An 18-year-old was "passed from pillar to post" by mental health services before taking her own life, her heartbroken family said. Chloe Barber from Driffield in East Yorkshire died in November 2021 after being failed by systemic gaps in mental health care transitions.
Senior coroner Prof Paul Marks filed a Prevention of Future Deaths Report highlighting nationwide problems with the transfer between child and adult mental health services. He said there was probably "no realistic opportunity to prevent her death" but identified serious systemic failures that need addressing.
Mental health system failures
Chloe first contacted mental health services in 2017 after taking an overdose following serious bullying at school and online. After several spells in psychiatric wards and hospitalisation in Sheffield in early 2021, she returned home in July but refused to engage with adult mental health services after turning 18.
The coroner warned about the lack of a "clearly defined pathway" between Child and Adolescent Mental Health Services (CAMHS) and adult mental health services as a nationwide problem, according to Yorkshire Live. He expressed concerns about poor documentation, communication failures between services, and inadequate aftercare provision.
The coroner also noted that stopping the antipsychotic drug aripiprazole "may have more than minimally, trivially or negligibly resulted in increased emotional instability leading to impulsive behaviour".
Family left without support
Chloe's family said they were never informed about her diagnosis of emerging unstable personality disorder, what it meant, or how they could support her. There was a "multitude of social workers and mental health professionals assigned to her case in a short period" with no clear protocol for the transition to adult services.
The family described "a consistent lack of record-keeping and information sharing between services" which meant important information about Chloe's risk of self-harm was not identified. They said there was "complete lack of support for the family throughout, particularly when Chloe was discharged from inpatient services into the community".
'Amazing, brilliant and beautiful'
"It's difficult to put into words the kind of person Chloe was," the family said. "She was amazing, bright, brilliant, beautiful, caring and stubborn. A truly wonderful young lady." They described how she loved music, was always wearing headphones, and danced to "Pocketful of Sunshine".
Chloe was a gifted artist whose work was proudly displayed on the family home walls. She loved shopping at Primark and her pets, especially her dog Chester. "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," the family said.
Legal response and trust statement
Chloe's family were represented by solicitors Iftikhar Manzoor and Soraya Mehdizadeh, of Hudgell Solicitors. Manzoor said Chloe was "effectively abandoned" when discharged from children's services without proper assessment.
He said the case "exposed worrying gaps in the system" and noted that "turning 18 does not make somebody with a serious mental health illness suddenly able to make decisions in their own best interests". Once Chloe was discharged from mental health care, her family were left fearing the worst would happen, and it did.
Humber Teaching NHS Foundation Trust said the coroner found "no evidence of causation attributable to the Trust" and that learnings from the case have been "embedded effectively". The trust extended "thoughts and heartfelt condolences to Chloe's family and loved ones".
For confidential support, Samaritans can be contacted for free around the clock 365 days a year on 116 123.
Sources used: "Manchester Evening News", "Yorkshire Live" Note: This article has been edited with the help of Artificial Intelligence.
