PFD report

Robyn Lily Audrey SKILTON · Prevention of Future Deaths report

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Issued 7 Aug 2022•West Sussex

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
3

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 raised3

  1. Delays in tier 3 CAMHS acceptance
    Part of recurring concern: Excessive waiting times for NHS mental health services
  2. Lack of resourcing and provision for young people’s mental health services
    Part of recurring concern: Insufficient mental health service capacity for timely patient care
  3. Delays in specialist child mental health assessment
    Part of recurring concern: Failure to complete timely direct mental health assessments after referralPart of recurring concern: Failure to ensure experienced mental health professional involvement in care decisions
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

    Invest additional funding to expand children’s mental health services and increase access to community and eating disorder services.

    Stated by Department of Health and Social CareStated completedThe respondent said that this action was complete when they made their response on 30 September 2022.
  2. Action

    Expand and strengthen the NHS mental health workforce, including adding 27,000 mental health professionals by 2023/24.

    Stated by Department of Health and Social CareStated in progressThe respondent said that this action was in progress when they made their response on 30 September 2022.
  3. Action

    Work with NHS England on next steps following consultation on proposed mental health waiting-time standards.

    Stated by Department of Health and Social CareStated in progressThe respondent said that this action was in progress when they made their response on 30 September 2022.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.1

  1. Position

    Local commissioners are responsible for commissioning healthcare services that meet local population needs and expanding mental health services.

    Stated by Department of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.

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

Delays in tier 3 CAMHS acceptance

Wider context from the report

“Robyn was failed by the Mental Health Services quite frankly due to the current lack of resourcing and provision in place to support young people struggling with their mental health. Due to the lack of availability of a Child Psychiatrist there are long waiting times for children to be assessed. Robyn was not seen by a Child Psychiatrist and/or Psychologist, despite there being a need for this to happen, thereby enabling her to be diagnosed and receive a treatment plan. Robyn’s parents did everything they could during this period to support Robyn, including paying for a private counsellor, but sadly Robyn’s mental health continued to deteriorate during this time, and she took her own life. Robyn initial acceptance into tier 3 Children and Mental Health Services (CAMHS) similarly did not happen in a timely manner. I do appreciate that the landscape that the local mental health Trust (Sussex Partnership Foundation Trust) was working under and the fact that Covid heightened the level of complexity across many services but there were many failings in the care provided to Robyn. It became very clear during the Inquest that there is significant under funding of the local mental health Trusts who like many mental health Trusts see an explosion of referrals to their Children and Mental Health services (CAMHS). By way of an example:- Referrals to West Sussex CAMHS have increased by 95.6% from May 2019 (389) to May 2022 (761) West Sussex CAMHS caseload has increased by 85% from May 2019 (2239) to May 2022 (4147) West Sussex CAMHS Duty caseload has increased by 112% from May 2021 (492) to May 2022 (1494) Mental Health A&E presentations, in period April 2021 - March 2022, have increased by 40% on previous year (April 2020 - March 2021). Additionally, across Sussex CAMHS, as a whole, the referrals data shows:- • May 2022 was the highest number of referrals the service has ever received (1350). • Of those 1350 referrals, 80% (1,081) were accepted into the service. • In comparison, in May 2019, 579 were accepted (65% accepted) • So, an additional 502 young people have been accepted in May 2022 compared to May 2019 Despite the increase in numbers accessing CAMHS there has not been any relative increase in resources to meet this demand and therefore the current position is is unsustainable and it is putting many young people’s lives at risk. ”

Is this part of a recurring concern?

Yes — Excessive waiting times for NHS mental health services.

Open source report

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 resourcing and provision for young people’s mental health services

Wider context from the report

“Robyn was failed by the Mental Health Services quite frankly due to the current lack of resourcing and provision in place to support young people struggling with their mental health. Due to the lack of availability of a Child Psychiatrist there are long waiting times for children to be assessed. Robyn was not seen by a Child Psychiatrist and/or Psychologist, despite there being a need for this to happen, thereby enabling her to be diagnosed and receive a treatment plan. Robyn’s parents did everything they could during this period to support Robyn, including paying for a private counsellor, but sadly Robyn’s mental health continued to deteriorate during this time, and she took her own life. Robyn initial acceptance into tier 3 Children and Mental Health Services (CAMHS) similarly did not happen in a timely manner. I do appreciate that the landscape that the local mental health Trust (Sussex Partnership Foundation Trust) was working under and the fact that Covid heightened the level of complexity across many services but there were many failings in the care provided to Robyn. It became very clear during the Inquest that there is significant under funding of the local mental health Trusts who like many mental health Trusts see an explosion of referrals to their Children and Mental Health services (CAMHS). By way of an example:- Referrals to West Sussex CAMHS have increased by 95.6% from May 2019 (389) to May 2022 (761) West Sussex CAMHS caseload has increased by 85% from May 2019 (2239) to May 2022 (4147) West Sussex CAMHS Duty caseload has increased by 112% from May 2021 (492) to May 2022 (1494) Mental Health A&E presentations, in period April 2021 - March 2022, have increased by 40% on previous year (April 2020 - March 2021). Additionally, across Sussex CAMHS, as a whole, the referrals data shows:- • May 2022 was the highest number of referrals the service has ever received (1350). • Of those 1350 referrals, 80% (1,081) were accepted into the service. • In comparison, in May 2019, 579 were accepted (65% accepted) • So, an additional 502 young people have been accepted in May 2022 compared to May 2019 Despite the increase in numbers accessing CAMHS there has not been any relative increase in resources to meet this demand and therefore the current position is is unsustainable and it is putting many young people’s lives at risk. ”

Is this part of a recurring concern?

Yes — Insufficient mental health service capacity for timely patient care.

Open source report

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

Delays in specialist child mental health assessment

Wider context from the report

“Robyn was failed by the Mental Health Services quite frankly due to the current lack of resourcing and provision in place to support young people struggling with their mental health. Due to the lack of availability of a Child Psychiatrist there are long waiting times for children to be assessed. Robyn was not seen by a Child Psychiatrist and/or Psychologist, despite there being a need for this to happen, thereby enabling her to be diagnosed and receive a treatment plan. Robyn’s parents did everything they could during this period to support Robyn, including paying for a private counsellor, but sadly Robyn’s mental health continued to deteriorate during this time, and she took her own life. Robyn initial acceptance into tier 3 Children and Mental Health Services (CAMHS) similarly did not happen in a timely manner. I do appreciate that the landscape that the local mental health Trust (Sussex Partnership Foundation Trust) was working under and the fact that Covid heightened the level of complexity across many services but there were many failings in the care provided to Robyn. It became very clear during the Inquest that there is significant under funding of the local mental health Trusts who like many mental health Trusts see an explosion of referrals to their Children and Mental Health services (CAMHS). By way of an example:- Referrals to West Sussex CAMHS have increased by 95.6% from May 2019 (389) to May 2022 (761) West Sussex CAMHS caseload has increased by 85% from May 2019 (2239) to May 2022 (4147) West Sussex CAMHS Duty caseload has increased by 112% from May 2021 (492) to May 2022 (1494) Mental Health A&E presentations, in period April 2021 - March 2022, have increased by 40% on previous year (April 2020 - March 2021). Additionally, across Sussex CAMHS, as a whole, the referrals data shows:- • May 2022 was the highest number of referrals the service has ever received (1350). • Of those 1350 referrals, 80% (1,081) were accepted into the service. • In comparison, in May 2019, 579 were accepted (65% accepted) • So, an additional 502 young people have been accepted in May 2022 compared to May 2019 Despite the increase in numbers accessing CAMHS there has not been any relative increase in resources to meet this demand and therefore the current position is is unsustainable and it is putting many young people’s lives at risk. ”

Is this part of a recurring concern?

Yes — Failure to complete timely direct mental health assessments after referral; Failure to ensure experienced mental health professional involvement in care decisions.

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

Invest additional funding to expand children’s mental health services and increase access to community and eating disorder services.

Verbatim wording from the response

“This is why, in 2021/22 we provided an additional £79million to expand children’s mental health services, allowing around 22,500 more children and young people to access community health services, 2,000 more to access eating disorder services, as well as a faster increase in the coverage of mental health support teams in schools and colleges. There are currently 287 mental health support teams supporting schools and colleges, covering 20-25% of the country, with 13 planned or in operation across the Sussex integrated care system.”

Source location

Response from department of Health and Social Care
Page 2 · response
Published 30 September 2022

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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

Expand and strengthen the NHS mental health workforce, including adding 27,000 mental health professionals by 2023/24.

Verbatim wording from the response

“Growth of the mental health workforce, as well as retaining and re-skilling our current workforce, is the key strategic priority to ensure we can deliver our commitments to expand services and increase access. This is why, through the Plan we are committed to expanding the NHS workforce, with an aim of having and additional 27,000 mental health professionals by 2023/24, to deliver the expansion and transformation of mental health services, including those for children and young people.”

Source location

Response from department of Health and Social Care
Page 2 · response
Published 30 September 2022

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

Work with NHS England on next steps following consultation on proposed mental health waiting-time standards.

Verbatim wording from the response

“More broadly, NHS England consulted on the potential to introduce a range of new waiting time standards as part of its Clinically-led Review of NHS Access Standards⁴. These include:”

Source location

Response from department of Health and Social Care
Page 3 · response
Published 30 September 2022

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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

Local commissioners are responsible for commissioning healthcare services that meet local population needs and expanding mental health services.

Verbatim wording from the response

“A significant portion of this funding is provided through baseline funding to local commissioners (formerly clinical commissioning groups and now through the integrated care boards that replaced them). This is supporting them to deliver on their responsibilities to commission healthcare services that meet the needs of their local populations and to expand mental health services in line with the aims of the Long Term Plan and the NHS Mental Health Implementation Plan 2019/20 – 2023/24², which provides the framework for local delivery.”

Source location

Response from department of Health and Social Care
Page 1 · response
Published 30 September 2022

Open published response

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

    Launch a cross-government public call for evidence on mental health, wellbeing and suicide prevention and analyse the responses.

    Stated by Department of Health and Social CareStated in progressThe respondent said that this action was in progress when they made their response on 30 September 2022.

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

Launch a cross-government public call for evidence on mental health, wellbeing and suicide prevention and analyse the responses.

Verbatim wording from the response

“Finally, we launched a public call for evidence on what can be done across government in the longer term to support mental health, wellbeing and suicide prevention. We asked the public for their views on a wide range of questions, from prevention through to acute mental health care. This is a key part of our commitment to ‘level up’ and improve unequal outcomes and life chances across the country. The call for evidence closed on 7 July 2022. We are currently analysing the responses.”

Source location

Response from department of Health and Social Care
Page 3 · response
Published 30 September 2022

Open published response
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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