The Healthcare Safety Investigations Branch (HSIB) detail the findings of their second safety investigation

policy digest

28 / 08 / 2018

Investigation into the transition from child and adolescent mental health services to adult mental health services
Healthcare Safety Investigations Branch, July 2018

In their second full report into a breach of patient safety, the Healthcare Safety Investigations Branch (HSIB) detail the case of a patient who died by suicide after transitioning from child and adolescent mental health services (CAMHS) to adult mental health services (AMSS). Investigating and reporting without apportioning blame to either individuals or organisations, HSIB make a series of recommendations for trusts working in this area in order to try and prevent the same circumstances in future.

The report closely looks at the care given to the patient before and after the transition and details the specifics of the transition itself. Chiefly, the report finds that the transition was not planned in such a way as to ensure a seamless transition for the patient and this had a negative impact on the patient’s wellbeing. Having gathered together and analysed evidence provided by clinical and managerial staff at the trust in question, the report makes a series of observations about what might have contributed to this case. These include

  1. High workloads and difficulties coordinating staff made it difficult for CAHMS and AMHS to meet with the patient and his mother, thus inhibiting a smooth transition.
  2. A lack of consensus between frontline CAMHS staff and managers on the exact transition age. Staff felt a pressure to move young people from CAMHS to AMHS on turning 18 where trust managers believed staff should have the flexibility to work with people beyond 18 in some cases.
  3. Current commissioning arrangements meant that the patient required a referral to an AMHS service despite CAMHS staff determining that he would require ongoing treatment. A lack of clarity on which service would accept him made the transition even more difficult.
  4. The patient was not managed in line with the Care Programme Approach guidance. Had he been, there may have been more opportunities to review his care and consider what might help.
  5. The inability to properly recognise the escalating severity of the patient’s condition was probably due to the escalation taking place during the transition.

The report does make two positive observations; that the CAHMS accepted a GP referral for the patient aged 17 ½ and the AHMS accepted the patient despite the severity of his condition not appearing to be sufficient to meet the criteria for referral.

Drawing upon these findings HSIB make 6 key recommendations

  1. Within the long-term plan; NHS England works with partners to identify and meet the needs of young adults who have mental health problems but do not meet the current criteria for access to adult mental health services.
  2. NHS England require Clinical Commissioning Groups to demonstrate the budget identified for current children and young people’s services - those delivering care up to the age of 18 – is spent only on this group.
  3. NHS England and NHS Improvement ensure transition guidance, pathways or performance measures, require structured conversations to take place with the young person transitioning to access their readiness, develop their understanding of their condition and empower them to ask questions. NHS England and NHS Improvement must ensure the effectiveness is robustly evaluated.
  4. Within the long-term plan; NHS England requires services to move from aged based transition criteria towards more flexible criteria based on an individual’s needs.
  5. NHS England and NHS Improvement work with commissioners and providers of mental health services to ensure that the care of a young person before during and after transition is shared in line with best practice, including joint agency working.
  6. The Care Quality Commission extend its remit of its inspections to ensure the whole care pathway, from child and adolescent mental health services to adult mental health services, is examined.

The authors note that the findings and recommendations of this report have been circulated to NHS England, NHS Improvement and the Care Quality Commission. These organisations are expected to respond within 90 days and responses will be published on HSIB’s website.


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