“As I made clear during the Inquest I was concerned about the adequacy of the CAMHS, GP…”
Dated 24 May 2019, from the coroner for South Yorkshire West. Sent to 1 organisation or person.
A coroner wrote this report after an inquest, to warn the organisations below about a risk of further deaths.
The 56-day response deadline
All responses publishedOrganisations that receive a report must reply to the coroner within 56 days, saying what they will do or why they will do nothing. We show whether a response is published on judiciary.uk; a reply may have been sent and not yet published.
- Report dated24 May 2019
- Deadline19 Jul 2019
- Published on judiciary.uk14 Aug 2019
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Sheffield Children's NHS Foundation TrustNamed in the report as “Sheffield Children’s NHS Trust” | Response publishedPublished on judiciary.uk in August 2019. |
Some responses were published as scans, so their text was read automatically. Check the wording against the original before you quote it.
The coroner’s concerns
– 1. As I made clear during the Inquest I was concerned about the adequacy of the CAMHS, GP referral form. , Noah’s GP, was inexperienced she had not completed a CAMHS referral form before. She accepted that she had not provided sufficient detail in the form. This resulted in CAMHS being unable to assess Noah’s risk and declining Noah’s referral. This in turn meant that Noah did not receive an appointment with CAMHS before his death. The Trust’s investigation report stated that the evidence “suggests that the current referral form does not capture the information required to process referrals without delay.” , CAMHS Clinical Lead, said that there had not been any other problems with the form with GP’s not completing them sufficiently. I am not sure how is able to be so confident about this. I was told that redesigning the form had been considered by the Trust but was told that this was not the answer. Instead, further training has been provided to GPs within the area. Guidance is attached to the form to assist GPs in completing the form. Having carefully considered the evidence I am not satisfied that steps have been put in place to ameliorate the risk identified. Given the realities of the pressures on a GP’s day expecting a GP to use their 10 minute appointment to extract sufficient information for the referral and then at some point complete a referral form, with which they may be unfamiliar, creates the risk that relevant information may not be provided. I would invite the Trust to reconsider whether the form could be improved to reduce the risk of inadequate or insufficient information being provided which may result in a delay in care.
An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.
- Source
- judiciary.uk, Prevention of Future Deaths reports, 2019-0186
- Added to Minute Book
- 8 Oct 2026
- Reuse
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Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0
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