Benjamin Robert Compton · Prevention of Future Deaths report

On 10 February 2022 an investigation was commenced into the death of Benjamin Robert Compton. The investigation concluded at the end of the inquests held on 4 -5 March and 10 March 2025. The conclusion of the inquest was as follows:

On 1 February 2022 Benjamin Robert Compton died after being hit by a lorry on the M5, Devon, between junctions 29 and 28.

Road Traffic Collision

Benjamin was diagnosed with having an autism Spectrum disorder.

In September 2021 Benjamin started to suffer a deterioration in his physical and mental wellbeing; according to the evidence this was probably due to an episode of swallowing water in a swimming pool; that event started a pathway of decline over several months. The evidence at the inquest supports the conclusion that the cause was multifactorial and there are a number of possible contributory factors to the deterioration in his health and the escalation in his disruptive behaviour, these include:

- Aspects of his physical health
- His medications
- The removal from his GP Practice
- Placement on the Special Allocation Scheme
- The lack of an effective medication review and
- Changes in his routines

Benjamin required multidisciplinary input into all aspects of his care planning; including primary care for prescribing medication for emotional wellbeing and pain, from psychology for safe interventions, specialist sensory occupational therapy for communication and interaction with the world.

In January 2022 when Benjamin was in crisis, clinical support and advice was limited – he was not able to see a GP, he did not receive a full and effective medication review and in the early part of January 2022 he was not in receipt of a full and effective social care package.

The inquest heard evidence about the Devon Adult Autism Intervention Team (commissioned by The Devon Integrated Care Board and operated by Devon Partnership Trust). This team forms part of the Devon Health and Social Care Systems response to the needs of autistic adults across Devon, although it was not fully operational when Benjamin died. The team offers signposting and advice, consultation for professionals and assessment, formulation and provision of direct interventions where needed. This is a clinical team consisting of Psychology, Speech & Language, Occupational Therapy and Psychiatry. However the team is only able to offer limited interventions and not in circumstances where the individual is in crisis.

In the early hours of the 1 February 2022, at a time when he was distressed and overwhelmed by his emotions and difficulties tolerating change, Benjamin left his accommodation where he was being supported by carers and walked barefoot and in his night clothes to the M5 where he was hit by a lorry.

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

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