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Teenager dies after GP mental health referral is rejected

A 16-year-old boy died by suicide after he was unable to access mental health services through CAMHS, despite being referred by his GP. 

A GP from a Milton Keynes practice referred 16-year-old Sam Grant to his local CAMHS service after he presented with irritability, anger, and a report that he was close to being excluded from school.

However, he did not meet the threshold of ‘moderate to severe’ mental health issues, and so was unable to access support from CAMHS.

Though his GP suggested other services that Mr Grant could voluntarily get in contact with, he did not access any of these and later died by suicide.

A coroner has called for a change to local mental health services following the death.

Coroner Elizabeth Gray said in a prevention of future deaths report: ‘CAMHS rejected the referral because Sam did not meet their threshold of moderate to severe mental health issues. CAMHS did not suggest any alternative assistance.

‘The GP did follow up with Sam to signpost him to two independent organisations who Sam would have to approach independently for help.’

She added: ‘The GP made it clear in his evidence that there is a lack of lower-level assistance for young people who present with “life issues” such as low mood, irritability and anger issues, but who nonetheless need help and assistance but do not meet the criteria for access to CAMHS services.’

The coroner recommended that action be taken to prevent future deaths under similar circumstances, and highlighted gaps within the local mental health provision.

These included a reduction in healthcare provision at Mr Grant’s school, and in particular the removal of a medically qualified person, meaning that health information is no longer shared between the school and GP surgery.

The coroner also said the GP did not know the boy had accessed COMPASS services through school referral, which would have enabled the GP and CAMHS to make better, fully informed decisions.

A spokesperson for NHS Milton Keynes CCG said: 'Our condolences go out to Sam’s family. We can confirm that a safeguarding review was undertaken following the very sad event of Sam’s death and commissioners have been working with mental health services providers to look at ways in which such an event can be prevented in future.

'Improvements in referral processes have since taken place to mitigate against tragic circumstances such as this happening in the future.'

It follows calls by a coroner to change the mental health referral form for CAMHS in Sheffield, following the death of a 15-year-old boy


Readers' comments (21)





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  • David Banner

    It has been stated many times by Pulse readers that children will have to die before the scandal that is CAMHS policy of rejecting most GP referrals (to reach their access targets) is exposed and condemned. There is zero pleasure in being proved so brutally right.

    But what really sticks in the craw is CAMHS “Crisis? What crisis?” stance. Instead of highlighting their chronic underfunding to deal with a huge increase in referrals (encouraged by decades of “increasing awareness” campaigns aimed at improving GP detection), CAMHS repeatedly claim they have everything under control, other than the annoyance of having to reject and divert 80% of “inappropriate” GP referrals. Hitting targets has superseded the proper assessment of suicidal children.

    If CAMHS can’t come clean about their rank inability to deal with workload, then those at the top need to be removed from their posts, and quickly.

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  • GP is to blame, bury the GP. That's what the system is about - only GPs are responsible and accountable - nobody else has accountability esp not the NHS Management with atheromas building in their fat and lazy arteries.

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  • Vinci Ho

    This is now becoming a ‘pattern’ , no matter what . My worry is people will try to use the new kid on the block namely , GP networks, PCNs , to get them out of jail . Rejection of GP referrals is also a social norm in NHS sleepwalking into more medical disasters at all levels . And I cannot see how Department of Health and Social Care can spin by saying how much money they had ‘invested’ mental health services to have an impact .
    Mr Hancock , I suppose you wanted to consult all your tech-advisors and AI fanatics to help you out on this one??

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  • Another one. More will come. Just blame the GP again. GPs are highly trained and do not like referring. I do not think any referrals should be blocked.

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  • I’m not sure a mental health service should be the right place for children to get help for feeling angry and upset. Surely this is best held somewhere else?
    Schools counsellor, parents etc.

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  • i work in one CCG where children under 18 have access to walk in clinics, on line services and anger management support, the one next door has nothing apart from cams who reject everything and you have to refer to a private charity for support for teenagers. in the first i can refer or the patient can self refer and parents have access to parenting classes and support, the other i send them to A^E where cams legally have to see them - if i am concerned. the system is broken. so can't wait to leave the NHS.

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  • If suicidal ideation is not 'moderate to severe', then what is?
    GPs correctly identify vague symptoms of 'unhappiness' and deteriorating relations with school, family, police, as signs of 'moderate to severe' difficulty, yet only when the patient is dead or raped do the secondary care teams accept there might be a significant problem - but it is cheaper for them to provide care if the patient is dead, so NHS wins, and workload stays down.

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  • ‘but it is cheaper for them to provide care if the patient is dead, so NHS wins, and workload stays down.’

    It is sad that I entertain the thought that someone in an office somewhere might have made such a calculation.

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  • I have always felt that with mental health referrals, you need to be perched on the bridge or have the noose around your neck before they consider it a crisis.

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  • Rejection of referrals by 'multidisciplinary teams' hiding behind 'policies and protocols' is too easy and risk-free for those making the decision.
    If rejections were approved by a doctor, who personally bore overall responsibility for the decision, things might be different. However, crown immunity for secondary care doctors probably reduces any feeling of vulnerability.

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  • I dont think a GP referral should ever be rejected. By all means offer use advise if you feel the patient my benefit from a different service. But an outright refusal to see is simply dangerous.

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  • My favourite recently was a letter from CAHMS psychiatrist. This man referred from you (GP) has ASPD.. depression, ADHD, lives in bail hostel with no close family and openly admitted he enjoyed hurting people. We have started him on Drug X and he has reported stability so I discharge him back to your care. Fabulous. Let’s chat about mindfulness shall we in ten mins.

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  • Poor boy- abandoned and became so low he took his own life.

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  • Child mental health has become and area of extreme concern CAHMS have so few workers they are having to consistently raise the bar which is excluding many more vulnerable children
    This Cinderella service is definitely failing to represent the best interest of children who are then turning to drugs THe GP is expected to fill the gaps

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  • Took Early Retirement

    I'd like to know who commissioned these rubbish services and who allowed them to set their own terms?

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  • This is a tragic story but I read the comments above and really wish doctors would stop the 'blame' culture. All doctors are working in a system stretched to breaking point. I don't think that slating our colleagues is ever helpful. The NHS is overstretched. There isn't enough money. In general the GP's I know are doing the best they can and I believe that is the same in CAMHS. The system may be broken but let's support our colleagues. Slating other healthcare professionals is not where our energy should be directed.

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  • If you can’t afford to see someone privately then you’re stuffed. This is speaking from both personal and professional experience.

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  • Having a noose around your neck is not enough. I had a young man dangling by his neck, from a noose, and cut down by his girlfriend. 'Are you sure this requires our service...' I was told. After police and ambulance refused to take him to hospital.

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  • My local CAMHS (18 month waiting list)have some clever tricks

    1 Any referral not made on DXS is rejected.
    2 They don't let us know that the referral is rejected.
    3 The DXS referrals are also rejected as it is the wrong DXS referral form that you are taken to on the prompt

    I now do the correct DXS referral with the parent/s present. I suggest that they ring CAMHS once a week for the first 4 weeks and every day thereafter. They are to refuse any request to go back to the GP as I forewarn them of that old tactic.

    I don't like to be difficult but action is needed to highlight this disastrous service.

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