Joshua Weavers

Private & Confidential 

Mr Jacques Howell 
Area Coroner 
Hertfordshire Coroner Service 

Dear Mr Howell, 

The Forum 
Marlowes 
Hemel Hempstead 
Hertfordshire 
HP1 1DN 

04 April 2025 

Email:

https://hertsandwestessex.icb.nhs.uk 

Re: Regulation 28 Report to Prevent Future Deaths - Death of Joshua James Weavers who died 
on 4 March 2021 

Thank you for your Report to Prevent Future Deaths dated 17 February 2025 concerning the death of 
Joshua Jay Weavers on 4th March 2021. In advance of responding to the specific concerns raised in 
your report, I would like to express my deep condolences to Joshua’s family. Hertfordshire and West 
Essex Integrated  Care Board (ICB)  are  keen  to  assure  the  family  and  the  coroner  that  the  concerns 
raised about Joshua’s care have been listened to and reflected upon. 

Within your report, you highlighted the below as matters of concern for the ICB: 

“That  whilst  the  local  mental  health  Trust  has  plans  to  reform  the  manner  in  which  autism 
spectrum  disorder  (ASD)  assessments  for  patients  under  their  care  are  undertaken,  the 
implementation of those plans awaiting input from the Integrated Care Board. This means that 
waiting times for ASD assessments in Hertfordshire remain lengthy which in turn gives rise to a 
risk of future deaths occurring for the reasons set out above.” 

As you have noted in your report, nationally waiting times for ASD assessments are very long, and NHS 
services across England are encountering ongoing challenges in meeting the increased demand for ASD 
assessment and services, including Hertfordshire and West Essex ICB. We understand this is a worrying 
time for individuals and families which are seeking assessment and rely on treatments for their wellbeing, 
and we are taking steps to support the ongoing work to improve access. 

There are significant numbers of children and young people in both Hertfordshire and West Essex waiting 
for assessment for both autism and ADHD.    Locally, we have seen a marked change in the levels of 
demand for assessment for both autism and ADHD.  For example, five years ago we were seeing a year-
on-year increase in demand of around 10% whereas now the annual increase in demand is just below 
25%.  This rise is predicted to increase year on year, and in response we are seeking to redesign our 
approach to better be able to continue to respond to this increasing demand.   

Work to improve services (The Children and Young People Neurodiversity Transformation programme) 
has developed a model that responds to the needs of the child and family, rather than one driven by 
specific diagnostic findings.  This offers much more timely, individually tailored and appropriate services 
to neurodiverse children and their families and carers. This approach has the aim of improving the clinical 
and wellbeing outcomes for the young person and their families and carers. 

, Chief Executive                                                                                   

, Chair

 
 
 
 
 
 
 
                                                           
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Work  has commenced  in a measured  and  stepped way across  our  service  providers.    Key  elements 
include: 

•  providing better pre (and post) diagnosis support 
•  Using inputs from a wider range of non-clinical and clinical staff specialisms to support diagnosis 
• 

implementing a standardised and consistent referral and triage process. 

Through  this,  we  can  provide  more  timely  and  appropriate  support,  better  meet  demand  and reduce 
wasted patient, family and clinical time.   

The  model  has  been  developed  in  partnership  through  the  Hertfordshire  Mental  Health,  Learning 
Disabilities  and  Autism  Health  and  Care  Partnership  (MHLDA  HCP).  It  has  involved  NHS  and  Local 
Government partners, VCFSE organisations, local GPs and people with lived experience through Herts 
Parent/Carer  Involvement  Network  (HPCI).  Significant  co-production  and  engagement  with  services, 
allied  professions,  and  parent  carers  has  identified  areas  where  the  pathways  can  work  better  for 
professionals and families. 

There  are  different  elements  of  an  ASD  assessment,  and  our  new  model  establishes  the  resources 
required to operationalise this activity, specifically:  

•  The continuation and development of the Neurodiversity Support Hub and the development of a 
support offer to support parent carers, families and children to live well with autism and ADHD 
regardless of diagnosis status 

•  The  development  of  a  new  ‘front  door’  to  ensure  a  consistent  quality  of  referrals,  improved 
collation  of  information  to  support  the  diagnostic  process,  easier  follow  up  with  professionals 
where there is missing or incomplete information and improved data collection 

•  A  new  combined clinical  pathway for triage and assessment  across NHS  provider  Trusts that 

supports best use of clinical resource across Hertfordshire 

•  The development of a care coordinator role to support families as they go through the clinical 
pathway, releasing clinical time and ensuring that families are better engaged and informed of 
progress 

It is important to note that for those waiting for ASD assessments, children and young people are rated 
Red, Amber, or Green (RAG) against both clinical and safeguarding criteria and monitored against this. 
Service providers periodically contact families and share support information to ensure they are aware 
of and endeavour to respond to changes that may happen whilst people wait.  If there is any change to 
circumstances, or risk for the child or young person waiting, the family or the child or young person’s GP 
can contact the provider for additional support. 

We also recognise that there are some children and young people who are receiving inpatient care in a 
mental health setting, and they may undergo assessment and receive a diagnosis whilst an inpatient. 
Ongoing treatment and support would be managed through their individual care plan and support given 
on discharge. 

All age strategy 

Hertfordshire has developed a new All Age Autism Strategy, which sets out the broad priorities for health 
and care services, based on what autistic people and their families and carers say is important to them.  
The Strategy commits system partners to key priorities, including:  

i)  People  have access  to a  timely  diagnosis,  support  whilst  waiting  for  a  diagnosis  and post 

diagnosis support.  

ii)  Autistic people have equitable access to reasonably adjusted mental health services when 

they need them. 

, Chief Executive                                                                                   

, Chair

 
 
 
 
 
 
 
                                                           
 
 
 
 
 
 
 
 iii)  Autistic people and their families have access to a range of support in their local communities. 

iv)  Autistic people have equitable access to reasonably adjusted physical healthcare services 

when they need them and improving health outcomes for autistic people. 

Additional support for those waiting in Hertfordshire  

In order to continue to provide further support for those waiting a resource pack has been created for 
parents  and  carers  with  details  of  services  available  for  them  to  access,  including  whilst  waiting  for 
assessment, and this can be found here - The Hertfordshire Local Offer.  

GPs are also encouraged to share the following video with parents and carers  - Your guide to ADHD 
and autism support in Hertfordshire on the Local Offer website - YouTube. Additional resources available 
to parents include - Supporting Your Neurodiverse Child, and the neurodiversity service directory is also 
available - Neurodiversity Service Directory.  

Summary 

We  are  working  intensively  on  these  issues  to  support  our  providers  to deliver  safe  and  timely  care, 
including  significant  investment  in  pathways.  We  have  provided additional  funding  for  the  work  listed 
above for financial years 2023/24 at circa £3 million and 2024/25 at approximately £4.1 million, further 
funding of £4.3 million is baselined into providers budgets for coming financial years from 2025/26 to 
continue  to  support  the  development  of  the  model  previously  mentioned.  However,  it  must  be 
acknowledged that despite all the efforts detailed above it is expected that long waits for assessment 
will remain without wider national support, given the ongoing rises in demand that are persisting.   

We  await  the  outcome  of  the  NHS  10-year-plan  to  understand  whether  the  government  will  further 
prioritise ASD, therefore potentially reduce wait times for ASD assessment.    

Thank  you for  bringing these important  patient  safety  issues to my  attention. I  do  hope my  response 
provides some assurance to you and Joshua’s family regarding the actions being taken in relation to the 
waiting times for ASD assessments in Hertfordshire, and the support to those waiting. 

Please do not hesitate to contact me should you require any further information or clarification. 

Yours sincerely 

Chief Executive 
NHS Hertfordshire and West Essex ICB 

, Chief Executive                                                                                   

, Chair

Chief Executive:  

Sent via email: 

Hertfordshire County Council 

CHO 0238, Robertson House 
               Six Hills Way, Stevenage, SG1 2FQ 

Tel: 
     Contact: 
My ref: 
Your ref: 
Date: 

                   01992 555200 

                   10 April 2025 

Dear 

 - Senior Coroner's Officer 

Re: Regulation 28 Notice – Joshua Weavers 

Thank you for your 2025 Regulation 28: Report to Prevent Future Deaths dated 17 
February 2025. We would like to take this opportunity to express our sincere 
condolences to the family of Joshua Weavers; our thoughts are with them. 

The safety of the public using our bridges and infrastructure is paramount. We 
appreciate your report and provide our response to the concerns raised which relate to 
our duties and powers as local highway authority, namely: 

That the safety measures in place on the 
pedestrians either jumping or falling from the bridge do not meet current guidance 
and therefore gives rise to a risk of future deaths occurring. 

 to guard against 

Immediately after Joshua's sad death, we erected notices on the footbridge and road 
bridge to help deter future suicide attempts by signposting people to the Samaritans. 
Additionally, we considered what could be done in relation to the heights of the 
parapets on the bridges. As your report noted, these are lower than the current 
standards for new bridges. These standards were introduced relatively recently and 
are not retrospective on existing structures. Many other bridges both locally and 
nationally have similar or lower parapets than those set out in the current standards. 

We explored simple ways to raise the height of the parapets on the footbridge but 
unfortunately, concluded that this could not be done safely without up-to-date 
information on the condition of the structure, parts of which are impossible to access 

County of opportunity 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
                                         
                   
 
 
                   
 
                   
 
 
 
 
 
  
 
 
 
 
 
 
 under normal circumstances. Regrettably, there are no 'quick fixes' available to raise 
the height of the footbridge parapets.  

We therefore considered an alternative approach of closing the footbridge.  This would 
create a lengthy diversion for pedestrians to access the southern road bridge and an 
increased risk of pedestrians crossing the dual carriageway at an unsafe location.  

The southern road bridge was built at a similar time to the footbridge and also has 
relatively low parapets. It would be possible to raise the parapets on the southern road 
bridge, however in working with other agencies involved, the relative isolation of the 
footbridge was the principal concern. It was also considered that diverting people to 
the southern road bridge, would exacerbate the isolation of the foot bridge.  

With no immediate options to improve suicide prevention, we felt it was better to wait 
for the Inquest's input before considering other options. This requires a Principal 
Inspection of the bridge to assess the condition of the structure and we could then 
ensure this takes into account the findings from the Inquest. 

To inspect the footbridge and southern road bridge safely, we need Network Rail's 
permission for a time when the railway is closed and the overhead power lines turned 
off. We will use the next Principal Inspection to assess the feasibility of raising or 
replacing the parapets with new, higher versions. We are currently liaising with 
Network Rail and will undertake the Principal Inspection at the first opportunity. Once 
this is complete, we will be able to better understand the feasibility and costs of 
parapet improvements and consider the most appropriate course of action. 

We take our responsibilities in these matters very seriously and having considered 
immediate responses, with the benefit of the report of the Inquest’s findings, we are 
exploring all appropriate options to help reduce the risk of another death at this site.  

Once again, we offer our heartfelt sympathies to Joshua’s family for their loss.  

Yours sincerely 

Chief Executive 

County of opportunity

Mr Jacques Howell 
HM Area Coroner  
Hertfordshire Coroner Service 
The Old Courthouse 
St Albans Road East 
Hatfield  
Hertfordshire  
AL10 0ES 

Dear Coroner, 

National Medical Director  
NHS England  
Wellington House 
133-155 Waterloo Road  
London 
SE1 8UG 

27 May 2025  

Re: Regulation 28 Report to Prevent Future Deaths – Joshua Jay Weavers who 
died on 4 March 2021.  

Thank  you  for  your  Report  to  Prevent  Future  Deaths  (hereafter  “Report”)  dated  17 
February  2025  concerning  the  death  of  Joshua  Jay  Weavers  on  4  March  2021.  In 
advance of responding to the specific concerns raised in your Report, I would like to 
express my deep condolences to Joshua’s family and loved ones. NHS England are 
keen to assure the family and the Coroner that the concerns raised about Joshua’s 
care have been listened to and reflected upon.   

Your  Report  raised  the  concern  that  national  waiting  times  for  Autism  Spectrum 
Disorder (ASD) assessments are very long and, combined with the increased risk of 
suicidal behaviour amongst people diagnosed with ASD, there is a risk of future deaths 
occurring due to the national delays.  

My response to the Coroner has been aided by engagement with our national mental 
health, learning disability and autism teams and East of England regional colleagues.  

NHS England recognises the significant national challenge in ensuring timely access 
to  ASD  assessments  and  the  impact  that  long  waits  can  have  on  individuals  and 
families.  We  also  acknowledge  the  Coroner’s  concern  that  a  delay  in  diagnostic 
assessment, particularly for autistic young people at risk of suicide, may contribute to 
avoidable harm.  

In  April  2023,  NHS  England  published  the  National  Framework  and  Operational 
Guidance  for  Autism  Assessment  Services.  This  framework  sets  out  a  clear 
expectation that autism assessment pathways must not operate in isolation from wider 
services. Critically the operational guidance for Integrated Care Boards states:  

‘For  health-related  needs,  the  referrer  or  local  primary  or  secondary  care 
services  must not  omit  providing assessment  or  interventions  relevant to the 
person’s needs while they are waiting for an autism assessment. Clarity about 
a possible autism diagnosis, in almost all instances, does not negate input for 
current needs, symptoms or difficulties that appear linked to physical or mental 
health.’  

                                                                                                                       
 
 
 
 
 
  
 
  
 
 
 
 
 
 
  
 This principle is vital in cases where an individual presents with significant distress or 
risk – as was true in Joshua’s case. While a completed ASD assessment can support 
more  tailored  care,  it  should  not  act  as  a  prerequisite  for  accessing  timely  mental 
health support.  

Meeting  the  needs  of  Autistic  Adults  in  Mental  Health  Services  guidance  was 
published  the  same  year,  in  December  2023,  and  highlights  the  importance  of 
recognising and responding to distress and suicidality in people who are autistic, with 
the latter significantly over-represented when compared to the general population. The 
guidance  addresses  the  risk  of  diagnostic  overshadowing  –  where  symptoms  of 
distress  or  mental  illness  may  be  incorrectly  attributed  to  autism –  and  the  need  to 
ensure continuity of care for autistic people and those with suspected autism across 
all settings. These principles are relevant to transition-aged young people and support 
the  expectation  that  interventions  should  not  be  paused  while  awaiting  diagnostic 
clarity.  

NHS England’s Staying Safe from Suicide guidance (April 2025) further highlights the 
need for a coordinated, multi-agency approach to suicide prevention and emphasises 
the  importance  of  providing  responsive  and  compassionate  care  during  periods  of 
diagnostic  uncertainty.  The  guidance  reinforces  the  role  of  personalised  safety 
planning and the importance of ensuring that young people at risk of suicide are not 
left without therapeutic support due to delays in formal diagnosis.  

I hope that the publication of the above guidance in 2023 and 2025 provides assurance 
to the Coroner and Joshua’s family that actions have been taken since Joshua’s death 
across  the  NHS  to  help  address  the  concerns  raised.  NHS  England  continues  to 
support local systems to implement the guidance across their commissioned services. 
Further information on the work and progress of our Learning Disability and Autism 
Programme can be found here: https://www.england.nhs.uk/learning-disabilities/  

I  note  that  your  Report  has  also  been  addressed  to  Hertfordshire  and  West  Essex 
Integrated Care Board (ICB). NHS England has been sighted on their response to the 
Coroner and notes the work being undertaken to make improvements across service 
providers, with key elements including: 

•  providing better pre and post diagnosis support 
•  using inputs from a wider range of non-clinical and clinical staff specialisms to 

support diagnosis 
implementing a standardised and consistent referral and triage process.   

• 

I refer you to Hertfordshire and West Essex ICB’s response to your Report for further 
information on the actions they are taking.  

I  would  also  like  to  provide  further  assurances  on  the  national  NHS  England  work 
taking  place around  the  Reports  to  Prevent Future  Deaths.  All  reports  received  are 
discussed  by  the  Regulation  28  Working  Group,  comprising  Regional  Medical 
Directors,  and  other  clinical  and  quality  colleagues  from  across  the  regions.  This 
ensures  that  key  learnings  and  insights  around  events,  such  as  the  sad  death  of 
Joshua, are shared across the NHS at both a national and regional level and helps us 

 
 
 
 
 
  
 
 
 to  pay  close  attention  to  any  emerging  trends  that  may  require  further  review  and 
action.   

Thank you for bringing these important patient safety issues to my attention and please 
do not hesitate to contact me should you need any further information.  

Yours sincerely,  

National Medical Director