THIS REPORT IS BEING SENT TO: NHS England, PO Box 16738, Redditch, B97 9PT.
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CORONER I am Nicholas Rheinberg assistant coroner, for the coroner area of Wiltshire and Swindon
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CORONER’S LEGAL POWERS I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013.
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INVESTIGATION and INQUEST On 12th March 2020 an inquest was opened into into the death of Alice, Sarah, Dearden (Alice) aged 19. The investigation concluded at the end of the inquest on 28th April 2026. The conclusion of the inquest was that Alice died by suicide [REDACTED].
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CIRCUMSTANCES OF THE DEATH Alice suffered from mental health difficulties as a result of anorexia nervosa and emotionally unstable personality disorder. Her conditions resulted in acts of self-harm which included overdoses. From the age of 16 Alice came under the care of Child and Adolescent Mental Health Services. Her relationship with the health professionals in the CAMHS team was good and her progress was encouraging. Alice did not respond well to the transfer from CAMHS to Adult Mental Health services, she lost faith in the process of mental health delivery and as a result her mental health suffered. The evidence showed that commissioning restrictions meant that after her 18th birthday funding was no longer available for services hitherto delivered by CAMHS. The lack of an ability to more gradually wind down therapy delivered by CAMHS whilst taking up therapies from Adult Mental Health services prejudiced a smooth transition which in turn adversely affected Alice’s mental health. An expert to the inquest concluded that it is not always possible to orchestrate a gradual transition from child to adult mental health services to coincide with the individual’s 18th birthday and that the artificiality of setting the age of 18 as a rigid cut off date could prejudice recovery in certain cases.
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CORONER’S CONCERNS During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you.
The MATTER OF CONCERN is as follows. Evidence received at the above inquest suggested that commissioning mental health provision for children and adolescents with a strict cut off date of the individual’s 18th birthday could be prejudicial to mental health in certain circumstances.
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ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe your organisation has the power to take such action.
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YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 25th June 2026. I, the coroner, may extend the period.
Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed.
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COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons Alice’s family, South Wilts Grammar School, Avon & Wiltshire Mental Health Partnership NHS Trust, Wiltshire Council, Oxford Health NHS Foundation Trust and Red Jackets
I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it.
I may also send a copy of your response to any other person who I believe may find it useful or of interest.
The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest.
You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response.
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Dated this 29th day of April 2026 NICHOLAS RHEINBERG
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