Last month the deputy coroner for West Yorkshire, Professor Paul Marks, announced the outcome of an inquest into the death of Gareth Oates. Gareth died on March 2nd 2010, less than a month after his 18th birthday. He threw himself under a train at Marsden Station.
- You can read about the case HERE.
‘There was a global failure in his assessment, management and access to specialist services, amounting to neglect,’
Coroner Prof Paul Marks
This was a desperately sad case. Gareth was a high-functioning autistic young man. The coroner was aware that a number of state agencies had been involved in Gareth’s care, so he decided to hold a full inquiry into the cause of death under Article 2 of the European Court of Human Rights.
A coroner’s role is limited by law to answering four factual questions:
- who the deceased was;
- where he died;
- when; and
- how he came by his death.
A coroner may not make findings of civil or criminal liability.
Gareth had a diagnosis of autism when he was very young. He had a statement of special educational needs. At 11 years, he began to express suicidal thoughts. He had considerable support at school, and managed to weather some stormy periods. In 2008, aged 16, he went to a college of further education. He found the transition difficult, because the 25-hour a week one-to-one support which he had at school was withdrawn.
Gareth experienced bullying from local youths, sometimes on his way to college and sometimes at college. In July 2009, after college had broken up, he went to some cliffs in Sheringham, Norfolk, with the intention of throwing himself off. He left his mother a voicemail to say he was committing suicide, and a suicide note. He then changed his mind. The police detained him under the Mental Health Act 1983, section 136. A hospital psychiatrist and a social worker concluded that he was not suitable for admission for hospital.
Thereafter, Gareth and his mother experienced great difficulty trying to access any services. The family was repeatedly told that there was a gap in services for people like Gareth. Unfortunately, it seems that this is an all too common problem for young people with autistic spectrum disorder. Eventually, he was able to access specialist counselling.
Early in 2010, Gareth started expressing suicidal thoughts again, and was assessed by a community mental health team. They referred him to a psychiatrist. Gareth committed suicide the day after he saw the psychiatrist, who could find no signs of mental illness.
The coroner heard evidence from mental health experts and the author of a serious case review commissioned by Suffolk County Council. He accepted evidence that there was a number of failings in Gareth’s psychiatric management amounting to ‘gross failure’. In particular, he accepted evidence that:
- Autism has a high co-morbidity rate with other mental health disorders, which can occur in 40% of cases;
- Pharmacological treatment for psychiatric co-morbidity was not pursued, when it should have been;
- ‘Talking therapies’ were inadequate;
- There were failures in communication between the agencies caring for Gareth;
- No comprehensive longitudinal assessment of his autism took place;
- No consideration was given to the possibility of him having any psychiatric co-morbidity;
- There were gaps in service provision, with no specialist service for people like Gareth, and a hiatus between child and adult services for those aged 16-18;
- There was a lamentable lack of a named expert in autism to take charge of his care and adopt a holist approach to his needs;
- There was no satisfactory transition plan to ease Gareth’s move to college.
Recording a narrative verdict of suicide, the coroner said that the failings amounted to ‘neglect’. In his view, on the balance of probabilities, either detention under the Mental Health Act or treatment with drugs would have averted Gareth’s death. He noted that the Autism Act 2009 ironically came into force in 2010. He expressed his intention to write (under the Coroners’ Rules, rule 43) to the Secretary of State for Health and to the Royal College of Psychiatrists about the gap in psychiatric services for 16-18 year olds and to Suffolk County Council for a report on its progress in implementing its obligations under the Autism Act 2009. It is to be hoped that the Coroner’s report will help to improve services for young people like Gareth nationally.