Coroner writes to health secretary after vulnerable man died in care home that had not been inspected by watchdog

A coroner has written to the health secretary expressing concerns about the shortage of suitable supported accommodation for vulnerable people with Asperger syndrome following the death of a man in a home that had not even been inspected by the care regulator.

Robin Richards, 33, had a long history of mental health issues and was sectioned after taking novel psychoactive substances and becoming aggressive and suicidal.

Private hospitals warned over failing safety and quality standards Read more

Richards was receiving care in a psychiatric ward, but when he was judged well enough to leave no suitable accommodation could be found and he was forced to stay for a total of four months, which left him extremely distressed.



When he was finally discharged, he was placed in a new private care home, in Burnham-on-Sea, Somerset, that had yet to be visited by the Care Quality Commission (CQC).

During the two weeks he spent there, Richards cut his head with a knife, twice stepped out in front of cars and tried to get to a bottle of bleach in a locked cupboard before he was found dead.



An inquest jury ruled that Richards had killed himself and concluded that issues contributing to his death included communication problems, information sharing, training, discharge and care planning and risk assessment.

Tony Williams, the senior coroner for Somerset, has written a “prevention of future deaths” report to Jeremy Hunt and to Peter Lewis, the chief executive of Somerset Partnership NHS foundation trust, which runs mental health services.

Williams wrote: “There exists a shortage of suitable supported accommodation for those diagnosed with Asperger syndrome both in Somerset and nationally.” He said this shortage had resulted in Richards remaining on a psychiatric ward when it was not in his best interests.

The coroner said there were a number of shortcomings on the part of the trust including “an inadequacy in the risk-assessment process” and a “failure to communicate with Mr Richards at a time of crisis”.

Williams said the health secretary and Lewis had 56 days to reply with details of action taken or proposed to be taken. “Otherwise you must explain why no action is proposed,” he wrote.

Richards’s sister, Amanda Richards, welcomed the coroner’s report. She said: “This recognition of the national problem facing those with a diagnosis of Asperger syndrome is the culmination of years of emotional turmoil in the battle to get the right care for Robin.

“The lack of suitable accommodation meant that he had nowhere to reside but on a psychiatric hospital ward for many months. The delays and uncertainty, so much more detrimental for a person with a diagnosis of an autistic spectrum condition than most, resulted in a severe decline in Robin’s mental health.

“He was then transferred to a care home where he was cared for by staff with no experience or training in Asperger syndrome. We hope that this report will prompt serious and urgent action from the Department of Health.”

Deborah Coles, director of the charity Inquest, which supported the family, said: “Robin’s case is one of an increasing number we are seeing involving failures around the assessment and provision of mental health care for people with Asperger’s and autism. We fear that the needs of this particular group have slipped outside the government’s focus in its work around mental health.”

A spokesperson for the Department of Health and Social Care said advances had been made in the treatment of people with autism. They said: “But we must speed up progress even further. We are working alongside people affected, to make sure they have access to healthcare with adjustments made for their conditions. The NHS’s five-year plan for mental health will transform mental health care and improve the processes to get people with autism out of hospital and back into the community.”

Lewis said: “I would like to apologise to the family and friends of Robin Richards. I have offered to meet with them to share the lessons we have learned from this tragic incident, and the changes we have made in our services. We will continue to work closely with the coroner in considering and responding to his report.”

The coroner did not write to the care home involved, Highbridge Court. When the CQC inspected it after Richards’s death, concerns were raised, but in its most recent inspection it was judged to be safe and effective.

• In the UK, Samaritans can be contacted on 116 123 or email jo@samaritans.org. In the US, the National Suicide Prevention Lifeline is 1-800-273-8255. In Australia, the crisis support service Lifeline is 13 11 14. Other international suicide helplines can be found at www.befrienders.org.