Recurring concern

Unreliable mental health support pathways for young people who disengage

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First reported 2 Sep 2014•Latest report 9 Mar 2017

Definition

What this concern includes

Includes dedicated mental health arrangements for young people who resist, cannot sustain or disengage from engagement with services, including formal pathways, step-down or transition arrangements, proactive outreach, re-engagement, support-network involvement and escalation or follow-up needed to maintain access to care.

Not included

  • Excludes general mental health service delays, treatment-quality problems or capacity shortages where disengagement or difficulty engaging is not a material part of the unsafe condition.
  • Excludes failures in routine mental health referrals, appointments or discharge processes where no specific difficulty engaging or disengagement is identified.
  • Excludes generic family involvement, communication or care-coordination deficiencies unless they directly impair the pathway for a young person who resists or disengages from mental health care.
  • Excludes adult mental health service failures unrelated to supporting young people who disengage or transition away from care.
Reports
2

Distinct published reports

Individual concerns
2

A report can raise multiple concerns

Date range
2014–2017

First to latest report issue date

Stated actions
0

Described in published responses

Reports over time

Reports over time

Reports about this concern issued each year.

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

Most frequent recipients

Most frequent recipients

Reports about this concern sent to each recipient.

CAMHS East – Cross Street Clinic1
Department for Education1
GeoAmey PECS Limited1
Midlands Partnership University NHS Foundation Trust1
South Yorkshire Police1
Youth Justice Board for England and Wales1

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.

  1. Staffordshire South

    AI-generated summary

    Annabel Mae LEWIS · 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

    Annabel Mae LEWIS, aged 15, died by asphyxia from external airway obstruction after placing a plastic bag over her head at home. The report raised concerns about CAMHS referral handling, including the lack of recorded risk assessment, follow-up arrangements, attempts to engage her parents, and proactive support after she declined an appointment because of difficulty accessing the venue.

    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 engage parents or other support networks when young people have difficulty engaging

    Wider context from the report

    “(1) At the inquest it was evident that Annabel had been referred by her GP to your team in November 2015 but that referral had not been accepted. She was referred again on 20/10/2016 by her school. This time the referral was accepted and your team made contact with her by telephone on 21/10/2016. She declined an appointment because she felt she could not get to the venue. No level of risk was recorded and next of kin details were not available. The date of appointment offered and declined were not recorded. Alternative time for appointment was not recorded. No follow up arrangements were recorded. There was no attempt to contact Annabel thereafter. An unsuccessful attempt to contact the referrer was made on 4/11/2016- the day Annabel took her own life. The time period between referral and initial contact and attempted follow up appears considerable. No attempt appears to have been made to engage with her parents who would have been in a position to assist with transport arrangements. The expectation that young people such as Annabel would 'opt in 'to the system may be unrealistic given the difficulties that she had in engaging. Annabel might well have benefitted had she been offered a more proactive service. ”

    Source location

    Annabel Mae LEWIS · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  2. South Yorkshire (Western)

    AI-generated summary

    Peter Stanley · 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

    Peter Stanley, aged 17, was found hanging in woodland on 2 August 2013 after a history of mental health concerns, suicidal thoughts and a previous suicide attempt. The report identified missed opportunities for mental health assessment and care, alongside concerns about information-sharing, homelessness and accommodation, custody assessments, and support for young people.

    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 formal step-down process for young people leaving or disengaging from adult mental health services

    Wider context from the report

    “(2) When young people are discharged from, or have failed to engage with, Adult Mental Health Services there is no formal 'step-down' policy. The Sheffield Child Death Overview Panel advise me that this should include a referral to a Multi Agency Support Team or Community Youth team who can then establish a key worker and 'team around the child' approach. ”

    Source location

    Peter Stanley · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report
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Data last updated 7 September 2026