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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)

  • I just got another 2 CAMHS referrals rejected. I am so used to it. Another case I did not even bother to refer; I just ask mum to take her to A/E. She mentioned about suicidal ideation. Straight to a/E. Our Crisis team is hopeless. Sorry A/E team. I had no choice. The system is broken. I don’t want death in my hands.

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  • There is also a problem with the demand side, ie what is the threshold that anxious parents and schools reckon that a given moody teenager has a 'mental health issue' . This is now exceedingly low. Combine this with the open ended urging by 'awareness charities' to go see your GP and the demand becomes basically infinity.

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  • Trefor roscoe | Locum GP20 Aug 2019 10:27pm

    There is nothing stopping YOU from donating all your money to 'solve' this. That is, if you're happy to trust a middle man/the state, to effectively solve this for you.

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  • DrRubbishBin

    Christopher Ho | GP Partner/Principal21 Aug 2019 1:30am
    for gods sake Christopher shut up

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  • Vinci Ho

    I deliberately wait to read your comments before writing anything. The problem is indeed pervasive and omnipresent in NHS and this case represents only a tip of the iceberg . I certainly have a collection of cases where my referrals were rejected because either information was so called not enough but more frequently, an ‘inappropriate’ referral . Ultimately, the child and family are shuffled to different service providers and there is a lack of coordination and organisation, in my opinion . Time was consumed unnecessarily which appeared to be paramount in this case . It is an issue of rationing but also a matter of safety of these children and their family . I am sure we are not the only country under whatever health system , which has to face this potentially dangerous health issue . The world is unsafe , at present time , and is certainly not a happy one . We have to protect my children and youngsters. This government, once again as I wrote before , have a big decision to make .....

    PS please send in more comments. We have not had an article with more than 100 comments for a while.

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  • |MonkeyTyping | Locum GP|21 Aug 2019 8:32am

    Christopher Ho | GP Partner/Principal21 Aug 2019 1:30am
    for gods sake Christopher shut up

    LOL An excellent, concise, reasoned argument made there. I'm glad I got a rise out of you.

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  • Vinci- Without wanting to brown-nose you write some brilliant and well thought out comments on here. Have you considered politics?

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  • Dear All
    Just been through the same argument with our local CAMHS. In fact the Consultant was very understanding, took my point that i had satisfied my legal and professional responsibilities under GMC rules 15(c) and 22 by writing my referral letter. I did not need to do anything else.
    i also pointed out that the rejection of the referral was in fact a clinical decision made about the management of a patient and therefore the clinician who made the decision, or under who's delegation the decision was made, needed to be named on the rejection letter.
    Paul C

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  • Paul C
    That doesn’t help the patient or parents though.

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  • Good for the Coroner. A year ago I referred a child to CAMHS. I was contacted by a CAMHS team member who congratulated me for the information provided in the referral form, however, the referral was declined as I had not seen the child face to face. She didn’t want to come for a review appointment and only her mum attended. I had met both of them before.
    I think I lost it a bit when they declines d the referral. I said that I wasn’t going to waste more time with this referral and that I refused to take responsibility for anything that could have happened to the patient. We agreed to disagree and at the end I said that it would be for a Coroner to apportion blame.
    At the end, CAMHS contacted mum on the phone and we received a complaint as the team member had required counselling and support. We were offered a meeting with them to discuss referral procedures and cooperation. We declined. We thought it would be better for them to use their time meeting patients than us!!

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