Serious and systemic CAMHS failures contribute to death of 17-year-old with autism and ADHD | Maya Sikand KC acted for the family

Jennifer (‘Jen’) Chalkley was just 17 years old when she took her own life on 12 October 2021, at her home in Surrey. A wide ranging Article 2 ECHR Inquest into Jen’s death, before the Surrey Senior Coroner, Richard Travers, has found that multiple failures on the part of Surrey and Borders’ Child and Adolescent Mental Health Services (CAMHS),a failure by Surrey County Council to properly manage Jen’s Educational Health Care Plan (‘EHCP’) process and other multi-agency failures contributed to Jen’s death. The Senior Coroner provided his findings and conclusions in a far-reaching 81-paged ruling. He said that he was satisfied that, had that specialist input been provided in a timely manner, Jen’s final crisis would probably have been avoided or managed, such as to avoid her death. He has directed Surrey and Borders NHS Foundation Trust, Surrey County Council and three educational establishments to provide PFD evidence. 

Jen was a teenager with complex special needs. She had been diagnosed with ADHD when she was 10 years of age and Autistic Spectrum Disorder when she was aged 11 years. The Senior Coroner found that these two neurodevelopmental conditions, together with associated excessive anxiety, low mood, and emotional dysregulation which she suffered periodically, resulted in a persisting but fluctuating risk of suicide. 


In 2021, the same year she died, Jen was hospitalised twice after attempting to take her own life. After each incident, Jen was referred to CAMHS. On each occasion, she received no proper intervention or treatment from her local CAMHS community team.

She was twice discharged by CAMHS over a three-year period, having not been assessed, diagnosed, or having had any therapeutic treatment or her medication reviewed.

Jen’s last discharge from CAMHS took place three months before her death, in June 2021, after a 15-minute audio call, by practitioners who had not properly reviewed her medical history. The Senior Coroner found that the assessment was wholly insufficient and discharge took place without proper consultation. He found that the two practitioners who agreed to discharge Jen gave dishonest evidence and tried to mislead him in evidence

The Senior Coroner concluded that Jen’s death was more than minimally contributed to by : 

(i) A failure by Surrey and Borders Partnership NHS Foundation Trust’s Child and Adolescent Mental Health Service properly to assess, diagnose and treat Jennifer following referrals made in May 2018 and January 2021 in order to manage her conditions and minimise her risk of suicide, 

(ii) A failure by Surrey County Council’s Special Educational Needs Department to ensure that Jennifer’s Educational, Health and Care Plan contained sufficient and updated information about her mental and emotional health needs and her risk of suicide, such as to enable the college she attended from September 2021, to understand and meet her consequential needs and manage the consequential risk, and 

(iii) A multi-agency failure to share information and work together to ensure that Jennifer was supported effectively to manage her neurodevelopmental and mental and emotional health needs, and her risk of suicide, especially from June 2021 onwards. 

The Senior Coroner also found that:

  • CAMHS lost sight of the vital role that it should have played in managing the risk to Jen’s life.
  • There was  pressure on CAMHS practitioners to refer patients away from the service and discharge them, rather than treat them, which was probably driven by the level of demand CAMHS faced;
  • There were missed opportunities to put in place an EHCP for Jen at a significantly earlier stage;
  • There were missed opportunities to ensure Jen was placed in an appropriate educational setting and that she received the specific and targeted support she needed. 
  • Educational establishments were misguided about the criteria for applying for an EHCP.

Maya was instructed by Daniel Lemberger Cooper and Patrick Dunne of Imran Khan and Partners solicitors.  

IKP / INQUEST press release can be found here.

Other interested persons represented at the inquest were Surrey and Borders Partnership NHS Trust (who are also responsible for Surrey CAMHS), Guildford College, Surrey County Council, and a former employee of Surrey and Borders Partnership’s Child and Adolescent Mental Health Services. Alison Hewitt, 5 Essex Chambers, is Counsel to the Inquest.