Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0434, written 10 Jun 2024. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 10 Jun 2024 |
|---|---|
| Reference | 2024-0434 |
| Deceased | Sailor Court |
| Coroner | Sebastian Naughton |
| Coroner area | South London |
| Category | Suicide (from 2015) · Child Death (from 2015) |
| Organisation named | South London and Maudsley NHS Foundation Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
South London Coroner's Court 2nd Floor Davis House Robert Street Croydon CR0 1QQ Telephone 020-8313 1883 REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. The National Medical Director, NHS England, 2. Secretary of State for Health and Social Care, the Rt Hon Victoria Atkins MP 1 CORONER I am Sebastian Naughton, Assistant Coroner, for the coroner area of South London. 2 CORONER’S LEGAL POWERS I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. 3 INVESTIGATION and INQUEST On 8 December 2021 an investigation into the death of Sailor (previously known as Sara) COURT, who died following an overdose of September 2021. aged 14 years on 17 Sailor was non-binary and chose to be referred to by the pronouns “they / them”. The investigation concluded at the end of the inquest on 7 June 2024. The conclusion of the inquest was that Sailor took their life by suicide. At the time of their death, Sailor was on the waiting list for treatment under the Community Child and Adolescent Mental Health Service, which is operated by the South London and Maudsley NHS Foundation Trust (“CAMHS”). 4 CIRCUMSTANCES OF THE DEATH Sailor was first referred to the CAMHS in October 2020 aged 13 due to low mood and self-harm. The referral was accepted in November 2020. Sailor was advised that the waiting time for the mental health assessment appointment would approximately one year, in November 2021. In fact, after an episode of self-harm in mid 2021 and the intervention of the CAMHS crisis team, the assessment due to take place in around November 2021 was superseded by an earlier assessment in mid 2021, and on 20 August 2021 Sailor and South London Coroner's Court 2nd Floor Davis House Robert Street Croydon CR0 1QQ Telephone 020-8313 1883 their parents were advised that Sailor had been added to the list for and treatment which at that time was approximately 10 months. Sailor took their life some four weeks later on 17 September 2021 when they were found deceased in their bedroom at home by their parents. Toxicology and circumstantial evidence showed that Sailor had taken an overdose of which had been prescribed by their GP. I concluded that the overdose was an intentional act amounting to a suicide. 5 CORONER’S CONCERNS During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. – (1) The anticipated waiting times before Sailor’s assessment (approximately one year) was unacceptably long. (2) The length of time before treatment could be delivered thereafter (approximately 10 months) was unacceptably long. (3) The Court heard evidence that the waiting times for assessment and treatment have not improved since Sailor’s death, and in fact both have significantly increased. This means that a teenager referred today into the CAMHS could be waiting for around / upwards of two years before they receive treatment. This is an unacceptably long delay. (4) The Court heard evidence that the Trust is attempting to mitigate the problem by way of a proactive “Keeping in Touch” team with the potential to streamline / re- organise the waiting list. However, due to the number of individuals on the waiting list (estimated to be over 1,000) and the number of staff engaged in the Keeping in Touch team (three) and the scale of the task, I was not re-assured that the Keeping in Touch team could realistically and / or safely assess or re-prioritise those on the waiting list in most urgent need of assessment or treatment. (5) The Court heard evidence that the long waiting lists were a result of a lack of resources which has not kept pace with significantly increased (and increasing) demand. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action. 7 YOUR RESPONSE South London Coroner's Court 2nd Floor Davis House Robert Street Croydon CR0 1QQ Telephone 020-8313 1883 You are under a duty to respond to this report within 56 days of the date of this report, namely by 7 August 2024. I, the Coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: 1. Sailor’s parents; 2. The Chief Executive of the South London and Maudsley NHS Foundation Trust. I have also sent copies to the following who may find it useful or of interest: - - - The local safeguarding school (since Sailor was a minor under the age of 18); The Head Teacher at Sailor’s school; Sailor’s GP. I am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner. 9 10 June 2024
2 responses published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
Parliamentary Under Secretary of State For Patient Safety, Women’s Health and Mental Health. 39 Victoria Street London SW1H 0EU 12 August 2024 Our Ref: S ebastian Naughton Assistant Coroner South London Coroner ’s Office 2 nd Floor Da vis House Robert Street Croydon CR0 1Q Q By email: Dear Mr Naughton, Thank you for your Regulation 28 report to prevent future deaths dated 10 June 2024 about the death of Sailor Court and I’d like to thank you for agreeing an extension. I am replying as the recently-appointed Minister with responsibility for patient safety and mental health. Firstly, I would like to say how saddened I was to read of the circumstances of Sailor’s death and I offer my sincere condolences to their family and loved ones. The circumstances your report describes are concerning and I am grateful to you for bringing these matters to my attention. I understand and share the concerns you have rightly raised in your report about the long waiting times for assessment and treatment in some children and young people’s mental health services. This Government recognises how important it is that children and young people with mental ill health get the level of care that is appropriate for their needs early on, and we want to ensure that they have access to the right mental health support, in the right place, and at the right time. As stated in your concerns, it is unacceptable that waiting times for some mental health services are far too long meaning that too many children and young people are not receiving the care they deserve. We are determined to change that. As part of our mission to build an NHS that is fit for the future and that serves the patients that need it, this Government will recruit 8,500 additional staff across children’s and adult mental health services, introduce a specialist mental health professional in every school and roll out Young Futures hubs in every community to intervene earlier with more timely mental health support. With regards to your concerns about the “keeping in touch team” at South London and Maudsley NHS Foundation Trust. I have been in touch with Stephen Powis at NHS England to discuss the service. I understand that colleagues at NHS England will address these concerns in more detail in its response to your report. I hope this response is helpful. Thank you for bringing these concerns to my attention. Yours sincerely,
Mr Sebastian Naughton
Assistant Coroner
South London Coroner’s Court
2nd Floor, Davis House
Robert Street
Croydon
CR0 1QQ
National Medical Director
NHS England
Wellington House
133-155 Waterloo Road
London
SE1 8UG
05/08/2024
Dear Coroner,
Re: Regulation 28 Report to Prevent Future Deaths – Sailor Court who died on
17 September 2021
Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 10
June 2024 concerning the death of Sailor Court on 17 September 2021. In advance of
responding to the specific concerns raised in your Report, I would like to express my
deep condolences to Sailor’s family and loved ones. NHS England are keen to assure
the family and the Coroner that the concerns raised about Sailor’s care have been
listened to and reflected upon.
Your Report raises concerns relating to the national resourcing of children and young
people’s mental health (CYPMH) services, sometimes referred to as Child and
Adolescent Mental Health Services (CAMHS), the available workforce in CYPMH
including the “Keeping in Touch” team operated by the South London and Maudsley
NHS Foundation Trust (SLaM) and increasing levels of need together with long waiting
lists.
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 £900 million in 2023/24. We have made significant progress towards this
commitment, with 758,000 children and young people receiving support from the NHS
in the 12 months to January 2024. This has been achieved through investment in the
CYPMH workforce, which has increased by 46% since the start of the LTP in January
2019, 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 has also increased following the
pandemic in 6-16 year olds, from one in nine to one in six, and in 17-19 year olds from
one in ten to one in six. Many services face significant demand and, therefore,
increasing access to support continues to be a priority.
The NHS LTP also includes 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.
NHS England has also been sighted on the response to the Coroner from South East
London Integrated Care System. We note that they have increased funding and
available capacity, and that SLaM is undertaking a quality improvement collaborative
to increase the percentage of young people receiving their first contact within 28 days.
I refer you to their response dated 18 July for further information on this.
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 Sailor,
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.
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
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