Mental Health Services Under-Resourced ? Yes ! Suicide Prevention Minister And Related Reports Covering The Meltdown

For issues specific to caring for someone with mental ill health.
NHS England loses 6,000 mental health nurses in 10 years.

Recruitment and training crisis " Hits the most vulnerable in society ", says Royal College of Nursing.


The number of mental health nurses in England has slumped by more than a tenth over the past decade, new figures have revealed. This is despite commitments from both Theresa May and her predecessor, David Cameron, to boost resources for mental health services, which many medical professionals say are now in crisis.

The total mental health nursing workforce has decreased by 10.6% since 2009, according to the Royal College of Nursing (RCN).

While numbers of mental health nurses have grown in some areas, such as community care, they have fallen elsewhere. Numbers are down by a quarter (25.9%) in acute care and inpatient care – where the number of mental health nurses has fallen by more than 6,000 over the decade.

Donna Kinnair, appointed as RCN chief executive and general secretary last month, will use a speech to the group’s annual congress on Monday to call on ministers to address England’s 40,000 nursing vacancies, and point out the new figures on the reduction in specialist mental health nurses.

“Thousands of experienced professionals have been lost in recent years as the investment failed to match the rhetoric,” she will say.

“The shortage of beds, too, leaves vulnerable people often sent hundreds of miles from home and their loved ones for the care they need. As a country and a health service, we are letting down people who must be able to rely on us most.

As a country and a health service, we are letting down people who must be able to rely on us most. We must draw a line under this and allocate serious resources to mental health care, including the right number of staff.”

Senior medics are also warning privately of frontline problems in some areas. Some hospitals have had to temporarily close beds because of staff shortages, with some wards threatened with closure.

There have already been warnings of a postcode lottery, with some regions having little more than half the resources of the best-funded. According to research from the charity Mind, the average annual spend on mental health services per head of population is £124.48 in parts of Surrey, compared with £220.63 in South Yorkshire.

A drive to recruit more mental health specialists as part of the long-term NHS plan announced earlier this year supports premiums for undergraduates studying the subject or learning disability nursing. The scheme targets mature students and aims to have an additional 4,000 people in training by 2023-24.

Department of Health officials said they were aware of the challenges involved in recruiting the numbers needed to meet targets for improving mental health care. Applications for nursing degree courses have plummeted by 32% since bursaries were scrapped in England in 2016.

The RCN figures demonstrate the continuing pressures on the NHS. There are also complaints that major delays to government plans to tackle adult social care are adding to those pressures. According to information released to Labour under the Freedom of Information Act, more than 28,000 people are sent into residential care away from their home area every year – in one case a person was more than 500 miles from their home authority. The research found that working age adults are disproportionately likely to be sent away for care, with more than one in three being in a care home outside their home area.

A department spokesperson said: “Expanding the mental health workforce across the NHS is a key priority and we’re committed to recruiting and retaining nurses – part of our plan to transform mental health provision with an additional £2.3bn a year investment as set out in the NHS Long Term Plan.

“We’re supporting students to embark on more flexible undergraduate degrees in mental health or learning disability training with an ambition of an extra 4,000 people in training in five years’ time.”
" Why are children in London worth three times more than those in Norfolk and Suffolk ? " - Mental health governors.



Governors at the region's mental health trust have demanded answers over why spending on children in London is more than three times that on those in the east,

A report from the Children's Commissioner last month revealed that children in the east of England have the least money spent on their mental health care in the country - just £5.32 per head compared to the highest of £17.88 per head in London.

Due to different definitions of services and interpretation of data the report recognised it was difficult to compare between regions.

But those elected to Norfolk and Suffolk Foundation Trust's Council of Governors have hit out at "unacceptable waiting lists and services" for children and asked what was planned to bring funding up to the national average of £14 per child for low-level care.

Low-level mental health services provide preventative and early intervention support for problems such as anxiety, depression and eating disorders.

In a letter sent to MPs and health and social care bosses co-lead governors Nigel Boldero and Howard Tidman said: "Putting things more directly, is the mental health of a London child considered to be worth more than three times that of a child living in Norfolk and Waveney?"

While they recognised some variations in cost, their letter said: "But it would seem unlikely that these are anywhere near the variants shown."

In Suffolk Richard Watson, deputy chief officer for NHS Ipswich and East Suffolk and NHS West Suffolk clinical commissioning groups, said they had reassured the governors and outlined "significant spending increase" in the past few years.

He said: "Our investment in mental health has equalled, and in many years exceeded, our growth in resources."

For 2019/20 the CCGs planned to spend £9.758m on services, up from £6.845 in 2016/17.

While in Norfolk and Waveney, bosses said they were writing to MPs and governors and added: "It is difficult to effectively compare spend on services due to different ways of reporting and monitoring expenditure within commissioning organisations."

But a spokesman said £33m had been put into all children's mental health services, with another £1.1m promise for 2019/2020.

He added: "Finance is only one important element of service improvement. We have undertaken a review of children and young people's mental health provision and are now working to transform services, to make it easier to find help and to enable us to increase the number of children and young people who are able to access help and treatment."

Since receiving the letter Norman Lamb, MP for North Norfolk, has written to health secretary Matt Hancock and other health and social care leaders, asking for clarification on spending and how to address the shortfall.

He said: "I am dismayed that such huge variations in spend on children's mental health support occur from region to region.

"It is wholly unacceptable that children and young people face a postcode lottery when it comes to receiving the support and care they deserve and are entitled to.

"Our children and young people across the region deserve to have access to mental health support.

"At present they are being badly let down."

The children's commissioner, Anne Longfield, said last month: "Those who are accepted for treatment often have to wait months for help, children have even told me they had to threaten to take their own life before they managed to access treatment. This situation has to change."

Researchers found nationally £226m was allocated for low-level services in 2018/19, just over £14 per child.

Around half of this funding comes from local authorities (LAs) and half from NHS sources.

In 2018/19, the top 25pc of local areas spent £1.1m or more on low-level mental health services, while the bottom 25pc spent £177,000 or less.
Children in Norfolk's feel they're " Swinging on a chair about to fall " - report into mental health.

Only a complete overhaul of children's mental health services would have a shot at stopping long waiting times and youngsters being " Bounced between " services.



That was the conclusion of a report into children and young people's (CYP) mental health services in Norfolk and Waveney.

The report said there had been suggestion that money which had been meant for children's mental health care had been held back to help organisations balanced the books.

But Rebecca Hulme, chief nurse at Great Yarmouth and Waveney Clinical Commissioning Group (CCG) denied this was the case and said all £1.9m extra a year put aside for CYP services had been spent in the area.

The report, commissioned by the county council and NHS also found:

- Relationships between providers and those holding the purse strings were "very poor";

- Those on the frontline line had significant concerns about the closure of children's centres in Norfolk;

- And Norfolk County Council children's services department boss could now take over the overall running on CYP mental health services in the area.

The report, which was carried out by consultancy Rethink Partners - not to be confused with the mental health charity of a similar name - also found there was considerable tension between the vast number of players in the CYP system, and a "reluctance to surface and address difficult or contentious issues".

But Sara Tough, director of children's services at Norfolk County Council, said many of the issues highlighted had already been tackled and that bosses felt positive about the future vision.

She said: "Between the county council and the CCGs, we both felt we had done some good work around our local transformation plan for children's mental health, but it was not having the impact in terms of the preventative intervention we were hoping for, what we really wanted to do was be more creative."

Ms Tough said the idea was for the council and CCGs to work closer together, and already she had been heading up work on CYP services.

Ms Hulme said: "We had initially some really excellent services but they were not connecting well.
A young woman suffering from depression is consoled by her friend. Photo: Time to ChangeA young woman suffering from depression is consoled by her friend. Photo: Time to Change

One of the biggest challenges for CYP services was money, and the report found there was "a clear perception that not all of the additional funds that were allocated for CYP mental health services were actually released, with some organisations holding funding back to offset wider financial pressures. There is a lack of transparency over this issue, causing considerable mistrust and some resentment across the system".

But Ms Hulme said this was not the case and that different commissioners had spent the money in different ways, while there had been confusion over whether this was extra money or not.

She said: "The funding that came through, that NHS funding, we had to find that in budgets."

She added: "The money is being spent, and I think there's been a lot of confusion."

Ms Tough also said problems identified in the report of organisations clashing had been fixed. She said: "I think we're already overcoming many of those issues simply by doing these pieces of work."

And she said by acknowledging organisations wanted to work together many of those walls were coming down.

But she stopped short of saying it was a merger, and added: "I think it would be different if we were talking about mergers."

Both Ms Tough and Ms Hulme said the criticism in the report did not come as a surprise, but both the county council and the NHS were keen for a new way forward.

Ms Tough's authority also came under scrutiny over the decision to close 38 of Norfolk's 53 children's centres, as the report revealed in several cases organisations had "significant concerns about the possible knock on impact of the proposals on other services".

Ms Tough said: "We are really excited about this, there is a lot of motivation to work together. That feels like a really positive place."

How do the children feel ?

One of the participants in a focus group, as part of the research, said: "You know when you're swinging on a chair? That moment where you're not sure if it's about to fall? That's how I feel, all day, every day."

The report found: "Children and young people in Norfolk and Waveney are overwhelmingly contemplating emotional and mental health issues in their daily lives.

They appear resilient on the face of it, but they have a perception that they need to 'deal' with issues themselves - in order to avoid burdening friends and family.

There is a dearth of opportunities for young people to discuss emotional wellbeing and to build resilience and skills and there is little knowledge on how to access support."

Meanwhile GPs reported being "exasperated" by the system, and staff delivering services "highly pressurised and in parts undervalued".

'This is not good enough'

Liz Wormald, a family support worker at Allsorts CIC in Lowestoft, said her experience of children and young people's mental health service drove her to start her own support groups.

Ms Wormald's 14-year-old daughter Holly struggled to get help to the extent that Ms Wormald and her husband had to take photographs of the self-harm wounds to try and get her into services. She said: "This is not good enough, we need to all work together, waiting times are horrendous."

She said that her daughter was able to hide her illness and would tell professionals she was okay, but that was not the case. However it led to her not getting the help she needed. She said: "Parents do need to take better responsibility and we need to stop CAMHS [children and adolescent mental health] bashing, but we also need the parent bashing to stop."

What does the future hold ?

The report said there was a "strong vision for the future [...] that breaks down traditional tiers, focuses on prevention and resilience and is driven by outcomes".

But at the moment this is not well understood, and there is not a clear way forward.

It was suggested that CYP mental health and children's services would work closer together, and the report writers suggested doing away with differentiating between services which provide less intensive support and more intensive support.

Ms Tough said: "I'm hoping children and parents will be able to say 'we don't experience lots of waiting times any more, we don't feel we are being pushed from one service to another service'."

Ms Hulme added: "We've all got that shared vision and outcomes. We will all be working towards the same end goal. I would hope the experience is a lot easier to access."
Mental health hospital where patients were secluded in unfurnished, unsafe rooms, rated inaequate by watchdog.

CQC has given 12 previous warnings about unjustified use of segregation where staff found patients' behaviour too challenging.


Vulnerable patients at one of England’s largest charity-run mental health hospitals were kept in unsafe seclusion rooms for excessive amounts of time and without beds, blankets or pillows, a damning report has found.

The Care Quality Commission (CQC) has rated adolescent mental health services at St Andrew’s Healthcare hospital in Northampton ”inadequate”.

It has given the charity six months to turn around services at FitzRoy House, a specialist centre for up to 100 young people with mental health, learning disabilities and autism, or it will lose its registration.

Inspectors found “the majority of seclusion rooms” lacked basic furnishings, and examples of patients’ dignity not being respected.

This included an occasion where a female patient's clothes were changed in the presence of male staff.

The CQC said there were safety risks posed by sharp edges in seclusion rooms, CCTV blind spots and lapses in checks on cutlery which could cause patients harm.

“We were particularly concerned about how the service responds to patients whose behaviour staff find challenging,” said CQC deputy chief inspector of hospitals Dr Paul Lelliott after finding multiple examples of patients kept in seclusion longer than necessary without adequate reviews.

This is the third inspection of the service in three years and Dr Lelliott said “in some important respects the safety of care had deteriorated”.

"On one occasion, staff did not respect a patient’s privacy and dignity when changing her clothing.” Dr Lelliott added. “While female staff were present, there were also male staff there at the time. It was the inspection team’s view that this was uncaring, undignified and disrespectful to the patient."

The report comes after concerns about the use of restraint and seclusion at the hospital in the wake of a patient Ayla Haines trying to kill herself by swallowing a toothbrush.

There have also been calls for a England-wide review of the use of long term seclusion and inpatient care for people with learning disabilities after revelations of abuse at privately run Whorlton Hall Hospital.

The inspection of St Andrews Healthcare also found some examples of outstanding care, including a wide range of facilities and support for LGBTQ+ patients and staff from diverse backgrounds.

The charity said it addressed many of the safety issues identified at FitzRoy House and had closed the service to new patients temporarily while it made changes, including a review of seclusion and segregation across its sites.

“We deeply regret that we have fallen below the standards we aim to uphold, and those expected by the CQC,” Katie Fisher, chief executive, St Andrew’s Healthcare.

“We are confident that when the CQC returns to inspect the St Andrew’s Healthcare Child and Adolescent Mental Health Service in the next six months, they will see significant improvement that will be reflected in an improved rating.”
NHS England loses 6,000 mental health nurses in 10 years.

A quick look on the internet to help my caree, over 50 private pyschotherapists/councellors, generally you can get an appointment in a couple of days. But £40-£50 an hour.

That's where all the mental health staff are, you can work from home, do your own hours.

Nowadays you are just referred to a charity for councelling, just doesn't seem to exist through the NHS.

But you have to wait 24 weeks, thats about christmas, if you have the money you can get help straight away, if you haven't you have to wait clearly unfair
Charity criticises lack of parent-infant mental health teams.

NHS bodies are overlooking needs of at-risk children aged two and under, report says.


Families whose young children are at risk of developing mental health problems because the parents are struggling face a “shocking” lack of help from the NHS, a report says.

The charity Parent Infant Partnership (PIP) UK found that only a handful of health service bodies across the UK had a specialist parent-infant relationship team to help children in households where there was domestic violence, substance misuse or a parent who was mentally ill.

It said the absence of dedicated support for such families was “a source of disgrace”.

PIP has established there are just 27 specialist teams across more than 200 local NHS bodies in the UK.

Local councils believe around 20,000 babies in England alone are in need as a result of risks they face in the parental home.

PIP’s report says: “Parents-infant teams can transform the life chances of babies, yet the majority of babies live in an area where these services do not exist.”


The teams work with parents to help them develop loving, supportive relationships with their offspring at a time when babies are undergoing a vital period of brain development.

The Conservative MP Tim Loughton, a former children’s minister, backed the report’s findings and its call for the NHS to instigate an expansion of such teams.

“Parent-infant relationships are vital for children’s development. Parent-infant teams can enable all services in a local area to support these relationships better, as well as providing world-class therapeutic interventions for families who are struggling the most,” he said.

The report says NHS bodies that commission child and adolescent mental health services (CAMHS) “are overlooking the needs of the youngest children in their own right. In some areas commissioners do not commission any mental health services for young children.”

PIP found that CAMHS teams in 42% of clinical commissioning group areas of England do not accept referrals for children aged two or under. In more than a third (36%) of the CCG areas where CAMHS did accept such referrals, no children that age were accessing care.

“The statistics uncovered for this report are shocking and should be a source of disgrace, just as it would be if services excluded children because of other characteristics such as disability, race or sex, or if commissioners were failing to fund other services such as cancer services for young children,” the report says.

There are no figures for how many children aged two and under have any sort of mental health problem because children that age are too young to be diagnosed with a mental illness.

However, an in-depth study of children’s mental health published by NHS Digital last November said one in 18 children of pre-school age in England had at least one mental health disorder such as anxiety or depression.

The findings were the first to try to quantify the extent of such problems in under-fives. Overall., 11.2% of five- to 15-year-olds and 12.8% of five- to 19-year-olds have a mental health disorder, according to NHS Digital.

An NHS spokesperson said: “The NHS long-term plan clearly recognises the importance of early years care and is committed to creating a comprehensive, joined-up mental health service for nought to 25-year-olds, as well as ramping up specialist perinatal services to cover the first two years of a child’s life.

“While support for parents and carers to ensure babies and infants develop physically and mentally comes from a range of professionals including GPs, community paediatricians, health visitors and children’s services, we also need other partners such as local authorities to do their bit by investing in services.”
North Essex Partnership : Review ordered into mental health trust failings.

A national review has been ordered into " Significant failings " at a health trust dating back more than a decade.



The ombudsman found care shortcomings by the former North Essex Partnership University Trust (NEP) in the case of two vulnerable young men who died.

It uncovered a "systemic failure to tackle repeated and critical failings over an unacceptable period of time".

The trust's successor offered its sympathies and said it would support the review "in every way possible".

Rob Behrens, Parliamentary and Health Service Ombudsman, said the men had been "badly let down".

"The lack of timely safety improvements following their deaths is completely unacceptable and it's important the NHS understands why this happened and what lessons can be learned to prevent the same mistakes happening again."

The review, to be led by NHS Improvement, will consider whether to recommend a public inquiry.

Marjorie Wallace, chief executive of the mental health charity Sane, said the trust had shown "an almost cavalier attitude" to patient welfare.

"Little was done despite repeated criticisms and recommendations, some as fundamental as to remove ligature points, let alone take steps to change culture and practice and provide acceptable treatment," she said.

Sally Morris, chief executive of Essex Partnership University NHS Foundation Trust (EPUT), which took over from NEP in 2017, said the families had "our deepest sympathies".

She added: "We will carry out the Ombudsman's recommendations and will support NHS Improvement's forthcoming review into the former NEP in every way possible."

'Should never have died'

One of the cases reviewed was that of 20-year-old Matthew Leahy, who died from hanging at the trust's Linden Centre in November 2012.

It found failures in the trust's response when Mr Leahy reported being raped, said it did not write his care plan until after his death, and was "not open and honest" with his mother about safety improvements.

Mr Leahy's parents Melanie and Michael said his death had "left a void nothing can fill".

"Our son was ready to go travelling and celebrate his 21st birthday. He should never have died.

"Sectioned under the Mental Health Act, he was alone, scared and failed in the most appalling way by those entrusted with his care."

The ombudsman said the trust should apologise to Mrs Leahy and acknowledge its failings, explain how it would avoid them recurring and pay her £500 for having provided "inaccurate information" about safety changes in February 2015.

The trust said it was "very sorry indeed for the additional pain and distress" caused to Mr and Mrs Leahy.

The other case investigated by the Ombudsman was that of a man identified only as Mr R, who was admitted to the Linden Centre in 2008 with an early diagnosis of attention deficit hyperactive disorder (ADHD) and considered at risk of taking his own life.

The investigation found there were missed opportunities to mitigate the risk of him taking his own life, staff did not respond adequately when Mr R threatened to harm himself and the Trust failed to properly assess and manage risk.

Essex Police carried out an investigation into up to 25 deaths at the trust. Though the force found "basic failings", the case did not meet the threshold for corporate manslaughter.

The Health and Safety Executive continues to conduct a separate investigation into how the trust managed wards in relation to ligature points between October 2004 and March 2015.
NHS care providers left autistic children at risk of self-harm.

Inquiry finds needs of highly troubled under-18s in Staffordshire were neglected.


Potentially suicidal autistic children with mental health problems in Staffordshire have been left at risk of self-harm after receiving inadequate and unsafe care, according to a damning leaked internal NHS report.

An inquiry, sparked by parents’ serious concerns, found that the needs of highly troubled under-18s in the county were neglected as a result of significant failings in care provision by the two NHS-funded providers in the area.

The inquiry team’s unpublished 37-page report – seen by the Guardian – outlines how vulnerable young autistic people with problems including anxiety faced long delays in receiving specialist help and were repeatedly passed between different services. The two care providers argued over which of them was responsible for the child’s care, as one focused on autism and the other on mental health issues.

NHS clinical commissioning groups (CCGs) in Staffordshire commissioned the Northumberland Tyne and Wear (NTW) NHS mental health trust to review services for young people with autism in its area. It was triggered by longstanding criticism of two providers, Midlands Psychology (MP), which had a focus on autism, and Midlands Partnership NHS Foundation Trust (MPFT), from families.

The inquiry found that health professionals dealing with the young people did not carry out proper risk assessments, and did not record risky behaviour by them that showed they were in danger of harming themselves, even though under-18s with autism are at higher risk of trying to take their own life.

It also found that autistic youngsters who were experiencing a mental health crisis received poor support, despite that also raising their risk of self-harm or suicide.

The NTW experts concluded that: “We as a team did not feel that the current approach to risk assessment and management to be robust, co-ordinated or safe.”

They were so worried by what they found that as soon as their inspection ended last July, they wrote to the NHS bodies that brought them in urging them to order the two providers to take “immediate action” to tackle five areas of inadequate practice that, in their view, posed a risk of harm to young people, without waiting for its formal report to arrive.

The CCGs received the report last November, but have not published it. Families fear that the NHS is trying to suppress the “scandal” of autistic young people’s care. Despite the report making a raft of recommendations, little has changed, they claim.

Although the flaws in care were first identified in January 2015, they continued to cause problems and were still apparent during its three-day inspection of services last July, despite promises to eradicate them, the report from the evaluation team says.
MP and mental health campaigner Norman Lamb MP

“These are really alarming findings. It is deeply disturbing that families report that nothing has really changed seven months after the report was delivered to the CCGs, and the best part of a year after serious early concerns were first reported back [to them],” said the Liberal Democrat MP Norman Lamb, who was the minister for mental health in 2012-15.

Tom Madders, the campaigns director of Young Minds, said: “It’s deeply worrying that there are reports of failings in CAMHS [child and adolescent mental health services] care in Staffordshire, and it’s crucial that these are addressed. When children don’t get the help they need from mental health services, it can lead to problems getting worse unnecessarily.”

Tracey Hay claims she received very little help and faced long delays getting care when her son was in a mental health crisis, despite him tying ligatures around his neck and threatening to kill her. A member of the CAMHS team [at MPFT] told her to ignore him if he said he wanted to kill himself, she added.

The inquiry also found that either one or both providers were breaching a number of guidelines issued by NHS England, the Department of Health and National Institute for health and Care Excellence (NICE) to ensure or improve care for those with autism. For example, Midlands Psychology were diagnosing autism using an approach that did not have NICE’s backing “and nor is it effective in meeting the needs of young people with autism and clearly lacks a person-centred approach”.

Families of autistic children found Midlands Psychology “extremely difficult to contact by telephone” because its switchboard was only open between 9am and 1pm. That was not long enough and the social enterprise should extend that to at least 9am to 5pm, the team said. Despite the recommendation, the opening hours remain unchanged.

The report blames many of the problems on longstanding “difficulties” and “tension” between the two providers, who refused to treat certain patients, saying it was the other’s responsibility. “As a result of this confusion young people and their families would often be caught up in a series of multiple referrals between CAMHS and MP,” the report found.

This undermined quality of care because “the two services were not effectively working together to provide young people with autism the appropriate, co-ordinated assessment, support, interventions and care”.

Claire Bailey, managing director of the children and families care group at MPFT, said: “Patient safety is a priority for MPFT and I would like to provide reassurance that there are no cases of individuals coming to harm. [But] I acknowledge that there were identified failings included in the draft report.” Improvements were being made.

Angela Southall, chief executive officer of Midlands Psychology, said it had won awards from the National Autistic Society for the quality of care it provided. An action plan to address the problems has been identified and changes hadalready been made, she added.

Case study

Julia Carter has complained to the NHS about the care received by her 14-year-old son, whom she prefers not to name. She is one of the parents whose concerns triggered last year’s independent inquiry into the services provided by Midlands Partnership NHS Foundation Trust and Midlands Psychology, who between them care for under-18s in Staffordshire with autism and mental health problems.

My son has autistic spectrum condition, severe dyspraxia and profound dyslexia. He was never diagnosed as psychotic, but I felt that he had psychotic episodes, when he was talking to himself, asking a voice in his head if should harm himself, crying and rocking. The care he received from the two services who should have stepped in to help him at a critical time was appalling.

The doctor who saw him at MPFT’s child and adolescent mental health services [CAMHS] was more interested in who should be responsible for his care than in actually treating him, and the psychologists at Midland Psychology, after finally seeing my son, initially sent me to my GP claiming that it was the quickest way to get a referral to CAMHS, and this was not the case.

He was 11 at the time. He had recently become very anxious and begun refusing food and hurting himself. From the start his mental health was not properly managed and I had to give up work in order to support him. That had a big knock-on effect on family life. He was under the care of Midlands Psychology for his autism, but his GP referred him to MPFT’s CAMHS team. However, the trust refused to accept the referral and advised the GP that he should go back to Midlands Psychology. When the NHS Ombudsman later investigated my complaint about this, MPFT admitted it should have accepted the referral.

Then, to make matters worse, when the trust did finally accept the referral – after Midlands Psychology said it was urgent – they should have seen him that day or the next working day. However, they then didn’t offer him an appointment for 11 days or assess him until five days after that. The ombudsman found that that was a breach of the trust’s urgent referral timeframe.

The impact on my son has been profound and long-term. We are still dealing with it. Initially, because of the delay in treatment he was unable to begin high school in Year 7. He had to stay at home, eventually receiving tuition paid for by the local authority. Often these lessons would take place with my son hidden in the cupboard underneath the stairs or he simply could not cope with them at all.

In terms of the emotional impact, this has also been profound. Our family struggled to keep my son safe during his episodes of extremely poor mental health. He would pace up and down having conversations with himself about escaping, and how he needed everything to stop. He was not aware of his surroundings or me during these episodes. It was frightening and heartbreaking to see. His two sisters, one then 16 and one 10, had to help guard the doors and windows in case he tried to flee during these episodes, while I tried to bring him through them, and calm him.

Both services let him down at a critical period in his young life and what we went through because of that should not be allowed to happen ever again. People commissioning NHS services for young people as troubled as my son have to start having more rigorous oversight of services because next time a parent might not get to a window quickly enough.

When a child asks a parent for help, the natural thing for any parent is to provide that support. When your child is asking you for help and their life is at risk, not knowing if you can get any help for them has a huge effect on you. It changes you and life is never really the same again, as you feel you let your child down, that your best hard fought battle was not good enough, that you should have done more. But I like so many parents in Staffordshire are struggling to know what more we can do, when brick walls are put up in place of compassion and care.”