A better managed and more flexible system for transitioning young people from child to adult mental health services needs to be in place, a review by the Healthcare Safety Investigation Branch has concluded.

The 84-page report was conducted following the death of an 18-year old man who committed suicide after transitioning from child and adolescent mental health services (CAMHS) to adult support services.

Among recommendations made by the safety investigation body is to ensure that pathways and transition guidance are in place within ‘structured conversations’ with the person moving between services.

The investigation heard the man and his mother were not given the opportunity to meet with CAMHS or adult mental health services (AMHS) to discuss the changeover, and no standardised methods or tools were being used to manage users’ transitions.

The Care Quality Commission should also extend its remit of its inspections to ensure the ‘whole-care pathway’, from CAMHS to AMHS, are examined, the safety body said.

It is estimated that as many as 25,000 young people transition from CAMHS each year.

The branch’s chief investigator Keith Conradi said: ‘Experts have documented the elements of a safe and effective transition for many years however, many young people still do not have a positive experience and, as a result, disengage from services.

‘I believe this is a very important issue of increasing significance for young people today.’

Sean Duggan, chief executive of the Mental Health Network, part of the NHS Confederation, said the report ‘illustrates the tragic consequences’ of transitions, which are not always as flexible and joined up as they should be.

He said: ‘Services absolutely must be flexible and commissioning joined up, just as there needs to be greater collaboration among providers. There needs to be more clarity around commissioning and wherever these gaps are emerging, they must be closed.’