5 Jul 2022 Antony Christopher MCLELLAN · Prevention of Future Deaths report North Yorkshire and York
View report summary
Concerns raised 4 Failure to provide autism treatment in North Yorkshire View source Higher suicide risk among the expanding population of autistic individuals open to mental health services View source Failure to incorporate autism into assessment and management of self-harm risk View source Underdeveloped and insufficiently accessible specialist autism support for mental health patients View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Antony Christopher MCLELLAN · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Antony Christopher McLellan was found unresponsive, hanging by a ligature in the garage at his home on 9 July 2021; his death was recognised that afternoon and the inquest concluded that he died by suicide. Concerns included that assessment and formulation of risks and safety did not fully explore the impact of his autism, including how he might communicate distress and risk, and that autism-informed support and services required significant improvement and expansion.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Humber and North Yorkshire Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to provide autism treatment in North Yorkshire
Wider context from the report “1 Mr McLellan was diagnosed over 2016/16 as being autistic with a designation of Asperger’s Syndrome. He was also diagnosed as experiencing Bipolar Disorder, an attribution he did not accept which he repeatedly asserted to both previous Mental Health care providers and the subsequent Trust clinicians tasked with supporting him at the time of his death, Tees Esk and Wear Valleys NHS Foundation Trust (“TEWV”)
2 He insisted his difficulties were linked to his autism and not mental disorder. It was accepted that he experienced autism and that was part of his individuality and that in addition he may have had a mental health disorder. It was accepted that his care and treatment cannot unbundle the two but he should be treated holistically.
3 Assessment and formulation of risks and safety summary did not fully explore the impact of his autism. There was little to suggest that TEWV staff) considered the higher prevalence of suicide for individuals with a diagnosis of autism and that Mr McLellan may have communicated his distress and risks information differently to an individual without a diagnosis of autism during his periods of crisis or increased risk and c) made sufficient reasonable adjustments in relation to the impact of his autism.
4 At the time of his death, TEWV had progressed from a low baseline in the Trust’s work in North Yorkshire to address perceived underdevelopment in their services for the autistic patient when presenting with a mental health disorder. It had expanded the use of a specialist team (Autism Project Team- “APT”) to extend its work into North Yorkshire caseload. The steps taken were incremental and not all staff understood that Team and access to that important resource. It is recognised that improvements would take time and be resource dependent as well however.
5 APT has three specialist and autism dedicated practitioners working exclusively with autism across the whole Trust in both its regions of commissioned care although there are also non-dedicated clinicians with some expertise of autism within TEWV. TEWV does not treat autism in North Yorkshire.
6 TEWV in its recent audit indicates about 17% of the individuals open to TEWV (over 10,000 in number) have an autism marker or have an ICD-10 diagnosis of autism or experience suspected/confirmed autism or have a referral including being suspected as autistic.
7 There was no direct causation to the suicide found that directly attributed the acts he took to his autism from the evidence. However Mr McLellan’s distress and stressors before his death included his feelings that he was not getting what he saw to be the right help and that he would not lose his feelings of helplessness such that he took his own life.
The concern is that the very significant number of those open to TEWV with an autism marker has increased and will continue to do so and that the higher prevalence of suicide within that expanding group will lead to higher risk of, and numbers of, autistic individuals dying because of suicide both within TEWV locally but also nationally.
Urgent solutions are required to prevent further deaths of autistic individuals especially those with mental health disorder by rapidly improving and expanding provisions for assessment and management of risk of harm to themselves for individuals within the autism spectrum while presenting with a mental health disorder.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Humber and North Yorkshire Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Higher suicide risk among the expanding population of autistic individuals open to mental health services
Wider context from the report “1 Mr McLellan was diagnosed over 2016/16 as being autistic with a designation of Asperger’s Syndrome. He was also diagnosed as experiencing Bipolar Disorder, an attribution he did not accept which he repeatedly asserted to both previous Mental Health care providers and the subsequent Trust clinicians tasked with supporting him at the time of his death, Tees Esk and Wear Valleys NHS Foundation Trust (“TEWV”)
2 He insisted his difficulties were linked to his autism and not mental disorder. It was accepted that he experienced autism and that was part of his individuality and that in addition he may have had a mental health disorder. It was accepted that his care and treatment cannot unbundle the two but he should be treated holistically.
3 Assessment and formulation of risks and safety summary did not fully explore the impact of his autism. There was little to suggest that TEWV staff) considered the higher prevalence of suicide for individuals with a diagnosis of autism and that Mr McLellan may have communicated his distress and risks information differently to an individual without a diagnosis of autism during his periods of crisis or increased risk and c) made sufficient reasonable adjustments in relation to the impact of his autism.
4 At the time of his death, TEWV had progressed from a low baseline in the Trust’s work in North Yorkshire to address perceived underdevelopment in their services for the autistic patient when presenting with a mental health disorder. It had expanded the use of a specialist team (Autism Project Team- “APT”) to extend its work into North Yorkshire caseload. The steps taken were incremental and not all staff understood that Team and access to that important resource. It is recognised that improvements would take time and be resource dependent as well however.
5 APT has three specialist and autism dedicated practitioners working exclusively with autism across the whole Trust in both its regions of commissioned care although there are also non-dedicated clinicians with some expertise of autism within TEWV. TEWV does not treat autism in North Yorkshire.
6 TEWV in its recent audit indicates about 17% of the individuals open to TEWV (over 10,000 in number) have an autism marker or have an ICD-10 diagnosis of autism or experience suspected/confirmed autism or have a referral including being suspected as autistic.
7 There was no direct causation to the suicide found that directly attributed the acts he took to his autism from the evidence. However Mr McLellan’s distress and stressors before his death included his feelings that he was not getting what he saw to be the right help and that he would not lose his feelings of helplessness such that he took his own life.
The concern is that the very significant number of those open to TEWV with an autism marker has increased and will continue to do so and that the higher prevalence of suicide within that expanding group will lead to higher risk of, and numbers of, autistic individuals dying because of suicide both within TEWV locally but also nationally.
Urgent solutions are required to prevent further deaths of autistic individuals especially those with mental health disorder by rapidly improving and expanding provisions for assessment and management of risk of harm to themselves for individuals within the autism spectrum while presenting with a mental health disorder.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Humber and North Yorkshire Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to incorporate autism into assessment and management of self-harm risk
Wider context from the report “1 Mr McLellan was diagnosed over 2016/16 as being autistic with a designation of Asperger’s Syndrome. He was also diagnosed as experiencing Bipolar Disorder, an attribution he did not accept which he repeatedly asserted to both previous Mental Health care providers and the subsequent Trust clinicians tasked with supporting him at the time of his death, Tees Esk and Wear Valleys NHS Foundation Trust (“TEWV”)
2 He insisted his difficulties were linked to his autism and not mental disorder. It was accepted that he experienced autism and that was part of his individuality and that in addition he may have had a mental health disorder. It was accepted that his care and treatment cannot unbundle the two but he should be treated holistically.
3 Assessment and formulation of risks and safety summary did not fully explore the impact of his autism. There was little to suggest that TEWV staff) considered the higher prevalence of suicide for individuals with a diagnosis of autism and that Mr McLellan may have communicated his distress and risks information differently to an individual without a diagnosis of autism during his periods of crisis or increased risk and c) made sufficient reasonable adjustments in relation to the impact of his autism.
4 At the time of his death, TEWV had progressed from a low baseline in the Trust’s work in North Yorkshire to address perceived underdevelopment in their services for the autistic patient when presenting with a mental health disorder. It had expanded the use of a specialist team (Autism Project Team- “APT”) to extend its work into North Yorkshire caseload. The steps taken were incremental and not all staff understood that Team and access to that important resource. It is recognised that improvements would take time and be resource dependent as well however.
5 APT has three specialist and autism dedicated practitioners working exclusively with autism across the whole Trust in both its regions of commissioned care although there are also non-dedicated clinicians with some expertise of autism within TEWV. TEWV does not treat autism in North Yorkshire.
6 TEWV in its recent audit indicates about 17% of the individuals open to TEWV (over 10,000 in number) have an autism marker or have an ICD-10 diagnosis of autism or experience suspected/confirmed autism or have a referral including being suspected as autistic.
7 There was no direct causation to the suicide found that directly attributed the acts he took to his autism from the evidence. However Mr McLellan’s distress and stressors before his death included his feelings that he was not getting what he saw to be the right help and that he would not lose his feelings of helplessness such that he took his own life.
The concern is that the very significant number of those open to TEWV with an autism marker has increased and will continue to do so and that the higher prevalence of suicide within that expanding group will lead to higher risk of, and numbers of, autistic individuals dying because of suicide both within TEWV locally but also nationally.
Urgent solutions are required to prevent further deaths of autistic individuals especially those with mental health disorder by rapidly improving and expanding provisions for assessment and management of risk of harm to themselves for individuals within the autism spectrum while presenting with a mental health disorder.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Humber and North Yorkshire Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Underdeveloped and insufficiently accessible specialist autism support for mental health patients
Wider context from the report “1 Mr McLellan was diagnosed over 2016/16 as being autistic with a designation of Asperger’s Syndrome. He was also diagnosed as experiencing Bipolar Disorder, an attribution he did not accept which he repeatedly asserted to both previous Mental Health care providers and the subsequent Trust clinicians tasked with supporting him at the time of his death, Tees Esk and Wear Valleys NHS Foundation Trust (“TEWV”)
2 He insisted his difficulties were linked to his autism and not mental disorder. It was accepted that he experienced autism and that was part of his individuality and that in addition he may have had a mental health disorder. It was accepted that his care and treatment cannot unbundle the two but he should be treated holistically.
3 Assessment and formulation of risks and safety summary did not fully explore the impact of his autism. There was little to suggest that TEWV staff) considered the higher prevalence of suicide for individuals with a diagnosis of autism and that Mr McLellan may have communicated his distress and risks information differently to an individual without a diagnosis of autism during his periods of crisis or increased risk and c) made sufficient reasonable adjustments in relation to the impact of his autism.
4 At the time of his death, TEWV had progressed from a low baseline in the Trust’s work in North Yorkshire to address perceived underdevelopment in their services for the autistic patient when presenting with a mental health disorder. It had expanded the use of a specialist team (Autism Project Team- “APT”) to extend its work into North Yorkshire caseload. The steps taken were incremental and not all staff understood that Team and access to that important resource. It is recognised that improvements would take time and be resource dependent as well however.
5 APT has three specialist and autism dedicated practitioners working exclusively with autism across the whole Trust in both its regions of commissioned care although there are also non-dedicated clinicians with some expertise of autism within TEWV. TEWV does not treat autism in North Yorkshire.
6 TEWV in its recent audit indicates about 17% of the individuals open to TEWV (over 10,000 in number) have an autism marker or have an ICD-10 diagnosis of autism or experience suspected/confirmed autism or have a referral including being suspected as autistic.
7 There was no direct causation to the suicide found that directly attributed the acts he took to his autism from the evidence. However Mr McLellan’s distress and stressors before his death included his feelings that he was not getting what he saw to be the right help and that he would not lose his feelings of helplessness such that he took his own life.
The concern is that the very significant number of those open to TEWV with an autism marker has increased and will continue to do so and that the higher prevalence of suicide within that expanding group will lead to higher risk of, and numbers of, autistic individuals dying because of suicide both within TEWV locally but also nationally.
Urgent solutions are required to prevent further deaths of autistic individuals especially those with mental health disorder by rapidly improving and expanding provisions for assessment and management of risk of harm to themselves for individuals within the autism spectrum while presenting with a mental health disorder.
” Open source report
Concerns raised 10 Lack of multidisciplinary clinical assessment and formulation addressing autism View source Gap in acute and crisis mental health support alongside commissioned autism care View source Lack of local specialist autism assessment and adapted psychological therapy View source Failure to understand autism-related trauma in risk assessment View source Failure to respond promptly to distress and remove discounted diagnostic references View source Failure of communication and shared information across autism and mental health teams View source Failure to make timely reasonable sensory and environmental adjustments View source Failure to provide a care coordinator and effective care plan View source Lack of person-centred autism-informed holistic care planning View source Failure to avoid attributing an undiagnosed personality disorder to an autistic patient View source See 7 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Zoe Emma ZAREMBA · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Zoe Emma ZAREMBA, who had a history of repeated self-harm and suicide attempts, ingested an unknown quantity of a substance after going missing from home and was found unresponsive on 21 June 2020; her death was established as resulting from the ingestion. The report identified concerns about clinicians’ failure to understand and adapt care to her autism, the unsubstantiated attribution of Emotionally Unstable Personality Disorder, inadequate coordinated mental health support, and the absence of effective care planning and risk assessment.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Humber and North Yorkshire Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of multidisciplinary clinical assessment and formulation addressing autism
Wider context from the report “The evidence indicated:
1 Zoe was diagnosed at age 16 years as being autistic by CAMHS with a designation of Asperger’s Syndrome. Her medical records recorded that.
2 In or about 2016 she was wrongly attributed by the Mental Health Service, TEWV, clinicians - who knew of her autism -as undergoing Emotionally Unstable Personality Disorder (“EUPD”).
3 That attribution was not formally diagnosed, and not discussed with Zoe who found out by chance when looking at her records. She continued to be regarded and treated as if she was experiencing that condition and clinicians would not adapt to her distress caused by that attribution. There was inertia and excessive delay (to May 2020) in removing reference to EUPD which had been discounted in October 2018 all of which added to her distress. These actions and inactions destroyed her relationship with community mental health clinicians and she did not trust them enough to try to restore any effective care relationship.
4 She suffered repeated trauma derived from her autistic condition revisiting the causes of her distress which she re-experienced time and again with ‘film reel’ recollection. That trauma was again not understood.
5 In short, her autism (and thus risk assessment) was misunderstood by the clinicians tasked to keep her safe.
6 TEWV’s provision for cares of autistic conditions were underdeveloped, reflecting national want of provision, to include:-
A no multidisciplinary clinical assessment and formulation addressed her autism ;
B no reasonable adjustments were then made in terms of her sensory and environmental needs in any timely fashion, or at all;
C no person centred (thus autism centred) holistic plan was developed to work in partnership with Zoe that took account of her autism, and her gender. As the evidence revealed one “cannot uncouple autism and other psychological/psychiatric experiences”. Instead, she withdrew from engagement with TEWV community health clinicians.
D there was no local provision within TEWV for specialist autism assessment and adapted psychological therapy. Commissioned providers of these essential cares were outwith TEWV, requiring specific Funding Request (which was granted) for a course of assessment and therapy. Those providers did not offer statutory acute mental health services support, including out of hours/crisis support. TEWV did not provide what the commissioning providers were supplying. There was a want of effective communications between these ‘teams’ not least as patient data was not accessible by one to the others electronic records (patient consent permitting) and the fact of disengagement. There was a sense of ‘silo’ working, militating against partnership working, that encouraged unfavourably the undesirable “uncoupling” of experiences;
E statistical evidence indicated that autistic individuals are more at risk of suicide than those with no neurodevelopmental condition, and females at greater risk than their male counterparts;
F there was a clinical (but not measured) experience that more patients were presenting to the statutory service with autistic conditions and, it follows, more patients would be at risk of suicide;
G from 2016 to her death, Zoe was detained under ss 2/3 MHA 1983 17 times and presented to A and E around 37 times with evident self harm and apparent attempts on her life. She repeated high risk behaviours. She had no Care Co-ordinator nor effective Care Plan (which ought to have been in place) because she had not engaged with TEWV community services;
H Zoe lurched from crisis to crisis remaining at high risk to her own safety; she died because she could no longer cope with the sense of injustice caused by others that overwhelmed her thinking. She felt she was not being listened to by community mental health services. Her therapy from outside providers - which was proving helpful to her - was disrupted by COVID-19 limitations on face to face consultations;
Both locally, including regional, but also nationally the evidence revealed a number of serious issues that require urgent and immediate action to support autistic people well, not just from a sensory and environmental basis (which TEWV have started to improve albeit from a low baseline according to the evidence received). Urgent solutions are required to prevent future deaths of autistic patients especially with mental health needs.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Humber and North Yorkshire Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Gap in acute and crisis mental health support alongside commissioned autism care
Wider context from the report “The evidence indicated:
1 Zoe was diagnosed at age 16 years as being autistic by CAMHS with a designation of Asperger’s Syndrome. Her medical records recorded that.
2 In or about 2016 she was wrongly attributed by the Mental Health Service, TEWV, clinicians - who knew of her autism -as undergoing Emotionally Unstable Personality Disorder (“EUPD”).
3 That attribution was not formally diagnosed, and not discussed with Zoe who found out by chance when looking at her records. She continued to be regarded and treated as if she was experiencing that condition and clinicians would not adapt to her distress caused by that attribution. There was inertia and excessive delay (to May 2020) in removing reference to EUPD which had been discounted in October 2018 all of which added to her distress. These actions and inactions destroyed her relationship with community mental health clinicians and she did not trust them enough to try to restore any effective care relationship.
4 She suffered repeated trauma derived from her autistic condition revisiting the causes of her distress which she re-experienced time and again with ‘film reel’ recollection. That trauma was again not understood.
5 In short, her autism (and thus risk assessment) was misunderstood by the clinicians tasked to keep her safe.
6 TEWV’s provision for cares of autistic conditions were underdeveloped, reflecting national want of provision, to include:-
A no multidisciplinary clinical assessment and formulation addressed her autism;
B no reasonable adjustments were then made in terms of her sensory and environmental needs in any timely fashion, or at all;
C no person centred (thus autism centred) holistic plan was developed to work in partnership with Zoe that took account of her autism, and her gender. As the evidence revealed one “cannot uncouple autism and other psychological/psychiatric experiences”. Instead, she withdrew from engagement with TEWV community health clinicians.
D there was no local provision within TEWV for specialist autism assessment and adapted psychological therapy. Commissioned providers of these essential cares were outwith TEWV, requiring specific Funding Request (which was granted) for a course of assessment and therapy. Those providers did not offer statutory acute mental health services support, including out of hours/crisis support. TEWV did not provide what the commissioning providers were supplying. There was a want of effective communications between these ‘teams’ not least as patient data was not accessible by one to the others electronic records (patient consent permitting) and the fact of disengagement. There was a sense of ‘silo’ working, militating against partnership working, that encouraged unfavourably the undesirable “uncoupling” of experiences;
E statistical evidence indicated that autistic individuals are more at risk of suicide than those with no neurodevelopmental condition, and females at greater risk than their male counterparts;
F there was a clinical (but not measured) experience that more patients were presenting to the statutory service with autistic conditions and, it follows, more patients would be at risk of suicide;
G from 2016 to her death, Zoe was detained under ss 2/3 MHA 1983 17 times and presented to A and E around 37 times with evident self harm and apparent attempts on her life. She repeated high risk behaviours. She had no Care Co-ordinator nor effective Care Plan (which ought to have been in place) because she had not engaged with TEWV community services;
H Zoe lurched from crisis to crisis remaining at high risk to her own safety; she died because she could no longer cope with the sense of injustice caused by others that overwhelmed her thinking. She felt she was not being listened to by community mental health services. Her therapy from outside providers - which was proving helpful to her - was disrupted by COVID-19 limitations on face to face consultations;
Both locally, including regional, but also nationally the evidence revealed a number of serious issues that require urgent and immediate action to support autistic people well, not just from a sensory and environmental basis (which TEWV have started to improve albeit from a low baseline according to the evidence received). Urgent solutions are required to prevent future deaths of autistic patients especially with mental health needs.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Humber and North Yorkshire Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of local specialist autism assessment and adapted psychological therapy
Wider context from the report “The evidence indicated:
1 Zoe was diagnosed at age 16 years as being autistic by CAMHS with a designation of Asperger’s Syndrome. Her medical records recorded that.
2 In or about 2016 she was wrongly attributed by the Mental Health Service, TEWV, clinicians - who knew of her autism -as undergoing Emotionally Unstable Personality Disorder (“EUPD”).
3 That attribution was not formally diagnosed, and not discussed with Zoe who found out by chance when looking at her records. She continued to be regarded and treated as if she was experiencing that condition and clinicians would not adapt to her distress caused by that attribution. There was inertia and excessive delay (to May 2020) in removing reference to EUPD which had been discounted in October 2018 all of which added to her distress. These actions and inactions destroyed her relationship with community mental health clinicians and she did not trust them enough to try to restore any effective care relationship.
4 She suffered repeated trauma derived from her autistic condition revisiting the causes of her distress which she re-experienced time and again with ‘film reel’ recollection. That trauma was again not understood.
5 In short, her autism (and thus risk assessment) was misunderstood by the clinicians tasked to keep her safe.
6 TEWV’s provision for cares of autistic conditions were underdeveloped, reflecting national want of provision, to include:-
A no multidisciplinary clinical assessment and formulation addressed her autism;
B no reasonable adjustments were then made in terms of her sensory and environmental needs in any timely fashion, or at all;
C no person centred (thus autism centred) holistic plan was developed to work in partnership with Zoe that took account of her autism, and her gender. As the evidence revealed one “cannot uncouple autism and other psychological/psychiatric experiences”. Instead, she withdrew from engagement with TEWV community health clinicians.
D there was no local provision within TEWV for specialist autism assessment and adapted psychological therapy . Commissioned providers of these essential cares were outwith TEWV, requiring specific Funding Request (which was granted) for a course of assessment and therapy. Those providers did not offer statutory acute mental health services support, including out of hours/crisis support. TEWV did not provide what the commissioning providers were supplying. There was a want of effective communications between these ‘teams’ not least as patient data was not accessible by one to the others electronic records (patient consent permitting) and the fact of disengagement. There was a sense of ‘silo’ working, militating against partnership working, that encouraged unfavourably the undesirable “uncoupling” of experiences;
E statistical evidence indicated that autistic individuals are more at risk of suicide than those with no neurodevelopmental condition, and females at greater risk than their male counterparts;
F there was a clinical (but not measured) experience that more patients were presenting to the statutory service with autistic conditions and, it follows, more patients would be at risk of suicide;
G from 2016 to her death, Zoe was detained under ss 2/3 MHA 1983 17 times and presented to A and E around 37 times with evident self harm and apparent attempts on her life. She repeated high risk behaviours. She had no Care Co-ordinator nor effective Care Plan (which ought to have been in place) because she had not engaged with TEWV community services;
H Zoe lurched from crisis to crisis remaining at high risk to her own safety; she died because she could no longer cope with the sense of injustice caused by others that overwhelmed her thinking. She felt she was not being listened to by community mental health services. Her therapy from outside providers - which was proving helpful to her - was disrupted by COVID-19 limitations on face to face consultations;
Both locally, including regional, but also nationally the evidence revealed a number of serious issues that require urgent and immediate action to support autistic people well, not just from a sensory and environmental basis (which TEWV have started to improve albeit from a low baseline according to the evidence received). Urgent solutions are required to prevent future deaths of autistic patients especially with mental health needs.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Humber and North Yorkshire Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to understand autism-related trauma in risk assessment
Wider context from the report “The evidence indicated:
1 Zoe was diagnosed at age 16 years as being autistic by CAMHS with a designation of Asperger’s Syndrome. Her medical records recorded that.
2 In or about 2016 she was wrongly attributed by the Mental Health Service, TEWV, clinicians - who knew of her autism -as undergoing Emotionally Unstable Personality Disorder (“EUPD”).
3 That attribution was not formally diagnosed, and not discussed with Zoe who found out by chance when looking at her records. She continued to be regarded and treated as if she was experiencing that condition and clinicians would not adapt to her distress caused by that attribution. There was inertia and excessive delay (to May 2020) in removing reference to EUPD which had been discounted in October 2018 all of which added to her distress. These actions and inactions destroyed her relationship with community mental health clinicians and she did not trust them enough to try to restore any effective care relationship.
4 She suffered repeated trauma derived from her autistic condition revisiting the causes of her distress which she re-experienced time and again with ‘film reel’ recollection. That trauma was again not understood.
5 In short, her autism (and thus risk assessment) was misunderstood by the clinicians tasked to keep her safe .
6 TEWV’s provision for cares of autistic conditions were underdeveloped, reflecting national want of provision, to include:-
A no multidisciplinary clinical assessment and formulation addressed her autism;
B no reasonable adjustments were then made in terms of her sensory and environmental needs in any timely fashion, or at all;
C no person centred (thus autism centred) holistic plan was developed to work in partnership with Zoe that took account of her autism, and her gender. As the evidence revealed one “cannot uncouple autism and other psychological/psychiatric experiences”. Instead, she withdrew from engagement with TEWV community health clinicians.
D there was no local provision within TEWV for specialist autism assessment and adapted psychological therapy. Commissioned providers of these essential cares were outwith TEWV, requiring specific Funding Request (which was granted) for a course of assessment and therapy. Those providers did not offer statutory acute mental health services support, including out of hours/crisis support. TEWV did not provide what the commissioning providers were supplying. There was a want of effective communications between these ‘teams’ not least as patient data was not accessible by one to the others electronic records (patient consent permitting) and the fact of disengagement. There was a sense of ‘silo’ working, militating against partnership working, that encouraged unfavourably the undesirable “uncoupling” of experiences;
E statistical evidence indicated that autistic individuals are more at risk of suicide than those with no neurodevelopmental condition, and females at greater risk than their male counterparts;
F there was a clinical (but not measured) experience that more patients were presenting to the statutory service with autistic conditions and, it follows, more patients would be at risk of suicide;
G from 2016 to her death, Zoe was detained under ss 2/3 MHA 1983 17 times and presented to A and E around 37 times with evident self harm and apparent attempts on her life. She repeated high risk behaviours. She had no Care Co-ordinator nor effective Care Plan (which ought to have been in place) because she had not engaged with TEWV community services;
H Zoe lurched from crisis to crisis remaining at high risk to her own safety; she died because she could no longer cope with the sense of injustice caused by others that overwhelmed her thinking. She felt she was not being listened to by community mental health services. Her therapy from outside providers - which was proving helpful to her - was disrupted by COVID-19 limitations on face to face consultations;
Both locally, including regional, but also nationally the evidence revealed a number of serious issues that require urgent and immediate action to support autistic people well, not just from a sensory and environmental basis (which TEWV have started to improve albeit from a low baseline according to the evidence received). Urgent solutions are required to prevent future deaths of autistic patients especially with mental health needs.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Humber and North Yorkshire Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to respond promptly to distress and remove discounted diagnostic references
Wider context from the report “The evidence indicated:
1 Zoe was diagnosed at age 16 years as being autistic by CAMHS with a designation of Asperger’s Syndrome. Her medical records recorded that.
2 In or about 2016 she was wrongly attributed by the Mental Health Service, TEWV, clinicians - who knew of her autism -as undergoing Emotionally Unstable Personality Disorder (“EUPD”).
3 That attribution was not formally diagnosed, and not discussed with Zoe who found out by chance when looking at her records. She continued to be regarded and treated as if she was experiencing that condition and clinicians would not adapt to her distress caused by that attribution . There was inertia and excessive delay (to May 2020) in removing reference to EUPD which had been discounted in October 2018 all of which added to her distress. These actions and inactions destroyed her relationship with community mental health clinicians and she did not trust them enough to try to restore any effective care relationship.
4 She suffered repeated trauma derived from her autistic condition revisiting the causes of her distress which she re-experienced time and again with ‘film reel’ recollection. That trauma was again not understood.
5 In short, her autism (and thus risk assessment) was misunderstood by the clinicians tasked to keep her safe.
6 TEWV’s provision for cares of autistic conditions were underdeveloped, reflecting national want of provision, to include:-
A no multidisciplinary clinical assessment and formulation addressed her autism;
B no reasonable adjustments were then made in terms of her sensory and environmental needs in any timely fashion, or at all;
C no person centred (thus autism centred) holistic plan was developed to work in partnership with Zoe that took account of her autism, and her gender. As the evidence revealed one “cannot uncouple autism and other psychological/psychiatric experiences”. Instead, she withdrew from engagement with TEWV community health clinicians.
D there was no local provision within TEWV for specialist autism assessment and adapted psychological therapy. Commissioned providers of these essential cares were outwith TEWV, requiring specific Funding Request (which was granted) for a course of assessment and therapy. Those providers did not offer statutory acute mental health services support, including out of hours/crisis support. TEWV did not provide what the commissioning providers were supplying. There was a want of effective communications between these ‘teams’ not least as patient data was not accessible by one to the others electronic records (patient consent permitting) and the fact of disengagement. There was a sense of ‘silo’ working, militating against partnership working, that encouraged unfavourably the undesirable “uncoupling” of experiences;
E statistical evidence indicated that autistic individuals are more at risk of suicide than those with no neurodevelopmental condition, and females at greater risk than their male counterparts;
F there was a clinical (but not measured) experience that more patients were presenting to the statutory service with autistic conditions and, it follows, more patients would be at risk of suicide;
G from 2016 to her death, Zoe was detained under ss 2/3 MHA 1983 17 times and presented to A and E around 37 times with evident self harm and apparent attempts on her life. She repeated high risk behaviours. She had no Care Co-ordinator nor effective Care Plan (which ought to have been in place) because she had not engaged with TEWV community services;
H Zoe lurched from crisis to crisis remaining at high risk to her own safety; she died because she could no longer cope with the sense of injustice caused by others that overwhelmed her thinking. She felt she was not being listened to by community mental health services. Her therapy from outside providers - which was proving helpful to her - was disrupted by COVID-19 limitations on face to face consultations;
Both locally, including regional, but also nationally the evidence revealed a number of serious issues that require urgent and immediate action to support autistic people well, not just from a sensory and environmental basis (which TEWV have started to improve albeit from a low baseline according to the evidence received). Urgent solutions are required to prevent future deaths of autistic patients especially with mental health needs.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Humber and North Yorkshire Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure of communication and shared information across autism and mental health teams
Wider context from the report “The evidence indicated:
1 Zoe was diagnosed at age 16 years as being autistic by CAMHS with a designation of Asperger’s Syndrome. Her medical records recorded that.
2 In or about 2016 she was wrongly attributed by the Mental Health Service, TEWV, clinicians - who knew of her autism -as undergoing Emotionally Unstable Personality Disorder (“EUPD”).
3 That attribution was not formally diagnosed, and not discussed with Zoe who found out by chance when looking at her records. She continued to be regarded and treated as if she was experiencing that condition and clinicians would not adapt to her distress caused by that attribution. There was inertia and excessive delay (to May 2020) in removing reference to EUPD which had been discounted in October 2018 all of which added to her distress. These actions and inactions destroyed her relationship with community mental health clinicians and she did not trust them enough to try to restore any effective care relationship.
4 She suffered repeated trauma derived from her autistic condition revisiting the causes of her distress which she re-experienced time and again with ‘film reel’ recollection. That trauma was again not understood.
5 In short, her autism (and thus risk assessment) was misunderstood by the clinicians tasked to keep her safe.
6 TEWV’s provision for cares of autistic conditions were underdeveloped, reflecting national want of provision, to include:-
A no multidisciplinary clinical assessment and formulation addressed her autism;
B no reasonable adjustments were then made in terms of her sensory and environmental needs in any timely fashion, or at all;
C no person centred (thus autism centred) holistic plan was developed to work in partnership with Zoe that took account of her autism, and her gender. As the evidence revealed one “cannot uncouple autism and other psychological/psychiatric experiences”. Instead, she withdrew from engagement with TEWV community health clinicians.
D there was no local provision within TEWV for specialist autism assessment and adapted psychological therapy. Commissioned providers of these essential cares were outwith TEWV, requiring specific Funding Request (which was granted) for a course of assessment and therapy. Those providers did not offer statutory acute mental health services support, including out of hours/crisis support. TEWV did not provide what the commissioning providers were supplying. There was a want of effective communications between these ‘teams’ not least as patient data was not accessible by one to the others electronic records (patient consent permitting) and the fact of disengagement. There was a sense of ‘silo’ working, militating against partnership working , that encouraged unfavourably the undesirable “uncoupling” of experiences;
E statistical evidence indicated that autistic individuals are more at risk of suicide than those with no neurodevelopmental condition, and females at greater risk than their male counterparts;
F there was a clinical (but not measured) experience that more patients were presenting to the statutory service with autistic conditions and, it follows, more patients would be at risk of suicide;
G from 2016 to her death, Zoe was detained under ss 2/3 MHA 1983 17 times and presented to A and E around 37 times with evident self harm and apparent attempts on her life. She repeated high risk behaviours. She had no Care Co-ordinator nor effective Care Plan (which ought to have been in place) because she had not engaged with TEWV community services;
H Zoe lurched from crisis to crisis remaining at high risk to her own safety; she died because she could no longer cope with the sense of injustice caused by others that overwhelmed her thinking. She felt she was not being listened to by community mental health services. Her therapy from outside providers - which was proving helpful to her - was disrupted by COVID-19 limitations on face to face consultations;
Both locally, including regional, but also nationally the evidence revealed a number of serious issues that require urgent and immediate action to support autistic people well, not just from a sensory and environmental basis (which TEWV have started to improve albeit from a low baseline according to the evidence received). Urgent solutions are required to prevent future deaths of autistic patients especially with mental health needs.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Humber and North Yorkshire Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to make timely reasonable sensory and environmental adjustments
Wider context from the report “The evidence indicated:
1 Zoe was diagnosed at age 16 years as being autistic by CAMHS with a designation of Asperger’s Syndrome. Her medical records recorded that.
2 In or about 2016 she was wrongly attributed by the Mental Health Service, TEWV, clinicians - who knew of her autism -as undergoing Emotionally Unstable Personality Disorder (“EUPD”).
3 That attribution was not formally diagnosed, and not discussed with Zoe who found out by chance when looking at her records. She continued to be regarded and treated as if she was experiencing that condition and clinicians would not adapt to her distress caused by that attribution. There was inertia and excessive delay (to May 2020) in removing reference to EUPD which had been discounted in October 2018 all of which added to her distress. These actions and inactions destroyed her relationship with community mental health clinicians and she did not trust them enough to try to restore any effective care relationship.
4 She suffered repeated trauma derived from her autistic condition revisiting the causes of her distress which she re-experienced time and again with ‘film reel’ recollection. That trauma was again not understood.
5 In short, her autism (and thus risk assessment) was misunderstood by the clinicians tasked to keep her safe.
6 TEWV’s provision for cares of autistic conditions were underdeveloped, reflecting national want of provision, to include:-
A no multidisciplinary clinical assessment and formulation addressed her autism;
B no reasonable adjustments were then made in terms of her sensory and environmental needs in any timely fashion, or at all ;
C no person centred (thus autism centred) holistic plan was developed to work in partnership with Zoe that took account of her autism, and her gender. As the evidence revealed one “cannot uncouple autism and other psychological/psychiatric experiences”. Instead, she withdrew from engagement with TEWV community health clinicians.
D there was no local provision within TEWV for specialist autism assessment and adapted psychological therapy. Commissioned providers of these essential cares were outwith TEWV, requiring specific Funding Request (which was granted) for a course of assessment and therapy. Those providers did not offer statutory acute mental health services support, including out of hours/crisis support. TEWV did not provide what the commissioning providers were supplying. There was a want of effective communications between these ‘teams’ not least as patient data was not accessible by one to the others electronic records (patient consent permitting) and the fact of disengagement. There was a sense of ‘silo’ working, militating against partnership working, that encouraged unfavourably the undesirable “uncoupling” of experiences;
E statistical evidence indicated that autistic individuals are more at risk of suicide than those with no neurodevelopmental condition, and females at greater risk than their male counterparts;
F there was a clinical (but not measured) experience that more patients were presenting to the statutory service with autistic conditions and, it follows, more patients would be at risk of suicide;
G from 2016 to her death, Zoe was detained under ss 2/3 MHA 1983 17 times and presented to A and E around 37 times with evident self harm and apparent attempts on her life. She repeated high risk behaviours. She had no Care Co-ordinator nor effective Care Plan (which ought to have been in place) because she had not engaged with TEWV community services;
H Zoe lurched from crisis to crisis remaining at high risk to her own safety; she died because she could no longer cope with the sense of injustice caused by others that overwhelmed her thinking. She felt she was not being listened to by community mental health services. Her therapy from outside providers - which was proving helpful to her - was disrupted by COVID-19 limitations on face to face consultations;
Both locally, including regional, but also nationally the evidence revealed a number of serious issues that require urgent and immediate action to support autistic people well, not just from a sensory and environmental basis (which TEWV have started to improve albeit from a low baseline according to the evidence received). Urgent solutions are required to prevent future deaths of autistic patients especially with mental health needs.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Humber and North Yorkshire Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to provide a care coordinator and effective care plan
Wider context from the report “The evidence indicated:
1 Zoe was diagnosed at age 16 years as being autistic by CAMHS with a designation of Asperger’s Syndrome. Her medical records recorded that.
2 In or about 2016 she was wrongly attributed by the Mental Health Service, TEWV, clinicians - who knew of her autism -as undergoing Emotionally Unstable Personality Disorder (“EUPD”).
3 That attribution was not formally diagnosed, and not discussed with Zoe who found out by chance when looking at her records. She continued to be regarded and treated as if she was experiencing that condition and clinicians would not adapt to her distress caused by that attribution. There was inertia and excessive delay (to May 2020) in removing reference to EUPD which had been discounted in October 2018 all of which added to her distress. These actions and inactions destroyed her relationship with community mental health clinicians and she did not trust them enough to try to restore any effective care relationship.
4 She suffered repeated trauma derived from her autistic condition revisiting the causes of her distress which she re-experienced time and again with ‘film reel’ recollection. That trauma was again not understood.
5 In short, her autism (and thus risk assessment) was misunderstood by the clinicians tasked to keep her safe.
6 TEWV’s provision for cares of autistic conditions were underdeveloped, reflecting national want of provision, to include:-
A no multidisciplinary clinical assessment and formulation addressed her autism;
B no reasonable adjustments were then made in terms of her sensory and environmental needs in any timely fashion, or at all;
C no person centred (thus autism centred) holistic plan was developed to work in partnership with Zoe that took account of her autism, and her gender. As the evidence revealed one “cannot uncouple autism and other psychological/psychiatric experiences”. Instead, she withdrew from engagement with TEWV community health clinicians.
D there was no local provision within TEWV for specialist autism assessment and adapted psychological therapy. Commissioned providers of these essential cares were outwith TEWV, requiring specific Funding Request (which was granted) for a course of assessment and therapy. Those providers did not offer statutory acute mental health services support, including out of hours/crisis support. TEWV did not provide what the commissioning providers were supplying. There was a want of effective communications between these ‘teams’ not least as patient data was not accessible by one to the others electronic records (patient consent permitting) and the fact of disengagement. There was a sense of ‘silo’ working, militating against partnership working, that encouraged unfavourably the undesirable “uncoupling” of experiences;
E statistical evidence indicated that autistic individuals are more at risk of suicide than those with no neurodevelopmental condition, and females at greater risk than their male counterparts;
F there was a clinical (but not measured) experience that more patients were presenting to the statutory service with autistic conditions and, it follows, more patients would be at risk of suicide;
G from 2016 to her death, Zoe was detained under ss 2/3 MHA 1983 17 times and presented to A and E around 37 times with evident self harm and apparent attempts on her life. She repeated high risk behaviours. She had no Care Co-ordinator nor effective Care Plan (which ought to have been in place) because she had not engaged with TEWV community services;
H Zoe lurched from crisis to crisis remaining at high risk to her own safety; she died because she could no longer cope with the sense of injustice caused by others that overwhelmed her thinking. She felt she was not being listened to by community mental health services. Her therapy from outside providers - which was proving helpful to her - was disrupted by COVID-19 limitations on face to face consultations;
Both locally, including regional, but also nationally the evidence revealed a number of serious issues that require urgent and immediate action to support autistic people well, not just from a sensory and environmental basis (which TEWV have started to improve albeit from a low baseline according to the evidence received). Urgent solutions are required to prevent future deaths of autistic patients especially with mental health needs.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Humber and North Yorkshire Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of person-centred autism-informed holistic care planning
Wider context from the report “The evidence indicated:
1 Zoe was diagnosed at age 16 years as being autistic by CAMHS with a designation of Asperger’s Syndrome. Her medical records recorded that.
2 In or about 2016 she was wrongly attributed by the Mental Health Service, TEWV, clinicians - who knew of her autism -as undergoing Emotionally Unstable Personality Disorder (“EUPD”).
3 That attribution was not formally diagnosed, and not discussed with Zoe who found out by chance when looking at her records. She continued to be regarded and treated as if she was experiencing that condition and clinicians would not adapt to her distress caused by that attribution. There was inertia and excessive delay (to May 2020) in removing reference to EUPD which had been discounted in October 2018 all of which added to her distress. These actions and inactions destroyed her relationship with community mental health clinicians and she did not trust them enough to try to restore any effective care relationship.
4 She suffered repeated trauma derived from her autistic condition revisiting the causes of her distress which she re-experienced time and again with ‘film reel’ recollection. That trauma was again not understood.
5 In short, her autism (and thus risk assessment) was misunderstood by the clinicians tasked to keep her safe.
6 TEWV’s provision for cares of autistic conditions were underdeveloped, reflecting national want of provision, to include:-
A no multidisciplinary clinical assessment and formulation addressed her autism;
B no reasonable adjustments were then made in terms of her sensory and environmental needs in any timely fashion, or at all;
C no person centred (thus autism centred) holistic plan was developed to work in partnership with Zoe that took account of her autism, and her gender . As the evidence revealed one “cannot uncouple autism and other psychological/psychiatric experiences”. Instead, she withdrew from engagement with TEWV community health clinicians.
D there was no local provision within TEWV for specialist autism assessment and adapted psychological therapy. Commissioned providers of these essential cares were outwith TEWV, requiring specific Funding Request (which was granted) for a course of assessment and therapy. Those providers did not offer statutory acute mental health services support, including out of hours/crisis support. TEWV did not provide what the commissioning providers were supplying. There was a want of effective communications between these ‘teams’ not least as patient data was not accessible by one to the others electronic records (patient consent permitting) and the fact of disengagement. There was a sense of ‘silo’ working, militating against partnership working, that encouraged unfavourably the undesirable “uncoupling” of experiences;
E statistical evidence indicated that autistic individuals are more at risk of suicide than those with no neurodevelopmental condition, and females at greater risk than their male counterparts;
F there was a clinical (but not measured) experience that more patients were presenting to the statutory service with autistic conditions and, it follows, more patients would be at risk of suicide;
G from 2016 to her death, Zoe was detained under ss 2/3 MHA 1983 17 times and presented to A and E around 37 times with evident self harm and apparent attempts on her life. She repeated high risk behaviours. She had no Care Co-ordinator nor effective Care Plan (which ought to have been in place) because she had not engaged with TEWV community services;
H Zoe lurched from crisis to crisis remaining at high risk to her own safety; she died because she could no longer cope with the sense of injustice caused by others that overwhelmed her thinking. She felt she was not being listened to by community mental health services. Her therapy from outside providers - which was proving helpful to her - was disrupted by COVID-19 limitations on face to face consultations;
Both locally, including regional, but also nationally the evidence revealed a number of serious issues that require urgent and immediate action to support autistic people well, not just from a sensory and environmental basis (which TEWV have started to improve albeit from a low baseline according to the evidence received). Urgent solutions are required to prevent future deaths of autistic patients especially with mental health needs.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Humber and North Yorkshire Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to avoid attributing an undiagnosed personality disorder to an autistic patient
Wider context from the report “The evidence indicated:
1 Zoe was diagnosed at age 16 years as being autistic by CAMHS with a designation of Asperger’s Syndrome. Her medical records recorded that.
2 In or about 2016 she was wrongly attributed by the Mental Health Service, TEWV, clinicians - who knew of her autism -as undergoing Emotionally Unstable Personality Disorder (“EUPD”) .
3 That attribution was not formally diagnosed , and not discussed with Zoe who found out by chance when looking at her records. She continued to be regarded and treated as if she was experiencing that condition and clinicians would not adapt to her distress caused by that attribution. There was inertia and excessive delay (to May 2020) in removing reference to EUPD which had been discounted in October 2018 all of which added to her distress. These actions and inactions destroyed her relationship with community mental health clinicians and she did not trust them enough to try to restore any effective care relationship.
4 She suffered repeated trauma derived from her autistic condition revisiting the causes of her distress which she re-experienced time and again with ‘film reel’ recollection. That trauma was again not understood.
5 In short, her autism (and thus risk assessment) was misunderstood by the clinicians tasked to keep her safe.
6 TEWV’s provision for cares of autistic conditions were underdeveloped, reflecting national want of provision, to include:-
A no multidisciplinary clinical assessment and formulation addressed her autism;
B no reasonable adjustments were then made in terms of her sensory and environmental needs in any timely fashion, or at all;
C no person centred (thus autism centred) holistic plan was developed to work in partnership with Zoe that took account of her autism, and her gender. As the evidence revealed one “cannot uncouple autism and other psychological/psychiatric experiences”. Instead, she withdrew from engagement with TEWV community health clinicians.
D there was no local provision within TEWV for specialist autism assessment and adapted psychological therapy. Commissioned providers of these essential cares were outwith TEWV, requiring specific Funding Request (which was granted) for a course of assessment and therapy. Those providers did not offer statutory acute mental health services support, including out of hours/crisis support. TEWV did not provide what the commissioning providers were supplying. There was a want of effective communications between these ‘teams’ not least as patient data was not accessible by one to the others electronic records (patient consent permitting) and the fact of disengagement. There was a sense of ‘silo’ working, militating against partnership working, that encouraged unfavourably the undesirable “uncoupling” of experiences;
E statistical evidence indicated that autistic individuals are more at risk of suicide than those with no neurodevelopmental condition, and females at greater risk than their male counterparts;
F there was a clinical (but not measured) experience that more patients were presenting to the statutory service with autistic conditions and, it follows, more patients would be at risk of suicide;
G from 2016 to her death, Zoe was detained under ss 2/3 MHA 1983 17 times and presented to A and E around 37 times with evident self harm and apparent attempts on her life. She repeated high risk behaviours. She had no Care Co-ordinator nor effective Care Plan (which ought to have been in place) because she had not engaged with TEWV community services;
H Zoe lurched from crisis to crisis remaining at high risk to her own safety; she died because she could no longer cope with the sense of injustice caused by others that overwhelmed her thinking. She felt she was not being listened to by community mental health services. Her therapy from outside providers - which was proving helpful to her - was disrupted by COVID-19 limitations on face to face consultations;
Both locally, including regional, but also nationally the evidence revealed a number of serious issues that require urgent and immediate action to support autistic people well, not just from a sensory and environmental basis (which TEWV have started to improve albeit from a low baseline according to the evidence received). Urgent solutions are required to prevent future deaths of autistic patients especially with mental health needs.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Work with TEWV to resolve internal and external communication issues affecting patient care.
Verbatim wording from the response “The CCG/ICB are aware; from reviewing the evidence from the inquest and from discussions with TEWV that there are communication issues internally and externally which need to be resolved for the benefit of the patient. This appears to go beyond incompatibility of IT systems (for example within the inquest there is reference to the autism service provided to other geographical parts of TEWV but not being available within the North Yorkshire part of the organisation). Both TEWV and the ICB are committed to working closely to resolve this. It is anticipated that ultimately the establishment and development of Provider Collaboratives within the ICB will support with these type of issues in the future.” Source location Response from Humber and North Yorkshire Health Care Partnership
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Audit individual funding referrals to identify demand for autism-related therapy and inform service planning.
Verbatim wording from the response “The CCG/ICB has audited the referrals for individual funding which it has received within the last 24 months and there is a trend for requests for therapy for those with autism spectrum disorder which appears to highlight a need for further consideration of the commissioned service. The CCG/ICB is clear that TEWV are the commissioned mental health provider of services and as such; even where a patient” Source location Response from Humber and North Yorkshire Health Care Partnership
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Hold learning events with TEWV and service users to inform autism-related therapy commissioning and delivery.
Verbatim wording from the response “has a dual diagnosis of autism spectrum disorder and some other mental health condition; TEWV should be in a position to deliver adjusted services to support their needs. The level of requests for additional therapy for those with autism diagnosis suggests that this is not proving to be fully effective at this time. The CCG/ICB is therefore working on a series of learning events with both TEWV and service users at present whilst considering how services ought to be commissioned and delivered moving forwards, whilst also looking at more immediate and interim arrangements based on the findings in the regulation 28 notice and from direct discussions and queries with service users.” Source location Response from Humber and North Yorkshire Health Care Partnership
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Examine immediate and interim arrangements for autism-related therapy in light of the Regulation 28 notice and service-user discussions.
Verbatim wording from the response “has a dual diagnosis of autism spectrum disorder and some other mental health condition; TEWV should be in a position to deliver adjusted services to support their needs. The level of requests for additional therapy for those with autism diagnosis suggests that this is not proving to be fully effective at this time. The CCG/ICB is therefore working on a series of learning events with both TEWV and service users at present whilst considering how services ought to be commissioned and delivered moving forwards, whilst also looking at more immediate and interim arrangements based on the findings in the regulation 28 notice and from direct discussions and queries with service users.” Source location Response from Humber and North Yorkshire Health Care Partnership
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Consider how autism-related services should be commissioned and delivered in future.
Verbatim wording from the response “has a dual diagnosis of autism spectrum disorder and some other mental health condition; TEWV should be in a position to deliver adjusted services to support their needs. The level of requests for additional therapy for those with autism diagnosis suggests that this is not proving to be fully effective at this time. The CCG/ICB is therefore working on a series of learning events with both TEWV and service users at present whilst considering how services ought to be commissioned and delivered moving forwards, whilst also looking at more immediate and interim arrangements based on the findings in the regulation 28 notice and from direct discussions and queries with service users.” Source location Response from Humber and North Yorkshire Health Care Partnership
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Pandemic-related disruption to services was outside the control of the CCGs, TEWV and the Retreat Centre.
Verbatim wording from the response “Unfortunately the disruption to services caused by the Covid-19 pandemic was out of the control of the CCGs, TEWV and the Retreat (Tuke) Centre. That said, as the Retreat (Tuke) Centre was not providing core services to Zoe; there would be an expectation that she would be kept safe utilising core mental health services provided by TEWV. This should have meant that Zoe's core mental health care would have been provided by TEWV and risk assessed by them however as TEWV had adapted their model of care delivery for Zoe it may be that this was not appreciated in the usual practice of community mental health services.” Source location Response from Humber and North Yorkshire Health Care Partnership
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation TEWV is responsible for delivering core mental health care and making reasonable adjustments for patients with autism.
Verbatim wording from the response “This is therapy which is beyond that which TEWV can provide as the primary mental health provider. That does not change the expectation that TEWV be in a position to make appropriate adjustments to their mental health support for those with any neuro development diagnosis. By this we mean that we would expect TEWV to be in a position to support those with a mental health condition even where they have a diagnosis of autism spectrum disorder however it is recognised by the CCG/ICB that there may be cases where there is additional specialist input required. This is when IFR requests are made. The CCG/ICB accepts that this is becoming more frequent and the reasons for this are not clear but are sufficient for the CCG/ICB to be considering the commissioning pathway for this type of therapy.” Source location Response from Humber and North Yorkshire Health Care Partnership
Open published response
Concerns raised 3 Lack of guidance on accessible self-help therapies and online training for lay supporters of people experiencing suicidal crisis View source Insufficient exploration of family support to provide mental health scaffolding during delays in professional help View source Failure to share potentially key welfare and safety information between private therapy services and primary care View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
ROBIN ANDREW JAMES MCEWAN · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
On 26 January 2018, Robin Andrew James McEwan was found hanging in the basement of his home after returning from drinks with workmates. He was taken to Harrogate Hospital, where he was considered brain stem dead and died on 2 February 2018 after life support was withdrawn. The concerns included a lack of direct communication between his private therapy service and GP, limited guidance and support during delays in accessing specialist mental health services, and further possible exploration of family support.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Humber and North Yorkshire Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of guidance on accessible self-help therapies and online training for lay supporters of people experiencing suicidal crisis
Wider context from the report “Within the contexts of
a) Primary Care and
b) acknowledgement that referral access to specialist mental health services is considerably delayed and
c) recourse to private therapy was sought in the meantime pending any referral and
d) there are resources that can be shared in the ‘waiting’ period then:
(1) there was a disconnect in communication between that private therapy service and the GP. They were not sharing directly potentially key information that may have influenced concerns and decisions as to Mr McEwan’s welfare and safety;
(2) there was evidence of regard to specific mental health approach and self help by the GP but it was stated that there were other approaches and in particular that a significant number of Health Trusts and CCGs reportedly subscribe to one known as “Zero Suicide Alliance”;
(3) that there was no other guidance specifically to particular self help therapies that might be free of charge (or covered by the CCG if not), nor to online training package(s) for lay people supporting others experiencing suicidal crisis ;
(4) there might have been more exploration of potential support by and working with the patient’s family to the intent that mental health ‘scaffolding’ was in place when no other professional help might be immediately available
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Humber and North Yorkshire Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Insufficient exploration of family support to provide mental health scaffolding during delays in professional help
Wider context from the report “Within the contexts of
a) Primary Care and
b) acknowledgement that referral access to specialist mental health services is considerably delayed and
c) recourse to private therapy was sought in the meantime pending any referral and
d) there are resources that can be shared in the ‘waiting’ period then:
(1) there was a disconnect in communication between that private therapy service and the GP. They were not sharing directly potentially key information that may have influenced concerns and decisions as to Mr McEwan’s welfare and safety;
(2) there was evidence of regard to specific mental health approach and self help by the GP but it was stated that there were other approaches and in particular that a significant number of Health Trusts and CCGs reportedly subscribe to one known as “Zero Suicide Alliance”;
(3) that there was no other guidance specifically to particular self help therapies that might be free of charge (or covered by the CCG if not), nor to online training package(s) for lay people supporting others experiencing suicidal crisis;
(4) there might have been more exploration of potential support by and working with the patient’s family to the intent that mental health ‘scaffolding’ was in place when no other professional help might be immediately available
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Humber and North Yorkshire Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to share potentially key welfare and safety information between private therapy services and primary care
Wider context from the report “Within the contexts of
a) Primary Care and
b) acknowledgement that referral access to specialist mental health services is considerably delayed and
c) recourse to private therapy was sought in the meantime pending any referral and
d) there are resources that can be shared in the ‘waiting’ period then:
(1) there was a disconnect in communication between that private therapy service and the GP. They were not sharing directly potentially key information that may have influenced concerns and decisions as to Mr McEwan’s welfare and safety ;
(2) there was evidence of regard to specific mental health approach and self help by the GP but it was stated that there were other approaches and in particular that a significant number of Health Trusts and CCGs reportedly subscribe to one known as “Zero Suicide Alliance”;
(3) that there was no other guidance specifically to particular self help therapies that might be free of charge (or covered by the CCG if not), nor to online training package(s) for lay people supporting others experiencing suicidal crisis;
(4) there might have been more exploration of potential support by and working with the patient’s family to the intent that mental health ‘scaffolding’ was in place when no other professional help might be immediately available
” Open source report
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Addressed to NHS North Yorkshire Clinical Commissioning Group, now represented here by NHS Humber and North Yorkshire Integrated Care Board.
Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations