Eden Street

Trust Headquarters 
Willerby Hill 
Beverley Road 
Willerby 
HU10 6ED 
Tel: 01482 389107 

Ref: 

25 February 2025 

Professor Marks 
Hull Coroner’s Court 
The Guildhall, 
Alfred Gelder Street,  
Hull  
HU1 2AA 

Dear Professor Marks 

This is the Trust’s Response to the Regulation 28 report issued by yourself at the conclusion of the 
Inquest touching upon the sad death of Eden Street. 

Humber Teaching NHS Foundation Trust would like to express our deepest condolences to the family 
of Eden Street. We take all patient deaths very seriously and investigate them thoroughly to establish 
if lessons can be learned or services can be improved. 

The concern outlined in that report was described as follows: 

“Whereas  the  Humber  Teaching  NHS  Foundation  Trust  has  implemented  a  number  of 
measures  following  the  publication  of  a  Serious  Incident  Investigation  Report  in  light  of 
admitted failings, evidence was heard that information provided by parents of autistic children 
via a telephone helpline operated by the Trust, is not fed back to the weekly audit meeting 
convened by the Trust.  As a result, information about children with neurodiversity issues that 
might have altered for the worse, may not be available to those who can alter their clinical 
priorities.” 

The Trust made further enquiries via those representing Eden’s family and sought detail of the case 
that had been referred to during the Inquest, which we understand was the basis for the PFD report. 
Helpful information was forthcoming including the name of the child, which enabled the Trust to review 
that matter.  It transpires that child was not and is not on the Trust’s Core CAMHS waiting list and the 
circumstances pertaining to that child do not in any way relate to the substantive issue raised within 
the PFD report.   

I do however take this opportunity to re-iterate the reassurance as to the substance of the issue raised 
within the report which was discussed at the Inquest.  The nub of the concern is that you can have a 
child, who may have neurodiversity issues (diagnosed or undiagnosed) on a core CAMHS waiting list 
for support with therapy for their mental health.  They may have been triaged, assessed and thereafter 
based  on  these  assessments  allocated  a  routine  slot  on  the  waiting  list  for  therapy  deemed  most 
suitable  to their  needs.    Whilst  waiting  for  the  intervention/therapy  to commence,  information may 
become available which could suggest a change in presentation or risk and such information is often 
received via contact from parents, education or healthcare professionals. 

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Chief Executive, 

 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 If a call is received about a child on the waiting list, we have dedicated duty workers, who are senior 
band 7 nurses, whose sole responsibility is to operate the duty system, a large part of the role being 
to receive calls into the service.  The senior clinician receiving the call will ascertain the nature of the 
information, and where the call is related to concerns or changes related to mental health presentation 
or safeguarding information, they will gather information and assess need via the telephone  in this 
call.  Immediate safety planning work will be included as clinically indicated.  Further to the call, a 
decision will be made regarding next appropriate steps which may form part of the safety plan.  These 
could include further telephone contact with the young person or their carer, a face-to-face contact 
with the young person, a referral to the crisis and/or intensive home treatment service for more prompt 
intervention if clinically indicated, or the young person’s referral to the waiting list as “routine” could 
be  upgraded  to  “urgent”  and  allocated  accordingly.  Having  senior  clinicians  undertaking  this  role 
provides  assurance  that  we  have  a  consistent  and  expert  response  to  calls  received  outside  of 
planned contact by core CAMHS, both in relation to children who are neuro divergent and those who 
are  not.  In  addition,  it  is  now  mandatory  for  all  Trust  staff  to  have  received  the  Oliver  McGowan 
Mandatory  Training  on  Learning  Disability  and  Autism.      The  duty  team incorporate this  into  their 
assessments  and  decision  making  for  those  on  the  waiting  list  that  may  have  a  diagnosis  or  be 
awaiting assessment for autism.  Matthew’s Hub, a specific autism charity has been commissioned 
as waiting list support. They are a specialist voluntary agency who can be directly contracted through 
Humber Teaching NHS Foundation Trust to offer waiting list support to young people aged 13+ and 
parents of all-age children. This support currently involves one-to-one sessions with a peer mentor; 
topics are needs-led; training sessions for young people and parents; school training, a youth club 
and small group sessions on specific issues (as identified by young people), for example, emotional 
regulation, daily living skills. 

An additional safeguard is that where contact about a young person has been received and dealt with 
as above by the duty worker, then where there is an increase in risk (e.g. expressions of suicidality of 
any degree, or a change in known risk profile, no matter what the outcome of that contact, the contact 
is referenced within a clinical discussion within three working days at the weekly waiting list or weekly 
MDT meeting (whichever is next due to take place). This gives an opportunity for any further input 
into  the  information  and  decision-making  to  be  provided  by  the  broader  professional  group.    This 
would  include  cases  where  the  outcome  of  the  contact  is  that  there  will  be  no  change  to  clinical 
prioritisation, and this gives an opportunity for this decision to be “double checked” by the wider group 
and safeguarding responses provided if required.  

Additionally, the Trust is implementing a new electronic record keeping system and as part of that, is 
introducing a risk review form for use by the duty team which will capture calls made to the service.  
The form will outline the nature of the call and the information provided, and the agreed actions with 
the supporting clinical rationale.  This form will be used as the basis for review of such contacts in the 
weekly waiting list or weekly MDT meetings.  (The use of these forms is just being introduced now 
with the new electronic system and in the future record keeping audits will include checks to see they 
are being utilised.) 

Additionally, the team are establishing ‘safety huddles’ in March 2025, which are a brief daily meeting 
allowing  for  staff  to  raise  any  areas  of  concern  –  this  will  provide  a  more  frequent  forum  for  duty 
clinicians to gain wider clinical perspectives on decision making. 

I would like to thank you for drawing your concerns to my attention.  However, with the benefit of the 
additional information which came to light post inquest confirming the name of the young person which  

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Chief Executive, 

 
  
 
 
 
 
 
 
 
 
 
 
 
 
 Eden’s family had referred to, which we understand was the basis for the PFD report, we do not think 
there  is  in  fact  evidence  that  there  is  a  systemic  issue  or  that  the  system  was  not  operating  as 
described.  As detailed above, the young person is not known to the Trust’s Core CAMHS or autism 
services. I am reassured that there is a robust system for dealing with contacts received in relation to 
children and young people on the CAMHS waiting list. 

I hope the above is helpful in addressing your concerns.  Please let me know if you require any further 
information or clarification in relation to these matters. 

Yours sincerely  

Chief Executive 

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Chief Executive, Michele Moran