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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.’

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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.