There were 16 PFDs following conclusions of inquests relating to autistic people in 2023, and I’ve reviewed some here and others here. This is the next three deaths, with one further post to follow.

Liam Bentley was 25 when he died in June 2022. The Senior Coroner for Mid Kent and Medway, Patricia Harding, who sat with a jury, reports that Liam took his own life, but his intention in doing so was unclear. Liam was autistic, and had ADHD, and was detained at HMP Swaleside at the time of his death (due for release in 2024).

The coroner identified a number of failings, some of which possibly contributed to Liam’s death, some which could not be found too. These were:

• failure to provide adequate physiological support through SOS and/or a psychologist
• failure to open an ACCT on or after 16th April.
• failure to instigate a care plan
• inadequate response to missed medication from 16th April onwards.
• the Management of the self seclusion plan was inadequate, and failures to implement agreed actions from CSIP and SIM meetings.
• ineffective communication between the prison and the health care provider
• staff shortages and gaps in training.

SOS is the Swaleside Outreach Service, described in a Prisons and Probation Ombudsman’s report as “a partnership service between HMPPS and Oxleas, run by prison staff, psychologists and clinicians to help prisoners whose behaviour is complex, challenging, violent and/or disruptive”.

ACCT is Assessment, Care in Custody and Teamwork, the process for care-planning and monitoring prisoners identified as being at risk of suicide and self-harm.

We can learn from the PFD that Liam was moved to HMP Swaleside on 25 March 22. ACCT had been instigated on 19 previous occasions for self-harm and at least one suicide attempt in establishments Liam had been held in earlier in his sentence. Once at Swaleside he told the staff he was scared of other prisoners and wanted to move to a new wing.

Following his transfer he informed prison staff that he was in fear of other prisoners and wanted a move to another wing. He caused a superficial cut to his hand and said that he wanted to kill himself before anyone else did. An ACCT was not opened, the evidence being that officers after further speaking to him did not regard this as a self harm issue, the focus being to engineer a wing move.

He was moved to a different wing but continued to express concerns about prisoners on the new wing. A self seclusion document was opened, a local policy closely aligned to the ACCT process aimed at reintegrating the
prisoner to the regime was started but was not managed in accordance with the policy with assessments and reviews being done weeks after they should have been and no management plan were not put in place.

Required daily interactions were sometimes done, sometimes not, referrals to psychology and SOS were either not made having been identified as necessary through the self seclusion, CSIP and SIM processes or made and not actioned.

The PPO report includes some more detail, provided to them by Liam’s family. It says:

Mr Bentley’s family told us that another prisoner had tried to stab Mr Bentley at Swaleside and that he was too frightened to leave his cell to collect his medication. They said that prison staff had opened Mr Bentley’s legal correspondence and had assaulted him around four weeks before he died. Mr Bentley’s family told us that his telephone calls to them often disconnected, that he was unable to access the Samaritans and that he was unable to have or clean his own clothes. They also told us that communication from the prison’s family liaison officer was poor.

The PPO report includes much more detail of the repeated and multiple failings in the care provided to Liam.

The coroner’s PFD identified two matters of concern

(1) There was evidence from prison staff from which it was concluded by the jury that the safety of deceased was compromised as a result in staff shortages
(2) The current complement of Band 2 Operational Support Group staff is 71% this is predicted to further reduce to 54%, the current complement of Band 3 Prison Officers is 68% this is predicted to further reduce to 46%.

Oleg Khala was 56 when he died by suicide in January 2022. The Senior Coroner for Inner West London, Fiona Wilcox, found that he probably would not have died when he did if he had been admitted into hospital when his health declined.

Oleg was autistic and diagnosed with ADHD, schizoaffective disorder and had an historic diagnosis of bipolar disorder. He lived alone in temporary accommodation and the coroner described him as “very vulnerable” due to difficulties he experienced with “interpersonal relationships with neighbours and officials”. Oleg’s main supporter, and advocate, was a social worker from Glass Door, a charity that works with people who are homeless.

Mr Khala suffered with severe and enduring mental and neurodevelopmental illnesses which together made his needs complex and him vulnerable. He had a past history of non-engagement with services in part due to autistic spectrum disorder.

Oleg moved often and consequently came under the care of different mental health services.

He came under the care of West London Mental Health Services in February of 2021, referred from Croydon. He was allocated to the Mental Health Integrated Network Team (MINT). He did not have a care-coordinator despite his severe and enduring mental health issues, and ongoing symptomatology. He was placed on a list for a care- coordinator in July 2021, but had not been allocated one prior to his death, due to a shortage of and waiting list for care-coordinator provision.

The PFD tells us that Oleg’s mental health began to deteriorate and his “mood began to fall” in autumn 2021. The social worker noticed a real change in his mood and behaviour from October, and they accompanied him to appointments and attempted to support him.

Oleg was assessed by a psychiatrist from MINT on 6 December 2021.

He presented as capacitous, with some insight, complex, and intelligent. He was able to give a good account of his past experiences and issues. His diagnoses were considered, and further assessment was required. Follow up appointments were offered but sadly he had died before these occurred.

On 17 December Oleg intended to end his life, but instead asked for help from staff at a railway station. He was taken to Chelsea and Westminster Hospital, where he was seen by the Crisis Assessment and Treatment Team (CATT) and discharged.

He was taken by police to Chelsea and Westminster Hospital where he was assessed by liaison psychiatry and requested admission. He gave a history of intrusive suicidal thoughts, sleeplessness due to issues with a neighbour and to be at risk of suicide. Sleeplessness was a relapse indicator for him, and his social isolation was recognised. Admission was recommended by psychiatric liaison.

He was referred to the CATT who found him not to be suicidal and discharged him with a tablet of diazepam and for follow up with MINT without discussion with a consultant nor psychiatric liaison.

Whilst the records taken by psychiatric liaison were full and descriptive and gave a thorough impression of appearance and behaviour, presentation and assessment of his presenting complaints, the assessment by CATT was generic in style. Evidence taken live from CATT was that Mr Khala was underplaying his suicidality to CATT, but never the less he was discharged.

The court heard that more than half of patients assessed by CATT for informal admission are discharged for community follow up, and that one of the roles of CATT is specifically to explore alternatives to admission. Patients discharged without admission by MINT are not discussed with the on-call psychiatrists, whilst patients to be admitted are.

The PFD states that attempts were made by MINT to follow up with Oleg after he was discharged by CATT, but these were not successful.

Eleven days later, on 28 December, Oleg again attended Chelsea and Westminster Hospital communicating that he was suicidal. He was assessed by a different psychiatric liaison nurse.

Again, a thorough assessment was undertaken. He was found to be suicidal, avoiding eye contact, intermittently covering his face with his face mask when distressed, to have slept only one night since he was last seen, and to have been wandering the streets at night rather than go home, and he requested and required admission to keep him safe due to his suicidality, to review his medication and care needs.

He was again seen by CATT. The notes recorded were again generic, and tick box in style. In live evidence it was accepted that he did have on going suicidal thoughts but no plans nor intent, his complexity appeared underappreciated and many questions put to the CATT witness based upon the assessment by psychiatric liaison centring on his demeanour and sleeplessness, which had taken place just a few hours previously, were not answered clearly by the CATT witness. The witness claimed that admission had been discussed with Mr Khala but declined and follow up by MINT agreed with him, despite its previous failure. The discussion which the CATT witness stated to have taken place about admission was not recorded in the notes.

The court had some questions of credibility of evidence of the CATT witness who saw Mr Khala on 28th December 2021.

Oleg was sent home from hospital with two sleeping tablets and told that MINT would follow up with him. Despite this approach failing ten days earlier, Oleg requesting admission twice in a short time period, and telling the nurse he’d only had one nights sleep.

His case was also not discussed with the on-call psychiatrist. The psychiatrist from MINT stated that such cases should and could have been discussed with the on-call psychiatrist, especially given the differing views of psychiatric liaison and CATT, and his complexity, risk and vulnerability.

The view of the psychiatrist was that Mr Khala should have been admitted and would have benefited from admission with the opportunities that admission would have afforded to Mr Khala to keep him safe and review his treatment and care plan.

Oleg was found deceased by police on 1 January 2022. There were no suspicious circumstances.

The coroner highlighted 6 matters of concern and stated:

The evidence was that all cases whether discharged or admitted should be discussed with the on-call psychiatrist, that there was a shortage of care-coordinators and Mr Khala should have had one, and that MINT has no access to specialist advice or assessment for ASD or ADHD within MINT which if this was available would also have been of potential benefit to patients such as Mr Khala.

I don’t know how old Philip Malone, was when he died by suicide in July 2023, but he was at least in his 40s because Area Coroner for Birmingham and Solihull, James Bennett, in his PFD, states that Philip was diagnosed with treatment resistant schizophrenia in 1983. He had been detained under the Mental Health Act many times and two months before he died he was diagnosed as autistic. He lived in supported accommodation.

A routine review on 15 June found Philip’s antipsychotic medication was at a sub-therapeutic level, insufficient to keep Philip well. This was not notified to clinicians.

About nine days later, on 24 June, Philip’s mental health had significantly deteriorated and he was displaying symptoms of “thought disorder, anxiety, and responding to hallucinations”. A Mental Health Act Assessment on 28 June left clinicians wanting to detain Philip under Section 2 of the MHA 1983. This did not happen as there were no inpatient psychiatric beds available.

No inpatient psychiatric bed was available. Whilst he awaited a bed, he remained in the community with daily visits from the mental health team. Last contact was on 1st July when he accepted his medication and appeared more settled. There was no answer when he was visited on 2nd July.

The following day, 3 July, Philip’s room was entered and he was found dead. The coroner noted that recently he had not expressed any suicidal ideation, however he did find his death was a death by suicide.

The coroner identified four matters of concern including that Birmingham and Solihull Mental Health Foundation Trust had written a root cause analysis report after Philip’s death that stated he needed to be admitted in June 2023, but was not due to bed capacity, but the report “identified no remedial action”. He added:

The Patient Safety Manager [REDACTED] gave evidence that the lack of psychiatric bed capacity remains an ongoing problem and has not been resolved, and there is a genuine risk of the same problem with another patient in the future. [REDACTED] added there was an exceptional process, which required a considered decision at a high level, to make a bed available through identifying someone currently occupying a bed space to be discharged. In my view, this process is unsatisfactory as it creates a different set of risks around the patient being discharged, and amplifies the chronic shortage of beds.

The coroner referenced two previous PFDs issued that both focused on “the chronic lack of mental health resources in Birmingham and Solihull”. Leroy Hamilton died in December 2021 and one of the five matters of concern at his inquest was the lack of inpatient mental health beds and psychiatric decisions unit spaces. Peter Fleming died by suicide in November 2022. There were five matters of concern identified in the PFD issued following his inquest including the first highlighting a lack of resource:

There continues to be a chronic lack of resources to treat seriously mentally ill patients in Birmingham and Solihull. In the summer of 2022 Birmingham and Solihull Mental Health Trust (‘BSMHFT’) wanted to admit the deceased to an inpatient psychiatric unit, however, no bed was available, and he remained in the community. Shortly before his death, the deceased had been detained by the police under section 136 of the mental health act. There was no available ‘place of safety’ and he had to be taken to an emergency department. The police, BSMHFT, and hospital Drs agreed the deceased needed to be assessed under the mental health act, however Birmingham City Council could not provide an approved mental health practitioner (‘AMPH’) to attend in a 24-hour period. When the section 136 lapsed the deceased was discharged home after a review by a mental health nurse. At the time of his death the deceased was on BSMHFT’s waiting list for a care- coordinator. The lack of care-coordinators, mental health inpatient beds, ‘place of safety’, and AMHPs, presents a risk seriously mentally ill people are not receiving necessary treatment. The evidence is that these issues are a consequence of a chronic lack of resources at a local and national level. The Birmingham and Solihull coroners have been repeating identical concerns in Prevention of Future Death Reports for many years.

Philip Malone’s PFD is the latest in a long list to highlight the risk of deaths due to a lack of appropriate care and support for people who are mentally unwell:

The issue of adequately funding psychiatric beds is a local and national issue. Locally, BSMHFT require their commissioners to provide the necessary funding. My principal concern is that the above dates indicate available psychiatric bed capacity in Birmingham and Solihull remains inadequate. Whilst some action may have been taken it is insufficient to resolve the problem.

It follows there is a genuine risk of future deaths directly connected to a shortage of psychiatric bed spaces in Birmingham and Solihull unless further action is taken.

How many more times does a risk need to be highlighted?