This site is intended for health professionals only

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



Visit Pulse Reference for details on 140 symptoms, including easily searchable symptoms and categories, offering you a free platform to check symptoms and receive potential diagnoses during consultations.