“My concern in this case is that a vulnerable young person can be known to the County…”
Dated 16 Feb 2022, from the coroner for Cambridgeshire and Peterborough. Sent to 2 organisations or people.
A coroner wrote this report after an inquest, to warn the organisations below about a risk of further deaths.
The 56-day response deadline
Deadline passedReplies were due by 13 Apr 2022. A reply may have been sent and not yet published.
Organisations 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.
- Report dated16 Feb 2022
- Deadline13 Apr 2022
- Published on judiciary.uk21 Feb 2022
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Cambridgeshire and Peterborough NHS Foundation Trust | Deadline passedNo response published on judiciary.uk so far. The 56-day deadline was 13 Apr 2022. A reply may have been sent and not yet published. |
| Cambridgeshire County Council | Deadline passedNo response published on judiciary.uk so far. The 56-day deadline was 13 Apr 2022. A reply may have been sent and not yet published. |
The coroner’s concerns
– My concern in this case is that a vulnerable young person can be known to the County Council and Mental Health Trust and yet not receive the support they need pending substantive treatment. Danny was repeatedly assessed as not meeting the criteria for urgent intervention and yet the waiting list for psychological therapy was likely to be over a year from point of first presentation. That gap between urgent and non-urgent services is potentially dangerous for a vulnerable young person, where there is a chronic risk of an impulsive act. I understand that there is a long term plan to extend young people’s services to age 25, but I remain concerned about the ongoing situation, and that a young person today could be faced with the same challenges in finding support pending substantive treatment. I believe this concern is the combined responsibility of Cambridgeshire County Council and CPFT. These organisations may wish to consult in preparing their response to this report. The inquest heard evidence about the considerable delay in obtaining appointments for the Gender Identity Clinic, and about the shortage of availability for psychological therapies such as CBT. These are matters for policy and funding. This report will therefore be copied to NHS England and The Secretary of State for Health for information purposes only.
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, 2022-0047
- Added to Minute Book
- 8 Oct 2026
- Reuse
- We show short extracts and link to the original. We don’t host the full report.
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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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