Gross failures in the care given to a bullied autistic teenager from Stowmarket who died when he threw himself in front of a train amounted to negligence, a coroner said yesterday.
Gareth Oates died instantly a month after his 18th birthday when he was hit by a train after travelling to Marsden Station, near Huddersfield, West Yorkshire.
A three-day inquest in Bradford heard how he was bullied while he studied at West Suffolk College, in Bury St Edmunds, with some students routinely calling him ‘suicide boy’.
Bradford Coroner Paul Marks heard how Gareth’s mother, Glenys Oates, mounted a desperate battle to get appropriate mental health intervention for her son in the run up to his death on March 2, 2010.
He had already tried to kill himself once and had talked of suicide from the age of 11.
Yesterday, Professor Marks said Gareth was failed by a number of agencies including those dealing with mental health, social services and education.
He said it was probable that treatment with certain drugs or the appropriate use of the powers under the Mental Health Act would have ‘averted his death’.
The coroner said there was a clear gap in provision in psychiatric care for young people between 16 and 18 years old who were too old for child services but too young to benefit from adult interventions.
He said this was probably a national problem and he said he would be writing to the Secretary of State for Health and the Royal College of Psychiatrists about his concerns.
In a narrative verdict, Prof Marks said there were gross failures in the assessment and management of Gareth’s case as well as the access he was given to specialist services ‘amounting to negligence’.
Earlier, the coroner said: “There was a lamentable lack of a named expert in autism to take overall charge of his care and adopt an holistic approach to his needs.”
The inquest heard that Gareth was diagnosed with high functioning Autistic Spectrum Disorder when he was five and had specialist help throughout his pre-16 schooling, often on a one-to-one basis.
Earlier this week, Mrs Oates told the inquest how Gareth had been bullied at secondary school but this was dealt with.
Things got worse when he started at college, partly because he travelled independently and was targeted by youths on the train and in other public places.
Administrator Mrs Oates said she had later received an apology from Suffolk Police for not dealing with this more robustly.
She said her son found the transition to college from school difficult for a range of reasons.
Although the college put a number of measures in place to help, she believed it was not enough.
In the summer of 2009 the taunting caused Gareth to run out of college into a wood and phone his mother her saying: ‘Mum, I’m going to kill myself’.
His mother explained to the coroner how a month after this she found a message on her phone from her son saying he was on top of cliffs at Sheringham, Norfolk, preparing to jump.
She said the message said: ‘This is the last time you’ll hear my voice.’
Mrs Oates described how she became more and more concerned about her son’s suicidal tendencies over the summer of 2009 but could not convince mental health services of the seriousness of his situation.
She told the inquest: “Nobody seemed to get their act together after he’d attempted suicide in July 2009.”
She added: “Until I started to kick up a fuss, nobody did anything.”
Gareth eventually started a course of cognitive behavioural therapy in September 2009.
His mother described how he became obsessed with the 1985 action film The Runaway Train - which ends with one of the main characters killing himself in front of the locomotive.
Mrs Oates said she believed some of the details of her son’s death mirrored that in the film.
She told the coroner she believed her son travelled to the Huddersfield area because he had once been obsessed with a DVD about the last days of steam engines in the Pennines, which featured the spot where he died.
In his narrative verdict, Prof Marks said: “On many occasions throughout his life he (Gareth) expressed suicidal ideation.
“His transition between secondary school and college education was difficult for him and this was compounded by bullying.
“He had contact with many agencies and there was a global failure in his assessment, management and access to specialist services, amounting to neglect.”
The coroner said he accepted evidence that cognitive behavioural therapy was not enough in Gareth’s case and ‘pharmacological treatment should have been tried’.
Prof Marks said: “Apart from health and psychiatric services, Gareth was involved with a variety of other agencies such as social services and the educational authority, to name but two.
“I have accepted expert evidence that he was failed globally by these agencies.”
He said: “Although no one individual’s failing can be identified, the summation of failings in his psychiatric management amounted to gross failure in the care delivered to him.”
The coroner added: “I have accepted expert evidence that there were gaps in service provision and that treatment with drugs or detention under the provisions of the Mental Health Act 1983 would, on the balance of probabilities,
have averted his death on March 2, 2010.”
The coroner said he believed the 2010 Autism Bill, which he said came into force just after the tragedy, would address some of the issues raised by this case and ‘help to prevent similar tragedies’.
But he said he would be writing to Suffolk County Council to ensure the legislation has been implemented locally.
After the hearing, Mrs Oates thanked the coroner and said she hoped his recommendations would be acted on by all the agencies concerned.
She said: “I hope that the lack of appropriate services for young people with autism such as Gareth will soon be a thing of the past.
“I continue to be deeply saddened by Gareth’s death, as do the rest of his family.
“We hope that other young people with autism will be better protected in the future.”
In a statement, West Suffolk College said: “West Suffolk College takes all reports of bullying very seriously and we take action to address them when they are reported.
“College staff had no knowledge of Gareth being called ‘suicide boy’ (as has been quoted) by other students or evidence of bullying while attending college.
“The college carried out a thorough investigation at the time of Gareth’s tragic death in 2010.
“Gareth was supported by teaching staff and our student welfare team during his time here. He appeared to be coping well with his course.
“We are very sorry for Mrs Oates’ loss.
“Everyone at the college who knew Gareth was very upset, and we offered support to staff and fellow students at the time.”
Mel Carr, transitions co-ordinator for The National Autistic Society, said: “The tragic case of Gareth Oates underlines the very real difficulties facing young people with autism as they make the transition into adulthood and the very real need for support at that time.
“Young people with autism are two to three times more likely to be bullied than their peers and the impact is devastating. If the right support is available then these problems need not escalate.
“Gareth was let down by a system that failed to recognise his needs.
“This must not happen again and all agencies must do more to help young people with autism who find themselves in such troubling circumstances.”
Aidan Thomas, Chief Executive of Norfolk and Suffolk NHS Foundation, said: “On behalf of the former Suffolk Mental Health Partnership Trust I would like to express our condolences to the family of Gareth Oates at this distressing time.
“Now the verdict has been given and recommendations have been made we note that the coroner identifies a failure in the system.
“As such, we are interested in seeing the section 43 letters that will be sent to partner agencies in order to identify where our Trust can help them achieve their action plans.
“The Trust is already making improvements and has this week been awarded the Suffolk Wellbeing Service contract, which will support our existing clinical services in Suffolk for everyone aged 13 upwards.
“Last week also saw the launch of a new pilot youth service in the Trust offering support, early detection and reaching out to marginalised groups of young people with complex mental health needs - also helping the bridge the gap between our existing child and adult services.
“The Trust is also one of a number of agencies in Suffolk taking part in a county wode autism strategy looking at particular issues for people with autism.
“I appreciate these improvements are being made too late for Gareth but we are determined to learn from what happened and with our partners will make real changes.”