Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0538, written 24 Oct 2025. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 24 Oct 2025 |
|---|---|
| Reference | 2025-0538 |
| Deceased | Caitlin Imber |
| Coroner | John Gittins |
| Coroner area | North Wales (East and Central) |
| Category | Mental Health related deaths · Wales prevention of future deaths reports (2019 onwards) |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
John Adrian Gittins
Senior Coroner for North Wales (East and Central)
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO: BCUHB, Ysbyty Gwynedd, Penrhosgarnedd, Bangor,
Gwynedd LL57 2PW.
CORONER
1
I am John Adrian Gittins, Senior Coroner for North Wales (East and Central)
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 the 19th of December 2022 I commenced an investigation into the death of Caitlin Rachel
Imber (“Caiti”) (DOB 23.3.06 DOD 13.12.22). The investigation concluded at the end of the
inquest on the 17th of October 2025. The cause of death was recorded as being due to 1(a)
Hanging and the conclusion of the inquest was the following narrative:
Around the age of fourteen, Caitlin Imber ('Caiti') fell prey to the
and criminal exploitation, which despite parental support led to numerous episodes of her going
missing and recreational drug use. As a result of this behaviour it became necessary for the local
authority to play their part in seeking to keep Caiti safe, and in March 2022, she was placed at
a residential home
For the first five or six months of
her placement, Caiti largely thrived in this environment, although understandably, she remained
significantly traumatized by her previous experiences and as a consequence at the end of
August she was appropriately provided with medication, namely sertraline, primarily intended to
aid her sleeping. Both the dosage and associated risks of this medication were properly
managed, however the anticipated benefits of the same did not materialize. In the Autumn and
early Winter of 2022, coinciding with the increased freedoms available to Caiti as a result of her
choosing to no longer further her studies in-house, Caiti's mental health deteriorated. Despite
this she did not give any significant indications of an intention to self-harm, instead presenting at
times as both a typical moody teenager and the child which she still was, excited at the prospect
of the coming Christmas. On the 11th of December 2022, unbeknown to those caring for her,
Caiti gave an indication to another resident of a wish to harm herself, and whilst she had been
upset during the evening of the 12th of December, her presentation did not demonstrate any real
and immediate risk to her life. After retiring to her bedroom, Caiti
resulting in her
death which was confirmed on the morning of the 13th of December 2022. Whilst it is not
possible from the available evidence to positively establish Caiti's intention by her actions, it is
probable that she did not intend to end her life.
4
CIRCUMSTANCES OF THE DEATH
The circumstances of the death are in accordance with the narrative conclusion above.
Coroner's Office, County Hall, Wynnstay Road, Ruthin, LL15 1YN
Tel 01824 708047 |
5
CORONER’S CONCERNS
During the course of the inquest the evidence revealed the following matter giving rise to
concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the
circumstances it is my statutory duty to report to you.
The MATTER OF CONCERN is as follows. –
On the 9th of May 2022, CAMHS received a referral from a community paediatrician dated the
19th of April 2022. This identified the need for support care and treatment to be provided to a
traumatized, vulnerable child, however as the referral did not contain any contact numbers, the
referral was closed without any additional enquiries being made to further the matter.
A further referral was received on the 31st of May 2022 and was then accepted by CAMHS,
representing a delay of 42 days from the original paediatrician’s referral to any action being
taken.
Whilst this was not contributory to Caiti’s death, I am concerned by the apparent lack of effort to
locate missing information and progress a referral and I consider that if this situation continues to
prevail, then there is a risk that future deaths could occur.
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
You are under a duty to respond to this report within 56 days of the date of this report, namely by
19th December 2025 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 Family of the Deceased and to the Chief Coroner.
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
Dated 24th October 2025
Signature
Senior Coroner for North Wales (East and Central)
Coroner's Office, County Hall, Wynnstay Road, Ruthin, LL15 1YN
Tel 01824 708047 |
1 response 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.
Bloc 5, Llys Carlton, Parc BusnesLlanelwy, Llanelwy, LL17 0JG ---------------------------------- Block 5, Carlton Court, St Asaph Business Park, St Asaph, LL17 0JG Dyddiad / Date: 19 December 2025 Mr John Gittins HM Senior Coroner for North Wales (East & Central) County Hall Wynnstay Road Ruthin LL15 1YN Dear Mr Gittins, Inquest of Caitlin Rachel Imber I am writing in response to the Regulation 28 Report to Prevent Future Deaths (PFD) dated 24 October 2025, issued by yourself to Betsi Cadwaladr University Health Board, following the inquest touching the death of Caitlin Rachel Imber. I would like to begin with offering my deepest condolences to Caitlin’s loved ones. In the notice, you highlighted your concern that a referral to Child and Adolescent Mental Health Services (CAMHS) from a community paediatrician identified the need for care and treatment to be provided, however as the referral did not contain any contact numbers, the referral was closed without any additional enquiries being made to further the matter. A further referral was then received which was accepted by CAMHS, representing a delay of 42 days from the original paediatrician’s referral to any action being taken. You found this was not contributory to Caitlin’s death but were concerned at the apparent lack of effort to locate missing information and progress a referral and considered that if this situation continues to prevail, then there is a risk that future deaths could occur. In response to the notice, we have given this significant consideration. I can confirm that CAMHS have changed their standard operating procedure, and an appointment is now offered even where contact numbers are not provided. This change was made following completion of the investigation and ensures all referrals receive an appointment. The service is also undertaking an audit to confirm the changes that have been made are embedded in practice. The learning from the inquest is planned to be shared via the Regional CAMHS Forum, supporting learning across our services. In addition, your notice has been shared through our Reducing Avoidable Mortality Group, chaired by the Associate Medical Director (Mortality) and attended by senior medical staff and clinicians from all our divisions. All PFD notices are shared through this group to support learning across the Health Board. Cyfeiriad Gohebiaeth ar gyfer y Cadeirydd a'r Prif Weithredwr / Correspondence address for Chairman and Chief Executive: Swyddfa'r Gweithredwyr / Executives’ Office Ysbyty Gwynedd, Penrhosgarnedd Bangor, Gwynedd LL57 2PW Gwefan: www.pbc.cymru.nhs.uk / Web: www.bcu.wales.nhs.uk I hope this letter sets out for you the actions we have taken to ensure the concerns raised by yourself are being addressed and mitigated. We would be happy to meet with you and discuss our plans in more detail, or provide further information and assurance should that be helpful. Once again, I offer my deepest condolences to Caitlin’s loved ones for their loss. Yours sincerely Cyfarwyddwr Gweithredol Nyrsio a Bydwreigiaeth / Executive Director of Nursing and Midwifery cc , Executive Medical Director , Deputy Director for Legal Services
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