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recurance

Oliver Sharp

1 Oct 2019 · Coroner Alison Mutch · Manchester (South)

This report repeats 1 earlier warning, and was raised again 1 time later. See the linked reports.

The coroner's concerns

  1. 1. inconsistent mental health service provision for 16-25 year olds

    “The inquest was told that the provision of mental health services post 16 varies widely across the country”
  2. 2. delayed autism diagnosis

    “The inquest was told that it is important for autism to be diagnosed as early as possible so that appropriate support can be put in place”
  3. 3. educational acceleration causing mental health risks

    “During the inquest evidence was heard that acceleration ahead of a chronological school age might cause relatively few difficulties in peer relationships up to about year 9 but post”
  4. 4. negative impact of disability labeling on autistic youth

    “The inquest heard that [the deceased] had found the autism label and the label of disability that was attached to it very difficult to accept as time went on”
  5. 5. stigmatizing language around autism

    “The language that it would have been more helpful to use widely would have been difference rather than disability”

Linked reports

Repeats an earlier warningDaisy French9 Nov 2017 · 1 year 11 months earlier
Closely relatedConfidence 0.80 · moderate

Earlier report

“Out of hour's provision for 16 to 18 years. (During working hours they are considered children and therefore are the responsibility of CAMHS,”
Original on judiciary.uk ↗

This report

“The inquest was told that the provision of mental health services post 16 varies widely across the country.”
Full chain: Inconsistent mental health service provision for 16-18 year olds
Raised again laterBlackpool & Fylde3 Apr 2023 · 3 years 6 months later
Identical hazardConfidence 0.90 · high

This report

“The inquest was told that it is important for autism to be diagnosed as early as possible so that appropriate support can be put in place.”

Later report

“With finite resources, it is acknowledged that it may not be possible for all young people to be assessed in as timely a manner as required,”
Original on judiciary.uk ↗
Full chain: Delayed autism diagnosis in young people

Responses

No published response was found on judiciary.uk.

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Source: Prevention of Future Deaths reports and responses published by the Courts and Tribunals Judiciary at judiciary.uk. Crown copyright, used under the Open Government Licence v3.0. Data updated 26 Oct 2026.

A link shows that a similar concern was raised again, not why. It is not a finding about any organisation or person. Methodology and responsible use · Report an error