Prevention of Future Deaths report - Sky Rollings (16 October 2021)

Summary

Sky Rollings had been diagnosed with Emotionally Unstable Personality Disorder (EUPD) and was sectioned under the Mental Health Act. She was transferred from a Children and Adolescent Mental Health Hospital to the Acute Adult Unit at the Harplands Hospital on 4 November 2019. She died on 9 November at the Royal Stoke University Hospital.

Content

In her report, the Coroner raised the following concerns:

1. During the inquest, evidence was heard about the differences in the way CAMHS Hospitals and Adult mental Health Hospitals approached the care of the patients on their wards. When hearing evidence during the inquest it was established that when a child turned 18, and was a patient on a Mental health ward, once transferred to an adult Mental Health Hospital they would immediately be treated in accordance with the adult provisions.
2. It was accepted that there is currently no one in-patient provision for people between the ages of 14-25. It was also accepted that simply because a child becomes 18 does not mean that they are an adult. The lack of this provision in a mental health in-patient setting leads me to conclude that there is a risk of further deaths resulting. 

This report has been sent to The Huntercombe Group Limited and the Care Quality Commission.