Betsi Cadwaladr University Health Board
NHS / Health Body
Action Taken
CAMHS has changed its standard operating procedure to offer appointments even when contact numbers are missing from referrals, and is undertaking an audit to confirm these changes are embedded in practice. The learning from the inquest is planned to be shared via the Regional CAMHS Forum. (AI summary)
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Dear Mr Gittins,
Inquest of Caitlin Rachel Imber
I am writing in response to the Regulation 28 Report to Prevent Future Deaths (PFD) dated 24 October 2025, issued by yourself to Betsi Cadwaladr University Health Board, following the inquest touching the death of Caitlin Rachel Imber.
I would like to begin with offering my deepest condolences to Caitlin’s loved ones.
In the notice, you highlighted your concern that a referral to Child and Adolescent Mental Health Services (CAMHS) from a community paediatrician identified the need for care and treatment to be provided, however as the referral did not contain any contact numbers, the referral was closed without any additional enquiries being made to further the matter. A further referral was then received which was accepted by CAMHS, representing a delay of 42 days from the original paediatrician’s referral to any action being taken. You found this was not contributory to Caitlin’s death but were concerned at the apparent lack of effort to locate missing information and progress a referral and considered that if this situation continues to prevail, then there is a risk that future deaths could occur.
In response to the notice, we have given this significant consideration.
I can confirm that CAMHS have changed their standard operating procedure, and an appointment is now offered even where contact numbers are not provided. This change was made following completion of the investigation and ensures all referrals receive an appointment.
The service is also undertaking an audit to confirm the changes that have been made are embedded in practice.
The learning from the inquest is planned to be shared via the Regional CAMHS Forum, supporting learning across our services.
In addition, your notice has been shared through our Reducing Avoidable Mortality Group, chaired by the Associate Medical Director (Mortality) and attended by senior medical staff and clinicians from all our divisions. All PFD notices are shared through this group to support learning across the Health Board.
Dyddiad / Date: 19 December 2025 Mr John Gittins HM Senior Coroner for North Wales (East & Central) County Hall Wynnstay Road Ruthin LL15 1YN Bloc 5, Llys Carlton, Parc BusnesLlanelwy, Llanelwy, LL17 0JG
---------------------------------- Block 5, Carlton Court, St Asaph Business Park, St Asaph, LL17 0JG
I hope this letter sets out for you the actions we have taken to ensure the concerns raised by yourself are being addressed and mitigated.
We would be happy to meet with you and discuss our plans in more detail, or provide further information and assurance should that be helpful.
Once again, I offer my deepest condolences to Caitlin’s loved ones for their loss.
Inquest of Caitlin Rachel Imber
I am writing in response to the Regulation 28 Report to Prevent Future Deaths (PFD) dated 24 October 2025, issued by yourself to Betsi Cadwaladr University Health Board, following the inquest touching the death of Caitlin Rachel Imber.
I would like to begin with offering my deepest condolences to Caitlin’s loved ones.
In the notice, you highlighted your concern that a referral to Child and Adolescent Mental Health Services (CAMHS) from a community paediatrician identified the need for care and treatment to be provided, however as the referral did not contain any contact numbers, the referral was closed without any additional enquiries being made to further the matter. A further referral was then received which was accepted by CAMHS, representing a delay of 42 days from the original paediatrician’s referral to any action being taken. You found this was not contributory to Caitlin’s death but were concerned at the apparent lack of effort to locate missing information and progress a referral and considered that if this situation continues to prevail, then there is a risk that future deaths could occur.
In response to the notice, we have given this significant consideration.
I can confirm that CAMHS have changed their standard operating procedure, and an appointment is now offered even where contact numbers are not provided. This change was made following completion of the investigation and ensures all referrals receive an appointment.
The service is also undertaking an audit to confirm the changes that have been made are embedded in practice.
The learning from the inquest is planned to be shared via the Regional CAMHS Forum, supporting learning across our services.
In addition, your notice has been shared through our Reducing Avoidable Mortality Group, chaired by the Associate Medical Director (Mortality) and attended by senior medical staff and clinicians from all our divisions. All PFD notices are shared through this group to support learning across the Health Board.
Dyddiad / Date: 19 December 2025 Mr John Gittins HM Senior Coroner for North Wales (East & Central) County Hall Wynnstay Road Ruthin LL15 1YN Bloc 5, Llys Carlton, Parc BusnesLlanelwy, Llanelwy, LL17 0JG
---------------------------------- Block 5, Carlton Court, St Asaph Business Park, St Asaph, LL17 0JG
I hope this letter sets out for you the actions we have taken to ensure the concerns raised by yourself are being addressed and mitigated.
We would be happy to meet with you and discuss our plans in more detail, or provide further information and assurance should that be helpful.
Once again, I offer my deepest condolences to Caitlin’s loved ones for their loss.