Recurring concern

Insufficient age-appropriate mental health provision for young people transitioning to adulthood

First to latest report 17 Dec 2014 — 29 Apr 2026

Reports that mention this concern: 8
Times this concern has been raised: 11
Stated actions linked to this concern: 17

What this concern includes

Includes failures in mental health provision for young people approximately aged 16–25 where child, adult or secure services do not provide an appropriate and continuous option, including absent secure provision, unsuitable adult placement, inadequate out-of-hours provision and gaps in alternative care.

What is not included

Excludes general mental health service shortages, waiting times or treatment-quality failures without a material age-transition or age-appropriate-provision condition.
Excludes failures in ordinary child-to-adult healthcare transition where the mental health provision or placement itself is not deficient.
Excludes generic psychiatric bed shortages or secure-unit capacity failures without a specific impact on age-appropriate provision for young people transitioning to adulthood.
Excludes occupational therapy, education, social-care or other support gaps where the mental health provision boundary is not directly identified.

Trends

Reports over time

Reports mentioning this concern, 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 Care5

Department for Education2

NHS England2

Cheshire and Wirral Partnership NHS Foundation Trust1

Greater Manchester Health and Social Care Partnership1

Greater Manchester Mental Health NHS Foundation Trust1

Health and Safety Executive1

NHS Greater Manchester Integrated Care Board1

NHS South Yorkshire Integrated Care Board1

North Staffordshire Combined Healthcare NHS Trust1

Pennine Care NHS Foundation Trust1

Sheffield Children's Hospital1

Sheffield Health Partnership University NHS Foundation Trust1

Reports and published responses 8 reports

See individual reports that have raised this concern, and the actions taken in response

29 Apr2026
Wiltshire and Swindon
Concerns raised1
1. Commissioning mental health provision for children and adolescents with a strict 18th-birthday cut-off
Linked response

NHS England
Stated actions 2
1. NHS England
  Develop and publish transition guidance promoting personalised, planned moves from children’s to adult mental health services without automatic age-based transfer.
2. NHS England
  Work with regulators and royal colleges to clarify clinical responsibilities for 16- and 17-year-olds and inform forthcoming transition guidance.
AI-generated summary

Alice, Sarah, Dearden (Alice) · 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

Alice had mental health difficulties associated with anorexia nervosa and emotionally unstable personality disorder, including acts of self-harm and overdoses. She died by suicide at age 19. Evidence suggested that a strict commissioning cut-off at age 18 could adversely affect mental health by making transitions from child to adult mental health services insufficiently gradual.

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
Commissioning mental health provision for children and adolescents with a strict 18th-birthday cut-off
Wider context from the report
“Evidence received at the above inquest suggested that commissioning mental health provision for children and adolescents with a strict cut off date of the individual’s 18th birthday could be prejudicial to mental health in certain circumstances. ”
Source location
Alice, Sarah, Dearden (Alice) · 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
Develop and publish transition guidance promoting personalised, planned moves from children’s to adult mental health services without automatic age-based transfer.

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 children to adult mental health services. A core principle is continuity of care, with transition decisions based on the individual needs and circumstances of the young person, rather than on age alone.”

Source location
Response from NHS England
Page 1 · response
Published 2 July 2026
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
Work with regulators and royal colleges to clarify clinical responsibilities for 16- and 17-year-olds and inform forthcoming transition guidance.

Verbatim wording from the response
“In 2024, NHS England partnered with the NHS Youth Forum to investigate this further, receiving survey responses from young people across the country. The results identified a gap in care for 16–17 year olds with many being discharged from paediatric services before being told they weren't old enough to access adult ones.”

Source location
Response from NHS England
Page 2 · response
Published 2 July 2026
Open published response
16 Oct2021
Stoke-on-Trent and North Staffordshire
Concerns raised2
1. Lack of mental health inpatient provision for people aged 14-25
2. Failure to provide age-appropriate transitional care when mental health inpatients turn 18
Linked responses

NHS England
The Trust
Stated actions 3
1. The Trust
  Review and update the Transition of Young People to Adult Mental Health Service Policy to address person-centred adjustments, monitoring, escalation and case-by-case care.
2. The Trust
  Share the updated transition policy with inpatient areas and community teams.
3. The Trust
  Develop a 14–25 transition service with social care and third-sector children and young people partners to improve continuity of care during transition.
Respondent positions 3
1. NHS England
  A single 14–25 inpatient ward is not recommended because developmental differences and safeguarding risks could place vulnerable young people at risk.
  Disputes the concern
1. NHS England
  Young people are not automatically transferred to adult mental health wards when they turn 18.
  Disputes the concern
2. NHS England
  Existing individualised discharge and admission planning, involving relevant professionals and families, addresses transition between child and adult services.
  Existing arrangements considered sufficient
AI-generated summary

Sky Louise Rollings · 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

Sky Louise Rollings was transferred from a child and adolescent mental health hospital to an adult mental health unit on 4 November 2019 and died at Royal Stoke University Hospital on 9 November 2019, following an incident at Harplands Hospital. The inquest heard concerns about differences between child and adult mental health care and the lack of inpatient provision for people aged 14 to 25, which was considered to create a risk of further deaths.

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 mental health inpatient provision for people aged 14-25
Wider context from the report
“During the inquest evidence was heard about the differences in the way CAMHS Hospitals and Adult mental Health Hospitals approached the care of the patients on their wards. When hearing evidence during the inquest it was established that when a child turned 18, and was a patient on a Mental health ward, once transferred to an adult Mental Health Hospital they would immediately be treated in accordance with the adult provisions. It was accepted that there is no provision there is currently no one in-patient provision for people between the ages of 14-25. It was also accepted that simply because a child becomes 18 does not mean that they are an adult. The lack of this provision in a mental health in-patient setting leads me to conclude that there is a risk of further deaths resulting. ”
Source location
Sky Louise Rollings · Prevention of Future Deaths report
Page 1 · 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
Failure to provide age-appropriate transitional care when mental health inpatients turn 18
Wider context from the report
“During the inquest evidence was heard about the differences in the way CAMHS Hospitals and Adult mental Health Hospitals approached the care of the patients on their wards. When hearing evidence during the inquest it was established that when a child turned 18, and was a patient on a Mental health ward, once transferred to an adult Mental Health Hospital they would immediately be treated in accordance with the adult provisions. It was accepted that there is no provision there is currently no one in-patient provision for people between the ages of 14-25. It was also accepted that simply because a child becomes 18 does not mean that they are an adult. The lack of this provision in a mental health in-patient setting leads me to conclude that there is a risk of further deaths resulting. ”
Source location
Sky Louise Rollings · Prevention of Future Deaths report
Page 1 · 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 and update the Transition of Young People to Adult Mental Health Service Policy to address person-centred adjustments, monitoring, escalation and case-by-case care.

Verbatim wording from the response
“(1) The Trust has initiated a further review of the Transition of Young People to Adult Mental Health Service Policy following the inquest. The review will include the above concerns raised during the inquest relating to the transition from a young person’s inpatient facility to an adult mental health facility (which may include an adult mental health inpatient ward).”

Source location
2021-0354-Response-from-North-Staffordshire-Combined-Healthcare-NHS-Trust_Published
Page 1 · response
Published 21 October 2021
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
Share the updated transition policy with inpatient areas and community teams.

Verbatim wording from the response
“• Highlight the importance of reviewing the approach to patient care on a case-by-case basis – not simply applying an approach to care based on the person being placed on an adult ward as they have legally reached the age of adulthood now and this is how it is. | Lead: ████████ | Completion date: 31st March 2022 | Updated section to the Policy in line with the actions raised. Policy will be shared with all in patient areas/community teams.”

Source location
2021-0354-Response-from-North-Staffordshire-Combined-Healthcare-NHS-Trust_Published
Page 3 · response
Published 21 October 2021
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
Develop a 14–25 transition service with social care and third-sector children and young people partners to improve continuity of care during transition.

Verbatim wording from the response
“(2) Whilst the Trust acknowledges there is no in-patient provision for people between the ages of 14-25, as part of the Community Transformation agenda we have commenced work with the partners relating to community transformation in social care and third sector CYP support to support the development of a 14-25 Transition (Preparing for Adulthood) service. This service will seek to align to the Good Mental Health Services for Young People (Royal College of Psychiatry, 2017) good practice paper.”

Source location
2021-0354-Response-from-North-Staffordshire-Combined-Healthcare-NHS-Trust_Published
Page 2 · response
Published 21 October 2021
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
A single 14–25 inpatient ward is not recommended because developmental differences and safeguarding risks could place vulnerable young people at risk.

Verbatim wording from the response
“There are safeguarding concerns and implications that need to be taken into consideration in having young people under 18 years and those over 18 years on the same ward, which will usually mean requiring increased observations (which places additional pressure on staffing and can feel restrictive for young people themselves).”

Source location
2021-0354-Response-from-NHS-England_Published
Page 2 · response
Published 21 October 2021
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
Young people are not automatically transferred to adult mental health wards when they turn 18.

Verbatim wording from the response
“In response to your first concern I can confirm that young people are not all automatically transferred at 18 year of age. Where it is feasible for their episode of”

Source location
2021-0354-Response-from-NHS-England_Published
Page 1 · response
Published 21 October 2021
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 individualised discharge and admission planning, involving relevant professionals and families, addresses transition between child and adult services.

Verbatim wording from the response
“Discharge and admission planning processes are in place, and someone would not ‘immediately be treated in accordance with the adult provisions’. The development and clinical decision making in a young person’s care plan and discharge plan are considered by the young person’s current Tier 4 CAMHS provider’s clinical team. This includes multi-agency/ professionals e.g. social worker, community mental health services, the young person and their family’s views and again is individualised to each patient’s needs and circumstances.”

Source location
2021-0354-Response-from-NHS-England_Published
Page 2 · response
Published 21 October 2021
Open published response
1 Oct2019
Manchester South
Concerns raised1
1. Variation and limited transition provision in post-16 mental health services
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Oliver Sharp · 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

Oliver Sharp died after taking a fatal dose of heroin; his death was confirmed at Wythenshawe Hospital on 18 October 2018. The inquest identified concerns about failures by mental health services to recognise and respond to his increasing level of risk during his transition from child and adolescent mental health services to reduced post-16 provision, as well as concerns about delays in autism assessment and variation in post-16 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
Variation and limited transition provision in post-16 mental health services
Wider context from the report
“The inquest was told that the provision of mental health services post 16 varies widely across the country. In some areas there is a CAMHS 16-25 mental health service provision similar to the national 16 and under service whereas in other areas there a limited transition service or move back to primary care for re-referral to adult services. The inquest was told that this creates a cliff edge high risk situation for adolescents. The reason for the difference was resources and decisions taken by CCGs. ”
Source location
Oliver Sharp · Prevention of Future Deaths report
Page 4 · concerns
Open source report
24 Jul2019
Manchester South
Concerns raised2
1. Lack of alternative mental health provision for young adults
2. Lack of suitable acute mental health beds for young adults
This report raised 9 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Hannah Dolly Kaur Bharaj · 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

Hannah Dolly Kaur Bharaj had anorexia, depression and fluctuating suicidal ideation, and died at Salford Royal Hospital on 13 July 2018 from injuries sustained after jumping from a first-floor café. Concerns included inadequate communication and discharge planning, unsuitable placement and care coordination, incomplete sharing of clinical information, and the safety of the café balustrade and adjacent table.

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 alternative mental health provision for young adults
Wider context from the report
“3. The suitability of acute mental health beds for young adults and lack of alternative provision The inquest heard that Hannah went to an acute adult psychiatric bed because the EDU felt that it was the wrong environment for her and there was no other alternative. The inquest heard that there were concerns regarding the placement of a young adult in such a setting and how frightening it was to her; ”
Source location
Hannah Dolly Kaur Bharaj · Prevention of Future Deaths report
Page 3 · 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 suitable acute mental health beds for young adults
Wider context from the report
“3. The suitability of acute mental health beds for young adults and lack of alternative provision The inquest heard that Hannah went to an acute adult psychiatric bed because the EDU felt that it was the wrong environment for her and there was no other alternative. The inquest heard that there were concerns regarding the placement of a young adult in such a setting and how frightening it was to her; ”
Source location
Hannah Dolly Kaur Bharaj · Prevention of Future Deaths report
Page 3 · concerns
Open source report
3 Apr2019
South Yorkshire (Western)
Concerns raised1
1. Lack of available urgent mental health services for 16- and 17-year-olds
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses

NHS South Yorkshire Integrated Care Board
Sheffield Children'S NHS Foundation Trust
Sheffield Health Partnership University NHS Foundation Trust
Stated actions 6
1. NHS South Yorkshire Integrated Care Board and Sheffield Children'S NHS Foundation Trust
  Complete and approve the business case for the CAMHS Home Intensive Treatment Team.
2. NHS South Yorkshire Integrated Care Board and Sheffield Children'S NHS Foundation Trust
  Reconfigure the existing Sheffield Treatment and Recovery Service into a CAMHS Home Intensive Treatment Team for young people up to age 18.
3. NHS South Yorkshire Integrated Care Board and Sheffield Children'S NHS Foundation Trust
  Recruit nursing staff for the new CAMHS Home Intensive Treatment Team.
1. NHS South Yorkshire Integrated Care Board and Sheffield Children'S NHS Foundation Trust
  Establish a Mental Health Liaison Team supporting 0–18-year-olds attending designated emergency departments, with out-of-hours cover.
2. NHS South Yorkshire Integrated Care Board and Sheffield Children'S NHS Foundation Trust
  Implement the temporary care pathway change agreed with Sheffield Health and Social Care NHS Foundation Trust.
3. Sheffield Children'S NHS Foundation Trust and Sheffield Health Partnership University NHS Foundation Trust
  Implement jointly approved policy arrangements providing out-of-hours emergency home treatment to eligible 16- and 17-year-olds requiring crisis intervention.
AI-generated summary

Aryan Akhgar · 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

Aryan Akhgar, aged 17, died on 6 March 2018 after hanging himself with the intent to take his own life. The report identified a gap in urgent mental health services for 16- and 17-year-olds in Sheffield: although an urgent response was recommended on 9 January 2018, the first visit by mental health professionals did not occur until 15 January 2018. The report also raised concern that funding for additional CAMHS resources was not guaranteed.

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 available urgent mental health services for 16- and 17-year-olds
Wider context from the report
“5.1 A gap in services was identified for 16 and 17 years old’s with urgent mental health issues, such as Aryan had. On 9th January 2018, Aryan was assessed as requiring urgent mental health input, commencing the next day. This was not available as a service for under 18’s in Sheffield and Aryan did not receive any contact from Child and Adolescent Mental Health Services (CAMHS) until 15th January 2018. In evidence I was told that additional resources in the CAMHS service were close to agreement in order to prevent this kind of problem arising in the future. However, this would be subject to a commissioning process from the Clinical Commissioning Group for Sheffield which could not be guaranteed. 5.2 It was accepted in evidence by the Medical Director of the Sheffield Children’s Hospital on behalf of CAMHS that such additional resource was required. The delivery of the necessary funding to properly resource the CAMHS team was not guaranteed. ”
Source location
Aryan Akhgar · 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
Complete and approve the business case for the CAMHS Home Intensive Treatment Team.

Verbatim wording from the response
“At the time of writing, the business case for the HITT team has been completed and was approved by the CCG on 7th May 2019, with a plan to begin a phased implementation from the autumn 2019. The service will be evaluated to ensure that it meets the needs of the young people who are its service users.”

Source location
2019-0115-Response-by-Sheffield-Childrens-NHS-CCG
Page 2 · response
Published 9 June 2019
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
Reconfigure the existing Sheffield Treatment and Recovery Service into a CAMHS Home Intensive Treatment Team for young people up to age 18.

Verbatim wording from the response
“Sheffield Children’s NHS Foundation Trust and NHS Sheffield Clinical Commissioning Group have been working collaboratively to develop a robust long term solution to the issues you have highlighted. The two organisations have considered the potential models and have agreed the most appropriate way forward to be through the reconfiguration of the existing Sheffield Treatment and Recovery (STAR) Service into a CAMHS Home Intensive Treatment Team (HITT).”

Source location
2019-0115-Response-by-Sheffield-Childrens-NHS-CCG
Page 1 · response
Published 9 June 2019
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
Recruit nursing staff for the new CAMHS Home Intensive Treatment Team.

Verbatim wording from the response
“The CCG and the Trust recognise that there is urgency to the situation and are working closely to ensure that there is no delay to its implementation noting also the temporary change in pathway agreed between Sheffield Children’s NHS Foundation Trust and Sheffield Health and Social Care NHS Foundation Trust. Furthermore, the Trust has already begun to recruit nursing staff to the new service in anticipation of its formal commissioning.”

Source location
2019-0115-Response-by-Sheffield-Childrens-NHS-CCG
Page 2 · response
Published 9 June 2019
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 Mental Health Liaison Team supporting 0–18-year-olds attending designated emergency departments, with out-of-hours cover.

Verbatim wording from the response
“This new team will be responsible for children and young people up to the age of 18 years and will be aligned with, and where appropriate, undertake, joint working with the Home Intensive Treatment Services provided by Sheffield Health and Social Care NHS Foundation Trust. In addition the Mental Health Liaison Team will support 0-18 year olds attending either Sheffield Children’s or the Northern General Hospital’s Emergency Departments. Access to the HITT will be within 24 hours when required whilst the Liaison Team will operate to meet the demands through the Emergency Departments with an on call rota in place for out of hours.”

Source location
2019-0115-Response-by-Sheffield-Childrens-NHS-CCG
Page 2 · response
Published 9 June 2019
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
Implement the temporary care pathway change agreed with Sheffield Health and Social Care NHS Foundation Trust.

Verbatim wording from the response
“The CCG and the Trust recognise that there is urgency to the situation and are working closely to ensure that there is no delay to its implementation noting also the temporary change in pathway agreed between Sheffield Children’s NHS Foundation Trust and Sheffield Health and Social Care NHS Foundation Trust. Furthermore, the Trust has already begun to recruit nursing staff to the new service in anticipation of its formal commissioning.”

Source location
2019-0115-Response-by-Sheffield-Childrens-NHS-CCG
Page 2 · response
Published 9 June 2019
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
Implement jointly approved policy arrangements providing out-of-hours emergency home treatment to eligible 16- and 17-year-olds requiring crisis intervention.

Verbatim wording from the response
“1. An addendum to the Transitions Policy has been jointly approved by both Trusts that ensures that emergency home treatment will be provided to 16/17 year olds by Sheffield Health and Social Care’s adult services, should they require crisis intervention out of hours and where they are not known to Child and Adolescent Mental Health Services which mirrors that already present for those known to the Services. This was implemented with effect from January 2019.”

Source location
2019-0115-Response-by-Sheffield-Childrens-NHS-Trust
Page 2 · response
Published 9 June 2019
Open published response
9 Nov2017
South Yorkshire (Western)
Concerns raised2
1. Placement of under-18s in adult crisis houses
2. Inadequate out-of-hours mental health provision for 16 to 18 year olds
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses

Department of Health and Social Care
Sheffield Children'S NHS Foundation Trust
Sheffield Health Partnership University NHS Foundation Trust
Stated actions 6
1. Sheffield Children'S NHS Foundation Trust and Sheffield Health Partnership University NHS Foundation Trust
  Develop and obtain governance approval for a protocol safeguarding under-18s admitted to an adult crisis house.
2. Sheffield Children'S NHS Foundation Trust and Sheffield Health Partnership University NHS Foundation Trust
  Map crisis and emergency care pathways for 16- and 17-year-olds to identify provision gaps.
3. Sheffield Children'S NHS Foundation Trust and Sheffield Health Partnership University NHS Foundation Trust
  Maintain a Section 136 bed for children and young people within the Children’s Trust.
1. Sheffield Children'S NHS Foundation Trust and Sheffield Health Partnership University NHS Foundation Trust
  Operate the Sheffield Adult Liaison Service continuously to provide timely responses to 16- and 17-year-olds attending adult emergency care.
2. Sheffield Children'S NHS Foundation Trust and Sheffield Health Partnership University NHS Foundation Trust
  Appoint a fully funded CAMHS Mental Health Liaison Consultant to support care coordination for 16- and 17-year-olds.
3. Sheffield Children'S NHS Foundation Trust and Sheffield Health Partnership University NHS Foundation Trust
  Work with local commissioners on benchmarking CAMHS mental health liaison provision against the national service specification.
Respondent positions 2
1. Sheffield Children'S NHS Foundation Trust and Sheffield Health Partnership University NHS Foundation Trust
  Existing out-of-hours services ensure timely responses for 16- and 17-year-olds until more robust commissioning and provision are available.
  Existing arrangements considered sufficient
1. Department of Health and Social Care
  Local NHS organisations are responsible for reviewing concerns about local mental health services and taking appropriate action.
  Redirects responsibility
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
Placement of under-18s in adult crisis houses
Wider context from the report
“4) Placement of an under 18 year old in a Crisis house for adults ”
Source location
Daisy French · Prevention of Future Deaths report
Page 3 · 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
Inadequate out-of-hours mental health provision for 16 to 18 year olds
Wider context from the report
“3) Out of hour’s provision for 16 to 18 years. (During working hours they are considered children and therefore are the responsibility of CAMHS, out of hours the same individuals are considered adults and are therefore assessed by and potentially admitted to adult psychiatric units. ”
Source location
Daisy French · Prevention of Future Deaths report
Page 3 · 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
Develop and obtain governance approval for a protocol safeguarding under-18s admitted to an adult crisis house.

Verbatim wording from the response
“SHSC is working with Rethink Mental Illness to develop a protocol for under 18 year olds being admitted into the adult crisis house. This is to ensure that appropriate safeguards are put in place to provide support when such a requirement arises and when it is clinically indicated that this is a better alternative to admitting under 18 year olds to an adult psychiatric ward.”

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
Map crisis and emergency care pathways for 16- and 17-year-olds to identify provision gaps.

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
Maintain a Section 136 bed for children and young people within the Children’s Trust.

Verbatim wording from the response
“It has been agreed that SHSC will continue to provide as necessary, assessment and treatment for under 18 year olds, out of hours. The Section 136 bed for Children & Young People is now in operation within SC NHS FT. The Sheffield Adult Liaison Service now operates 24/7, 365 days per year. This will ensure a timely response to any 16 or 17 year old presenting to the adult A&E Department. This provision will remain in place until such time as more robust commissioning and provision is in place.”

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
Operate the Sheffield Adult Liaison Service continuously to provide timely responses to 16- and 17-year-olds attending adult emergency care.

Verbatim wording from the response
“It has been agreed that SHSC will continue to provide as necessary, assessment and treatment for under 18 year olds, out of hours. The Section 136 bed for Children & Young People is now in operation within SC NHS FT. The Sheffield Adult Liaison Service now operates 24/7, 365 days per year. This will ensure a timely response to any 16 or 17 year old presenting to the adult A&E Department. This provision will remain in place until such time as more robust commissioning and provision is in place.”

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 a fully funded CAMHS Mental Health Liaison Consultant to support care coordination for 16- and 17-year-olds.

Verbatim wording from the response
“SC NHS FT has also recognised the gap in provision of a fully funded CAMHS Mental Health Liaison Consultant, and at cost to the Trust, has appointed into this position, so as to support the current CAMHS service and provide a point of reference around the care co-ordination of the 16 and 17year olds.”

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
Work with local commissioners on benchmarking CAMHS mental health liaison provision against the national service specification.

Verbatim wording from the response
“SC NHS FT awaits the national publication of a CAMHS mental health liaison service specification, which will allow the city to benchmark on its current provision. SC NHS FT will work with local commissioners on the benchmarking exercise.”

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 position was interpreted

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

PFD Monitor interpretation
Existing out-of-hours services ensure timely responses for 16- and 17-year-olds until more robust commissioning and provision are available.

Verbatim wording from the response
“It has been agreed that SHSC will continue to provide as necessary, assessment and treatment for under 18 year olds, out of hours. The Section 136 bed for Children & Young People is now in operation within SC NHS FT. The Sheffield Adult Liaison Service now operates 24/7, 365 days per year. This will ensure a timely response to any 16 or 17 year old presenting to the adult A&E Department. This provision will remain in place until such time as more robust commissioning and provision is in place.”

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 position was interpreted

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

PFD Monitor interpretation
Local NHS organisations are responsible for reviewing concerns about local mental health services and taking appropriate action.

Verbatim wording from the response
“You ask whether it is appropriate for the NHS in Sheffield to review the systems and procedures in place for mental health services for 16 to 18 year olds. Where there are concerns about local health services, it is the responsibility of the local NHS organisations to review those concerns and take action as appropriate. We are clear that learning lessons where things have gone wrong is essential to ensuring the NHS provides safe, high quality care.”

Source location
2017-0264-Response-by-Department-of-Health
Page 4 · response
Published 9 November 2017
Open published response
7 Dec2016
Manchester (North)
Concerns raised1
1. Lack of specialist inpatient provision for young adults with mental health problems
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Dominic Adam Travis · 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

Dominic Adam Travis, an 18-year-old man with mental health problems and regular use of cannabis and other substances, died in hospital on 18 May 2015 after suffering catastrophic injuries when he fell or jumped from a derelict mill following an acute psychotic deterioration and absconding from supported accommodation. The concerns raised included whether specialist inpatient provision adequately met the needs of young adults with mental health problems and whether the NHS Trust’s investigation into his care was sufficiently independent, transparent and timely.

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 specialist inpatient provision for young adults with mental health problems
Wider context from the report
“1. Department of Health: Dominic was aged just 18 when admitted to an acute psychiatric ward that cared for adults aged 18-65. Given: i) the very stark differences between the mental health needs of younger adults and older adults, ii) an overall increase in the levels of vulnerability in such young people (by virtue of their age, condition, varying levels of maturity etc.), iii) that acute psychiatric ward environments often care for older adult patients with profound and enduring mental health problems (that are extremely frightening to the younger adult inpatient) & iv) the very different mental health requirements of young people, I am concerned that the needs of the latter are not being appropriately or adequately met, in the absence of specialist/specialist inpatient provision. The vulnerability of young adults is clearly recognised and acknowledged in other areas such as young offenders under the age of 21 who are sentenced to YOI establishments rather than being sent to an adult prison, however no such recognition appears to exist in relation to young adults with mental health problems. ”
Source location
Dominic Adam Travis · Prevention of Future Deaths report
Page 2 · concerns
Open source report
17 Dec2014
Nottinghamshire
Concerns raised1
1. Lack of secure mental health care provision for young adults aged 18-24 with a similar clinical picture
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Linked response

Department of Health and Social Care
Respondent positions 1
1. Department of Health and Social Care
  Existing adult wards and transition guidance are considered capable of meeting the clinical and transition needs of young adults aged 18 to 24.
  Existing 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
Lack of secure mental health care provision for young adults aged 18-24 with a similar clinical picture
Wider context from the report
“2. That there is no provision for secure mental health care for young adults in the age range 18-24, with a clinical picture similar to Rebecca’s. ”
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
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

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

Data last updated 7 September 2026

What this concern includes

Trends

Reports mentioning this concern, over time

Concerns raised1

Commissioning mental health provision for children and adolescents with a strict 18th-birthday cut-off

Linked response

Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2

Concerns raised2

Lack of mental health inpatient provision for people aged 14-25

Failure to provide age-appropriate transitional care when mental health inpatients turn 18

Linked responses

Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3

Concerns raised1

Variation and limited transition provision in post-16 mental health services

Concerns raised2

Lack of alternative mental health provision for young adults

Lack of suitable acute mental health beds for young adults

Concerns raised1

Lack of available urgent mental health services for 16- and 17-year-olds

Linked responses

Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.6

Concerns raised2

Placement of under-18s in adult crisis houses

Inadequate out-of-hours mental health provision for 16 to 18 year olds

Linked responses

Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.6

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2

Stated actions 2

Stated actions 3

Respondent positions 3

Stated actions 6

Stated actions 6

Respondent positions 2