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Coroner warns government over lack of community care for autism

A coroner has issued a damning warning to the government over the lack of community care for autistic people after an inquest into the death of a teenager at a psychiatric hospital.

Penelope Schofield, senior coroner for West Sussex, Brighton and Hove, wrote a prevention of future deaths (PFD) report to the Department of Health and Social Care at the end of the inquest into the death of 19-year-old Jessie Eastland-Seares.

autism, autism awareness, mental health

Eastland-Seares, who was autistic, self-harmed and had been diagnosed with a variety of disorders and mental health conditions, had been living in emergency accommodation, supported by an unregulated agency, before being admitted to Royal Sussex County Hospital for physical issues, where she was later detained under the Mental Health Act.

She was admitted to Caburn ward, part of the Sussex Partnership Foundation Trust, on 4th March 2022.

At the time of her death, she was on checks which should have taken place on an hourly basis. However, in the early hours of 17th May 2022, staff found her unresponsive. A doctor commenced CPR and an ambulance was called, but she sadly passed away.

The inquest jury concluded that ‘systematic failures’ in health and social care led to a series of events that culminated in regular self-harm, ultimately ending in death by misadventure.

‘Sadly this case exposes the total inadequate level of community provision for the care and treatment of those with suffering with Autism,” Schofield wrote in her PFD report. ‘This is a national problem and sadly leads to many experiencing unnecessary admissions to inpatient mental health facilities and also A&E attendances.

‘Despite a report from the Health and Social Care committee from 2021 this case showed that there does not seem to have been any real improvement and more lives are likely to be lost.’

The parliamentary committee report said that investment and provision of community support for autistic people and those with learning difficulties was ‘significantly below’ the required level.

‘The Inquest heard that two years on there still remains an acute shortage of provision,’ Schofield wrote. ‘Evidence was heard that East Sussex Council had tried over 30 providers to help put in place support for Jessie but they could not find a placement for her so the only provision that they were able to offer her was supported housing with temporary care agency staff. This provision broke down which exacerbated Jessie’s mental health. This then led to a Hospital mental inpatient admission.’

The family’s lawyer, Chris Callender of Sinclairslaw, said: ‘What we have heard throughout this inquest is that the care provided to Jessie was simply not suitable for her needs. Jessie experienced 30 different placements from the age of 14 years of age, and was no doubt in utter despair about her future when she died.

‘What is deeply concerning in Jessie’s case was that rather than learn lessons and improve services for her care in the community, the Council appears to have given up and placed in her wholly unsuitable accommodation with a care team ill equipped and unsupervised, to look after a highly vulnerable young person. Ineveitably this culminated in her mental health deteriorating and yet another detention in psychiatric care. The Council were able to effectively wash their hands of any responsibility.

‘The consequences, for Jessie, were catastrophic.

‘It is imperative that action is now taken to improve the care that is available to people with complex neurodevelopmental, mental and physical health needs. That means a properly funded system, with training and adequate remuneration for staff and suitable accommodation for these vulnerable people.’

Image: karelinlestrange

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