TEENAGE Chloe Barber was found dead at home by her 15-year-old brother after “slipping through the gaps” of NHS mental health care.
The “bright, brilliant and beautiful” 18-year-old from Driffield, East , struggled with her after being cruelly bullied at school and on .
In 2017, Chloe overdosed on pain relief medication and was referred to the Child and Adolescent Services (CAMHS).
Four years later, in November 2021, Chloe’s body was found by her 15 year-old brother after she ended her own life.
Her heartbroken family say the teen was left with a “complete lack of support” as she came of age and tried to transition from child to adult mental health services.
“Chloe was passed from pillar to post and we lost her because she was allowed to slip through gaps in the system,” they stated.
Two reports commissioned following her death - including a serious Incident report byHumber Teaching NHS Foundation Trustand an independent Safeguarding Adults Review (SAR) - found a string of mental health service failings, which may have contributed to her death.
A coroner who examined Chloe’s case found there was not a “clear path” for patients to transition from child and adolescent to adult mental health services,
He intends to issue a Prevention of Future Deaths report to protect other teens in Chloe’s position.
“It’s difficult to put into words the kind of person Chloe was,” her family said in a statement.
“She was amazing, bright, brilliant, beautiful, caring and stubborn. A truly wonderful young lady.
“She loved all kinds of music and was always wearing headphones. She was always dancing around to the song Pocketful of Sunshine.
“She was a gifted artist and loved drawing, and we always proudly displayed her artwork on the walls of our family home.
“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.”
After being referred to CAMHS in 2017, Chloe continued to struggle with her mental health for the next four years.
She made another attempt at self harm in 2018 and had stays in several psychiatric units.
In early 2021, she was sectioned under the Mental Health Act and hospitalised at Cygnet Hospital in , where she remained until July.
Chloe was diagnosed with unstable personality disorder “evolvingly unstable personality disorder”, characterised by “difficulties on how an individual feels about themselves and is associated with impulsive behaviour”, per the BBC.
But her family claimed they weren’t informed of her diagnosis or how they could support her.
Chloe was due to transfer to adult mental health services but struggled to engage with CAMHS and the Complex Emotional Needs Service (CENS).
Just before her eighteenth birthday, she request that her medication be reviewed.
But her family claimed: “This never took place as no one in any service took responsibility for who would be responsible for managing and monitoring Chloe’s medication in the community.
“She became so frustrated with the ‘faffing around’ that she told them not to bother.”
Iftikhar Manzoor, a senior litigation executive at Hudgell Solicitors who represented Chloe’s family, added: “When she was discharged from children’s mental health care and into adult care, she was effectively abandoned without a full assessment or care plan being devised and without any appropriate support being offered to her family.
“Just a week before she took her own life, her father reported an incident of serious self-harm, which left her needing hospital treatment, and yet she was still not referred to Vulnerable Adults Risk Management.”
This is a forum that could have considered Chloe’s case from a safeguarding perspective.
Following her death, an independent SAR review flagged a number of failures from Humber Teaching NHS Foundation Trust regarding Chloe’s care.
This included a failure to assess and consider Chloe’s need for aftercare services and a failure to ensure Chloe had an updated safety plan for use in the community.
This is a case which has exposed worrying gaps in the system.Turning 18 does not make somebody with a serious mental health illness suddenly able to make decisions in their own best interests
Iftikhar ManzoorHudgell Solicitors
The SAR also identified failures in relation to the local authority including failure by adult social care to accept Chloe’s referral and failure by Children’s services to re-refer Chloe to adult social care when she turned 18.
Senior coroner Professor Paul Marks, who conducted an inquest in Chloe’s death, said there was a “lack of documentation and poor communication between services and partner organisations”.
But he concluded that, on the balance of probabilities, these failures and missed opportunities only minimally contributed to Chloe’s death.
While “many matters were true or partially true, no causation flows from them”, he said.
“The unpredictability of impulsive behaviour with evolving emotional personality disorder coupled with services offered makes it probable there was no realistic opportunity to prevent her death,” the coroner concluded.
A spokesperson for the Humber Teaching NHS Foundation Trust told Hull Live : “The coroner’s inquest conclusion found no evidence of causation attributable to the Trust and acknowledged that any learnings taken from the case have already been embedded effectively by the Trust.
“We would like to thank HM Senior Coroner for his careful and thorough consideration of the circumstances surrounding the sad death of Chloe Barber, a patient discharged from our care in 2021.
“Our organisation remains committed to continually learning and making meaningful improvements to the safety and quality of the care we provide.
“Our thoughts and heartfelt condolences are extended to Chloe’s family and loved ones.”
‘Worrying gaps in the system’
Chloe’s family said in a statement: “There was a multitude of social workers and mental health professionals assigned to her case in a short period of time, and there was no clear protocol or process in place that could be followed when Chloe was due to transition from CAMHS to adult services following her eighteenth birthday.
“There was a consistent lack of record keeping and information sharing between services, which we feel is utterly unacceptable.
“Consequently, important information that highlighted Chloe’s risk of harm to herself was not identified.
“We feel there was a complete lack of support for the family throughout, particularly when Chloe was discharged from inpatient services into the community.”
Mr Manzoor added: “Chloe and her family were completely failed by mental health services.
“Chloe was a vulnerable young person with a history of serious mental health issues that made her a clear risk to herself.
“She had made repeated attempts on her own life, had avoided taking medication which helped her and she had repeatedly talked of ending her life.
“Her family were perplexed and concerned that after several years of support and treatment, including inpatient admissions to hospitals, Chloe was deemed at the age of 18 to be able to decline all services, despite the risk she posed to herself and her history of self-harm.
“This is a case which has exposed worrying gaps in the system.
“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 , her family were left fearing the worst would happen, and it did.”
