Chloe Barber’s family said the ‘bright’ and ‘caring’ 18-year-old was ‘passed from pillar to post’ by mental health services before her death
The family of a teenager said she was passed “from pillar to post” by mental health services before she took her own life.
A coroner has raised concerns regarding the transfer of care of 18-year-old Chloe Barber who took her own life in November 2021. The teenager, from Driffield in East Yorkshire, was first in contact with mental health services in 2017 after taking an overdose having suffered serious bullying at school and online.
After several spells in psychiatric wards at Humber Teaching NHS Foundation Trust, Chloe was hospitalised in early 2021 in Sheffield.
After returning home in July, she refused to engage with adult mental health services after turning 18. She died in November 2021.
While senior coroner Prof Paul Marks said there was probably “no realistic opportunity to prevent her death”, he filed a Prevention of Future Deaths Report.
In the report, he warned the lack of a “clearly defined pathway” between Child and Adolescent Mental Health Services (CAMHS) and adult mental health services is a nationwide problem, reports Yorkshire Live.
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He said there was “valid concern about the lack of documentation and poor communication between services and partner organisations” and expressed further concerns about the provision of aftercare services, such as the lack of a care programme, capacity assessments, and the Vulnerable Adults Risk Management process.
He also said stopping taking antipsychotic drug aripiprazole “may have more than minimally, trivially or negligibly resulted in increased emotional instability leading to impulsive behaviour”.
In a statement, Chloe’s family said she was “passed from pillar to post” and they lost her because “she was allowed to slip through gaps in the system”.
They added: “There was a multitude of social workers and mental health professionals assigned to her case in a short period of time, and there was no clear protocol or process in place that could be followed when Chloe was due to transition from CAMHS to Adult Services following her 18th birthday.
“There was a consistent lack of record-keeping and information sharing between services, which we feel is utterly unacceptable.
“Consequently, important information that highlighted Chloe’s risk of harm to herself was not identified. We feel there was a complete lack of support for the family throughout, particularly when Chloe was discharged from inpatient services into the community.
“We were never informed about Chloe’s diagnosis of emerging unstable personality disorder, what that meant or how we could support Chloe.”
The statement continued: “It’s difficult to put into words the kind of person Chloe was. She was amazing, bright, brilliant, beautiful, caring and stubborn. A truly wonderful young lady. She loved all kinds of music and was always wearing headphones. She was always dancing around wherever she was to the song Pocketful of Sunshine.
“She was a gifted artist and loved drawing, and we always proudly displayed her artwork on the walls of our family home. She loved to shop, spending all her money in Primark and loved animals, especially her pets and her dog, Chester. Our hearts have been broken beyond repair since she left us, but we are so proud of Chloe and grateful for the time we had her in our lives.”
Chloe’s family were represented by Iftikhar Manzoor and Soraya Mehdizadeh, of Hudgell Solicitors. Mr Manzoor said Chloe and her family were “completely failed by mental health services”.
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He said Chloe was “effectively abandoned” when she was discharged from children’s services into adult care without a full assessment.
He added: “This is a case which has exposed worrying gaps in the system. Turning 18 does not make somebody with a serious mental health illness suddenly able to make decisions in their own best interests.
“Once Chloe was discharged from mental health care, her family were left fearing the worst would happen, and it did.”
A spokesperson for the Humber Teaching NHS Foundation Trust said: “The coroner’s inquest conclusion found no evidence of causation attributable to the Trust and acknowledged that any learnings taken from the case have already been embedded effectively by the Trust.
“We would like to thank HM Senior Coroner for his careful and thorough consideration of the circumstances surrounding the sad death of Chloe Barber, a patient discharged from our care in 2021.
“Our organisation remains committed to continually learning and making meaningful improvements to the safety and quality of the care we provide. Our thoughts and heartfelt condolences are extended to Chloe’s family and loved ones.”
For confidential support, Samaritans can be contacted for free around the clock 365 days a year on 116 123.