Tragedy as brother, 15, finds sister, 18, dead at home after she ‘slipped through the gaps' in NHS care

The Sun

4 days ago

TEENAGE Chloe Barber was found dead at home by her 15-year-old brother after "slipping through the gaps" of NHS mental health care.
The "bright, brilliant and beautiful" 18-year-old from Driffield, East Yorkshire, struggled with her mental health after being cruelly bullied at school and on social media.
In 2017, Chloe overdosed on pain relief medication and was referred to the Child and Adolescent Mental Health Services (CAMHS).
Four years later, in November 2021, Chloe's body was found by her 15 year-old brother after she ended her own life.
Her heartbroken family say the teen was left with a "complete lack of support" as she came of age and tried to transition from child to adult mental health services.
"Chloe was passed from pillar to post and we lost her because she was allowed to slip through gaps in the system," they stated.
Two reports commissioned following her death - including a serious Incident report by Humber Teaching NHS Foundation Trust and an independent Safeguarding Adults Review (SAR) - found a string of mental health service failings, which may have contributed to her death.
A coroner who examined Chloe's case found there was not a "clear path" for patients to transition from child and adolescent to adult mental health services,
He intends to issue a Prevention of Future Deaths report to protect other teens in Chloe's position.
"It's difficult to put into words the kind of person Chloe was," her family said in a statement.
"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 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.
"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."
After being referred to CAMHS in 2017, Chloe continued to struggle with her mental health for the next four years.
She made another attempt at self harm in 2018 and had stays in several psychiatric units.
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In early 2021, she was sectioned under the Mental Health Act and hospitalised at Cygnet Hospital in Sheffield, where she remained until July.
Chloe was diagnosed with unstable personality disorder "evolvingly unstable personality disorder", characterised by "difficulties on how an individual feels about themselves and is associated with impulsive behaviour", per the BBC.
But her family claimed they weren't informed of her diagnosis or how they could support her.
Chloe was due to transfer to adult mental health services but struggled to engage with CAMHS and the Complex Emotional Needs Service (CENS).
Just before her eighteenth birthday, she request that her medication be reviewed.
But her family claimed: "This never took place as no one in any service took responsibility for who would be responsible for managing and monitoring Chloe's medication in the community.
How to get help
EVERY 90 minutes in the UK a life is lost to suicide
It doesn't discriminate, touching the lives of people in every corner of society – from the homeless and unemployed to builders and doctors, reality stars and footballers.
It's the biggest killer of people under the age of 35, more deadly than cancer and car crashes.
And men are three times more likely to take their own life than women.
Yet it's rarely spoken of, a taboo that threatens to continue its deadly rampage unless we all stop and take notice, now.
If you, or anyone you know, needs help dealing with mental health problems, the following organisations provide support:
CALM, www.thecalmzone.net, 0800 585 858
Heads Together, www.headstogether.org.uk
HUMEN www.wearehumen.org
Mind, www.mind.org.uk, 0300 123 3393
Papyrus, www.papyrus-uk.org, 0800 068 41 41
Samaritans, www.samaritans.org, 116 123
"She became so frustrated with the 'faffing around' that she told them not to bother."
Iftikhar Manzoor, a senior litigation executive at Hudgell Solicitors who represented Chloe's family, added: "When she was discharged from children's mental health care and into adult care, she was effectively abandoned without a full assessment or care plan being devised and without any appropriate support being offered to her family.
"Just a week before she took her own life, her father reported an incident of serious self-harm, which left her needing hospital treatment, and yet she was still not referred to Vulnerable Adults Risk Management."
This is a forum that could have considered Chloe's case from a safeguarding perspective.
Following her death, an independent SAR review flagged a number of failures from Humber Teaching NHS Foundation Trust regarding Chloe's care.
This included a failure to assess and consider Chloe's need for aftercare services and a failure to ensure Chloe had an updated safety plan for use in the community.
The SAR also identified failures in relation to the local authority including failure by adult social care to accept Chloe's referral and failure by Children's services to re-refer Chloe to adult social care when she turned 18.
Senior coroner Professor Paul Marks, who conducted an inquest in Chloe's death, said there was a 'lack of documentation and poor communication between services and partner organisations'.
But he concluded that, on the balance of probabilities, these failures and missed opportunities only minimally contributed to Chloe's death.
While "many matters were true or partially true, no causation flows from them", he said.
"The unpredictability of impulsive behaviour with evolving emotional personality disorder coupled with services offered makes it probable there was no realistic opportunity to prevent her death," the coroner concluded.
Depression... the signs to look for and what to do
Depression can manifest in many ways.
We all feel a bit low from time to time.
But depression is persistent and can make a person feel helpless and unable to see a way through.
They may also struggle to about daily life.
Mind says these are some common signs of depression that you may experience:
How you might feel
Down, upset or tearful
Restless, agitated or irritable
Guilty, worthless and down on yourself
Empty and numb
Isolated and unable to relate to other people
Finding no pleasure in life or things you usually enjoy
Angry or frustrated over minor things
A sense of unreality
No self-confidence or self-esteem
Hopeless and despairing
Feeling tired all the time
How you might act
Avoiding social events and activities you usually enjoy
Self-harming or suicidal behaviour
Difficulty speaking, thinking clearly or making decisions
Losing interest in sex
Difficulty remembering or concentrating on things
Using more tobacco, alcohol or other drugs than usual
Difficulty sleeping, or sleeping too much
No appetite and losing weight, or eating more than usual and gaining weight
Physical aches and pains with no obvious physical cause
Moving very slowly, or being restless and agitated
If you feel this way, visit your GP who can help you.
If you, or anyone you know, needs help dealing with mental health problems, the following organisations provide support.
The following are free to contact and confidential:
Samaritans, www.samaritans.org, 116 123, [e-mail]
CALM (the leading movement against suicide in men) www.thecalmzone.net, 0800 585 858
Papyrus (prevention of young suicide) www.papyrus-uk.org, 0800 068 41 41
Shout (for support of all mental health) www.giveusashout.org/get-help/, text 85258 to start a conversation
Mind, www.mind.org, provide information about types of mental health problems and where to get help for them. Email [e-mail] or call the infoline on 0300 123 3393 (UK landline calls are charged at local rates, and charges from mobile phones will vary).
YoungMinds run a free, confidential parents helpline on 0808 802 5544 for parents or carers worried about how a child or young person is feeling or behaving. The website has a chat option too.
Rethink Mental Illness, www.rethink.org, gives advice and information service offers practical advice on a wide range of topics such as The Mental Health Act, social care, welfare benefits, and carers rights. Use its website or call 0300 5000 927 (calls are charged at your local rate).
A spokesperson for the Humber Teaching NHS Foundation Trust told Hull Live: '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.'
'Worrying gaps in the system'
Chloe's family said in a statement: "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 eighteenth 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."
Mr Manzoor added: "Chloe and her family were completely failed by mental health services.
"Chloe was a vulnerable young person with a history of serious mental health issues that made her a clear risk to herself.
"She had made repeated attempts on her own life, had avoided taking medication which helped her and she had repeatedly talked of ending her life.
"Her family were perplexed and concerned that after several years of support and treatment, including inpatient admissions to hospitals, Chloe was deemed at the age of 18 to be able to decline all services, despite the risk she posed to herself and her history of self-harm.
"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.