Chloe Louise Barber · Prevention of Future Deaths report

On 8th November 2021, I commenced an investigation into the death of Chloe Louise Barber, aged 18 years. The investigation concluded at the end of the inquest on 18th July 2025. The conclusion of the inquest was: a narrative conclusion (see section 4 below).

Chloe Louise Barber had a history of self-harm and of taking multiple overdoses of tablets. She was detained under various sections of the Mental Health Act 1983. Her last admission was to the Cygnet facility in Sheffield where her detention was pursuant to section 3 of the Mental Health Act 1983. Whilst an inpatient, she showed improvement in various aspects of her mental health, probably due to the administration of the atypical antipsychotic drug, aripiprazole. She was at a point in her life where she was making a transition between children's and adolescent mental health services and adult services. She was adamant in her refusal to engage with adult mental health services. Concern exists about the provision of assistance and support measures including S117 aftercare, a care programme approach, capacity assessments and the Vulnerable Adults Risk Management process. There was also valid concern about the lack of documentation and poor communication between services and partner organisations. Whilst many of these matters are true or partially true, no causation flows from them. The issue of cessation of aripiprazole therapy may have more than minimally, trivially or negligibly resulted in increased emotional instability leading to impulsive behaviour, but this was one of a number of issues which may have contributed to her death on 3rd November 2021. Chloe was found ████████ by her brother at her home address on 3rd November 2021. He cut her down, commenced cardiopulmonary resuscitation and called the ambulance service who attended promptly. Following assessment by the paramedics, Chloe displayed signs unequivocally associated with death and this was confirmed at 17:05 hours on 3rd November 2021. The unpredictability of impulsive behaviour associated with evolving emotionally unstable personality disorder, coupled with Chloe's lack of engagement with provided services or services that may have been offered, makes it probable that there was no realistic opportunity to prevent her death. Moreover, there was no indication that she should be detained under any of the provisions of the Mental Health Act 1983, and hence be the subject of compulsory treatment. Whilst her decision to suspend herself may have been impulsive, she nevertheless intended her actions to result in her death.

1. Evidence was heard at inquest from several expert witnesses that concern exists and continues to exist nationwide that there is not necessarily an clearly defined pathway that assists young persons making the transition between Childhood and Adolescent Mental Health Service (CAMHS) and adult psychiatric services, to ensure a smooth transit and continuity of care.
2. Concern was expressed by professional witnesses and experts that there are no clear guidelines about where and by whom depot preparations of antipsychotic may be administered.
3. There was considerable uncertainty and ignorance about the provision of aftercare pursuant to s117 of the Mental Health Act 1983 amongst some healthcare workers and social workers, who should in any event be closely liaising with each other as well as with other allied professionals.