Alice Dearden

I am Nicholas Rheinberg assistant coroner, for the coroner area of Wiltshire and Swindon

On 12 th March 2020 an inquest was opened into into the death of Alice, Sarah, Dearden  (Alice) aged 19. The investigation concluded at the end of the inquest on 28 th April 2026. The conclusion of the inquest was that Alice died by suicide  [REDACTED].

Alice suffered from mental health difficulties as a result of anorexia nervosa and  emotionally unstable personality disorder. Her conditions resulted in acts of self-harm  which included overdoses. From the age of 16 Alice came under the care of Child and Adolescent Mental Health  Services. Her relationship with the health professionals in the CAMHS team was good  and her progress was encouraging. Alice did not respond well to the transfer from CAMHS to Adult Mental Health services,  she lost faith in the process of mental health delivery and as a result her mental health  suffered. The evidence showed that commissioning restrictions meant that after her 18 th birthday  funding was no longer available for services hitherto delivered by CAMHS. The lack of  an ability to more gradually wind down therapy delivered by CAMHS whilst taking up  therapies from Adult Mental Health services prejudiced a smooth transition which in turn adversely affected Alice’s mental health. An expert to the inquest concluded that it is not always possible to orchestrate a gradual transition from child to adult mental health services to coincide with the individual’s 18 th birthday and that the artificiality of setting the age of 18 as a rigid cut off date could  prejudice recovery in certain cases.

During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the  circumstances it is my statutory duty to report to you. The MATTER OF CONCERN is as follows. Evidence received at the above inquest suggested that commissioning mental health provision for children and adolescents with a strict cut off date of the individual’s 18 th birthday could be prejudicial to mental health in certain circumstances.

In my opinion action should be taken to prevent future deaths and I believe your organisation has the power to take such action.