On 2 October 2012 I commenced an investigation into the death of Shannon Kimberley Gee aged 16 years. The investigation concluded at the end of a four day inquest on 29 January 2015. I made a determination that Shannon died as the result of an Accident.

Shannon was recognised as a Child in Need. Intervention by Social Care had been considered but instead her case was referred to the Children and Adolescents Mental Health Team (CAMHT.) It was identified that a large part of Shannon’s difficulties related to the fact that both her parents suffered from mental health issues. For the purposes of this letter it is the position of Mrs Gee that is relevant. The inquest heard from currently the Acting Clinical Lead for OSW. A copy of her statement is enclosed and your attention is drawn to paragraph one on page two. Of note: ‐ Due to the non-receipt of notes and records that had been requested in other cases OSW no longer routinely requested such information from CMHT; ‐ There was a gap in the provision of mental health services in that (and others) were deemed too ill for OSW yet too well for CMHT. This resulted in a stand-off and the patient not being treated as a consequence. It is right to acknowledge that the two organisations have recognised the less than desirable state of affairs. At inquest I was told that since October 2014 a four-stage process has been put in place for determining any such clinical disputes with decision-making ultimately lying with the Kernow Clinical Commissioning Group. Another witness, (no relation) told me she had experience of patients who had been through the process which she said had taken ‘weeks’ to resolve.