Long delays in mental health services are putting children’s lives at risk, a coroner has warned after the death of a 14-year-old who took their own life while waiting for help.
Sailor Court was referred for treatment by their GP and school while battling low moods, but was told the wait for just the initial appointment was likely to be more than a year.
The teenager was hospitalised after self-harming during the delay, and was then told treatment would not start for another ten months.
Sailor died from an overdose of prescription medication in September 2021, while still on the waiting list for mental health treatment.
Coroner Sebastian Naughton concluded Sailor’s death was suicide and issued a report slamming “unacceptably long” delays in the system.
He called for urgent action to prevent further child deaths, and warned that the situation appears to have got worse rather than better since Sailor’s death.
“The anticipated waiting times before Sailor’s assessment (approximately one year) was unacceptably long”, he said.
“The length of time before treatment could be delivered thereafter (approximately 10 months) was unacceptably long.
“The court heard evidence that the waiting times for assessment and treatment have not improved since Sailor’s death, and in fact both have significantly increased. This means that a teenager referred today into the CAMHS could be waiting for around/upwards of two years before they receive treatment. This is an unacceptably long delay.”
The coroner set out how Sailor, who was non-binary, was put on a waiting list for treatment in the Community Child and Adolescent Mental Health Service (CAMHS), under South London and Maudsley NHS Foundation Trust in October 2020, at the age of 13.
“The referral was accepted in November 2020. Sailor was advised that the waiting time for the mental health assessment appointment would approximately one year, in November 2021.
“In fact, after an episode of self-harm in mid-2021 and the intervention of the CAMHS crisis team, the assessment due to take place in around November 2021 was superseded by an earlier assessment in mid-2021, and on 20 August 2021 Sailor and their parents were advised that Sailor had been added to the list for and treatment which at that time was approximately ten months.”
Sailor was found dead in their bedroom at home by their parents, having taken an overdose of prescription medication.
The inquest was told the Trust has tried to fix the problem with a team in charge of monitoring the waiting list to try to fast-track urgent cases.
But the coroner said he is “not re-assured” that the team of three staff members, handling a waiting list of over a thousand, could “realistically and/or safely assess or re-prioritise those on the waiting list in most urgent need of assessment or treatment”.
“The court heard evidence that the long waiting lists were a result of a lack of resources which has not kept pace with significantly increased (and increasing) demand”, the coroner added.
NHS England, which responded to the coroner’s report, accepted child mental health services are facing “significant demand”, and said there has been additional funding.
The body added that South London and Maudsley NHS Foundation Trust has put additional money into its services, and it is “undertaking a quality improvement collaborative to increase the percentage of young people receiving their first contact within 28 days”.
