Chloe Barber

Parliamentary Under-Secretary of State for    
Women’s Health and Mental Health  

39 Victoria Street   
London  SW1H 0EU   

3rd November 2025  

Professor Paul Marks  
The Guildhall  
Alfred Gelder Street  
Hull   
HU1 2AA  

Dear Professor Marks, 

Thank you for your Regulation 28 report of 12 August 2025 sent to the Minister of State at 
the Department of Health and Social Care, about the death of Chloe Louise Barber. I am 
replying as the Minister with responsibility for mental health.        

Firstly, I would like to say how saddened I was to read of the circumstances of Chloe’s death, 
and I offer my sincere condolences to her family and loved ones. The circumstances your 
report describes are very concerning and I am grateful to you for bringing these matters to 
my attention.  

Your report raises concerns over the transition between children and young people’s mental 
health services and adult mental health services; a lack of guidance around administering 
depot  preparations  of  antipsychotic  medication;  and  the  provision  of  aftercare  following 
discharge from mental health care. In responding, I have liaised with NHS England.     

We  know  that  the  transition  from  children  and  young  people’s  mental  health  services  to 
appropriate support from adult mental health services can be challenging for some young 
people and that more needs to be done to improve patient experience and outcomes at this 
critical  stage.  A  key  priority  for  children  and  young  people’s  mental  health  services  is 
ensuring  continuity  of  care  and  a  smooth  transition  for patients  moving  to  adult  services. 
NHS England released funding in 2022/23 to transform and focus improvement on the young 
adult mental health pathway. In the year ending March 2025, the majority of integrated care 
boards  reported  improvement  in  the  way  they  manage  transitions  to  adult  services.  This 
includes removing rigid age-based thresholds for transition; involving young adults and their 
families/carers  in  decisions  about  their  care;  and  ensuring  there  are  strong  working 
relationships  and  embedded  shared  responsibility  between  children  and  adults’  mental 
health services.   

NHS  England  is  also  developing  a  personalised  care  framework  which  sets  out  the  core 
principles of care that people should expect when accessing mental health services. This 
will be applicable across children and young people’s and adult services to help ensure that 
transitions are smooth and care is consistent across settings.   
Turning  to  your  concerns  about  the  administration  of  depot  preparations  of  antipsychotic 
medication,  prescribing  guidelines  on  Depot  Antipsychotic  Medication  Prescribing  and 

 
    
  
  
  
  
  
  
  
  
   
   
   
  
 Administration are available for healthcare professionals in the Hull and East Riding Area.at: 
https://www.hey.nhs.uk/herpc/prescribing-guidelines/ (under Central Nervous System).  

In general, the Department expects healthcare professionals to work within the limits of their 
clinical competence. For example, all medical doctors, physician assistants and physician 
assistants  in anaesthesia  registered  with  the  General Medical Council  (GMC), must  meet 
the  expected  standards  set  out  in  the  GMC’s  Good  medical  practice1 to  work  in  the  UK. 
Doctors must also hold a licence to practise. Good medical practice states that doctors must 
propose, provide or prescribe drugs or treatment based on the best available evidence, and 
only when they have adequate knowledge of the patient’s health and are satisfied that the 
drugs or treatment will meet their needs. Failure to uphold and adhere to the principles within 
Good  medical  practice  and  related  guidance  will  put  a  professionals’  registration  with  the 
GMC at risk. If a concern is raised about a professional’s fitness to practise, the GMC has a 
statutory duty to investigate and take action to safeguard the health and well-being of the 
public where necessary.  

With regard to your concerns around a lack of knowledge amongst some healthcare staff 
and social workers about section 117 aftercare, it is vital that organisations across the health 
system  work  together  to  ensure  effective  discharge  planning  and  the  best  outcomes  for 
people who are discharged from hospital. Section 117 of the Mental Health Act places a joint 
duty on local authorities and integrated care boards, in co-operation with voluntary agencies, 
to  provide  or  arrange  for  the  provision  of  aftercare  to  patients  detained  in  hospital  for 
treatment under section 3 (and some other sections) who then cease to be detained.   

We  are  aware  that  there  can  sometimes  be  disagreements  between  organisations  as  to 
which one should be responsible for aftercare under section 117, which can delay access to 
aftercare. To  address  this,  statutory guidance  on  discharges  from  mental  health  inpatient 
settings2  was  published  in  January  2024  which  provides  clarity  in  relation  to  how 
organisations across the health system work together to ensure effective discharge planning 
and the best outcomes for people who are discharged from hospital. It includes additional 
guidance on how budgets and responsibilities are shared to pay for aftercare under section 
117.    Integrated  care  boards,  as  commissioners  of  health  services  in  their  areas,  should 
ensure that all providers of mental health services are aware of this guidance.    

Further to this, the Mental Health Bill, currently being considered by Parliament, will amend 
section  117  to  apply  the  existing  ‘deeming  rules’  under  social  care  legislation  to  the 
determination  of  ordinary  residence,  to  identify  which  local  authority  is  responsible  for 
arranging section 117 aftercare to an individual patient. These rules already exist under the 
Children Act 1989, the Care Act 2014 and the Social Services and Well-being (Wales) Act 
2014.  The  deeming  rules  will  also  more  closely  align  the  local  authority,  social  care  and 
integrated  care  board  rules  for  determining  where  a  person  is  ‘ordinarily  resident’  for  the 
purposes  of  section  117,  aiming  to  support  the  joint  provision  and  planning  for  aftercare 
services. Our intention is that the deeming rules will add clarity and consistency to an often-
litigious system.  

1 https://www.gmc-uk.org/professional-standards/professional-standards-for-doctors/good-medical-practice 2 
https://www.gov.uk/government/publications/discharge-from-mental-health-inpatient-settings/dischargefrom-
mental-health-inpatient-settings  

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

All good wishes,   

PARLIAMENTARY UNDER-SECRETARY OF STATE FOR  
WOMEN’S HEALTH AND MENTAL HEALTH

Professor Paul Marks 
Senior Coroner 
East Riding & Hull Coroner’s Service  
The Guildhall 
Alfred Gelder Street 
Hull  
HU1 2AA 

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

28th October 2025 

Dear Professor Marks, 

Re: Regulation 28 Report to Prevent Future Deaths – Chloe Louise Barber who 
died on 3 November 2021.  

Thank  you  for  your  Report  to  Prevent  Future  Deaths  (hereafter  “Report”)  dated  12 
August 2025 concerning the death of Chloe Louise Barber on 3 November 2021. In 
advance of responding to the specific concerns raised in your Report, I would like to 
express my deep condolences to Chloe’s family and loved ones. NHS England is keen 
to assure the family and yourself that the concerns raised about  Chloe’s care have 
been listened to and reflected upon.   

I am grateful for the further time granted to respond to your Report, and I apologise for 
any  anguish  this  delay  may  have  caused  to  Chloe’s  family  or  friends.  I  realise  that 
responses to Coroners’ Reports can form part of the important process of family and 
friends coming to terms with what has happened to their loved ones, and I appreciate 
this will have been an incredibly difficult time for them.  

Your report raises the following concerns:  

1.  There  is  no  clearly  defined  pathway  that  assists  young  people  making  the 
transition between Child and Adolescent Mental Health Services (CAMHS) and 
adult psychiatric services, to ensure a smooth transition and continuity of care.   

2.  There are no clear guidelines about where and by whom depot preparations of 

antipsychotic medication may be administered.  

3.  There  was  considerable  uncertainty  and  ignorance  about  the  provision  of 
aftercare  pursuant  to  s117  of  the  Mental  Health  Act  1983  amongst  some 
healthcare  workers  and  social  workers,  who  should  in  any  event  be  closely 
liaising with each other as well as with other allied professionals.  

Transition between CAMHS and adult psychiatric services  

The NHS is committed to ensuring that every area across the country commissions a 
comprehensive mental health offer for children and young people, with a clear focus 
on supporting young adults as they move from child to adult mental health services. A 
key priority is ensuring continuity of care and a smooth transition between services. 
Funding  was  released  to  healthcare  systems  in  2022/23  to  transform  and  focus 

                                                                                                                       
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 improvement on the young adult mental health pathway. As of 2024/25, the majority 
of Integrated Care Boards (ICBs) across the country report that they have removed 
rigid  age-based  thresholds,  involving  young  adults  and  their  families/carers  in  their 
care, and ensuring that there are strong working relationships and embedded shared 
responsibility between child and adult mental health services.  

Administration of depot (long-acting injection) medication  

All  Trusts  should  have  an  up  to  date  policy  setting  out  the  expected  practise  and 
responsibilities of both prescribers and those administering depot medications. This 
should  cover  prescribing,  storage,  dispensing,  administration  and  monitoring 
requirements in line with the organisation’s overarching Medicines Policy.  

Policies  for  the  prescribing/administration/dispensing  of  depot  medication  are 
generally  determined  at  local  level  (ICB).  Depot  medication  is  normally  initiated  by 
specialist  secondary  care  services,  but  when  a  patient  is  considered  to  be  ‘stable’, 
prescribing  may  be  transferred  to  primary  care  under  a  locally  agreed  shared  care 
protocol.  Some  areas  may  also  make  additional  payments  available  to  support  the 
transfer  of  depot  prescribing  to  primary  care,  for  example  under  a  local  enhanced 
service  with  funding agreed  with  local  commissioners.  In other areas  local systems 
may agree that all depot prescribing should remain under secondary care specialist 
responsibility.  

In July 2024, NHS England released new guidance for Integrated Care Boards (ICBs) 
to  improve  community  mental  health  services,  focusing  on  intensive  and  assertive 
treatment  for people  with  Severe  Mental  Illness  (SMI)  who  struggle  to  engage  with 
standard services. This includes additional guidance on the use of depot medication, 
available here: NHS England » Guidance to integrated care boards on intensive and 
assertive community mental health care.  

If the prescribing of depot medication is switched to primary care, this would be done 
under  a  shared  care protocol.  This  guidance includes the  range  of  information  that 
should  be  included  as  part  of  a  request  for  primary  care  to  take  over  prescribing 
responsibility. This includes Summary of NICE, BNF, SPC or other guidance, where 
applicable  (and  a  web  link  to  access  the  full  guidance),  Licensed  indications  & 
therapeutic  class,  Dose,  route  of  administration  and  duration  of  treatment,  Adverse 
effects (incidence, identification, importance and management), Cautions and contra-
indications,  Monitoring  requirements  and  responsibilities,  Clinically  important  drug 
interactions and their management, Peer-reviewed references for product usage and 
Contacts for more detailed information.  

Over  the  next  two  years  the  government  has  announced  its  intention  to  develop  a 
single  national  formulary  (SNF)  for  prescribed  medicines  in  England.  Although  the 
precise details of how the SNF will be implemented are currently being developed, it 
is  expected 
in  prescribing 
reduce 
practices/policies and this should help reduce uncertainties stemming from the current 
variations in prescribing and shared care protocols. 

the local  variation 

the  SNF will 

that 

S117 Aftercare  

 
 
 
 
 National guidance has been issued by NHS England and the Department of Health 
and Social Care (DHSC) providing staff with clear information about s117 and when 
this applies, including the following:  

•  Mental Health Act 1983 Code of Practice 
•  Discharge from mental health inpatient settings - GOV.UK 
•  NHS England » Acute inpatient mental health care for adults and older adults 

NHS England’s adult acute guidance referenced above states that:  

Many people admitted to hospital will already be in contact with a community-based 
mental health or learning disability team and have a named key worker. On admission, 
anyone without a named key worker should be assigned one within 72 hours wherever 
possible.  

Key workers should:  

•  Maintain contact with the person whilst they are in hospital.  
•  Share relevant information with the inpatient team to reduce the need for repeat 
assessments  and avoid  the  distress  of  the  person  retelling  their  story, which 
can be trigger past traumas.  

•  Work closely with the inpatient team, Crisis Resolution and Home Treatment 
Team (CRHTT), local authorities and other key services to plan the support the 
person will need both for discharge and for maintaining their wellbeing in the 
community  (including  working  with  local  authorities  to  plan  s117  aftercare, 
where applicable).  

Planning for discharge, including arrangements for s117 aftercare, should begin early 
and  be  undertaken  collaboratively,  in  partnership  with  other  services.  This  helps  to 
ensure  a  smooth  transition  from  hospital  to  the  community  and  supports  the 
individual’s ongoing recovery and stability.  

Colleagues from NHS England’s North East and Yorkshire region have advised that 
the concerns raised in your Report relate to locally commissioned services rather than 
specialised  services.  During  Chloe’s  admission  to  the  Cygnet  Hospital  in  Sheffield, 
oversight  was  provided  by  the  Regional  NHS  England  Mental  Health,  Learning 
Disability and Autism (MHLDA) Specialised Commissioning Team. Case management 
was  in  place  to  support the  commissioning process  and ensure  the  quality  of  care, 
including regular engagement with the provider and monitoring of Chloe’s care and 
pathway. Prior to discharge, multi-agency planning meetings were held, including a 
section 117 Mental Health Act discharge planning meeting. These meetings involved 
the multidisciplinary team (MDT), local CAMHS, adult mental health services, the local 
authority children’s social worker, as well as Chloe and her parents. The outcome was 
a comprehensive discharge plan which was agreed and documented.  

Modern Service Framework 

We  are  taking  several  steps  to  ensure  there  is  consistency  in  the  quality  of  care 
provided  by  mental  health  services,  while  ensuring  the  people  responsible  for 
providing care are not overburdened by excessive central control. This includes the 

 
 
 
 
 
 
 
 
 development  of A  Modern  Service  Framework  for  severe  mental  illness,  which  will 
support  consistent,  high  quality,  and  high  value  care.    The  Modern  Service 
Frameworks  will  support  consistent,  high  quality,  and  high  value  care  across  key 
clinical pathways. 

The Modern Service Frameworks will: 

•  define an aspirational, long-term outcome goal 
• 

identify the best evidenced interventions that would support progress towards this 
goal  

•  set standards on how those interventions should be used 
•  and identify areas where innovation is needed to drive progress. 

This  is  part  of  wider  programme  following  the  10  Year  Health  Plan  to  improve 
outcomes, reduce unwarranted variation, and align provider payments with provision 
of high-quality care. 

NHS England is also finalising a new ‘Personalised Care Framework’ which sets out 
the minimum expected standards of care for people needing secondary mental health 
services. The Framework will apply to both CYP and Adult services, meaning a greater 
level of consistency in the offer across both services, giving young people transitioning 
between CYP and adult care will have greater clarity about what they should expect 
from their care. 

Wider improvements 

NHS England’s case managers work across inpatient providers and the wider health 
system  in  accordance  with  the  National  Institute  for  Health  and  Care  Excellence 
(NICE) guidance  on  the  transition  of  young  people  from  child  to adult  services. We 
recognise that transition remains a key area of focus across ICBs, adult mental health 
services and the broader system. This priority was also reflected in the NHS England 
Improvement  Plan  following  the  independent  investigation  by  NICHE  Health  and 
Social  Care  Consulting  into  West  Lane  Hospital,  published  in  March  2023,  which 
highlighted  the  need  for  robust  transition  processes.  In  2023,  regional  discussions 
were  held  to  reinforce  the  importance  of  NHS  England,  NHS  providers  and  local 
authorities being assured that transitions are completed in line with the relevant NICE 
guidance.   

Within the North East and Yorkshire Region, work is underway to strengthen pathways 
for young people transitioning from  CAMHS  into adult mental health  services using 
personalised  care  approaches.  The  priority  is  to ensure  a  safe,  seamless  transition 
with  continuity  of  care.  Alongside  this,  section  117  aftercare,  and  ensuring 
personalised,  consistent  and  appropriate  support  for  all  those  entitled  to  it,  is  an 
identified area of focus within regional discussions and planned work.  

 
 
 
 
 
 
 Provider  case  management  and  clinical  teams  work  collaboratively  in  supporting 
young adults in their personalised transition from CAHMS services to Adult Services; 
supporting  discharge  arrangements  whereby  a  young  person  is  discharged  from 
hospital.  Transition  is  a  priority  in  the  work  of  the  Mental  Health  Trusts,  Provider 
Collaboratives  and  the  work  of  Humber  and  North  Yorkshire  Mental  Health  and 
Learning Disability Collaborative.  

Humber  Teaching  NHS  Foundation  Trust,  which  provides  a  variety  of  services  for 
people with mental health concerns, have many improvement initiatives and priorities 
relevant to transitions for children and young people into adult services, particularly in 
mental  health  which  includes  a  Person-Centred  Approach  in  CAMHS  and  Mental 
Health  Services  and  strengthening  formulation  in  mental  health,  learning  disability, 
CAMHS and forensic services. This includes:  

- 

Improving  how  care  is  planned  and  delivered  across  the  lifespan  –  ensuring 
assessments and formulations are tailored to individual needs, which is critical 
during transition phases. 

-  Co-production  with  young  people  with  the  Trust  has  developed  the  Connect 

website in collaboration with young people.  

-  Emergency  department  Streaming  Pathway  –  a  new  pathway  has  been 
introduced  to  support  young  people  presenting  with  mental  health  issues  in 
acute settings.  

Humber Complex Emotional Needs Service for people who may meet the criteria for 
a diagnosis of a Personality Disorder has been working to support carers, families and 
friends by offering the Family Connections  programme as well as refining their offer 
for care leavers and for those transitioning from Child and Adolescent services and 
now offer Dialectical Behaviour Therapy, EMDR therapies and Care Coordination, and 
an increased consultation offer to colleagues across the Trust and statutory partners.  

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 Chloe, 
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  
NHS England