HSIB investigation report mental healthThis investigation followed the Healthcare Safety Investigation Branch being notified of an 18-year-old who died by suicide shortly after transitioning from child and adolescent to adult mental health services. The investigation identified possible issues regarding the transition process.

This second report is the culmination of many months of rigorous and independent investigation, working closely with the organisations involved in the incident, as well as relevant organisations, and subject matter experts.

A series of different methodologies were used which included: review of records, policies and procedures, and practice relating to transitioning of young people into adult services, and the identification of the needs of individual young people and the response to those needs.

A focus group involving up to 14 young people who had either transitioned from CAMHS to AMHS or were in the process of transitioning provided the investigation with a lived experience of the issues and concerns for young people and where services were not meeting their needs.

If you would like to view the full investigation report click here

If you would like to view the Executive Summary please click here