Zoe Zaremba
A similar concern from this report was raised again 1 time later. See the linked reports.
The coroner's concerns
1. misunderstanding of autism by clinicians
“[the deceased] was diagnosed at age 16 years as being autistic by CAMHS with a designation of Asperger's Syndrome”
2. lack of autism-specific care pathways
“TEWVs provision for cares of autistic conditions were underdeveloped, reflecting national want of provision”
3. disproportionate suicide risk among autistic females
“autistic individuals are more at risk of suicide than those with no neurodevelopmental condition, and females at greater risk that their male counterparts”
4. repeated high-risk presentations without coordinated care
“[the deceased] was detained under ss 2/3 MHA 1983 17 times and presented to A and E around 37 times with evident self harm”
5. systemic failure to support autistic individuals with mental health needs
“Both locally, including regional, but also nationally the evidence revealed a number of serious issues that require urgent and immediate action to support autistic people well”
Linked reports
This report
“She had no Care Co-ordinator nor effective Care Plan (which ought to have been in place)”
Later report
“there was a gap in the provision of care for individuals suffering with autism and in crisis”
Responses
2022-0117-Reponse-from-Tees-Esk-and-Wear-Valleys-NHS-Foundation-Trust-17-June.pdf ↗· Tees Esk and Wear Valley NHS Foundation Trust
Stated action · 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determining if and how the diagnosis has been shared and made clear in the records. 3) whether the diagnosis has been withdrawn and if so, how this has been communicated both to people and to services. 4) engaging with clinical teams proactively and acknowledge that this could possibly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”
2022-0117-Response-from-Department-of-Health-and-Social-Care.pdf ↗· NHS England
Stated action · 1 July 2022
“registered providers are required to ensure their staff receive specific training on learning disability and autism appropriate to their role”
Stated action · March 2023
“investing £1.5 million into the development and trialling of autism training for staff working in adult inpatient mental health settings by March 2023”
Stated action · 2022/2023
“investing £70 million to prevent avoidable admissions and improve community support for autistic people and people with a learning disability”
Stated action · 2022/2023
“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.”
2022-0117-Response-from-Humber-and-North-Yorkshire-Health-Care-Partnership.pdf ↗· North Yorkshire Clinical Commissioning Group
Stated action · 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.”
2022-0117-Response-from-NHS-England.pdf ↗· NHS England
Stated action · 2023
“£7 million for local areas to test ways to improve the quality of autism diagnostic pathways”
2022-0117-Response-from-Tees-Esk-and-Wear-Valleys-NHS-Foundation-Trust-21-June.pdf ↗· Tees Esk and Wear Valley NHS Foundation Trust
Stated action · 2023
“We have commenced examining these unique identifiable records with a view to: 1) understand the rationale and the validity of the diagnosis in these cases, in view of the potential for diagnostic confusion 2) determine if and how the diagnosis has been shared and made clear in the records 3) identify whether the diagnosis has been withdrawn and if so, how this has been communicated both to people and to services. 4) engage with the identified patient and clinical teams proactively and compassion”
2022-0117-Response-from-TEWV.pdf ↗· Tees Esk and Wear Valley NHS Foundation Trust
Stated action · 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”