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  • Prevention of Future Deaths report – Daniel France (16 February 2022)

    Patient Safety Learning
    • UK
    • Reports and articles
    • Pre-existing
    • Public domain
    • No
    • Coroner, Philip Barlow
    • 16/02/22
    • Health and care staff, Patient safety leads


    On 8 April 2020 the coroner commenced an investigation into the death of Daniel France, age 17.

    Danny was 17 years old and was living at a YMCA hostel. He was on medication for depression and had been referred to secondary mental health services. He had made previous suicide attempts. On 3 April 2020 he took his own life. The medical cause of death was asphyxiation by hanging and the conclusion was suicide. 

    Danny was a vulnerable teenager: he had left home and was living in hostel accommodation; he had changed his GP practice; he was trans, had changed his name and had been referred to the Gender Identity Clinic; he had recently been discharged from secondary mental health services in Suffolk and had been referred to mental health services in Cambridge; he had previously been under CAMHS and was now being referred to adult mental health services; he had diagnoses of anxiety and depression and had been prescribed medication; he had made previous suicide attempts and had long term suicidal thoughts

    He had been assessed by First Response Service but had been considered as not requiring urgent intervention. Safeguarding referrals about Danny were made to Cambridgeshire County Council in October 2019 and January 2020. Both referrals were closed and it was accepted that the decision to close both referrals was incorrect. In December 2019 Danny’s new GP referred him to Cambridgeshire & Peterborough NHS Foundation Trust (CPFT). He had been seen by the Primary Care Mental Health Services but was still awaiting assessment by the Adult Locality Team at the time of his death. 


    Coroner's Matters of Concern

    • The concern in this case is that a vulnerable young person can be known to the County Council and Mental Health Trust and yet not receive the support they need pending substantive treatment. Danny was repeatedly assessed as not meeting the criteria for urgent intervention and yet the waiting list for psychological therapy was likely to be over a year from point of first presentation. That gap between urgent and non-urgent services is potentially dangerous for a vulnerable young person, where there is a chronic risk of an impulsive act.
    • Although I understand that there is a long term plan to extend young people’s services to age 25, but I remain concerned about the ongoing situation, and that a young person today could be faced with the same challenges in finding support pending substantive treatment.
    • I believe this concern is the combined responsibility of Cambridgeshire County Council and CPFT. These organisations may wish to consult in preparing their response to this report. The inquest heard evidence about the considerable delay in obtaining appointments for the Gender Identity Clinic, and about the shortage of availability for psychological therapies such as CBT. These are matters for policy and funding. This report will therefore be copied to NHSE and The Secretary of State for Health for information purposes only. 
    Prevention of Future Deaths report – Daniel France (16 February 2022) https://www.judiciary.uk/publications/daniel-france-prevention-of-future-deaths-report/
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