suicideThere is a “shocking” lack of a coherent system in place for the recording, monitoring and publication of deaths of children receiving in-patient mental health care across England and Wales, research has found.

Research by INQUEST has found that at least 9 children died while receiving in-patient psychiatric care between 2010 and 2014. But the true number of deaths is likely to be higher as many bodies that provide in-patient services either refused to provide data when requested or said they did not hold the information requested, INQUEST added.

INQUEST submitted a series of Parliamentary Questions and conducted a wide-scale Freedom of Information (FoI) exercise to all relevant government departments, public bodies, NHS trusts and private providers involved in the provision and management of child and adolescent mental health services (CAMHS) in England and Wales. INQUEST sent out 245 FoI requests seeking information for the period 2010 to 2014, but report that this failed to produce any clear picture of the number or circumstances concerning the deaths of children receiving mental health in-patient care. 

Tonight [April 11], BBC Panorama will tell the story of Sara Green, a child who died in a mental health setting. The programme will reveal the evidence collated by INQUEST about the lack of accurate data on the number of child in-patient deaths in mental health settings.  

Key findings from INQUEST’s research include that:

• No single body is responsible for recording the deaths of children who died as mental health in-patients. This crucial information is neither collated nor analysed or made public by any one body or government department

• Despite running 47% of in-patient CAMHS, private providers refused to answer the FoI requests, responding that as private providers the Freedom of Information Act does not apply to them

• There is no system in place requiring an independent investigation of child deaths, with almost all deaths investigated by the same institution where the death occurred. This prevents the additional transparency and external scrutiny which would come from an independent investigation. 

Panorama follows the case of 17-year-old Sara Green who died in 2014 at the privately-run Priory Group Cheadle Royal Hospital in Cheshire. INQUEST has worked with Sara’s family since her death. At Sara’s inquest, the Coroner concluded that a lack of appropriate NHS placement and a failure to manage her discharge from the Cheadle Royal was a contributory factor to the act of self-harm that ended her life. Sara’s family have contributed to Panorama in order to highlight the poor care Sara received by CAMHS and the Priory. It points to serious concerns about the current state of mental health provision for children and young people. 


Deborah Coles, INQUEST director, said: “Sara Green was a vulnerable child failed by a mental health system that was supposed to protect her. Every day we are hearing about mental health services for children and young people in crisis. The tragedy is that Sara’s story is not an isolated one as we know from our casework. That the Government does not know how many children are dying in mental health settings is truly shocking. This is yet another disturbing feature of a system failing our children in mental health need. 

“How can we ensure learning and improvement so urgently needed across children’s mental health services without the knowledge and robust examination of the circumstances of these young deaths. The government must act now to ensure effective systems of scrutiny and accountability for the public and private bodies responsible for the treatment of vulnerable children in their care.”

Jane Evans, Sara Green’s mother, added: “The system both Sara and I trusted to provide the help she needed cruelly let her down, with devastating consequences. Sara's case highlights the shocking reality of a child and adolescent mental health system that is not only wholly unacceptable, but quite frankly dangerous.

“INQUEST assisted us in getting a thorough inquiry into what happened to Sara and it is my hope that public exposure of Sara's story will initiate a much needed national debate and ultimately force the government to implement necessary changes to prevent any more child deaths in mental health settings.”

In a statement, released to the BBC, Alastair Burt, minister for community and social care for England, said: "Panorama's investigation has unearthed questions about record-keeping and I'm seeking assurances from NHS England that they have the right processes in place for recording any such death and that lessons are learned."