An east London coroner has issued a stark warning to the Health Secretary, stating that preventable child suicides are likely to increase unless the government provides urgent and sustained funding for mental health services.
Nadia Persaud, the coroner who led the inquest into the death of 12-year-old Allison Aules, wrote to Health Secretary Steve Barclay following the conclusion of the inquest in July 2022. In her report, she stressed that similar tragedies could occur “unless action is taken.”
At the conclusion of the inquest, Coroner Persaud identified a series of serious failures by North East London NHS Foundation Trust (NELFT) that contributed to Allison’s death.
In her formal verdict, she stated:
Allison didn’t receive the mental health care which she should have received, and I find that the absence of care contributed to her death.
Nadia Persaud
As a result, the inquest raised serious concerns about the standard of mental health care available to children and young people.
In a strongly worded Prevention of Future Deaths report, Coroner Persaud identified the under-resourcing of Child and Adolescent Mental Health Services (CAMHS) as a significant contributing factor.
The report, addressed to the Health Secretary, NHS England, and two Royal Colleges, highlighted:
Importantly, Persaud made clear that these issues were not isolated to one trust. Instead, she described under-resourcing in CAMHS as a national concern affecting services across England.
The inquest revealed that Allison’s mental health deteriorated significantly during the Covid-19 lockdown. Her school referred her to NELFT in May 2021 due to concerns including:
However, despite the seriousness of these concerns, Allison waited nine months for an assessment. Tragically, she never received any face-to-face mental health treatment.
Coroner Persaud noted that such delays were common within CAMHS, particularly during and after the pandemic.
The inquest also found that Allison was inappropriately discharged from services just weeks before her death. This decision involved a management-led initiative aimed at reducing a large backlog of cases created during the pandemic.
Persaud strongly criticised this approach, especially given the scale of demand. At the time, the region was receiving around 140 CAMHS referrals per week, compared with just 10–12 referrals per week in the 2010s.
Coroner Persaud warned that unless CAMHS services receive proper funding and staffing, future child deaths are likely to occur. She emphasised that rising demand combined with ongoing under-resourcing creates an unsafe system for vulnerable children.
Under the Coroners and Justice Act 2009, the Health Secretary and NHS England have been given until 25 October to respond. They must explain:
If no action is proposed, they must provide clear reasons why.
The Department for Health and Social Care expressed its condolences to Allison’s family. It also confirmed a commitment to invest an additional £2.3 billion per year into mental health services by 2024.
According to the government, this funding aims to enable an extra 345,000 children and young people to access NHS-funded mental health support. The department stated that it is carefully considering the coroner’s recommendations and will respond within the required timeframe.
If you have lost a loved one due to inadequate mental health care, you may be entitled to pursue a medical negligence claim. You may also need support during the inquest process to understand what went wrong.
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