PFD report

Sky Louise Rollings · Prevention of Future Deaths report

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Issued 16 Oct 2021•Stoke-on-Trent and North Staffordshire

Report record

Published report and response evidence

This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.

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Concerns
2

Raised in this report

Recipients
2

Named on the report

Responses found
2

Of 2 recipients

Stated actions
4

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised2

  1. Lack of mental health inpatient provision for people aged 14-25
    Part of recurring concern: Insufficient age-appropriate mental health provision for young people transitioning to adulthoodPart of recurring concern: Insufficient psychiatric inpatient bed capacity
  2. Failure to provide age-appropriate transitional care when mental health inpatients turn 18
    Part of recurring concern: Insufficient age-appropriate mental health provision for young people transitioning to adulthood
Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

Actions described in response An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.3

  1. Action

    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.

    Stated by The TrustStated in progressThe respondent said that this action was in progress when they made their response on 21 October 2021.
  2. Action

    Develop a 14–25 transition service with social care and third-sector children and young people partners to improve continuity of care during transition.

    Stated by The TrustStated in progressThe respondent said that this action was in progress when they made their response on 21 October 2021.
  3. Action

    Share the updated transition policy with inpatient areas and community teams.

    Stated by The TrustStated plannedThe respondent said that this action was planned when they made their response on 21 October 2021.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.3

  1. Position

    Existing individualised discharge and admission planning, involving relevant professionals and families, addresses transition between child and adult services.

    Stated by NHS EnglandExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

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. ”

Is this part of a recurring concern?

Yes — Insufficient age-appropriate mental health provision for young people transitioning to adulthood; Insufficient psychiatric inpatient bed capacity.

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Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

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. ”

Is this part of a recurring concern?

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

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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

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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

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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

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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

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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

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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

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Other statements in published responses

These actions and other statements could not be clearly connected to one concern in this report.

Recipient-stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.1

  1. 1

    Share the Prevention of Future Deaths report and learning from the Trust plan with Mental Health Trusts through Regional Teams.

    Stated by NHS EnglandStated plannedThe respondent said that this action was planned when they made their response on 21 October 2021.

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 Prevention of Future Deaths report and learning from the Trust plan with Mental Health Trusts through Regional Teams.

Verbatim wording from the response

“This PFD report will be shared with Mental Health Trusts through the Regional Teams at NHS England and NHS Improvement as well as learning from the Trust plan.”

Source location

2021-0354-Response-from-NHS-England_Published
Page 3 · response
Published 21 October 2021

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Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026