Alice Dearden

Nicholas Rheinberg  
Assistant Coroner for  
Wiltshire and Swindon, 
Wiltshire and Swindon Coroner’s Service 
26 Endless Street 
Salisbury 
Wiltshire  
SP1 1DP 

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

22nd June 2026  

Dear Mr Rheinberg, 

Re: Regulation 28 Report to Prevent Future Deaths – Alice Sarah Dearden who 
died on 28th February 2020.  

Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 29th 
April  2026  concerning  the  death  of  Alice  Sarah  Dearden  on  28th  February  2020.  In 
advance of responding to the specific concerns raised in your Report, I would like to 
express my deep condolences to Alice’s family and loved ones. NHS England is keen 
to assure the family and yourself that the concerns raised about Alice’s care have been 
listened to and reflected upon.   

Your Report raised concerns with the commissioning arrangements for children and 
adolescents’ mental health services, in particular the abrupt transition from children’s 
to adult services at age 18.  

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 children to adult mental health services. 
A core principle is continuity of care, with transition decisions based on the individual 
needs and circumstances of the young person, rather than on age alone. 

The  Children  and  Young  People’s  Transformation  Programme,  along  with  key 
stakeholders,  have  developed  transition  guidance  on  supporting  young  people  to 
move into adult services. The guidance, which was published in April 2026, states that 
rigid, age based thresholds should be avoided and that young people should not be 
transferred automatically at age 18. Instead, the point of transition should take place 
at a relatively stable point in the young person’s life, supported by a personalised and 
planned approach.  

The guidance outlines key principles and examples of a 0 – 25 year old model of care 
including clearer accountability and improved services for those aged 16 – 17.   

                                                                                                                       
 
 
 
 
 
 
 
 
  
 
 
 
 
 This  guide  would  be  applicable  to  all  healthcare  conditions,  physical  and  mental 
health,  and  has  been  developed  with  the  support  of  young  people  with  long  term 
conditions as well. The principles of age-appropriate services set out in this document 
apply to young people receiving care for the first time as well as those already on a 
transition pathway.  

In 2024, NHS England partnered with the NHS Youth Forum to investigate this further, 
receiving  survey  responses  from  young  people  across  the  country.  The  results 
identified  a  gap  in  care  for  16  –  17  year  olds  with  many  being  discharged  from 
paediatric services before being told they weren't old enough to access adult ones.   

To address this, NHS England is working with regulators and royal college colleagues 
to ensure there is clarity over the clinical responsibilities for this age group. The forum's 
findings  are  also  informing  upcoming  guidance  on  supporting  young  people  to 
transition into adolescent and adult services.   

Furthermore, the National Child Mortality Database (NCMD) are investigating how this 
lack of clarity and resulting delays may have caused  avoidable harm with the most 
tragic of outcomes. They will publish their report later this year. 

Guidance published on Children & Young People’s eating disorders in January 2026 
also emphasises that services should take an individualised and flexible approach to 
transitions, to support safety, engagement and continuity of care. 

We  hope  that  this  new  guidance,  informed  by  feedback  from  young  people 
themselves, will specifically address the concerns raised in this tragic case. 

Regional Response 

NHS England’s South West regional team have liaised with the Integrated Care Board 
(ICB) regarding the concern your raised. Bath and North East Somerset, Swindon and 
Wiltshire (BSW) ICB had advised that they are committed to commissioning mental 
health services with parity across all ages, ensuring that children, young people, adults 
and  older  adults  have  equitable  access  to  timely,  evidence-based  support.  This  is 
detailed  with  the  BSW  ICB  Mental  Health  Strategy  2025-2030.  This  all-age 
commissioning  approach  is  designed  to  remove  artificial  boundaries  between 
services, promote continuity of care, and address inequalities in outcomes, reflecting 
the system’s commitment to parity of esteem and population need.” 

A description of the commissioned delivery model, specific skill set and resourcing to 
support  a  person-centred  approach  regarding  age  specific  transitions  is  provided 
below: 

BE  U  Swindon:  The  commissioned  and  operational  model  is  designed  to  provide 
flexibility  and  continuity  of  support  for  young  people  approaching  or  transitioning 
beyond their 18th birthday, where clinically appropriate. 

 
 
 
 Within  the  school-based  Mental  Health  Support  Teams  (MHST)  offer,  support  is 
available  to  young  people  accessing  Higher  Education  within  MHST-covered 
educational settings, enabling intervention and continuity of care for young people up 
to the age of 19. In addition, the MHST delivers a whole school and college approach, 
to  build  emotionally  healthy 
working  collaboratively  with  education  settings 
environments,  improve  early  identification,  and  strengthen  support  pathways  for 
children and young people across the wider system. 

The  service  also  works  with  children  and  young  people  with  Special  Educational 
Needs  (SEN)  up  to  the  age  of  25  where  appropriate,  recognising  the  additional 
vulnerabilities and transitional challenges this cohort can experience and supporting a 
more developmentally informed approach to care. 

Across  the  wider  community  offer,  young  people  who  turn  18  whilst  awaiting 
intervention may still be offered support where this is assessed as the most clinically 
appropriate  first-line  intervention.  This  ensures  that  support  is  not  automatically 
withdrawn solely due to age and helps minimise disruption to care pathways during 
periods of transition. 

In  addition,  the  BE  U  Swindon  Single  Point  of  Access  (SPA)  operates  in  close 
partnership with local mental health and voluntary sector services including Avon and 
Wiltshire  Mental  health  Partnership  NHS  Trust  (AWP),  Talking  Therapies,  Second 
Step, and Swindon & Gloucestershire Mind. These services provide support for young 
people  from  the  age  of  16  onwards  and  enable  coordinated  advice,  guidance, 
signposting, and onward referral arrangements for young people and families where 
another service is assessed as being better placed to meet the presenting need. This 
approach  supports  smoother  transitions  between  children  and  young  people’s 
services  and  adult  provision,  reducing  the  potential  risks  associated  with  rigid  age-
related service boundaries. 

Swindon &  Gloucestershire  (S&G)  Mind:  Their  Young  People’s  Services  support 
individuals aged 16–25, intentionally covering the transitional period around a young 
person’s 18th birthday and acting as a safety net during what can often be a vulnerable 
time.  They  attend  the  monthly  CAMHS  transition  panel,  enabling  them  to  identify 
young people who are leaving CAMHS but do not meet the criteria for Adult Mental 
Health  Teams.  In  these  circumstances,  S&G  Mind  can  provide  up  to  12  months  of 
community-based  support  tailored  to  the  individual’s  presentation  and  needs.  This 
may include crisis support, counselling, community groups, and one-to-one wellbeing 
support,  helping  to  ensure  continuity  of  care  and  reduce  the  risk  of  young  people 
disengaging from mental health support during transition. 

Oxford Health Foundation Trust, CAMHS: With the introduction of 16-25 Consultant 
Mental Health Practitioners the service provides flexible transitions designed around 
the needs of Children & Young People. At times Children & Young People will remain 
with  CAMHS  past  their  18th  birthday,  usually  when  they  are  receiving  a  treatment 
which once completed could lead to a reduced need to transfer to adult mental health 
services.  

Children & Young People are more likely to require transfer at 18 if the symptoms of 
their mental health raise concerns regarding safety, including significant self-harm or 

 harm to others. They are also likely to transition if they require an inpatient admission 
as this will need to be within the adult inpatient estate.   

Avon & Wiltshire Mental Health NHS Partnership Trust: AWP teams across the 
three  localities  work  closely  with  Oxford  Health  NHS  Foundation  Trust  (OHFT)  and 
Voluntary, Community, and Social Enterprise (VSCE) partners to ensure young people 
access  the  mental  health  support  they  need  and  that  service  pathways  are  clear.  
OHFT are commissioned to provide the 16–25 year old transition service in BSW, with 
the  consultant  mental  health  practitioners  holding  honorary  contracts  with  AWP, 
working 50% of their capacity across adult service. One of their tasks is to improve 
and progress of the transition panels across BSW, deliver training across adult teams, 
provide  consultation  and  hold  a  small  caseload  of  individuals  who  are  transitioning 
from CAMHs to adults services, providing a point of continuity.  

Talking Therapies in the ICB accepts people of 16 years and older who can either self-
refer or be referred. Early Intervention for Psychosis accepts people aged 14 years 
and above.  

In light of this case, BSW ICB will convene a working group with systemwide delivery 
partners to review the commissioned provision and delivery models spanning the 16-
25  pathway,  with  a  view  to  identifying  opportunities  to  develop  and  strengthen 
approaches,  and  implement  responsive  action  plans  and/or  cases  of  need  where 
required.  

This  workstream  will  report  to  the  BSW  Mental  Health  Delivery  Group  from  an 
follow 
oversight  perspective.  Any 
organizational governance processes. 

required  approvals/decision  making  with 

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 Alice,  
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