The family of a teenager who took her own life after discharging herself from mental health services when she turned 18 say she was allowed to “slip through gaps in the system” and that they were left with a “complete lack of support” in trying to help her. An inquest into the death of Chloe Barber, of Driffield, East Yorkshire, highlighted a string of failures or missed opportunities in relation to her treatment and care.
In the wake of it, the coroner issued a Prevention of Future Deaths report over concerns there is not necessarily a clear path nationwide for transition between children’s mental health and adult services.
Chloe was first referred to the Child and Adolescent Mental Health Services (CAMHS) in 2017 after taking an overdose, having suffered from serious bullying at school and on social media, which her family reported to police. Over the following four years, she continued to struggle with her mental health, with her family saying she was “passed from pillar to post” by Humber Teaching NHS Foundation Trust.
In early 2021 Chloe was hospitalised in Sheffield, where she remained until July of that year and on discharge, aged 17, she returned home. Due to transfer to adult mental health services, Chloe struggled to engage with CAMHS and the Complex Emotional Needs Service (CENS) in the community and continued to engage in deliberate self-harm.
In November 2021, she was found by her 15-year-old brother to have taken her own life. At the time of Chloe’s death, her case had been closed by both CAMHS and the CENS and adult social care had also declined to accept an earlier referral concerning Chloe.
(Image: Family of Chloe Barber)
‘Our hearts have been broken beyond repair since she left us’
In a statement following the inquest, Chloe’s family said: “Chloe was passed from pillar to post and we lost her because she was allowed to slip through gaps in the system. There was a multitude of social workers and mental health professionals assigned to her case in a short period of time and there was no clear protocol or process in place that could be followed when Chloe was due to transition from CAMHS to adult services following her 18th birthday.
Citing an “utterly unacceptable” lack of record keeping and information sharing between services, highlighting that Chloe’s risk of harm to herself was not identified, the family said: “We feel there was a complete lack of support for the family throughout, particularly when Chloe was discharged from in-patient services into the community.
“We were never informed about Chloe’s diagnosis of emerging unstable personality disorder, what that meant, or how we could support Chloe.” A request by Chloe for a medication review in the community, just before her 18th birthday, never took place.
“She became so frustrated with the ‘faffing around’ that she told them not to bother.” Her family described her as “amazing, bright, brilliant, beautiful, caring and stubborn, a truly wonderful young lady” and spoke of her love of music and drawing, and of her pets.
“Our hearts have been broken beyond repair since she left us, but we are so proud of Chloe and grateful for the time we had her in our lives.”
Reports identified Trust and local authority failures
Following Chloe’s death, two reports into her death were commissioned – a serious incident report by Humber Teaching NHS Foundation Trust and an independent Safeguarding Adults Review (SAR). The SAR identified a string of failures or missed opportunities by the Trust in relation to Chloe’s care including:
- Failure to assess and consider Chloe’s need for aftercare services
- Failure to ensure Chloe had an updated safety plan for use in the community
- Failure to ensure that Chloe had a relapse prevention plan, crisis plan, and contingency plan
- Failure to carry out a formal capacity assessment on Chloe’s decision to transition to adult services and to make decisions as to her medication
- Failure to refer Chloe to the Vulnerable Adults Risk Management (VARM) framework – which is a forum that could have considered Chloe’s case from a safeguarding perspective
- The lack of any protocol and “confusion” around the administration and monitoring of Chloe’s depot medication in the community
The SAR also identified failures in relation to the local authority including:
- Failure by adult social care to accept Chloe’s referral
- Failure by children’s services to re-refer Chloe to adult social care when she turned 18
- Failure by both children’s and adult services to refer Chloe to VARM
Coroner issues Prevention of Future Deaths report
Professor Paul Marks, senior coroner, highlighted concerns around the provision of various support and assistance measures to Chloe, the lack of capacity assessments being conducted, the absence of a referral to the VARM process, and the “lack of documentation and poor communication between services and partner organisations”. He concluded that it could not be said, on the balance of probabilities, that these failures and missed opportunities more than minimally contributed to Chloe’s death, but he did say that the cessation of Chloe’s depot [slow-release/long-acting] medication may have more than minimally resulted in an increased emotional instability, leading to impulsive behaviour around the time of her death.
The coroner concluded by confirming that he would be exercising his powers to issue a Prevention of Future Deaths report over concerns that there is not necessarily a clear path nationwide for transition between CAMHS and adult services, and that the administration of depot medication seems to be “somewhat erratic with no clear guidelines of who administers this and where”.
‘Completely failed by mental health services’
Chloe’s family were represented by Iftikhar Manzoor and Soraya Mehdizadeh, of Hudgell Solicitors. Mr Manzoor, said after the hearing: “Chloe and her family were completely failed by mental health services.
“Chloe was a vulnerable young person with a history of serious mental health issues that made her a clear risk to herself. She had made repeated attempts on her own life, had avoided taking medication which helped her, and she had repeatedly talked of ending her life.
“Her family were perplexed and concerned that after several years of support and treatment, including in-patient admissions to hospitals, Chloe was deemed at the age of 18 to be able to decline all services, despite the risk she posed to herself and her history of self-harm.
“When she was discharged from children’s mental health care and into adult care, she was effectively abandoned without a full assessment or care plan being devised, and without any appropriate support being offered to her family. Just a week before she took her own life, her father reported an incident of serious self-harm, which left her needing hospital treatment, and yet she was still not referred to VARM.
“This is a case which has exposed worrying gaps in the system. Turning 18 does not make somebody with a serious mental health illness suddenly able to make decisions in their own best interests. Once Chloe was discharged from mental health care, her family were left fearing the worst would happen, and it did.”
A spokesperson for the Humber Teaching NHS Foundation Trust said: “The coroner’s inquest conclusion found no evidence of causation attributable to the Trust and acknowledged that any learnings taken from the case have already been embedded effectively by the Trust. We would like to thank HM Senior Coroner for his careful and thorough consideration of the circumstances surrounding the sad death of Chloe Barber, a patient discharged from our care in 2021.
“Our organisation remains committed to continually learning and making meaningful improvements to the safety and quality of the care we provide. Our thoughts and heartfelt condolences are extended to Chloe’s family and loved ones.”
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