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Coroner urges revision of mental health referral form after 15-year-old boy dies

Exclusive A coroner has called for a review of a referral form for mental health service CAMHS after the death of a 15-year-old boy.

Sheffield Children’s Hospital NHS Foundation Trust has been told to examine its referral form after ‘insufficient’ information led to delays in the 15-year-old boy accessing treatment.

In a prevention of future deaths report, assistant coroner in South Yorkshire Angharad Davies, added that it was a ‘risk’ to expect GPs to extract sufficient information to fill in the current form with a 10-minute appointment, ‘given the realities of the pressures on a GP’s day’.

The patient, Noah Lomax, who died by suicide in August 2018, was referred to CAMHS by his GP at Crookes Practice in Sheffield in July 2018.

However, CAMHS declined the referral due to ‘insufficient information’ for a risk assessment to be performed, and instead invited the GP to provide further information.

Another GP appointment was scheduled for 6 August 2018 to obtain this further information, but Mr Lomax died on 1 August, before he had seen CAMHS and before the second GP appointment.

The Trust accepted the current referral form does not capture the information to process referrals without delay, according to the coroner. However, she added that the Trust decided against redesigning the form and instead opted to provide further training for GPs within the area.

Ms Davies said: ‘CAMHS clinical lead said that there had not been any other problems with the form with GPs not completing them sufficiently. I am not sure how [name redacted] is able to be so confident about this.’

She added: ‘Having carefully considered the evidence, I am not satisfied that steps have been put in place to ameliorate the risk identified.

‘Given the realities of the pressures on a GP’s day expecting a GP to use their 10 minute appointment to extract sufficient information for the referral and then at some point complete a referral form, with which they may be unfamiliar, creates the risk that relevant information may not be provided.

‘I would invite the Trust to reconsider whether the form could be improved to reduce the risk of inadequate or insufficient information being provided which may result in a delay in care.’

A spokesperson for Crookes GP practice said: 'We were all extremely saddened at the practice by the tragic death of Noah and welcome the revision of the CAMHS referral form.'

Sally Shearer, director of nursing and quality at Sheffield Children's NHS Foundation Trust, said: 'Noah’s death was tragic and we support the coroner’s efforts to ensure health professionals are working together and supporting families as much as possible.

'Before the inquest we reviewed our processes and have made a number of changes to safeguard children being referred to CAMHS. We put in place a system so that if a referral comes through with insufficient information, we will contact the GP to find out more. In addition, if a referral is being declined, we contact the GP and the family to let them know. We also provided additional guidance to support GPs completing the referral form. These actions have been put in place alongside our new patient record system which makes it easier for us to share information with GPs.

'We also took on board the coroner’s view that the referral form itself should be reviewed again, and have completed this work alongside GPs.'

It follows news that almost all mental health in-patients in England who are placed in out-of-area beds are done so inappropriately, according to NHS Digital.

 

Readers' comments (34)

  • The Trust said:
    "we have done nothing wrong at all. Lots of us spent months designing this form it's really good. We like it and we aren't going to change it. Of course, we could always contact the patient directly for more information ourselves, but we aren't going to do this it's too much trouble!"

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  • Children's mental health services are a national disgrace. Well done Coroner for highlighting a particularly egregious aspect. GPs simply do not have the time to fill out forms which are designed to enable a hard pressed service to turn people away.
    Its almost got to the point where it's easier to recruit a partner than get a distressed teenager helped.
    And silently and unnoticed there is increasing reliance on and expectation of use of the voluntary sector for adult mental health.

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  • Just blame the form and not a lack of staffing and appointments at CAMHS or parents taking some interest and responsibility. Looks like the same trick is being used uk wide. GP referrals are bouncing all over the country.

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  • Two major problems here. One, CAMHS not staffed sufficiently, so tendency to bounce almost all GP referrals, and long waits for the ones that are accepted. Two, if there is not enough info on the form, why on earth ask the GP for more info; if they had that info it would have been on the form. It's like passing the admin down to a minion to get, rather than taking responsibility and actually contacting the family directly and getting an accurate answer, rather than the GP having to be the go-between. As that GP might not be in on the day the request for more info arrives, yet more unnecessary delays. The system is broken. it will take more resources AND a change of attitude to sort it.

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  • Can we start asking for forms to be filled in before patients can see us?

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  • Unusually a third person / party having some insight into the difficulties GPs face.... I wonder if Nikita Kanani could learn from this? Or 'Oh! we'll make them open more with resources they haven't got...' - what about professional development? What about staff retention? What about the recruitment crisis? Nikita doesnt see the harm her daft ideas do.... let alone do anything practical to fix them.... heading back to Australia soon.... thankfully

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  • National Hopeless Service

    The GPC/BMA/GMC has made it abundantly clear over the years we are under an obligation to refer but we are under no obligaton to fill in any specific referral forms. If CAMH want specific information they can contact parents/schools.

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  • What I am most impressed about this case is how much insight this rare coroner has into General Practice. Far more pragmatic and insightful than CAMHS who is in the NHS. GPs are highly trained professionals and if they refer, CAMHS should just see them. But there is insufficient resources/staff. So much for envy of the world and "best care". Gone are the days.

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  • Everyone needs to take a step back and understand the primary contractual point at which a GP can refer - is the point at which they feel they need extra help. That is all.

    There is no requirement for forms, thresholds and other markers to be met. It is for the local health services to make sure that services are commissioned to meet the above requirement. It also means that a referral cannot be declined if the GP thinks it meets the primary referral point, but does not meet any other made up criteria to accept a referral.

    Any forms or pre-referral steps are just optional. Should remain optional and should be at the goodwill of GPs. They should be incentivised - if you really want them done, but that incentive should again be totally optional.

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  • Forms are there to be barriers to treatment so that CAMHS don’t become even more overwhelmed than they already are. This boys death is a predictable consequence of this. There will be more.
    The next scandal is loss of essential risk information amongst the huge amounts of data collected and difficult to separate or distinguish between in electronic mental health records.

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