Allison Aules

Coroner's concerns

AI summary

Under-resourced and underfunded CAMHS services, coupled with a lack of consultant leadership, led to significant delays in mental health assessments for children, despite rapidly increasing demand.

View full coroner's concerns

The Inquest identified multiple failings in the care provided to Allison. The failings occurred within a children and adolescent mental health service which was significantly under resourced.

The Inquest heard evidence that the under resourcing of CAMHS services is not confined to this local Trust but is a matter of National concern.

The under resourcing of CAMHS services contributed to delays in Allison being assessed by the mental health team. The delay between triage to assessment was 9 months. The Inquest heard evidence that this delay is not unusual within CAMHS teams across the country.

There was very little evidence of any consultant psychiatrist leadership within the CAMHS team. The Inquest heard of the difficulties in recruiting suitably qualified psychiatrists to CAMHS teams.

The Inquest heard that funding for CAMHS teams within the allocation of funding for general mental health is poor.

The Inquest heard that the number of children presenting to CAMHS teams is increasing significantly. The number of referrals of children to the local CAMHS team in the early 2010s was between 10 – 12 per week. The current number of referrals is in the region of 140 patients per week.

There is a concern that ongoing under resourcing of CAMHS services (whilst demand continues to increase), will result in future similar deaths.

Responses

4 respondents

NHS England NHS / Health Body

30 Aug 2023 PDF

Action Taken

NHS England is increasing access to CYPMH services, with 702,000 children and young people receiving support in the 12 months to June 2023 and a 46% increase in the CYPMH workforce since the start of the LTP. They will also ensure regional leadership are aware of the report's findings and the Regulation 28 Working Group will discuss all reports received. (AI summary)

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Dear Coroner,

Re: Regulation 28 Report to Prevent Future Deaths – Allison Vivian Jacome Aules who died on 19 July 2022.

Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 30 August 2023 concerning the death of Allison Vivian Jacome Aules on 19 July 2022. In advance of responding to the specific concerns raised in your Report, I would like to express my deep condolences to Allison’s family and loved ones. NHS England are keen to assure the family and the coroner that the concerns raised about Allison’s care have been listened to and reflected upon.

This response focuses on the national NHS England policy and programmes relevant to the matters of concern you have identified in your Report. The concerns you have raised relating to the provision of local support and the actions taken in providing that support to Allison would need to be addressed by the relevant local commissioners and providers.

Your Report however does raise concerns relating to national resourcing of children and young people’s mental health (CYPMH) services, sometimes referred to as Child and Adolescent Mental Health Services (CAMHS) and concerns over the available workforce in CYPMH and increasing levels of need.

Improving mental health support for children and young people is a priority for NHS England. The NHS Long Term Plan (LTP) sets an ambitious commitment that access will increase, with 345,000 more children aged 0-25 accessing support in 2023/24 compared to 2019. This commitment came with significant additional funding, rising to over £900m in 2023/24. We have made significant progress towards this commitment with 702,000 children and young people receiving support from the NHS in the 12 months to June 2023. This has been achieved through investment in the children and young people’s mental health workforce, which has increased by 46% since the start of the LTP, and by 70% since 2016.

We accept your finding that demand for support for mental health and wellbeing is increasing. The prevalence of mental health need in children and young people has increased following the Covid-19 pandemic and many services are facing significant demand. Increasing access to support therefore continues to be a priority.

National Medical Director NHS England Wellington House 133-155 Waterloo Road London SE1 8UG

18 October 2023

The NHS LTP also included a ten-year ambition that 100% of children and young people who need specialist support should be able to access help by the end of the decade.

The NHS Long Term Workforce Plan (June 2023) sets out the importance of continued investment in the mental health workforce and in 2022, NHS England consulted on potential new access and waiting time standards including for children and young people’s mental health. Delivering these ambitions will be subject to future funding settlements and we will clarify plans in due course.

We will ensure that the leadership across NHS regions and Clinical Network are aware of the findings of this Report. I would also like to provide further assurances on 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 preventable deaths are shared across the NHS at both a national and regional level and helps us 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.

North East London NHS Foundation Trust NHS / Health Body

25 Oct 2023 PDF

Action Planned

NELFT will implement the Oxford Centre for Suicide Research’s model of risk formulation and co-produce safety plans with clients and families, including training and system changes to support the roll out. (AI summary)

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Dear Madam

Re: Preventing Future Deaths (Regulation 28) Report – Allison Aules

I refer to your letter dated 30 August 2023 and the Regulation 28 report detailing your concerns about the risk of future deaths in light of the inquest findings.

I would like to extend my sincere condolences to the family of Allison Aules. This must have been an extremely difficult time for them, and I hope that my response provides them and you with assurances that NELFT NHS Foundation Trust is taking action to address the issues set out in your report.

The Trust is determined to ensure that all patients receive care in a person-centred approach and that the patient’s voice is at the centre of planning the patient’s care. The Trust’s expectation is that the young person's voice is heard in the triage, initial assessment, care/treatment plan, and follow-ups alongside their parents / responsible adults. We continue to work in this area, not least through regular audit of our work. In addition, each member of staff has monthly supervision with their clinical supervisor, who scrutinises the records of randomly selected young persons to ensure that the voice of the young person has been captured and considered at every contact. We will also continue to work to ensure that the voice of the young person is also discussed at clinical Multidisciplinary Team Meetings, Post Assessment Discussion meetings, Complex Case Discussion meetings, and safeguarding supervision.

I would also like to use this opportunity to reiterate that, in response to learning from incidents in the Trust, and following the publication of NICE Guidelines 225 (Self-harm: assessment, management and preventing recurrence - September 2022), the Trust is transitioning to a new approach to assessing, identifying, and managing the clinical risks of the patients.

This guidance calls for a move away from the risk stratification model and a transition towards a risk formulation and safety planning approach. Risk formulation requires psychosocial assessment, formulation and risk planning. This approach conceptualizes risk as dynamic and fluid, rather than static and categorical (e.g. low, medium, high) and is focused on a personal understanding of risk that understands how the risk has escalated and what, for that specific individual, will support it to reduce in the future or may lead to further escalation.

As part of the consultation process, the Trust considered various models for the implementation of objectives set out in the NICE Guidelines and opted to implement the Oxford Centre for Suicide Research’s model of risk formulation. This model looks at completing a psychosocial assessment that will lead to risk formulation and then safety planning. This safety plan is co-produced with the client, family and significant others within their social group.

We will be taking forward this work focusing on how this new model can enable clinicians to identify the actual risks, recognise the dynamics of these risks, and devise safety plans to address the identified risks more effectively. We are putting training and system changes in place to support the roll out of our work in this area.

In respect of the specific concerns, expressed by you at the hearing and within the Regulation 28 report, the Trust has put actions in place that aim to address these specific areas for improvement in order to strengthen the safety of our services further. Please find attached an action plan which sets out these actions.

I hope that we have provided you with some assurance that NELFT NHS Foundation Trust is taking steps to address the concerns expressed in your report and that we are continuing to take action to prioritise patient safety and quality of care.

Thank you for raising this matter with NELFT NHS Foundation Trust. If I can be of any further assistance or if you would like a further update on the progress made to address your concerns, I would be happy to provide a further update.

I look forward to hearing from you.

North East London Integrated Care Board Integrated Care Board

6 Nov 2023 PDF

Action Planned

NHS North East London is developing a business case for additional CAMHS funding, including proposals for seven-day/evening working and face-to-face initial assessments. They are also reviewing the current clinical model and participating in transformation work via their Mental Health, Learning Disability and Autism Collaborative. (AI summary)

View full response

Dear Ms Persaud

In the matter of Allison Aules Prevention of Future Deaths Report: Date of report: 30/08/2023 Ref: 2023-0313

I write in relation to the above, to update you on some of the actions NHS North East London have taken and are planning to take.

Firstly, I’d like take this opportunity to formally acknowledge this was a tragic case and our sympathies are with the family.

Secondly, I wanted contextualise my response by outlining that NHS North East London are committed to improving the mental health and well-being of people across North East London and it is one of our key strategic priorities across the Integrated Care System (ICS).

For ease I shall update as below:

Under-resourcing of CAMHS services and the delays this is causing to assessment
• We are developing a business case to secure additional funding to support improved resourcing of CAMHS services within NELFT.
• The business case will include a proposal for seven day and evening working as it is felt that this will improve recruitment/retention.
• The business case will also include requirements to implement a face to face approach for initial CAMHS assessments.
• In partnership with NELFT, NHS North East London are reviewing the current clinical model
• CAMHS services are also part of transformation work which is being led by our Mental Health, Learning Disability and Autism Collaborative Difficulties in recruiting consultant psychiatrists to CAMHS teams
• Recruitment of consultant psychiatrists is a national issue which we recognise locally
• NHS North East London is working with NELFT and other providers to support recruitment and looking at innovative ways of recruiting. This work is being led by our Chief People and Culture Officer,

The growing demand in CAMHS referrals and the lack of capacity to deal with this. Ms Nadia Persaud Area Coroner Coroner’s Court of East London

2
• We recognise the growing demand in CAMHS services and this demand is being reviewed as part of the wider transformation work via our Mental Health, Learning Disability and Autism Collaborative
• With NELFT we are reviewing the current CAHMS community model with the aim of reducing referrals into the service
• In the short term for CAHMS for NELFT we have developed a business case for more funding to support this demand.

I trust this letter addresses your questions.

Should you have any further questions please feel free to come back to me.

Department of Health and Social Care Central Government

9 May 2024 PDF

Noted

The Department of Health and Social Care acknowledges concerns about CAMHS resourcing and highlights increased spending on mental health services and workforce development initiatives, including training programmes and a new suicide prevention strategy. (AI summary)

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Dear Miss Persaud,

Thank you for your Regulation 28 report to prevent future deaths dated 30 August 2023 about the death of Allison Vivian Jacome Aules. I am replying as the Minister with responsibility for mental health and patient safety.

Firstly, I would like to say how saddened I was to read of the circumstances of Allison’s death and I offer my sincere condolences to her family and loved ones. The circumstances your report describes are concerning and I am grateful to you for bringing these matters to my attention. Please accept my sincere apologies for the significant delay in responding to this matter.

I understand that NHS England, North East London Integrated Care Board and North East London NHS Foundation Trust have each already carefully considered the matters of concern in your report and have provided you with comprehensive responses setting out the actions being taken to improve care quality and patient safety.

I recognise your concerns regarding the resourcing of children and young people’s mental health services and I acknowledge that we are facing a significant increase in demand for children and young people mental health services. I can assure you that, from a national perspective, the Government is working hard towards addressing this.

Under the NHS Long Term Plan, the NHS forecasts that, between 2018/19 and 2023/24, spending on mental health services has increased by £4.7 billion in cash terms, compared to the target of £3.4 billion set out at the time of the NHS Long Term Plan in 2019. Spend specifically on children and young people’s mental health services has increased from £841 million in 2019/20 to just over £1 billion in 2022/23.

NHS England is working to support an increase in access to high-quality children and young people's mental health services. NHS England’s priorities and operational planning guidance for 2024/25 sets out the aim to increase the number of children and young people aged 0-25 years accessing transformed models of community mental health to 345,000 by the end of March 2025 compared to 2019.

We are also making positive progress on our ambition to grow the mental health workforce by an extra 27,000 staff between 2019/20 and 2023/24. We delivered three quarters of this (around 20,800) by December 2023 with further growth expected to have been achieved once the full year figures for 2023/24 are available. In December 2023, there were nearly 149,000 full time equivalents in the mental health workforce. This is over 10,300 more (7.5% increase) since December 2022. 

The number of full-time equivalent psychiatry consultants working in all NHS trusts and other core organisations in England has increased by 8.7% from 4,121 in September 2010 to 4,479 in September 2023.

We are committed to attracting, training, and recruiting the mental health workforce of the future as well as retaining and re-skilling our current workforce. We are also continuing to increase our education and training commissions (across all mental health training programmes) alongside continuing to develop new roles and using existing roles to transform service delivery and enhance service user experiences. The NHS aims to meet this commitment through a range of different training programmes, including:

• continued workforce growth, through the commissioning of wellbeing practitioners and children and young people’s talking therapies training programmes;
• supporting existing workforce development through upskilling training opportunities, for example Service Leadership training;
• supporting the implementation of mental health support teams in schools and colleges through the commissioning of education mental health practitioner (EMHP) training and supervision;
• supporting initiatives to ensure widening participation in the workforce; and
• ensuring workforce development and training for staff in inpatient settings, including development of the children and young people’s mental health inpatient competency framework. 

I would add that we published a new 5-year Suicide Prevention Strategy for England on 11 September with over 130 actions that we believe will make progress towards our ambition to reduce the suicide rate within two and a half years. The strategy is a call to action for national and local government, the health service, the VCSE sector, employers and individuals to work together to help prevent suicides.

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

Report sections

Investigation and inquest

On 3 August 2022 I commenced an investigation into the death of Allison Vivian Jacome Aules. Allison was 12 years old when she passed away on the 19th July 2022. The investigation concluded at the end of the inquest on the 17th August 2023. The conclusion was that Allison died as a result of suicide, contributed to by neglect.

Circumstances of the death

Allison Aules was referred to the mental health team in May 2021 with concerns around evidence of self-harm, low mood, anxiety and enuresis. Her case was inappropriately screened as routine and the referral was triaged 8 weeks later. Allison was not communicated with at this time, but her mother shared a full account of concerns with the triage psychologist. Additional concerns were raised during triage and the matter was taken to a multi-disciplinary team. The team decided that Allison should be assessed face to face. They determined the case to be low risk and placed it in the green zone. The concerns shared with the service should have resulted in a more urgent face to face assessment. The assessment of Allison took place 9 months later. This was not a face-to-face assessment, as directed by the multi-disciplinary team. There was a telephone discussion, initially with Allison's mother alone. Allison later spoke to the assessor but there was no full assessment of her mental state. There was no full exploration of the concerns raised in the referral and in the triage discussion. There was no evidence of the assessor determining the cause of Allison's worrying presentation. There was no carefully documented assessment of risk. There was no carefully devised risk management plan. A decision was made to discharge Allison from the mental health team, with no multi-disciplinary review or liaison with the referrer. Allison continued to receive counselling provided at her school, but this concluded at the end of term, on the 15 July 2022. On the 18 July 2022 Allison was found suspended in her bedroom. The failure to provide basic mental health care to Allison contributed to her death.

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involved in the Inquest. The report will also be sent to the Care Quality Commission, to the Child Death Overview Panel and to the local Director of Public Health

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