Recurring concern

Insufficient CAMHS staffing capacity and competence for safe care

First to latest report 3 Jul 2014 — 30 Apr 2024

Reports that mention this concern: 4
Times this concern has been raised: 6
Stated actions linked to this concern: 4

What this concern includes

Includes recurring failures in CAMHS staffing capacity, coverage, skill mix, recruitment or retention, consultant caseload capacity, and experience or training of staff working with children and adolescents where these leave CAMHS unable to provide safe care.

What is not included

Excludes staffing or competence deficiencies outside CAMHS unless the report explicitly connects them to CAMHS staffing arrangements.
Excludes generic mental-health service capacity, psychiatric-bed or appointment-access concerns where CAMHS staffing capacity or competence is not the unsafe condition.
Excludes isolated clinical errors or individual performance concerns where no recurring CAMHS staffing or competence deficiency is identified.
Excludes failures in CAMHS referrals, communication, care planning or multidisciplinary coordination when staffing capacity or competence is not the shared unsafe condition.

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.

NHS England2

Cumbria County Council1

Department of Health and Social Care1

London Borough of Hounslow1

London Office1

National Referral Support Service1

North Cumbria Integrated Care NHS Foundation Trust1

Royal College of Paediatrics and Child Health1

Royal College of Psychiatrists1

Reports and published responses 4 reports

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

30 Apr2024
East Sussex
Concerns raised1
1. Insufficient specialist workforce capacity within CAMHS and paediatrics for gender identity services
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response

NHS England
Stated actions 2
1. NHS England
  Establish new regional Children and Young People’s Gender Incongruence Services under an interim service specification.
2. NHS England
  Develop a substantive service specification strengthening infrastructure and regional links between specialist centres and local services.
Respondent positions 1
1. NHS England
  Expanding clinical capacity is constrained by shortages of suitable workforce potential in children’s and adult gender services, rather than funding.
  Unable to act
AI-generated summary

Jason PULMAN · 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

Jason Pulman, aged 15, was found dead on 19 April 2022 and the inquest concluded that he died by suicide, by hanging. Evidence indicated that he had not received specialist gender dysphoria treatment while waiting for GIDS and was awaiting further CAMHS assessment. The principal concern was that unclear referral mechanisms and inadequate resources for mental health support during waits for gender services could lead to similar circumstances recurring.

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
Insufficient specialist workforce capacity within CAMHS and paediatrics for gender identity services
Wider context from the report
“2. On 10 April 2024, i.e. during the course of the inquest, ████████ published her report on the independent review of gender identity services for children and young people (the Cass review). Her recommendations included that: “a smaller number of secondary services within CAMHS and paediatrics should be identified initially to act as Designated Local Specialist Services (DLSS) within each area. This would increase the available workforce through a flexible, multi-site staff group working between the DLSS and the regional centre, with the opportunity to provide targeted training and upskilling.” ”
Source location
Jason PULMAN · 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 new regional Children and Young People’s Gender Incongruence Services under an interim service specification.

Verbatim wording from the response
“Children and Young People’s Gender Incongruence Services”

Source location
Response from NHS England
Page 1 · response
Published 9 May 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
Develop a substantive service specification strengthening infrastructure and regional links between specialist centres and local services.

Verbatim wording from the response
“The two new services that are operational work to an interim service specification pending the outcome of work to build a new substantive service specification in 2024/25, for adoption in April 2025, through a process of stakeholder engagement and public consultation, to reflect the final recommendations of the Cass Report.”

Source location
Response from NHS England
Page 2 · response
Published 9 May 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
Expanding clinical capacity is constrained by shortages of suitable workforce potential in children’s and adult gender services, rather than funding.

Verbatim wording from the response
“The main constraint in building a new clinical workforce is not funding, it is the shortage of workforce potential for both children’s and adult gender services. NHS England’s overall planned spend on all gender dysphoria services (adults and children) in 2023/24 was £78.17m – up from £33.4m in 2018/19, representing an overall increase in funding of 134% in five years. NHS England’s planning assumption is that the new providers of CYP gender services will begin to draw patients from the waiting list from November 2024, with the priority focus between April and October 2024 being the ongoing care of patients transferred from the Tavistock GIDS.”

Source location
Response from NHS England
Page 2 · response
Published 9 May 2024
Open published response
11 Aug2022
East London
Concerns raised2
1. Lack of adequate numbers of suitably trained CAMHS staff
2. Excessive consultant caseloads in CAMHS
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Lily May Girton · 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

Lily May Girton, who had anxiety, depression and emotional dysregulation, died after taking her own life while suffering from mental illness. The inquest found that her death was contributed to by failures in the community CAMHS team concerning psychiatric assessment, risk management and titration of antidepressant medication. It also raised concerns that inadequate staffing and resources in CAMHS services pose a risk of future deaths of 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 adequate numbers of suitably trained CAMHS staff
Wider context from the report
“The Inquest heard that CAMHS services nationally have a lack of adequate staffing levels in the form of doctors, in the form of psychiatrists, registered mental health nurses and psychotherapy staff. The Inquest heard that consultants often have an average of 130 to 150 active cases on their caseloads. This is substantially higher than the recommended caseloads by the Royal College of Psychiatrists. The lack of staffing and resources contributed to Lily’s death and there is a concern that the ongoing shortages of suitably trained staff within CAMHS teams poses a risk of future deaths of young people. ”
Source location
Lily May Girton · 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
Excessive consultant caseloads in CAMHS
Wider context from the report
“The Inquest heard that CAMHS services nationally have a lack of adequate staffing levels in the form of doctors, in the form of psychiatrists, registered mental health nurses and psychotherapy staff. The Inquest heard that consultants often have an average of 130 to 150 active cases on their caseloads. This is substantially higher than the recommended caseloads by the Royal College of Psychiatrists. The lack of staffing and resources contributed to Lily’s death and there is a concern that the ongoing shortages of suitably trained staff within CAMHS teams poses a risk of future deaths of young people. ”
Source location
Lily May Girton · Prevention of Future Deaths report
Page 2 · concerns
Open source report
3 Oct2016
West Sussex
Concerns raised1
1. Inadequate staffing levels for one-to-one care in inpatient CAMHS units
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response

Priory Group
Respondent positions 2
1. Priory Group
  Existing staffing reviews, multidisciplinary support, on-call arrangements and staff redeployment are considered sufficient to determine appropriate staffing levels.
  Existing arrangements considered sufficient
1. Priory Group
  Existing staffing guidance, continual staffing reviews, multidisciplinary support and escalation arrangements are considered sufficient to determine appropriate staffing levels.
  Existing arrangements considered sufficient
AI-generated summary

Amy El-Keria · 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

Amy El-Keria, aged 14, died on 13 November 2012 after tying a ligature around her neck and suspending herself from a radiator while receiving inpatient mental health care. The inquest identified concerns about staffing levels being insufficient to provide the one-to-one support in her care plan and the shortage of acute mental health beds for young people close to home, limiting family support.

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 staffing levels for one-to-one care in inpatient CAMHS units
Wider context from the report
“(1) The Jury in this Inquest found that the staffing levels, which were in line with the ONIC staffing ratio, were inadequate to give Amy sufficient one to one time in accordance with her care plan. It is understood that in December 2014 the Department of Health tasked NICE with developing guidance on staffing levels for inpatient CAMHS units but this appears to have been discontinued. There is currently no national guidance on staffing levels for inpatient CAHMS ”
Source location
Amy El-Keria · 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 staffing reviews, multidisciplinary support, on-call arrangements and staff redeployment are considered sufficient to determine appropriate staffing levels.

Verbatim wording from the response
“We note your comments in relation to the QNIC guidance published by the Royal College of Psychiatrists and we consider that this is still an appropriate reference point for the staffing of CAMHS units and continues to be used by many providers in determining and monitoring appropriate staffing levels.”

Source location
2016-0347-Response-by-Priory-Group
Page 1 · response
Published 3 October 2016
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 staffing guidance, continual staffing reviews, multidisciplinary support and escalation arrangements are considered sufficient to determine appropriate staffing levels.

Verbatim wording from the response
“We note your comments in relation to the QNІC guidance published by the Royal College of Psychiatrists and we consider that this is still an appropriate reference point for the staffing of CAMHS units and continues to be used by many providers in determining and monitoring appropriate staffing levels.”

Source location
2016-0347 - Response from Priory
Page 1 · response
Published 3 October 2016
Open published response
3 Jul2014
South and East Cumbria
Concerns raised2
1. Inadequate CAMHS staffing numbers
2. Insufficient CAMHS staff experience and training in working with teenagers
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response

North Cumbria Integrated Care NHS Foundation Trust
Stated actions 2
1. North Cumbria Integrated Care NHS Foundation Trust
  Increase CAMHS staffing from 45 to 63 and improve skill mix through development plans.
2. North Cumbria Integrated Care NHS Foundation Trust
  Deliver the identified CAMHS staff training programme, including prioritised suicide-prevention training.
AI-generated summary

Helena Kathleen Farrell · 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

Helena Kathleen Farrell had bulimia, had been sexually assaulted, took an overdose, self-harmed, and wrote letters that appeared to be suicide letters after her death. She died from hanging following a period in which she was not seen by CAMHS until the day before her death, and those dealing with her did not recognise her suicidal feelings and intentions. The concerns included failures in the CAMHS referral and follow-up system, inadequate staffing and training, failure to recognise escalating seriousness, unrealistic demands on the school nurse, and insufficient checking of the school counsellor’s credentials.

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 CAMHS staffing numbers
Wider context from the report
“(2) Staffing levels at CAMHS were inadequate in terms of pure numbers and also in terms of experience and training in connection with teenagers. ”
Source location
Helena Kathleen Farrell · 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
Insufficient CAMHS staff experience and training in working with teenagers
Wider context from the report
“(2) Staffing levels at CAMHS were inadequate in terms of pure numbers and also in terms of experience and training in connection with teenagers. ”
Source location
Helena Kathleen Farrell · 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
Increase CAMHS staffing from 45 to 63 and improve skill mix through development plans.

Verbatim wording from the response
“The Trust, with commissioners, has fully implemented the recommendations of the independent, external review of CAMHS in 2012 which has resulted in the staffing levels across the service increasing from 45 to 63, with improved skill mixes and clear development plans. Significant training has been identified, planned and delivery has commenced. Suicide prevention training was prioritised and delivered as shown in the action plan, point 10.”

Source location
2014-0309-Response-by-Cumbria-NHS-Foundation-Trust
Page 2 · response
Published 3 July 2014
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
Deliver the identified CAMHS staff training programme, including prioritised suicide-prevention training.

Verbatim wording from the response
“The Trust, with commissioners, has fully implemented the recommendations of the independent, external review of CAMHS in 2012 which has resulted in the staffing levels across the service increasing from 45 to 63, with improved skill mixes and clear development plans. Significant training has been identified, planned and delivery has commenced. Suicide prevention training was prioritised and delivered as shown in the action plan, point 10.”

Source location
2014-0309-Response-by-Cumbria-NHS-Foundation-Trust
Page 2 · response
Published 3 July 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

Insufficient specialist workforce capacity within CAMHS and paediatrics for gender identity services

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

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

Concerns raised2

Lack of adequate numbers of suitably trained CAMHS staff

Excessive consultant caseloads in CAMHS

Concerns raised1

Inadequate staffing levels for one-to-one care in inpatient CAMHS units

Linked response

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

Concerns raised2

Inadequate CAMHS staffing numbers

Insufficient CAMHS staff experience and training in working with teenagers

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

Stated actions 2

Respondent positions 1

Respondent positions 2

Stated actions 2