PFD report

Alice, Sarah, Dearden (Alice) · Prevention of Future Deaths report

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Issued 29 Apr 2026•Wiltshire and Swindon

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
1

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

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 raised1

  1. Commissioning mental health provision for children and adolescents with a strict 18th-birthday cut-off
    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.2

  1. Action

    Work with regulators and royal colleges to clarify clinical responsibilities for 16- and 17-year-olds and inform forthcoming transition guidance.

    Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 2 July 2026.
  2. Action

    Develop and publish transition guidance promoting personalised, planned moves from children’s to adult mental health services without automatic age-based transfer.

    Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 2 July 2026.

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

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. ”

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

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

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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 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

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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.2

  1. 1

    Discuss all Prevention of Future Deaths reports through the Regulation 28 Working Group and share learning across national and regional NHS services.

    Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 2 July 2026.
  2. 2

    Publish eating-disorder transition guidance emphasising individualised and flexible approaches that support safety, engagement and continuity of care.

    Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 2 July 2026.

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

Discuss all Prevention of Future Deaths reports through the Regulation 28 Working Group and share learning across national and regional NHS services.

Verbatim wording from the response

“I would also like to provide further assurances on the national NHS England work taking place around the Reports to Prevent Future Deaths. All reports received are discussed by the Regulation 28 Working Group, comprising Regional Medical Directors, and other clinical and quality colleagues from across the regions. This ensures that key learnings and insights around events, such as the sad death of Alice, are shared across the NHS at both a national and regional level and helps us to pay close attention to any emerging trends that may require further review and action.”

Source location

Response from NHS England
Page 4 · response
Published 2 July 2026

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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

Publish eating-disorder transition guidance emphasising individualised and flexible approaches that support safety, engagement and continuity of care.

Verbatim wording from the response

“Guidance published on Children & Young People’s eating disorders in January 2026 also emphasises that services should take an individualised and flexible approach to transitions, to support safety, engagement and continuity of care.”

Source location

Response from NHS England
Page 2 · response
Published 2 July 2026

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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