Allison Aules

From Maria Caulfield MP 
Parliamentary Under Secretary of State 
Department of Health & Social Care 

39 Victoria Street 
London 
SW1H 0EU 

9 May 2024  

Miss N Persaud  
HM Coroner  
Coroner's Court  
124 Queens Road  
Walthamstow  
London  
E17 8QP  

Dear Miss Persaud,  

Thank you for your Regulation 28 report to prevent future deaths dated 30 August 2023 
about the death of Allison Vivian Jacome Aules.  I am replying as the Minister with 
responsibility for mental health and patient safety.       

Firstly, I would like to say how saddened I was to read of the circumstances of Allison’s 
death and I offer my sincere condolences to her family and loved ones. The circumstances 
your report describes are concerning and I am grateful to you for bringing these matters to 
my attention. Please accept my sincere apologies for the significant delay in responding to 
this matter.  

I understand that NHS England, North East London Integrated Care Board and North East 
London NHS Foundation Trust have each already carefully considered the matters of 
concern in your report and have provided you with comprehensive responses setting out 
the actions being taken to improve care quality and patient safety.  

I recognise your concerns regarding the resourcing of children and young people’s mental 
health services and I acknowledge that we are facing a significant increase in demand for 
children and young people mental health services. I can assure you that, from a national 
perspective, the Government is working hard towards addressing this.   

Under the NHS Long Term Plan, the NHS forecasts that, between 2018/19 and 2023/24, 
spending on mental health services has increased by £4.7 billion in cash terms, compared 
to the target of £3.4 billion set out at the time of the NHS Long Term Plan in 2019. Spend 
specifically on children and young people’s mental health services has increased from £841 
million in 2019/20 to just over £1 billion in 2022/23.   

NHS England is working to support an increase in access to high-quality children and 
young people's mental health services. NHS England’s priorities and operational planning 
guidance for 2024/25 sets out the aim to increase the number of children and young people 
aged 0-25 years accessing transformed models of community mental health to 345,000 by 
the end of March 2025 compared to 2019.  

 
 
 
 
  
   
  
  
  
  
  
  
  
  
 We are also making positive progress on our ambition to grow the mental health workforce 
by an extra 27,000 staff between 2019/20 and 2023/24. We delivered three quarters of this 
(around 20,800) by December 2023 with further growth expected to have been achieved 
once the full year figures for 2023/24 are available.  In December 2023, there were nearly 
149,000 full time equivalents in the mental health workforce. This is over 10,300 more 
(7.5% increase) since December 2022.   

The number of full-time equivalent psychiatry consultants working in all NHS trusts and 
other core organisations in England has increased by 8.7% from 4,121 in September 2010 
to 4,479 in September 2023.  

We are committed to attracting, training, and recruiting the mental health workforce of the 
future as well as retaining and re-skilling our current workforce. We are also continuing to 
increase our education and training commissions (across all mental health training 
programmes) alongside continuing to develop new roles and using existing roles to 
transform service delivery and enhance service user experiences. The NHS aims to meet 
this commitment through a range of different training programmes, including: 

•  continued workforce growth, through the commissioning of wellbeing practitioners 

and children and young people’s talking therapies training programmes;  

•  supporting existing workforce development through upskilling training opportunities, 

for example Service Leadership training;  

•  supporting the implementation of mental health support teams in schools and 

colleges through the commissioning of education mental health practitioner (EMHP) 
training and supervision;  

•  supporting initiatives to ensure widening participation in the workforce; and  
•  ensuring workforce development and training for staff in inpatient settings, including 
development of the children and young people’s mental health inpatient competency 
framework.   

I would add that we published a new 5-year Suicide Prevention Strategy for England on 11 
September with over 130 actions that we believe will make progress towards our ambition 
to reduce the suicide rate within two and a half years. The strategy is a call to action for 
national and local government, the health service, the VCSE sector, employers and 
individuals to work together to help prevent suicides.  

I hope this response is helpful. Thank you for bringing these concerns to my attention.   

Yours sincerely, 

MARIA CAULFIELD

Nadia Persaud 
East London Coroner’s Court  
Queens Road 
Walthamstow 
E17 8QP  

Dear Coroner, 

National Medical Director  
NHS England  
Wellington House 
133-155 Waterloo Road  
London 
SE1 8UG 

18 October 2023  

Re: Regulation 28 Report to Prevent Future Deaths – Allison Vivian Jacome 
Aules who died on 19 July 2022.  

Thank  you  for  your  Report  to  Prevent  Future  Deaths  (hereafter  “Report”)  dated  30 
August 2023 concerning the death of Allison Vivian Jacome Aules on 19 July 2022. In 
advance of responding to the specific concerns raised in your Report, I would like to 
express my deep condolences to Allison’s family and loved ones. NHS England are 
keen to assure the family and the coroner that the concerns raised about Allison’s care 
have been listened to and reflected upon.  

This response focuses on the national NHS England policy and programmes relevant 
to the matters of concern you have identified in your Report. The concerns you have 
raised relating to the provision of local support and the actions taken in providing that 
support to Allison would need to be addressed by the relevant local commissioners 
and providers.  

Your Report however does raise concerns relating to national resourcing of children 
and young people’s mental health (CYPMH) services, sometimes referred to as Child 
and  Adolescent  Mental  Health  Services  (CAMHS)  and  concerns  over  the  available 
workforce in CYPMH and increasing levels of need.  

Improving mental health support for children and young people is a priority for NHS 
England. The NHS Long Term Plan (LTP) sets an ambitious commitment that access 
will  increase,  with  345,000  more  children  aged  0-25  accessing  support  in  2023/24 
compared to 2019. This commitment came with significant additional funding, rising to 
over £900m in 2023/24.  We have made significant progress towards this commitment 
with  702,000  children  and  young  people  receiving  support  from  the  NHS  in  the  12 
months to June 2023. This has been achieved through investment in the children and 
young people’s mental health workforce, which has increased by 46% since the start 
of the LTP, and by 70% since 2016.  

We  accept  your  finding  that  demand  for  support  for  mental  health  and  wellbeing  is 
increasing. The prevalence of mental health need in children and young people has 
increased following the Covid-19 pandemic and many services are facing significant 
demand. Increasing access to support therefore continues to be a priority.  

                                                                                                                       
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 The NHS LTP also included a ten-year ambition that 100% of children and young 
people who need specialist support should be able to access help by the end of the 
decade.  

The NHS Long Term Workforce Plan (June 2023) sets out the importance of continued 
investment in the mental health  workforce and in 2022, NHS England consulted on 
potential  new  access  and  waiting  time  standards  including  for  children  and  young 
people’s  mental  health.  Delivering  these  ambitions  will  be  subject  to  future  funding 
settlements and we will clarify plans in due course. 

We will ensure that the leadership across NHS regions and Clinical Network are 
aware of the findings of this Report.   

I would also like to provide further assurances on 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 preventable deaths are shared across the NHS at both 
a national and regional level and helps us pay close attention to any emerging trends 
that may require further review and action.  

Thank you for bringing these important patient safety issues to my attention and please 
do not hesitate to contact me should you need any further information. 

Yours sincerely, 

National Medical Director

PRIVATE  & CONFIDENTIAL  

Ms Nadia Persaud  
HM Coroner 
East London Coroners Service 
124 Queens Road 
Walthamstow 
London 
E17 8QP 

Chief Executive 
Trust Head Office 
West Wing 
CEME Centre 
Rainham 
Essex 
RM13 8GQ 

 25 October 2023 

Dear Madam 

Re: Preventing Future Deaths (Regulation 28) Report – Allison Aules 

I refer to your letter dated 30 August 2023 and the Regulation 28 report detailing your concerns 
about the risk of future deaths in light of the inquest findings.  

I would like to extend my sincere condolences to the family of Allison Aules. This must have been 
an extremely difficult time for them, and I hope that my response provides them and you with 
assurances that NELFT NHS Foundation Trust is taking action to address the issues set out in 
your report. 

The Trust is determined to ensure that all patients receive care in a person-centred approach 
and that the patient’s voice is at the centre of planning the patient’s care. The Trust’s expectation 
is that the young person's voice is heard in the triage, initial assessment, care/treatment plan, 
and follow-ups alongside their parents / responsible adults.  We continue to work in this area, not 
least through regular audit of our work.  In addition, each member of staff has monthly supervision 
with their clinical supervisor, who scrutinises the records of randomly selected young persons to 
ensure that the voice of the young person has been captured and considered at every contact.  
We will also continue to work to ensure that the voice of the young person is also discussed at 
clinical Multidisciplinary Team Meetings, Post Assessment Discussion meetings, Complex Case 
Discussion meetings, and safeguarding supervision. 

I would also like to use this opportunity to reiterate that, in response to learning from incidents in 
the  Trust,  and  following  the  publication  of  NICE  Guidelines  225  (Self-harm:  assessment, 
management and preventing recurrence - September 2022), the Trust is transitioning to a new 
approach to assessing, identifying, and managing the clinical risks of the patients.  

www.nelft.nhs.uk 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
                                     
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 This guidance calls for a move away from the risk stratification model and a transition towards a 
risk  formulation  and  safety  planning  approach.  Risk  formulation  requires  psychosocial 
assessment, formulation and risk planning. This approach conceptualizes risk as dynamic and 
fluid, rather  than  static  and  categorical (e.g.  low, medium,  high)  and  is  focused on  a  personal 
understanding  of  risk  that  understands  how  the  risk  has  escalated  and  what,  for  that  specific 
individual, will support it to reduce in the future or may lead to further escalation.  

As part of the consultation process, the Trust considered various models for the implementation 
of objectives set out in the NICE Guidelines and opted to implement the Oxford Centre for Suicide 
Research’s model of risk formulation. This model looks at completing a psychosocial assessment 
that will lead to risk formulation and then safety planning. This safety plan is co-produced with 
the client, family and significant others within their social group.  

We  will  be  taking  forward  this  work  focusing  on  how  this  new  model  can  enable  clinicians  to 
identify the actual risks, recognise the dynamics of these risks, and devise safety plans to address 
the  identified  risks  more  effectively.    We  are  putting  training  and  system  changes  in  place  to 
support the roll out of our work in this area. 

In respect of the specific concerns, expressed by you at the hearing and within the Regulation 28 
report, the Trust has put actions in place that aim to address these specific areas for improvement 
in order to strengthen the safety of our services further. Please find attached an action plan which 
sets out these actions. 

I hope that we have provided you with some assurance that  NELFT NHS Foundation Trust is 
taking steps to address the concerns expressed in your report and that we are continuing to take  
action to prioritise patient safety and quality of care. 

Thank you for raising this matter with NELFT NHS Foundation Trust. If I can be of any further 
assistance or if you would like a further update on the progress made to address your concerns, 
I would be happy to provide a further update. 

I look forward to hearing from you.  

Yours sincerely  

Chief Executive 

Enc:   Regulation 28 action plan

www.nelft.nhs.uk

Ms Nadia Persaud 
Area Coroner  
Coroner’s Court of East London  

Chief Nurse 
4th Floor – Unex Tower 
5 Station Street 
London E15 1DA 

Monday 6 November 2023 

Dear Ms Persaud   

In the matter of Allison Aules Prevention of Future Deaths Report: Date of report: 30/08/2023 
Ref: 2023-0313 

I write in relation to the above, to update you on some of the actions NHS North East London have 
taken and are planning to take. 

Firstly, I’d like take this opportunity to formally acknowledge this was a tragic case and our 
sympathies are with the family. 

Secondly, I wanted contextualise my response by outlining that NHS North East London are 
committed to improving the mental health and well-being of people across North East London and it 
is one of our key strategic priorities across the Integrated Care System (ICS).  

For ease I shall update as below: 

Under-resourcing of CAMHS services and the delays this is causing to assessment  

•  We are developing a business case to secure additional funding to support improved 

resourcing of CAMHS services within NELFT.  

•  The business case will include a proposal for seven day and evening working as it is felt that 

this will improve recruitment/retention. 

•  The business case will also include requirements to implement a face to face approach for 

initial CAMHS assessments. 
In partnership with NELFT, NHS North East London are reviewing the current clinical model  

• 
•  CAMHS services are also part of transformation work which is being led by our Mental 

Health, Learning Disability and Autism Collaborative 

Difficulties in recruiting consultant psychiatrists to CAMHS teams  

•  Recruitment of consultant psychiatrists is a national issue which we recognise locally 
•  NHS North East London is working with NELFT and other providers to support recruitment 
and looking at innovative ways of recruiting. This work is being led by our Chief People and 
Culture Officer, 

The growing demand in CAMHS referrals and the lack of capacity to deal with this.  

1 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 •  We recognise the growing demand in CAMHS services and this demand is being reviewed 
as part of the wider transformation work via our Mental Health, Learning Disability and 
Autism Collaborative 

•  With NELFT we are reviewing the current CAHMS community model with the aim of 

• 

reducing referrals into the service  
In the short term for CAHMS for NELFT we have developed a business case for more 
funding to support this demand. 

I trust this letter addresses your questions.  

Should you have any further questions please feel free to come back to me. 

Yours sincerely 

Chief Nursing Officer  
NHS North East London 

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