Recurance · prevention of future deaths reports
Pre-inquest brief
Inadequate transition pathway from CAMHS to adult services
The earlier warning
Daisy French · 9 Nov 2017 · Louise Slater, South Yorkshire (West)
“During the course of the inquest the evidence revealed matters giving raise to concern. The MATTER OF CONCERN for the Secretary of State to consider is as follows:”
judiciary.uk/prevention-of-future-death-reports/daisy-french
What was promised
Stated action 1 · response to Daisy French (9 Nov 2017) · stated timescale: none stated
“SC NHS FT will work with local commissioners on the benchmarking exercise”
judiciary.uk/…/2017-0264-Response-by-Sheffield-Health-and-Socia…
Stated action 2 · response to Daisy French (9 Nov 2017) · stated timescale: January 2018
“the NHS in Sheffield has taken a number of measures to address the concerns raised. This includes training for staff on transitions; the opening of a Section 136 suite at Sheffield Children's Hospital; and the employment of a Mental Health Liaison Consultant to commence in January 2018. In addition, an information sharing agreement is to be drawn up between NHS organisations in Sheffield.”
judiciary.uk/…/2017-0264-Response-by-Department-of-Health.pdf
What recurred
- 12 Aug 2025 · Chloe Barber · Paul Marks · Closely related · confidence 0.90 (high)
The clearest link, quoted from both reports:
Earlier · Daisy French · 9 Nov 2017
“During the course of the inquest the evidence revealed matters giving raise to concern. The MATTER OF CONCERN for the Secretary of State to consider is as follows:”
Later · Chloe Barber · 12 Aug 2025
“Evidence was heard at inquest from several expert witnesses that concern exists and continues to exist nationwide that there is not necessarily any clearly defined pathway that assists young persons making the transition between Childhood and Adolescent Mental Health Service (CAMHS) and adult psychiatric services,”
What happened next
No web check of the stated actions has been published for this chain.