“Sam’s GP referred Sam to CAMHS when he presented to the GP with irritability, anger and a…”

The coroner’s concerns

1) Sam’s GP referred Sam to CAMHS when he presented to the GP with irritability, anger and a report that he was close to being excluded from school. CAMHS rejected the referral because Sam did not meet their threshold of moderate to severe mental health issues. CAMHS did not suggest any alternative assistance. The GP did follow up with Sam to sign post him to two independent organisations who Sam would have to approach independently for help. The GP made it clear in his evidence that there is a lack of lower level assistance for young people who present with ‘life issues’ such as low mood, irritability and anger issues, but who nonetheless need help and assistance but do not meet the criteria for access to CAMHS services. 2) Sam had been referred to, and was receiving the services of COMPASS having been referred by his School. The GP was not made aware of this engagement and was unable to take this into account at the time when Sam did present himself to the GP. The evidence from COMPASS is that they maintain the confidentiality of patients even minors using their services unless they have express consent to disclose that information from the patient themselves. Without all relevant information neither the GP nor CAMHS was in a position to make a fully informed decision about the Sam’s needs. Sharing of information between relevant health agencies to ensure fully informed decisions are made as regards the healthcare needs of an individual should be a priority. 3) Evidence at the inquest from the GP also indicated that a reduction in healthcare provision at Sam’s school and in particular the removal of a medically qualified person(s) has meant that confidential health information is no longer shared between the school and the GP surgery. The school now only engages First Aiders, who are not medically qualified, and who do not therefore exchange information which in the past has proved essential in flagging concerns between the GP and the School. This is another route which has been closed and which would have allowed a potential flag to have been raised in respect of concerns around Sam and his wellbeing to be shared confidentially between GP and school. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you (and/or your organisation) have the power to take such action. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 20th September 2019. I, the Assistant Coroner, may extend the period.

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, 2019-0285

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8 Oct 2026

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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