“During the course of the inquest, I heard evidence from health professionals from the…”
Dated 1 Jul 2025, from the coroner for Black Country. Sent to 3 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 20 Jan 2026, after the 56 days for replies had ended (26 Aug 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 dated1 Jul 2025
- Deadline26 Aug 2025
- Published on judiciary.uk20 Jan 2026
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Walsall Healthcare NHS Trust | Response publishedPublished on judiciary.uk in January 2026. |
| Walsall Local Authority | 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. |
| Birchill’s Health Centre | Response publishedPublished on judiciary.uk in January 2026. |
The coroner’s concerns
– 1. During the course of the inquest, I heard evidence from health professionals from the Hospital Trust, Local authority service providers and an expert, Paediatric Nephrologist. 2. My concern is that Joshua was never formally diagnosed with Autism and there appears to be nationally, a variation in practice before an assessment for autism can be made. Some areas specify 3 years of age or above but there is no clear national guidance. 3. Regrettably, without a formal diagnosis of autism being made, there was no onward referral to dieticians with experience of autism and therefore an understanding of the link between autism and Avoidant restrictive food intake disorder (ARFID). 4. In addition, I heard expert evidence that Joshua’s death wasn’t an isolated incident and another autistic child died in very similar circumstances by developing dehydration. 5. The expert evidence also indicated that the Capillary Refill Time (CRT) test used to assess dehydration by checking peripheral blood flow is a very insensitive test and can provide misleading reassurance. Therefore, my concern is that young children with similar circumstances to Joshua maybe at risk when assessing levels of dehydration. NHS England may wish to consider reviewing their guidance for health professionals. 6. In summary, all the agencies involved in Joshua’s care, may wish to consider reviewing your guidance and approach for assessing children with complex medical needs of autism and ARFID.
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, 2026-0012
- 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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