Dear Coroner, Re: Regulation 28 Report to Prevent Future Deaths – Joshua Jay Weavers who died on 4 March 2021.

Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 17 February 2025 concerning the death of Joshua Jay Weavers on 4 March 2021. In advance of responding to the specific concerns raised in your Report, I would like to express my deep condolences to Joshua’s family and loved ones. NHS England are keen to assure the family and the Coroner that the concerns raised about Joshua’s care have been listened to and reflected upon.

Your Report raised the concern that national waiting times for Autism Spectrum Disorder (ASD) assessments are very long and, combined with the increased risk of suicidal behaviour amongst people diagnosed with ASD, there is a risk of future deaths occurring due to the national delays.

My response to the Coroner has been aided by engagement with our national mental health, learning disability and autism teams and East of England regional colleagues.

NHS England recognises the significant national challenge in ensuring timely access to ASD assessments and the impact that long waits can have on individuals and families. We also acknowledge the Coroner’s concern that a delay in diagnostic assessment, particularly for autistic young people at risk of suicide, may contribute to avoidable harm.

In April 2023, NHS England published the National Framework and Operational Guidance for Autism Assessment Services. This framework sets out a clear expectation that autism assessment pathways must not operate in isolation from wider services. Critically the operational guidance for Integrated Care Boards states:

‘For health-related needs, the referrer or local primary or secondary care services must not omit providing assessment or interventions relevant to the person’s needs while they are waiting for an autism assessment. Clarity about a possible autism diagnosis, in almost all instances, does not negate input for current needs, symptoms or difficulties that appear linked to physical or mental health.’ National Medical Director NHS England Wellington House 133-155 Waterloo Road London SE1 8UG

27 May 2025

This principle is vital in cases where an individual presents with significant distress or risk – as was true in Joshua’s case. While a completed ASD assessment can support more tailored care, it should not act as a prerequisite for accessing timely mental health support.

Meeting the needs of Autistic Adults in Mental Health Services guidance was published the same year, in December 2023, and highlights the importance of recognising and responding to distress and suicidality in people who are autistic, with the latter significantly over-represented when compared to the general population. The guidance addresses the risk of diagnostic overshadowing – where symptoms of distress or mental illness may be incorrectly attributed to autism – and the need to ensure continuity of care for autistic people and those with suspected autism across all settings. These principles are relevant to transition-aged young people and support the expectation that interventions should not be paused while awaiting diagnostic clarity.

NHS England’s Staying Safe from Suicide guidance (April 2025) further highlights the need for a coordinated, multi-agency approach to suicide prevention and emphasises the importance of providing responsive and compassionate care during periods of diagnostic uncertainty. The guidance reinforces the role of personalised safety planning and the importance of ensuring that young people at risk of suicide are not left without therapeutic support due to delays in formal diagnosis.

I hope that the publication of the above guidance in 2023 and 2025 provides assurance to the Coroner and Joshua’s family that actions have been taken since Joshua’s death across the NHS to help address the concerns raised. NHS England continues to support local systems to implement the guidance across their commissioned services. Further information on the work and progress of our Learning Disability and Autism Programme can be found here: https://www.england.nhs.uk/learning-disabilities/

I note that your Report has also been addressed to Hertfordshire and West Essex Integrated Care Board (ICB). NHS England has been sighted on their response to the Coroner and notes the work being undertaken to make improvements across service providers, with key elements including:

• providing better pre and post diagnosis support
• using inputs from a wider range of non-clinical and clinical staff specialisms to support diagnosis
• implementing a standardised and consistent referral and triage process.

I refer you to Hertfordshire and West Essex ICB’s response to your Report for further information on the actions they are taking.

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 Joshua, 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 Howell,

Re: Regulation 28 Report to Prevent Future Deaths - Death of Joshua James Weavers who died on 4 March 2021

Thank you for your Report to Prevent Future Deaths dated 17 February 2025 concerning the death of Joshua Jay Weavers on 4th March 2021. In advance of responding to the specific concerns raised in your report, I would like to express my deep condolences to Joshua’s family. Hertfordshire and West Essex Integrated Care Board (ICB) are keen to assure the family and the coroner that the concerns raised about Joshua’s care have been listened to and reflected upon.

Within your report, you highlighted the below as matters of concern for the ICB:

“That whilst the local mental health Trust has plans to reform the manner in which autism spectrum disorder (ASD) assessments for patients under their care are undertaken, the implementation of those plans awaiting input from the Integrated Care Board. This means that waiting times for ASD assessments in Hertfordshire remain lengthy which in turn gives rise to a risk of future deaths occurring for the reasons set out above.”

As you have noted in your report, nationally waiting times for ASD assessments are very long, and NHS services across England are encountering ongoing challenges in meeting the increased demand for ASD assessment and services, including Hertfordshire and West Essex ICB. We understand this is a worrying time for individuals and families which are seeking assessment and rely on treatments for their wellbeing, and we are taking steps to support the ongoing work to improve access.

There are significant numbers of children and young people in both Hertfordshire and West Essex waiting for assessment for both autism and ADHD. Locally, we have seen a marked change in the levels of demand for assessment for both autism and ADHD. For example, five years ago we were seeing a year- on-year increase in demand of around 10% whereas now the annual increase in demand is just below 25%. This rise is predicted to increase year on year, and in response we are seeking to redesign our approach to better be able to continue to respond to this increasing demand.

Work to improve services (The Children and Young People Neurodiversity Transformation programme) has developed a model that responds to the needs of the child and family, rather than one driven by specific diagnostic findings. This offers much more timely, individually tailored and appropriate services to neurodiverse children and their families and carers. This approach has the aim of improving the clinical and wellbeing outcomes for the young person and their families and carers.

The Forum Marlowes Hemel Hempstead Hertfordshire HP1 1DN

04 April 2025

Email:

Private & Confidential

Mr Jacques Howell Area Coroner Hertfordshire Coroner Service

, Chief Executive , Chair

Work has commenced in a measured and stepped way across our service providers. Key elements include:
• providing better pre (and post) diagnosis support
• Using inputs from a wider range of non-clinical and clinical staff specialisms to support diagnosis
• implementing a standardised and consistent referral and triage process.

Through this, we can provide more timely and appropriate support, better meet demand and reduce wasted patient, family and clinical time.

The model has been developed in partnership through the Hertfordshire Mental Health, Learning Disabilities and Autism Health and Care Partnership (MHLDA HCP). It has involved NHS and Local Government partners, VCFSE organisations, local GPs and people with lived experience through Herts Parent/Carer Involvement Network (HPCI). Significant co-production and engagement with services, allied professions, and parent carers has identified areas where the pathways can work better for professionals and families.

There are different elements of an ASD assessment, and our new model establishes the resources required to operationalise this activity, specifically:

• The continuation and development of the Neurodiversity Support Hub and the development of a support offer to support parent carers, families and children to live well with autism and ADHD regardless of diagnosis status
• The development of a new ‘front door’ to ensure a consistent quality of referrals, improved collation of information to support the diagnostic process, easier follow up with professionals where there is missing or incomplete information and improved data collection
• A new combined clinical pathway for triage and assessment across NHS provider Trusts that supports best use of clinical resource across Hertfordshire
• The development of a care coordinator role to support families as they go through the clinical pathway, releasing clinical time and ensuring that families are better engaged and informed of progress

It is important to note that for those waiting for ASD assessments, children and young people are rated Red, Amber, or Green (RAG) against both clinical and safeguarding criteria and monitored against this. Service providers periodically contact families and share support information to ensure they are aware of and endeavour to respond to changes that may happen whilst people wait. If there is any change to circumstances, or risk for the child or young person waiting, the family or the child or young person’s GP can contact the provider for additional support.

We also recognise that there are some children and young people who are receiving inpatient care in a mental health setting, and they may undergo assessment and receive a diagnosis whilst an inpatient. Ongoing treatment and support would be managed through their individual care plan and support given on discharge.

All age strategy Hertfordshire has developed a new All Age Autism Strategy, which sets out the broad priorities for health and care services, based on what autistic people and their families and carers say is important to them. The Strategy commits system partners to key priorities, including: i) People have access to a timely diagnosis, support whilst waiting for a diagnosis and post diagnosis support. ii) Autistic people have equitable access to reasonably adjusted mental health services when they need them.

, Chief Executive , Chair

iii) Autistic people and their families have access to a range of support in their local communities.

iv) Autistic people have equitable access to reasonably adjusted physical healthcare services when they need them and improving health outcomes for autistic people.

Additional support for those waiting in Hertfordshire

In order to continue to provide further support for those waiting a resource pack has been created for parents and carers with details of services available for them to access, including whilst waiting for assessment, and this can be found here - The Hertfordshire Local Offer.

GPs are also encouraged to share the following video with parents and carers - Your guide to ADHD and autism support in Hertfordshire on the Local Offer website - YouTube. Additional resources available to parents include - Supporting Your Neurodiverse Child, and the neurodiversity service directory is also available - Neurodiversity Service Directory.

Summary

We are working intensively on these issues to support our providers to deliver safe and timely care, including significant investment in pathways. We have provided additional funding for the work listed above for financial years 2023/24 at circa £3 million and 2024/25 at approximately £4.1 million, further funding of £4.3 million is baselined into providers budgets for coming financial years from 2025/26 to continue to support the development of the model previously mentioned. However, it must be acknowledged that despite all the efforts detailed above it is expected that long waits for assessment will remain without wider national support, given the ongoing rises in demand that are persisting.

We await the outcome of the NHS 10-year-plan to understand whether the government will further prioritise ASD, therefore potentially reduce wait times for ASD assessment.

Thank you for bringing these important patient safety issues to my attention. I do hope my response provides some assurance to you and Joshua’s family regarding the actions being taken in relation to the waiting times for ASD assessments in Hertfordshire, and the support to those waiting.

Please do not hesitate to contact me should you require any further information or clarification.

Dear
- Senior Coroner's Officer

Re: Regulation 28 Notice – Joshua Weavers

Thank you for your 2025 Regulation 28: Report to Prevent Future Deaths dated 17 February 2025. We would like to take this opportunity to express our sincere condolences to the family of Joshua Weavers; our thoughts are with them.

The safety of the public using our bridges and infrastructure is paramount. We appreciate your report and provide our response to the concerns raised which relate to our duties and powers as local highway authority, namely:

That the safety measures in place on the to guard against pedestrians either jumping or falling from the bridge do not meet current guidance and therefore gives rise to a risk of future deaths occurring.

Immediately after Joshua's sad death, we erected notices on the footbridge and road bridge to help deter future suicide attempts by signposting people to the Samaritans. Additionally, we considered what could be done in relation to the heights of the parapets on the bridges. As your report noted, these are lower than the current standards for new bridges. These standards were introduced relatively recently and are not retrospective on existing structures. Many other bridges both locally and nationally have similar or lower parapets than those set out in the current standards.

We explored simple ways to raise the height of the parapets on the footbridge but unfortunately, concluded that this could not be done safely without up-to-date information on the condition of the structure, parts of which are impossible to access

County of opportunity under normal circumstances. Regrettably, there are no 'quick fixes' available to raise the height of the footbridge parapets.

We therefore considered an alternative approach of closing the footbridge. This would create a lengthy diversion for pedestrians to access the southern road bridge and an increased risk of pedestrians crossing the dual carriageway at an unsafe location.

The southern road bridge was built at a similar time to the footbridge and also has relatively low parapets. It would be possible to raise the parapets on the southern road bridge, however in working with other agencies involved, the relative isolation of the footbridge was the principal concern. It was also considered that diverting people to the southern road bridge, would exacerbate the isolation of the foot bridge.

With no immediate options to improve suicide prevention, we felt it was better to wait for the Inquest's input before considering other options. This requires a Principal Inspection of the bridge to assess the condition of the structure and we could then ensure this takes into account the findings from the Inquest.

To inspect the footbridge and southern road bridge safely, we need Network Rail's permission for a time when the railway is closed and the overhead power lines turned off. We will use the next Principal Inspection to assess the feasibility of raising or replacing the parapets with new, higher versions. We are currently liaising with Network Rail and will undertake the Principal Inspection at the first opportunity. Once this is complete, we will be able to better understand the feasibility and costs of parapet improvements and consider the most appropriate course of action.

We take our responsibilities in these matters very seriously and having considered immediate responses, with the benefit of the report of the Inquest’s findings, we are exploring all appropriate options to help reduce the risk of another death at this site.

Once again, we offer our heartfelt sympathies to Joshua’s family for their loss.