• Healthcare Safety Investigation Branch publishes interim bulletin into child and adolescent mental health services
  • The safety watchdog has flagged up safety concerns into how young people with mental health problems are transitioned into adult services
  • It said the variation in how this was managed was a safety issue
  • HSIB will continue its investigation and publish a full report in due course

The safety of young people with mental health problems is at risk due to the inconsistent way they are being transitioned into adult services, the new safety watchdog has warned.

The Healthcare Safety Investigation Branch has published its interim bulletin into the transition from child and adolescent mental health services to adult mental health services today.

It follows the branch’s investigation into a teenager who committed suicide within months of being transferred from CAMHS to adult services, and is the second into safety in the mental health sector.

The bulletin, shared with HSJ, identified a number of safety concerns about how children and young people are transitioned into adult services when they are old enough.

These were:

  • The transition pathway from CAMHS to AMHS;
  • The variation in commissioning, service design, delivery and regulation of the transition from CAMHS to AMHS; and
  • The benefits of learning from how other healthcare sectors manage transition from paediatrics to adult services.

The bulletin said: “The way in which mental health services are commissioned and delivered for young adults varies across England.

“Transitioning from CAMHS to AMHS is complex. Care provided by the two services often have very different thresholds for access.

“Some young adults may not be ready to transition to AMHS at 18 and benefit from additional short term support which may negate the need for AMHS.

“For those requiring longer term involvement with mental health services, the experience of AMHS can be very different from CAMHS, leaving patients vulnerable to a deterioration in their mental health or withdrawing from the services available to them.

“There is national guidance to support the transition process from CAMHS to AMHS. However, there is variance across England as to how mental healthcare for young adults is commissioned by specialist and local groups and how it is delivered by NHS trusts and other providers.”

HSIB was set up by health secretary Jeremy Hunt to investigate and provide system wide learning from errors.

HSIB has not named the patient or the trust, but is looking at system wide problems highlighted by the particular case.

The safety watchdog said the incident, which sparked the investigation was not an isolated event and it will publish a full investigation report with recommendations in due course.

The report said: “Through this investigation, there is the potential for the HSIB to develop an understanding of the variation in the commissioning and provision of mental health services for young adults and the way that transitions between CAMHS and AMHS impact the delivery of safe and effective care.

“The HSIB also considers that learning from child to adult transitions in the context of other complex and/or chronic illnesses, such as cardiac conditions or diabetes, may help to improve transitions into young adult mental health services.”