A grieving family has demanded the replacement of the coroner investigating the death of their autistic daughter, who they say was let down by the authorities charged with keeping her safe.

Colette McCulloch, who had high-functioning autistic spectrum disorder, died aged 35 after being hit by a lorry while walking along a dual carriageway in the early hours of the morning of 28 July 2016. Diagnosed with anorexia and OCD as a child, her autism wasn’t discovered until she was 33.

“It is in the public interest that the circumstances of Colette’s death are fully and fearlessly investigated, to prevent it happening again,” said Amanda, her mother.



Three investigations by public bodies, including a safeguarding review, have identified failings and neglect. But Colette’s parents have not been directly involved in these investigations and the investigations have not focused on how the failings contributed to their daughter’s death.

Solicitors for the McCulloch family have now asked for the coroner to be replaced, citing “the ‘complete loss of confidence and trust of the bereaved family’ in Ian Pears, the acting senior coroner for Bedfordshire and Luton. We need a full inquest to establish a proper understanding of how the acts and omissions by those responsible for her care contributed to this tragedy,” Amanda said.

At the pre-inquest review in December 2016, Pears announced he only intended to hold a short inquest, looking at the death solely as a road traffic accident.

After almost a year of pressure from the family’s lawyers at Leigh Day solicitors and their barristers at Doughty Street Chambers, Pears agreed to marginally widen the inquiry. He is still, however, refusing to call witnesses that her parents say are vital to discovering the truth, including themselves and Colette’s care co-ordinator from Sussex NHS.

Merry Varney, a partner in Leigh Day’s human rights department, made the application for Pears’ replacement to the chief coroner, Judge Mark Lucraft QC.

“When Colette was finally diagnosed at 33, we really thought that now we would get proper care and treatment,” said Amanda. But her parents say that Colette was still not given proper care. She died two years later.

After her diagnosis, Colette was accepted by Pathway House, a residential care home specialising in autism that is part of the privately run Milton Park Therapeutic Campus near Bedford. “They said they could treat her,” said Colette’s father Andy. “It turned out that they couldn’t even keep her safe.”

In the weeks leading up to her death, Colette’s behaviour became increasingly self-destructive, self-harming and dangerous. Despite concerns raised by her family, they believe no meaningful steps were taken by Milton Park to properly protect Colette.

“Colette’s distress was entirely predictable, but Pathway House failed to put in safeguards,” said Andy. “She shouldn’t have been on a motorway in the early hours. She should have been at the care home, which promised her that they could and would keep her safe.”

In June 2016, six weeks before she died, Colette jumped off a bridge into the river. She had to be pulled to safety and taken to A&E. Her psychiatrist at Pathway House described her action as “being with suicidal intent”. Yet his requests for her to be assessed under the Mental Health Act and sectioned were turned down four times by the local NHS Approved Mental Health Service service, who insisted that she was not at risk.

Without an assessment, Pathway House said Colette could no longer live there. They gave her an eviction notice, and she and her family understood that she would be evicted with little or no notice if she did not comply with her care plan, regardless of whether she had somewhere else to live or not.

Colette McCulloch at 17. Photograph: courtesy of McCulloch family

Sussex Partnership NHS trust, who were funding Colette’s care, found her a new care home but change is highly distressing for autistic people. In the days leading up to the move, Colette’s behaviour deteriorated further and, the family say, Pathway House failed to do all they could to keep her safe.



“Colette’s death is not just another statistic to be swept under the carpet,” said Andy. “She had an extraordinary mind. She could have had a life.”

The family are now crowdsourcing to raise funds to pay for a judicial review to reverse the coroner’s decision. “Colette used to say, ‘Don’t give up on me, mum and dad. Don’t give up on me,’” said Amanda. “We will never give up until justice is done.”

Preventable injuries often lead to death among people with autism, a recent study found. Autistic adults die, on average, 16 years younger than the general population, with those labelled as “high-functioning” – as Colette was – twice as likely to die young from preventable causes.

Jane Asher, president of the National Autistic Society, said: “There can be nothing more terrible than the death of one’s child, except knowing that it might have been prevented.



“It’s vital that Colette’s death is thoroughly investigated,” she added. “If there’s any possibility that a lack of care for this vulnerable young woman contributed to her death, then it’s essential that we learn from her tragedy.”

Pears said he is aware of the family’s request to have him replaced as their daughter’s coroner. “It would be inappropriate for me to comment while the chief coroner is considering the family’s request,” he said. “I will await the chief coroner’s decision.”

A spokesperson for Pathway House said: “Our priority at all times is the wellbeing, safety and health of the people we support, and we raised concerns about [Colette] on multiple occasions with the health authorities and police.”

A spokesperson for Sussex Partnership NHS trust promised to “cooperate fully” with the inquest. “We cannot comment in more detail at this point in time, other than to say we have reviewed the way we monitor the care of people who have been placed in specialist units outside of our local area,” a spokesperson added.