Shortage of autism-specific crisis care services
NHS England received 6 coroners' reports about this hazard between 21 Oct 2020 and 19 Mar 2025.
They came from 6 different coroners in 6 coroner areas. A similar concern was raised again 5 times after the first warning.
A published response was found for 4 of the 5 earlier reports, stating 9 specific actions.
The story, report by report
Spacing grows with the time between reports.
“It would appear from the circumstances of Ms [name redacted] death that the NHS are unable to provide a place of safety for those who are suffering from Asperger's syndrome, or indeed other forms of autism, when they are also suffering additional mental health problems such as bipolar.”
Original on judiciary.uk ↗ No published response from NHS England was found for this report.
- 1 year 6 months later
Raised again · 1st time
Zoe Zaremba↗
25 Apr 2022 · John Broadbridge · North Yorkshire and York including North Yorkshire Western District
“She had no Care Co-ordinator nor effective Care Plan (which ought to have been in place)”
Original on judiciary.uk ↗ NHS England responded, stating 7 specific actions.Response (PDF) ↗Response (PDF) ↗Response (PDF) ↗Response (PDF) ↗
“£7 million for local areas to test ways to improve the quality of autism diagnostic pathways”
Stated timescale: 2023
Web search (Tavily): No evidence found either way
How Can We Improve Delivery of Diagnostic Assessment for Children with Possible Autism? – Social Science Space ↗“We have begun to examine these unique identifiable records with a view to: 1) understanding the rationale and the validity of the diagnosis in these cases, in view of the potential for diagnostic confusion. 2) determining if and how the diagnosis has been shared and made clear in the records. 3) whether the diagnosis has been withdrawn and if so, how this has been communicated both to people and to services. 4) engaging with clinical teams proactively and acknowledge that this could possibly be”
Stated timescale: 1st June 2022
5 more stated actions in the Promises tab.
- 2 months later
“Urgent solutions are required to prevent further deaths of autistic individuals especially those with mental health disorder by rapidly improving and expanding provisions”
Original on judiciary.uk ↗ NHS England responded, stating 1 specific action.Response (PDF) ↗
“all health and social care providers registered with the Care Quality Commission (CQC) must ensure that their staff receive training on learning disabilities and autism appropriate to their role”
Stated timescale: 1 July 2022
Web search (Tavily): Evidence found that the action was carried out
The Oliver McGowan Mandatory Training on Learning Disability and Autism | NHS England | Workforce, training and education ↗ - 1 year 3 months later
“acute psychiatric ward was considered but not deemed appropriate to meet his needs and as there were no specialist beds available he was discharged back to his home with increased support as the best option available.”
Original on judiciary.uk ↗ NHS England responded.Response (PDF) ↗
- 1 year 4 months later
Raised again · 4th time
Sapphire Bernard↗
5 Feb 2025 · Penelope Scofield · West Sussex, Brighton and Hove
Closely relatedConfidence 0.80 · moderatea different coroner“The evidence was that the environment in A&E as a holding place is not conducive for those suffering with Autism and/or who are neurodiverse.”
Original on judiciary.uk ↗ Repeated from the earlier report:placesufferingAutism
NHS England responded, stating 1 specific action.Response (PDF) ↗
“We are aware of the increasing numbers of patients waiting in emergency departments for mental health beds and, since the time of this incident, we have introduced national level monitoring of all patients in emergency departments waiting over 72 hours for mental health placements.”
Stated timescale: Winter 2024/25
Web search (Tavily): No evidence found either way
CBP-7281.pdf ↗ - 1 month laterClosely relatedConfidence 0.90 · higha different coroner
“The evidence reveals that there was a gap in the provision of care for individuals suffering with autism and in crisis, that remains the case today both in Devon and nationally.”
Original on judiciary.uk ↗ NHS England responded.Response (PDF) ↗Response (PDF) ↗Response (PDF) ↗
- All reports to NHS England
Each row is one judged link between an earlier and a later report. Open a row to read both quotes, found word for word in the originals.
2020 → 2025Sapphire Bernard4 years 4 months after Siân Hewitt · different coronerClosely relatedConfidence 0.80 · moderate
Closely relatedConfidence 0.80 · moderateBoth reports highlight that the current NHS provision fails to offer a safe, suitable environment for autistic individuals who also have mental health needs. The earlier report focuses on a lack of appropriate placements for autism with comorbid conditions, while the later report points out that A&E settings worsen mental health for autistic/neurodiverse patients.
Siân Hewitt · 21 Oct 2020
“the NHS are unable to provide a place of safety for those who are suffering from Asperger's syndrome, or indeed other forms of autism, when they are also suffering additional mental health problems such as bipolar”
Original on judiciary.uk ↗ Sapphire Bernard · 5 Feb 2025
“The evidence was that the environment in A&E as a holding place is not conducive for those suffering with Autism and/or who are neurodiverse.”
Original on judiciary.uk ↗ 2023 → 2025Benjamin Compton1 year 6 months after Benjamin Hazelden · different coronerClosely relatedConfidence 0.90 · high
Closely relatedConfidence 0.90 · highBoth reports highlight a shortage of suitable specialist care options for autistic individuals experiencing crisis or self‑harm risk. The earlier report focuses on closed specialist beds limiting urgent placements, while the later report notes a continuing gap in crisis provision for autism outside mental health act criteria.
Benjamin Hazelden · 26 Sept 2023
“acute psychiatric ward was considered but not deemed appropriate to meet his needs and as there were no specialist beds available he was discharged back to his home with increased support as the best option available.”
Original on judiciary.uk ↗ Benjamin Compton · 19 Mar 2025
“The evidence reveals that there was a gap in the provision of care for individuals suffering with autism and in crisis, that remains the case today both in Devon and nationally.”
Original on judiciary.uk ↗ 2022 → 2025Benjamin Compton2 years 8 months after Antony McLellan · different coronerClosely relatedConfidence 0.86 · high
Closely relatedConfidence 0.86 · highBoth reports highlight insufficient care and support for autistic individuals experiencing crisis or mental health distress. They differ in that the earlier report focuses on improving risk assessment and management, while the later report notes a continuing gap in crisis care provision.
Antony McLellan · 5 Jul 2022
“Urgent solutions are required to prevent further deaths of autistic individuals especially those with mental health disorder by rapidly improving and expanding provisions”
Original on judiciary.uk ↗ Benjamin Compton · 19 Mar 2025
“there was a gap in the provision of care for individuals suffering with autism and in crisis, that remains the case today both in Devon and nationally.”
Original on judiciary.uk ↗ 2022 → 2025Benjamin Compton2 years 11 months after Zoe Zaremba · different coronerClosely relatedConfidence 0.85 · high
Closely relatedConfidence 0.85 · highBoth reports highlight a lack of adequate care and support for autistic people experiencing crisis or mental health needs. The earlier report focuses on missing care coordination and care plans, while the later report notes a continuing gap in crisis provision for autistic individuals.
Zoe Zaremba · 25 Apr 2022
“She had no Care Co-ordinator nor effective Care Plan (which ought to have been in place)”
Original on judiciary.uk ↗ Benjamin Compton · 19 Mar 2025
“there was a gap in the provision of care for individuals suffering with autism and in crisis”
Original on judiciary.uk ↗ Stated action in the response to the earlier report
“registered providers are required to ensure their staff receive specific training on learning disability and autism appropriate to their role”
2020 → 2025Benjamin Compton4 years 5 months after Siân Hewitt · different coronerClosely relatedConfidence 0.85 · high
Closely relatedConfidence 0.85 · highBoth reports highlight insufficient NHS provision for autistic individuals experiencing mental health crises or additional psychiatric conditions. They differ in the earlier focus on a lack of safe placement for autism combined with bipolar disorder, while the later report stresses a broader gap in crisis care for autism irrespective of treatable mental health conditions.
Siân Hewitt · 21 Oct 2020
“It would appear from the circumstances of Ms [name redacted] death that the NHS are unable to provide a place of safety for those who are suffering from Asperger's syndrome, or indeed other forms of autism, when they are also suffering additional mental health problems such as bipolar.”
Original on judiciary.uk ↗ Benjamin Compton · 19 Mar 2025
“The evidence reveals that there was a gap in the provision of care for individuals suffering with autism and in crisis, that remains the case today both in Devon and nationally.”
Original on judiciary.uk ↗
No published response from NHS England was found for this report.
Stated action · timescale: 2023
“£7 million for local areas to test ways to improve the quality of autism diagnostic pathways”
What happened next: No evidence found either way
The sources discuss autism diagnostic pathways and funding but do not mention a specific £7 million promise for 2023.
“The prevalence of autism in children has risen significantly in recent years, studies from US Centers for Disease Control and Prevention, Northern Ireland and South Korea suggesting this currently sits at 1.5 to 3 percent of children in the western world. This is an increase from UK figures in 2006, which first suggested prevalence had reached 1 percent. This has resulted in an imbalance between”
“Securing £40.5m funding to improve Learning Disability and Autism care pathways - NHS SCW Support and Transformation for Health and Care NHS SCW Support and Transformation for Health and Care NHS SCW Support and Transformation for Health and Care.”
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No evidence found does not mean the action did not happen.
Stated action · timescale: 1st June 2022
“We have begun to examine these unique identifiable records with a view to: 1) understanding the rationale and the validity of the diagnosis in these cases, in view of the potential for diagnostic confusion. 2) determining if and how the diagnosis has been shared and made clear in the records. 3) whether the diagnosis has been withdrawn and if so, how this has been communicated both to people and to services. 4) engaging with clinical teams proactively and acknowledge that this could possibly be”
What happened next: No evidence found either way
The organisation has not provided a specific completion date for the promised examination of identifiable records, only stating that the work has begun.
“The aim of this study is to understand the experiences of accessing inpatient mental health services for individuals with a diagnosis of autism a”
No evidence found does not mean the action did not happen.
Stated action · timescale: 1 July 2022
“the CCG commissioned TEWV to provide mental health services for the population regardless of whether someone also has a diagnosis of a neuro developmental disorder/condition. The ICB have now had that contract novated to them upon the establishment of the ICB on 1 July 2022.”
What happened next: No evidence found either way
The ICB was established on 1 July 2022, but no source confirms that it commissioned TEWV to provide mental health services by that date or at any time.
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“Takeaways * **Contract novation replaces one party with another in a legally binding way.** It extinguishes the original contract and creates a new one where the incoming party assumes all rights and obligations”
No evidence found does not mean the action did not happen.
Stated action · timescale: 1 July 2022
“registered providers are required to ensure their staff receive specific training on learning disability and autism appropriate to their role”
What happened next: Evidence found that the action was carried out
The Care Quality Commission confirms that since 1 July 2022, all CQC-registered providers must ensure staff receive learning disability and autism training appropriate to their role, as mandated by the Health and Care Act 2022.
“Since 1 July 2022, all CQC registered health and social care providers have been required to provide training for their staff in learning disability and autism, including how to interact appropriately with autistic people and people with a learning disability. This should be at a level appropriate to their role.”
“The Health and Care Act 2022 requires all CQC-registered health and social care staff to complete learning disability and autism training. This training must be appropriate to their role.”
“The [name redacted] on Learning Disability and Autism is named after [name redacted], whose death shone a light on the need for health and social care staff to have better training.”
Stated action · timescale: March 2023
“investing £1.5 million into the development and trialling of autism training for staff working in adult inpatient mental health settings by March 2023”
What happened next: No evidence found either way
No source confirms the promised £1.5 million investment in autism training for staff in adult inpatient mental health settings by March 2023.
“This was published under the 2019 to 2022 Johnson Conservative government”
“Overall, the findings expose an acute lack of autism-specific training that has detrimental impacts.”
“Significant work is needed to provide autistic adults with affordable quality MH services.”
No evidence found does not mean the action did not happen.
Stated action · timescale: 2022/2023
“investing £70 million to prevent avoidable admissions and improve community support for autistic people and people with a learning disability”
What happened next: No evidence found either way
No source confirms the promised £70 million investment for autistic people and people with a learning disability was carried out within 2022/2023.
“Participants allocated to HomeHealth had a significant reduct”
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No evidence found does not mean the action did not happen.
Stated action · timescale: 2022/2023
“includes £40 million to improve the capacity and capability of 7-day specialist multidisciplinary and crisis support for autistic people and people with a learning disability in every area of the country.”
What happened next: No evidence found either way
The promised £40 million investment to expand 7-day specialist multidisciplinary and crisis support for autistic people and those with learning disabilities across all areas of England by 2022/2023 is not referenced in the provided sources.
“# The national strategy for autistic children, young people and adults: 2021 to 2026 Updated”
“Better care for people with a learning disability and people with autism”
No evidence found does not mean the action did not happen.
Stated action · timescale: 1 July 2022
“all health and social care providers registered with the Care Quality Commission (CQC) must ensure that their staff receive training on learning disabilities and autism appropriate to their role”
What happened next: Evidence found that the action was carried out
The NHS England page confirms that the Health and Care Act 2022 introduced a statutory requirement for CQC-registered providers to ensure staff receive learning disability and autism training appropriate to their role, effective from 1 July 2022.
“The Health and Care Act 2022 introduced a statutory requirement that CQC-registered providers must ensure their staff receive learning disability and autism training appropriate to their role.”
“From 1 July 2022, all health and social care providers registered with CQC must ensure that their staff receive training on learning disabilities and autism appropriate to their role.”
“Since 1 July 2022, all CQC registered health and social care providers have been required to provide training for their staff in learning disability and autism, including how to interact appropriately with autistic people and people with a learning disability.”
No specific action could be extracted with a verified quote.
Stated action · timescale: Winter 2024/25
“We are aware of the increasing numbers of patients waiting in emergency departments for mental health beds and, since the time of this incident, we have introduced national level monitoring of all patients in emergency departments waiting over 72 hours for mental health placements.”
What happened next: No evidence found either way
The NHS England statement references national monitoring of patients waiting over 72 hours for mental health beds in emergency departments, but no source confirms this monitoring was introduced by winter 2024/25.
“NHS key statistics: England Summary: NHS pressures before and after the pandemic 1 Emergency care: A&E and emergency admissions 2 Waiting times for hospital treatment 3 Cancer waiting times 4 Ambulance response times and demand 5 Diagnostic tests 6 Workforce levels and vacancies 7 Bed availability and discharges 8 GP appointments NHS key statistics: England”
“For the first time since February 2026, more than 10% of all patients attending A&E waited over 12 hours to be admitted, transferred, or discharged.”
No evidence found does not mean the action did not happen.
No specific action could be extracted with a verified quote.
No specific action could be extracted with a verified quote.
No specific action could be extracted with a verified quote.
- Each report's concerns were extracted by Nemotron 3 Nano on Nebius Token Factory, each with a quote copied from the report.
- Concerns from reports to NHS England at least six months apart were compared by meaning (Qwen3 embeddings) and wording (TF-IDF).
- The closest pairs were judged by Nemotron 3 Super with reasoning on. Only identical or closely related, with confidence of at least 0.70, are shown.
- Every quote was checked by code as an exact substring of the original text. Names of staff and family are redacted, and the deceased are named by report title only.
| Link | Meaning | Wording | Judge | Coroner |
|---|---|---|---|---|
| 2020 → 2025 | 0.71 | 0.18 | Closely related · 0.80 | different |
| 2023 → 2025 | 0.87 | 0.08 | Closely related · 0.90 | different |
| 2022 → 2025 | 0.78 | 0.17 | Closely related · 0.86 | different |
| 2022 → 2025 | 0.81 | 0.25 | Closely related · 0.85 | different |
| 2020 → 2025 | 0.76 | 0.12 | Closely related · 0.85 | different |
Judge model: nvidia/nemotron-3-super-120b-a12b. How Nemotron did the work · Full methodology.
Next
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This shows that a similar concern was raised again after an earlier report. It does not say why, and it is not a finding about any organisation or person. To report an error, see the corrections route.