Prevention of Future Deaths reports · 2023
Regulation 28 report to prevent future deaths, reference 2023-0068, written 19 Feb 2023. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 19 Feb 2023 |
|---|---|
| Reference | 2023-0068 |
| Deceased | Stefan Kluibenschadl |
| Coroner | Catherine Wood |
| Coroner area | North East Kent |
| Category | Suicide (from 2015) · Child Death (from 2015) |
| Organisation named | North East London NHS Foundation Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
REPORT TO PREVENT FUTURE DEATHS
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
1. NHS Kent and Medway integrated care board
1
CORONER
I am Catherine Wood, assistant coroner, for the coroner area of North East Kent.
2
CORONER’S LEGAL POWERS
I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009
and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013.
3
INVESTIGATION and INQUEST
On the 8th April 2022 I opened an inquest into the death of Stefan Kluibenschadl. At the
inquest, which lasted two days and heard from a few of those involved in Stefan’s short
life, I concluded on 1st December 2022 with a narrative conclusion “He died as a
consequence of his own actions, his intention being unknown”
4
CIRCUMSTANCES OF THE DEATH
1. Stefan suffered from autism and was at school at Laleham gap where he had
been since April 2013. He had annual reviews of his placement at the school and
was doing well and at the start of the winter 2020 term had managed to obtain a
part time job and was considering career options of either the army or food
industry. He had an extremely supportive family and parents who made significant
efforts to ensure that he had access to the support he needed.
2. Both his parents and his school noted a decline in his mental health in December
2021 and he met with the school alongside his parents and his timetable was
amended and steps to obtain additional support considered. On 14th January
2022 he told a member of staff at school that he had contacted the National
Suicide Prevention helpline but later appeared to deny this. He apparently did not
express any intent to harm himself but did express feelings of being low.
3. His parents, having tried to see what help was available locally, took steps to try
to arrange private counselling and arranged for this to start after the February half
term. The service the family approached did not consider Stefan was suitable for
short term counselling and advice was given to approach his General
Practitioner(GP). On 15th March 2022 Stefan’s Mum spoke to his GP and asked
for a letter to apply for funding from specific autism related counselling which his
GP did but this was rejected and the letter received on 17th March 2022. At the
consultation which occurred on the telephone between Stefan’s mother and his
GP there was no mention of suicidal ideation or self-harm. On Sunday 20th March
Stefan was found hanging at home in his bedroom by his family and he was taken
to hospital and subsequently transferred to Kings College hospital where sadly he
died on 26th March 2022.
4.
In the course of hearing the evidence it was clear that local mental health services
were considered to be accessible via a Single Point of Access and that anyone
could refer in this way and the healthcare provider would then screen any referral
which was made and possibly provide treatment. However such a referral was not
made for Stefan because it was not clear that this was available to Stefan’s family
who would have taken whatever steps they could have done to ensure
appropriate support. His General Practitioner was aware of the Single Point of
Access and that there were groups available but waits for specific services for
those with autism in her experience were at least 3 months and instead she
referred him to a different service at South London and the Maudsley which she
considered may better suit his needs. The referral was rejected but the
correspondence on this only came to light after Stefan’s sad death.
5
CORONER’S CONCERNS
During the course of the inquest the evidence revealed matters giving rise to concern. In
my opinion there is a risk that future deaths could occur unless action is taken. In the
circumstances it is my statutory duty to report to you.
The MATTERS OF CONCERN are as follows. –
1. During the course of the inquest reference was made to the National Institute for
Clinical Excellence (NICE) guidance “Autistic Spectrum disorder in under 19s:
support and management.” Published on 28 August 2013 and in particular
paragraph 1.1.4 which states that “Local autism teams should ensure that every
child or young person diagnosed with autism has a case manager or key worker
to manage and coordinate treatment, care, support and transition to adult care in
line with the NICE guideline on autism in children and young people (covering
identification and diagnosis).” Stefan did not have a case manager or key worker.
2.
I am unable to say if the lack of a case manager or key worker caused or
contributed more than minimally to Stefan’s death but had one been available
they may have been able to assist Stefan and his family to navigate the services
available which in turn may have led to intervention which may have made a
difference. I am prohibited from returning a conclusion which comments on issues
where there is no clear causal link with the death however the Coroner’s and
Justice Act 2009 creates a duty on Coroners to report an issue which gives rise to
a concern which may lead to future deaths.
3.
I asked for further evidence on the provision of case managers/key workers in
accordance with the NICE guidance after the inquest from North East London
Foundation Trust and from Kent and Medway Integrated Care Board. It is clear
from the evidence provided that such a service is only provided to those under 19
year olds who have both a learning disability and/or a diagnosis of autism and are
at risk of admission to a mental health hospital or where there is a significant
sudden deterioration in the community and the multi disciplinary team has not
been responsive. The lowest level of service outlined in reply to the court
indicated that referrals could be made to a key worker to sign post families not
that they would have a key worker allocated to them. This sets the bar at a level
which means a large number of young people with a learning disability and/or
autism would not have a key worker nor would they be expected to have one .
4.
In the evidence provided it was outlined that “Keyworkers will make sure that
these children, young people and families get the right support at the right time.
They will make sure that local systems are responsive to fully meeting the young
people’s needs in a joined-up way and that whenever it is possible to provide care
and treatment in the community with the right support this becomes the norm.” If
every autistic child or young person had a key worker this would enable them or
their family the opportunity to liaise with their key worker rather than having to try
to navigate services themselves. This, in turn, may prevent others from
encountering the issues faced by Stefan’s family and ultimately prevent future
deaths.
6
ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I believe you have the
power to take such action.
7
YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date of this report,
namely by 17th April 2023. I, the coroner, may extend the period.
Your response must contain details of action taken or proposed to be taken, setting out
the timetable for action. Otherwise you must explain why no action is proposed.
8
COPIES and PUBLICATION
I have sent a copy of my report to the Chief Coroner and to the following Interested
Persons namely the family, his GP and North East London NHS Foundation Trust.
I am also under a duty to send the Chief Coroner a copy of your response.
The Chief Coroner may publish either or both in a complete or redacted or summary
form. He may send a copy of this report to any person who he believes may find it useful
or of interest. You may make representations to me, the coroner, at the time of your
response, about the release or the publication of your response by the Chief Coroner.
9
19 February 2023
Catherine Wood
Assistant Coroner
North East Kent
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