Recurring concern

Failure to integrate mental health and education pastoral services

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First reported 14 Jul 2015•Latest report 1 Aug 2019

Definition

What this concern includes

Includes deficiencies in the shared operation of mental health services and education pastoral services, including unclear connections, inconsistent coordination or referral arrangements, and other dedicated failures that prevent integrated support for mentally ill children and adolescents.

Not included

  • Excludes generic training, staffing, documentation or communication deficiencies that are not explicitly tied to integration between mental health services and education pastoral services.
  • Excludes failures concerning unrelated inter-organisational or inter-service arrangements.
  • Excludes individual clinical or pastoral care failures that do not concern coordination between the named mental health and education pastoral services.
Reports
3

Distinct published reports

Individual concerns
3

A report can raise multiple concerns

Date range
2015–2019

First to latest report issue date

Stated actions
4

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.

Department of Health and Social Care3
Department for Education2
Calderdale Borough Council1
Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust1
NHS England1
NHS West Yorkshire Integrated Care Board1

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. Plymouth, Torbay and South Devon

    AI-generated summary

    Daniel Cameron SHORROCKS · 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

    Daniel Cameron SHORROCKS discussed ending his life with a friend on 1 January 2018, sent a text stating “Dead at Berry Head”, and was found dead at the foot of a cliff at Berry Head. The report’s concerns relate to the availability of qualified and experienced staff for local authorities with many young people in care, and the integration of care, adolescent mental health, and education pastoral 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

    Failure to integrate care, adolescent mental health and education pastoral services

    Wider context from the report

    “(2) I would also ask your Department to review the integration of services between Local Authority Care Services, Adolescent Mental Health Services and Pastoral Care provided in education settings. ”

    Source location

    Daniel Cameron SHORROCKS · 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

    Establish NHS-funded Mental Health Support Teams in 20–25% of the country by 2023 to provide additional school- and college-based mental health support.

    Verbatim wording from the response

    “Improving the join up between local health and education services is at the heart of this programme of work led by NHS England, the Department of Health and Social Care, the Department for Education and Health Education England. The new NHS funded Mental Health Support Teams resulting from the consultation, which will be established in 20-25 per cent of the country by 2023, are designed to work in and around schools and colleges to provide additional capacity to address the mental health needs of children and young people. These teams will deliver interventions for those with mild to moderate mental health issues, support education settings to develop whole school or college approaches to promote good mental health and help children and young people with more severe needs to access the right support by working with schools and colleges to provide a link to specialist NHS services.”

    Source location

    2019-0282-Response-by-Department-of-Health-and-Social-Care
    Page 3 · response
    Published 18 October 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

    Make the Department for Education-funded Link Programme available across England to connect schools, colleges and children’s mental health services.

    Verbatim wording from the response

    “Finally, to further support the integration between schools and colleges, and local mental health services, over the next four years, from 2019 to 2023, the Department for Education-funded Link Programme will be made available to all areas and CCGs, and through them to every school and college (including alternative provision settings) and children and young people's mental health services in England. The Link Programme encourages better join-up and communication between education settings and specialist children and young people’s mental health services. This will help more children and young people get the right support when they need it and help prevent individuals falling between the cracks in provision or experiencing poor transition between services.”

    Source location

    2019-0282-Response-by-Department-of-Health-and-Social-Care
    Page 4 · response
    Published 18 October 2019

    Open published response

  2. West Yorkshire (Western)

    AI-generated summary

    Ursula Niamh MacEochaigh Keogh · 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

    On 22 January 2018, 11-year-old Ursula Niamh MacEochaigh Keogh left school, got off the bus early and jumped from North Bridge in Halifax; she was later found in the river and pronounced deceased. The inquest heard concerns about inconsistent advice and communication between health and education professionals regarding referral for assessment of Ursula’s self-harm, as well as preventative measures at North Bridge.

    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 provide consistent referral advice between health and education professionals

    Wider context from the report

    “During the inquest I heard that Ursula’s mother contacted Ursula’s GP at Spring Hall Medical Centre by telephone on 13/11/17 in order to discuss her concerns about Ursula’s history of self-harm and that this resulted in her mother being advised by a GP to get Ursula’s school involved. Although the school subsequently advised Ursula’s mother to contact her GP, during the telephone conversation of 14/12/17 to further discuss Ursula’s self-harming, the GP advised her mother to contact the Psychology Team attached to the school, so that Ursula could be assessed for referral to Child & Adolescent Mental Health Team if necessary, in accord with the protocol previously issued by Calderdale CAMHS referral pathway, notwithstanding that at this time the school did not have the services of a Psychology team to make the referral. ”

    Source location

    Ursula Niamh MacEochaigh Keogh · 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 CAMHS referral pathway for GPs and schools.

    Verbatim wording from the response

    “1. To review the current practice of referral by GP to the school for consideration as to the appropriateness of referral to CAMHS.”

    Source location

    2018-0370-Response-by-Calderdale-CCG
    Page 1 · response
    Published 10 May 2019

    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 existing CAMHS referral pathway was considered accurate and sufficient, although external training and education gaps required new actions.

    Verbatim wording from the response

    “1. To review the current practice of referral by GP to the school for consideration as to the appropriateness of referral to CAMHS.”

    Source location

    2018-0370-Response-by-Calderdale-CCG
    Page 1 · response
    Published 10 May 2019

    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 services and local authorities are responsible for responding to the concerns and learning from deaths to improve service safety.

    Verbatim wording from the response

    “Your report raises three matters of concern and is directed to NHS Calderdale Clinical Commissioning Group (CCG) and Calderdale Council, as well as the Department of Health and Social Care. I am aware that the Calderdale CCG has responded to your concerns from a local perspective, advising you of a series of actions that are being undertaken in light of the report. We expect the local NHS to take action to respond to concerns and learn from deaths to ensure the safety of healthcare services and I am encouraged that the local NHS is looking into these matters carefully.”

    Source location

    2018-0370-Response-by-Department-of-Health-and-Social-Care
    Page 1 · response
    Published 10 May 2019

    Open published response

  3. Nottinghamshire

    AI-generated summary

    Emma Carpenter · 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

    Emma Carpenter was treated as an outpatient by child and adolescent mental health services from February 2004 to November 2006 and died from multi-organ failure caused by severe anorexia nervosa. The report identified insufficient physical-health monitoring, lack of specialist paediatric or physician input, and delay in accessing effective inpatient treatment as concerns.

    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 clear connections between mental health professionals and education pastoral care staff

    Wider context from the report

    “4. In the absence of school nurses, there is a lack of clear connections between the mental health professionals and those in the education system who have responsibility for the pastoral care of mentally ill children and adolescents. ”

    Source location

    Emma Carpenter · 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

    Pilot a single point-of-access programme linking specialist community CAMHS with schools across at least 15 CCGs, including joint NHS and school staff training.

    Verbatim wording from the response

    “• NHS England are about to pilot an initiative with the Department for Education to develop a programme for single points of access in Tier 3 (specialist community) CAMHS and schools, testing it over at least 15 CCGs. The training will be for an identified member of staff from the NHS CAMHS team plus a member of the school staff and additional colleagues such as, Special Educational Needs Co-ordinators, school nurses and counsellors. This is linked to a recommendation from Future in Mind. The Spring Budget allocated £1.5 million to support this pilot over the next year from July 2015 to June 2016.”

    Source location

    2015-0276-Response-by-NHS-England
    Page 3 · response
    Published 14 July 2015

    Open published response
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Data last updated 7 September 2026