Benjamin Compton
19 Mar 2025 · Coroner Philip Spinney · Devon, Plymouth and Torbay
This report repeats 5 earlier warnings. See the linked reports.
The coroner's concerns
1. gap in provision of care for autistic individuals in crisis
“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”
2. removal from GP practice and placement on Special Allocation Scheme
“[the deceased] was removed from his GP practice due to violent behaviour and allocated to the Special Allocation Scheme”
Linked reports
Closely relatedConfidence 0.90 · high
Earlier report
“Evidence at the inquest suggested that there was an insufficient understanding of the special needs and vulnerabilities of those prisoners who are within the autistic spectrum”
This report
“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.”
Closely relatedConfidence 0.85 · high
Earlier report
“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.”
This report
“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.”
Closely relatedConfidence 0.85 · high
Earlier report
“She had no Care Co-ordinator nor effective Care Plan (which ought to have been in place)”
This report
“there was a gap in the provision of care for individuals suffering with autism and in crisis”
Closely relatedConfidence 0.86 · high
Earlier report
“Urgent solutions are required to prevent further deaths of autistic individuals especially those with mental health disorder by rapidly improving and expanding provisions”
This report
“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.”
Closely relatedConfidence 0.90 · high
Earlier report
“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.”
This report
“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.”