Dear Ms Emma Serrano, Re: Regulation 28 Report to Prevent Future Deaths – Sky Louise Rollings, who died on 9 November 2019 Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 16 October 2021 concerning the death of Sky Louise Rollings on 9 November 2019. Firstly, I would like to express my deep condolences to Sky’s family. I note the recent inquest concluded Sky’s death was a result of misadventure contributed to by neglect. Following the inquest, you raised concerns in your Report to NHS England as follows:
1. During the inquest evidence was heard about the differences in the way CAMHS Hospitals and Adult Mental Health Hospitals approached the care of the patients on their wards. When hearing evidence during the inquest it was established that when a child turned 18, and was a patient on a mental health ward, once transferred to an adult Mental Health Hospital they would immediately be treated in accordance with the adult provisions.
2. It was accepted that there is no provision there is currently no one in-patient provision for people between the ages of 14-25. It was also accepted that simply because a child becomes 18 does not mean that they are an adult. The lack of this provision in a mental health in-patient setting leads me to conclude that there is a risk of further deaths resulting. In response to your first concern I can confirm that young people are not all automatically transferred at 18 year of age. Where it is feasible for their episode of National Medical Director and Interim Chief Executive, NHSI Skipton House 80 London Road London SE1 6LH 20 January 2022

care to be completed within the CYPMH (or CAMHS) unit safely and quickly, and with subsequent discharge into the community, this is often preferred and supported. I can confirm that NHS England and Improvement (NHSEI) is the responsible commissioner for specialised inpatient services for Tier 4 CAMHS patients up to the age of 18. The regional teams of NHS England and Improvement commission specialised services for inpatient Tier 4 CAMHS provision against the national service specification. The current specification for the type of service where Sky was treated is available here: tier-4-camhs-general
-adolescent-service-sp Discharge and admission planning processes are in place, and someone would not ‘immediately be treated in accordance with the adult provisions’. The development and clinical decision making in a young person’s care plan and discharge plan are considered by the young person’s current Tier 4 CAMHS provider’s clinical team. This includes multi-agency/ professionals e.g. social worker, community mental health services, the young person and their family’s views and again is individualised to each patient’s needs and circumstances. In Sky’s case – discharge planning and involvement of adult acute services and adult social worker and care coordinator commenced 6 months prior to her discharge date on 29 October 2019. It was noted that adult acute or adult PICU provision would need to be considered if a community placement was not able to meet SK’s needs. In response to your second concern, under the Current Mental Health Act 1983: section 131A states that “the patient’s environment in the hospital is suitable having regard to his age (subject to his needs)”. While it allows 16- and 17-year-olds to still be looked after on adult wards occasionally in exceptional circumstances, such as if they need to be admitted as an emergency, under-16s should not be being treated there. The Care Quality Commission (CQC) does not recommend admissions for under 18 years onto adult wards and every under 18 years admission onto an adult ward is reported as a SI. There are safeguarding concerns and implications that need to be taken into consideration in having young people under 18 years and those over 18 years on the same ward, which will usually mean requiring increased observations (which places additional pressure on staffing and can feel restrictive for young people themselves). Subsequently, from safeguarding perspective we would not be recommending inpatients wards 14-25 years of age as there are significant developmental differences between a 14 year old and 25 year old young person that would place vulnerable young people at risk (many of our CYPMH units have a disproportionately

high number of young people with autism and other neurodevelopmental needs in addition to their mental health needs). I have however reviewed the Trust response and I can see that they have commenced work with the partners relating to community transformation in social care and third sector CYP support to support the development of a 14-25 Transition (Preparing for Adulthood) service. I further note that the Trust plan for this service to align to the Good Mental Health Services for Young People (Royal College of Psychiatry, 2017) good practice paper.

This PFD report will be shared with Mental Health Trusts through the Regional Teams at NHS England and NHS Improvement as well as learning from the Trust plan.

Thank you for bringing these important patient safety issues to my attention and please do not hesitate to contact me should you need any further information.

Dear Mrs Serrano Regulation 28 Report – Prevent Future Deaths – Sky Louise Rollings During the course of the inquest for Sky Louise Rollings, the evidence revealed matters giving rise to concern. In my opinion, there is a risk that future deaths will occur unless action is taken. In the circumstances, it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows: (1) During the inquest, evidence was heard about the differences in the way CAMHS Hospitals and Adult mental Health Hospitals approached the care of the patients on their wards. When hearing evidence during the inquest, it was established that when a child turned 18, and was a patient on a Mental Health ward, once transferred to an adult Mental Health Hospital they would immediately be treated in accordance with the adult provisions. (2) It was accepted that there is no provision; there is currently no one in-patient provision for people between the ages of 14-25. It was also accepted that simply because a child becomes 18 does not mean that they are an adult. The lack of this provision in a mental health in-patient setting leads me to conclude that there is a risk of further deaths resulting. Trust responses to Matters of Concern Above (see appendix 1 for Action Plan) (1) The Trust has initiated a further review of the Transition of Young People to Adult Mental Health Service Policy following the inquest. The review will include the above concerns raised during the inquest relating to the transition from a young person’s inpatient facility to an adult mental health facility (which may include an adult mental health inpatient ward) Date: 16th December 2021

Emma Serrano, Area Coroner Stoke-on-Trent & North Staffordshire Coroner Stoke on Trent and North Staffordshire Stoke Town Hall, Kingsway, Stoke-on-Trent, ST4 1HH

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and the need to ensure appropriate reasonable adjustments are made in line with person centred care and that appropriate monitoring and escalation processes are robust and in place.

(2) Whilst the Trust acknowledges there is no in-patient provision for people between the ages of 14-25, as part of the Community Transformation agenda we have commenced work with the partners relating to community transformation in social care and third sector CYP support to support the development of a 14-25 Transition (Preparing for Adulthood) service. This service will seek to align to the Good Mental Health Services for Young People (Royal College of Psychiatry, 2017) good practice paper. The service seeks to improve the continuity of care provided to young people and their families as they undergo transition between services and improve understanding between services regarding thresholds of care and models of care, exploring and understanding the differences of intensity of support for young people and that of adults by ensuring appropriate person centred requirements and improving education/training for adult mental health services.

Please do not hesitate to contact me should you need any further information.