Previous posts as follows:

Post 1: Lugh Baker and David Hemmings

Post 2: Owen Garnett, Steven Duquemin and Matthew Dale

Post 3: Claire Twinn, Mark McKessy and Shane West

This is the final post reviewing 2023 Prevention of Future Death Reports into people with a learning disability (with/without autism). At some stage I will review the reports I’ve identified for autistic people, who were not referred to as having a learning disability (I am aware this is an arbitrary distinction, its crass. I’ve made the distinction based on information within the PFDs and partly to just report deaths in similar situations).

Lucy Walles

Lucy was born in November 1997 and was just 24 when she died. She died in hospital in February 2022, a week after sustaining injuries when she took actions to end her life by suicide (I’m not reporting how). The Senior Coroner for Berkshire, Heidi Connor, reported that Lucy, who had a mild learning disability and “capacity to make her own decisions and go out alone” lived in supported accommodation in Reading. It was funded by Wokingham Borough Council and her support worker was provided by Dimensions. The coroner also said that Lucy required “support with everyday tasks and remembering to do things”.

The coroner said that “Lucy had some interactions with mental health services over the years” and the inquest focused on her most recent contacts. Lucy had been under the care of the Crisis Home Resolution and Treatment Team for three weeks and one day, from 11 January 2022, after she had taken an overdose.

She was discharged from mental health services with a recommendation to refer herself to a group called SUN (Service Users Network). She had been told at that point that she did not meet the criteria for the learning disabilities team and was advised to speak to her GP herself from that point.

[Disabled but apparently not disabled enough. I wonder how many people with learning disabilities have to die, having been told by services that they do not meet the criteria for support from learning disability services. I’m thinking of Chris Nota

C: It was also reported to us by Trust staff that the view of the local authority was that Chris’s IQ was above 80 and therefore he did not meet the criteria for support from the local authority learning disability team.

— Chris N Inquest (@ChrisNInquest) January 4, 2023

and Sammy Alban-Stanley as examples of inquests I’ve reported from the last couple years, there are many more].

C: As consequence Samuel was seen by social workers from children social work team who were unfamiliar with range of services that could have been provided to a child with disabilities and their family

— SammyInquest (@SammyInquest) November 29, 2021

Back to Lucy. Lucy saw a mental health practitioner based at her GP surgery, two weeks after being discharged from mental health services on 15 February.

She told them that she had plans to end her life, and how.

The crisis team was contacted. Their advice was that, Lucy had been discharged recently from the service, and that she did not meet the criteria for being taken on by them. The recommendation for Lucy to refer herself to the SUN group remained. They did not speak to Lucy at that point. They did not offer her support from other mental health teams.

[I don’t know for sure what is going on here, I’m not as up to speed I used to be about NHS targets, but I’d bet my bottom dollar on the fact that there’s a measure somewhere of number of re-admissions into a service within a time period of discharge, failed discharges effectively. What other explanation is there for refusing to help someone who clearly needs your help, without even bothering to speak to them].

Clearly Lucy was mentally unwell, asking for help, and being told that she had to refer herself to a peer support group.

The coroner reports that Lucy’s inquest also looked at four safeguarding referrals made in the last year of Lucy’s life (noting that there was at least one before that period). The first referral was made nine months before Lucy died. A referral, referencing Lucy’s “past history of deliberate self-harm” was sent to Reading Borough Council after Lucy took an overdose in May 2021. The referral was not reviewed for three months, and then when it was in August 2021, it was closed “when it was deemed to be an inappropriate referral on the basis that it did not describe abuse or neglect”.

On 10 January 2021 a safeguarding concern was again raised with Reading Borough Council, regarding an overdose Lucy had taken.

On 18 January, an update to the previous referral provided information relating to additional incidents, including ingestion of a hazardous substance. The coroner reported the note made by the safeguarding team when they spoke to the referrer, a member of Dimensions staff, as follows:

When this was followed up by telephone (with the person who had made the referral) RBC’s record of this conversation includes the following:

Lucy has allegedly done a few more self-harm attempts…she is making several threats of suicide ([REDACTED]). Today she tried to [REDACTED] … her mental health seems to be deteriorating…Dimensions believe she needs more support than what they can provide as they are not mental health skilled professionals.

[The use of allegedly. This has been discussed by people trying to access support for years, the iatrogenic harm caused by people working in systems that are meant to help. The language, the disbelief, the inference that people are just attention seeking and if they wanted to end their lives they’d do a better job of it, all not even under the surface, bubbling away on top of it].

The coroner continues:

Subsequent to the referrals on 10th and 18th January, a social worker recorded that she did not think that Section 42 [of the Care Act] criteria were met. She also concluded that there was “robust support from agencies involved and appropriate measures have been taken to address risks posed by her threats of self-harm. No serious harm has occurred to Miss Walles”.

Two days later, on 20 January, the ambulance service (South Central) made a safeguarding referral, relating to an overdose and Lucy’s mental health deterioration. Their report included the information that Lucy had said to them “she did not want to be here anymore”.

Rather incredulously, Lucy was never once contacted, in relation to any safeguarding referrals or concerns. This is despite Making Safeguarding Personal guidance being introduced thirteen years earlier, in 2009.

During all of these safeguarding referrals, Lucy was not contacted at all. It appears that the only information taken into account in reaching conclusions was the initial safeguarding report itself and information on Reading Borough Council’s computer system (Mosaic). These would have included earlier safeguarding reports. After the third safeguarding concern was raised by the ambulance service, no review or action took place before the tragic events of 16th February 2022.

The coroner had numerous matters of concerns arising from Lucy’s inquest relating to three areas:

1. Safeguarding
2. Mental health provision
3. Inter-agency communication (particularly where there is some doubt over who should provide additional support needed by a person).

The coroner reported that there had been no Safeguarding Adults Review conducted into circumstances relating to Lucy’s death, despite the Safeguarding Adults Board considering her case. Wokingham BC (who were commissioning and paying for Lucy’s care) told the court that they were “not at that time aware of the number of safeguarding referrals that had been made”.

The coroner noted:

A decision was made (some six days before the inquest) that a SAR will now be conducted. The evidence of the Assistant Director of Adult Social Care was that this is likely to be completed within 1-3 months after the inquest.

The coroner issued her Prevention of Future Deaths report to two recipients, Reading Borough Council (who were responsible for safeguarding) and Berkshire Health Care (who were responsible for mental health services) and she set out her concerns for both parties, eight for the council and four for the healthcare provider.

Ryan Evans

Ryan was 20 when he died, on 3 April 2018. The jury at his inquest concluded that he took his own life while suffering from depression. Ryan had a learning disability and was disabled. He was diagnosed with depression two years before his death, in 2016. Ryan was “physically fit and was living on his own in assisted living with seven hours of support a week”.

In their narrative, the jury noted that Ryan had been adopted, together with his older siblings, when he was two. They noted they:

… were brought up in a close family unit with his adoptive parents, following a traumatic early childhood. Ryan was vulnerable due to his learning disability and depression, recent self-harm and attempts of suicide. Ryan’s mental health had deteriorated over approximately seven months due to a number of contributory factors.

The contributory factors the jury noted included:

• Ryan being given notice to leave his accommodation, and the uncertainty about where he’d live in the future
• Ryan finding out on social media how his biological father had died (by suicide)
• Ryan’s use of substances (medication, drugs and alcohol)
• A breakdown in the relationship between Ryan and the management of his support provider, ACASA.

The day before he died Ryan was arrested outside the ACASA offices for “outstanding criminal damage, threatening behaviour, and violent/abusive phone calls”.

Ryan was taken to Frimley Park Hospital by ambulance following collapse in the police van with chest and abdomen pain, his self-harm injuries were dressed and no physical issues were discovered so he was released into police custody. Despite evidence of self-harm, no Mental Health Assessment was carried out at this point.

On booking into police custody, Ryan was noticeably upset. He was referred to and visited by a Health Care Professional (HCP) and Hampshire Liaison and Diversion Service (HLDS) at the request of the police custody sergeant.

The jury noted that whilst at Basingstoke Custody Centre, a healthcare professional visited Ryan, reviewed his physical condition and re-dressing his self-harm injury.

Ryan was also visited by someone from the Hampshire Liaison and Diversion Service (HLDS), at the time provided by Southern Health NHSFT. A liaison and diversion service is intended to provide care and support to those alleged of a criminal offence, who are thought to be vulnerable due to mental ill health, learning disabilities, neurodivergence or trauma.

HLDS failed to document the encounter on the RIO system and only updated the custody record with a screening document. This follows a failure to update the RIO system in January 2018 when Ryan was previously seen by HLDS. There was failure to carry out a Mental Health Assessment and no record of Ryan refusing to be assessed.

The jury concluded that these failings could not be found to have significantly shortened Ryan’s life.

The Southern Health HLDS worker completed a report screen and uploaded it onto Ryan’s custody record. It made no reference to a mental health assessment being required, or being declined, by Ryan.

Throughout Ryan’s stay in custody he expressed suicidal ideations on multiple occasions, spoke to the Samaritans and concerns were raised by family which were reported back to the custody Sergeant. Communication of this information was ineffective.

Additionally, across the custody suite there was a sense of complacency with references to Ryan’s behaviour being “attention seeking” and no future referrals to HLDS were made. Despite no formal guidance, it is regrettable that on disposal, no verbal handover was done with Ryan’s father.

Again it was said that these failings could not be found to have significantly shortened Ryan’s life.

At 10:30pm that night Ryan was released from Police custody, into the care of his father. Ryan’s father was not given any verbal handover from police or health staff and the jury noted that at the time Ryan was in a distressed state about the conditions of his discharge, and the information he had learnt about his biological father’s suicide.

Ryan refused to go home to his parents residence and wanted to go to his own accommodation. His father dropped him off around midnight and waited till Ryan was safely in the building.

Ryan was found dead the following morning in a communal area of the building where he lived.

Ryan had a long standing history of depression and several suicide attempts. Ryan John Glyn EVANS took his own life while suffering from the diagnosed medical illness of depression.

Ryan’s inquest concluded in January 2023. The Assistant Coroner for Hampshire, Portsmouth and Southampton, Darren Stewart (who will always be known in my head as Connor’s coroner) issued his Prevention of Future Death Report in December 2023.

In it he states “I received further evidence in writing from the Interested Persons’ subsequent to the completion of the Inquest in relation to these concerns” and that he was satisfied that some concerns were allayed, but others were not, which I suspect explains the delay in issuing the PFD report.

The concerns that he felt were addressed related to:

a) Referral to Psychiatric Liaison Services for patients presenting with self-harm injuries and suicidal ideation (including those in Police custody) at Frimley Park Hospital A&E, including the extent to which the NICE guidance is complied with or provides effective guidance to staff in such circumstances

b) The conduct of Mental Health Assessments in a custody setting by liaison and diversion staff including the adequacy of policy and guidelines relating to triggers to conduct such assessments and the manner in which refusals are dealt with

c) The passage of information both between custody staff, as well as with healthcare staff in relation to concerns of a mental health nature for a detained person including the extent to which the custody record is used as an effective means to communicate concerns/observations of detained persons mental health

d) The process of release of a vulnerable detained person following disposal, including interaction with family or other persons collecting the detained person.

The coroner said that he was satisfied that the measures Hampshire Constabulary and Southern Health NHS Foundation Trust had put in place to address the failures above, addressed the concerns in relation to their organisations.

He continued:

I also received evidence from the Frimley Health NHS Foundation Trust concerning the measures which that organisation had undertaken in their area of responsibility to address my concern detailed at a (above). This evidence has not allayed my concern in relation to a (above).

In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you.

He then provided further details about the matters of concern in relation to Ryan’s care at Frimley Park Hospital, including the evidence from the Police officers attending the hospital with Ryan.

Police officers stated that Mr. Evans was open with hospital staff about his feelings of self-harm depression, and thoughts of ending his own life. Officers further recalled that hospital staff noticed and commented on the self-harm marks on Mr. Evan’s arms, including whilst staff were dressing a recent self-harm wound on Mr. Evan’s left arm.

Officers also recalled Mr. Evans commenting when offered food by hospital staff that he would rather starve to death.

One of the accompanying police officers expressed surprise at the fact that Mr. Evans was not subject to a mental health referral or assessment, in the context of him commenting to multiple hospital staff members about his self-harm actions and ideation.

The coroner also highlighted the evidence given by a consultant working in the Frimley Park Emergency Department who told the court that no mental health assessment was, or would have been, necessary because Ryan’s presenting complaint was recorded as chest pains, not self-harm or suicidal ideation.

[This is a consultant giving evidence at an inquest following Ryan ending his life, having been open about his suicidal ideation and self-harm with staff in the ED department. Much like Valerie Murphy giving evidence in Connor’s inquest that he was not having epileptic seizures, after he drowned in the bath as a result of an epileptic seizure. How can anyone have the audacity to tell a court care was not required].

An emergency department consultant at Frimley Park gave evidence which suggested that no mental health assessment was or would have been necessary where Ryan’s presenting complaint was recorded as chest pains rather than of self- harm and/or suicidal ideation. Although self-harm had been noted in the records, no explanation could be provided for why Ryan’s suicidal ideation had not been recorded.

The coroner states that the consultant was questioned in relation to the NICE Guidance for Self-Harm that was in place at the time (it has since been updated). He described the guidance as “national guidelines that ought to feed into practice at the hospital” and quotes from them, before continuing:

Evidence received during the course of the Inquest was not able to reconcile the contradiction between the NICE guidelines on self-harm and Mr. Evans having had no mental health assessment despite obvious signs of self-harm and further evidence of disclosure of suicidal ideation.

The jury in their Narrative Conclusion found that ‘Despite evidence of self-harm, no mental health assessment was carried out at this point.’

The coroner stated that he remained concerned as to how such a situation would be avoided in the future if a patient presented in a similar manner to Mr Evans.

The additional evidence on PFD matters provided by Frimley Health NHS Foundation Trust does not refer to or address the NICE guidelines on self-harm or explain what would now be done differently were a patient such as Mr. Evans were to be seen again.

The Frimley Health NHS Foundation Trust additional evidence refers to matters being in the process of introduction and new referral criteria with Surrey and Borders Partnership NHS Foundation Trust, but this does not explain how this would prevent the future risk of a patient such as Mr. Evans leaving the hospital without a mental health assessment.

[Frimley Park Hospital was the hospital where the psychiatric liaison team refused to see Sasha Forster on the day that she then ended her life. There were multiple failures in the care and support provided, or not provided, to Sasha, but this is all very familiar, and this is a Consultant from the Emergency Department giving evidence to the court, six years after Sasha died. The coroner in Sasha’s case, David Reid, issued three PFDs, all linked on the page above].

Benn Curran-Nicholls

[It goes without saying that all PFDs induce a feeling of sadness and rage in me, and I don’t want to get into a game of preventable death top trumps, but this death hollowed me out with sadness. Perhaps because it is one where there were no care failings].

Benn was just 14 when he died by misadventure, in September 2022. Benn had moved from Australia to Didsbury in Manchester with his family, three months before he died. Benn had autism and a learning disability and would regularly go on walks in local parks with his family, and in one park there was a tree he liked to climb.

This is what the Assistant Coroner for Manchester City, Andrew Bridgman reported:

Benn suffered severe autism with intellectual impairment, and daily walks in the local parks became a part of his daily routine. On the morning of 18.09.22 Benn and his father went for a walk in Fletcher Moss Park where, among other things, there was a yew tree that Benn liked to climb. Benn ate some yew tree berries and also some of the leaves.

Benn’s father was not aware of the poisonous nature of yew tree berries/leaves, and so took no action. Interestingly neither was, in his evidence to me, Manchester City Council’s Neighbourhood Manager for Environmental Health aware that yew trees were poisonous. 

Later that day at about 6pm Benn suddenly collapsed. He was admitted to Royal Manchester Children’s Hospital by emergency ambulance where he died in the early hours of 19 September 2022. 

[Another day I’ll offer some thoughts about the language used in coroners courts of people suffering from disabilities, being impaired and the like].

Benn died from refractory cardiogenic shock as a result of poisoning (taxane alkaloid) from ingesting the yew tree berries and leaves.

Toxicological evidence was that yew tree poisoning in humans was rare, but that a number of cases had been reported.

The coroner issued his Prevention of Future Deaths Report to the UK Health Security Agency (UKHSA) and to Manchester City Council.

Following Benn’s death the coroner said there had been a long series of communications between the two parties where the UKHSA had concluded that they would not issue communications about the dangers of ingesting yew tree berries, as it was considered that it might increase the risk of it’s occurrence in self-harm or suicide. They also stated that they were not aware yew tree poisoning was a frequent problem, but if that became apparent they would revisit their decision.

The coroner states:

The medical cause of death is yew tree poisoning. Yew tree poisoning is rare but is documented.

The reason for not sending out comms messages for educational/warning and informational purposes because the message is about something that a person wouldn’t usually eat is illogical. Berries and the like might be attractive to young children who would not recognise the dangers and risks, of even illness let alone death. The poisonous nature of the yew tree is not, on the evidence, well known to the public.

The decision appears to be focused on comms solely about the yew tree and the risks of identifying an additional means of deliberate ingestion for suicide. No consideration was given to highlighting the risks of eating wild berries and/or leaves in more general terms.

In the circumstance it is my view that the decision not to put out public health messages, either specific to the yew tree or in more general terms, was not properly and fully thought through. It should be re-visited.

Manchester City Council had given evidence to the coroner that they were in the process of carrying out a risk assessment of yew trees in its parks, including assessing the dangers posed from climbing on them. The coroner said:

In respect of the highly poisonous (with fatal consequences) nature of the yew tree no assessment of that specific risk is, in my view, required. There may be other trees and plants in these parks that, if any parts are eaten, risk poisoning. I heard that the assessment did not include the identification of any such trees and plants.

No consideration had been given to putting up notices warning of the poisonous nature of the yew tree, and risks of eating its berries/leaves. Neither at the entrances to the parks nor at the trees themselves.

Further, no consideration had been given to the posting of notices warning, in general terms rather than specifically yew trees, that, by way of example that some of the trees and plants are poisonous and may cause severe illness and perhaps death if eaten. Again, neither at the entrances and/or dotted around the parks.

The coroner concluded that his matters of concern for both parties were as follows:

There is a risk of a death arising in similar circumstances, and informing the public will clearly reduce the risk of those deaths. Perhaps particularly so for a child whose carer would be so informed.