A London coroner has warned the health secretary that preventable child suicides are likely to increase unless the government provides more funding for mental health services.
Nadia Persaud, the east London area coroner, told Steve Barclay that the suicide of Allison Aules, 12, in July 2022 highlighted the risk of similar deaths “unless action is taken”.
In a damning prevention of future deaths report addressed to Barclay, NHS England and two royal colleges, Persaud said the “under-resourcing of CAMHS [child and adolescent mental health services] contributed to delays in Allison being assessed by the mental health team”.
An inquest into Allison’s death last month found that a series of failures by North East London NHS foundation trust (NELFT) contributed to her death.
In her report, Persaud said delays and errors that emerged in the inquest exposed wider concerns about funding and recruitment problems in mental health services.
“The failings occurred with a children and adolescent mental health service which was significantly under-resourced. Under-resourcing of CAMHS services is not confined to this local trust but is a matter of national concern,” she said.
The inquest heard that Allison’s mood changed completely during the Covid lockdown. She was referred by her school to NELFT for help in May 2021 over concerns about evidence of self-harm, low mood, anxiety and bed-wetting. But she was not assessed for nine months and was never seen in person by the service.
Persaud’s report said: “The inquest heard evidence that this delay is not unusual within CAMHS teams across the country.” Persaud said there was little evidence that any consultant psychiatrist was in charge of the team, and noted difficulties in recruiting qualified psychiatrists.
The inquest also heard that Allison was inappropriately discharged weeks before her death after input from a management team tasked with clearing a backlog of cases that had built up since the pandemic.
The coroner said funding of CAMHS was poor at a time when the service in the region was facing 140 referrals of children and adolescents each week, up from 10 to 12 in the 2010s.
“There is a concern that ongoing under-resourcing of CAMHS services (while demand continues to increase) will result in similar future deaths,” Persaud said. “In my opinion there is risk that future deaths could occur unless action is taken.”
Barclay has until 25 October to respond. Under the Coroners and Justice Act 2009, as recipients of such a report, Barclay and the NHS must set out details of action taken or proposed to be taken to prevent similar deaths in future. The response must also set out a timetable for action. Persaud’s report reminded Barclay that if no action is proposed, he must explain why.
A spokesperson for the Department for Health and Social Care said: “Our sympathies go out to Allison’s family. We’re continuing to invest in mental health services for children and young people with an additional £2.3bn a year on overall mental health services by 2024. This will mean an additional 345,000 children and young people will be able to access NHS-funded mental health support, including through the vital mental health support teams we are rolling out to schools and colleges across the country. We are carefully considering the coroner’s recommendations and will respond within the required timeframe.”
A copy of the report, which was also addressed to the Royal College of Paediatrics and Child Health and the Royal College of Psychiatrists, will be sent to the Care Quality Commission, the regulator.
• In the UK and Ireland, Samaritans can be contacted on freephone 116 123, or email jo@samaritans.org or jo@samaritans.ie. In the US, you can call or text the National Suicide Prevention Lifeline on 988, chat on 988lifeline.org, or text HOME to 741741 to connect with a crisis counsellor. In Australia, the crisis support service Lifeline is 13 11 14. Other international helplines can be found at befrienders.org
