Locket Williams
14 Oct 2024 · Coroner Richard Travers · Surrey
The coroner's concerns
1. no psychiatric in-patient beds for children in Surrey
“at the time of [the deceased]'s death, there were no psychiatric in-patient beds available for children in Surrey”
2. underestimation of suicide risk
“[the deceased]'s death was contributed to by the Trust's underestimation of their risk of suicide”
3. substitution of 'distress' for 'suicide' in safety plans
“some plans may not refer to suicide and may not therefore ensure that the nature of the risk is clearly conveyed”
4. lack of staff attendance at core group meetings
“staff within CAMHS did not always attend or engage with Core Group Meetings”