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Investigation and inquest
On 9 May 2024, I concluded the inquest into the death of Brandon William Turner, also known as Amelia Turner, who died on 21/6/23 at the age of 21. In accordance with the wishes of his mother who attended inquest, I shall refer to him hereafter as Brandon.
I recorded the cause of death as
1a) Asphyxia
1b) Fatal pressure on the neck;
II) PTSD; Autism
I concluded Brandon died from suicide.
Circumstances of the death
Brandon had suffered adverse childhood experiences including neglect and emotional abuse that led to his adoption along with his brother. As he grew into adolescence and then early adulthood mental health difficulties emerged that led to a diagnosis of complex PTSD/emotionally unstable personality disorder. Additionally, he had a diagnosis of autistic spectrum disorder.
In total, Brandon had five Mental Health Act assessments between May 2021 and May 2023, to include two on consecutive days on 14 and 15 May 2023, the latter following detention under s136.
I heard at inquest that it is contrary to national guidance and local policy to admit someone with PTSD/EUPD into hospital and, absent any other therapeutic option, the consultant psychiatrist referred Brandon to the local CMHT. He was discussed at MDT on 23/5/23 and a duty worker spoke to him on 16/6/23 when a decision was made to put him on the CMHT therapy pathway. He was found deceased five days later before any treatment had commenced.
On reflection, it was noted that referrals would aim to be actioned within five days but took 16 here. The inquest heard that the CMHT was short-staffed at the time and the Manager confirmed was fulfilling two roles.
Coroner’s concerns
(1) Shortage of staff. This has been a longstanding concern in Cornwall. I am aware there have been initiatives undertaken nationally and internationally and yet the problem remains. It seems this is not an issue that can be resolved by the local ICB and so this concern is directed to the Secretary of State for her attention and formal response.
The following two issues require a response from the ICB and not the Secretary of State.
(2) As noted above, the inquest was informed that where patients with complex PTSD/EUPD present in crisis, national and local practice is not to detain in a secure hospital. The inquest also heard that in other areas of the country there is a therapeutic alternative of admission to a day hospital (ie not detained, but somewhere to permit de-escalation) or to a crisis unit/house/café. That option is not currently available in Cornwall.
(3) The inquest heard that CPFT is commissioned to assess 140 patients annually for autism. The current waiting list for assessment is in the region of two years. In other words, the demand for the service greatly exceeds the current supply.
Information checked against the published report and official responses