Luke Wilden

Office of the Chief Medical Officer 
Trust Headquarters 
5th Floor 
9 Alie Street 
London E1 8DE 

Website: www.elft.nhs.uk 

11 March 2022 

Private & Confidential 

Coroner Emma Whitting  
Senior Coroner for Bedfordshire and Luton 
The Court House  
Woburn Street  
Ampthill  
Bedfordshire  
MK45 2HX 

Dear Madam, 

Re:  Luke Wilden Regulation 28 Response 

This is a formal response to your Regulation 28 report dated 16 January 2022 relating to 
issues arising during the inquest into the death of Luke Wilden which concluded on 20 
July 2021. Your concerns are as follows:   

“Transition arrangements within ELFT for individuals with high functioning autism 
were inadequate when Luke turned 18 and, as a result, he was not transferred to 
the appropriate adult mental health team for continued treatment and to enable 
provision of an appropriate adult social care package, including suitable 
accommodation for him. Whilst I understand that changes have been made 
within ELFT in order to address this gap in services, I am concerned that these 
may still not be sufficient. Furthermore, I am concerned that this gap in services 
may also exist on a national level.” 

I wish to assure you and the family of Mr Wilden that East London NHS Foundation (the 
Trust) takes these issues very seriously. I outline the steps that have been taken to 
address your concerns, within the Trust below.  

Reinforcing transition protocols 

I understand that you heard oral evidence at the inquest into Mr Wilden’s death that the 
Trust’s Bedford and Luton Directorate have already taken measures to reinforce its 
transition policy and protocols.  

In particular, the serious incident report into Mr Wilden’s death and the Trust’s transition 
policy and protocols were reviewed with relevant staff members at the CAMHS away day 
on 16 September 2020.  

Additionally, since 31 December 2020, the administrator within each CAMHS team, pulls a 
list of all existing service users on a monthly basis. Those age 17.5 (6 months from their 

1 

 
 
 
 
 
 
 18th birthday) are identified and discussed at the relevant CAMHS teams’ multidisciplinary 
meeting so that appropriate planning and transitioning to the correct adult services may be 
commenced.  

CAMHS supervisors were also reminded of the importance of the transition policy and 
protocols and their monthly clinical supervision with staff members now includes 
performance monitoring of the transition policy and protocols.  

An audit was also undertaken. A sample of 5 patients were reviewed over a period of 3 
months to assess services’ compliance with the protocols. All cases reviewed met the 
required targets.  

Since the inquest into Mr Wilden’s death, further work to reinforce transition protocols has 
been undertaken. Audits take place on a quarterly basis to review service user’s transition 
from children to adult services. The audits aim to identify and share good practice, ensure 
the young person and their family carers voice is central to support provided, identify 
areas for improvement and share the learning from this.  More recently, both CAMHS and 
adult services have committed to undertaking joint audits to promote cross team learning 
and ensure improvements to the young person’s experience remains central to practice.  

Additionally, Bedford and Luton’s Transition Policy has come up for review. A decision has 
been made that the policy be revamped to include the latest transition protocols with both 
CAMHS and Adult Mental Health services feeding into the final document. It is anticipated 
that this will be complete on 14 April 2022. The new policy will be reviewed at the first 
CAMHS away day following completion and reinforced through supervisors via monthly 
supervision.  

Additional capacity for supporting transitions 

To assist staff in reinforcing the transition policies and protocols outlined above, the Trust 
has also increased its capacity for supporting transitions from CAMHS to adult mental 
health and social care services. I understand that at the inquest you received submissions 
outlining various changes that the Trust had already undertaken specifically in relation to 
transition arrangements for individuals with high-functioning autism.  

Since 1 March 2020, a full-time transition worker has been based in the Neuro 
Developmental Team dedicated to supporting the transitions of young people with autistic 
spectrum disorders including high-functioning autism. The transition worker works with 
patients from identification (6 months before their 18th birthday), through the transition 
and after their birthday to support and embed the transition. This includes supporting the 
young person, their family, partner agencies and the relevant adult service to smooth the 
transition as far as possible. They work with both referring and receiving local authority 
where relevant to ensure progress in transition planning. Particularly where the patient is 
be referred into a non-specialist neurodevelopmental team, the transition worker will also 
provide advice on engagement and support of that young person. Since the inquest, a 2nd 
transition worker has joined the Neurodevelopmental Team. 

As of February 2022, two additional transition support workers have been hired to work 
across CAMHS to support service users on transition pathways from 6 months prior to 
their 18th birthday until they are embedded within adult mental health and social services.  

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 The Trust has just appointed a Strategic Transitions Lead. This role will provide system 
leadership across all agencies, including ensuring that robust transitions systems between 
children’s (CAMHS) and Adult Mental Health Care are maintained.   They will also work 
with the relevant local authorities to ensure that robust transition pathways are in place 
across mental health services. They will ensure that the experience of the young person is 
at the heart of how of the systems and processes develop and operate.  

Working with Local Authorities 

Since the inquest, it has become clear that the Trust’s transition protocols and policies 
across both mental health services and adult social care would benefit from more 
cohesive working with the relevant local authority’s children’s services.  

There is currently a safeguarding adults review (SAR) taking place in relation to Mr 
Wilden’s case. Bedford Borough Council safeguarding has requested a specific joint multi-
agency, task and finish group (Task Group) to identify gaps in transitions across local 
authority and health. The findings will be fed back to the safeguarding board. The Trust is 
taking an active role in the SAR and the Task Group. Any significant findings will be fed 
into Trust Policy. 

As part of the newly appointed Strategic Transitions Lead’s role, ELFT will propose a 
strategic multi-agency forum be established with all key partners, particularly its local 
authority partners, to ensure that transitions retains a system wide focus and that 
leadership can be provided on a collaborative basis, to the many teams and services that 
have the potential to interface with a young person and their family carers during their 
journey to adulthood.  

We will outline this proposal to the Bedford Borough Council, Central Bedfordshire 
Borough Council and Luton Borough Council by 31 March. ELFT proposes to go ahead 
with this work regardless of local authority participation – but notes it will not be as 
affective without our key partners engagement.  

To conclude, I hope this reassures you and Mr Wilden’s family that the Trust has 
undertaken a full review of the concerns and addressed them robustly. The Trust remains 
open to continuing dialogue with Mr Wilden’s family if they would find it helpful in order to 
answer questions, clarify action or address additional concerns.  

I also look forward to reviewing NHS England’s response and any further national 
guidance that may result.  

Yours sincerely 

Chief Medical Officer 

3

Ms Emma Whitting 
Senior Coroner for 
Bedfordshire and Luton Coroner Service 
Coroner’s Office,  
The Court House,  
Woburn Street,  
Ampthill,  
Bedfordshire  
MK45 2HX 

Dear Ms Whitting, 

National Medical Director and Interim 
Chief Executive of NHS Improvement 
Skipton House 
80 London Road 
London 
SE1 6LH 

england.coronersr28@nhs.net 

17th March 2022 

Re: Regulation 28 Report to Prevent Future Deaths – Luke Richard Wilden who 
died on 22 May 2020. 

Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 16 
January 2022 concerning the death of Luke Richard Wilden on 22 May 2020. I would 
like to express my deep condolences to Luke’s family.  

I note the inquest concluded Luke’s death was a result of cardiotoxicity arising from 
cocaine and heroin use.  

Following the inquest, you raised concerns in your Report regarding the adequacy of 
transition arrangements within East London Foundation Trust (ELFT) for individuals 
with high functioning autism, stating that when Luke turned 18, he was not 
transferred to the appropriate adult mental health team for continued treatment and 
to enable provision of an appropriate adult social care package, including suitable 
accommodation for him. You raised a second concern that this gap in services may 
also exist on a national level.  

I understand that ELFT are responding to you directly regarding the transitional 
arrangements for Luke to Adult Mental Health Services. They have shared their 
progress, and which is summarised below:  

• Since this incident CAMHS and Adult services have completed a review of the

•

protocol in place governing transition from children's to adult services. There is an
audit process in place for assurance.
In relation to the link with social care and multi-agency transitions, there are positive
professional relationships in place and escalation pathways, but continues to require
strengthening through increased knowledge and understanding of transitions issues
in each other’s areas and a shared transition protocol or protocols that link together.
It is hoped that the work below will do this as part their review.

• The safeguarding board have commissioned children's and adult social care, Mental
health and P2R to look at leaving care pathways and mental health transitions to
establish if there are any multi agency gaps and propose solutions.

NHS England and NHS Improvement 

 •  This group will meet until the task is complete.  

In regards to the concern that a gap between Children and Young People’s Mental 
Health Services and Adult Mental Health Services exists on a national level, I can 
confirm that NHS England and Improvement (NHSE/I) have been progressing a 
number of commitments in the Long Term Plan which I have set out in more detail 
below. I understand the cause of concern and appreciate it being bought to our 
attention whilst we work to deliver these commitments so that, when transforming 
services, we can ensure that all children and young people get the help they need, 
when they need it.  

Improving transitions between Children and Young People’s Mental Health Services 
and Adult Mental Health Services is a key priority within NHSE/I’s LTP commitments 
regarding mental health. The LTP sets out a commitment that a comprehensive 
support offer for children and young people, between the ages of 0 to 25 years, 
would be in place in all areas of the country by March 2024. Critical to this ambition 
is improving support and care for young adults (18 to 25 years) with the expectation 
that by March 2024 no age-based thresholds will be in place and that all services are 
adapted to meet the needs of young adults. In planning guidance to local systems for 
2022/23, NHSE/I has highlighted the importance of services having particular regard 
for the needs of high risk groups, including those young adults with co-existing 
substance use, co-existing physical health conditions or disabilities (including 
neurodevelopmental disorders). 

Further the planned Integrated Care Systems (ICS) are a vehicle for integrated 
planning to ensure those who need it have access to comprehensive mental health 
support which is integrated across health, social care, education, and the voluntary 
sector. The vision for greater local system integration and autonomy is being 
implemented for specialised mental health, learning disability and autism services, 
by giving responsibility for a given population to Provider Collaboratives. Provider 
Collaboratives will improve links to other care settings, to improve the entire pathway 
and reduce reliance on the most specialised services by reinvesting in community 
provision. 

NHSE/I are committed to improving care and support for autistic people. The LTP 
recognised the need to ensure all NHS services are reasonably adjusted to ensure 
they are better able to meet the needs of autistic people. We know that the transition 
to adult services does not always work well for children and young people and their 
families, acknowledging that this was the case here. It is so important that there are 
good multi-agency planning/actions, before young people turn 18, to ensure that they 
get the support they need as they move to adulthood services. It is even more 
important that there is effective support for young people, such as Luke, who 
experience multiple additional challenges. It is for this reason that we have made 
transition one of the key priorities for the Learning Disability and Autism Programme 
and are working with partners in other agencies to ensure there is an effective cross 
system response to young people experiencing difficulty and crisis. 

NHSE/I has announced additional funding in 2021-22 to improve the quality and 
availability of inpatient mental health support and alternatives to admission for 
Children and Young People. 

 
 
 
  
 
 The LTP  sets out that by 2023/24 all children and young people experiencing a 
mental health crisis will be able to access age appropriate crisis care 24 hours a day, 
7 days a week, via NHS 111, combining crisis assessment, brief response and 
intensive home treatment functions. This will not end when young people turn 18, 
with a commitment to connect urgent mental health services to Integrated Urgent 
Care services to allow this access to crisis care 24/7 via NHS111 by 2023/24 for all 
adults. 

These services for children and young people may include blended models with 
inpatient care and/or existing adult team practitioners who are trained and competent 
in meeting the specific mental health needs of children and young people. When a 
response is provided by adult mental health services, there must be an integrated 
approach with Children and Young People Mental Health Services, including 
knowledge of community pathways and systems, as well as appropriate training in 
place to ensure the team has an understanding of the developmental and 
safeguarding needs of children and young people.  

Across the country, people now have access to dedicated 24/7 NHS urgent mental 
health helplines to ensure everyone, including children, young people and young 
adults, can get the urgent care they need without going to A&E. Details of  which 
local helpline to call, can be found on an easy to use service finder on the NHS 
website: https://www.nhs.uk/service-search/mental-health/find-an-urgent-mental-
health-helpline  

Thank you for bringing these important patient safety issues to my attention and 
please do not hesitate to contact me should you require any further information. I do 
hope the above information sets out clearly the steps that we here at NHSE/I are 
taking to respond to these known concerns. 

Yours sincerely, 

National Medical Director