr Wilden’s death that the Trust’s Bedford and Luton Directorate have already taken measures to reinforce its transition policy and protocols.”

Source location
2022-0015-Response-from-NHS-East-London-NHS-Foundation-Trust_Published
Page 1 · response
Published 24 January 2022
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Identify CAMHS service users approaching adulthood monthly and discuss their transition planning at multidisciplinary team meetings.

Verbatim wording from the response
“Additionally, since 31 December 2020, the administrator within each CAMHS team, pulls a list of all existing service users on a monthly basis. Those age 17.5 (6 months from their”

Source location
2022-0015-Response-from-NHS-East-London-NHS-Foundation-Trust_Published
Page 1 · response
Published 24 January 2022
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Include transition-policy performance monitoring in CAMHS supervisors’ monthly clinical supervision.

Verbatim wording from the response
“CAMHS supervisors were also reminded of the importance of the transition policy and protocols and their monthly clinical supervision with staff members now includes performance monitoring of the transition policy and protocols.”

Source location
2022-0015-Response-from-NHS-East-London-NHS-Foundation-Trust_Published
Page 2 · response
Published 24 January 2022
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Conduct quarterly transition audits, including cross-team audits, to identify improvements, share learning and promote better transitions.

Verbatim wording from the response
“An audit was also undertaken. A sample of 5 patients were reviewed over a period of 3 months to assess services’ compliance with the protocols. All cases reviewed met the required targets.”

Source location
2022-0015-Response-from-NHS-East-London-NHS-Foundation-Trust_Published
Page 2 · response
Published 24 January 2022
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Revamp the Bedford and Luton Transition Policy with current protocols and joint CAMHS and adult mental health input, then review and reinforce it after completion.

Verbatim wording from the response
“Additionally, Bedford and Luton’s Transition Policy has come up for review. A decision has been made that the policy be revamped to include the latest transition protocols with both CAMHS and Adult Mental Health services feeding into the final document. It is anticipated that this will be complete on 14 April 2022. The new policy will be reviewed at the first CAMHS away day following completion and reinforced through supervisors via monthly supervision.”

Source location
2022-0015-Response-from-NHS-East-London-NHS-Foundation-Trust_Published
Page 2 · response
Published 24 January 2022
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Increase transition-support staffing for autistic young people through a dedicated worker, an additional worker and two further support workers.

Verbatim wording from the response
“To assist staff in reinforcing the transition policies and protocols outlined above, the Trust has also increased its capacity for supporting transitions from CAMHS to adult mental health and social care services. I understand that at the inquest you received submissions outlining various changes that the Trust had already undertaken specifically in relation to transition arrangements for individuals with high-functioning autism.”

Source location
2022-0015-Response-from-NHS-East-London-NHS-Foundation-Trust_Published
Page 2 · response
Published 24 January 2022
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Appoint a Strategic Transitions Lead to provide cross-agency leadership and maintain robust transition pathways.

Verbatim wording from the response
“The Trust has just appointed a Strategic Transitions Lead. This role will provide system leadership across all agencies, including ensuring that robust transitions systems between children’s (CAMHS) and Adult Mental Health Care are maintained. They will also work with the relevant local authorities to ensure that robust transition pathways are in place across mental health services. They will ensure that the experience of the young person is at the heart of how the systems and processes develop and operate.”

Source location
2022-0015-Response-from-NHS-East-London-NHS-Foundation-Trust_Published
Page 3 · response
Published 24 January 2022
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Participate in the multi-agency task group identifying transition gaps across local authority and health services.

Verbatim wording from the response
“There is currently a safeguarding adults review (SAR) taking place in relation to Mr Wilden’s case. Bedford Borough Council safeguarding has requested a specific joint multi-agency, task and finish group (Task Group) to identify gaps in transitions across local authority and health. The findings will be fed back to the safeguarding board. The Trust is taking an active role in the SAR and the Task Group. Any significant findings will be fed into Trust Policy.”

Source location
2022-0015-Response-from-NHS-East-London-NHS-Foundation-Trust_Published
Page 3 · response
Published 24 January 2022
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Outline a proposal to establish a strategic multi-agency transitions forum to the three named local authorities by 31 March.

Verbatim wording from the response
“As part of the newly appointed Strategic Transitions Lead’s role, ELFT will propose a strategic multi-agency forum be established with all key partners, particularly its local authority partners, to ensure that transitions retains a system wide focus and that leadership can be provided on a collaborative basis, to the many teams and services that have the potential to interface with a young person and their family carers during their journey to adulthood.”

Source location
2022-0015-Response-from-NHS-East-London-NHS-Foundation-Trust_Published
Page 3 · response
Published 24 January 2022
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Establish a comprehensive mental health support offer for people aged 0–25 in every area, without age-based thresholds and adapted to young adults’ needs.

Verbatim wording from the response
“Improving transitions between Children and Young People’s Mental Health Services and Adult Mental Health Services is a key priority within NHSE/I’s LTP commitments regarding mental health. The LTP sets out a commitment that a comprehensive support offer for children and young people, between the ages of 0 to 25 years, would be in place in all areas of the country by March 2024. Critical to this ambition is improving support and care for young adults (18 to 25 years) with the expectation that by March 2024 no age-based threshold will be in place and that all services are adapted to meet the needs of young adults.”

Source location
2022-0015-Response-from-NHS-Improvement_Published
Page 2 · response
Published 24 January 2022
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Ensure NHS services make reasonable adjustments to better meet autistic people’s needs.

Verbatim wording from the response
“NHSE/I are committed to improving care and support for autistic people. The LTP recognised the need to ensure all NHS services are reasonably adjusted to ensure they are better able to meet the needs of autistic people. We know that the transition to adult services does not always work well for children and young people and their families, acknowledging that this was the case here. It is so important that there are good multi-agency planning/actions, before young people turn 18, to ensure that they get the support they need as they move to adulthood services. It is even more important that there is effective support for young people, such as Luke, who experience multiple additional challenges.”

Source location
2022-0015-Response-from-NHS-Improvement_Published
Page 2 · response
Published 24 January 2022
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Prioritise transition within the Learning Disability and Autism Programme and work with partner agencies on an effective cross-system response to young people experiencing difficulty or crisis.

Verbatim wording from the response
“It is for this reason that we have made transition one of the key priorities for the Learning Disability and Autism Programme and are working with partners in other agencies to ensure there is an effective cross system response to young people experiencing difficulty and crisis.”

Source location
2022-0015-Response-from-NHS-Improvement_Published
Page 2 · response
Published 24 January 2022
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
ELFT is responsible for responding directly regarding Luke’s transition arrangements to adult mental health services.

Verbatim wording from the response
“Following the inquest, you raised concerns in your Report regarding the adequacy of transition arrangements within East London Foundation Trust (ELFT) for individuals with high functioning autism, stating that when Luke turned 18, he was not transferred to the appropriate adult mental health team for continued treatment and to enable provision of an appropriate adult social care package, including suitable accommodation for him. You raised a second concern that this gap in services may also exist on a national level.”

Source location
2022-0015-Response-from-NHS-Improvement_Published
Page 1 · response
Published 24 January 2022
Open published response
9 Nov2017
South Yorkshire (Western)
Concerns raised1
1. Failure of safe transition of care from CAMHS to Adult Services
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 5
1. Action
  Strengthen, jointly approve and regularly audit the cross-Trust Transitions Protocol for 16- and 17-year-olds.
  Stated by Sheffield Children'S NHS Foundation Trust and Sheffield Health Partnership University NHS Foundation TrustStated in progress
2. Action
  Produce a patient journey pathway incorporating feedback from pre- and post-transition questionnaires.
  Stated by Sheffield Children'S NHS Foundation Trust and Sheffield Health Partnership University NHS Foundation TrustStated in progress
3. Action
  Conduct a joint transition workshop involving experts by experience and clinicians from both Trusts.
  Stated by Sheffield Children'S NHS Foundation Trust and Sheffield Health Partnership University NHS Foundation TrustStated completed
1. Action
  Appoint an Operational Director Lead to oversee transitions and timely action on identified requirements.
  Stated by Sheffield Children'S NHS Foundation Trust and Sheffield Health Partnership University NHS Foundation TrustStated completed
2. Action
  Continue consulting on measures to transform children’s and young people’s mental health services, including improving transition into adult support.
  Stated by Department of Health and Social CareStated in progress
Respondent positions 1
1. Position
  Early Intervention in Psychosis services can appropriately accept referrals from young people aged 14 to 18.
  Stated by Department of Health and Social CareDisputes the concern
AI-generated summary

Daisy French · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Daisy French, who had a history of serious mental health difficulties and was transitioning from child to adult mental health services, died after deliberately placing herself in front of a high-speed train at Meadowhall Railway Station on 19 April 2017. The concerns included communication and information sharing between services, transition of care, differing out-of-hours arrangements for 16- to 18-year-olds, placement of an under-18-year-old in an adult crisis house, and returning her to accommodation without staff on duty after a mental health assessment.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure of safe transition of care from CAMHS to Adult Services
Wider context from the report
“2) Transition of care from CAMHS to Adult services. ”
Source location
Daisy French · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Strengthen, jointly approve and regularly audit the cross-Trust Transitions Protocol for 16- and 17-year-olds.

Verbatim wording from the response
“We recognise how critical multi-agency collaboration is in order to safely transition a young person, to ensure that all parties are working collaboratively and in the best interests of the young person. We are strengthening the existing Transitions Protocol for 16 and 17 year olds across multiple areas, including but not exclusive to:-”

Source location
2017-0264-Response-by-Sheffield-Health-and-Social-Care
Page 2 · response
Published 9 November 2017
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Produce a patient journey pathway incorporating feedback from pre- and post-transition questionnaires.

Verbatim wording from the response
“Transition lead nurses from both SC NHS FT and SHSC are working together to produce a patient journey pathway that incorporates feedback from the pre and post transition questionnaires.”

Source location
2017-0264-Response-by-Sheffield-Health-and-Social-Care
Page 2 · response
Published 9 November 2017
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Conduct a joint transition workshop involving experts by experience and clinicians from both Trusts.

Verbatim wording from the response
“Preparatory events have taken place involving both Trusts in November 2017, for example a Transition workshop which involved experts by experience as well as clinicians from both Trusts/services. In addition, an event will take place on 5 January 2018 concentrating on mapping the crisis and emergency care pathways for 16 and 17 year olds, which should give more clarity on the city’s provision and highlight gaps.”

Source location
2017-0264-Response-by-Sheffield-Health-and-Social-Care
Page 2 · response
Published 9 November 2017
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Appoint an Operational Director Lead to oversee transitions and timely action on identified requirements.

Verbatim wording from the response
“SHSC has also identified an Operational Director Lead, ████████, who will oversee transitions going forward to ensure timely action against the points identified above.”

Source location
2017-0264-Response-by-Sheffield-Health-and-Social-Care
Page 3 · response
Published 9 November 2017
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Continue consulting on measures to transform children’s and young people’s mental health services, including improving transition into adult support.

Verbatim wording from the response
“Also relevant here is the Transforming Children and Young People’s Mental Health Provision: a Green Paper, published in December 2017 by the Department of Health and the Department for Education, which builds on our commitments through Future in Mind. We are currently consulting on a range of measures to transform children’s and young people’s mental health services, which includes issues such as improving transition for young people who require ongoing mental health support into adulthood.”

Source location
2017-0264-Response-by-Department-of-Health
Page 2 · response
Published 9 November 2017
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Early Intervention in Psychosis services can appropriately accept referrals from young people aged 14 to 18.

Verbatim wording from the response
“Your Report states that Daisy was to be transferred from the CAMHS to the local EIT service, which is an adult psychiatric service. My officials have suggested that this refers to the Early Intervention in Psychosis (EIP) service. EIP services can start from age 14 and it is appropriate for young people to be referred to them.”

Source location
2017-0264-Response-by-Department-of-Health
Page 3 · response
Published 9 November 2017
Open published response
20 Feb2015
Carmarthenshire & Pembrokeshire
Concerns raised1
1. Breakdown in information transition and passing between Child/Adolescent and Adult Mental Health Teams
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 1
1. Action
  Circulate transition guidelines between child and adult mental health services.
  Stated by Hywel Dda University LHBStated completed
AI-generated summary

Laura Hill · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Laura Hill, aged 21, was admitted to a psychiatric ward after a serious overdose and later absconded twice before being found hanging from a tree in a wooded area. The concerns identified included information-sharing failures, stretched staffing, training needs around police handovers, absconding, personality disorders and detention powers, and the ward door policy.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Breakdown in information transition and passing between Child/Adolescent and Adult Mental Health Teams
Wider context from the report
“(1) That there appears to be a breakdown in the transition and passing of information between the Child/Adolescent and the Adult Mental Health Teams. ”
Source location
Laura Hill · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Circulate transition guidelines between child and adult mental health services.

Verbatim wording from the response
“In January 2013, the Health Board provided transition guidelines in relation to Specialist Child and Adolescent Mental Health Services to Adult Mental Health and Learning Disability Services. The document was circulated across all the relevant teams and provides clear transition guidelines in line with best practice and government guidelines with regards to transitions between services. It is recognised that times of transition can pose potential risks if they are not robustly managed and the guidance enhances the safety of the transition process with clear steps for professionals to follow.”

Source location
2015-0092-Response-by-University-Health-Board
Page 1 · response
Published 20 February 2015
Open published response
17 Dec2014
Nottinghamshire
Concerns raised1
1. Failure to ensure that immediate transfers at age 18 are in the person's best interests
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Respondent positions 3
1. Position
  The cited legislation is not known to require immediate transfer, preventing comment on that specific issue pending clarification.
  Stated by Department of Health and Social CareUnable to act
1. Position
  The transfer was planned for months, clinically assessed as appropriate, and could not safely be delayed or replaced by community discharge.
  Stated by Department of Health and Social CareDisputes the concern
2. Position
  Existing adult wards and transition guidance are considered capable of meeting the clinical and transition needs of young adults aged 18 to 24.
  Stated by Department of Health and Social CareExisting arrangements considered sufficient
AI-generated summary

Rebecca Louise Overy · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Rebecca Louise Overy died from hypoxic brain injury caused by asphyxia while in adult secure mental health detention. Her fatal injury was self-inflicted after she was transferred from child and adolescent secure mental health detention to an adult admission ward the day after her 18th birthday, without a gradual transition plan; concerns included the immediate transfer and the lack of secure mental health care for young adults aged 18–24 with a similar clinical picture.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to ensure that immediate transfers at age 18 are in the person's best interests
Wider context from the report
“1. That the immediate transfer of Miss Overy the day after her 18th birthday was not in her best interests, was detrimental to her mental health and occurred purely due to the operation of s 30 of the Health and Social Care Act, whereby the commissioners were obliged to arrange an immediate transfer, and the clinicians to concur with it, lest they be in breach of the act. ”
Source location
Rebecca Louise Overy · Prevention of Future Deaths report
Page 1 · concerns
Open source report
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
The cited legislation is not known to require immediate transfer, preventing comment on that specific issue pending clarification.

Verbatim wording from the response
“You refer to the “operation of a section 30 of the Health and Social Care Act, whereby the commissioners were obliged to arrange an immediate transfer”. I am not aware of a provision from either the Health and Social Care Act or the Mental Health Act which stipulates this, so am unable to comment on this specific matter. However, if you are able to provide clarification for this reference I am happy to respond further on this point.”

Source location
2014-0535R
Page 3 · response
Published 17 December 2014
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
The transfer was planned for months, clinically assessed as appropriate, and could not safely be delayed or replaced by community discharge.

Verbatim wording from the response
“NHS England have assured me that Miss Overy’s future care had been considered for many months prior to her transfer including the appropriate type of environment and level of security required. They have confirmed that an independent clinical access assessment had been undertaken that identified that Miss Overy should be in an adult low secure placement when she turned 18. The CAMHS placement where she was, was not of a low secure environmental or therapeutic standard that would meet her identified needs. In addition, Miss Overy’s significant levels of risk and patterns of behaviour meant that she would not have been able either to remain within a CAMHS or be discharged to the community when she became an adult.”

Source location
2014-0535R
Page 3 · response
Published 17 December 2014
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Existing adult wards and transition guidance are considered capable of meeting the clinical and transition needs of young adults aged 18 to 24.

Verbatim wording from the response
“You were concerned that there is no provision for secure mental health care for young adults aged 18–24 with a similar clinical picture. Whilst there are no dedicated wards for 18 to 24 year olds, there are wards that meet the clinical needs of patients with the same and similar presentation to Miss Overy. There is transition guidance in place which advises that arrangements are made within adult wards to ensure that appropriate patient needs, as highlighted in clinical assessments, are met. Receiving providers should make appropriate plans and extend the services available to aid the transition arrangements for young adults.”

Source location
2014-0535R
Page 4 · response
Published 17 December 2014
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Lack of a clearly defined transition pathway between CAMHS and adult psychiatric services

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.4

Concerns raised2

Lack of national guidance and support for the multi-agency transition approach

Lack of a recognised multi-agency transition pathway with clear risk, accountability and support arrangements

Concerns raised2

Lack of a transfer protocol or pathway for transition from childhood to adulthood

Lack of an effective review process for adults

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.5

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1

Concerns raised2

Inadequate transition arrangements for individuals with high functioning autism reaching adulthood

National gap in transition services for individuals with high functioning autism

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.12

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1

Actions described in response 4

Actions described in response 5

Respondent positions 1

Actions described in response 12

Respondent positions 1