NHS England
NHS / Health Body
Action Taken
NHS England has already published new transition guidance in April 2026, which advises against rigid, age-based transfers for young people moving from children's to adult mental health services, promoting a personalised and planned approach. A regional ICB will also convene a working group to review local commissioned provision for the 16-25 pathway. (AI summary)
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Dear Mr Rheinberg, Re: Regulation 28 Report to Prevent Future Deaths – Alice Sarah Dearden who died on 28th February 2020.
Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 29th April 2026 concerning the death of Alice Sarah Dearden on 28th February 2020. In advance of responding to the specific concerns raised in your Report, I would like to express my deep condolences to Alice’s family and loved ones. NHS England is keen to assure the family and yourself that the concerns raised about Alice’s care have been listened to and reflected upon.
Your Report raised concerns with the commissioning arrangements for children and adolescents’ mental health services, in particular the abrupt transition from children’s to adult services at age 18. 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 children to adult mental health services. A core principle is continuity of care, with transition decisions based on the individual needs and circumstances of the young person, rather than on age alone. The Children and Young People’s Transformation Programme, along with key stakeholders, have developed transition guidance on supporting young people to move into adult services. The guidance, which was published in April 2026, states that rigid, age based thresholds should be avoided and that young people should not be transferred automatically at age 18. Instead, the point of transition should take place at a relatively stable point in the young person’s life, supported by a personalised and planned approach.
The guidance outlines key principles and examples of a 0 – 25 year old model of care including clearer accountability and improved services for those aged 16 – 17. National Medical Director NHS England Wellington House 133-155 Waterloo Road London SE1 8UG
22nd June 2026
This guide would be applicable to all healthcare conditions, physical and mental health, and has been developed with the support of young people with long term conditions as well. The principles of age-appropriate services set out in this document apply to young people receiving care for the first time as well as those already on a transition pathway. In 2024, NHS England partnered with the NHS Youth Forum to investigate this further, receiving survey responses from young people across the country. The results identified a gap in care for 16 – 17 year olds with many being discharged from paediatric services before being told they weren't old enough to access adult ones. To address this, NHS England is working with regulators and royal college colleagues to ensure there is clarity over the clinical responsibilities for this age group. The forum's findings are also informing upcoming guidance on supporting young people to transition into adolescent and adult services. Furthermore, the National Child Mortality Database (NCMD) are investigating how this lack of clarity and resulting delays may have caused avoidable harm with the most tragic of outcomes. They will publish their report later this year. Guidance published on Children & Young People’s eating disorders in January 2026 also emphasises that services should take an individualised and flexible approach to transitions, to support safety, engagement and continuity of care.
We hope that this new guidance, informed by feedback from young people themselves, will specifically address the concerns raised in this tragic case.
Regional Response NHS England’s South West regional team have liaised with the Integrated Care Board (ICB) regarding the concern your raised. Bath and North East Somerset, Swindon and Wiltshire (BSW) ICB had advised that they are committed to commissioning mental health services with parity across all ages, ensuring that children, young people, adults and older adults have equitable access to timely, evidence-based support. This is detailed with the BSW ICB Mental Health Strategy 2025-2030. This all-age commissioning approach is designed to remove artificial boundaries between services, promote continuity of care, and address inequalities in outcomes, reflecting the system’s commitment to parity of esteem and population need.” A description of the commissioned delivery model, specific skill set and resourcing to support a person-centred approach regarding age specific transitions is provided below: BE U Swindon: The commissioned and operational model is designed to provide flexibility and continuity of support for young people approaching or transitioning beyond their 18th birthday, where clinically appropriate.
Within the school-based Mental Health Support Teams (MHST) offer, support is available to young people accessing Higher Education within MHST-covered educational settings, enabling intervention and continuity of care for young people up to the age of 19. In addition, the MHST delivers a whole school and college approach, working collaboratively with education settings to build emotionally healthy environments, improve early identification, and strengthen support pathways for children and young people across the wider system. The service also works with children and young people with Special Educational Needs (SEN) up to the age of 25 where appropriate, recognising the additional vulnerabilities and transitional challenges this cohort can experience and supporting a more developmentally informed approach to care. Across the wider community offer, young people who turn 18 whilst awaiting intervention may still be offered support where this is assessed as the most clinically appropriate first-line intervention. This ensures that support is not automatically withdrawn solely due to age and helps minimise disruption to care pathways during periods of transition. In addition, the BE U Swindon Single Point of Access (SPA) operates in close partnership with local mental health and voluntary sector services including Avon and Wiltshire Mental health Partnership NHS Trust (AWP), Talking Therapies, Second Step, and Swindon & Gloucestershire Mind. These services provide support for young people from the age of 16 onwards and enable coordinated advice, guidance, signposting, and onward referral arrangements for young people and families where another service is assessed as being better placed to meet the presenting need. This approach supports smoother transitions between children and young people’s services and adult provision, reducing the potential risks associated with rigid age- related service boundaries. Swindon & Gloucestershire (S&G) Mind: Their Young People’s Services support individuals aged 16–25, intentionally covering the transitional period around a young person’s 18th birthday and acting as a safety net during what can often be a vulnerable time. They attend the monthly CAMHS transition panel, enabling them to identify young people who are leaving CAMHS but do not meet the criteria for Adult Mental Health Teams. In these circumstances, S&G Mind can provide up to 12 months of community-based support tailored to the individual’s presentation and needs. This may include crisis support, counselling, community groups, and one-to-one wellbeing support, helping to ensure continuity of care and reduce the risk of young people disengaging from mental health support during transition. Oxford Health Foundation Trust, CAMHS: With the introduction of 16-25 Consultant Mental Health Practitioners the service provides flexible transitions designed around the needs of Children & Young People. At times Children & Young People will remain with CAMHS past their 18th birthday, usually when they are receiving a treatment which once completed could lead to a reduced need to transfer to adult mental health services. Children & Young People are more likely to require transfer at 18 if the symptoms of their mental health raise concerns regarding safety, including significant self-harm or
harm to others. They are also likely to transition if they require an inpatient admission as this will need to be within the adult inpatient estate. Avon & Wiltshire Mental Health NHS Partnership Trust: AWP teams across the three localities work closely with Oxford Health NHS Foundation Trust (OHFT) and Voluntary, Community, and Social Enterprise (VSCE) partners to ensure young people access the mental health support they need and that service pathways are clear. OHFT are commissioned to provide the 16–25 year old transition service in BSW, with the consultant mental health practitioners holding honorary contracts with AWP, working 50% of their capacity across adult service. One of their tasks is to improve and progress of the transition panels across BSW, deliver training across adult teams, provide consultation and hold a small caseload of individuals who are transitioning from CAMHs to adults services, providing a point of continuity. Talking Therapies in the ICB accepts people of 16 years and older who can either self- refer or be referred. Early Intervention for Psychosis accepts people aged 14 years and above. In light of this case, BSW ICB will convene a working group with systemwide delivery partners to review the commissioned provision and delivery models spanning the 16- 25 pathway, with a view to identifying opportunities to develop and strengthen approaches, and implement responsive action plans and/or cases of need where required. This workstream will report to the BSW Mental Health Delivery Group from an oversight perspective. Any required approvals/decision making with follow organizational governance processes.
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 Alice, 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.
Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 29th April 2026 concerning the death of Alice Sarah Dearden on 28th February 2020. In advance of responding to the specific concerns raised in your Report, I would like to express my deep condolences to Alice’s family and loved ones. NHS England is keen to assure the family and yourself that the concerns raised about Alice’s care have been listened to and reflected upon.
Your Report raised concerns with the commissioning arrangements for children and adolescents’ mental health services, in particular the abrupt transition from children’s to adult services at age 18. 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 children to adult mental health services. A core principle is continuity of care, with transition decisions based on the individual needs and circumstances of the young person, rather than on age alone. The Children and Young People’s Transformation Programme, along with key stakeholders, have developed transition guidance on supporting young people to move into adult services. The guidance, which was published in April 2026, states that rigid, age based thresholds should be avoided and that young people should not be transferred automatically at age 18. Instead, the point of transition should take place at a relatively stable point in the young person’s life, supported by a personalised and planned approach.
The guidance outlines key principles and examples of a 0 – 25 year old model of care including clearer accountability and improved services for those aged 16 – 17. National Medical Director NHS England Wellington House 133-155 Waterloo Road London SE1 8UG
22nd June 2026
This guide would be applicable to all healthcare conditions, physical and mental health, and has been developed with the support of young people with long term conditions as well. The principles of age-appropriate services set out in this document apply to young people receiving care for the first time as well as those already on a transition pathway. In 2024, NHS England partnered with the NHS Youth Forum to investigate this further, receiving survey responses from young people across the country. The results identified a gap in care for 16 – 17 year olds with many being discharged from paediatric services before being told they weren't old enough to access adult ones. To address this, NHS England is working with regulators and royal college colleagues to ensure there is clarity over the clinical responsibilities for this age group. The forum's findings are also informing upcoming guidance on supporting young people to transition into adolescent and adult services. Furthermore, the National Child Mortality Database (NCMD) are investigating how this lack of clarity and resulting delays may have caused avoidable harm with the most tragic of outcomes. They will publish their report later this year. Guidance published on Children & Young People’s eating disorders in January 2026 also emphasises that services should take an individualised and flexible approach to transitions, to support safety, engagement and continuity of care.
We hope that this new guidance, informed by feedback from young people themselves, will specifically address the concerns raised in this tragic case.
Regional Response NHS England’s South West regional team have liaised with the Integrated Care Board (ICB) regarding the concern your raised. Bath and North East Somerset, Swindon and Wiltshire (BSW) ICB had advised that they are committed to commissioning mental health services with parity across all ages, ensuring that children, young people, adults and older adults have equitable access to timely, evidence-based support. This is detailed with the BSW ICB Mental Health Strategy 2025-2030. This all-age commissioning approach is designed to remove artificial boundaries between services, promote continuity of care, and address inequalities in outcomes, reflecting the system’s commitment to parity of esteem and population need.” A description of the commissioned delivery model, specific skill set and resourcing to support a person-centred approach regarding age specific transitions is provided below: BE U Swindon: The commissioned and operational model is designed to provide flexibility and continuity of support for young people approaching or transitioning beyond their 18th birthday, where clinically appropriate.
Within the school-based Mental Health Support Teams (MHST) offer, support is available to young people accessing Higher Education within MHST-covered educational settings, enabling intervention and continuity of care for young people up to the age of 19. In addition, the MHST delivers a whole school and college approach, working collaboratively with education settings to build emotionally healthy environments, improve early identification, and strengthen support pathways for children and young people across the wider system. The service also works with children and young people with Special Educational Needs (SEN) up to the age of 25 where appropriate, recognising the additional vulnerabilities and transitional challenges this cohort can experience and supporting a more developmentally informed approach to care. Across the wider community offer, young people who turn 18 whilst awaiting intervention may still be offered support where this is assessed as the most clinically appropriate first-line intervention. This ensures that support is not automatically withdrawn solely due to age and helps minimise disruption to care pathways during periods of transition. In addition, the BE U Swindon Single Point of Access (SPA) operates in close partnership with local mental health and voluntary sector services including Avon and Wiltshire Mental health Partnership NHS Trust (AWP), Talking Therapies, Second Step, and Swindon & Gloucestershire Mind. These services provide support for young people from the age of 16 onwards and enable coordinated advice, guidance, signposting, and onward referral arrangements for young people and families where another service is assessed as being better placed to meet the presenting need. This approach supports smoother transitions between children and young people’s services and adult provision, reducing the potential risks associated with rigid age- related service boundaries. Swindon & Gloucestershire (S&G) Mind: Their Young People’s Services support individuals aged 16–25, intentionally covering the transitional period around a young person’s 18th birthday and acting as a safety net during what can often be a vulnerable time. They attend the monthly CAMHS transition panel, enabling them to identify young people who are leaving CAMHS but do not meet the criteria for Adult Mental Health Teams. In these circumstances, S&G Mind can provide up to 12 months of community-based support tailored to the individual’s presentation and needs. This may include crisis support, counselling, community groups, and one-to-one wellbeing support, helping to ensure continuity of care and reduce the risk of young people disengaging from mental health support during transition. Oxford Health Foundation Trust, CAMHS: With the introduction of 16-25 Consultant Mental Health Practitioners the service provides flexible transitions designed around the needs of Children & Young People. At times Children & Young People will remain with CAMHS past their 18th birthday, usually when they are receiving a treatment which once completed could lead to a reduced need to transfer to adult mental health services. Children & Young People are more likely to require transfer at 18 if the symptoms of their mental health raise concerns regarding safety, including significant self-harm or
harm to others. They are also likely to transition if they require an inpatient admission as this will need to be within the adult inpatient estate. Avon & Wiltshire Mental Health NHS Partnership Trust: AWP teams across the three localities work closely with Oxford Health NHS Foundation Trust (OHFT) and Voluntary, Community, and Social Enterprise (VSCE) partners to ensure young people access the mental health support they need and that service pathways are clear. OHFT are commissioned to provide the 16–25 year old transition service in BSW, with the consultant mental health practitioners holding honorary contracts with AWP, working 50% of their capacity across adult service. One of their tasks is to improve and progress of the transition panels across BSW, deliver training across adult teams, provide consultation and hold a small caseload of individuals who are transitioning from CAMHs to adults services, providing a point of continuity. Talking Therapies in the ICB accepts people of 16 years and older who can either self- refer or be referred. Early Intervention for Psychosis accepts people aged 14 years and above. In light of this case, BSW ICB will convene a working group with systemwide delivery partners to review the commissioned provision and delivery models spanning the 16- 25 pathway, with a view to identifying opportunities to develop and strengthen approaches, and implement responsive action plans and/or cases of need where required. This workstream will report to the BSW Mental Health Delivery Group from an oversight perspective. Any required approvals/decision making with follow organizational governance processes.
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 Alice, 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.