Transgender teenager's death preventable, coroner says

Daniel France's family say he just "wanted the world to be a better place for those he loved"

The death of a "vulnerable" transgender teenager who struggled to get help 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 3 April 2020.

The coroner said his death showed a "dangerous gap" between services.

The council said changes had been made. CPFT had improved staff training, services and processes.

Daniel's 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.

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 his 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.

A coroner says Mr France's death highlighted a "dangerous gap" in mental health services

His sister Katie France, on behalf of the family, 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 favourite band, his love for fluffy animals, his favourite 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."

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Cambridgeshire County Council had received two safeguarding referrals for Daniel, 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 [the] mental health trust and yet not receive the support they need pending substantive treatment."

He highlighted Daniel 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," Me Barlow said.

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".

A spokesperson for Cambridgeshire County Council said it makes "every effort to understand if more could have been done to support young people like Danny".

"We have already put in place actions that will improve our practice when dealing with young people in vulnerable situations including revisions to our parental involvement policy and commissioning specific training for staff working in this challenging area in both social care and Early Help, " they added.

"We are aware as partners that there is a responsibility to collectively learn from Danny's tragic death and we continue to work with our colleagues in mental health services and the voluntary sector to do so."

A spokesperson for CPFT said: "Danny's death was tragic, and our sympathies remain with all of his friends, family and loved ones.

"We have since made changes to our services and processes, including increased suicide awareness training for our staff, and we continue to work with partners to learn any additional lessons and further improve treatment pathways so that all young people can access the support they need as quickly as possible."

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