Dear Coroner, Re: Regulation 28 Report to Prevent Future Deaths – Benjamin Robert Compton who died on 1 February 2022

Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 19 March 2025 (concerning the death of Benjamin Robert Compton on 1 February 2022. In advance of responding to the specific concerns raised in your Report, I would like to express my deep condolences to Benjamin’s family and loved ones. NHS England are keen to assure the family and the Coroner that the concerns raised about Benjamin’s care have been listened to and reflected upon.

Gap in the provision of care Your Report raises concerns over a gap in the provision of care nationally for individuals suffering with autism and in mental health crisis. It is for NHS Devon Integrated Care Board, who I note you have also sent your Report to, to respond to your concerns regarding provision of care within Devon. NHS England recognises the seriousness of the issues raised regarding the care of autistic individuals experiencing crisis, particularly where the threshold for detention under the Mental Health Act is not met, but where proactive, multidisciplinary intervention is still clearly needed. NHS England remains committed to working with local systems to address such gaps and to reduce the risk of similar tragic outcomes. In December 2023, NHS England published Meeting the Needs of Autistic Adults in Mental Health Services, which provides guidance to Integrated Care Boards and health providers on delivering accessible, autism-informed care. Key areas of relevance to your Report include:
• Improving crisis pathways by supporting tailored, multidisciplinary input for autistic people, particularly where access to traditional mental health services may be limited.
• Strengthening the interface between primary care and specialist mental health services, ensuring autistic adults can access support for co-occurring mental health needs at any level of care. National Medical Director NHS England Wellington House 133-155 Waterloo Road London SE1 8UG

14 May 2025

• Embedding sensory-informed care, including environmental adaptations and the use of health passports, to improve accessibility and safety across both urgent and planned care.
• Addressing diagnostic overshadowing, where a person’s autistic traits, including communication style, behaviour, or presentation, are misattributed to an existing mental health or neurodevelopmental condition, delaying appropriate assessment or support.
• Maintaining access to timely clinical oversight and continuity of care, especially for autistic individuals in acute distress. In addition, NHS England’s Staying Safe from Suicide guidance (April 2025) emphasises the importance of a whole-system approach to suicide prevention, which includes supporting personalised safety planning and ensuring that people experiencing distress, regardless of diagnosis, are able to access timely, compassionate, and coordinated care. The guidance underscores the need for services to work together to address gaps and transitions that may place individuals at heightened risk. Special Allocation Scheme Your Report also raises a concern over the Special Allocation Scheme (SAS) and states that consideration should be given to ensuring that patients are properly assessed as being suitable for the scheme before they are allocated, to ensure they get the appropriate care and treatment. GP contract regulations specify the grounds on which a contractor (i.e. a GP practice) may request that a person be removed from its list of patients with immediate effect. These are namely that: a) the person has committed an act of violence against any of the persons specified [essentially any member of the practice, a visitor or other patients] or has behaved in such a way that any of those persons has feared for their safety.

b) the contractor has reported the incident to the police. The regulations do not include a list of objectively defined behaviours or medical conditions which are excluded from referral; this is in recognition of the complex interactions that can take place in healthcare settings and the importance of ensuring that practices can maintain a safe environment for their patients and their staff. In practice, this means there is a balanced need for ‘careful considerations’ to be undertaken. On the one hand, by the provider, prior to referring a patient into the scheme and, on the other hand, by providers of GP SAS services when accepting a patient on to the scheme. NHS England publishes national guidance to GP practices and commissioners on the implementation of, and commissioning and monitoring of, GP SAS services. This is contained in Chapter 7 of NHS England » Primary medical services policy and guidance manual (PGM).

The PGM was updated on 15 July 2024 to include the following key updates in the SAS section: a) Remind GP practices of the need to undertake careful considerations prior to referring a patient into the scheme, having considered the patient’s protected characteristics, past medical history, learning disability and neurodiversity. b) Implement a prompt to GP practices when completing the online referral on the need for careful consideration (Status: in the process of implementation). c) An action request for commissioners to consider establishing and embedding initial appropriateness assessments into all commissioned SAS services. This would be subject to consideration when new services are commissioned or when existing services are reviewed, as well as funding availability. At the time of Benjamin’s death, a previous version of the PGM was in effect that did not include these items. The PGM available at the time (and still present in the current version) includes guidance on ‘behaviours this scheme does not ordinarily cover’. Paragraph 7.4.14 of the PGM states: “consideration should be given as to the history and circumstances of a patient including:
• wherever the behaviour can be ascribed to a condition capable of being rapidly alleviated by treatment, eg mental health illness or medical/acute conditions with known behavioural changes (eg head injury)
• whether it relates to a patient who has never been aggressive before and/or who is clearly suffering mental or physical distress
• careful consideration of any mitigating circumstances must be given as to whether a referral to the scheme is in the best interests of the patient.”

SAS services exist to provide a secure environment to patients who have been removed from their GP practice and allocated to the SAS scheme, so they can continue to receive primary medical services (GP services). SAS providers are commissioned to deliver primary medical services (through GP practices) with additional safeguards in place for supporting violent patients. This will include, for instance, ensuring that staff have a sufficient training and skill mix for supporting violent patients, security provisions and considering patient rehabilitation needs for addressing any contributing factors which may be influencing the behaviour. Aside from ensuring patients have continuing access to GP services, the aim of the SAS is to support rehabilitation and discharge patients back into mainstream GP services. When patients are in the SAS, they can expect to receive the full range of primary medical services as would be provided at any other GP practice and, as such, the provision to receive appropriate clinical care and treatment is already a given expectation of service. I would also like to provide further assurances on the national NHS England work taking place around the Reports to Prevent Future Deaths. All reports received are discussed by the Regulation 28 Working Group, comprising Regional Medical Directors, and other clinical and quality colleagues from across the regions. This

ensures that key learnings and insights around events, such as the sad death of Benjamin, are shared across the NHS at both a national and regional level and helps us to pay close attention to any emerging trends that may require further review and action.

Thank you for bringing these important patient safety issues to my attention and please do not hesitate to contact me should you need any further information.

Dear Mr Spinney,

NHS Devon acknowledges receipt of the Regulation 28 report following the inquest into the death of Benjamin Robert Compton. We would first like to extend our condolences to Benjamin’s family, friends, and all those who cared for and supported him. We recognise the impact of his death and the importance of the coroner's concerns in ensuring future improvements to the health and care system. This letter sets out NHS Devon’s response to the matters of concern you have identified.

Matters of Concern and Responses

Concern 1: 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. Evidence was heard that a gap exists with autistic people in distress and or dysregulation with no treatable mental health condition and there is a grey area around treatment. This is beyond the skills of social care providers. And unless the individual meets the criteria for treatment under the Mental Health Act there is very little support.

Consideration should be given to reviewing the process of supporting and providing interventions to those individuals suffering with autism and in crisis.

Response: Devon ICB recognises the existing commissioning gap for individuals with autism who experience crisis. In response, significant work has been undertaken in 2023–2024 to

2 raise awareness and implement reasonable adjustments to better meet their mental health needs.

In 2022, Devon received capital investment to develop a new community inpatient service dedicated to people with learning disabilities and autism requiring mental health treatment. This regional centre, one of two in the Southwest, aims to become a centre of excellence providing specialist expertise, training, and system-wide support. The first inpatient beds are scheduled to open in June 2025.

Alongside this, an outreach and inreach service will be integrated into the pathway to prevent unnecessary admissions and ensure timely, appropriate care.

Furthermore, the implementation of the Oliver McGowan mandatory training will enhance community skills and promote reasonable adjustments across services, ensuring that autistic individuals in crisis receive appropriate support.

To review and improve current processes for crisis support, the Learning Disability and Neurodiversity commissioning team will conduct a comprehensive community delivery review in 2025/2026. This review will cover primary care, secondary care, social care, and acute services to optimise care pathways for this population.

A full commissioning review and improvement plan will also be presented to the Devon ICB executive in the last quarter of this financial year.

Concern 2: Benjamin was removed from his GP practice due to violent behaviour and allocated to the Special Allocation Scheme. This scheme was not able to meet the needs of a patient such as Benjamin with a diagnosis of Autism Spectrum Disorder.

Consideration should be given to ensuring that when patients are allocated to the GP Special Allocation Scheme they are properly assessed as being suitable for the scheme and receive the appropriate clinical care and treatment.

Response: We have previously made improvements to processes and requirements in this scheme since this case. The changes include reviewing the process the practice has followed to ensure it meets all the requirements for allocation to the Special Allocation Scheme and where an appeal is made, the panel agenda has clear items to check/ensure the practice has followed the appropriate processes for assigning to the scheme.

Regarding the application of our process in this case, we have also reflected previously on this case that a choice should have been given to whether the family wished for the appeal panel to take place, following this person's death, rather than ceasing all communication in an intended act of respect.

Following receiving this Prevention of Future Deaths notice we have additionally considered what extra action can be taken to additionally strengthen arrangements. We have determined to make a modification to the Special Allocation Scheme Standard Operating Procedures (SOP) that specifically requires written confirmation from Practices that they considered all possible alternative approaches to providing primary medical services prior to making the placement. This change was enacted in May 2025.

3

In summary the death of Benjamin highlights the need for continued improvement in how services respond to autistic individuals in crisis. Devon ICB is committed to taking forward the actions outlined above, strengthening our approach, and working with partners to ensure compassionate, appropriate, and timely support is available when it is most needed.

Should any further information or clarification be required, we would be pleased to provide it.

Dear Mr Spinney

Re. Mr Benjamin Robert Compton – Regulation 28 report.

I write in my capacity as Chief Nursing Officer and Allied Professions Lead at Devon Partnership NHS Trust (the Trust) in response to your regulation 28 report dated 19 March 2025.

Can I first of all pass on my condolences to Mr Compton’s family and friends.

In your report you highlighted areas of concern to Devon Integrated Care Board, Director for Primary Care NHS Devon, and NHS England along with us Devon Partnership NHS Trust (DPT).

In respect to the concerns pertinent to DPT I respond as below:

MATTERS OF CONCERN are as follows: The evidence reveals that there was a gap in the provision of care for individuals suffering with autism and in crisis, which remains the case today both in Devon and nationally. Evidence was heard that a gap exists with autistic people in distress and or dysregulation with no treatable mental health condition and there is a grey area around treatment. This is beyond the skills of social care providers. And unless the individual meets the criteria for treatment under the Mental Health Act there is very little support:

At the time of, and during the period leading up to Mr Compton’s death, as you highlight the Trust and wider Devon system did not have access to a specific autism crisis team. This was, and remains, a known gap in commissioning across the country.

At the time, as described by in her testimony in court, the Devon Adult Autism Intervention Team (DAAIT), had recently been commissioned to provide a countywide service for autistic adults with the aim to:

• Prevent unnecessary hospital admission
• Reduce length of stay
• Prevent placement/accommodation breakdown including within family home
• Support the individual and their team(s)/supporters to better understand where autism is impacting on the person’s stability, and the barriers to interventions/treatment options and solutions, where autism is the key or contributing factor to individuals needs/concerns.

As also explained, DAAIT at that time were in the developmental phase and not yet operational. The team was not scheduled to become operational (become open to referrals, commence clinical work) until April 2020. This timeframe was achieved.

However, had DAAIT been operational at the time of Mr Compton’s distress there still would not have been a specific dedicated autism crisis pathway that he could access. The DAAIT service operates with a duty worker system 5 days per week, staffed by team members. Because of the low demand on duty in terms of volume of queries, and DAAIT service not commissioned to provide an “urgent response”, there is a time frame for response of 48hrs, predominantly this accessed via email queries. This provision is noted in the service Standard Operating Procedure. If there was a significant concern that there was an immediate threat to life then the staff member dealing with the query would contact the police via 999.

DAAIT is a very small team, and as part of its commissioning it is explicitly not able to provide:

• A care coordination function, and as a result the expectation is that DAAIT staff will work as part of the overall health and/or social care network around the person at that time. Any work, regardless of tier, will be time limited.
• An emergency or crisis response.
• Services/treatment which can be provided by mainstream services, with reasonable adjustments. Subsequent regional developments: Regionally the lack of specifically designed inpatient environments to best assesses/treat adults with a learning disability and/or who are autistic with co-morbid mental health issues was acknowledged by NHS England and led to a range of funding to build x2 ten bedded inpatient units for this cohort. Devon Partnership Trust has been the lead provider for one of these (The Brook), which is currently under construction in Dawlish, Devon, and is due to open summer 2025. The other unit (The Kingfisher) is being built in Bristol but is not due to open until later in 2026. As part of the regional development a Learning Disability/Autism Outreach team has been commissioned to sit alongside each unit as part of what is being seen as regional a Learning Disability/Autism service. The LD/A outreach linked with The Brook, is due to become operational at a similar time to the unit opening. It is important to stress that the LD/A Outreach is not commissioned to provide crisis support/intervention in the same way that mental health crisis/home treatment teams are but will be able to work closely with these teams and other services, the patients network etc providing specific autism relevant advice/guidance and interventions.

Benjamin was removed from his GP practice due to violent behaviour and allocated to the Special Allocation Scheme. This scheme was not able to meet the needs of a patient such as Benjamin with a diagnosis of autism spectrum disorder.

Devon Partnership NHS Trust are not able to comment on this specific question as it is a Primary Care/GP related one.

I trust the above responds clearly to your question.