Colette had a smile that would light up a room. She painted, she drew, she wrote. She hardly slept and at primary school she had only one friend. Moving on to secondary school was difficult. She stopped eating and was diagnosed with anorexia and OCD (obsessive compulsive disorder). She was in and out of eating disorder units for years. She nearly died twice.
In those days nobody linked autism with anorexia. Nowadays that link is clearly established, but then Colette felt like she was misunderstood. She wrote poems about it:
I am an entity, bereft of that other part that makes me function, that makes me whole. I am a teapot without a handle, I’ll burn you when you touch.
Finally, at 33, she was diagnosed as having high functioning autistic spectrum disorder, and Colette and her family really thought that now she’d get proper care and treatment. It didn’t happen. Despite a history of suicide attempts, mental health professionals refused to assess her. They said she was not at risk.
The Coroner found:
Colette died on the A1 Southbound in the early hours of the 28th July 2016. She had been resident at Pathway House Milton Park and at a secure unit since the 29th December 2015. She was a voluntary patient. In 2014 an assessment of her found that she did not have the capacity to keep herself safe and she was very vulnerable. At times of anxiety she could turn to alcohol and did so on the night she died. She was failed by the lack of mental health assessment and by an inadequate regime at Milton Park which left her at large on the day of her death for far too long. No one will ever know how she came to be on the A1, but it is there she died.
Colette was a vibrant young woman, with a smile that would light up a room. She was a talented artist and writer and a much loved family member and friend. At 33 she was diagnosed as having high functioning autistic spectrum disorder and we really thought that diagnosis would lead to care and treatment. It didn’t happen.
Colette died at 3am on 28 July 2016 after being hit by a lorry on the A1. At the time of her death she was under the care of Pathway House, a residential care home, part of the privately-run “Award Winning Autistic Spectrum Disorder Provider” Milton Park Therapeutic Campus, near Bedford. She was placed there, out of her local area, by Sussex Partnership NHS Trust.
Five requests for an assessment under the Mental Health Act were rejected by the local Approved Mental Health Service, run jointly by Bedford Borough Council, Central Bedfordshire Council and East London NHS Foundation Trust.
We feel that Colette’s death was predictable and preventable. She had been displaying highly risky behaviour for months before her death but she was left to her own devices with no support, structure or activities at Pathway House. We repeatedly raised our concerns but these repeatedly fell on deaf ears. The ‘person-centred treatment’ advertised by Milton Park, in its brochure, is certainly not what Colette received. We feel let down by everyone who was supposed to care for her and keep her safe.
We would like to thank HM Coroner Martin Oldham for his thorough investigation into Colette’s death, especially after our experience with his predecessor. We are grateful that the failings in her care have finally been examined as part of the inquest process.
We would like to add our thanks to Merry Varney, Dan Webster and all at Leigh Day, and Sam Jacobs and all at Doughty Street Chambers for their tireless work and incredible support. We would never have got here without them. We would also like to thank George Julian for her amazing online campaigning.
It is crucial that the failures in Colette’s care are not swept under the carpet. It is essential that systems and staff are not allowed to repeat the same mistakes again.