Chloe Barber

Dear Professor Marks, Re: Regulation 28 Report to Prevent Future Deaths – Chloe Louise Barber who died on 3 November 2021.

Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 12 August 2025 concerning the death of Chloe Louise Barber on 3 November 2021. In advance of responding to the specific concerns raised in your Report, I would like to express my deep condolences to Chloe’s family and loved ones. NHS England is keen to assure the family and yourself that the concerns raised about Chloe’s care have been listened to and reflected upon.

I am grateful for the further time granted to respond to your Report, and I apologise for any anguish this delay may have caused to Chloe’s family or friends. I realise that responses to Coroners’ Reports can form part of the important process of family and friends coming to terms with what has happened to their loved ones, and I appreciate this will have been an incredibly difficult time for them.

Your report raises the following concerns:
1. There is no clearly defined pathway that assists young people making the transition between Child and Adolescent Mental Health Services (CAMHS) and adult psychiatric services, to ensure a smooth transition and continuity of care.
2. There are no clear guidelines about where and by whom depot preparations of antipsychotic medication may be administered.
3. There was considerable uncertainty and ignorance about the provision of aftercare pursuant to s117 of the Mental Health Act 1983 amongst some healthcare workers and social workers, who should in any event be closely liaising with each other as well as with other allied professionals.

Transition between CAMHS and adult psychiatric services

The NHS is committed to ensuring that every area across the country commissions a comprehensive mental health offer for children and young people, with a clear focus on supporting young adults as they move from child to adult mental health services. A key priority is ensuring continuity of care and a smooth transition between services. Funding was released to healthcare systems in 2022/23 to transform and focus National Medical Director NHS England Wellington House 133-155 Waterloo Road London SE1 8UG

28th October 2025

improvement on the young adult mental health pathway. As of 2024/25, the majority of Integrated Care Boards (ICBs) across the country report that they have removed rigid age-based thresholds, involving young adults and their families/carers in their care, and ensuring that there are strong working relationships and embedded shared responsibility between child and adult mental health services.

Administration of depot (long-acting injection) medication

All Trusts should have an up to date policy setting out the expected practise and responsibilities of both prescribers and those administering depot medications. This should cover prescribing, storage, dispensing, administration and monitoring requirements in line with the organisation’s overarching Medicines Policy. Policies for the prescribing/administration/dispensing of depot medication are generally determined at local level (ICB). Depot medication is normally initiated by specialist secondary care services, but when a patient is considered to be ‘stable’, prescribing may be transferred to primary care under a locally agreed shared care protocol. Some areas may also make additional payments available to support the transfer of depot prescribing to primary care, for example under a local enhanced service with funding agreed with local commissioners. In other areas local systems may agree that all depot prescribing should remain under secondary care specialist responsibility. In July 2024, NHS England released new guidance for Integrated Care Boards (ICBs) to improve community mental health services, focusing on intensive and assertive treatment for people with Severe Mental Illness (SMI) who struggle to engage with standard services. This includes additional guidance on the use of depot medication, available here: NHS England » Guidance to integrated care boards on intensive and assertive community mental health care. If the prescribing of depot medication is switched to primary care, this would be done under a shared care protocol. This guidance includes the range of information that should be included as part of a request for primary care to take over prescribing responsibility. This includes Summary of NICE, BNF, SPC or other guidance, where applicable (and a web link to access the full guidance), Licensed indications & therapeutic class, Dose, route of administration and duration of treatment, Adverse effects (incidence, identification, importance and management), Cautions and contra- indications, Monitoring requirements and responsibilities, Clinically important drug interactions and their management, Peer-reviewed references for product usage and Contacts for more detailed information. Over the next two years the government has announced its intention to develop a single national formulary (SNF) for prescribed medicines in England. Although the precise details of how the SNF will be implemented are currently being developed, it is expected that the SNF will reduce the local variation in prescribing practices/policies and this should help reduce uncertainties stemming from the current variations in prescribing and shared care protocols.

S117 Aftercare

National guidance has been issued by NHS England and the Department of Health and Social Care (DHSC) providing staff with clear information about s117 and when this applies, including the following:

• Mental Health Act 1983 Code of Practice
• Discharge from mental health inpatient settings - GOV.UK
• NHS England » Acute inpatient mental health care for adults and older adults

NHS England’s adult acute guidance referenced above states that:

Many people admitted to hospital will already be in contact with a community-based mental health or learning disability team and have a named key worker. On admission, anyone without a named key worker should be assigned one within 72 hours wherever possible.

Key workers should:
• Maintain contact with the person whilst they are in hospital.
• Share relevant information with the inpatient team to reduce the need for repeat assessments and avoid the distress of the person retelling their story, which can be trigger past traumas.
• Work closely with the inpatient team, Crisis Resolution and Home Treatment Team (CRHTT), local authorities and other key services to plan the support the person will need both for discharge and for maintaining their wellbeing in the community (including working with local authorities to plan s117 aftercare, where applicable).

Planning for discharge, including arrangements for s117 aftercare, should begin early and be undertaken collaboratively, in partnership with other services. This helps to ensure a smooth transition from hospital to the community and supports the individual’s ongoing recovery and stability.

Colleagues from NHS England’s North East and Yorkshire region have advised that the concerns raised in your Report relate to locally commissioned services rather than specialised services. During Chloe’s admission to the Cygnet Hospital in Sheffield, oversight was provided by the Regional NHS England Mental Health, Learning Disability and Autism (MHLDA) Specialised Commissioning Team. Case management was in place to support the commissioning process and ensure the quality of care, including regular engagement with the provider and monitoring of Chloe’s care and pathway. Prior to discharge, multi-agency planning meetings were held, including a section 117 Mental Health Act discharge planning meeting. These meetings involved the multidisciplinary team (MDT), local CAMHS, adult mental health services, the local authority children’s social worker, as well as Chloe and her parents. The outcome was a comprehensive discharge plan which was agreed and documented.

Modern Service Framework We are taking several steps to ensure there is consistency in the quality of care provided by mental health services, while ensuring the people responsible for providing care are not overburdened by excessive central control. This includes the

development of A Modern Service Framework for severe mental illness, which will support consistent, high quality, and high value care. The Modern Service Frameworks will support consistent, high quality, and high value care across key clinical pathways. The Modern Service Frameworks will:
• define an aspirational, long-term outcome goal
• identify the best evidenced interventions that would support progress towards this goal
• set standards on how those interventions should be used
• and identify areas where innovation is needed to drive progress.

This is part of wider programme following the 10 Year Health Plan to improve outcomes, reduce unwarranted variation, and align provider payments with provision of high-quality care. NHS England is also finalising a new ‘Personalised Care Framework’ which sets out the minimum expected standards of care for people needing secondary mental health services. The Framework will apply to both CYP and Adult services, meaning a greater level of consistency in the offer across both services, giving young people transitioning between CYP and adult care will have greater clarity about what they should expect from their care.

Wider improvements

NHS England’s case managers work across inpatient providers and the wider health system in accordance with the National Institute for Health and Care Excellence (NICE) guidance on the transition of young people from child to adult services. We recognise that transition remains a key area of focus across ICBs, adult mental health services and the broader system. This priority was also reflected in the NHS England Improvement Plan following the independent investigation by NICHE Health and Social Care Consulting into West Lane Hospital, published in March 2023, which highlighted the need for robust transition processes. In 2023, regional discussions were held to reinforce the importance of NHS England, NHS providers and local authorities being assured that transitions are completed in line with the relevant NICE guidance.

Within the North East and Yorkshire Region, work is underway to strengthen pathways for young people transitioning from CAMHS into adult mental health services using personalised care approaches. The priority is to ensure a safe, seamless transition with continuity of care. Alongside this, section 117 aftercare, and ensuring personalised, consistent and appropriate support for all those entitled to it, is an identified area of focus within regional discussions and planned work.

Provider case management and clinical teams work collaboratively in supporting young adults in their personalised transition from CAHMS services to Adult Services; supporting discharge arrangements whereby a young person is discharged from hospital. Transition is a priority in the work of the Mental Health Trusts, Provider Collaboratives and the work of Humber and North Yorkshire Mental Health and Learning Disability Collaborative.

Humber Teaching NHS Foundation Trust, which provides a variety of services for people with mental health concerns, have many improvement initiatives and priorities relevant to transitions for children and young people into adult services, particularly in mental health which includes a Person-Centred Approach in CAMHS and Mental Health Services and strengthening formulation in mental health, learning disability, CAMHS and forensic services. This includes:
- Improving how care is planned and delivered across the lifespan – ensuring assessments and formulations are tailored to individual needs, which is critical during transition phases.
- Co-production with young people with the Trust has developed the Connect website in collaboration with young people.
- Emergency department Streaming Pathway – a new pathway has been introduced to support young people presenting with mental health issues in acute settings.

Humber Complex Emotional Needs Service for people who may meet the criteria for a diagnosis of a Personality Disorder has been working to support carers, families and friends by offering the Family Connections programme as well as refining their offer for care leavers and for those transitioning from Child and Adolescent services and now offer Dialectical Behaviour Therapy, EMDR therapies and Care Coordination, and an increased consultation offer to colleagues across the Trust and statutory partners.

I would also like to provide further assurances on the national NHS England work taking place around the Reports to Prevent Future Deaths. All reports received are discussed by the Regulation 28 Working Group, comprising Regional Medical Directors, and other clinical and quality colleagues from across the regions. This ensures that key learnings and insights around events, such as the sad death of Chloe, are shared across the NHS at both a national and regional level and helps us to pay close attention to any emerging trends that may require further review and action.

Thank you for bringing these important patient safety issues to my attention and please do not hesitate to contact me should you need any further information.

Dear Professor Marks,

Thank you for your Regulation 28 report of 12 August 2025 sent to the Minister of State at the Department of Health and Social Care, about the death of Chloe Louise Barber. I am replying as the Minister with responsibility for mental health.

Firstly, I would like to say how saddened I was to read of the circumstances of Chloe’s death, and I offer my sincere condolences to her family and loved ones. The circumstances your report describes are very concerning and I am grateful to you for bringing these matters to my attention.

Your report raises concerns over the transition between children and young people’s mental health services and adult mental health services; a lack of guidance around administering depot preparations of antipsychotic medication; and the provision of aftercare following discharge from mental health care. In responding, I have liaised with NHS England.

We know that the transition from children and young people’s mental health services to appropriate support from adult mental health services can be challenging for some young people and that more needs to be done to improve patient experience and outcomes at this critical stage. A key priority for children and young people’s mental health services is ensuring continuity of care and a smooth transition for patients moving to adult services. NHS England released funding in 2022/23 to transform and focus improvement on the young adult mental health pathway. In the year ending March 2025, the majority of integrated care boards reported improvement in the way they manage transitions to adult services. This includes removing rigid age-based thresholds for transition; involving young adults and their families/carers in decisions about their care; and ensuring there are strong working relationships and embedded shared responsibility between children and adults’ mental health services.

NHS England is also developing a personalised care framework which sets out the core principles of care that people should expect when accessing mental health services. This will be applicable across children and young people’s and adult services to help ensure that transitions are smooth and care is consistent across settings. Turning to your concerns about the administration of depot preparations of antipsychotic medication, prescribing guidelines on Depot Antipsychotic Medication Prescribing and

Administration are available for healthcare professionals in the Hull and East Riding Area.at:

In general, the Department expects healthcare professionals to work within the limits of their clinical competence. For example, all medical doctors, physician assistants and physician assistants in anaesthesia registered with the General Medical Council (GMC), must meet the expected standards set out in the GMC’s Good medical practice1 to work in the UK. Doctors must also hold a licence to practise. Good medical practice states that doctors must propose, provide or prescribe drugs or treatment based on the best available evidence, and only when they have adequate knowledge of the patient’s health and are satisfied that the drugs or treatment will meet their needs. Failure to uphold and adhere to the principles within Good medical practice and related guidance will put a professionals’ registration with the GMC at risk. If a concern is raised about a professional’s fitness to practise, the GMC has a statutory duty to investigate and take action to safeguard the health and well-being of the public where necessary.

With regard to your concerns around a lack of knowledge amongst some healthcare staff and social workers about section 117 aftercare, it is vital that organisations across the health system work together to ensure effective discharge planning and the best outcomes for people who are discharged from hospital. Section 117 of the Mental Health Act places a joint duty on local authorities and integrated care boards, in co-operation with voluntary agencies, to provide or arrange for the provision of aftercare to patients detained in hospital for treatment under section 3 (and some other sections) who then cease to be detained.

We are aware that there can sometimes be disagreements between organisations as to which one should be responsible for aftercare under section 117, which can delay access to aftercare. To address this, statutory guidance on discharges from mental health inpatient settings2 was published in January 2024 which provides clarity in relation to how organisations across the health system work together to ensure effective discharge planning and the best outcomes for people who are discharged from hospital. It includes additional guidance on how budgets and responsibilities are shared to pay for aftercare under section
117. Integrated care boards, as commissioners of health services in their areas, should ensure that all providers of mental health services are aware of this guidance.

Further to this, the Mental Health Bill, currently being considered by Parliament, will amend section 117 to apply the existing ‘deeming rules’ under social care legislation to the determination of ordinary residence, to identify which local authority is responsible for arranging section 117 aftercare to an individual patient. These rules already exist under the Children Act 1989, the Care Act 2014 and the Social Services and Well-being (Wales) Act
2014. The deeming rules will also more closely align the local authority, social care and integrated care board rules for determining where a person is ‘ordinarily resident’ for the purposes of section 117, aiming to support the joint provision and planning for aftercare services. Our intention is that the deeming rules will add clarity and consistency to an often- litigious system.

1 https://www.gmc-uk.org/professional-standards/professional-standards-for-doctors/good-medical-practice 2

mental-health-inpatient-settings

I hope this response is helpful and thank you for bringing these concerns to my attention.

All good wishes,

PARLIAMENTARY UNDER-SECRETARY OF STATE FOR WOMEN’S HEALTH AND MENTAL HEALTH