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recurance

Molly-Ann Sergeant

19 Feb 2023 · Coroner Sonia Hayes · Essex

The coroner's concerns

  1. 1. delayed diagnosis of Autism

    “[name redacted] had a delayed diagnosis of Autism. [name redacted] was diagnosed during her detention at the St. Aubyn Centre when she experienced a mental health crisis and detained under the Mental Health Act”
  2. 2. insufficient assessment of Autism impact for discharge planning

    “There was insufficient assessment for discharge planning purposes of the impact of [name redacted]'s recent diagnosis of Autism by Essex Partnership NHS Foundation Trust”
  3. 3. insufficient consideration of Autism impact on suicide risk in discharge planning

    “There was insufficient consideration given to the impact of [name redacted]'s delayed diagnosis of Autism on her chronic high risk of suicide in her discharge and discharge planning in a background of [name redacted] not accepting her diagnosis”
  4. 4. lack of escalation to Essex County Council

    “Lack of escalation to Essex County Council when there was a failure to respond to requests for assessment and attendance at discharge planning meetings and the key worker/care co-ordinator carrying too heavy a workload as a consequence”
  5. 5. failure to act on referrals and conduct assessments and understand detention impact

    “Essex County Council did not: a. act on appropriate referrals to social care by Essex Partnership NHS Trust b. conduct required assessments of [name redacted] during her detention did not appoint a social worker until after [name redacted] was discharged There was a lack of understanding of the impact of [name redacted]'s detention on her right to assessment as a child in need and how this changed during her detention under the Mental Health Act”
  6. 6. lack of understanding of section 117 rights and impact of autism diagnosis

    “lack of understanding of section 117 Mental Health Act rights and potential for consideration for entitlements to meet [name redacted]'s needs related to her mental health disorder, by Essex County Council: a. compelling [name redacted] to choose between family members as part of her discharge planning and then as a consequence changing [name redacted]'s status during her detention from homeless. b. Lack of assessment for any s117 needs to facilitate discharge Lack of appreciation of the impact of [name redacted]'s autism diagnosis in”

Responses

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Source: Prevention of Future Deaths reports and responses published by the Courts and Tribunals Judiciary at judiciary.uk. Crown copyright, used under the Open Government Licence v3.0. Data updated 26 Oct 2026.

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