Bridging the Gap: Streamlining Transition to Adult Services

Darren is a nationally qualified youth worker, with 28 years’ experience providing youth work support in a variety of settings.  He has previously worked on the Teenage Cancer Unit at Leeds, and his current youth work role is with the Paediatric & Young Adult Diabetes Team at LTHT.  In 2023 he produced a research paper for an MA award, which explored how the role of Youth Work can help to reduce DNA rates and improve the transition experience for patients who are living with Type 1 and Type 2 Diabetes.  He aims to publish the findings of this research later this year and is also planning to base his future PhD research on this topic.   He lives in Leeds with is wife and dog, and spends much of his spare time wondering if he’ll ever feel like he’s winning the never-ending war with his garden. 

Hello, my name is Holly O’Connor, Lead Nurse for Transition in NHS Humber Health Partnership on the South Bank. I am extremely passionate about getting Transition right within our organisation and championing the importance of hearing the young person’s perspective. I graduated from Leeds Metropolitan University in 2006 with a BSc Hons in Adult Nursing and have since undertaken further postgraduate study, including being certified as a Health Coach and an Independent Non-Medical Prescriber. I worked within the Community sector as a Community Matron and this is where I first became involved with a transition patient. Although challenging at first, after a lot of work the end outcome of this patient’s transition was a positive one. After this, I began to see there were gaps. I started in post as Lead Nurse Transition 18 months ago. I can now really see the positive changes we have made and significantly improved the care we provide to our children and young people preparing them better for the transition into adult services.

Siobhan Weaver is a nationally recognised children’s nurse, clinical leader, and strategic thinker in the field of SEND, transitions, and complex care. With over 25 years’ experience, she is currently the Designated Clinical Officer for SEND and Clinical Lead for Children with Complex Needs in Cambridgeshire and Peterborough. Her work spans assurance, co-production, commissioning, and quality improvement across health and education systems.

Siobhan is known for her reflective and values-led approach to care, challenging traditional constructs of “transition” and advocating for a return to the artistry of nursing — where compassion, humility, and relational practice are central. She brings a strong voice to national conversations on developmentally appropriate care and system design that holds, rather than fragments, young people’s experiences.

In 2023, she was awarded the Chief Nursing Officer for England’s Silver Award for her outstanding contributions to children with disabilities and SEND.

Bethan Williams is the Transition Lead at Lewisham and Greenwich NHS Trust, where she plays a central role in managing patient transitions between care settings. Drawing on her experience in clinical coordination and quality improvement, Bethan develops and implements streamlined pathways to support safe, timely hospital discharges and transfers. She collaborates closely with multidisciplinary teams—from inpatient wards to community partners—to ensure seamless continuity of care.

In addition to her transition role, Bethan contributes to the Trust’s broader improvement and transformation initiatives. She supports the embedding of quality improvement methodologies across the organisation, empowering staff and patients to engage in sustainable change efforts 

Bethan’s work enhances clinical governance, improves patient flow, and strengthens integration between acute and community health services—ensuring high‑quality care throughout the care journey.

Jackie Elliott was appointed as a Senior Clinical Lecturer and Honorary Consultant in Diabetes at the University of Sheffield in 2013.    Her current research interests include complex interventions to examine the best way in which to deliver education to different patient groups, for example to those with Type 1 diabetes (DAFNE – Dose Adjustment for Normal Eating),  young people (WICKED – Working with Insulin, Carbs, Ketones and Exercise in Diabetes), and how best to integrate technology.  She is proud to be part of a clinical team that has won awards for their newly diagnosed Type 1 pathway, improving outcomes in the young persons clinic and outreach University clinics.  She is the diabetes clinical lead in Sheffield and runs MDT specialist clinics for pump / CGM users, adolescents / university students, and also a specialist hypoglycaemia unawareness clinic.  Jackie serves as Chair on the national DAFNE executive board and is a member of the Diabetes Technology Network UK committee.

Cillian Gray is the Lead Cardiac Adolescent and Transition Clinical Nurse Specialist at Great Ormond Street Hospital for Children NHS Foundation Trust. With over 15 years of experience in healthcare across Ireland, Australia, and the UK, Cillian brings international insight and clinical expertise to his practice.

A qualified cardiac and respiratory intensive care nurse, he is currently completing a master’s degree in cardiac nursing. In his specialist role, Cillian supports adolescents with congenital heart disease as they prepare to transfer from paediatric to adult services. His work focuses on promoting long-term follow-up, building self-management skills, and empowering young people to take ownership of their health.

Cillian also brings a unique and personal perspective to his role—born with congenital heart disease, he has navigated the transition journey himself. This lived experience informs his empathetic and practical approach to transition care, helping improve outcomes for every young person in his care.