REDACTED
PFD Report
Historic (No Identified Response)
Ref: 2023-0115
Coroner's Concerns (AI summary)
Unacceptably long waiting times for young people's assessments due to finite resources placed children at risk, suggesting that earlier diagnosis and professional support could prevent deaths.
View full coroner's concerns
In the circumstances it is my statutory duty to send the report: The MATTER OF CONCERN is as follows.
• With finite resources, it is acknowledged that it may not be possible for all young people to be assessed in as timely a manner as required, but there must surely come a point whereby, notwithstanding those finite resources, the wait for assessment is taking too long.
• The wait for assessment placed at risk, and other children will be similarly at risk in the absence of a timely assessment.
• It is possible that had he been diagnosed earlier, and with enough time for the relevant professionals to have been able to carry out some meaningful work with him, and had his extremely supportive Parents been given more support, death may have been avoided.
• With finite resources, it is acknowledged that it may not be possible for all young people to be assessed in as timely a manner as required, but there must surely come a point whereby, notwithstanding those finite resources, the wait for assessment is taking too long.
• The wait for assessment placed at risk, and other children will be similarly at risk in the absence of a timely assessment.
• It is possible that had he been diagnosed earlier, and with enough time for the relevant professionals to have been able to carry out some meaningful work with him, and had his extremely supportive Parents been given more support, death may have been avoided.
Part of a Series
9 separate reports were issued from this inquest, each sent to different organisations.
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2019-0397
Sent to: College of Policing;No responses yet
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2020-0061
Sent to: Department of Health and Social Care; NHS England;All responded
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2022-0036
Sent to: Broadgate General Practice; General Medical Council;1 of 2 responded
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2022-0095
Sent to: Coventry and Warwickshire Partnership NHS Trust;No responses yet
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2024-0031
Sent to: London Fire Brigade;All responded
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2025-0045
Sent to: Unite Group plc;All responded
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2025-0314
Sent to: 49 Marine Avenue Surgery; Department of Health and Social Care; Moorbridge School; North East and North Cumbria Integrated Care Board; Northumbria Healthcare NHS Foundation Trust;All responded
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None
Sent to: Domestic Abuse Management Board Surrey PoliceSurrey County Council1 of 2 responded
This report (2023-0115) is shown above.
Sent To
- Department for Education
- Department of Health and Social Care
Response Status
Linked responses
0 of 3
56-Day Deadline
29 May 2023
About PFD responses
Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Report Sections
Investigation and Inquest
The death of on 24th September 2022 at his home address was reported to me and I opened an investigation which concluded by way of an inquest held on 29th March 2023.
Circumstances of the Death
In addition to the contents of section 3 above, the following is of note:
• At the time he died, was in the early stages of an assessment process aimed at confirming if he had a diagnosis of autism. His Parents had long suspected he was different from their other children.
• He had attended a review on 23/07/22 with a Consultant Paediatrician, but there was more work to be done.
• His family feel that had he been assessed earlier, and a diagnosis made, they may have been more equipped to deal with on his more challenging days.
• The court was informed that he had waited around three years for assessment. This was immensely frustrating. His Parents regularly learned that young people perceived to be more challenging were added to the waiting list at a much later stage, and allocated a place higher up that waiting list, with the inevitable consequence that assessment was further delayed.
• In April 2022, there was finally some progress and they became aware that the assessment process was to commence, but as it turned out not in sufficient time for him to have been assessed, diagnosed, and for his Parents to be given the help they feel they needed to support him before he died.
• In a witness statement provided for the inquest, Father described some of his character traits including:
• was a very physical, affectionate child;
• He was interested in the outdoors, nature, wildlife, arts and crafts.
• He was making excellent academic progress;
• He was very self-deprecating 8
• He was a risk taker.
• He was impulsive.
• Although the assessment process was in motion by the time he died, his Parents remained of the opinion that once assessed, he would most likely have been diagnosed with Attention Deficit Hyperactivity Disorder [ADHD].
• At the time he died, was in the early stages of an assessment process aimed at confirming if he had a diagnosis of autism. His Parents had long suspected he was different from their other children.
• He had attended a review on 23/07/22 with a Consultant Paediatrician, but there was more work to be done.
• His family feel that had he been assessed earlier, and a diagnosis made, they may have been more equipped to deal with on his more challenging days.
• The court was informed that he had waited around three years for assessment. This was immensely frustrating. His Parents regularly learned that young people perceived to be more challenging were added to the waiting list at a much later stage, and allocated a place higher up that waiting list, with the inevitable consequence that assessment was further delayed.
• In April 2022, there was finally some progress and they became aware that the assessment process was to commence, but as it turned out not in sufficient time for him to have been assessed, diagnosed, and for his Parents to be given the help they feel they needed to support him before he died.
• In a witness statement provided for the inquest, Father described some of his character traits including:
• was a very physical, affectionate child;
• He was interested in the outdoors, nature, wildlife, arts and crafts.
• He was making excellent academic progress;
• He was very self-deprecating 8
• He was a risk taker.
• He was impulsive.
• Although the assessment process was in motion by the time he died, his Parents remained of the opinion that once assessed, he would most likely have been diagnosed with Attention Deficit Hyperactivity Disorder [ADHD].
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.