Family handoutThe mother of a teenager who took her own life following spells in psychiatric units says she wants lessons to be learnt from her daughter’s story.
Chloe Barber, 18, from Driffield, East Yorkshire, had a history of self-harm and was found dead at home by a member of her family on 3 November 2021.
A coroner said it was “probable there was no realistic opportunity to prevent her death” and filed a Prevention of Future Deaths Report, raising concerns there was not a “clearly defined pathway” for patients to transition from child and adolescent to adult mental health services.
Chloe’s mother, Kirsten, said she wanted “accountability for the failures” and her daughter’s legacy to be one of “change”.
Humber Teaching NHS Foundation Trust maintained that the coroner found “no evidence of causation attributable to us” but said it welcomed an opportunity to “share any further learnings”.
An inquest into Miss Barber’s death last month heard the teenager was referred to the Child and Adolescent Mental Health Services (CAMHS) in 2017 after her first attempt to self-harm when she was bullied at school.
According to senior coroner Prof Paul Marks, Miss Barber had a history of taking multiple overdoses and was an inpatient at psychiatric hospitals in Hull and Sheffield after being sectioned under the Mental Health Act.
Miss Barber was “adamant in her refusal to engage with adult mental health services” and returned home in July 2021 after a successful appeal to be discharged.
She died four months later.
In his report, Prof Marks raised a number of issues which “may have contributed to her death”, including the decision to stop a treatment that “may have more than minimally, trivially or negligibly resulted in increased emotional instability leading to impulsive behaviour” near the time of her death.
He also noted “considerable uncertainty and ignorance” for the provision of support measures and aftercare, and said the lack of a clearly defined pathway was a nationwide issue.
“There was also valid concern about the lack of documentation and poor communication between services and partner organisations,” he said.
Family handoutMrs Barber said: “They were supposed to be professionals. They just thought of Chloe as a name on a piece of paper.
“I’m not sure really what will happen or if anything will change.”
Pleading for accountability, she said: “Don’t we as a family have the right to that, at least?
“What are they going to do about the clear lack of transition from adolescent to adult services?
“I want Chloe to have a legacy for change and to make sure that any other vulnerable person has a clear pathway from adolescent to adult services.”
The NHS trust said: “As always, our organisation remains committed to continually learning and making meaningful improvements to the safety and quality of the care we provide.”
The Department of Health and Social Care said it would consider the coroner’s report fully before responding after admitting youngsters transitioning to adult services “have not always been getting the care they need where they need it”.
NHS England has been approached for comment.
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