Caitlin Imber
PFD Report
All Responded
Ref: 2025-0538
All 1 response received
· Deadline: 19 Dec 2025
Coroner's Concerns (AI summary)
CAMHS closed a referral for a vulnerable child due to missing contact information without making further enquiries, causing a significant and potentially dangerous delay in support.
View full coroner's concerns
The MATTER OF CONCERN is as follows. –
On the 9th of May 2022, CAMHS received a referral from a community paediatrician dated the 19th of April 2022. This identified the need for support care and treatment to be provided to a traumatized, vulnerable child, however as the referral did not contain any contact numbers, the referral was closed without any additional enquiries being made to further the matter.
A further referral was received on the 31st of May 2022 and was then accepted by CAMHS, representing a delay of 42 days from the original paediatrician’s referral to any action being taken.
Whilst this was not contributory to Caiti’s death, I am concerned by the apparent lack of effort to locate missing information and progress a referral and I consider that if this situation continues to prevail, then there is a risk that future deaths could occur.
On the 9th of May 2022, CAMHS received a referral from a community paediatrician dated the 19th of April 2022. This identified the need for support care and treatment to be provided to a traumatized, vulnerable child, however as the referral did not contain any contact numbers, the referral was closed without any additional enquiries being made to further the matter.
A further referral was received on the 31st of May 2022 and was then accepted by CAMHS, representing a delay of 42 days from the original paediatrician’s referral to any action being taken.
Whilst this was not contributory to Caiti’s death, I am concerned by the apparent lack of effort to locate missing information and progress a referral and I consider that if this situation continues to prevail, then there is a risk that future deaths could occur.
Responses
Action Taken
CAMHS has changed its standard operating procedure to offer appointments even when contact numbers are missing from referrals, and is undertaking an audit to confirm these changes are embedded in practice. The learning from the inquest is planned to be shared via the Regional CAMHS Forum. (AI summary)
CAMHS has changed its standard operating procedure to offer appointments even when contact numbers are missing from referrals, and is undertaking an audit to confirm these changes are embedded in practice. The learning from the inquest is planned to be shared via the Regional CAMHS Forum. (AI summary)
View full response
Dear Mr Gittins,
Inquest of Caitlin Rachel Imber
I am writing in response to the Regulation 28 Report to Prevent Future Deaths (PFD) dated 24 October 2025, issued by yourself to Betsi Cadwaladr University Health Board, following the inquest touching the death of Caitlin Rachel Imber.
I would like to begin with offering my deepest condolences to Caitlin’s loved ones.
In the notice, you highlighted your concern that a referral to Child and Adolescent Mental Health Services (CAMHS) from a community paediatrician identified the need for care and treatment to be provided, however as the referral did not contain any contact numbers, the referral was closed without any additional enquiries being made to further the matter. A further referral was then received which was accepted by CAMHS, representing a delay of 42 days from the original paediatrician’s referral to any action being taken. You found this was not contributory to Caitlin’s death but were concerned at the apparent lack of effort to locate missing information and progress a referral and considered that if this situation continues to prevail, then there is a risk that future deaths could occur.
In response to the notice, we have given this significant consideration.
I can confirm that CAMHS have changed their standard operating procedure, and an appointment is now offered even where contact numbers are not provided. This change was made following completion of the investigation and ensures all referrals receive an appointment.
The service is also undertaking an audit to confirm the changes that have been made are embedded in practice.
The learning from the inquest is planned to be shared via the Regional CAMHS Forum, supporting learning across our services.
In addition, your notice has been shared through our Reducing Avoidable Mortality Group, chaired by the Associate Medical Director (Mortality) and attended by senior medical staff and clinicians from all our divisions. All PFD notices are shared through this group to support learning across the Health Board.
Dyddiad / Date: 19 December 2025 Mr John Gittins HM Senior Coroner for North Wales (East & Central) County Hall Wynnstay Road Ruthin LL15 1YN Bloc 5, Llys Carlton, Parc BusnesLlanelwy, Llanelwy, LL17 0JG
---------------------------------- Block 5, Carlton Court, St Asaph Business Park, St Asaph, LL17 0JG
I hope this letter sets out for you the actions we have taken to ensure the concerns raised by yourself are being addressed and mitigated.
We would be happy to meet with you and discuss our plans in more detail, or provide further information and assurance should that be helpful.
Once again, I offer my deepest condolences to Caitlin’s loved ones for their loss.
Inquest of Caitlin Rachel Imber
I am writing in response to the Regulation 28 Report to Prevent Future Deaths (PFD) dated 24 October 2025, issued by yourself to Betsi Cadwaladr University Health Board, following the inquest touching the death of Caitlin Rachel Imber.
I would like to begin with offering my deepest condolences to Caitlin’s loved ones.
In the notice, you highlighted your concern that a referral to Child and Adolescent Mental Health Services (CAMHS) from a community paediatrician identified the need for care and treatment to be provided, however as the referral did not contain any contact numbers, the referral was closed without any additional enquiries being made to further the matter. A further referral was then received which was accepted by CAMHS, representing a delay of 42 days from the original paediatrician’s referral to any action being taken. You found this was not contributory to Caitlin’s death but were concerned at the apparent lack of effort to locate missing information and progress a referral and considered that if this situation continues to prevail, then there is a risk that future deaths could occur.
In response to the notice, we have given this significant consideration.
I can confirm that CAMHS have changed their standard operating procedure, and an appointment is now offered even where contact numbers are not provided. This change was made following completion of the investigation and ensures all referrals receive an appointment.
The service is also undertaking an audit to confirm the changes that have been made are embedded in practice.
The learning from the inquest is planned to be shared via the Regional CAMHS Forum, supporting learning across our services.
In addition, your notice has been shared through our Reducing Avoidable Mortality Group, chaired by the Associate Medical Director (Mortality) and attended by senior medical staff and clinicians from all our divisions. All PFD notices are shared through this group to support learning across the Health Board.
Dyddiad / Date: 19 December 2025 Mr John Gittins HM Senior Coroner for North Wales (East & Central) County Hall Wynnstay Road Ruthin LL15 1YN Bloc 5, Llys Carlton, Parc BusnesLlanelwy, Llanelwy, LL17 0JG
---------------------------------- Block 5, Carlton Court, St Asaph Business Park, St Asaph, LL17 0JG
I hope this letter sets out for you the actions we have taken to ensure the concerns raised by yourself are being addressed and mitigated.
We would be happy to meet with you and discuss our plans in more detail, or provide further information and assurance should that be helpful.
Once again, I offer my deepest condolences to Caitlin’s loved ones for their loss.
Sent To
- BCUHB
Response Status
Linked responses
1 of 1
56-Day Deadline
19 Dec 2025
All responses received
About PFD responses
Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Report Sections
Investigation and Inquest
On the 19th of December 2022 I commenced an investigation into the death of Caitlin Rachel Imber (“Caiti”) (DOB 23.3.06 DOD 13.12.22). The investigation concluded at the end of the inquest on the 17th of October 2025. The cause of death was recorded as being due to 1(a) Hanging and the conclusion of the inquest was the following narrative:
Around the age of fourteen, Caitlin Imber ('Caiti') fell prey to the and criminal exploitation, which despite parental support led to numerous episodes of her going missing and recreational drug use. As a result of this behaviour it became necessary for the local authority to play their part in seeking to keep Caiti safe, and in March 2022, she was placed at a residential home For the first five or six months of her placement, Caiti largely thrived in this environment, although understandably, she remained significantly traumatized by her previous experiences and as a consequence at the end of August she was appropriately provided with medication, namely sertraline, primarily intended to aid her sleeping. Both the dosage and associated risks of this medication were properly managed, however the anticipated benefits of the same did not materialize. In the Autumn and early Winter of 2022, coinciding with the increased freedoms available to Caiti as a result of her choosing to no longer further her studies in-house, Caiti's mental health deteriorated. Despite this she did not give any significant indications of an intention to self-harm, instead presenting at times as both a typical moody teenager and the child which she still was, excited at the prospect of the coming Christmas. On the 11th of December 2022, unbeknown to those caring for her, Caiti gave an indication to another resident of a wish to harm herself, and whilst she had been upset during the evening of the 12th of December, her presentation did not demonstrate any real and immediate risk to her life. After retiring to her bedroom, Caiti resulting in her death which was confirmed on the morning of the 13th of December 2022. Whilst it is not possible from the available evidence to positively establish Caiti's intention by her actions, it is probable that she did not intend to end her life.
Around the age of fourteen, Caitlin Imber ('Caiti') fell prey to the and criminal exploitation, which despite parental support led to numerous episodes of her going missing and recreational drug use. As a result of this behaviour it became necessary for the local authority to play their part in seeking to keep Caiti safe, and in March 2022, she was placed at a residential home For the first five or six months of her placement, Caiti largely thrived in this environment, although understandably, she remained significantly traumatized by her previous experiences and as a consequence at the end of August she was appropriately provided with medication, namely sertraline, primarily intended to aid her sleeping. Both the dosage and associated risks of this medication were properly managed, however the anticipated benefits of the same did not materialize. In the Autumn and early Winter of 2022, coinciding with the increased freedoms available to Caiti as a result of her choosing to no longer further her studies in-house, Caiti's mental health deteriorated. Despite this she did not give any significant indications of an intention to self-harm, instead presenting at times as both a typical moody teenager and the child which she still was, excited at the prospect of the coming Christmas. On the 11th of December 2022, unbeknown to those caring for her, Caiti gave an indication to another resident of a wish to harm herself, and whilst she had been upset during the evening of the 12th of December, her presentation did not demonstrate any real and immediate risk to her life. After retiring to her bedroom, Caiti resulting in her death which was confirmed on the morning of the 13th of December 2022. Whilst it is not possible from the available evidence to positively establish Caiti's intention by her actions, it is probable that she did not intend to end her life.
Circumstances of the Death
The circumstances of the death are in accordance with the narrative conclusion above.
Coroner's Office, County Hall, Wynnstay Road, Ruthin, LL15 1YN Tel 01824 708047 |
Coroner's Office, County Hall, Wynnstay Road, Ruthin, LL15 1YN Tel 01824 708047 |
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.