Antony McLellan
5 Jul 2022 · Coroner Joan Broadbridge · North Yorkshire and York
A similar concern from this report was raised again 1 time later. See the linked reports.
The coroner's concerns
1. higher risk of autistic individuals dying by suicide
“The concern is that the very significant number of those open to TEWV with an autism marker has increased and will continue to do so and that the higher prevalence of suicide within that expanding group will lead to higher risk of, and numbers of, autistic individuals dying because of suicide both within TEWV locality but also nationally.”
2. inadequate risk assessment for autistic patients
“Assessment and formulation of risks and safety summary did not fully explore the impact of his autism. There was little to suggest that TEWV staff a) considered the higher prevalence of suicide for individuals with a diagnosis of autism and b) that Regulation 28 - After Inquest”
3. lack of autism-specific treatment in North Yorkshire
“TEWV does not treat autism in North Yorkshire”
4. insufficient autism mental health risk management provisions
“Urgent solutions are required to prevent further deaths of autistic individuals especially those with mental health disorder by rapidly improving and expanding provisions for assessment and management of risk of harm to themselves for individuals within the autism spectrum while presenting with a mental health disorder”
Linked reports
Closely relatedConfidence 0.86 · high
This report
“Urgent solutions are required to prevent further deaths of autistic individuals especially those with mental health disorder by rapidly improving and expanding provisions”
Later report
“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.”
Responses
2022-0207-Response-from-NHS-England.pdf ↗· NHS England
Stated action · 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”