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CAMHS won't see you now

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)

  • you do an urgent referral they get rejected, family take to A^E they get seen by cams. tells you all you need to know about the service. i send a referral letter with the form back with lots of IDK in them. pointless

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  • David Banner

    The GP here avoided criticism because they actually referred the patient. The constant stream of CAMHS rejecting our referrals leads to defeatism, meaning many GPs have stopped referring as it seems pointless. This is a deadly mistake, as we will stand responsible for any consequences. Keep referring, with a form or not, if you feel it is necessary, don’t be the fall guy. As these tragedies pile up the penny might drop and CAMHS will finally receive the investment it badly needs.

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  • It used to be a useful trick in my area to start the under 16s on an SSRi and then CAHMs would actually see them quickly to take them off it. It just shows how desperate the children's mental health provision is getting that the system had to be 'gamed' to get any sensible service.

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  • DrRubbishBin

    For every case like this where the CMHTs barriers to access has been specifically mentioned in a corner statement there are many many more that are not. The response from the CMHT is arrogant and lacking in insight. They propose 'training' for GPs to ensure they comply with their arbitrary referral process. Where is the evidence that these forms are safe? How much will this 'training' cost? Who will be paying for it? How often will it take place? Has a cost benefit analysis been done showing this is appropriate? Who will see the ill people who won't be seen because the GP is on a training course in CMHT administration? What about locums and temporary staff? If you require training in how to complete a referral form it is almost by definition a crap referral form. Someone needs to take them to court and sue them. This is awful and so wide spread it's a national issue but
    like so much of the primary-secondary care interface so common it's completely overwhelming

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  • I am personally going to report this Trust (oxymoron) to the CQC.

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  • They should never be allowed to reject a referral just because a box isn't ticked on a form. It's terrible this has happened and I hope all hospital trusts learn from this and stop the obsession with referral form box ticking

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  • |Eilidh Renwick | GP Partner/Principal|20 Aug 2019 11:02am
    "The system is broken. it will take more resources AND a change of attitude to sort it."

    Would you pay more tax to this government (who I assume you trust implicitly), in the hope that it gets to this service? If you simply want the govt to spend less on some things and spend more on others like this then sure, but we're broke, if you didn't know already, so if you want the government to borrow more/mortgage our kids futures, then you're simply kicking the problem down the line for them to deal with. The problem here is rationing, which is a unique problem that stems from unrestricted demand and dependency, and central planning.

    |MonkeyTyping | Locum GP|20 Aug 2019 3:25pm

    Its interesting you question the cost/effectiveness of the recommendations/policies here, yet swallow with no scepticism whatsoever, that of state-funded abortion policies. Why not be sceptical of everything that comes from the state?

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  • I think only named clinicians should be able to reject a GP referral.

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  • hide of a cow, hide of a cow, hide of a cow.
    any CCG GP who agreed to rejection of referral based on a form should fall other sword

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  • I work in Sheffield. The system is at faut not any individual. There needs to be a lot more money to allow this to be solved

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