Trans Teenager's Death Preventable, Coroner Says
February 25, 2022The death of a “vulnerable” trans teenager who struggled to get help from mental health services was preventable, a coroner has said.
Daniel France, 17, was known to Cambridgeshire County Council and Cambridgeshire and Peterborough Foundation Trust (CPFT) when he took his own life on April 3, 2020.
His death showed a “dangerous gap” between urgent and non-urgent services, the coroner said.
His family said the coroner's report highlighted the “gaps for young, vulnerable people to fall into which significantly increases their risk.”
When he died Mr. France was in the process of being transferred from children and adolescent mental health services (CAMHS) in Suffolk to adult services in Cambridgeshire, according to the BBC.
His GP had referred him to CPFT for mental health care, but he was still waiting on an assessment by the adult locality team when he died.
He had made previous suicide attempts and had tried to refer himself for counselling but was denied as he was “considered too high risk,” assistant coroner for Cambridgeshire Philip Barlow said in a Prevention of Future Deaths Report.
The First Response Service, which provides help for people experiencing a mental health crisis, also assessed Mr. France but he had been considered not in need of urgent intervention, the coroner's report said.
His sister, Katie France, said: “Danny was an incredibly genuine, caring, and passionate person and his loss has left a huge void in our lives.
“His passion and enthusiasm was infectious, be that about his favorite band, his love for fluffy animals, his favorite subject, or his loathing of politicians! He wanted the world to be a better place for those he loved.
“The report from the coroner importantly addresses that there are gaps for young, vulnerable people to fall into which significantly increases their risk.
“We know that the individuals providing care are doing their absolute best with the resources available to them, there just are not sufficient resources.
“We want this to be addressed and policy and funding to be improved in order to help others.”
Cambridgeshire County Council had received two safeguarding referrals for Mr. France, in October 2019 and January 2020, but had closed both.
“It was accepted that the decision to close both referrals was incorrect”, Mr. Barlow said in his report.
Mr. Barlow wrote in his report, sent to both the council and CPFT: “My concern in this case is that a vulnerable young person can be known to the County Council and Mental Health Trust and yet not receive the support they need pending substantive treatment.”
He highlighted that Mr. France was “repeatedly assessed as not meeting the criteria for urgent intervention” but that waiting lists for phycological therapy could mean more than a year between asking for help and being given it.
“That gap between urgent and non-urgent services is potentially dangerous for a vulnerable young person, where there is a chronic risk of an impulsive act.”
The coroner said he was aware of a long-term plan to extend young people's services to age 25 but was “concerned about the ongoing situation, and that a young person today could be faced with the same challenges in finding support pending substantive treatment.”
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