We read with interest Dr Subotsky’s review of issues for child and adolescent mental health services (CAMHS) when copying letters to patients (Psychiatric Bulletin, June 2005, 29, 201-203). A survey of our CAMHS (66% response rate, 39 respondents) showed that many practitioners write to families as a matter of course.

In our service the two most common reasons for not copying letters to patients were those cited by Subotsky, i.e. when practitioners had child protection concerns or when information was about a third party. Our survey also revealed a third potentially important exception: practitioners may wish to communicate their clinical impressions or concerns to the referrer at an early stage of the assessment process, before the practitioner feels ready to discuss these views and their implications with the family. The most commonly cited example of this is if a practitioner has concerns that a young person might be psychotic.

Our colleagues sometimes resolve this dilemma by writing separate letters to referrers and to the family. Although this may superficially address the need to balance communication with both the family and professionals, this practice is not in keeping with the Department of Health guidelines which aim ‘ to improve communications with patients to benefit their healthcare without jeopardising communication with other professionals’ (Department of Health, 2003). When worrying clinical information is apparent early in assessments, our service is considering whether no letter, an incomplete letter or a letter that is not shared with the patient is in the best interests of the child.