Recurance · prevention of future deaths reports
Pre-inquest brief
The earlier warning
Siân Hewitt · 21 Oct 2020 · Tom Osborne, Milton Keynes
“It would appear from the circumstances of Ms [name redacted] death that the NHS are unable to provide a place of safety for those who are suffering from Asperger's syndrome, or indeed other forms of autism, when they are also suffering additional mental health problems such as bipolar.”
What was promised
Stated action 1 · response to Zoe Zaremba (25 Apr 2022) · stated timescale: 2023
“£7 million for local areas to test ways to improve the quality of autism diagnostic pathways”
Stated action 2 · response to Zoe Zaremba (25 Apr 2022) · stated timescale: 1st June 2022
“We have begun to examine these unique identifiable records with a view to: 1) understanding the rationale and the validity of the diagnosis in these cases, in view of the potential for diagnostic confusion. 2) determining if and how the diagnosis has been shared and made clear in the records. 3) whether the diagnosis has been withdrawn and if so, how this has been communicated both to people and to services. 4) engaging with clinical teams proactively and acknowledge that this could possibly be”
Stated action 3 · response to Zoe Zaremba (25 Apr 2022) · stated timescale: 1 July 2022
“the CCG commissioned TEWV to provide mental health services for the population regardless of whether someone also has a diagnosis of a neuro developmental disorder/condition. The ICB have now had that contract novated to them upon the establishment of the ICB on 1 July 2022.”
judiciary.uk/…/2022-0117-Response-from-Humber-and-North-Yorkshi…
6 further stated actions are listed on the full chain page.
What recurred
- 25 Apr 2022 · Zoe Zaremba · John Broadbridge
- 5 Jul 2022 · Antony McLellan · Joan Broadbridge
- 26 Sept 2023 · Benjamin Hazelden · Catherine Wood
- 5 Feb 2025 · Sapphire Bernard · Penelope Scofield · Closely related · confidence 0.80 (moderate)
- 19 Mar 2025 · Benjamin Compton · Philip Spinney · Closely related · confidence 0.90 (high)
The clearest link, quoted from both reports:
Earlier · Benjamin Hazelden · 26 Sept 2023
“acute psychiatric ward was considered but not deemed appropriate to meet his needs and as there were no specialist beds available he was discharged back to his home with increased support as the best option available.”
Later · Benjamin Compton · 19 Mar 2025
“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.”
What happened next
No evidence found either way · stated action 1
“The prevalence of autism in children has risen significantly in recent years, studies from US Centers for Disease Control and Prevention, Northern Ireland and South Korea suggesting this currently sits at 1.5 to 3 percent of children in the western world. This is an increase from UK figures in 2006, which first suggested prevalence had reached 1 percent. This has resulted in an imbalance between”
How Can We Improve Delivery of Diagnostic Assessment for Children with Possible Autism? – Social Science Space · socialsciencespace.com/…/how-can-we-improve-delivery-of-diagnos…
“Securing £40.5m funding to improve Learning Disability and Autism care pathways - NHS SCW Support and Transformation for Health and Care NHS SCW Support and Transformation for Health and Care NHS SCW Support and Transformation for Health and Care.”
Securing £40.5m funding to improve Learning Disability and Autism care pathways - NHS SCW Support and Transformation for Health and Care · scwcsu.nhs.uk/…/securing-40-5m-funding-from-nhse-to-improve-lea…
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The national strategy for autistic children, young people and adults: 2021 to 2026 - GOV.UK · gov.uk/…/the-national-strategy-for-autistic-children-young-peop…
No evidence found does not mean the action did not happen.
No evidence found either way · stated action 2
“The aim of this study is to understand the experiences of accessing inpatient mental health services for individuals with a diagnosis of autism a”
“I Don’t Think Anyone’s Ever Asked Me About the Two Before”: Making Sense of Co-occurring Autism and BPD in Inpatient Mental Health Settings | Journal of Autism and Developmental Disorders | Springer Nature Link · link.springer.com/article/10.1007/s10803-025-07050-0
No evidence found does not mean the action did not happen.
No evidence found either way · stated action 3
“A unique aspect of doing business with the federal government is the built-in limits on a contractor's right to assign the contract or the right to payment under the contract to third parties.”
Novation Agreements under Federal Contracts · contractorsperspective.com/…/novation-agreements-under-federal-…
“Takeaways * **Contract novation replaces one party with another in a legally binding way.** It extinguishes the original contract and creates a new one where the incoming party assumes all rights and obligations”
How Contract Novation Works: Steps, Benefits & Examples · sirion.ai/library/contracts/contract-novation
No evidence found does not mean the action did not happen.
Evidence found · stated action: “registered providers are required to ensure their staff receive specific training on learning disability and autism appropriate to their role”
“Since 1 July 2022, all CQC registered health and social care providers have been required to provide training for their staff in learning disability and autism, including how to interact appropriately with autistic people and people with a learning disability. This should be at a level appropriate to their role.”
Training staff to support autistic people and people with a learning disability - Care Quality Commission · cqc.org.uk/…/training-staff-support-autistic-people-and-people-…
“The Health and Care Act 2022 requires all CQC-registered health and social care staff to complete learning disability and autism training. This training must be appropriate to their role.”
Mandatory Autism and Learning Disability Training · firstresponsetraining.com/…/autism-and-learning-disability
“The [name redacted] on Learning Disability and Autism is named after [name redacted], whose death shone a light on the need for health and social care staff to have better training.”
The Oliver McGowan Mandatory Training on Learning Disability and Autism | NHS England | Workforce, training and education · hee.nhs.uk/…/oliver-mcgowan-mandatory-training-learning-disabil…
No evidence found either way · stated action: “investing £1.5 million into the development and trialling of autism training for staff working in adult inpatient mental health settings by March 2023”
“This was published under the 2019 to 2022 Johnson Conservative government”
The national strategy for autistic children, young people and adults: 2021 to 2026 - GOV.UK · gov.uk/…/the-national-strategy-for-autistic-children-young-peop…
“Overall, the findings expose an acute lack of autism-specific training that has detrimental impacts.”
Staff Training in Autism: The One-Eyed Wo/Man… · pmc.ncbi.nlm.nih.gov/articles/PMC4962257
“Significant work is needed to provide autistic adults with affordable quality MH services.”
Community Mental Health Services for Autistic Adults: Good News and Bad News · pmc.ncbi.nlm.nih.gov/articles/PMC6821445
No evidence found does not mean the action did not happen.
No evidence found either way · stated action: “investing £70 million to prevent avoidable admissions and improve community support for autistic people and people with a learning disability”
“Participants allocated to HomeHealth had a significant reduct”
Funding Health Promotion Activities to Reduce Avoidable Hospital Admissions in Frail Older Adults (HomeHealth): Further Challenges to the “Cost-Effective but Unaffordable” Paradox · pmc.ncbi.nlm.nih.gov/articles/PMC12535928
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Study: Reducing Potentially Avoidable Hospitalizations for Patients Receiving Medicare and Medicaid Could Save Millions | RTI · rti.org/…/study-reducing-potentially-avoidable-hospitalizations…
No evidence found does not mean the action did not happen.
No evidence found either way · stated action: “includes £40 million to improve the capacity and capability of 7-day specialist multidisciplinary and crisis support for autistic people and people with a learning disability in every area of the country.”
“# The national strategy for autistic children, young people and adults: 2021 to 2026 Updated”
The national strategy for autistic children, young people and adults: 2021 to 2026 - GOV.UK · gov.uk/…/the-national-strategy-for-autistic-children-young-peop…
“Better care for people with a learning disability and people with autism”
Better care for people with a learning disability and people with autism - GOV.UK · gov.uk/…/better-care-for-people-with-a-learning-disability-and-…
No evidence found does not mean the action did not happen.
Evidence found · stated action: “all health and social care providers registered with the Care Quality Commission (CQC) must ensure that their staff receive training on learning disabilities and autism appropriate to their role”
“The Health and Care Act 2022 introduced a statutory requirement that CQC-registered providers must ensure their staff receive learning disability and autism training appropriate to their role.”
The Oliver McGowan Mandatory Training on Learning Disability and Autism | NHS England | Workforce, training and education · hee.nhs.uk/…/oliver-mcgowan-mandatory-training-learning-disabil…
“From 1 July 2022, all health and social care providers registered with CQC must ensure that their staff receive training on learning disabilities and autism appropriate to their role.”
New training requirement for all staff who support people with a learning disability and autistic people coming in on 1 July · content.govdelivery.com/accounts/UKCQC/bulletins/31c717e
“Since 1 July 2022, all CQC registered health and social care providers have been required to provide training for their staff in learning disability and autism, including how to interact appropriately with autistic people and people with a learning disability.”
Training staff to support autistic people and people with a learning disability - Care Quality Commission · cqc.org.uk/…/training-staff-support-autistic-people-and-people-…
No evidence found either way · stated action: “We are aware of the increasing numbers of patients waiting in emergency departments for mental health beds and, since the time of this incident, we have introduced national level monitoring of all patients in emergency departments waiting over 72 hours for mental health placements.”
“NHS key statistics: England Summary: NHS pressures before and after the pandemic 1 Emergency care: A&E and emergency admissions 2 Waiting times for hospital treatment 3 Cancer waiting times 4 Ambulance response times and demand 5 Diagnostic tests 6 Workforce levels and vacancies 7 Bed availability and discharges 8 GP appointments NHS key statistics: England”
CBP-7281.pdf · researchbriefings.files.parliament.uk/…/CBP-7281.pdf
“For the first time since February 2026, more than 10% of all patients attending A&E waited over 12 hours to be admitted, transferred, or discharged.”
NHS performance dashboard | Nuffield Trust · nuffieldtrust.org.uk/qualitywatch/nhs-performance-dashboard
No evidence found does not mean the action did not happen.