“The evidence reveals that there was a gap in the provision of care for individuals…”
Dated 19 Mar 2025, from the coroner for Devon, Plymouth and Torbay. Sent to 4 organisations or people.
A coroner wrote this report after an inquest, to warn the organisations below about a risk of further deaths.
The 56-day response deadline
Report put online after its 56 daysOrganisations that receive a report must reply to the coroner within 56 days, saying what they will do or why they will do nothing. We show whether a response is published on judiciary.uk; a reply may have been sent and not yet published.
judiciary.uk put this report online on 18 Jun 2025, after the 56 days for replies had ended (14 May 2025). These dates can’t tell us whether a reply was due before it went online. A reply may have been sent and not yet published.
- Report dated19 Mar 2025
- Deadline14 May 2025
- Published on judiciary.uk18 Jun 2025
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| NHS Devon Integrated Care BoardNamed in the report as “Devon Integrated Care Board” | Response published, not yet matchedA response is published with this report. We haven’t yet matched it to the organisation it’s from, so it may be this one’s. |
| Devon Partnership NHS TrustNamed in the report as “Devon Partnership Trust” | Response publishedPublished on judiciary.uk in June 2025. |
| Primary Care NHS Devon | Response published, not yet matchedA response is published with this report. We haven’t yet matched it to the organisation it’s from, so it may be this one’s. |
| NHS England | Response publishedPublished on judiciary.uk in June 2025. |
The coroner’s concerns
(1) 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. Evidence was heard that a gap exists with autistic people in distress and or dysregulation with no treatable mental health condition and there is a grey area 2 around treatment. This is beyond the skills of social care providers. And unless the individual meets the criteria for treatment under the Mental Health Act there is very little support. (2) Benjamin was removed from his GP practice due to violent behaviour and allocated to the Special Allocation Scheme. This scheme was not able to meet the needs of a patient such as Benjamin with a diagnosis of Autism Spectrum disorder.
An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.
- Source
- judiciary.uk, Prevention of Future Deaths reports, 2025-0285
- Added to Minute Book
- 8 Oct 2026
- Reuse
- We show short extracts and link to the original. We don’t host the full report.
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Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0
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